Does the Etiology, Phenomenology and Motor Subtype of Delirium Differ When It Occurs in Patients With An Underlying Dementia?: A Multi-Site, International Study.

OBJECTIVES: To compare the etiology, phenomenology and motor subtype of delirium in patients with and without an underlying dementia. METHODS: A combined dataset (n = 992) was collated from two databases of older adults (>65 years) from liaison psychiatry and palliative care populations in Ireland and India. Phenomenology and severity of delirium were analysed using the Delirium Symptom Rating Scale Revised (DRS-R98) and contributory etiologies for the delirium groups were ascertained using the Delirium Etiology Checklist (DEC). Delirium motor subtype was documented using the abbreviated version of the Delirium Motor Subtype Scale (DMSS4). RESULTS: Delirium superimposed on dementia (DSD) showed greater impairment in short term memory, long term memory and visuospatial ability than the delirium group but showed significantly less perceptual disturbance, temporal onset and fluctuation. Systemic infection, cerebrovascular and other Central nervous system etiology were associated with DSD while metabolic disturbance, organ insufficiency and intracranial neoplasm were associated with the delirium only group. CONCLUSION: The etiology and phenomenology of delirium differs when it occurs in the patient with an underlying dementia. We discuss the implications in terms of identification and management of this complex condition.

Clinician Reasons for Stopping Clozapine: A Retrospective Cohort Study.

BACKGROUND: Little information is available on clozapine discontinuation rates in developing country settings. AIM: The present study aimed to evaluate the incidence and reasons clinicians stopped clozapinine in patients after initiating treatment with the same. In addition, the study also aimed to assess the rechallenge rate, that is, restarting clozapine after a decision to discontinue the same by the clinicians. METHODOLOGY: The treatment records of 859 patients started on clozapine were reviewed to identify the patients for whom the clinician stopped clozapine at least once because of any reason. The reasons for stopping clozapine were reviewed. In addition, the treatment records were also examined for rechallenge with clozapine at a later date. RESULTS: Clozapine was stopped by the clinicians in 44 of the 859 patients (5.12%). The most common reason for stopping clozapine was blood dyscrasias (n = 12), followed by poor adherence making the hematological monitoring difficult (n = 9), and intolerable sedation (n = 7). In half of the patients (n = 22), clozapine was restarted by the clinicians for further management of schizophrenia. Successful rechallenge was done in 58.33% of patients with blood dyscrasias, 44.44% with poor adherence, and 71.4% with intolerable sedation. CONCLUSIONS: The present study suggests clinicians stop clozapine in only 5.14% of cases. The most common reasons for clozapine discontinuation by clinicians include blood dyscrasias, poor medication adherence making it challenging to monitor the hemogram, and sedation. However, in half of the patient's clozapine was rechallenged, and all the attempts of rechallenging were successful.

Factors Associated With Poor Response to Clozapine in Schizophrenia: A Study From Northern India.

PURPOSE/BACKGROUND: Limited numbers of studies have assessed the predictors of clozapine nonresponse. This study aimed to assess the demographic and clinical factors associated with an inadequate response to clozapine in patients with treatment-resistant schizophrenia (TRS). METHODS/PROCEDURES: Two hundred eighty-seven outpatients with TRS receiving clozapine for more than 1 year were divided into 2 groups based on the need for a second antipsychotic medication and/or electroconvulsive therapy after receiving clozapine in the maximum tolerable dose for at least 3 months. RESULTS/FINDINGS: One hundred two patients (35.4%) were considered to be clozapine nonresponders. Compared with responders, clozapine nonresponders were more often unemployed at the time of starting clozapine (P = 0.04), had a longer duration of untreated psychosis (P = 0.007), had received significantly higher number of adequate antipsychotic trials in the past (P = 0.02), had received antipsychotic polypharmacy in the past (P = 0.01), had experienced adverse effects with first- (P < 0.001) and second-generation antipsychotics (P = 0.01), and had more medical comorbidities (P = 0.03). The nonresponders more frequently had visual hallucinations (P = 0.001), and feelings/acts or impulses attributed to some external source (P = 0.03) in the lifetime, and had a significantly higher Clinical Global Impression severity score at the time of starting of clozapine (P < 0.001). While on clozapine, nonresponders received significantly higher dose of clozapine (P = 0.001) and higher proportion of them experienced constipation (P = 0.04), hypersalivation (P = 0.002), and obsessive-compulsive symptoms (P = 0.05) as adverse effects of clozapine. CONCLUSIONS/IMPLICATIONS: The present study shows that approximately one-third of patients with TRS do not respond to clozapine. However, clozapine nonresponders, although broadly similar in sociodemographic profile to clozapine responders, differ from clozapine responders on past treatment profile.

