Correspondence
wherein cohorts were limited to people
with a subsequent health visit within
the 14 to 90 day period after diagnosis
(as shown in the appendix of the
Article).1
With the benefits of the longer
follow-up that is now available com­
pared with when we did the study,
we ran an additional sensitivity
analysis in which the same cohorts
of patients (ie, with COVID-19 and
influenza) as in our primary analysis
were followed up until Feb 12, 2021.
This analysis allowed us to distinguish
people who were potentially lost to
follow up in the 3 months after their
diagnosis from people who had not
yet made contact with a health-care
organisation from the network. In
this additional analysis, there was
substantially less difference in the
follow-up rates between cohorts,
particularly at 15 days, where the
number of people who were at risk of
psychiatric illness differed only by 0·2%
(ie, 62·2% of the COVID-19 cohort vs
62·0% of the influenza cohort). In this
analysis, at 90 days, the relative risk of
having had a psychiatric illness in the
COVID-19 versus influenza cohorts
was 1·86 (95% CI 1·65–2·06), which is
similar to that in the primary analysis.
This similarity provides further
evidence that differences in loss of
patients to follow-up do not account
for the observed differences in rates of
psychiatric diagnoses.
Regarding the exclusion of patients
from the analysis who had died after
the index event, we included these
patients as part of a sensitivity analysis
in a follow-up study.2 Similar findings
were obtained when patients who had
died were included.
SL is an employee of TriNetX. All other authors
declare no competing interests. MT and PJH
accessed and verified the data in the study and the
corresponding author had final responsibility for the
decision to submit for publication.
Maxime Taquet, Sierra Luciano,
John R Geddes, *Paul J Harrison
paul.harrison@psych.ox.ac.uk
Department of Psychiatry, University of Oxford,
Oxford OX3 7JX, UK (MT, JRG, PJH); TriNetX,
Cambridge MA, USA (SL)
www.thelancet.com/psychiatry Vol 8 May 2021 361
1 Taquet M, Luciano S, Geddes JR, Harrison PJ.
Bidirectional associations between COVID-19
and psychiatric disorder: retrospective cohort
studies of 62 354 COVID-19 cases in the USA.
Lancet Psychiatry 2021; 8: 130–40.
2 Taquet M, Geddes JR, Husain M, Luciano S,
Harrison PJ. Six-month neurological and
psychiatric outcomes in 236 379 survivors of
COVID-19: retrospective cohort studies using
electronic health records. Lancet Psychiatry
2021; 8: 416–26.
India needs rigorously
tested, culturally
adapted cognitive
behavioural therapy
As of 2017, the Global Burden
of Disease study estimated that
approximately one in seven people
living across 29 states in India were
affected by mental illness.1 Some
challenges that were highlighted
were the mental health treatment
gap, the need for community-based
psychological interventions, and
the need for cultural adaptation
of psychological interventions
like cognitive therapies, keeping
in mind the existing plurality in
approaches to treatment. Beck and
colleagues 2 emphasised the need
for increased acceptance of, and
access to, culturally adapted models
of cognitive behavioural therapy
as a potential solution to the vast
unmet mental health treatment gap
in low-income and middle-income
countries. In support of adaptation
of psychotherapy for indigenous
populations, Bhargava and colleagues3
reported that the integration of Indian
theories such as karma and rebirth,
drawn from the Bhagwad Gita, with
cognitive behavioural therapy have
been beneficial. Other systems, such
as the Patanjali Yoga philosophy,
the Siddha philosophy, and the
Ayurveda, describe aetiology, stages
of progression, and treatment for
mental disorders, and aim for holistic
mental health. In India, these systems
of wellbeing are widely accepted and
popular. Although attempts to infuse
Eastern concepts and practices into
Western psychotherapy have been
promising, cultural adaptations of
psychological therapies are limited
to language of delivery and context
and cultural orientation of the
therapist, rather than content. 4
Models of adaptation of Western psy­
chotherapies need to be improved
through studies of systematic
adap­ t ation in conformance with
specific requirements of a population.5
One of us, DS, is a practicing psy­
chotherapist, who, to improve accep­
tance for psychological therapies, has
introduced the concept of therapy
in the non-clinical setting of coffee
shops in Pune, India. DS has felt the
need for indigenisation of cognitive
behavioural therapy, not only for
rural populations but also for middle
and lower socioeconomic groups
in urban centres. In India, concepts
of Karma-phal (cycle of actions
and consequences), Prarabdha
(sins connected to past lives), Moh
(attachment), and Dukkha (suffering)
are preferred over sophisticated but
unfamiliar western philosophy, to
explain and cope with psychological
suffering. Psychotherapists improvise
to include the client’s religious
and cultural concepts in therapy,
compromising its empirical basis.
We urge organisations and
researchers to endeavour to create
and test a comprehensive model of Published Online
psychotherapy that combines principles March 10, 2021
https://doi.org/10.1016/
of cognitive behavioural therapy S2215-0366(21)00076-6
with the philosophy and practices
from the Bhagwad Gita, the Patanjali
Yoga Darshan, and the Ayurveda.
Psychotherapy in India needs to shift
from an individual and ad hoc approach
to an empirical and standardised one to
improve mental health outcomes.
DS has a private psychotherapy practice.
BPC declares no competing interests.
Debasmita Sinha,
*Biswa Prasun Chatterji
biswaprasun@gmail.com
School of Liberal Arts, Ajeenkya DY Patil
University, Pune, India (DS); School of
Engineering, Ajeenkya Dy Patil University,
Pune 421105, India (BPC)
 Correspondence
1 India State-Level Disease Burden Initiative
Mental Disorders Collaborators. The burden of
mental disorders across the states of India:
the Global Burden of Disease Study
1990–2017. Lancet Psychiatry 2020; 7: 148–61.
