Pathways to Care for Patients with Bipolar-I Disorder: An Exploratory Study from a Tertiary Care Centre of North India.

INTRODUCTION: Understanding the pathways to psychiatric care is important from a public health perspective. Only a few Indian studies have focused on this, particularly for severe mental disorders. The present study was planned to assess it in patients with Bipolar-I disorder (BD-I). MATERIALS AND METHODS: Sixty-four patients with DSM 5 diagnosis of BD-I and their caregivers were included. A semi-structured interview proforma was used to gather information. RESULTS: Psychiatrists were the first care provider in 43.8% of the cases, followed by traditional faith healers (32.8%) and general physician/neurologists (17.2%). The median duration of untreated bipolar disorder (DUB) was 21 days (1 day to 152 months). Relatively long DUB (3.5 ± 3.5 years) was found for 17.2% of the sample. The median duration of the first contact with a psychiatrist was 45 days and the interval between the contact with the first care provider and a psychiatrist was 90 days (1 day to 151 months). At the time of first treatment seeking, 64% of patients and caregivers had poor awareness regarding psychiatric treatment. CONCLUSIONS: Patients with BD-I seek help from psychiatrists, faith healers or other medical practitioners for multiple reasons. There is a need to sensitise the community and various service providers about early identification and optimum management of BD-I.

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.

Familial study of attentional and behavioural problems in children with Dyslexia and their first-degree relatives in Indian setting.

BACKGROUND: Dyslexia is one of the common problems seen in children worldwide. There is high co-morbidity of dyslexia with attentional and behaviour problems which could have familial pattern. This study aims to compare the attentional and behavioural problems in children with dyslexia and their first-degree relatives with controls. METHODS: This is a cross-sectional comparative study with single interview method in an out-patient setting. Formally diagnosed (ICD-10) cases of 30 children with specific reading disorder and 30 healthy matched controls and their first-degree relatives were assessed using scales in a single setting after application of inclusion and exclusion criteria. RESULTS: The children with dyslexia had significantly more problems in the domains of selective attention and behavioural problems as compared to controls and the siblings of the cases had significant problems in selective attention but not in behavioural problems. Also, no difference was seen in ADHD symptoms of parents in cases and controls. CONCLUSION: The results from our study are keeping with most of the published literature. We expect that this study will help in laying a good foundation for further studies with stronger methodologies incorporating molecular genetics.

Assessment of cognitive functions in bipolar I disorder: A 1-year naturalistic follow-up study.

OBJECTIVE: Available findings from cross-sectional studies have demonstrated cognitive impairments in bipolar I disorder (BD-I) during various phases of illness. However, very little is known about the longitudinal course of these cognitive impairments. The purpose of the study was to explore the longitudinal pattern of changes in cognitive functioning of BD-I patients. METHODS: A total of 129 BD-I subjects (manic, depressed and euthymic groups) and 49 healthy controls were recruited using predefined selection criteria. All four study groups were assessed on various clinical and cognitive parameters (for attention, memory, executive functions and working memory) at study intake and at 3-monthly intervals over the next year. RESULTS: All three patient groups performed poorly compared to controls on all cognitive measures at study intake and on some cognitive measures at the 3-, 6-, 9- and 12-month assessments. No significant time effects were observed for any cognitive test. A significant group by time interaction effect was found for executive functions (ß = -44.74; P = .018) and working memory (ß = 0.77; P ≤ .019) in the depressed group at 12 months; for visual memory (ß = 1.21; P = .039) and working memory (ß = 1.17; P ≤ .029) in the manic group at 12 months; and for working memory (ß = -0.52; P ≤ .036) in the euthymic group at 12 months. CONCLUSION: The patient groups showed significant impairments in all or some test domains relative to controls at all time-points. The cognitive functions largely remained stable in all patient groups, with slight improvement over time in a few tests. Further investigation is warranted in larger samples in longitudinal studies.

Ethics in Psychiatric Research: Issues and Recommendations.

Psychiatric research has increased remarkably over recent decades to help in understanding the current trends and better therapeutic options for illness. On the other hand, there is also a trend toward higher rates of retraction of published papers in the recent years. Ethics is required to maintain and increase the overall quality and morality of research. Psychiatric research faces several unique ethical challenges. Ethical guidelines are very important tool of research which safeguards participants; however, there is a dearth of such guidelines in India. The present paper aims to review available ethical issues and guidelines pertaining to psychiatric research. A search was conducted on Pubmed using search terms (e.g., "ethics," "psychiatry," "research"). Relevant studies were selected for the review after manual screening of title/abstract. Additional sources were referred to using cross references and Google Scholar. Psychiatric research has several important ethical issues which are different from other medical disciplines. These issues are related to informed consent, confidentiality, conflict of interest, therapeutic misconception, placebo related, vulnerability, exploitation, operational challenges, among others. The current paper has made several recommendations to deal with ethical challenges commonly faced in psychiatric research. The ethical guidelines are utmost needed for Indian psychiatric research. Specific guidelines are lacking pertaining to psychiatric research. The issues and recommendations merit a further discussion and consideration.

