Pattern and prevalence of substance use and dependence in two districts of Union Territory of Jammu & Kashmir: Special focus on opioids.

BACKGROUND: Kashmir has been at the centre of conflict between India and Pakistan after partition of erstwhile British India in 1947. While research suggests that conflict exposure may result in increased substance use, the prevalence of substance use disorders has remained an under-searched area in Kashmir. METHOD: We employed respondent-driven sampling (RDS) for recruiting substance users from two districts of Kashmir. Estimation of substance dependence was done using benchmarkmultiplier method. RESULTS: Prevalence of any substance dependence was estimated to be 1.95% while as for any opioids, it was 1.80%. Heroin was the most common opioid with last year use by 84.33% respondents. Current prevalence of injection drug use was 0.95% and heroin was the most common opioid among Injection Drug User (IDU), being used by 91.12% IDUs followed by Pentazocine (5.92%). CONCLUSION: Our results indicate that RDS was a feasible and acceptable sampling method for recruiting 'difficult to reach 'participants like illicit substance users including IDUs. Our results further demonstrate that opioids are highly prevalent in Kashmir and heroin injection is not uncommon. All these findings call for attention from policy makers as opioids are one of the important contributors to mortality and morbidity related to substances.

Obsessive Compulsive Disorder Presenting as Neurological Emergency.

Chronic epilepsy is leading to behavioral changes including obsessive-compulsive symptoms has been well-studied and shown to be about 22%, but the converse has not been reported. Here, we present a case discussion of a 45-year-old female, who presented with recurrent seizures with hyponatremia, which latter was ascribed to her undiagnosed obsessive compulsive disorder (OCD). This patient later did well on anti-obsessional treatment without any antiepileptic. This embarks the need for detailed psychiatric evaluation for patients in emergency care settings and gives a rare presentation of OCD.

Sociodemographic profile and pattern of opioid abuse among patients presenting to a de-addiction centre in tertiary care Hospital of Kashmir.

BACKGROUND: The substances abuse has become one of the major public health problems of present society. Recently there has been an increase in the incidence of substance abuse including that of opioids throughout the world. The proper assessment of the current trends and pattern of opioid abuse can be helpful in more effective intervention of this menace. MATERIALS AND METHODS: To find out various socio-demographic variables and pattern of opioid abuse, a predevised questionnaire was administered to 200 opioid patients who presented to de-addiction center for treatment. RESULTS: Majority of the participants (75%) were of young age group (20-30 years) and the mean age of subjects was 27.6 years. More than half of participants (55%) were abusing the opioid substances for < 3 years followed by 30% of the abusers who were using the opioids for 4-6 years. Oral route was the most common route(35%)of substance administration followed by chasing(13%) and intravenous(11%) routes. Diverted pharmaceuticals emerged as one of the common substances of abuse, and peer pressure was found to be the main reason to start substance abuse. CONCLUSION: A comprehensive preventive program targeting young adults needs to be formulated and strict laws against sales of diverted pharmaceuticals to be implemented.

Effects of switching from olanzapine to aripiprazole on the metabolic profiles of patients with schizophrenia and metabolic syndrome: a double-blind, randomized, open-label study.

BACKGROUND: Patients with schizophrenia suffer high rates of metabolic derangements on some antipsychotic medications that predispose them to cardiovascular diseases. Keeping this fact in mind, we planned this open-label study to see the effect on various metabolic parameters after switching stable schizophrenia subjects, who had developed metabolic syndrome on olanzapine, to aripiprazole. METHODS: Sixty-two patients with schizophrenia who were stable on olanzapine and were fulfilling modified National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP-III) criteria for the presence of metabolic syndrome were enrolled on the study. Patients were randomly assigned either to switch to aripiprazole or to stay on olanzapine, on a 1:1 basis. Cross-tapering over a period of 1 month was done while switching patients to aripiprazole. Laboratory assessment for metabolic parameters was done at baseline, 8 weeks, and 24 weeks after enrollment; efficacy assessment was done using the Positive and Negative Syndrome Scale (PANSS) at baseline and 24 weeks, the Clinical Global Impressions severity subscale (CGI-S) at baseline, and the Clinical Global Impressions improvement subscale (CGI-I) at 24 weeks. RESULTS: All parameters of metabolic syndrome (waist circumference, blood pressure, triglyceride level, fasting blood glucose, and high-density lipoprotein cholesterol) kept deteriorating in the stay group, compared with a continuous improvement in the switch group over time. At the end of the study, 26 patients (100%) from the stay group and 15 patients (42.8%) from switch group met the modified NCEP ATP-III criteria for presence of metabolic syndrome (P<0.001). There were no statistically significant differences between groups in psychopathology changes as measured by the PANSS total score and CGI-I scores. CONCLUSION: Clinically stable patients with schizophrenia who are taking olanzapine and who have evidence of metabolic syndrome can be successfully switched to aripiprazole, with improvement in various parameters of metabolic syndrome and without any significant change in efficacy measures.

