Feasibility and effectiveness of stress management skill training in medical students.

Background: There is limited literature on stress management interventions targeting Indian medical undergraduates. With this background, the study aimed to evaluate the feasibility and effectiveness of stress management intervention on perceived stress, coping and burnout amongst first-year medical undergraduates. Methods: It was a quasi-experimental study assessing the effect of "Comprehensive Stress Management Skill Training Program". This intervention emphasized on self-awareness of early warning signs of stress, adopting a healthy lifestyle, developing assertiveness at work, maintaining work-life balance. The stress reduction techniques mainly consisted of deep breathing exercises, progressive muscular relaxation and visualization. It was delivered by a team of a psychiatrist and a nurse to hundred first year medical undergraduate students. Medical Students Stressor Questionnaire, Brief COPE Questionnaire and Maslach Burnout Inventory-Student Survey were applied for assessment of perceived stress, burn out, and coping, respectively, at baseline, finish of one and three months of intervention. Results: Significant improvement was noted in academic stress, interpersonal-related stress, teaching learning-related stress, and total stress scores, emotional exhaustion, and emotion-focused coping at the end of the three months of intervention. Positive feedback about the intervention was given by majority of the students. Conclusion: Stress management intervention was found to be feasible and effective in improving stress, coping, and emotional exhaustion in first year medical students.

A Cross-Sectional Study to Assess the Frequency of Restraint, and Knowledge and Attitudes of the Caregivers of Patients Toward Restraint in a General Hospital Psychiatry Setting from South India.

Background: There is limited Indian data on the epidemiology of hospital-based restraint practices and the knowledge and attitude of caregivers toward restraint. Therefore, this study aimed to report the frequency and pattern of restraints in a general hospital psychiatry setting and assess the knowledge and attitude about restraint practices among caregivers of patients. Methods: We calculated the frequency of restraints (physical and chemical) over one year. The knowledge and attitude toward restraint were assessed in 75 caregivers each of patients from inpatient and outpatient settings, using a questionnaire designed by the authors and pretested in a pilot study. Results: The frequency of any form of restraint was 19%. The frequency of chemical and physical restraints was 19% and 0.5%, respectively. Less than 20% of caregivers in both groups reported that restraint was either stigmatizing (5.33% inpatient caregivers vs. 12% outpatient caregivers), cruel (8% inpatient caregivers vs. 15.33% outpatient caregivers), or a measure of punishment (9% inpatient caregivers vs. 16% outpatient caregivers). No significant difference was found between knowledge and attitude about restraint between caregivers of outpatients and inpatients, except for a significantly greater number of caregivers of outpatients reporting that the restraint practices in the hospital were similar to those adopted by faith healers or religious/spiritual centers. Conclusion: The frequency of either physical or chemical restraint was less compared to the existing international and Indian data. In addition, most caregivers of patients of both outpatients and inpatients did not report a negative attitude toward restraints.

Stress, Burnout, and Coping among First-Year Medical Undergraduates.

Background and Objectives Stress, burnout, and coping have been found to be interlinked with each other. Several adverse psychological outcomes have been associated with stress and burnout. Improving coping can decrease the stress and burnout. There is limited literature on perceived stress, coping, and burnout among first-year medical undergraduates from India. With this background, the study aimed to assess perceived stress, coping, and burnout among first-year medical undergraduates. Methods It was a cross-sectional study assessing 100 undergraduates studying in the first year of medical school. Medical Students Stressor Questionnaire, Brief COPE questionnaire, and Maslach burnout inventory-student survey were applied for assessment of perceived stress, burnout, and coping, respectively. Socio-demographic profile was assessed by a semi-structured proforma. Results Majority of students reported facing moderate level of stress in most of the domains, with stress being the highest for the academic aspects and least for social-related and drive- and desire-related areas. The stress was significantly greater in female students. Burnout was identified in 62% students by two-dimensional criteria and 30% by three-dimensional criteria. Among the coping strategies, active coping was most commonly used and substance use was less commonly used. No differences were found in coping between males and females except for active coping, which was significantly better in females. Conclusion The stress was of moderate degree in majority of students and academic stress was the most common stress. Burnout was present in at least one-third of the students. However, majority of the students practiced active coping.

Efficacy of adjunctive D-Cycloserine for the treatment of schizophrenia: a systematic review and meta-analysis of randomized controlled trials.

