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.

Telepsychiatry clinical decision support system used by non-psychiatrists in remote areas: Validity & reliabilityof diagnostic module.

BACKGROUND & OBJECTIVES: A knowledge-based, logically-linked online telepsychiatric decision support system for diagnosis and treatment of mental disorders was developed and validated. We evaluated diagnostic accuracy and reliability of the application at remote sites when used by non-psychiatrists who underwent a brief training in its use through video-conferencing. METHODS: The study was conducted at a nodal telepsychiatry centre, and three geographically remote peripheral centres. The diagnostic tool of application had a screening followed by detailed criteria-wise diagnostic modules for 18 psychiatric disorders. A total of 100 consecutive consenting adult outpatients attending remote telepsychiatry centres were included. To assess inter-rater reliability, patients were interviewed face to face by non-specialists at remote sites using the application (active interviewer) and simultaneously on online application via video-conferencing by a passive assessor at nodal centre. Another interviewer at the nodal centre rated the patient using Mini-International Neuropsychiatric Interview (MINI) for diagnostic validation. RESULTS: Screening sub-module had high sensitivity (80-100%), low positive predictive values (PPV) (0.10-0.71) but high negative predictive value (NPV) (0.97-1) for most disorders. For the diagnostic sub-modules, Cohen's kappa was >0.4 for all disorders, with kappa of 0.7-1.0 for most disorders. PPV and NPV were high for most disorders. Inter-rater agreement analysis revealed kappa >0.6 for all disorders. INTERPRETATION & CONCLUSIONS: Diagnostic tool showed acceptable to good validity and reliability when used by non-specialists at remote sites. Our findings show that diagnostic tool of the telepsychiatry application has potential to empower non-psychiatrist doctors and paramedics to diagnose psychiatric disorders accurately and reliably in remote sites.

Are childhood externalizing disorders the harbinger of early-onset alcohol dependence?

BACKGROUND & OBJECTIVES: The subtyping of alcohol dependence (AD) into early-onset (EO) and late-onset (LO) subgroups has been shown to have clinical and biological validity. As externalizing disorders (EDs) predate AD, the link of ED with age of onset of alcohol dependence needs to be investigated. The aim of this study was to examine the relationship of EDs such as disruptive behaviour disorder (DBD) and attention deficit hyperactivity disorder (ADHD) with age at onset of AD in a sample of male subjects. METHODS: One hundred consecutive male subjects with AD presenting to the De-Addiction Services and an equal number of biologically unrelated non-substance-dependent control subjects were included in the study. The AD subjects were divided into EO (age of onset of AD ≤25 yr; n = 21) and LO (age of onset of AD >25 yr; n = 79). Subjects were examined for evidence of DBD and ADHD in childhood, and current ADHD using structured instruments such as Semi-Structured Assessment for the Genetic of Alcoholism-IV (SSAGA-IV) and Kiddie - SADS - Present and Lifetime Version (K-SADS-PL). The odds ratio of association of EDs with EO and LO AD was calculated by comparing these subgroups with the biologically unrelated control group. Later, both the subgroups of alcohol dependence were compared for the presence of EDs. RESULTS: All EDs (DBDs/childhood or adult ADHD) were more common in AD individuals as compared to the controls. However, when AD subgroups were compared with controls, the association of DBDs and ADHD reached a significant level only in the EO subgroup. A comparison of EO and LO AD showed that more EO individuals had history of both childhood disruptive disorder and ADHD compared to LO subgroup. Adult ADHD was also over-represented in EO subgroup. INTERPRETATION & CONCLUSIONS: Our study showed more EDs in alcohol dependent individuals compared to controls. Further, the association observed between EDs and EO alcohol dependence points towards a developmental continuum between these two conditions.

Candidate genes for alcohol dependence: A genetic association study from India.

