Feasibility and effectiveness of stress management skill training in medical students

Background

There is limited literature on stress management interventions targeting Indian medical undergraduates. With this background, the study aimed to evaluate the feasibility and effectiveness of stress management intervention on perceived stress, coping and burnout amongst first-year medical undergraduates.

Methods

It was a quasi-experimental study assessing the effect of "Comprehensive Stress Management Skill Training Program". This intervention emphasized on self-awareness of early warning signs of stress, adopting a healthy lifestyle, developing assertiveness at work, maintaining work-life balance. The stress reduction techniques mainly consisted of deep breathing exercises, progressive muscular relaxation and visualization. It was delivered by a team of a psychiatrist and a nurse to hundred first year medical undergraduate students. Medical Students Stressor Questionnaire, Brief COPE Questionnaire and Maslach Burnout Inventory-Student Survey were applied for assessment of perceived stress, burn out, and coping, respectively, at baseline, finish of one and three months of intervention.

Results

Significant improvement was noted in academic stress, interpersonal-related stress, teaching learning-related stress, and total stress scores, emotional exhaustion, and emotion-focused coping at the end of the three months of intervention. Positive feedback about the intervention was given by majority of the students.

Conclusion

Stress management intervention was found to be feasible and effective in improving stress, coping, and emotional exhaustion in first year medical students.

A Cross-Sectional Study to Assess the Frequency of Restraint, and Knowledge and Attitudes of the Caregivers of Patients Toward Restraint in a General Hospital Psychiatry Setting from South India

BACKGROUND

There is limited Indian data on the epidemiology of hospital-based restraint practices and the knowledge and attitude of caregivers toward restraint. Therefore, this study aimed to report the frequency and pattern of restraints in a general hospital psychiatry setting and assess the knowledge and attitude about restraint practices among caregivers of patients.

METHODS

We calculated the frequency of restraints (physical and chemical) over one year. The knowledge and attitude toward restraint were assessed in 75 caregivers each of patients from inpatient and outpatient settings, using a questionnaire designed by the authors and pretested in a pilot study.

RESULTS

The frequency of any form of restraint was 19%. The frequency of chemical and physical restraints was 19% and 0.5%, respectively. Less than 20% of caregivers in both groups reported that restraint was either stigmatizing (5.33% inpatient caregivers vs. 12% outpatient caregivers), cruel (8% inpatient caregivers vs. 15.33% outpatient caregivers), or a measure of punishment (9% inpatient caregivers vs. 16% outpatient caregivers). No significant difference was found between knowledge and attitude about restraint between caregivers of outpatients and inpatients, except for a significantly greater number of caregivers of outpatients reporting that the restraint practices in the hospital were similar to those adopted by faith healers or religious/spiritual centers.

CONCLUSION

The frequency of either physical or chemical restraint was less compared to the existing international and Indian data. In addition, most caregivers of patients of both outpatients and inpatients did not report a negative attitude toward restraints.

Stress, Burnout, and Coping among First-Year Medical Undergraduates

Background and Objectives  Stress, burnout, and coping have been found to be interlinked with each other. Several adverse psychological outcomes have been associated with stress and burnout. Improving coping can decrease the stress and burnout. There is limited literature on perceived stress, coping, and burnout among first-year medical undergraduates from India. With this background, the study aimed to assess perceived stress, coping, and burnout among first-year medical undergraduates. Methods  It was a cross-sectional study assessing 100 undergraduates studying in the first year of medical school. Medical Students Stressor Questionnaire, Brief COPE questionnaire, and Maslach burnout inventory-student survey were applied for assessment of perceived stress, burnout, and coping, respectively. Socio-demographic profile was assessed by a semi-structured proforma. Results  Majority of students reported facing moderate level of stress in most of the domains, with stress being the highest for the academic aspects and least for social-related and drive- and desire-related areas. The stress was significantly greater in female students. Burnout was identified in 62% students by two-dimensional criteria and 30% by three-dimensional criteria. Among the coping strategies, active coping was most commonly used and substance use was less commonly used. No differences were found in coping between males and females except for active coping, which was significantly better in females. Conclusion  The stress was of moderate degree in majority of students and academic stress was the most common stress. Burnout was present in at least one-third of the students. However, majority of the students practiced active coping.

Effectiveness of Brief Educational Training on Medical Students' Attitude toward Suicide Prevention

Objectives  Medical students are future physicians, and their attitude toward suicide attempters can impact outcome of patient management and quality of care. This study aimed to assess the effects of brief educational intervention on medical students' attitude toward suicide prevention.

Materials and Methods  The prospective study was conducted at a tertiary care center in northwestern India. The total enumeration method was employed to recruit 243 medical students. Attitude toward suicide prevention scale was applied before and after three hours’ training on management of suicide attempters and strategies for suicide prevention.

Statistical Analysis  Mean, median, standard deviation, frequencies, and percentages were calculated through descriptive statistics. Mean values were compared before and after the intervention through paired sample student's t -test. Chi-square test or Fischer exact test was used to compare categorical variables and p ≤ 0.05 was set for level of significance.

Results  Ten out of 14 attitudinal statements were significantly more favorable after imparting brief training on suicide prevention and management of suicide attempters. They reported lesser resentment, more responsible efforts, with greater competence and positive expectation associated with working for suicidal patients. They agreed on the need for multidisciplinary efforts for effective suicide prevention. After the intervention, they considered the possibility of suicidal ideas emerging due to the need for help, not for the purpose of attention-seeking, and instead of considering suicidal communication as individual's choice, they agreed on substantial preventability of suicide with comprehensive management. Their misconceptions were resolved to a greater extent.

