Neurochemical correlates of cognitive functions in euthymic patients with bipolar disorder: 1H-MRS study.

OBJECTIVES: We assessed and correlated neurochemical levels and cognitive functions in left dorsolateral prefrontal cortex (DLPFC) and left hippocampus in euthymic patients with bipolar disorder and compared these with healthy controls METHODOLOGY: Twenty-five right-handed euthymic patients (HAM-D score < 7, and YMRS score < 7) with bipolar disorder and 20 age and gender matched controls were compared for neurometabolites (n-acetylaspartate - tNAA, choline - Cho, creatinine - Cr, myoinositol - Ins, and glutamine/glutamate - Glu/Gln) measured in left DLPFC and left hippocampus using single voxel magnetic resonance spectroscopy (MRS) and cognitive functions assessed using trail making test (TMT - A and B), wisconsin card sorting test (WCST), and wechsler memory scale (WMS-III Indian adaptation). RESULTS: The two groups were comparable on socio-demographic variables. tNAA levels in DLPFC and hippocampus, and glutamate levels in hippocampus were found to be significantly lower and Inositol and glutamine levels in hippocampus were found to be significantly higher in patients as compared to controls. Patients performed significantly poorly as compared to controls on TMT A & B, all subscales of WMS - III, 5 subscales of WCST, including perseverative responses and errors. The tNAA and glutamate levels in left DLPFC in patients correlated with scores on TMT A & B, and several subscales of WCST and WMS-III. tNAA concentration in left hippocampus in patients correlated with scores on subscales of WMS-III. CONCLUSION: Neurochemical dysfunction in select brain areas directly correlates with impairment in cognitive functions seen in patients with bipolar disorder in euthymic phase.

A preliminary association study between serotonin transporter (5-HTTLPR), receptor polymorphisms (5-HTR1A, 5-HTR2A) and depression symptom-clusters in a north Indian population suffering from Major Depressive Disorder (MDD).

INTRODUCTION: Major Depressive Disorder (MDD) is a broad heterogeneous diagnostic construct. Previous studies have shown that it can be resolved into several symptom-clusters which are proposed to be associated with single nucleotide polymorphisms (SNPs) of the serotonergic pathway (5-HTTLPR, 5HTR1A, 5-HTR2A). METHODS AND MATERIAL: In a cross-sectional study conducted at a tertiary level mental health care set-up in north India, 80 out-patients with MDD were evaluated with Montgomery Asberg Depression Rating Scale (MADRS) and then genotyping was done. The different clinical and genetic variables were compared across the factor structures of MADRS. Also, the comparison of the genetic data of cases was done with the pre-existing database of the non-blood related healthy ethnically-matched controls. RESULTS: There was no significant association between age, gender, other clinical variables, SNPs like 5-HTTLPR SS/SL, rs6295 CC/CG/GG, rs6311GG/GA/AA, rs6313 CC/CT/TT and different factor-structures like 'detachment' consisting of items like concentration difficulty, lassitude, inability to feel; 'psychic anxiety' consisting of suicidal thoughts and inner tension; 'mood-pessimism' consisting of symptoms like apparent sadness, reported sadness, pessimistic thoughts and 'vegetative symptoms' like decreased sleep, poor appetite. Neither there was any association between genotype of the cases compared with the controls. CONCLUSIONS: No significant association was obtained between the four-factor structures of depression in MADRS and serotonin transporter and receptor SNPs in a study with a small sample size. This study evaluates whether depression symptom-clusters have distinct genotypic determinants and necessitates more comprehensive studies for unravelling the genetic determinants of depression.

Physical comorbidity in schizophrenia & its correlates.

The presence of common physical comorbidities, their demographic and clinical correlates and impact on functioning was assessed in 100 patients with schizophrenia. The patients had a mean age of 35.12±10.7 yr with mean duration of illness of 8.3±0.58 years. Seventy per cent were detected to have a comorbid physical condition. Common conditions included hypertension (21%), diabetes mellitus (15%) and anaemia (12%). Increasing age, being female, being married, longer duration of illness and longer duration of treatment were associated with higher risk of having a comorbid physical illness. Further studies need to be done with a large sample to confirm these findings.