Cost of the Illness of Treatment-Resistant Schizophrenia: A Mirror Image Study Comparing Clozapine With Other Antipsychotics.

PURPOSE/BACKGROUND: This study aimed to evaluate and compare the cost of illness in patients with treatment-resistant schizophrenia (TRS) during 3 months before starting clozapine and for the initial 3 months of treatment with clozapine. METHODS/PROCEDURES: Fifty-two patients with TRS were evaluated for the cost of illness (direct, indirect, and provider cost) by using a structured questionnaire for the period of 3 months before starting clozapine and then at the end of the 3 months of clozapine therapy. FINDINGS/RESULTS: Total treatment cost for the period of 3 months before starting clozapine was Indian rupees (INR) 40,372 (560.72 US dollars), and the total treatment cost for the first 3 months of clozapine therapy was INR 40,553 (563.23 US dollars). At both the assessments, indirect cost formed the main bulk of the total cost, with no significant difference in the indirect cost. The total direct treatment cost reduced from INR 13,931.6 (193.49 US dollars) to INR 8756 (121.61 US dollars), and the difference between the 2 assessments was statistically significant, with an advantage for clozapine. Overall, after starting clozapine, the total direct cost reduced from 34.5% to 21.6%, and the total indirect cost reduced from 54.3% to 40.2%. After starting clozapine, total provider cost increased from 11.2% to 38.2% of the totalcost. IMPLICATIONS/CONCLUSIONS: Treatment with clozapine is not associated with a significant increase in the overall treatment cost, in the short term. However, there is a significant reduction in direct treatment costs.

Does the Starting of Clozapine Influence Coprescription of Other Medications?: A Study From India.

PURPOSE/BACKGROUND: Little is understood about the prescription load before and after the starting of clozapine. Accordingly, this study aimed to evaluate the medication load of patients receiving clozapine, just before starting clozapine and after being on clozapine for at least 1 year. Additionally, the impact of clozapine on severity of illness was evaluated. METHODS/PROCEDURES: Two hundred seventy-seven outpatients receiving clozapine were prospectively evaluated for their prescription after at least 1 year of starting clozapine. Additionally, these patients were assessed on the Clinical Global Impression-Improvement scale to evaluate the overall clinical benefit with clozapine. FINDINGS/RESULTS: They had been receiving clozapine for 6.55 (SD, 4.8; range, 1-24; median, 5) years at the time of assessment. At the start of clozapine, more than one third of the patients were receiving 2 antipsychotics. A small proportion was receiving other psychotropics, such as antidepressants, mood stabilizers, and benzodiazepines. After being on clozapine for 1 year, there was a significant reduction in the number of patients receiving two antipsychotic medications (P < 0.001), number of patients receiving antidepressants (if amitriptyline was left out), benzodiazepine (P < 0.001), and anticholinergic medications (P < 0.001). Further, there was a reduction in the mean chlorpromazine equivalent of antipsychotics (P < 0.001) and the total number of medications received by the patients (P < 0.001). However, there was an increase in the prescription rates of antihypertensive drugs (P = 0.03), anti-diabetic medications (P < 0.01), and anti-dyslipidemic medications. At follow-up, there was a significant improvement in symptoms as assessed by Clinical Global Impression-Improvement scale. IMPLICATIONS/CONCLUSIONS: This study suggests that long-term use of clozapine is associated with substantial improvement in symptoms with a reduction in the medication load.

A comparative study evaluating insight in different phase of illness among patients with bipolar disorder by using multiple scales.

