Why Do People Live or Die? A Retrospective Study from a Crisis Intervention Clinic in North India.

Background: Suicide results from complex interactions of various risk factors-reasons for dying (RFD)-and protective factors-reasons for living (RFL). Suicide is not necessarily a wish to die but may be an appeal for help. We analyzed RFD and RFL in persons who had attempted suicide, through their clinical records at a Crisis Intervention Clinic (CIC). Methods: We retrospectively analyzed demographic and clinical data, and classified RFD and RFL, among patients with either ideas or attempt of suicide registered at our CIC (N = 83). Using two open-ended questions from the clinical history data, we derived their RFD or RFL; (n = 53) completed these questions regarding RFD-RFL. Results: In the total sample, males and females were equally represented and educated, but males were significantly older. Most common diagnosis was nonpsychotic mood disorder. Commonest mode of suicide attempt was hanging. Family conflict vs. family responsibility, hope vs. hopelessness, stressful life events, and negative cognitions about the self and the world were important RFD. RFL included feeling responsible, love for family and for self, hope, career success, and religious beliefs. Conclusion: RFD and RFL could both be grouped in similar categories related to family, career, hope, etc.

Feasibility, acceptability and evaluation of meditation to augment yoga practice among persons diagnosed with schizophrenia.

OBJECTIVE: To design a meditation protocol and test its feasibility, acceptability and efficacy in conjunction with yoga training (YT) for persons with schizophrenia (SZ). METHODS: The meditation protocol consisted of Anapana (observing normal respiration) and Yoga Nidra (supine, restful awareness). In a single-blind randomised controlled trial, medicated and clinically stable outpatients diagnosed with SZ were randomised to receive treatment as usual (TAU), TAU augmented with YT or TAU augmented with meditation and yoga training (MYT) for 3 weeks (N = 145). Acceptability, clinical, social and cognitive functions were assessed after 3-week and 3-month post-randomisation using within-group and between-group analyses with repeated measures multivariate tests. RESULTS: No group-wise differences in compliance, study discontinuation, major/serious side effects or adverse events were noted. For six assessed clinical variables, the direction of changes were in the desired direction and the effect sizes were greater in the MYT group compared with the TAU group at both time points. Changes in social function variables were greater at 3 months than at 3 weeks. Nominally significant improvement in individual cognitive domains were noted in all groups at both time points. All effect sizes were in the small to medium range. CONCLUSION: MYT is feasible and acceptable and shows modest benefits for persons with SZ. MYT can also improve quality of life and clinical symptoms. Larger studies of longer duration are warranted.

A Randomized Controlled Trial to Assess Feasibility and Acceptability of Telephone-Based Psychosocial Interventions in Individuals who Attempted Suicide.

BACKGROUND: Brief contact interventions such as telephone-based contacts appear to be useful in individuals who attempted suicide. Most studies of telephone-based contacts in such individuals typically consisted of frequent phone reminders for adherence to treatment and seeking help for mental health issues. Telephone-based psychosocial interventions that incorporate elements of supportive and problem-solving strategies are of interest in Indian settings due to their potential application in mitigating the wide mental health gap. Feasibility studies of telephone-based psychosocial interventions could help ascertain the difficulties that arise in the implementation of such treatments. METHODS: A multicentric randomized controlled trial (RCT) is currently underway in general hospital settings in two Indian cities to study the efficacy of telephone-based psychosocial interventions in individuals with a recent suicide attempt, with routine telephone contacts (TCs) serving as the comparator. Prior to that RCT, this feasibility study was conducted to assess the acceptability of the telephone-based intervention and telephone contacts. Feasibility was assessed using dropout rates. Acceptability was assessed using participant-rated Likert-based visual analog scores from 0 to 10, with higher scores indicating greater acceptability. RESULTS: Dropout rates and mean acceptability scores for telephone-based psychosocial interventions were 38.5% and 8.63, while those for TCs were 41.7% and 7.57, respectively. CONCLUSIONS: Telephone-based psychosocial interventions are feasible and acceptable in individuals with a recent suicide attempt.