Association of serotonin transporter (SLC6A4) and receptor (5HTR1A, 5HTR2A) polymorphisms with response to treatment with escitalopram in patients with major depressive disorder: A preliminary study.

BACKGROUND & OBJECTIVES: Genetic factors have potential of predicting response to antidepressants in patients with major depressive disorder (MDD). In this study, an attempt was made to find an association between response to escitalopram in patients with MDD, and serotonin transporter (SLC6A4) and receptor (5HTR1A, 5HTR2A) polymorphisms. METHODS: Fifty five patients diagnosed as suffering from MDD, were selected for the study. The patients were treated with escitalopram over a period of 6-8 wk. Severity of depression, response to treatment and side effects were assessed using standardised instruments. Genetic variations from HTR1A (rs6295), HTR2A (rs6311 and rs6313) and SLC6A4 (44 base-pair insertion/deletion at 5-HTTLPR) were genotyped. The genetic data of the responders and non-responders were compared to assess the role of genetic variants in therapeutic outcome. RESULTS: Thirty six (65.5%) patients responded to treatment, and 19 (34.5%) had complete remission. No association was observed for genotype and allelic frequencies of single nucleotide polymorphisms (SNPs) among remitter/non-remitter and responder/non-responder groups, and six most common side-effects, except memory loss which was significantly associated with rs6311 ( p0 =0.03). INTERPRETATION & CONCLUSIONS: No significant association was found between the SNPs analysed and response to escitalopram in patients with MDD though a significant association was seen between the side effect of memory loss and rs6311. Studies with larger sample are required to find out genetic basis of antidepressant response in Indian patients.

Contributions of general hospital psychiatric units to psychiatric research in India.

BACKGROUND: General hospital psychiatric units (GHPUs) are one of the major service and training providers in the field of mental health in India. However, there has not been any systematic attempt at their contributions toward research. AIM: The present paper reports on contributions of the GHPUs toward the psychiatric research based on analysis of publications in the Indian Journal of Psychiatry (IJP). MATERIALS AND METHODS: All the issues of IJP of the last 25 years (1989-2013) were manually searched for original research papers, brief reports, and case reports. A semi-structured performa was used to collect information on various parameters. RESULTS: About two-thirds of the papers were contributed by the GHPUs, most being multi-authored and from tertiary care centers. The research covered a variety of psychiatric disorders including schizophrenia, mood disorders, and common mental disorders. Most of the research reported was self-funded. CONCLUSION: GHPUs have contributed significantly to psychiatric research in India in the last 25 years.

IPS multicentric study: Functional somatic symptoms in depression.

BACKGROUND: As a pilot project, Indian Psychiatric Society conducted the first multicentric study involving diverse settings from teaching institutions in public and private sectors and even privately run psychiatric clinics. AIM OF THE STUDY: To study the typology of functional somatic complaints (FSC) in patients with first episode depression. MATERIALS AND METHODS: A total of 741 patients from 16 centers across the country participated in the study. They were assessed on Bradford Somatic Symptom inventory for FSC, Beck Depression Inventory for severity of depression, and Comprehensive Psychopathological Rating Scale- anxiety index (CPRS-AI) for anxiety symptoms. RESULTS: The mean age of the study sample was 38.23 years (SD-11.52). There was equal gender distribution (male - 49.8% vs. females 50.2%). Majority of the patients were married (74.5%), Hindus (57%), and from nuclear family (68.2%). A little over half of the patients were from urban background (52.9%). The mean duration of illness at the time of assessment was 25.55 months. Most of the patients (77%) had more than 10 FSCs, with 39.7% having more than 20 FSCs as assessed on Bradford Somatic Inventory. The more common FSC as assessed on Bradford Somatic Inventory were lack of energy (weakness) much of the time (76.2%), severe headache (74%) and feeling tired when not working (71%), pain in legs (64%), aware of palpitations (59.5%), head feeling heavy (59.4%), aches and pains all over the body (55.5%), mouth or throat getting dry (55.2%), pain or tension in neck and shoulder (54%), head feeling hot or burning (54%), and darkness or mist in front of the eyes (49.1%). The prevalence and typology of FSCs is to a certain extent influenced by the sociodemographic variables and severity of depression. CONCLUSION: Functional somatic symptoms are highly prevalent in Indian depressed patients and hence deserve more attention while diagnosing depression in Indian setting.

