Efficacy of whole system ayurveda management protocol in major depressive disorder- A randomized controlled clinical trial.

BACKGROUND: Major Depressive Disorder (MDD) is one of the common depressive disorder. MDD has high comorbidity and has greater implications on quality of life. Whole system Ayurveda management protocol (WSAP) is explored for it's possible role in management of MDD. OBJECTIVE: To evaluate the efficacy of Whole system Ayurveda management protocol on Major Depressive Disorder. MATERIAL AND METHODS: Study was a randomized controlled trial. Total 50 patients of MDD meeting the DSM V criteria, age group 20-70 years of either sex participated in the study. They were randomly divided into two groups, control group received Escitalopram 10 mg twice a day and Ayurveda group was on WSAP. Interventions were for 60 days. Assessments were done through various clinical parameters like Hamilton Depression Rating Scale (HDRS), Hamilton Anxiety Rating Scale (HARS), Brief psychiatric rating scale (BPRS), Pittsburgh Sleep Quality Index (PSQI), WHO Quality of Life- BREF (WHOQOL-BREF), Clinical Global Improvement scale (CGI), UKU Side effect scale. Assessments during intervention was on every 15th day. RESULTS: Study showed that Ayurveda group produced significant outcome improvement compared to control group in HDRS (p = 0.01), HARS (p = 0.03), PSQI (p = 0.03), WHOQOL-Bref (p < 0.001) and UKU side effect scale (p = 0.02). Both the group showed improvements in all the parameters except in WHOQOL-Bref where Ayurveda group only showed improvements (p < 0.001). Effect size showed large effect in WHOQOL-Bref. Mild side effects were reported in control group and none in Ayurveda group. CONCLUSION: WSAP was effective in management of MDD and had better side effect profile. Further studies needed.

Efficacy of tDCS on craving in patients of alcohol dependence syndrome: A single-blind, sham-controlled trial.

Background: Craving is attributed as one of the main reasons for relapse in alcohol dependence syndrome. Neurostimulation techniques targeting craving in substance use disorders are being researched. Neuroimaging has shown dorsolateral prefrontal cortex (DLPFC) as one of the potential targets responsible for craving, with frontal dysfunction being quintessential in alcohol use disorder. Evidence suggests that stimulation of DLPFC with low-dose current can help in reducing craving. Objectives: To study the effectiveness of transcranial direct current stimulation (tDCS) on craving in patients with alcohol dependence syndrome. Materials and Methods: We performed a single-blind, sham-controlled study involving 76 patients with alcohol dependence syndrome (according to ICD-10 DCR). Participants with Clinical Institute of Withdrawal Assessment in Alcohol Withdrawal (CIWA-Ar) scores less than 10, not on any anti-craving medications were included in the study. Patients were allocated to active and sham tDCS groups in a ratio of 1:1. Such that 38 patients received active, and 38 patients sham tDCS stimulations; with anode as right DLPFC and cathode as left DLPFC receiving 2 mA current (twice daily session, total of 10 sessions). The Alcohol Craving Questionnaire (ACQ-NOW) was administered to measure the severity of alcohol craving at baseline and after the last tDCS session. Results: Our study showed a significant reduction in craving in the Post-tDCS, ACQ-NOW scores as compared to sham tDCS. There was a significant reduction in the compulsivity and emotionality domain of craving after tDCS. The effect size for treatment with time interaction was (0.58). Conclusions: tDCS was superior to sham in reducing caving in patients with alcohol dependence syndrome.

Capacity to Consent for Treatment in Patients with Psychotic Disorder: A Cross-Sectional Study from North Karnataka.

