Challenges and priorities for suicide prevention in Southeast Asia: Insights from the Partnerships for Life regional workshop on suicide prevention.

Compared to the West, suicide prevention in the Southeast Asian (SEA) region is challenging due to resource constraints, a relatively greater contribution of social compared to psychological factors, and low levels of general awareness coupled with high stigma around suicide and mental illness. Collaboration and knowledge sharing are essential to circumvent these challenges. The Partnerships for Life (PfL) initiative of the International Association of Suicide Prevention aims to enhance knowledge sharing, foster collaboration between nations, and support the development and implementation of evidence-informed approaches to suicide prevention. In February 2024, the SEA region of the PfL conducted the first regional workshop on suicide prevention, in which representatives from 10 out of 12 SEA nations participated. In this paper, we outline the key priorities, challenges, strengths, and opportunities for suicide prevention in the region with a view to inform resource-effective suicide prevention strategies that have optimal utility and uptake.

Surgical Outcome of Pharmaco Refractory Epilepsy in the National Epilepsy Center of Sri Lanka.

BACKGROUND: The National Epilepsy Center (NEC) in Sri Lanka was established in 2017. Seizure outcome, effects on quality of life (QOL) and surgical complications among nonpediatric patients who underwent epilepsy surgery from October 2017 to February 2023 are described. METHODS: Nineteen patients (≥14 years) underwent epilepsy surgery at the NEC. We used Engel classification and Quality of Life in Epilepsy 31 (QOLIE-31) questionnaire to assess seizure outcome and QOL respectively. Surgical complications were categorized into neurological and complications related to surgery. RESULTS: Nine female and 10 male patients underwent surgery (mean age 27.5 years (range 14-44 years). The mean follow-up duration was 10.5 months (range 6-55 months). Twelve patients underwent temporal lobe resections. At 6-months follow-up, 83.3% (10/12) had favorable seizure outcomes with Engel class I/II. At 1-year follow-up 6/8 patients (75.0%) and at 2-year follow-up, 5/7 patients (71.4%) had a favorable outcome. Seven patients had extra-temporal lobe surgeries and one defaulted. Seizure freedom was observed in 6/6 at 6 months, 3/3 at 1-year, and 2/2 at 2-year follow-up. Five patients (26.3%) experienced minor post-operative surgical site infection. Two (11.1%) had persistent quadrantanopia. Meaningful improvement in QOL (change in QOLIE-31 score ≥11.8) was observed irrespective of seizure outcome or type of surgery (P < 0.001). CONCLUSIONS: Epilepsy surgery is effective in developing countries. Seizure outcomes in our patients are comparable to those worldwide. Clinically important QOL improvement was observed in our series. This is the first published data on epilepsy surgery outcomes in nonpediatric patients from Sri Lanka.

All in a scent - naphthalene dependence confined to pregnancy: a case report.

BACKGROUND: Inhalant or volatile substance use is a health issue with significant medical and psychiatric sequelae. Inhalants or volatile substances are volatile organic substances found in domestic and commercial products which are inhaled to obtain pleasurable effects. They are easily accessible, cheap, and legal. Common inhalants are spray, paints, glue and shoe polish whilst naphthalene or 'mothball' abuse is reported less commonly. We report a case of a 29-year-old female who inhaled and ingested naphthalene during her pregnancy. This case report is unique because the dependence on naphthalene was confined to pregnancy and resolved as soon as she delivered. This brings up the question whether pregnancy in general increases the risk of substance dependence in vulnerable populations or whether the dependence in this patient during pregnancy is due to individual factors. CASE PRESENTATION: The patient we report is a 29-year-old female who developed a strong desire to inhale mothballs during her third pregnancy. The pattern of use started in the first trimester meeting the criteria for dependence syndrome and resolved completely by the second day following delivery. She had features suggestive of harmful use in her second pregnancy as well. CONCLUSIONS: The case report emphasizes that pregnant women should be screened for psychoactive substance use. Equally important is the need for adequate psychoeducation about the myths and cultural beliefs associated with pregnancy-related cravings and the potentially devastating consequences of harmful cravings on the neonate and the mother. The case highlights how chemicals used in day-to-day activities can lead to dependence.

Corrigendum to "Those Who Hear Music: Three Cases on Musical Hallucinations".

[This corrects the article DOI: 10.1155/2018/9361382.].

Cognitive Behavioral Therapy Management of a Patient with Atypical Anorexia Nervosa.

Eating disorders are becoming more common in nonwestern societies and some of these presentations are atypical variants such as atypical anorexia nervosa. There is very little data on how to treat these patients. This case study reports the treatment of a young adult female in Sri Lanka who presented with atypical anorexia nervosa and moderate depressive disorder. She was successfully treated with nine sessions of enhanced cognitive-behavioural therapy (CBT-E). According to our knowledge this is the first case report that describes the management of a patient with atypical anorexia nervosa using psychological therapy specifically adapted to nonwestern context.