Pattern and profile of children using substances in India: Insights and recommendations.

India has one of the largest proportion of children and adolescents in the world, but the threat posed by child substance use remains under-researched. Only recently a large study, the first of its kind in India, was carried out with a sample of nearly 4000 children using substances (school-going, out-of-school as well as street children) across more than a hundred cities/towns. We discuss (i) the existing knowledge on the prevalence of child substance abuse in India; (ii) perspectives and insights gained from the recent nation-wide study on its pattern and profile; and (iii) recommendations for substance use prevention and treatment among children in the Indian context. A multipronged approach involving all stakeholders is required to address the issues of prevention and treatment.

Cue-induced craving among inhalant users: Development and preliminary validation of a visual cue paradigm.

INTRODUCTION: Cue-induced craving is known to be associated with a higher risk of relapse, wherein drug-specific cues become conditioned stimuli, eliciting conditioned responses. Cue-reactivity paradigm are important tools to study psychological responses and functional neuroimaging changes. However, till date, there has been no specific study or a validated paradigm for inhalant cue-induced craving research. The study aimed to develop and validate visual cue stimulus for inhalant cue-associated craving. METHOD: The first step (picture selection) involved screening and careful selection of 30 cue- and 30 neutral-pictures based on their relevance for naturalistic settings. In the second step (time optimization), a random selection of ten cue-pictures each was presented for 4s, 6s, and 8s to seven adolescent male inhalant users, and pre-post craving response was compared using a Visual Analogue Scale(VAS) for each of the picture and time. In the third step (validation), craving response for each of 30 cue- and 30 neutral-pictures were analysed among 20 adolescent inhalant users. RESULTS: Findings revealed a significant difference in before and after craving response for the cue-pictures, but not neutral-pictures. Using ROC-curve, pictures were arranged in order of craving intensity. Finally, 20 best cue- and 20 neutral-pictures were used for the development of a 480s visual cue paradigm. CONCLUSION: This is the first study to systematically develop an inhalant cue picture paradigm which can be used as a tool to examine cue induced craving in neurobiological studies. Further research, including its further validation in larger study and diverse samples, is required.

Chlorpromazine as Prophylaxis for Bipolar Disorder with Treatment- and Electroconvulsive Therapy-Refractory Mania: Old Horse, New Trick.

A 22-year-old male diagnosed with bipolar affective disorder presented to us with a 3rd episode mania resistant to both olanzapine and haloperidol as well as electroconvulsive therapy. He, however, responded to chlorpromazine (CPZ) which was also effective as a mood stabilizer. The patient had a relapse of his illness when CPZ was stopped and responded again when it was started. The case demonstrates that CPZ may have a role in as both an anti-manic agent and for the maintenance for bipolar disorders. The possible underlying mechanism for this role is also discussed.

Thyroid and Cortisol hormones in Attention Deficit Hyperactivity Disorder: A case-control study.

AIM: There is paucity of research in the putative role of hormonal biomarkers in Attention Deficit Hyperactivity Disorder (ADHD). The current study aimed to analyze the clinical profile, socio-demographic status, co-morbidity, hormonal biomarkers namely Thyroid hormones and Cortisol in children with ADHD and compare them with healthy controls and to explore the association of the hormonal biomarkers with severity of ADHD. METHODS: Thirty children with DSM-IV TR diagnosis of ADHD were assessed using semi structured proforma, Conners' Parent Rating Scale revised short (CPRS - R: S) , Mini international neuropsychiatric interview for children and adolescents and Childrens' Global Assessment Scale as well as serum levels of total Triiodothyronine (T3) ,total Thyroxine (T4) , Thyroid Stimulating Hormone (TSH) and Cortisol using chemiluminescent immunometric assay and compared with 30 age- and gender -matched controls. RESULTS: The typical profile of cases of ADHD was of a male with mean age of 9.47 years (S.D=2.43) belonging to Hyperactive subtype of ADHD. Serum T4 was significantly lower in cases compared to controls. No significant difference was found in serum T3, TSH and Cortisol levels. No significant correlation between the CPRS : R-S scores and the hormonal biomarkers. CONCLUSIONS: There is need for exploration of Serum T4 as putative biomarker for ADHD with replication in future studies. It may also be important to report the negative finding of Cortisol as a biomarker of ADHD in the context of effective utilization of resources for research with special relevance to resource deficit developing countries.

Concept and Identification of "Soft Bipolarity" in Patients presenting with Depression: Need for Careful Screening by Physicians.

