Legal aspects of proxy practices in clinical psychiatry in India.

Proxy procedures in psychiatry include proxy consultations, proxy prescriptions, covert and refill medications. Before Mental Healthcare Act (MHCA) 2017, there was minimal emphasis on the rights of individuals with Severe Mental Illness (SMI), leading family members to use proxy practices. With the new legislation, these practices have to be seen in a new light. Proxy consultations may be allowed for information, advice, etc. but not for giving medications or making a diagnosis. Proxy prescriptions can be given if the patient gives prior authorization or through nominated representative in advanced directive. Psychiatrists may consider covert medications if the patient lacks capacity, but not in emergencies. Medication refills can be given with physicians' recommendation for a specific duration.

Issues in the pharmacological treatment of obsessive-compulsive disorder.

AIMS: Obsessive-compulsive disorder (OCD) preferentially responds to a class of antidepressants called serotonin reuptake inhibitors (SRI). This review discusses certain issues unique to pharmacological treatment of OCD: choice of SRI, dose and duration of treatment, options after first failed SRI trial and treatment of SRI non-responders. METHODS: We performed a MEDLINE search for pharmacotherapy studies published until December 2006. In addition, the reference sections of major articles, and reviews were also screened. We also considered clinical guidelines and narrative reviews in writing this review. RESULTS: The SRIs are equally effective in treating OCD. Meta-analyses suggest that clomipramine may be superior to other SRIs. OCD tends to respond to higher doses of SRIs than that used to treat depression. Response to treatment is usually delayed and may take up to 8-12 weeks. Atypical antipsychotics are the only proven augmenting agents in SRI non-responders. Cognitive behaviour therapy (CBT) is an effective treatment strategy in treating OCD and possibly has a role in treating SRI non-responders. DISCUSSION: Side effect profile and drug-drug interactions largely determine the choice of SRI. Those who fail to respond to one SRI trial may well respond to another SRI trial. Clomipramine is recommended if 2-3 trials of SRIs fail to produce response. Atypical antipsychotics are the first-line augmenting agents in SRI non-responders. CBT should be considered in all patients with OCD and is a potential option in SRI non-responders. CONCLUSION: OCD is a chronic and debilitating disorder. In responders, SRIs have to be continued in the same doses (if possible) for a minimum of 1-2 years and may be lifelong in those with persistent symptoms and in those with multiple relapses. CBT has to be offered in combination with SRIs wherever facilities for CBT exist.

A 5-year course of predominantly obsessive vs. mixed subtypes of obsessive-compulsive disorder.

BACKGROUND: Obsessive-compulsive disorder (OCD) is considered a heterogeneous disorder. One of the traditional approaches to subtype OCD is based on the predominance of obsessions, compulsions or both. Some studies suggest that the "predominantly obsessive" subtype of OCD may have poor outcome, whereas few other studies suggest that "mixed" OCD is associated with poor outcome. Therefore, it is not clear if the long-term course of "predominantly obsessive" subjects is different from those with "mixed" OCD. In the establishment of diagnostic validity of psychiatric conditions, differential course is an important validating factor. AIM: This study compares the 5-6 year course of the "predominantly obsessive" subtype with that of the "mixed" subtype of OCD with the objective of determining if the course of OCD differs according to subtypes and whether course could be a validating factor for subtyping OCD based on predominance of obsessions, compulsions or both. SETTING AND DESIGN: Tertiary hospital, institutional setting. The study has a retrospective cohort design. MATERIALS AND METHODS: Fifty-four subjects with "predominantly obsessions" and an equal number of the "mixed" subtype of OCD were recruited from the database of a specialty OCD clinic of a major psychiatric hospital. They were followed up after 5-6 years. The Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) checklist and severity rating scale was used for assessing OCD. The course of OCD was determined according to predefined criteria. STATISTICS: The Chi-square/Fisher's exact test and the independent samples "t" test were used to compare categorical and continuous variables, respectively. Correlations were tested using the Pearson's correlation analysis. RESULTS: Thirty-eight "predominantly obsessive" (70%) and 39 "mixed" (72%) OCD subjects could be traced and evaluated. The course of illness was similar in the two subtypes. A majority of the sample (72%) did not have clinical OCD at follow-up. CONCLUSIONS: "Predominantly obsessive" subjects have a course similar to those with "mixed" OCD. Clinically, it is reassuring to know that obsessive subjects do not have an unfavorable course as was suggested by some previous studies. In this sample, course did not validate the subtyping method employed, but it would be premature to conclude that the subtyping method employed is incorrect based on the course alone. Prospective study of the course in larger samples and neurobiological and family-genetic data may help further validation.