Madison to Manipal: A narrative review of modified assertive community treatment programs.

BACKGROUND: Assertive community treatment (ACT) is a multidisciplinary, team-based approach providing comprehensive individualized care for the patients with various mental illness, has been adapted variably across the world in terms of patient-staff ratio, selection of patients, the pattern of service delivery and frequency of contact. We aim to review the extant literature on the modifications of ACT programs for severe mental disorders and their effectiveness. METHODS: Studies on modified ACT approaches for mental illnesses were searched in multiple databases. We adopted a rapid appraisal approach. The searches were restricted to articles published in English. We appraised the fidelity assessment of the ACT studies wherever available. In addition, we assessed the study quality using a grading tool based on ten practice components of ACT. RESULTS: We found 23 reports (10 RCTs and 13 non-controlled studies) on modified ACT. The extant literature on modified ACT programs is heterogeneous. The modifications in ACT included changes in patient-to-staff ratio, team composition, service hours, and interventions carried out. Most controlled studies were conducted in high-income settings and had inconsistent outcome, possibly due to the comprehensive nature of the 'usual care.' In contrast, modified ACT services from low and middle-income countries reduced hospitalization rates and improved treatment adherence. CONCLUSIONS: Modifications in ACT programs were done to cater to specific subpopulation and the changes in program structure to suit the resources and setting. The outcome of modified ACT appears heterogenous, though the findings from low and middle-income countries are promising.

Re-examining Psychometric Properties of Fertility Problem Inventory: A Clinic-Based Study from India.

Background: The fertility problem inventory (FPI) is one of the most widely used measures that tap the diverse psychological problems faced by infertile couples. Research on translated versions of FPI has also reflected its high clinical significance. Aim: This research aimed to explore the psychometric properties and the clinical validity of the original 46-item FPI in an Indian sample. Setting and Design: This cross-sectional study was conducted in a tertiary hospital setup of a medical college. Materials and Methods: The original FPI was translated and pilot tested. The translated FPI was taken by 205 consenting infertile patients (113 women and 92 men). The psychometric properties of FPI were thus explored. Statistical Analysis: Exploratory factor analysis with minimum residual method of extraction followed by oblimin rotation was performed. Perceived Stress Scale was used to establish the convergent validity of the newly developed FPI-Kannada version (FPI-K). A cut-off score for the FPI-K was obtained separately for males and females using ROC analysis in which hamilton anxiety scale was used as the gold standard. Results: Only 32 items of the original FPI had factor loadings above 0.3 and overall six factors explained these items with a cumulative percentage variation of 32%. Overall Cronbach's alpha for FPI-K was 0.671 and it had a good convergent validity. Conclusions: The new FPI-K had 6 sub-domains and the clinical utility of same is discussed.

Efficacy and safety of maintenance electroconvulsive therapy (M-ECT) in treatment-resistant schizophrenia: A case series.

BACKGROUND: Treatment-resistant schizophrenia (TRS) is a substantial burden to patients, caregivers, and the treating team. There is a lack of robust evidence to support the efficacy of various pharmacological and non-pharmacological measures to augment clozapine in this population. When used in conjunction with clozapine or other combination antipsychotic regimens, maintenance electroconvulsive therapy (M-ECT) can be a potential therapeutic option in preventing symptom exacerbation in TRS. However, there is limited evidence supporting the role of M-ECT in TRS. AIM: To evaluate the efficacy and safety of maintenance electroconvulsive therapy in patients with TRS. METHODOLOGY: Sociodemographic details, illness characteristics, details of M-ECT procedure, adverse events, and course of the illness were evaluated using a retrospective chart review at a tertiary care psychiatry centre in south India. Scores on Clinical Global Impression-Severity (CGI-S), Social and Occupational Functioning Assessment Scale (SOFAS), and Hindi Mental Status Examination were compared before and after the course of M-ECT. RESULTS: Seven male and three female patients received M-ECT in the last eight years (range of 22-172 sessions). There was a reduction in hospitalizations for acute exacerbation and significant improvement in the patient's overall functioning without significant adverse effects. CONCLUSION: Maintenance ECT can be a safe and effective treatment option for achieving symptom control in the long-term management of refractory schizophrenia. Controlled trials are needed in this area for further evidence.

Association between functional polymorphisms in serotonin transporter gene (SLC6A4) and escitalopram treatment response in depressive patients in a South Indian population.

