Does Prescription Length of Buprenorphine Influence Treatment Outcomes in Opioid Use Disorder? A Retrospective Cohort Study from North India

OBJECTIVE

Buprenorphine (BUP) effectively suppresses non-prescription opioid use and increases treatment retention in opioid use disorder (OUD). However, short prescription length may interfere with treatment retention and recovery. We wanted to examine whether the outcomes of BUP treatment differ in high (HPL up to 4 wk) and low-prescription (LPL 1-2 wk) length groups.

METHODS

We compared time to treatment discontinuation (TD), non-prescription opioid-positive urine screen, buprenorphine-negative urine screen, and self-reported non-prescription opioid use between two different cohorts of LPL (case record: June 2018 to August 2019; n = 105; observation endpoint: 31 October 2019) and HPL groups (case record: June 2020 to Aug 2021; n = 133; observation endpoint: 31 October 2021). We used Kaplan-Meier survival analysis and log-rank tests for between-group comparisons. We used Cox regression analysis to adjust for age, opioid potency, comorbidities, family income, and marital status.

RESULTS

Subjects' age and buprenorphine dose were significantly lower, and the percentage of high-potency opioid users was significantly higher in the LPL group. In the unadjusted survival analysis, the median time to BUP discontinuation in the HPL was longer than that of the LPL [LPL= 22.4 ± 4.3 wk; HPL = 33.1 ± 8.5 wk; χ2(1)= 5.7; p=.02]. The survival distributions of other outcomes did not differ between groups. When adjusted for covariates, neither the prescription length nor other covariates independently predicted any treatment outcome.

CONCLUSION

Higher prescription length might be associated with longer treatment retention. We provide preliminary evidence to support greater flexibility in BUP treatment, enhancing its scalability and attractiveness.

Effectiveness of buprenorphine (naloxone) for opioid dependence does not differ across opioid categories: a retrospective cohort study from India

We aimed to examine whether treatment retention, abstinence, and adherence to buprenorphine-naloxone (BNX) differ among individuals with opioid dependence (OD) across three common categories of opioids- heroin, opium, and low-potency pharmaceutical. In a retrospective cohort study, we analyzed outpatient treatment records from March 2020 through February 2022. Opioid category was determined by lifetime and current opioid use. We defined treatment retention as weeks of uninterrupted clinic attendance. Abstinence and BNX adherence were calculated by weeks of extra-medical opioid-negative and buprenorphine-positive urine screening from treatment initiation. Four-hundred-thirteen patients were eligible; 406 (98.3%) were included in the final analysis. Two-hundred-ninety (71.4%) patients were dependent on heroin; 66 (16.3%) were natural opioid dependent, and 50 (12.3%) were dependent on low-potency pharmaceutical opioids. BNX effectiveness in treatment retention, abstinence, and adherence did not differ in patients dependent on heroin, natural, and low-potency pharmaceutical opioids. Patients on ≥8 mg daily BNX had better retention and adherence than those on <8 mg daily. Patients from lower socioeconomic status (SES) had higher odds of retention, abstinence, and adherence than those from upper/middle SES. Treatment outcomes on BNX did not differ across opioid categories. However, BNX should be dosed adequately.

Neurocognitive Functions in Patients with Comorbid Hepatitis C and Opioid Dependence: A Comparative Study

Background

Hepatitis C virus (HCV) infection is commonly comorbid with opioid dependence (OD). We wanted to compare the neurocognitive functions of OD subjects with or without HCV [HCV (+), HCV (-)] and healthy controls (HC).

Methods

We recruited 40 adult subjects (age 18-55 years) in each group. HCV(+) group had a detectable viral load. Subjects with HIV or hepatitis B infection, head injury, epilepsy, or comorbid mental illness were excluded. We administered Standard Progressive Matrices (SPM), Wisconsin Card Sorting Test, Iowa Gambling Task (IGT), trail-making tests A and B, and verbal and visual N-back tests (NBT) one week after opioid abstinence. The group differences in cognitive performance were adjusted for age and years of education. Effect size (ES) is expressed as Cohen's D.

Results

The HCV(+) and HCV(-) groups did not differ in potential effect modifiers (age and years of education) or confounders (age of opioid initiation, duration of use, dependence severity, tobacco use, and cannabis use) of neuropsychological functioning. HCV(+) showed significantly poorer performance than HCV(-) in SPM (P = 0.006; ES = 0.72). Both HCV(+) and HCV(-) performed worse than controls in IGT(P < 0.001; ES = 0.8) and visual NBT[P < 0.01 and ES > 1 for total errors]; HCV(+) had a larger ES of group difference than HCV(-). HCV(+) had higher error scores in verbal NBT than control.

Conclusion

HCV(+) has poorer general intellectual ability and reasoning than HCV(-) persons and controls. Chronic HCV infection causes a higher magnitude of dysfunction in decision-making and visual working memory in opioid-dependent individuals.

How did the COVID-19 lockdown impact patients with dual diagnoses?

Purpose

Individuals with dual diagnoses might experience significant clinical and social vulnerabilities during the pandemic and lockdown. This study aims to compare medication adherence, substance use, clinical stability and overall functioning before and during lockdown periods.

Design/methodology/approach

This was a cross-sectional survey among patients registered in dual diagnosis clinic of an addiction psychiatry center in Northern India between March 2019 and February 2020. This study approached 250 patients for telephonic interviews. This study assessed adherence to medications with the brief adherence rating scale (BARS). Global functioning was measured by global assessment of functioning. Clinical interviews assessed substance use and the clinical status of psychiatric disorders.

Findings

One hundred fifty patients were recruited. The mean age of the sample was 35.8 years. The sample had a slight preponderance of alcohol dependence. Depressive disorder was the largest category of psychiatric diagnosis. Compared to prelockdown period, during the lockdown, there were an increased number of days of nonadherence (X2 17.61, p <  0.05), proportion of patients underdosing (X2 8.96, p = 0.003) and lower BARS scores (t = 10.52, df = 144, p < 0.0001). More patients were abstinent from substances during the lockdown (X2 49.02, p < 0.0001). Clinical stability of psychiatric disorders did not differ during the two-time points, but overall functioning decreased during the lockdown (t = 2.118, p = 0.036). This study observed a small positive correlation (r = 0.2, p = 0.02) between functioning and adherence levels.

Originality/value

Lockdown was associated with poor medication adherence, change in substance use patterns and functional impairment. In the future, treatment programs and policies must take preemptive steps to minimize the effects of restrictions.

Course and Correlates of Stigma in Patients on Opioid Agonist Treatment: A Prospective Study from an Outpatient Treatment Program in India

BACKGROUND

Individuals with opioid dependence experience stigma and discrimination. Stigma can potentially reduce treatment-seeking and negatively affect treatment outcomes. We aimed to study the course of stigma and its correlates among patients receiving opioid agonist treatment (OAT).

METHODS

We recruited 51 subjects (aged between 18 and 45 years) registered in the OAT clinic from February to September 2019. We excluded subjects dependent on alcohol and other drugs (except for cannabis and tobacco), with severe mental illness, intellectual disability, and organic brain disease. We assessed the internalized and enacted stigma and quality of life at the treatment entry and after 3 months. Relationship of stigma with quality of life, socio-demographic, and other clinical variables were examined at the treatment entry.

