The co-occurrence of multiple sclerosis and bipolar disorder: A case series on clinical and neuroimaging correlates.

There is a dearth of studies on neuroimaging correlates of Bipolar Disorder (BD) in Multiple Sclerosis (MS). We describe the clinical profile and neuroimaging findings of four cases of MS with BD. Among them, two patients had multiple mood episodes preceding the neurological symptoms, one had concurrent manic and neurological symptoms, and one had multiple depressive episodes and an isolated steroid-induced manic episode. Frontal and temporal lobes, and Periventricular White Matter were involved in all four cases, and hence may be considered biological substrates of BD in MS. Larger studies are needed to validate the utility of these findings.

Development of a tool for infant facial emotion recognition (InFER) for postpartum mothers with mental illnesses.

Understanding deficits in recognition of infant emotions in mothers with mental illnesses is limited by the lack of validated instruments. We present the development and content validation of the infant facial emotion recognition tool (InFER) in India to examine the ability of mothers to detect the infants' emotions. A total of 164 images of infant faces in various emotional states were gathered from the parents of four infants (two male and two female: up to 12 months old). Infant emotion in each image was identified by the respective mother. Content validation was carried out by 21 experts. Images with ≥70% concordance among experts were selected. The newly developed tool, InFER, consists of a total 39 infant images representing the six basic emotions. This tool was then administered among mothers during their postpartum period-10 healthy mothers and 10 mothers who had remitted from any schizophrenia spectrum disorder, bipolar affective disorder or major depressive disorder. The mean age and mean years of education for both groups were comparable (age∼25 years, education ∼15 years). A significant difference was found between the two groups in their ability to recognize infant emotions (Mann-Whitney U = 12.5; p = 0.004). InFER is a promising tool in Indian settings for understanding maternal recognition of infant emotions.

La comprensión de los déficits en el reconocimiento de las emociones del infante en madres con enfermedades mentales está limitada por la falta de instrumentos validados. Presentamos el desarrollo y la validación de contenido de una herramienta para reconocer la emoción facial del infante (InFER) en la India. para examinar la habilidad de las madres para detectar las emociones del infante. Se recogió un total de 164 imágenes de caras de infantes en varios estados emocionales, aportadas por los progenitores de 4 infantes (dos varones y dos niñas: de hasta 12 meses de edad). La mamá respectiva identificó la emoción del infante en cada imagen. La validación del contenido la llevaron a cabo 21 expertos. Para la construcción de esta herramienta se seleccionaron las imágenes que presentaban el ≥70% de concordancia entre los expertos. La recientemente desarrollada herramienta, InFER está compuesta de un total de 39 imágenes de infantes las cuales representan las seis emociones básicas. Esta herramienta entonces se puso en práctica entre madres durante su período de postparto ­10 madres saludables y 10 madres que habían sido remitidas en relación con cualquiera de los trastornos de la gama de la esquizofrenia, el trastorno afectivo bipolar o un trastorno depresivo mayor. El promedio de edad y el promedio de años de educación en ambos grupos eran comparables (edad ∼25 años, educación ∼15years). Una diferencia significativa se encontró entre los dos grupos en cuanto a su habilidad de reconocer las emociones del infante (Mann­Whitney U = 12.5; p = 0.004). InFER es una herramienta prometedora en entornos de la India para comprender el reconocimiento materno de las emociones del infante.

La compréhension des déficits dans la reconnaissance des émotions du bébé chez les mères ayant des maladies mentales est limitée par le manque d'instruments validés. Nous présentons le développement et la validation du contenu d'un outil de reconnaissance de l'émotion faciale du nourrisson (InFER) en Inde afin d'examiner la capacité des mères à détecter les émotions du bébé. Un total de 164 images de visages de bébés dans des états émotionnels variés ont été assemblées de parents de 4 bébés (deux garçons et deux filles: jusqu'à l'âge de 12 mois) L'émotion du bébé dans chaque image a été identifiée par la mère respective. La validation du contenu a été faite par 21 experts. Des images avec ≥70% de concordance entre les experts ont été sélectionnées pour la construction de l'outil. Ce nouvel outil, InFER, consiste en un total de 39 images de bébés représentant les six émotions de base. Cet outil a ensuite été utilisé chez des mères durant leur période postpartum ­ 10 mères en bonne santé et 10 mères s'étant remises soit d'un trouble du spectre schizophrénique, soit d'un trouble affectif bipolaire ou d'un trouble dépressif majeur. La moyenne d'âge et la moyenne d'années d'éducation pour les deux groupes étaient comparables (âge∼25ans, éducation ∼15ans). Une différence importante a été trouvée entre les deux groupes dans leur capacité à reconnaître les émotions du bébé (Mann­Whitney U = 12,5; p = 0,004). InFER est un outil prometteur dans les contextes de l'Inde pour comprendre la reconnaissance maternelle des émotions du bébé.

