Development, validation and clinical utility of short-term adverse-effects of electroconvulsive therapy (SAVE) checklist.

Electroconvulsive therapy (ECT) is one of the most effective treatments in psychiatry. However, it has many cognitive and non-cognitive adverse effects (AEs). There are lacunae in the literature on systematic assessment of non-cognitive AEs. There is a need for a standard, comprehensive and specific clinical tool to evaluate this. Hence, a checklist of short-term AEs of ECT (SAVE) with a 2-phase assessment was developed. Content validation was done using 15 experts' ratings and predefined content validity ratio and index (CVR and CVI) in a two-stage modified Delphi method. The checklist had a good CVR and CVI with a final tool of 39 items. The tool was sensitive and identified the non-cognitive AEs after ECT. Cardiovascular and musculoskeletal systems displayed the highest incidence. Many participants exhibited delayed recovery in orientation, gait, and stance, highlighting a necessity for meticulous monitoring. SAVE is the first standardised tool to assess short-term ECT-related AEs systematically. This checklist likely identifies clinically significant incidences of adverse effects. Its regular use may enhance the safety of ECT and patient comfort by supporting early identification and intervention for AEs. However, given the transient nature of AEs, further studies are needed to determine their predictive validity for long-term consequences.

Standards for medical devices: Electroconvulsive therapy machine.

The manuscript calls for establishing a standard for electroconvulsive devices by manufacturers for better regulation in India. This is most relevant in the context of two recent developments, (a) Notification of medical devices rules, 2017 with classification of ECT as Class C and (b) Recent change in classification of ECT devices by US-FDA in 2018. The establishment of standards would help in upregulating the standard of ECT devices as well as ECT practices.

Dose response of transcranial near infrared light stimulation on brain functional connectivity and cognition in older adults-A randomized comparison.

Photobiomodulation, also called low-level light therapy, has been reported in animal studies to have an effect on brain activity and cognition. However, studies in humans regarding its effect on cognition and brain functional connectivity, and the required dose threshold for achieving the same have been very limited. We compared the effects of different doses of photobiomodulation (PBM) on cognition and resting state brain functional connectivity in 25 cognitively normal adults aged 55-70 years. They were randomized to a single session of the sham group, "low-dose" and "high-dose" groups receiving NIR light with transcranial fluence of 26 and 52 J/cm2 respectively, and intranasal fluence of 9 and 18 J/cm2 respectively. There was a significant increase in resting state functional connectivity of the left superior frontal gyrus (SFG) with the left planum temporale (PT), p = 0.0016, and with the left inferior frontal gyrus, pars triangularis, p = 0.0235 in the "high-dose" group only compared to the "sham" group. There was also a significant improvement in visual search and processing speed (p = 0.012) in the "high-dose" group. Replication of these findings in an adequately powered randomized sham-controlled study in healthy older adults can pave the way for clinical application of NIRL as a therapeutic modality in patients with Alzheimer's disease.

Empathic Accuracy Task: Indian Adaptation and Validation.

Background: The Empathic Accuracy Task (EAT) is an objective measure to assess empathic accuracy. Due to the variability in the number and linked emotions of the narrated events, we adapted EAT for the Indian sociocultural setting as Indian EAT (I-EAT). Methods: Eight videos were adapted in three languages (English, Hindi, and Kannada), narrating emotional events with a uniform representation of age groups, different emotions, and sex. The adapted I-EAT was then validated by cross-sectional comparison with different tests similar to EAT and those that assessed concepts different from or similar to empathy, in 29 healthy young adults, 23 healthy older adults (aged ≥60 years) along with clinical groups of 15 young people with depression, 15 older people with depression, and 15 young people with schizophrenia. Results: We selected eight videos with good content validity and internal consistency (Cronbach's alpha = 0.73. We obtained satisfactory concurrent validity of the EAT scores with the self-reported empathic assessments using the Questionnaire of Cognitive and Affective Empathy (Cognitive empathy score = 0.29, p = .034; Total score = 0.29, p = .035) and Interpersonal Reactivity Index (Empathic concern score = 0.45, p = .001). Good divergent validity was revealed in the high inverse correlation recorded with the Apathy Evaluation Scale ( = -0.67, p < .001). I-EAT did not correlate significantly with measures of social cognition. Known-groups validity was adequate in young adults with the significantly lower EAT scores (Cohen's d: 0.77 to 1.15) in the Schizophrenia group and higher EAT-N scores (Cohen's d: 0.51) in the Depression group, compared to the Healthy group. The Healthy group of the geriatric population also achieved significantly higher EAT scores (Cohen's d: 0.71 to 0.85) than the Depression group. Conclusion: With a good validity and internal consistency, I-EAT can be used in the Indian population to assess empathic accuracy without compromising performance of the original EAT.

