Long-term Outcomes of Intensive Inpatient Care for Severe, Resistant Obsessive-Compulsive Disorder: Résultats à long terme de soins intensifs à des patients hospitalisés pour un trouble obsessionnel-compulsif grave et résistant.

OBJECTIVE: A substantial proportion of severely ill patients with obsessive-compulsive disorder (OCD) do not respond to serotonin reuptake inhibitors (SRIs) and are unable to practice cognitive behavioral therapy (CBT) on an out-patient basis. We report the short-term (at discharge) and long-term (up to 2 years) outcome of a multimodal inpatient treatment program that included therapist-assisted intensive CBT with adjunctive pharmacotherapy for severely ill OCD patients who are often resistant to SRIs and are either unresponsive or unable to practice outpatient CBT. METHODS: A total of 420 patients, admitted between January 2012 and December 2017 were eligible for the analysis. They were evaluated using the Mini International Neuropsychiatric Interview, the Yale-Brown Obsessive Compulsive Scale (YBOCS), and the Clinical Global Impression (CGI) scale. All patients received 4 to 5 therapist-assisted CBT sessions per week along with standard pharmacotherapy. Naturalistic follow-up information at 3, 6, 12, and 24 months were recorded. RESULTS: At baseline, patients were mostly severely ill (YBOCS = 29.9 ± 4.5) and nonresponsive to ≥2 SRIs (83%). Mean duration of inpatient stay was 42.7 ± 25.3 days. At discharge, there was a significant decline in the mean YBOCS score (29.9 ± 4.5 vs. 18.1 ± 7.7, P < .001, Cohen's d = 1.64); 211/420 (50%) were responders (≥35% YBOCS reduction and CGI-I≤2) and an additional 86/420 (21%) were partial responders (25% to 35% YBOCS reduction and CGI-I≤3). Using latent class growth modeling of the follow-up data, 4 distinct classes were identified, which include "remitters" (14.5%), "responders" (36.5%), "minimal responders" (34.7%), and "nonresponders" (14.6%). Shorter duration of illness, better insight, and lesser contamination/washing symptoms predicted better response in both short- and long-term follow-up. CONCLUSION: Intensive, inpatient-based care for OCD may be an effective option for patients with severe OCD and should be considered routinely in those who do not respond with outpatient treatment.

Use of Family CAGE-AID questionnaire to screen the family members for diagnosis of substance dependence.

BACKGROUND & OBJECTIVES: CAGE-AID questionnaire is a short, useful screening tool for substance dependence. Assessment of one family member for the screening of substance dependence in the family could be useful in clinical practice and research. In this study, we aimed to assess the validity of the Family CAGE-AID questionnaire for the diagnosis of substance dependence. METHODS: Cross-sectional assessments using CAGE-AID and Family CAGE-AID questionnaires were conducted both for the study participants (n = 210) and their family members. The participants were recruited from two different treatment settings: a treatment seeking population from a de-addiction centre, and non-treatment seekers for substance use disorders from the psychiatry outpatient department. ICD-10 criteria and subsequent detailed clinical interview by a trained psychiatrist were used for the final diagnosis of substance dependence. RESULTS: In the psychiatry outpatient group, the scores on CAGE-AID and Family CAGE-AID questionnaires were significantly correlated with the ICD-10 symptom score (r=0.81 and 0.70, respectively). In the same group, inter-rater agreement of the Family CAGE-AID was good with CAGE-AID and moderate with ICD-10 diagnosis of substance dependence (Cohen's kappa 0.78 and 0.61, respectively). A cut-off score of three on Family CAGE-AID was found to be 95·8 per cent sensitive and 100 per cent specific. INTERPRETATION & CONCLUSIONS: Family CAGE-AID questionnaire is a valid screening instrument for the diagnosis of substance dependence, with acceptable sensitivity and specificity of a cut-off score of three. The simplicity and the brevity of such an instrument can be valuable in the clinical settings of developing countries and also for epidemiological studies.

Influence of religion and supernatural beliefs on clinical manifestation and treatment practices in patients with bipolar disorder.

