Contributing risk factors of common psychiatric disorders in the Pakistani population.

With an increasing incidence of psychiatric disorders worldwide, there is a need for a better understanding of the population-specific contributing risk factors that are associated with common psychiatric conditions. This study aimed to assess the correlation between socioeconomic, environmental and clinical features associated with major depression (MDD n = 479), bipolar disorder (BD n = 222) and schizophrenia (SHZ n = 146), in the Pakistani population. Multinomial logistic regression and Pearson's correlation were applied to assess the association and correlation between demographic, socioeconomic, environmental, and clinical features of MDD, BD and SHZ. In the present study, MDD was found to be more prevalent than BD and SHZ. The average age at onset (AAO), was observed to be earlier in females with BD and SHZ, in addition, females with a positive family history of MDD, BD and SHZ also had an earlier AAO. The fitted multinomial logistic regression model indicated a significant association of; aggression, tobacco use, drugs abuse, history of head injuries and family history with BD as compared to MDD, while insomnia and suicidality were significantly associated with MDD. Strong positive correlations were observed mainly between age/AAO, AAO/tobacco use and aggression/insomnia in all three cohorts. In conclusion, the present study identifies possible contributing socio-demographic, biological and environmental factors that are correlated and associated with the psychiatric conditions in the Pakistani population.

Association of dopamine ß-hydroxylase polymorphism rs1611115 and serum levels with psychiatric disorders in Pakistani population.

AIM: Dopamine ß-hydroxylase (DBH) is a copper-containing enzyme that has an important role in maintaining the cellular homeostasis between the two neurotransmitters, dopamine (DA) and nor-adrenaline (NA). DBH functional polymorphisms are associated with multiple neuro-psychiatric conditions and are found to alter the DBH protein levels in serum affecting DBH enzymatic activity. The current study was conducted to determine the genetic and serum levels association of DBH rs1611115 functional polymorphism with major depressive disorder (MDD), bipolar disorder (BD) and schizophrenia (SHZ) in the Pakistani population. METHODS: In total n = 1097 subjects including MDD (n = 427), BD (n = 204), SHZ (n = 134) and healthy controls (n = 332), were screened for the functional polymorphism by polymerase chain reaction-restriction fragment length polymorphism. Univariate logistic regression analysis was applied and the results were adjusted for age and sex. The DBH levels in serum were determined through enzyme-linked immunosorbent assay (ELISA) and the Mann Whitney U test was applied. RESULTS: The minor allele (-1021 C > T) was found to be significantly associated with a higher risk of developing BD and SHZ in both univariable and multivariable analyses. The overall total serum concentration of DBH was comparatively raised in MDD, however, in cross-comparison DBH serum levels were found markedly higher in CC homozygotes compared to TT homozygotes within the BD group. CONCLUSION: The present study suggested a significant association of DBH rs1611115 with BD and SHZ and also the effect of rs1611115 on DBH serum levels in MDD and BD for the first time in the Pakistani population.

Comparison of effectiveness between Haloperidol and Quetiapine in acute manic episode.

This study was conducted to compare the response rate of Quetiapine and Haloperidol in patients with acute manic episodes. A total of 120 patients with acute episode of mania with baseline Young Mania Rating Scale (YMRS) of more than 20 were included and randomly allocated to either Quetiapine (Group A) or Haloperidol (Group B). Each patient was assessed at baseline. YMRS was administered at the start and at follow-up visit after six weeks. Comparison of response rate (>50% reduction in YMRS) was not statistically significant between the two groups (70% vs. 71.7%; p=0.410) after six weeks in acute manic episode. Quetiapine and Haloperidol emerged as equally effective pharmacological strategies for the treatment of bipolar mania. Quetiapine may be used as an alternative to conventional antipsychotics; Haloperidol can be used as replacement of Quetiapine as well, as it is of low cost.

Dialectal Behavioural Therapy: Is it an Answer to Difficult Questions Posed on Mental Health Professionals by Gen Z?

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Transcranial Magnetic Stimulation: Is it an Answer to Difficult Questions Posed to Psychiatrists and Neurologists in Pakistan?