Comparative trial to study the effectiveness of clonidine hydrochloride and buprenorphine-naloxone in opioid withdrawal - a hospital based study.

OBJECTIVES: Prevalence of opioid addiction has alarmingly increased over the recent years. In South Asian region alone there are more than 10 million opioid abusers amounting to 2% of world population. Detoxification remains to be the first step for the successful treatment of opioid addiction. The present study was carried out to compare the relative efficacy and safety of buprenorphine -naloxone and clonidine hydrochloride in the detoxification of opioid-dependents. MATERIALS AND METHODS: Present trial was conducted at De- addiction centre of Institute of Mental and Neurosciences (IMNS), GMC Srinagar. Fifty four (54) treatment seeking subjects, 15-50 years of age, fulfilling DSM-1V TR (American Psychiatric association`s Mental Disorders-1V text revision) criteria for opioid dependence were included and randomized into two groups. The groups received either clonidine hydrochloride (Group A) or buprenorphine- naloxone (Bup-Nax) (Group B) for the duration of 10 days. The efficacy of the two drugs in controlling the opioid withdrawal was evaluated by Clinical Opioid Withdrawal Scale (COWS) and their effect on the desire for the abused substance was measured by Visual Analogue Scale (VAS). The safety of the two drugs was measured by taking the side effect profile of the two compared drugs into consideration. RESULTS: There was significant difference of COWS-score between the two groups which was evident from day 3 (14.85 ± 3.43 vs. 11.67 ± 2.40, p<0.005) and continued till day 6 (2.56 ± 1.40 vs. 0.30 ± 0.61, p<0.005), for Group A and group B respectively. The effect of two drugs in controlling the craving for the abused substance also showed significant difference from day 2 (66.30 ± 10.80 vs. 47.40 ± 12.90, p<0.005) till day 5 (7.78 ± 6.41 vs. 1.85 ± 6.22, p<0.005), for Group A and Group B respectively. CONCLUSION: Administration of buprenorphine-naloxone was more efficient in reducing the signs and symptoms of opioid withdrawal and in controlling the craving for the abused substance during the first few days of detoxification.

Prevalence of psychiatric disorders in patients with a diagnosis of polycystic ovary syndrome in kashmir.

BACKGROUND: Polycystic ovary syndrome (PCOS) is one of the common endocrine disorders and is associated with reproductive, metabolic, and psychological disturbances affecting one in five women of reproductive age group. OBJECTIVE: To investigate the prevalence of psychiatric disorders among women in ambulatory treatment with a diagnosis of PCOS. MATERIALS AND METHODS: One hundred and ten patients of PCOS were evaluated using Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition criteria by means of Mini International Neuropsychiatric Interview, English version 5.0.0. Diagnosis of PCOS was confirmed according to the National Institute of Health/National Institute of Child Health and Human Development, 1990 consensus conference criteria. Forty subjects without PCOS who were matched for age and body mass index were taken as a comparison group. RESULTS: About 23% of cases had major depressive disorder as compared to 7.5% of controls, 1.8% had dysthymia, 15.45% had panic disorder compared to 5% of controls, 6.36% had obsessive compulsive disorder compared to 2.5% of controls, 8% cases had suicidality, 2.72% of cases were bipolar affective disorder, and 15.45% had generalized anxiety disorder (GAD). CONCLUSION: A high prevalence of mental disorders was observed, especially major depression, panic disorder, and GAD in patients with PCOS in our study. The results suggest that screening and appropriate management for psychiatric disorders should be part of the routine evaluation of these patients.

Diabetes mellitus and impaired glucose tolerance in patients with schizophrenia, before and after antipsychotic treatment.

