Innovations and changes in the ICD-11 classification of mental, behavioural and neurodevelopmental disorders.

Following approval of the ICD-11 by the World Health Assembly in May 2019, World Health Organization (WHO) member states will transition from the ICD-10 to the ICD-11, with reporting of health statistics based on the new system to begin on January 1, 2022. The WHO Department of Mental Health and Substance Abuse will publish Clinical Descriptions and Diagnostic Guidelines (CDDG) for ICD-11 Mental, Behavioural and Neurodevelopmental Disorders following ICD-11's approval. The development of the ICD-11 CDDG over the past decade, based on the principles of clinical utility and global applicability, has been the most broadly international, multilingual, multidisciplinary and participative revision process ever implemented for a classification of mental disorders. Innovations in the ICD-11 include the provision of consistent and systematically characterized information, the adoption of a lifespan approach, and culture-related guidance for each disorder. Dimensional approaches have been incorporated into the classification, particularly for personality disorders and primary psychotic disorders, in ways that are consistent with current evidence, are more compatible with recovery-based approaches, eliminate artificial comorbidity, and more effectively capture changes over time. Here we describe major changes to the structure of the ICD-11 classification of mental disorders as compared to the ICD-10, and the development of two new ICD-11 chapters relevant to mental health practice. We illustrate a set of new categories that have been added to the ICD-11 and present the rationale for their inclusion. Finally, we provide a description of the important changes that have been made in each ICD-11 disorder grouping. This information is intended to be useful for both clinicians and researchers in orienting themselves to the ICD-11 and in preparing for implementation in their own professional contexts.

Is obstructive sleep apnea the missing link between metabolic syndrome and second-generation antipsychotics: Preliminary study.

BACKGROUND: Metabolic syndrome in individuals taking second-generation antipsychotics is thought to be mediated by antipsychotic-induced weight gain. However, recent literature challenges this notion, and theoretically, it may also be mediated through obstructive sleep apnea (OSA). This study explores the contribution of OSA in antipsychotic-induced metabolic syndrome. MATERIALS AND METHODS: Forty-three participants suffering from schizophrenia spectrum disorder and major depressive disorder, taking second-generation antipsychotics were included in this study. Treatment history was taken in detail, and lifetime exposure to antipsychotics was converted to olanzapine-equivalent doses. Physical characteristics were noted. OSA was screened through the Hindi version of Berlin Questionnaire. Plasma glucose, serum total cholesterol, serum high-density lipoprotein, and serum triglyceride were measured after 12-h fasting. Adult treatment Panel-III criteria were used to diagnose metabolic syndrome. RESULTS: Gender distribution was comparable in the study sample. About 27% had continuous illness, 25.6% of participants had metabolic syndrome, and 20.9% were at high risk for sleep apnea. Participants with and without metabolic syndrome were comparable with regard to demographic variables, duration of illness, and lifetime exposure to antipsychotics. Logistic regression depicted that OSA (odds ratio [OR] = 15.09), waist circumference (OR = 1.15), and fasting plasma glucose (OR = 1.21) increased the risk of metabolic syndrome. CONCLUSION: Results of the present study suggest that metabolic syndrome in participants taking second-generation antipsychotics is mediated through OSA.

Willis-Ekbom disease/restless legs syndrome in patients with opioid withdrawal.

INTRODUCTION: Many patients with opioid use disorder report symptoms similar to restless legs syndrome (RLS) during withdrawal. However, whether these symptoms are true RLS, their predictors and effect of treatment with pregabalin are still unknown. METHOD: A total of 19 consecutive patients with opioid use disorder who were admitted for detoxification were included in this study after obtaining informed consent. Information regarding addiction was noted, and they were screened for RLS every morning and evening. Patients were also asked to provide information regarding their sleep quality during the previous night. To control opioid withdrawal, they were prescribed buprenorphine. Pregabalin was prescribed to patients who developed RLS. For analysis, patients were divided in two groups: those with RLS and those without RLS. RESULTS: The average age of the subjects included in this study was 30.2 (±10.4) years. Mean duration of substance abuse was 56.8 (±38.4) months. Ten patients developed symptoms of RLS. Groups with RLS and without RLS were comparable with reference to demographics, laboratory parameters, and dose of buprenorphine that was required to control withdrawal symptoms. On average, RLS appeared after 1.7 days of abstinence. Patients described their symptoms such as crawling, creeping sensation in the muscles or "just pain". Eight out of 10 subjects reported symptoms limited to legs; however, two described similar problems in their upper limbs as well. A change in sleep pattern was observed with delayed sleep onset at night, delayed wake time in the morning, and spending a major proportion of day asleep. Pregabalin brought significant relief to the symptoms of RLS and sleep quality. CONCLUSION: RLS during opioid withdrawal was an independent illness seen in half of the patients. It appeared to be mediated through mu-receptors, with contributions from other factors. Pregabalin improved symptoms of RLS and quality of sleep in these patients.

