Psychiatric comorbidities in patients suffering from systemic lupus erythematosus admitted to a tertiary care hospital in Northern India.

BACKGROUND: Systemic Lupus Erythematosus (SLE) is an autoimmune disease with multiorgan involvement presenting with a myriad of symptoms, including neuropsychiatric symptoms. Although many studies have evaluated screening questionnaires based psychiatric morbidity, very few studies have used contemporary diagnostic criteria. OBJECTIVE: This study aimed to evaluate the prevalence of psychiatric disorders in patients with SLE admitted to a tertiary care hospital. METHODS: A total of 79 patients diagnosed with SLE for at least for 1 year, who were not in delirium were assessed by a qualified psychiatrist for psychiatric morbidity as per the International Classification of Diseases, 10th Revision (ICD-10) criteria. Additionally, these patients were assessed on Patient Health Questionnaire-9 (PHQ-9) item version, Patient Health Questionnaire-15 (PHQ-15) item version, Generalized Anxiety Disorder-7 item scale and Montreal Cognitive Assessment (MoCA). RESULTS: 51% (n = 40) of the participants were diagnosed with a psychiatric diagnosis, with depressive disorders being the most common, seen in 36.7% (n = 29) of the participants. Additionally, 10% (n = 8) participants were diagnosed with adjustment disorder and 2.5% (n = 2) were diagnosed with anxiety (not otherwise specified). Only one patient was diagnosed with organic psychosis. On PHQ-9, 39.8% (n = 33) were diagnosed with depression. 44.3% (n = 35) expressed death wishes and/or suicidal ideations. On PHQ-15, 17.7% (n = 14) of the participants scored for severe somatic distress (score >15). On GAD-7, 55.7% (n = 44) screened positive for anxiety symptoms, but only 7.6% (n = ) had a score of 15 or more to indicate severe anxiety. Nearly half (n = 43; 52%) of the participants also had cognitive impairment as assessed on MoCA, with 13.3% (n = 11) of the participants having scores indicating severe dementia. CONCLUSIONS: Patients with SLE have a high prevalence of psychiatric comorbidities and should be routinely screened for psychiatric morbidity. They should be appropriately treated, to improve the overall treatment outcomes.

Augmentation strategies for clozapine resistance: a systematic review and meta-analysis.

BACKGROUND: Several augmentation strategies have been used to improve symptomatology in patients not adequately responding to clozapine. Several randomised controlled trials (RCTs) have evaluated the efficacy of different strategies to augment clozapine. This systematic review and meta-analysis reviewed the available RCTs that have evaluated the clinical efficacy of various pharmacological agents, non-pharmacological strategies (occupational therapy, cognitive behaviour therapy), and somatic treatment [electroconvulsive therapy (ECT), repetitive transcranial magnetic stimulation, etc.)] as augmenting agents to clozapine. METHODS: Data were extracted using standard procedures, and risk of bias was evaluated. Effect sizes were computed for the individual studies. RESULTS: Forty-five clinical trials were evaluated. The pooled effect size for various antipsychotic medications was 0.103 (95% CI: 0.288-0.493, p < 0.001); when the effect size was evaluated for specific antipsychotics for which more than one trial was available, the effect size for risperidone was -0.27 and that for aripiprazole was 0.57. The effect size for lamotrigine was 0.145, and that for topiramate was 0.392. The effect size for ECT was 0.743 (CI: 0.094-1.392). Risk of bias was low (mean Jadad score - 3.93). Largest effect sizes were seen for mirtazapine (effect size of 5.265). Most of the studies can be considered underpowered and limited by small sample sizes. CONCLUSIONS: To conclude, based on the findings of the present systematic review and meta-analysis, it can be said that compared to other treatment strategies, clozapine non-responsive patients respond maximum to mirtazapine followed by ECT.

A comparative study of retinal layer changes among patients with schizophrenia and healthy controls.