Conclusion  Brief educational intervention was found effective in improving their attitude toward suicide prevention. The medical curriculum should incorporate regular educational programs, suicide prevention and comprehensive assessment, and management of suicide attempters.

Antiphospholipid syndrome presenting as treatment resistant bipolar disorder and thrombocytopenia in a young male

Antiphospholipid syndrome (APS), an autoantibody mediated disease, is characterized by presence of antibodies against the proteins bound to the phospholipid membranes. The antibodies are predominantly formed against beta-2-glycoprotein I (b2GPI) which is considered pathogenic, but presence of lupus anticoagulant is a predictor of thrombotic events. The thrombotic events in APS may manifest as venous or arterial or small vessel thrombosis in any tissue or organ and pregnancy related complications namely, recurrent (three or more) and early spontaneous miscarriages before 10 weeks of gestation or unexplained deaths of normal fetus at or beyond 10 weeks, eclampsia or severe pre-eclampsia, intra-uterine growth retardation and pre-term births. However, lately its role as an etiological mechanism in causation of certain neuro-psychiatric disorders has been put forth. It has been suggested that one should suspect APS in psychiatric manifestations which are atypical, resistant to treatment, associated with cognitive decline and dementia, abnormal involuntary movements, livedo reticularis, migraine, thrombotic events like stroke or transient ischemic attacks, obstetrical complications. In this brief communication, we describe the case of young male who has been suffering from treatment resistant and difficult to manage bipolar affective disorder (BPAD) with fluctuating thrombocytopenia and neurological findings with positive lupus anticoagulant. We propose it to be a consequence of an atypical presentation of APS.

Prevalence and predictors of family accommodation in obsessive-compulsive disorder in an Indian setting

BACKGROUND

Family accommodation (FA) is a phenomenon whereby caregivers assist/facilitate rituals or behaviors related to obsessive-compulsive disorder (OCD). FA, however, has been explored primarily in the Western population, and it is unclear to what extent it might be present in diverse cultural settings. At present, little is known about the extent and predictors of FA among caregivers of adult OCD patients in India.

AIMS

The study aims to assess the extent, clinical correlates, and predictors of FA in the caregivers of adults with OCD.

SETTINGS AND DESIGN

Cross-sectional study conducted in an outpatient setting in a tertiary-care hospital.

MATERIALS AND METHODS

Hundred and one adult patients of either gender with Diagnostic and Statistical Manual of Mental Disorders-5 diagnosis of OCD and 101 caregivers were included. The patients were assessed using Yale-Brown Obsessive Compulsive Scale (YBOCS), Hamilton Rating Scale for Depression (HAM-D), World Health Organization Disability Assessment Schedule Version 2.0 12-item version (WHO-DAS 2.0.12), Clinical Global Impressions Scale for Severity (CGI-S), and Clinical Global Impressions Scale for Improvement. The FA Scale-Self Rated Version (FAS-SR) was applied on caregivers after Hindi translation.

STATISTICAL ANALYSIS

Descriptive statistics, group comparisons, and Pearson's product moment correlations were carried out. Multiple linear regression modeling was performed with the total FAS-SR score as the dependent variable.

RESULTS

About 92% of caregivers displayed at least some form of FA. Higher scores on HAM-D, YBOCS, WHODAS, and CGI-S were associated with higher scores on FAS-SR scale, which reached statistical significance (P < 0.01).

CONCLUSIONS

FA in OCD appears to be a frequent phenomenon. Higher FA is associated with higher symptom severity and disability, emphasizing its clinical and research relevance for future studies.

Suicide Prevention Strategies for General Hospital and Psychiatric Inpatients: A Narrative Review

BACKGROUND

In-patient (IP) suicides contribute a small but significant proportion of overall suicides. Despite this, suicide prevention strategies focusing on the general hospital IP population remain relatively underresearched. This paper is intended to provide an overview of various proposed suicide prevention approaches in the general hospital, including psychiatric IP, settings, and their evidence base.

METHODOLOGY

Electronic searches of MEDLINE through PubMed, ScienceDirect, and Google Scholar databases were performed to identify potentially relevant articles from inception till January 2019. The generated abstracts were systematically screened for their eligibility to be included in the review. Included articles were grouped under five broad themes: environmental modification, staff education, pharmacotherapy, psychotherapy, and brain stimulation. Data extraction was done using a structured proforma.

RESULTS

Environmental modifications and educating the health care professionals appear to be the most promising strategies to reduce suicide-related mortality among IPs. Among pharmacological methods, ketamine has shown initial promise in reducing suicidal ideations. Follow-up data are lacking for most of the described methods. Limited but positive evidence exists for cognitive therapies focusing on the immediate postadmission period and brain stimulation techniques, and it warrants further replication.

CONCLUSION

There is a striking paucity of original research on IP suicide prevention. Given the ethical and methodological issues in carrying out studies with IP suicide as the primary outcome, there is a need to focus on intermediate suicide outcome measures, such as knowledge, attitude, and skills among staff handlers of suicidal patients.

