Clinical perspectives on the management of common psychiatric disorders in India

Psychiatric disorders are common health problems in patients of all age groups, under-diagnosis and under-treatment of these disorders can result in disability and serious complications. With an objective of creating a comprehensive evidence-based consensus on common mental health disorders and their management in the Indian setting, 10 expert groups meetings involving 98 psychiatrists across India were conducted in the month of May 2020. Clinical insights related to burden, signs and symptoms, diagnosis and management were summarized based on the discussions during these meetings. Experts agreed that depressive disorders and anxiety disorders represent two important psychiatric disorders in India. Selective serotonin reuptake inhibitors (SSRIs) are commonlyused for the treatment of depression. Benzodiazepines are effective for the treatment of comorbid anxiety in patients with depression, but their long-term use causes adverse events such as dependence and withdrawal reaction. Obsessive compulsive disorder (OCD), bipolar disorder, substance use especially alcohol withdrawal syndrome, and sleep disorders are other common psychiatric disorders found among Indian patients. Lithium and valproate represent the commonly used and effective pharmacological treatments for bipolar disorder. SSRIs are preferred drugs in the treatment of OCD,whereas benzodiazepines such as chlordiazepoxide and diazepam represent important pharmacological treatment optionsfor alcohol withdrawal. Early identification and timely and effective treatment of psychiatric disorders is important for prevention of complications. Treatment should be individualized based on efficacy, tolerability profile of the medicine, risk of drug interactions, and cost. This consensus may be useful to psychiatrists and general practitioners treating common psychiatric conditions in Indian patients.

A study of alanine aminotransferase - aspartate aminotransferase as a marker of advanced alcoholic liver disease

Background: Alcohol is one of the most common etiology for chronic liver disease. There are several enzymes which remain elevated in both excessive Alcohol consumption and Alcohol induced liver cirrhosis1. But none is sensitive or specific. The ratio of Aspartate transaminase (AST) with Alanine transaminase (ALT) is one of the best marker for alcohol liver disease. Current study mainly compares the ratio of AST/ALT with both Alcoholic liver disease and excessive Alcohol consumption patients.Methods: Observational, cross sectional study conducted on 50 patients diagnosed with alcoholic liver disease and 50 patients of alcohol withdrawal syndrome. Either admitted or seen on outpatient basis at Bangalore medical college and research institute and data was compared among the groups and appropriate statistical methods are applied.Results: The mean ratio of AST/ALT ratio in 50 patients of alcoholic liver disease group was 3.45, whereas the mean ratio in 50 patient of alcohol withdrawal was about 99. When compared statistically this ratio was significant in chronic liver disease group.Conclusions: Most of the patients with heavy alcohol drinking had high AST and alt levels. But ratio of AST/ALT levels was significant high and suggest chronic liver disease secondary to alcohol.

Efeito do álcool na ilusão da máscara côncava: uma revisão / Effect of alcohol on the hollow-face illusion: a review / Efecto del alcohol en la ilusión de la máscara cóncava: una revisión

A ilusão da máscara côncava ocorre quando o observador a determinada distância percebe uma máscara facial côncava como convexa. Isso pode ser explicado pela sobreposição dos processos de alta ordem da percepção visual sobre os de baixa ordem. Pesquisas com indivíduos intoxicados e em Síndrome de Abstinência do Álcool (SAA) revelaram um prejuízo em perceber essa ilusão. O objetivo foi realizar uma revisão da literatura sobre o tema. Após buscas em bases indexadas, cinco pesquisas foram encontradas. Os resultados para os alcoolistas em SAA moderada revelaram uma menor frequência nas respostas de percepção da ilusão. Os resultados foram contraditórios quanto ao grupo de alcoolistas com SSA leve. Pesquisas futuras com metodologias diferentes são necessárias para testar as hipóteses explicativas da ilusão da máscara côncava em alcoolistas. É importante considerar os processos de tomada de decisão do observador diante da observação dos objetos como base a Teoria de Detecção de Sinal (TDS)