AIM: This study aimed to evaluate the retinal nerve fibre layer changes among different group of patients with schizophrenia and compare it with healthy controls by using swept-source optical coherence tomography. METHODOLOGY: Patients with first-episode schizophrenia (n = 21) in remission (n = 35) or with treatment-resistant schizophrenia (TRS) (n = 35) and 36 healthy controls were evaluated for retinal thickness. RESULTS: Patients with psychotic illnesses had significantly lower sub-foveal choroidal thickness (effect size 0.84-0.86), when compared to the healthy controls. When patients with first-episode schizophrenia were compared with patients with TRS, TRS patients had significant lower sub-foveal choroidal thickness (left eye) when the various confounders (such as age, gender, duration of treatment, smoking, current medications, body mass index, waist circumference, blood pressure, fasting glucose, HbA1c, presence or absence of metabolic syndrome) were taken into account. When the patients with TRS were compared with healthy controls, initially significant differences were observed for the macular volume (left and right) and the ganglion cell thickness (right eye) but these differences disappeared after controlling for the various covariates. CONCLUSIONS: Compared to healthy controls, patients with schizophrenia, psychotic illnesses have thinning of the retina, especially in the sub-foveal choroidal thickness.

Misconceptions Related to Covid-19 Infection Among the Medical Students During the Early Part of the Covid-19 Pandemic.

BACKGROUND: The COVID-19 pandemic has led to widespread controversies related to the transmission, treatment, prevention, and management of COVID-19 infection. Medical students have been involved in patient care across the globe and many a times the general public looks forward towards the medical professionals to get proper information about various issues related to COVID-19. We aimed to evaluate the knowledge and misconceptions held by the medical students on various aspects of COVID-19 infection. SUBJECTS AND METHODS: An online cross-sectional survey was conducted through the Survey Monkey® platform using the Whatsapp®, among the medical undergraduate students of a tertiary care Institute of Eastern India. RESULTS: 236 medical students (of different years of medical training/MBBS) participated in the survey and the response rate to the survey was 47.2%. The mean age of the participants was 20.91 (SD-1.86) years, and about three-fifths were males (58.5%). One-third students were either in their first year of MBBS (31.8%) or the final year (35.16%) of MBBS. Incorrect beliefs related to various preventive aspects, risk of increasing chance of getting infection and modes of spread of infection were present in a significant proportion of students, with a wide variation for specific issues. When the number of participants with at least one incorrect related to any of the aspects of COVID-19 infection was evaluated, it ranged from 59% to 85% in different domains. CONCLUSIONS: This survey highlights the widespread prevalence of misconceptions about various aspects of COVID-19 among medical students, which needs to be addressed by proper education and awareness.

Demographic & clinical profile of patients with COVID-19 at a tertiary care hospital in north India.

BACKGROUND & OBJECTIVES: The COVID-19 pandemic emerged as a major public health emergency affecting the healthcare services all over the world. It is essential to analyze the epidemiological and clinical characteristics of patients with COVID-19 in different parts of our country. This study highlights clinical experience in managing patients with COVID-19 at a tertiary care centre in northern India. METHODS: Clinical characteristics and outcomes of consecutive adults patients admitted to a tertiary care hospital at Chandigarh, India, from April 1 to May 25, 2020 were studied. The diagnosis of SARS-CoV-2 infection was confirmed by real-time reverse transcriptase polymerase chain reaction (RT-PCR) on throat and/or nasopharyngeal swabs. All patients were managed according to the institute's consensus protocol and in accordance with Indian Council of Medical Research guidelines. RESULTS: During the study period, 114 patients with SARS-CoV-2 infection were admitted. The history of contact with COVID-19-affected individuals was available in 75 (65.8%) patients. The median age of the patients was 33.5 yr (13-79 yr), and there were 66 (58%) males. Of the total enrolled patients, 48 (42%) were symptomatic. The common presenting complaints were fever (37, 77%), cough (26, 54%) and shortness of breath (10, 20.8%). Nineteen (17%) patients had hypoxia (SpO2<94%) at presentation and 36 (31%) had tachypnoea (RR >24). Thirty four (29.8%) patients had an accompanying comorbid illness. Age more than 60 yr and presence of diabetes and hypertension were significantly associated with severe COVID-19 disease. Admission to the intensive care unit (ICU) was needed in 18 patients (52%), with three (2.6%) patients requiring assisted ventilation. Mortality of 2.6 per cent (3 patients) was observed. INTERPRETATION & CONCLUSIONS: Majority of the patients with COVID-19 infection presenting to our hospital were young and asymptomatic. Fever was noted only in three-fourth of the patients and respiratory symptoms in half of them. Patients with comorbidities were more vulnerable to complications. Triaged classification of patients and protocol-based treatment resulted in good outcomes and low case fatality.

