Psychometric properties and factor structure of the suicidal narrative inventory in major depression: A multicentric evaluation.

BACKGROUND: The Suicidal Narrative Inventory (SNI) is a 38-item self-report measure developed to assess elements of the suicidal narrative, a subacute, predominantly cognitive, presuicidal construct. Our objectives were to assess the factor structure, validity, and reliability of the SNI-38 among adults with major depressive disorder (MDD). METHODS: Using a cross-sectional design, we administered the Hindi version of the SNI along with other self-report measures to adults with MDD, recruited from 24 tertiary care hospitals across India. Confirmatory factor analysis (CFA) was performed to assess the factor structure of SNI-38. Reliability (internal consistency) was assessed using Cronbach's alpha (α). Convergent, discriminant, and criterion validity of the SNI-38 were tested by comparing it against other appropriate measures. RESULTS: We collected usable responses from 654 Hindi-speaking participants (Mean age = 36.9 ± 11.9 years, 50.2% female). The eight-factor solution of the SNI showed good model fit indices (χ2[637] = 3345.58, p <.001, CFI =.98, and RMSEA =.08). Internal consistencies for the SNI subscale scores were good to excellent, α ranging from .73 to.92. While most subscales significantly converged with other measures, associations were comparatively weaker and inconsistent for the 'thwarted belongingness' and 'goal reengagement' subscales. CONCLUSION: Consistent with prior data, our study confirmed an eight-factor solution and demonstrated adequate psychometric properties for the Hindi version of the SNI-38 in our sample. These findings provide empirical support for the use of SNI to assess the suicidal narrative among Indian adults with MDD.

Disability and its correlates among persons with bipolar disorder: Exploratory findings from the bipolar disorder course and outcome study from India (BiD-CoIN study).

Aim: This study aimed to evaluate the disability and its correlates in persons with Bipolar Disorder during the remission phase. Materials and Methods: As part of the multicentric study, 773 patients with bipolar disorder, currently in clinical remission, were evaluated for disability on the Indian Disability Assessment Evaluation Scale. Results: About one-fifth of the participants had some level of disability in the domain of self-care, one-third had some level of disability in the interpersonal domain, one-fourth had some level of disability in communication and understanding, and a maximum proportion (43.7%) had some disability in the domain of work. Overall, about one-fifth (18.4%) were considered to have a benchmark disability (i.e., disability >40%). In terms of correlates, those with a disability had a short duration of current remission, a higher number of manic and mixed episodes, a higher mean number of total episodes, spent more time in the episodes, had lower severity of the depressive episodes, higher residual depressive and manic symptoms, had overall higher manic affective morbidity, had a higher level of cognitive deficits, and had poorer insight. Conclusion: A significant proportion of patients with bipolar disorder have disability in work domain, and the presence of residual symptoms of either polarity are associated with higher level of disability.

Subjective cognitive deficits and its correlates among patients with bipolar disorder: Findings from the bipolar disorder course and outcome study from India (BiD-CoIN study).

Aim: This study aimed to evaluate the prevalence of subjective cognitive complaints and their association with clinical variables, insight, and disability. Methodology: Seven hundred and seventy-three subjects with bipolar disorder (BD), recruited across 14 centers, currently in the euthymic phase were cross-sectionally evaluated on Cognitive Complaints in Bipolar Disorder Rating Assessment (COBRA). Results: The mean total COBRA score was 9.79 (SD: 6.99), and 322 (41.7%) of the participants were found to have subjective cognitive complaints when the cut-off of >10 was used. Compared to those without cognitive complaints, those with cognitive complaints more often had depression as the first episode in their lifetime, had a higher prevalence of alcohol dependence, a higher number of depressive episodes (first five years of illness, lifetime, and per year of illness), a higher number of manic episodes in the first five years of illness, more often had depressive or indeterminate predominant polarity, lower prevalence of at least one-lifetime episode with psychotic symptoms, higher severity of residual symptoms, spent more time in the episodes in the lifetime, had poorer insight and higher disability. Conclusion: The present study suggests subjective complaints complaints are associated with more severe illness, higher levels of residual symptoms, poor insight, and higher disability.