The hollow-face illusion happens when the observer perceives a concave facial mask as convex, at a given distance. This can be explained by the overlap of top-down on bottom-up visual processes. Researches demonstrated that intoxicated and Alcohol Withdrawal Syndrome (AWS) individuals had deficit in perceiving this illusion. This study aimed to review the literature on this topic. A survey of indexed databases found five studies. The results for alcoholics with moderate AWS were similar and showed a lower frequency in the answers of illusion perception. However, results were contradictory to the alcoholic group with mild AWS. Future researches with different methodologies are necessary to test the hollow-face illusion hypotheses in alcoholics. Therefore, it is also important to consider the observer's decision-making processes in the objects observation based on the Signal Detection Theory (SDT)

La ilusión de la máscara cóncava ocurre cuando el observador a cierta distancia percibe una máscara facial cóncava como convexa. Esto puede ser explicado por la superposición de los procesos de alto orden de la percepción visual sobre los de bajo orden. Las investigaciones con individuos intoxicados y en el Síndrome de Abstinencia del Alcohol (SAA) revelaron un perjuicio en percibir esa ilusión. El objetivo fue realizar una revisión de la literatura sobre el tema. Después de buscar en bases indexadas, se encontraron cinco encuestas. Los resultados para los alcohólicos en SAA moderada revelaron una menor frecuencia en las respuestas de percepción de la ilusión. Los resultados fueron contradictorios en cuanto al grupo de alcohólicos con SSA leve. Las investigaciones futuras con metodologías diferentes son necesarias para probar las hipótesis explicativas de la ilusión de la máscara cóncava en alcohólicos. Es importante considerar los procesos de toma de decisión del observador ante la observación de los objetos como base la Teoría de Detección de Señal (TDS)

To Study Predictors For Withdrawal Seizures In Patients Of Alcohol Withdrawal Syndrome

Introduction– The alcohol withdrawal seizure(WS) occurs during the early phase of withdrawal and is characterized by reduction in the seizure threshold and it emerges within 48 hours of cessation of prolonged drinking (Brathen G et al,1999;Victor M et al,1967.)The appearance of a withdrawal seizure represents a strong risk factor for progression into a severe withdrawal state with following development of DT in up to 30% of cases(Victor M et al,1967). Aim– The purpose of the current study is to identify the most parsimonious collection of risk factors present at the time of hospital admission that were predictive for the development of WS. METHODOLOGY– 102 subjects admitted at deaddiction centre, SMS hospital were selected using a screening performa which was followed by a comprehensive assessment of alcohol use followed by relevant laboratory investigations with blood pressure and pulse rate recording. Severity of alcohol withdrawal syndrome (AWS) was determined in analogy to the revised Clinical Institute Withdrawal Assessment for Alcohol (CIWA–Ar) scale. Patients were put on standard treatment based upon institute guidelines and withdrawal was assessed for 1 week. Patients were monitored for withdrawal seizure and diagnosis was made as per criteria of ICD 10. RESULTS– Age of onset of drinking, duration of alcohol abuse and daily ethanol intake were found to be significantly correlated to the development of WS. Systolic BP, Diastolic BP, Heart rate had significant correlation to the occurrence of WS which can be attributed to the autonomic hyperactivity during the withdrawal state. CIWA–Ar score also came out to be a significant risk factor to the development of WS.Previous history of seizures, delirium tremens, previous alcohol withdrawal syndrome and previous detoxification episodes were also a significant risk factor for the occurrence of WS . CONCLUSION– The various variables that were found to be significantly correlated to the occurrence of WS are mentioned as follows: age, duration of abuse, daily alcohol intake, CIWA–Ar score>15, systolic & diastolic BP, previous history of WS and DT, previous history of alcohol withdrawal syndrome and previous detoxification episodes.