BACKGROUND: Religious and supernatural beliefs influence help seeking and treatment practices in bipolar disorder, but these are rarely explored by clinicians. This study aimed to understand religiousness, magico-religious beliefs, prevalence of religious and supernatural psychopathology and treatment practices among patients with bipolar disorder in euthymic state. METHODOLOGY: A total of 185 patients of bipolar disorder currently in remission were assessed cross-sectionally for their clinical profile, current clinical status on the Hamilton Depression Rating Sscale (HDRS), Young Mania Rating Scale (YMRS) and the Global Assessment of Functioning (GAF). A semi structured instrument for magico-religious beliefs, aetiological models, treatment seeking and treatment practices was administered. RESULTS: More than a third of patients (37.8%) had psychopathology with either religious or supernatural content or both in their lifetime. Almost half (45.4%) the patients believed in a supernatural/religious aetiology for their illness. Among the specific causes, planetary influences (13.5%) and God's will (30.8%) were the most common supernatural and religious cause, respectively. Almost half (44.3%) of patients had first treatment contact with religious/supernatural treatment providers. More than 90% of patients reported belief in God, yet about 70% reported that their doctors did not ask them sufficient questions to understand their religiosity. CONCLUSION: Magico-religious beliefs are common in bipolar disorder and a large number of patients attribute these as aetiological factors for their illness. Consequently they tend to seek treatment from traditional practitioners prior to approaching medical practitioners and may continue treatment with them alongside medical management.

Combined use of clozapine and ECT: a review.

OBJECTIVE: This paper aims to review the available evidence for the use of clozapine and electroconvulsive therapy (ECT) in combination. METHODOLOGY: Electronic searches were carried out to identify reports describing the combined use of clozapine and ECT. RESULTS: Forty reports including 208 patients were identified. The majority of reports were in the form of case reports and case series, with few retrospective and open-label studies. The majority of patients were aged between 18 and 65 years and diagnosed with schizophrenia or schizoaffective disorder. Most of the patients refractory to clozapine were started on ECT as an augmentation therapy; however, in some reports, both ECT and clozapine were started concurrently, and in few cases clozapine was started after ECT. In terms of effectiveness, 37.5-100% patients improved in short-term, and sustained long-term improvement (3 weeks to 24 months) was described in few studies. In terms of the side-effect profile, five patients each had delirium and tachycardia and only four patients were described to have prolonged seizures. Overall, the combination was considered effective and safe. CONCLUSION: There is evidence for the effectiveness and safety of the clozapine-ECT combination and it should be used in patients with treatment-resistant schizophrenia who do not respond to clozapine.

A Cross-Sectional Comparative Study of Sleep Disturbances in Children with ADHD and Matched Controls.

Background: Systematic reviews conducted on sleep disturbances in attention deficit hyperactivity disorder (ADHD) have found inconsistent results due to the presence of several moderating variables which were not controlled for in previous studies. The aim of this study was to examine sleep disturbances in children with ADHD compared to their typically developing peers after controlling for moderating variables (age, sex, medication status, body mass index, and psychiatric and medical comorbidities). Methods: ADHD was diagnosed using DSM-IV-TR criteria (Diagnostic and Statistical Manual of Mental Disorders) and Conners' Parent Rating Scales. Children recruited (aged 6−12 years) for the ADHD group (n = 40) met the following criteria: IQ > 80, unmedicated, and no psychiatric or medical comorbidities. The control group consisted of age- and sex-matched typically developing peers (n = 40). Sleep was assessed subjectively (through parent reported questionnaires and sleep logs) and objectively (using video polysomnography). Results: 65% of children with ADHD had a sleep disorder, as compared to 17% of controls. The ADHD group reported more sleep disturbances and disorders, both on subjective measures and objective measures. Conclusions: Sleep disturbances and primary sleep disorders in children with ADHD exist independent of moderating variables and differences in sleep assessment methods, thereby bolstering support for previously documented literature on the ADHD and sleep connection.

Internalized Stigma and Psychiatric Morbidity among Patients with Psoriasis: A Study from North India.