Schizophrenia with and without obsessive-compulsive symptoms: a comparative analysis of performance on trail making test and disability on WHODAS.

BACKGROUND: Presence of obsessive-compulsive symptoms (OCS) affects performance on tests of some cognitive functions, such as the trail making test (TMT), and may affect the level of disability in schizophrenia (SZ). AIMS: The aim of the present study was to compare performance on TMT and disability on WHO Disability Assessment Schedule (WHODAS) in persons with SZ with and without OCS in a cross-sectional study. METHODS: Persons with SZ (n=200) fulfilling DSM-V (Diagnostic and Statistical Manual) diagnostic criteria were assessed on Yale Brown Obsessive Compulsive Scale (YBOCS) and divided into two groups based on presence or absence of OCS. TMT and WHODAS V.2.0 were applied. The two groups as a whole, as well as a subsample matched on age, gender and age of onset were compared. RESULTS: Out of 200 persons with SZ, 37 (18.5%) reported OCS. The OCS group took a significantly longer mean time to complete TMT-A (Z=-3.02, p=0.003) as well as TMT-B (Z=-3.551, p<0.001). Significant correlations were found between TMT-A and total YBOCS Scores (r=0.351, p=0.033), as well as TMT-A and YBOCS compulsion scores (r=0.404, p=0.013) but not with TMT-B Scores. The OCS group reported greater disability in all domains separately as well as on average WHODAS Scores (Z=-5.969, p<0.001). Significant correlations were found between YBOCS obsession scores and YBOCS total scores with average WHODAS Scores (r=0.614, p<0.001 and r=0.406, p=0.013, respectively). We obtained essentially similar results with the matched subsample as well as with the entire group. CONCLUSION: Persons with SZ and comorbid OCS had significantly poorer performance on TMTs and greater disability in comparison to persons with SZ alone. Magnitude of disability correlated with severity of OCS.

Psychiatric Problems Amongst Adolescents Living With HIV at a Tertiary Care Centre in India.

OBJECTIVE: To assess the prevalence of psychiatric problems among adolescents living with HIV (ALHIV). METHODS: Questionnaire-based cross-sectional study conducted at pediatric HIV clinic of a tertiary care hospital. Participants: 101 ALHIV between 10-18 years of age. RESULTS: Of the 101 ALHIV, 12 (11.88%) met criteria for psychiatric disorders, of which dysthymi (5,41.6%) and oppositional defiant disorder (6,50%) were the commonest. Father of 7 (58.34%) and mother of 8 (66.6%) screen positive patients were dead as compared to 22 (24.7%) and 13 (14.6%) of screen negative patients (P=0.016 and P=0.0003, respectively). CONCLUSION: Psychiatric problems are common in ALHIV in the age group more than 15 years.

A preliminary study to investigate resting state fMRI as a potential group differentiator for schizophrenia.

Schizophrenia (SZ) is found to be associated with dysconnectivity between the various regions of the brain. These aberrant connections in brain networks responsible for various mental processes in schizophrenia. We examined differences in functional connectivity among persons with SZ (n = 30) and an equal number of their unaffected relatives using resting state functional Magnetic Resonance Imaging (rsfMRI). Subjects were interviewed using the Diagnostic Interview for Genetic Studies (DIGS) and Family Interview for Genetic Studies (FIGS). Cognition was assessed using the Computerized Neuropsychological Battery (CNB) and Trail Making Tests A and B. The resting state functional data were acquired using 3.0 T Magnetic Resonance Imaging system and analysed using Statistical Package for the Social Sciences (SPSS) version 21 and FSL version 5.01 (FMRIB's) Software. The persons with SZ performed significantly worse on tasks of cognition and executive functioning. On rsfMRI, a significantly reduced connectivity was noted in the case group in right and left precentral gyri, right post central gyrus, right and left middle temporal gyrus, left paracingulate gyrus, anterior and posterior cingulate, right planum temporale, right pallidum, left cerebellum-6,7b and 8 lobules. Increased connectivity was noted between areas of right temporal pole and left hippocampus, posterior cingulate and the precuneus, right planum polare and right amygdala, right Heschl's gyrus and left posterior supramarginal gyrus, right amygdala with right insular cortex and left cerebellum 6 with bilateral postcentral gyrus in the same group. These differences in connectivity could be utilised as potential group differentiator for schizophrenia.

