Prescription patterns and medication adherence in preadolescent children with attention deficit hyperactivity disorder.

BACKGROUND: Nonadherence in attention deficit hyperactivity disorder (ADHD) can be as high as 80%, yet studies on adherence to medications in preadolescent children are few. Recent Indian trends in prescription patterns are lacking. AIM: The present study assesses prescription patterns and adherence to medications in preadolescent children with ADHD. MATERIALS AND METHODS: Fifty children aged 5-12 years with ADHD, who were on medications for at least 6 months, were enrolled. Their sociodemographic factors and prescription details were noted. Vanderbilt ADHD Diagnostic Parents Rating Scale and Compliance Rating Scale were administered. RESULTS: Sixty-two percent of the children had good compliance, whereas 38% showed reluctance. Adherence was better in children with shorter duration of illness, lesser severity, absence of side effects, and stimulant prescription. Non-stimulant-based combination (40%) was more common compared to stimulants (28%), with atomoxetine and risperidone being the most commonly prescribed medications. CONCLUSIONS: Adherence to medications in preadolescent children with ADHD is good. Associated factors and implications are discussed.

Facets of clinical stigma after attempted suicide in Mumbai, India.

Community stigma studies may neglect clinically relevant experience and views of stigma that are important features of mental health problems. After attempting suicide, patients in a hospital emergency ward in Mumbai, India, were assessed for stigma referring to underlying prior problems motivating their deliberate self-harm (DSH) event, the DSH event itself and serious mental illness generally based on both anticipated community views and distinctive personal views. In this cultural epidemiological study of 196 patients, assessment items and four corresponding indexes were analysed and compared on a four-point scale, 0 to 3, for prominence of indicated stigma. Narratives from patients with high, low and discordant levels of stigma for prior problems and DSH events were analysed and compared. Disclosure, critical opinions of others and problems to marry were greater concerns for DSH events than prior problems. Problem drinking, unemployment, and sexual or financial victimization were common features of prior problems. Impulsivity of the DSH event and externalizing blame were features of lower levels of stigma. Ideas about most people's views of serious mental illness were regarded as more stigmatizing than patients' prior problems and DSH event; patients' personal views of serious mental illness were least stigmatizing. Findings suggest linking suicidality and stigmatized mental illness may discourage help seeking. Suicide prevention strategies should therefore emphasize available help needed for severe stress instead of equating suicidality and mental illness. Findings also indicate the relevance of assessing clinical stigma in a cultural formulation and the value of integrated qualitative and quantitative stigma research methods.

Gender Variability of Perceived Stress and Negative Inferential Feedback in Depression.

BACKGROUND: The role of negative inferential feedback and perceived stress in hopelessness depression is known. However, studies on their gender variability are lacking. The difference in various domains of negative inferential feedback and its impact on cognitive hopelessness, depression, and outcome of psychotherapy between men and women has been hypothesized. AIMS: This study analyzed the difference in stress levels and hopelessness in the form of negative inferential feedback in depressed men and women. METHODOLOGY: In all, 35 men and 35 women suffering from depression were recruited. They were first assessed on the Hamilton's Depression Rating Scale, and their sociodemographical details were recorded. They were then administered the Perceived Stress Scale (PSS) and the Adaptive Inferential Feedback Questionnaire. RESULTS: Perceived stress in depressed women showed a positive correlation with negative inferential feedback (r = 0.39, P = 0.04). Levels of depression were comparable in the two genders. Comparison between the two genders showed no difference in proportion across the levels of severity of depression (χ2 = 5.44, P = 0.14). Depressed women rated higher stress, mainly in the helplessness domain of the PSS (P = 0.04). Women were shown to have more negative inferential feedback and attribute their hopelessness to more stable and global causes when compared with men (P = 0.04). CONCLUSION: Depressed women perceive more stress and receive more negative feedback, than men, to negative life events. Women attribute their hopelessness to more stable and global causes when compared with men.

Role of personality in tobacco smoking behavior in corporate sector: A cross-sectional study.