AIM: This cross-sectional study aimed to evaluate insight and its correlates among patients with bipolar disorder (BD). METHODOLOGY: 180 patients with BD were evaluated on Scale to Assess Unawareness of Mental Disorders (SUMD), Insight scale for affective disorders (ISAD), Mood Disorders Insight Scale (MDIS), and Beck Cognitive Insight Scale (BCIS). RESULTS: About half of the patients were in clinical remission (N = 94; 52.2%), one-fifth (N = 37; 20.55%) were in the phase of mania and one-fourth (N = 49; 27.2%) were in a depression. There was no significant difference in the level of insight between those in clinical remission and those in depression except for one of the domains of BCIS. Patients with mania had poorer insight compared to those in remission and depression. In terms of association of insight as assessed by different scales, in the whole sample and all the three subgroups, SUMD current and past scores had a significant positive correlation with the ISAD total score. In the whole sample, among patients currently in remission and those currently in depression, ISAD total score had significant negative correlation with MDIS total score. Poorer insight as assessed on SUMD (current and past), ISAD and MDIS was associated with poorer medication adherence. CONCLUSION: The present study demonstrates that patients with mania have poor insight when compared to the patients in clinical remission and depression. The present study also demonstrates that the assessment of clinical insight is not affected much by the type of scale used.

Attitude towards and experience with clozapine of patients and their caregivers after three months of starting of clozapine.

AIM: To evaluate the patients' perceptions of clozapine and that of their family caregivers about the positive and negative effects of clozapine. METHODOLOGY: 52 patients and their family caregivers were assessed for their perception of the positive and negative effects of clozapine by using a self-designed questionnaire. RESULTS: About half (53.8%) of the patients were not distressed of frequent blood testing. At least two-thirds of the patients acknowledged a reduction in psychopathology, achieving clinical stability, improvement in the behavior of others towards them, improvement in their behavior towards others, improvement in regularity in medication intake, agreed that their clinical state will worsen if clozapine is stopped, and reported overall satisfaction/happiness with the intake of clozapine. In general, caregivers also reported similar perceptions. In terms of caregiver outcomes, about two-third to three-fourth of the caregivers reported a reduction in caregiving needs, personal caregiver distress and tension, caregiver burden and time spent in caregiving. About half of the caregivers reported a reduction in the cost of treatment, since the starting of clozapine. CONCLUSIONS: To conclude, the present study suggests that a significant proportion of patients receiving clozapine for three months and their relatives report positive perception and experience with the molecule.

Effect of clozapine on psychological outcomes of caregivers of patients with treatment resistant schizophrenia.

BACKGROUND: There is limited information on caregiver outcomes of patients with treatment-resistant schizophrenia (TRS). AIM: This study aimed to evaluate the impact of short-term treatment with clozapine (i.e. 3 months) on caregiver burden, expressed emotions, caregiver abuse, and psychological morbidity among the caregivers in patients with TRS. 52 caregivers of patients with TRS were evaluated on the Family Burden Interview Schedule, Perceived Criticism Measure, Caregiver Abuse Screening Questionnaire, and General Health Questionnaire-12. RESULTS: Maximum caregiver burden was seen in the domain of disruption of routine family activities, and this was followed by the domains of disruption of family leisure, disruption of family interaction, and the effect on mental health on others. At the baseline assessment, three-fourth of the caregivers scored ≥12 on the objective burden. With 3 months of clozapine therapy, there was a significant reduction in the caregiver burden in all the domains of objective burden, subjective burden, and the global objective burden as per the clinician rating, in the expressed emotions as per both patients and the caregivers, caregiver abuse, and psychological morbidity among the caregivers. CONCLUSION: To conclude, this study suggests that caregivers of patients with TRS, experience significantly higher caregiver burden, and a large proportion of them suffer from psychological morbidity and indulge in expressed emotions and abuse of the patient. Treatment with clozapine for 3 months leads to a reduction in the caregiver burden, expressed emotions, caregiver abuse, and psychological morbidity among the caregivers.

Effectiveness of clozapine on quality of life and functioning in patients with treatment-resistant schizophrenia.

