Assessment of Contributing Factors and Treatment Practices for Therapeutic Efficacy and Drug-Related Problems in Suicidal Psychotic Patients.

Suicide, a deliberate act of self-harm with the intention to die, is an emerging health concern but, unfortunately, the most under-researched subject in Pakistan, especially in Khyber Pukhtunkhwa (KPK). In this study, we aimed to identify risk factors that can be associated with suicidal behavior (SB) and to evaluate the prevailing treatment practices for therapeutic efficacy and drug-related problems (DRPs) in psychotic patients among the local population of KPK. A prospective, multicenter study was conducted for suicidal cases admitted to the study centers by randomized sampling. Socio-demographics and data on suicidal behavior were assessed using the Columbia-Suicide Severity Rating Scale (C-SSRS), socioeconomic condition by Kuppuswamy socioeconomic scale (KSES) and treatment adherence by Morisky Medication-Taking Adherence Scale (MMAS-4). Drug-related problems and the therapeutic efficacy of prevailing treatment practices were assessed at baseline and follow-up after 3 months of treatment provided. Regarding suicidality (N = 128), females reported more ideations (63.1%), while males witnessed more suicidal behavior (66.6%, p < 0.001). Suicide attempters were mostly married (55.6%, p < 0.002); highly educated (53.9%, p = 0.004); dissatisfied with their life and had a previous history (p < 0.5) of suicide attempt (SA) (20.6%), self-injurious behavior (SIB) (39.7%) and interrupted (IA) or aborted attempts (AA) (22.2%). A greater improvement was observed in patients receiving combination therapy (p = 0.001) than pharmacotherapy (p = 0.006) or psychotherapy (p = 0.183), alone. DRPs were also detected, including drug-selection problems (17.88%), dose-related problems (20.64%), potential drug−drug interactions (24.31%), adverse drug reactions (11.46%) and other problems like inadequate education and counseling (21.55%). Furthermore, it was also found that psychotic patients with suicidal ideations (SI) were significantly (p = 0.01) more adherent to the treatment as compared to those with suicidal attempts. We concluded that suicide attempters differed significantly from patients with suicidal ideations in psychotic patients and presented with peculiar characteristics regarding socio-demographic factors. A combination of therapies and adherence to the treatment provided better outcomes, and targeted interventions are warranted to address drug-related problems.

Prescription analysis and cost of antidepressant drugs in major depressive disorder outpatients at the tertiary care hospital of Pakistan: a prospective approach.

OBJECTIVES: To assess prescribing care indicators, utilization pattern, cost per prescription, cost ratios, and percent cost variation of antidepressants (ADs). METHOD: A prospective cross-sectional study was carried out at the tertiary care hospital of Peshawar, Pakistan among major depressive disorder (MDD) outpatients from July 2019 to February 2020. The ideal standards for World Health Organization (WHO) prescribing care indicators were used. The ePharma Guide was used to calculate the cost in Pakistani rupees (Rs) and United States dollar (USD) 2021 (exchange rate: 1 USD = 154.43 Rs). RESULTS: A total of 296 MDD patients received 846 drugs (average 2.86; range:1-8), of which 366 were ADs (average number ADs/prescription; 1.23). About 23% (n = 68) of patients received more than one AD. Only 21 (5.7%) generic ADs were prescribed, and 346 (94.5%) ADs were prescribed from the hospital formulary list. Selective serotonin reuptake inhibitors (SSRIs) were the most prescribed ADs (67.5%). The average cost of ADs per prescription per month was 700.95 Rs (4.54 USD). Escitalopram (5.69 Rs; 0.04 USD) showed highest cost ratio and maximum percentage cost variation (468.97%). CONCLUSION: This study observed low generic prescribing, a higher prescribing trend of SSRI, wide differences in cost ratio and percentage cost variation among ADs.

Clinical Investigation on the Impact of Cannabis Abuse on Thyroid Hormones and Associated Psychiatric Manifestations in the Male Population.