PURPOSE: Ethnicity plays a key role in deciding the direction of the association between serotonin transporter gene polymorphisms and treatment response of selective serotonin reuptake inhibitors (SSRIs). The present study explored the association of 5HTTLPR and 5HTTLPR-rs25531 polymorphisms with the treatment response of escitalopram in South Indian patients with major depressive disorder. METHODS: A total of 148 depressive patients receiving escitalopram 10-20 mg/day were genotyped for 5HTTLPR and rs25531 polymorphisms. Clinical assessment was done at baseline and after 4, 8, and 12 weeks using the 17-item Hamilton Depression Rating Scale (HDRS-17), Montgomery-Asberg Depression Rating Scale (MADRS), and Clinical Global Impression Scale (CGI). At the end of week 12, patients were defined as responders and non-responders based on HDRS17 and MADRS scores. Chi-square test and logistic regression analysis were performed to investigate the genotypic influence on treatment response. Comparison of continuous variables among different groups was done using Student's t test or one-way ANOVA. RESULTS: Out of 148 study subjects, 65 (43.9%) were responders and 83 (56.08%) were non-responders. We observed a significant (p value < 0.001) association between LL genotype, LALA haplotypes, and 2 LA functional group with better treatment response to escitalopram. The decline in HDRS17 and MADRS score from baseline was significantly higher (p value < 0.001) in LL genotypes and homozygous LA carriers compared with other groups. CONCLUSION: Results suggest that 5HTTLPR and rs-25531 polymorphisms can influence escitalopram treatment response in depressive patients in a South Indian population, LL genotypes and LALA haplotypes being the predictors of better treatment response.

Distress in Infertile Males in Manipal-India: A Clinic Based Study.

BACKGROUND: Being infertile comes as an overwhelming realization for couples trying to conceive. In consideration of rising rates of infertility worldwide, clinicians in India have also begun exploring this field for new possibilities, development and research. The purpose of this study was to estimate the proportion and predictors of infertility specific stress in males diagnosed with primary infertility. METHODS: This cross-sectional research was conducted in an assisted reproduction center, Manipal, India, on 300 infertile married males. The tools were "semi-structured questionnaire" compiled by the authors, "ICD-10 Classification of Mental and Behavioural Disorders (Clinical Descriptions and Diagnostic Guidelines) and" Psychological Evaluation Test for infertility. Multiple logistic regression analysis was carried out on data with p-value fixed as 0.05. RESULTS: The presence of stress was reported in 72% of male participants. The predictors of stress were nature and severity of their infertility diagnosis, sperm defects, urological condition and experience of corrective surgery undergone for it. Psychological stress in men was also predicted by present and past history of significant psychiatric morbidity and coping difficulties associated with it. CONCLUSION: The stress is both a common experience and at times a clinical condition associated with deteriorating mental and physical health in men seeking fertility treatments. As a prerequisite, Indian fertility clinics need to treat stress as an identifiable condition and devise ways of addressing it at all stages of assisted conception and reproductive treatments.

A Cross-sectional, Comparative Study of Insight in Schizophrenia and Bipolar Patients in Remission.

AIMS: To study insight correlates in schizophrenia and bipolar mood disorder in remission among out-patients attending the Psychiatry Department of a Tertiary Care Hospital. SETTINGS AND DESIGN: In a cross-sectional, naturalistic study, adult patients with schizophrenia and bipolar mood disorder in remission (n = 80; schizophrenia-40, mania-20, bipolar depression-20) were compared on insight measures and clinical correlates. MATERIALS AND METHODS: Scale to Assess the Unawareness of Mental Disorders (SUMD) was used as the main tool to assess current and past measures of insight. Hogan's Drug Attitude Inventory was used to assess the drug attitude and compliance. Positive and Negative Symptom Scale for Schizophrenia, Young's Mania Rating Scale, and HAMD were used to rate psychopathology. Clinical Global Improvement was used as a screening tool for remission. STATISTICAL ANALYSIS: For comparison of the three clinical groups, analysis of variance and Chi-square test were used. In the post-hoc analysis, the Ryan-Einot-Gabriel-Welsch test was used to find the group difference. RESULTS: About 40% in the schizophrenia group were unaware of their mental illness as against none in the bipolar group. The awareness of mental disorder for the current period, the awareness of the achieved effects of medications, and the awareness of social consequence was better in the bipolar group. The drug attitude (compliant positive attitude) increased as the SUMD item scale decreased or in other words, as the insight improved. CONCLUSIONS: Insight, both current and retrospect, showed significant differences between the schizophrenia and bipolar patients. Insight is significantly correlated with the observed compliance and drug attitude of the patient groups.

Mirtazapine for antipsychotic-induced acute akathisia: a systematic review and meta-analysis of randomized placebo-controlled trials.