BACKGROUND: Although it is well known that treatment with clozapine is associated with improvement in core symptoms of schizophrenia, little information is available about its impact on other outcome variables. Accordingly, this study aimed to evaluate the short term (3 months) effectiveness of clozapine in patients with treatment-resistant schizophrenia (TRS) in terms of quality of life, disability, and level of functioning. METHODS: This naturalistic follow-up study evaluated 52 participants at the baseline and three months (±1 week) after initiation of clozapine (prospective assessment) on Positive and Negative Syndrome Scale for schizophrenia, Calgary Depression Scale for Schizophrenia, Yale-Brown Obsessive-Compulsive Scale Checklist and Scale, Clinical Global Impression (CGI) scale, Beck Cognitive Insight Scale (BCIS), Scale to Assess Unawareness of Mental Disorders (SUMD), Social Occupational Functioning Scale - SOFS, Functioning Assessment Short Test (FAST), Indian Disability Evaluation and Assessment Scale (IDEAS), World Health Organisation Quality Of Life-BREF (WHOQOL-BREF) and Self-report Quality of Life Measure for people with schizophrenia. RESULTS: Treatment with clozapine led to significant improvement in the quality of life, functioning, and disability; reduction in psychopathology (positive, negative, general psychology, depression), the severity of illness, compulsive behavior, and improvement in insight including cognitive insight. CONCLUSIONS: Treatment with clozapine leads to improvement in core symptoms of schizophrenia and is also associated with significant improvement in the quality of life, functioning, and disability.

Comparative study of effectiveness of augmentation with ECT in clozapine resistant schizophrenia (CRS) and non-clozapine resistant schizophrenia (Non-CRS).

BACKGROUND: There is limited evidence for different treatment strategies in patients with clozapine resistant schizophrenia (CRS). AIM: To determine the effectiveness of ECT in patients with clozapine resistant schizophrenia and compare the same with a group of patients with non-clozapine resistant schizophrenia, receiving ECT. RESULTS: Out of a total of 68 patients with schizophrenia, 27 (38.66%) of patients had CRS. With 6 ECTs, there was a significant reduction in PANSS positive, negative, general psychopathology, prosocial score and depression symptoms in the CRS (p < 0.001) and Non-CRS group (p < 0.001), but no statistically significant difference was seen between the 2 groups in terms of proportion of patients showing >40% response on PANSS total score. The reduction in PANSS score of >40% in CRS group was seen in 48.1% of patients in the positive symptoms subscale, in 25.9% of patients in negative symptoms subscale, in 46.7% of cases in the general psychopathology subscale, in 44.4% of the patients in Depression subscale, in 29.6% of the patients in the modified prosocialsubscaleand in 29.6% of the patients in total PANSS score. CONCLUSION: ECT is an effective augmentation strategy for patients with CRS and it is as effective as when used in patients with non-CRS.

Attitudes to Medication-Treatment Among Patients and Caregivers: A Longitudinal Comparison of Bipolar Disorder and Schizophrenia From India.

BACKGROUND: Attitudes toward medication treatment are thought to significantly influence adherence in bipolar disorder (BD) and schizophrenia. However, the actual impact of patients' treatment attitudes on adherence and determinants of attitudes is still uncertain. METHODS: A longitudinal examination of treatment attitudes and their correlates was conducted among patients with BD and their caregivers compared with those with schizophrenia. Structured assessments of symptom severity, functioning, insight, medication side effects, knowledge of illness, medication adherence, treatment attitudes, and treatment satisfaction were performed among 176 selected patients (106 with BD and 70 with schizophrenia) and their caregivers. Participants were reassessed on these parameters at 3 and 6 months. RESULTS: Rates of nonadherence at baseline varied widely between self-reports, clinician ratings, and serum levels. Though symptoms and functioning improved with treatment, overall rates of nonadherence increased in the first 3 months because of early dropouts and remained stable thereafter. However, treatment attitudes and treatment satisfaction remained largely unchanged among patients and caregivers. Both positive and negative attitudes were commonly held and patients' attitudes did not differ between BD and schizophrenia. Patients' attitudes were significantly associated with adherence, insight, knowledge about illness, treatment satisfaction, symptom severity, social disadvantage, and side effects together with caregivers' knowledge, attitudes, and satisfaction. Caregivers of patients with schizophrenia were more knowledgeable and had more positive attitudes than patients. CONCLUSIONS: Patients' attitudes to medication treatment are associated with adherence over time. They are relatively enduring and mainly associated with insight, knowledge of illness, and treatment satisfaction among patients and their caregivers. These findings could inform psychosocial interventions aiming to improve treatment attitudes and adherence in BD and schizophrenia.

Safety of Use of Clozapine in Patients With Schizophrenia With Comorbid Diabetes Mellitus.