BACKGROUND & OBJECTIVES: Search for candidate genes for alcohol dependence (AD) has been inconsistent and inconclusive. Moreover, most of the research has been confined to a few specific ethnic groups. Hence, the aim of our study was to explore specific candidate genes for AD in north Indian male population. METHODS: In this clinic-based genetic association study, 210 males with AD and 200 controls matched for age, gender and ethnicity were recruited from the clinic and the general population, respectively. Cases were diagnosed with Semi-structured Assessment for Genetics of Alcoholism-II (SSAGA-II). Single-nucleotide polymorphism genotyping was done by real-time quantitative-polymerase chain reaction (PCR) using Taq Man assay (ABI 7500) fast real-time PCR system. RESULTS: Both at the genotypic level and at allelic frequency, Met158 variant of catechol-O-methyl transferase (COMT) showed significant increase in cases as compared to controls. The frequency of heterozygous genotype (A/G) of gamma-aminobutyric acid receptor A1 (GABRA1) was significantly lower in cases as compared to controls. Likewise, for GABRA2, the frequency of homozygous recessive genotype (G/G) was significantly higher in the control group. With respect to the 5-hydroxytryptamine (5HT) transporter long promoter region (5HTTLPR), cholinergic receptor muscarinic (CHRM2) and alcohol dehydrogenase 1B (ADH1B) genes, there was no significant difference between the cases and the controls. Aldehyde dehydrogenase (ALDH2) gene was found to be monomorphic in our study population. INTERPRETATION & CONCLUSIONS: Our study findings showed COMT polymorphism conferring risk and GABRA polymorphism as a protective genotype for Indian male with AD. Genes for alcohol metabolism, serotonin transporter and cholinergic receptor gene polymorphism were perhaps not contributory to AD for Indian population.

Symptom profile of alcohol withdrawal delirium: factor analysis of Delirium Rating Scale-Revised-98 version.

BACKGROUND: The symptom profile of alcohol withdrawal delirium (AWD), relative to deliriums of other etiology, remains uncertain. OBJECTIVE: To evaluate the factor structure of symptoms in patients with AWD, as assessed by the Delirium Rating Scale-Revised-98 (DRS-R-98). METHOD: A total of 112 patients aged 18 years or more with AWD were assessed on DRS-R-98. RESULTS: The mean age of participants was 44.2 years. About two-third of the patients developed delirium within 24 hours of the last intake of alcohol and the mean duration of delirium at the time of assessment was 3.9 days. In 46% of cases the delirium was attributed solely to alcohol withdrawal; in the remaining subjects alcohol withdrawal was a major contributory factor. Three separate principal component analysis (whole sample, pure AWD and AWD with associated etiologies) were carried out. In all the factor analyses, one of the factors included cognitive symptoms (attention, orientation and visuospatial disturbances) along with or without short- and long-term memory impairment; the second factor included motoric symptoms along with sleep-wake cycle disturbances; the third factor included psychotic symptoms. For the whole group and subgroup of AWD with associated etiologies, items of higher level thinking (i.e. language disturbances and thought process abnormality) loaded along with cognitive symptoms. In pure AWD group, these items along with memory disturbances loaded with psychotic symptoms. CONCLUSIONS: Results of the current factor analyses suggest that the factor structure of pure AWD is different from AWD with associated etiologies. Hence, attention to the symptom profile of patients with AWD may provide clues to delirium etiology.

Comparison of symptoms of delirium across various motoric subtypes.

