New onset gender dysphoria in bipolar affective disorder - A case series.

Gender confusion in the context of mania is very less frequently described in the literature. The actuality of a primary psychiatric condition in gender identity complaint has significant bearing on the applicable operation and prognostic. This case series describes cases of bipolar affective complaint presenting in a manic occasion whose mania was marked by hypersexuality and the desire to be of opposite gender. Both of these symptoms resolved with treatment of the manic occasion. Case 1 describes a 17-year-old male presenting with an episodic illness, with current manic episode. He is currently interested in boys and has started enjoying feminine activities. Upon treatment, his symptoms showed improvement. Case 2 describes a 22-year-old gay male, with a total duration of 7 years, current episode mania. Now, he is considering himself a lesbian and feels he is mentally a modern female. After 4 months of treatment, there was significant improvement in his complaints and he stopped cross-dressing as a female. Case 3 shows a 21-year-old female, with manic episode. After 1 month, the patient began acting and speaking more like a boy. The patient has shown improvement while taking lithium 900 mg, divalproex sodium 1000 mg, risperidone 6 mg, and chlorpromazine 150 mg. Gender dysphoria occurring along with a psychotic episode and resolving with management of the primary psychiatric disorder are rarely recorded. The central issue in similar cases is a proper workup and diagnosis. Psychiatrists should be aware of this scenario so that proper treatment strategies for gender incongruence can be planned and not be brushed aside as "just another symptom."

Disordered eating behaviors, body dissatisfaction and their determinants in Indian adolescents: A cross-sectional observational study.

Objective: Although the prevalence of disordered eating is maximum in high-income countries, the most significant rise occurred in East Asia and South Asia over the last three decades. Body dissatisfaction and disordered eating behaviors (DEBs) are more common than full-blown eating disorders. The cognitive distortion leading to these manifestations mainly occurs during adolescence and early adulthood. In this study, we assess the burden of DEBs in a cohort of Indian adolescents and determine their correlation with body dissatisfaction, calorie intake, and clinicosocial determinants. Methods: The study was conducted from November 2016 to November 2020 and enrolled 180 adolescents of 10-18 years attending the outpatient department of a tertiary-care hospital. Subjects were screened for DEBs, using a 15-item Screening Questionnaire for Eating Distress Syndromes, and for body dissatisfaction, using Photographic-Figure-Rating-Scale. Clinicosocial interviews, dietary and anthropometric evaluation, and psychiatric screening using a Mini-International Neuropsychiatric Interview (MINI-KIDS screen) were conducted. Results: DEB was present in 17.2% of adolescents, while 81.1% had body dissatisfaction and 32.2% had some psychiatric symptoms. The prevalence of DEBs in females was much higher than in males (OR = 7.89, 95%CI: 2.25-27.75, P = 0.001). More males (84.1%) reported body dissatisfaction than females (76.7%) [χ² =9.2, P = 0.010]. However, while females wished to lose weight, males desired weight gain, as measured by body dissatisfaction score (t = 2.9, P = 0.004). Apart from sex, other factors found significant in predicting DEBs in multivariate analysis were education, body dissatisfaction, BMI, and the number of siblings. Conclusion: We conclude that, unlike overt eating disorders, DEBs are common in Indian adolescents. The development of DEBs is influenced by gender, education, body dissatisfaction, BMI, and the number of siblings.

A rare case report of pseudo-pregnancy in a menopausal female.

Pseudo-pregnancy is an uncommon psychiatric presentation, often having a complex interplay of psycho-social factors making it difficult to manage. It is common to present in the reproductive age range, rarely in postmenopausal women. We are reporting a rare presentation of a 48-year post-menopausal widowed HIV-positive female with no live issues having two years of secondary amenorrhea complaining to have documented weight gain and experience of perceiving fetal movements for the past 5 months. However, she persistently insisted on antenatal care despite repeated reports of ultra-sonographic pelvis imaging and gynecological examination pointed toward menopausal changes and the absence of any live issue. This case report emphasizes the clinical presentation and management strategies for patients with pseudocyesis, a peculiar and rare psychiatric manifestation.

Stepped Care Model for Developing Pathways of Screening, Referral, and Brief Intervention for Depression in Pregnancy: A Mixed-Method Study from Development Phase.