Factors associated with lifetime suicide attempts: findings from the bipolar disorder course and outcome study from India (BiD-CoIN study).

AIM: To evaluate the risk factors associated with lifetime suicide attempts in bipolar disorder (BD) patients. METHODOLOGY: 773 BD patients with a duration of illness of at least ten years, currently in clinical remission, were evaluated for suicidal attempts in their lifetime. Those with and without lifetime suicide attempt(s) were compared for various demographic and clinical risk factors. RESULTS: 242 (31.3%) patients had a history of at least one lifetime suicide attempt. Compared to those without lifetime suicide attempts, those with suicidal attempts were less educated, were more often females, spent more time in episodes, and had a significantly more number of total episodes (in the lifetime, first five years of illness, and per year of illness), had significantly more number of total depressive episodes (in the lifetime, first five years of illness, and per year of illness), spent more time in depressive episodes, had more severe depressive episodes, more often had depression as the first episode in the lifetime, spent more time in mania/hypomania/mixed episodes, had higher residual depressive and manic symptoms, more often had rapid cycling affective disorder pattern in the lifetime, use of cannabis in dependence pattern, had poorer insight into their illness and had a higher level of disability (especially in three out of the four domains of Indian disability evaluation assessment scale). CONCLUSIONS: About one-third of the patients with BD have at least one-lifetime suicidal attempt, and those with suicide attempts usually have a poorer course of illness.

Prevalence and association of comorbid substance dependence on the course and outcome of bipolar disorder: Findings from the bipolar disorder course and outcome study from India (BiD-CoIN study).

Aim: To evaluate the prevalence of substance use disorder (SUD) and its association with the course and outcome of bipolar disorder (BD). Materials and Methods: A total of 773 patients with BD were recruited from 14 centers in different parts of India, and they were evaluated for the prevalence of comorbid substance dependence, course and outcome, subjective cognitive functioning, and disability. Results: About one-fourth (22.9%) of the participants had one or more substance dependence. In terms of specific substance of abuse, 136 (17.6%) had nicotine dependence, 80 (10.3%) patients had alcohol dependence, 13 (1.7%) had cannabis dependence, and nine (1.2%) had opioid dependence. Compared to those without comorbid substance dependence, those with a dual diagnosis (i.e., using at least one substance in a dependent pattern) were less educated, more often males, more often currently single, more often employed, had a lower number of depressive episodes per year of illness, had a higher number of manic and mixed episodes per year of illness in the first 5 years of illness, had a higher level of disability, and more often had a history of hospitalization and a history of receiving electroconvulsive therapy (ECT); also, a higher proportion of them had manic predominant polarity, more often had recurrent mania course, and were more often receiving a combination of lithium and valproate. Conclusion: About one-fourth of BD patients have comorbid SUDs, and presence of SUD has a negative impact on the course and outcome of BD.

Prevalence of psychotic symptoms and their impact on course and outcome of patients with bipolar disorder: Findings from the Bipolar Disorder Course and Outcome study from India (BiD-CoIN study).

AIM: Most of the available data on the prevalence and impact of psychotic symptoms on the course of bipolar disorder (BD) is from Western countries. We aimed to study the prevalence of at least one psychotic episode in the lifetime in patients with BD and its association with the long-term course and outcome. METHODOLOGY: 773 patients recruited as part of the Bipolar Disorder Course and Outcome study from India (BiD-CoIN study) were divided into 2 groups, based on the presence or absence of at least one psychotic episode in the lifetime. RESULTS: 326 (42.2%) patients had at least one psychotic episode in their lifetime. At least one psychotic episode in the lifetime was associated with overall more severe illness in terms of lower age of onset, a higher number of episodes in the first 5 years of illness; higher rates of BD-II, a higher rate of lifetime history of at least 1 suicide attempt, lifetime history of hospitalization, history of receiving Electroconvulsive Therapy, and a higher prescription rates of antipsychotics. However, presence of psychotics symptoms was associated with better cognitive functioning. CONCLUSIONS: Our findings suggest that the presence of psychotic symptoms during episodes in patients with BD is associated with poorer course of BD.