BACKGROUND: India's corporate sector has grown steadily over the past decade, and it is providing a lot of work opportunities to Indian youth. Around 20% of employees in the corporate sector in India smoke cigarettes. In general, addictive behaviors including smoking are associated with certain personality dimensions. Hence, we conducted a study with the aims to assess the level of nicotine dependence in tobacco smokers (working in corporate sector), study their personality profile, and association of their personality traits with continuing smoking behavior. MATERIALS AND METHODS: The study proposal along with its intended aims and objectives was cleared by the Institutional Ethical Review Board. It was a cross-sectional study. We used FTND for level of nicotine dependence and NEO FFI 3 for personality profile along with a structured proforma. RESULTS: Most of the clients were of very low to low level of nicotine dependence. As high as 40% of the clients did not even attempt to quit smoking, most common reason for attempt at quitting was health concerns. Major causes of relapse were friends, people at workplace, and nature of work. Clients were high on neuroticism, average on extraversion and openness, and low on agreeableness and conscientiousness. Neuroticism was significantly associated with the level of nicotine dependence. Extraversion and openness were associated with health concerns, while agreeableness and conscientiousness were associated with social factors as a reason to quit. Extraversion and agreeableness were associated with occupational factors and social factors as reasons to relapse. CONCLUSION: Understanding one's personality would be helpful to identify health-enhancing (which help to attempt at quitting) and health-destructive (which were responsible for relapse) behaviors. This can further help in framing interventions that particularly target these personality traits and behaviors.

Soft Neurological Signs and Cognitive Function in Obsessive-compulsive Disorder Patients.

OBJECTIVE: Modern research on obsessive-compulsive disorder (OCD) indicates that the primary cause of OCD, which was earlier explained only on basis of psychoanalytical theories, is biological. Our study attempts to investigate the neurobiological signs in form of soft neurological signs and cognitive function in OCD. METHODS: A cross sectional study was conducted at psychiatric facility of Seth G.S. Medical College and KEM Hospital. MATERIALS AND METHOD: 50 OCD patients and age- and education-matched controls were selected for the study. Established instruments were used to assess the neurological soft signs (NSS) and the cognitive deficits. RESULTS: OCD patients had significant more NSS in tests for motor coordination, sensory integration, complex motor tasks, hard signs, and right/left and spatial orientation. Cognitive deficits in the domains of visuospatial ability, executive function, attention, and working memory were significantly more in OCD patients compared to controls. CONCLUSION: Our study highlights the role of biological factors in form of soft neurological signs and cognitive dysfunction in the development of the OCD.

Elderly mental health: needs.

This paper highlights the mental health needs of the elderly. It tackles the issues of their institutionalisation and community care. Rapid urbanisation in Indian society throws up special problems in elderly care. There is great evidence of a raise in morbidity, mortality, hospitalisation and loss of functional status related to common mental disorders in the elderly patients. Overlap of depression and anxiety is very common with up to almost half of the elderly patients reporting significant depressive and anxiety symptoms. Also, depression is the most common psychiatric disorder in late life. Growth in the elderly population means a direct increase in age related diseases such as dementia and poor mental health outcomes such as depression, anxiety, suicide and serious constraints on the quality of life among elderly individuals. The need to identify new and unmet problem areas and develop efficient therapeutic outcomes for this special population is stressed.

Neuropsychiatric manifestations of methyl iodide.

Methyl iodide is a monohalomethane and with a chemical formula CH(3)I. Acute exposures to methyl iodide have frequently occurred in the workplace. Predominantly, neuropsychiatric symptoms of acute exposure to monohalomethanes consist of headache, nausea, vomiting, drowsiness, dizziness, giddiness, diarrhea, confusion, ataxia, slurred speech, paralysis, convulsions, delirium, coma, and death. We report two cases who presented to our emergency services after accidental exposure to methyl iodide for a short duration. These case reports highlighted concurrence of frankly psychotic features and acute confusional state in workers vulnerable to industrial exposure to toxic chemicals. Understanding the mechanism of neuro-toxicity will perhaps throw some light on co-existence of both psychiatric and neurological symptoms. Awareness of these toxic effects at vulnerable work places will lead to timely and appropriate interventions. Importance of safety precautions and education of both workers and supervisors cannot be overemphasized here.

Explaining suicide: identifying common themes and diverse perspectives in an urban Mumbai slum.

Rates, demographics and diagnostics, which are the focus of many studies of suicide, may provide an insufficient account without adequate consideration of psychological, social and cultural contexts and motives. Furthermore, reported explanations of suicide are shaped not only by events but also the relationship of survivor respondents explaining the suicide. An explanatory model interview for sociocultural autopsy has been used to assess underlying problems and perceived causes. This study in a low-income community of Mumbai in 2003-2004 compared accounts of the closest family survivors and more distant relationships. Our study design distinguished series-level agreement (i.e., consistency of accounts within a group) and case-level agreement for particular cases. Serious mental illness was the perceived cause reported by a respondent in either group for 22.0% of index suicides, but case-level agreement was only 6.0%. Regarding financial stressors, more closely related family respondents focused on acute stressors instead of enduring effects of poverty. Case-level agreement was high for marital problems, but low for other sources of family conflict. Tension was a feature of suicide reported in both groups, but case-level agreement on tension as a perceived cause was low (kappa = 0.14). The role of alcohol as a perceived cause of suicide had high series level agreement (46.0% in both groups) and case-level agreement (kappa = 0.60), suggesting comparable community and professional views of its significance. The study shows that it is relevant and feasible to consider general community patterns and particular survivor interests. Findings from this study recommend an approach to sociocultural autopsy to assess reasons for suicide in community studies. Findings clarify diverse views of underlying problems motivating suicide that should be considered to make mental health care more effective in assessing risk and preventing suicide.