BACKGROUND: Psoriasis is a chronic inflammatory dermatosis associated with psychological morbidity. Like mental illness, it is also associated with stigma. Very few studies from India have evaluated stigma experienced by patients with psoriasis. AIM OF THE STUDY: To study stigma in patients with psoriasis (in the form of internalized stigma, perceived stigma, and social-participation-restriction stigma) and its relationship with demographic and clinical variables. METHODOLOGY: 104 patients with psoriasis assessed on the internalized stigma of mental illness scale (ISMIS), explanatory model interview catalogue stigma scale, participation scale (P-scale), perceived social support, total score of Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder (GAD-7) scale, Dermatology Life Quality Index, and Psoriasis disability index. RESULTS: On ISMIS, overall, 27.9% had experienced stigma. On domains, majority of the participants experienced discrimination (52.9%) followed by stigma resistance (51.9%), stereotype (26.0%), social withdrawal (24.1%), and alienation (23.1%). Majority of them reported mild restriction. As per the evaluation by a qualified psychiatrist, about 30% of the participants had at least one psychiatric diagnosis. On comparison, those with the presence of co-morbid psychiatric illness experienced a higher level of stigma on each domain of ISMIS except discrimination and stigma resistance. Lower social support was associated with higher stigma in all the domains. All the domains of ISMIS except discrimination and stigma resistance were associated with a higher level of anxiety and depression, poor quality of life, and higher disability. CONCLUSION: The patients with psoriasis experience a significant amount of stigma and stigma is associated with the presence of psychiatric morbidity, lower social support, higher restriction, and more disability.

Stigma Experienced by the Caregivers of Patients with Chronic Plaque Psoriasis.

BACKGROUND: Psoriasis is a chronic inflammatory dermatosis associated with psychological morbidity. Very few studies have evaluated stigma among caregivers of patients with psoriasis. OBJECTIVE: This study aimed to evaluate the prevalence of stigma and its correlates among the caregivers of patients with psoriasis. METHODOLOGY: Forty-nine caregivers of patients with psoriasis were evaluated on psoriasis adapted version of caregiver of people with mental illness (CPMI) to assess internalized stigma, Explanatory Model Interview Catalogue Stigma Scale, Family Burden Inventory (FBI), Multidimensional aspect of perceived social support scale (PSS), Cognitive behavioral avoidance scale (CBAS), and Coping checklist. RESULTS: Majority of the caregivers were either spouse (42.8%) or parents (36.7%) of the patients. The caregivers were involved in the care of the patients for a mean duration of 6.5(SD; 4.8) years. On CPMI, the mean score was highest for the affective domain (3.1), this was followed by affective (2.9), and behavioral (2.9) domain. Very few (12.2%) caregivers reported significantly high caregiver burden. A higher level of stigma was associated with more often use of avoidance coping. Presence of higher social support was associated with higher level of stigma as assessed by using CPMI. A higher level of caregiver burden in all the domains of FBI was associated with higher level of stigma. CONCLUSION: Stigma is highly prevalent among the caregivers of patients with psoriasis. These findings suggest that there is an urgent need to identify the stigma and address the same.

Transcranial direct current stimulation for treatment-resistant obsessive-compulsive disorder-A large case series.

OBJECTIVE: The present study is a large case series evaluating the benefits of transcranial direct current stimulation (tDCS) in treatment-resistant obsessive compulsive disorder (OCD). METHODS: We reviewed the charts of 32 patients with treatment-resistant OCD who received 10-20 sessions of anodal pre-SMA tDCS. RESULTS: Overall, 9 (28 %) showed at least partial response to tDCS at the end of 10-20 sessions [responders = 8 (25 %), partial responders = 1 (3%)]. Two out of three partial responders at the end of 10 sessions had response at the end of 20 sessions. CONCLUSIONS: tDCS may benefit a proportion of patients with treatment-resistant OCD.

Tolerance of transcranial direct current stimulation in psychiatric disorders: An analysis of 2000+ sessions.

Transcranial direct current stimulation (tDCS), a non-invasive, neuromodulatory technique, is being increasingly applied to several psychiatric disorders. In this study, we describe the side-effect profile of repeated tDCS sessions (N = 2005) that were administered to 171 patients (156 adults and 15 adolescents) with different psychiatric disorders [schizophrenia [N = 109], obsessive-compulsive disorder [N = 28], alcohol dependence syndrome [N = 13], mild cognitive impairment [N = 10], depression [N = 6], dementia [N = 2] and other disorders [N = 3]]. tDCS was administered at a constant current strength of 2 mA with additional ramp-up and ramp-down phase of 20 s each at the beginning and end of the session, respectively. Other tDCS protocol parameters were: schizophrenia and obsessive-compulsive disorder: 5-days of twice-daily 20-min sessions with an inter-session interval of 3-h; Mild cognitive impairment/dementia and alcohol dependence syndrome: at least 5-days of once-daily 20-min session; Depression: 10-days of once-daily 30 min session. At the end of each tDCS session, any adverse event observed by the administrator and/or reported by the patient was systematically assessed using a comprehensive questionnaire. The commonly reported adverse events during tDCS included burning sensations (16.2%), skin redness (12.3%), scalp pain (10.1%), itching (6.7%), and tingling (6.3%). Most of the adverse events were noted to be mild, transient and well-tolerated. In summary, our observations suggest that tDCS is a safe mode for therapeutic non-invasive neuromodulation in psychiatric disorders in adults as well as the adolescent population.