Indian Psychiatric Society multicentre study: Diagnostic patterns, comorbidity and prescription practices for patients with Dementia.

Background: There are more than 5 million people with dementia in India. Multicentre studies looking at details of treatment for people with dementia In India are lacking. Clinical audit is a quality improvement process which aims to systematically assess, evaluate, and improve patient care. Evaluating current practice is the key to a clinical audit cycle. Aim: This study aimed to assess the diagnostic patterns and prescribing practices of psychiatrists for patients with dementia in India. Method: A retrospective case file study was conducted across several centers in India. Results: Information from the case records of 586 patients with dementia was obtained. Mean age of the patients was 71.14 years (standard deviation = 9.42). Three hundred twenty one (54.8%) were men. Alzheimer's disease (349; 59.6%) was the most frequent diagnosis followed by vascular dementia (117; 20%). Three hundred fifty five (60.6%) patients had medical disorders and 47.4% patients were taking medications for their medical conditions. Eighty one (69.2%) patients with vascular dementia had cardiovascular problems. Majority of the patients (524; 89.4%) were on medications for dementia. Most frequently prescribed treatment was Donepezil (230; 39.2%) followed by Donepezil-Memantine combination (225; 38.4%). Overall, 380 (64.8%) patients were on antipsychotics. Quetiapine (213, 36.3%) was the most frequently used antipsychotic. Overall, 113 (19.3%) patients were on antidepressants, 80 (13.7%) patients were on sedatives/hypnotics, and 16 (2.7%) patients were on mood stabilizers. Three hundred nineteen (55.4%) patients and caregivers of 374 (65%) patients were receiving psychosocial interventions. Conclusions: Diagnostic and prescription patterns in dementia which emerged from this study are comparable to other studies both nationally and internationally. Comparing current practices at individual and national levels against accepted guidelines, obtaining feedback, identifying gaps and instituting remedial measures help to improve the standard of care provided.

Deep phenotyping and genomic data from a nationally representative study on dementia in India.

The Harmonized Diagnostic Assessment of Dementia for the Longitudinal Aging Study in India (LASI-DAD) is a nationally representative in-depth study of cognitive aging and dementia. We present a publicly available dataset of harmonized cognitive measures of 4,096 adults 60 years of age and older in India, collected across 18 states and union territories. Blood samples were obtained to carry out whole blood and serum-based assays. Results are included in a venous blood specimen datafile that can be linked to the Harmonized LASI-DAD dataset. A global screening array of 960 LASI-DAD respondents is also publicly available for download, in addition to neuroimaging data on 137 LASI-DAD participants. Altogether, these datasets provide comprehensive information on older adults in India that allow researchers to further understand risk factors associated with cognitive impairment and dementia.

Impact of structured physical activity program on the level of functional ability of Persons with Mental Illness.

BACKGROUND: A structured physical activity program has many health benefits. Physical activity improves the functional ability of a patient with mental illness as an adjunctive treatment. This study aimed to evaluate the efficacy of a physical activity program on the level of functional ability of patients with mental illness. MATERIALS AND METHODS: A pre-experimental research design and one group pre-post design were adopted. Thirty-one in-patients with mental illness who met the inclusion criteria were recruited for the study using convenient sampling. Baseline data were collected using sociodemographic and illness profiles developed by the researcher and validated by the experts. Functional ability and illness severity were assessed using the standardized World Health Organization Disability Assessment Schedule (WHODAS) (36-item version) and the Clinical Global Improvement Scale. Pretest, i.e., intervention with structured physical activity, was administered for 40 consecutive days. A posttest was given 30 days after the intervention ended to assess the impact of the structured physical activity program on the level of functional ability among the study participants. RESULTS: The impact of structured physical activity on functional ability was measured using the WHODAS 2.0, a 36-item version. The paired Sample t-test and the Wilcoxon Rank test analyzed the data. There was a significant improvement in the overall functional ability of study participants at P = 0. 001. CONCLUSION: The study findings support that structured physical activity substantially impacts functional ability among patients with mental illnesses.

Is Thalamic Lesion a Contributing Factor for Inappropriate Sexual Behavior in Older Adults with Cognitive Impairment?

Thalamus is a group of nuclei located deep inside the brain, well known for its sensory and cognitive functions. However, its role in the reward and behavior regulation is less explored. In this case series, we have presented four cases with inappropriate sexual behaviors (ISB) that are temporally related to thalamic infarction. We have discussed about the limbic part of thalamus and its extensive connections with other regions in regulating sexual behaviors. Although in all the four cases described there was underlying cognitive impairment that can itself increase the risk of ISB, there was potential contributing role of thalamic lesions.

Extension for Community Healthcare Outcomes Based Telementoring of Physicians for Dementia-Effectiveness in India.

