Revisiting lorazepam challenge test: Clinical response with dose variations and utility for catatonia in a psychiatric emergency setting.

OBJECTIVE: Catatonia can be life-threatening unless timely identified and treated. Lorazepam's ubiquitous response has led to its universal acceptance as being the first-line management of catatonia and alludes to catatonia's neurobiological underpinnings. Lorazepam challenge test (LCT) is widely used to either confirm a catatonia diagnosis or determine lorazepam sensitivity. It has a proposed schedule for administering lorazepam. However, efficacy of recommended LCT doses lack systematic evidence, resulting in variable LCT doses used in clinical and research settings contributing to findings that are challenging to generalize or assist with developing standardized lorazepam treatment protocols for catatonia. Given the same, this study aimed to objectively compare the response between two groups receiving different LCT doses and factors influencing the same. METHODS: The 6-month study in a psychiatric emergency setting at a tertiary neuropsychiatric center in India evaluated 57 catatonia patients, before and after administration of single 2 mg (n = 37; LCT-2) or 4 mg (n = 20; LCT-4) lorazepam dose, applying Bush Francis Catatonia Rating Scale (BFCRS), Mini International Neuropsychiatric Interview (MINI 5.0) and obtaining sociodemographic, clinical data. RESULTS: No between-group differences (LCT-2 vs LCT-4) for sociodemographic, clinical profiles or BFCRS severity score changes to lorazepam on Mann-Whitney U test were noted. Applying Wilcoxon signed rank test comparing individual sign severity demonstrated response variability, with significant response noted to both doses (stupor, mutism, staring, posturing, withdrawal, ambitendency, automatic obedience) and others selectively to 2 mg (echolalia, rigidity, negativism, mitgehen). Notably, sign resolution (present/absent) only to 2 mg was significant for stupor, mutism, staring, posturing, echolalia, rigidity, negativism and mitgehen. CONCLUSION: This study suggests 2 mg lorazepam may be an optimal LCT dose, given significant response to most catatonic signs thereby ensuring accurate detection and preventing misinterpretation of response. It offers future studies direction for standardizing lorazepam dosing schedules for catatonia management and exploring neurobiological underpinnings for individual catatonic signs that may be potentially different, given these findings.

Panic disorder: Epidemiology, disability, and treatment gap from nationally representative general population of India.

Introduction: Panic disorder (PD) is one of the most common and debilitating anxiety disorder. Individuals with PD seek frequent healthcare and emergency services leading to frequent work absenteeism and economic burden. However, its prevalence patterns in the Indian context are poorly understood. Hence, this article discusses the epidemiology, disability, and treatment gap from India's National Mental Health Survey 2016. Materials and Methods: National Mental Health Survey 2016 was a nationally representative epidemiological survey of adult respondents from 12 states of India. Mini International Neuropsychiatric Interview 6.0.0 is used to diagnose psychiatric disorders. Sheehan disability scale was used to assess the disability. The current weighted prevalence of PD was estimated. Association between PD and its sociodemographic correlates was done using Firth penalized logistic regression. The treatment gap and disability in PD were also calculated. Results: The lifetime and current weighted prevalence of PD was 0.5% (95% confidence interval 0.49-0.52) and 0.3% (95% confidence interval 0.28-0.41), respectively. The male gender and unemployed have significantly lesser odds with current PD. The elderly, Urban metro, and the married/separated group have significantly higher odds with current PD. The most common comorbid psychiatric disorder is agoraphobia (42.3%) and depression (30.9%) followed by Generalized Anxiety Disorder (10%). Among respondents with current PD in the past 1 month across three domains, around 80% had a disability of any severity and 20%-25% had marked disability. The overall treatment gap of current PD is 71.7%. Conclusion: It is the first study reporting prevalence from a nationally representative sample from the general population of India. The survey has shed light on the epidemiology and the challenges faced by those with PD which emphasizes the urgency of bridging the treatment gap. These findings are paramount to the development of more inclusive and effective mental health policies and interventions to tackle the current burden due to PD.

Predictors of future suicide attempts in individuals with high suicide risk admitted to an acute psychiatry suicide intervention unit in India. A survival analysis study.

