Self-stigma in patients with major depressive disorder: An exploratory study from India.

BACKGROUND: One of the barriers to effective care in patients with depression is stigma associated with having a mental disorder, which also acts as a barrier to recovery and increases the disability. AIMS: To study the stigma and disabilities experienced by the patients with depressive disorders seeking treatment in a tertiary care hospital. METHODOLOGY: Fifty patients diagnosed to have depressive disorder as per ICD-10 were recruited by convenient sampling. To measure the stigma, the Discrimination and Stigma Scale -12 was applied. The severity of depression was determined by applying Hamilton Depression Rating Scale (HAMD). The disability was calculated by using WHO Disability Assessment Schedule 2.0. RESULTS: Fifty percentages of the participants reported unfair treatment and they experienced discrimination in at least one life domain. There was significant positive correlation between unfair treatment subscale of stigma and disability. Around one fourth of the participants reported to be treated unfairly by their own families. Seventy percent reported to have concealed their mental health problems, 54% have stopped themselves from having a close personal relationship and 32% didn't apply for work in anticipating discrimination. Experienced and anticipated discrimination were significantly associated with concealing the mental health problem. CONCLUSION: Stigma due to having depression acts as a barrier to vocational & social integration and functional recovery. Concealment of the diagnosis of depression is itself barrier for help seeking and to receiving appropriate treatment. Small sample size and adopting the purposive sampling method are the limitations of the study.

Cost of Illness of Major Neurocognitive Disorders in India.

BACKGROUND: Major neurocognitive disorders (major NCD) predominantly affect the elderly. Major NCD results in significant morbidity and socioeconomic burden. OBJECTIVES: To estimate the individual cost of care of a person with major NCD according to disease severity and component costs. METHODS AND MATERIAL: Fifty patients of major NCD with primary caregivers attending memory clinic of tertiary care center were included. A detailed questionnaire administered after inclusion provided demographic and clinical information. Caregivers were interviewed about details of care provided. Cognitive function was assessed by Hindi mental state examination (HMSE), and major NCD severity was determined by clinical dementia rating scale (CDR). RESULTS: The annual cost of care per patient with mild to moderate and severe major MCD was INR 78288 and INR 167808, respectively. Costs increased with increasing severity of the disease. Direct nonmedical costs were significantly higher than direct medical costs in severe major NCD group and vice versa was found in mild to moderate major NCD group. CONCLUSION: Increasing population of elderly and prevalence of major NCD suggest an economic burden on caring families and hence the government. Comprehensive health policy toward providing affordable care to people with major NCD is the need of the hour.

Reduced integrity of superior longitudinal fasciculus and arcuate fasciculus as a marker for auditory hallucinations in schizophrenia: A DTI tractography study.

AIMS AND OBJECTIVES: The study aimed to assess and compare fractional anisotropy (FA) in bilateral superior longitudinal fasciculi (SLF) and arcuate fasciculi (AF) across schizophrenia with auditory hallucinations(AH), without AH, and healthy controls using diffusion tensor imaging (DTI) tractography. METHODOLOGY: Right-handed adult (18-50 years) individuals with DSM-5 diagnosis of schizophrenia with AH (group-I; n=30) were compared to those without lifetime AH (group-II; n=32) and healthy controls (group-III; n=30). Severity of psychosis in groups-I and II was assessed using SAPS, SANS, and CGI-SCH, and psychopathology was assessed using PSYRATS. The FA was calculated for all images on DTI studio-version 3.0 using tractography technique. RESULTS: All three groups were comparable for age, gender, education and illness-severity. Schizophrenia subjects with AH had significantly lower FA values in bilateral SLF and AF compared to those without AH and healthy controls. No difference was observed in corresponding FA values between schizophrenia without AH and healthy controls. CONCLUSION: White matter disruptions in bilateral SLF and AF appear to be specific to schizophrenia with AH and must be explored further as potential marker of AH, pending replication in other studies.

Identification and management of "delirious mania:" A rare clinical entity.

Little is known about the entity of delirious mania, apart from a few reports. Delirious mania, though a potentially lethal condition, has not found a place in the current classification system. We discuss the approach to the identification and management of delirious mania in a female patient presenting with catatonic and delirious features, with a past history of recurrent mood episodes. However, it must be emphasized that it is likely to be a rare clinical presentation of bipolar disorder and should not be the first diagnostic consideration. As a rule, any patient presenting with delirium or clouded consciousness first warrants a thorough medical workup and other specialty referrals.

A controlled study of plasma fatty acids in Indian patients with depressive episode.