Cannabis abuse is a common public health issue and may lead to considerable adverse effects. Along with other effects, the dependence on cannabis consumption is a serious problem which has significant consequences on biochemical and clinical symptoms. This study intends to evaluate the harmful effects of the use of cannabis on thyroid hormonal levels, cardiovascular indicators, and psychotic symptoms in the included patients. This prospective multicenter study was conducted on cannabis-dependent patients with psychotic symptoms (n = 40) vs. healthy control subjects (n = 40). All participants were evaluated for psychiatric, biochemical, and cardiovascular physiological effects. Patients were selected through Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV criteria and urine samples, exclusively for the evaluation of cannabis presence. Serum thyroid stimulating hormone (TSH), T3, and T4 levels were measured using the immunoassay technique. Patients were assessed for severity of depressive, schizophrenic, and manic symptoms using international ranking scales. Various quantifiable factors were also measured for the development of tolerance by cannabis. Among the patients of cannabis abuse, 47.5% were found with schizophrenia, 20% with schizoaffective symptoms, 10% with manic symptoms, and 22.5% with both manic and psychotic symptoms. In the group-group and within-group statistical analysis, the results of thyroid hormones and cardiovascular parameters were non-significant. The psychiatric assessment has shown highly significant (p < 0.001) difference of positive, negative, general psychopathology, and total scores [through Positive and Negative Syndrome Scale (PANSS) rating scales] in patients vs. the healthy control subjects. The study revealed that cannabis abuse did not significantly alter thyroid hormones and cardiovascular parameters due to the development of tolerance. However, the cannabis abuse might have a significant contributing role in the positive, negative, and manic symptoms in different psychiatric disorders.

Relative Risk of Anxiety and Depression among COVID-19 Survivor Healthcare Workers from a Tertiary Care Hospital in Pakistan: A Pilot Cohort Study.

Longitudinal studies for determining the risk of anxiety and depression among COVID-19 survivor healthcare workers are lacking. This study aimed to determine the risk of anxiety and depression among healthcare workers that survived COVID-19 infection through a six-month post-recovery follow-up. This was a cohort study conducted at the Department of Obstetrics and Gynecology, Lady Reading Hospital, Peshawar, from 1st March to 30th August 2020. A total of 64 subjects participated. Hospital Anxiety and Depression Scale (HADS) was used for assessing the anxiety and depression symptoms. HADS has three score cutoff as normal, borderline abnormal and, abnormal anxiety/depression. For the purpose of the study, borderline and above scores were taken as positive for anxiety/depression. Data was analysed using STATA Corp 15.1. There was no increased risk of anxiety or depression six months post-COVID-19 infection in the infected HCW, compared to uninfected HCW. It is recommended to conduct longitudinal studies with large sample and longer follow-up. Key Words: Relative risk, Anxiety, Depression, HADS, COVID-19, Healthcare workers.

Prevalence of QTc interval prolongation and its associated risk factors among psychiatric patients: a prospective observational study.

BACKGROUND: QT interval prolongation is a growing concern worldwide, posing psychiatric patients to life-threatening fatal arrhythmias i.e., torsade de pointes. This study aimed to identify the prevalence of QT interval prolongation, its associated risk factors and prescribing patterns of QT prolonging drugs among psychiatric patients. METHOD: A prospective observational study was conducted that included psychiatric patients from a tertiary care hospital and a psychiatry clinic in Peshawar, Khyber Pakhtunkhwa, Pakistan. Electrocardiogram was recorded of those patients who were using psychotropic medications for ≥7 days, aged 18 years or more, and of either gender, male or female. The Fredericia correction formula was used for measuring QTc values (corrected QT). Chi-square test was applied to estimate differences between patients with or without prolonged QTc interval whereas, logistic regression analysis was performed to identify various predictors of QT interval prolongation. RESULTS: Out of 405 patients, the QTc interval was prolonged in 23 (5.7%) patients including 1 (0.2%) patient with highly abnormal prolonged QTc interval (> 500 ms). QT drugs (91.6%), female sex (38.7%) and hypertension (10.6%) were the most common QT prolonging risk factors. Prolonged QTc interval was significantly higher among male patients (p = 0.007). CONCLUSION: In the present study, QT interval prolongation was observed in a considerable number of psychiatric patients. While, the high prevalence of QT prolonging risk factors among these patients warrants the increased risk of fatal arrhythmias. Therefore, risk assessment and electrocardiographic monitoring, and prescription of safer alternatives are highly recommended.