Protocol of a Multi-centric Randomized Controlled Trial to Evaluate Efficacy of Telephone-Based Psychosocial Interventions on Future Suicide Risk in Suicide Attempters.

BACKGROUND: Persons with previous history of a suicide attempt are at increased future risk of death by suicide. These vulnerable individuals, however, do not seek receive or seek help from mental health services. Telephone-based psychosocial interventions are potential strategies in augmenting mental health care in such persons. METHODS: We aim to compare the efficacy of telephone-based psychosocial interventions (TBPI) with routine telephone reminders in persons with recent suicide attempts using a multi-site, parallel group, rater-blind, two-arm randomized controlled trial design in 362 participants. In the first group, participants will receive three sessions of TBPI comprising of brief supportive interventions, problem-solving strategies, and reminders for adherence to prescribed mental health treatment at weekly intervals. In the second group, participants will receive three telephone reminders for adherence to prescribed mental health treatment at weekly intervals. We will follow up participants for 6 months. Primary outcomes are suicidal ideation scores on Beck's Scale for Suicide Ideation and number of repeat suicide attempts. Secondary outcomes are scores on Beck's Hopelessness Scale, Beck's Depression Inventory, Connor-Davidson Resilience Scale and Visual Analogue Rating Scales for acceptability of interventions. Outcomes will be assessed at 1, 3, and 6 months after receiving telephone interventions or reminders. RESULTS: The trial is currently underway after prospective registration under Clinical Trials Registry of India and has recruited 260 participants till August 15, 2020. CONCLUSION: This study has potential to generate evidence on additional strategies for use along with standard mental health treatments in management of high-risk suicide behaviors.

Perceived parental style, cognitive style, and resilience in females with dissociative disorder in India.

BACKGROUND: Dissociative disorders are theorized to be caused by extremely stressful situations, including abuse, kidnapping, incest, rape, and other threats of death. Such childhood experiences alter one's cognitive style as well as one's ability to deal with adverse situations. It is important to understand how cognitive style influences the relationship between parental style and resilience to help in the management. We aimed to assess the relationship between perceived parental styles and resilience mediated by cognitive styles in females with dissociative disorder. MATERIALS AND METHODS: Sample comprised 60 females between 18 and 50 years of age with dissociative disorder (International Classification of Diseases-10 criteria) in a cross-sectional observational study. Perceived parental style of the participant was assessed using s-EMBU, cognitive style using the Cognitive Style Inventory, and resilience using the Conner and Davidson's Resiliency Scale. Data were analyzed using Shapiro-Wilk to assess the normality of the data and Spearman rank correlation for determining the relationship between the variables. RESULTS: The results indicated a significant relationship between emotional warmth and systematic-cognitive style (r s= 0.398, P = 0.01) and between systematic-cognitive style and high resilience (r s= 0.256, P = 0.05). A significant regression equation was found (F[1, 58] = 9.146, P < 0.004), with an R2= 0.136 to predict systematic-cognitive style based on emotional warmth as the perceived parental style. To predict resilience based on systematic-cognitive style, a significant regression equation was found (F[1, 58] = 6.006, P < 0.017), with an R2= 0.094. CONCLUSION: The more emotional warmth was perceived by the participants, the more systematic they were in their perception of the environment, in turn being more resilient. The study findings help in establishing protective psychological factors in dissociative disorder.