D-Cycloserine is a partial agonist at the glycine site of the N-methyl-D-aspartate (NMDA) receptor. Results have been inconsistent in trials on the efficacy of D-Cycloserine in patients with schizophrenia. We examined the efficacy of D-Cycloserine against negative and cognitive symptoms (primary and co-primary outcomes). Secondary outcomes were efficacy of D-Cycloserine against positive symptoms and the examination of early treatment outcomes. A systematic literature search was carried out using following selection criteria: Population = Patients with Schizophrenia; Intervention = Trials using D-Cycloserine either as monotherapy or adjuvant therapy; Comparison = Placebo or active comparator; Outcome = Change in negative symptoms, cognitive symptoms and positive symptoms; Study design = Randomized controlled trials with parallel design. We used the Cochrane Collaboration tool for risk of bias for study quality appraisal. Effect sizes for trials were calculated separately for negative, positive and cognitive symptom dimensions using the DerSimonian-Laird random effects model. Seven studies (pooled N = 413) provided data for meta-analysis. The pooled Standardized Mean Difference (SMD) for negative, cognitive, and positive symptom change scores were - 0.32 (95% CI, - 0.75 to 0.11), - 0.05 (95% CI, - 0.91 to 0.81), and - 0.08 (95% CI, - 0.37 to 0.20), respectively. No significant improvement was noted with regard to early outcome. I2 values for heterogeneity were 61%, 67%, and 0% for studies assessing negative, cognitive, and positive symptom ratings, respectively. D-Cycloserine did not exhibit significant efficacy in treating negative, cognitive, or positive symptoms of schizophrenia at either study-defined endpoint (4-36 weeks) or at four weeks (early outcome).

Effectiveness of Brief Educational Training on Medical Students' Attitude toward Suicide Prevention.

Objectives Medical students are future physicians, and their attitude toward suicide attempters can impact outcome of patient management and quality of care. This study aimed to assess the effects of brief educational intervention on medical students' attitude toward suicide prevention. Materials and Methods The prospective study was conducted at a tertiary care center in northwestern India. The total enumeration method was employed to recruit 243 medical students. Attitude toward suicide prevention scale was applied before and after three hours' training on management of suicide attempters and strategies for suicide prevention. Statistical Analysis Mean, median, standard deviation, frequencies, and percentages were calculated through descriptive statistics. Mean values were compared before and after the intervention through paired sample student's t -test. Chi-square test or Fischer exact test was used to compare categorical variables and p ≤ 0.05 was set for level of significance. Results Ten out of 14 attitudinal statements were significantly more favorable after imparting brief training on suicide prevention and management of suicide attempters. They reported lesser resentment, more responsible efforts, with greater competence and positive expectation associated with working for suicidal patients. They agreed on the need for multidisciplinary efforts for effective suicide prevention. After the intervention, they considered the possibility of suicidal ideas emerging due to the need for help, not for the purpose of attention-seeking, and instead of considering suicidal communication as individual's choice, they agreed on substantial preventability of suicide with comprehensive management. Their misconceptions were resolved to a greater extent. Conclusion Brief educational intervention was found effective in improving their attitude toward suicide prevention. The medical curriculum should incorporate regular educational programs, suicide prevention and comprehensive assessment, and management of suicide attempters.

Antiphospholipid syndrome presenting as treatment resistant bipolar disorder and thrombocytopenia in a young male.

Antiphospholipid syndrome (APS), an autoantibody mediated disease, is characterized by presence of antibodies against the proteins bound to the phospholipid membranes. The antibodies are predominantly formed against beta-2-glycoprotein I (b2GPI) which is considered pathogenic, but presence of lupus anticoagulant is a predictor of thrombotic events. The thrombotic events in APS may manifest as venous or arterial or small vessel thrombosis in any tissue or organ and pregnancy related complications namely, recurrent (three or more) and early spontaneous miscarriages before 10 weeks of gestation or unexplained deaths of normal fetus at or beyond 10 weeks, eclampsia or severe pre-eclampsia, intra-uterine growth retardation and pre-term births. However, lately its role as an etiological mechanism in causation of certain neuro-psychiatric disorders has been put forth. It has been suggested that one should suspect APS in psychiatric manifestations which are atypical, resistant to treatment, associated with cognitive decline and dementia, abnormal involuntary movements, livedo reticularis, migraine, thrombotic events like stroke or transient ischemic attacks, obstetrical complications. In this brief communication, we describe the case of young male who has been suffering from treatment resistant and difficult to manage bipolar affective disorder (BPAD) with fluctuating thrombocytopenia and neurological findings with positive lupus anticoagulant. We propose it to be a consequence of an atypical presentation of APS.

Prevalence and predictors of family accommodation in obsessive-compulsive disorder in an Indian setting.