How valid is Obsessive-Compulsive Inventory-Revised Scale Among Sri Lankan adults?

BACKGROUND: Obsessive-compulsive disorder (OCD) is a neuropsychiatric disorder with a lifetime prevalence of 1.9%-3.0% in the general population. It is an easily missed diagnosis. Although several paper-based tools have been developed, none are culturally validated for Sri Lankans to screen for OCD at field level. AIMS: This study aimed to translate and assess the validity and reliability of obsessive-compulsive inventory-revised scale (OCI-R) for Sri Lankan adults. SETTING AND DESIGN: This study was a case-control study. MATERIALS AND METHODS: This was conducted among 89 OCD patients and 89 controls recruited from the National Hospital of Sri Lanka to assess the criterion validity of OCI-R (an 18-item tool on common OCD symptoms using six subscales), by applying it and the gold standard (clinical diagnosis made by two independent consultant psychiatrists) to the same patient simultaneously. Before this, the tool was translated into local language (Sinhala) by bilingual experts and two psychiatrists using the forward-backward translation method. Receiver operating characteristics (ROC) curve was drawn to determine the cutoff value to identify OCD in Sri Lanka. RESULTS: The translated tool demonstrated the following: sensitivity 84.4%, specificity 85.6%, positive predictive value 85.4%, negative predictive value 84.6%, and positive and negative likelihood ratios of 5.86 and 0.18, respectively. The cutoff value for diagnosing OCD was 21 according to the ROC curve. Internal consistency (Cronbach's alpha reliability coefficient) of all six domains and the total scale showed values exceeding Nunnally's criteria of 0.7. CONCLUSIONS: Sinhala version of the OCI-R scale was identified as a valid and reliable screening instrument to be applied in Sri Lankan adults.

Depression and psychological distress in patients with chronic renal failure: Prevalence and associated factors in a rural district in Sri Lanka.

OBJECTIVE: Chronic Kidney Disease (CKD) is known to adversely affect mental health. The study was aimed at estimating the prevalence of depression and psychological distress and the associated factors among CKD patients living in Anuradhapura, a rural district in Sri Lanka. METHOD: A community-based, cross-sectional study included a representative sample of 1174 CKD patients, drawn proportionately from all registered patients in all 19 Medical Officer of Health areas in the district of Anuradhapura. Trained paramedical staff visited the households and administered the locally validated Centre for Epidemiologic Studies Depression Scale and General Health Questionnaire-12 to screen for depression and psychological distress. Information related to associated factors was obtained through an interviewer-administered questionnaire. RESULTS: A total of 1118 CKD patients participated, with a response rate of 95.2%. The mean age was 58.3 (SD 10.8) years. 62.7% of participants were males. The majority of participants was in CKD stage 4 (58.3%). The screening revealed that 75.0% (95% CI 72.5-77.5) of participants were psychologically distressed while 65.2% (95%CI 62.4-68.0) were found to be depressed. Multiple logistic regression analysis revealed advanced age, unemployment and poor health related quality of life contributed significantly to both depression and psychological distress. CONCLUSION: Depression and psychological distress were significant in this community. Policymakers should consider the likely high prevalence of psychological distress and depression among CKD patients as well as the need for specific mental health services to confirm diagnosis and initiate effective management. Identified associated factors should be used to identify targeted preventative interventions.

Those Who Hear Music: Three Cases on Musical Hallucinations.

Musical hallucination carries no diagnostic significance on its own. However, it is an interesting phenomenon which can occur in various organic and psychiatric disorders. We report three patients who presented with musical hallucinations due to different aetiologies, namely, due to hearing impairment, intracerebral haemorrhage, and schizophrenia. The case series also highlights the fact that different aetiologies should be managed differently for the patients to be benefited.

Retinal Layer Abnormalities as Biomarkers of Schizophrenia.

Objective: Schizophrenia is associated with several brain deficits, as well as visual processing deficits, but clinically useful biomarkers are elusive. We hypothesized that retinal layer changes, noninvasively visualized using spectral-domain optical coherence tomography (SD-OCT), may represent a possible "window" to these abnormalities. Methods: A Leica EnvisuTM SD-OCT device was used to obtain high-resolution central foveal B-scans in both eyes of 35 patients with schizophrenia and 50 demographically matched controls. Manual retinal layer segmentation was performed to acquire individual and combined layer thickness measurements in 3 macular regions. Contrast sensitivity was measured at 3 spatial frequencies in a subgroup of each cohort. Differences were compared using adjusted linear models and significantly different layer measures in patients underwent Spearman Rank correlations with contrast sensitivity, quantified symptoms severity, disease duration, and antipsychotic medication dose. Results: Total retinal and photoreceptor complex thickness was reduced in all regions in patients (P < .0001). Segmentation revealed consistent thinning of the outer nuclear layer (P < .001) and inner segment layer (P < .05), as well as a pattern of parafoveal ganglion cell changes. Low spatial frequency contrast sensitivity was reduced in patients (P = .002) and correlated with temporal parafoveal ganglion cell complex thinning (R = .48, P = .01). Negative symptom severity was inversely correlated with foveal photoreceptor complex thickness (R = -.54, P = .001) and outer nuclear layer thickness (R = -.47, P = .005). Conclusions: Our novel findings demonstrate considerable retinal layer abnormalities in schizophrenia that are related to clinical features and visual function. With time, SD-OCT could provide easily-measurable biomarkers to facilitate clinical assessment and further our understanding of the disease.

