Indian Psychiatric Society multicentre study: Diagnostic patterns, comorbidity and prescription practices for patients with Dementia.

Background: There are more than 5 million people with dementia in India. Multicentre studies looking at details of treatment for people with dementia In India are lacking. Clinical audit is a quality improvement process which aims to systematically assess, evaluate, and improve patient care. Evaluating current practice is the key to a clinical audit cycle. Aim: This study aimed to assess the diagnostic patterns and prescribing practices of psychiatrists for patients with dementia in India. Method: A retrospective case file study was conducted across several centers in India. Results: Information from the case records of 586 patients with dementia was obtained. Mean age of the patients was 71.14 years (standard deviation = 9.42). Three hundred twenty one (54.8%) were men. Alzheimer's disease (349; 59.6%) was the most frequent diagnosis followed by vascular dementia (117; 20%). Three hundred fifty five (60.6%) patients had medical disorders and 47.4% patients were taking medications for their medical conditions. Eighty one (69.2%) patients with vascular dementia had cardiovascular problems. Majority of the patients (524; 89.4%) were on medications for dementia. Most frequently prescribed treatment was Donepezil (230; 39.2%) followed by Donepezil-Memantine combination (225; 38.4%). Overall, 380 (64.8%) patients were on antipsychotics. Quetiapine (213, 36.3%) was the most frequently used antipsychotic. Overall, 113 (19.3%) patients were on antidepressants, 80 (13.7%) patients were on sedatives/hypnotics, and 16 (2.7%) patients were on mood stabilizers. Three hundred nineteen (55.4%) patients and caregivers of 374 (65%) patients were receiving psychosocial interventions. Conclusions: Diagnostic and prescription patterns in dementia which emerged from this study are comparable to other studies both nationally and internationally. Comparing current practices at individual and national levels against accepted guidelines, obtaining feedback, identifying gaps and instituting remedial measures help to improve the standard of care provided.

Delaying clozapine: how long is too long?

BACKGROUND: Although clozapine is the most effective drug for treatment-resistant schizophrenia, its use remains restricted in clinical practice in India. The delay in initiating treatment with clozapine and its impact on disease outcome needs evaluation. AIM: To identify the implications of delaying clozapine initiation in clinical outcomes among people with treatment-resistant schizophrenia. METHODS: Subjects with treatment-resistant schizophrenia, stabilised on clozapine monotherapy, were recruited from the outpatient clinic of a general hospital psychiatry unit offering tertiary care services in Thrissur district, Kerala, India. A retrospective cohort design was employed, and information on duration of illness, total duration of treatment and duration of treatment with clozapine was collected. Present symptom status was measured using the Positive and Negative Syndrome Scale. Factors associated with higher symptom scores were analysed using an independent sample t test, Spearman correlation and multiple linear regression. RESULTS: Forty subjects stabilised on long-term clozapine therapy formed the study sample. The mean dose of clozapine used in the study population was 200 mg. The mean duration of antipsychotic treatment before starting clozapine was 89.3 months (7.4 years). The duration of treatment before starting clozapine was found to have a significant positive association with the total Positive and Negative Syndrome Scale score (correlation coefficient 0.40; p=0.01) and negative symptom score (correlation coefficient 0.33; p=0.04). The multiple regression analysis adjusting for covariates showed that the duration of treatment before starting clozapine was an independent factor associated with a higher negative symptom score in the Positive and Negative Syndrome Scale (slope ß=0.05; p=0.02; R2=0.27). CONCLUSION: Poor treatment outcomes in treatment-resistant schizophrenia could be secondary to a delay in initiating clozapine therapy.

Prevalence and Factors associated with Depression among Clinically Stable People Living with HIV/AIDS on Antiretroviral Therapy.

