Elevated mirror neuron system activity in bipolar mania: Evidence from a transcranial magnetic stimulation study.

OBJECTIVES: The role of the "mirror neuron system" (MNS) in the pathophysiology of mood disorders is not well studied. Given its posited role in the often-impaired socio-emotional processes like intention detection, empathy, and imitation, we compared putative MNS-activity in patients with bipolar mania and healthy comparison subjects. We also examined the association between putative MNS-activity and hyper-imitative behaviors in patients. METHODS: We studied 39 medication-free individuals diagnosed with mania and 45 healthy comparison subjects. TMS-evoked motor cortical reactivity was measured via single- and paired-pulse stimuli (assessing SICI-short and LICI-long interval intracortical inhibition) while subjects viewed a static image and goal-directed actions. Manic symptom severity and imitative behaviors were quantified using the Young's Mania Rating Scale and a modification of the Echolalia Questionnaire. RESULTS: Two-way repeated measures analysis of variance demonstrated a significant group ×time interaction effect indicating greater facilitation of cortical reactivity during action-observation (putative MNS-activity) in the patient group as compared to the healthy group. While LICI-mediated MNS-activity had a significant association with manic symptom severity (r = 0.35, P = 0.038), SICI-mediated MNS-activity was significantly associated with incidental echolalia scores in a subgroup of 17 patients with incidental echolalia (r = 0.75, P < 0.001). CONCLUSIONS: Our findings demonstrate that putative MNS-activity is heightened in mania, possibly because of disinhibition, and associated with behavioral consequences (incidental echolalia).

Cortical inhibition in symptomatic and remitted mania compared to healthy subjects: A cross-sectional study.

OBJECTIVES: Transcranial magnetic stimulation (TMS)-derived cortical reactivity studies provide a unique opportunity to non-invasively study gamma amino butyric acid (GABA)-mediated inhibitory neurotransmission in bipolar disorder (BD). Earlier studies were conducted in smaller samples and on patients who were on medications that can potentially confound the results. We aimed to study short-interval (SICI) and long-interval intracortical inhibition (LICI) in medication-naïve/free symptomatic (manic) BD patients (n=39), first episode mania (FEM) patients who had recently (≤6 months) remitted with treatment (remitted FEM; n = 28) and healthy subjects (HSs; n = 45). METHODS: Resting motor threshold (RMT), stimulation intensity to elicit a 1-mV motor evoked potential (MEP) (SI1 mV ), SICI and LICI were measured in three groups using single- and paired-pulse TMS. RESULTS: Motor thresholds were higher in the manic BD and HS groups compared to the remitted FEM group (P < .001). SICI was lower (P = .026) but LICI was higher (P = .044) in the manic BD and remitted FEM groups compared to the HS group. CONCLUSIONS: Lower motor thresholds in remitted FEM perhaps reflect the effect of treatment, and could be studied as potential prognostic neuromarkers. Inverse findings for SICI (reduced) and LICI (increased) in BD indicate a possible differential involvement of the GABAA and GABAB subreceptor systems. These could be trait markers as they are impaired in both mania and euthymia.

Cognitive deconstruction of parenting in schizophrenia: the role of theory of mind.

OBJECTIVE: Schizophrenia patients experience impairments across various functional roles. Emotional unresponsiveness and an inability to foster intimacy and display affection may lead to impairments in parenting. A comprehensive cognitive understanding of parenting abilities in schizophrenia has the potential to guide newer treatment strategies. As part of a larger study on functional ability in schizophrenia patients, we attempted a cognitive deconstruction of their parenting ability. METHODS: Sixty-nine of the 170 patients who participated in a study on social cognition in remitted schizophrenia were parents (mean age of their children: 11.8 ± 6.2 years). They underwent comprehensive assessments for neurocognition, social cognition (theory of mind, emotion processing, social perception and attributional bias), motivation and insight. A rater blind to their cognitive status assessed their social functioning using the Groningen Social Disabilities Schedule. We examined the association of their functional ability (active involvement and affective relationship) in the parental role with their cognitive performance as well as with their level of insight and motivation. RESULTS: Deficits in first- and second-order theory of mind (t = 2.57, p = 0.01; t = 3.2, p = 0.002, respectively), speed of processing (t = 2.37, p = 0.02), cognitive flexibility (t = 2.26, p = 0.02) and motivation (t = 2.64, p = 0.01) had significant association with parental role dysfunction. On logistic regression, second-order theory of mind emerged as a specific predictor of parental role, even after controlling for overall functioning scores sans parental role. CONCLUSIONS: Second-order theory of mind deficits are specifically associated with parental role dysfunction of patients with schizophrenia. Novel treatment strategies targeting theory of mind may improve parenting abilities in individuals with schizophrenia.