Antipsychotic-associated weight gain: management strategies and impact on treatment adherence.

Antipsychotic-induced weight gain is a major management problem for clinicians. It has been shown that weight gain and obesity lead to increased cardiovascular and cerebrovascular morbidity and mortality, reduced quality of life and poor drug compliance. This narrative review discusses the propensity of various antipsychotics to cause weight gain, the pharmacologic and nonpharmacologic interventions available to counteract this effect and its impact on adherence. Most antipsychotics cause weight gain. The risk appears to be highest with olanzapine and clozapine. Weight increases rapidly in the initial period after starting antipsychotics. Patients continue to gain weight in the long term. Children appear to be particularly vulnerable to antipsychotic-induced weight gain. Tailoring antipsychotics according to the needs of the individual and close monitoring of weight and other metabolic parameters are the best preventive strategies at the outset. Switching to an agent with lesser tendency to cause weight gain is an option, but carries the risk of relapse of the illness. Nonpharmacologic interventions of dietary counseling, exercise programs and cognitive and behavioral strategies appear to be equally effective in individual and group therapy formats. Both nonpharmacologic prevention and intervention strategies have shown modest effects on weight. Multiple compounds have been investigated as add-on medications to cause weight loss. Metformin has the best evidence in this respect. Burden of side effects needs to be considered when prescribing weight loss medications. There is no strong evidence to recommend routine prescription of add-on medication for weight reduction. Heterogeneity of study methodologies and other confounders such as lifestyle, genetic and illness factors make interpretation of data difficult.

Metformin in prevention and treatment of antipsychotic induced weight gain: a systematic review and meta-analysis.

BACKGROUND: Most antipsychotics are associated with weight gain and other metabolic complications. Several randomized trials have shown metformin to be effective, but this still hasn't been included in clinical guidelines on managing antipsychotic induced weight gain. METHODS: All double blind placebo controlled trials assessing the efficacy of metformin in the treatment of antipsychotic induced weight gain were included. Cochrane Central Register of Controlled Trials (CENTRAL) and MEDLINE were searched for the period January 2000-December 2015. Meta-analysis was carried out using the random effects model. RESULTS: Meta analysis of 12 published studies with a total of 743 patients found that in patients treated with antipsychotics, metformin treatment resulted in significantly better anthropometric and metabolic parameters than placebo. The mean change in weight was -3.27 kg (95 % CI -4.66 to -1.89) (Z = 4.64, p < 0.001). Metformin compared to placebo resulted in significant reduction in BMI [-1.13 kg/m2 (95 % CI -1.61 to -0.66)] and insulin resistance index [-1.49 (95 % CI -2.40 to -0.59)] but not fasting blood sugar [-2.48 mg/dl (95 % CI -5.54 to 0.57]. CONCLUSION: This meta-analysis confirms that metformin is effective in treating antipsychotic induced weight gain in patients with schizophrenia or schizoaffective disorder.

Simvastatin-induced cognitive dysfunction: two case reports.

BACKGROUND: Simvastatin is commonly prescribed for hypercholesterolemia to reduce vascular risk in patients. Some of these patients have dementia with cognitive defects of several domains. Although protective effects seem to be present, there is emerging evidence that statins cause cognitive impairment. The role of cholesterol in cognitive function is complex. This is reflected in the effects that statins show on cognition functions. The reduction in cholesterol levels seen with statins is effective in improving learning and memory in some patients. However, there is emerging evidence that statins may worsen cognitive function. Similarly, there are major concerns over whether statins alleviate or worsen cognitive problems. The correlation between cholesterol levels and cognitive function is still controversial, mainly due to a lack of robust evidence. CASE PRESENTATION: We report the cases of two Asian patients who developed cognitive deficits after starting simvastatin. A 32-year-old man and a 54-year-old woman developed different but clear cognitive deficits that reversed after stopping simvastatin. CONCLUSIONS: The possibility of new-onset cognitive dysfunction and the deterioration of existing cognitive deficits should be considered when prescribing simvastatin to patients.

