Benzodiazepine use in medical out-patient clinics: a study from a developing country.

OBJECTIVE: To estimate the prevalence of Benzodiazepine use in the outpatient setting of general medicine clinics at a single tertiary care centre. METHODS: The prospective prevalence study was conducted in the outpatient setting of Internal Medicine Clinics at Aga Khan University Hospital, Karachi, from November to December 2009. All subjects were interviewed after informed consent and variables were recorded on a specially-designed proforma. Apart from basic demographics and comorbid conditions, duration, frequency and route of benzodiazepine use, as well as the reason and who initiated it was noted. Chi-square test and t test was applied to see the association of socio demographic or clinical factors with the use of benzodiazepine. RESULTS: Of the 355 patients, 129 (36.33%) reported using the drug. The majority (n=86; 24.2%) were taking it on a daily basis. The highest numbers of patients using the drug were suffering from cardiovascular problems, 32 (25%) followed by 22 (17%) from endocrinology. Diazepam equivalent dose was around 7.04+4, with a inter-quartile range of 3-96 weeks. Alprazolam (9%) was the most frequently prescribed Benzodiazepine. CONCLUSION: Benzodiazepine use is alarmingly high in the outpatient clinics of General Internal Medicine Department. There is no implementation of law to prevent its hazardous sale. In this regard all concerned should work collectively for awareness and irrational drug sale and use.

Antipsychotic treatment and weight gain: does risperidone behave differently in Pakistani psychiatric patients?

BACKGROUND: Studies from the Western world have shown that antipsychotic medications in psychiatric patients result in weight gain and other metabolic diseases. This study was undertaken to investigate whether any one of the five most commonly prescribed antipsychotics, (risperidone, olanzepine, trifluoperazine, quetiapine and haloperidol) could behave differently in terms of causing weight gain among patients attending the psychiatric outpatient clinics in a tertiary care hospital in Karachi, Pakistan. METHODS: For this retrospective cohort study, data were collected from outpatient records of the Aga Khan University Hospital, from 2003 to 2007. Demographic and clinical data were analysed. Repeated measures ANOVA, using a linear mixed model approach was used to assess weight gain over time due to the use of antipsychotic medications. RESULTS: A total of 124 subject records (68 males and 56 females) were evaluated. One-way ANOVA revealed that the groups being prescribed with antipsychotics were comparable with respect to age, duration of treatment and weight measurements. Frequencies were calculated which showed that weight increases significantly over time with respect to the prescribed antipsychotic medications, except for risperidone. Repeated measures ANOVA using the linear mixed model approach showed that the serial weight measurements were significantly different across the follow up times (p<0.05). CONCLUSION: Four of the commonly prescribed antipsychotic drugs do result in an increase in weight; however risperidone has no such effect, making it an option in-treating psychiatric disorders without worrying for any gain in weight. In view of the increased prevalence of obesity and other metabolic diseases, measures should be taken towards careful prescription of antipsychotic medications.

Guarding the guardians: Bioethics curricula for psychiatrists-in-training in developing countries.

A good physician must be both clinically and ethically competent. High ethical standards are especially important in psychiatry in which several unique challenges present due to a vulnerable patient population, intimate physician-patient relationships, diagnoses made on signs and symptoms rather than irrefutable laboratory investigations, and therapeutic options directed at altering thinking and behaviour. It is critical that psychiatric training equip practitioners with the ability to identify ethical dilemmas in clinical practice and research and respond appropriately. Despite a call to action and the development of guidelines for ethical practice by several regulatory bodies, formal ethics teaching in psychiatry training programmes is still in embryonic stages in the developed world and virtually non-existent in the developing world. Here we highlight the current status of bioethics teaching in psychiatry residency programmes in Pakistan, an example of a developing country where such training is vital, as unethical practices abound in resource-poor settings where clinical and research practices are non-transparent and there are no effective regulatory, legal and accountability bodies. It is critical and urgent that needs-responsive bioethics curricula are developed, institutionalized and implemented in medical schools and post-graduate training programs across the developing world. [Box: see text] [Box: see text].

Well-being of medical students and their awareness on substance misuse: a cross-sectional survey in Pakistan.

