Suicide attempts in schizophrenia - A large retrospective cohort study from a tertiary care psychiatry centre in India.

The extent of variability in identified risk factors for suicide attempts (SA) in schizophrenia limits their generalization. This study aimed to identify the rates and associated correlates of SA in schizophrenia by reviewing a large cohort (n=500). Nearly one-fourth had a history of SA, which was independently associated with a family history of SA, more inpatient admissions, and better long-term treatment response. These findings highlight the complex interaction between biological factors influencing SA and illness determinants in schizophrenia. Furthermore, they reinforce the need for future research to unravel the association between suicide vulnerability and the pathophysiology of schizophrenia to attenuate morbidity and mortality associated with the same.

Predictors of future suicide attempts in individuals with high suicide risk admitted to an acute psychiatry suicide intervention unit in India. A survival analysis study.

OBJECTIVE: Determination of suicide vulnerability remains challenging in mental illness. Variability in risk factors identified compound its poor predictability. Longitudinal studies, offering more reliable indices of risk, from developing countries are conspicuously limited. Furthermore, research advances allude to inherent vulnerability. This study, the first of its kind from India, consequently aimed to delineate factors influencing subsequent attempts in mental illness and acute suicidality. METHOD: Baseline and follow-up information (up to five years) was obtained from medical records of individuals (n = 130) with acute suicidality [recent attempt (first attempt/ reattempt) and high-risk ideators]. Variables were compared between individuals with, and without subsequent suicide attempts. Time to attempt and factors influencing the same was determined using survival analysis, and Cox proportional hazard for estimating the likelihood of a subsequent suicide attempt. RESULTS: Median duration of follow up of the sample (n = 130) was 23 months. The sample comprised of individuals with a recent attempt (first-time attempt), recent reattempt and recent high-risk ideators. Subsequent suicide attempts were noted in 30 (23.1 %) patients. Baseline sociodemographic and clinical variables, including suicidality, could not differentiate individuals with a subsequent suicide attempt. Survival analysis indicated that 65 % of subsequent attempts occurred within 9 months of discharge. Family history of suicide and the presence of impulsive-aggressive traits were associated with both, reduced survival time and overall increased risk of a subsequent suicide attempt. CONCLUSION: This study delineates both, the time frame associated with greatest risk, as well as individuals most likely to reattempt suicide. It thereby offers insights into potential windows of opportunity to mitigate prospective suicide risk. Strategies such as enhanced after-care and integrating specific interventions to attenuate impulsive-aggressive behaviors could be a focus to prevent future attempts, thereby decreasing rates of suicide amongst those with mental illness. Furthermore, the findings of this study reaffirm the role of factors that independently confer vulnerability to suicide. Traversing noted regional variations, the findings importantly reinforce the distinct pathophysiological underpinnings of suicide in mental illness.

Complexities of cooccurrence of catatonia and autoimmune thyroiditis in bipolar disorder: A case series and selective review.

In recent years the neurobiological underpinnings of catatonia have been an emerging area of interest. Catatonia is frequently encountered in mood disorders, neurological disorders and systemic illnesses. Furthermore, the manifestation of catatonia in autoimmune disorders such as NMDA receptor antibody encephalitis and thyroiditis reinforces its neuropsychiatric nature. Irrespective of cause benzodiazepines and electroconvulsive therapy remain the standard treatments for catatonia, although a proportion fail to respond to the same. This report describes three women with pre-existing bipolar disorder presenting in catatonia. Interestingly in all three, while benzodiazepines and electroconvulsive therapy failed, a dramatic resolution of catatonia with corticosteroids was noted following the detection of Hashimoto's thyroiditis. Hashimoto's encephalopathy presenting as catatonia has been reported, but our patients' profile differed in having had an a priory diagnosis of bipolar disorder. Given that both catatonia and thyroid dysfunction are frequently encountered in bipolar disorder, Hashimoto's encephalopathy as a potential cause for this concurrent manifestation in bipolar disorder may be overlooked. Therefore, it is essential to suspect Hashimoto's encephalopathy when catatonia manifests in bipolar disorder. A timely evaluation would be prudent as they may fail to respond to standard treatments for catatonia but respond remarkably to corticosteroids, saving much time and angst. Recent evidence implicates immune system dysfunction, with neuroinflammation and peripheral immune dysregulation contributing to the pathophysiology of bipolar disorder as well as catatonia. Findings from this study reaffirm the role of immune system dysfunction common to the etiopathogenesis of all these disorders, highlighting the complex interplay between catatonia, thyroiditis and bipolar disorder.