Investigational applications of transcranial magnetic stimulation (TMS) in Mood Disorders: Studies from a tertiary care center in India.

The investigational potential of TMS in psychiatry is largely underutilized. In the current article, we present the results of five studies with similar TMS protocols that looked at the investigative applications of TMS via measuring cortical reactivity as potential biomarkers in mood disorders. The first two studies, evaluate potential of TMS parameters and Motor neuron system (MNS) as state or trait markers of BD. Third and fourth studies evaluate these as endophenotypic markers of BD. The fifth study which is an RCT evaluating add-on yoga in UD, evaluates if markers of CI can index the therapeutic response of yoga. In study one MT1 was significantly greater in the SM (symptomatic-mania) group compared to HC (healthy-control) (P=0.032). The cortical inhibition measures SICI was reduced in SM(P=0.021) and BD (remitted Bipolar) (P=0.023) groups compared to HC. LICI was increased in the SM(0.021) and BD(P=0.06) groups compared to HC. In study two, a significant group x time interaction effect was observed indicating higher putative MNS-activity mediation in patients compared to HC on SlCl(P=0.024), LlCl(P=0.033). There were no significant group differences noted in the endophenotype studies. The fifth study showed a significant time X group interaction for CSP, favoring improvement in YG (yoga-group) (p<0.01).No significant change was observed for LICI(p=0.2), SICI(p=0.5). Limitations of these studies notwithstanding, we conclude that cortical reactivity measured using TMS is a potential biomarker across the course of mood disorders, starting from state and trait markers to understanding the therapeutic mechanism of a particular treatment modality in these disorders.

Empathic Accuracy Task: Indian Adaptation and Validation.

Background: The Empathic Accuracy Task (EAT) is an objective measure to assess empathic accuracy. Due to the variability in the number and linked emotions of the narrated events, we adapted EAT for the Indian sociocultural setting as Indian EAT (I-EAT). Methods: Eight videos were adapted in three languages (English, Hindi, and Kannada), narrating emotional events with a uniform representation of age groups, different emotions, and sex. The adapted I-EAT was then validated by cross-sectional comparison with different tests similar to EAT and those that assessed concepts different from or similar to empathy, in 29 healthy young adults, 23 healthy older adults (aged ≥60 years) along with clinical groups of 15 young people with depression, 15 older people with depression, and 15 young people with schizophrenia. Results: We selected eight videos with good content validity and internal consistency (Cronbach's alpha = 0.73. We obtained satisfactory concurrent validity of the EAT scores with the self-reported empathic assessments using the Questionnaire of Cognitive and Affective Empathy (Cognitive empathy score = 0.29, p = .034; Total score = 0.29, p = .035) and Interpersonal Reactivity Index (Empathic concern score = 0.45, p = .001). Good divergent validity was revealed in the high inverse correlation recorded with the Apathy Evaluation Scale ( = -0.67, p < .001). I-EAT did not correlate significantly with measures of social cognition. Known-groups validity was adequate in young adults with the significantly lower EAT scores (Cohen's d: 0.77 to 1.15) in the Schizophrenia group and higher EAT-N scores (Cohen's d: 0.51) in the Depression group, compared to the Healthy group. The Healthy group of the geriatric population also achieved significantly higher EAT scores (Cohen's d: 0.71 to 0.85) than the Depression group. Conclusion: With a good validity and internal consistency, I-EAT can be used in the Indian population to assess empathic accuracy without compromising performance of the original EAT.

Obsessive belief and emotional appraisal correlates of symptom dimensions and impairment in obsessive-compulsive disorder.