Perspectivas del síndrome de supresión etílica: tratamiento a la mexicana / Perspectives about withdrawal alcoholic syndrome: Mexican treatment

Resumen El síndrome de supresión etílica es un problema de salud pública de especial atención en hospitales de segundo nivel en México. Clasificado como un padecimiento neuropsiquiátrico, la evidencia actual refleja daño sistémico más allá del sistema nevioso central. El manejo de estos pacientes se efectúa en las salas de hospitalización de Medicina Interna, cuando los síntomas son severos, requiere un abordaje multisistémico en la Unidad de Cuidados Intensivos. Si bien los criterios diagnósticos de la Sociedad Americana de Psiquiatría no se han modificado en las últimas ediciones (DSM-4 y 5), el tratamiento durante la última década se ha extendido por el gran espectro de opciones terapéuticas. El costo de hospitalización es elevado debido a las múltiples comorbilidades acompañantes encontradas en el paciente alcohólico. La finalidad de este trabajo es realizar una reseña de la perspectiva internacional y nacional de las diferentes guías en el manejo del cuadro, remembrando que sobre el clínico avezado recae la decisión terapéutica individualizada en cada caso.

Abstract Alcohol withdrawal syndrome is a public health problem of special attention in second level hospitals in Mexico. Classified as a neuropsychiatric condition, the current evidence reflects systemic involvement beyond the central nervous system. The management of these patients is carried out in the internal medicine hospitalization rooms; when the symptoms are severe, it requires a multisystemic approach in the Intensive Care Unit. Although the diagnostic criteria of the American Psychiatric Society have not been modified in the last editions (DSM-4 and 5), treatment during the last decade has been extended by the wide spectrum of therapeutic options in its management. The cost of hospitalization is high due to the multiple accompanying comorbidities found in the alcoholic patient. Therefore, the purpose of this paper is to review the international and national perspective of the different guidelines in the management of the disease, recalling that on the seasoned clinician falls the individualized therapeutic decision in each case.

Manejo del síndrome de abstinencia alcohólica en los pacientes críticos / Management of the syndrome of alcohol withdrawal in critical patients

El manejo del síndrome de abstinencia alcohólica es un desafío en los pacientes críticos. Con frecuencia, se desconocen los antecedentes de consumo de alcohol o este dato es incompleto, lo que limita la identificación de quienes pueden desarrollar este síndrome. El cese abrupto del consumo de alcohol coloca a estos pacientes en alto riesgo de sufrir síndrome de abstinencia alcohólica grave. Típicamente, las benzodiacepinas son consideradas las drogas de primera línea para el manejo de estos casos. Sin embargo, si el paciente progresa a un estado más grave con convulsiones o delirium tremens, puede ser necesario administrar medicación adyuvante a las benzodiacepinas, como el propofol o la dexmedetomidina, o emplear estas últimas drogas como terapias alternativas en aquellos que no responden a las benzodiacepinas. La aparición de convulsiones representa un fuerte factor de riesgo para la progresión a un síndrome de abstinencia alcohólica grave, con el desarrollo posterior de delirium tremens hasta en el 30% de los casos. El delirium tremens es el cuadro más grave y ocurre en el 5-20% de los pacientes con este síndrome, con una mortalidad hasta del 25% sin tratamiento y que se reduce al 0-1% con tratamiento. Es importante conocer el antecedente del consumo de alcohol para evitar el síndrome de abstinencia alcohólica o tratar rápidamente sus síntomas más graves, y mejorar la supervivencia de estos pacientes.(AU)

Alcohol withdrawal syndrome (AWS) is a well-known and a challenging condition occurring in critically ill patients. Frequently, history of alcohol abuse is unknown when the patient is admitted to the intensive care unit, limiting the identification of those who could develop AWS. The abrupt cessation of a heavy or constant drinking put these patients in high risk of suffering from this syndrome in its severe form. Typically, benzodiazepines are considered the first line of treatment. However, if clinical conditions progress to epileptic seizures or delirium tremens or are refractory to benzodiazepines, adjuvant drugs like propofol or dexmedetomidine might be an option to control the severe symptoms. Delirium tremens can occur in up to 30% of patients; it is the most severe picture with a mortality of 25% without treatment and that can be reduced to almost 0-1% with treatment. It is important to appropriately identify alcohol abuse in order to avoid the early clinical manifestations of AWS or rapidly treat its most severe symptoms and improve survival.(AU)