Treatment of substance use disorders through the government health facilities: Developments in the "Drug De-addiction Programme" of Ministry of Health and Family Welfare, Government of India.

Substance use disorder (SUD) is a major problem worldwide, including in India, and contributes significantly to morbidity and mortality. The Ministry of Social Justice and Empowerment, Government of India, addresses the prevention and rehabilitation aspect of substance use through the establishment of "rehabilitation centers" run by nongovernmental organizations. The Drug De-addiction Programme (DDAP) was initiated in 1988 under the Ministry of Health and Family Welfare, Government of India, and was mandated with provision of treatment for SUDs. Through the DDAP, de-addiction centers (DACs) have been established in government hospitals by providing a one-time financial grant by the central government, with the recurring expenses to be borne by the state governments. In addition, some premier institutions as well as DACs from Northeastern region are provided annual recurring grants for their functioning. Capacity building has been a major focus area of DDAP in which nonspecialist medical officers working in government hospitals have been trained, and various training materials have been developed. Another major area of work is the development of "drug abuse monitoring system" to track the pattern of drug use and profile among individuals seeking treatment in the DACs. Monitoring and evaluation exercises carried out show that the existing model of inpatient treatment and of shared responsibility between central and state governments is partially successful. The establishment of drug treatment clinics on pilot basis with a focus on outpatient treatment and direct support from the DDAP for staff as well as for medicines is showing encouraging results.

Pharmacological and toxicological investigations of etodolac loaded gum katira microspheres prepared by W1/O/W2 emulsion solvent evaporation technique in rats

ABSTRACT Etodolac is a non-steroidal anti-inflammatory drug (NSAID) and approved by USFDA as a COX2 inhibitor. Although etodolac therapy provides clinical benefits, it is associated with upper gastrointestinal (GI) tract complications also. Etodolac loaded gum Katira microsphere (ELGKM) was prepared by W1/O/W2 emulsion solvent evaporation technique. The gastric irritation properties of orally administered pure etodolac, ELGKM and blank microspheres (without etodolac) were evaluated in experimental rats treated for 6 days. The stomach examination and biochemical investigation of stomach tissue of treated rats indicated that ELGKM formulation remarkably reduced ulcerogenecity as compared to pure etodolac. The anti-inflammatory activities of pure etodolac and ELGKMs were ascertained by the implantation of cotton pellets in rats for 6 days. Based on the results, ELGKMs showed significant anti-inflammatory activities (P<0.01) as compared to control group. The cotton pellets test suggested that ELGKM formulation retained more anti-inflammatory properties among the groups. The hematological changes, biochemical analysis and histopathological studies of subacute toxicity in rats revealed that ELGKM were the effective sustained release formulation in the treatment of chronic pain and inflammation. In conclusion, the physicochemical characterization, pharmacological and toxicological studies suggest that ELGKMs may represent as a potential candidate for sustained drug delivery (10-12 hours) in chronic joint pain related diseases with remarkably diminished gastrointestinal side effects.

Preferences for Treatment Setting by Substance Users in India.

BACKGROUND: Drug and alcohol use is a growing public health concern for India. Treatment services delivery for substance use disorders is available through three sectors viz. Government (GO) centres under Ministry of Health and FW, Non-Government (NGO) under Ministry of Social Justice and Empowerment and the private sector. Information on ttreatment utilisation and preferences of treatment settings by substance users are not available for India. METHODS: A performa was filled up prospectively for each consecutive new patient seeking treatment for drug/alcohol use (excluding tobacco) at De-addiction centres funded by MOH&FW; NGOs under MoSJE and private psychiatrists between 15(th) July to 15(th) October, 2011. All data available for 182 drug using persons from private, 1228 persons from 35 NGOs and 1700 persons from GO organizations were entered into SPSS-21.0, data quality checks performed and analysed. RESULTS: There was a variance in the population profile in the three sectors providing treatment delivery for substance users in India. Treatment seeking for illicit drugs (heroin, opiates and cannabis) was higher in GO sector; injection drug use was higher in NGO sector while alcohol was higher in private sector. CONCLUSIONS: Strengthening linkages between GO and NGO sector is important for an improved coverage and quality of treatment services in the country. The Andersen's Behavioural Model as theoretical background to clarify some issues in analyzing with larger datasets is warranted.

Treatment Seeking Behavior of Inhalant Using Street Children: Are We Prepared to Meet Their Treatment Needs.