Background: Recently, the Mental Healthcare Act (MHCA) 2017 was introduced in India. Being a right-based act, it has made the assessment of the capacity to consent an integral part of clinical work. To the best of our knowledge, there are no Indian studies on this topic. Hence, this study aimed to assess the capacity to consent to mental healthcare and treatment in patients with functional psychosis and the factors affecting the same. Methods: This cross-sectional study included participants with the ICD-10 DCR diagnosis of a psychotic disorder admitted in the psychiatry ward of a tertiary health care center in Karnataka, India. MacArthur Competence Assessment Tool for Treatment was used to assess the capacity to consent to treatment. Brief Psychiatric Rating Scale (BPRS) and the Beck Cognitive Insight Scale were applied to assess the severity of psychosis and level of insight, respectively. Results: A hundred participants were recruited. Twenty-four were found to have an intact capacity to consent to treatment. High BPRS scores (P value = 0.0002) and low insight scores (P value = 0.0002) were associated with an impaired capacity. Conclusion: About one-fourth of participants had an intact capacity to consent to treatment. Higher severity of psychosis and a poorer insight into the illness were associated with impaired capacity to consent.

Public-Private Partnership (PPP) Model of Psychiatry Day Care Center in India: Its Challenges and Opportunities-A 2-Year Experience.

Background Most patients admitted in day care center are suffering from schizophrenia who do not recover fully due to nagging negative symptoms and cognitive deficits which linger and persist making the patients unfit and unacceptable for employment. But regular employment can help in recovery. In this way, day care centers would help in recovery of patients and hence the need for these kinds of centers. In India, day care centers are in infancy stage and to a larger extent are inadequately used. There is no data available from psychiatry day care center run as public-private partnership (PPP) project in a tertiary care general hospital psychiatry unit (GHPU). This model is first of its kind in India. Here, we narrate experiences gained in last 2 years. Objectives This article narrates the challenges and opportunities in a psychiatry day care center in PPP model. Materials and Methodology It a cross-sectional study. Description of day care center: Day care center was started as PPP model called Manasadhara model in the state of Karnataka, first of its kind in India. Recruitment Patients currently asymptomatic are recruited into the center after initial interview/assessment of patients and family members from the in-charge psychiatrist after obtaining informed consent. Statistical Analysis Data are analyzed using mean and median mode. A p -value of < 0.05 was considered significant. Appropriate statistical methods were applied. Results Total number of patients recruited in the study were 33 ( n = 33). Mean age of the patients was 34.5 (7.4) years. Majority (51.52%) of patients were in the age group of between 26 and 35 years. Majority (51.52%) of patients' age of onset of illness fell between 21 and 30 years, and 63.64% of patients' duration of illness ranged between 11 and 15 years. Conclusion Running a day care center in PPP model that too in a GHPU set up is difficult. Skills in which patients need to be trained should be decided based on patients' profile and cultural basis of the place. Common problems faced were poor placements, transportation, financial difficulties, and poor funding.

Neurocognitive Profile in Indian Individuals Genetically at Risk of Schizophrenia.

BACKGROUND: Cognitive deficits have been noted in patients of schizophrenia in remission, as well as in first-degree relatives. This study aims to evaluate the neurocognitive performance in unaffected first-degree relatives of patients of schizophrenia in comparison with healthy controls, as well as patients of schizophrenia in remission. METHODS: It was a 1-year case-control study by purposive sampling. Patients with a diagnosis of schizophrenia, first-degree relatives of patients of schizophrenia, and controls from nongenetic relatives of patients were recruited as per inclusion and exclusion criteria. Samples were matched for age and educational status. The General Health Questionnaire 28 (GHQ-28) screened them and they were checked for remission by Positive and Negative Syndrome Scale (PANSS) and then subjected to various instruments for assessment of neurocognition, standardized for the Indian population. To remove the effect of symptoms as confounding factors, PANSS score of <3 for each individual item was set as the criterion for remission. Intelligence quotient (IQ) was screened in all participants to exclude mental retardation. Statistical analysis used was the analysis of variance (ANOVA) with post hoc Fisher's least significant difference (LSD). RESULTS: Significant neurocognitive impairments were detected in the patients and first-degree relatives when compared with the control subjects. The most common impairment in the patient group was in speed of processing, and among unaffected first-degree relatives, it was in the working memory. CONCLUSION: Indian individuals genetically at risk of schizophrenia showed significant neurocognitive impairments in all domains compared with controls.