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Difference in Patterns of Psychiatric Emergencies in Different Cultures: Do Psychiatric Residents Need More Than Written in Books?

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Using Pensieve: Guiding and Evaluating a Learning Session on Reflections.

The objectives of this study were to guide students on reflective essay writing, evaluate their understanding and explore the immediate impact of a well-designed session on learning of students. A 1.5-hour learning session was designed following Gagne's nine events of instruction and conducted on final year MBBS students to guide them on reflective practice and its significance. The session was evaluated by a self-designed, structured questionnaire given as a pre-test and post-test. Of 158 students, self-scoring of reflective essay, by hand raising method, revealed that nearly 60% students were critical reflectors, 30% were reflectors and 10% were non-reflectors. Five out of nine questions showed a significant effect (p <0.001) in two-tailed t-test. This learning session led to a significant improvement in understanding of students regarding role of reflective practice in modifying their future behaviour, and its role in making them a better professional. Key Words: Learning, Reflections, Satisfaction, Feedback, Written, Educational assessment, Medical students.

Rise in Child and Adolescent Emergency Psychiatric Presentations: Is it an Evolving Challenge for Mental Health Professionals?

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Audit of Documentation of Forensic History on Admission Form in a Psychiatric Intensive Care Unit.

OBJECTIVE: To study the documentation of relevant components of forensic history on admission form for male patients admitted in psychiatric intensive care unit (PICU)/OAK ward of Phoenix Care Center. STUDY DESIGN: Clinical audit. PLACE AND DURATION OF STUDY: Psychiatric intensive care unit/OAK ward of Phoenix Care Center, from August 2019 to July 2020. METHODOLOGY: Charts of all patients admitted in PICU from August 2019 to July 2020 were analysed, and admission forms were reviewed for documentation of relevant parameters of forensic history. A structured tool was made after literature search, which included drug and alcohol history, history of assaults, protection/barring orders, number of previous PICU admissions, previous charges, pending charges, use of depot medications and previous encounters with police without pending charges. RESULTS: A total of 50 patients were admitted during the given time period. Drug and alcohol history was documented in 98% of the cases, previous charges were documented in 88% of the cases, protection/baring order was documented in 62% of the cases, while previous encounter with the police without being charged was documented in only 32% of the cases. CONCLUSION: Drugs and alcohol and previous charges were documented in most of the cases, but documentation of protection/baring order and encounter with the police without being charged was a neglected area, which should be worked upon in future. Key Words: Admission form, Forensic history, Medical audit.

Filicide In Depressive Psychosis: Case Report Of An Emotionally Unstable Woman Slaughtering Her Two Children.

Filicide is the murder of a child by the parent. It is associated with various psychiatric and nonpsychiatric conditions. We herein present a case report of a filicide by an emotionally unstable mother suffering from depressive psychosis. A thirty years old woman previously treated for depression with psychotic features, having undergone electro-convulsive therapy and on oral medication three years ago was brought by the police for psychiatric assessment. She had slaughtered her two sons of 4 and 7 years of age three days ago without any guilt or remorse. She had low mood, irritability, crying spells, hopelessness and loss of sleep, appetite and sexual desires for the past six months along with the delusions of poverty and infidelity for the past two months. She was a chain smoker. Multiple deliberate self-harm and suicidal attempts were reported in the past two months. She had disturbed family life and multiple conflicts with the husband. Psychometrics revealed BDI score of 32, BPRS score of 39 and PCL-R score of 28. She was diagnosed as a case of depressive psychosis with emotionally unstable personality traits leading to impaired judgment and poor comprehension of the consequences of her actions. This case report highlights the importance of accurately and timely diagnosing and managing a mental health disorder in order to avoid the harm towards self and others.

Comparison Of Effectiveness Of Antipsychotics In Schizophrenia: Second-Generation Versus The Irstgeneration.