AIM: To study the plasma omega 3 and omega 6 fatty acid levels in patients with depressive episode and in matched healthy controls. METHOD: Thirty patients with first episode depression and thirty healthy matched control subjects were recruited from a tertiary care hospital setting. We measured plasma omega-3 and omega-6 fatty acid levels of the study and the control group. RESULT: There were no significant differences in plasma omega 3 fatty acid levels between study group and control group. The plasma omega 6 fatty acid levels of study group were significantly less than that of control group. CONCLUSIONS: The present study is an initial attempt to investigate the link between fatty acids and depression in a clinical setting in India. This comparative study with normal controls did not etiologically link these polyunsaturated fatty acids in this sample of depressive disorder.

Psychological adaptation of Indian expeditioners during prolonged residence in Antarctica.

BACKGROUND: In view of the growing human activities in Antarctica and increasing exposure of humans to prolonged isolation under extreme conditions, such as space travel and deep sea diving, it is necessary to study the psychological adaptation to such an environment. The current study aimed to assess the psychological adaptation of Indian expeditioners to prolonged residence in Antarctica. MATERIALS AND METHODS: Twenty-four winter team members of 27th Indian Scientific Expedition to Antarctica were administered seven instruments 5 times during the expedition. The instruments measured cognition and memory, general psychological health and tobacco, and alcohol consumption. RESULTS: Alcohol consumption was maximum during the initial days of arrival on the continent and decreased thereafter, with another spike during the peak of the winter season. Externalized psychological reactions peaked during the midwinter period. Anxiety and insomnia peaked during the coldest period whereas depressive symptoms did not change throughout the expedition. Cognition was at its worst during the final phase of Antarctic residence. No significant change was noted in the third quarter of wintering. CONCLUSION: Each phase of Antarctic residence could be equated with a particular stage in psychological adaptation. There was no third quarter phenomenon.

Diffusion tensor imaging tractography study in bipolar disorder patients compared to first-degree relatives and healthy controls.

AIM: We aimed to compare white matter structural changes in specific tracts by diffusion tensor imaging (DTI) tractography in patients with bipolar disorder (BD) I, non-ill first-degree relatives (FDR) of the patients, and healthy controls (HC). METHODS: In a cross-sectional study, we studied right-handed subjects consisting of 16 euthymic BD I patients, 15 FDR, and 15 HC. The anterior thalamic radiation, uncinate fasciculus, corpus callosum, and cingulum bundle were reconstructed by DTI tractography. Mean fractional anisotropy (FA) and apparent diffusion coefficient (ADC) values were compared for group differences followed by post-hoc analysis. RESULTS: The three groups did not differ in terms of sociodemographic variables. There were significant group differences in the FA values among the BD I patients, their FDR, and the HC for the corpus callosum, the dorsal part of the right cingulum bundle, the hippocampal part of the cingulum bundle bilaterally, and the uncinate fasciculus (P < 0.001). The FA values in the patients were significantly lower than in controls, and FDR also showed similar differences; however, they were smaller than those in patients. No significant difference was found between the groups for FA values of the dorsal part of the left cingulum bundle and anterior thalamic radiation. Significant differences were present for ADC values among the groups for the corpus callosum, the dorsal and hippocampal parts of the cingulum, anterior thalamic radiation, and uncinate fasciculus bilaterally (P < 0.01). The FA and ADC values did not correlate significantly with age or any clinical variables. CONCLUSION: These findings suggest that BD patients and their FDR show alterations in microstructural integrity of white matter tracts, compared to the healthy population.

Use of clozapine alongside chemotherapy in a treatment-resistant bipolar disorder patient with ovarian carcinoma: A case report and brief review.

Regular monitoring of blood counts ensures the safety of clozapine use; however, certain clinical situations may pose a dilemma for management such as use of clozapine in the presence of myelosuppressive chemotherapy. Further, there is very limited literature to guide such decisions. We report a case of a clozapine-stabilized, treatment-resistant bipolar disorder patient with ovarian carcinoma requiring chemotherapy. The clinical challenges are discussed in light of a brief review of the available reports.

Pituitary Macroadenoma Presenting with Multiple Psychiatric Complications.

We report a case of pituitary macroadenoma with multiple physical and psychiatric complications, which posed a significant diagnostic dilemma and management challenge for the treating teams of neurosurgery, endocrinology and psychiatry. A pragmatic approach comprising of interdisciplinary collaboration resulted in satisfactory management of the case.

Catatonia: an unusual manifestation of Wilson's disease.

Wilson's disease, characterized by abnormal copper accumulation in the human body, may present with psychiatric manifestations in about one-fifth of patients. The authors report a patient with Wilson's disease who initially presented with acute psychosis and later developed catatonic symptoms. The atypical presentation led to a delay in diagnosis and institution of appropriate treatment. Wilson's disease can be ruled out in all young patients presenting with psychiatric symptoms for the first time by screening for a Kayser-Fleischer ring.