Objective: The study aimed to evaluate the effectiveness of a program based on the telementoring model [Extension for Community Healthcare Outcomes (ECHO)] for primary care physicians in diagnosing and treating patients with dementia. Method: The ECHO model was adapted through 12 live sessions of 2 h every 2 weeks consisting of a didactic presentation by the expert, peer-led new case discussions, and follow-up discussions. In addition, there were 10 h of self-paced e-learning and interim assignments. The impact was examined by noting participation, session ratings, monthly clinical reports, and comparing knowledge and competency scores before and after the course. Results: Among the 63 participants, 39.7% attended at least 80% of the sessions; completing the program successfully. The ratings for all sessions ranged from "good" to "excellent." The paired sample t-test revealed a statistically significant improvement (p < 0.001) in self-rated skills and confidence in diagnosing and treating dementia with an effect size of 1.25 and 1.37, respectively. No change in the knowledge score was observed throughout the course. A considerable increase in dementia-related clinical practice was observed during four monthly summary of clinical cases. Due to the limited data of monthly reports during the COVID pandemic, no statistical analysis was attempted. Conclusion: The ECHO model appears to have a positive immediate impact on the clinical ability of primary care physicians to diagnose and treat dementia. Its direct impact on patient health and at the community level should be aimed at in future studies.

Reflected image processing abnormalities in dementia - a case series and review.

Dementia is a neurodegenerative condition with progressive decline in cognitive faculties and associated with different clinical phenomena. Mirror phenomenon in terms of both mirror agnosia and mirror image agnosia wherein there is difficulty in processing and perception of reflected images is not uncommonly seen, and understanding the same can contribute to early diagnosis and prognostication. We report two elderly women with Alzheimer's dementia and frontotemporal dementia, respectively, presenting with features of abnormalities in mirror image processing. The former had features of both mirror agnosia and mirror image agnosia and the latter had predominantly features of mirror image agnosia with preoccupation with her mirror image. Understanding neuroanatomical networks underlying these phenomena can help early identification and subtyping dementia. Clinically differentiating these phenomena from psychotic symptoms of dementia can help in initiating appropriate non-pharmacological measures rather than resorting to use of psychotropics, the use of which may be counterproductive.

Clinical efficacy and neurobiological correlates of electroconvulsive therapy in patients with clozapine-resistant/intolerant schizophrenia: study protocol of multi-site parallel arm double-blind randomized sham-controlled study.

Background: A substantial proportion of patients with treatment resistant schizophrenia do not respond well or partially to clozapine, with a subset that does not tolerate an adequate trial of clozapine. Electroconvulsive therapy (ECT) is regarded as one of the augmenting options, but there is a lack of high-quality evidence for this practice. This protocol describes a double-blind randomised sham-controlled modified-ECT trial to evaluate its efficacy in patients with clozapine resistant/intolerant schizophrenia. The study also involves multimodal investigations to identify the response predictors and the mechanistic basis of modified ECT in this population. Methods: One hundred consenting schizophrenia patients with resistance/intolerance to clozapine referred by clinicians for ECT would be randomly assigned to receive true ECT or sham ECT at three study centers. Sham ECT would mimic all the procedures of modified ECT including anaesthesia and muscle relaxation, except the electrical stimulation. After a blinded course, non-responders to sham ECT would be offered open-label true ECT. Clinical assessments, neurocognitive assessments and multimodal investigations (magnetic resonance imaging [MRI], electroencephalography, heart rate variability, investigative transcranial magnetic stimulation-transcranial direct current stimulation, gene polymorphism) would be conducted at baseline and repeated after the end of the trial, as well as open-label ECT course. The trial would evaluate the improvement in positive symptoms (scale for assessment of positive symptoms) of schizophrenia as the primary outcome measure with prediction of this change by resting-state functional-MRI based brain-connectivity as the second primary objective. Registration: Clinical Trial Registry of India (Reg no: CTRI/2021/05/033775) on 24 th May 2021.

Plasma neurofilament L to amyloid ß42 ratio in differentiating Alzheimer's type from non-Alzheimer's dementia: A cross-sectional pilot study from India.

Based on the reduction of amyloid ß plaques, US FDA has recently approved Aducanumab as a disease modifying treatment for Alzheimer's disease (AD). With high pricing and the potential risks likely with this treatment, certainty of AD diagnosis becomes crucial. The current pilot study evaluated plasma levels of neurofilament L, an axonal injury marker and amyloid ß42, a major component of amyloid plaques for discriminating AD from non-AD dementia (NAD). Results with Simoa assays indicate that a combination of neurofilament L and amyloid ß42 can be considered as a screening tool in identifying eligible subjects for AD treatment/ clinical trials.

Future-Proofing Geriatric Mental Health Care Services in India: Training and Policy Directions.

