Emergency department visits for psychiatric care during the first lockdown in Melbourne.

OBJECTIVE: We investigated the nature of patients presenting to an emergency department (ED) during the first lockdown in Melbourne. METHOD: This study compared adult patients in the North West Area Mental Health Service catchment area who presented to the local ED during the lockdown (16 March-12 May 2020) and the control (16 March-12 May 2019) periods. RESULTS: The control and lockdown periods included 321 and 332 patients, respectively. Compared to the control period, patients with non-English speaking backgrounds and presenting complaints of suicidal behaviour were lower, whereas patients with anxiety symptoms and needing compulsory assessments were higher in the lockdown period. Diagnostically, the lockdown period included more patients with anxiety disorders, substance use disorders and psychotic disorders. CONCLUSIONS: ED access for acute psychiatric care can vary depending upon certain patient characteristics during lockdowns.

COVID-19 and ECT - a Victorian perspective.

OBJECTIVES: (i) to describe the operational strategies implemented to practise electroconvulsive therapy (ECT) safely, and (ii) to explore the effect of the lockdown and operational strategies on the characteristics of patients who received ECT during the initial 6 months of the COVID-19 lockdown. METHODS: At first, the operational strategies that were implemented at the Broadmeadows ECT suite were summarised. Subsequently, the characteristics of patients who received ECT in the lockdown period (16 March-16 September 2020) and in the comparison period (16 March-16 September 2019) were compared. RESULTS: Many safety measures were implemented, and there was no COVID-19 infection among mental health staff and patients. In the lockdown period, the number of patients (23.9%) and the total number of ECTs (29.4%) were less. This pattern was more prominent among the aged patients. CONCLUSION: Safe practices are essential to provide ECT during lockdowns even when the community transmission of COVID-19 is high.

An interpretative phenomenological analysis (IPA) of coercion towards community dwelling older adults with dementia: findings from Mysore studies of natal effects on ageing and health (MYNAH).

PURPOSE: Limited availability of specialist services places a considerable burden on caregivers of Persons with Dementia (PwD) in Low- and Middle-Income Countries (LMICs). There are limited qualitative data on coercive behavior towards PwD in an LMIC setting. AIM: The aim of this study was to find relevant themes of the lived experience of relatives as caregivers for PwD in view of their use of coercive measures in community setting in South India. METHOD: Primary caregivers (n = 13) of PwDs from the Mysore study of Natal effects on Ageing and Health (MYNAH) in South India were interviewed to explore the nature and impact of coercion towards community dwelling older adults with dementia. The narrative data were coded using an Interpretative Phenomenological Analysis (IPA) approach for thematic analysis and theory formation. RESULTS: Caregivers reported feeling physical and emotional burn-out, a lack of respite care, an absence of shared caregiving arrangements, limited knowledge of dementia, and a complete lack of community support services. They reported restrictions on their lives through not being able take employment, a poor social life, reduced income and job opportunities, and restricted movement that impacted on their physical and emotional well-being. Inappropriate use of sedatives, seclusion and environmental restraint, and restricted dietary intake, access to finances and participation in social events, was commonly reported methods of coercion used by caregivers towards PwD. Reasons given by caregivers for employing these coercive measures included safeguarding of the PwD and for the management of behavioral problems and physical health. CONCLUSION: There is an urgent need for training health and social care professionals to better understand the use of coercive measures and their impact on persons with dementia in India. It is feasible to conduct qualitative research using IPA in South India.

A 6-month study on the pattern of emergency department presentations for schizophrenia and other psychotic disorders during COVID-19 lockdown.