RESULTS

Mean age of the subjects was 26.7 (± 5) years. At the end of three months, 33 (64.7%) patients were retained in the treatment. Internalized stigma correlated negatively with the social and environmental domains of quality of life. The strength of the correlations was modest. No significant correlation was found between demographic and clinical variables and internalized stigma and enacted stigma scores. Both internalized and enacted stigma scores reduced significantly at 3 months follow-up. The significance levels were retained even after controlling for the baseline quality of life scores. Stigma at the treatment entry did not predict early dropout.

CONCLUSION

Despite higher severity at the treatment entry, the level of internalized and enacted stigma reduced significantly within three months of an outpatient-based OAT program.

Predictors of Five-year Readmission to an Inpatient Service among Patients with Opioid Use Disorders

Background Opioid use disorder (OUD), a relapsing-remitting chronic medical disease, accounts for a sizable proportion of all-cause adult inpatient stays. We evaluated the incidence and predictors of any and multiple readmissions to inpatient care for OUD. Methods This retrospective, register-based cohort study assessed consecutive patients with OUD admitted to a federally-funded inpatient service of an addiction treatment center in North India between January 2007 and December 2014. Binary logistic regression was used to determine independent readmission predictors based on demographic, clinical, and treatment variables that significantly differed in bivariate analysis. Results Among 908 patients, 306 (33.7%) and 106 (11.7%) had any and multiple readmissions, respectively. Injection drug use (Odds ratio [OR] 2.92, 95% confidence interval [CI] 1.90-4.49), comorbid severe mental illness (OR 2.80, 95% CI 1.42-5.55) and common mental disorder (OR 3.4 95% CI 1.65-6.95), antagonist treatment (OR 1.6 95% CI 1.14-2.27), and urban residence (OR 1.38 95% CI 1.01-1.90) increased odds of readmission. 'Improved' discharge status (OR 0.48 95% CI 0.34-0.70) in first admissions reduced odds of any readmission. Similar risk factors also influenced multiple readmissions with higher odds ratios. Conclusions Identification and adequate treatment of risk factors may reduce the chances of readmission.

A Scoping Review of the Prevalence and Correlates of Sexual Dysfunction in Adults With Substance use Disorders

BACKGROUND

Substance use may affect sexual functioning in both men and women. Comorbid sexual dysfunction adds to the clinical burden of substance use disorders (SUD).

AIMS

The broad aims were to identify research conduct, types of the available evidence, and research gaps in (i) estimating the incidence, prevalence, type, and severity of sexual dysfunction in adults with SUD; (ii) exploring correlates of sexual dysfunction in SUD.

METHODS

We conducted systematic searches on PubMed, Google Scholar, and Embase for studies published in the English language between August 1954 and November 2020. We included prospective and cross-sectional observational studies that had examined the prevalence or incidence of any sexual dysfunction in adults of either gender with substance use disorders. Review articles and those with an exclusive focus on tobacco use disorders were excluded. The review was registered in PROSPERO.

RESULTS

Our search identified 65 relevant articles, including five prospective studies. All the prospective studies and most of the cross-sectional studies (n = 40) were done among men and subjects with alcohol (n = 20) and opioid (n = 23) use disorders in clinical populations. Substance use and sexual dysfunction were assessed by a wide range of instruments. Prospective studies reported a prevalence of sexual dysfunction at 75% and 61% for alcohol and opioid use disorders, respectively. The prevalence of any sexual dysfunction in cross-sectional studies ranged between 15 and 100 percent. Erectile dysfunction was the most commonly studied and observed sexual dysfunction. Comorbidity and socioeconomic deprivation were consistently associated with a higher occurrence of sexual dysfunctions.

STRENGTHS

We did not limit our review by the type of substances and year of publication. We adhered to the standards of conducting and reporting scoping reviews; hence, our review results should be replicable, transparent, and reliable.

LIMITATIONS

The wide clinical and methodological heterogeneity precluded a systematic review.

CONCLUSION

Research gaps exist in women, non-clinical population, stimulants, and cannabis use disorders, and effect of treatment of SUD in sexual functioning. The quality of evidence is poor. Ghosh A, Kathiravan S, Sharma K, Mattoo SK. A Scoping Review of the Prevalence and Correlates of Sexual Dysfunction in Adults With Substance use Disorders. J Sex Med 2022;19:216-233.

Quality of Life, Social Support, Coping Strategies, and Psychiatric Morbidity in Patients with Rheumatoid Arthritis

Background and Objectives  Patients with rheumatoid arthritis (RA) have greater psychological morbidity, despite that research in this area is scarce from developing countries. This study was aimed to assess the association of quality of life, social support, coping strategies, and psychological morbidity in patients with RA.

Materials and Methods  In this cross-sectional study, 40 patients with RA, who were not receiving steroids or disease modifying antirheumatic drugs, were recruited through purposive sampling. Social support questionnaire, coping strategy check list, and World Health Organization quality of life-BREF (WHOQOL-BREF) were administered to assess social support, coping, and quality of life, respectively.

Results  More than half of the patients had psychiatric disorders (60%), with depression being the commonest disorder (52.5%). Internalization coping and disease severity indicators like tender joints counts, swollen joints counts, pain, and disease activity were found as significant predictors for psychiatric disorders, while externalization coping, quality of life (all domains), and physical functions were found to protect against psychiatric morbidity.

Conclusions  Coping, quality of life, disease severity, and physical functions predicted the psychiatric disorders in RA. Multipronged interventions to enhance quality of life with promoting adaptive coping and timely treatment may further improve their mental health and overall disease course.

Predictors of Five-Year Readmission to an Inpatient Service among Patients with Alcohol Use Disorders: Report from a Low-Middle Income Country

BACKGROUND

Alcohol use disorder (AUD) is a relapsing-remitting disease that accounted for a sizable proportion of all-cause adult inpatient stays.

OBJECTIVES

To determine the predictors of any and multiple readmissions to inpatient care for AUD within 5 years of the index admission.

METHODS

This retrospective, register-based cohort study assessed consecutive patients with AUD admitted to a publicly-funded inpatient service between January 2007 and December 2014. Binary logistic regression was used to determine independent predictors for readmissions based on relevant demographic, clinical, and treatment variables that showed significant differences (p < 0.05) on univariate analysis.

RESULTS

Among 938 patients (age 35.9 ± 10.3 years; duration of alcohol use 159.6 ± 104.5 months; dual diagnosis 19%; comorbidity of substance use disorder 49.3%; medical disorder 34.8%, 299 (31.9%) and 115 (12.3%) had any and multiple readmissions, respectively. Comorbid "severe mental illness" (Odds ratio [OR] 1.99, 95% confidence interval [CI] 1.11-3.57) and urban residence (OR 1.58, 95% CI 1.13-2.18) increased the odds of any readmission; "Improved" status at discharge (OR 0.51, 95% CI 0.35-0.72) during index hospitalization reduced odds of readmission. Additionally, any medical or psychiatric comorbidities increased (OR 2.23, 95% CI 1.26-3.97), and comorbid substance use disorder decreased (OR 0.41, 95% CI 0.19-0.89) risk of multiple readmissions.