AIM: The aim of this study was to determine the correlation between delirium motor subtypes and other symptoms of delirium. METHODS: Three hundred and twenty-one (n = 321) consecutive patients referred to consultation-liaison psychiatry services were evaluated on Delirium Rating scale-Revised-98 version and amended Delirium Motor Symptom Scale. RESULTS: Half of the patients had hyperactive subtype (n = 161; 50.15%) delirium. One-quarter of the study sample met the criteria for mixed subtype (n = 79; 24.61%), about one-fifth of the study sample met the criteria for hypoactive delirium subtype (n = 64; 19.93%), and only very few patients (n = 17; 5.29%) did not meet the required criteria for any of these three subtypes and were categorized as 'no subtype'. When the hyperactive and hypoactive subtypes were compared, significant differences were seen in the prevalence of perceptual disturbances, delusions, lability of affect, thought process abnormality, motor agitation and motor retardation. All the symptoms were more common in the hyperactive subtype except for thought process abnormality and motor retardation. Compared to hyperactive subtype, the mixed subtype had significantly higher prevalence of thought process abnormality and motor retardation. Significant differences emerged with regard to perceptual disturbances, delusions, lability of affect and motor agitation when comparing the patients with mixed subtype with those with hypoactive subtype. All these symptoms were found to be more common in the mixed subtype. No significant differences emerged for the cognitive symptoms as assessed on Delirium Rating scale-Revised-98 across the different motoric subtypes. CONCLUSION: Different motoric subtypes of delirium differ on non-cognitive symptoms.

Comparative study of prevalence of metabolic syndrome in bipolar disorder and schizophrenia from North India.

BACKGROUND: Very few studies have compared the prevalence of metabolic syndrome (MS) between patients with bipolar disorder and schizophrenia. AIM: The study aimed to compare the prevalence of MS in patients with bipolar disorder and schizophrenia. MATERIALS AND METHODS: By consecutive sampling, 126 patients with schizophrenia and 72 patients with bipolar disorder admitted to a psychiatry inpatient unit were evaluated for the presence of MS using the criteria of International Diabetes Federation (IDF) and modified National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP-III). A control group of 50 healthy subjects was used to represent the general prevalence of MS in the community. RESULTS: In the bipolar disorders group, 40 patients (55.55%) fulfilled IDF criteria and 45 (62.5%) satisfied modified NCEP ATP-III criteria for MS. These figures were significantly higher than those for the schizophrenia group (34.1% IDF and 36.5% modified NCEP ATP-III criteria). Prevalence of MS was 6% in the healthy control group and significantly less than both schizophrenia and bipolar disorder group. CONCLUSION: In the sample studied, prevalence of MS is significantly higher in bipolar disorder compared with schizophrenia. The prevalence of MS in both the clinical groups was significantly higher than the healthy control group.

Symptom profile and outcome of delirium associated with alcohol withdrawal syndrome: a study from India.

AIM: To study the profile of delirium associated with alcohol withdrawal syndrome (AWS) in a developing country in terms of symptomatology, associated risk factors/physical complications, and outcome. METHODOLOGY: Using a prospective design, 112 patients in whom delirium could be attributed to AWS as either the sole or a contributory cause were assessed by Delirium Rating Scale-Revised-98 and the associated etiological factors were assessed by using delirium etiology checklist. FINDINGS: In all patients, delirium was acute in onset and all patients had disturbance of sleep-wake cycle and inattention. Other common symptoms were: disorientation (99.1%), fluctuation in symptoms (97.3%), motor agitation (94.6%), and short-term memory disturbance (92.9%). In terms of delirium etiology checklist etiological categories, besides alcohol withdrawal, the most common factors were metabolic/endocrine abnormalities (76%), followed by organ insufficiency and infection (37% and 35%, respectively). Most patients (67%) improved or recovered completely from delirium during the short stay of 4 days. During the short stay of mean duration of 4 days 13.4% of the patients died during the hospital stay. CONCLUSION: Delirium associated with alcohol withdrawal is characterized by an acute onset of symptoms with high prevalence of disturbance of sleep-wake cycle, inattention, disorientation, fluctuation in symptoms, motor agitation, and disturbance in short-term memory. There are certain differences in the symptom profile of delirium associated with alcohol withdrawal and that associated with medical-surgical causes. About one-sixth of the patients developing delirium due to alcohol withdrawal die during the short hospital stay of 4 days.

Electroconvulsive therapy in adolescents: a retrospective study from north India.