Eating Disorders: An Overview of Indian Research

There has been sporadic research on eating disorders in India, with no published attempt to collate and summarize the literature landscape. Hence, the present narrative review aims to summarize Indian work related to eating disorders, discern current trends, and highlight gaps in research that will provide directions for future work in the area. Electronic search using the MEDLINE, Google Scholar, and PsycINFO databases was done to identify relevant peer-reviewed English language articles, in October 2018, using combinations of the following medical subject headings or free text terms: "eating disorders," "anorexia nervosa," "bulimia," "treatment," "epidemiology," "co-morbidity," "management," "medications," "behavioral intervention," and "psychosocial intervention." The data extracted from studies included details such as author names, year, from which of the states in India the work originated, type of intervention (for interventional studies), comparator (if any), and major outcomes. There is increasing research focused on eating disorders from India over the last decade, but it continues to be an under-researched area as evidenced by the relative paucity of original research. The cultural differences between east and west have contributed to variations in the presentation as well as challenges in the diagnosis. Hence, there is a need for the development of culturally sensitive instruments for diagnosis, as well as generating locally relevant epidemiological data about eating disorders from community and hospital settings.

Atypical neuroleptic malignant syndrome - A case report

Neuroleptic malignant syndrome (NMS) is a potentially fatal adverse effect of antipsychotics. Atypical presentation of NMS with drugs which are not potential D2 blockers raises question for an alternative hypothesis for NMS. A 30 year old male presented with irritability, assaultive behavior, persecutory delusion and auditory hallucination for three days. Past history of 3 similar episodes. 1st episode preceded by fever and associated with cerebral edema. Subsequent episodes not preceded by fever and patient was treated with Risperidone and Olanzapine. After admission patient was started on Risperidone along with THP when he had fever, tremors, altered sensorium and rigidity at 3 mg dose. After stopping Risperidone fever and rigidity improved with worsening of psychotic symptoms. Following this Olanzapine was started and very gradually uptitrated to 7.5 mg when patient had recurrence of fever and disorientation without tremors and minimal rigidity. Both the instances blood investigations including CPK levels were normal except for thrombocytopenia and leucopenia. Provisional impression of NMS was made in both instances. After stopping Olanzapine fever subsided with improvement of blood counts. Following this patient had catatonic symptoms for which patient received 9 sessions of Electroconvulsive therapy (ECT). In atypical presentations of NMS, hyperthermia and muscle rigidity may be absent, posing diagnostic dilemma. So there is a need for broadening the diagnostic criteria and NMS must be considered with a high index of suspicion.

Uttar Pradesh Association of Physicians of India Position Statement: Betel Quid (Paan) and Diabetes

Betel quid (paan) chewing is common in India, especially in Uttar Pradesh. Betel quid has multifaceted relationship with health, including metabolic and psychosocial health. The current recommendations have been released keeping in view the public health and clinical importance of this addictive behavior. The objective of this document is to offer clinical guidance for screening, diagnosis and management of co-occurring betel quid chewing among persons with Diabetes Mellitus (DM). The document aims to provide education and guidance to clinicians engaged in care and management of persons with DM, and improve access to treatment for co-occurring betel quid chewing among persons with DM. The current recommendation grades are based on published evidence, and categorized as strong, intermediate, weak and no evidence. The strength of these recommendations is based on the level of evidence.

Deciphering the paradoxical incidence of cancer in schizophrenia

OBJECTIVES:

The incidence of cancer in schizophrenia has been an area of controversy. The current article aims to provide a commentary outlining the contradictory findings of incidence of cancer in schizophrenia as well as discuss the available theories linking cancer with schizophrenia and address the methodological issues of the studies which could lead to the discrepant findings.

METHOD:

A literature search was carried out primarily using the electronic database of MEDLINE through PubMed using the search terms 'cancer' and 'schizophrenia'. Google Scholar was used to supplement the search.

RESULTS:

The findings were inconclusive, with studies documenting increased, decreased as well as no risk of cancer in patients with schizophrenia, compared with the general population. Several methodological limitations exist with regard to measures of assessment, sample size and selection bias.

CONCLUSIONS:

The association between cancer and schizophrenia remains controversial. Genetic as well as environmental theories exist explaining the paradoxical incidence of cancer in schizophrenia. The methodological factors could contribute to the discrepant findings.

Is menstrual Psychosis a Forgotten Entity?

The connection between menstruation and psychosis has been recognized since the 18^th Century. However, there are few case reports available in modern times describing about 30 patients with this condition. The psychosis may occur in the premenstrual phase in some patients and in others it begins with the onset of menses. Polymorphic psychosis is the commonly described clinical picture in these patients with an admixture of mood symptoms and psychotic symptoms. We describe a 42-year old lady who developed psychotic symptoms with the onset of her menses. The patient had irritability and aggression, persecutory ideas, hallucinatory behavior, increased religiosity, formal thought disorder, disorganized behavior and poor self-care lasting for about 20 days after which she will spontaneously remit for about 10 days till the onset of her next menses. These symptoms began about 13 years after her last childbirth and were present in this cyclical manner for the last seven years. She was admitted in view of gross disorganization and was treated with 4 mg per day of risperidone. She did not develop symptoms with onset of her next menstrual period and was discharged. She maintained well on the prophylaxis for a period of three months. After that, she discontinued medications and had a relapse of symptoms lasting the first two weeks of her menstrual cycle and remained well for about two weeks thereafter. Hormonal assays did not reveal abnormal levels of gonadal hormones. We discuss the association between menstrual cycles and the potential association of psychosis with estrogen levels. Various conditions that lead to fluctuation in estrogen levels, such as menopause, postpartum period as well as post-oopherectomy period have been described to lead to a risk for psychotic symptoms. Similarly, the cyclical changes in estrogen levels during the course of a menstrual cycle leads to psychosis in some women.

