Does the Etiology, Phenomenology and Motor Subtype of Delirium Differ When It Occurs in Patients With An Underlying Dementia?: A Multi-Site, International Study

OBJECTIVES

To compare the etiology, phenomenology and motor subtype of delirium in patients with and without an underlying dementia.

METHODS

A combined dataset (n = 992) was collated from two databases of older adults (>65 years) from liaison psychiatry and palliative care populations in Ireland and India. Phenomenology and severity of delirium were analysed using the Delirium Symptom Rating Scale Revised (DRS-R98) and contributory etiologies for the delirium groups were ascertained using the Delirium Etiology Checklist (DEC). Delirium motor subtype was documented using the abbreviated version of the Delirium Motor Subtype Scale (DMSS4).

RESULTS

Delirium superimposed on dementia (DSD) showed greater impairment in short term memory, long term memory and visuospatial ability than the delirium group but showed significantly less perceptual disturbance, temporal onset and fluctuation. Systemic infection, cerebrovascular and other Central nervous system etiology were associated with DSD while metabolic disturbance, organ insufficiency and intracranial neoplasm were associated with the delirium only group.

CONCLUSION

The etiology and phenomenology of delirium differs when it occurs in the patient with an underlying dementia. We discuss the implications in terms of identification and management of this complex condition.

SAFE USE OF FLUOROSCOPY AND PERSONAL PROTECTION EQUIPMENT IN TRAUMA & ORTHOPAEDICS

Fluoroscopy is an indispensable tool that forms a significant part of the standard practice in many trauma and orthopaedic (T&O) procedures, as it facilitates dynamic assessment and aids intraoperative visualization and decision-making. It exposes patients and theatre staff to the potential hazards of ionizing radiation. Thus, the awareness of these hazards and proper use of personal protective equipment (PPE) will help mitigate increased exposure. This audit aimed to assess awareness regarding the safe use of fluoroscopy in T&O theatres, evaluate the level of PPE use and the knowledge of relevant guidelines, such as the British Orthopaedic Association (BOA) recommendations and local trust policy.A prospective audit was performed between June and July 2023 using an online survey sent to healthcare professionals working in T&O theatres across two hospital sites. Data were collected using an online questionnaire and responses kept anonymous and thus implied consent was applied. Standards followed the local trust policy at the University Hospitals Sussex NHS Trust and the BOA guidelines.Of the 49 respondents, 59% were fully aware of radiation hazards, and only the theatre radiographers were all fully aware. Surgeons (56%) and anaesthetists (46%) considered themselves to have adequate knowledge of these hazards. Just over half of the respondents (69%) could identify the major source of radiation, while only 37% understood the effect of distance on dose exposure. Of those surveyed, 49% knew the local trust policy, while 39.6% knew the BOA guidelines; less than half had formal training (40.8%). The results showed that less than half of the participants used the full PPE highlighted in the guidelines. Statistical analysis showed that only 46% of participants used a protective lead apron/lead skirt with a coat and thyroid shield. Of the survey participants, 84% never used eye protection during fluoroscopy procedures, and 58% had never received any formal training on radiation safety.The findings from this audit highlight the lack of awareness of the guidelines, resulting in suboptimal use of PPE in procedures with fluoroscopy. Recommendations for improvement include mandatory training for all theatre personnel. Methods of increasing awareness include using posters, performing regular audits to monitor the usage of PPE, and discussing the results in clinical governance meetings.

OCCUPATIONAL HAZARDS IN ORTHOPAEDIC PROCEDURES-A NARRATIVE REVIEW OF CURRENT LITERATURE

Orthopaedic surgeries pose various risks to the health of orthopaedic surgeons: radiation, noise, infection, chemical exposure, and musculoskeletal injury. These are associated with short and long-term health problems including malignancy and teratogenicity. Orthopaedic surgeons' health is critical to ensure optimal patient care. Most of these hazards can be obviated or minimized by adopting rigorous prevention protocols and raising awareness. Further related research is warranted and guidelines regarding prevention need to be framed by regulatory bodies.

Psychiatric morbidity among patients attending a rural non-communicable disease clinic

Background

The presence of psychiatric illness among patients with physical illnesses leads to poor treatment adherence, poor lifestyle, increased cost of treatment, poor quality of life, worsening of physical illness, work absenteeism, increased hospital visits, poor self-care and higher mortality. The study evaluated the prevalence of cognitive impairment and psychiatric morbidity in non-communicable disease patients. The study highlights that NCD patients should be provided information about the development of cognitive impairment in order to prevent it.

Methods

It was a cross-sectional study conducted among the patients attending the non-communicable disease clinic of a rural community health centre run in collaboration with the Postgraduate Institute Medical Education and Research (PGIMER), Chandigarh. We registered 124 patients after obtaining written informed consent. Instruments: Hindi Mental Status Examination (HMSE), Patient Health Questionnaire-9, Generalized anxiety disorder-7 (GAD-7) scale. Analysis of covariance was applied to see the relationship between the domain of the HMSE and NCDs.