How do Our Patients Respond to the Concept of Psychiatric Advance Directives? An Exploratory Study From India.

BACKGROUND: Psychiatric advance directives have been incorporated in the Mental Health Care Act 2017 despite strong concerns about their feasibility and utility in the Indian patient population. Data on its utility in India is very scarce. AIMS: To determine the possible treatment options our clients make as a part of psychiatric advance directives. MATERIALS AND METHODS: Fifty consecutive individuals with severe mental illness were interviewed using a self-designed semi-structured tool to find out the possible choices they make as part of advance directives and the factors affecting their choices. RESULTS: About 10% of the participants failed to understand the concept of advance directives. Of those who understood, 89% were willing to make advance directives, 15% refused future hospitalizations, 47% refused future electroconvulsive therapies (ECTs), and 62% refused physical restraints in future. CONCLUSION: The majority of the participants agreed to make advance directives. The majority of those who agreed to make advance directives refused to undergo ECTs and physical restraints in future episodes of illness. Approximately 10% of the patients could not understand the concept of advance directives.

Safe Administration of Electroconvulsive Therapy in Patient with Ventricular Septal Defect Patch: A Rare Case Report.

Electroconvulsive therapy (ECT) is a safe and effective treatment for many psychiatric illnesses. Even in cardiac patients, it is a low-risk procedure as compared to chronic use of the medications with possible side effects. Although rare, cardiovascular events during ECT remain a principal cause of morbidity and mortality. Therefore, administration of ECT in cardiac patients remained questionable. There is no data regarding the safety of ECT administration in patients with repaired ventricular septal defect (VSD), and to the best of our knowledge, this is the first case report of safe administration of ECT in patient with VSD. In this case report, we describe a patient with bipolar affective disorder, with repaired VSD, who was safely and successfully treated with ECT. It is essential that appropriate cardiac management be provided before, during, and after ECT by a multidisciplinary team of psychiatrists, cardiologists, and anesthesiologists. This case report suggests that ECT can be safely given to patients with repaired VSD, wherever there is an absolute indication for ECT.

Psychological Dissection of Patients Having Dissociative Disorder: A Cross-sectional Study.

BACKGROUND: Patients present with dissociative disorders as a decompensation to underlying stressful situation. It is clinically important to evaluate the presence, type, and temporal relation of the stressors resulting in dissociation. Further knowing the sociodemographic and psychological profile of the dissociative patient helps in better management. MATERIALS AND METHODS: The study included 55 dissociative patients aged between 5 to 45 years. Psychiatric diagnosis was made using ICD-10 DCR. Psychosocial stressors and stressful life events were assessed using presumptive stressful life events scale/life events scale for Indian children and clinical interview. Personality and temperament traits were assessed using medico psychological questionnaire and temperament measurement schedule, respectively. Intelligence quotient (IQ) was assessed using standard progressive matrices and colored progressive matrices. Statistical analysis was done using Epi Info 7 software. RESULTS: All patients had significant psychosocial stressors preceding dissociation. Precipitating factor with temporal association was observed in only 83.64%. Family disharmony (41.82%) followed by education-related problems (29.09%) was the most common psychosocial stressors. 61.82% of the dissociative patients had psychiatric comorbidity. Mean IQ of study sample was 92.47. Dissociative children had high emotionality and energy levels but low sociability, rhythmicity, and distractibility. 50% of the adults were neurotic and had emotionally unstable personality. CONCLUSION: Dissociative disorders are commonly seen in females, adolescents, and in those from lower socioeconomic status and rural areas. They are always preceded by psychosocial stressors. Most of them have comorbid psychiatric disorders such as depression and anxiety. Neuroticism and emotionally unstable personality traits are common in adult patients while temperamental traits such as low sociability, low rhythmicity, low distractibility, high emotionality, and high energy levels are common in children.

