Research Studies

People with Severe Mental Illness (SMI) die on average 10-20 years earlier than the general population. Around 80% of deaths in people with SMI are due to preventable physical illnesses, most commonly cardio-metabolic diseases, respiratory disorders, and infectious diseases.

In this study we aim to determine the prevalence and distribution of physical disorders and lifestyle health risk behaviours in people with SMI in South Asia. We also want to compare our findings with those from the general population. In addition, we aim to determine the association between physical disorders, health risk behaviours, health related quality of life and various demographic, behavioural, cognitive, psychological and social variables.

We are conducting a cross-sectional survey among clinically diagnosed SMI patients recruited at specialist mental health institutions in Bangladesh, India and Pakistan. In Bangladesh, the survey is taking place at the National Institute of Mental Health (NIMH), Dhaka; in India, at the National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore; and in Pakistan, at the Institute of Psychiatry (IoP), Rawalpindi. All three are national institutes offering tertiary care specialist mental health services.

The study will help us understand access to physical healthcare for people with SMI, and what support to address health risk behaviours is offered to this population.

This study was adapted as a result of the Covid-19 pandemic to explore the impact of the pandemic and the related response (e.g. health promotion messaging, lockdown and social distancing), on mental illness, well-being, health risk behaviours, socioeconomic parameters, quality of life and use of healthcare for people with SMI. These are being compared with people who don’t have SMI.

The protocol for the study is below, if you would like further information please contact us.

Tobacco use is one of the leading contributors to morbidity and mortality worldwide, causing seven million deaths. South Asian countries have some of the highest rates of tobacco use. In particular, tobacco use is high in people with Severe Mental Illness (SMI), with estimates ranging from 50-90%. Limited data from South Asian studies suggest smoking prevalence is as high as 50% among people with SMI.  Those with SMI smoke more heavily, have more severe nicotine dependence, and face worse health outcomes as a result. Although smoking is one of the most common modifiable unhealthy behaviours among people living with SMI, the benefits of smoking cessation programmes have not been extended to this population.

The 4S study aims to adapt an evidence based, combined behavioural and pharmacological support intervention for smoking cessation to tailor it for people with severe mental illness. We are working with smoking cessation specialists, behavioural scientists, policy makers, practitioners and people with SMI.  We have run workshops to identify the changes needed to adapt a successful intervention used for the SMI population in the UK (the Scimitar study) and an intervention developed for people with suspected TB in South Asia. We have developed the 4S intervention, based on this work, including a 4S intervention manual (which can be found below in the supporting documents).

We plan to conduct a feasibility trial of 4S. In response to the challenges presented by the Covid-19 pandemic, are now adapting the 4S intervention further to allow remote delivery.

The protocol for the study is below, if you would like further information please contact us.

Depression in non-communicable diseases
Depression is currently the third leading contributor to years lived with disability and predicted to be the second by 2020. Despite this, there is a large ‘treatment gap’, with the great majority of depression not being diagnosed or treated, particularly in low and middle income countries (LMICs).

Depression is 2-3 times more common in non-communicable diseases (NCD). NCDs are chronic illnesses such as heart disease and diabetes. The presence of depression alongside NCDs is important as it worsens outcomes for both disorders.

Behavioural activation
Psychological interventions such as Behavioural Activation (BA) delivered by non-specialist health workers have been found to be effective for depression. However, we do not know whether BA delivered within NCD services is effective in people with coexisting NCD in LMIC in South Asia.

The ‘BEACON’ Study (Behavioural Activation for Comorbid depression in NCD) aims to adapt BA for the cultural and resource context and test feasibility of the adapted intervention. This work will help to plan a future large trial evaluation of BA for depression in NCDs in LMICs in South Asia.

We have completed studies in Bangladesh and Pakistan to explore the feasibility of introducing BA in NCD services through facility-based surveys and interviews with patients, healthcare providers and policy makers in two districts. The report of our findings can be read here.

In India, this work is currently underway led by NIMHANS.

Findings from the BEACON study have supported development of our NIHR RIGHT DiaDeM programme.

The protocol for the study is below. If you would like further information please contact us.

Core outcomes
To help patients and health professionals make decisions about treatments, they need evidence about what works best. Treatments are developed and tested by researchers to ensure they are safe and to estimate whether they improve the lives of patients. This is done by looking at the effect of any treatment, also known as the ‘outcome’.

Different outcomes for the same treatment can be explored by researchers to test different options for the improvement of a condition. As a health professional, this is challenging, as it is often difficult to determine what outcomes to consider when deciding the usefulness of a treatment.

