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.

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.

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.

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.

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.

Insight in patients with bipolar disorder: Findings from the bipolar disorder course and outcome study from India (BiD-CoIN study).

Background: There are limited number of studies evaluating insight among patients with bipolar disorder (BD). Aim: This study aimed to examine insight and its correlates in BD using the data from the multicenter BD course and outcome study from India (BiD-CoIN). The additional aim was to evaluate the insight in patients with BD using different scales and understand the correlates of insight. Materials and Methods: 773 BD patients presently in clinical remission were evaluated on the Insight Scale for Affective Disorders (ISAD), insight items of the Hamilton Depression Rating Scale (HDRS), and the Young Mania Rating Scale (YMRS). Results: The assessment scales influenced the prevalence of poor insight. Poorer insight irrespective of the assessment scale was consistently associated with higher residual depressive and manic symptoms, and a higher level of cognitive impairment and disability. Poor insight as assessed by ISAD was associated with a higher number of episodes in the lifetime, shorter duration of current remission, a higher number of depressive episodes, a higher amount of time spent in depressive episodes, higher depressive affective morbidity, a higher number of manic episodes, and higher residual depressive and manic symptoms. Conclusion: Poor insight in BD is consistently associated with higher residual depressive and manic symptoms and a higher level of cognitive impairment and disability. However, in terms of course variables, the correlates vary depending on the assessment method.

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.

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.

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.

A comparative study on quality of life of patients of schizophrenia with and without depression.

Depression in schizophrenia has been recognized as one of the important factors influencing the Quality of Life (QOL). For this study 60 patients with a clinical diagnosis of schizophrenia as per ICD-10 (DCR version) were divided into two groups (with and without depression) on the basis of their score on Calgary Depression Rating Scale for Schizophrenia (CDSS). Thereafter, all patients were assessed on Positive and Negative Syndrome Scale for Schizophrenia (PANSS) for psychopathology, on Lehman Quality of Life Interview (QOLI)-brief version for QOL, on World Health Organization Disability Assessment Schedule-II (WHODAS-II) for disability, on UKU Side Effect Rating Scale for side effects of drugs and on Social Support Questionnaire (SSQ) for perceived social support. The two (depressed and non-depressed schizophrenia) groups differed significantly on symptoms of general psychopathology of PANSS and disability as per WHODAS-II, with the depressed group scoring higher. In the total sample, positive symptoms and the symptoms of general psychopathology of PANSS had a strong negative correlation with all three (subjective, objective and combined) domains of QOL, whereas, disability and medication side effects had a negative correlation with subjective and combined domains of QOL. CDSS total score did not significantly correlate with QOL. General psychopathology symptoms of PANSS emerged as the sole significant predictor of subjective and combined QOL, while positive symptoms of PANSS emerged as the sole predictor of objective QOL. Hence, it can be concluded that general psychopathology on PANSS had significant effect whereas depression as rated on CDSS had no significant effect on QOL in patients with schizophrenia. Treatments to improve QOL in schizophrenia should focus on symptoms of general psychopathology of PANSS.

Association of insight, avoidance behavior, indecisiveness, and inflated responsibility with other clinical characteristics in children and adolescents with obsessive-compulsive disorder.

OBJECTIVES: Although the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) includes ancillary symptom dimensions - insight, avoidance, degree of indecisiveness, inflated sense of responsibility, pervasive slowness/disturbance of inertia, and pathological doubting -, we know little about their clinical/scientific utility. We examined these ancillary dimensions in childhood obsessive-compulsive disorder (OCD), and tested their associations with clinical characteristics. METHODS: Treatment-seeking children and adolescents (n=173) with a DSM-5 OCD diagnosis were recruited from six centers in India and evaluated with a semi-structured proforma for sociodemographic/clinical details, the Structured Clinical Interview for DSM-5, the CY-BOCS, the Children's Depression Rating Scale, and the Family Interview for Genetic Studies. Regression analysis was used to study the associations between ancillary dimensions (independent variables) and clinical variables (dependent variables). RESULTS: 87.9% of the sample reported at least a mild-moderate severity of ancillary dimensions, which were highly intercorrelated. Multiple ancillary dimensions were correlated with illness severity on the CY-BOCS. On regression analysis, only insight and avoidance retained significance. There were few differential associations between OCD symptom and ancillary dimensions. CONCLUSION: Ancillary dimensions are more a feature of illness severity than differentially associated with individual symptom dimensions in childhood OCD. Insight and avoidance should be considered for inclusion in the assessment of illness severity in childhood OCD.

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.

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.

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.

Clinical profile of obsessive-compulsive disorder in children and adolescents: A multicentric study from India.