2 Beck A, Nadkarni A, Calam R, Naeem F,
Husain N. Increasing access to cognitive
behaviour therapy in low and middle income
countries: a strategic framework.
Asian J Psychiatr 2016; 22: 190–95.
3 Bhargava R, Kumar N, Gupta A. Indian
perspective on psychotherapy: cultural issues.
J Contemp Psychother 2017; 47: 95–103.
4 Chowdhary N, Jotheeswaran AT, Nadkarni A,
et al. The methods and outcomes of cultural
adaptations of psychological treatments for
depressive disorders: a systematic review.
Psychol Med 2014; 44: 1131–46.
5 Koc V, Kafa G. Cross-cultural research on
psychotherapy: need for a change.
J Cross Cult Psychol 2018; 50: 100–15.
The COVID-19 pandemic
Published Online
has reinforced the need
March 16, 2021
https://doi.org/10.1016/
for community mental
S2215-0366(21)00070-5 health-care models in
Uganda
As seen elsewhere, the COVID-19
pandemic in Africa has created an
urgent need for an isolated space
in which to manage patients with
COVID-19. In high-income countries
such as China, the UK, and the USA,
standalone units were built to
cater for the extra isolation space
required to manage a surge in
COVID-19 confirmed cases. In much
of Africa, building such units was
not possible because of financial,
infrastructural, and human resource
constraints. 1 Mental health units
that conventionally stand alone,
far from other health services,
were deemed appropriate for the
isolation of patients with COVID-19.
In Uganda, the only national referral
inpatient mental health unit (Butabika
Hospital, Kampala, Uganda) has
only 638 inpatient psychiatric
beds for a population of almost
50 million people. Between Jan 1 and
Dec 31, 2018, the bed occupancy rate
of Butabika Hospital was 149%.2 Even
with such a high demand for beds in
Butabika Hospital, lower level regional
362 www.thelancet.com/psychiatry Vol 8 May 2021
psychiatric units were converted into
isolation units for COVID-19.3
The transformation of psychiatric
units into isolation centres in low-
income countries such as Uganda
requires mental health providers to
adopt new care models that do not
involve these standalone units. Models
for community mental health care,
such as integrating psychiatric care
into everyday clinical practices, are
crucial during this pandemic. Integrated
mental health care is an attempt to
combine behavioural health services
wholly or partly with general and
specialty medical services.4 Care models
that ensure staff and patient safety
while managing psychiatric and non-
psychiatric patients together should
also be promoted. For example, the
Safewards model aims to reduce conflict
between patients and health-care
workers so that coercive or restrictive
measures are not put in place.5 Musisi
and colleagues have even argued for the
introduction of outreach mobile mental
health clinics.6
Community mental health care needs
to become the primary form of care
for patients with psychiatric illness in
African countries both during and after
the COVID-19 pandemic. With a surge
of the pandemic in African countries,
the need for isolated spaces and the
alternative use of inpatient psychiatric
beds for patients with COVID-19 are
only expected to rise. An expected
increase in the incidence of mental
health-related complications will
also pose a challenge because of the
inadequate space; yet existing patients
need ongoing care. Now rather than
later, a discussion of community models
of care for patients with mental illness
need to be expedited. Because of the
insufficient financing available before
the onset of the COVID-19 pandemic,
alternative care models were never fully
developed in low-resource settings such
as Uganda.1 More substantial funding is
required to scale up community mental
health services, integrated care, and
the Safewards model. This scale-up
will ensure that after the COVID-19
pandemic, health systems can help
reduce the possibility of a second
pandemic, this time of mental illness.
We declare no competing interests.
*Emmanuel Kiiza Mwesiga,
Noeline Nakasujja,
Wilson Winstons Muhwezi,
Seggane Musisi
emwesiga@chs.mak.ac.ug
Department of Psychiatry (EKM, NN, WWM, SM)
and NURTURE Mental Health subgroup (EKM, NN,
SM), College of Health Sciences, Makerere
University, Kampala 7062, Uganda
1 Ssebunnya J, Kangere S, Mugisha J, et al.
Potential strategies for sustainably financing
mental health care in Uganda.
Int J Ment Health Syst 2018; 12: 74.
2 Mwesiga EK, Nakasujja N, Nakku J, et al.
One year prevalence of psychotic disorders
among first treatment contact patients at the
National Psychiatric Referral and Teaching
Hospital in Uganda. PLoS One 2020;
3
15: e0218843.
The Independent. Soroti hospital creates more
space for COVID-19 patients. June 13, 2020.
https://www.independent.co.ug/soroti-
hospital-creates-more-space-for-covid-19-
patients/ (accessed Feb 6, 2021).
4 Wakida EK, Okello ES, Rukundo GZ, et al.
Health system constraints in integrating
mental health services into primary healthcare
in rural Uganda: perspectives of primary care
providers. Int J Ment Health Syst 2019; 13: 16.
5 Gerdtz M, Daniel C, Jarden R, Kapp S. Use of the
Safewards Model in healthcare services:
a mixed-method scoping review protocol.
BMJ Open 2020; 10: e039109.
6 Okpaku SO. Essentials of global mental health.
Cambridge: Cambridge University Press, 2014.
Sociocultural influences
on interventions for
anorexia nervosa
In The Lancet Psychiatry, M Solmi
and colleagues reported a network
meta-analysis, which found that
psychological interventions are
associated with modest, but clin­
ically significant improvements
for adults with anorexia nervosa.1
However, none of the well known
specialty interventions were better
than treatment as usual. Solmi and
colleagues suggest investigating
patient level and therapist level factors
that might influence outcomes. In an
associated Comment, Evelyn Attia
recommends mechanism-based