Long term outcome of schizophrenia - a cross-sectional study

Objective: To assess the Positive and Negative Symptoms Scale pattern and World Health Organization Quality of Life-BREF scale scores of patients with schizophrenia after seven years of the initial diagnosis

Study Design: A cross sectional observational study

Place and Duration of Study: Department of Psychiatry, Military Hospital Rawalpindi from Jan 2007 to Dec 2008

Material and Methods: Thirty patients who were invalided out of military service with the diagnosis of schizophrenia in 2000 and 2001 were subjected to psychometric evaluation seven years after the initial diagnosis in 2007 and 2008. They were assessed for their current symptoms and Quality of life using Positive and Negative Symptoms Scale [PANSS] and World Health Organization Quality of Life [WHOQoL-BREF] scale respectively. Both are established psychometric tools to assess the entire spectrum of schizophrenia and quality of life

Result: All patients were males. Forty three percent of the subjects had Positive and Negative Symptoms Scale [PANSS] score i.e. below cut off value of 65. Mean PANSS score of the group was 72. A score of more than 12 on World Health Organization Quality of Life-BREF [WHOQoL-BREF] scale indicating better quality of life was seen in 43 % of the patients. Factors linked with PANSS score > 65 and poor Quality of life [Qol score 4-12] were being single, unemployed, living in cities, using psychoactive substances and in initial years of military service

Conclusion: More than half of the patients with diagnosis of schizophrenia continue to show high Positive and Negative Symptoms Scale [PANSS] score and poor quality of life after seven years of initial diagnosis of schizophrenia

prevalence of post traumatic growth among troops in post deployment phase

Objective: To determine the prevalence of post-traumatic growth [PTG] and its association with socio demographic factors among a cohort of troops in post deployment phase

Study Design: Descriptive cross sectional

Place and Duration of Study: A Military battalion in Lahore from Jan-April 2015, one year after deployment in the combat area

Material and Methods: A sample of 296 combat troops was selected using non-probability convenient sampling technique. After taking informed written consent the data was collected using Urdu version of psychometric tool Post Traumatic Growth Inventory [PTGI]. Data was entered and analyzed SPSS version 20

Results: The mean age of the respondents was 29 +/- 6.2 years. Married and unmarried were 214 [72.3%] and 82 [27.7%] respectively. The mean years of service of the troops were 11. In our study the majority of troops 279[94.3%] exhibited greater degree of positive growth [75] ,15 [5.1%] had moderate degree of positive growth [74-51] while only 2[0.7%] had no post traumatic growth[<50]. There was a significant negative correlation of PTG with the age [p < 0.01] and a significant association of Ethnicity with PTG [p=0.03]. However there was no significant association of PTG with marital status [p= 0.06], education [/7=0.52], income [p=0.71], rank [p= 0.96] and years of service [p= 0.49] at 95% confidence level

Conclusion: It was concluded that there was a high prevalence of resilience as PTG in majority of troops one year after deployment in a combat area

Efficacy of eye movement desensitization and reprocessing beyond complex post traumatic stress disorder: a case study of EMDR in Pakistan