BACKGROUND: Obsessive-compulsive disorder (OCD) is a heterogeneous and debilitating illness. Symptom dimensions of OCD lend homogeneous avenues for research. Variations in one's appraisal of thoughts and emotions can influence symptom dimensions and impairment. However, little is known about the combined influence of these appraisals in OCD. A clear understanding of these relationships has putative treatment implications. AIM: The aim of the study is to examine the associations among obsessive beliefs, emotional appraisals, and OCD symptom dimensions in adults. MATERIALS AND METHODS: We examined 50 drug-naïve/drug-free adults with active OCD. Symptom dimensions and impairment were assessed using the Dimensional Yale-Brown Obsessive-Compulsive Severity Scale. Obsessive beliefs and emotional appraisals were studied using the Obsessive Beliefs Questionnaire-44 and Perception of Threat from Emotion Questionnaire. RESULTS: Tobit regression analysis showed the differential association of obsessive beliefs and symptom dimensions - perfectionism/certainty associated with contamination and responsibility/threat estimation associated with aggressive obsessions. Impairment was associated with dimensional symptom severities and with the perception of threat from anger. This association remained even after controlling for depression severity and obsessive beliefs. CONCLUSIONS: OCD symptom dimensions are heterogeneous in underlying obsessive beliefs. Emotional appraisals contribute significantly to impairment alongside symptom severity. Emotion-focused interventions must be included in the psychotherapeutic interventions for OCD.

Yoga therapy for social cognition in schizophrenia: An experimental medicine-based randomized controlled trial.

Negative symptoms and cognitive deficits are difficult-to-treat symptoms of schizophrenia. In this single blind randomized controlled study, we compared change in social cognitive performance in persons with Schizophrenia (PWS) (as per DSM-5), after 6 weeks of yoga intervention with a waitlist control group. We also examined changes in putative Mirror Neuron System (MNS) activity measured by Transcranial Magnetic Stimulation (TMS) in a subset of sample (n = 30). 51 PWS stabilized on antipsychotic medication for at least 6 weeks, were assigned to add-on yoga therapy (YT) (n = 26) or waitlist (WL) (n = 25). Subjects in the YT group received add-on yoga therapy (20 sessions in 6 weeks). Both the groups continued their standard treatment and were assessed at baseline and after 6 weeks for social cognition, clinical symptoms and social disability. RM-ANOVA showed significant interaction between time and group for social cognition composite score (SCCS) (F = 42.09 [1,44], P < 0.001); negative symptoms (SANS) (F = 74.91 [1,45], P < 0.001); positive symptoms (SAPS) (F = 16.05 [1,45], P < 0.001) and social disability (GSDS) (F = 29.91 [1,46], P < 0.001). MNS activity had increased after 6 weeks in both groups but not of statistical significance. This study demonstrates that 6 weeks of add-on yoga therapy could improve social cognition in PWS compared to waitlist control subjects. However, the change in social cognition was not associated with a change in the putative MNS-activity. It necessiatates further studies to investigate the mechanistic processes of yoga and replicate these observations in a larger sample.

Association between emotional and behavioral problems and perceived parenting in attention deficit hyperactivity disorder: An exploratory study.

BACKGROUND: Parent-child relationship difficulties are seen in families of children and adolescents diagnosed with attention deficit hyperactivity disorder (ADHD), and they may contribute to long-term negative outcomes. AIM: Our aim was to examine perceived parenting and its correlation with emotional and behavioral problems in children and adolescents with a diagnosis of ADHD. MATERIALS AND METHODS: This was a cross-sectional study involving 38 children and adolescents, between 8 and 16 years of age, diagnosed to have ADHD. Parents rated the children and adolescents on the Strengths and Difficulties Questionnaire (SDQ), whereas children/adolescents rated parents on the Alabama Parenting Questionnaire (APQ). RESULTS: The study population primarily consisted of males (86.8%), between 8 and 12 years (68%), and belonged to urban families (82%). Warm, attentive, and engaged parenting behaviors which were subsumed under the domain of parental involvement in the APQ were associated with fewer total problem behaviors as well as specifically lower conduct and peer problems on the SDQ. Similarly, parents who used positive disciplining strategies as per the APQ had fewer total behavioral problems as well as specifically lower emotional problems on the SDQ. Children with comorbid oppositional defiant disorder reported lesser mean scores in all domains of parenting and significantly in the domains of parental involvement and positive parenting as per the APQ. CONCLUSIONS: Parental involvement and positive parenting were significantly associated with fewer emotional and behavioral problems in children and adolescents diagnosed with ADHD. This has direct implications for clinical practice. Further studies are needed to adapt parenting strategies to the Indian context.