IPS multicentric study: Antidepressant prescription patterns.

BACKGROUND: There are very few studies from India which have evaluated the prescription pattern for antidepressants by psychiatrists for treatment of depression. AIM: To study the psychotropic prescription patterns of patients with first episode depression from diverse settings including teaching institutions in public and private sectors and even privately run psychiatric clinics. MATERIALS AND METHODS: Prescription data of 706 patients with first episode depression, who participated in the IPS multicentric study, were evaluated. RESULTS: Escitalopram was the most commonly prescribed antidepressant, comprising 40% of the total prescriptions. This was followed by sertraline (17.6%) and fluoxetine (16.3%). In total, selective serotonin reuptake inhibitors (SSRIs) formed 79.2% of all the prescriptions. Tricyclic antidepressants formed a small part (15.15%) of total prescriptions, with imipramine being the most commonly used tricyclic antidepressant. Serotonin-norepinephrine reuptake inhibitors (venlafaxine, desvenlafaxine and duloxetine) were prescribed to 11.3% of patients with equal share of venlafaxine and duloxetine. About one-sixth (N=104; 14.7%) of the patients were prescribed more than one antidepressant. Nearly three-fourth of the patients (N=523; 74.1%) were prescribed a benzodiazepine, with clonazepam being the most preferred agent, prescribed to nearly half of the participants (49%) and formed nearly two-third of the total benzodiazepine prescriptions (346 out of 523). CONCLUSION: Escitalopram is the most commonly prescribed antidepressant and SSRIs are the most commonly prescribed class of antidepressants. Poly pharmacy in the form of concomitant use of two antidepressants is practiced infrequently. However, benzodiazepines are used quite frequently as the co-prescription.

Forensic evaluations in psychiatry.

Forensic psychiatry is an important subspecialty of psychiatry. Forensic psychiatrists play an important role in the society in assisting the judiciary in many complicated cases. In India, forensic psychiatry work is undertaken mostly by the general psychiatrists. Forensic psychiatric assessments are often associated with an element of anxiety or fear for a young psychiatrist. The present paper aims at familiarizing the readers with forensic evaluation in various situations so that they are able to carry out the assessments in real-life situations comfortably. Various steps of forensic assessment in different situations are discussed in the background of real-life cases. Assessment areas include criminal responsibility, fitness to plead, issue of guardianship, assessment of mental status, testamentary capacity and others. The paper gives some general guidelines on forensic psychiatric assessment in practical situations in our country. The readers are advised to refer to the standard textbooks and the Indian law for further details.

Six decades of community psychiatry in India.

The community psychiatry movement started in India in the early 1950s. It has gone through different phases of development, beginning with family care of people who are mentally ill in the campus of the mental hospitals, followed by satellite clinics and a national mental health programme. Other initiatives have included the camp approach, initiatives by non-government organisations and the media, and mental health services for disaster-affected populations. The paper traces the development of community psychiatry in India over the past six decades.

Clozapine induced eosinophilia.

Clozapine is associated with a number of side effects and careful monitoring of them is a very important aspect of management of the patients receiving the same. Common side effects of clozapine are sedation, sialorrhoea, weight gain etc. Rarely clozapine is also associated with eosinophilia. Here we present a case of schizoaffective disorder who was receiving clozapine and developed eosinophilia during the initial weeks of treatment with clozapine which came down to baseline after a few weeks of continuation of therapy. Although there are reports of eosinophilia developing in course of treatment with clozapine among patients suffering from schizophrenia but this may be the first case of eosinophilia associated with clozapine use in case of schizoaffective disorder.

Changing trends of services used as first contact by patients with mental health problems.