BACKGROUND: Individuals with HIV/AIDS are prone for psychiatric/psychological morbidities. Many studies have reported significantly higher prevalence of depression in people living with HIV/AIDS (PLWHA's) when compared to general population. However, there are only very few studies looking at the prevalence of depression in patients on antiretroviral therapy (ART). OBJECTIVES: To estimate the prevalance and factors associated with depression among clinically stable PLWHAs. MATERIALS AND METHODS: We used a cross-sectional study design to estimate the prevalence of depression and factors associated with it among clinically stable PLWHAs with CD4 cell count >400 cells/mm3 and on ART for >2 years. We assessed 100 PLWHAs and diagnosed depression using ICD-10 diagnostic criteria. RESULTS: The prevalence of depression was 30% in this sample. Female gender, lack of family support, and HIV-positive status of the spouse were associated with depression in this study. Multiple logistic regression analysis showed lack of family support significantly associated with depression. High prevalence of depression and its association with stressful life circumstances even in individuals stable on ART points toward need for psychosocial interventions to improve metal health and well-being of these patients.

Psychiatric morbidity in the community: A population based-study from Kerala.

BACKGROUND: Estimates of psychiatric morbidity in the community will help service development. Participation of trained nonspecialist health-care providers will facilitate scaling up of services in resource-limited settings. AIMS: This study aimed to estimate the prevalence of priority mental health problems in populations served by the District Mental Health Program (DMHP). SETTINGS AND DESIGN: This is a population-based cross-sectional survey. MATERIALS AND METHODS: We did stratified cluster sampling of households in five districts of Kerala. Trained Accredited Social Health Activists (ASHAs) identified people who had symptoms suggestive of schizophrenia or bipolar disorder. Clinicians evaluated the information collected by the ASHAs and designated individuals as probable cases of psychosis or noncases. Screening instruments such as General Health Questionnaire-12, CAGE questionnaire, and Everyday Abilities Scale for India were used for identifying common mental disorders (CMDs), clinically significant alcohol-related problems, and functional impairment. RESULTS: We found 12.43% of the adult population affected by mental health conditions. We found CMD as most common with a prevalence of 9%. The prevalence of psychosis was 0.71%, clinically significant alcohol-related problems was 1.46%, and dementia and other cognitive impairments was 1.26%. We found informant-based case finding to be useful in the identification of psychosis. CONCLUSIONS: Mental health problems are common. Nonspecialist health-care providers can be trained to identify psychiatric morbidity in the community. Their participation will help in narrowing the treatment gap. Embedding operational research to DMHP will make scaling up more efficient.

A case of adrenoleukodystrophy presenting with manic symptoms in a patient on steroids for Addison's disease.

Adrenoleukodystrophy (ALD) is an X-linked disorder with diverse clinical presentations. A 30-year-old male, previously diagnosed with Addison's disease, on steroid supplementation for 18 years, presented to us with manic symptoms for 4 years. He was found to have white matter hypodensities in computed tomography head and had white matter signal changes in magnetic resonance imaging, and therefore a diagnosis of ALD was made.

Prevalence and risk factors for depression among community resident older people in Kerala.

BACKGROUND: Depression is the most common mental health problem in late-life. We need more information about the incidence and prevalence of major and minor syndromes of depression in older people. This will help in service development. AIMS: To estimate the prevalence of depressive disorders among community resident older people in Kerala, India and to identify factors associated with late-life depression. MATERIALS AND METHODS: Two hundred and twenty community resident older subjects were assessed for depression by clinicians trained in psychiatry. They used a symptom checklist based on International Classification of Diseases Tenth Revision (ICD-10) Diagnostic criteria for research for Depression and Montgomery Asberg Depression Rating Scale for assessment of symptoms. A structured proforma was used to assess sociodemographic characteristics and medical history. The point prevalence of depression was estimated. Univariate analysis and subsequent binary logistic regression were carried out to identify factors associated with depression. RESULTS: Prevalence of any ICD-10 (World Health Organization, 1992) depressive episode was 39.1% (95% confidence interval [CI] 32.6-45.9). There was significant correlation between depression and female gender (odds ratio [OR] 2.33; 95% CI 1.07-5.06) and history of a significant life event in the previous year (OR 2.39; 95% CI 1.27-4.49). CONCLUSION: High prevalence rate of late-life depression is indicative of high burden due to depression among older people in the community. Better awareness among primary care clinicians can result in better detection and management of late-life depression.

Cost of care: a study of patients hospitalized for treatment of psychotic illness.