"Kundalini-like experience as psychopathology: A case series and brief review".

Kundalini concept comes from ancient yogic philosophy in which it is believed that certain spiritual practices will cause Kundalini awakening. The phenomenon of Kundalini awakening can sometimes mimic mental illness and results in difficulty for mental health practitioners to distinguish between them. While there are ample literatures suggesting the benefits of yogic practices in mental illness, it is also worth understanding the side effects of these practices, especially if advanced yogic practices are not performed properly with necessary preparations and precautions under the guidance of an expert. In this context, we discuss a series of cases demonstrating altered mental experiences related to Kundalini, from both modern psycho-pathology and traditional yoga view points and try to differentiate severe mental illness from advanced spiritual states perceived after practicing Kundalini yoga.

Cross cultural and global uses of a digital mental health app: results of focus groups with clinicians, patients and family members in India and the United States.

BACKGROUND: Despite significant advancements in healthcare technology, digital health solutions - especially those for serious mental illnesses - continue to fall short of their potential across both clinical practice and efficacy. The utility and impact of medicine, including digital medicine, hinges on relationships, trust, and engagement, particularly in the field of mental health. This paper details results from Phase 1 of a two-part study that seeks to engage people with schizophrenia, their family members, and clinicians in co-designing a digital mental health platform for use across different cultures and contexts in the United States and India. METHODS: Each site interviewed a mix of clinicians, patients, and their family members in focus groups (n = 20) of two to six participants. Open-ended questions and discussions inquired about their own smartphone use and, after a demonstration of the mindLAMP platform, specific feedback on the app's utility, design, and functionality. RESULTS: Our results based on thematic analysis indicate three common themes: increased use and interest in technology during coronavirus disease 2019 (COVID-19), concerns over how data are used and shared, and a desire for concurrent human interaction to support app engagement. CONCLUSION: People with schizophrenia, their family members, and clinicians are open to integrating technology into treatment to better understand their condition and help inform treatment. However, app engagement is dependent on technology that is complementary - not substitutive - of therapeutic care from a clinician.

Antidepressant effects of ketamine and ECT: A pilot comparison.

BACKGROUND: To compare the antidepressant effects and cognitive adverse effects of intravenous ketamine infusion and Electro-convulsive therapy (ECT) in persons with severe depressive episodes. METHODS: This assessor-blinded randomized control trial included 25 patients (either sex; 18-65 years) meeting ICD-10 criteria for severe depression (bipolar or unipolar). Patients received either ECT (n = 13) or intravenous infusions of ketamine hydrochloride (0.5 mg/kg over 45 min; n = 12) for six alternate day sessions over a period of two weeks. Severity of depression was assessed at baseline and on every alternate day of intervention using the Hamilton Depression Rating Scale (HDRS) and self-reported Beck Depression Inventory (BDI). RESULTS: Baseline socio-demographic and clinical variables including HDRS (ECT: 25.15±6.58; Ketamine: 23.33±4.05, p = 0.418) and BDI (ECT: 37.07±6.58; Ketamine: 33.33±9.29; p = 0.254) were comparable. Repeated-measures analysis of variance revealed that ECT patients showed significantly greater reduction in HDRS (group*time interaction effect; F = 4.79; p<0.001) and BDI scores (group*time interaction effect; F = 3.83; p<0.01). ECT patients had higher response rate than ketamine patients [HDRS: ECT- 13/13(100%) vs ketamine- 8/12 (66.70%); p = 0.04]. This was true for remission as well [ECT- 12/13(92.30%) vs ketamine- 6/12(50%), p = 0.030; both HDRS and BDI]. Performance on Digit Symbol Substitution Test (as part of the Battery for ECT-Related Cognitive Deficits scale) significantly improved in ketamine patients (p = 0.02) while that in ECT patients worsened non significantly (p = 0.30). LIMITATIONS: Relatively small sample size; higher proportion of dropouts in the Ketamine arm. CONCLUSION: This study favoured ECT over ketamine for a better efficacy over six treatment sessions in severe depression. The results need to be replicated in larger studies. TRIAL REGISTRATION: CTRI/2019/09/021184.

Network neurobiology of electroconvulsive therapy in patients with depression.

