Pattern of Psychiatric Emergencies in Children and Adolescents at a Tertiary Care Centre After Onset of COVID-19 Pandemic

Objective: To assess changes in profile of psychiatric emergencies in children and adolescents (aged <19 year) during the coronavirus disease 2019 (COVID-19) pandemic compared to pre-pandemic period. Methods: The psychiatric emergency records were analyzed for the period of April, 2019 – September, 2021 to assess the pattern and profile of mental health emergencies in children and adolescents in the period before and after the onset of the pandemic lockdown (i.e., 23 March, 2020). Results: 379 consecutive child and adolescent psychiatric emergencies were identified, of which 219 were seen after the onset of pandemic. Commonest reason for referral in the pandemic group was attempted self-harm (44.3%). The ICD-10 neurotic, stress-related and somatoform disorders constituted the commonest diagnostic category, similar to pre-pandemic period. A significantly higher proportion (44% vs 28%) of children was prescribed benzodiazepines in the pandemic period, compared to the pre-pandemic period. Conclusion: The average monthly psychiatric emergencies in children and adolescents showed no increase during the pandemic period. Self-harm was the commonest cause of psychiatric referral in emergency services mental health crisis in the younger population.

Substance use and its associated factors among school students

Background. There is lack of comprehensive data on substance use and associated factors among school students in Delhi, India. Methods. We used a cluster sampling method based on sections of classes in schools to conduct this study in two government-run schools in Delhi. All enrolled students from 8th, 9th and 11th grades participated (n = 405). The WHO Student Drug Use questionnaire was administered in a single session for a class section for assessing substance use. Results. The participation rate was 90.6%. The rates of past 12 months’ use of tobacco, alcohol, cannabis and inhalants were 22%, 12.1%, 12.1% and 8.6%, respectively, while rates for ‘sedatives and tranquillizers’ were 4.9%, opium 2.7% and other opioids 1.2%. Lifetime use of heroin was reported by two students and use in the past 12 months by one student. Multiple substance use was high. Higher age was associated with the use of alcohol and cannabis. According to logistic regression model results, use by a family member significantly increased the probability of using tobacco (adjusted odds ratio [AOR] 11.3; 95% confidence interval (CI) 3.4–37.8) and alcohol (AOR 3.75; 95% CI 5.1–1059.3). Similarly, use by peers significantly increased the probability of tobacco (AOR 7.7; 95% CI 2.0–29.8) and cannabis use (AOR 5.7; 95% CI 1.5–21.5). Having poor harm perception significantly increased the chances of inhalant use by students (AOR 5.5; 95% CI 1.5–20.1). Conclusion. The study results bring to attention the prevalent and important problem of substance use among schoolchildren. We recommend that (i) intervention strategies for school settings are important and need to factor in the use of illicit substances (cannabis); (ii) psychosocial intervention by trained school counsellors in school settings is the mainstay for intervention for cannabis and inhalants; and (iii) heroin users should be referred to healthcare facilities for detoxification.

Protocolo de estudo para relatar a eficácia da terapia de realidade virtual em combinação com o protocolo de fisioterapia para melhorar o equilíbrio em amputados traumáticos de membros inferiores / Study protocol to report the effectiveness of virtual reality therapy in combination with physical therapy protocol for improving balance in traumatic lower limb amputees: A parallel, open-label, randomized controlled trial