PURPOSE/BACKGROUND: To evaluate the outcome of diabetes mellitus among patients of schizophrenia who had diabetes mellitus before starting clozapine. METHODS: Clozapine data were screened to detect the patients who had diabetes mellitus before starting clozapine. Those who had diabetes mellitus before starting clozapine were taken up for the study. RESULTS: Of the 468 records screened, 28 patients (5.6%) had diabetes mellitus before starting clozapine. Among the 28 patients, 15 (53.6%) were females, and 13 (46.4%) were male. In three-fourths (75%) of the patients, clozapine was started while these patients were admitted to the inpatient unit. Twenty-six patients had type 2 diabetes mellitus and 2 patients had type 1 diabetes mellitus at the time of starting clozapine. Most patients also had deranged blood glucose levels at the time of starting clozapine and required close monitoring of blood glucose levels and also starting/continuation of antidiabetic medications. None of the patients developed diabetic ketoacidosis during the initial part of the treatment. At the mean follow-up duration of 16 months, most patients were on regular follow-up for more than 1 year, and their blood glucose levels were maintained close to the reference range. Majority of these patients showed good response to clozapine. CONCLUSIONS: The present study suggests that presence of diabetes mellitus should not stop the clinicians to use clozapine among patients with schizophrenia. However, close monitoring of blood glucose levels must be done.

Caregiver distress in schizophrenia and mood disorders: the role of illness-related stressors and caregiver-related factors.

BACKGROUND: Studies using the stress-appraisal-coping model to examine caregiving in schizophrenia and mood disorders are limited. AIM: This study attempted to examine psychological distress among caregivers of persons with schizophrenia and mood disorders using the framework of the stress-coping theory. The impact of illness-related stressors and caregiver-related factors on caregiver-distress was also explored. METHODS: In this cross-sectional study, 176 of the 238 selected outpatients with remitted schizophrenia, bipolar and recurrent depressive disorders identified over a 1-year period underwent standardized assessments of psychopathology and functioning. Assessments of burden, appraisal, coping, social support, neuroticism, familial-cultural variables and psychological distress (as an index of caregiving-outcome) were also carried out among family-caregivers of these persons. RESULTS: High levels of caregiver-burden and caregiver-distress and a mix of positive and negative appraisal, adaptive and maladaptive coping, and high and low levels of perceived support among caregivers characterized the caregiving experience. Univariate analyses revealed that both illness-related stressors (symptom-severity, level of functioning, objective burden) and caregiver-related factors (subjective burden, appraisal, coping, perceived support, family-cohesion, neuroticism, time spent in caregiving) influenced caregiver-distress. However, multivariate analyses demonstrated that caregiver-related factors such neuroticism, perceived support, time spent in caregiving, subjective burden and negative appraisal had a much greater influence on caregiver-distress than illness-related stressors. CONCLUSIONS: Although interactions between illness-related stressors and caregiver attributes appear to determine caregiver-distress, subjective perceptions and other attributes of caregivers may have a greater impact on distress. Therefore, interventions to reduce caregiver-distress should place equal, if not more emphasis on caregiver-related factors which influence distress.

Psychosocial aspects of colour vision deficiency: Implications for a career in medicine.

Colour vision deficiency (CVD) is a common problem and persons with CVD experience difficulties in daily life, early learning and development, education, choice of careers and work performance. Medical professionals with CVD also report difficulties in everyday tasks, training in medicine and performance of medical duties. However, because of limited evidence, the real impact of CVD on the lives of medical professionals is unclear, especially regarding the practice of medicine by doctors. The nature and severity of CVD, awareness of its impact, personal circumstances and the ability to cope with the deficiency are the major factors that determine the impact of CVD. However, there is a paucity of methodologically sound research on social and psychological aspects of CVD. Currently, early detection, enhancing awareness and offering support are the only proven ways of helping medical professionals with CVD. With the growing emphasis on equality and inclusivity of those with deficiencies, it is desirable to strike a balance between concerns about patient care and the rights of medical professionals with CVD to pursue their careers. Therefore, any future research also needs to focus on psychological aspects of CVD while exploring its impact on a career in medicine.

Telepsychiatry clinical decision support system used by non-psychiatrists in remote areas: Validity & reliabilityof diagnostic module.