Prevalence and clinical correlations of obsessive-compulsive symptoms in schizophrenia.

INTRODUCTION: Obsessive compulsive symptoms are often present in persons with schizophrenia. Adequately powered studies to evaluate the effect of such symptoms in the course of the disorder, are few. AIM: We aimed to estimate the prevalence and type of obsessive-compulsive symptoms in persons with schizophrenia. METHODS: We evaluated 200 outpatients with schizophrenia (DSM-V) on the Positive and Negative Symptom Scale (PANSS) and the Yale Brown Obsessive Compulsive Scale (YBOCS). Participants with or without obsessive compulsive symptoms were matched on age, gender and age of onset of schizophrenia. Appropriate analysis by comparisons and correlations were performed. RESULTS: Prevalence of obsessive-compulsive symptoms was 18.5% (n = 37/200). Most common obsession was contamination and compulsion was cleaning/washing with a prevalence of 51.35% and 63.33% respectively. There were no significant differences between the two groups on age, gender, marital status, residence, age of onset or total duration of illness of schizophrenia. The OC symptoms group had significantly higher general psychopathology and PANSS total scores. There was significant positive correlation between YBOCS total obsession scores (To) and total PANSS scores (r = 0.358) (p = 0.030), as well as PANSS general psychopathology subscale scores (Gt) (r = 0.395) (p = 0.016) and finally between total YBOCS scores (To + Tc) and PANSS positive subscale scores (Pt)(r = 0.344) (p = 0.037). CONCLUSION: There was a significant subgroup of schizophrenia patients (almost one fifth) who complained of obsessive-compulsive symptoms. This group reported significantly higher general psychopathology and could thus be said to be more seriously ill, in an adequately powered cross sectional study.

Relationship between Craving and Early Relapse in Alcohol Dependence: A Short-Term Follow-up Study.

BACKGROUND: The role of craving in alcohol dependence and its relationship with relapse has been studied widely in the past decade. The present study was undertaken to assess the role of craving in short-term relapse of patients seeking treatment for alcohol dependence and changes in craving score at the end of detoxification and at follow-up. MATERIALS AND METHODS: A total of 34 male individuals with alcohol dependence (excluding comorbid drug dependence, organic or psychiatric disorder), after detoxification and discharge, consented. No anticraving medicine, aversive or psychotherapy, was advised. They were diagnosed on the International Statistical Classification of Diseases-10 using Diagnostic Interview for Genetic Studies. Severity of Alcohol Dependence Questionnaire (SADQ) and Clinical Institute Withdrawal Assessment Scale-Alcohol-Revised (CIWA-AR) were administered at the time of admission. Penn Alcohol Craving Scale (PACS) was applied at the time of discharge and follow-up to measure craving for alcohol. RESULTS: Out of a total of thirty patients analyzed after dropout, 21 relapsed at the end of 1 month. On comparing PACS scores between relapsed and nonrelapsed patients, the difference was significant at both time points, i.e., at discharge and follow-up (t = 4.15, P < 0.0001 and t = 4.01, P < 0.001, respectively). In the total sample, SADQ and CIWA-AR scores were positively correlated (r = 0.47, P = 0.009). PACS at discharge was compared with PACS at follow-up, of which the correlation was high (r = 0.832, P < 0.0001). CONCLUSION: Craving seems to be a main factor related to relapse. Its measurement with PACS can be a useful tool to predict subsequent drinking and to identify individual risk for relapse during treatment.

A preliminary study of association of genetic variants with early response to olanzapine in schizophrenia.