Results

The mean age of the participants was 55.5 years (SD-11.9, Range-26-90). A little more than one third (N = 48, 38.7%) were diagnosed with hypertension only, one-sixth (N = 22; 17.7%) were diagnosed with diabetes mellitus only, and 54 (43.5%) patients were diagnosed with both hypertension and diabetes mellitus. A slightly more than one-third of the study participants were diagnosed with depressive disorder (N = 44, 35.5%), and 29% (N = 36) of the participants were diagnosed with an anxiety disorder. About one-fourth of patients with NCD have cognitive impairment and 39.51% have psychiatric morbidity.

Conclusions

The prevalence of cognitive impairment is higher among patients of NCD with psychiatric morbidity. Patients with NCDs should be routinely screened for cognitive functioning and provided information about the development of cognitive impairment.

Key messages

Because of high prevalence of cognitive impairment and psychiatric morbidity in NCD patients, patients should be provided information to prevent it. There is a need to screen NCD patients routinely for cognitive functioning, and provide them information to prevent cognitive impairment.

Teaching and training in psychiatry in India: potential benefits of links with the Royal College of Psychiatrists

Education in modern medicine in India began in 1835 with the establishment of the Madras Medical College, in what is now Chennai. Initially the growth of new medical schools was slow but it gathered pace after independence in 1947. In the past decade or so, the growth in terms of the creation of new medical schools has been phenomenal.

Positive Aspects of Caregiving and Its Correlates among Caregivers of Bipolar Affective Disorder

OBJECTIVE

To evaluate the positive aspects of caregiving and its correlates (socio-demographic and clinical variables, caregiver burden, coping, quality of life, psychological morbidity) in the primary caregivers of patients with bipolar affective disorder (BPAD).

METHODS

A total of 60 primary caregivers of patients with a diagnosis of BPAD were evaluated on the Scale for Positive Aspects of Caregiving Experience (SPACE) and the Hindi version of Involvement Evaluation Questionnaire, Family Burden Interview Schedule (FBIS), modified Hindi version of Coping Checklist, shorter Hindi version of the World Health Organization Quality of Life (WHOQOL-BREF), and Hindi translated version of 12-item General Health Questionnaire (GHQ-12).

RESULTS

Caregivers of patients with BPAD had the highest mean score in the SPACE domain of Motivation for caregiving role (2.45), followed by Caregiver satisfaction (2.38) and Caregiving personal gains (2.20). The mean score was the lowest for the domain of Self-esteem and social aspect of caring (2.01). In terms of correlations, age of onset of BPAD had a negative correlation with various domains of SPACE. The mean number of total lifetime affective and depressive episodes correlated positively with Self-esteem and social aspect of caring. Caregiver satisfaction correlated negatively with FBIS domains of Disruption of routine family activities, Effect on mental health of others, and subjective burden. Coercion as a coping mechanism correlated positively with domains of Caregiving personal gains, Caregiver satisfaction, and the total score on SPACE. Three (Physical health, Psychological health, Environment) out of 5 domains of the WHOQOL-BREF correlated positively with the total SPACE score. No association was noted between GHQ-12 and SPACE scores.

CONCLUSION

Positive caregiving experience in primary caregivers of patients with BPAD is associated with better quality of life of the caregivers.

Prescribing Pattern of Antidepressants in Children and Adolescents: Findings from the Research on Asia Psychotropic Prescription Pattern

OBJECTIVE

Pharmacotherapy of depression in children and adolescents is complex. In the absence of research into the efficacy and safety of antidepressants in this group of patients, their off-label prescription is common. This paper aimed to illustrate the prescription pattern of antidepressants in children and adolescents from major psychiatric centres in Asia.

METHODS

The Research on Asia Psychotropic Prescription Pattern on Antidepressants worked collaboratively in 2013 to study the prescription pattern of antidepressants in Asia using a unified research protocol and questionnaire. Forty psychiatric centres from 10 Asian countries / regions participated and 2321 antidepressant prescriptions were analysed.

RESULTS

A total of 4.7% antidepressant prescriptions were for children and adolescents. Fluoxetine, sertraline, and escitalopram were the most common antidepressants prescribed for children and adolescents. Almost one-third (30.3%) of prescriptions were for diagnoses other than depressive and anxiety disorders. There was less antidepressant polypharmacy and concomitant use of benzodiazepine, but more concomitant use of antipsychotics in children and adolescents compared with adults.

CONCLUSION

Off-label use of antidepressants in children and adolescents was reported by 40 Asian psychiatric institutions that participated in the study. In-service education and regulatory mechanisms should be reinforced to ensure efficacy and safety of antidepressants in children and adolescents.

Antidepressant Prescription Pattern in the Presence of Medical Co-morbidity: REAP-AD 2013 Study

OBJECTIVE

To evaluate the prescription pattern of antidepressants in patients with medical co-morbidity from major psychiatric centres in Asia.

METHODS

The Research on Asian Psychotropic Prescription Pattern for Antidepressants (REAP-AD 2013) collected data from 42 psychiatric centres in 10 Asian countries and regions. Antidepressant prescriptions of 2320 patients with various psychiatric disorders were evaluated. Of these, 370 patients who had specified medical co-morbidities formed the study cohort.