OBJECTIVE: To investigate psychological well-being and substance abuse among medical students in Pakistan. METHODS: A cross-sectional questionnaire-based survey was conducted in six medical colleges across Pakistan. Final-year medical students were interviewed by either a postgraduate trainee in psychiatry or a consultant psychiatrist. RESULTS: A total of 540 medical students were approached; 342 participated and the response rate was 64.5%. Mean age was 23.73 years (SD 2.45 years); 52.5% were male and 90% single. Two out of every five respondents reported that work/study at medical school affected their personal health and well-being. A considerable proportion of students were aware of alcohol and smoking as coping strategies for stress in medical students. The main factors causing stress were heavy workload (47.4%), relationship with colleagues (13.5%) and staff (11.9%). A total of 30% reported a history of depression and 15% among them had used an antidepressant. More than half were aware of depression in colleagues. The majority of respondents said that teaching provided on substance misuse in the areas of alcohol and illegal drugs, management/treatment of addiction, and models of addiction was poor. There was significant association (p = 0.044) between stress and awareness about alcohol as a coping strategy for stress among medical students. A significant negative association was also found between medical colleges in public sector (p = 0.052), female gender (p = 0.003) and well-being. CONCLUSION: The majority of the medical students reported a negative impact of heavy workload on their psychological well-being. Significant numbers of medical students think that substance misuse is a coping strategy for stress. Teaching on addiction/addictive substances is poor at undergraduate level in Pakistani medical colleges.

Pattern of benzodiazepine use in psychiatric outpatients in Pakistan: a cross-sectional survey.

BACKGROUND: Benzodiazepines (BDZ) are the largest-selling drug group in the world. The potential of dependence with BDZ has been known for almost three decades now. In countries like Pakistan where laws against unlicensed sale of BDZ are not implemented vigorously the risk of misuse of and dependence on these drugs is even higher. Previous studies have shown that BDZ prevalence among patients/visitors to general outpatient clinics in Pakistan may be as high as 30%. However, no research has been carried out on the prevalence of BDZ use in psychiatric patients in Pakistan. METHODS: We carried out a cross-sectional survey over 3 months in psychiatry outpatient clinics of two tertiary care hospitals in Karachi and Lahore. Besides basic socio-demographic data the participants were asked if they were taking a BDZ at present and if yes, the frequency, route and dosage of the drug, who had initiated the drug and why it had been prescribed. We used chi-square test and t-test to find out which socio-demographic or clinical factors were associated with an increased risk of BDZ use. We used Logistic Regression to find out which variable(s) best predicted the increased likelihood of BDZ use. RESULTS: Out of a total of 419 participants 187 (45%) of the participants had been currently using at least one BDZ. Seventy-three percent of the users had been using the drug for 4 weeks or longer and 87% were taking it every day. In 90% of cases the BDZ had been initiated by a doctor, who was a psychiatrist in 70% of the cases. Female gender, increasing age, living in Lahore, and having seen a psychiatrist before, were associated with an increased likelihood of using BDZ. CONCLUSION: The study shows how high BDZ use is in psychiatric outpatients in Pakistan. Most of the users were taking it for a duration and with a frequency which puts them at risk of becoming dependent on BDZ. In most of the cases it had been initiated by a doctor. Both patients and doctors need to be made aware of the risk of dependence associated with the use of BDZ.

Bullying of trainee psychiatrists in Pakistan: a cross-sectional questionnaire survey.

OBJECTIVE: Bullying is widely prevalent in health care organizations and medical institutions. It leads to stress, anxiety, depression, sickness absences, and intention to leave the job. This issue has not been studied widely and thoroughly in most developing countries. METHODS: The authors surveyed all postgraduate psychiatry trainees in the College of Physicians and Surgeons, Pakistan, with a cross-sectional questionnaire. In addition to sociodemographic data, the questionnaire included a bullying scale that asked whether the respondents had experienced in the preceding 12 months any of the 21 bullying behaviors listed and who had perpetrated the bullying. RESULTS: Out of 84 psychiatry trainees registered with the College of Physicians and Surgeons in May 2007, 60 participated in the survey. Eighty percent of participating trainees reported experiencing at least one bullying behavior in the preceding 12 months. There was no significant association between likelihood of experiencing bullying and any of the sociodemographic variables. However, in view of the small number of psychiatry trainees in Pakistan, this finding needs to be interpreted cautiously. Consultants were the most likely perpetrators of bullying. CONCLUSION: Most postgraduate psychiatry trainees in Pakistan have experienced bullying. Measures need to be taken to increase awareness of what constitutes bullying and how it affects its victims. It may be necessary to introduce antibullying policies at least at the organizational level.