BACKGROUND: The choice of the antipsychotic medication is based upon the risks, benefits and the cost. There has been still a debate that which group of antipsychotics is overall better amongst the two so we planned this study with the objective to compare the efficacy of the 1st & 2nd generation antipsychotics for the treatment of schizophrenia. METHODS: This RCT was conducted at in/out patient department of Psychiatry at a tertiary care hospital of Pakistan over the time period of six months. All the patients of schizophrenia between 18-50 years of age of either gender and all the socioeconomic groups were included in the study. Each patient was assessed with the Simpson-Angus Scale (SAS) for the EPS and the Positive and Negative Syndrome Scale (PANSS) for the schizophrenia at the baseline, 6 weeks and 12 weeks after starting the designated medication. RESULTS: The mean age of the 350 patients included in the study was 34.25±16.74 years. One hundred and forty-eight (42.3%) patients were female and 202 (57.7%) were male. The overall response of 1st Generation & 2nd Generation antipsychotics was 51 (140) 36% and 135 (210) 64% respectively (p-value=0.00024). Sixty-three (45%) patients who were taking 1st Generation Antipsychotics had relapse of the disease as compared to the 29 (13.7%) patients who were taking the 2nd Generation antipsychotics. Dryness of mouth, sedation and EPS were the common side effects with the 1st generation antipsychotics while dryness of mouth, cardiac arrhythmias, and sexual dysfunction were the common side effects with the 2nd generation antipsychotics. CONCLUSIONS: This study concluded that the 2nd generation antipsychotics were superior to the 1st generation antipsychotics among the patients of schizophrenia in terms of the success rate, relapse rate and the tolerability.

Erotomania in Depressive Psychosis: Mood Incongruent Delusion in a Depressive Young Woman.

Erotomania is a delusional phenomenon in which patient believes that some celebrity is in love with her. It is associated with various psychiatric illnesses. We herein present a report of a young woman with erotomanic delusion diagnosed with recurrent depression, current episode being severe with psychotic features. A 22-year woman, previously treated for a depressive episode three years ago, was brought by the mother for evaluation. The woman presented with symptoms of depression for the past six months along with the delusion that famous singer SY is in love with her for the past two months. This has resulted in a gross decline in social and academic functioning. Psychometrics revealed Beck's depression inventory (BDI) score of 36 and brief psychiatric rating scale (BPRS) score of 41. A diagnosis of recurrent depression with current severe episode with psychotic features, was made at our psychiatric facility. This case report highlights that psychotic depression can present with a rare mood incongruent delusion of erotomanic content and accurate diagnosis and management require adequate knowledge about this phenomenon.

Relationship between the Quality of Sleep and Psychiatric Morbidity among the Patients of Head and Neck Tumours.

OBJECTIVE: To assess the difference between mean sleep (PSQI) scores in the patients with head and neck tumours with and without the psychiatric morbidity; and assess the associated socio-demographic factors. STUDY DESIGN: Descriptive cross-sectional study. PLACE AND DURATION OF STUDY: Pakistan Institute of Medical Sciences (PIMS), Islamabad, from May to November 2017. METHODOLOGY: One hundred and seventy patients suffering from the tumours of head and neck region were analysed in this study, which were treated in the E.N.T Department. Pittsburgh Sleep Quality Index (PSQI) was used to record the sleep quality of the study participants. General Health Questionnaire 12 (GHQ-12) was used to look for the presence of psychiatric morbidity among these patients. Mean sleep scores were compared in the patients with and without the presence of psychiatric morbidity. Relationship of the socio-demographic factors was also studied with the presence of poor sleep quality among the study participants. RESULTS: A total of 170 patients filled the PSQI; out of them, 58 (34.1%) had scores lying within the range of normal sleep quality while 112 (65.9%) had insufficient quality of sleep. One hundred and eight (63.5%) patients had significant psychiatric morbidity; whereas, 62 (36.5%) had no psychiatric morbidity on GHQ-12. Mean PSQI score in patients without psychiatric morbidity was (6.2 ±3.2) while in the patients with psychiatric morbidity was 9.4 ±4.6 (p <0.001). CONCLUSION: Patients suffering from head and neck tumours showed high frequency of both poor sleep quality and psychiatric morbidity. Patients with presence of psychiatric morbidity or who had undergone surgical resection of tumour should be routinely screened for the sleep problems.