Abstinência alcoólica: implicações da síndrome na percepção binocular de profundidade ou relevo da máscara côncava / Alcohol withdrawal: syndrome implications in the binocular perception of depth or relief of concave mask / Abstinencia del alcohol: implicaciones de síndrome en percepción de profundidad binocular o relieve de máscara hueca

Esta pesquisa teve por objetivo investigar a percepção binocular da ilusão da máscara côncava em indivíduos com Síndrome de Abstinência do Álcool comparativamente aos saudáveis. Indivíduos saudáveis, com Síndrome de Abstinência do Álcool leve e com moderada, observaram com os dois olhos, a face côncava de uma boneca disposta dentro de uma caixa, a classificam como côncava ou convexa e atribuíram centímetros a sua classificação. Apenas os observadores com Síndrome de Abstinência do Álcool moderada apresentaram um déficit em realizar a inversão visual da máscara côncava, diferindo estatisticamente do grupo de observadores saudáveis. Os grupos não diferiram quanto às atribuições métricas de profundidade ou relevo à máscara côncava. Constatou-se que a máscara côncava é um instrumento efetivo na detecção de possíveis prejuízos perceptuais em indivíduos com Síndrome de Abstinência do Álcool moderada.

This research aimed to investigate the binocular perception of the hollow-mask illusion in individuals with alcohol withdrawal syndrome compared to healthy. Healthy subjects, with mild and moderate alcohol withdrawal syndrome, observed with both eyes, the concave face of a doll willing inside of a box. They classified the mask as concave or convex and attributed centimeters your ranking. Only observers with moderate alcohol withdrawal syndrome showed a deficit in visual inversion of the concave mask statistically different from the healthy group observers. The groups did not differ with respect to metrics assignments depth or relief with the hollow mask. It was found that the concave mask is an effective tool in detecting possible perceptual impairments in subjects with moderate alcohol withdrawal syndrome.

Esta investigación tiene como objetivo investigar la percepción binocular de la ilusión de la máscara hueca en las personas con síndrome de abstinencia de alcohol en comparación con los sanos. Los individuos sanos, con síndrome de abstinencia de alcohol leve e moderado, observado con los dos ojos, la cara cóncava de una muñeca dispuestos en una caja, para clasificar como cóncava o convexa y atribuyeron centímetros su ranking. Solamente los observadores con síndrome de abstinencia de alcohol moderada mostraron un déficit en la realización de la inversión visual de la máscara cóncava, estadísticamente diferentes entre el grupo de los observadores sanos. Los grupos no mostraron diferencias con respecto a profundidad métricas asignaciones o criados con la máscara hueca. Se encontró que la máscara cóncava es una herramienta eficaz en la detección de posibles deficiencias de percepción en los individuos con síndrome de abstinencia alcohólica moderada.

Management of Alcohol Withdrawal Syndrome and Alcohol Withdrawal Seizure

Alcohol withdrawal syndrome (AWS) is a common condition occurring after intentional or unintentional abrupt cessation of alcohol in an alcohol-dependent individual. AWS represents a major problem in our society and alcohol withdrawal seizure is the major cause of seizures encountered by neurology residents in the emergency department. Patients with AWS present with mild symptoms of tremulousness and agitation or more severe symptoms including withdrawal seizures and delirium tremens. Particularly, severe AWS can produce significant rates of the morbidity (complications) and mortality. When diagnosed and managed insufficiently, the morbidity and mortality rates increase. Nevertheless, patients with AWS may be neglected and are often marginalized and the teaching about AWS to neurology residents is usually minimal. Also, attending neurologists are often poorly informed on the topic. Although there is insufficient consensus about the optimal investigation and management, the purpose of this review is to serve as a summary of the appropriate identification and management of this important condition in a neurological setting.