INTRODUÇÃO: A intervenção em realidade virtual (RV) foi viável em amputados de membros inferiores (AMI). Até onde sabemos, não existe um estudo controlado randomizado disponível sobre a reabilitação do AMI usando RV. As evidências sugerem que são necessárias mais pesquisas para reabilitação de amputados usando VR. OBJETIVO: Comparar a eficácia da terapia de RV como um complemento terapêutico adicional com o protocolo de fisioterapia nos limites de estabilidade e estabilidade postural, dor e qualidade de vida entre os AMI. MÉTODOS: Um total de 100 AMI foi recrutado por amostragem aleatória simples (gerador de número aleatório) do JPN Apex Trauma Center, AIIMS, para participar de um ensaio clínico randomizado. O AMI recrutado foi dividido aleatoriamente em dois grupos: terapia de realidade virtual juntamente com o grupo protocolo de fisioterapia (VRT-PTP) e o grupo protocolo de fisioterapia (PTP). A duração do tratamento será de 30 minutos em uma sessão / dia, durante 4 dias / semana, durante 3 semanas. Assim, cada AMI receberá 12 sessões no total. O Sistema de Equilíbrio Biodex para medir o equilíbrio dinâmico, NPRS para dor e qualidade de vida pelo WHOQOL-BREF da OMS (WHOQOL-BREF) são as medidas de resultado que serão registradas na linha de base, no final do período pós-intervenção de três semanas. O acompanhamento será realizado na 6ª e 9ª semana após a inscrição. RESULTADOS: A normalidade dos dados coletados será confirmada pelo teste de Kolmogorov-Smirnov. A significância estatística intra e inter grupos será determinada por testes apropriados. O tamanho do efeito e a análise de potência serão realizados. CONCLUSÃO: Este estudo apresentará dados para a eficácia do VRT na melhora do equilíbrio e da marcha, além do PTP.

INTRODUCTION: Virtual reality (VR) intervention was found to be feasible in lower limb amputees (LLA). To best of our knowledge, only there is no randomized controlled trial available regarding the rehabilitation of LLA using VR. Evidence suggest that more researches for amputee rehabilitation using VR is warranted. OBJECTIVE: To compare the effectiveness of VR therapy as an additional therapeutic adjunct with physical therapy protocol on limits of stability and postural stability, pain and quality of life among LLA. METHODS: A total of 100 LLA will be recruited by the simple random sampling (random number generator) from JPN Apex Trauma Centre, AIIMS to participate in randomized controlled trial. Recruited LLA will be randomly divided into two groups, virtual reality therapy along with physical therapy protocol (VRT-PTP) group and physical therapy protocol (PTP) group. Duration of the treatment will be 30 minutes in one session/day for 4 days/week for 3 weeks. Thus, each LLA will receive 12 sessions in total. The Biodex Balance System for measuring dynamic balance, NPRS for pain and quality of life by WHO Quality of Life-BREF (WHOQOL-BREF) are the outcome measures will be recorded at baseline, end of 3-week post-intervention period. The follow-up will be taken at 6th and 9th week after enrollment. RESULTS: Normality of the collected data will be confirmed by Kolmogorov-Smirnov test. Statistical significance within and between the groups will be determined. Effect size and power analysis will be performed. CONCLUSION: This study will present data for the efficacy of the VRT in improving balance and gait in addition to PTP.

Escitalopram Induced Hyponatremia

National and international pharmacovigilance committee reports and case-control studies also implicate paroxetine, fluoxetine, sertraline. However, there have been only few reported cases of hyponatremia associated with escitalopram. The objective of this case report is to highlight a strong association of hyponatremia and SIADH (Syndrome of Inappropriate ADH secretion) in a middle-aged patient receiving escitalopram, a drug less commonly known to cause such side effects. Methods: We report a case of escitalopram induced severe hyponatremia in a middle-aged man where the association of hyponatremia with escitalopram is clearly established. Patient developed hyponatremia on the rechallenge with escitalopram (serum sodium = 94 mEq/L) within two days of initiation of treatment. The patient was free from other medical illnesses and was not taking other medications known to cause hyponatremia (confounders present in previous case reports suggesting an association between escitalopram and SIADH). Results: Our case suggests a strong association of escitalopram use and development of hyponatremia and SIADH in the absence of another drug use and medical comorbidity. Conclusion: Escitalopram, an SSRI is associated with hyponatremia and SIADH even in middle-aged individuals. There is a need for case-control studies especially involving a younger and middle age group. ASEAN Journal of Psychiatry, Vol. 17 (2): July – December 2016: XX XX.

Effect of controlled breathing exercises on the psychological status and the cardiac autonomic tone : Sudarshan Kriya and Prana-Yoga.