Absence of SARS-CoV-2 infection in the semen of men recovering from COVID-19 infection: An exploratory study and review of literature.

The effect of COVID-19 on the male reproductive tract has been sparsely studied. This exploratory study was designed to determine the presence of SARS-CoV-2 in the semen of men recovering from COVID-19. A systematic literature review was also performed as per PRISMA guidelines to gather perspective on this topic. The prospective study included men 21 years and older recovering from COVID-19 with nasopharyngeal swab negative for SARS-CoV-2 or at least two weeks from the last COVID RT-PCR positivity. After clinical evaluation, freshly ejaculated semen sample by masturbation was collected in a sterile container. Samples were processed for the detection of SARS-CoV-2 by RT-PCR. Twenty-one patients were contacted for the study, 11 of which consented to provide a semen sample. The mean age of the cohort was 29.72 ± 4.52 years. None of the patients gave a history of epididymo-orchitis or sexual dysfunction at the time of assessment. None of the semen samples demonstrated SARS-CoV-2 on RT-PCR. Median duration of semen sample collection from the COVID positivity was 44 days (Range 19-59 days). Detailed literature review revealed that SARS-CoV-2 is not found in patients recovering from COVID-19 infection. We conclude that SARS-CoV-2 is not found in the semen of patients recovering from COVID-19.

Comparative study of effectiveness of augmentation with ECT in clozapine resistant schizophrenia (CRS) and non-clozapine resistant schizophrenia (Non-CRS).

BACKGROUND: There is limited evidence for different treatment strategies in patients with clozapine resistant schizophrenia (CRS). AIM: To determine the effectiveness of ECT in patients with clozapine resistant schizophrenia and compare the same with a group of patients with non-clozapine resistant schizophrenia, receiving ECT. RESULTS: Out of a total of 68 patients with schizophrenia, 27 (38.66%) of patients had CRS. With 6 ECTs, there was a significant reduction in PANSS positive, negative, general psychopathology, prosocial score and depression symptoms in the CRS (p < 0.001) and Non-CRS group (p < 0.001), but no statistically significant difference was seen between the 2 groups in terms of proportion of patients showing >40% response on PANSS total score. The reduction in PANSS score of >40% in CRS group was seen in 48.1% of patients in the positive symptoms subscale, in 25.9% of patients in negative symptoms subscale, in 46.7% of cases in the general psychopathology subscale, in 44.4% of the patients in Depression subscale, in 29.6% of the patients in the modified prosocialsubscaleand in 29.6% of the patients in total PANSS score. CONCLUSION: ECT is an effective augmentation strategy for patients with CRS and it is as effective as when used in patients with non-CRS.

Perceptions of Psychiatrists Toward the Use of Long-Acting Injectable Antipsychotics: An Online Survey Study From India.

PURPOSE/BACKGROUND: Despite proven benefits of long-acting injectables (LAIs), these are frequently underused by the psychiatrists. Accordingly, this study aimed to explore the perceptions of psychiatrists toward the use of LAI antipsychotics in their routine clinical practice. METHODS/PROCEDURE: An online e-mail survey was conducted by using Survey Monkey platform. RESULTS: A total of 622 psychiatrists with a mean age of 41 years who were in psychiatric practice for approximately 14 years participated in the survey. Participants reported using LAI, mainly for patients with schizophrenia, with LAI prescribed to approximately one-tenth (9.30%) of their patients in acute phase of illness and in one-fifth (18.42%) of patients in stabilization/stable phase. Fluphenazine decanoate (32.7%) was the most commonly used LAI followed by flupenthixol decanoate (19.5%), haloperidol decanoate (17.8%), and olanzapine pamoate (11.1%). The most common reasons for starting LAI were history of medication (100%) and treatment (80.5%) nonadherence, followed by having frequent relapses/exacerbations of symptoms (54.8%). Overall, more than half of the participants felt the level of acceptance of LAI among patients offered to be quite reasonable (54.3%), and mostly, LAIs were used as combination therapy with oral antipsychotics (73.6%). Despite all these, approximately three-fifths (59%) of the participants reported that they underuse LAI to a certain extent, with most common reasons that deter them from using LAI being the cost (55.45%), lack of interest of patients in receiving LAI (42.9%), lack of regular availability (41.3%), and patients being scared of receiving injectables (41.2%). CONCLUSIONS/IMPLICATIONS: The LAI antipsychotics despite having several benefits are still underused by a substantial proportion of practicing psychiatrists.