The development of “core outcome sets” is an approach that addresses these challenges by involving stakeholders from research and practice. Core outcome sets are the minimum set of outcomes that all studies researching a particular health condition should include. This is very important for communication and to build a global evidence base as studies exploring the same health condition using the same set of outcomes can easily be compared and combined. This helps health professionals make better decisions about the treatments they offer to patients.

Multimorbidity
A specific focus of the IMPACT collaboration is on multimorbidity. Multimorbidity is defined as having two or more health conditions, such as mental disorders, non-communicable diseases, and/or communicable diseases, at the same time. People can experience a wide range of different combinations of conditions such as diabetes and depression or hypertension and heart disease. Studying multimorbidity is important as it poses particular challenges for (1) the person living with multiple conditions, (2) for healthcare services that are usually set up to deal with a single condition, and (3) for society because of the significant impacts on costs of healthcare, employment and the wider economy.

The COSMOS study
Decisions regarding which outcomes should be included in the core outcome set need to be made after a discussion with the appropriate stakeholders. The outcomes need to reflect the opinions of the users of these outcomes; mainly patients, carers, health professionals and researchers. The COSMOS study aims to address this by developing core outcome sets for a) prevention studies and b) treatment studies investigating multimorbidity in low- and middle-income countries settings.

In order to develop the outcome set, we will first search existing studies to generate a list of outcomes that are currently used. Next we will add to this list from findings from interviews with patients, carers, health professionals with expertise in treating and caring for people with multimorbidity and health researchers around the globe; building on our network in over 36 countries.

Finally, we will use a tool to help develop consensus, also known as a Delphi survey. Experts in multimorbidity from different parts of the world will be asked in two rounds to anonymously give their opinion on which outcomes are most important. As before, these experts will include patients, carers, health professionals with expertise in treating and caring for people with multimorbidity and health researchers. A meeting with global representatives will review the responses and agree on a consensus for the ranking of outcomes.

A report on what the experts have agreed to be the most important outcomes will be produced and it will highlight the ‘core outcomes’ for preventing and treating multimorbidity.

It is hoped that these outcomes will then be reported in all studies investigating multimorbidity and help improve quality of care and management of multimorbidity.

Further links:

Visit the Core Outcome Measures in Effectiveness Trials (COMET) initiative who have prepared resources to explore the importance of Core Outcome Sets:
If you are interested in our research, the following pages provide more detail on our activities:
Project registration 
Systematic review registration

If you would like further information please contact us.

The association between depression and chronic communicable diseases has been well established but is known to be complex. Depression in infectious diseases may occur for a number of reasons- due to the stress of living with chronic infection, the side effects of  treatments, or the effects of these diseases on the immune system or central nervous system. Conversely, depression can make people more vulnerable to infectious diseases such as TB and hepatitis.

TB and chronic hepatitis are among the most common global health issues and are prevalent in low and middle income countries (LMIC). People suffering from TB are 4 times more likely to have depression than the general population. Similarly, depression is more common in people suffering from chronic hepatitis. Depression coexisting with TB or with chronic hepatitis has a number of negative impacts, including lower adherence to treatments, poorer health outcomes and quality of life and increased mortality.

Effective treatments for depression are available that could also potentially improve outcomes for the co-existing communicable diseases as well.  However, depression is rarely recognised or treated in people with these conditions, being frequently overlooked by those providing healthcare.

Integrating depression care in well-established TB and hepatitis services in LMICs presents an efficient pathway for improving mental health, and possibly also chronic communicable disease outcomes for this population.

The IMPACT-CCD TB and hepatitis studies aim to develop and test the feasibility of integrating depression care in these services in South Asia (India, Bangladesh and Pakistan).

We aim to:

• Understand the facilitators and barriers to integration of depression care in TB and hepatitis services through stakeholder consultations.
• Develop co-designed plans and materials for integration of depression case-finding and treatment. Co-design will help engage patients, families and healthcare staff.
• Evaluate the feasibility of the co-designed plans and materials.

If you would like further information please contact us.

Mental health is highly stigmatised in Bangladesh and patients with non-communicable diseases (NCDs) generally do not seek care for mental health problems.

Although the burden of mental illness is growing in Bangladesh there is very little or no evidence on how mental health care can be integrated in primary care, particularly in rural communities.

This qualitative study aims to understand the perceptions, beliefs and norms about common mental disorders among patients with NCDs and their close family members. It also aims to explore the perspectives of healthcare providers on integrating mental healthcare in primary health care facilities in Bangladesh.

The research will be conducted in two district (Upazila) health complexes and one district hospital in the Munshiganj district.

In-depth interviews will be carried out with patients and family members receiving care at the selected facilities. The research team will also conduct interviews with health care providers and focus group discussions with community health workers.