RESULTS

Escitalopram (20%) and mirtazapine (20%) were the most commonly prescribed antidepressants in patients with medical co-morbidity followed by sertraline (16%), trazodone (15%), and paroxetine (12%). Overall, more than half (52%; 247/476) of prescriptions comprised selective serotonin reuptake inhibitors. Slightly less than two-thirds (63%; n = 233) of patients received at least 1 selective serotonin reuptake inhibitor. In addition, 79% of patients were prescribed only 1 antidepressant. The mean number of antidepressants used per patient was 1.25 (standard deviation, 0.56). There were subtle differences in the most preferred antidepressant across medical illnesses such as diabetes mellitus, liver dysfunction, acid peptic disease, and cerebrovascular disease. Differences were also seen in prescription patterns across different countries.

CONCLUSION

Although selective serotonin reuptake inhibitors formed the bulk of antidepressant prescriptions in the presence of medical co-morbidity, mirtazapine was also commonly used in the presence of medical co-morbidities. Specified medical morbidities do influence the selection of antidepressants.

Association of Clozapine with Seizures: A Brief Report Involving 222 Patients Prescribed Clozapine

OBJECTIVE

To study the prevalence and incidence of seizures in patients prescribed clozapine.

METHODS

The treatment records of 222 patients commenced on clozapine were retrospectively reviewed during the period of January 2007 to June 2014 to evaluate the prevalence of seizures before and after starting clozapine.

RESULTS

The majority of patients commenced on clozapine were male (65%), single (65%), and unemployed (57%). The mean (± standard deviation) dose of clozapine was 277.9 ± 102.5 mg/day. A history of seizure was present in 6 patients who were also prescribed antiepileptic medication; of these 6 patients, only 1 case had recurrence of seizure while taking clozapine due to poor compliance with ongoing antiepileptic medication. The incidence rate of new-onset seizure with clozapine was 6% (12/216). Most patients who developed seizures were male, aged between 24 and 41 years, and had a long duration of illness (≥ 10 years). The risk of seizure was associated with the dose of clozapine used: 3% (5/159) with dose up to 300 mg/day, 8% (4/49) with 325 to 500 mg/day, and 38% (3/8) in those receiving > 500 mg/day. More than half of the patients (7/12) who developed seizures while prescribed clozapine were managed with reduction in the dose of clozapine. In one-third of cases (4/12) an antiepileptic medication was added and in 1 case, clozapine was stopped. All patients who continued on clozapine remained seizure-free at follow-up that ranged from 6 months to 4 years.

CONCLUSION

The incidence of seizures with clozapine was 6% and the risk of seizures increased with higher doses.

Relationship between first treatment contact and supernatural beliefs in caregivers of patients with schizophrenia

OBJECTIVE. To explore the relationship between attribution of symptoms to supernatural beliefs and first treatment contact in caregivers of patients with schizophrenia attending a tertiary care hospital located in North India. METHODS. A total of 122 caregivers (aged ≥ 18 years, staying with patient ≥ 1 year and involved in patients' care) of consecutive patients with diagnosis of schizophrenia (according to the ICD-10) were evaluated for their supernatural beliefs and first treatment contact. RESULTS. The first treatment contact was a government or private psychiatrist in slightly more than half (53.3%) of the patients, while it was faith healers in 23.8% of the patients. Around three quarters (74.6%) of the caregivers attributed patients' symptoms to ≥ 1 supernatural belief (like sorcery / witchcraft, ghosts, spirit intrusion, divine wrath, planetary influences, evil spirits, and bad deeds in previous life) and more than half (57.4%) of the caregivers attributed patients' symptoms to > 1 supernatural belief. It was observed that those who contacted faith healers for their patients' treatment had significantly higher attribution of the symptoms to supernatural causes. CONCLUSIONS. Supernatural beliefs were common in caregivers of patients with schizophrenia and the majority attributed their patients' symptoms to these beliefs. It signifies an urgent need for mental health literacy in India.

Symptoms and aetiology of delirium: a comparison of elderly and adult patients

OBJECTIVE. To compare the symptoms of delirium as assessed by the Delirium Rating Scale-Revised-98 (DRS-R-98) and associated aetiologies in adult and elderly patients seen in a consultation-liaison service. METHODS. A total of 321 consecutive patients with a DSM-IV-TR diagnosis of delirium were assessed on the DRS-R-98 and a study-specific aetiology checklist. RESULTS. Of the 321 patients, 245 (76%) aged 18 to 64 years formed the adult group, while 76 (24%) formed the elderly group (≥ 65 years). The prevalence and severity of various symptoms of delirium as assessed using the DRS-R-98 were similar across the 2 groups, except for the adult group having statistically higher prevalence and severity scores for thought process abnormalities and lability of affect. For both groups and the whole sample, factor analysis yielded a 3-factor model for the phenomenology. In the 2 groups, the DRS-R-98 item loadings showed subtle differences across various factors. The 2 groups were similar for the mean number of aetiologies associated with delirium, the mean number being 3. However, the 2 groups differed with respect to hepatic derangement, substance intoxication, withdrawal, and postpartum causes being more common in the adult group, in contrast lung disease and cardiac abnormalities were more common in the elderly group. CONCLUSION. Adult and elderly patients with delirium are similar with respect to the distribution of various symptoms, motor subtypes, and associated aetiologies.