Objective : The objective of the study was to observe the effect of controlled breathing exercises including Sudarshan Kriya (SK) and Prana-Yoga (PY) on the psycho-physiological status. Methods : The study group included 60 healthy volunteers (M:30, F:30) in the age group of 18 to 30 years (21.3±3.2 yrs), randomly divided in to three groups of 20 subjects each – (1) The SK group (2) the PY group and the (3) Control group. The psycho-physiological data was collected at the following four time interventions: Baseline, 6th, 60th and the 150th day. Psychological assessment was done using questionnaires and for the autonomic tone quantification Heart Rate Variability (HRV) analysis was done using the standard lead II electrocardiogram recordings. In a post-hoc analysis each group was further sub divided in to the following two patterns, based on the baseline values of normalized Low Frequency (LF) power (cutoff 64 ms2) : (i) Pattern A-Subjects with low level LF power, and (ii) Pattern B- subjects with high level LF power. Results : The stress management skills have shown significant increase in SK group but not in PY and Control group. Subjects of SK, PY, and control group showed significant increase in LF value and LF:HF ratio for pattern A and significant decrease for pattern B. Plotted LF value for pattern A & B in SK and PY practitioners showed convergence, coming to a mean value over the period of 150 days.The LF:HF ratio curve plotted over time for pattern A & B showed convergence in SK group only. No such convergence in LF value & LF/HF ratio for pattern A & B was seen in control group. Conclusion : In conclusion, Sudarshan Kriya positively modifies stress coping behavior and initiates appropriate balance in cardiac autonomic tone.

INCLEN Diagnostic Tool for Attention Deficit Hyperactivity Disorder (INDT-ADHD): Development and Validation.

Objective: To develop and validate INCLEN Diagnostic Tool for Attention Deficit Hyperactivity Disorder (INDT-ADHD). Design: Diagnostic test evaluation by cross sectional design. Setting: Tertiary care pediatric centers. Participants: 156 children aged 65-117 months. Methods: After randomization, INDT-ADHD and Connor’s 3 Parent Rating Scale (C3PS) were administered, followed by an expert evaluation by DSM-IV-TR diagnostic criteria. Main outcome measures: Psychometric evaluation of diagnostic accuracy, validity (construct, criterion and convergent) and internal consistency. Results: INDT-ADHD had 18 items that quantified symptoms and impairment. Attention deficit hyperactivity disorder was identified in 57, 87 and 116 children by expert evaluation, INDT-ADHD and C3PS, respectively. Psychometric parameters of INDT-ADHD for differentiating attention deficit hyperactivity disorder and normal children were: sensitivity 87.7%, specificity 97.2%, positive predictive value 98.0% and negative predictive value 83.3%, whereas for differentiating from other neuro-developmental disorders were 87.7%, 42.9%, 58.1% and 79.4%, respectively. Internal consistency was 0.91. INDT-ADHD has a 4-factor structure explaining 60.4% of the variance. Convergent validity with Conner’s Parents Rating Scale was moderate (r =0.73, P= 0.001). Conclusions: INDT-ADHD is suitable for diagnosing attention deficit hyperactivity disorder in Indian children between the ages of 6 to 9 years.

INCLEN Diagnostic Tool for Autism Spectrum Disorder (INDT-ASD): Development and Validation.

Objective: To develop and validate INCLEN Diagnostic Tool for Autism Spectrum Disorder (INDT-ASD). Design: Diagnostic test evaluation by cross sectional design Setting: Four tertiary pediatric neurology centers in Delhi and Thiruvanthapuram, India. Methods: Children aged 2-9 years were enrolled in the study. INDT-ASD and Childhood Autism Rating Scale (CARS) were administered in a randomly decided sequence by trained psychologist, followed by an expert evaluation by DSM-IV TR diagnostic criteria (gold standard). Main outcome measures: Psychometric parameters of diagnostic accuracy, validity (construct, criterion and convergent) and internal consistency. Results: 154 children (110 boys, mean age 64.2 mo) were enrolled. The overall diagnostic accuracy (AUC=0.97, 95% CI 0.93, 0.99; P<0.001) and validity (sensitivity 98%, specificity 95%, positive predictive value 91%, negative predictive value 99%) of INDT-ASD for Autism spectrum disorder were high, taking expert diagnosis using DSM-IV-TR as gold standard. The concordance rate between the INDT-ASD and expert diagnosis for ‘ASD group’ was 82.52% [Cohen’s κ=0.89; 95% CI (0.82, 0.97); P=0.001]. The internal consistency of INDT-ASD was 0.96. The convergent validity with CARS (r = 0.73, P= 0.001) and divergent validity with Binet-Kamat Test of intelligence (r = -0.37; P=0.004) were significantly high. INDT-ASD has a 4-factor structure explaining 85.3% of the variance. Conclusion: INDT-ASD has high diagnostic accuracy, adequate content validity, good internal consistency high criterion validity and high to moderate convergent validity and 4-factor construct validity for diagnosis of Autistm spectrum disorder.