Prevalence of Suicide Ideation and its Relationship with Depression among Transgender Population.

OBJECTIVE: To record the prevalence of suicidal ideation in the transgender population and assess the relationship of depression with the suicidal ideation. STUDY DESIGN: Cross-sectional study. METHODOLOGY: The study group comprised of 156 transgender people of Rawalpindi and Islamabad. Suicidal ideation was assessed by the scale for suicide ideation (SSI). Hamilton rating scale for depression (HAM-D) was used to look for the presence and severity of depression among the target population. Relationship of the age, smoking, family income, illicit substance use, and depression was studied with the presence of suicidal intent among these transgender population of twin cities. RESULTS: One hundred and fifty-six transgender people were included in this study. Mean age of the study participants was 39.26 ±4.28 years. Out of them, 89 (57.1%) had no suicidal ideations, while 67 (42.9%) had suicidal ideation. Fifty-seven (36.5%) did not showed depression, while 99 (63.5%) had depression on HAM-D. With binary logistic regression, depression and illicit substance were found to be significantly related to the presence of suicidal ideations in the target population (p <0.05). CONCLUSION: A high prevalence of suicidal ideation among the transgender population of twin cities was found in this study. Depression, illicit substance use, and other mental health illnesses should be screened routinely on this high risk population for early recognition and treatment.

Relationship Of Suicide Attempt With Depression And Other Socio-Demographic Factors Among The Transgenders.

BACKGROUND: This study was conducted assess the frequency of suicide attempt among the transgender population and analyse the relationship of depression and other socio-demographic factors with the suicide attempt Cross-sectional study. METHODS: The sample population comprised of one hundred and forty-eight transgender people of Rawalpindi and Islamabad. Suicidal attempt was assessed by the simple question that "Have you ever performed an action with the intent to take your own life in your life time?" Answer of yes or no was recorded. Hamilton rating scale for Depression (HAM-D) was used to look for the presence of depression among the target population. Relationship of the age, smoking, family income, illicit substance use and depression was studied with the presence of suicidal attempt among these transgender population of twin cities of Pakistan. RESULTS: A total of 148 transgender people were included in the final analysis. Mean age of the study participants was 38.24±3.18. Out of these, 70.9% had no suicidal attempt in their whole life while 29.1% had one or more suicidal attempts during the course of their life. Twelve had more than one suicidal attempt while 19 had attempt in last one year. Fifty-five did not showed depression while 93 had depression on HAM-D. With binary logistic regression we found that presence of depression and low income had significant association with the presence of suicidal attempt among the target population. CONCLUSIONS: This study showed a high prevalence of suicidal attempts among the transgender population of twin cities of Pakistan. Routine screening for mental health problems should be performed on this high-risk group and adequate employment resources should be generated in order to enable them to earn their livelihood and prevent them from making attempts to take their own life.

Anti-NMDA Receptor Encephalitis in a Young Girl with Altered Behaviour and Abnormal Movements.

Autoimmune encephalitis is a rare central nervous system disorder in which the patient presents with neuropsychiatric symptoms. We herein present a case of anti-NMDA receptor encephalitis in which the patient initially presented in the psychiatric department. A 14-year girl was brought with complains of irritability, altered behaviour, abnormal movements, self biting, and decreased sleep for the past 10 days. Her condition deteriorated during the admission and she became mute, immobile, and drowsy. Her baseline investigations and CT scan brain were normal. CPK was high and the CSF showed pleocytosis. Autoimmune encephalitis profile showed presence of antibodies against the NMDA receptors. Improvement in the symptoms was noted after treatment with steroids and plasmapharesis. This case report highlights the importance of multidisciplinary approach involving the neurologist, psychiatrist, and immunologist in accurately diagnosing and managing a rare neurological disorder presenting mainly with psychiatric symptoms.

Bipolar Affective Disorder in a Patient of Profound Deafness.