Prevalence and type of functional somatic complaints in patients with first-episode depression

OBJECTIVE. To study the prevalence and type of functional somatic complaints in patients with first-episode depression. METHODS. A total of 164 patients attending the outpatient department of a general hospital psychiatric unit were evaluated using the Patient Health Questionnaire-15 (PHQ-15) and Hamilton Depression Rating Scale (HDRS). RESULTS. More than half of the sample were male (n = 85; 52%) and most of the subjects were married (n = 128; 78%). The mean (standard deviation) HDRS score was 19.9 (5.4). All patients had at least 1 functional somatic complaint, and that the mean (range) number of functional somatic complaints per patient on the PHQ-15 was 8 (1-15). The most common functional somatic complaints included feeling tired or having little energy (93%); trouble sleeping (80%); nausea, gas and indigestion (68%); headache (68%); pain in arms, legs, or joints (66%); and feeling the heart racing (65%). Total PHQ-15 scores indicated the presence of moderate-to-severe severity of functional somatic complaints. Back pain, as well as pain in arms, legs, or joints, were found to be more common in females. The number and severity of functional somatic complaints did not differ significantly in relation to other socio-demographics (locality, marital status, age, education, income) and clinical variables (duration, physical co-morbidity, and atypical features). CONCLUSIONS. Functional somatic complaints are quite prevalent in subjects with first-episode depression. Hence, clinicians should routinely evaluate patients with depression for these symptoms.

Clinical evaluation of Deep Anterior Lamellar Keratoplasty (DALK) for stromal corneal opacities

BACKGROUND

Corneal scars are commonly formed following many diseases of the eye like trauma, inflammation and infections. They lead to permanent diminution of vision which can be managed by Penetrating Keratoplasty (PK). PK is removing diseased as well as healthy tissues and is associated with many post-operative complications. Deep Anterior Lamellar Keratoplasty (DALK) is a relatively newer procedure which replaces only the diseased stroma, leaving the original corneal endothelium intact. This procedure is associated with lesser incidence of post-operative complications.

METHODS

The study was conducted at a large tertiary care centre. 10 patients with stromal corneal scars were subjected to DALK and results were analysed after 06 months. Poor quality donor corneal tissue of B- and C grade was used in all cases.

RESULTS

7 out of 10 patients (70%) undergoing DALK had post-operative visual acuity of 6/24 or better. 03 patients who did not have adequate recovery of visual acuity were due to over-riding of the graft in 01 case (10%), fungal keratitis in 01 case (10%) and interface haze in 01 case (10%).

CONCLUSION

DALK is a promising new technique for management of superficial corneal stromal scars using poor quality donor corneal tissue. Initial results are encouraging with minimal complications.

Psychoeducational intervention for caregivers of Indian patients with schizophrenia: a randomised-controlled trial

OBJECTIVE

There are hardly any randomised-controlled trials of structured family interventions for schizophrenia from India. This study attempted to evaluate the impact of a structured psychoeducational intervention for schizophrenia, compared with standard out-patient treatment, on various patient- and caregiver-related parameters.

METHOD

Seventy-six patients with DSM-IV schizophrenia and their caregivers were randomly allocated to receive either a structured psychoeducational intervention (n = 38) consisting of monthly sessions for 9 months or 'routine' out-patient care (n = 38) for the same duration. Psychopathology was assessed on monthly basis. Disability levels, caregiver-burden, caregiver-coping, caregiver-support and caregiver-satisfaction were evaluated at baseline and upon completion.

RESULTS

Structured psychoeducational intervention was significantly better than routine out-patient care on several indices including psychopathology, disability, caregiver-support and caregiver-satisfaction. The psychoeducational intervention package used was simple, feasible and not costly.

CONCLUSION

Structured psychoeducational intervention is a viable option for treatment of schizophrenia even in developing countries like India.

Psychosocial impact of dysthymia: a study among married patients

BACKGROUND

Unlike major depression, the psychosocial impact of dysthymia has received far less research attention. This study attempted to assess the psychosocial consequences of dysthymia.

METHODS

The sample consisted of 30 married patients with DSM-IV dysthymic disorder and a matched control group of 30 married patients with recurrent major depressive disorder (RDD), diagnosed using structured interviews. Apart from ratings of severity of depression, assessments of psychosocial impact included quality of life (QOL), disability, perceived social support and marital adjustment. Psychosocial parameters were evaluated using vernacular versions of well-validated scales previously used in similar populations. Matched normal/medically ill controls were derived from Indian studies which had assessed the same parameters using the same instruments.

RESULTS

Patients with dysthymia were significantly impaired on measures of QOL, disability, social support and marital adjustment compared to normal/medically ill controls. On the other hand, the two groups of dysthymia and RDD were comparable on these measures apart from significantly lower social support among patients with dysthymia. Duration of illness and severity of depression emerged as the most important correlates, particularly of impaired QOL and disability levels.