Specialty choices of postgraduate medical students: Are they related to the kind of animal identified with oneself.

Background: Research has pointed to a possible role of certain personality attributes in the choice of medical specialties, but not much is known about the Indian setting. Furthermore, most personality assessments are quite lengthy and time-consuming. Objective: The study aimed to explore if the specialty choices of Indian postgraduate students are related to their personality attributes, using a brief projective animal question. Methods: The study was carried out as a retrospective survey (n=450) of responses to a projective question, in which students were asked to name the animal they identified themselves with the most and their reasons. Results: Mean age was 25.46±1.94 years (Males: 71.8% males; females: 28.2%). Reasons for identification with the stated animal were categorized as aggressive 11.8%, autonomous 40%, nurturing 30.4% and aesthetic 17.8%. Technology-oriented specialties were associated with aggressive/ autonomous responses (p<0.01), while pre/paraclinical specialties were associated with nurturing/aesthetic responses (p<0.01). Females had twice the odds (OR: 1.86) of choosing a personoriented clinical specialty over a technology-oriented specialty. Conclusion: Research in this direction is needed to assist the career counseling of medical students.

Clinical Profile of Mood Disorders in Children.

Objective: To described the clinical profile of pediatric mood disorders. Design: Retrospective record review; Ages 16 y. Setting: Tertiary case hospital. Participants: Children 16 year with a DSM-IV diagnosis of Mood disorders. Methods: Records were screened for the period between June 1, 2008 and May 31, 2010. Results: The prevalence of mood disorders was 4.1% (38/930). Mood was depressed in 51.9% and irritable in 33.3% of depressive disorders. Other common symptoms were anhedonia, sleep/appetite disturbances, concentration difficulty and anxiety. Nearly 13.2% had suicidal ideation and 28.5% had comorbid psychiatric disorder. Family history was positive in 39.5%, while an identifiable stressor was present in 50%. Conclusions: The pediatric mood disorders have a unique clinical presentation and requires more research, especially from Indian setting.

Feasibility of Self-Assessment of Acute Mania: Comparison of Self-Rated and Observer-Rated Scales of Mania in Naturalistic Setting.

Mania is one of the commonest psychiatric disorders causing severe social and functional disturbances and thus requiring immediate intervention. Rating scales of mania are limited, especially the self-rating scales. Aim: To study correlation between the self-rated and observer rated scales of mania over 4 weeks period; To study the resolution and persistence of symptoms of mania with respect to clinical characteristics and treatment in the naturalistic ward setting over 4 weeks period. Methods: 40 consecutive hospitalized patients of either sex between 15-55 years with diagnosis of Mania (ICD-10 – Diagnostic criteria for research) were recruited for the study. The subjects were assessed using semistructured Performa covering socio-demographic and clinical characteristics of patient and his/her illness and by using following rating scales: Clinician Administered Rating Scale for Mania (CARS-M) [Altman et al, 1994]; Altman Self-Rating Mania scale (ARSM) [Altman et al 1997]; Hamilton Rating Scale for Depression (HAM-D) [M Hamilton 1960]; Clinical Global Impression Scale (CGI) (modified by Brandit et al, 1996). Results: The scores of the CARSM, ARSM, HAM-D, CGIS-S AND CGIS-1 showed the decreasing trends in the subsequent weekly assessments. This indicated improvement in the illness in the due course of treatment, which is an expected phenomenon. The reliability analysis scale (alpha) among the respective ARSM and CARSM scores showed the value as 0.8846 indicating that each self-rating is significantly reliable enough with the respective objective ratings. There are similar correlation patterns among CGI-S scores vs. the ASRM scores. However the correlation between the scores of CGI-I vs. ARSM in the first week does not seem to correlate significantly (p=.568), but the subsequent scores from 2nd through 4th week do correlate significantly. The HAM-D scores do not seem to correlate with the ARSM scale at any point except on the third week of the symptoms that resolved first were the hallucinations and disorientations. Insomnia and disordered thinking (incoherence/ extreme pressure of speech) disappeared nearly at the end of 2 weeks, followed subsequently by distractibility, excess energy and the delusions. Lack of insight and judgment, and euphoric/irritable mood were among the last to disappear.