Predominant polarity in bipolar disorder: Findings from the bipolar disorder course and outcome study from India (BiD-CoIN study).

AIM: This cross-sectional study aimed to assess the predominant polarity (PP) in patients with bipolar disorder (BD) and the factors associated with PP. METHODOLOGY: For this study, 773 participants with at least 10 years of illness, were recruited from 14 centres, were evaluated using the National Institute of Mental Health- Retrospective Life Charts to assess the course of illness and PP was determined by both Barcelona proposal and the Harvard Index. RESULTS: According to Barcelona proposal for PP, 20.6% of the patients belonged to depressive PP, 45.8% belonged to manic PP and 33.6% belonged to indeterminate polarity. According to Harvard index of PP, 31.6% of the patients belonged to depressive PP, 56.1% belonged to manic polarity and 12.3% of the patients could not be categorized into any of these categories and hence, were considered to have indeterminate polarity. Those with depressive PP were more often having BD-II, had later age of onset, spent more time in episodes, had higher residual depressive symptoms, had lower residual manic symptoms, more often had depression as the first lifetime episode, and less often had at least one psychotic episode. CONCLUSION: In the Indian subcontinent, although the prevalence of PP is influenced by the definition used, the most common PP is that of mania.

Residual symptoms in bipolar disorders: Findings from the bipolar Disorder course and outcome study from India (BiD-CoIN study).

AIM: To explore the prevalence of residual symptoms (both depressive and manic) and their correlates in subjects with bipolar disorder in clinical remission. METHODOLOGY: This multicentric cross-sectional study included patients in clinical remission recruited across the 14 centers. The patients were evaluated on the Hamilton Depression Rating Scale (HDRS) and Young Mania Rating Scale (YMRS) for the prevalence of residual symptoms. A score of ≤7 on both scales defined the presence of residual symptoms. RESULTS: Four-fifth (79.8%) of the participants had residual symptoms, with 130 (16.8%) having only residual depressive symptoms, 74 (9.6%) having only residual manic symptoms, and 413 (53.4%) having both depressive and manic residual symptoms, on HDRS and YMRS. The residual symptoms were related to the polarity of the most recent episode and the lifetime predominant polarity. Higher numbers of lifetime depressive episodes are associated with higher residual depressive symptoms, and higher numbers of lifetime manic episodes are associated with higher chances of having residual manic symptoms. CONCLUSIONS: A large proportion of patients with bipolar disorder have residual symptoms during the remission phase. Clinicians need to make efforts to identify and address the same to improve the treatment outcome.

Is unipolar mania a distinct entity: findings from the bipolar disorder course and outcome study from India (BiD-CoIN study).

AIM: This study aimed to evaluate the prevalence of unipolar mania (UM) in a group of patients of bipolar disorder (BD). Additionally, effort was made to evaluate the demographic, clinical and treatment related factors, which distinguish subjects of UM from BD. METHODOLOGY: Seven hundred and seventy-three patients with BD, of at least 10 years duration, recruited from 14 General Hospital Units of tertiary care centers from India were evaluated for UM. RESULTS: The prevalence of UM, varied from 5.4% to 20.3%, depending on the definition used. With the most stringent definition of ≥4 episodes of mania and at least 5 years of follow-up, the prevalence of UM was 5.4%. Compared to patients of BD, who have episodes other than mania too, those with UM had lower proportion of patients with lifetime history of suicide attempts, spent less time in the episodes in their lifetime and had lower severity of residual depressive and manic symptoms. Further, compared to those with episodes other than mania too, those with UM had higher number of manic episodes per year of illness, had higher proportion of patients who had more than five episodes in the lifetime and had higher proportion of those with at least one episode with psychotic symptoms in the lifetime. CONCLUSION: The present study suggests that a small proportion of patients with BD have UM course and this runs a different clinical course compared to that seen in patients with traditionally recognized as BD.