CONTEXT: There is a lack of evidence for help and treatment seeking behavior of street children using inhalants. AIMS: The present study was planned to provide a comprehensive understanding on the patterns, correlates of inhalant use and treatment seeking behavior of street children from Delhi, India. MATERIAL AND METHODS: Participants were a purposive sample of 100 inhalant using street children below 18 years identified with the assistance of five community service organizations/nongovernmental organization working with street children in the city of Delhi. Information on a semi-structured questionnaire with items pertaining to the demographic and drug use parameters was collected by trained research staff in a one-to-one in field setting. STATISTICAL ANALYSIS: All data were entered into SPSS 12.0, data quality checks performed and examined. RESULTS: The sample had an average age of 12.8 ± 2.4 years (range 4-17 years), 96.5% reported regular past month and 87.0% past 24 h use of inhalants. The mean age of onset of inhalant use was 9.3 ± 2.8 years The substances most commonly reported were toluene from eraser fluid (by 83.0%), glues (34.0%) and petroleum products (3.0%); mean frequency of use was 9.8 times in a day. Of the sample, 18% used inhalants when they were alone, and the rest reported using with drug using network friends; 76% reported tolerance and mild withdrawal symptoms such as restlessness, anxiety, craving, irritability and lethargy. A variety of problems and perceived benefits due to inhalant use were reported; 46% inhalant users had never abstained from its use, and 77% reported never having sought any medical help. CONCLUSIONS: Study findings provide a better contemporary understanding of inhalant abuse among Delhi street children. This information can assist in the formulation of a needs-based intervention for the inhalant using street children.

Ketamine dependence in an anesthesiologist: an occupational hazard?

Substance abuse among medical professionals is a cause for concern. Certain psychotropic substances such as ketamine are at easy dispense to anesthesiologists increasing the likelihood of misuse and dependence and raise several issues including safety of patients. We discuss a case demonstrating ketamine dependence in an anesthesiologist from India. The reported psychotropic effects of ketamine ranged from dissociation and depersonalization to psychotic experiences. There was also development of significant tolerance to ketamine without prominent physical withdrawal symptoms and cyclical use of very high doses was observed. Issues related to management of health professionals are also discussed.

A retrospective chart review of treatment seeking middle aged individuals at a tertiary care substance use disorder treatment centre in North Part of India over five successive years: findings from drug abuse monitoring system.

Adolescents and young adults continue to remain the main focus of attention with regards to substance use related problems. There has been a limited focus on illicit substance use among middle aged and elderly population. The current study explored the changing trends of substance use among treatment seeking middle aged individuals (aged 40-60 years) at a tertiary level drug dependence treatment centre. The questionnaire used to gather information for the study is a 19-item structured questionnaire. It includes information on various sociodemographic variables, "current," and "ever" use of substance. Information is also collected on variables related to high risk injecting drug use and HIV status of the individuals. There has been consistent increase in the population of treatment seekers over five years. Over the five-year period, the absolute percentage increase in treatment seeking population is approximately 21%. Polysubstance use was found to increase significantly over five-study years (P(Trend) = 0.007).

Addiction research centres and the nurturing of creativity: National Drug Dependence Treatment Centre, India--a profile.

The National Drug Dependence Treatment Centre (NDDTC) is a part of the All India Institute of Medical Sciences, a premier autonomous medical university in India. This article provides an account of its origin and its contribution to the field of substance use disorder at the national and international levels. Since its establishment, the NDDTC has played a major role in the development of various replicable models of care, the training of post-graduate students of psychiatry, research, policy development and planning. An assessment of the magnitude of drug abuse in India began in the early 1990s and this was followed by a National Survey on Extent, Patterns and Trends of Drug Abuse in 2004. Several models of clinical care have been developed for population subgroups in diverse settings. The centre played an important role in producing data and resource material which helped to scale up opioid substitution treatment in India. A nationwide database on the profile of patients seeking treatment (Drug Abuse Monitoring System) at government drug treatment centres has also been created. The centre has provided valuable inputs for the Government of India's programme planning. Besides clinical studies, research has also focused on pre-clinical studies. Capacity-building is an important priority, with training curricula and resource material being developed for doctors and paramedical staff. Many of these training programmes are conducted in collaboration with other institutions in the country. The NDDTC has received funding from several national and international organizations for research and scientific meetings, and, most recently (2012), it has been designated as a World Health Organization Collaborating Centre on Substance Abuse.

Post marketing surveillance of sublingual buprenorphine naloxone combination tablets.