OBJECTIVES: There are minimal data on the use of electroconvulsive therapy (ECT) in adolescents from India. The present study aimed to evaluate the clinical profile and effectiveness of ECT in adolescents (aged 13-18 years). METHODS: A retrospective chart review was carried out to identify adolescents (aged 13-18 years) who had received ECT during the period 1999-2011. During the study period, 39 such patients received ECT; complete records of 25 patients were available. Details regarding their sociodemographic, clinical, and treatment data were extracted from these records for the present study. RESULTS: During the study period, 658 patients received ECT, of which 39 were aged 18 or younger (5.9%). Schizophrenia (n = 14; 56%) was the commonest diagnosis for which ECT was used in adolescents, followed by depression (n = 3; 12%). Catatonic symptoms (n = 17; 68%) were the most common symptoms among these subjects. Electroconvulsive therapy was considered as a treatment of choice taking the clinical picture account in about three fourths of the patients (n = 19; 76%). The mean (SD) numbers of ECTs administered per patient were 10.1 (4.87) (range, 2-21). The mean (SD) response rate to ECT was 76% (23.3%) (range, 31%-100%). Response rates according to diagnosis were the following: 76.3% for schizophrenia, 87.2% for depression, 81.8% for psychosis (not otherwise specified), and 77.7% for acute and transient psychosis. Response rate in patients with catatonia was 91.6%. Prolonged seizures, nausea and vomiting, and headache were reported in 2 cases each. CONCLUSION: Electroconvulsive therapy is used less frequently in children and adolescents compared to the older patients. This study shows that ECT is effective in the treatment of severe psychiatric disorders in adolescents and is associated with the same frequency of adverse effects as the adults.

Delirium in elderly people: a study of a psychiatric liaison service in north India.

BACKGROUND: Very few studies from India have studied the phenomenology of delirium. The aim of the present study was to study the phenomenology as measured using the Delirium Rating Scale-Revised-98 (DRS-R98), the associated etiologies and the outcome of delirium among the elderly participants seen by the consultation-liaison psychiatric service in India. In addition, an attempt was made to study the factor structure of symptoms using principal components analysis. METHODS: The case notes of 109 elderly patients referred to psychiatry liaison services were reviewed. RESULTS: The mean age of the sample was 73.35 years (SD: 7.44; range 65-95 years) and two-thirds of the sample had hospital emergent delirium. The mean DRS-R98 severity score was 18.77 and the DRS-R98 total score was 24.81. In 15 patients the DRS-R98 scores were in the subsyndromal range. Among the various symptoms present, most patients had sleep-wake cycle disturbance, disturbance in orientation, attention and short-term memory impairments, fluctuation of symptoms, temporal onset of symptoms and a physical disorder. Principal components analysis identified three factors which explained 43.5% of variance of symptomatology and it yielded a three-factor structure. Endocrine/metabolic disturbances were the commonest associated etiological category with delirium. The mean hospital stay after being referred to psychiatry referral services was 8.89 days, after which delirium improved in 58.7% of cases. The mortality rate during the inpatient stay was 16.5%. CONCLUSIONS: Results suggest that the symptoms of delirium as assessed by DRS-R98 separate out into a three-factor structure. Delirium is commonly associated with metabolic endocrine disturbances and about one-sixth of the patients die during the short inpatient stay.

Is the temperamental trait of high persistence protective in siblings? - A comparative, exploratory study of healthy siblings, and attention deficit hyperactivity disorder probands.