Prescription patterns in clinically stable patients with bipolar disorder: Findings from the Bipolar Disorder Course and Outcome from India (BiD-CoIN) study.

AIM: To evaluate the prescription pattern of patients with BD, currently in clinical remission. Additional aim of the study was tocompare the prescription pattern across different study centres. METHODOLOGY: Prescription of 773 patients, currently in clinical remission, recruited from the outpatient setting of 14 General Hospital Tertiary Care Units of tertiary care centres in the country were evaluated. RESULTS: Almost all (98.1 %) participants were on medications at the time of assessment. In terms of conventional mood stabilizers, those receiving valproate (44.2 %), out-numbered those receiving lithium (38.9 %). A small proportion (7.4 %) was receiving a combination of both valproate and lithium. About two-third (62.5 %) were receiving at least one antipsychotic medication, with olanzapine (31.7 %) being the most commonly prescribed antipsychotic, followed by quetiapine (11.1 %), and risperidone (9.6 %). About one-third (34.4 %) of the participants were receiving antidepressants, with sertraline (22.6 %) forming bulk of the prescription. Less than half (43.9 %) of the participants were also receiving a benzodiazepine medication at the time of assessment, with chlordiazepoxide (18 %) being the most common agent, followed by clonazepam (14.5 %). There was variation in the prescription patterns across different centres, in terms of monotherapy, polypharmacy, use of preferred conventional mood stabilizers, use of various antipsychotics and antidepressants. CONCLUSION: Besides conventional mood stabilizers, about two-third of patients with bipolar disorder received concomitant antipsychotics, one-third received concomitant antidepressants and less than half received benzodiazepines.

Bipolar Disorder Course and Outcome Study from India (BiD-CoIN study): Sample Description & Methods.

OBJECTIVES: This multicentric study from India aimed to evaluate the long term course and outcome of bipolar disorder (BD). METHOD: Seven hundred and seventy-three participants diagnosed with BD, attending 14 outpatient clinic centers across the country, were evaluated using the National Institute of Mental Health- Retrospective Life Charts to assess the long term course of BD. RESULTS: The mean age of onset of the first episode of illness of the study sample was 26.3 (8.54) years, and mean duration of illness at the time of assessment was 233.05 (94.55) months. In terms of the total number of lifetime episodes, the mean number of manic episodes (mean: 3.68; SD: 4.75) exceeded the mean number of depressive episodes (mean: 3.36; SD: 5.51). The mean numbers of total lifetime episodes were 8.58 (10.6%). When the number of episodes per year was computed, the mean number of manic episodes per year exceeded that of the mean number of depressive episodes. Compared to females, a higher proportion of males had a history of comorbid substance dependence. LIMITATIONS: The course was assessed retrospectively and the study was limited to participants attending the outpatient clinics. CONCLUSIONS: The course of BD in India differs from that described from developed countries in the form of a number of manic episodes exceeding the depressive episodes.

Stigma experienced by patients with severe mental disorders: A nationwide multicentric study from India.

This study aimed to evaluate the stigma and its correlates among patients with severe mental disorders. Patients with diagnosis of schizophrenia (N = 707), bipolar disorder (N = 344) and recurrent depressive disorder (N = 352) currently in clinical remission from 14 participating centres were assessed on Internalized Stigma of Mental Illness Scale (ISMIS). Patients with diagnosis of schizophrenia experienced higher level of alienation, sterotype endorsement, discrimination experience and total stigma when compared to patients with bipolar disorder and recurrent depressive disorder. Patients with bipolar disorder experienced higher stigma than those with recurrent depressive disorder in the domain of stigma resistance only. Overall compared to affective disorder groups, higher proportion of patients with schizophrenia reported stigma in all the domains of ISMIS. In general in all the 3 diagnostic groups' stigma was associated with shorter duration of illness, shorter duration of treatment and younger age of onset. To conclude, this study suggests that compared to affective disorder, patients with schizophrenia experience higher self stigma. Higher level of stigma is experienced during the early phase of illness. Stigma intervention programs must focus on patients during the initial phase of illness in order to reduce the negative consequences of stigma.