Expressed emotions in patients with obsessive compulsive disorder: a case control study.

BACKGROUND: Expressed emotion (EE) is the attitude that the relatives show towards the illness and the person. EE is identified as a direct factor in the relapse of patients with psychological disorders. Literature on EE in anxiety disorders is limited. Role of EE in obsessive compulsive disorder (OCD) may help in better understanding of the role of social factors in OCD. AIM: To compare EE in patients with OCD and compare with controls. MATERIALS AND METHODS: The sample included 30 cases and 30 age and sex matched controls. The patients were diagnosed as having OCD using International Classification of Diseases-10 Diagnostic Criteria for Research (ICD-10 DCR) criteria. Yale-Brown Obsessive Compulsive Scale (Y-BOCS) was used to assess severity of OCD among patients. General health questionnaire (GHQ) was used to rule out any psychiatric disorder among control population. EE was assessed in cases and controls using Family Emotional Involvement and Criticism Scale (FEICS). Chi-square test and t-test were used to assess the difference between two groups. RESULTS: OCD patients in comparison controls had significantly increased total FEICS score (P = 0.001). There was an increase in both subscales of perceived criticism (PC) with P = 0.001 and emotional involvement (EI) with P = 0.001 in patients with OCD than controls. CONCLUSION: EE are significantly increased in patients with OCD. EE should be assessed regularly in patients with OCD.

Rubinstein-taybi syndrome with psychosis.

Rubinstein-Taybi syndrome (RTS) is a rare genetic disorder with characteristic physical anomalies. It is characterized by mental retardation, postnatal growth deficiency, microcephaly, specific facial characteristics, broad thumbs, and big toes. Behavioral problems are common with RTS; they include mental retardation, impulsivity, distractibility, instability of mood, stereotypes, poor coordination, atypical depression, and mania. To date, there is lack of literature on the presence of schizophrenia or non-affective psychosis with RTS. Here, we describe two cases where there is co-morbid psychosis with RTS. One case is diagnosed as paranoid schizophrenia and the other as psychosis possibly schizophrenia. Genetic analysis was not done due to unavailability. The possible etiological factors for the association of psychosis with RTS are discussed. Factors such as regulators of RNA polymerase II and hypoxia-inducible factor 1 alpha (HIF1A) may be some common etiological factors for the association of schizophrenia or non-affective psychosis and RTS. Schizophrenia / non-affective psychosis can be a comorbid psychiatric condition with RTS.

Clonazepam in the treatment of essential palatal tremors.

Essential Palatal tremor (EPT) is a rare disorder presenting as unilateral or bilateral rhythmic involuntary movements of the soft palate. There is mention of the utility of benzodiazepines like clonazepam probably because of their gamma amino butyric acid (GABA) agonistic property. But no reports are available for the same. Here we report a 30-year old married female patient who presented with the complaints of pain in the lower part of face, behind the ears, back side of neck and clicking sound in her. General physical examination (GPE) revealed symmetrical rhythmic flapping movements of the soft palate and the uvula. Central nervous system (CNS) examination did not reveal any focal deficits and Magnetic resonance imaging (MRI) of the brain was normal. She was diagnosed as having EPT and treated successfully with clonazepam.

Psychosis in patients with systemic lupus erythematosus.

Neuropsychiatric manifestations in systemic lupus erythematosus (SLE) are common; however, psychosis per se is bit uncommon. They may be cognitive deficit, lupus headache, psychoses, seizures, peripheral neuropathy, and cerebrovascular events. Psychiatric symptoms in SLE can be functionally independent psychiatric disorders. It can be due to drugs (steroids) used for SLE or secondary to SLE because of its brain involvement, which is termed as neuropsychiatric systemic lupus erythematosus (NPSLE). No single clinical, laboratory, neuropsychological, and imaging test can be used to differentiate NPSLE from non-NPSLE patients with similar neuropsychiatric manifestations. Presently we are discussing about three cases of SLE with psychosis and which had different clinical presentation. The present reports also depict the approach to case differential diagnosis and management of the same.