Neuroimaging findings in obsessive-compulsive disorder: A narrative review to elucidate neurobiological underpinnings.

Obsessive compulsive disorder (OCD) is a common psychiatric illness and significant research has been ongoing to understand its neurobiological basis. Neuroimaging studies right from the 1980s have revealed significant differences between OCD patients and healthy controls. Initial imaging findings showing hyperactivity in the prefrontal cortex (mainly orbitofrontal cortex), anterior cingulate cortex and caudate nucleus led to the postulation of the cortico-striato-thalamo-cortical (CSTC) model for the neurobiology of OCD. However, in the last two decades emerging evidence suggests the involvement of widespread associative networks, including regions of the parietal cortex, limbic areas (including amygdala) and cerebellum. This narrative review discusses findings from structural [Magnetic Resonance Imaging (MRI), Diffusion Tensor Imaging(DTI)], functional [(functional MRI (fMRI), Single photon emission computed tomography (SPECT), Positron emission tomography (PET), functional near-infrared spectroscopy (fNIRS)], combined structural and functional imaging studies and meta-analyses. Subsequently, we collate these findings to describe the neurobiology of OCD including CSTC circuit, limbic system, parietal cortex, cerebellum, default mode network and salience network. In future, neuroimaging may emerge as a valuable tool for personalised medicine in OCD treatment.

Stigma and its Correlates among Caregivers of Patients with Bipolar Disorder.

BACKGROUND: Stigma associated with mental illness is multifaceted, and it extends to even those who take care of the afflicted persons. Research shows that stigma has maximal impact on patients who have schizophrenia and their caregivers, but information pertaining to caregivers of patients with bipolar disorder is minimal. Accordingly, this study aimed to evaluate stigma and its correlates among caregivers of patients with bipolar disorder. METHODOLOGY: This cross-sectional study conducted at a tertiary care hospital purposively enrolled 103 caregivers of patients with bipolar disorder-I. The caregivers were assessed on the stigma scale for caregivers of people with mental illness (CPMI) and the Explanatory Model Interview Catalogue (EMIC) stigma scale. RESULTS: The majority of caregivers attributed the illness of the patient to stress (54.4%), chemical imbalance (48.5%), or heredity (29.1%), while nearly one-fourth believed it to be the will of God. The mean weighted scores on various domains of CPMI were comparable [affective domain = 2.24 (standard deviation (SD) = 0.51); cognitive domain = 2.25 (SD = 0.54) and behavioral domain = 2.23 (SD = 0.55)]. The mean score on EMIC was 28.00 (SD = 14.57). Caregivers with low income reported higher stigma in affective and cognitive domains. Also, lesser time spent with the patient correlated with higher stigma in the affective domain. Furthermore, poor functioning of the patient was associated with high caregiver stigma in cognitive and behavioral domains. CONCLUSION: Caregivers of patients with bipolar disorder experience significant affiliate and courtesy stigma, and higher stigma is associated with lower income of the caregivers and lesser time spent in caregiving.

Efficacy of pre-supplementary motor area transcranial direct current stimulation for treatment resistant obsessive compulsive disorder: A randomized, double blinded, sham controlled trial.