Background: Study of temperament in first-degree relatives is an important line of inquiry to substantiate temperament as an etiological marker. Aim: This study aims to compare temperament in children with attention deficit hyperactivity disorder (ADHD) and their healthy siblings and to assess the association between ADHD symptoms and temperament dimensions in healthy siblings. Settings and Design: The study was carried out in the outpatient department of psychiatry in a tertiary care teaching hospital. A cross-sectional design with nonprobabilistic sampling technique was used for data collection. Materials and Methods: A hundred children (50 children with ADHD and 50 siblings-one for each child with ADHD) were assessed retrospectively on temperament measurement schedule (TMS) and conners parent rating scale-revised: short form (CPRS-R: S). Statistical Analysis: IBM SPSS Statistics for Windows, Version 20.0 was used for statistical analysis. Mean and standard deviation and frequency and percentage were computed for continuous and categorical variables, respectively. Student's t-test was computed to compare means of the two groups and regression analysis was computed to see for the variance in ADHD subscale scores explained by temperament scores on TMS. Results: Siblings scored highest on the intensity of reaction and lowest on threshold of responsiveness. Compared to probands, siblings scored significantly higher on persistence and lower on activity level, even after controlling for gender. Persistence trait had a significant negative correlation with and explained 7.4% to 21% of variance of all CPRS-R: S subscales. Persistence and distractibility together explained 23.2% of inattention scores. Conclusion: Higher persistence in siblings appears to offer protection to these at-risk individuals who do not have ADHD; favoring the dual pathway model of ADHD.

Diagnosis, prognosis, and treatment of brief psychotic episodes: a review and research agenda.

Brief psychotic episodes represent an intriguing paradox in clinical psychiatry because they elude the standard knowledge that applies to the persisting psychotic disorders such as schizophrenia. This Review describes key diagnostic considerations such as conceptual foundations, current psychiatric classification versus research-based operationalisations, epidemiology, and sociocultural variations; prognostic aspects including the risk of psychosis recurrence, types of psychotic recurrences, other clinical outcomes, prognostic factors; and therapeutic issues such as treatment guidelines and unmet need of care. The advances and challenges associated with the scientific evidence are used to set a research agenda in this area. We conclude that brief psychotic episodes can be reconceptualised within a clinical staging model to promote innovative translational research and improve our understanding and treatment of psychotic disorders.

Training nonspecialists in clinical evaluation for telepsychiatry using videoconferencing: A feasibility and effectiveness study.

AIMS: Videoconferencing-based telepsychiatry has been used successfully for the assessment and management of psychiatric disorders. However, training mental health professionals through videoconferencing has seldom been attempted. Online decision support systems for diagnosing psychiatric disorders had been developed earlier at the Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, as a part of a project for delivering telepsychiatric services to remote areas. The feasibility of videoconferencing for training nonspecialist staff in the use of the online tool to diagnose psychiatric disorders was examined. The effectiveness of training was evaluated using ratings of diagnostic agreement between trainees and trainers and estimations of training costs. METHODS: The Skype platform was used for videoconferences (VCs). Broadband internet connections had bandwidths of 4 mbps and speeds of 512 kbps. A total of 62 training sessions were conducted by the PGIMER team for remote-site teams using role-play techniques and actual patient interviews. RESULTS: Videoconferencing-based training was considered to be convenient, satisfactory, and useful by all the participants. Diagnostic agreement between trainees and trainers was 89%-100%. Such training also appeared to be cost-effective. The main problems encountered were poor connectivity and poor audiovisual quality of the VCs. CONCLUSIONS: Videoconferencing can be feasible and effective for training nonspecialists to diagnose psychiatric disorders.

Growing up with the families of ß-thalassaemia major using an accelerated longitudinal design.

BACKGROUND & OBJECTIVES: It is difficult for a single investigator to study the psychosocial changes that occur over the life span of an individual affected with a chronic illness like ß-thalassaemia major. Therefore, a developmental epidemiological perspective is required to understand the chain of events and problems of psychological nature. We aimed to construct the picture of developmental epidemiology for psychosocial aspects in families of ß-thalassaemia major patients attending a tertiary care hospital in north India. METHODS: The accelerated longitudinal design was used. The sample consisted of 100 children with ß-thalassaemia and their 150 parents, both groups were subdivided further so that each group represented the continuum of longitudinal course. The sampling was done for a period of 16 months from January 2004 to April 2005. RESULTS: Overall 54 per cent of children had significant psychopathology. Within the parents groups, 10 per cent had adjustment disorder, 33.3 per cent depressive disorder, and 10 per cent had anxiety disorder and 11 per cent somatoform disorder; 95 per cent of the parents of newly diagnosed children expressed feeling of dazed and shock, fear of death, hopelessness, separation anxiety and problems with their memory and concentration. There was significant difference only in the domain of psychological health in all the three groups of parents with respect to the quality of life. Among children, quality of life improved with their progression of illness. Growing up with ß-thalassaemic family was analyzed. INTERPRETATION & CONCLUSIONS: The developmental epidemiological perspective was constructed in ß -thalassaemic children and their family using an accelerated longitudinal design. Such a design can test the hypothesized aetiological or developmental function of a targeted risk factor within a developmental path and may be used in studying the psychological impact of even other chronic illnesses over the life span of an individual for conceptual and holistic understanding.