Dilemmas in private psychiatric practice.

BACKGROUND: A practicing psychiatrist faces dilemmas on a number of occasions, in deciding the best course of action he/she needs to undertake while treating a patient. At times, this choice may not be in accordance with the ethical and moral principles and may in fact appear to violate patient's autonomy and rights. AIM: To study the nature of psychiatric practice by the practicing psychiatrist in the areas of admission, discharge, consent, physical restraint, electroconvulsive therapy (ECT), certification, treatment, suicide and psychotherapy. SETTINGS AND DESIGN: Cross-sectional observational study. MATERIALS AND METHODS: Forty-eight psychiatrists gave consent to participate in the study. A special proforma was prepared, which addresses the common dilemmas in the clinical psychiatric practice. All the psychiatrists were given specially designed profoma and were requested to fill the proforma with appropriate answers. Statistical analysis was done using SPSS software. RESULTS: There were 42 male and 6 female psychiatrists. The age of the psychiatrists ranged from 28 to 65 years with a mean of 43.08 years. The mean duration of practice of these psychiatrists was 14.81±11.07 years. Question and answers related to admission, discharge, consent, physical restraint, ECT, certification, treatment, suicide and psychotherapy are discussed. CONCLUSIONS: The present standard and practice especially in private psychiatric set-up does not confirm to the rules, recommendations, and regulations suggested by Mental Health Act 1987, Mental Health Authorities and various guidelines of practice. Indian Psychiatric Society and other professional bodies need to take steps to prepare guidelines for a good psychiatric practice.

A Cross-sectional Descriptive Study of Prevalence and Nature of Psychiatric Referrals from Intensive Care Units in a Multispecialty Hospital.

CONTEXT: The prevalence of psychiatric comorbidity in general hospital range from 20% to 60%. Presence of psychiatric morbidity compounds the disability and suffering in medical patients. There is a limited literature on the prevalence of psychiatric morbidity in patients admitted in the intensive care units (ICUs). AIMS: The aim of the study was to estimate the prevalence and nature of comorbid psychiatric illness in the cases referred from ICUs. SETTINGS AND DESIGN: Cross-sectional observational study. MATERIALS AND METHODS: This study included all the consecutive patients referred from different ICUs to psychiatry department for consultation during the four-year period from January 1, 2000 to December 31, 2003, assessment was done by psychiatrist and diagnosis was made using ICD-10. STATISTICAL ANALYSIS: Descriptive statistics. RESULTS: There were 309 (1.97%) referrals from ICUs to psychiatry department during the period of study. Among the referred patients, diagnosis of organic mental disorders was the commonest psychiatric diagnosis present in 104 (33.65%) patients followed by suicidal attempt in 101 (32.69%); anxiety disorders in 40 (12.94%); depressive disorders in 21 (6.8%); Psychotic illness in 10 (3.24%); other psychiatric illnesses in 28 (9.06%); and nil psychiatric illness in 5 (1.62%) patients. CONCLUSION: Prevalence of psychiatric referrals from ICUs was low. This could be due to stigma and lack of awareness among physicians. There is increased need for recognition and treatment of comorbid psychiatric illness by the treating physicians which may help to decrease morbidity and overall cost of the treatment.

Genital self-mutilation in depression: a case report.

Genital self-mutilation is a rare severe form of self-injurious behaviour usually described in psychotic disorders with delusions & hallucinations. It has been ascribed to sexual conflicts, body image distortion, internalized aggression and suicidal intent. This phenomenon has been described in schizophrenia, affective psychosis, alcohol intoxication and personality disorders. In the present case genital self-mutilation in a case of Major-Depressive Disorder in an 82 yrs old male is being reported and psychosocial factors are discussed. This case has some unusual features.