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.

Prevalence of Anxiety and Depressive disorders and the Role of Coping Strategies in females with Infertility

Background: Adjustment, anxiety and depressive disorders are amongst the most common psychiatricmorbidities in infertile women in previous studies. Different women cope with the unpredictable, chronicstress of infertility in different ways. Coping strategies may have an impact on the development of psychiatricmorbidity. Hence this study was undertaken.Methods: A cross sectional study was conducted by interviewing 68 consecutive patients with primary orsecondary infertility. Socio-demographic details were taken using the study proforma. Psychiatric morbiditywas diagnosed as per ICD-10 criteria. Severity was assessed using HAM-A and MADRS. Coping wasevaluated on the COMPI Coping Strategy Scale. Statistical Packages of Social Sciences version 20 was usedto compile, tabulate and analyze the data.Results: A majority (67.7 %) of infertile females had psychiatric morbidity, the most common beingAdjustment disorder (37 %), followed by Mixed anxiety and depressive disorder (32.6 %) and Mood(depressive) disorder (30.4 %).Conclusion: A high use of active confronting and meaning based coping was seen in majority of the femaleswho did not have psychiatric morbidity. The use of active confronting coping in majority (64.7 %) of thosewith Adjustment disorder was found to be statistically significant

Bupivacaine 0.125% versus bupivacaine 0.125% with different doses of fentanyl for epidural labour analgesia: A randomised double blind study.

Background: Epidural analgesia is the most commonly used method for labour analgesia. Aims & Objective: To evaluate the safe dose of fentanyl added to Bupivacaine 0.125% and its effect on quality and duration of analgesia with side-effects. Materials and Methods: Forty-five healthy nulliparous women, ASA physical status I and II with an uncomplicated pregnancy and single fetus in vertex position were given lumbar epidural analgesia. Patients in Group A (n=15) received Bupivacaine 0.125 percent; Group B (n=15) and C (n=15) received the same agents as Group A but with addition to the initial dose of 2 mcg/ml or 4 mcg/ml of fentanyl respectively. All the patients were evaluated for duration and quality of analgesia, duration of labour, method of delivery and side effects. Results: Addition of either 2 mcg/ml or 4mcg/ml of fentanyl resulted in longer duration of analgesia (132.2 ± 12.4 minutes and 188.20 ± 18.5 minutes respectively versus 92.5 ± 10.2 minutes) and also decreased number of top up doses significantly. Quality of analgesia was better in Group B and Group C as compared to Group A. Addition of fentanyl did not affect the duration of labour, the method of delivery and fetal outcome. Conclusion: Combination of Fentanyl 2 mcg/ml and Fentanyl 4 mcg/ml with Bupivacaine 0.125% is both and safe for providing labour analgesia via epidural route.

Comparison between hyperbaric Bupivacaine and hyperbaric Bupivacaine plus Fentanyl intrathecally in major gynaecological surgeries.

Background: Subarachnoid block is commonest anaesthetic technique used for most gynaecological surgeries. Local anaesthetic agents have traditionally been used for this, but with the discovery of opioid receptors in spinal cord in substantia gelatinosa. Possibility of synergism between opioids & local anaesthetics co-administered intrathecally has been explored for various lower abdominal surgeries. Aims & Objective: To study was to compare effect of intrathecal bupivacaine with bupivacaine, fentanyl mixture to assess safety and efficacy, peri –operative hemodynamic stability postoperative pain relief in major gynecological surgeries. Materials and Methods: 60 female patients with American society of anaesthesiologists (ASA) grade I OR II were divided in two groups after matching. Group BF received inj. Bupivacaine 15 mg (0.5%) 3 ml + inj. Fentanyl 25 mcg, (50 mcg/ml), 0.5 ml and Group B: (inj. Bupivacaine 15 mg (0.5%) 3 ml + Normal Saline (0.5 ml), total volume was 3.5 ml in each group. Spinal anaesthesia was given with conventional technique. Results: Duration of sensory block and effective analgesia was prolonged while there was no change in duration of motor block with intrathecally bupivacaine with fentanyl as compared to inj. Bupivacaine alone. Conclusion: Intrathecal Fentanyl as an adjuvant to bupivacaine improves quality of block with longer duration of sensory block & prolongs duration of effective analgesia.

Delusional disorder: prevalence, clinical correlates and co morbidity

Background: Delusional disorder is on a spectrum between more severe psychosis and overvalued ideas. Rates of psychiatric co morbidity in patients with delusional disorder have been found to be high, with affective disorders being the most common co morbid entity. Growing literature has revitalized the efforts to understand, define, characterize and treat this disorder. However, despite these, more studies are needed to clarify the role of mood disturbances in delusional disorder to provide for a better therapeutic approach. Aims: To study the prevalence, socio demographic profile and co morbid depression in delusional disorder patients. Methods: All patients diagnosed as delusional disorder in the last 3 years and attending the psychiatry outpatient department of a general teaching hospital were included. Semi-structured proforma specifically designed for the study was administered to collect socio-demographic data and illness related information. Results: In our study, 53 (1.88%) met the criteria of delusional disorder. Co morbid depression was seen in 17 (32.08%) of these patients. Conclusion: Delusional disorder is a unique entity with considerable psychiatric co morbidity especially depression.