Bell's mania as a clinical presentation in a neurosurgical setting from a tertiary care neuropsychiatric hospital in India.

Bell's mania is the co-occurrence of delirium and mania. We present two cases of Bell's mania in a neurosurgical setting. The first case is of a 52-year-old male who presented with holocranial headache, disorientation, and manic symptoms for five months. He was found to have suprasellar craniopharyngioma. He significantly improved with olanzapine, but re-emergence of mood symptoms was noted after surgery. The second case is of a 42-year-old male who presented with a 15-day history of seizures and disorientation. He was found to have a dural arteriovenous fistula. He developed Bell's mania in the post-procedural period, which improved with olanzapine. Compression of the hypothalamo-pituitary stalk in the first case and vascular and inflammatory changes in the second case could have led to Bell's mania. Atypical age of onset and presence of neurological symptoms in patients presenting with psychiatric symptoms should raise the suspicion of an underlying organicity. Atypical anti-psychotics can be a useful management strategy for Bell's mania.

Psychiatric manifestations of neurosyphilis over past two decades: Findings from a tertiary care neuropsychiatric hospital in south India.

OBJECTIVE: To assess presentation of neurosyphilis with a focus on the psychiatric aspects. METHOD: File review of the cases with a positive cerebrospinal fluid venereal disease research laboratory test between 1999 to 2020. RESULTS: Medical records of 143 neurosyphilis patients were analysed. Hallucinations, delusions, and catatonia were the commonest psychiatric symptoms. Brain atrophy was the commonest neuroimaging finding. The number of neurosyphilis patients and the proportion with delirium or catatonia declined during the second decade (2010-2020). CONCLUSION: Atypical presentation of psychiatric symptoms around the fifth decade, with associated neurological symptoms or brain imaging changes, should prompt evaluation for neurosyphilis.

Women's awareness of perinatal mental health conditions and the acceptability of being asked about mental health in two regions in India: a qualitative study.

BACKGROUND: Mental health conditions are common during pregnancy and the first year after childbirth. Early detection allows timely support and treatment to be offered, but identifying perinatal mental health conditions may be challenging due to stigma and under-recognition of symptoms. Asking about symptoms of mental health conditions during routine antenatal and postnatal appointments can help to identify women at risk. This study explores women's awareness of perinatal mental health conditions, their views on the acceptability of being asked about mental health and any preference for specific assessment tools in two regions in India. METHODS: Focus group discussions (FGDs) were conducted with pregnant, post-partum and non-perinatal women in Kangra, Himachal Pradesh (northern India) and Bengaluru, Karnataka (southern India). Settings included a hospital antenatal clinic and obstetric ward, Anganwadi Centres and Primary Health Centres. FGDs were facilitated, audio-recorded and transcribed. Narratives were coded for emerging themes and analysed using thematic analysis. RESULTS: Seven FGDs including 36 participants were conducted. Emerging themes were: manifestations of and contributors to mental health conditions; challenges in talking about mental health; and the acceptability of being asked about mental health. Difficult familial relationships, prioritising the needs of others and pressure to have a male infant were cited as key stressors. Being asked about mental health was generally reported to be acceptable, though some women felt uncomfortable with questions about suicidality. No preference for any specific assessment tool was reported. CONCLUSIONS: Women face many stressors during the perinatal period including difficult familial relationships and societal pressure to bear a male infant. Being asked about mental health was generally considered to be acceptable, but questions relating to suicidality may be challenging in a community setting, requiring sensitivity by the interviewer. Future studies should assess the acceptability of mental health assessments in 'real world' antenatal and postnatal clinics and explore ways of overcoming the associated challenges in resource-constrained settings.

Postpartum psychosis: a public involvement perspective across three continents.