Acute and Transient Psychotic Disorders: Newer Understanding.

PURPOSE OF REVIEW: We review the ongoing research in the area of acute and transient psychotic disorders (ATPDs) with regard to their nosology, epidemiology, clinical description, genetics, and neurobiology, examining evidence for distinctiveness or otherwise of ATPDs. We further highlight the lacuna in research in ATPDs. RECENT FINDINGS: Studies on ATPDs as defined in the ICD 10 have been reported from different parts of the world, more so from the developing countries. There is consistent evidence that there exist a group of ATPDs that occur more commonly among females, are often precipitated by stressful life events or exposure to physiological stresses like fever, child birth, are associated with well-adjusted premorbid personality, and show complete recovery in a short period. Although in some cases of ATPDs, there is symptomatic overlap with schizophrenic symptoms in the acute phase, they follow a completely different course and outcome, exhibit genetic distinctiveness, and do not share genetic relationship with schizophrenias or bipolar affective disorder (BPAD). Comparative studies on neurophysiology and neuroimaging in ATPDs and schizophrenias have demonstrated evidence of hyper arousal and hyper metabolism in ATPDs vs hypo arousal and hypo metabolism as noted in the P300 response and on FDG PET studies, respectively. Immune markers such as IL-6, TNF-alpha, and TGF-beta show higher levels in ATPDs as compared to healthy controls. Findings on the neurobiological mechanisms underlying ATPDs, so far, point towards significant differences from those in schizophrenia or BPAD. Although the studies are few and far between, nevertheless, these point towards the possibility of ATPDs as a distinct entity and underscore the need for pursuing alternate hypothesis such as neuro inflammatory or metabolic. Research on ATPDs is limited due to many reasons including lack of harmony between the ICD and DSM diagnostic systems and clinician biases. Available research data supports the validity of ATPDs as a distinct clinical entity. There is also evidence that ATPDs are different from schizophrenias or BPAD on genetic, neuroimaging, neurophysiological, and immunological markers and require further studies.

Obsessive-compulsive symptoms in schizophrenia: a review.

OBJECTIVE: To review the available literature on obsessive-compulsive symptom (OCS)/obsessive-compulsive disorder (OCD) in patients with schizophrenia. METHODOLOGY: Electronic searches were carried out to locate studies reporting various aspects of OCS/OCD in patients with schizophrenia. RESULTS: Available evidence suggests that prevalence of OCS/OCD in patients with schizophrenia is much higher than prevalence in general population and it is seen in all the stages of schizophrenia, starting from at risk mental state to chronic/stabilisation/deficit phases. Symptom profile of OCS/OCD in schizophrenia is similar to that seen in patients with OCD only. Presence of OCS/OCD is associated with higher severity of symptoms of schizophrenia and more negative outcome. At present there is very limited data on the efficacy/effectiveness of various pharmacological measures and psychological interventions, for management of OCS/OCD in patients with schizophrenia. There is some evidence pointing towards beneficial effect of certain antipsychotics, antidepressants and cognitive behaviour therapy. Management of OCS/OCD in patients with schizophrenia involves proper assessment. If the OCS/OCD is related to use of particular antipsychotic use, initial attempt must be made to reduce the dose of antipsychotics, however, if this is not effective, than addition of a selective serotonin reuptake inhibitor (SSRIs) must be considered. If the OCS/OCD is not related to the use of antipsychotic medication, than depending up on the severity of psychotic symptoms, addition of SSRIs must be considered. CONCLUSION: This review suggests that OCS/OCD is highly prevalent among patients with schizophrenia and there is limited good quality evidence to make any specific recommendations for management.