OBJECTIVE: To conduct a systematic review and meta-analysis of randomized placebo-controlled trials of mirtazapine for the treatment of antipsychotic-induced acute akathisia (AIAA). METHODS: Studies were identified using online searches of PUBMED/MEDLINE and Cochrane database (CENTRAL), along with websites recording trial information such as www.clinicaltrials.gov, www.controlled-trials.com, and www.clinicalstudyresults.org. The study eligibility criteria were randomized, double-blind clinical trials comparing mirtazapine with placebo for AIAA with standardized rating for akathisia as outcome measure. The methodological quality of included trials was assessed using the Jadad Scale. Separate meta-analyses were undertaken for each outcome (response rate and complete remission) and treatment effects were expressed as Mantel-Haenszel risk ratio (RR). Fixed-effect meta-analysis was performed as heterogeneity was not significant. Number need to treat (NNT) as a measure of relative treatment effectiveness was calculated. RESULTS: A systematic review of the literature revealed six studies that had assessed mirtazapine for the treatment of AIAA. Of these, two studies (n = 86) met the review inclusion criteria and were included in the final analysis. A meta-analysis was performed to see the effect size of response rate and complete remission. For response rate, RR was 6.67 [95% confidence interval (CI) 2.14-20.78], favoring mirtazapine compared with placebo, and the overall effect was significant (p = 0.001, NNT 4, 95% CI 2.6-8.6). For complete remission, RR was 6.20 (95% CI 1.74-22.08), favoring mirtazapine compared with placebo, and the overall effect was significant (p = 0.005, NNT 5, 95% CI 2.9-11.6). CONCLUSIONS: Although limited to only two studies and small sample, existing data support the efficacy of mirtazapine for the treatment of AIAA, with one in four patients showing partial response and one in five patients showing complete remission.

Co-morbidity in Bipolar Disorder: A Retrospective Study.

BACKGROUND: Bipolar disorder is a relatively common, long-term, and disabling psychiatric illness that is associated with high levels of functional impairment, morbidity, mortality, and an increased risk of suicide. Psychiatric co-morbidity in bipolar disorder ranges from 57.3% to 74.3%, whereas medical co-morbidity varies from 2.7-70%. Indian scenario in this aspect is not clear. MATERIALS AND METHODS: The objective was to ascertain the prevalence of physical and psychiatric co-morbidities in patients attending a tertiary care center over a period of 1 year and its relationship with socio-demographic and clinical variables. One hundred and twenty-five case record files were included in the review. OPCRIT software was used for re-establishing the diagnosis of bipolar disorder, which yielded 120 cases. A semi-structured pro-forma, specifically designed for the study, was used to collect the socio-demographic and clinical details. RESULTS: Co-morbid psychiatric disorders were found in 52 (43.3%) of the sample, whereas co-morbid physical illness was present in 77 (64.2%) patients. The most common psychiatric disorder associated was substance use disorder (27.5%), whereas co-morbid cardiovascular disorder was the most frequent physical diagnosis in the sample (20%). DISCUSSION: The prevalence of co-morbid psychiatric disorders in bipolar patients was lower than that reported in western literature. It could be related to retrospective nature of study or reflect true lower prevalence rates. Also, certain disorders such as eating disorders were absent in our sample, and migraine diagnosis was very infrequent.

Multiplex ligation-dependant probe amplification study of children with idiopathic mental retardation in South India.

BACKGROUND: Mental retardation (MR) is a heterogeneous dysfunction of the central nervous system exhibiting complex phenotypes and has an estimated prevalence of 1-3% in the general population. However, in about 50% of the children diagnosed with any form of intellectual disability or developmental delay the cause goes undetected contributing to idiopathic intellectual disability. MATERIALS AND METHODS: A total of 122 children with developmental delay/MR were studied to identify the microscopic and submicroscopic chromosome rearrangements by using the conventional cytogenetics and multiplex ligation dependent probe amplification (MLPA) analysis using SALSA MLPA kits from Microbiology Research Centre Holland [MRC] Holland. RESULTS: All the recruited children were selected for this study, after thorough clinical assessment and metaphases prepared were analyzed by using automated karyotyping system. None was found to have chromosomal abnormality; MLPA analysis was carried out in all subjects and identified in 11 (9%) patients. CONCLUSION: Karyotype analysis in combination with MLPA assays for submicroscopic micro-deletions may be recommended for children with idiopathic MR.

Study of the association of serotonin transporter triallelic 5-HTTLPR and STin2 VNTR polymorphisms with lithium prophylaxis response in bipolar disorder.

