Association between urban upbringing and functional brain connectivity in schizophrenia

Background

Environmental factors considerably influence the development of the human cortex during the perinatal period, early childhood, and adolescence. Urban upbringing in the first 15 years of life is a known risk factor for schizophrenia (SCZ). Though the risk of urban birth and upbringing is well-examined from an epidemiological perspective, the biological mechanisms underlying urban upbringing remain unknown. The effect of urban birth and upbringing on functional brain connectivity in SCZ patients is not yet examined.

Methods

This is a secondary data analysis of three studies that included 87 patients with SCZ and 70 healthy volunteers (HV) aged 18 to 50 years. We calculated the developmental urbanicity index using a validated method in earlier studies. Following standard pre-processing of resting functional magnetic resonance imaging (fMRI) scans, seed-return on investment (ROI) functional connectivity analysis was performed.

Results

The results showed a significant association between urban birth and upbringing on functional connectivity in SCZ patients and HV (P < 0.05). In SCZ patients, connections from the right caudate, anterior cingulate cortex, left and right intracalcarine cortices, left and right lingual gyri, left posterior parahippocampal cortex to the cerebellum, fusiform gyri, lateral occipital cortex, and amygdala were significantly associated with the urbanicity index (P < 0.05).

Conclusions

These study findings suggest a significant association between urban birth and upbringing on functional brain connectivity in regions involved in reward processing and social cognition in SCZ. Assessment of social cognition could have implications in developing an in-depth understanding of this impairment in persons with SCZ.

A close critical look of India's National Mental Health Survey 2016

The National Mental Health Survey 2016 (NMHS 2016) was a large epidemiological study, one of its kind, conducted by the National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru to overcome the shortcomings of the previous surveys. The detailed report of the study is available in two parts- 'mental health systems' and 'prevalence, pattern and outcomes'. Though done comprehensively, there are some inevitable limitations. The private sector, a substantial health care provider in the country was not a participant in the survey. Though MINI version 6.0 is a standard and structured instrument, it does not cover many commonly encountered mental illnesses like somatoform disorders. Further, the methodology of the survey makes it difficult for an accurate calculation of the prevalence of individual major psychiatric disorders. The survey has been appraised using a standard checklist for prevalence studies. The detailed qualitative data has not been shared in the report. The contribution of the traditional indigenous systems of healthcare and accessibility of services in rural areas have not been elaborated. Thus, the need for a comprehensive and culturally sensitive assessment tool, involvement of the private sector, and enhancing funding provision to improve the infrastructure are emphasized as future directions for the subsequent phases of the survey.

Work productivity (absenteeism and presenteeism) in persons with common mental disorders: An observational study from South India

Background

The greatest contributor to the economic impact of common mental disorders (CMDs) is said to be the loss of work productivity. There is a paucity of studies from India that looks at the impact of CMDs on the productivity of work, which costs both patient and society significantly.

Aim

To assess and compare work productivity by evaluating both absolute and relative presenteeism and absenteeism, in persons with CMDs.

Materials and Methods

This was a cross-sectional observational study on 220 subjects (110, 58, and 52 patients with depressive disorder, anxiety disorders, and somatoform disorders, respectively), recruited through purposive sampling. We evaluated work productivity using the World Health Organization Health and Work Performance Questionnaire.

Results

Absolute absenteeism was significantly different before and after treatment for CMDs as a group but not for individual disorders. Relative absenteeism, absolute presenteeism, and relative presenteeism were all significantly different before and after treatment among both CMDs as a group and also among individual disorders. Both presenteeism and absenteeism (absolute as well as relative) did not differ significantly across the diagnostic groups. Work productivity has been linearly associated with illness severity and disability.

Conclusion

CMDs are associated with a significant loss of work productivity. Presenteeism is costlier than absenteeism in affecting work productivity. Loss of work productivity appears to be transdiagnostic across all CMDs. Also, the severity of loss of work productivity is associated linearly with the severity of illness and disability.