ECT in schizophrenia: a review of the evidence.

Electroconvulsive therapy (ECT) was initially used for the treatment of schizophrenia, but over the years with the advent of antipsychotics, its use in schizophrenia has been limited. Treatment guidelines vary in their recommendations for the use of ECT in schizophrenia. The usual indications of its use among patients with schizophrenia include treatment resistance, to augment pharmacotherapy, to manage catatonia, suicidal behaviour, severe agitation and clozapine-resistant schizophrenia. Available literature, including meta-analysis and systematic reviews, suggest that ECT is a safe and effective treatment in patients with schizophrenia. However, despite the available evidence, it is highly underutilised and is often used as one of the last resort among patients with schizophrenia. This review focuses on the indications of use of ECT in schizophrenia, studies evaluating its effectiveness, efficacy in certain special situations like first episode schizophrenia, adolescents, catatonia etc., predictors of response to ECT in schizophrenia and influence of various ECT-related parameters on efficacy/effectiveness among patients with schizophrenia. From the review, it can be concluded that ECT is not only is beneficial as an augmenting strategy in treatment-resistant schizophrenia but also can be used effectively in patients with schizophrenia in various other situations.

A Naturalistic Evaluation of Change in Antidepressant Prescription in Patients With Affective and Anxiety Disorders in a Tertiary Care Hospital of India.

BACKGROUND: Although many studies have evaluated prescription patterns, there is lack of information on the choice of antidepressants among patients who do not respond antidepressants. Similarly, information on switching strategies is also limited. This naturalistic study aimed to evaluate the switching strategies and preferred antidepressants by the psychiatrists among patients who do not respond to or who are not able to tolerate an antidepressant. METHODS: A cross-sectional observational study design was followed. Patients diagnosed with affective and anxiety disorders, who were recommended a change in antidepressant, were recruited. Details of antidepressant before switching, antidepressants considered at the time of switching, coprescription advised at the time of switching, reasons considered for switching, and strategy advised at the time of switching were noted down. RESULTS: A total of 102 patients were recruited. The most common change strategy was selective serotonin reuptake inhibitor (SSRI) to a serotonin norepinephrine reuptake inhibitor (SNRI) (N = 42; 41.17%), and this was followed by SSRI to SSRI (N = 18; 17.64%) and SNRI to SSRI (N = 10; 9.8%). In majority of the patients (N = 79; 77.45%) cross-taper of older antidepressant with gradual increase in dose of newer antidepressants was followed. About 44.1% of the patients were on adjuvant medications at the time of considering change in antidepressants, and 37.25% of the patients were additionally started on some adjuvant medications during the change of antidepressants. CONCLUSIONS: The present study suggests that the most common strategy followed during change of antidepressant is from SSRI to SNRI and this is followed by SSRI to SSRI and SNRI to SSRI. Cross-taper switching strategy along with the use of adjuvant medications like benzodiazepines during the process of switching is most commonly followed.

Cross-cultural and psychological issues in irritable bowel syndrome.

Irritable bowel syndrome (IBS) is one of the most common functional gastrointestinal disorders encountered by gastroenterologists worldwide. Of all the etiological factors that had been postulated to explain the pathophysiology of IBS, cultural and psychological factors are unique and difficult to understand. Culture plays an important role in coloring the presentation of IBS, and many a times, it has a significant role in several treatment aspects too. Psychological aspects like personality profiles, family relationships, societal myths, and abuse in any form are equally important in the management perspectives of IBS. In this brief review, we had tried to specifically focus on these aspects in IBS and have explained the evidences in favor of these factors. Knowledge about various cross-cultural aspects and psychological factors in patients with IBS is essential for taking an appropriate history and for undertaking a holistic approach for the management of the same. A collaborative team effort by psychiatrists and gastroenterologists could help in reducing the burden of this difficult to treat functional bowel disorder.