CONTEXT: Data from the Western countries suggest that obsessive-compulsive disorder (OCD) in children and adolescents is associated with male preponderance, comorbid neurodevelopmental disorders, and high family loading. However, data are limited from the developing countries with respect to the demographic and clinical characteristics of OCD in children and adolescents. AIMS: To study the demographic and clinical characteristics of children and adolescents (age ≤18 years) with OCD. SETTING AND DESIGN: This was a cross-sectional study, conducted in outpatient treatment setting, across six centers in India. MATERIALS AND METHODS: Participants were assessed using a semi-structured pro forma for sociodemographic information, clinical characteristics, the Children's Yale Brown Obsessive Compulsive Scale (CYBOCS), Structured Clinical Interview for Diagnostic and Statistical Manual, 5th Edition Research Version, Children's Depression Rating Scale, and Family Interview for Genetic Studies. RESULTS: The sample was largely male with a moderate illness severity. Nearly 75% of the sample had illness onset before the age of 14 years. Aggressive, contamination-related obsessions and washing, checking, and repeating compulsions were the most common symptoms. CYBOCS assessment revealed that >2/3rd of children and adolescents endorsed avoidance, pathological doubting, overvalued sense of responsibility, pervasive slowness, and indecisiveness. Family history and comorbidity rates were low. OC-related disorders were present in about 10% of the sample. CONCLUSIONS: This study suggests that the clinical characteristics of OCD in children and adolescents in developing countries differ on certain aspects as reported from developed countries.

Gender differences in obsessive-compulsive disorder: Findings from a multicentric study from India.

Obsessive-compulsive disorder (OCD) is phenotypically heterogeneous. Gender is an important factor mediating this heterogeneity. We examined gender differences in a large sample (n = 945) of OCD patients under a multi-centric study in India. Cross-sectional assessments were done on consecutive adult (>18 years) treatment-seeking patients with a DSM-5 diagnosis of OCD. Subjects were assessed on Structured Clinical Interview for DSM-5-Research Version for comorbid psychiatric illnesses, Yale Brown Obsessive Compulsive Scale for OCD phenomenology and symptom severity, Brown Assessment of Beliefs Scale for insight, Beck's Depression Inventory for severity of depressive symptoms, and the Obsessive Beliefs Questionnaire. On multivariate backward Wald logistic regression analysis, males (59.7%) had more years of education, had a higher rate of checking compulsions and comorbid substance use disorders. Women were more likely to be married, more commonly reported precipitating factors, had a higher rate of hoarding compulsions and comorbid agoraphobia. Findings from this large study validate gender as an important mediator of phenotypic heterogeneity in OCD. The mechanistic basis for these differences might involve complex interactions between biological, cultural and environmental factors.

Clinical course and treatment outcome of Koro: A follow up study from a Koro epidemic reported from West Bengal, India.

BACKGROUND: Koro, as a culture bound syndrome is predominantly reported from Asian countries. There is dearth of well-designed research focussing on course and outcome of Koro. METHOD: In the index study, 64 consecutive consenting patients with symptoms of Koro reported in different disciplines of a tertiary care Government Hospital of West Bengal were recruited over a period of 3 months. They were treated by standard treatment protocol and followed up for next 3 months. Data was collected on clinical course and treatment outcome by a pretested semi-structured proforma, specially developed for this study. RESULTS: A typical subject was a young single male, educated up to primary standard, agricultural worker by occupation and belonged to Hindu rural joint family. Among the whole sample 23% were female. Majority were referred from either private doctors or hospitals or government hospitals and reported first at non-psychiatric OPD. Dropout and recovery rates were 28% (male 33%, female 13%) and 89% (male 89%, female 92%) respectively. 20%, 75%, 9%, 31%, 19% of patients needed indoor admission, oral anxiolytics, injectable tranquilizers, specific pharmacological and psychosocial treatment, supportive medical treatment respectively. There was a subtle difference in course and treatment outcome noted between the genders. A new modality of psycho-sexual intervention 'sex education in vivo' was applied on patients of Koro with favourable result. CONCLUSION: Female counterpart represented a significant proportion. Overall improved trend of utilizing medical care facilities was observed. But sceptical attitude towards Psychiatric treatment is prevailing. An overall good treatment outcome was noted among the Koro victims.

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.

Association of insight, avoidance behavior, indecisiveness, and inflated responsibility with other clinical characteristics in children and adolescents with obsessive-compulsive disorder

Objectives: Although the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) includes ancillary symptom dimensions - insight, avoidance, degree of indecisiveness, inflated sense of responsibility, pervasive slowness/disturbance of inertia, and pathological doubting -, we know little about their clinical/scientific utility. We examined these ancillary dimensions in childhood obsessive-compulsive disorder (OCD), and tested their associations with clinical characteristics. Methods: Treatment-seeking children and adolescents (n=173) with a DSM-5 OCD diagnosis were recruited from six centers in India and evaluated with a semi-structured proforma for sociodemographic/clinical details, the Structured Clinical Interview for DSM-5, the CY-BOCS, the Children's Depression Rating Scale, and the Family Interview for Genetic Studies. Regression analysis was used to study the associations between ancillary dimensions (independent variables) and clinical variables (dependent variables). Results: 87.9% of the sample reported at least a mild-moderate severity of ancillary dimensions, which were highly intercorrelated. Multiple ancillary dimensions were correlated with illness severity on the CY-BOCS. On regression analysis, only insight and avoidance retained significance. There were few differential associations between OCD symptom and ancillary dimensions. Conclusion: Ancillary dimensions are more a feature of illness severity than differentially associated with individual symptom dimensions in childhood OCD. Insight and avoidance should be considered for inclusion in the assessment of illness severity in childhood OCD.