Clinical efficacy and neurobiological correlates of electroconvulsive therapy in patients with clozapine-resistant/intolerant schizophrenia: study protocol of multi-site parallel arm double-blind randomized sham-controlled study

Background: A substantial proportion of patients with treatment resistant schizophrenia do not respond well or partially to clozapine, with a subset that does not tolerate an adequate trial of clozapine. Electroconvulsive therapy (ECT) is regarded as one of the augmenting options, but there is a lack of high-quality evidence for this practice. This protocol describes a double-blind randomised sham-controlled modified-ECT trial to evaluate its efficacy in patients with clozapine resistant/intolerant schizophrenia. The study also involves multimodal investigations to identify the response predictors and the mechanistic basis of modified ECT in this population. Methods: One hundred consenting schizophrenia patients with resistance/intolerance to clozapine referred by clinicians for ECT would be randomly assigned to receive true ECT or sham ECT at three study centers. Sham ECT would mimic all the procedures of modified ECT including anaesthesia and muscle relaxation, except the electrical stimulation. After a blinded course, non-responders to sham ECT would be offered open-label true ECT. Clinical assessments, neurocognitive assessments and multimodal investigations (magnetic resonance imaging [MRI], electroencephalography, heart rate variability, investigative transcranial magnetic stimulation-transcranial direct current stimulation, gene polymorphism) would be conducted at baseline and repeated after the end of the trial, as well as open-label ECT course. The trial would evaluate the improvement in positive symptoms (scale for assessment of positive symptoms) of schizophrenia as the primary outcome measure with prediction of this change by resting-state functional-MRI based brain-connectivity as the second primary objective. Registration: Clinical Trial Registry of India (Reg no: CTRI/2021/05/033775) on 24 th May 2021.

Clinical efficacy and neurobiological correlates of electroconvulsive therapy in patients with clozapine-resistant/intolerant schizophrenia: study protocol of multi-site parallel arm double-blind randomized sham-controlled study

Background: A substantial proportion of patients with treatment resistant schizophrenia do not respond well or partially to clozapine, with a subset that does not tolerate an adequate trial of clozapine. Electroconvulsive therapy (ECT) is regarded as one of the augmenting options, but there is a lack of high-quality evidence for this practice. This protocol describes a double-blind randomised sham-controlled modified-ECT trial to evaluate its efficacy in patients with clozapine resistant/intolerant schizophrenia. The study also involves multimodal investigations to identify the response predictors and the mechanistic basis of modified ECT in this population. Methods: One hundred consenting schizophrenia patients with resistance/intolerance to clozapine referred by clinicians for ECT would be randomly assigned to receive true ECT or sham ECT at three study centers. Sham ECT would mimic all the procedures of modified ECT including anaesthesia and muscle relaxation, except the electrical stimulation. After a blinded course, non-responders to sham ECT would be offered open-label true ECT. Clinical assessments, neurocognitive assessments and multimodal investigations (magnetic resonance imaging [MRI], electroencephalography, heart rate variability, investigative transcranial magnetic stimulation-transcranial direct current stimulation, gene polymorphism) would be conducted at baseline and repeated after the end of the trial, as well as open-label ECT course. The trial would evaluate the improvement in positive symptoms (scale for assessment of positive symptoms) of schizophrenia as the primary outcome measure with prediction of this change by resting-state functional-MRI based brain-connectivity as the second primary objective. Registration: Clinical Trial Registry of India (Reg no: CTRI/2021/05/033775) on 24th May 2021.

Age Related Prevalence of Mild Cognitive Impairment in Type 2 Diabetes Mellitus Patients in the Indian Population and Association of Serum Lipids With Cognitive Dysfunction