Effects of Early Administration of Dexmedetomidine on Benzodiazepine Requirements of ICU Patients with Alcohol Withdrawal Syndrome / 中国药师

Objective:To evaluate the effects of early administration of dexmedetomidine on benzodiazepine ( BZD) requirements of intensive care unit ( ICU) patients with alcohol withdrawal syndrome ( AWS) .Methods:Totally 60 adult patients with severe AWS were chosen and randomly divided into groups A and group B with 30 patients in each .The patients in group A received benzodiazepine simultaneously with early administration of dexmedetomidine , and those in group B received only benzodiazepine .After the first admin-istration of dexmedetomidine , the 24-h cumulative BZD requirement , stay length in ICU and hospital , condition of mechanical ventila-tion and incidence of hypotension and bradycardia were recorded .Results:The 24-h cumulative BZD requirement in group A was obvi-ously lower than that in group B [(8.6 ±1.2) mg vs (25.6 ±4.9) mg, P<0.05].The number of patients with mechanical ventila-tion in the two groups was similar, while the duration of intubation in group A was less than that in group B [(24.9 3.1) h vs (48.8 6.9) h, P<0.05].Additionally, group A had higher incidence of bradycardia when compared with group B (57% vs 13%, P<0.05).Conclusion:As the adjuvant treatment for alcohol withdrawal syndrome , early administration of dexmedetomidine can notably decrease the benzodiazepine requirement of ICU patients .

Ilusão da máscara côncava durante a síndrome de abstinência leve do álcool / Hollow-face illusion during during mild alcohol withdrawal syndrome

A ilusão da máscara côncava caracteriza-se pela inversão visual da profundidade durante a observação do reverso de uma máscara da face humana, que é percebido como convexo. O objetivo deste trabalho foi investigar a percepção monocular da profundidade ou relevo de uma máscara côncava, sob quatro condições de iluminação distintas, em 8 indivíduos com a Síndrome de Abstinência do Álcool (SAA) leve comparativamente a 8 participantes saudáveis. As contribuições nesta área de investigação são escassas e os resultados encontrados são controversos. Além disso, resta investigar a condição monocular de observação do estímulo. A máscara côncava foi posicionada no interior deuma caixa e observada através de um visor. Não foram observadas diferenças significativas entre os indivíduos com a SAA leve e os observadores saudáveis. A maioria dos observadores realizou a inversão visual da profundidade da máscara côncava, percebendo a face ilusória convexa. Ressalta-se a supremacia dos processos cognitivos, de alta ordem (top-down), sobre os processos sensoriais, de baixa ordem (bottom-up), na ilusão da máscara côncava. A observação monocular facilitou a ilusão e não foi adequada para investigar os prejuízos no processamento cognitivo de informações visuais causados pela SAA leve

The hollow-face illusion is the visual depth inversion that happens when a hollow mask of a human face is perceived as convex. The aim of thiswork was to investigate the monocular perception of depth or relief of a hollow mask, under four distinct illumination conditions, in 8 individuals with mild alcohol withdrawal, comparing to 8healthy participants. Scientific contributions in this research area are scarce and the results are controversial. Furthermore, it remains to investigate the status of monocular observationof the stimulus. The hollow mask was placed inside of a box and observed through a viewfinder. There was not significant differences between the individuals with mild alcohol withdrawal and the healthy observers. The significant majority of the observers made the visual depth inversion,perceiving the convex illusory face. It is important to notice the dominance of the high order, cognitive process (top-down) over low ordersensorial process (bottom-up) in the hollow-face illusion. The monocular observation facilitated illusion and it was not suitable to investigate the impairments in the cognitive processing of visual information caused by mild SAA