Background: Depression in pregnancy affects nearly one in five women in low- and middle-income countries and is associated with adverse obstetric and neonatal outcome. Burden of morbidity is high, but specialized mental health resources are meager. Effective low intensity psychosocial interventions hold promise to fill the treatment gap for maternal depression. In this paper, we aim to describe the process of development of a stepped care model incorporating screening, providing brief intervention, and referral pathways developed for managing depression in pregnancy in antenatal care health facilities in India. Methodology: Using complex intervention development and evaluation method of Medical Research Council, United Kingdom, we searched evidence-based strategies from preexisting manuals, conducted formative research for need assessment and stakeholder engagement, and developed the intervention following an expert review panel. We conducted pilot testing to assess the feasibility and acceptability of intervention supplemented by three focused group discussions. Results: Manual review identified psychoeducation, empathetic listening, behavior activation, and supportive counseling as important elements. Need assessment revealed huge gap in perinatal mental health knowledge. Nearly 92% of total 272 perinatal women had poor awareness and 35%-70% of total 62 health-care providers had poor knowledge. In qualitative interview, women reported depressive symptoms as a normal part of pregnancy and had poor help seeking, behavior symptoms of depression were more prominent. A stepped care algorithm was developed for screening all expectant mothers in each trimester for depression using Patient Health Questionnaire-9 (PHQ-9). Women with PHQ-9 score >19 or reporting self-harm ideation were urgently referred to psychiatrist. Women with PHQ-9 score 5-19 were given brief intervention for depression in pregnancy intervention by antenatal nurse. The intervention developed consists of three sessions of psychoeducation, relaxation exercise, and mental health promotion, each lasting 20 min and at gap of 2 weeks each. Service providers and mothers reported good acceptability of psychosocial intervention and reported satisfaction with content and delivery of intervention. Conclusion: Low intensity brief psychosocial interventions can be adapted for implementation if relevant stakeholders are engaged at each step right from development of such as screening, intervention pathway to delivery, and effectiveness study.

Perceived stress, marital satisfaction, and sexual satisfaction in spouses of males having bipolar disorder with and without alcohol use disorder: A cross-sectional study.

BACKGROUND: Bipolar affective disorder (BPAD) and alcohol use disorder (AUD) are frequently comorbid and affect the social, occupational, and personal domains of patients and their spouses. AIM: This cross-sectional study was conducted to assess and compare the levels of stress, marital satisfaction, and sexual satisfaction between the spouses of males with BPAD + AUD and of those without AUD. MATERIALS AND METHODS: Spouses of 100 males with diagnosed BPAD, currently in remission, including fifty patients having comorbid AUD, were recruited as participants. Participants were assessed with Perceived Stress Scale-10, Dyadic Adjustment Scale, and Sexuality Scale. STATISTICAL ANALYSIS: Descriptive statistics, Chi-square, t-test, analysis of variance, and correlation on SPSS were used for statistical analysis. RESULTS: More stress (59%), poorer marital (53%) and sexual satisfaction (89%) were found in the majority participants, with significantly higher stress in the group with husbands having both BPAD + AUD (P < 0.01). Duration of cohabitation had a direct, and education and family income had inverse relations with stress. CONCLUSIONS: BPAD worsens stress, marital satisfaction, and sexual satisfaction in the study participants, the stress increasing further with comorbid AUD. Education, family income, and duration of cohabitation have a significant bearing on stress.

Development of a brief psychological intervention for perinatal depression (BIND-P).

BACKGROUND: Lack of recognition in national programs, poor referral system, and non-availability of trained human resources are the important barriers for the delivery of perinatal depression (PND) services in low- and middle-income countries (LAMICs). To address this there is an urgent need to develop an integrative and non-specialist-based stepped care model. As part of its research thrust on target areas of India's National Mental Health Programme (NMHP), the Indian Council of Medical Research funded a research project on the outcome of PND at four sites. In this article, we describe the development of the primary health care worker-based stepped care model and brief psychological intervention for PND. METHODS: A literature review focused on various aspects of PND was conducted to develop a model of care and intervention under NMHP. A panel of national and international experts and stakeholders reviewed the literature, opinions, perspectives, and proposal for different models and interventions, using a consensus method and WHO implementation toolkit. RESULTS: A consensus was reached to develop an ANM (Auxillary nurse midwife)-based stepped-care model consisting of the components of care, training, and referral services for PND. Furthermore, a brief psychological intervention (BIND-P) was developed, which includes the components of the low-intensity intervention (eg, exercise, sleep hygiene). CONCLUSION: The BIND-P model and intervention provide a practical approach that may facilitate effective identification, treatment, and support women with PND. We are currently evaluating this model across four study sites in India, which may help in the early detection and provision of appropriate and integrative care for PND.