Stigma experienced by caregivers of patients with severe mental disorders: A nationwide multicentric study.

BACKGROUND: Stigma is very common among caregivers of patients with severe mental disorder; however, there is lack of national level data from India. AIM: To assess affiliate stigma and its correlates among caregivers of patients with severe mental disorders. METHOD: For this, caregivers of patients with schizophrenia ( N = 707), bipolar disorder ( N = 344) and recurrent depressive disorder ( N = 352) were assessed on Stigma scale for Caregivers of People with Mental Illness and General Health Questionnaire. RESULTS: Caregivers of patients with schizophrenia reported significantly higher stigma than patients with bipolar disorder and recurrent depressive disorder. Caregiver of patients with bipolar disorder reported significantly greater stigma than the caregivers of patients with recurrent depressive disorder. Higher caregiver stigma in all the diagnostic groups was associated with higher psychological morbidity in caregivers. Higher stigma in caregivers of schizophrenia was seen when the patient had younger age of onset and longer duration of treatment. In the bipolar disorder group, higher stigma in caregivers was seen when patient had higher residual manic symptoms. CONCLUSION: This study suggests that caregivers of patients with schizophrenia experience higher stigma than the caregivers of patients with bipolar disorder and recurrent depressive disorder. Higher stigma is associated with higher psychological morbidity in the caregivers. Therefore, the clinicians managing patients with severe mental disorders must focus on stigma and psychological distress among the caregivers and plan intervention strategies to reduce stigma.

Indian psychiatric society multicentric study: Correlates of prescription patterns of psychotropics in India.

BACKGROUND: There is a lack of information on the clinical and sociodemographic correlates of prescription of psychotropics by psychiatrists. AIM AND OBJECTIVE: This study aimed to evaluate the relationship of prescription patterns with various clinical and sociodemographic variables. METHODOLOGY: Data of prescription patterns, psychiatric diagnosis, sociodemographic variables, and comorbid physical illnesses were collected for 4480 patients, across 11 centers. RESULTS: Females are more often prescribed escitalopram, sertraline, amitriptyline, amisulpride, nonlithium mood stabilizers, and benzodiazepines, whereas males are more often prescribed fluoxetine, olanzapine, two antipsychotics concurrently, typical antipsychotics, valproate, lithium, and more than one benzodiazepine. Elderly (>65 years) participants are more often prescribed sertraline when compared to adolescents. In addition, elderly more often receive quetiapine and less often are prescribed benzodiazepines. Those with comorbid neurological disorders are commonly prescribed antipsychotics, amitriptyline, and more than one antidepressant and are less commonly prescribed lithium, combination of two mood stabilizers, and benzodiazepines. Those with cardiac ailments are more commonly prescribed sertraline, quetiapine, and lithium and less frequently prescribed amitriptyline, fluoxetine, olanzapine, risperidone, and typical antipsychotics. Those with diabetes mellitus more often received escitalopram and quetiapine. Presence of more than one psychiatric diagnosis was associated with the use of more number of medications. Further, diagnosis of affective disorders was associated with the use of a higher number of medications. CONCLUSION: Findings of the present study suggest that sociodemographic variables and physical and psychiatric comorbidity influence the prescription patterns of psychotropics.

Phenomenology and beliefs of patients with Dhat syndrome: A nationwide multicentric study.