BACKGROUND & OBJECTIVES: A knowledge-based, logically-linked online telepsychiatric decision support system for diagnosis and treatment of mental disorders was developed and validated. We evaluated diagnostic accuracy and reliability of the application at remote sites when used by non-psychiatrists who underwent a brief training in its use through video-conferencing. METHODS: The study was conducted at a nodal telepsychiatry centre, and three geographically remote peripheral centres. The diagnostic tool of application had a screening followed by detailed criteria-wise diagnostic modules for 18 psychiatric disorders. A total of 100 consecutive consenting adult outpatients attending remote telepsychiatry centres were included. To assess inter-rater reliability, patients were interviewed face to face by non-specialists at remote sites using the application (active interviewer) and simultaneously on online application via video-conferencing by a passive assessor at nodal centre. Another interviewer at the nodal centre rated the patient using Mini-International Neuropsychiatric Interview (MINI) for diagnostic validation. RESULTS: Screening sub-module had high sensitivity (80-100%), low positive predictive values (PPV) (0.10-0.71) but high negative predictive value (NPV) (0.97-1) for most disorders. For the diagnostic sub-modules, Cohen's kappa was >0.4 for all disorders, with kappa of 0.7-1.0 for most disorders. PPV and NPV were high for most disorders. Inter-rater agreement analysis revealed kappa >0.6 for all disorders. INTERPRETATION & CONCLUSIONS: Diagnostic tool showed acceptable to good validity and reliability when used by non-specialists at remote sites. Our findings show that diagnostic tool of the telepsychiatry application has potential to empower non-psychiatrist doctors and paramedics to diagnose psychiatric disorders accurately and reliably in remote sites.

Lifestyle related factors & impact of metabolic syndrome on quality of life, level of functioning & self-esteem in patients with bipolar disorder & schizophrenia.

BACKGROUND & OBJECTIVES: Though studies have reported high prevalence rates of metabolic syndrome among patients with bipolar disorder (BPAD) and schizophrenia, there is lack of data on the impact of the same on the patients' life. This study was aimed to assess the lifestyle related factors associated with metabolic syndrome (MetS) and to study the impact of MetS on functioning and quality of life (QOL) in patients with BPAD and schizophrenia. METHODS: A total of 102 patients with BPAD and 72 patients with schizophrenia attending the output unit of a tertiary care hospital in north India were evaluated for MetS. These patients were assessed on Health Promoting Lifestyle Profile scale II (HPLP II), World Health Organization QOL -Bref Version (WHOQOL-Bref), Impact of Weight on Quality of Life- Lite version (IWOQOL -Lite), Body weight, Image and Self-esteem Evaluation questionnaire (BWISE), Obesity-related Problem scale (OP scale) and Global Assessment of Functioning (GAF) scale. RESULTS: MetS was associated with lower scores on domains of health responsibility and nutrition habit domain on HPLP-II scale in both groups, and additionally on physical activity and stress management domain in BPAD group. On WHOQOL-Bref, MetS was associated with lower scores on the domains of physical and psychological health in both groups. On IWQOL-Lite, scores on personal distress and self esteem domains were higher in those with obesity in both groups and also on physical activity domain in schizophrenia group. Those with MetS had lower level of functioning as measured by GAF in schizophrenia group. Fulfillment of higher number of criteria of MetS correlated with poorer quality of life and higher problems in both groups. INTERPRETATION & CONCLUSIONS: Many modifiable lifestyle factors increase the risk of MetS. MetS was found to be associated with poorer QOL in patients with BPAD and schizophrenia; in addition, obesity led to poor self-esteem and excessive personal distress.

Symptom profile of alcohol withdrawal delirium: factor analysis of Delirium Rating Scale-Revised-98 version.