Comparison of anxiety, depression, and post-traumatic stress symptoms in relatives of ICU patients in an American and an Indian public hospital.

CONTEXT: An intensive care unit (ICU) admission of a patient causes considerable stress among relatives. Whether this impact differs among populations with differing sociocultural factors is unknown. AIMS: The aim was to compare the psychological impact of an ICU admission on relatives of patients in an American and Indian public hospital. SETTINGS AND DESIGN: A cross-sectional study was carried out in ICUs of two tertiary care hospitals, one each in major metropolitan cities in the USA and India. MATERIALS AND METHODS: A total of 90 relatives visiting patients were verbally administered a questionnaire between 48 hours and 72 hours of ICU admission that included the Hospital Anxiety and Depression Scale (HADS), Beck Depression Inventory-II (BDI-II) and Impact of Events Scale-Revised (IES-R) for post-traumatic stress response. STATISTICAL ANALYSIS: Statistical analysis was done using the Mann-Whitney and chi-square tests. RESULTS: Relatives in the Indian ICU had more anxiety symptoms (median HADS-A score 11 [inter-quartile range 9-13] vs. 4 [1.5-6] in the American cohort; P<0.0001), more depression symptoms (BDI-II score 14 [8.5-19] vs. 6 [1.5-10.5], P<0.0001) but a comparable post-traumatic stress response (IES-R score>30). 55% of all relatives had an incongruous perception regarding "change in the patient's condition" compared to the objective change in severity of illness. "Change in worry" was incongruous compared to the perception of improvement of the patient's condition in 78% of relatives. CONCLUSIONS: Relatives of patients in the Indian ICU had greater anxiety and depression symptoms compared to those in the American cohort, and had significant differences in factors that may be associated with this psychological impact. Both groups showed substantial discordance between the perceived and objective change in severity of illness.

Are the effects of cannabis dependence on glucose metabolism similar to schizophrenia? An FDG PET understanding.

BACKGROUND: Cannabis has been associated with transient psychotic states; however, the causal relationship between cannabis and schizophrenia continues to remain a matter of debate. Epidemiological and some biological studies hint at cannabis being an independent risk factor for schizophrenia; this has not been definitively proved. AIMS: We aimed to understand the patterns of glucose uptake in important brain regions among individuals with cannabis dependence and schizophrenia. Furthermore, we compared the interregional metabolic rates in pertinent neural circuits among individuals with cannabis dependence, schizophrenia and normal controls. SETTING AND DESIGN: This is a case-control cross-sectional study that was carried out by a general psychiatry department in collaboration with a nuclear diagnosis unit. MATERIALS AND METHODS: Male volunteers with cannabis dependence, schizophrenia and normal controls underwent FDG PET scanning. Glucose uptakes in pre-selected regions of interest were compared using MANOVA. Finally, Chow tests were used to compare interregional metabolic relationships in the mesocortical and cortical-subcortical-cerebellum circuits. RESULTS: Significant differences (P<0.05) were noted among individuals with cannabis dependence and schizophrenia in the medial and lateral temporal regions. When the neural circuits were compared, significant interregional differences (P<0.05) were noted between individuals with cannabis dependence and normal controls. However, among individuals with cannabis dependence and schizophrenia, no significant differences (P>0.05) were noted in these patterns. CONCLUSIONS: Our findings suggest that cannabis dependence can alter interregional relationships in a manner similar to schizophrenia. This indicates that cannabis could potentially play a role in the development of psychosis by altering neural circuits.

Lorazepam-induced Short-term Remission of Symptoms in a Case of Paranoid Schizophrenia.

Conventionally, antipsychotics are used to treat schizophrenia due to predominant dopamine antagonist activity. The use of various types of Benzodiazepines (BZDs) in the treatment of Schizophrenic symptoms like agitation and psychotic excitement in general and control of florid psychotic symptoms such as hallucinations and delusions in particular is well known. However, the use of BZDs, specifically in remission of paranoid schizophrenia, is not reported so far. Here, we are reporting a case of an elderly female patient with chronic paranoid schizophrenia showing short-term remission in paranoid symptoms with injectable lorazepam.