BACKGROUND: Treatment with antipsychotics increases the risk of developing diabetes in patients of schizophrenia but this diabetogenic potential of different antipsychotics seems to be different. Moreover, there may be an independent link between schizophrenia and diabetes. So we plan to study the prevalence of glucose dysregulation in patients of schizophrenia before and after treatment with various antipsychotics. MATERIALS AND METHODS: Fifty patients (32 males and 18 females) diagnosed with schizophrenia were evaluated for glucose dysregulation using oral glucose tolerance test, initially (drug naive) and after antipsychotic treatment. Age- and sex-matched healthy volunteer group of 50 subjects (35 males and 15 females) was taken for comparison. Results were interpreted using American Diabetic Association criteria. RESULTS: Though the glycemic status of the patient group was comparable with healthy controls initially but antipsychotic treatment was associated with glucose dysregulation. For first 6 weeks the antipsychotic (olanzapine, risperidone, haloperidol and aripiprazole)-induced glucose dysregulation was comparable, which was seen to be maximum with the olanzapine-treated group at the end of this study, 14 weeks. CONCLUSION: We conclude that antipsychotic treatment of nondiabetic drug naive schizophrenia patients was associated with adverse effects on glucose regulation. For initial 6 weeks the antipsychotic-induced glucose dysregulation was comparable, which was seen to be maximum with olanzapine at the end of study, i.e. 14 weeks. Keeping this at the back of mind we can stabilize a patient initially with a more effective drug, olanzapine, and later on shift to one with less metabolic side effects.

Rapid Response of Long-Standing, Treatment-Resistant Non-Catatonic Mutism in Paranoid Schizophrenia with Single ECT session.

CONTEXT: Mutism is a common manifestation of catatonia, but mutism due to other forms of psychopathology and neurological disorders have also been described. Although not common, long-standing mutism has also been a feature of non-catatonic schizophrenia and traditionally responds less to conventional therapies. CASE REPORT: We describe a rare case of paranoid schizophrenia presenting with continuous mutism for about 4 years. This 26-year-old male had symptoms of schizophrenia without catatonia. After failed trial of adequate pharmacotherapy and psychological intervention and considering his level of dysfunction, he was started on electroconvulsive therapy (ECT). To our surprise, he improved with a single session of ECT while he was on concurrent pharmacotherapy. We also discuss the possible explanation for this rapid effect of ECT in such clinical presentation. To our knowledge, this is the first case of non-catatonic mutism of schizophrenia of this long duration responding so promptly to ECT, although there are other reports as well in literature, but multiple ECT sessions were applied in those cases. CONCLUSION: Non-catatonic mutism is perhaps presenting as a cultural variant in this part of the world and whenever encountered, ECT should be an option. Further research should be carried out to validate this idea.

Socio-demographic and Clinical Profile of Substance Abusers Attending a Regional Drug De-addiction Centre in Chronic Conflict Area: Kashmir, India.

BACKGROUND: The menace of substance abuse is not only a socially unacceptable reality, but in its entirety is a disease and emerging as a major public health challenge. OBJECTIVE: To study the socio-demographic and clinical profile of patients attending the drug de-addiction centre. METHODS: A descriptive study was undertaken in a drug de-addiction centre at the Police Hospital in Srinagar, and all patients (198) who were admitted during this period were interviewed. RESULTS: The mean (SD) age of patients was 26.8 years (SD 7.37), and over half (56%) belonged to the lower-middle social class. Poly-substance abuse was seen in 91.9%; medicinal opioids and cannabis were the most common substances abused. Most common age of initiation was 11-20 years (76.8%), with peer pressure and relief from a negative mood state being the most common reasons given for starting the drug(s). Prevalence of a co-morbid psychiatric disorder was high, on the order of 49.5%. A high rate of volatile substance use was observed among adolescents (54.5%). CONCLUSION: A pattern of poly-substance abuse was found to be quite common in patients, and use of volatile substances at a very young age emerged as a new trend. The dreadful repercussions of substance abuse justify the urgency to evolve a comprehensive strategy.

Duloxetine in treatment of refractory chronic tennis elbow: two case reports.

INTRODUCTION: Tennis elbow is a common musculoskeletal disorder; management options include physiotherapeutic, medical, surgical, and other forms of intervention. Some patients remain symptomatic despite best efforts. We present two patients who did not respond to medical and surgical treatments, and whose symptoms were relieved with duloxetine. This is the first report on the use of duloxetine to treat tennis elbow. CASE PRESENTATION: Two mentally healthy young Asian women aged 32 and 27 years, each with tennis elbow of about 18 months duration continued to suffer pain despite treatment with analgesics, local steroid injections, physiotherapy, cryotherapy, ultrasound, and surgical release, among other interventions. Both showed substantial improvement within 4 to 6 weeks of receiving monotherapy with duloxetine 60 mg/day. Both were pain-free with continued treatment at a 6-month follow-up. CONCLUSION: Duloxetine may be a useful treatment option in patients with chronic tennis elbow, even those who have failed conventional medical, physiotherapeutic, surgical, and other forms of management.