Antidepressants in People With Chronic Liver Disease and Depression: When Are They Warranted and How to Choose the Suitable One?

Most chronic medical illnesses are associated with significant psychiatric comorbidity, especially in the form of depression, anxiety, and suicidality. Chronic liver disease (CLD) is no exception to this and rather is placed uniquely as compared to other diseases because of its intersection with alcohol use disorder and other substance use, which in itself is a mental illness. Patients with CLD may have comorbid psychiatric illnesses; the pharmacokinetic concerns arising out of hepatic dysfunction which affects pharmacotherapy for depression and vice versa. The high prevalence of medical comorbidities with CLD may further complicate the course and outcome of depression in such patients, and diagnostic and management issues arise from special situations like transplant evaluation, alcohol use disorder, and hepatic encephalopathy or multifactorial encephalopathy seen in a disoriented or agitated patient with CLD. For this narrative review, we carried out a literature search in PubMed/PubMed Central and in Google Scholar (1980-2023) with the keywords "depression in cirrhosis", "antidepressants in liver disease", "anxiety in liver disease", "depression in liver transplantation", and "drug interactions with antidepressants". This review presents a comprehensive view of the available research on the use of antidepressants in patients with CLD, including deciding to use them, choosing the right antidepressant, risks, drug interactions, and adverse reactions to expect, and managing the same. In addition, liver transplant fitness and the overlap of hepatic encephalopathy with neuropsychiatric illness will be discussed.

A Rapid Systematic Review of the Prevalence of Suicide and Self-Harm Behaviors in Adolescents During the COVID-19 Pandemic.

Background: COVID-19 has caused psychological, social, and physical isolation in adolescents resulting in varying rates of suicidal behavior and self-harm. Aims: We investigated the pandemic's impact on adolescent suicidal behavior and self-harm by reviewing the existing literature. Methods: We searched PubMed using keywords: adolescent, suicide, suicidal behavior, self-harm, prevalence, and COVID-19 and included studies reporting primary data only. Results: Of the 551 studies identified, we included 39 studies in the final analysis. Two of the six high-quality population-based suicide registry studies reported increased suicide rates during the pandemic. Seven of fifteen emergency department-based studies out of which four were of high quality and three high-quality population-based health registry studies reported increased self-harm. A few school and community-based surveys and national helpline data also reported an increase in suicidal behavior or self-harm. Limitations: Methodological heterogeneity of the included studies. Conclusions: There is wide variation in study methodology, population, settings, and age groups in the included studies. Suicidal behavior and self-harm were increased in specific study settings and adolescent populations during the pandemic. More methodologically rigorous research is needed to evaluate the impact of COVID-19 on adolescent suicidal behavior and self-harm.

Impact of online dating on the adolescent population: a brief review of the literature with special reference to the Indian scenario.

BACKGROUND: Online dating is becoming more and more popular not only among the adult population, but also among adolescents, which comes with its own advantages and disadvantages. Adolescents are more vulnerable to a number of issues connected with online dating, including online grooming, bullying, emotional abuse, revenge porn, harassment, and lack of social interaction. AIM: We aimed to briefly review the available literature exploring the impact of online dating on adolescents, with special reference to the current Indian Scenario. METHODS: A brief literature search was conducted in PubMed and Google Scholar in September 2022 with no date limits. Keywords included various combinations of terms such as online dating, dating applications, social media, mental illness, psychiatric disorders, adolescents, and mental health. Original studies and review articles exploring the impact of online dating on adolescents and published in English were reviewed in our work. A descriptive strategy was used to summarise the findings. RESULTS: The impact of online dating on adolescents is discussed in the light of (1) issues associated with online dating among adolescents, (2) the international context, and (3) Indian context. CONCLUSION: Since the beginning of the COVID-19 pandemic, online dating has grown in popularity among adolescents, which has led to a number of worrying situations, including increased risk of sexually transmitted infections, dating violence, and mental health issues. All of these issues are described in the literature in the context of unsupervised use of technology, peer pressure, and desire to fit into the society. Data from India remain scarce on this topic, highlighting the need for research exploring the influence of online dating on adolescents.