Cannabis dependence: Effects of cannabis consumption on inter-regional cerebral metabolic relationships in an Indian population.

BACKGROUND: The effects of cannabis consumption on neurophysiological function have been a matter of considerable debate. With the legalization of medical marijuana, understanding the consequences of cannabis dependence has become extremely important. AIM: We attempted to understand the influence of cannabis on cerebral glucose metabolism in certain predetermined regions of interest (ROIs). Furthermore, we also explored inter-regional metabolic relationships between ROIs forming the "addiction" and "cognitive dysmetria" circuit. MATERIALS AND METHODS: 2-fluoro, 2-deoxy-glucose positron emission tomography (FDG PET) scans were carried out in 16 male patients (age: 25.3±10.38 years) with cannabis dependence, 8-12 hours after the last cannabis consumption. Resting glucose uptake in 14 pre-determined ROIs was compared with glucose uptake in 16 non-drug using volunteers (age: 29.2±8.39 years). RESULTS: The two groups differed in their lateral and medial temporal glucose uptakes by approximately 16-24%. The relationships between inter-regional glucose uptakes in the two circuits were compared using the Chow Test. Significant differences in inter-regional correlations in the medial temporo-frontal and parieto-thalamic were noted between the two groups. CONCLUSION: The altered metabolic relationships among various brain regions can have potentially important implications for understanding cannabis dependence and cannabis-induced psychopathology.

Explaining suicide in an urban slum of Mumbai, India: a sociocultural autopsy.

BACKGROUND: Health demographic mortality studies use verbal autopsies to identify suicide as a cause of death. Psychological autopsies focus almost exclusively on associated high-risk psychiatric disorders. New approaches considering contextual factors are needed for preventing suicide and promoting mental health. AIMS: This study examined explanations of suicide reported by surviving family members or close friends with reference to social, cultural, and environmental conditions as well as the challenges of life in the Malavani slum of Mumbai. METHODS: An EMIC (Explanatory Model Interview Catalog) interview based on a cultural epidemiological framework considered underlying problems, perceived causes, and sociocultural contexts. It was administered to survivors of 76 people who had died by suicide (56.6% women). RESULTS: Accounts of underlying problems typically referred to various aspects of tension (73.7%). Perceived causes often identified multiple factors. The sociocultural contexts of suicide included the victimization of women, the personal and social impact of problem drinking, marital problems, physical health problems, mental tension, possession and sorcery. Women were particularly vulnerable to the impact of problem drinking by a spouse or father. CONCLUSIONS: This study demonstrates the value of an approach to sociocultural autopsy examining local contexts and explanations of suicide. Findings highlight needs for both mental health services and culturally sensitive social interventions.

Gender, suicide, and the sociocultural context of deliberate self-harm in an urban general hospital in Mumbai, India.

Recognizing the complementary effects of social contexts and psychiatric disorders, this study clarifies the role of gender in suicidal behavior in urban Mumbai by considering psychiatric diagnoses and patient-identified sociocultural features. The cultural epidemiological approach suggests the critical impact of situational sociocultural factors that complement the customary psychopathological accounts for those who harm or kill themselves. The cultural epidemiology of deliberate self-harm (DSH), it is argued, is critical to planning for suicide prevention, community mental health and psychiatric practice. This study, based on a cultural epidemiological framework, compares male and female admissions for DSH, evaluating conditions with SCID-I and EMIC interviews. We assessed features and narratives of suicidal behavior, patient-identified underlying problems, their perceived causes and triggers. The study included 92 women and 104 men. A diagnosis of depressive disorder was made for 48.9 percent of women and 39.4 percent of men. Many patients (50.0 percent of women and 41.3 percent of men) did not fulfill the criteria for any diagnosis, or did so only for an adjustment disorder or a V-code. Men typically explained DSH with reference to work problems, financial problems and problem drinking. Women typically discussed domestic problems, in-law relations and victimization. Problem drinking affected women living with men who drank. Social and situational factors appear to play a relatively greater role than psychiatric illness in self-harm and suicide in Mumbai, as in other Asian studies, compared with Europe and North America.

Clinical diagnostic and sociocultural dimensions of deliberate self-harm in Mumbai, India.