OBJECTIVE: Determination of suicide vulnerability remains challenging in mental illness. Variability in risk factors identified compound its poor predictability. Longitudinal studies, offering more reliable indices of risk, from developing countries are conspicuously limited. Furthermore, research advances allude to inherent vulnerability. This study, the first of its kind from India, consequently aimed to delineate factors influencing subsequent attempts in mental illness and acute suicidality. METHOD: Baseline and follow-up information (up to five years) was obtained from medical records of individuals (n = 130) with acute suicidality [recent attempt (first attempt/ reattempt) and high-risk ideators]. Variables were compared between individuals with, and without subsequent suicide attempts. Time to attempt and factors influencing the same was determined using survival analysis, and Cox proportional hazard for estimating the likelihood of a subsequent suicide attempt. RESULTS: Median duration of follow up of the sample (n = 130) was 23 months. The sample comprised of individuals with a recent attempt (first-time attempt), recent reattempt and recent high-risk ideators. Subsequent suicide attempts were noted in 30 (23.1 %) patients. Baseline sociodemographic and clinical variables, including suicidality, could not differentiate individuals with a subsequent suicide attempt. Survival analysis indicated that 65 % of subsequent attempts occurred within 9 months of discharge. Family history of suicide and the presence of impulsive-aggressive traits were associated with both, reduced survival time and overall increased risk of a subsequent suicide attempt. CONCLUSION: This study delineates both, the time frame associated with greatest risk, as well as individuals most likely to reattempt suicide. It thereby offers insights into potential windows of opportunity to mitigate prospective suicide risk. Strategies such as enhanced after-care and integrating specific interventions to attenuate impulsive-aggressive behaviors could be a focus to prevent future attempts, thereby decreasing rates of suicide amongst those with mental illness. Furthermore, the findings of this study reaffirm the role of factors that independently confer vulnerability to suicide. Traversing noted regional variations, the findings importantly reinforce the distinct pathophysiological underpinnings of suicide in mental illness.

Suicide prevention in the context of COVID-19: An Indian perspective.

The ongoing COVID-19 pandemic has impacted the health and wellbeing of communities worldwide. Measures to limit transmission, have enhanced vulnerability of individuals to well identified risk factors associated with mental illness and suicide. These include a sense of loneliness, anxiety, depression, insomnia, PTSD, harmful alcohol and drug use. Given that the potential for increased rates of suicide persist, the suicide prevention agenda remains urgent and essential. The same is one of the cornerstones of resilience in a society that is facing an array of challenges due to the pandemic. In this article, we recommend few possible strategies for attenuating suicide risk amidst the COVID-19 pandemic with particular relevance to the Indian context.

"Kundalini-like experience as psychopathology: A case series and brief review".

Kundalini concept comes from ancient yogic philosophy in which it is believed that certain spiritual practices will cause Kundalini awakening. The phenomenon of Kundalini awakening can sometimes mimic mental illness and results in difficulty for mental health practitioners to distinguish between them. While there are ample literatures suggesting the benefits of yogic practices in mental illness, it is also worth understanding the side effects of these practices, especially if advanced yogic practices are not performed properly with necessary preparations and precautions under the guidance of an expert. In this context, we discuss a series of cases demonstrating altered mental experiences related to Kundalini, from both modern psycho-pathology and traditional yoga view points and try to differentiate severe mental illness from advanced spiritual states perceived after practicing Kundalini yoga.

Diagnosing catatonia and its dimensions: Cluster analysis and factor solution using the Bush Francis Catatonia Rating Scale (BFCRS).

Advances in research into catatonia in the preceding two decades has offered increasing clarity and an improved understanding of various aspects of this complex syndrome. Despite the above, there are several aspects that hinder a broader interpretation of these findings, the most common being a lack of consensus on the criteria required for diagnosing catatonia. Whilst being the most frequently used tool for diagnosis, the number of signs from Bush-Francis Catatonia Rating Scale (BFCRS) needed to diagnose catatonia remain unclear. This study aimed to determine the number of signs required to accurately diagnose catatonia using BFCRS and delineate its dimensions in an acute inpatient unit in the Indian setting. A random sample of 300 patients were evaluated for catatonia within 24 h of admission. Cluster Analysis followed by discriminant analysis and receiver operating curve analysis (ROC) provided cut-off values for diagnosing catatonia syndrome. Principle Component Analysis (PCA) with varimax rotation was used to identify factors in those with catatonia. Findings revealed that a cut off of two signs from both Bush-Francis Catatonia Screening Instrument or BFCSI (sensitivity of 100 %, specificity of 96.2 % as well as a positive predictive value [PPV] of 79.6 % and negative predictive value [NPV] 100 % with ROC AUC value of 0.98) and complete BFCRS (sensitivity of 100 % and specificity of 90.7 %, PPV of 80.7 and NPV of 100 % with ROC AUC for at least two items cut-off being 0.95) accurately detected catatonia. However, the prevalence of catatonia in the same population increased by 4% from 16.3% to 20.3% using the BFCRS rather than the BFCSI. The BFCRS generated a 3-factor model accounting for 65.48 % variance offering the best fit, indicating three discrete dimensions to catatonia, namely retarded, excited and what we named as "aberrant volitional". Interestingly, the aberrant volitional dimension comprises of signs that need to be elicited rather than passively observed and excluding one, none of them are part of the BFCSI. Findings of this study suggest that the BFCRS more accurately detects catatonia rather than the BFCSI. Additionally, three dimensions of catatonia more coherently explain the catatonic syndrome given that 55.7 % of the sample had signs from more than one factor concurrently. We propose that the BFCRS rather than BFCSI be routinely administered for evaluating all suspected cases of catatonia to ensure more accurate detection as well as identifying the aberrant volitional dimensional signs more consistently. The three-dimensional model also offers great opportunities to further unravel the pathophysiological basis of catatonic signs more systematically.