The magnitude of type 2 diabetes mellitus (T2DM) is ever-increasing in India, and at present, ~77 million people live with diabetes. Studies have established that T2DM increases the risk of neurodegenerative disorders. This study aimed to determine the age-related prevalence of mild cognitive impairment (MCI) in T2DM patients in the Indian population and to identify link between cognitive dysfunction in T2DM patients and serum lipid composition through untargeted and targeted lipidomic studies. Using a cross-sectional study, we evaluated 1278 T2DM patients with Montreal cognitive assessment test (MoCA) and digit symbol substitution test (DSST) for cognitive functions. As per MoCA, the prevalences of MCI in T2DM patients in age groups below 40, 41-50, 51-60, 61-70, 71-80 and 81-90 years were 13.7, 20.5, 33.5, 43.7, 57.1 and 75% with DSST scores of 45.8, 41.7, 34.4, 30.5, 24.2 and 18.8% respectively. Binomial logistic regression analysis revealed serum HbA1c ≥ 7.51, duration of T2DM over 20 years, age above 41 years, and females were independent contributors for cognitive dysfunction in T2DM patients. Preliminary studies with untargeted lipidomics of the serum from 20 T2DM patients, including MCI and normal cognition (NC) group, identified a total of 646 lipids. Among the identified lipids, 33 lipids were significantly different between MCI and NC group, which comprised of triglycerides (TGs, 14), sphingolipids (SL, 11), and phosphatidylcholines (PC, 5). Importantly, 10 TGs and 3 PCs containing long-chain polyunsaturated fatty acids (PUFA) were lower, while 8 sphingolipids were increased in the MCI group. Since brain-derived sphingolipids are known to get enriched in the serum, we further quantified sphingolipids from the same 20 serum samples through targeted lipidomic analysis, which identified a total of 173 lipids. Quantitation revealed elevation of 3 species of ceramides, namely Cer (d18:1_24:1), Hex1Cer (d16:0_22:6), and Hex2Cer (d28:1) in the MCI group compared to the NC group of T2DM patients. Overall, this study demonstrated an age-related prevalence of MCI in T2DM patients and highlighted reduced levels of several species of PUFA containing TGs and PCs and increased levels of specific ceramides in T2DM patients exhibiting MCI. Large-scale lipidomic studies in future could help understand the cognitive dysfunction domain in T2DM patients, while studies with preclinical models are required to understand the functional significance of the identified lipids.

Guidelines for TMS/tES clinical services and research through the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic has broadly disrupted biomedical treatment and research including non-invasive brain stimulation (NIBS). Moreover, the rapid onset of societal disruption and evolving regulatory restrictions may not have allowed for systematic planning of how clinical and research work may continue throughout the pandemic or be restarted as restrictions are abated. The urgency to provide and develop NIBS as an intervention for diverse neurological and mental health indications, and as a catalyst of fundamental brain research, is not dampened by the parallel efforts to address the most life-threatening aspects of COVID-19; rather in many cases the need for NIBS is heightened including the potential to mitigate mental health consequences related to COVID-19.

OBJECTIVE

To facilitate the re-establishment of access to NIBS clinical services and research operations during the current COVID-19 pandemic and possible future outbreaks, we develop and discuss a framework for balancing the importance of NIBS operations with safety considerations, while addressing the needs of all stakeholders. We focus on Transcranial Magnetic Stimulation (TMS) and low intensity transcranial Electrical Stimulation (tES) - including transcranial Direct Current Stimulation (tDCS) and transcranial Alternating Current Stimulation (tACS).

METHODS

The present consensus paper provides guidelines and good practices for managing and reopening NIBS clinics and laboratories through the immediate and ongoing stages of COVID-19. The document reflects the analysis of experts with domain-relevant expertise spanning NIBS technology, clinical services, and basic and clinical research - with an international perspective. We outline regulatory aspects, human resources, NIBS optimization, as well as accommodations for specific demographics.

RESULTS

A model based on three phases (early COVID-19 impact, current practices, and future preparation) with an 11-step checklist (spanning removing or streamlining in-person protocols, incorporating telemedicine, and addressing COVID-19-associated adverse events) is proposed. Recommendations on implementing social distancing and sterilization of NIBS related equipment, specific considerations of COVID-19 positive populations including mental health comorbidities, as well as considerations regarding regulatory and human resource in the era of COVID-19 are outlined. We discuss COVID-19 considerations specifically for clinical (sub-)populations including pediatric, stroke, addiction, and the elderly. Numerous case-examples across the world are described.

CONCLUSION

There is an evident, and in cases urgent, need to maintain NIBS operations through the COVID-19 pandemic, including anticipating future pandemic waves and addressing effects of COVID-19 on brain and mind. The proposed robust and structured strategy aims to address the current and anticipated future challenges while maintaining scientific rigor and managing risk.