CONCLUSIONS

Clinicians could identify patients at-risk for any and multiple readmissions during the index hospitalization. A policy aimed at reducing the risk of rehospitalization, healthcare cost, and stigma should pay attention to the predictors of readmission. Such policy should further benefit resource-limited settings.

Predictors of retention in the treatment for opioid dependence: A prospective, observational study from India

BACKGROUND

Literature on a longitudinal study of the determinants of treatment retention for patients with opioid dependence is limited.

AIM

To find out patient- and treatment-related (buprenorphine-naloxone-assisted treatment [BNX treatment] versus naltrexone treatment) predictors for retention in maintenance treatment.

MATERIALS AND METHODS

A total of 100 participants with opioid dependence were recruited by convenience sampling. The primary outcome was treatment retention - 3 months and 6 months postentry into maintenance treatment. Multiple assessments were done for the severity of opioid dependence and withdrawal, high-risk behavior, quality of life, and recovery capital - baseline and 3 and 6 months. The secondary outcome was to assess the change observed in the above-listed variables.

RESULTS AND CONCLUSIONS

Bivariate analysis across retained and the dropout groups brought out significant differences for some (type of opioids and route of administration) but not for other (age, employment, and education) patient-related factors. Multivariate analysis, adjusting for the type of maintenance treatment, rendered these associations statistically insignificant. BNX-based treatment (compared to naltrexone maintenance) was the most significant predictor of treatment retention both at the end of 3 months and 6 months. Even after controlling for the severity of opioid dependence and withdrawal, type and route of opioid use, and high-risk behavior, patients on BNX were eleven times (14 times at the end of 6 months) more likely to be retained in the treatment. BNX group had significant improvements in the domains of recovery capital, quality of life, addiction severity, and severity of opioid dependence. There is a need to scale up the BNX-assisted treatment program in India and elsewhere.

Telemedicine-assisted stepwise approach of service delivery for substance use disorders in India

Restricted access to healthcare during COVID-19 pandemic warranted an urgent adaptation of telemedicine practice. We describe a synchronous, stepwise (telephonic, video, and in-person consultation) direct-care model. From 18th May to 31st August 2020, 128 new and 198 follow-up patients received consultation. Eighty-nine percent of new patients required video-consultation. Sixty-eight percent of follow-up cases were managed by telephonic consultation. A third of new and a fifth of the follow-up patients had to be called for physical consultation. Limited access to and understanding of the technologies, potential breach in privacy, and restrictions imposed on online prescription of medications posed significant challenges.

Disulfiram Ethanol Reaction with Alcohol-Based Hand Sanitizer: An Exploratory Study

Aims

We conducted a cross-sectional survey to estimate the prevalence and clinical manifestation of disulfiram ethanol reaction (DER) and isopropanol toxicity (IT) in patients with alcohol use disorders, on disulfiram. Alcohol-based hand rub contains either ethanol or isopropanol or both. COVID-19 pandemic has led to wide scale usage of sanitizers. Patients with alcohol use disorders, on disulfiram, might experience disulfiram ethanol like reactions with alcohol-based sanitizers.

Methods

We telephonically contacted 339 patients, prescribed disulfiram between January 2014 and March 2020. The assessment pertained to the last 3 months (i.e. third week of March to third week of June 2020).

Result

The sample consisted of middle-aged men with a mean 16 years of alcohol dependence. Among the 82 (24%) patients adherent to disulfiram, 42 (12.3%) were using alcohol-based hand rubs. Out of these, a total of eight patients (19%; 95% CI 9–33) had features suggestive of DER; four of whom also had features indicative of IT. Five patients (62.5%) had mild and self-limiting symptoms. Severe systemic reactions were experienced by three (37.5%). Severe reactions were observed with exposure to sanitizers in greater amounts, on moist skin or through inhalation.

Conclusion

Patients on disulfiram should be advised to use alternate methods of hand hygiene.

Tapentadol, the new kid on the block in India: Is it time to worry?

BACKGROUND AND OBJECTIVES

Large-scale prospective case series of tapentadol abuse or dependence in India is not available. Hence, we aimed to study the prevalence and profile of tapentadol users in a treatment-seeking population.

MATERIALS AND METHODS

The study had prospective and retrospective arms. We collected 8-month prospective data by face-to-face interviews (n = 70) and 8-year retrospective data from case notes (n = 26) with either tapentadol misuse/abuse or dependence in patients attending a de-addiction center.

RESULTS

The prevalence of tapentadol abuse or dependence was 25% among the pharmaceutical opioid users. Concurrent use of other opioids was seen in >80% of participants of both the arms. Major sources of tapentadol were chemists (without a prescription) (53%) and doctors (prescriptions) (40%). Patients in the tapentadol dependence group had a significantly higher dose, duration, and pharmaceutical opioid use.

CONCLUSION

India needs awareness promotion, training, availability restriction, and provision of treatment for tapentadol abuse or dependence.

Extended lockdown and India's alcohol policy: a qualitative analysis of newspaper articles

Objectives

Since 25th March 2020 India went into a complete and extended lockdown. Alcohol production, sales, and purchase were barred with this overnight prohibition order. We conducted a qualitative analysis of the media reports published within the first month of the nationwide lockdown with the objectives (a) using the media reports as indications of possible public health impact and population response of a sudden alcohol prohibition in India, (b) suggesting areas for future research.

Methods

We performed thematic and content analysis of 350 articles published online in national newspapers between the 26th March, 2020 and 25th April, 2020. Initial inductive, followed by deductive coding was done in this exploratory thematic analysis.

Results

The thematic analysis revealed four main themes: the beneficial aspects of the policy, the harmful aspects of the policy, non-compliance and attempts to change and / or subvert the policy, popularity and level of public buy-in of the policy. We generated relevant sub-themes under main themes. Two additional themes, not directly related to the sudden prohibition, were use of stigmatizing language and ethical concerns. The content analysis showed the frequency of the appearance of the main themes and proportions of sub-themes and codes under those main themes.

Conclusion

The harms, perceived from the media reports, should be balanced against the potential benefits. Absence of a national-level alcohol policy was made apparent by the reflexive, disconnected, and conflictual measures. Future research could systematically examine the potential ramifications of alcohol prohibition on public health, social, and economic aspects.

Opioid substitution therapy with buprenorphine-naloxone during COVID-19 outbreak in India: Sharing our experience and interim standard operating procedure

Coronavirus disease 2019 (COVID-19) has been declared as a pandemic by the World Health Organization on March 11, 2020. It has affected most countries of the world, including India. Both the disease and the unavoidable national response to it have posed unique challenges to our health-care system. A particular vulnerable group of patients is those with opioid dependence maintained on opioid substitution therapy (OST). These patients are pharmacologically dependent on the OST medication (buprenorphine, buprenorphine-naloxone combination [BNX], and methadone) for their healthy functioning and recovery. COVID-19 outbreak, lock-down, and difficult access to medical care, all are likely to induce stress and withdrawal, which is a potential risk for relapse among individuals with opioid dependence, who are anyway more vulnerable due to social, housing, living, and medical conditions. In this context, it is essential to re-strategize the existing OST services to adapt to the challenging circumstances. In this communication, we share our experience and formulate interim standard operating procedures (SOPs) for running a hospital-based OST service utilizing take-home BNX. The challenges, principles to meet the challenges, and interim SOPs are shared as being currently practiced in our center. Individual institutes, agencies, hospitals, and clinics running OST service with BNX can adapt these SOPs according to their characteristics, needs, demand, and resources; so long as, the basic principles are adhered to.

