Association of insight, avoidance behavior, indecisiveness, and inflated responsibility with other clinical characteristics in children and adolescents with obsessive-compulsive disorder

Objectives: Although the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) includes ancillary symptom dimensions - insight, avoidance, degree of indecisiveness, inflated sense of responsibility, pervasive slowness/disturbance of inertia, and pathological doubting -, we know little about their clinical/scientific utility. We examined these ancillary dimensions in childhood obsessive-compulsive disorder (OCD), and tested their associations with clinical characteristics. Methods: Treatment-seeking children and adolescents (n=173) with a DSM-5 OCD diagnosis were recruited from six centers in India and evaluated with a semi-structured proforma for sociodemographic/clinical details, the Structured Clinical Interview for DSM-5, the CY-BOCS, the Children's Depression Rating Scale, and the Family Interview for Genetic Studies. Regression analysis was used to study the associations between ancillary dimensions (independent variables) and clinical variables (dependent variables). Results: 87.9% of the sample reported at least a mild-moderate severity of ancillary dimensions, which were highly intercorrelated. Multiple ancillary dimensions were correlated with illness severity on the CY-BOCS. On regression analysis, only insight and avoidance retained significance. There were few differential associations between OCD symptom and ancillary dimensions. Conclusion: Ancillary dimensions are more a feature of illness severity than differentially associated with individual symptom dimensions in childhood OCD. Insight and avoidance should be considered for inclusion in the assessment of illness severity in childhood OCD.

Functional somatic symptoms in patients with major depressive disorder in a tertiary care hospital

Background: Functional somatic symtpoms are common in patients with major depressive disorder. The aim of the research was to study the prevalence and typology of Functional Somatic Symptoms (FSS) in patients with depression. Methodology: A total of 50 patients participated in the study. They were assessed on Bradford Somatic Symptom inventory for Functional Somatic Symptoms (FSS), Beck Depression Inventory (BDI) for severity of depression, and Comprehensive Psychopathological Rating Scale? anxiety index (CPRS?AI) for anxiety symptoms. Results: The mean age of the study sample was 41.36 years (SD?12.79). Gender distribution was gender distribution (male ? 60% vs. females 40%). Majority of the symptoms were found in married (84%), Hindus (92%), and from nuclear family (58%). A more than half of the patients were from urban background (76%). The mean duration of illness at the time of assessment was 36 months. As per BDI severity score 36% have mild, 38% have moderate and 26% have severe depression. Total mean CPRS-AI is (8.78±4.46).The more common FSS as assessed on Bradford Somatic Inventory were severe headache (88%), feeling tired when not working (86%), lack of energy (weakness) much of the time (84%), pain in legs (82%), aches and pains all over the body (72%), mouth or throat getting dry (72%), head feeling heavy (70%), head feeling hot or burning (68%), pain or tension in neck and shoulder (66%), low back trouble (66%) and sweating a lot (64%). The prevalence and typology of FSS was to a certain extent influenced by the sociodemographic variables and severity of depression. Conclusion: Functional somatic symptoms are highly prevalent in depressed patients and hence deserve more attention while diagnosing depression

Screen Time in Under-five Children

Context:Screen-viewing in childhood is primarily a mean of entertainment, during the unstructured time. We aimed to review the burdenof the problem, delineate the associated factors and correlates, evaluate the impact of screen-time on the overall health of under-fivechildren, and the interventions to reduce screen-time. Evidence acquisition:Published articles from January 2009 to June 2018 weresearched through PubMed, Clinical Key, Scopus, Embase, and Google Scholar using key Medical Subject Heading words. Results: Theburden of screen-time varied from 21% to 98% in the middle-income, and 10% to 93.7% in the high-income countries. The socialecological model was used to illustrate associated factors and correlates including child, caregiver, micro and macro digital-mediaenvironment related factors. The interventions included increase in the physical activity, reduction in the body mass index, improvingsleep and dietary behaviors etc. The effectiveness of these interventions ranged from 0.3 minutes (standard error 13.3) to -47.16minutes (standard error 2.01). Conclusion: Clinicians should obtain history of screen-time in children, and advise limiting the screenexposure according to the child’s age. There is a need to generate evidence on burden and effectiveness of interventions amongchildren in the Indian settings, owing to the limited data.