Meningocele and ankyloblepharon following in utero exposure to olanzapine

Although atypical antipsychotics are widely used during pregnancy, their safety is not well established. This case highlights the possible teratogenic effect of olanzapine, in which the baby was born with meningocele and ankyloblepharon. It is suggested that olanzapine may interfere with embryonic development at different stages of pregnancy.

Melancholic Versus Non-Melancholic Depression: a Prospective Study

BACKGROUND

The binarian model views melancholia as a distinct depressive class, whereas the unitarian model views it as a more severe expression of depression. This study aims to investigate the sociodemographic, clinical, and course differences between melancholic and non-melancholic depression.

METHODS

This prospective observational study was carried out at Kasturba Hospital, Manipal, India from November 2010 to September 2011. We recruited consecutive inpatients aged 18 to 60 years who have a diagnosis of depressive disorder (based on ICD-10), with or without any psychiatric or physical comorbidities. Patients were categorised into melancholia and non-melancholia using the CORE questionnaire, with scores of ≥8 indicating the presence of melancholic depression. In addition, patients were evaluated using the Hamilton Depression Rating Scale, Hamilton Anxiety Rating Scale, Somatoform Symptom Checklist, Columbia Suicide Severity Rating Scale, Clinical Global Impression, and Presumptive Stressful Life Events Scale at baseline and at 1, 3, and 6 months.

RESULTS

Of 87 inpatients with a diagnosis of depression, 50 met the inclusion criteria and 37 were excluded. Compared with patients with non-melancholic depression, patients with melancholic depression had higher depression score (30.8 vs 23.8, p < 0.001), had higher number of patients with psychotic depression (39.1% vs 7.4%, p = 0.007), had higher overall illness severity score (5.9 vs 4.8, p < 0.001), and had higher number of patients with suicidal ideation and suicidal behaviour. Regarding the course of melancholia, the number of melancholic patients decreased from 23 at baseline to eight at 1 month, three at 3 months, and three at 6 months. Scores of non-interactiveness, retardation, and agitation decrease significantly over 3 months.

CONCLUSIONS

The construct and course of melancholia may be viewed as a part of depression, more in line with severe depression. Melancholia increases the risk for suicidal ideation and suicidal behaviour.

Transcranial electrical and magnetic stimulation (tES and TMS) for addiction medicine: A consensus paper on the present state of the science and the road ahead

There is growing interest in non-invasive brain stimulation (NIBS) as a novel treatment option for substance-use disorders (SUDs). Recent momentum stems from a foundation of preclinical neuroscience demonstrating links between neural circuits and drug consuming behavior, as well as recent FDA-approval of NIBS treatments for mental health disorders that share overlapping pathology with SUDs. As with any emerging field, enthusiasm must be tempered by reason; lessons learned from the past should be prudently applied to future therapies. Here, an international ensemble of experts provides an overview of the state of transcranial-electrical (tES) and transcranial-magnetic (TMS) stimulation applied in SUDs. This consensus paper provides a systematic literature review on published data - emphasizing the heterogeneity of methods and outcome measures while suggesting strategies to help bridge knowledge gaps. The goal of this effort is to provide the community with guidelines for best practices in tES/TMS SUD research. We hope this will accelerate the speed at which the community translates basic neuroscience into advanced neuromodulation tools for clinical practice in addiction medicine.

Auditory P300 event-related potential: Normative data in the Indian population

OBJECTIVE

To generate the normative data of auditory P300 event-related potential for various age groups in the Indian population.

MATERIALS AND METHODS

Auditory P300 event-related potentials, using the oddball paradigm, of healthy control participants in studies carried out at our institute were included to generate normative data in the age range of 10-50 years. The amplitude and latency of P300 for Fz, Cz, and Pz were selected for analysis.

RESULTS

For P300 amplitude, overall multivariate analysis of variance (MANOVA) was significant [Pillai's Trace F (9/453) = 3.46, P < 0.001]. Follow-up ANOVA showed significant difference across age groups at Fz, Cz, and Pz. For P300 latency, there was a trend towards significance for overall MANOVA [Pillai's Trace F (9/453) = 1.68, P = 0.09]. Follow-up ANOVA showed a trend towards significant difference across age groups at Fz only.