To demonstrate the efficacy of EMDR in complex multiple psychological trauma after failed drug treatment from selective serotonin reuptake inhibitor [SSRI] in a diagnosed case of post-traumatic stress disorder [PTSD]. Single participant of this case study, a sitting session judge of judicial governmental scaffold reported to this mental health tertiary care facility at his own accord with features of intense anxiety, depression, maladjustment issues and post- traumatic stress for a duration of several months. As a partial responder to full trial of SSRI he was enrolled for EMDR therapy to address his symptoms of intense anxiety, panic attacks, being overwhelmingly fearful, depressed, low self-esteem, inappropriate feelings of guilt, flashbacks, avoidance, nightmares, hyper-arousal and inability to perform as a judicial head in active war stricken area of northern Pakistan. Complete psychiatric evaluation was carried out and after the discontinuation of SSRIs he was scored on Impact of Event Scale [IES]. He fulfilled the diagnostic criteria for PTSD as evaluated by the English version of the PTSD module of the Structured Clinical Interview for DSM-IV administered once before commencement of EMDR. Safe place of the client was established and 8 staged protocol of EMDR was started with him. Multiple EMDR sessions were conducted. The case presented in this paper had multiple psychological trauma forms and failed drug treatment and yet it was observed that EMDR provided marked improvement in all the domains of his deficits and this was at a prompt speed as compared to cognitive behavioural therapy [CBT] which usually takes longer duration of therapy to achieve similar results. EMDR provides marked improvement in all domains of complex mental trauma and traumatic memories. Improvement attained was prompt and enduring as compared to other forms of established therapies and drug treatment indicating permanent changes happening at neurobiological levels of brain

Short duration medical education workshops - analysis of participants' response

The aim of present study was to assess the response of the participants of short duration medical education workshops [one day, approximate 4-5 hours duration] conducted by the faculty of department of medical education. A descriptive study. Study was carried out by the Department of Medical Education [DME], Army Medical College, Rawalpindi, Pakistan from 2008 to 2010. Between 2008-2010, five teacher educational workshops were arranged by the department of medical education [DME], Army Medical College, Rawalpindi, Pakistan. Both clinical and pre-clinical teachers attended the workshop. Considering the very busy schedule, particularly of the clinical teachers the workshops were planned as short duration [one day] and contents of workshop were therefore very carefully selected. A total of 120 teachers participated in five workshops and at the end of workshop a questionnaire was filled by each participant. A total of 120 participants attended the five different workshops. The duration of workshop, which was our main concern, was regarded adequate by most of the participants, 53-96% and rest responded the duration as short particularly case base learning [CBL] workshop. Surprisingly one participant of assessment technique and 2 participants of OSCE, OSPE workshop, thought the duration to be long. The handouts were regarded as useful [55-70%] very useful [30-45%]. Computer presentations and transparencies were regarded as above average by majority [52-78%]. The facilitation by the facilitators was well appreciated with >80% responding as top scale, majority of the participants regarded these as very useful activity and stressed to continue such activities. Majority of the participants responded the short duration workshops in very positive way and found them useful for teachers training

Adverse metabolic effects of conventional and atypical antipsychotics: a comparative study

To compare the adverse metabolic effects [changes in Body Mass Index, fasting blood glucose and serum cholesterol levels] of conventional and atypical antipsychotics in patients of psychosis. Randomized Control Trials [RCT]. Department of Psychiatry, Military Hospital Rawalpindi from August 2007 to August 2008. A total of 110 patients were assigned to treatment with haloperidol [n=35], risperidone [n=36] and olanzapine [n=39]. Fasting blood glucose, serum cholesterol levels and BMI were computed at baseline and subsequently repeated at 2nd week, 6th week and 8th week of treatment. In all the subjects, all the blood samples were drawn as a fasting sample in early morning. ANOVA analyses indicated that changes in mean fasting glucose and cholesterol levels reached significance in period 2 [from 2nd week to 6th week] but not in period 1 [from 0 to 2nd week] and period 3 [from 6th week to 8th week]. The increase in mean fasting glucose and cholesterol levels over time reached statistical significance in the olanzapine group after 6 weeks. No significant change in glucose was detected in the haloperidol and risperidone groups. The largest weight gain was seen with olanzapine [mean=2.4 Kg], followed by risperidone [mean=1.25 Kg]. There was minimal weight gain with haloperidol [mean=0.3 Kg]. There was a higher risk of adverse metabolic effects with olanzapine treatment as compared to risperidone and haloperidol in the study population. The metabolic effects appear between 2 to 6 weeks after starting treatment.