Association between antipsychotics and weight gain among psychiatric outpatients in Pakistan: a retrospective cohort study.

BACKGROUND: It has been known for a long time that use of antipsychotics, particularly atypical antipsychotics, is associated with weight gain and increase in risk of metabolic disturbances. In this study we have tried to find out if use of antipsychotics is associated with increase in weight and body mass index (BMI) in the Pakistani population. METHODS: We performed a case note review of all patients who had been prescribed antipsychotic medication at the psychiatry outpatient clinic of a tertiary care university hospital in Pakistan over a 4-year period. RESULTS: A total of 50% of patients had a BMI in the overweight or higher range at baseline. Patients showed a mean weight gain of 1.88 kg from baseline in 3 months and 3.29 kg in 6 months. Both of these values were statistically significant. The increase in mean BMI from baseline was 0.74 and 1.3 in 3 months and 6 months, respectively. In patients for whom we had at least one further weight measurement after baseline, 48% (39/81) showed a clinically significant weight gain. CONCLUSION: Pakistani patients are just as likely to put on weight during antipsychotic treatment as patients from other countries. Considering that this population already has a much higher prevalence of diabetes mellitus compared to the Western countries, the consequences of increased weight may be even more serious in terms of increased morbidity and mortality.

Psychotherapy and pharmacotherapy randomized controlled trials are equally likely to report a positive outcome.

A very high proportion of controlled trials of psychotropic drugs report a positive outcome. To determine if the population of positive outcome in psychotherapy trials is as high as reported, a cohort of consecutive randomized controlled trials published in four internal psychiatry journals over a five-year period were analyzed. Chi square test and descriptive analysis were conducted. A total of 237 trials were included. Out of 188 pharmacotherapy trials, 164 (88%) reported a positive outcome. Out of 49 psychotherapy trials, 44 (90%) reported a positive outcome. The difference between above reported population was not statistically significant on chi-square test (p=0.626). It was concluded that positive outcome reports in published psychotherapy trials are as common as in pharmacotherapy trials.

Bullying among medical and nonmedical students at a university in Eastern Saudi Arabia.

BACKGROUND: Many medical students, junior doctors, and other health-care professionals have been affected by the negative experience of bullying. Research is scarce on bullying experienced by medical and nonmedical students in Saudi Arabia unlike what is found in Western countries. It is unclear whether being a nonmedical student modifies the risk of being bullied. MATERIALS AND METHODS: A cross-sectional study included 400 university students using convenient sampling. The sample comprised 295 students who responded and were stratified into medical (n = 176) and nonmedical (n = 119) groups. Statistical Package for the Social Sciences (SPSS) version 22.0 was used to analyze our data. Normality was measured using the Kolmogorov-Smirnov test. Statistical significance was tested using chi-square test for categorical variables, and t-test for continuous variables. RESULTS: Almost half of the respondents were found to have experienced some bullying, victimization, or other harassment during their medical education. The most common forms of bullying were verbal abuse and undue pressure to produce work (43.8%; n = 77). Nonmedical students experienced more bullying than medical students and were more likely to be female, single, and younger in age. The number of medical students subjected to sexual harassment (1.7%; n = 3) was higher than nonmedical students (0.8%; n = 1). Physical violence was more towards nonmedical (4.2%; n = 5) than medical students (1.1%, n = 2). The rates of bullying continue to be associated with anxiety and depression. CONCLUSIONS: Our data suggest similar bullying rates in the developed world but higher than previously reported in a Saudi study. Bullying or harassment affects both medical and nonmedical students and is associated with high levels of anxiety and depression.

Psychiatric rating scales in Urdu: a systematic review.