CONCLUSION

Our study generated a P300 amplitude and frequency normative database at Fz, Cz, and Pz, which will serve as a reference for future studies attempting to define P300 abnormalities in various psychiatric disorders in Indian population.

Gender Differences in Perceived Social Support and Stressful Life Events in Depressed Patients

OBJECTIVE

To study the gender differences in perceived social support and life events in patients with depression.

METHODS

A total of 118 patients aged 18 to 60 years, with depressive disorder according to the DSM-IV-TR, were evaluated using the Multidimensional Scale of Perceived Social Support and Presumptive Stressful Life Events Scale.

RESULTS

The perceived social support score was significantly higher in males than females (p < 0.001). Males perceived significantly higher social support from friends than females (p < 0.001), whereas support from significant others was higher in females. There was a higher mean number of total life events as well as specific type of life events in males that became apparent after controlling for education (p < 0.05). Financial loss or problems was the most commonly reported life event in both males and females. Work-related problems were more commonly reported by males, whereas family and marital conflict were more frequently reported by females.

CONCLUSION

Perceived social support and stressful life events were higher in males with depression than females.

Olanzapine-Induced Reversible Pellagroid Skin Lesion

Adverse cutaneous reactions are frequently reported to occur with the use of psychotropic medications, which may lead to poor drug compliance. As compared to other groups of psychotropic medication, antipsychotics, both typical and atypical, are less likely to cause adverse cutaneous reactions. The most frequent cutaneous adverse reactions associated with antipsychotics include fixed drug eruptions, exanthematous eruptions, photosensitivity reactions and altered skin pigmentation. Most of these commonly seen cutaneous adverse reactions are benign and easily treatable. Rarely, severe cutaneous adverse reactions such as erythema multiforme, Steven-Johnson syndrome are toxic epidermal necrolysis and have also been associated with antipsychotics. Olanzapine is one of the most commonly prescribed atypical antipsychotic with metabolic complications as most common adverse effects. Dermatological reactions are rarely observed with olanzapine. We report occurrence of pellagroid skin lesions over exposed areas of upper limbs with olanzapine that resolved completely after its discontinuation.

Co-morbidity of Obsessive-compulsive Disorder and Other Anxiety Disorders with Child and Adolescent Mood Disorders

OBJECTIVE

To assess the co-morbidity of obsessive-compulsive disorder (OCD) and other anxiety disorders in child and adolescent mood disorders.

METHODS

A total of 100 patients aged < 18 years with mood disorders according to the DSM-IV-TR were screened for OCD and other anxiety disorders using Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime version.

RESULTS

The prevalence of co-morbid anxiety disorders was 22%; OCD was present in 4%, and subthreshold obsessive-compulsive symptoms were present in 2%. Among others, 8% had panic disorder, 7% had generalised anxiety disorder, 3% had separation anxiety disorder, and 1% had social phobia; multiple anxiety disorders were present in 3% of patients.

CONCLUSION

Co-morbid anxiety disorder was found in one-fifth of children and adolescents with mood disorder.

Depression and anxiety as potential correlates of post-transplantation renal function and quality of life

The objective of this study was to determine anxiety and depression and its relationship with quality of life (QOL) in renal transplant (RT) recipients. A total of 105 consecutive patients were assessed cross-sectionally at least 3 months after RT. Hospital Anxiety and Depression Scale was applied to assess anxiety and depression. QOL was assessed through the abbreviated version of World Health Organization QOL scale. Patients’ awareness of illness and treatment was assessed through Structured Interview for Renal Transplantation. Nine (8.57%) patients had syndromal anxiety and 9 (8.57%) had syndromal depression. Both these groups had significantly lower scores in almost all domains of QOL compared with their non-anxious and non-depressed counterparts. There were a higher number of hospitalizations and episodes of complication or rejection in post-RT patients with anxiety as compared to those without (P = 0.001). Syndromal depression and anxiety are associated with poor QOL and syndromal anxiety is associated with significantly higher number of hospitalizations, rejections and complications in post-RT patients.