Perinatal depression-knowledge gap among service providers and service utilizers in India.

INTRODUCTION: Lack of access to perinatal mental health (PMH) services is a significant public health problem in India. Barriers to accessing PMH services include the stigma, non-availability of services, poor knowledge, negative perception, attitude among perinatal women (PWs) and service providers. The present study attempted to examine the knowledge gap regarding perinatal depression (PD) among service providers [Nursing providers (NPs), Medical Practitioners (MPs)] and service utilizers (PWs). METHODS: This cross-sectional study was conducted in two tertiary care teaching hospitals of India, one in a major metro and the other in a rural area. PWs, MPs and NPs were assessed for knowledge about PD using a semi-structured proforma and Perinatal Depression Monitor. RESULTS: Among the 270 PWs, 8.51% were knowledgeable (PWA) and 91.49% were ignorant (PWB) about depression. PWB group were low educated (n = 140, 56.68%), and unemployed (n = 207, 83.80%) with lower family income [(≤₹10,356 per month), n = 170, 68.28%)]. There was knowledge discrepancy among NPs, MPs and PWA group in terms of a) PD is a normal part of pregnancy (agree- NPs = 71.52%, MPs = 10.00%, PWA-17.39%), b)biological causes of PD (agree- NPs = 45.23%, MPs = 70.00%, PWA = 26.03%) and c)antidepressant medications for PD (useful- NPs = 23.80%, MPs = 70.00%, PWA = 21.73%). Majority of the respondents agreed that all women should be screened for depression during pregnancy (NPs = 34.78%, MPs = 80.95%, PWA = 95.00%) and postpartum periods (NPs = 34.78%, MPs = 76.19%, PWA = 90.00%). CONCLUSIONS: Low PD literacy among the PWs, misconception about aetiology and management among the NPs could be major barrier for delivery and utilisation of PD services. Thus, there is an urgent need to improve PD literacy among PWs and NPs.

Effect of selective serotonin reuptake inhibitors on markers of bone loss.

Several preclinical and clinical studies show that selective serotonin reuptake inhibitors (SSRI's) are associated with bone loss and an increase in fracture risk, not many reports on their effect on bone turnover markers. This cross-sectional study evaluated the effect of SSRIs treatment on bone turnover markers in Indian population for the first time. Inclusion criteria were subjects of either sex and age 18-45 years undergoing treatment with an SSRI for at least 3 months, regardless of the indication. The results were compared with age-matched healthy controls. A total of 141 subjects were screened out of which 85 were enrolled, 44 in treatment and 41 in the control group. Serum Procollagen Type 1 Amino Terminal Propeptide (P1NP) levels were decreased in patients on SSRI treatment whereas no change was observed in the beta-C-terminal telopeptide (ß-CTX) and receptor activator of nuclear factor kappa-Β ligand (RANKL) levels suggesting that these drugs can reduce bone formation but not resorption. Patients on SSRI treatment also showed reduced pCREB levels indicating that reduced bone formation is possibly through the gut mediated pathway. Our study suggests that SSRIs treatment at therapeutic doses may have a deteriorating effect on bone requiring caution in patients with additional risk factors.

Validation of hindi translation of DSM-5 level 1 cross-cutting symptom measure.

BACKGROUND: The DSM-5 Level 1 Cross-Cutting Symptom Measure is a self- or informant-rated measure that assesses mental health domains which are important across psychiatric diagnoses. The absence of this self- or informant-administered instrument in Hindi, which is a major language in India, is an important limitation in using this scale. AIM: To translate the English version of the DSM-5 Level 1 Cross-Cutting Symptom Measure to Hindi and evaluate its psychometric properties. MATERIALS AND METHODS: The study was conducted at a tertiary care hospital in Delhi. The DSM-5 Level 1 Cross-Cutting Symptom Measure was translated into Hindi using the World Health Organization's translation methodology. STATISTICAL ANALYSIS: Mean and standard deviation were evaluated for continuous variables while for categorical variables frequency and percentages were calculated. The translated version was evaluated for cross-language equivalence, test-retest reliability, internal consistency, and split half reliability. RESULTS: Hindi version was found to have good cross-language equivalence and test-retest reliability at the level of items and domains. Twenty two of the 23 items and all the 23 items had a significant correlation (ρ < 0.001) in cross language concordance and test-retest reliability data, respectively. The Cronbach's alpha was 0.95, and the Spearman-Brown Sphericity value was 0.79 for the Hindi version. CONCLUSION: The present study shows that cross-language concordance, internal consistency, split-half reliability, and test-retest reliability of the Hindi version of the measure are excellent. Thus, the Hindi version of DSM-5 Level 1 Cross-Cutting Symptom Measure as translated in this study is a valid instrument.