Does Cannabis Dependence Add on to the Neurocognitive Impairment Among Patients With Opioid Dependence? A Cross-Sectional Comparative Study

BACKGROUND AND OBJECTIVES

Chronic opioid exposure has been linked with neurocognitive impairments. Evidence of residual impairment with cannabis use is less consistent. We investigated whether patients with opioid and cannabis dependence perform poorly compared with those with opioid dependence alone.

METHODS

We recruited three groups of participants aged 18 to 55 years: opioid and cannabis dependence (OCaD; n = 21), only opioid dependence (OD; n = 19), and a control group (HC; n = 20). Subjects with other substance use, human immunodeficiency virus, head injury, epilepsy, and severe mental illness were excluded. Cognitive tests, performed after at least 1 week of abstinence, consisted of the Wisconsin card sorting test (WCST), Iowa gambling task (IGT), trail making tests A and B (TMT-A and B), verbal and visual N-back test (NBT), and standard progressive matrices for intelligence quotient (IQ). The general linear model was used to compare the groups with age and years of education as covariates.

RESULTS

IQ and severity of opioid dependence were comparable in the three groups. The mean duration of cannabis use was 76.2 (±39.4) months. Compared with the HC, both OD and OCaD had significant impairment on the IGT, WCST, TMTs, and NBT. No significant group difference was observed between the OD and OCaD groups.

DISCUSSION AND CONCLUSIONS

Opioid dependence is associated with impairments in decision making, executive function, working memory, and attention. Co-morbid cannabis dependence had similar profiles of cognitive impairments.

SCIENTIFIC SIGNIFICANCE

Co-morbid cannabis dependence might not add on to the existing cognitive dysfunction in opioid dependence. Further studies should be done with a larger sample. (Am J Addict 2020;29:120-128).

Age of onset of substance use in patients with dual diagnosis and its association with clinical characteristics, risk behaviors, course, and outcome: A retrospective study

RESEARCH QUESTION

Do patients with dual diagnosis (DD) with an early initiation of substance use and subsequent early onset substance use disorder (EOS) differ from those with late onset substance use disorder (LOS) regarding characteristics, sex-related risk behaviors, course, and outcome?

OBJECTIVES

The aim is to study EOS and LOS groups of patients with DD attending a treatment center with regard to clinical characteristics, type of psychiatric disorders, risk behaviors, and short-term outcome.

MATERIALS AND METHODS

Retrospective chart review of patients diagnosed with DD (n = 307) with regard to the above variables. Diagnoses of both substance use disorders (SUDs) and psychiatric disorders were made by qualified psychiatrists as per the International Classification of Diseases, 10^th revision.

RESULTS

Among 307 participants with DD, 100 were in EOS group (onset of SUD before 18 years of age as assessed clinically) and 207 in LOS group. Cannabis as the primary substance was more prevalent in the EOS (30%) than that of the LOS group (12%). Psychotic disorders were more prevalent in the EOS group (41%) followed by mood disorders (30%), while the reverse was true in the LOS group (27.5% and 56.5%, respectively). When compared to the LOS group, the EOS group had higher number of psychiatric admissions, reported higher prevalence of risky sexual behaviors (unprotected sexual intercourse, multiple sexual partners, and history of sexual intercourse with commercial sex workers), showed poorer treatment adherence, and worse outcome regarding both psychiatric disorder and SUD (all differences significant at P < 0.05).

CONCLUSIONS

DD patients differ significantly based on the age of onset of substance use. These may have therapeutic and management implications.

Initial treatment dropout in patients with substance use disorders attending a tertiary care de-addiction centre in north India

Background & objectives:

Dropout from substance use disorders treatment is associated with poor outcomes. Although many factors have been associated with an early dropout of patients, the reasons for dropping out of treatment prematurely remain poorly understood particularly in the Indian context. This study was aimed to study socio-demographic and clinical variables predicting initial dropout of patients attending a tertiary care de-addiction treatment centre in north India.

Methods:

Information was extracted from the records of consecutive newly registered patients from January 2011 to December 2014. The patients who did not come for follow up within 30 days of the first contact were defined as initial dropouts.

Results:

Data of 7991 patients could be retrieved. Majority of the sample consisted of male, married and employed individuals. Of them, 4907 patients (61.3%) were considered initial dropouts. Multivariate analysis revealed that after controlling for other factors, greater age, being employed, lower educational status, lesser duration of substance use, use of alcohol, opiate, tobacco, cannabis or sedative-hypnotic use but the absence of multi-substance use predicted initial drop out.

Interpretation & conclusions:

This study identified some socio-demographic and clinical variables which might predict treatment attrition in substance use disorders. Clinician's awareness towards these factors and tailor-made intervention might improve initial treatment retention. Future research could be directed to find the validity of this assumption.

Brief intervention in substance use disorders

Unhealthy substance use lies on a wide range that extends from occasional mild risky/harmful/hazardous use to severe substance use disorder. Brief intervention (BI) is a technique, used to initiate change for an unhealthy or risky substance use. It can be delivered by a vast array of trained professionals, in opportunistic settings (i.e. in people seeking help not for their substance use, but either its consequences or for completely unrelated physical or psychiatric disorders), and across substances, age and ethno-cultural groups. The six common elements of BIs are summarized by the acronym FRAMES, consisting of Feedback, Responsibility, Advise, Menu for change, Empathy, and enhancing Self-efficacy. BI has also been strategically combined with referral to appropriate treatment services. BI has shown efficacy for reducing substance use and its harmful consequences. The evidence for post-BI improved functionality and quality of life are also emerging.

A 5 kA pulsed power supply for inductive and plasma loads in large volume plasma device

This paper describes 5 kA, 12 ms pulsed power supply for inductive load of Electron Energy Filter (EEF) in large volume plasma device. The power supply is based upon the principle of rapid sourcing of energy from the capacitor bank (2.8 F/200 V) by using a static switch, comprising of ten Insulated Gate Bipolar Transistors (IGBTs). A suitable mechanism is developed to ensure equal sharing of current and uniform power distribution during the operation of these IGBTs. Safe commutation of power to the EEF is ensured by the proper optimization of its components and by the introduction of over voltage protection (>6 kV) using an indigenously designed snubber circuit. Various time sequences relevant to different actions of power supply, viz., pulse width control and repetition rate, are realized through optically isolated computer controlled interface.

Organ transplant & the psychiatrist: An overview

Organ transplantation has emerged as the saving grace for those who are suffering from end organ disease. Advent of modern surgical procedures and immunosuppressants further decrease morbidity and mortality. Meta-analyses have shown that post-organ transplantation quality of life improves for social, physical and daily activity functioning, but not consistently for psychological health. Psychiatrists can play a useful role not only in selecting the best suitable candidate for the procedure by psychosocial screening but also to tackle post-operation psychological issues that trouble patients as well as caretakers and decrease their quality of life. Issues like selection of patients with psychiatric disorders and substance abuse for transplantation process and their treatment both pre- and post- operation, risky health behaviours, treatment adherence for immunosuppressants and psychological support for caretakers can be better addressed by a psychiatrist who is sensitive towards these issues. Prescribing various psychotropics and immunosuppressants in the background of impaired organ function and drug-drug interaction is further challenging. Thus, psychiatrists need to be knowledgeable about these issues and should be an integral part of organ transplantation team for overall better outcome.