Alcohol-Related Neurologic Disorders: Ten Years of Experiences

Alcohol-related disorders are among the most costly health problems worldwide. Ingested alcohol is mainly metabolized by an oxidative pathway in the liver. Alcohol and its metabolic products (e.g., acetaldehyde and reactive oxygen species) have toxic effects on multiple organs, especially the nervous system. The diverse mechanisms of alcohol-related neurologic disorders include the direct toxic effects of alcohol, the alcohol withdrawal effect, nutritional deficiency secondary to alcoholism, and abnormalities of serum electrolytes and osmolality. We analyzed 156 cases of alcoholrelated neurologic disorders among admitted patients that had been referred in Korea during the previous 10 years. The duration of alcohol consumption ranged from 0.5 to 47 years (mean=17.8 years) and the mean amount of alcohol intake per day was 245.5 g. The 156 patients had the following diseases: Wernicke's encephalopathy (n=81, 51.9%), peripheral neuropathy (n=68, 43.6%), delirium tremens (n=59, 37.8%), Rum fit (n=31, 19.9%), pellagra encephalopathy (n=29, 18.6%), Korsakoff's psychosis (n=22, 14.2%), cerebellar atrophy (n=11, 7.0%), and alcoholic myopathy (n=6, 3.8%). We report on these cases and review the literature on alcohol-related neurologic disorders.

Prognosis and Clinical Outcome of Alcohol Withdrawal Syndrome in Trauma Patients

PURPOSE: Abrupt abstinence from alcohol in cause of chronic alcohol addiction can trigger alcohol withdrawal syndrome. The authors studied the effect of post-operative alcohol withdrawal syndrome in patients who require intensive care due to trauma. METHODS: For the study group, we selected 70 patients who had undergone emergency surgery from May 2003 to March 2007 due to trauma and who had been treated with prophylactic thiamine. Data was collected retrospectively. We excluded those who extended their hospital stay for other than traumatic causes, those who died within 3 days of surgery after trauma, those who transferred to other institutions, and those who received a psychiatric diagnosis. Patient groups were determined by the existence or the non-existence of withdrawal syndrome. Age, sex, injury mechanism, mortality, complications, durations of hospital stay and intensive care, use of mechanical ventilator, and sedative use were investigated. A Chi-square test and The Mann-Whitney method were used for statistical analysis in this study. RESULTS: Twenty-four (24) patients from the 58 who had an ISS of 16 or more showed alcohol withdrawal syndrome, and men were shown to be affected with the syndrome significantly more than women. Although ISS was higher in the group with alcohol withdrawal syndrome, statistically, the difference was not significant (p<0.08). The total hospital stay in the patient group with alcohol withdrawal syndrome was on average 10 days longer. However, the difference was not significant (p<0.054). The duration of intensive care in the patient group with alcohol withdrawal syndrome was significantly longer (p<0.029). The patients with alcohol withdrawal syndrome showed no significant difference in the duration of mechanical ventilator use (p<0.783), or in the duration of sedative use (p<0.284). Respiratory distress, pneumonia, upper airway infection, sepsis, acute renal failure, and mortality in the alcohol withdrawal syndrome group were investigated, but no statistically significant difference were noted. CONCLUSION: We found that the duration of intensive care in chronic alcohol abusers was longer due to the development of alcohol withdrawal syndrome. We also discovered that, when the patients overcame the symptoms of alcohol withdrawal syndrome after intensive care, no difference was found in the frequency of developing complications, the morbidity, and the mortality. Therefore, we conclude that intensive care in trauma patients who are chronic alcohol abusers decreases the incidence of complications found in patients with postoperative alcohol withdrawal syndrome and does not adversely impact the prognoses for those patients.

Clinical Predictors of Alcohol Withdrawal Syndrome in Patients with Alcoholic Liver Disease / 대한간학회지

BACKGROUND/AIMS: Although alcohol withdrawal syndrome (AWS) is often developed in the patients with alcoholic liver disease, the studies about which clinical factors are associated with the development of AWS have been rarely studied. The aim of this study was to reveal clinical factors indicating a higher risk for the development of AWS at admission. METHODS: The retrospective case-controlled study was conducted among patients with alcoholic liver disease. The cases were divided into two groups according to whether AWS was developed or not. We compared their past medical history, physical examination and laboratory data at admission. RESULTS: AWS was significantly developed in patients who had experienced AWS in the past, increased serum chloride concentration at admission. CONCLUSIONS: It is possible to predict the patients who are more likely develop to AWS by means of past medical history and a serum biochemical test at admission. We suggest more intensive therapy will be required to prevent the development of AWS in these patients. These results are preliminary and need further prospective development and validation, particularly regarding the variety of variables.