Validation of the Sinhala version of the Repeatable Battery for Assessment of Neuropsychological Status (RBANS)

Introduction: Only the Mini mental state examination (MMSE) and Montreal Cognitive Assessment scale have been validated in a Sri Lankan population for the assessment of cognitive functions. Both tests are deficient in the number of domains assessed. Therefore validation of Repeatable Battery for Assessment of Neuropsychological Status is important as it assesses most of the cognitive domains. Objectives: To culturally adapt RBANS and investigate the validity and reliability of culturally adapted RBANS (RBANS-S). Methods: Fifty four participants with major neurocognitive disorder and 60 normal controls aged >50 were administered with RBANS-S at the Cognitive Assessment Unit, Faculty of Medicine, Colombo and National Hospital of Sri Lanka. The participants were selected after a detailed clinical assessment according to Diagnostic and Statistical Manual ­ 5 criteria. Data were analysed using SPSS data package. Results: The mean age of the sample was 69.5 years. RBANS-S total scale correlated highly with MMSE total score, (Pearson correlational coefficient = 0.793 p=0.01). Criterion validity was assessed using receiver operating curve characteristic analysis and the area under the curve was 0.937. RBANS-S showed strong concurrent validity us indicated by its significant correlations with the MMSE. All of the RBANS-S subtests demonstrated significant correlations with the MMSE subsets. The sensitivity and specificity for RBANS-S was 89% and 85% respectively at a totals score of 80.5. The RBANS-S yielded a reliability coefficient of 0.929. Conclusions: Culturally adapted RBANS-S is a valid and reliable instrument which can be used in assessment of cognitive functions.

Metformin for treatment of antipsychotic-induced weight gain in a South Asian population with schizophrenia or schizoaffective disorder: A double blind, randomized, placebo controlled study.

BACKGROUND: Antipsychotic-induced weight gain causes serious health problems. We investigated the efficacy and safety of metformin in treating antipsychotic-induced weight gain in South Asian patients. METHODS: Sixty six adult patients with schizophrenia or schizoaffective disorder treated, with atypical antipsychotics, and who had increased by more than 10% their pre treatment body weight, were randomly assigned to receive metformin or placebo in a double-blind study. Patients received usual treatment and metformin 500 mg or placebo twice daily for 24 weeks. The primary outcome measure was change in body weight from baseline to week 24. Linear mixed models were used in the analysis. RESULTS: Mean change in body weight in the metformin group was -1.56 kg (95% CI=-3.06 to -0.05) and 1.0 kg (95% CI=0.03-1.97) in the placebo group. Between-group difference was 2.56 kg. At 24 weeks the between-group difference showed significant time-by-treatment interaction (F=3.23, p=0.004). Between-group difference in BMI showed significant time-by-treatment interaction (F=3.41 p=0.03). There was no significant difference in waist-hip ratio or fasting blood sugar. CONCLUSIONS: Metformin is effective in reducing weight in South Asian patients with schizophrenia or schizoaffective disorder who had increased their body by more than 10% after treatment with atypical antipsychotics.

Use of lithium in clozapine-induced neutropenia: a case report.

BACKGROUND: The literature describing the long-term use of lithium carbonate to reinstate reduced levels of white blood cell counts in patients treated with clozapine is scarce. We describe a case of successful recommencement of clozapine on a patient who developed risk level of neutropenia which was corrected by lithium carbonate. He was followed up for a period of one year. CASE PRESENTATION: We report a 40-year-old Sri Lankan male who developed neutropenia and low white blood cell counts following commencement of clozapine. We were successful in restarting clozapine after the addition of lithium carbonate to increase the cell counts. Clozapine was increased to 700 mg a day with 500 mg of lithium carbonate. The patient remains stable after one year with no further episodes of neutropenia. CONCLUSION: Lithium carbonate can successfully be used to treat clozapine-induced neutropenia.

Phagophobia: a case report.

BACKGROUND: Phagophobia is a rare disorder and the literature is sparse. There is no specific treatment described for this life threatening condition. CASE PRESENTATION: The patient is a 25-year-old Sri Lankan female with recurrent difficulty in swallowing. Following her initial episode which lasted one year, she presented to us with inability to swallow for one week. She was dependent on liquids and semisolids. The medical team confidently excluded an organic cause. She had difficulty swallowing solids with behaviours like swallowing with the aid of water and swallowing small boluses. She had difficulty eating in front of a crowd as well. She was preoccupied with misconceptions related to food and gastrointestinal disorders like gastritis. The symptom was soon becoming a maladaptive coping mechanism as it occurred when she was under stress and had difficulty solving a problem. The patient was managed with graded exposure and cognitive techniques. CONCLUSION: The possibility of a psychological cause for dysphagia should be borne in mind although the occurrence is rare. Although no definitive treatment methods for phagophobia are described, cognitive behavioural techniques can successfully be used in the treatment.