Psychiatry-past, present & future.

An overview of psychiatry during the last three decades as practised in a general teaching hospital is presented. Psychiatry as an academic subject has matured tremendously during this period. The empirical treatments of the 1950s and the 1960s which evoke nostalgic memories, have been replaced by modern methods of treatment. However, there is a need to exercise caution against the blind acceptance of new and sophisticated research findings in biological psychiatry. Inspite of the bright future facing psychiatry, the identity of psychiatry as a medical discipline must be preserved at all cost. Psychiatrists should also realise the dangers of gradual fractionation and impersonalisation which threatens the speciality, and makes all possible efforts to prevent this.

A psychiatric evaluation of referred cancer and medical patients: a comparative study.

We evaluated the psychiatric status of referred cancer patients (N = 39) and referred medical patients at two other institutions (N = 64, N = 62). Depression, anxiety, psychosis, delirium occurred with comparable frequency in both groups. Cancer patients presented with somatic complaints more frequently. However the average number of referrals of cancer patients to the psychiatric service was very low (3/months) compared to referral of medically ill patients (32/month, 10/month). The data suggests that a comparable level of psychological distress exists in cancer patients, and psychiatric referral may help in its early recognition and alleviation.

Delay in specialist consultation in cancer patients.

A psychiatric evaluation of 75 cases of different types of cancer revealed significant psychological morbidity in 81% of cases. The time lag, if any, between primary diagnosis and presentation to oncologists was noted and the reasons for the delay were ascertained. 62% of patients (N = 47) delayed three months or more and this group also showed significantly greater (p < 0.05) psychological morbidity compared to those who delayed less than three months (N = 28). 89% of patients used denial as a mental defence mechanism and there was no significant difference in the degree of denial displayed by both groups. Psychological reasons such as denial of the illness, fear of cancer, fear of its treatment, and domestic difficulty were commonly cited as causes of delay. It is hoped that addressing these issues will reduce delay and help early detection in cancer programmes.

The Explanatory Model Interview Catalogue (EMIC). Contribution to cross-cultural research methods from a study of leprosy and mental health.

The Explanatory Model Interview Catalogue (EMIC) has been developed to elicit illness-related perceptions, beliefs, and practices in a cultural study of leprosy and mental health in Bombay. Leprosy is an especially appropriate disorder for studying the inter-relationship of culture, mental health and medical illness because of deeply rooted cultural meanings, the emotional burden, and underuse of effective therapy. Fifty per cent of 56 recently diagnosed leprosy out-patients, 37% of 19 controls with another stigmatised dermatological condition (vitiligo), but only 8% of 12 controls with a comparable non-stigmatised condition (tinea versicolor) met DSM-III-R criteria for an axis I depressive, anxiety or somatoform disorder. Belief in a humoral (traditional) cause of illness predicted better attendance at clinic.

Clinical efficacy of centporpazine-a new antidepressant.

Efficacy of centpropazine, a new antidepressant, has been evaluated in forty two patients of endogenous depression. The 4 week open trial was carried out in a dose-range of 40 to 120mg per day. A significant lowering of Hamilton Depression Rating Scale (HDRS) score was observed in 34 patient. The antidepressant effect could be detected in 9 patients within one week, in 28 cases in two weeks and in all the 34 patients by third week. Giddiness, headache, dryness of mouth and weakness were reported by 11 patients.

Psychiatric referrals in two general hospitals.

A prospective study was undertaken to compare the patterns of psychiatric referrals in two general hospitals in Bombay viz. the King Edward Memorial Hospital (64 cases) and the Jaslok Hospital and Research Centre (62 cases). It was observed that depressive symptoms were the most common presenting symptoms in these patients attending either of the hospitals. Similarly, the commonest diagnoses were depression and organic mental disorder. Attempted suicide with organophosphorous compounds was the commonest reason for hospitalization at K.E.M. Hospital (p less than 0.001). A significant number of these patients were females (p less than 0.05). The psychiatric referrals at Jaslok had been hospitalized mainly for suspected medical or neurological illness (p less than 0.001). These patients belonged to higher economic strata and hence had a better paying capacity compared to patients at KEM hospital, a significant number of whom were unemployed (p less than 0.001). The duration of pre-referred illness of patients and their stay at Jaslok hospital were longer as compared to those at KEM Hospital (p less than 0.01). The number of non-relevant special investigations carried out on patients in Jaslok was more (p less than 0.01). Further analysis of diagnoses revealed that a significant number of patients at KEM Hospital were admitted as primary psychiatric illness (p less than 0.05).