Biological rhythm impairment in bipolar disorder: A state or trait marker?

CONTEXT

There is limited research on biological rhythms in bipolar disorder (BD) from the Indian setting despite its intricate relationship with metabolic syndrome (MS) and functioning.

AIMS

The study aimed to assess "trait marker" status of biological rhythms as well as correlates of biological rhythm impairment in euthymic BD.

SETTING AND DESIGN

Cross-sectional observational study over 6 months was carried out in hospital setting.

MATERIALS AND METHODS

Biological Rhythms Interview of Assessment in Neuropsychiatry Questionnaire (BRIAN) and Functioning Assessment Short Test (FAST) were used to assess biological rhythms and functioning, respectively. MS was diagnosed as per modified National Cholesterol Education Program- Adult Treatment Panel III. Depressive symptoms were assessed by the Hamilton Depression Rating Scale (HDRS). Euthymia was defined as symptomatic remission for at least 8 weeks. Ethical approval was taken.

RESULTS

Fifty cases of euthymic BD and fifty apparently healthy controls were recruited. Total as well as certain domain-specific BRIAN and FAST scores were significantly higher in cases compared to controls. A significant positive correlation was found between the total BRIAN score with HDRS as well as FAST score. No correlation was obtained between biological rhythms and metabolic parameters.

CONCLUSIONS

Our results support the hypothesis that biological rhythm impairment is a trait marker in patients with BD. The study supports the need for management of subsyndromal depressive symptoms even in inter-episodic period.

Cognitive Functions among Recently Detoxified Patients with Alcohol Dependence and Their Association with Motivational State to Quit

CONTEXT

Cognitive impairments are common among patients with alcohol dependence. It may involve frontal executive dysfunction, global cognitive impairments, or both. Motivation to quit alcohol involves recognition of alcohol use as a problem. This ability may be construed as a cognitive symptom.

AIMS

The aim is to study the frequency of cognitive dysfunction among patients with alcohol dependence and to study the association between cognitive dysfunction and the motivation to quit alcohol.

MATERIALS AND METHODS

Fifty-six adult males with alcohol dependence (International Classification of Diseases-10) who had completed a course of detoxification and who did not have active withdrawal symptoms or acute medical illnesses were recruited for this study. Their cognitive functions were tested using the Montreal Cognitive Assessment (MoCA) and Frontal Assessment Battery (FAB). Their motivation levels were assessed using the Stages of Change Readiness and Treatment Eagerness Scale. Clinical details were collected using a semi-structured pro forma.

RESULTS

Global cognitive impairment (MoCA < 26) was seen in 81% and frontal executive dysfunction (FAB < 12) in 16% of patients. Higher MoCA and FAB scores correlated with better education, while lower FAB scores correlated with higher age. The 14 patients (25%) with good motivation did not differ in age, education, years of dependence, or MoCA or FAB scores from poorly motivated patients. FAB scores, but not MoCA, were associated with poor motivation. All nine patients with FAB < 12 were poorly motivated to quit alcohol; likelihood score = 5.731, P = 0.017.

CONCLUSIONS

Four-fifths of patients with alcohol dependence had global cognitive impairments after the detoxification period. One-sixth had frontal executive dysfunction. Cognitive functions were not significantly correlated with the duration of dependence. Presence of frontal executive dysfunction was associated with almost six times likelihood that the patient will be poorly motivated to quit alcohol.

Pharmacotherapy for relapse prevention of alcohol use disorder in the Indian setting: A systematic review

Alcohol use disorders (AUDs) is an important public health concern as estimates of the prevalence of AUD range at 4%-6% in the Indian population. Currently, there is limited literature on the pharmacotherapeutic interventions for AUD in the Indian setting. It is imperative to identify the possible variations in their effects from Western studies, and hence the current review was attempted to perform a comprehensive evaluation and critical appraisal of the methodology of the evidence on pharmacological strategies of relapse prevention of AUD in the Indian setting. A total of 18 studies were included in the review. Disulfiram was the most common pharmacological agent to be studied. The initial literature before 2000 focused primarily on disulfiram, whereas the studies in the next decade compared it to acamprosate and naltrexone and emerging interest in anticraving agents such as baclofen and topiramate had been noted over the past few years. No studies were available on newer agents such as ondansetron, selective serotonin reuptake inhibitors or formulations such as depot and implants. Deterrent agents were found to be better when compared to anticraving agents in terms of abstinence and relapse, whereas the latter were more effective for control of craving. Among the pharmacological agents studied, the greatest evidence exists for disulfiram for relapse prevention which could be due to affordability of disulfiram and social support in the Indian context. The chief methodological limitations include the lack of randomized trials and objective measures for assessing abstinence.