Conventional and atypical antipsychotics; changes in glucose and cholesterol levels

The objective of the study was to compare changes in fasting blood glucose and serum cholesterol levels following initiation of conventional and atypical antipsychotics in patients of psychosis. Study An Interventional Comparative design was used. The study was conducted at Department of Psychiatry, Military Hospital Rawalpindi from August 2007 to August 2008. Patients and A total of 110 patients were assigned to treatment with haloperidol [n=35], risperidone [n=36] and olanzapine [n=39]. Fasting blood glucose and serum cholesterol levels were recorded at baseline and subsequently repeated at 02nd week, 06th week and 08th week of treatment. In all the subjects, all the blood samples were drawn as a fasting sample in early morning. ANOVA analyses indicated that changes in mean fasting glucose and cholesterol levels reached significance in period 2 [from 2nd week to 6th week] but not in period 1 [from 0 to 2nd week] and period 3 [from 6th week to 8th week]. The increase in mean fasting glucose and cholesterol levels over time reached statistical significance in the olanzapine group after 6 weeks. No significant change in glucose was detected in the haloperidol and risperidone groups. There is a higher risk of hyperglycemia and hypercholesterolemia with olanzapine treatment as compared to risperidone and haloperidol in the study population. These changes appear between 2 to 6 weeks after starting treatment

Trigyclic anti depress ants; efficacy of the treatment of depression, with and without therapeutic drug monitoring; a comparative study

Despite advancements in the treatment of depression and availability of newer compounds, TCAs like amitriptyline remain to be the cornerstone of antidepressive therapy for more than three decades, however significantly more patients receiving a tricyclic withdraw from treatment mainly because of side effects. Higher response, lower incidence of side effects and improved compliance can be enhanced by the optimal use of Therapeutic Drug Monitoring [TDM]. No research data is currently available on the therapeutic drug monitoring of TCAs in Pakistan. To compare the relative efficacy of Tricyclic antidepressant in the treatment of depression, with and without Therapeutic Drug Monitoring Changes in HAMD scores in patients on TCAs. A Quasi experimental study design was used. The study was conducted at Department of Psychiatry, Military Hospital Rawalpindi. 34 patients completed the study in the monitored group [with TDM] and 33 in control group [without TDM]. Serum TCA levels and HAMD scores at baseline and subsequently at sixth, eighth and tenth week of treatment were collected. In all the subjects, all the blood samples were drawn as a fasting sample in early morning. The mean age of the monitored group was 31.97 years [SD=10.432] while that of the control group was 33.52 years [SD=9.385]. in the monitored group 20 [58.82%] of the patients were males while 14 [41.17%] were females, in the control group 22 [66.66%] were males and 11 [33.33%] were female patients. A significant reduction in HAMD scores was noted at 8 weeks of treatment. The groups did not differ in terms of efficacy of TCAs, however the monitored group had fewer dropouts than the control group. Lower incidence of side effects and improved compliance can be enhanced by the optimal use of Therapeutic Drug Monitoring [TDM] of TCAs

Psychosocial impact of October 2005 earthquake on children and adolescents aged 9 to 18 years, assessed after one year in Kashmir, Pakistan

On 8 October 2005, an earthquake of 7.6 magnitude hit Pakistan leaving about 75,000 dead and thousands homeless. Worst damage was in the territory of Kashmir. Children exposed to a natural disaster can develop symptoms of post-traumatic stress symptoms and disorder whose prevalence, associated symptoms and vulnerability varies from population to population. To asses post-traumatic stress symptoms and disorder, associated other symptoms and trauma related risk factors in children and adolescents one year after the earthquake. This is a comparative study to assess post traumatic stress disorder in children who faced the disasters of earthquake and comparisons were made with same age and gender children who faced the earthquake but did not face the disaster. The psychometric tools included Impact of Event Scale, Strengths and Difficulties Questionnaire and post-traumatic stress symptoms and disorder part of Kiddie-SADS Present and Lifetime [K-SADS PL] version 1.0. The mean age of cases was 11 years and they showed significantly high [p=0.03] levels of psychological impact of the disaster [49.2%] as compared to the controls [12.8%]. They also showed more difficulties in coping with life [mean SDQ=18] as compared to the controls [mean Strengths and Difficulties Questionnaire = 21]. Posttraumatic Stress Disorder was 8.6% in the exposed group and 1.2% in control group. A considerable proportion of children and adolescents exhibited difficulties as post-traumatic symptoms, and 8.6% had the psychological disorders. Policy message: Health care providers should be aware that children and adolescents need psychological evaluation and therapy in post disaster situations