Prescription pattern of antidepressants in five tertiary care psychiatric centres of India.

Background & objectives: Limited data are available on prescription patterns of the antidepressants from India.We studied antidepressants’ prescription pattern from five geographically distant tertiary psychiatric care centers of the India. Method: In this cross-sectional study, all patients who attended outpatients department or were admitted in the psychiatry wards at Lucknow, Chandigarh, Tiruvalla, Mumbai and Guwahati on a fixed day, who were using or had been prescribed antidepressant medications, were included. The data were collected on a unified research protocol. Results: A total of 312 patients were included. Mean age was 39±14.28 yr and 149 (47.76%) were females, 277 (87.5%) were outpatients. Among the patients receiving antidepressants, 150 (48.1%) were of diagnoses other than depression. Diabetes mellitus 18 (5.78%) was the most common co-morbid medical illness. A total of 194 (62.2%) patients were using selective serotonin reuptake inhibitors (SSRIs) with escitalopram 114 (36.53%) being the most common antidepressant used. Overall, 272 (87.18%) patients were using newer antidepressants. Thirty (9.62%) were prescribed more than one antidepressant; 159 (50.96%) patients were prescribed hypnotic or sedative medications with clonazepam being the most common (n=116; 37.18%). Interpretation & conclusions: About half of the patients with diagnoses other than depression were prescribed antidepressants. SSRIs were the most common group and escitalopram was the most common medication used. Concomitant use of two antidepressants was infrequent. Hypnotic and sedatives were frequently prescribed along with antidepressants.

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.

Internal consistency & validity of Indian Disability Evaluation and Assessment Scale (IDEAS) in patients with schizophrenia.

Background & objectives: The Indian Disability Evaluation and Assessment Scale (IDEAS) has been recommended for assessment and certification of disability by the Government of India (GOI). However, the psychometric properties of IDEAS as adopted by GOI remain understudied. Our aim, thus, was to study the internal consistency and validity of IDEAS in patients with schizophrenia. Methods: A total of 103 consenting patients with residual schizophrenia were assessed for disability, quality of life (QOL) and psychopathology using the IDEAS, WHO QOL-100 and Positive and Negative symptom scale (PANSS) respectively. Internal consistency was calculated using Cronbach’s alpha. For construct validity, relations between IDEAS, and psychopathology and QOL were studied. Results: The inter-item correlations for IDEAS were significant with a Cronbach’s alpha of 0.721. All item scores other than score on communication and understanding; total and global IDEAS scores correlated significantly with the positive, negative and general sub-scales, and total PANSS scores. Communication and understanding was significantly related to negative sub-scale score only. Total and global disability scores correlated negatively with all the domains of WHOQOL-100 (ρ<0.01). The individual IDEAS item scores correlated negatively with various WHOQOL-100 domains (ρ< 0.01). Interpretation & conclusions: This study findings showed that the GOI-modified IDEAS had good internal consistency and construct validity as tested in patients with residual schizophrenia. Similar studies need to be done with other groups of patients.

How can we use rating scales more appropriately?

Use of rating scales is an integral part of psychiatric practice and research. However, training for use of scales appropriately is not available. Due to lack of proper training, especially in the hands of non-mental health professionals, rating scales are used at face value and as a substitute for clinical interview. There is a need to increase the awareness about proper use of rating scales. Additionally appropriate training must be obtained prior to use of rating scales.

Suicidal behaviour in adolescents: what can be done?

Adolescents in India form a major proportion of the population. This age group encounters many stressful events which are more specific to this age group like need to perform in exams, compete for various professional courses, broken love affairs etc. Besides this is the age group for onset of major psychiatric disorders. All these factors make this population very vulnerable to suicidal behaviours. However, there is limited data with regard to suicidal behaviour in this population from India. There is an urgent need to study the various factors associated with suicidal behaviour and how suicidal behaviour can be prevented in this age group.

Challenges and recommendations for conducting epidemiological studies in the field of epilepsy pharmacogenetics.