Assessment of attitudes of patients with psychiatric disorders regarding electroconvulsive therapy as a treatment option.

OBJECTIVE: To assess the attitudes of psychiatric patients towards electroconvulsive therapy (ECT) as a treatment modality. METHODS: This descriptive cross-sectional study was conducted from 1st January, 2017 to 15th April, 2018 in Department of Psychiatry, MTI, Lady Reading Hospital, Peshawar. It comprised of total 154 patients, having previous experience with electroconvulsive therapy (ECT) who were selected through a non-probability consecutive sampling. Their attitude was assessed by their responses to 15 questions on a Likert Scale, each question scoring 01-05 with a summed up cut-off score of 45 points. Score over 45 points is considered positive and below 45 as negative while those scoring exactly 45 points were considered as having Ambivalent attitude towards ECT. RESULTS: Of all, 73% patients revealed positive and 27% negative attitude towards ECT. Mean age of the sample was 35 years. Out of all patients, 67.5% were males & 32.5% females, 73% were married & 27% unmarried, 47% were illiterate & 53% variably educated, 43% were employed while 57% were unemployed. CONCLUSION: A significant majority of the patients accepted ECT as an effective treatment modality. However, to make the procedure more acceptable, it may be made more effective and safe to the expectations of the patients and medical professionals for better outcomes.

Pattern of peer review proforma of medical journals of Pakistan.

OBJECTIVE: To analyze the contents and format of peer review proforma of Medical journals of Pakistan. METHODS: This descriptive study was conducted in the Department of Orthopaedics and Traumatology Lady reading Hospital Peshawar Pakistan from 3rd August 2018 to 9th February 2019.An email was sent to the chief editors of all the medical journals listed on the official website (www.pmdc.org.pk) of Pakistan Medical and Dental Council (PM&DC).They were requested to send peer review proformas of their journals. The received proformas were analyzed for major contents and format or style. The proforma had a structured format when each portion of the manuscript i.e, title, abstract, key words, methodology, results, discussion, conclusion and references were individually sectioned for evaluation. Whereas in the unstructured proformas the reviewer was asked to assess the manuscript as a whole. RESULTS: We received 41 proformas via emails. Majority (82.9%) of the proformas were structured while 17% were unstructured. A scoring or rating system for the manuscript was present in 31.7% of the proformas while 43.9% of the proformas were without any scoring system. Guidelines for the peer reviewers were given in 58.5% of the proformas. The peer review policy (closed or open) was mentioned in only 7.3%.About 9.7% of the proformas asked the reviewers to disclose conflict of interests. CONCLUSION: A spectrum of contents and format of peer review proformas of medical journals were observed. We found structured peer review proforma with a scoring scale comprehensive and more appropriate for peer review.

Schizophrenia medication adherence in a resource-poor setting: randomised controlled trial of supervised treatment in out-patients for schizophrenia (STOPS).

BACKGROUND: Most people with schizophrenia in low- and middle-income (LAMI) countries receive minimal formal care, and there are high rates of non-adherence to medication. AIMS: To evaluate the effectiveness of an intervention that involves a family member in supervising medication administration - supervised treatment in out-patients for schizophrenia (STOPS) - in improving treatment adherence and clinical outcomes. METHOD: Individuals (n = 110) with schizophrenia or schizoaffective disorders were allocated to STOPS or to treatment as usual (TAU) and followed up for 1 year. The primary outcome was adherence to the treatment regimen. Positive and Negative Syndrome Scale for Schizophrenia and Global Assessment of Functioning scores were also assessed. RESULTS: Participants in the STOPS group had better adherence (complete adherence: 37 (67.3%) in STOPS v. 25 (45.5%) in TAU; P<0.02) and significant improvement in symptoms and functioning. CONCLUSIONS: STOPS may be useful in enhancing adherence to treatment for schizophrenia in LAMI countries.