Which Criteria to Use to Identify Metabolic Syndrome among Patients with Addictive Disorders?: Observations among Patients with Alcohol and Opioid Dependence Syndrome

In spite of various psychoactive substances (including tobacco, alcohol, and opioids) being closely associated with development of metabolic syndrome (MS), little research exists on the prevalence of MS among persons with addictive disorders. The criteria used to diagnose MS varied across these studies, and part of the variation in the prevalence rate (5.1%-30.6%) could be attributable to this fact. The current study aimed to assess the prevalence of MS in patients with alcohol dependence syndrome (ADS) and opioid dependence syndrome (ODS) using revised National Cholesterol Education Programme Adult Treatment Panel (NCEP ATP-III) criteria and International Diabetes Federation (IDF) criteria. We tried to assess the impact of the choice of the diagnostic criteria on the prevalence rate of MS in the persons with ADS and ODS. This was a cross-sectional observational study. Semi-structured pro forma was used to collect information on the sociodemographic profile and clinical profile. Anthropometric measurements included waist circumference, height, weight, and body mass index (BMI). The systolic and diastolic blood pressure, fasting blood sugar (FBS), serum triglycerides, and serum high-density lipoprotein were measured. Patients were diagnosed as having MS by using revised NCEP ATP-III and IDF criteria. Statistical analysis was done by Chi-square (Fischer's exact test), independent sample Student's t-test, and Cohen's kappa. Among the individuals with ADS, the prevalence of MS was found to be 20.8% and 9.9% according to revised NCEP ATP III criteria and IDF criteria, respectively. Among individuals with ODS, the prevalence of MS was found to be 20.3% and 5.1% according to revised NCEP ATP III criteria IDF criteria, respectively. While there was a good degree of concordance between IDF and modified NCEP-ATP III criteria for MS for ADS (n = 256) (κ = 0.649, P < 0.001), the concordance was only fair for ODS (κ = 0.333, P < 0.001). The findings of our study thereby support the recommendation that revised NCEP ATP-III criteria is better choice than IDF criteria for identification of MS in individuals having addictive disorders, especially opioid dependence.

Depression and physical noncommunicable diseases: The need for an integrated approach

Depression is globally the third-leading cause of disability in terms of disability-adjusted life-years. Depression in patients with diseases such as cancer, diabetes mellitus, stroke or cardiovascular disease is 2-4-fold more prevalent than in people who do not have physical noncommunicable diseases, and may have a more prolonged course. The significant burden due to depression that is comorbid with chronic physical disease, coupled with limited resources, makes it a major public health challenge for low- and middle-income countries. Given the bidirectional relation between depression and chronic physical disease, the clear way forward in managing this population of patients is via a system in which mental health care is integrated with primary care. Central to this integrated approach is the Collaborative Care Model, adapted to the local sociocultural context. In this model, care is jointly led by the primary care physician, supported by a case manager and a mental health professional. Various successful initiatives in low- and middle-income countries may be used as templates for collaborative care in other low-resource settings. The model involves a range of interwoven components, such as capacity-building, task-sharing, task-shifting, developing good referral and linkage systems, anti-stigma initiatives and lifestyle modifications. Policies based on adoption of this approach would not only directly address depression that is comorbid with physical noncommunicable disease but also facilitate achievement of Sustainable Development Goal 3, to "ensure healthy lives and promote well-being for all at all ages".

Sickness Behavior and Seasonal Affective Disorder: An Immunological Perspective of Depression

We describe a case of 45-year-old female suffering from chronic hepatitis B and bronchial asthma who presented with symptoms of seasonal affective disorder and sickness behavior. The case report illustrates syndromal and sub syndromal presentations of depression such as sickness behavior in support of "malaise theory of depression" from psychoneuroimmunological perspective. The current case depicts the complex interplay of inflammatory physical illness, medication and manifestations of depression in an individual case. Thus, the physicians and psychiatrists must be vigilant regarding the psychiatric manifestations of physical illness with immune-inflammatory component.

Personality traits such as neuroticism and disability predict psychological distress in medically unexplained symptoms: A three-year experience from a single centre

BACKGROUND

People with medically unexplained symptoms (MUS) may have psychological co-morbidities.

AIMS

Our objectives were to assess the rates and identify correlates of psychological distress in MUS.

METHODS

A total of 171 subjects with MUS seeking treatment at a tertiary care facility were assessed over a 3-year period. Psychological distress was assessed using the Tamil version of General Health Questionnaire-12. Apart from socio-demographic factors, personality, coping, perceived social support and subjective disability were assessed using standard instruments.

RESULTS

Ninety subjects (52.6%) endorsed symptoms of psychological distress. MUS subjects with psychological distress reported higher levels of neuroticism (p < 0.001), lower extraversion (p < 0.001), lower perceived social support (p = 0.002), higher disability (p < 0.001), lower problem focused engagement (p = 0.378) and higher emotion focused engagement (p = 0.009). In multivariate analysis, high neuroticism scores (odds ratio 1.579, 95% CI 1.108 to 2.251) and high disability (odds ratio 1.302, 95% CI 1.147 to 1.478) emerged as independent predictors of psychological distress in MUS.

CONCLUSION

More than half of subjects with MUS have associated psychological distress. High levels of neuroticism and disability are potential markers of psychological distress in MUS. Copyright © 2017 John Wiley & Sons, Ltd.

Implications of comorbid ADHD in ASD interventions and outcome: Results from a naturalistic follow up study from south India

BACKGROUND

Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder commonly associated with Attention Deficit Hyperactivity Disorder (ADHD), the prevalence ranging from 14-70%. The current study attempted to assess the impact of comorbid ADHD in children with ASD, in terms of challenges in diagnosis, treatment, intervention outcomes and parental stress and coping through a naturalistic design.