AIM: To assess the phenomenology and associated beliefs in patients with Dhat syndrome. METHODS: A total of 780 male patients aged more than 16 years were recruited from 15 centers spread across the country and were assessed on Dhat Syndrome Questionnaire. RESULTS: The most commonly reported reasons for passage of Dhat were excessive masturbation (55.1%), sexual dreams (47.3%), excessive sexual desire (42.8%) and consumption of high energy foods (36.7%). The most common situation in which participants experienced passage of Dhat were as 'night falls' (60.1%) and 'while passing stools' (59.5%). The most common consequence due to passage of Dhat was weakness in sexual ability (75.6%). In terms of psychological and somatic symptoms, the common symptoms included bodily weakness (78.2%); feeling tired or having low energy (75.9%); feeling down, depressed, or hopeless (67.9%); and little interest or pleasure in doing things (63.7%). In terms of treatment expectations, about half of the patients (49.1%) expected that energizing medications like vitamins/tonics/tablets were required and more than one-third (38.2%) expected that there was a need for taking energizing injections. CONCLUSION: Present study shows that Dhat syndrome is a distinct clinical entity seen all over India, with its characteristic features.

Indian Psychiatric Society multicentric study on assessment of health-care needs of patients with severe mental illnesses as perceived by their family caregivers and health-care providers.

AIM: To study the health-care needs of the patients with severe mental disorders as perceived by their family caregivers and the treating psychiatrists. MATERIALS AND METHODS: Caregivers of patients with severe mental disorders and their treating psychiatrists were assessed using Camberwell Assessment of Need-Research Version (CAN-R) scale and indigenously designed Supplementary Assessment of Needs Scale (SNAS). RESULTS: The study included 1494 patients recruited from 15 centers. The mean needs as per the CAN-R, perceived by the caregivers were 7.8 and treating psychiatrists were 8.1. About one-third of needs were unmet. On SNAS, both caregivers and treating psychiatrists reported a mean of 7.9 needs, of which more than half were unmet as per the caregivers. As per the treating psychiatrists, 45.5% of the needs as assessed on SNAS were unmet. There was a high level of correlation between needs perceived by the patients, caregivers and the treating psychiatrists. On CAN-R, main domains of needs as reported by the caregivers were those of money, relief of psychological distress, information about the illness and treatment, welfare benefits, transport, company and food. As per the treating psychiatrists, the most common total needs identified were those of relief of psychological distress, welfare benefits, information about the illness and treatment, money, transport, company self-care and physical health. The most common domains of needs as assessed on SNAS as per the caregivers were those of free treatment, medical reimbursement, psychoeducation, financial help, social support, insurance, more time from the clinicians and travel concession. The treating psychiatrists identified dealing with caregiver's stress as the most common need. CONCLUSIONS: According to the family caregivers and treating psychiatrists, about one-third of the needs of the patients as assessed using CAN-R and about half of the needs as assessed using SNAS are unmet.

Comorbidity in patients with Dhat syndrome: a nationwide multicentric study.

INTRODUCTION: There are limited numbers of studies on Dhat syndrome. Major limitations of the existing literature are heterogeneous assessment methods used to describe the comorbidity and small sample size from isolated centers. AIM: To assess comorbidity with a common methodology in patients with Dhat syndrome from multiple centers across India. METHODS: Using a cross-sectional design, this multicentric study involved assessment of 780 male patients, aged more than 16 years, across 15 study centers. MAIN OUTCOME MEASURES: ICD-10 criteria (for evaluation of psychiatric morbidity and sexual dysfunction) RESULTS: About one-third (32.8%) of the cases had no comorbidity. One-fifth (20.5%) of the patients had comorbid depressive disorders and another one-fifth (20.5%) had comorbid neurotic, stress-related and somatoform disorders. Half (51.3%) of the study sample had comorbid sexual dysfunction. When various combinations of comorbidities were evaluated, it was seen that more than one-fourth (28.7%) of the patients had only comorbid sexual dysfunction and one-sixth (15.9%) had only comorbid depressive/anxiety disorders. A little more than one-fifth (22.6%) had comorbidity of both sexual dysfunction and depressive/anxiety disorders. CONCLUSION: Comorbid sexual dysfunction is seen in half of the cases of Dhat syndrome, and it is more common than comorbid depressive and anxiety disorders.