BACKGROUND: Combination of ill health and poverty poses special challenges to health care providers. Mental illness and costs are linked in terms of long-term treatment and lost productivity, and it affects social development. The purpose of the present study is to assess the economic burden of poor families when a family member needs hospitalization due to psychosis. MATERIALS AND METHODS: The information was gathered from caregivers of 100 psychotic inpatients of Medical College Hospital of Kerala during a period of 6 months. Data regarding components of expenses such as cost of medicine, laboratory investigations, food, travel, and other miscellaneous expenses during their inpatient period were collected by direct personal interview using specially designed proforma. The data were analyzed using Epi-info software. The patients below the poverty line (BPL) were compared with those above poverty line (APL). RESULTS: There was no significant difference between patients from BPL and APL in respect of amounts spent on the studied variables except for laboratory investigations during the hospital stay. CONCLUSIONS: The results showed that the studied subjects are facing financial difficulties not only due to hospitalization, but also due to the recurrent expense of their ongoing medication. The study recommends the need of financial support from the government for the treatment of psychotic patients.

Mental health care of older people: can the district mental health program of India make a difference?

BACKGROUND: District mental health program (DMHP) is the flagship program of Government of India to deliver mental health-care throughout the country. Being an out-reach program, it is likely that elderly people with mental health programs are accessing it more frequently. If this is the case, there is potential for including additional components in this program so that something more than the generic service is offered to them. AIM: This study aims to find out whether the elderly are accessing the DMHP services frequently. MATERIALS AND METHODS: We compared the proportion of elderly people attending two mental health-care facilities: - A Government Medical College Out-patient Department and the clinics run by the DMHP of the same department. RESULTS: A significantly higher number of elderly people are attending the clinics of the DMHP compared to the outpatient service of a teaching hospital. CONCLUSION AND IMPLICATION: It is concluded that DMHP can be further strengthened by adding additional components like service for the elderly. This is important in view of the increasing number of older people who may need these services in future.

School dropouts: examining the space of reasons.

BACKGROUND: Dropping out of school is a worldwide phenomenon with drastic mental health consequences for children, families and society. AIM AND MATERIALS METHODS: This study examines school dropouts in one district in Kerala with an emphasis on looking at multiple reasons for the problem. RESULTS: The most common "reason" was various Physical disorders (80, 21.8%) followed by Mental Retardation (77, 20.9%). Child labour (Employment) came last (30, 8.1%) as a "reason" while financial issues constituted 50 (13.6%). Family issues accounted for 63 (17.1%) and School-related issues 68 (18.5%). CONCLUSION: This study highlights the need to examine a space of reasons for this phenomenon with active involvement and coordination of multiple agencies to examine and support getting children back to school and prevent dropouts.

Revalidation: Are we Meeting Training Needs? Training and its Influence on the Practice of Child Psychiatry and Psychotherapy.

Revalidation and renewal of registration are issues of concern to most psychiatrists. Keeping up-to-date with current knowledge is an essential part of the renewal of license to practice. Training needs of psychiatrists are addressed in postgraduate courses and the gaps in training and updating of knowledge addressed through continuing medical education programs. This study aims to look at whether the training needs of psychiatrists working in the state of Kerala are being met. Two aspects of training and practice, child and adolescent psychiatry and psychotherapy, were assessed using a questionnaire. A significant number of respondents had not received any training in either of these areas in their postgraduate training. This did not affect their practice; most respondents continued to practice psychotherapy and see child patients despite not being trained. These two areas can thus be identified as lacunae in the curriculum as well as a need which should be addressed through Continuation Medical education programs.

Indian research on aging and dementia.

All the articles published in the Indian Journal of Psychiatry (IJP) from 1958 to 2009 on aging, dementia and other mental health issues of late life were systematically reviewed. There were only a limited number of research articles on dementia in the IJP. Most of the Indian studies on dementia were published elsewhere. People above the age of 60 years constitute about 5% of patients seen in tertiary care settings. High prevalence of psychiatric morbidity was reported among community resident older people. Depression was the commonest mental health problem in late life. We need to develop community-based interventions for management of common conditions like depression in late life. The effectiveness of these interventions needs to be established. It is important to identify risk factors for depression and dementia in our population. We could then try and modify these factors to reduce the prevalence of these conditions.