METHODS

Fifty children aged 2-6 years with ASD were recruited, assessed and followed up for six months. Twenty children were found to have comorbid ADHD. Severity of ASD and ADHD was assessed by Childhood Autism rating scale and Connor's abbreviated rating scale respectively. Parental stress and coping was assessed by Family Interview for stress and coping.

RESULTS

The diagnosis of ASD was apparently obscured by ADHD symptoms in about 22% of cases, as only diagnosis of ADHD was made at the time of referral to our centre. ADHD was the most common comorbidity followed by intellectual disability and seizure disorder. About 66% of children received combination of pharmacological and behavioral interventions. Clonidine was the most common medication to be used and was well tolerated. The improvement in ADHD symptomatology showed positive correlation with improvement with ASD-specific interventions as reflected by change in severity scores. Severity of ADHD significantly also predicted parental stress and coping, and thereby engagement in ASD-specific interventions.

CONCLUSION

The current study highlights the need for screening and early diagnosis of comorbid ADHD in children with ASD and vice versa considering the management challenges. In case of multiple comorbid neurodevelopmental disorders, early interventions for one disorder can improve the outcome of the other.

Current status of vaccines in psychiatry-A narrative review

INTRODUCTION

Vaccines are one of the newer therapeutic modalities being researched in psychiatric illnesses with limited role of pharmacological interventions. Preclinical studies on vaccines have shown favorable results in conditions like Substance use Disorders and Alzheimer's Dementia. However, the utility of Mumps Measles Rubella vaccine has been overshadowed by controversy linked to causation of Autism. With this background, the current narrative review aimed to comprehensively and critically evaluate the current status of vaccines in Psychiatric illnesses.

METHODS

Preliminary literature search using the electronic databases of MEDLINE and Google Scholar between May 1967 and May 2017 using the search terms "Vaccines" and "Psychiatry" was carried out and articles were found in the following areas of research: Substance use, Alzheimer Dementia, Autism, Human Immunodeficiency Virus and Human Papilloma Virus Further, the refined search was done using combinations of search terms "Vaccine", "Nicotine", "Cocaine", "Opioid", "Alzheimer Dementia", "Autism", and "Pervasive Developmental Disorders" and peer - reviewed original articles published in English conducted among human subjects and published in English language were included for review.

RESULTS

A total of 31 articles found eligible were organized into appropriate sections synthesizing the literature on role of vaccines in specific disorders such as Substance Use Disorders, Alzheimer Dementia and Pervasive Developmental Disorders.

DISCUSSION

The therapeutic potential of vaccines in Substance Use Disorders and Alzheimer Dementia was found to be limited in comparison to the results from animal studies. Safety profile of the immunogens and the adjuvants in humans is possibly the most important limitation. No causal association between Measles Mumps Rubella vaccine and Autism was found.

Role of Yoga in Management of Substance-use Disorders: A Narrative Review

Substance use disorders are comparable to chronic medical illnesses and have a chronic relapsing course. Despite being significant contributors to morbidity and mortality, limited treatment options exist. The current narrative review was aimed at providing an overview of yoga therapy in substance-use disorders and discuss the relevant methodological issues. Articles published in English language till May 2017 indexed with PubMed, PubMed central, and Google Scholar were searched using search terms "Yoga," "Substance use," "Drug dependence," "Nicotine," "Tobacco," "Alcohol," "Opioids," "Cannabis," "Cocaine," "Stimulants," "Sedative hypnotics," "Inhalants," and "Hallucinogens" for inclusion in the review. A total of 314 studies were found fulfilling the stated criteria. Out of which, 16 studies were found to fulfill the inclusion and exclusion criteria and 12 were randomized control trials. The majority of studies were available on the role of yoga in management of nicotine dependence. Sample size of these studies ranged from 18 to 624. The majority of studies suggested the role of yoga in reducing substance use as well as substance-related craving (especially in nicotine-use disorders) in short term. However, more studies are required for demonstrating the long-term effects of yoga therapy in substance-use disorder.

ADHD research in India: A narrative review

INTRODUCTION

Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder with no clear etiopathogenesis. Owing to unique socio cultural milieu of India, it is worthwhile reviewing research on ADHD from India and comparing findings with global research. Thereby, we attempted to provide a comprehensive overview of research on ADHD from India.

METHODS

A boolean search of articles published in English from September 1966 to January 2017 on electronic search engines Google Scholar, PubMed, IndMED, MedIND, using the search terms "ADHD", "Attention Deficit and Hyperactivity Disorder", "Hyperactivity" ,"Child psychiatry", "Hyperkinetic disorder", "Attention Deficit Disorder", "India"was carried out and peer - reviewed studies conducted among human subjects in India were included for review. Case reports, animal studies, previous reviews were excluded from the current review.

RESULTS

Results of 73 studies found eligible for the review were organized into broad themes such as epidemiology, etiology, course and follow up, clinical profile and comorbidity, assessment /biomarkers, intervention/treatment parameters, pathways to care and knowledge and attitude towards ADHD.

DISCUSSION

There was a gap noted in research from India in the domains of biomarkers, course and follow up and non-pharmacological intervention. The prevalence of ADHD as well as comorbidity of Bipolar Disorder was comparatively lower compared to western studies. The studies found unique to India include comparing the effect of allopathic intervention with Ayurvedic intervention, yoga as a non pharmacological intervention. There is a need for studies from India on biomarkers, studies with prospective research design, larger sample size and with matched controls.