Concurrent catatonia and COVID-19 infection - An experiential account of challenges and management of cases from a tertiary care psychiatric hospital in India.

Catatonia has been reported as one among many neuropsychiatric manifestations associated with COVID-19 infection. Catatonia and COVID-19 co-occurrence remain clinical concerns, often posing challenges pertaining to diagnosis, and especially management. Limited information is available regarding the appropriate approaches to the management of catatonia in COVID-19 infection, particularly with reference to the safety and efficacy of benzodiazepines and Electro-convulsive therapy (ECT). We present our experience of five patients with catatonia consequent to heterogeneous underlying causes and concurrent COVID-19 infection, who received care at the psychiatric COVID unit of our tertiary care psychiatric hospital. An interesting observation included varying underlying causes for catatonia and the potential role that COVID-19 infection may have played in the manifestation of catatonia. In our experience, new-onset catatonia with or without pre-existing psychiatric illness and concurrent COVID-19 can be safely and effectively managed with lorazepam and/or ECTs. However, critical to the same is the need to implement modified protocols that integrate pre-emptive evaluation for COVID-19 disease and proactive monitoring of its relevant clinical parameters, thereby permitting judicious and timely implementation of catatonia-specific treatment options.

Resting state functional connectivity and structural abnormalities of the brain in acute retarded catatonia: an exploratory MRI study.

In this first cross-sectional MRI study in acute catatonia, we compared the resting state whole-brain, within-network and seed (left precentral gyrus)-to-voxel connectivity, as well as cortical surface complexity between a sample of patients in acute retarded catatonic state (n = 15) diagnosed as per DSM-5 criteria and a demographically matched healthy control sample (n = 15). The patients had comorbid Axis-I psychiatric disorders including schizophrenia spectrum disorders and psychotic mood disorders, but did not have diagnosable neurological disorders. Acute retarded catatonia was characterized by reduced resting state functional connectivity, most robustly within the sensorimotor network; diffuse region of interest (ROI)-ROI hyperconnectivity; and seed-to-voxel hyperconnectivity in the frontoparietal and cerebellar regions. The seed (left precentral gyrus)-to-voxel connectivity was positively correlated to the catatonia motor ratings. The ROI-ROI as well as seed-to-voxel functional hyperconnectivity were noted to be higher in lorazepam responders (n = 9) in comparison to the non-responders (n = 6). The overall Hedges' g effect sizes for these analyses ranged between 0.82 and 3.53, indicating robustness of these results, while the average Dice coefficients from jackknife reliability analyses ranged between 0.6 and 1, indicating fair (inter-regional ROI-ROI connectivity) to perfect (within-sensorimotor network connectivity) reliability of the results. The catatonia sample showed reduced vertex-wise cortical complexity in the right insular cortex and contiguous areas. Thus, we have identified neuroimaging markers of the acute retarded catatonic state that may show an association with treatment response to benzodiazepines. We discuss how these novel findings have important translational implications for understanding the pathophysiology of catatonia as well as for the mechanistic understanding and prediction of treatment response to benzodiazepines.

Suicide prevention in the context of COVID-19: An Indian perspective.

The ongoing COVID-19 pandemic has impacted the health and wellbeing of communities worldwide. Measures to limit transmission, have enhanced vulnerability of individuals to well identified risk factors associated with mental illness and suicide. These include a sense of loneliness, anxiety, depression, insomnia, PTSD, harmful alcohol and drug use. Given that the potential for increased rates of suicide persist, the suicide prevention agenda remains urgent and essential. The same is one of the cornerstones of resilience in a society that is facing an array of challenges due to the pandemic. In this article, we recommend few possible strategies for attenuating suicide risk amidst the COVID-19 pandemic with particular relevance to the Indian context.

Homozygous PLA2G6 (PARK 14) gene mutation associated neuropsychiatric phenotypes from southern India.

PLA2G6 gene associated neurodegenerative disorders resulting from homozygous c. 2222G > A (p.Arg741Gln) mutation were detected in two cases having variable neuropsychiatric phenotypic and imaging findings. Exome analysis helped identification of rare alleles, reinforcing ethnographic antecedents to geographical clustering of rare mutations and, essential to understanding biology of neurodegenerative disorders.

