World Psychiatric Association-Asian Journal of Psychiatry Commission on Psychiatric Education in the 21st century.

Psychiatric practice faces many challenges in the first quarter of 21st century. Society has transformed, as have training requirements and patient expectations, underlining an urgent need to look at educational programmes. Meanwhile, awareness has grown around psychiatric disorders and there are evolving workforce trends, with more women going to medical school and specialising in psychiatry. Trainee psychiatrists carry different expectations for work-life balance and are increasingly becoming conscious of their own mental health. A tendency to see health as a commodity and the litigious nature of society has elicited additional pressures for healthcare professionals. Cartesian mind-body dualism has created further complexity and this can often be frustrating for patients and care-partners alike. In many cultures across Asia and beyond, patients can present with physical symptoms to express underlying psychological distress with increasing physical investigations. Simultaneously, in various countries, a shift from asylums to community-based interventions and then home treatments have changed psychiatric care in remarkable ways. These changes have added to pressures faced by mental healthcare professionals. However, trainees and other mental healthcare professionals continue to receive similar training as they did a generation ago. The tensions and differences in ideology/orientation between different branches of psychiatry have made responses to patient needs challenging. Recognising that it is difficult to predict the future, this World Psychiatric Association-Asian Journal of Psychiatry Commission makes recommendations that could help institutions and individuals enhance psychiatric education. This Commission draws from existing resources and recent developments to propose a training framework for future psychiatrists.

Capacity to Consent for Treatment in Patients with Psychotic Disorder: A Cross-Sectional Study from North Karnataka.

Background: Recently, the Mental Healthcare Act (MHCA) 2017 was introduced in India. Being a right-based act, it has made the assessment of the capacity to consent an integral part of clinical work. To the best of our knowledge, there are no Indian studies on this topic. Hence, this study aimed to assess the capacity to consent to mental healthcare and treatment in patients with functional psychosis and the factors affecting the same. Methods: This cross-sectional study included participants with the ICD-10 DCR diagnosis of a psychotic disorder admitted in the psychiatry ward of a tertiary health care center in Karnataka, India. MacArthur Competence Assessment Tool for Treatment was used to assess the capacity to consent to treatment. Brief Psychiatric Rating Scale (BPRS) and the Beck Cognitive Insight Scale were applied to assess the severity of psychosis and level of insight, respectively. Results: A hundred participants were recruited. Twenty-four were found to have an intact capacity to consent to treatment. High BPRS scores (P value = 0.0002) and low insight scores (P value = 0.0002) were associated with an impaired capacity. Conclusion: About one-fourth of participants had an intact capacity to consent to treatment. Higher severity of psychosis and a poorer insight into the illness were associated with impaired capacity to consent.

Neurocognitive Profile in Indian Individuals Genetically at Risk of Schizophrenia.

BACKGROUND: Cognitive deficits have been noted in patients of schizophrenia in remission, as well as in first-degree relatives. This study aims to evaluate the neurocognitive performance in unaffected first-degree relatives of patients of schizophrenia in comparison with healthy controls, as well as patients of schizophrenia in remission. METHODS: It was a 1-year case-control study by purposive sampling. Patients with a diagnosis of schizophrenia, first-degree relatives of patients of schizophrenia, and controls from nongenetic relatives of patients were recruited as per inclusion and exclusion criteria. Samples were matched for age and educational status. The General Health Questionnaire 28 (GHQ-28) screened them and they were checked for remission by Positive and Negative Syndrome Scale (PANSS) and then subjected to various instruments for assessment of neurocognition, standardized for the Indian population. To remove the effect of symptoms as confounding factors, PANSS score of <3 for each individual item was set as the criterion for remission. Intelligence quotient (IQ) was screened in all participants to exclude mental retardation. Statistical analysis used was the analysis of variance (ANOVA) with post hoc Fisher's least significant difference (LSD). RESULTS: Significant neurocognitive impairments were detected in the patients and first-degree relatives when compared with the control subjects. The most common impairment in the patient group was in speed of processing, and among unaffected first-degree relatives, it was in the working memory. CONCLUSION: Indian individuals genetically at risk of schizophrenia showed significant neurocognitive impairments in all domains compared with controls.

Prevalence and clinical correlates of depression in chronic kidney disease patients in a tertiary care hospital.

BACKGROUND: Prognosis and associated complications of chronic kidney disease (CKD) may result in psychological distress and mood disorders especially depression. Prevalence and clinical correlates of depression in CKD patients in the Indian context are not well studied and established. MATERIALS AND METHODS: This cross-sectional study included 84 CKD patients. The diagnosis was made based on the diagnostic and statistical manual, 4th edition criteria; psychiatric disorders were ruled out through the mini-neuropsychiatric interview. Montgomery-Asberg Depression Rating Scale was used to assess the severity of depression. Suicidal ideations were evaluated by using a modified scale of suicidal ideations. Data were analyzed using Epi Info 7 software. RESULTS: The prevalence of major depression was 44.05%, while the prevalence of depressive symptoms was 82.14%. Age of the patients (P = 0.0065), patients on dialysis (P < 0.0001), and serum creatinine levels >5 (P = 0.0180) showed a statistically significant association with depression. The prevalence of depression was significantly associated with dialysis (P < 0.0001). The severity of depression and the severity of suicidal ideations were well correlated with each other (P < 0.0001). CONCLUSION: The increased prevalence of depression and suicidal ideations was observed in CKD patients. We strongly recommend initiating screening of depression in CKD patients for appropriate rehabilitation and improved the quality of life.