Effect of fasting during Ramadan on serum lithium level and mental state in bipolar affective disorder.

The Muslims fast every year during the month of Ramadan. A fasting day can last 12-17 h. The effects of fasting on serum lithium levels and the mood changes in patients suffering from bipolar affective disorder during Ramadan are not well studied. We aimed to compare the serum lithium levels, side effects, toxicity and mental state in patients suffering from bipolar affective disorder and on prophylactic lithium therapy before, during and after Ramadan. Sixty-two patients meeting the International Classification of Diseases, Tenth Revision, Research Diagnostic Criteria of bipolar affective disorder receiving lithium treatment for prophylaxis were recruited in a tertiary care teaching hospital in Peshawar, Pakistan. Serum lithium, electrolytes, Hamilton Depression Rating Scale (HDRS) and Young Mania Rating Scale (YMRS) were assessed at three points, 1 week before Ramadan, midRamadan and 1 week after Ramadan. The side effects and toxicity were measured by a symptoms and signs checklist. There was no significant difference in mean serum lithium levels at three time points (preRamadan=0.45±0.21, midRamadan=0.51±0.20 and postRamadan=0.44±0.23 milli equivalents/litre, P=0.116). The scores on HDRS and YMRS showed significant decrease during Ramadan (F=34.12, P=0.00, for HDRS and F=15.6, P=0.000 for YMRS). The side effects and toxicity also did not differ significantly at three points. In conclusion, the patients who have stable mental state and lithium levels before Ramadan can be maintained on lithium during Ramadan. Fasting in an average temperature of 28°C for up to 12 h per day did not result in elevated serum lithium levels or more side effects and did not have adverse effects on mental state of patients suffering from bipolar affective disorder.

Frequency of anxiety and psychosocial stressful events in patients with acute myocardial infraction.

BACKGROUND: The impact of psychological factors in acute coronary events is only now emerging. A growing body of evidence attests to the influence of emotional and stress-related psychosocial factors in the aetiology of Coronary Artery Disease (CAD) and morbidity and mortality among individuals with coronary heart disease. The objectives were to look for the frequency of anxiety and psychosocial stressful events in patients with acute myocardial infarction. METHODS: Two hundred consecutive patients of Acute Myocardial Infarction (AMI) without complications who presented to the Coronary Care Unit of Cardiology Department, Lady Reading Hospital Peshawar, and 200 healthy controls among relatives of patients were assessed on Holmes Rahe Social scale (HRS) and Hospital Anxiety and Depression Scale (HADS) scale for the presence of anxiety and stressful life events in period preceding AMI. RESULTS: Sixty-three percent of the patients were male in both groups. Mean age of patients was 59 years while that of controls was 52 years. For scores of anxiety on HADS, 34% of the controls had normal score compared to of the 19% AMI group (p<0.001), while 57% of the AMI patients had abnormal score compared to 39% of the control group (p<0.001). The number events reported on HRS scale in patients with AMI were significantly more (4.2 +/- 2) compared to the number of events (2.7 +/- 1.6) in the control group with (p<0.001). Scores for the number of events on HRS scale were significantly less (98 +/- 64) in controls compared to (158 +/- 5.8) in group with AMI (p<0.001). Anxiety was diagnosed in 70% of the female patients compared to 50% of the male patients. CONCLUSION: Significant number of patients with acute myocardial infarction when assessed on standard scales had anxiety and stressful life events in the weeks preceding the event. These were more common in female than male patients.