Findings from the study will provide vital information regarding the perceived belief and norms about mental health services and the barriers and possible opportunities to improve services.

Low and middle-income countries are experiencing a high disease burden caused by comorbid common mental disorders (CMDs) such as depression and anxiety, and non-communicable diseases (NCDs), such as diabetes and COPD.

In 2015 WHO indicated that about 4.4% of the global population live with depression and 3.6% suffer from an anxiety disorder. Of this, 27% of all people with depressive disorders and 23% of people with anxiety disorders are from South Asia (WHO, 2017). A recent systematic review found a high prevalence of depression and anxiety in people with NCDs in the 3 largest South Asian countries, Bangladesh, India and Pakistan (Uphoff et. al., 2019). With evidence of a prevalence of CMD comorbidity in the NCD population between 20%-30%, the study highlighted the importance of research, practice and policy to address this growing comorbidity burden.

Building appropriate strategies to address the burden of CMD and NCD comorbidity requires detailed knowledge of the epidemiology of mental-physical comorbidity. Using routinely collected data, for example information collected by healthcare organisations, or surveillance and large epidemiological study data that are already available, is a cost-effective means to estimate the epidemiological burden and perhaps to explore the effectiveness of policy and healthcare interventions. The NIHR IMPACT group aims to explore available data sources, platforms and systems that may provide evidence and statistics on CMDs and NCDs in Bangladesh, India and Pakistan.

Given the large geographical area and complexities of healthcare organisations, we will focus on selected regions where we are already conducting IMPACT studies.  The aim is to identify relevant data sources and to create a repository of information on relevant data and information systems that could be used to inform policy and research. It may also help in timely health service planning, especially at a regional level. Furthermore, systematic searching for data records on CMD and NCDs can help avoid duplication of information gathering and ensure a more efficient use of resources.

Healthcare services for both CMD and NCD in these countries are likely to involve a diverse set of public and private data collection systems including cross-sectional and longitudinal health surveys, administrative enrolment, billing and medical records which may be used by various entities, including public and private hospitals, private physicians’ clinics, and public and private health insurance plans.

This mapping exercise aims to:

• Identify all sources of routine data-records and periodic cohort and cross-sectional surveys that provide information on CMDs and NCDs.
• Collate and understand the nature of information stored in these different sources.
• Identify and list the mechanisms of access for data, including identification of key stakeholders/institutions responsible for granting access.
• Identify routine information systems for hospitals and institutions regarding available information on staff. This may include expenditure on personnel, skills, training and professional development activities.
• Explore within hospitals how patient records relate to management of CMDs and NCDs and understand how they are collected and collated at different levels, and shared across different facilities to document approaches to record keeping.

For existing trial and intervention based data or records we will also seek to identify whether baseline data are available from trial registries and other sources on study population, recruitment procedures, key outcome indicators, whether resource utilisation are being collected, length of trial/intervention evaluation, number of data collection points and sources of funding. We aim to explore the availability of local registries for trials and epidemiological studies on mental health and NCDs in particular, as well as whether these studies are also registered internationally.

If you would like further information please contact us.

People with severe mental illness (e.g. schizophrenia, related psychotic disorders, bipolar disorder) are likely to suffer disproportionately from being either over- or underweight because of complex, multiple disadvantages. These include: lower employment, income, poorer physical health and healthcare and compromised ability to self-care (Ul-Haq, Mackay, Fenwick, & Pell, 2014).

The prevalence of obesity in people with SMI has been reported to be twice that of the general population (Naslund et al., 2016). There is less information on the prevalence of underweight. However, a systematic review reported a higher prevalence of underweight among those with schizophrenia compared to the general public (Sugawara et al., 2018).

62% of individuals from LMICs are overweight or obese and 29.6% have been reported to be underweight (Ng et al., 2014; WHO, 2008, 2013).  More than 80% of people who have mental illness reside in LMICs. The prevalence of obesity or underweight in those with SMI is likely to be higher in LMICs than high-income countries (HICs). However, the evidence for this is missing.

Obesity contributes to the near doubling of cardiovascular mortality (Schreurs, Vancampfort, & Van Winkel, 2009). Theres is a 2-3 times higher overall mortality rate in people with SMI than the general population. Concerningly, this mortality gap appears to be widening in recent decades (Vancampfort et al., 2015). Obesity is also an economic burden for health care systems; the global economic impact of obesity is roughly $2.0 trillion, or 2.8% of global GDP, which reflects the fact that obesity places a burden on both developed and developing economies  (Dobbs et al., 2016).