The therapeutic alliance between the child, parents, and health professionals.

Therapeutic alliance (TA), a term first used by Zetzel (1956), refers to the collaborative relationship between a patient and a therapist, leading to the development of an affective bond during the process of treatment/therapy and an agreement on treatment/therapy-related tasks and goals. Over time, it became clear that therapeutic alliance has a bidirectional nature, not unique to any one form of therapy but universal in all forms of helping relationships. Engagement of both patient and therapist is essential to its development. Trust, empathy, acceptance, and honesty are among the many constituents of a TA. Alongside this, characteristics of healthcare professionals influence TA, with a warm, empathic, gentle, and accepting therapist enhancing positive TA and a rigid, critical, and less involved therapist posing a hindrance to the development of TA. Literature is sparse for TA in children, and it also essentially involves multiple relationships, namely child alliance, caregiver alliance, and child-parent relationship, which need to be taken into account. Developmental aspects should also be kept in mind while dealing with children and adolescents. It is seen that a strong and positive caregiver alliance influences the development of child alliance. There are ways to foster TA with the child and parent/caregiver to maximize benefits from therapy.

Informed consent & ethical issues in paediatric psychopharmacology.

Issues relating to informed consent and ethics in paediatric psychopharmacology limit research in this population. Children vary in their levels of cognitive development, and presence of psychiatric disorder may further impair their ability to give informed consent. In decisional impairment subjects, various methods used for consent are assent/dissent; inclusion of advance directives; and/or alternative decision-makers. India is emerging as a new market for clinical trials in recent years. Moreover, in India the sociocultural realities are different from those in the western countries making it necessary for professionals to be cautious in conducting drug trials. In this review, issues regarding informed consent in children and adolescent with psychiatric diagnosis are discussed for information, discussion and debate by professionals, parents, society and legal experts to create awareness and to facilitate development of guidelines that are appropriate and applicable to the Indian system.

A model for digital mental healthcare: Its usefulness and potential for service delivery in low- and middle-income countries.

BACKGROUND: Using digital technology to deliver mental health care can possibly serve as a viable adjunct or alternative to mainstream services in lessening the mental health gap in a large number of resource deficient and LAMI countries. Conventional models of telepsychiatric services available so far, however, have been inadequate and ineffective, as these address only a small component of care, and rely on engagement of specialists who are grossly insufficient in numbers. AIM: To describe an innovative digital model of mental health care, enabling and empowering the non-specialists to deliver high quality mental health care in remote areas. METHODS: The model is powered by an online, fully automated clinical decision support system (CDSS), with interlinked modules for diagnosis, management and follow-up, usable by non-specialists after brief training and minimal supervision by psychiatrist, to deliver mental health care at remote sites. RESULTS: The CDSS has been found to be highly reliable, feasible, with sufficient sensitivity and specificity. This paper describes the model and initial experience with the digital mental health care system deployed in three geographically difficult and remote areas in northern hill states in India. The online system was found to be reasonably comprehensive, brief, feasible, user-friendly, with high levels of patient satisfaction. 2594 patients assessed at the three remote sites and the nodal center represented varied diagnoses. CONCLUSIONS: The digital model described here has the potential to serve as an effective alternative or adjunct for delivering comprehensive and high quality mental health care in LAMI countries like India in the primary and secondary care settings.