Biological markers of psychological trauma: a review

To review current evidence on the patho-physiology of psychotrauma and its biological markers. The authors made a comprehensive literature search using internet databases, PubMed, Medicine and google search engine, Am J Psychiatry, British Journal of Psychiatry, Arch Gen Psychiatry, J Neurosci, ISTSS journal for evidence for biological markers of Psychotrauma spanning over a period last 28 years, up to 1980. The key words used for the search were psychotrauma and biological marker. A total of 109 papers and articles were included in the study. The patho-physiology of psychotrauma involves a complex interplay between trauma-related factors and the neurobiological and psychosocial influences that determine individual differences in resilience and vulnerability. In psychotrauma, dysregulation of HPA axis takes place associated with changes in autonomic nervous system. The structures mostly related to psychotrauma are amygdale, hippocampus, anterior cingualte cortex, prefrontal cortex etc. The related hormones are CRF, ACTH, Cortisol, Catecholamines, Serotonin, GABA, Dopamine, Opioids, and Substance P. Psychotrauma is not a mere psychological or a social pathology. There are clear and well-defined biological markers of the change seen in consequence to exposure to trauma. The understanding of patho-phsyiology of the consequent disorders is however still infancy. This calls for consorted scientific enquiry into the biological basis of psychotrauma through rigorous methods

Mental illness and violence: myth and reality

To compare the frequency and risk factors of violent behaviour in psychiatric patients, non-psychiatric patients and healthy population with the violent criminal offenders. A cross-sectional analytical survey. The study was conducted at three tertiary care facilities in Lahore. The sample of criminal offenders was drawn from Kot Lakhpat jail, Lahore and the study was completed in six months. One hundred and twenty subjects between the ages of 18-60 years were included in the study with 30 subjects being drawn from each population group. The psychiatric patients were those admitted with a diagnosis of a major psychiatric disorder such as schizophrenia, affective disorder, personality disorder and substance abuse based on ICD-10. The variables were categorised into personal, historical, contextual and clinical and endorsed by trained rating staff at each facility after interviewing every subject. Psychopathy, anger and impulsiveness were measured by using the Psychopathy Checklist, Novaco Anger Inventory and Barrett Impulsiveness Scale respectively. Psychiatric morbidity was excluded from the non-psychiatric and criminal population by using the General Health Questionnaire [GHQ-12]. Amongst the demographic variables, age group [18-45 yrs 58.2%] and marital status [single 70%] were significantly associated with a history of violence. Other significant associations with violence included presence of violent fantasies [85%], ideas of self harm [70%], drug abuse [87%] and high scores on psychopathy and impulsiveness scales. The violent criminal population scored high on psychopathy [>12 SD=4.9] and impulsivity [>72 SD=10]. Mean scores of psychopathy and impulsiveness for the psychiatric population sample dropped significantly when cases of drug abuse and personality disorder were excluded. Patients with major psychiatric disorders as a group are not as violent as criminals. It is not the mental illness but history of drug abuse, deliberate self-harm, psychopathy and impulsiveness that are the common denominators in violent individuals, irrespective of a psychiatric diagnosis

Suppression of humoral immune response due to psychological stress in survivors of large scale natural disaster