BACKGROUND: The symptom profile of alcohol withdrawal delirium (AWD), relative to deliriums of other etiology, remains uncertain. OBJECTIVE: To evaluate the factor structure of symptoms in patients with AWD, as assessed by the Delirium Rating Scale-Revised-98 (DRS-R-98). METHOD: A total of 112 patients aged 18 years or more with AWD were assessed on DRS-R-98. RESULTS: The mean age of participants was 44.2 years. About two-third of the patients developed delirium within 24 hours of the last intake of alcohol and the mean duration of delirium at the time of assessment was 3.9 days. In 46% of cases the delirium was attributed solely to alcohol withdrawal; in the remaining subjects alcohol withdrawal was a major contributory factor. Three separate principal component analysis (whole sample, pure AWD and AWD with associated etiologies) were carried out. In all the factor analyses, one of the factors included cognitive symptoms (attention, orientation and visuospatial disturbances) along with or without short- and long-term memory impairment; the second factor included motoric symptoms along with sleep-wake cycle disturbances; the third factor included psychotic symptoms. For the whole group and subgroup of AWD with associated etiologies, items of higher level thinking (i.e. language disturbances and thought process abnormality) loaded along with cognitive symptoms. In pure AWD group, these items along with memory disturbances loaded with psychotic symptoms. CONCLUSIONS: Results of the current factor analyses suggest that the factor structure of pure AWD is different from AWD with associated etiologies. Hence, attention to the symptom profile of patients with AWD may provide clues to delirium etiology.

Influence of religion and supernatural beliefs on clinical manifestation and treatment practices in patients with bipolar disorder.

BACKGROUND: Religious and supernatural beliefs influence help seeking and treatment practices in bipolar disorder, but these are rarely explored by clinicians. This study aimed to understand religiousness, magico-religious beliefs, prevalence of religious and supernatural psychopathology and treatment practices among patients with bipolar disorder in euthymic state. METHODOLOGY: A total of 185 patients of bipolar disorder currently in remission were assessed cross-sectionally for their clinical profile, current clinical status on the Hamilton Depression Rating Sscale (HDRS), Young Mania Rating Scale (YMRS) and the Global Assessment of Functioning (GAF). A semi structured instrument for magico-religious beliefs, aetiological models, treatment seeking and treatment practices was administered. RESULTS: More than a third of patients (37.8%) had psychopathology with either religious or supernatural content or both in their lifetime. Almost half (45.4%) the patients believed in a supernatural/religious aetiology for their illness. Among the specific causes, planetary influences (13.5%) and God's will (30.8%) were the most common supernatural and religious cause, respectively. Almost half (44.3%) of patients had first treatment contact with religious/supernatural treatment providers. More than 90% of patients reported belief in God, yet about 70% reported that their doctors did not ask them sufficient questions to understand their religiosity. CONCLUSION: Magico-religious beliefs are common in bipolar disorder and a large number of patients attribute these as aetiological factors for their illness. Consequently they tend to seek treatment from traditional practitioners prior to approaching medical practitioners and may continue treatment with them alongside medical management.

A comparative study of caregivers' perceptions of health-care needs and burden of patients with bipolar affective disorder and schizophrenia.

BACKGROUND: Although many studies in schizophrenia have evaluated health-care needs, there is a lack of data on the needs of patients with bipolar affective disorder (BPAD), with only occasional studies evaluating them, and no study has evaluated the relationship of health-care needs of patients with caregiver's burden. AIM: To study the relationship of caregiver's burden and needs of patients as perceived by caregivers of patients with BPAD and schizophrenia. METHOD: Caregivers of patients with BPAD and schizophrenia were assessed using the Camberwell Assessment of Needs - Research version (CAN-R) and Supplementary Needs Assessment Scale (SNAS), the Family Burden Interview schedule (FBI) and the Involvement Evaluation Questionnaire (IEQ). RESULTS: Mean total needs of patients on CAN-R were 7.54 (SD 3.59) and 7.58 (SD 4.24) for BPAD and schizophrenia respectively. Mean total needs for SNAS were 7.24 (SD 3.67) and 7.68 (SD 5.02) for BPAD and schizophrenia groups, respectively. Total objective and subjective burden as assessed on FBI was significantly more for the schizophrenia group. Caregivers of patients with BPAD perceived significantly less disruption of routine family activities and lower impact on the mental health of others. On IEQ, the mean score on the domain of supervision was significantly higher for the BPAD group. In the schizophrenia group, positive correlations were seen between the total number of unmet and total (met and unmet) needs and certain aspects of burden, but no such correlations emerged in the BPAD group. CONCLUSION: There is no correlation between number of needs and burden in the BPAD group; however, in the schizophrenia group the number of needs correlated with the perceived burden. Accordingly, orienting services to address needs of patients with schizophrenia can lead to reduction in burden among caregivers.