The bipolar spectrum is a broader concept, which questions the strict dichotomous categorical division of erstwhile manic-depressive illness into two discrete categories viz. bipolar disorder and major depressive disorder, thereby overlooking a wide 'spectrum' of patients which lie 'in between' the two extremes. The presence of underlying bipolar 'spectrum' or 'soft bipolarity' often goes undetected in patients presenting with major depression. This sub-group of patients may not stabilize with indiscriminate use of anti-depressant drugs, and without proper management, it may be associated with continued non-responsive symptoms, increased suicidality and poorer prognosis. There is a need to suspect and identify such cases of soft bipolarity/spectrum by early screening of patients with major depression presenting to medical settings. The review paper covers the current concepts and understanding of bipolar spectrum disorders which is aimed to facilitate early identification, management and referral of cases detected to have soft bipolarity in the general medical settings.

ADHD research in India: A narrative review.

INTRODUCTION: Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder with no clear etiopathogenesis. Owing to unique socio cultural milieu of India, it is worthwhile reviewing research on ADHD from India and comparing findings with global research. Thereby, we attempted to provide a comprehensive overview of research on ADHD from India. METHODS: A boolean search of articles published in English from September 1966 to January 2017 on electronic search engines Google Scholar, PubMed, IndMED, MedIND, using the search terms "ADHD", "Attention Deficit and Hyperactivity Disorder", "Hyperactivity" ,"Child psychiatry", "Hyperkinetic disorder", "Attention Deficit Disorder", "India"was carried out and peer - reviewed studies conducted among human subjects in India were included for review. Case reports, animal studies, previous reviews were excluded from the current review. RESULTS: Results of 73 studies found eligible for the review were organized into broad themes such as epidemiology, etiology, course and follow up, clinical profile and comorbidity, assessment /biomarkers, intervention/treatment parameters, pathways to care and knowledge and attitude towards ADHD. DISCUSSION: There was a gap noted in research from India in the domains of biomarkers, course and follow up and non-pharmacological intervention. The prevalence of ADHD as well as comorbidity of Bipolar Disorder was comparatively lower compared to western studies. The studies found unique to India include comparing the effect of allopathic intervention with Ayurvedic intervention, yoga as a non pharmacological intervention. There is a need for studies from India on biomarkers, studies with prospective research design, larger sample size and with matched controls.

Potential biomarkers for bipolar disorder: Where do we stand?

Bipolar disorder (BD) is a severe, recurrent mood disorder, associated with a significant morbidity and mortality, with high rates of suicides and medical comorbidities. There is a high risk of mood disorders among the first-degree relatives of patients with BD. In the current clinical practice, the diagnosis of BD is made by history taking, interview and behavioural observations, thereby lacking an objective, biological validation. This approach may result in underdiagnosis, misdiagnosis and eventually poorer outcomes. Due to the heterogeneity of BD, the possibility of developing a single, specific biomarker is still remote; however, there is a set of promising biomarkers which may serve as predictive, prognostic or treatment markers in the future. The review presents a critical appraisal and update on some of the most promising candidates for biomarkers, namely, neuroimaging markers, peripheral biomarkers and genetic markers, including a brief discussion on cognitive endophenotypes as indicative of genetic risk. The lessons learnt from other fields and specialties in medicine need to be applied to psychiatry to translate the knowledge from 'bench to bedside' by means of clinically useful biomarkers. Overall, the biomarkers may help in pushing the shift towards personalized medicine for psychiatric patients.

Twelve-month prevalence and treatment gap for common mental disorders: Findings from a large-scale epidemiological survey in India.

BACKGROUND: Common mental disorders, such as mood, anxiety, and substance use disorders, are significant contributors to disability globally, including India. Available research is, however, limited by methodological issues and heterogeneities. AIM: The present paper focuses on the 12-month prevalence and 12-month treatment for anxiety, mood, and substance use disorders in India. MATERIALS AND METHODS: As part of the World Health Organization World Mental Health (WMH) Survey Initiative, in India, the study was conducted at eleven sites. However, the current study focuses on the household sample of 24,371 adults (≥18 years) of eight districts of different states, covering rural and urban areas. Respondents were interviewed face-to-face using the WMH Composite International Diagnostic Interview after translation and country-specific adaptations. Diagnoses were generated as per the International Classification of Diseases, 10th edition, Diagnostic Criteria for Research. RESULTS: Nearly 49.3% of the sample included males. The 12-month prevalence of common mental disorders was 5.52% - anxiety disorders (3.41%), mood disorders (1.44%), and substance use disorders (1.18%). Females had a relatively higher prevalence of anxiety and mood disorders, and lower prevalence of substance use disorders than males. The 12-month treatment for people with common mental disorders was 5.09% (range 1.66%-11.55% for individual disorders). The survey revealed a huge treatment gap of 95%, with only 5 out of 100 individuals with common mental disorders receiving any treatment over the past year. CONCLUSION: The survey provides valuable data to understand the mental health needs and treatment gaps in the Indian population. Despite the 12-month prevalence study being restricted to selected mental disorders, these estimates are likely to be conservative due to under-reporting or inadequate detection due to cultural factors.