BACKGROUND: Treatment response can be predicted in schizophrenia by DNA information in the drug metabolism pathways. This study aimed to examine clinical characteristics and genetic determinant (s) of early response to olanzapine treatment in schizophrenia using specified drug metabolizing genes. MATERIALS AND METHODS: Consenting participants (n = 33) suffering from schizophrenia were diagnosed on Diagnostic Interview for Genetic Studies. Oral olanzapine was administered in an incremental dose up to 10 mg (2 weeks) and 20 mg (6 weeks). All participants were tested on Positive and Negative Syndrome Scale, Clinical Global Impressions, and Global Assessment of Functioning at 0, 2, and 6 weeks. Side effects were also evaluated. After 2 weeks, 11 (33.33%) fulfilled criteria for early response, whereas 17 (51.52%) responded at 6 weeks. We investigated the contribution of clinical factors and five polymorphisms (rs2740574, rs2470890, rs762551, rs3892097, and rs1065852) in predicting response to olanzapine at 2 and 6 weeks of treatment with a standard dose. RESULTS: Severity of positive symptoms at baseline was associated with response at 2 weeks (P = 0.01) while higher scores on Scale for the Assessment of Negative Symptoms (SANS) at baseline was associated with response at both 2 (P = 0.04) and 6 weeks (P = 0.03). None of the five single nucleotide polymorphisms (SNPs) selected were significantly associated with response to olanzapine. CONCLUSIONS: Olanzapine is an effective and safe drug. Positive and Negative Syndrome Scale positive score and SANS score were variably associated with response at 2 and/or 6 weeks. Replicate studies with bigger sample size are warranted for conclusive results in the Indian population for genetic association.

Emotion discrimination in humans: Its association with HSV-1 infection and its improvement with antiviral treatment.

BACKGROUND: Herpes simplex virus, type 1 (HSV-1) infects over 3.4 billion people, world-wide. Though it can cause encephalitis, in the vast majority it is asymptomatic, with lifelong latent infection in neurons. HSV-1 infected individuals have greater cognitive dysfunction than uninfected individuals, particularly persons with schizophrenia - even without encephalitis. We investigated whether HSV-1 related cognitive dysfunction is progressive or remediable. METHODS: In a prospective naturalistic follow up sample (PNFU), temporal changes in cognitive functions were analyzed in relation to baseline HSV-1 infection in persons with/without schizophrenia (N=226). Independently, in a randomized controlled trial (RCT), HSV-1 infected, clinically stabilized SZ outpatients received Valacyclovir (VAL, an HSV-1 specific antiviral, 1.5G twice daily for 16weeks) or placebo (PLA) added to standard antipsychotic treatment, using a stratified randomization design, following placebo run-in (N=67). In both samples, HSV-1 infection (seropositivity) was estimated using serum IgG antibodies. Clinical evaluations were blinded to HSV-1 or treatment status. Standardized Z scores for accuracy on eight cognitive domains were analyzed for temporal trajectories using generalized linear models (PNFU) and VAL/PLA differences compared with intent to treat analyses (RCT). RESULTS: PNFU: At baseline, HSV-1 infected participants had significantly lower accuracy scores for Emotion Identification and Discrimination (EMOD), Spatial memory and Spatial ability, regardless of SZ diagnosis (p=0.025, 0.029, 0.046, respectively). They also had significantly steeper temporal worsening for EMOD (p=0.03). RCT: EMOD improved in VAL-treated patients (p=0.048, Cohen's d=0.43). CONCLUSIONS: A proportion of age related decline in EMOD is attributable to HSV-1 infection.

Self-harm and suicide attempts in Schizophrenia.