Graph theory, a popular analytic tool for resting state fMRI (rsfMRI) has provided important insights in the neurobiology of depression. We aimed to analyze the changes in the network measures of segregation and integration associated with the administration of ECT in patients with depression and to correlate with both clinical response and cognitive deficits. Changes in normalised clustering coefficient (γ), path length (λ) and small-world (σ) index were explored in 17 patients with depressive episode before 1st and after 6th brief-pulse bifrontal ECT (BFECT) sessions. Significant brain regions were then correlated with differences in clinical and cognitive scales. There was significantly increased γ and σ despite significant increase in λ in several brain regions after ECT in patients with depression. The brain areas revealing significant differences in γ before and after ECT were medial left superior frontal gyrus, left paracentral lobule, right pallidum and left inferior frontal operculum; correlating with changes in verbal fluency, HAM-D scores and delayed verbal memory (last two regions) respectively. BFECT reorganized the brain network topology in patients with depression and made it more segregated and less integrated; these correlated with clinical improvement and associated cognitive deficits.

Asian Indians in America: The influence of values and culture on mental health.

Asian Indians represent a significant portion of the largest growing race of Asians in the past decade in the United States. This selective review examines major cultural themes related to first- and second-generation Asian Indians living in the United States as they impact psychological and psychiatric dysfunction in this population. Specifically, we review the impact of Asian Indian culture on mental health, discuss the impact of acculturation and ethnic identity development on the mental health of Indian-Americans, and focus on typical mental health problems of Asian Indian adolescents, women and elderly in America. Finally, we provide a brief overview of empirically-supported treatment approaches and cultural considerations for additional treatments relevant to this population. This review is intended to provide an important foundation for more systematic empirically-driven investigation into better understanding how Asian Indian cultural themes impact mental health for Indian-Americans, and how to develop effective treatments for these issues in this cultural group.

Schizophrenia patients experience substantial social cognition deficits across multiple domains in remission.

Knowledge about SC (social cognition) during remission would inform us whether such deficits are trait- or state-markers of the disorder, as well as highlight its relevance for rehabilitation. We aimed to compare SC deficits and their relative independence from NC (neuro-cognition) deficits in remitted schizophrenia patients and matched health controls using comprehensive, culturally sensitive standardized tools. 60 schizophrenia patients meeting modified standardized criteria for remission and 60 age, gender and education matched healthy controls were compared on culturally validated tests of SC-Social Cognition Rating Tool in Indian Setting (SOCRATIS) & Tool for Recognition of Emotions in Neuropsychiatric Disorders (TRENDS) to assess theory of mind, attributional bias, social perception and emotion recognition and NC-(attention/vigilance, speed of processing, visual and verbal learning, working memory and executive functions). Patients had deficits in both SC and NC compared to healthy controls. Deficits in SC were largely independent of NC performance, and SC deficits persisted after adjusting for deficits in NC function. The effect sizes (Cohen's d) for SC deficits ranged from 0.37 to 2.23. All patients scored below a defined cut-off in at least one SC domain. SC deficits are likely to be state-independent in schizophrenia, as they are present in remission phase of the illness. This supports their status as a possible composite-endophenotype in schizophrenia.

Validation of Social Cognition Rating Tools in Indian Setting (SOCRATIS): A new test-battery to assess social cognition.

Social cognition is a cognitive domain that is under substantial cultural influence. There are no culturally appropriate standardized tools in India to comprehensively test social cognition. This study describes validation of tools for three social cognition constructs: theory of mind, social perception and attributional bias. Theory of mind tests included adaptations of, (a) two first order tasks [Sally-Anne and Smarties task], (b) two second order tasks [Ice cream van and Missing cookies story], (c) two metaphor-irony tasks and (d) the faux pas recognition test. Internal, Personal, and Situational Attributions Questionnaire (IPSAQ) and Social Cue Recognition Test were adapted to assess attributional bias and social perception, respectively. These tests were first modified to suit the Indian cultural context without changing the constructs to be tested. A panel of experts then rated the tests on likert scales as to (1) whether the modified tasks tested the same construct as in the original and (2) whether they were culturally appropriate. The modified tests were then administered to groups of actively symptomatic and remitted schizophrenia patients as well as healthy comparison subjects. All tests of the Social Cognition Rating Tools in Indian Setting had good content validity and known groups validity. In addition, the social cure recognition test in Indian setting had good internal consistency and concurrent validity.