BACKGROUND: A significant proportion of obsessive compulsive disorder (OCD) patients do not respond to specific serotonin reuptake inhibitors (SSRIs). There is a need to evaluate novel treatment options for OCD. OBJECTIVE: In this double blinded, randomized, sham controlled study, we investigated the efficacy of add-on transcranial direct current stimulation (tDCS) in reducing the symptoms in SSRI-resistant OCD patients by employing anodal pre-supplementary motor area (pre-SMA) stimulation. METHOD: Twenty-five patients with DSM-IV OCD having persistent symptoms despite adequate and stable treatment with at least one SSRI were randomly allocated to receive 20 min of verum (active) 2-mA tDCS or sham stimulation twice daily on 5 consecutive days [anode over Pre-SMA; cathode over right supra-orbital area]. Response to treatment was defined as at least 35% reduction in the Yale-Brown Obsessive-Compulsive Scale (YBOCS) total score along with a Clinical Global Impression - Improvement (CGI-I) score of 1 (very much improved) or 2 (much improved). RESULTS: The response rate was significantly greater in the verum tDCS(4 out of 12) compared to sham-tDCS (0 out of 13) [Fisher's exact test, p = 0.04]. Repeated measures analysis of variance with tDCS type (verum vs. sham) as between subjects factor showed that there was a significant tDCS-type X time-point interaction with significantly greater reduction of YBOCS total score [F (1,22) = 4.95,p = 0.04,partial-η2 = 0.18] in verum-tDCS group. CONCLUSIONS: The results of this RCT suggest that tDCS may be effective in treating SSRI-resistant OCD. Future studies should examine the efficacy in larger samples of OCD and explore other potential target regions using randomized sham-controlled designs, in addition to examining the sustainability of the beneficial effects. TRIAL REGISTRATION: Clinical Trials Registry India (http://ctri.nic.in/Clinicaltrials/login.php): Registration Number- CTRI/2016/04/006837).

Prevalence of dual diagnosis among clinic attending patients in a de-addiction centre of a tertiary care hospital.

BACKGROUND & AIMS: Indian research on dual diagnosis is mostly on prevalence of co-morbidity in a particular type of substance use disorder or psychiatric disorder. They were not on overall prevalence of dual diagnosis in a clinical sample. The study aims to assess prevalence of dual diagnosis among first time visitors to a tertiary care deaddiction centre. METHODOLOGY: The study participants were recruited using computer-generated random number table from 10th Apr 2013 to 28 June 2013 from a deaddiction centre in North India. Psychiatric diagnosis was done by qualified psychiatrist and confirmed by Mini International Neuropsychiatric Interview (M.I.N.I.). RESULTS: One seventy nine participants were recruited during the study period. The prevalence of dual diagnosis was 58 (32.4%). Affective disorder group 22 (12.3%) is the most common group followed by anxiety disorders group 20 (11.2%) and psychotic disorder group 9 (5.0%). Duration of use and dependence (in months) of alcohol, opioids, and nicotine was shorter and of cannabis and benzodiazepines was longer in dual diagnosis group compared to non dual diagnosis group. CONCLUSIONS: This study screened the largest number of substance use disorders patients visiting a tertiary care centre in India using a sound methodology. The study reported that nearly one third of substance use disorder patients are cases of dual diagnosis. The prevalence reported in our study is lower than reported in some western hospital based and community based studies.

Effectiveness of electroconvulsive therapy in patients with treatment resistant schizophrenia: A retrospective study.

This study aimed to evaluate the effectiveness of electroconvulsive therapy (ECT) among patients with treatment resistant schizophrenia (TRS). Records of patients who had received ECT were reviewed to identify patients with TRS who were administered ECT in combination with clozapine. Socio-demographic, clinical data and ECT details were extracted. The most common diagnosis was of paranoid schizophrenia (49%) followed by undifferentiated schizophrenia (36%). A-fifth (22%) of the patients were judged to have poor response to clozapine. The mean number of ECTs given were 13.97 (SD-7.67) and mean clozapine dose was 287.5mgs/day (SD-100.1). About two-thirds (63%) of the patients showed >30% reduction in scores on different symptom-rating scales with combined use of clozapine and ECT. Among clozapine non-responders, approximately 69% responded to the combination. Post-ECT rise in blood pressure was the most common side effect (16.9%) followed by prolonged seizures (7%). Long-term follow-up data was available for 47 out of the 59 patients. More than two-third (N=34; 72%) followed-up for an average of 30 months (SD 32.3; range: 1-120), maintained well with continued clozapine treatment. To conclude, results of this study further endorse the effectiveness, safety and long-term benefits of the clozapine-ECT combination in TRS and clozapine-refractory schizophrenia.

Choking Phobia : An Uncommon Phobic Disorder, Treated with Behavior Therapy : A Case Report and Review of the Literature.

Choking phobia is a relatively uncommon phobic disorder which is often encountered by otorhinolaryngologists and referred to psychiatrists as a cause of psychogenic dysphagia. If not diagnosed early and treated appropriately, it can have severe detrimental effects on the physical and psychological health of an individual. We present a case of a 20 year old female who presented with choking phobia and was treated with behavior therapy. Additionally, we discuss the differential diagnosis and treatment strategies of this rare anxiety disorder.