Effect of co-morbid depression on neurocognitive functioning in patients with obsessive-compulsive disorder: a study from India

OBJECTIVE

To study neuropsychological function in subjects with obsessive-compulsive disorder (OCD) with and without co-morbid depression in comparison with healthy controls (HC).

METHODS

The 3 sample groups included subjects with OCD without depression (OCD group, n = 30); subjects with OCD and depression (OCDD group, n = 20); and HC (n = 25). All 3 groups were matched for age, gender, and years of education, and they were assessed on the following: Trail Making Tests A and B, Verbal Fluency Test, PGI Memory Scale, Stroop test, Tower of London Test, Raven's Standard Progressive Matrices, Wisconsin Card Sorting Test, and the Object Alternation Test.

RESULTS

Both OCD and OCDD groups performed more poorly than HC, whereas the OCDD group performed worse than OCD group. Besides, OCD and OCDD groups had significantly poorer performance on tests of attention, memory, executive functions, verbal fluency, and intelligence. The OCDD group performed worse than the OCD group notably on Verbal Fluency Test, PGI memory test, and Object Alternation Test.

CONCLUSION

On tests of neurocognitive functioning, the performance of the OCDD group was poorer than the OCD group, and both performed poorer than HC, suggesting that OCD is associated with neurocognitive dysfunction and that this is exacerbated in the presence of depression.

Cardiac risk factors and metabolic syndrome in patients with schizophrenia admitted to a general hospital psychiatric unit

OBJECTIVE

The study aimed to evaluate the prevalence of cardiovascular risk (CVR) factors and metabolic syndrome (MS) in patients with schizophrenia.

MATERIALS AND METHODS

By consecutive sampling, 143 patients (of age ≥ 20 years), out of total 159 patients with schizophrenia admitted to the inpatient unit were evaluated for the coronary heart disease (CHD) risk as per Framingham (10-year all CHD events) function/risk equation and systematic coronary risk evaluation (SCORE) - 10-year cardiovascular mortality risk (CMR). Prevalence of MS was estimated by using the consensus definition.

RESULTS

Fifty-two (36.4%) patients fulfilled the criteria for MS. 10-year CHD risk was 1.65%, and 10-year CMR was 1.39%. Compared to females, males had higher Framingham score (1.96 ± 2.74 vs. 1.09 ± 0.41, U value 1987.5*, P < 0.05).

CONCLUSION

Patients of schizophrenia have a high prevalence of MS and CVR factors. Hence, there is a need to screen the patient of schizophrenia for the same and manage the same as early as possible during the course of illness.

Cardiovascular risk factors among bipolar disorder patients admitted to an inpatient unit of a tertiary care hospital in India

OBJECTIVE

The study aimed to examine the prevalence of cardiovascular risk factors in patients with bipolar disorder.

METHODS

By consecutive sampling, 93 inpatients (aged ≥20 years) diagnosed with bipolar disorder were evaluated for 10 year coronary heart disease (CHD) risk and 10-year cardiovascular mortality risk (CMR) on the Framingham (10-year all CHD events) function/risk equation and Systematic Coronary Risk Evaluation (SCORE) respectively.

RESULTS

Ten-year CHD risk was 3.36% and 10-year CMR was estimated to be 1.73%. One tenth (10.7%) of the sample was found to have very high/high CHD risk (≥10) and 6.45% of the sample had high CMR risk (≥5). More than half (54.88%) of patients had metabolic syndrome. Compared to females, males had higher Framingham function score (4.09±5.75 vs 1.59±1.05, U value - 634.5*, p<0.05) and had higher very high/high CHD risk (≥10) (15.1% vs 0, χ(2) 4.58, p<0.05).

CONCLUSIONS

Findings of the present study suggest the presence of cardiovascular risk factors and higher rate of metabolic syndrome in patients with bipolar disorder. Considering this fact, there is an urgent need for routine screening for cardiovascular risk factors in these patients. Mental health professionals should be aware of these risks; there is need to develop preventive strategies to reduce the cardiovascular risk in this population.

Profile of inhalant users seeking treatment at a de-addiction centre in north India

BACKGROUND & OBJECTIVES

Inhalants are substances whose chemical vapors are inhaled to produce euphoric, disinhibiting, and exciting effects. Data on inhalant abuse in India are relatively scarce. We report the demographic and clinical profile of inhalant users among the treatment seekers at a Drug De-addiction and Treatment Centre in north India.

METHODS

The records of treatment seekers at the Drug De-addiction and Treatment Centre, over 10 years (2002-2011) were scanned to identify 92 cases reporting inhalant use. Of these 92 cases, the complete record files were available for 87 (94.6%) cases. These case files were reviewed and the relevant data were collected and analyzed.

RESULTS

Over the study period of 10 years, the number of cases with inhalant abuse per year rose steadily to peak at 20 cases (4.08% of new cases) in 2006 and then stabilized at 1-3 per cent of new cases annually. Of the 87 cases studied, all were males with a mean age of 18.9±4.12 yr, mean education of 9.8±3.42 yr and mean family income of Rs. 7676±7343.15 (median: Rs. 5000). Majority of subjects were unmarried (89.7%), urban resident (79.3%), and from a nuclear family (78.2%). About half of the subjects were students (50.6%). The most common inhalant used was typewriter correction fluid (73.6%) followed by typewriter diluent fluid (19.5%) and glue (6.9%). The most common reason for initiation was curiosity. The mean age of onset of inhalant use was 16.3±4.22 yr. Most subjects fulfilled the criteria for inhalant dependence (85.1%). Psychiatric co-morbidity and the family history of substance dependence were present in 26.4 and 32.9 per cent subjects, respectively. Majority of the subjects reported drug related problems, occupation and finance being the worst affected. Interpretations & conclusions: Our results showed that the inhalant users were mostly urban youth belonging to middle socio-economic class families. The principal sources of inhalant abuse were the commonly available substances like typewriter correction fluids and majority of the subjects initiated it out of curiosity. Nearly three-fourth of the subjects used some other substance of abuse in addition, tobacco being the most common. In view of associated drug related problems, there is a need for strategies to prevent this emerging health care problem.

Delirium: Predictors of delay in referral to consultation liaison psychiatry services

OBJECTIVE

To evaluate the predictors of delay in psychiatry referral for patients with delirium.

MATERIALS AND METHODS

The consultation liaison psychiatry registry and case notes of 461 patients referred to psychiatry consultation liaison services and diagnosed as having delirium were reviewed. Data pertaining to sociodemographic variables, clinical variables, Delirium Rating Scale-Revised 98 version, etiologies associated with delirium were extracted.

RESULTS

Older age, presence of and higher severity of sleep disturbance, presence of and higher severity of motor retardation, presence of visuospatial disturbances, presence of fluctuation of symptoms, being admitted to medical ward/medical intensive care units, and absence of comorbid axis-1 psychiatry diagnoses were associated with longer duration of psychiatric referral after the onset of delirium. Of these only four variables (presence of sleep disturbance, presence of motor retardation, being admitted to medical ward intensive care units and absence of comorbid axis-1 psychiatry diagnoses) were associated with longer duration of psychiatric referral in the regression analysis.