Uttar Pradesh Association of Physicians of India Position Statement: Tobacco Use and Metabolic Syndrome

Tobacco use is one of the main preventable causes of mortality and morbidity worldwide. The global disease burden due to tobacco use is huge with projected mortality of eight million lives per year by 2030. Metabolic syndrome (MS) is defined as a constellation of cardiovascular and endocrine risk factors such as insulin resistance, obesity, raised blood pressure, and abnormal lipid profile. The relationship between tobacco use and MS has been well established. Also, the causal association between tobacco use and development of individual components of MS is well established. The Uttar Pradesh Association of Physicians of India (UP API) has drafted this position statement on managing tobacco use among persons with or at risk of developing Metabolic Syndrome (MS). This position statement presents evidence-based recommendations as described below. Scope and purpose The objective of this position statement is to offer clinical recommendations for screening, diagnosis and management of tobacco use among persons with or at risk of developing Metabolic Syndrome (MS). The purpose of this document is to aid in identification and treatment of maladaptive patterns of tobacco use i.e. tobacco use disorder (tobacco dependence, harmful use, abuse) in person with or at risk of developing MS. Intended Audience The position statement is targeted at the clinicians engaged in care and management of person with or at risk of developing Metabolic Syndrome (MS). This might also be of relevance to the policy makers considering the public health burden of both MS and tobacco use disorders.

Indian College of Physicians Position Statement: Addictive Disorders Among Persons with Diabetes Mellitus

OBJECTIVES

Migraine, a common primary headache disorder which can be severely disabling, associated with poor health-related quality of life (HRQoL) amongst affected patients. The present study was performed to provide adequate clinical data on migraine and the management practices in India.

MATERIAL AND METHODS

A cross-sectional study was designed to assess disease burden, HRQoL, symptom profile, management trends and comorbidities associated with migraine patients across ten centres in India. This study assessed HRQoL using Migraine Specific Quality of life (MSQ) and Migraine Disability Assessment Scores (MIDAS) questionnaire. Categorical variables were summarized as frequency, and percentage and continuous variables as mean and standard deviation respectively.

RESULTS

A total of 705 patients were enrolled with a mean age of 35.2 years. Hypertension (7.0%) was the highest co-morbid illness associated with migraine. A higher MSQ score was observed in females as compared to males (39.3±12.4 and 37.4±11.6) while MIDAS showed a comparable score (27.7±47.6 and 27.2±35.4). Majority of migraine patients were unemployed (61.6%) and in profession, females had poor HRQoL than males by MIDAS and MSQ. Majority of patients had pulsating, bilateral attacks for the duration of 4h to 72 h. Paracetamol (47.1%) and propranolol (50.9%) was most commonly prescribed drugs for acute attack and prophylaxis, respectively.

CONCLUSION

The quality of life was superior in males as compared to females amongst migraine patients in India. Hypertension was the commonest comorbidity associated with migraine.

KEY MESSAGES

Migraine is associated with substantial disability with higher prevalence in females and older people (age >40 years). NSAIDs and propanol was widely prescribed drug in acute attacks and prophylaxis of migraine respectively. Cardiovascular diseases, diabetes mellitus and anxiety were common comorbidities associated with migraine.

Association of Attention-deficit Hyperkinetic Disorder with Alcohol Use Disorders in Fishermen

INTRODUCTION

Alcohol use is a widely prevalent problem and poses hazard during work for certain groups such as fishermen. Disorders such as Attention-Deficit/Hyperkinetic Disorder (ADHD) correlate with early onset and greater severity of alcohol use disorders.

AIMS

We planned to study the frequency of ADHD among fishermen in a fishing hamlet of southern India using adult ADHD self-reported scale (ASRS) and correlated with the severity of alcohol use disorder as evidenced by age at initiation of alcohol use, presence of harmful use, or dependence use as defined by Alcohol Use Disorders Identification Test (AUDIT).

SUBJECTS AND METHODS

This was a community-based interview using AUDIT questionnaire for severity of alcohol use and the ASRS to detect ADHD.

RESULTS

The prevalence of adult ADHD among fishermen in this study was 25.7% using the critical items of the ASRS. ADHD was about twice as likely in participants with dependence as those without dependence (odds ratio = 2.10). ADHD was also more likely in participants with onset of use before 30 years of age than others (25.1% vs. 15.4%) (P = 0.27).

DISCUSSION

We found a high frequency of alcohol use among fishermen (79.8%). However, only 9.9% had alcohol dependence which is higher than the general population (2.3%) in the region. Fishermen with alcohol dependence were twice as likely to have ADHD as those without alcohol dependence.

CONCLUSION

In a community-based survey of fishermen, the prevalence of alcohol dependence was about 10%. The presence of alcohol dependence predicted a two times higher likelihood of ADHD among fishermen than those without alcohol dependence.