This study investigated the characteristics of patients with schizophrenia and other psychotic disorders presenting to emergency departments (ED) for psychiatric treatment during the first six months of the COVID-19 lockdown in Melbourne. This cross-sectional data-base study included adult patients in the North West Area Mental Health Service's catchment area who had visited two emergency departments (EDs) during the study period (March 16-September 16, 2020) and the control period (March 16-September 16, 2019). Compared to the control period (n = 467), the lockdown period (n = 451) had a 6.8% more psychotic disorders. This increase was particularly noted for schizophrenia and acute transient psychosis. In a sub-analysis of psychotic disorder group alone, compared to the control period, more patients were discharged to the community in the lockdown period. In another sub-analysis, compared to the mood disorder group, psychotic disorder group included more patients in 26-35 and 46-55 age groups, men, emergency triage category, and hospital admissions and higher mean duration of ED stay in the lockdown period. Overall, patients with psychotic disorders had increased ED presentations and appeared to be in an emergency state when they present to ED during the lockdown.

COVID-19 and psychiatric admissions: An observational study of the first six months of lockdown in Melbourne.

Research on the effect of a prolonged lockdown on inpatient admissions is limited. In this background, this study was planned, and it included patients admitted to inpatient units of a large mental health network in Melbourne during the lockdown (March 16-September 16, 2020) and a similar time period in 2019. The results showed a 12% decrease in admissions. The lockdown period included patients with lower mean age and more patients with never married status, higher education status, students and patients with home duties, and certain psychiatric diagnoses. Overall, the patients needing inpatient treatment during a prolonged lockdown are different.

Electroconvulsive therapy in the treatment of delirious mania: a report of 2 patients.

Delirious mania also known as Bell mania is a syndrome of excitement, delirium, and psychosis, of acute onset. We report 2 patients who presented with acute onset of disorientation, aggressive behavior, double incontinence, grandiose ideas, and auditory hallucinations. Results of investigations to rule out organic etiology such as computed tomographic scan of brain, cerebrospinal fluid examination, and biochemical parameters were normal. Creatine kinase levels were only moderately elevated. A provisional diagnosis of delirious mania was made, and patients were empirically started on electroconvulsive therapy (ECT) session. Delirium resolved by the second ECT session, unmasking manic symptoms, and recovered completely at the end of sixth ECT session. Prophylactic lithium was started, and both patients continue to be in remission after 1 year. Differential diagnosis of the above clinical presentation includes neuroleptic malignant syndrome and malignant catatonia. Delirious mania is clinically important owing to the potential for diagnostic confusion and good response to ECTs.

A comparative study of access to inpatient psychiatric treatment in a public mental health service in Melbourne during COVID-19.

INTRODUCTION: Given the paucity of research on how COVID-19 pandemic-associated lockdowns have affected the access to inpatient treatment, the present study was carried out. AIMS: This study aims to describe (1) the characteristics of patients who accessed inpatient treatment, (2) the length of inpatient stay and readmissions, and (3) the quality and safety of care as indicated by the type of admission (voluntary/compulsory) and seclusion use during the lockdown period. MATERIALS AND METHODS: For this comparative database study conducted at North West Area Mental Health Service, the study group included patients who had an admission between March 16, 2020 (starting of social distancing measures in Victoria) and May 12, 2020 (when easing [Stage 1] of social restrictions started). The control group included patients admitted between March 16, 2019, and May 12, 2019. The hospital databases were sources of information. RESULTS: The study and control groups included 104 and 109 patients, respectively. Compared to the control group, the study group had significantly more patients with separated relationship status, a lower number of severe mental illnesses (SMIs), a higher number of substance use disorders, and lower readmissions. A subanalysis within the lockdown period showed more voluntary admissions in the initial phase whereas more compulsory admissions in the later phase at trend significance. CONCLUSION: Patients with a separated relationship status and a substance use disorder sought inpatient treatment more than others. Aside from exploring the reasons for these findings, it is also important to investigate why SMIs and readmissions decreased during the lockdown period through further studies.

Clinical correlates of saccadic eye movement in antipsychotic-naïve schizophrenia.