A comparative study of psychiatric comorbidity, quality of life and disability in patients with migraine and tension type headache.

OBJECTIVES: To compare psychiatric co-morbidity, quality of life and disability between patients of migraine and tension type headache and healthy controls. MATERIALS AND METHODS: Study subjects included 40 consecutive adult patients each with migraine and tension type of headache (TTH) of either gender fulfilling International Headache Society-II criteria and suffering for 2 years They were recruited from a headache clinic in a tertiary care teaching hospital and were assessed on Mini International Neuropsychiatric Interview (MINI), World Health Organization Quality of Life-BREF (WHOQOL-BREF) Hindi version and the Headache Impact Test-6 (HIT-6). Age and sex matched 40 healthy controls were assessed on MINI and WHOQOL-BREF. The three groups were compared for statistical significance on various scales. RESULTS: Depression emerged as the most prevalent psychiatric disorder in both the headache groups. There was significant impairment in quality of life on all domains along with functional disability in subjects with both types of headache. CONCLUSION: Psychiatric comorbidity, especially depression is common in patients with migraines and tension type headache. Quality of life and functional ability are significantly impaired in these patients. The clinician should remain aware of consequences of prolonged headache, and should provide timely intervention.

A controlled study of serum lipid profiles in Indian patients with depressive episode.

BACKGROUND: Lower levels of circulating lipid fractions and cholesterol are risk factors for impulsivity and depressive disorder. A lower level of serum cholesterol is also associated with patients presenting with history of self-harm. MATERIALS AND METHODS: A total of 30 depressive patients and 30 healthy matched control subjects were recruited from the department of Psychiatry of a tertiary care hospital. We measured serum total cholesterol (TC), low-density lipoprotein (LDL) and high-density lipoprotein cholesterol and triglyceride levels of both patient and control group. RESULTS: The serum TC and LDL-cholesterol levels were found to be significantly lower in study group than that of control group. CONCLUSION: Lower levels of serum cholesterol are associated with depressive disorder.

Lorazepam withdrawal catatonia: a case report.

Catatonia is a rare manifestation of benzodiazepine withdrawal in elderly patients who have used it for a long time. We present a case of lorazepam withdrawal catatonia and highlight issues in diagnosis and management.

Wires in the body: a case of factitious disorder.

Factitious disorder can present with a wide variety of symptomatology. We present a case of a young girl presenting with spontaneous extrusion of wires from her limbs. These metallic wires were present in both her upper and lower limbs in the muscle bulk and were visible on X-ray. She sought repeated surgical removal of these wires, but the wires would invariably reappear. The patient could not be engaged in a therapeutic relationship and the family took premature discharge against medical advice, as they believed in supernatural causation for the phenomenon and were afraid that medical intervention might bring further ill fortune. The case highlights the importance of belief systems of family members as a barrier in managing such cases.

Olanzapine induced neuroleptic malignant syndrome.

An 18 year old male diagnosed as a case of bipolar affective disorder (BPAD), developed neuroleptic malignant syndrome (NMS) following treatment with olanzapine (20 mg per day), an atypical antipsychotic drug. NMS is usually seen with typical antipsychotic drugs. The patient was diagnosed as a case of NMS, offending agent was immediately withdrawn and prompt treatment with bromocriptine and levodopa produced a good recovery. The various features of the case are discussed in view of the potential mortality of the syndrome.

A follow-up study of family burden in patients with bipolar affective disorder.

INTRODUCTION: Research in the last two decades has documented a high level of burden in caregivers of bipolar disorder. The present study is aimed at studying family burden among relatives of patients with bipolar affective disorder. METHODS: Thirty four consecutive hospitalized patients with bipolar affective disorder currently in mania and their relatives were assessed twice: at the time of admission and during follow-up four weeks after discharge. A semi-structured performa designed for the study was completed. Patients were assessed on Young's Mania Rating Scale and relatives were assessed on Family Burden Assessment Scale. RESULTS: More than 90% of family members reported severe subjective (rated by relative) and objective burden (rated by interviewer) at admission; none of them was free of burden. At the time of follow-up, about one quarter (23.5%) and two thirds (64.7%) of family members did not experience any objective and subjective burden respectively; subjective and objective family burden was moderate in about one third (35.3%) and a half (52.9%), respectively. None of the family members reported severe burden subjectively, while the objective burden was rated to be severe in a quarter (23.5%) of family members. LIMITATIONS: The study was limited by the lack of a control group from an outpatient setting as hospitalization increases family burden. Also, the rater at the second assessment was not blind to ratings at the first assessment. CONCLUSIONS: Almost all the family members experienced severe burden initially. Even when symptoms subsided, family members continued to experience burden specifically related to finances. OBJECTIVE: burden was significantly higher than subjective burden.