Postpartum psychosis is a psychiatric emergency that is currently not represented in diagnostic systems, to the detriment of people with lived experience. Engaging with stakeholders offers an important avenue to improve clinical practice and make research more impactful, by providing perspectives based on first-hand, expert experience. There is a paucity of reports on stakeholders' engagement in psychiatry. Activities have thus far been limited to Western countries and there are few reports on postpartum psychosis. We report the results of public involvement activities (in the form of discussion groups) with key stakeholders in India, Malawi and the UK. These discussions centred around the clinical picture of postpartum psychosis and the terminologies used to describe these episodes. Seven major areas were highlighted: how postpartum psychosis is handled within services, common symptoms and characteristics, impact of episode, barriers to care, non-medical approaches, terminology and research areas of interest. According to the discussions, postpartum psychosis presents similarly across countries, although there are differences in access to services, approaches to mental health and terminologies used within and across countries. With this understanding comes the foundation for cross-cultural assessment, service improvement and a stakeholder-informed research agenda.

Formation of a stakeholder group of women with a lived experience of Post-partum Psychoses (PP) - Experience from a perinatal psychiatry service in India.

Our paper describes the process of creating a stakeholder group for service development and research in Postpartum Psychosis (PP) at a Perinatal Psychiatry Service in India. We involved women who have recovered from PP as `experts by experience' in identifying areas that need attention from a research and service perspectives. A total of 13 group meetings were conducted, in which 9 group meetings involved women with lived experiences of PP and 4 group meetings were with the family members involved in the care of women during the PP episode. Of the 58 participants, 23 women and two family members expressed their willingness to participate in future stakeholder meetings. Involvement of women with PP and their caregivers as stakeholders in mental health decision-making appears feasible in a LMIC setting and should be encouraged.

Diagnostic accuracy of clinical signs and investigations for functional weakness, sensory and movement disorders: A systematic review.

INTRODUCTION: Patients with functional neurological disorders (FND) present with weakness, sensory or movement disorder without corresponding brain pathology. The current classificatory systems suggest an inclusionary approach to diagnose FND. Hence, there is a need to systematically evaluate the diagnostic accuracy of clinical signs and electrophysiological investigations in view of the lack of gold standard tests to diagnose FND. METHODS: PubMed and SCOPUS databases were searched for studies published from Jan 1950 to Jan 2022 which reported the diagnostic accuracy of clinical signs and electrophysiological investigations in patients with FND. The Newcastle Ottawa scale was used to assess the quality of the studies. RESULTS: Twenty-one studies (727 cases and 932 controls), of which 16 reported clinical signs and, five reported electrophysiological investigations, were included in the review. Two studies were of good quality, 17 of moderate quality, and two of poor quality. We identified 46 clinical signs (24 in weakness, 3 in sensory, and 19 in movement disorders) and 17 investigations (all in movement disorders). Specificity values for signs and investigations were comparatively high compared to the wide variance in sensitivity values. CONCLUSION: Electrophysiological investigations appear to have a promising role in diagnosing FND, particularly functional movement disorders. The combined use of individual clinical signs and electrophysiological investigations may support and improve diagnostic certainty of FND. Future research can focus on improving the methodology and validating the existing clinical signs and electrophysiological investigations to enhance the validity of the composite diagnostic criterias for FND diagnosis.

Cross-continental collaboration for understanding postpartum major depression with psychotic features.

Purpose: Assess postpartum depression and psychotic symptoms from three continents. Methods: Compare numbers of women with depression and psychotic symptoms, mania with or without psychotic features, or transient non-affective psychosis and medication choice. Results: The prevalence of postpartum depression and psychosis and treatment choice differed at each site. Conclusions: Best treatment for postpartum depression with psychotic features has not been established yet. Cross-continental collaboration with similar assessments holds promise to develop best practices for these high risk mother-infant dyads.

Neurocognition and Metacognition in Anxiety Disorders.