LIMITATIONS

Small hospital-based sample, normal/medically ill controls derived from other studies and cross-sectional assessments were the major limitations.

CONCLUSIONS

Dysthymia had considerable adverse psychosocial impact in terms of QOL, functioning (disability), social support and marital adjustment. Severity and chronicity appeared to be important mediators of this negative psychosocial impact. Increased awareness, improved recognition and adequate treatment might help negate some of the untoward social consequences of this condition.

Teaching and training in psychiatry in India: potential benefits of links with the Royal College of Psychiatrists

Education in modern medicine in India began in 1835 with the establishment of the Madras Medical College, in what is now Chennai. Initially the growth of new medical schools was slow but it gathered pace after independence in 1947. In the past decade or so, the growth in terms of the creation of new medical schools has been phenomenal.

Cost of ambulatory care of diabetes mellitus: a study from north India

BACKGROUND

Diabetes mellitus is a chronic and potentially disabling disease that represents an important public health and clinical concern because of the economic burden it imposes on the person, family, and society. Despite this, data regarding cost of care of diabetes mellitus from developing countries are scarce. This study aimed to assess the cost of care of Indian patients with diabetes mellitus.

METHODS

Cost of illness in 50 outpatients with diabetes mellitus (diagnosed according to WHO criteria, Expert Committee, 1997) was assessed over a six month period using a specially designed questionnaire, together with structured assessments of disability.

RESULTS

Total annual cost of care was 14 508 rupees (263.78 euros). The largest proportion of the total cost was made up of direct costs (68%), followed by indirect costs (28.76%) and provider's costs (2.8%). Drug costs were high. Total treatment cost was significantly higher in those who were more educated, those who visited the hospital more often, and those receiving a greater number of drugs.

CONCLUSION

From this study it can be concluded that diabetes mellitus is an expensive illness to treat even in developing countries. The main brunt of financial burden is borne by the family. Any efforts at cost reduction should, therefore, have the family as its focus, and relieving the family of this financial burden needs to be prioritised.

Cost of care of schizophrenia: a study of Indian out-patient attenders

OBJECTIVE

To assess the cost of care of Indian out-patients with schizophrenia.

METHOD

Cost of illness in 50 out-patients with schizophrenia was assessed over a 6-month period together with structured assessments of psychopathology and disability, and compared with 50 out-patients with diabetes mellitus.

RESULTS

Total annual costs of care of schizophrenia were 274 US dollars; these were not significantly different from diabetes mellitus. Indirect costs (63%) were higher than direct costs. Drug costs were high. The main brunt of financial burden was borne by the family. Total treatment costs in schizophrenia were significantly higher in those who were unemployed, those who visited the hospital more often, and were more severely ill and disabled.

CONCLUSION

Schizophrenia is an expensive illness to treat even in developing countries. Costs of care are similar to those of chronic physical illness, such as diabetes mellitus. Costs are higher in severely ill and disabled patients.

Dhat syndrome in a female- a case report

Dhat syndrome is a commonly diagnosed disorder in Indian male patients. Patients present with various physical and mental symptoms which are attributed to the passage of "Dhat"(commonly semen) in urine. A case of an adult female is described who presented with complaints of aches and pains, headaches and poor concentration which she attributed to "wetness" experienced per vaginum during sexual intercourse. Arguments are presented for the existence of "Female Dhat Syndrome"

Olanzapine in the treatment of schizophrenia : an open label comparative clinical trial from north India

The aim of the present study was to assess the efficacy and safety of olanzapine in the treatment of schizophrenic patients. 27 patients were randomly assigned to treatment with olanzapine or haloperidol over 12 weeks. The primary efficacy measure was the mean change from baseline to endpoint in total scores on the Brief Psychiatric Rating Scale (BPRS) and assessing treatment emergent adverse events. Secondary measures were positive symptoms, negative symptoms, general psychopathology depression, anxiety and quality of life. Compared to haloperidol, olanzapine had equal effect in improving overall psychopathology, positive symptoms, and severity of schizophrenic illness. Olanzapine showed supehor improvement on negative symptoms and secondary depressive features. Commonest side effects were weight gain, sleepiness and increased duration of sleep. Olanzapine is effective in improving overall psychopathology including positive symptoms, negative and secondary depressive features in Indian patients with schizophrenia and it is safe and well tolerated at dosage between 5 to 20 mg/day.

Impulse control disorders : nosology and concept

Impulse control disoders have long been recognized. Although included in nosological systems since two decades, their diagnostic validity individually, as well as a category remains in question. Conceptually, these have been linked to variety of other psychiatric or medical disorder viz. OCD, affective disorders, addictive disorders, organic mental conditions etc, but systematic studies have not been done. The present review focuses on the nosological and conceptual evolution of these disorders and highlights the overlap and boundaries with other psychiatric disorders.