The 5-hydroxy tryptamine transporter (5-HTT) gene has been previously implicated in lithium response, but the roles of the triallelic 5-HTT linked promoter region (5-HTTLPR) and variable number tandem repeats in the second intron [serotonin transporter intron 2 (STin2)] have not been reported. We examined these polymorphisms in 122 patients with bipolar I disorder, among which 49 patients were classified as good responders, 49 as nonresponders, and 24 as partial responders to lithium prophylaxis. We observed significant variation in the genotype frequencies of STin2 polymorphism among the response groups (P=0.02). There was also a significant association of haplotype consisting of the S allele of 5-HTTLPR and 10 repeat allele of STin2 with lithium response (P=0.01) and no such relationship was found with 5-HTTLPR variants. Our data support preliminary information of a possible association of STin2 and its combined effect with 5-HTTLPR variants with lithium response and also suggest that lithium is likely to be more effective for patients carrying 5-HTT polymorphisms associated with reduced transcriptional activity.

Amantadine for olanzapine-induced weight gain: a systematic review and meta-analysis of randomized placebo-controlled trials.

OBJECTIVE: The objective of this study was to conduct a systematic review and meta-analysis of randomized placebo-controlled trials of amantadine for the treatment of olanzapine-induced weight gain. METHODS: Studies were identified using online searches of PUBMED/MEDLINE and Cochrane database (CENTRAL), along with websites recording trial information such as ClinicalTrials.gov, Controlled-trials.com, and Clinicalstudyresults.org. Study eligibility criteria included randomized, double-blind clinical trials comparing amantadine with placebo for olanzapine-induced weight gain with body weight as an outcome measure and study duration of at least 12 weeks. The methodological quality of included trials was assessed using the Jadad Scale. Separate meta-analyses were undertaken for each outcome (body weight and frequency of weight loss >7%) and treatment effects were expressed as weighted mean differences (WMD) and Mantel-Haenszel odds ratio for continuous and categorical outcomes, respectively. RESULTS: A systematic review of literature revealed six studies that had assessed amantadine for olanzapine-induced weight gain. Of these, two studies (n = 144) met the review inclusion criteria and were included in the final analysis. Meta-analysis was performed to see the effect size of the treatment on body weight and frequency of body weight loss >7%. For body weight change, WMD was -1.85 (95% confidence interval [CI] -3.31 to -0.39) kg with amantadine as compared with placebo; the overall effect was statistically significant (p = 0.01). For frequency of body weight loss >7%, Mantel-Haenszel odds ratio for weight loss was 3.72 (95% CI 1.19-11.62), favoring amantadine as compared with placebo, and the overall effect was significant (p = 0.02). CONCLUSIONS: Existing data is limited to two studies, which support the efficacy of amantadine for olanzapine-induced weight gain and a significant proportion of patients might lose weight with amantadine compared with placebo.

A cross-sectional comparison of disability and quality of life in euthymic patients with bipolar affective or recurrent depressive disorder with and without comorbid chronic medical illness.

BACKGROUND: There are major health care implications of quality of life (QOL) and disability in long-standing disorders such as bipolar affective disorder (BAD) and recurrent depressive disorder (RDD). OBJECTIVES: To compare the inter-episode QOL and disability in patients with the diagnosis of BAD or RDD in remission with and without comorbid chronic medical illness. MATERIALS AND METHODS: Cross-sectional assessments of the four groups were carried out. Euthymic bipolar or RDD subjects with chronic comorbid medical illnesses were included in the study. QOL assessment was carried out using the World Health Organization (WHO)-QOL - Bref Kannada version. Disability was assessed using the Schedule for Assessment of Psychiatric Disability (SAPD), which is an Indian modification of the WHO Disability Assessment Schedule-II. RESULTS: Eighty patients were enrolled into the study (20 patients in each group). The mean disability scores in the BAD group was significantly more in 'social role' (P = 0.038), and in the RDD group it was more in 'home atmosphere' (P = 0.001) in the two groups (n = 40) with chronic comorbid medical illness. In the other group without comorbid chronic medical illness (n = 40), the BAD group had significantly more disability in 'overall behavior' (P = 0.002) and 'social role' (P = 0.001), and the RDD group had significantly more disability in 'assets and/or liabilities' (P = 0.004) and 'home atmosphere' (P = 0.001). The QOL measures did not differ significantly between the two disorders. CONCLUSIONS: The presence of chronic comorbid medical illness did not cause a difference in the QOL between the two groups in periods of euthymia. However, disability measures differed significantly between the groups.