Background: Neurocognitive deficits are noted in anxiety disorders (ADs), albeit with several inconsistencies. The relationship between neurocognition and metacognition may have potential implications for understanding cognitive dysfunction but is poorly understood in ADs. This study aimed to examine the relationship between neurocognition and metacognition in ADs, with a cross-sectional design. Methods: The sample included ADs (n = 25) and nonclinical (n = 25) groups matched on age, gender, and education. Neurocognition was assessed using tests for intelligence, attention, working memory, fluency, flexibility, set-shifting, inhibition, planning, and memory; and metacognition using Metacognition Questionnaire-30 (MCQ-30) and Metacognitive Awareness and Regulation Scale (MARS). Results: Compared to comparison/normative scores, the anxiety group showed significantly poorer performance on zoo map test (low demand trial; P = 0.007), rule shift cards 1 (P ≤ 0.001), rule shift cards 2 (P ≤ 0.001), and logical memory immediate recall (P ≤ 0.001) and delayed recall (P ≤ 0.001); greater negative beliefs about worry (P = 0.005), and poorer metacognitive awareness and regulation (P = 0.01). Greater cognitive self-consciousness was correlated with better planning (Spearman's rho = -0.509, P = 0.009). Conclusions: Individuals with ADs show neurocognitive difficulties in planning, set-shifting, and logical memory, dysfunctional metacognition, and reduced metacognitive awareness and regulation. Cognitive self-consciousness is linked to better planning. The interrelationships between neurocognition and metacognition may have potential implications for clarifying inconsistent findings and designing novel cognitive interventions in ADs.

Women with mental illness seeking conception counselling at a specialist perinatal psychiatry service in India.

AIMS: To study the clinical and sociodemographic profile of women with mental illness seeking conception counselling at perinatal psychiatry service. To compare women seeking preconception counselling (PCC) to that of those who sought help after unplanned pregnancy with exposure (UPE) to psychotropics. MATERIAL AND METHODS: Data was extracted from the clinical records of women between the year 2014-2017 who attended perinatal outpatient services. The details collected included sociodemographic details, illness details, contraception, infertility treatment and detailed treatment history. RESULTS: Of the 766 women who consulted perinatal psychiatry services (2014-17), 179 (23.37%) had consulted for conception counselling. Out of that 104 (58.1%) sought PCC, and 75 (41.9%) had UPE to psychotropics. PCC was sought by women with higher education, those having a severe mental illness, and a longer duration of illness. Women with medical comorbidities and receiving infertility treatment also sought PCC. Also, women who had earlier undergone PCC been more likely to seek PCC for further pregnancies. CONCLUSIONS: Women with mental illness should be counselled regarding planned pregnancies, contraception, and the impact of psychotropics on pregnancy and foetus. Also, liaison with other specialities like obstetricians, sonologist and paediatricians is essential.

A systematic review and meta-analysis of early childhood intervention programs for developmental difficulties in low-and-middle-income countries.

Early acknowledgment of developmental difficulties in young children strengthens both preventive and therapeutic approaches. Despite their feasibility, early intervention services are limited in Low-and-Middle-Income (LAMI) countries compared to high income countries. The aim of this study was to examine the evidence for early childhood intervention programs for developmental difficulties in children below five years in LAMI countries through a systematic review and meta-analysis. In this background, original studies published in peer-reviewed journals from 2010 to 2019 with a focus on developmental difficulties including delays and deviances; randomized research design with a clear description of the intervention and measurable outcomes, and conducted in LAMI countries were considered for the systematic review. Electronic databases, including ProQuest, PubMed, Ovid, EBSCOhost, and Google Scholar, were searched using a combination of specific keywords. PRISMA guidelines were followed to include the studies. Each of the selected study was assessed for quality before applying appropriate statistics to synthesize the data. Fourteen publications were identified from 2697 publications for the systematic review, out of which four were found compatible for a meta-analysis. The studies reviewed were conducted in Bangladesh, India, Pakistan, Uganda, Vietnam, and Zambia. A meta-analysis of four studies provided considerable evidence for the effects of early developmental intervention. This systematic review provides an evidence for early childhood intervention programs in LAMI countries. Implications of these findings for the early childhood programs are discussed in this article.

Neuropsychiatric manifestations in vitamin B12 deficiency.

Vitamin B12 deficiency can have distressing neuropsychiatric symptoms. It can have an etiological role in clinical presentations like depression, anxiety, psychosis, dementia, and delirium, requiring screening of at-risk populations. Few mechanisms that underlie the neuropsychiatric manifestations of B12 deficiency include alteration in one-carbon metabolism, genetic vulnerability, and alteration in folate metabolism. Maintaining a high serum B12 level in elderly can be protective against Alzheimer's disease (AD). In an established AD, its deficiency is associated with higher cognitive decline and risk for delirium. The other mental changes associated with B12 deficiency include apathy, agitation, impaired concentration, insomnia, persecutory delusions, auditory and visual hallucinations, and disorganized thought-process. Besides serum vitamin B12, plasma methylmalonic acid (MMA) and homocysteine helps in diagnosis. The chapter focuses on early recognition and effective treatment of these neuropsychiatric manifestations of vitamin B12 deficiency.