Seasonality and affective disorders: a report from North India

Case records of the patients with major affective disorders (ICD-10 criteria), seen over a 5 year period in a busy clinic in North India were examined for Seasonal Affective Disorder (SAD) as per DSM-III-R criteria. In addition, seasonality of episodes of all affective disorders was also studied. Around 5.67% of the cases (n=44) retrospectively met the DSM-III-R criteria of SAD and predominant pattern was that of summer depression (n=18). There was also a consistent pattern of seasonal mania either in conjunction with seasonal depression (n=18) or in form of seasonal recurrent mania (n=11). None of the cases of depression showed any atypical vegetative features. In cases not meeting criteria for SAD (n=731), there was a trend for peaks for depressive episodes in winter followed by a smaller peak in summer months while manic episodes had peaks towards rainy and winter months. As compared to seasonal patterns of affective disorders in temperate zones, there was a general trend for opposite patterns of seasonality in SAD as well as in non-SAD. The findings are discussed in context of the climatic conditions of North India.

Magico-religious beliefs in schizophrenia: a study from north India

Psychiatric disorders in India are often attributed to influence of supernatural phenomena, and many patients are subjected to various kinds of 'magico-religious' treatments. We studied 40 cases of schizophrenia and ascertained magico-religious beliefs held by their key relatives. The effects of such magico-religious beliefs on psychopathology and treatment-seeking behaviour were explored. The sample were schizophrenia patients diagnosed according to ICD-10 of the World Health Organisation. Psychopathology was assessed on the 9th version of the Present State Examination (PSE-9). Supernatural Attitude Questionnaire was administered to the key relatives of the patients to ascertain their beliefs about various supernatural phenomena and magico-religious treatments. It was observed that the majority of the patients had undergone magico-religious treatment (n = 23). Nearly 74% of the patients who had symptoms coloured by cultural influences such as delusional explanation in terms of paranormal phenomena had undergone magico-religious treatment. It was also seen that though many relatives denied personal conviction in such magico-religious beliefs, yet they sought some kind of magico-religious treatment for the patients. The prevalence of culturally influenced delusions as defined by the PSE-9 was very low. Belief in supernatural influences is common in patients' relatives from urban background and with adequate education, and treatment based upon such beliefs is sought to a considerable extent in such cases. Local and community belief in such phenomena appeared to be a factor in influencing the decision to seek magico-religious treatment.

Clinical variables as predictors of response to electroconvulsive therapy in endogenous depression

There is lack of consensus on the clinical variables that predict response to ECT. Identification of clinical variables could help in predicting the type of response before the start of ECT Therefore, a prospective study on 22 patients of severe depression, some of whom were drug-naive and others drug free at time of ECT was undertaken. A maximum of six ECT were administered with a prior definition of 'good response' (60% or greater reduction in Hamilton Depression Rating Scale scores) Results showed that three clinical variables could distinguish between good responders and poor responders Hence, response to ECT was associated with the duration of past depressive episodes, suicidal thoughts and somatic symptoms.

Late onset schizophrenia versus early onset schizophrenia : a comparison of clinical features

Patients of late onset schizophrenia (LOS) (13 subjects), early onset schizophrenia (EOS) current age above 40 years (15 subjects) and early onset schizophrenia (EOS)- current age at or below 40 years (15 subjects) were compared. The LOS group differed from the two EOS groups only in having higher score on the item 'persecutory delusions'. The findings do not support the diagnostic validity of LOS.

Rapid cycling affective disorder: a descriptive study from North India

A series of 33 (4.29%) cases of rapid cycling affective disorder (RCAD ICD-10-DCR) out of a pool of 770 consecutive cases of ICD-10 affective disorder (AD) was collected over a period of 5 years. All cases of RCAD belonged to bipolar affective disorder. RCAD when compared with non-rapid cycling bipolar affective disorder (BPAD) revealed a significantly longer mean duration of illness, greater number of total episodes, greater number of hospitalizations and stronger family loading of bipolar affective disorder. These findings implicate RCAD as a severe form of bipolar affective disorder.

Distress in wives of patients with psychosexual dysfunction : an exploratory study

The study was conducted with the aim of studying the wives of patients with psychosexual dysfunction with regard to the level of distress experienced and its relationship with their psychosocial dysfunction and marital adjustment. The sample comprised wives of 30 male patients with psychosexual dysfunction. Majority of the subjects was under matriculate, housewives, Hindus, and of urban background. Majority of their husbands suffered from combination of premature ejaculation and failure of genital response (60%). The subjects were found to be significantly more distressed, exhibited mild degree of psychosocial dysfunctioning. However, they had normal marital adjustment. The interrelationship between these three variables showed significantly positive correlation between distress and psychosocial dysfunction. Marital adjustment showed significant negative correlation with both the distress experienced and psychosocial dysfunctioning. These findings not only have implication for the management of these disorders, but may have prognostic value as well.

Response to first ect in depression : a predictor of outcome

Response to first ECT in depression and its value as a predictor of response to ECT is a poorly researched subject. Twenty-two antidepressant-free patients of severe depression (ICD - 10) were administered a course of 6 ECTs using bilateral sine-wave electrical stimulation with serial assessments on Hamilton Depression Rating Scale (HDRS). Using 'a priori' definition for 'good response' (≥ 60% reduction is baseline HDRS scores) patients were grouped and analysed. The reduction in HDRS scores after first ECT was significantly greater for Good Responders (GR) in comparison to 'Poor responders'. It appeared that ≥ 9% reduction in baseline HDRS scores after the first ECT was associated with 'Good Response'. Thus, it can be concluded that response to first ECT could be taken as a viable predictor of response in depression.