Epilepsy is one of the most prevalent neurological disorders, afflicting approximately 50 million Indians. Owing to affordability and easy availability, use of first-generation antiepileptic drugs (AEDs) is heavily encouraged for the treatment of epilepsy in resource-limited countries such as India. Although first-generation AEDs are at par with second-generation AEDs in terms of efficacy, adverse drug reactions (ADRs) are quite common with them. This could be attributed to the inferior pharmacokinetic parameters such as nonlinear metabolism, narrow therapeutic index and formation of toxic intermediates. In addition, epilepsy patients may differ in the pharmacokinetic and pharmacodynamic profiles, with about 1/3rd of the population failing to respond to treatment. A proportion of this interindividual variability in response may be explained by genetic heterogeneity in the activity and expression of the network of proteins such as metabolizing enzymes, transporters and targets of AEDs. Over the last two decades, a considerable effort has been made by the scientific community for unraveling this genetic basis of variable response to AEDs. However, there have been inconsistencies in such genetic association studies conducted across different territories of the world. There could be several reasons underlying the poor replicability of these studies, mainly nonuniform phenotypic definitions, poor sample size and interethnic variability. In the present review article, we provide an overview of heterogeneity in study designs for conducting pharmacogenetic studies. In addition, critical recommendations required for overcoming such challenges imposed by pharmacogenetic epidemiological studies have been briefly discussed.

Prevalence & determinants of depression in type 2 diabetes patients in a tertiary care centre.

Background & objectives: Depression is common among people with diabetes and it is associated with poor outcomes. This study was carried out to investigate the prevalence and determinants of depression in patients with established type 2 diabetes (T2DM) attending a tertiary care hospital in north India. Methods: Patients with established T2DM were evaluated for depression by administering the nine-item PHQ-9 (Hindi version). Binary logistic regression model was used to examine association between predictor variables and risk of depression. Results were expressed as odds ratio and 95 per cent confidence interval. Cronbach alpha was calculated to assess internal consistency of PHQ-9. Results: Patients with T2DM (n=300) were evaluated [147(49%) male and 153(51%) female]. The median duration of diabetes (IQ) was 8(4-13) yrs. Of the study patients, 68 (23%) met the criteria for major depression, 54 (18%) for moderate depression and the remaining 178 (59%) had no clinically significant depression. Depression was strongly associated with age >54 yr (OR 1.26, 95% CI 1.02-1.67; P<0.05), central obesity (OR 1.34, 95% CI 1.04-1.64; P<0.001), neuropathy (OR 1.94, 95% CI 1.03-3.66; P=0.002), nephropathy (OR 1.81, 95% CI 1.02-3.21; P=0.041), peripheral vascular disease (OR 6.08, 95% CI 1.07-34.6; P=0.042), diabetic foot disease (OR 2.32, 95% CI 1.06-5.86; P<0.001) and pill burden (>4) (OR 1.27, 95%CI 1.01-1.44; P=0.035 ). However, the likelihood of depression was not significant with duration of diabetes and insulin use. Interpretation & conclusion: This study showed high prevalence of depression in patients with T2DM. The risk factors for depression were age, central obesity, diabetic complications particularly neuropathy and diabetic foot disease and increased pill burden.

Delirium in general practice.

Delirium is a complex neuropsychiatric syndrome characterized by disturbances in consciousness, orientation, memory, thought, perception, and behaviour due to one or more structural and/or physiological abnormalities directly or indirectly affecting the brain. It is quite prevalent in medical and surgical settings and is associated with high rates of death and healthcare costs. We review its prevalence, clinical features, risk factors, pathogenesis, assessment instruments, differential diagnosis, management, prognosis and prevention. Special emphasis is given on the Indian research, which is quite meagre.

Trichotillomania in children.

In this paper, we describe the sociodemographic profile, clinical characteristics and treatment outcome of 20 children with trichotillomania. These children presented to the Child Adolescent Psychiatry Clinic over a period of 6 years, with a prevalence of 1.24% . Most subjects were females (85%), hindu by religion (65%), and belonged to urban nuclear family (70%). The mean age at first presentation was 10.1 yr (SD = 4.4). Comorbid psychiatric illness and family history of psychiatric disorders was present in 40% and 20% cases, respectively. Nearly two-third of these had associated impulse; 75% denied resistance to pluck. Children who continued treatment, showed improvement.