Centbutindole vs trifluoperazine: a double-blind controlled clinical study in acute schizophrenia.

Twenty-nine acute schizophrenic patients were treated under double-blind conditions for six weeks with either centbutindole in a dose range of 3 mg/day to 4.5 mg/day or trifluoperazine in the dose range of 15 mg/day to 22.5 mg/day. Both drugs produced a significant improvement in initial psychopathology. No significant differences were demonstrated between the two treatment conditions.

Humoral concepts of mental illness in India.

Based on interviews with patients at three allopathic psychiatric clinics in Bombay, Bangalore and Varanasi, employing a preliminary version of the Explanatory Model Interview for Classification (EMIC) to elicit indigenous explanations of illness and patterns of prior help seeking, we discuss popular humoral theories of mental disorder. Even though most laypersons are unfamiliar with the content of the classical treatises of Ayurveda, the humoral traditions which they represent influence current perceptions. Case vignettes clarify the nature of the relationship between cultural, familial and personal factors that influence the experience of illness.

Traditional concepts of mental disorder among Indian psychiatric patients: preliminary report of work in progress.

In a medically pluralistic setting a range of health care providers offer not only different forms of treatment, but different ways of understanding illness. Even within a single tradition, these concepts evolve over time. Chapters in the classical texts of Ayurveda describe varieties of severe mental disorder (unmada) arising from a particular humoral imbalance (dosa) or arising in association with specific demons and deities (bhuta) that produce distinct character changes and symptom patterns. Patients currently presenting for treatment of mental disorder may describe their illness with reference to these concepts, but they also rely on other indigenous traditional concepts such as astrology, karma, the effects of other humoral relationships, such as semen loss and so forth; or they may rely on ideas derived from cosmopolitan medicine or both. Patients presenting to allopathic psychiatric centers in India were studied to determine whether patterns of help seeking could be predicted from the conceptual model by which they understood their illness. We elicited explanatory models from patients and obtained a history of prior consultations to other types of healer. Preliminary findings were notable for the pervasiveness of prior use of folk healers and the prominence of somatic symptoms among patients presenting to these allopathic physicians. Hypotheses regarding the impact of explanatory models on patterns of medical help seeking require further study from a larger and more diverse data base.

Elevated cerebrospinal fluid noradrenaline in tardive dyskinesia.

Cerebrospinal fluid was collected from 28 psychiatric (mostly schizophrenic) inpatients from Bombay, India. These included eight patients with tardive dyskinesia, five with spontaneous dyskinesia and 15 without dyskinesia. The samples were flown to the National Institute of Mental Health, Washington, D.C., where they were analyzed "blind" for concentrations of noradrenaline and several monoamine metabolites. Patients with tardive dyskinesia had significantly higher noradrenaline concentrations in the CSF as compared with the other two groups. Spontaneous dyskinesia group had significantly lower concentrations of homovanillic acid in the CSF. Our results support the hypothesis of noradrenergic hyperactivity, rather than postsynaptic dopamine receptor supersensitivity, in tardive dyskinesia.

Effects of intravenous metoclopramide in 81 patients with tardive dyskinesia.

We compared acute effects of single intravenous administrations of metoclopramide (40 mg) and placebo in a double-blind crossover study involving 81 patients with tardive dyskinesia. Metoclopramide produced significantly greater reduction in mean total Abnormal Involuntary Movement Scale score as well as in ratings for six of the seven body areas, when compared with placebo. On adjusting each patient's metoclopramide response for his or her placebo response, we found that 35 of the 81 patients had 50% or greater placebo-corrected improvement. There were no apparent clinical differences between metoclopramide responders and nonresponders. Administration of 60 mg of metoclopramide to 15 patients produced greater improvement in tardive dyskinesia as compared with 40 mg; the incidence of acute dystonia, however, jumped from 10% with 40 mg to 33% with 60 mg.

Tardive dyskinesia in India: a prevalence study.

We screened the entire inpatient population (N = 1963) of a state hospital near Bombay, India, for tardive dyskinesia (TD) using specific diagnostic criteria. Prevalence of TD was found to be 9.6%, which was much lower than that reported from the Western countries. Percent prevalence of TD was greatest in the age group 41 to 50, after which it seemed to decline. TD patients had received neuroleptic treatment for significantly longer periods and in significantly greater amounts than non-TD patients. The principal reason for the relatively low prevalence of TD in India is probably the practice of using neuroleptics in comparatively small doses (mean daily dose is about 200 mg of chlorpromazine equivalents). A possible contribution of racial-genetic factors cannot be excluded.