Undergraduate Psychiatric Training: Insights from Emergency Room.

Context: Undergraduate medical training involves a number of subjects for the trainee to go through and develop the skills necessary to mange the cases. Subjects such as psychiatry are underrepresented during this training. Aims: This study aims to assess the quality of undergraduate psychiatric training through the management of psychiatry cases by MBBS graduated in the emergency department. Settings and Design: The study was carried out in the emergency department and OPD set up. The study used the consecutive sample inclusion. Methods and Materials: The study included the consecutive initial 40 consultation from the emergency department. The analysis included the management done by the emergency department, the reasons for referral and the differences in diagnosis/ management of emergency department staff and resident doctor of psychiatry. Statistical Analysis used: The data was analysed using SPSS ver 10. Results: The diagnosis in 15 cases was revised by the psychiatry resident doctor from that made by the emergency department staff. There were certain unusual reasons for referrals to a psychiatrist. There were differences in the line of management of some of the cases as per the emergency department staff and the psychiatry resident. Conclusion: There is a need to relook into the training curriculum of the undergraduate psychiatric training programme.

Patient-reported multiple drug reactions: Clinical profile and results of challenge testing.

Background: Some patients report hypersensitivity reactions to many drugs making it difficult to prescribe medications when they fall ill. Aim: To describe the clinical profile of multiple drug hypersensitivity and the results of challenge testing in a large teaching hospital.Methods: We performed a five-year retrospective review of the records of patients who complained of reactions to two or more unrelated drugs and avoided medication because of a fear of developing reactions. Oral challenge testing was carried out in hospital with drugs suspected by the patient to cause reactions and/or commonly prescribed medications. A positive reaction was diagnosed when symptoms and signs resembled previously experienced episodes and there was no such reaction with placebo. Results: Twenty three patients (aged 14-65 years; 19 females) underwent challenge testing. Their complaints had been present for 1-30 years, with 2-40 drug reaction episodes reported. Antibiotics and non-steroidal anti-inflammatory drugs (NSAIDs) were most commonly implicated, and urticaria/angioedema were the most often reported manifestations. The patients underwent 3-27 challenges with 1-24 drugs. Three had positive challenge reactions with various NSAIDs, 13 developed symptoms and signs that were judged not to be true reactions, and 7 had no reactions. None of our patients qualified for a diagnosis of true multiple drug hypersensitivity. Conclusion: Patients who believe they are allergic to multiple, pharmacologically unrelated drugs are usually mistaken. Challenge testing is a reliable way of demonstrating this and providing patients with a list of safe drugs.

Chronic mania: An unexpectidly long episode?

Mood disorders (unipolar and bipolar disorders) are one of the most distressing and disabling disorders known to man kind. Mood disorders may present as either a depressive phase or manic phase. Chronic mania by definition means presence of manic symptoms in excess of 2 yrs without remission. Chronic mania differs in its psychopathological presentation from the acute mania. Chronic mania also poses a diagnostic and management challenge. Along with the poor response to the treatment these patients are also likely to suffer from severe impairment in the social, familial, interpersonal and occupational functioning. These disturbances may add to the chronicity of the condition. This case underlines the significance of keeping possibility of chronic mania which has been overlooked in the recent literature.