How do Our Patients Respond to the Concept of Psychiatric Advance Directives? An Exploratory Study From India.

BACKGROUND: Psychiatric advance directives have been incorporated in the Mental Health Care Act 2017 despite strong concerns about their feasibility and utility in the Indian patient population. Data on its utility in India is very scarce. AIMS: To determine the possible treatment options our clients make as a part of psychiatric advance directives. MATERIALS AND METHODS: Fifty consecutive individuals with severe mental illness were interviewed using a self-designed semi-structured tool to find out the possible choices they make as part of advance directives and the factors affecting their choices. RESULTS: About 10% of the participants failed to understand the concept of advance directives. Of those who understood, 89% were willing to make advance directives, 15% refused future hospitalizations, 47% refused future electroconvulsive therapies (ECTs), and 62% refused physical restraints in future. CONCLUSION: The majority of the participants agreed to make advance directives. The majority of those who agreed to make advance directives refused to undergo ECTs and physical restraints in future episodes of illness. Approximately 10% of the patients could not understand the concept of advance directives.

Expressed emotions in patients with obsessive compulsive disorder: a case control study.

BACKGROUND: Expressed emotion (EE) is the attitude that the relatives show towards the illness and the person. EE is identified as a direct factor in the relapse of patients with psychological disorders. Literature on EE in anxiety disorders is limited. Role of EE in obsessive compulsive disorder (OCD) may help in better understanding of the role of social factors in OCD. AIM: To compare EE in patients with OCD and compare with controls. MATERIALS AND METHODS: The sample included 30 cases and 30 age and sex matched controls. The patients were diagnosed as having OCD using International Classification of Diseases-10 Diagnostic Criteria for Research (ICD-10 DCR) criteria. Yale-Brown Obsessive Compulsive Scale (Y-BOCS) was used to assess severity of OCD among patients. General health questionnaire (GHQ) was used to rule out any psychiatric disorder among control population. EE was assessed in cases and controls using Family Emotional Involvement and Criticism Scale (FEICS). Chi-square test and t-test were used to assess the difference between two groups. RESULTS: OCD patients in comparison controls had significantly increased total FEICS score (P = 0.001). There was an increase in both subscales of perceived criticism (PC) with P = 0.001 and emotional involvement (EI) with P = 0.001 in patients with OCD than controls. CONCLUSION: EE are significantly increased in patients with OCD. EE should be assessed regularly in patients with OCD.

Rubinstein-taybi syndrome with psychosis.

Rubinstein-Taybi syndrome (RTS) is a rare genetic disorder with characteristic physical anomalies. It is characterized by mental retardation, postnatal growth deficiency, microcephaly, specific facial characteristics, broad thumbs, and big toes. Behavioral problems are common with RTS; they include mental retardation, impulsivity, distractibility, instability of mood, stereotypes, poor coordination, atypical depression, and mania. To date, there is lack of literature on the presence of schizophrenia or non-affective psychosis with RTS. Here, we describe two cases where there is co-morbid psychosis with RTS. One case is diagnosed as paranoid schizophrenia and the other as psychosis possibly schizophrenia. Genetic analysis was not done due to unavailability. The possible etiological factors for the association of psychosis with RTS are discussed. Factors such as regulators of RNA polymerase II and hypoxia-inducible factor 1 alpha (HIF1A) may be some common etiological factors for the association of schizophrenia or non-affective psychosis and RTS. Schizophrenia / non-affective psychosis can be a comorbid psychiatric condition with RTS.

Clonazepam in the treatment of essential palatal tremors.

Essential Palatal tremor (EPT) is a rare disorder presenting as unilateral or bilateral rhythmic involuntary movements of the soft palate. There is mention of the utility of benzodiazepines like clonazepam probably because of their gamma amino butyric acid (GABA) agonistic property. But no reports are available for the same. Here we report a 30-year old married female patient who presented with the complaints of pain in the lower part of face, behind the ears, back side of neck and clicking sound in her. General physical examination (GPE) revealed symmetrical rhythmic flapping movements of the soft palate and the uvula. Central nervous system (CNS) examination did not reveal any focal deficits and Magnetic resonance imaging (MRI) of the brain was normal. She was diagnosed as having EPT and treated successfully with clonazepam.

Psychosis in patients with systemic lupus erythematosus.