Non-suicidal self-injury (NSSI) among emerging adults: Sub-group profiles and their clinical relevance.

BACKGROUND: High prevalence rates and variations in patterns of non-suicidal self-injury (NSSI) necessitate the identification of profiles of distinct sub-groups of self-injurers. AIM: To identify homogenous sub-groups of NSSI in a community-based sample of emerging adults. METHOD: Data was collected using a cross-sectional survey design from a sample of 1,574 emerging adults aged 18-25 years, via multi-stage sampling. Cluster analysis using the k-medoid partitioning method was used to identify homogenous sub-groups in the sub-sample of 353 self-injurers. Follow-up analysis was conducted on measures of self-criticism, brooding-rumination, emotion regulation difficulties, experiential avoidance, psychological distress, attachment style and perceived social support to explore the validity of the clusters. RESULTS: Five homogenous sub-groups were identified; Multimethod, Exclusively Severe, Female Minor, Male Minor and Experimental NSSI. The sub-groups showed distinct patterns of NSSI behaviour, differing on the basis of gender, severity, frequency, diversification, age of onset and functions of NSSI. The Multimethod and Exclusively severe NSSI group members showed significantly higher psychological distress and emotion regulation difficulties. CONCLUSION: Identification of distinct sub-groups highlights the heterogeneity in NSSI behaviour. This has implications for comprehensive assessment frameworks, early identification of more vulnerable groups of self-injurers, and planning of targeted interventions.

Suicide in the context of COVID-19 diagnosis in India: Insights and implications from online print media reports.

BACKGROUND: Suicide reports during the COVID pandemic is an increasing cause for concern. However, there is a limited understanding of suicide among individuals with positive/suspected COVID diagnosis specifically. Hence, this study, using online newspaper reports, aimed to determine factors influencing suicide among individuals withCOVID-19 infection status. METHODOLOGY: Information regarding positive/suspected COVID related suicide was obtained from online newspapers published in 4 languages between 30th Jan 2020 to 16th August 2020 using google news aggregator. Of 235 online identified, 93 were eligible for analysis after the exclusion and analysed using descriptive statistics. RESULTS: Median Age of COVID related suicide victims was 45 years (range 15 - 80) wherein 61.3% belonged to 30-59 year age group, and 75.3% were males. 50% of suicides occurred within the first week of COVID diagnosis confirmation, and 50% suicides occurred at COVID centres. Hanging (53.8%) was the commonest method of suicide, followed by jumping (12.9%). CONCLUSION: Higher risk for suicide was observed among male gender and those with positive/suspected COVID infection within the first week, while receiving treatment in COVID care centres. Hanging and jumping were the two commonest methods. The above highlight an urgent need to integrate suicide preventive strategies into standard care protocols of COVID-19 positive and suspected cases.

Revisiting lorazepam challenge test: Clinical response with dose variations and utility for catatonia in a psychiatric emergency setting.

OBJECTIVE: Catatonia can be life-threatening unless timely identified and treated. Lorazepam's ubiquitous response has led to its universal acceptance as being the first-line management of catatonia and alludes to catatonia's neurobiological underpinnings. Lorazepam challenge test (LCT) is widely used to either confirm a catatonia diagnosis or determine lorazepam sensitivity. It has a proposed schedule for administering lorazepam. However, efficacy of recommended LCT doses lack systematic evidence, resulting in variable LCT doses used in clinical and research settings contributing to findings that are challenging to generalize or assist with developing standardized lorazepam treatment protocols for catatonia. Given the same, this study aimed to objectively compare the response between two groups receiving different LCT doses and factors influencing the same. METHODS: The 6-month study in a psychiatric emergency setting at a tertiary neuropsychiatric center in India evaluated 57 catatonia patients, before and after administration of single 2 mg (n = 37; LCT-2) or 4 mg (n = 20; LCT-4) lorazepam dose, applying Bush Francis Catatonia Rating Scale (BFCRS), Mini International Neuropsychiatric Interview (MINI 5.0) and obtaining sociodemographic, clinical data. RESULTS: No between-group differences (LCT-2 vs LCT-4) for sociodemographic, clinical profiles or BFCRS severity score changes to lorazepam on Mann-Whitney U test were noted. Applying Wilcoxon signed rank test comparing individual sign severity demonstrated response variability, with significant response noted to both doses (stupor, mutism, staring, posturing, withdrawal, ambitendency, automatic obedience) and others selectively to 2 mg (echolalia, rigidity, negativism, mitgehen). Notably, sign resolution (present/absent) only to 2 mg was significant for stupor, mutism, staring, posturing, echolalia, rigidity, negativism and mitgehen. CONCLUSION: This study suggests 2 mg lorazepam may be an optimal LCT dose, given significant response to most catatonic signs thereby ensuring accurate detection and preventing misinterpretation of response. It offers future studies direction for standardizing lorazepam dosing schedules for catatonia management and exploring neurobiological underpinnings for individual catatonic signs that may be potentially different, given these findings.