Lithium-induced sinus node dysfunction at therapeutic serum levels

Lithium-induced cardiotoxicity, though rare at therapeutic levels, has been reported frequently in overdoses. We report a patient who developed sinus bradycardia while being treated with lithium carbonate even though the serum lithium levels were within the therapeutic range. It reversed following withdrawal of lithium and did not reappear with subsequent treatment with valproate.

Efficacy of repetitive transcranial magnetic stimulation in alcohol dependence: a sham-controlled study

OBJECTIVE

To study the anticraving efficacy of high-frequency repetitive transcranial magnetic stimulation (rTMS) of the right dorsolateral pre-frontal cortex (DLPFC) in patients with alcohol dependence.

METHODS

We performed a prospective, single-blind, sham-controlled study involving 45 patients with alcohol dependence syndrome (according to ICD-10 DCR), with Clinical Institute of Withdrawal Assessment in Alcohol Withdrawal (CIWA-Ar) scores <or=10. Patients were allocated to active and sham rTMS in a 2 : 1 ratio, such that 30 patients received active and 15 patients sham rTMS to the right DLPFC (10 Hz frequency, 4.9 seconds per train, inter-train interval of 30 seconds, 20 trains per session, total 10 sessions). The Alcohol Craving Questionnaire (ACQ-NOW) was administered to measure the severity of alcohol craving at baseline, after the last rTMS session and after 1 month of the last rTMS session.

RESULTS

Two-way repeated-measures analysis of variance (ANOVA) showed significant reduction in the post-rTMS ACQ-NOW total score and factor scores in the group allocated active rTMS compared to the sham stimulation. The effect size for treatment with time interaction was moderate (eta(2) = 0.401).

CONCLUSIONS

Right dorsolateral pre-frontal high-frequency rTMS was found to have significant anticraving effects in alcohol dependence. The results highlight the potential of rTMS which, combined with other anticraving drugs, can act as an effective strategy in reducing craving and subsequent relapse in alcohol dependence.

Schizencephaly associated with bipolar II disorder

A 55-year-old man with congenital hemiparesis of the right side, three episodes of generalised tonic-clonic seizure at 16 years of age, and two episodes of severe depression and two episodes of hypomania in the past, presented with severe depression with psychotic symptoms. Computed tomography of the brain showed a grey matter-lined cerebrospinal fluid-filled cleft in the left cerebral hemisphere, involving the temporoparietal region. He was diagnosed to have bipolar II disorder, and was currently severely depressed with psychotic symptoms and schizencephaly. He improved with sodium valproate 1,000 mg/day, quetiapine 450 mg/day and escitalopram 20 mg/day after three weeks without any emergent side effects, and was maintaining well at three months follow-up. Although uncommon, schizencephaly may be considered as one of the differentials in cases of bipolar disorder along with congenital hemiparesis, mental retardation and/or seizures; and neuroimaging should be done to confirm the diagnosis.

Topical lignocaine for vaginismus: a case report

Vaginismus is a sexual dysfunction in which spasm of vaginal musculature precludes penetrative intercourse. In many cases associated pain or fear of pain may contribute to the maintenance of vaginismus. We report a case of primary vaginismus with associated pain that benefited from topical application of lignocaine gel along with systematic desensitization resulting in successful consummation, and suggest that it may be a useful adjunct during finger dilatation in the treatment of vaginismus, specifically in patients who have associated pain or areas of hyperesthesia in the introitus.

Paroxetine overdose

Paroxetine is a commonly used antidepressant with a safe side-effect profile. A case of paroxetine overdose (560 mg) is reported in an 18-year-old female who attempted suicide and recovered without any sequelae, requiring only supportive treatment. This report highlights a case of pure paroxetine overdose and the safety profile of paroxetine in overdose.

Serotonin reuptake inhibitor induced sensory disturbances

Serotonin reuptake inhibitor induced sensory disturbances are reported rarely in the literature. This case report describes numbness and dysmorphic symptoms in the upper facial area associated with fluoxetine. There is no previous report of such an adverse reaction with any serotonin reuptake inhibitor in the literature and this report is intended to draw attention towards these unusual adverse effects.