Gender Issues in the Care of Elderly: A Narrative Review.

Aging is an inevitable physiological process. A significant increase has been noted in the elderly population over the years. Aging population face challenges with physical health conditions, but also mental health problems. Care of the elderly is influenced by health conditions, health services, as well socio cultural factors. Gender plays an important role in the aging process with significant differences noted in the aging process, variations in health conditions as well care received. The current review addresses the role of gender in the aging process and its influence in the prevalence, clinical presentation and course of various mental and physical health conditions in the elderly. The review identifies gaps in understanding the gender perspectives related to long-term elderly care, legal and financial issues. The review emphasizes the necessity to address the gender perspective in aging to adequately meet the health demands of the elderly.

Perinatal Mental Health Care for Women With Severe Mental Illness During the COVID-19 Pandemic in India-Challenges and Potential Solutions Based on Two Case Reports.

The ongoing COVID-19 pandemic in India has created several challenges in the care of women with perinatal mental illness. Access to healthcare has been disrupted by lockdowns, travel restrictions, and the unavailability of outpatient services. This report aims to discuss the challenges faced by women with severe mental illnesses during the perinatal period with the help of two case reports. Accordingly, we have highlighted the role of COVID-19 infection as a traumatic event during childbirth and its role in triggering a psychotic episode in women with vulnerabilities; difficulties faced by women with postpartum psychosis in accessing perinatal psychiatry services; and the challenges of admission into an inpatient Mother-Baby Unit (MBU). Further, we have discussed potential solutions from the perspectives of Lower and Middle-income (LAMI) countries that need to be extended beyond the pandemic. They include offering video consultations, reviewing hospital policies, and evolving strategies to mitigate traumatic experiences for pregnant and postpartum women with severe mental illnesses in both obstetric and psychiatric care.

Short-term outcome of mothers with severe mental illness admitted to a mother baby unit.

BACKGROUND: Mother baby psychiatry units (MBUs) are the expected standard of inpatient care internationally for postpartum mothers with severe mental illness (SMI) and favorable outcomes for mother infant dyads have been reported from these services. However, there are very few such units in low- and middle-income countries. The current study aimed to assess the short-term outcome of mothers in SMI admitted to an MBU in India. MATERIALS AND METHODS: Mother infant dyads admitted over a year in the MBU were assessed in detail at admission, discharge, and at 3 months. Tools used included the Brief Psychiatric Rating Scale (BPRS), Young's Mania Rating Scale, Edinburgh Postnatal Depression Scale, and Clinical Global Impression. Mother infant interaction was assessed using the NIMHANS maternal behavior scale. RESULTS: The mean age of the 43 mothers admitted in this period was 27.3 ± 6.2 years. For 27 (62.8%) mothers, this was a first episode of psychosis. Affective disorders and acute psychotic disorders were the most common diagnoses. The average duration of stay in the MBU was 25 days. While all mothers showed significant improvement at discharge, mothers with a first episode in the postpartum had higher BPRS scores (Ws = 309.5, P = 0.02) as compared to the others. At 3 months following discharge, all mothers sustained the improvement achieved. DISCUSSION: Mothers with SMI admitted to an MBU showed significant clinical and dyadic improvement at discharge which was sustained at 3 months. However, the lack of a control group limits the generalizability of the current findings. CONCLUSION: The study highlighted a favorable short-term outcome among mothers with SMI admitted to a MBU facility.

A virtual course in perinatal mental health for healthcare professionals.

Screening and treatment of perinatal mental health problems remain inadequate with one of the barrier being non-availability of trained health professionals. Virtual courses have been an important medium to enhance the knowledge and capacity of health professionals. A virtual certificate course in perinatal mental health was developed to train health professionals to identify and treat perinatal mental health disorders. Of the 41 participants, 90.2 % fulfilled the attendance criterion and 75.6 % of them secured the certification. Encouraging feedback (9.54/10) indicated that virtual courses could help enhance competency in health professionals to identify and treat perinatal mental health disorders.