BACKGROUND & OBJECTIVES: A combination of buprenorphine-naloxone (Addnok-N) tablets has been recently introduced in India as treatment for Opioid dependence. This study was undertaken to evaluate the possible adverse consequences following use of the buprenorphine-naloxone tablets through post marketing surveillance. METHODS: National Drug Dependence Treatment Centre (NDDTC), AIIMS, India, monitored all patients receiving buprenorphine-naloxone combination tablets from the centre over a period of two and half years. Evaluation included subjective and objective side effect checklist, physical examination, and laboratory investigation. RESULTS: Data was obtained from 1132 observations among 158 patients. Commonly reported medication effects, like muscle aches (44.0%), sleepiness (44.0%), relief from pain (41.3%), etc; are expected in opioid substitution treatment. Laboratory investigations were mostly normal except for liver enzyme abnormalities (52.2% of cases). Eight adverse events were reported in the study. No dangerous event or mortality was reported during the study.

Evaluation of a matrix tablet prepared with polyacrylamide-g-sodium alginate co-polymers and their partially hydrolyzed co-polymers for sustained release of diltiazem hydrochloride.

Diltiazem hydrochloride (DTZ) matrix tablets were prepared using polyacrylamide-grafted sodium alginate (PAam-g-SA) co-polymers having different percentages of grafting and their partially hydrolyzed products with a view to achieve sustained release of the highly water-soluble drug. PAam-g-SA co-polymers having different percentages of grafting were synthesized by free radical polymerization using acrylamide (Aam) as monomer and ammonium persulphate (APS) as initiator, and the resulting co-polymers were subjected to alkaline hydrolysis to produce their corresponding partially hydrolyzed co-polymers. Matrix tablets of DTZ were prepared by wet granulation using either PAam-g-SA co-polymers or partially hydrolyzed PAam-g-SA co-polymers. The effect of percentage grafting, drug load and calcium gluconate (CG), used as excipient, was studied in simulated gastrointestinal fluid. While the tablets prepared using the co-polymer having higher percentages of grafting provided faster drug release (100% in 5.5 h), the tablets prepared with the corresponding hydrolyzed co-polymer released the drug slowly (71% in 12 h). This behaviour in release appeared to be controlled by the relative magnitude of the viscosity and the swelling capacity of the copolymers. Moreover, increase in drug load tended to decrease the drug release from all types of tablets and increase in the amount of CG increased the drug release. FT-IR and DSC studies revealed the absence of any interaction between the drug and the co-polymers. The matrix tablet made of partially hydrolyzed graft co-polymer having the highest percentage of grafting provided the most sustained release of the drug.

Comparison of self-reported benzodiazepine use and urinalysis among consecutive treatment seekers at a tertiary care drug dependence treatment centre.

Information provided by drug dependent patients might be incomplete and/or discrepant. Benzodiazepines are frequently abused, but not necessarily reported, even bythe treatment seeking population. The study aims to compare the self reported benzodiazepine use with a quick and effective urinalysis method. A total of 51 consecutive adult patients were included after an informed consent during their first visit to a tertiary care drug dependence treatment centre. The socio-demographic and clinical details were recorded on a semi-structured proforma. Patients were specifically asked for ever, current and recent benzodiazepine use and thereafter ten ml urine sample was collected to perform urinalysis with cassette test for benzodiazepines. The sample, predominantly males, had a mean age of 37.86 +/-10.46 years. The common primary drugs of use were heroin (52.9%), alcohol (23.5%) and other opioids (21.6%). Drug use was uninterrupted in most of users (72.5%) and ranged from one to forty years. The recent benzodiazepine use was reported by 21.6% of all users whereas urinalysis by cassette test was positive in 50.9% of the treatment seekers. Denial among users was 69.2% and denial among negative self report was 45%. A poor level of agreement (K) was found between results of self-report and urinalysis for all the treatment seekers. Self report of benzodiazepine use is highly questionable among treatment seekers. The urinalysis with cassette test is a quick objective method which is recommended for routine screening.

Assessment of differential doses of buprenorphine for long term pharmacotherapy among opiate dependent subjects.

The aim of the present study was to evaluate, two different doses of sublingual buprenorphine (2 mg and 4 mg) among patients on maintenance treatment and to assess the relationship of steady state plasma level with craving. Twenty three male opioid dependent (ICD-10 DCR) subjects, were assigned to double blind randomized controlled trial of 2 and 4 mg/day doses of buprenorphine in an inpatient setting. They were evaluated thrice (2nd, 7th and 14th day) in 2 weeks for withdrawal symptoms (acute and protracted), sedation, euphoria, craving, side effects, global rating of well being and for measurement of plasma levels of buprenorphine. The data showed that there were no significant difference in scores of euphoria and sedation, protracted withdrawal symptoms and side effects, craving and overall well being and plasma level of buprenorphine among the subjects. However, both the groups had significant difference in score on almost all the measurements on final observation in comparison to initial observation. Both 2 mg/day and 4 mg/day dose of buprenorphine were effective in long term pharmacotherapy of opioid dependence without significant difference as compared by different measures used in the study.