Some aspects of saccadic performance have been found to be abnormal in chronic schizophrenia. The majority of this research has, however, been performed on patients treated with long-term antipsychotic medication. Very few studies have examined saccadic performance in antipsychotic-naïve/free patients. There are also very few studies describing the relationship between saccadic performance and clinical symptoms, particularly in antipsychotic free patients. In this study, we compared pro and antisaccade performance in a large sample of antipsychotic-naïve/free schizophrenia patients (N = 45) with healthy controls (N = 57). Clinical symptoms were assessed using Scale for Assessment of Positive Symptoms (SAPS) and Negative Symptoms (SANS). In the antisaccade task, patients made significantly more errors, and their correct antisaccades had smaller amplitudes in comparison to healthy controls. Higher error rates were associated with increased severity of hallucinations. In the prosaccade task, patients had less accurate final eye positions, and made saccades with slower latency and reduced amplitude compared to the healthy controls. These observations in schizophrenia patients without the potential confounds of antipsychotic treatment suggest intrinsic link between saccadic deficits and schizophrenia pathogenesis. The relationship between antisaccade errors and hallucination severity supports the potential link between hallucinations and deficits in inhibitory control.

Life course programming of stress responses in adolescents and young adults in India: Protocol of the Stress Responses in Adolescence and Vulnerability to Adult Non-communicable disease (SRAVANA) Study.

Background: Early life nutrition may affect individuals' susceptibility to adult non-communicable diseases (NCD). Psychological stress is a well-recognised NCD risk factor. Recent evidence suggests that impaired foetal nutrition alters neuro-endocrine pathways, and hypothalamic-pituitary-adrenal axis feedback systems, resulting in abnormal stress responses, and NCD risk. This study aims to examine adolescent cortisol and cardiovascular stress responses in relation to maternal nutrition and contemporaneous NCD risk markers. Methods: The study sample will be drawn from three well-established birth cohorts in India; the Parthenon cohort, Mysore (N=550, age~20y), the SARAS KIDS prenatal intervention cohort, Mumbai (N=300, age~10-12y) and the Pune Rural Intervention in Young Adults/ PRIYA cohort, Pune (N=100, age~22y). We will perform the 'Trier Social Stress Test (TSST)', a well-accepted stress-test module which involves participants performing 5-minutes each of public speaking and mental arithmetic tasks in front of unfamiliar 'judges' (stressor). Repeated measures of salivary cortisol and autonomic cardiovascular outcomes relative to the stressor will be assessed. Measures of psychological stress, cognitive function, blood pressure, glucose-insulin metabolism and depression will be carried out. Mechanistic studies including DNA methylation in gluco-corticoid receptor ( NR3C1) and 11ß-HSD2 gene loci and neuroimaging will be carried out in a subsample. Qualitative interviews and focus group discussions in a subsample of the Parthenon cohort will explore the perception of stress and stressors among the youth. We will convert repeated measures into time-weighted averages before analysis. We will carry out multivariable regression analysis to test the associations. We will further refine the analyses using the mixed-model regression and conditional analyses for the association with repeated measures.   Ethics and dissemination: This study has been approved by the research ethics committee of CSI Holdsworth Memorial Hospital, Mysore. The findings will be disseminated locally and at international meetings, and reports will be submitted to open access peer reviewed journals.

Neural Correlates of a Perspective-taking Task Using in a Realistic Three-dimmensional Environment Based Task: A Pilot Functional Magnetic Resonance Imaging Study.

OBJECTIVE: Perspective-taking ability is an essential spatial faculty that is of much interest in both health and neuropsychiatric disorders. There is limited data on the neural correlates of perspective taking in the context of a realistic three-dimensional environment. We report the results of a pilot study exploring the same in eight healthy volunteers. METHODS: Subjects underwent two runs of an experiment in a 3 Tesla magnetic resonance imaging (MRI) involving alternate blocks of a first-person perspective based allocentric object location memory task (OLMT), a third-person perspective based egocentric visual perspective taking task (VPRT), and a table task (TT) that served as a control. Difference in blood oxygen level dependant response during task performance was analyzed using Statistical Parametric Mapping software, version 12. Activations were considered significant if they survived family-wise error correction at the cluster level using a height threshold of p＜0.001, uncorrected at the voxel level. RESULTS: A significant difference in accuracy and reaction time based on task type was found. Subjects had significantly lower accuracy in VPRT compared to TT. Accuracy in the two active tasks was not significantly different. Subjects took significantly longer in the VPRT in comparison to TT. Reaction time in the two active tasks was not significantly different. Functional MRI revealed significantly higher activation in the bilateral visual cortex and left temporoparietal junction (TPJ) in VPRT compared to OLMT. CONCLUSION: The results underscore the importance of TPJ in egocentric manipulation in healthy controls in the context of reality-based spatial tasks.