Patients' accounts complement psychiatric assessment of deliberate self-harm (DSH). In this study we examined psychiatric disorders, and sociocultural and cross-cultural features of DSH. SCID diagnostic interviews and a locally adapted EMIC interview were used to study 196 patients after DSH at a general hospital in Mumbai, India. Major depression was the most common diagnosis (38.8%), followed by substance use disorders (16.8%), but 44.4% of patients did not meet criteria for an enduring Axis-I disorder (no diagnosis, V-code, or adjustment disorder). Psychache arising from patient-identified sociocultural contexts and stressors complements, but does not necessarily fulfill, criteria for explanatory psychiatric disorders.

A comparison of the level of functioning in chronic schizophrenia with coping and burden in caregivers.

BACKGROUND: A chronic mental illness such as schizophrenia is a challenging task for caregivers especially in the current era of de-institutionalization. In India, few studies have attempted to directly determine the relationship between coping mechanisms and burden; in the West, studies have found that improved coping in family members can decrease the perceived burden. AIM: To evaluate the burden and coping of caregivers in relation to the level of functioning in patients with chronic schizophrenia. METHODS: The sample was 100 patients with their primary caregivers attending a Psychiatry OPD. Patients were assessed on the Global Assessment of Functioning (GAF) scale while caregivers were administered the Burden Assessment Schedule (BAS) and Mechanisms of Coping (MOC) scale. RESULTS: Fatalism and problem-solving were the two most preferred ways of coping. Problem-focused coping, i.e. problem-solving and expressive-action decreased the burden of caregivers, while emotion-focused coping, i.e. fatalism and passivity, increased it. As the level of functioning of the patient decreased, the significance with which the coping mechanisms influenced the burden, increased. The use of problem-solving coping by caregivers showed a significant correlation with higher level of functioning in patients. CONCLUSION: Coping mechanisms such as problem-solving can decrease the burden of illness on caregivers and may even improve the level of functioning of patients.

A comparative study of coping skills and body image: Mastectomized vs. lumpectomized patients with breast carcinoma.

BACKGROUND: The diagnosis of breast cancer encompasses not only physical, but also social and psychological implications because of the importance of the breast in a woman's body image, sexuality and motherhood. Women may experience a range of concerns and fears including physical appearance and disfigurement, the uncertainty about recurrence and the fear of death. There are no Indian studies on this subject. AIM: This study explores the various concerns of mastectomized and lumpectomized (breast conserved) patients, determines the coping mechanisms employed and the resolution of concerns. The levels of anxiety and depression in both groups were also studied. METHODS: Seventy-five patients with breast carcinoma (50 mastectomized and 25 lumpectomized) were evaluated. The concern and coping checklist of Devlen was used. The severity of anxiety and depression was measured using the Hospital Anxiety and Depression Scale (HADS). RESULTS: Body image or disfigurement was a concern only in the mastectomized group. Concerns were equally resolved between the two groups except for sexual role and performance, wherein the concern was resolved to a lesser extent in the mastectomized group. Coping strategies employed were effective in the resolution of concerns except for sexual role and performance, and recurrence or relapse. No statistically significant difference was found in the depression and anxiety levels of the two groups. CONCLUSION: Concern regarding sexual role and performance was resolved to a lesser extent in the mastectomized group. Specific psychological intervention is necessary to enhance coping strategies with regard to concerns of body image, and sexual role and performance.

Isolated sleep paralysis.

Sleep paralysis (SP) is a cardinal symptom of narcolepsy. However, little is available in the literature about isolated sleep paralysis. This report discusses the case of a patient with isolated sleep paralysis who progressed from mild to severe SP over 8 years. He also restarted drinking alcohol to be able to fall asleep and allay his anxiety symptoms. The patient was taught relaxation techniques and he showed complete remission of the symptoms of SP on follow up after 8 months.

Contextualizing mental health: gendered experiences in a Mumbai slum.

Urban mental health programmes in developing countries remain in their infancy. To serve low-income communities, research needs to consider the impact of common life experience in slums, including poverty, bad living conditions, unemployment, and crowding. Our study in the Malavani slum of Mumbai examines afflictions of the city affecting the emotional well-being and mental health of women and men with respect to gender. This is a topic for which mental health studies have been lacking, and for which psychiatric assumptions based on middle-class clinical experience may be most tenuous. This study employs ethnographic methods to show how environmental and social contexts interact in shaping local experience with reference to common mental health problems. Focusing on the social and environmental context of the mental health of communities, rather than psychiatric disorders affecting individuals, findings are broadly applicable and sorely needed to guide the development of locally appropriate community mental health programmes. Identified afflictions affecting mental health include not only access to health care, but also sanitation, addictions, criminality, domestic violence, and the so-called bar-girl culture. Although effective clinical interventions are required for mental health services to treat psychiatric disorders, they cannot directly affect the conditions of urban slums that impair mental health.