'Family centric rehabilitation' for persons with mental illness in India: Conceptual framework using evidence-based case studies'.

PURPOSE OF THE STUDY: In India, people live in a collective society wherein family members are the primary caregivers for the person suffering from mental illness (PMI). Psychiatric rehabilitative models are individual-centric, focusing on individual level skills (emotional, social, self-management and vocational) and development to enhance successful community reintegration. If the entire family is considered to be a unit for rehabilitation, i.e. family centric rehabilitation, the possibility of empowering the family to function effectively is higher despite the illness. The objective of the case study is to conceptualize the framework 'Family centric Rehabilitation'. METHODS: Case study design. RESULTS: Family centric rehabilitation can be conceptualized as 'a process that facilitates families, dysfunctional due to PMI, to reach their optimal level of independent functioning by harnessing resources available within the community'. Family centric rehabilitation focuses on enhancing global functioning of the "family unit", in essence all members, rather than just the PMI. Strategies deployed include concurrently addressing and minimizing anticipated challenges across domains including medical, psychosocial, vocational as well as economic, thereby aiding in recovery of the family unit as a whole. CONCLUSIONS: Family centric rehabilitation is an important culture specific concept that aims to provide optimal level of functioning of all family members and can contribute to the family achieving self-sustenance, a sense of autonomy and empowerment.

Diagnosing catatonia and its dimensions: Cluster analysis and factor solution using the Bush Francis Catatonia Rating Scale (BFCRS).

Advances in research into catatonia in the preceding two decades has offered increasing clarity and an improved understanding of various aspects of this complex syndrome. Despite the above, there are several aspects that hinder a broader interpretation of these findings, the most common being a lack of consensus on the criteria required for diagnosing catatonia. Whilst being the most frequently used tool for diagnosis, the number of signs from Bush-Francis Catatonia Rating Scale (BFCRS) needed to diagnose catatonia remain unclear. This study aimed to determine the number of signs required to accurately diagnose catatonia using BFCRS and delineate its dimensions in an acute inpatient unit in the Indian setting. A random sample of 300 patients were evaluated for catatonia within 24 h of admission. Cluster Analysis followed by discriminant analysis and receiver operating curve analysis (ROC) provided cut-off values for diagnosing catatonia syndrome. Principle Component Analysis (PCA) with varimax rotation was used to identify factors in those with catatonia. Findings revealed that a cut off of two signs from both Bush-Francis Catatonia Screening Instrument or BFCSI (sensitivity of 100 %, specificity of 96.2 % as well as a positive predictive value [PPV] of 79.6 % and negative predictive value [NPV] 100 % with ROC AUC value of 0.98) and complete BFCRS (sensitivity of 100 % and specificity of 90.7 %, PPV of 80.7 and NPV of 100 % with ROC AUC for at least two items cut-off being 0.95) accurately detected catatonia. However, the prevalence of catatonia in the same population increased by 4% from 16.3% to 20.3% using the BFCRS rather than the BFCSI. The BFCRS generated a 3-factor model accounting for 65.48 % variance offering the best fit, indicating three discrete dimensions to catatonia, namely retarded, excited and what we named as "aberrant volitional". Interestingly, the aberrant volitional dimension comprises of signs that need to be elicited rather than passively observed and excluding one, none of them are part of the BFCSI. Findings of this study suggest that the BFCRS more accurately detects catatonia rather than the BFCSI. Additionally, three dimensions of catatonia more coherently explain the catatonic syndrome given that 55.7 % of the sample had signs from more than one factor concurrently. We propose that the BFCRS rather than BFCSI be routinely administered for evaluating all suspected cases of catatonia to ensure more accurate detection as well as identifying the aberrant volitional dimensional signs more consistently. The three-dimensional model also offers great opportunities to further unravel the pathophysiological basis of catatonic signs more systematically.