BACKGROUND: A burgeoning rise in the elderly subpopulation is being noted in India. This rise has already earned the designation as a shining nation by the United Nations/World Health Organization. This growth will take the elderly subpopulation to 324 million persons above 60 years by 2050. The mental health needs of this subpopulation are varied and nuanced compared to that of the general population. The risk and prevalence of mental health morbidity are also greater. There is an urgent need to gear up the health care systems. CONSIDERATIONS: Various aspects of the ongoing demographic transitions are considered alongside available health information. Legislative mandates and laws are also reviewed to provide context to qualify the action points and recommendations. Recommendations, India must act urgently to strengthen health care delivery systems in a concurrent multipronged approach. These efforts should focus on developing trained Human Resources and adequate infrastructural resources. Review mechanisms to inform on required updates on best practices and evidence-based medicine must also be incorporated and developed to perform periodically.

Electroconvulsive therapy services during COVID-19 pandemic.

The COVID-19 pandemic has hit the electroconvulsive therapy (ECT) services hard worldwide as it is considered an elective procedure and hence has been given less importance. Other reasons include the risk of transmission of infections, lack of resources, and the scarcity of anesthesiologists due to their diversion to intensive care units to manage COVID-19 patients. However, ECT is an urgent and life-saving measure for patients diagnosed with depression and other severe mental illnesses who have suicidality, catatonia, or require a rapid therapeutic response. COVID-19 pandemic is a significant source of stress for individuals due to its impact on health, employment, and social support resulting in new-onset psychiatric illnesses and the worsening of a pre-existing disorder. Hence, a continuation of the ECT services during the COVID-19 pandemic is of paramount importance. In this narrative review, the authors from India have compiled the literature on the ECT practice during the COVID-19 pandemic related to the screening and testing protocol, necessity of personal protective equipment, modification in ECT Suite, electrical stmulus settings, and anesthesia technique modification. The authors have also shared their experiences with the ECT services provided at their institute during this pandemic. This description will help other institutes to manage the ECT services uninterruptedly and make ECT a safe procedure during the current pandemic.

Anticholinergic Burden Among Hospitalised Older Adults with Psychiatric Illnesses- A Retrospective Study.

BACKGROUND: Drugs with anticholinergic properties are known to be associated with deleterious effects on cognition in older adults. There is a paucity of literature in this aspect in older adults with psychiatric disorders. OBJECTIVE: To examine the anticholinergic cognitive burden and its predictors in hospitalised older adults having psychiatric disorders. METHODS: Case records of older adults who sought in-patient care under the Geriatric Psychiatry Unit from January 2019 to June 2019 were reviewed. The anticholinergic burden was assessed with Anticholinergic Cognitive Burden (ACB) scale updated version, 2012. RESULTS: Sample included 129 older adults with an almost equal number of males (53.48%) and females (46.52%) having a mean age of 67.84 (SD = 6.96) years. The diagnostic spectrum included depression (34.89%), dementia (31.01%), mania (10.85%), psychosis (13.95%), delirium (6.20%), and others (3.1%). 60.47% of the patients had more than one medical illness. 48.84% of the older adults had clinically relevant anticholinergic cognitive burden (ACB score ≥ 3). Use of 3 or more psychotropic drugs (OR = 4.88), diagnosis of psychosis/mania (OR = 7.62) and dementia/ delirium (neurocognitive disorders group) (OR = 5.17) increased the risk of ACB score ≥ 3. CONCLUSION: Nearly half of the older adults in the psychiatry in-patient setting had a clinically relevant anticholinergic burden, which was associated with higher use of psychotropics. Our study highlights the importance of monitoringanticholinergic effects of psychotropics in older adults.

Prevalence of Common mental disorders in older adults: Results from the National Mental Health Survey of India.

OBJECTIVE: We estimate the prevalence of common mental disorders (CMD) among older adults and compare them with that of younger adults at the national level. METHOD: We analysed data on older adults from the National Mental Health Survey of India undertaken across 6 regions and 12 states of India during 2015-16. Multi-stage cluster sampling technique was adopted which permitted state level and subsequently pooled national estimates. Mini International NeuroPsychiatric Interview (MINI) adult version 6.0 was used for measuring psychiatric morbidity. RESULTS: Older adults had a higher lifetime (6.93%) and current (3.53%) prevalence of depressive disorders as compared to the younger adults (4.96% and 2.54%). There was no difference in the prevalence of anxiety disorders in different agegroups. The most prevalent anxiety disorder in older adults was specific phobias (1.72%) followed by agoraphobia (1.6%). All CMD in the older population were more common in females, those living in urban metros, the unemployed, who were not currently married and those with lower household income. DISCUSSION: These findings support planning better mental health policies and programs for older adults in India.