Life events and social support in married schizophrenics

Life events are associated with relapse in schizophrenia. However, the role and interplay of marriage and social support have not been explored in research on schizophrenia, especially stable patients. Life events and social support were assessed in two groups comprising 30 married and an equal number of unmarried patients of schizophrenia. The time frame for these assessments was a period of 6 months prior to such evaluation. The married group reported higher stress score and greater number of undesirable life events. Negative correlation was present for social support with number of undesirable life events in the sample as a whole. Hence, it is concluded that marriage leads to experiencing more stress but there are other psychosocial variables mitigating the same and preventing relapse.

A psychosocial study of 'self-immolation' in India

The phenomenon of self-immolation was studied in 22 young people, mostly students, who had indulged in this act to protest against the decision of the Government of India to enlarge the scope of reservations in jobs and educational institutions. Within a short span of time of arriving at one of the two treatment centres after attempting self-immolation, the subjects were interviewed and assessed on a semi-structured interview schedule to elicit sociodemographic and attitudinal data. The subjects were also rated on the Brief Psychiatric Rating Scale, Pierce's Suicide Intent Scale, the Superego Paranoia Depression Scale, the Hostility and Direction of Hostility Questionnaire, the PGI Locus of Control Scale and the Alienation Scale. All subjects except one were free of manifest psychopathology. The group as a whole had a high score on Pierce's Suicide Intent Scale and displayed internal locus of control orientation. Most were ambitious, aggressive, hostile and felt alienated. The absence of manifest psychopathology sets this group apart from cases of deliberate self-harm arising in the context of psychiatric morbidity. Thwarted ambitions, a sense of alienation and intropunitive hostility can lead to protest which at times becomes altruistic and results in self-immolation.

Subsyndromes of chronic schizophrenia: a phenomenological study

Statistical grouping of clinical symptoms and signs is one method of classifying schizophrenia. This study attempted to find factors of symptoms generated through clinical ratings on three scales, namely the Scale for the Assessment of Positive Symptoms (SAPS), the Scale for the Assessment of Negative Symptoms (SANS) and the Comprehensive Psychopathological Rating Scale (CPRS) in a sample of 80 stable chronic schizophrenics diagnosed by DSM-III-R. It was found that the positive-negative dichotomy could not be replicated. Inappropriate affect was found to be a clear misfit in the cluster of negative symptoms. Inclusion of CPRS led to the generation of a factor loading high on depressive and asthenic items, and this could be clearly distinguished from the factor of negative symptoms. This factor had not hitherto been identified.

Integrative approach to management of anorexia nervosa : a case report

In-patient management with initial focus on weight restoration for an emaciated young girl with anorexia nervosa is reported. Integrative approach to management of this case yielded gratifying results which are maintained beyond one year after-discharge period.

Familial reverse seasonal affective disorder - a case report

A patient with recurrent summer depression for seven consecutive years is described, whose mood significantly worsened with increased environmental temperature. She had a family history of recurrent summer depression in both her brother and paternal grandmother with symptoms similar to those of typical endogenous depression. The patient's mood switched to hypomania with antidepressant therapy.

Psychosexual dysfunction in Indian male patients: revisited after seven years

Short-term (1 year) outcome of 66 male patients with psychosexual dysfunction was studied in the context of patients' sociodemographic and clinical characteristics. A combination of erectile dysfunction and premature ejaculation was the most common diagnosis. Long-term (7 years) outcome of this cohort was evaluated in relation to short-term outcome. Improvement in the short-term indicated favorable long-term outcome. Initial dropout was associated with chronic and continuous sexual dysfunctioning.

Combined chlorpromazine and electroconvulsive therapy in mania

We report the efficacy of combined chlorpromazine and electroconvulsive therapy (ECT) in the treatment of mania. Two groups of 15 manic patients received eight ECT sessions either actual or simulated, in a double-blind, controlled study. All patients also received 600 mg of chlorpromazine daily until the sixth session. Results indicate that the group receiving the combination of chlorpromazine and ECT did significantly better than the other group.

Post-psychotic depression in schizophrenia

Post-psychotic depression (PPD) is defined as the development of depression during the phase of remission of schizophrenia. Two groups of DSM-III-R schizophrenics, one with PPD and the other without PPD (30 subjects in each group) were compared. Significantly more patients in PPD group belonged to nuclear families, had longer duration of psychotic phase of the illness, were hospitalised more frequently and had more sadness and anxiety-somatisation during florid illness phase. The PPD group also had more past history of depression. Although PPD patients had better premorbid personal-social adjustment in comparison with non-PPD group, they perceived themselves to be lacking in social support and had experienced more stressful life events. For patients in the PPD group, stepwise multiple regression analysis revealed age of onset, sadness during florid psychotic state, premorbid adjustment, social support and life events as significant determinants of severity of depression in the post-psychotic phase.