Relation between temperament dimensions and attention-deficit/hyperactivity disorder symptoms.

INTRODUCTION: The relation between temperament and attention-deficit/hyperactivity disorder (ADHD) is complex and understood in different ways, with the most common being risk model and spectrum model. However, the evidence is mixed and emerging. AIM: To assess the relationship between ADHD symptoms and temperament dimensions in a clinical sample of school-aged children. METHODS: A retrospective assessment of temperament of 50 children with ADHD was done on temperament measurement schedule. The mean and standard deviation was computed for continuous variables and frequency and percentage for discontinuous variables and correlation and regression analysis was computed. RESULTS: Children with ADHD were high on activity level, intensity of reaction, approach, and distractibility and low on persistence and threshold of responsiveness. The strength of significant correlations between temperamental dimensions and ADHD symptoms (P < 0.05) ranged from 0.32 to 0.41. On regression analysis, temperament could explain 22% variance of inattention subscale and around 20% variance in hyperactivity/impulsivity subscale. CONCLUSION: This moderate level of relation suggests that though certain temperamental traits are related to symptoms of ADHD, temperament and ADHD are phenotypically separate constructs, further favoring the risk model.

Vitamin D Deficiency in Children with Psychiatric Illness in a Tertiary Care Hospital in North India.

BACKGROUND: Vitamin D is increasingly recognized as important for brain health, apart from its role in endocrine and bone health. There is a growing recognition of worldwide "epidemic" of Vitamin D deficiency, and growing data from adult population illustrate the association between Vitamin D deficiency and psychiatric disorders. In children, its role is implicated in brain development, function, and psychiatric disorders. AIM: The aim of this study was to study the extent of Vitamin D deficiency in children and adolescents with psychiatric disorders. METHODOLOGY: Retrospective chart review of participants, who had attended the psychiatry outpatient department, was conducted to ascertain the extent of blood Vitamin D level requisition and its level. RESULTS: Out of 836, 60 participants had received the requisition for blood Vitamin D level, and results were documented for 40 participants (males - 28; females - 12). No specific reason was cited for getting Vitamin D level done. The mean Vitamin D level was in the deficient range, i.e. 13.34 ng/ml with 80% of the sample having Vitamin D deficiency and 13% having insufficient Vitamin D level. More males had Vitamin D deficiency, however, the small number of females in the study limits the generalizability of the results. Among the diagnostic categories, neurodevelopmental disorders had lower mean Vitamin D level, with lowest Vitamin D for autism, i.e., 10.9 ng/ml. CONCLUSION: The cause-effect relationship between Vitamin D deficiency and childhood psychiatric disorders could not be derived from the study. However, it provides important initial data for the relationship between Vitamin D deficiency and childhood psychiatric disorders from India.

Promoting child and adolescent mental health in low and middle income countries.

Children and adolescents in low and middle income countries (LAMIC) constitute 35-50% of the population. Although the population in many such countries is predominantly rural, rapid urbanisation and social change is under way, with an increase in urban poverty and unemployment, which are risk factors for poor child and adolescent mental health (CAMH). There is a vast gap between CAMH needs (as measured through burden of disease estimates) and the availability of CAMH resources. The role of CAMH promotion and prevention can thus not be overestimated. However, the evidence base for affordable and effective interventions for promotion and prevention in LAMIC is limited. In this review, we briefly review the public health importance of CAM disorders in LAMIC and the specific issues related to risk and protective factors for these disorders. We describe a number of potential strategies for CAMH promotion which focus on building capacity in children and adolescents, in parents and families, in the school and health systems, and in the wider community, including structural interventions. Building capacity in CAMH must also focus on the detection and treatment of disorders for which the evidence base is somewhat stronger, and on wider public health strategies for prevention and promotion. In particular, capacity needs to be built across the health system, with particular foci on low-cost, universally available and accessible resources, and on empowerment of families and children. We also consider the role of formal teaching and training programmes, and the role for specialists in CAMH promotion.