A comparative study of quality of life and marital satisfaction in patients with depression and their spouses.

Spouses of patients suffering from depression experience various forms of burden. Present study assesses and compares the marital satisfaction and quality of life (QOL) of the patients and their spouses. Further it assesses these variables in terms of illness severity, duration of untreated illness (DUI) and other demographic parameters especially gender. In this cross sectional study, 50 patients diagnosed with Depressive Disorder along with their spouses were recruited. Both groups were assessed separately for marital satisfaction and QOL along with demographic details followed by appropriate statistical analysis. A high level of marital distress found amongst both patients and their spouses whereas only patients reported poor QOL. Increasing DUI worsens both marital satisfaction and QOL in spouses with no effects on patients. Illness severity worsens QOL in both groups with no effect on marital satisfaction. Gender was not found to have any impact on either of the groups. Small sample size and cross sectional study design were main limitations. Early and faster intervention will be helpful in patient's prognosis, and also the perception and QOL of spouses. A better treatment response may be expected if focus is at improvement in QOL rather than only symptom control. Further work will be needed with a larger population and in a longitudinal study design. Future research also needs to focus upon establishment of better norms for the DUI for depressive disorder.

Knowledge, attitude and social distance practices of young undergraduates towards mental illness in India: A comparative analysis.

The success of the current model of psychiatric care depends on de-stigmatization of mental illnesses, highlighting the need for research on perception of mental illnesses. This study compared the knowledge, attitude and social distancing practices of the young undergraduate sub-population towards mental illness. A cross-sectional survey was done using a pretested questionnaire, which in addition to demographic details assessed exposure, knowledge, attitude and social distancing practices for mental illnesses. The study included (N=289; 55% Females; Average age 20.5 years) responses from nearly equal number of students from medical, psychology and other courses. Medical students chiefly attributed mental illness to biological factors while students from other courses perceived mental illness as God's punishment. More medical students believed that mental illnesses can be successfully treated and appeared to have less social distancing from the mentally ill. Males mostly reported stress and brain damage as the causative factors while females attributed mental illnesses to other biological factors. Males were found to be less afraid of a communication with mentally ill and more open to the possibility of marriage with someone suffering from a mental illness. Exposure to information about mental illness led to no significant variation in the studied variables. Thus, demographic variables and the academic course contribute to variations in knowledge and attitude of young adults. Education received by medical students has a positive impact on their attitudes, highlighting the need of introduction of informative awareness measures among other courses as well.

Olanzapine vs. Risperidone in Schizophrenia: A Cross-sectional Comparison of Quality of Life of Caregivers.

In schizophrenia, efficacy of antipsychotic therapy might be better measured by quality of life (QoL) of caregiver, due to less reliability of patient's account and greater burden of management on caregiver. Hence, we compared QoL of the primary caregiver of schizophrenics prescribed either olanzapine or risperidone. In a cross sectional analytical study, caregivers of 120 schizophrenic patients' on either olanzapine or risperidone filled the WHOQOL-BREF questionnaire containing physical, psychological, social and environmental domains. Scores of these domains in both the groups were compared. Majority (33.3%) of caregivers in both groups were parents. The mean transformed scores in all domains viz. physical (p=0.358), psychological (p=0.352), social relationships (p=0.332) and environmental (p=0.448) were statistically similar. More than 75% of the subjects in both groups showed the highest satisfaction in work capacity, personal relations, physical pain, requirement of medications, frequency of negative feelings, safety and body appearanc, whereas ≤ 50% of the caregivers in both groups expressed dissatisfaction with their financial situation. Thus, QoL of caregivers in both groups was comparable. On the basis of QoL of caregivers, olanzapine and risperidone were similarly effective therapeutic agents for schizophrenia.

Alteration of Heart Rate Variability in Patients of Depression.