CONCLUSION

The variables associated with delay in psychiatry referral for delirium suggest that there is a need to improve the understanding of the physicians and surgeons about the signs and symptoms, risk factors, and prognostic factors of delirium.

Performance of large electron energy filter in large volume plasma device

This paper describes an in-house designed large Electron Energy Filter (EEF) utilized in the Large Volume Plasma Device (LVPD) [S. K. Mattoo, V. P. Anita, L. M. Awasthi, and G. Ravi, Rev. Sci. Instrum. 72, 3864 (2001)] to secure objectives of (a) removing the presence of remnant primary ionizing energetic electrons and the non-thermal electrons, (b) introducing a radial gradient in plasma electron temperature without greatly affecting the radial profile of plasma density, and (c) providing a control on the scale length of gradient in electron temperature. A set of 19 independent coils of EEF make a variable aspect ratio, rectangular solenoid producing a magnetic field (B(x)) of 100 G along its axis and transverse to the ambient axial field (B(z) ~ 6.2 G) of LVPD, when all its coils are used. Outside the EEF, magnetic field reduces rapidly to 1 G at a distance of 20 cm from the center of the solenoid on either side of target and source plasma. The EEF divides LVPD plasma into three distinct regions of source, EEF and target plasma. We report that the target plasma (n(e) ~ 2 × 10(11) cm(-3) and T(e) ~ 2 eV) has no detectable energetic electrons and the radial gradients in its electron temperature can be established with scale length between 50 and 600 cm by controlling EEF magnetic field. Our observations reveal that the role of the EEF magnetic field is manifested by the energy dependence of transverse electron transport and enhanced transport caused by the plasma turbulence in the EEF plasma.

Comparative study of prevalence of metabolic syndrome in bipolar disorder and schizophrenia from North India

BACKGROUND

Very few studies have compared the prevalence of metabolic syndrome (MS) between patients with bipolar disorder and schizophrenia.

AIM

The study aimed to compare the prevalence of MS in patients with bipolar disorder and schizophrenia.

MATERIALS AND METHODS

By consecutive sampling, 126 patients with schizophrenia and 72 patients with bipolar disorder admitted to a psychiatry inpatient unit were evaluated for the presence of MS using the criteria of International Diabetes Federation (IDF) and modified National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP-III). A control group of 50 healthy subjects was used to represent the general prevalence of MS in the community.

RESULTS

In the bipolar disorders group, 40 patients (55.55%) fulfilled IDF criteria and 45 (62.5%) satisfied modified NCEP ATP-III criteria for MS. These figures were significantly higher than those for the schizophrenia group (34.1% IDF and 36.5% modified NCEP ATP-III criteria). Prevalence of MS was 6% in the healthy control group and significantly less than both schizophrenia and bipolar disorder group.

CONCLUSION

In the sample studied, prevalence of MS is significantly higher in bipolar disorder compared with schizophrenia. The prevalence of MS in both the clinical groups was significantly higher than the healthy control group.

Family burden in injecting versus noninjecting opioid users

BACKGROUND

A substance-dependent person in the family affects almost all aspects of family life that also impact the lives of the significant others and causes enormous burden.

OBJECTIVES

This study was aimed to assess the pattern of burden borne by the family caregivers of patients with opioid-dependence-injecting drug users (IDU) and noninjecting drug users (NIDU).

MATERIALS AND METHODS

A cross-sectional study was conducted with ICD-10 diagnosed-opioid-dependent subjects (IDU and NIDU, N = 40 in each group) and their family caregivers attending a de-addiction centre at a multispecialty teaching hospital in North India. Family Burden interview schedule was used to assess the pattern of burden borne by the family caregivers.

RESULTS

The IDU group was characterized by older age, longer duration of substance dependence, greater subjective and objective family burden in all the areas compared to NIDU group, and single status and unemployment were associated with severe objective burden. The family burden was associated neither with age, education, or duration of dependence of the patients, nor with family size, type of caregiver or caregiver's education in either group.

CONCLUSION

All caregivers reported a moderate or severe burden, which indicates the significance and need for further work in this area.

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.

Metabolic syndrome in alcohol-dependent men: a cross-sectional study

BACKGROUND

In the context to mental illness metabolic syndrome (MS) has gained significant attention in the last decade. The present research aimed to study the prevalence of MS and its correlates among the alcohol-dependent men at a deaddiction center in Northern India.

MATERIALS AND METHODS

A cross-sectional analysis was done for consecutive male subjects who met the diagnosis of alcohol-dependence syndrome currently using alcohol according to the International Clinical Diagnostic criteria- tenth revision mental and behavioral disorder- Clinical description and diagnostic guidelines criteria (ICD-10). The subjects were evaluated for alcohol consumption and the components of MS as per the International Diabetic Federation (IDF) and National Cholesterol Education Program Adult Treatment Panel-III (NCEP ATP-III).

RESULTS

A total of 200 male subjects were studied: 100 subjects meeting ICD-10 criteria for alcohol dependence currently using alcohol; 50 each of genetically related controls and nongenetically related healthy controls. As per the IDF (with ethnicity specific modifications for waist circumference) and NCEP ATP- III definitions, respectively, MS was found to be less prevalent in alcohol-dependent subjects (27% and 18%) in comparison the healthy controls (30% and 20%).

CONCLUSION

Findings of the study suggest that irrespective of the amount the current alcohol intake is associated with a lower prevalence of MS and a favorable effect on serum high density lipoproteins and waist circumference. However, the cross-sectional nature of our study does not allow any definitive causal inference.

Relationship between cognitive and non-cognitive symptoms of delirium

AIM

To study relationship between the cognitive and the non-cognitive symptoms of delirium.

METHODS

Eighty-four patients referred to psychiatry liaison services and met DSM-IVTR criteria of delirium were assessed using the Delirium Rating Scale Revised-1998 (DRSR-98) and Cognitive Test for Delirium (CTD).

RESULTS

The mean DRS-R-98 severity score was 17.19 and DRS-R-98 total score was 23.36. The mean total score on CTD was 11.75. The mean scores on CTD were highest for comprehension (3.47) and lowest for vigilance (1.71). Poor attention was associated with significantly higher motor retardation and higher DRS-R-98 severity scores minus the attention scores. There were no significant differences between those with and without poor attention. Higher attention deficits were associated with higher dysfunction on all other domains of cognition on CTD. There was significant correlation between cognitive functions as assessed on CTD and total DRS-R-98 score, DRS-R-98 severity score and DRS-R-98 severity score without the attention item score. However, few correlations emerged between CTD domains and CTD total scores with cognitive symptom total score of DRS-R-98 (items 9-13) and non-cognitive symptom total score of DRS-R-98 (items 1-8).

CONCLUSIONS

Our study suggests that in delirium, cognitive deficits are quite prevalent and correlate with overall severity of delirium. Attention deficit is a core symptom of delirium.

Family burden with substance dependence: a study from India

BACKGROUND & OBJECTIVES

A substance dependent person in the family affects almost all aspects of family life. This leads to problems, difficulties or adverse events which impact the lives of family members and causes enormous burden on family caregivers. The present study aimed to assess the pattern of burden borne by the family caregivers of men with alcohol and opioid dependence.