Diagnosis of common mental disorders by using PRIME-MD Patient Health Questionnaire.

BACKGROUND & OBJECTIVE: Primary care physicians in their clinical settings usually fail to diagnose common mental disorders (CMDs). Primary Care Evaluation of Mental Disorders (PRIME-MD) Patient Health Questionnaire (PHQ) has been shown to facilitate diagnosis of most CMDs seen in primary health care. Its utility in Indian setting has not been evaluated. We carried out this study in Indian setting to evaluate the extent of psychiatric morbidity as measured by PRIME-MD PHQ. METHODS: A total of 500 consenting patients attending Medical outpatient department were recruited. All subjects were first assessed by the physician for presence of any physical illness and psychiatric disorder and their socio-demographic data were collected. Subjects were asked to fill the PRIMEMD PHQ. Illiterate subjects were assisted by the research worker in filling up the questionnaire. RESULTS: At initial evaluation physicians opined that 30.4 per cent of the subjects had psychological disorder, the most common diagnostic category was of anxiety disorders (15.8%), followed by depression (6%) and somatoform disorders (5.6%). On PHQ 42 per cent subjects had at least one psychiatric diagnosis. The most common psychiatric diagnosis was panic disorder (18.4%), followed by other anxiety disorders (16.6%). On comparing the diagnosis of physicians and PHQ, out of 152 cases (30.4%) suspected to have any psychological disorder by the physicians in the initial evaluation, 105 were found to have PHQ diagnosis. Of the 348 cases in which physicians did not suspect any psychiatric diagnosis, 243 were also negative in PHQ screening. There was a significant correlation between physicians and PHQ diagnosis. INTERPRETATION & CONCLUSION: There is a high psychiatric morbidity in the general medical practice and in many cases psychiatric morbidity is either missed or is misdiagnosed and by the physicians. Our results showed that PHQ could be a valuable screening instrument for psychiatric morbidity in primary care and general medical practice.

Dependence syndrome and intoxication delirium associated with zolpidem.

The use of zolpidem by general practitioners and specialists alike has increased. Earlier, it was considered safe by physicians, i.e. devoid of dependence potential and the risk of serious adverse events. We report 5 patients seen over a 36-month period at the Post Graduate Institute of Medical Education and Research, which highlight the need for caution in the use of this drug.

Drug dependence in adolescents 1978-2003: a clinical-based observation from North India.

OBJECTIVE: To study the demographic and clinical profile of adolescent subjects (< or =18 yr) presenting to a state-funded drug de-addiction centre in north India. METHODS: Data on demographic and clinical features were extracted from available case notes of adolescent patients who presented to the centre during 1978-2003 (n=85). RESULTS: Many adolescents came from nuclear family (63.5%), of urban background (83.5%) and were school dropouts (54.1%). Mean age-at-first-use of the primary substance was 14.8 yr and mean age at first presentation was 17 yr. The commonest used primary class of substance was opioids (76.2%) and the commonest used opioid was heroin (36.5%). More than half of the subjects (54.2%) were also nicotine dependent at the time of presentation. The most common reason for starting the use of drugs was curiosity (78.8%). About one-fifth (21.2%) of the subjects indulged in high-risk behaviour such as having sexual intercourse with multiple sexual partners. Nearly half of the subjects had positive family history of either drug dependence (40.2%) or psychiatric disorder (5.5%). CONCLUSION: The results suggest that the development of substance dependence in children and adolescents is a combination of familial and social vulnerability factors, including the drug culture of the social milieu.

Psychotropics in pregnancy: weighing the risks.

With increase in the use of newer psychotropics, there is a growing concern in relation to the teratogenicity. Unfortunately, it is not possible to carry out prospective studies in pregnant women and as a result physicians caring for such patients have to rely on case reports, case series, and retrospective studies. Available evidence shows that the safety of psychotropics in pregnancy is still unresolved and the decision to prescribe psychotropics in pregnancy should be taken in the light of severity of mental disease, and drugs should be prescribed only when the potential risk to the foetus from exposure is outweighed by the risk of untreated maternal disorder. In this review we discussed the current evidence of the teratogenic risks with psychotropic drugs commonly used to treat psychiatric disorders and also focused on decision making in such patients.