Ethics in Psychiatric Research: Issues and Recommendations

Psychiatric research has increased remarkably over recent decades to help in understanding the current trends and better therapeutic options for illness. On the other hand, there is also a trend toward higher rates of retraction of published papers in the recent years. Ethics is required to maintain and increase the overall quality and morality of research. Psychiatric research faces several unique ethical challenges. Ethical guidelines are very important tool of research which safeguards participants; however, there is a dearth of such guidelines in India. The present paper aims to review available ethical issues and guidelines pertaining to psychiatric research. A search was conducted on Pubmed using search terms (e.g., "ethics," "psychiatry," "research"). Relevant studies were selected for the review after manual screening of title/abstract. Additional sources were referred to using cross references and Google Scholar. Psychiatric research has several important ethical issues which are different from other medical disciplines. These issues are related to informed consent, confidentiality, conflict of interest, therapeutic misconception, placebo related, vulnerability, exploitation, operational challenges, among others. The current paper has made several recommendations to deal with ethical challenges commonly faced in psychiatric research. The ethical guidelines are utmost needed for Indian psychiatric research. Specific guidelines are lacking pertaining to psychiatric research. The issues and recommendations merit a further discussion and consideration.

Thyroid and Cortisol hormones in Attention Deficit Hyperactivity Disorder: A case-control study

AIM

There is paucity of research in the putative role of hormonal biomarkers in Attention Deficit Hyperactivity Disorder (ADHD). The current study aimed to analyze the clinical profile, socio-demographic status, co-morbidity, hormonal biomarkers namely Thyroid hormones and Cortisol in children with ADHD and compare them with healthy controls and to explore the association of the hormonal biomarkers with severity of ADHD.

METHODS

Thirty children with DSM-IV TR diagnosis of ADHD were assessed using semi structured proforma, Conners' Parent Rating Scale revised short (CPRS - R: S) , Mini international neuropsychiatric interview for children and adolescents and Childrens' Global Assessment Scale as well as serum levels of total Triiodothyronine (T3) ,total Thyroxine (T4) , Thyroid Stimulating Hormone (TSH) and Cortisol using chemiluminescent immunometric assay and compared with 30 age- and gender -matched controls.

RESULTS

The typical profile of cases of ADHD was of a male with mean age of 9.47 years (S.D=2.43) belonging to Hyperactive subtype of ADHD. Serum T4 was significantly lower in cases compared to controls. No significant difference was found in serum T3, TSH and Cortisol levels. No significant correlation between the CPRS : R-S scores and the hormonal biomarkers.

CONCLUSIONS

There is need for exploration of Serum T4 as putative biomarker for ADHD with replication in future studies. It may also be important to report the negative finding of Cortisol as a biomarker of ADHD in the context of effective utilization of resources for research with special relevance to resource deficit developing countries.

DRESS syndrome: Addressing the drug hypersensitivity syndrome on combination of Sodium Valproate and Olanzapine

A case of an adolescent with symptoms of Mania, who developed Drug Reaction with Eosinophilia and Systemic Symptom (DRESS) syndrome on exposure to combination of oral Olanzapine and Sodium Valproate is presented. We have attempted to highlight the atypical presentation of DRESS syndrome in this patient as well as management difficulties in patient who develops DRESS syndrome with the conventional psychotropic medication. Hence, it is necessary for mental health professionals to be vigilant about this life threatening drug reaction associated with high morbidity and mortality, thus ensuring prompt diagnosis and management.

Cognitive Behavior Therapy for Medically Unexplained Symptoms: A Systematic Review and Meta-analysis of Published Controlled Trials

Medically unexplained symptoms (MUS) commonly present across the board in medical specialties and are often challenging to treat. Our objective was to assess the efficacy for cognitive-behavior therapy (CBT) in MUS. Electronic search of databases was carried out for published controlled trials in English language peer-reviewed journals from inception till August 2016. Effect sizes for the trials were computed using standardized mean difference, and I² test was used to assess sample heterogeneity. Pooled mean effect sizes were derived using a random-effects model. Critical appraisal of studies was done using the Cochrane risk of bias assessment tool. A total of 11 trials involving 1235 subjects were included in the study. Ten trials used standard CBT techniques while one studied the efficacy of mindfulness-based CBT technique. The control arms were treatment as usual in five trials, augmented care in four and waitlisted controls in two trials. The pooled mean effect size for CBT was 0.388 (range 0.055-0.806, 95% confidence intervals 0.316-0.461). The I² value was 0 using a random effects model indicating low heterogeneity among studies. Risk of bias was noted in many included studies. Egger plot intercept indicated potential publication bias. CBT was superior to the waiting list, treatment as usual or enhanced usual care with moderate effect sizes in the treatment of MUS. These findings are impacted by the limited number of studies in this area and questionable methodological rigor of included studies.

Concept and Identification of "Soft Bipolarity" in Patients presenting with Depression: Need for Careful Screening by Physicians

The bipolar spectrum is a broader concept, which questions the strict dichotomous categorical division of erstwhile manic-depressive illness into two discrete categories viz. bipolar disorder and major depressive disorder, thereby overlooking a wide 'spectrum' of patients which lie 'in between' the two extremes. The presence of underlying bipolar 'spectrum' or 'soft bipolarity' often goes undetected in patients presenting with major depression. This sub-group of patients may not stabilize with indiscriminate use of anti-depressant drugs, and without proper management, it may be associated with continued non-responsive symptoms, increased suicidality and poorer prognosis. There is a need to suspect and identify such cases of soft bipolarity/spectrum by early screening of patients with major depression presenting to medical settings. The review paper covers the current concepts and understanding of bipolar spectrum disorders which is aimed to facilitate early identification, management and referral of cases detected to have soft bipolarity in the general medical settings.