METHODS

A cross-sectional study was conducted with ICD-10 diagnosed substance dependence subjects and their family caregivers attending a de-addiction centre at a multispecialty teaching hospital in north India. Family Burden Interview Schedule was used to assess the pattern of burden borne by the family caregivers of 120 men with alcohol and/or opioid dependence.

RESULTS

Compared to opioid and alcohol+opioid dependence groups, more often the alcohol dependence group was older, married, currently working, having a higher income and with the wife as a caregiver. Family burden was moderate or severe in 95-100 per cent cases in all three groups and more for 'disruption of family routine', 'financial burden', 'disruption of family interactions' and 'disruption of family leisure'. Family burden was associated with low income and rural location. It was associated neither with age, education or duration of dependence of the patients, nor with family size, type of caregiver or caregiver's education and occupation.

INTERPRETATION & CONCLUSIONS

Almost all (95-100%) caregivers reported a moderate or severe burden, which indicates the gravity of the situation and the need for further work in this area.

Seroprevalence of anti-hepatitis C virus (anti-HCV) antibody and HCV-related risk in injecting drug users in northern India: comparison with non-injecting drug users

AIM

The current study was designed to study seroprevalence of anti-hepatitis C virus (anti-HCV) antibody in injecting drug users (IDUs) and non-injecting drug users (non-IDUs) with or without other HCV-related risk behaviour.

MATERIALS AND METHODS

Serum of male inpatients of the three groups in a tertiary-care hospital in north India was screened for anti-HCV antibody by enzyme-linked immunosorbent assay (ELISA) for two years. The presence of risk behaviours or risk exposure (sharing needle or other drug-related paraphernalia, multiple sex partners, unprotected sex with commercial sex workers/strangers, and blood transfusion) was assessed with the risk questionnaire.

RESULTS

One-hundred and three IDUs (n=103), non-IDUs with other HCV-related risk (n=124) and non-IDUs without other HCV-related risk (n=245) were screened (mean age 31.2 (SD=7.92), 32.6 (SD=9.98) and 36.9 (SD=10.63) years, respectively). Almost 46% of the IDUs, 8.1% among the non-IDUs with HCV-related risk and 3.7% among the non-IDUs without HCV-related risk were seropositive for anti-HCV antibody (p<0.001). A majority of the IDUs have been actively using the drugs (76.7%) for a mean duration of 60.9months (SD=57.05) and a majority used injection buprenorphine in combination with promethazine and/or diazepam (70.9%). Other HCV-related risk behaviours were significantly more common among non-IDUs with other HCV-related risk behaviour.

CONCLUSION

Seroprevalence of anti-HCV antibody is high in IDUs compared to non-IDUs, and it is primarily related to injecting risk behaviour.

Carisoprodol: an underrecognized drug of abuse in north India

BACKGROUND

There is limited literature on clinical profile of subjects abusing carisoprodol.

METHODS

Our series of 34 subjects shows that a typical subject was an unmarried, unemployed, urban resident from a nuclear family set up; was a substance abuser before being introduced to carisoprodol by another substance abuser; initiated the use to get a better "kick" and after regular use reported craving and withdrawal symptoms.

RESULTS

The effect of carisoprodol was dose dependent: a majority reported a feeling of general wellbeing on consuming up to three tablets; a hypomanic state with 4-10 tablets and confusion, disorientation and drowsiness with >10 tablets at a time.

CONCLUSION

Thus being an underrecognized drug of abuse, carisoprodol is in need of wider awareness and regulatory measures to prevent its emergence as a greater menace in the future.

Metabolic syndrome among substance dependent men: A study from north India

BACKGROUND

Substance abuse, alcohol in particular, is associated with increased risk of diabetes and metabolic syndrome (MS). The relationship between the substance abuse and MS is complex and the literature is sparse.

OBJECTIVES

The present research was aimed to study the prevalence and predictors of MS among outpatients with substance dependence.

MATERIALS AND METHODS

Patients with substance dependence were recruited from a deaddiction center in North India, who attended outpatient clinic from 1(st) January, 2010-31(st) December, 2010. MS was assessed using International Diabetes Federation (IDF) criteria.

RESULTS

Out of 250 subjects, 34 (13.6%) of the subjects met the IDF criteria for MS and highest being in alcohol group (21.6%). The commonest abnormality was increased triglycerides (TG; 54%) and increased waist circumference (36.8%). Age, body weight, body mass index, and obesity were significant predictor of MS.

CONCLUSION

MS was highest in subjects with alcohol dependence with the commonest abnormality of TG and blood pressure. Hence, routine screening is advisable in this population to address emerging MS.

Demographic and clinical profile of substance abusing women seeking treatment at a de-addiction center in north India

BACKGROUND

In the recent decades increasing number of women have been seeking deaddiction services. Despite that the report data is very limited from India.

OBJECTIVES

The present research aimed to study the demographic and clinical profile of women seeking deaddiction treatment at a tertiary care center in North India.

MATERIALS AND METHODS

Retrospective structured chart review of 100 women substance abusers seeking treatment at a deaddiction center between September 1978 and December 2011.

RESULTS

A typical case was of 36.3 years age, married (65%), urban (61%), nuclear family (59%) based housewife (56%), with good to fair social support (69%). The commonest substance of abuse was tobacco (60%), followed by opioids (27%), alcohol (15%), and benzodiazepines (13%). The common reasons for initiation of substance use were to alleviate frustration or stress (49%) and curiosity (37%). Family history of drug dependence (43%), comorbidity (25%), and impairments in health (74%), family (57%), and social domains (56%) were common. Only a third of the sample paid one or more follow visit, and of those 58% were abstinent at the last follow-up. Significant predictors identified were being non-Hindu and higher educational years for abstinent status at follow-up.

CONCLUSION

The common substances of abuse were tobacco, opioids, and alcohol and benzodiazepines; and family history of drug abuse and comorbidity were common. The follow-up and outcome were generally poor. This profile gives us some clues to address a hidden health problem of the community.

HIV Stigma and Specified Correlates in North India

BACKGROUND

Worldwide, the stigma and discrimination impede HIV-AIDS programs across the continuum of prevention to care. We studied stigma and related issues in HIV-positive subjects.

MATERIALS AND METHODS

At a tertiary care hospital in North India, we studied 100 HIV-positive outpatients not receiving antiretroviral therapy. The subjects self-administered 'Tanzania Stigma Indicator and Community Endline-Individual Questionnaire'. Psychiatric morbidity was screened with General Health Questionnaire (GHQ-I2 Hindi) and diagnosed with Structured Clinical Interview for DSM-IV (SCID).

RESULTS

A typical subject was middle aged (25-44 years, 77%), school non-completer (63%), village dweller (61%), and male (59%). Only 35 subjects could differentiate between HIV and AIDS, and only 24 were aware of antiretroviral therapy. Unprotected sex, sharing injections, and blood transfusions were reported spontaneously as possible sources of transmission by 56-79% subjects each. About 80% of subjects reported no fear in touching HIV-positive subjects or their objects. Avoiding injections, being faithful to uninfected partner, avoiding blood transfusions, using condoms, and avoiding sharing razors/blades were reported spontaneously as HIV preventive measures by 40 to 26 subjects each. Half of the subjects blamed self for contracting HIV. Only 38 subjects reported others behaving differently with HIV-positive subjects. HIV status disclosure was reported by 98 subjects (73 to family or relatives). Urban subjects reported higher primary stigma and shame or blame. Psychiatric disorders, present in 45 subjects, showed no association with stigma items.