Observational study of aggressive behaviour and coercion on an Indian acute ward.

OBJECTIVE: We evaluated prevalence of aggressive behaviour and coercive measures on an acute Indian psychiatric ward where relatives are always present at the ward. METHOD: Non-interacting, independent observers (specifically trained mental health clinicians) on an Indian acute, 20-bedded psychiatric ward gave structured reports on all violent episodes and coercive measures during a 30-day period. They used the Staff Observation Aggression Scale -Revised, Indian (SOAS-RI). The severity of the SOAS-RI reports were independently analysed by one of the authors. RESULTS: 229 violent incidents were recorded, involving 63% of admitted patients. 27% of all admitted patients were subjected to intravenous injections. Relatives provoked 35% of the incidents and were the target in 56% of the incidents. Patients own relatives were involved in managing the aggression in 35% of the incidents. Relatives of other patients were involved in 14% of the incidents. The likelihood of a patient to be physically restrained and that a relative would be participating in the coercive measures was increased when medical staff was targeted. CONCLUSION: Relatives are commonly triggers and victims of aggressions on the inverstigated acute Indian psychiatric wards. Doctors and nurses are less likely to be victims but aggression towards them leads more commonly to coercive measures.

Cognitive mapping deficits in schizophrenia: Evidence from clinical correlates of visuospatial transformations.

The 'cognitive mapping' component of spatial cognition, namely - the allocentric/egocentric function and its relation to symptoms in schizophrenia is relatively unexplored. In this study, we compared schizophrenia patients (N=44) to demographically-matched healthy controls (N=43) using computer-administered visuospatial transformation tasks with egocentric and allocentric components and analyzed their correlation with symptoms. Significant diagnosis X task-type interaction effect was seen on task accuracy. Patients performed significantly worse than controls in the allocentric letter rotation task (LRT) but not in the egocentric people rotation task (PRT). Accuracy in the LRT was significantly lesser than in PRT among patients but not among controls. Patients were significantly slower as compared to controls in both tasks. Both groups took longer to perform PRT as compared to LRT. LRT accuracy showed significant negative correlation with total positive symptoms as well as negative symptoms scores. Angle of rotation, perspective (front-facing/back-facing), orientation (mirrored/normal), and stimulus type (letter/number) were found to significantly influence performance in both groups of subjects. The present data support the finding that there is a differential impairment of allocentric abilities in schizophrenia patients. Further systematic research in this area may facilitate better understanding of schizophrenia pathogenesis.

Clinical correlates of parametric digit-symbol substitution test in schizophrenia.

Processing speed deficit, ascertained by digit-symbol substitution test (DSST), is considered as a fundamental impairment in schizophrenia. Clinical correlates of processing speed abnormalities, especially using the parametric version of DSST is yet to be evaluated comprehensively. In this study, we examined schizophrenia patients (N=66) and demographically matched healthy controls (N=72) using computer-administered parametric DSST (pDSST) with fixed (pDSSTF) as well as random (pDSSTR) conditions and analysed the relationship between pDSST performance and clinical symptoms. Psychopathology was assessed using Scale for Assessment of Positive Symptoms (SAPS)/Negative Symptoms (SANS) with good inter-rater reliability. In comparison with healthy controls, patients demonstrated significantly lesser number of correct responses (CN) in pDSSTF (t=8.0; p<0.001) and pDSSTR (t=7.8; p<0.001) as well as significantly prolonged reaction time in pDSSTF (t=7.1; p<0.001) and pDSSTR (t=7.0; p<0.001). The difference in CN between pDSSTF and pDSSTR [ΔCN] was significantly lesser in patients than healthy controls (t=2.61; p=0.01). The pDSST reaction time had significant positive correlation with negative syndrome scores as well as bizarre behaviour score. Significantly greater processing speed deficits in pDSST suggest potential relational memory/visual scanning abnormalities in schizophrenia. Furthermore, pDSST deficits demonstrated a significant association with the psychopathology, especially with the various negative symptoms and bizarre behaviour.