A follow up study of schizoaffective psyohosis: an appraisal of socio-clinical and diagnostic aspects

Sociodemographic, clinical and outcome characteristics of 29 cases who had the diagnosis of schizoaffective psychosis were studied. On the basis of longitudinal course of the illness, 2 distinct subgroup of patients could be delineated. Patients with episodic illness were more akin to affective disorders while those with continuous course of illness were conceptually closer to schizophrenia. Concordance of the ICD-9 diagnosis of these patients with other well known diagnostic systems tike Research Diagnostic Criteria, DSM-III-R and proposed ICD-10 was studied. Advantages and limitations of these diagnostic systems with regard to the diagnosis of schizoaffective psychosis are discussed.

Inpatient sociodemographic and diagnostic study from a psychiatric hospital in Libya

Sociodemographic and diagnostic characteristics of 1009 patients admitted to the Psychiatry Hospital, Benghazi (Libya) in one calendar year are reported. Five hundred and four (50%) were 'first admission' cases. There were an average of 2.05 admissions for each 'readmission' case. Eighty nine percent of patients were of Libyan origin, of whom 62% were males; 66% were between 15-34 years of age, 37% were married, 28% were unemployed and 16% were in military service. ICD-9 schizophrenic psychosis was the commonest diagnosis (39%), followed by affective psychosis (17%), neurotic disorders (12%), organic psychosis (8%) and acute psychosis (7%). Neurotic depression was the commonest type of neurotic disorder and antisocial personality was the commonest among personality disorders. Relationship of sociodemographic variables with major diagnostic categories was studied in Libyan patients. Sociodemographic profiles of 'first admission' and 'readmission' cases of Libyan origin were also compared. These findings are discussed in relation to the sociocultural context.

Social burden of positive and negative schizophrenia

Sixty patients diagnosed as 'positive' or 'negative' schizophrenics were studied to evaluate social burden experienced by a key relative. The study had a prospective design and the patients were followed for a period of six months. At the time of initial assessments, in the 'positive schizophrenia' group, no significant correlation between ratings on psychopathology and social burden was observed, although at the end of the period of follow-up significant reductions in ratings on psychopathology and social burden as well as significant correlation between severity of psychopathology and burden of care were noted. In the 'negative schizophrenia' group, the severity of psychopathology and social burden were significantly correlated, but at the end of six months no significant change either in severity of psychopathology or social burden emerged.

Neuroleptic malignant syndrome with trifluperidol

In a case of NMS subsequent to administration of trifluperidol to a young man, the patient responded remarkably quickly to bromocriptine. The authors point out the deficiencies in the diagnostic criteria, which need further refinement for a better understanding of the syndrome.

Negative and depressive symptoms in schizophrenia

Ninety-five schizophrenic patients were assessed using the Present State Examination, the Brief Psychiatric Rating Scale and the Scale for the Assessment of Negative Symptoms. Negative and depressive symptoms were frequent, and significant relationships among negative symptom complexes and depressive syndromes were noted. Retardation, lack of energy, slowness, and other symptoms of depression were significantly associated with the negative symptoms of schizophrenia. Depressed affect per se did not have a significant correlation with negative symptoms.

Prognostic variables in schizophrenia

This study examined the relationship between measures of outcome and socio-demographic arid diagnostic variables in schizophrenia. Product moment co-efficient of correlation and stepwise multiple regression were the main statistical techniques of analyses. The results of the study indicate that DSM-III diagnosis of schizophrenia, duration of illness, and Present State Examination-PSE Syndrome of non-specific psychosis are important predictors of outcome. CATEGO and Research Diagnostic Criteria-RDC diagnosis of Schizophrenia, and Schneiderian First Rank Symptoms were found to be poor predictors of outcome. Socio-demographic and clinical variables like gender of the patient, place of origin, impersistence at work, poor premorbid work record, hospitalization at the time of admittance into the study, loss of interest, affective flattening and incoherent speech were found to have prognostic implications.

The brief psychiatric rating scale in positive and negative subtypes of schizophrenia

Usefulness of the Brief Psychiatric Rating Scale (BPRS) in distinguishing positive and negative subtypes of schizophrenia is presented. Ninety five schizophrenic patients were assessed on BPRS. Significant differences emerged between positive and negative subtypes of schizophrenia on items like emotional withdrawal, guilt feelings, tension, hallucinatory behaviour, motor retardation, blunted affect and excitement. Discriminant function equation generated by these items had a high rate of prediction of group membership either to positive or negative schizophrenia group. Principal components analysis of BPRS scores yielded factors which favour categorization of patients in positive, negative subtypes. The study provides support for classification of schizophrenia into these subtypes.

Non-medical drug use among interns and house-officers

Self-administered questionnaire was given to a sample of 105 interns and house officers working in Govt. Medical College, Jammu. Questionnaire was designed to obtain information about socio-demographic characteristics, the frequency of non-medical drug use during the last one year and to enquire about "reasons" for drug intake. It was found that drugs commonly used were alcohol, tobacco, tranquillizers, amphetamines, cannabis. Most of the subjects used the same for 'company', festivity or curiosity.