Metabolic Disturbances, Side Effect Profile and Effectiveness of Clozapine in Adolescents.

INTRODUCTION: Data on effect of clozapine on metabolic syndrome in adolescent patients with psychosis are limited. This study aimed to evaluate the prevalence and incidence of metabolic syndrome in children and adolescents with psychotic disorders prior to clozapine and while receiving clozapine. Secondary aims were to study the effectiveness and side effect profile of clozapine. MATERIALS AND METHODS: Thirteen child and adolescent patients were evaluated at baseline, 3 months, and a follow-up beyond 6 months. Assessments were made for metabolic profile, effectiveness by positive and negative syndrome scale (PANSS), and side effects. RESULTS: Prior to starting of clozapine, the prevalence of metabolic syndrome was 23%. After 3 months on clozapine, 38.5% (5/13) patients fulfilled criteria of metabolic syndrome and further on follow-up beyond 6 months (with last observation carried forward) 46.2% (6/13) had developed metabolic syndrome. There was a significant reduction in PANSS scores at 3 months and follow-up more so in those who developed metabolic syndrome at 3 months. Among the other side effects, hypersalivation was the most common side effect (100%) followed by sedation (69%). CONCLUSION: Half the prevalence of metabolic syndrome in adolescents on clozapine can be attributed to other factors prior to starting of clozapine, and another half can be attributed to clozapine. Clozapine is effective in an adolescent population.

Predictors of response to serotonin reuptake inhibitors in obsessive-compulsive disorder.

INTRODUCTION: 40-60% of patients with obsessive compulsive disorder (OCD) do not respond adequately to serotonin reuptake inhibitors (SRIs). It is important to identify predictors of response to help individualize treatment and identify refractory patients early in the course of treatment. AREAS COVERED: We review the current literature on predictors of response to SRIs in adult patients with OCD including clinical features, neuropsychological profile, neuroimaging, genetics and other biological factors. We conducted a literature search in PUBMED database using the MeSH terms 'Obsessive-Compulsive Disorder', 'drug therapy', 'treatment outcome', 'neuroimaging', 'genetics' 'cytokines' and obtained 60 articles. Expert commentary: Poor-insight into obsessions, symmetry/hoarding and contamination/washing dimension and the presence of certain personality disorders are associated with poor response to SRIs. Orbitofrontal cortex, anterior cingulate cortex, caudate, putamen and thalamus volume changes in structural imaging studies and altered activity in the same regions in functional imaging studies were found predictive of poor response. However, there is inconsistency with regards to direction of change. Genes involving serotonergic and glutamatergic signalling pathways have emerged as predictors in recent studies. Studies with large sample size, standardised methodology and rigorous statistical analyses are required before predictors can be utilised in routine clinical practice.

Recovery and its correlates among patients with bipolar disorder: A study from a tertiary care centre in North India.

BACKGROUND AND AIM: The goal of treatment in mental illness has evolved from a symptom-based approach to a personal recovery-based approach. The aim of this study was to evaluate the predictors of personal recovery among patients with bipolar disorder. METHODOLOGY: A total of 185 patients with bipolar disorder, currently in remission, were evaluated on Recovery Assessment Scale (RAS), Internalized Stigma of Mental Illness Scale (ISMIS), Brief Religious coping scale (RCOPE), Duke University Religiosity Index (DUREL), Religiousness Measures Scale, Hamilton depression rating scale (HDRS), Young Mania rating scale (YMRS) and Global Assessment of Functioning (GAF) scale. RESULTS: The mean age of the sample was 40.5 (standard deviation (SD), 11.26) years. Majority of the participants were male, married, working, Hindu by religion and belonged to extended/joint families of urban background. In the regression analysis, RAS scores were predicted significantly by discrimination experience, stereotype endorsement and alienation domains of ISMIS, level of functioning as assessed by GAF, residual depressive symptoms as assessed by HDRS and occupational status. The level of variance explained for total RAS score and various RAS domains ranged from 36.2% to 46.9%. CONCLUSION: This study suggests that personal recovery among patients with bipolar disorder is affected by stigma, level of functioning, residual depressive symptoms and employment status of patients with bipolar disorder.