Thalamic shape abnormalities in antipsychotic naïve schizophrenia.

BACKGROUND: Neurodevelopmental hypothesis of schizophrenia states abnormal pruning as one of the pathogenetic mechanism in schizophrenia. Though thalamic volume abnormalities have been documented, the shape differences of thalamus in antipsychotic-free schizophrenia in comparison with age- and sex-matched healthy volunteers need validation. MATERIALS AND METHODS: We examined antipsychotic naïve schizophrenia patients (n=60) and age- and sex-matched healthy volunteers (n=44). The thalamic shape abnormalities were analyzed from their coded structural magnetic resonance imaging (MRI) data using three-dimensional automated image analysis software, FMRIB's (Oxford Center for the functional MRI of the brain) tools-FIRST (FMRIB's Integrated Registration and Segmentation Tool) by creating deformable mesh model. Correlation with the psychopathology scores was carried out using F-statistics. RESULTS: Patients with schizophrenia showed significant inward deformations in the regions corresponding to anterior, ventromedial, mediodorsal, and pulvinar nuclei. There was a direct correlation between negative syndrome score and the deformation in the right mediodorsal and right pulvinar nuclei. CONCLUSION: The inward deformations of thalamus in antipsychotic naive schizophrenia patients correspond to those nuclei which have reciprocal connections with frontal, superior temporal, and anterior cingulate regions and support the neurodevelopmental hypothesis of schizophrenia.

Off label use of lithium in the treatment of Huntington's disease: A case series.

Huntington's disease is characterized by choreic movements, psychiatric disorders, striatal atrophy with selective small neuronal loss, and autosomal dominant inheritance. The genetic abnormality is CAG expansion in Huntingtin gene. Newer therapeutic strategies are evolving to treat this progressive disorder. The neuroprotective agents are one such group of drugs being tried. Lithium has been used to treat Huntington's disease in the past due to its neuroprotective effects. Though the precise mechanism of action is not clear, Lithium can directly or indirectly modulate proteins involved in neuronal survival/differentiation which may account for its neuroprotective effects. We report three patients with Huntington's disease in whom Lithium prevented the progression of chorea and also helped stabilize mood.

Inferior parietal lobule volume and schneiderian first-rank symptoms in antipsychotic-naïve schizophrenia: a 3-tesla MRI study.

BACKGROUND: As per Frith's neuro-cognitive model, inferior parietal lobule (IPL) is implicated in the pathogenesis of Schneiderian first-rank symptoms (FRS) in schizophrenia. The specific role of IPL structural abnormalities in the pathogenesis of FRS is yet to be ascertained. MATERIALS AND METHODS: Using 3-tesla MRI scanner, this first-time study examined antipsychotic-naïve schizophrenia patients ( n = 28) (patients with FRS [FRS +]: N = 14, M: F = 7:7; and patients without FRS [FRS-]: N = 14, M: F = 7:7) in comparison with sex-, handedness-, education- and socioeconomic status-matched healthy controls (n = 14, M: F = 7:7). The volume of IPL was measured using a three-dimensional, interactive, semi-automated analysis, with good inter-rater reliability. RESULTS: FRS + patients showed significant volume deficit in right IPL in comparison with healthy controls (F = 4.0; P=.028) after controlling for the potential confounding effects of age, sex and intracranial volume. CONCLUSIONS: Right IPL volume deficit in FRS+patients adds further support to the Frith's model of FRS in schizophrenia.