INTRODUCTION: Altered cardiac autonomic functions in form of reduced Heart Rate Variability (HRV) have been found to be associated with increased cardiovascular morbidity and mortality in depressive patients. AIM: To investigate the relationship between HRV measures, which is a non-invasive marker of autonomic nervous system and depression. MATERIALS AND METHODS: The study included a convenient sample size of drug naive depressive patients (n=30) diagnosed on basis of ICD-10 and compared with age and gender matched healthy volunteers (n=30). Five minute ECG recording was done for HRV analysis and frequency domain measures like LF (Low Frequency), HF (High Frequency), LF/HF ratio as well as time domain measures like SDNN (Standard Deviation of all NN interval) and RMSSD (Root Mean Square of Successive differences of NN intervals) were obtained. RESULTS: In the frequency domain parameters, values of LF (nu) and LF/HF Ratio were found to be significantly higher (p<0.001) whereas, that of HF (nu) was significantly lower (p<0.001) in depression group as compared to control group. However, in the time domain parameters, no significant difference was observed in SDNN and RMSSD values in between the two groups. CONCLUSION: HRV recordings showed significant changes in frequency domain parameters in the patients suffering from depression. Thus, it could be said from our study that autonomic imbalance reflecting enhanced sympathetic activation relative to parasympathetic component is associated with depression.

Violence against women.

Violence against women (VAW) is a major public health problem in the country. The problem is grossly under-reported. A number of factors have been blamed for crimes against women. An inefficient law enforcing machinery has often been targeted for the increasing number of cases being reported. There is little recognition that psychiatric morbidity can perpetuate such crimes. Of late, there appears to a continuous increase in the number of crimes committed against women; especially the very serious ones like gang rapes. The latter have shaken the very conscience of people. Even harsher legislation does not seem to have made any effect. One wonders how this could be possible in a society heading toward high education, economic and technological development. Media has played a pivotal role by highlighting the problem to the masses. The need for the hour is for mental health professionals to take the challenge and present a comprehensive proposal for definite action to prevent all forms of VAW.

A cross-sectional study of body shape and eating attitude among Indian female healthcare students.

OBJECTIVE: The current study aimed at assessing eating attitude and body shape concerns among Indian female healthcare students who had received some teaching/training in Psychiatry. METHOD: The study was conducted at government medical and nursing college. All the undergraduate healthcare students enrolled with institute at the time of study constituted the sampling frame for the study. Survey-based methodology was used for data collection. Study scales included semi-structured proforma, Eating Attitudes Test-26 (EAT-26) (including the three sub-scales), and Body Shape Questionnaire (BSQ). Data were analyzed using Pearson's and Spearman's correlation statistics and ANOVA with post hoc analysis. RESULTS: A total of 498 students returned the completed study questionnaire. There was significant correlation between Body Mass Index (BMI) and EAT-26 scores) including the sub-scales score of EAT-26). Similarly, BMI and BSQ scores were also significantly correlated. DISCUSSION: The findings from current study help understand the body shape and eating attitudes of Indian female healthcare students who had received some teaching/training in Psychiatry.

Pseudocyesis Versus Delusion of Pregnancy: Differential Diagnoses to be Kept in Mind.

Pseudocyesis is a condition in which the patient has all signs and symptoms of pregnancy except for the confirmation of the presence of a fetus. The literature on delusions of pregnancy in schizophrenia is however scanty. We hereby present a case of delusion of pregnancy. The case highlights the possibility of delusion of pregnancy if a patient presents with features suggestive of pseudocyesis. The obstetricians being more familiar with pseudocyesis might tend to overlook the other possibility in such cases. This would be especially true if there are no associated clearcut psychotic features.

Impact of psychiatric education and training on attitude of medical students towards mentally ill: A comparative analysis.

BACKGROUND: A number of studies from the western world have explored the negative beliefs held by individuals towards people with mental illness. The knowledge of attitude and awareness of undergraduate medical students towards psychiatry, mental health and mental disorders is of utmost importance. OBJECTIVE: The current study aims at assessment of attitudes of medical students towards mental illness and mentally ill. MATERIALS AND METHODS: The study used a cross-sectional survey design. The instruments used included Beliefs toward Mental Illness (BMI) scale, Attitudes to Mental Illness Questionnaire (AMIQ). ANOVA was carried out to compare the in between group differences for the four study groups. Additionally Bonferroni correction was used to conduct the post hoc analysis. RESULTS: The interns were significantly more likely to agree with the statement that the mental disorders are recurrent; less likely to be of thought that the behavior of people with mental disorders is unpredictable; more likely to disagree with the fact that diagnosis of depression as described in the case vignette was going to damage the career of the individual; more likely to agree with the option of inviting a depressed person to a party; more likely to believe in fact that mentally ill individuals are more likely to be criminals as compared to medical students in different professional years. CONCLUSIONS: Adequate modifications to existing medical curriculum would help improve attitude of medical students towards mentally ill.