Personalized Approach in the Management of Difficult-to-Treat and Treatment-Resistant Depression With Second-Generation Antipsychotics: A Delphi Statement.

Background Major depressive disorder (MDD) has many facets including mixed or atypical depression that requires personalized care to improve treatment-related outcomes. Second-generation antipsychotics (SGAs) offer complementary mechanisms for clinical roles in difficult-to-treat depression and treatment-resistant depression cases. Aim/objective To further delineate a consensus on the clinical positioning of SGAs for MDD, mixed, or atypical depression, a Knowledge Attitude Perception (KAP)-mediated Delphi Statement was planned. Material/methods A literature review for the definition, diagnosis, and management of MDD, mixed, and atypical depression as treatment-resistant depression (TRD) or difficult-to-treat depression (DTD) was conducted by a steering committee of academic and clinical experts (n=6) while developing a validated KAP questionnaire. Scientific statements as clinical recommendations were evolved using the Delphi methodology before building a clinical expert consensus with an online survey (n=24). Results Twenty-four psychiatrists highlighted DTD to offer a multidimensional approach to assess treatment strategies involving selective serotonin reuptake inhibitors (SSRIs) or SGAs, while ensuring symptom, functional, and quality of life (QoL) domain improvement for improved outcomes and remission rates. MDD cases with anxiety, anhedonia, comorbidities, and risk traits require personalized care with early induction of SGAs for severe cases or symptom persisters with functional impairment. Early augmentation with SGAs including aripiprazole or cariprazine can provide a favorable risk-benefit profile for clinical cases of MDD with or without the antecedent of mixed depression or personality disorder.  Conclusion The literature review and KAP responses emphasize the importance of early identification for personalized care strategies with SGAs for DTD. Large-scale real-world evidence needs to evolve with due recognition of different phenotypes as TRD or DTD with partial or functional impairment to understand the impact of appropriate treatment pathways with SGAs.

Development and Validation of Yoga Protocol for Patients with Depression.

Background: Scientific evidence suggests that yoga is beneficial for treating mental health disorders. To the best of our knowledge, minimal studies have been done on the development of a yoga module for the specific clinical aspects of depression and there is no particular study on yoga protocol development for mild depression and moderate depression. Purpose: The primary aim of this study is to develop specific yoga protocol modules for treating patients affected with mild and moderate depression. Methods: Yoga protocols for treating mild and moderate depression were developed using classical yoga texts, previous literature, and with the help of yoga experts. 26 practices for mild depression and 35 practices for moderate depression were identified, each of which was scored as (a) not essential, (b) useful but not essential, and (c) essential, and content validity ratio (CVR) determined using Lawshe's formula for the validation. Results: Expert's opinion revealed that 13 out of 28 practices and 12 out of 35 practices showed significant CVR (>0.60) for mild and moderate depression. Conclusions: The yoga practices developed based on experts' opinion is the first step toward the development of a validated protocol for mild and moderate depression. This will be assessed for its effectiveness through a randomized controlled study to confirm the module's efficiency.

Impact of Serotonin Pathway Gene Polymorphisms and Serotonin Levels in Suicidal Behavior.

OBJECTIVE: Suicide is a significant public health issue and a major cause of death in all ages worldwide. Previous studies have shown the involvement of genetics in suicidal behaviour. This study aimed to assess the role of the genetic variants of the serotonin transporter genes (5HTTLPR, SLC6A4 intron 2) and receptor gene (5HTR2AT102C) in individuals who died of suicide. The study compares the serum levels of serotonin between the cases and controls. METHODS: We conducted a case control study with 120 cases and 126 controls. Socio-economic details of the subjects were collected using a semi-structured proforma and psychological autopsy was used to collect details of medical and other clinical conditions. Blood was drawn after taking informed consent and serum levels of serotonin were estimated by ELISA. Genotyping was performed using appropriate primers followed by polymerase chain reaction (PCR) and a restriction fragment length polymorphism (RFLP). RESULTS: Mean age was 32.59 ± 12.58 for cases and 33.64 ± 9.78 for controls. The risk associated LL genotype of 5HTTLPR was higher among cases. The heterozygous 12/10 genotype of SLC6A4 intron 2 polymorphism was increased among controls. Serum levels of serotonin were lower among cases. Variant genotypes of all the 3 polymorphisms showed significant interaction (OR= 39.26) indicating that this model may increase suicidal tendency. CONCLUSION: The findings of this study suggest that low serum levels of serotonin and two variants of the serotonin gene may influence suicide behaviour in a south Indian population.

A study on the venues of suicide.

This study was aimed to assess the venues of suicide and the related factors. One hundred and forty four (M-89. F-55) suicide cases undertaken for autopsy at the department of Forensic Medicine, Madras Medical College formed the study material. 33.71% of males and 3.64% of females had chosen the venues other than their houses. Most of the males suffering from mental illness (80%) had preferred places outside their house for this fatal act. Among the males, 71.74% of those who consumed insecticides and 87.5% who adopted self immolation, did so inside their houses. Comparatively lesser (53.33%) proportion of males resorted to hanging inside their houses.