A study of recovery and its variables in patients with schizophrenia

Background: Recovery orientation to psychiatric illness views that the patient is more than a sum of his symptoms. There is a great paucity of studies on recovery in schizophrenia in India. Aim: With this goal in mind this study was undertaken to study (1) the socio demographic profile of the sample and their relation with stages of recovery of schizophrenia, (2) the relationship between socio-occupational functioning and stages of recovery and to assess the relationship between stages of recovery and symptomatology. Methods: Study was conducted in Psychiatric outpatient department in general teaching hospital, on patients diagnosed as chronic schizophrenia. Semi-structured proforma, Positive and Negative Syndrome Scale (PANSS), Stages of Recovery Instrument (STORI) and Social and Occupational Functioning Scale (SOFAS) were used.In our study, 37 patients with a diagnosis of schizophrenia were included. Results: This study did not find any significant correlation between demographical variables and the stages of recovery. Stage of moratorium of STORI had significant positive correlation with all subscales of PANSS while stages of awareness, preparation and rebuilding and growth of STORI had significant negative correlation with all subscales of PANSS. Stage of preparation and growth had significant positive correlation with SOFAS while stage of moratorium had significant negative correlation with SOFAS. Thus each stage of recovery in schizophrenia had significant correlation with the level of functioning in our study. Conclusion: This clearly indicates that there is a significant relationship between psychopathological symptoms and the person’s ability to pursue the path of recovery.

Perception of burden by caregivers of patients with schizophrenia

Background: Schizophrenia being a debilitating illness leads to deterioration in occupational, interpersonal and self supporting abilities. This can pose numerous psychosocial difficulties for patients as well as family members who care for their loved ones resulting in burden of care. Due to the chronic stress of caring for these patients many caregivers develop psychiatric symptoms. Aims: This study was undertaken to assess the burden perceived by caregivers of schizophrenia patients, impact of socio-demographic and patient variables on perceived burden as well as the presence of psychological distress in the caregivers. Methods: 54 patients diagnosed as having schizophrenia as per the DSM IV TR with a duration of illness of two years or more and their caregivers were evaluated using the appropriate psychometric instruments to measure burden, anxiety and depression in caregivers. Results: Our study showed that overall burden perceived was 22.2% with no significant difference between the caregivers of either sex and burden perceived by the caregivers of the sample studied also had a significant impact on their anxiety and depression. Conclusion: Care-givers of schizophrenia patients experience burden as well as psychological distress secondary to caring for a relative with a chronic mental illness. Key message: Care-giver burden must be anticipated in schizophrenia patients and appropriate support must be provided.

Atrial septal defect closure on cardiopulmonary bypass in a sickle cell anemia: Role of hydroxyurea and partial exchange transfusion.

Partial exchange transfusion during cardiopulmonary bypass, while conducting cardiac surgery may be a useful technique in patients with high level of sickle hemoglobin. Along with this preoperative use of hydroxyurea and alternative analgesic modalities such as transcutaneous electrical nerve stimulation in postoperative period may be beneficial, in our opinion. A 16-year-old female of Turner's syndrome having sickle cell anemia scheduled for closure of arterial septal defect on cardiopulmonary bypass was managed with partial exchange transfusion and warm cardioplegia.

Bone marrow cells for myocardial repair-a new therapeutic concept.

AIM: To assess the safety and feasibility of transfusing autologous bone marrow stem cells (ABMSC) into the culprit coronary artery after an acute anterior wall myocardial infarction (MI) and further to see the ability of ABMSC to promote improvement in Left Ventricular lsqb;LV] function at follow-up. METHODS: In an ongoing phase I clinical trial, twenty-seven patients of uncomplicated acute anterior wall MI treated as per the current practicing guidelines have been included. Among these, seventeen patients received intra-coronary unfractionated ABMSCs from 77ndash;15 days after acute MI (ABMSC group) and ten patients acted as controls. RESULTS: All the procedures carried out were without any complications. After 6 months, cardiac function analysis of ten patients from the ABMSC group by LV angiography and Cardiac Magnetic Resonance Imaging (MRI) demonstrated a significant rise of 12.74% (p = 0.001) and 7.1% (p = 0.001), respectively in the LV ejection fraction [LVEF]. There was an improvement in the LV systolic function wherein LV end systolic volume (LVESV) decreased significanty to 28.75% (p = 0.010) and 16.49% (p = 0.022) by LV angiography and cardiac MRI, respectively. LV end diastolic volume (LVEDV) decreased marginally by LV angiography (p = 0.548) and by cardiac MRI (p = 0.514). Five patients of the control group by LV angiography demonstrated non-significant rise of 1.0% (p = 0.706) in LVEF, 12.79% (p = 0.332) in LVEDV and 22.56% (p = 0.308) in LVESV. By cardiac MRI controls demonstrated significant rise in EF of 3.2% (p = 0.0367rpar; but non-significant fall of only 2.32% (p = 0.812) in LVEDV and 6.47% (p 7equals; 0.508) in LVESV. CONCLUSION: This study shows that intracoronary infusion of ABMSC is safe and feasible after acute MI and shows a favourable trend towards the improvement of LV function and prevention of ventricular remodeling which determines long-term survival.

Multiple foreign bodies in the anterior and posterior urethra

Foreign bodies of the urethra and bladder are seen with iatrogenic injury, self-insertion, and rarely migration from adjacent sites. Treatment is focused on foreign body extraction, diagnosing complications, and avoiding compromise of erectile function. With advances in endourology, the majority of cases can now be managed endoscopically. We present a case of a man with multiple foreign bodies located both above and below the urogenital diaphragm. Advancing the posterior objects intravesically and extracting with a stone basket accomplished successful removal.

Mycophenolate mofetil: a promising immunosuppressive agent.

With avaibility of newer immunosuppressive agents, incidence of acute graft rejection has decreased. Mycophenolate mofetil is one such new drug, now available in the Indian market It has been found to be useful in prevention and treatment of acute and chronic rejection after transplantation. Besides transplant it has been used successfully in primary and secondary glomerulopathies (e.g. SLE) and other autoimmune diseases. The drug is well tolerated with side effects limited mainly to gastrointestinal system in the form of epigastric pain, vomiting and diarrhoea.