CONCLUSIONS

The subjects had a limited knowledge, especially of treatment aspects. Stigma showed no association with psychiatric disorders. The study reflects a strong need for public health measures to enhance awareness and knowledge about HIV/AIDS.

Revisiting plasma hysteresis with an electronically compensated Langmuir probe

The measurement of electron temperature in plasma by Langmuir probes, using ramped bias voltage, is seriously affected by the capacitive current of capacitance of the cable between the probe tip and data acquisition system. In earlier works a dummy cable was used to balance the capacitive currents. Under these conditions, the measured capacitive current was kept less than a few mA. Such probes are suitable for measurements in plasma where measured ion saturation current is of the order of hundreds of mA. This paper reports that controlled balancing of capacitive current can be minimized to less than 20 μA, allowing plasma measurements to be done with ion saturation current of the order of hundreds of μA. The electron temperature measurement made by using probe compensation technique becomes independent of sweep frequency. A correction of ≤45% is observed in measured electron temperature values when compared with uncompensated probe. This also enhances accuracy in the measurement of fluctuation in electron temperature as δT(pk-pk) changes by ~30%. The developed technique with swept rate ≤100 kHz is found accurate enough to measure both the electron temperature and its fluctuating counterpart. This shows its usefulness in measuring accurately the temperature fluctuations because of electron temperature gradient in large volume plasma device plasma with frequency ordering ≤50 kHz.

Substance-induced psychotic disorders: 13-year data from a de-addiction centre and their clinical implications

The relationship between substance use and psychotic disorder has been complex. Alcohol, cannabis, amphetamines, hallucinogens, and phencyclidine have been implicated as a causative factor for psychotic disorders. It is important to differentiate substance induced psychotic disorders (SIPDs) from primary psychotic disorders as management of the two conditions is different. There is paucity of research in the area of SIPD particularly from Asia. The present study was a retrospective study and it determines retrospectively the incidence rate and clinical characteristics of the SIPDs over a period of 13 years. The incidence of SIPDs was found to be 1.4% and all the subjects were males. In the present study, only alcohol and cannabis were implicated as causative agents for SIPDs. The most common type of psychosis was schizophrenia like psychosis, being more common in the cannabis group. The other forms of psychosis included delusional type, hallucinatory type and affective psychosis. 20% of the subjects had a change in diagnosis to either schizophrenia or affective psychosis on follow-up. The present study showed that the presentation of SIPDs is similar to the primary psychotic disorder and this has management implication.

Experimental observation of electron-temperature-gradient turbulence in a laboratory plasma

We report the observation of electron-temperature-gradient (ETG) driven turbulence in the laboratory plasma of a large volume plasma device. The removal of unutilized primary ionizing and nonthermal electrons from uniform density plasma and the imposition and control of the gradient in the electron temperature (T[Symbol: see text] T(e)) are all achieved by placing a large (2 m diameter) magnetic electron energy filter in the middle of the device. In the dressed plasma, the observed ETG turbulence in the lower hybrid range of frequencies ν = (1-80 kHz) is characterized by a broadband with a power law. The mean wave number k perpendicular ρ(e) = (0.1-0.2) satisfies the condition k perpendicular ρ(e) ≤ 1, where ρ(e) is the electron Larmor radius.

Personality disorders: prevalence and demography at a psychiatric outpatient in North India

BACKGROUND

Even though personality disorders are common among psychiatric populations, the data from India on their prevalence and demography are sparse.

AIM

To profile the prevalence and demography of personality disorders in North India.

METHODS

The retrospective study was based on patients attending the outpatient of a general hospital psychiatric centre in North India between June 1996 and June 2006. The specified data were collected from the case records of those receiving a primary or comorbid ICD-10 diagnosis of a personality disorder.

RESULTS

Personality disorders had a prevalence of 1.07%, with a preponderance of those aged 21-40 years (69.4%), men (64.9%), employed and students (37.3% and 32.8% respectively), unmarried (56%), graduates and undergraduates (27.6% each), and referred by the family (68.7%). The most common personality disorders were anxious-avoidant and borderline. Compared with the anxious-avoidant group, the borderline group was younger (mean age 24.44 vs 29.66 years) and had a preponderance of females (60% vs 27.1%).

CONCLUSION

The prevalence of personality disorders among the psychiatric outpatients was low compared to most of the research literature reporting clinically diagnosed personality disorders. The differences between the borderline and anxious-avoidant personality disorder subjects were largely explained by interrelated demographic variables.

Refractory delirium tremens: a case report and brief review

Delirium tremens is a common presentation in tertiary care hospitals. Severe and/or refractory delirium tremens is not as common, is potentially lethal, and requires intensive management. Usually delirium tremens responds to management with standard doses of benzodiazepines. Limited literature is available, however, for the management of refractory delirium tremens. We describe a case of refractory delirium tremens in which the patient was successfully managed with a combination of high doses of lorazapam, midazolam, and phenytoin.

Newer molecules in the treatment of schizophrenia: A clinical update

Schizophrenia is a heterogeneous psychiatric disorder in which multiple neurotransmitter systems have been implicated. Increased and decreased dopamine transmission in the subcortical meso-limbic and meso-cortical systems is closely linked to the “positive” and “negative” symptoms of schizophrenia, respectively. Important roles have also been found for serotonin and acetylcholine, both of which are closely linked to dopamine. An abnormality in glutamate functioning involving N-methyl-D-aspartic acid as well as other receptor subtypes may underlie the dopamine dysfunction observed in schizophrenia. Since the discovery of chlorpromazine in 1952, researchers have been developing new molecules targeting various neurotransmitter systems to maximize their efficacy and tolerability. The advancements in molecular genetics have opened up new horizons to manipulate the post-receptor protein cascade and gene expression. Although the magic-wand still eludes us, the newer molecules hold a lot of promise in this condition.

Anger attacks in obsessive compulsive disorder

BACKGROUND

Research on anger attacks has been mostly limited to depression, and only a few studies have focused on anger attacks in obsessive compulsive disorder.

MATERIALS AND METHODS

In a cross-sectional study all new obsessive compulsive disorder patients aged 20-60 years attending an outpatient clinic were assessed using the anger attack questionnaire, irritability, depression and anxiety scale (for the direction of the aggressive behavior) and quality of life (QOL).

RESULTS

The sample consisted of 42 consecutive subjects with obsessive compulsive disorder, out of which 21 (50%) had anger attacks. The obsessive compulsive disorder subjects with and without anger attacks did not show significant differences in terms of sociodemographic variables, duration of illness, treatment, and family history. However, subjects with anger attacks had significantly higher prevalence of panic attacks and comorbid depression. Significantly more subjects with anger attacks exhibited aggressive acts toward spouse, parents, children, and other relatives in the form of yelling and threatening to hurt, trying to hurt, and threatening to leave. However, the two groups did not differ significantly in terms of QOL, except for the psychological domain being worse in the subjects with anger attacks.

CONCLUSION

Anger attacks are present in half of the patients with obsessive compulsive disorder, and they correlate with the presence of comorbid depression.