Profound deafness is a lifelong impairment, leading to the physical disability as well as poor psychological adjustment. We herein present a mental health disorder rarely seen among the patients of profound deafness. A 16-year deaf and dumb girl, previously treated for depression, presented with unusual laughter, irritability, flight of ideas, decreased sleep, ideas of self importance, and decreased social functioning and educational performance. These problems were understood by the parents via sign language, who interpreted them to the interviewer. Her Young Mania Rating Scale (YMRS) score was 19 and Brief Psychiatric Rating Scale (BPRS) score was 52. She was diagnosed as a case of bipolar affective disorder (BPAD). Marked improvement in the symptoms and social and educational performance was noted after two weeks of the treatment with sodium valproate, resperidone and clonazepam. Treatment options were explained to the patient with risks and benefits, and she was involved in the decision-making. This case report highlights the importance of accurately diagnosing and managing a rare mental health disorder among the physically handicapped people, especially those who cannot communicate effectively and explain their unusual subjective experiences.

Assessment of Quality of Sleep and its Relationship with Psychiatric Morbidity and Socio-Demographic Factors in the Patients of Chronic Renal Disease Undergoing Hemodialysis.

OBJECTIVE: To assess the subjective sleep quality and its relationship with the presence of psychiatric morbidity in the patients suffering from chronic kidney disease (CKD) and undergoing the procedure of hemodialysis (HD); and analyze the associated socio-demographic factors. STUDY DESIGN: Cross-sectional descriptive study. PLACE AND DURATION OF STUDY: Nephrology Department, Military Hospital, Rawalpindi, from July to December 2016. METHODOLOGY: Patients of CKD undergoing the HD were included in the final analysis. Quality of sleep was determined by using the Pittsburgh Sleep Quality Index (PSQI). Psychiatric morbidity was determined by the General Health Questionnaire 12 (GHQ-12). Relationship of education, BMI, gender, age, duration of dialysis, dialysis count per week, marital status, level of family income, psychiatric morbidity, occupation, biochemical markers (urea, creatinine, BUN, albumin, calcium, phosphorous and hemoglobin), tobacco smoking, and use of naswar was determined with the sleep quality. RESULTS: One hundred and forty patients were screened through the PSQI; 44 (31.4%) had good quality of sleep while 96 (68.6%) had poor sleep quality. Statistical analysis revealed that presence of psychiatric morbidity, increasing age, female gender, being unmarried, low family income, and low frequency of dialysis had significant association with the poor sleep quality. CONCLUSION: Poor sleep quality was highly prevalent among the patients of CKD receiving the hemodialysis. The patients with low family income, more age, and with two or less dialysis sessions per week should be screened thoroughly for the sleep problems. Presence of psychiatric morbidity emerged as an independent factor responsible for the poor sleep quality in our target population.

Association Of Quality Of Sleep With Cognitive Decline Among The Patients Of Chronic Kidney Disease Undergoing Haemodialysis.

BACKGROUND: This study was conducted to determine the association between the subjective quality of sleep and cognitive decline among the patients of chronic kidney disease (CKD) undergoing haemodialysis. METHODS: In this cross-sectional study 106 patients of chronic kidney disease (CKD) undergoing haemodialysis at a tertiary care hospital in Rawalpindi, Pakistan were included in the final analysis. Cognitive decline was measured by British Columbia Cognitive Complaints Inventory (BC-CCI). Sleep quality was measured by using the Pittsburgh Sleep Quality Index (PSQI). Relationship of age, gender, marital status, education, occupation, BMI, duration of dialysis, dialysis count per week, family income, tobacco smoking and use of naswar was assessed with the cognitive decline.. RESULTS: Out of 106 patients screened through BC-CCI and PSQI, 13.1% had no cognitive decline while 86.9% had significant cognitive decline. Relationship between quality of sleep and cognitive decline was significant on binary logistic regression.. CONCLUSIONS: This study showed significant relationship between the sleep quality and cognitive decline among the patients of CKD undergoing haemodialysis. The findings of our study also call for a greater degree of understanding of the physical and psychological state of patients of CKD undergoing haemodialysis.