BACKGROUND: Researchers setting out to conduct research employing questionnaires in non-English speaking populations need instruments that have been validated in the indigenous languages. In this study we have tried to review the literature on the status of cross-cultural and/or criterion validity of all the questionnaires measuring psychiatric symptoms available in Urdu language. METHODS: A search of Medline, Embase, PsycINFO and http://www.pakmedinet.com was conducted using the search terms; Urdu psychiatric rating scale, and Urdu and Psychiatry. References of retrieved articles were searched. Only studies describing either cross-cultural or criterion validation of a questionnaire in Urdu measuring psychiatric symptoms were included. RESULTS: Thirty two studies describing validation of 19 questionnaires were identified. Six of these questionnaires were developed indigenously in Urdu while thirteen had been translated from English. Of the six indigenous questionnaires five had had their criterion validity examined. Of the thirteen translated questionnaires only four had had both their cross-cultural and criterion validity assessed. CONCLUSION: There is a paucity of validated questionnaires assessing psychiatric symptoms in Urdu. The BSI, SRQ and AKUADS are the questionnaires that have been most thoroughly evaluated in Urdu.

Benzodiazepine use among adults residing in the urban settlements of Karachi, Pakistan: a cross sectional study.

BACKGROUND: There are hardly any studies carried out in Pakistan on the usage of benzodiazepines at the level of community. This research was aimed to determine the frequency of benzodiazepine use, along with its associations with socio-demographic and clinical characteristics among community dwelling adults, residing in two urban settlements of Karachi, Pakistan. METHODS: We performed a cross sectional study from August 2008 to December 2009, in 2 areas of Karachi, namely Garden and Sultanabad. We followed the systematic sampling strategy to randomly select the households, with an adult of either sex and of age 18 years or more. Data collection was carried out through interview, using a pre-tested questionnaire, with items on socio-demographic position, medical history and benzodiazepine use. Student's t-test and χ2 test was employed to determine the associations between socio-demographic and clinical characteristics, and their relationship with benzodiazepine use was determined using applied logistic regression. RESULTS: The overall percentage of benzodiazepine consumption was estimated to be 14%. There were significantly more benzodiazepine users in the peri-urban Sultanabad community to the urban community of Garden (p-value = 0.001). The mean age (± SD) for users was 51.3 (± 15.6) years compared to 37.1 (± 14.4) years among non-users. Bromazepam was the most widely used benzodiazepine (29%); followed by diazepam, with a median duration on primary use being 144 weeks (IQR = 48-240). The adjusted logistic regression model revealed that increasing age, location, female sex, unemployment and psychiatric consultation were associated with increased likelihood of benzodiazepine use. CONCLUSION: We believe the unregulated over-the-counter sales of benzodiazepines and social conditions might be playing a role in this high consumption of benzodiazepines in the community.

Bullying of medical students in Pakistan: a cross-sectional questionnaire survey.

BACKGROUND: Several studies from other countries have shown that bullying, harassment, abuse or belittlement are a regular phenomenon faced not only by medical students, but also junior doctors, doctors undertaking research and other healthcare professionals. While research has been carried out on bullying experienced by psychiatrists and psychiatry trainees in Pakistan no such research has been conducted on medical students in this country. METHODOLOGY/PRINCIPAL FINDINGS: We conducted a cross-sectional questionnaire survey on final year medical students in six medical colleges of Pakistan. The response rate was 63%. Fifty-two percent of respondents reported that they had faced bullying or harassment during their medical education, about 28% of them experiencing it once a month or even more frequently. The overwhelming form of bullying had been verbal abuse (57%), while consultants were the most frequent (46%) perpetrators. Students who were slightly older, males, those who reported that their medical college did not have a policy on bullying or harassment, and those who felt that adequate support was not in place at their medical college for bullied individuals, were significantly more likely to have experienced bullying. CONCLUSION: Bullying or harassment is faced by quite a large proportion of medical students in Pakistan. The most frequent perpetrators of this bullying are consultants. Adoption of a policy against bullying and harassment by medical colleges, and providing avenues of support for students who have been bullied may help reduce this phenomenon, as the presence of these two was associated with decreased likelihood of students reporting having being bullied.