Neuropsychiatric manifestations in systemic lupus erythematosus (SLE) are common; however, psychosis per se is bit uncommon. They may be cognitive deficit, lupus headache, psychoses, seizures, peripheral neuropathy, and cerebrovascular events. Psychiatric symptoms in SLE can be functionally independent psychiatric disorders. It can be due to drugs (steroids) used for SLE or secondary to SLE because of its brain involvement, which is termed as neuropsychiatric systemic lupus erythematosus (NPSLE). No single clinical, laboratory, neuropsychological, and imaging test can be used to differentiate NPSLE from non-NPSLE patients with similar neuropsychiatric manifestations. Presently we are discussing about three cases of SLE with psychosis and which had different clinical presentation. The present reports also depict the approach to case differential diagnosis and management of the same.

Prevalence of the metabolic syndrome in schizophrenic patients receiving second-generation antipsychotic agents--a cross-sectional study.

OBJECTIVE: The present study was taken up to assess the prevalence of the metabolic syndrome in schizophrenic patients receiving second-generation antipsychotic agents and to determine the most sensitive and specific clinical parameters used for screening of metabolic syndrome in these patients. MATERIALS AND METHODS: The present study was taken up in a tertiary care hospital. Eighty patients diagnosed with schizophrenia and receiving a single second-generation antipsychotic for 3 months or more were enrolled in the study after obtaining written informed consent. Patients were screened for metabolic syndrome using American Heart Association and National, Heart, Lung and Blood Institute (AHA NHLBI)-modified National Cholesterol Education Program, Adult Treatment Panel III (NCEP ATP III) criteria. RESULTS: Prevalence of metabolic syndrome was found to be 35%. The clinical parameter with highest sensitivity for screening of metabolic syndrome is low-serum high-density lipoprotein cholesterol with a sensitivity of 89.28%. Elevated fasting blood glucose and increased waist circumference were found to have highest and equal specificity of 90.38%. CONCLUSION: There is a high prevalence of the metabolic syndrome in patients with schizophrenic patients receiving second-generation antipsychotic agents. Increasing awareness of this fact among psychiatrists will help to prevent, detect, and treat this condition that is associated with considerable morbidity and mortality.

Prevalence of specific learning disabilities among primary school children in a South Indian city.

OBJECTIVE: To measure the prevalence of specific learning disabilities (SpLDs) such as dyslexia, dysgraphia and dyscalculia among primary school children in a South Indian city. METHODS: A cross-sectional multi-staged stratified randomized cluster sampling study was conducted among children aged 8-11 years from third and fourth standard. A six level screening approach that commenced with identification of scholastic backwardness followed by stepwise exclusion of impaired vision and hearing, chronic medical conditions and subnormal intelligence was carried out among these children. In the final step, the remaining children were subjected to specific tests for reading, comprehension, writing and mathematical calculation. RESULTS: The prevalence of specific learning disabilities was 15.17% in sampled children, whereas 12.5%, 11.2% and 10.5% had dysgraphia, dyslexia and dyscalculia respectively. CONCLUSIONS: This study suggests that the prevalence of SpLDs is at the higher side of previous estimations in India. The study is unique due to its large geographically representative design and identification of the problem using simplified screening approach and tools, which minimizes the number and time of specialist requirement and spares the expensive investigation. This approach and tools are suitable for field situations and resource scarce settings. Based on the authors' experience, they express the need for more prevalence studies, remedial education and policy interventions to manage SpLDs at main stream educational system to improve the school performance in Indian children.

Relationship between serum lithium, salivary lithium, and urinary lithium in patients on lithium therapy.

Lithium carbonate is used in the treatment of both psychiatric and nonpsychiatric disorders. The aim of this study was to explore the relationship between serum lithium, salivary lithium, and urinary lithium. Blood, saliva, and urine samples were collected from 50 patients, and estimation of serum, salivary, and urine lithium was done using an atomic absorption spectrophotometer. Mean serum lithium was 0.75 ± 0.25 mEq/L, mean salivary lithium was 1.91 ± 0.80 mEq/L, and mean urine lithium was 7.16 ± 4.84 mEq/L. A significant direct correlation was found between serum lithium and salivary lithium (r = 0.695, p < 0.001). This correlation was higher in females (r = 0.770, p < 0.001) when compared to males (r = 0.665, p < 0.001). Even though a significant correlation was found between serum and salivary lithium levels, more studies are needed in this domain to establish salivary therapeutic monitoring as a feasible option for patients on lithium carbonate therapy.

Mania associated with complicated hereditary spastic paraparesis.

Hereditary spastic paraparesis (HSP) is an inherited group of neurological disorders with progressive lower limb spasticity. HSP can be clinically grouped into pure and complicated forms. Pure HSP is one without any associated neurological/psychiatric comorbidity. Depression is the most common psychiatric comorbidity. Presence of mania or bipolar affective illness with HSP is a rare phenomenon. We report a case of a 17-year-old boy who presented with classical features of HSP with complaints of excessive happiness, irritability, increased self-esteem and decreased sleep since 1 month. The patient also had complex partial seizure ever since he had features of HSP. The patient's father and younger sister suffer from pure HSP. The patient was diagnosed to have first episode mania with complicated HSP. The details of treatment and possible neurobiology are discussed in this case report.