BACKGROUND: The risk of suicide among persons with schizophrenia (SZ) is higher than in general population, with multiple contributory factors. We assessed the prevalence of risk of deliberate self-harm and suicide attempts, along with associated socio-demographic and clinical factors in a group of SZ outpatients (n=61) as part of a larger study on overall schizophrenia-associated risks. AIMS: To investigate factors associated with risk of deliberate self-harm and suicide among persons with schizophrenia. METHOD: Out of 270 SZ participants evaluated for various risks using Ram Manohar Lohia Risk Assessment Interview (RML-RAI), 61 reported risk of self-harm including suicide attempt/s. The factors associated with this risk were further evaluated on clinical details and Diagnostic Interview for Genetic Studies. RESULTS: Risk of reported self-harm was 22.59%. Among them, 10% had attempted suicide at least once. Current age and past month Global Assessment of Functioning score from DIGS (GAF) were significantly correlated with suicide attempt. Attempters had significantly lower current GAF score, indicating poorer functioning. Among 27 attempters, 9 attempted at the onset of illness while 6 others attempted suicide within one year. Most common method of attempt was ingestion of insecticides or overdose of medication, followed by hanging or jumping from height. CONCLUSION: In our hospital-based sample of suicide attempters, 10% had attempted suicide, among them over 55% within first year of illness. Attempters were significantly older than non-attempters and suffered from significantly more severe illness than non-attempters. Positive symptoms were significantly associated with attempt, irrespective of time at which suicide was attempted.

F-18 fluorodeoxyglucose positron emission tomography study of impaired emotion processing in first episode schizophrenia.

BACKGROUND: Schizophrenia cases have been consistently shown to have behavioural and neurofunctional abnormalities but studies during early course are scarce. The present work assesses the performance of acute first episode schizophrenia cases on correlation of a facial emotion perception task with brain function using fluorine-18 fluorodeoxyglucose (FDG) positron emission tomography (PET). METHODS: Twenty First episode schizophrenia cases and 20 matched healthy controls living in the community were enrolled. For cases, longest duration of illness was one year and treatment with neuroleptic did not exceed two weeks on the day of scan. To measure facial emotion perception (FEP) both groups were administered the Emotion battery from the Penn Computerized Battery followed by PET acquisition. SPM 8 analysis for group differences at p<0.001 was performed. RESULTS: Schizophrenia subjects showed hypoactivation of bilateral prefrontal cortices and fusiform gyrii, with significant hyperactivation of bilateral basal ganglia and left precuneus. Positive correlation of metabolism in prefrontal cortex and performance indices on emotions domain was seen. No correlation of chlorpromazine equivalent days with metabolism in basal ganglia was observed. CONCLUSIONS: The performance of schizophrenia cases on FEP task was significantly impaired in comparison to the control group. Brain regions implicated in emotion processing showed hypometabolism in cases as compared to controls. Failure of schizophrenia cases to optimally recruit brain circuitry may be contributing to deficits on FEP task. These findings suggest inherent deficits in neural circuitry of emotion processing in schizophrenia; devoid of confounding effects of neuroleptics and duration of illness.

A Hindi version of the Composite Scale of Morningness.

BACKGROUND: Several pen and paper measures of human circadian preference are available in English, but none are available in Hindi, hampering research in circadian behavior among Hindi speaking populations in India and elsewhere. The present study describes a Hindi version of the Composite Scale of Morningness (CSM), a self-reported questionnaire widely used to assess morningness/eveningness (M/E). M/E has been used a proxy for circadian phase in lieu of cumbersome and expensive laboratory studies. METHOD: The thirteen item English version of the CSM was translated into Hindi and independently back translated into English. Inconsistencies between the original and back translated versions were then resolved. Both versions were next administered to bilingual persons at Delhi, India (N=130). After intra-class correlations between the Hindi and the English versions were examined, the Hindi version was administered to community based participants representing different age groups (N=310). RESULTS: There was satisfactory intra-class correlation (ICC) between the total scores for the Hindi and the English versions of the CSM (Cronbach's alpha=0.873), with variation for individual items scores. Total CSM scores in the second sample suggested a significant association with age, consistent with published reports with the English CSM, i.e., morningness tendencies were more likely to be reported by older adults. Significant associations with gender or educational status were not observed. CONCLUSIONS: The Hindi CSM is a brief questionnaire that provides behavioral measures of diurnal preference. It is freely available for research in Hindi speaking populations.