To study the impact of psychological stress following a natural disaster on specific immunological parameters. The study was carried out over a 3 month period [Feb 2006 to May 2006] at the Armed Forces Institute of Pathology, Rawalpindi, Pakistan. Physically uninjured male adults between 15-60 years of age, with no prior history of an active physical or psychological disorder, who witnessed the earthquake on 8[th] Oct, 2005 in Pakistan but escaped physical injury, were included in the study. Age and gender matched healthy adults were also studied as control group. Analysis of haemoglobin, total leucocyte count, lymphocyte count, lymphocyte subsets, IgG, IgA, IgM levels, C reactive protein and nitrobluetetrazolium [NBT] dye reduction test was carried out on both the groups. Psychologically distressed individuals had increased CD 3+ cells [p=0.02], increased CD4:CD8 ration [p=0.04], reduced CD19+ cells count [p=0.03] and IgG levels [p=0.01]. Neutrophil oxidative burst activity without stimulation was increased [p=0.02]. Psychological stress consequent to exposure to a natural disaster can suppress humoral immune response

pattern of psychiatric morbidity in attendees of a dermatology clinc

The purpose of the study was to document the prevalence and pattern of psychiatric morbidity in dermatology outpatient clinics and to identify the risk factors for development of psychiatric disorders in patients with skin diseases. Descriptive study. A random sample of one hundred and fourteen patients attending Out Patient Department [OPD] of Dermatology at C.M.H Lahore was screened for psychiatric complaints by using Urdu version of General Health Questionnaire - 12. Patients scoring "two" and above on GHQ-12 were selected for the stage two interview based on Present State Examination. The final diagnosis was on criteria of International Classification of Diseases - 10. Those who had no diagnosable psychiatric illness were placed in non-ill or group "N". Those scoring >/= 2 on GHQ - 12 and confirmed to have psychiatric morbidity on clinical interview by a psychiatrist were placed in ill group "D". Out of 114 patients having dermatological disorders, 39 [34.11%] had psychiatric morbidity. Amongst psychiatric disorders depression was seen in 25 [21.9%], and Anxiety in 11 [9.64%], other diagnoses are uncommon. Commonest psychological symptoms reported by patients are loss of interest, reduced self-esteem, tendency to avoid people, depressed mood, disturbed sleep and ideas of self-harm. Extensive skin lesions on the exposed parts of the body and more than six months duration of skin complaints were major risk factors for psychiatric illness. Patients with chronic disfiguring lesions like acne, eczema, psoriasis and vitiligo have more chances to develop psychiatric morbidity. It is concluded that one-third of dermatology patients have significant psychiatric morbidity and with little training dermatologists can reliably identify psychiatric morbidity by simple inquiry and use of GHQ - 12, as screening instrument, which can be helpful in early detection and management of psycho-dermatological disorders

Mental health and psychosocial relief of earthquake survivors - activities and interventions

Earthquakes are natural calamities which are unpredictable and destructive in nature. The October 8[th], 2005 quake put forth a challenge for the whole nation. The authors describe the methods of appraisal of the situation, methods of needs assessment in emergency phase of disaster, organization of mental health relief efforts and implementation strategies of these services for the survivors, keeping in line with local cultural and social needs and consensus of world authorities on trauma psychiatry and disaster management. Three specific needs were identified, namely, need for psychosocial services for majority of the population, need for people in psychological distress requiring Psychological first aid and people with severe mental illnesses requiring long term psychiatric management. With the objectives of ensuring availability of Psychological first aid to maximum, early detection, intervention and establishing a chain of referral for the severely affected cases, incorporating psychosocial care and rational use of psychotropic in medical and surgical care at all tiers of health services, public mental health education, community mobilization and caring for the relief workers, the Dept. of Psychiatry MH Rawalpindi launched the comprehensive plan for the earthquake survivors. The summary describes the services rendered by the teams of the Dept. during the six months in tabulated forms