The additional economic burden due to underweight ranges from 2.5% to 3.8% of GDP (Bagriansky, Champa, Pak, Whitney, & Laillou, 2014; Stein & Qaim, 2007). Due to the personal and economic costs of obesity and underweight in SMI, it is important to obtain reliable, up to date estimates of the prevalence of both. This will help raise awareness amongst stakeholders and policy makers about the extent of the problem and mobilise support and inform strategies to tackle this growing epidemic.

Despite its importance, current evidence on the prevalence of obesity, overweight or underweight in people with SMI is lacking. Most research on SMI and weight has been targeted only on people living with obesity. Two systematic reviews investigated the prevalence of metabolic syndrome (which includes central obesity, high blood pressure, low high-density lipoprotein (HDL), cholesterol, elevated triglycerides and hyperglycaemia) in those with SMI; however, they excluded studies that only reported the prevalence of overweight and obesity (Mitchell et al., 2013; Vancampfort et al., 2015). Although obesity outcomes overlap with those of metabolic syndrome, it is important to examine obesity as a separate entity because the effects of obesity are broader than cardiovascular risk.

There has been much less research attention on those with SMI who are underweight. A recent systematic review conducted in 2017 (including 17 studies) only focused on schizophrenia, and estimated that  1 in 16 individuals with schizophrenia is underweight (Sugawara et al., 2018); bipolar disorder and schizoaffective disorder were not included.  An up to date synthesis, including the major diagnostic SMI subgroups (i.e., schizophrenia and related psychotic disorders, bipolar disorder) and examining the prevalence of obesity, overweight and underweight in this population is needed to inform evidence-based policy and practice to tackle this double burden of malnutrition and to help address the widening gap in health for this population.

The questions for our review will be:

What is the prevalence of obesity, overweight and underweight in people with SMI?
What is the relative risk of being obese, overweight and underweight in people with severe mental illness compared to the general population?

If you would like further information please contact us.

People with severe mental illness (SMI) experience poor physical health and are disproportionately exposed to and engage in behaviours which are detrimental to health (poor diet, low levels of physical activity, smoking and harmful alcohol use).  Influential reviews and position statements have taken note of evidence to mitigate these factors and improve physical health and have largely focussed on non-communicable diseases (NCDs). However there are no systematic reviews which focus on evidence from the perspective of LMICs, where trial based evidence will be essential in formulating practice and policy.

Disparities in health for people with SMI arise due to both communicable and non-communicable diseases, and the disproportionate presence of health risk behaviours can mediate the poorer outcomes which are observed.

The assumption that interventions which are effective in higher-resourced systems are directly transferable or adaptable to LMICs needs to be explored. Research evidence framed within less well-resourced health systems will be contextually useful and may have addressed the specific challenges of health improvement, behaviour change and prevention in diverse environments and populations.  In relation to communicable diseases, the specific exposures and responses to infectious agents will be different compared to higher income countries.

We are planning an evidence synthesis of the available trial based literature to i) identify ‘what works’, and ii) identify important evidence gaps to inform the future research agenda for the National Institute for Health Research (NIHR) IMPACT research programme.

We are undertaking a suite of three interlinked reviews under the umbrella of the NIHR IMPACT Group which will explore the interface between severe mental illness, disease and health in low and middle income countries. We will focus on three areas:

1. Non-communicable diseases. What works in the prevention or optimisation of the management of long term physical health conditions?
2. Communicable diseases. What works in the prevention or optimisation of the management of conditions caused by infectious diseases?
3. Behavioural risk factors. What works in the modification or elimination of behaviours that are detrimental to health or the promotion of behaviours that facilitate good health

If you would like further information please contact us.

The aim of this study is to document actions taken by the government and non-government agencies in Bangladesh in response to the Covid-19 pandemic. Activities include a scoping review of the contents of published electronic and print media on the major events relevant to COVID-19 and generating a comprehensive document for supporting government planning during the next phase of response to COVID-19. Our review focuses on 5 areas:
WP1: Situation analysis of Covid-19 in Bangladesh
WP2: Health Ministry’s response to Covid-19 epidemic in Bangladesh
WP3: Impact of Covid-19 on frontline workers
WP4: Financial stimulus by the government for supporting livelihoods in Covid-19 situation
WP5: Reaction and reflection of public via media about the measures taken by the government and non government agencies in response to the Covid-19 epidemic.

The study findings will generate evidence on the gaps in health systems preparedness and advocate for effective prevention of Covid-19 transmission in the country.

The contact person for this study is Nantu Chakma
Study lead Dr. Aliya Naheed
Co Leads David Mcdaid, Hannah Jennings
Team members Mir Nabila Ashraf, Saimul Islam, Noshin Farzana, Sunjida Islam, AKM Solayman

If you would like further information please contact us.