BACKGROUND: Family accommodation (FA) is a phenomenon whereby caregivers assist/facilitate rituals or behaviors related to obsessive-compulsive disorder (OCD). FA, however, has been explored primarily in the Western population, and it is unclear to what extent it might be present in diverse cultural settings. At present, little is known about the extent and predictors of FA among caregivers of adult OCD patients in India. AIMS: The study aims to assess the extent, clinical correlates, and predictors of FA in the caregivers of adults with OCD. SETTINGS AND DESIGN: Cross-sectional study conducted in an outpatient setting in a tertiary-care hospital. MATERIALS AND METHODS: Hundred and one adult patients of either gender with Diagnostic and Statistical Manual of Mental Disorders-5 diagnosis of OCD and 101 caregivers were included. The patients were assessed using Yale-Brown Obsessive Compulsive Scale (YBOCS), Hamilton Rating Scale for Depression (HAM-D), World Health Organization Disability Assessment Schedule Version 2.0 12-item version (WHO-DAS 2.0.12), Clinical Global Impressions Scale for Severity (CGI-S), and Clinical Global Impressions Scale for Improvement. The FA Scale-Self Rated Version (FAS-SR) was applied on caregivers after Hindi translation. STATISTICAL ANALYSIS: Descriptive statistics, group comparisons, and Pearson's product moment correlations were carried out. Multiple linear regression modeling was performed with the total FAS-SR score as the dependent variable. RESULTS: About 92% of caregivers displayed at least some form of FA. Higher scores on HAM-D, YBOCS, WHODAS, and CGI-S were associated with higher scores on FAS-SR scale, which reached statistical significance (P < 0.01). CONCLUSIONS: FA in OCD appears to be a frequent phenomenon. Higher FA is associated with higher symptom severity and disability, emphasizing its clinical and research relevance for future studies.

Suicide Prevention Strategies for General Hospital and Psychiatric Inpatients: A Narrative Review.

BACKGROUND: In-patient (IP) suicides contribute a small but significant proportion of overall suicides. Despite this, suicide prevention strategies focusing on the general hospital IP population remain relatively underresearched. This paper is intended to provide an overview of various proposed suicide prevention approaches in the general hospital, including psychiatric IP, settings, and their evidence base. METHODOLOGY: Electronic searches of MEDLINE through PubMed, ScienceDirect, and Google Scholar databases were performed to identify potentially relevant articles from inception till January 2019. The generated abstracts were systematically screened for their eligibility to be included in the review. Included articles were grouped under five broad themes: environmental modification, staff education, pharmacotherapy, psychotherapy, and brain stimulation. Data extraction was done using a structured proforma. RESULTS: Environmental modifications and educating the health care professionals appear to be the most promising strategies to reduce suicide-related mortality among IPs. Among pharmacological methods, ketamine has shown initial promise in reducing suicidal ideations. Follow-up data are lacking for most of the described methods. Limited but positive evidence exists for cognitive therapies focusing on the immediate postadmission period and brain stimulation techniques, and it warrants further replication. CONCLUSION: There is a striking paucity of original research on IP suicide prevention. Given the ethical and methodological issues in carrying out studies with IP suicide as the primary outcome, there is a need to focus on intermediate suicide outcome measures, such as knowledge, attitude, and skills among staff handlers of suicidal patients.

Eating Disorders: An Overview of Indian Research.

There has been sporadic research on eating disorders in India, with no published attempt to collate and summarize the literature landscape. Hence, the present narrative review aims to summarize Indian work related to eating disorders, discern current trends, and highlight gaps in research that will provide directions for future work in the area. Electronic search using the MEDLINE, Google Scholar, and PsycINFO databases was done to identify relevant peer-reviewed English language articles, in October 2018, using combinations of the following medical subject headings or free text terms: "eating disorders," "anorexia nervosa," "bulimia," "treatment," "epidemiology," "co-morbidity," "management," "medications," "behavioral intervention," and "psychosocial intervention." The data extracted from studies included details such as author names, year, from which of the states in India the work originated, type of intervention (for interventional studies), comparator (if any), and major outcomes. There is increasing research focused on eating disorders from India over the last decade, but it continues to be an under-researched area as evidenced by the relative paucity of original research. The cultural differences between east and west have contributed to variations in the presentation as well as challenges in the diagnosis. Hence, there is a need for the development of culturally sensitive instruments for diagnosis, as well as generating locally relevant epidemiological data about eating disorders from community and hospital settings.

Atypical neuroleptic malignant syndrome - A case report.

Neuroleptic malignant syndrome (NMS) is a potentially fatal adverse effect of antipsychotics. Atypical presentation of NMS with drugs which are not potential D2 blockers raises question for an alternative hypothesis for NMS. A 30 year old male presented with irritability, assaultive behavior, persecutory delusion and auditory hallucination for three days. Past history of 3 similar episodes. 1st episode preceded by fever and associated with cerebral edema. Subsequent episodes not preceded by fever and patient was treated with Risperidone and Olanzapine. After admission patient was started on Risperidone along with THP when he had fever, tremors, altered sensorium and rigidity at 3 mg dose. After stopping Risperidone fever and rigidity improved with worsening of psychotic symptoms. Following this Olanzapine was started and very gradually uptitrated to 7.5 mg when patient had recurrence of fever and disorientation without tremors and minimal rigidity. Both the instances blood investigations including CPK levels were normal except for thrombocytopenia and leucopenia. Provisional impression of NMS was made in both instances. After stopping Olanzapine fever subsided with improvement of blood counts. Following this patient had catatonic symptoms for which patient received 9 sessions of Electroconvulsive therapy (ECT). In atypical presentations of NMS, hyperthermia and muscle rigidity may be absent, posing diagnostic dilemma. So there is a need for broadening the diagnostic criteria and NMS must be considered with a high index of suspicion.