BACKGROUND: In the past, traditional faith healers and practitioners of alternative medicine have often been reported to be the first source of contact for Indian patients with mental health problems. However, over the past few decades, this trend seems to be changing. METHOD: Using a semi-structured questionnaire, we assessed 200 new patients at a psychiatric outpatient service in a general hospital for the first service contact used by them for their mental health problems. RESULTS: Psychiatrists, non-psychiatric physicians, traditional faith healers and practitioners of alternative medicine were the first service contact for 91 (45.5%), 88 (44%), 16 (8%) and 5 (2.5%) patients, respectively. Patients suffering from severe mental illnesses were more likely to choose a psychiatrist as the first contact, whereas those with neurotic, stress-related and organic mental disorders contacted a non-psychiatric physician. CONCLUSION: In the current scenario, psychiatrists and nonpsychiatric physicians serve as the first service contact for most patients with mental health problems in India, though traditional faith healers and practitioners of alternative medicine are contacted by a minority.

Augmentation effect of repetitive transcranial magnetic stimulation over the supplementary motor cortex in treatment refractory patients with obsessive compulsive disorder.

BACKGROUND: There are only a few effective treatment options currently available for treatment-refractory obsessive compulsive disorder (OCD). The supplementary motor area (SMA) has been reported to play an important role in the pathophysiology of OCD. Functional neuroimaging studies indicate that OCD is associated with increased activity in the SMA, caudate nucleus, and anterior cingulate gyrus. Novel treatment strategies like repetitive transcranial magnetic stimulation (rTMS) have been proposed for OCD refractory to standard treatments. These clinic-based data report on the efficacy of rTMS in medication-resistant OCD. MATERIALS AND METHODS: Twelve right-handed persons with medication-resistant OCD were administered rTMS as an add-on treatment. Stimulation was given at 1 Hz for 10 seconds followed by 15 seconds pause and 100 trains of stimulus over the SMA per session for 5 days in a week. Assessments were done on yale brown obsessive compulsive scale (Y-BOCS) at baseline and at the end of rTMS intervention. RESULTS: The subjects had a mean age of 33.17±12.74 years. Mean scores on Y-BOCS were 26.17 at baseline and 17.17 at the end of treatment, reflecting significant improvement. The subjects did not report any significant side effects except one person with known bipolar illness, who developed manic symptoms after the 3(rd) session of the rTMS. CONCLUSIONS: Low-frequency rTMS over the SMA appears a promising treatment strategy as an add-on treatment in treatment-refractory patients of OCD.

Clozapine for the treatment of neurogenic bladder.

Neurogenic bladder leading to urinary incontinence has been described in patients of stroke, dementia, Parkinson's disease, and some schizophrenia cases with cognitive impairment possibly due to impaired cortical inhibition of the urinary bladder. The underlying brain abnormalities for urinary incontinence are similar in such cases. We report here such a case of neurogenic bladder responding to treatment with clozapine. The possible mechanism of action and clinical implications are described.

An experience of provision of psychiatric services in the earthquake-affected area of Kashmir in India.

Developing psychiatric services for disaster-affected populations in a place with meagre resources is a challenge, especially if the place is remote and offers limited access, and the weather conditions are harsh. The earthquake in October 2005 posed just such a challenge (Makhdum & Javed, 2005). Massive damage was reported from Pakistan, as the epicentre was in Muzaffarabad, in Pakistani-controlled Kashmir. There was also extensive damage to life and property in some areas of Kashmir in India. The road and communication network had been completely destroyed in many of the affected areas.

Assessment of hospital services by consumers: a study from a psychiatric setting.

The present study revealed perception of forty-five patients and fifty nine family members selected from the outpatinet deptt. of a Psychiatric hospital. A semi-structured questionnaire was used. The issues like efficiency, punctuality, behaviour of doctors and other staff, waiting time, supply of draugs and diet and cleanliness of the hospital etc were enquired. More than ninety % of the patients and their escorts appreciated the services provided. Most of them (75-80%) was satisfied with supply of drugs, quality of diet, clinical care and cleanliness of the hospital. Measures for improvement were also suggested.

Amnesia for autobiographical memory: a case series.

Functional amnesia for autobiographical memory is a rare but pathognomic sign of dissociative disorders. Amnesia for part of one's personal history is sometimes also seen in other functional disorders like depression and schizophrenia but autobiographical amnesia in these disorders is relatively rar . Phenomenologically the autobiographical memory loss, amnesia for events during the amnestic episode and change of identity (as in fugae and dissociative identity disorder) are all expressions of altered memory organisation. This paper reports three cases of autobiographical amnesia with clinical diagnoses of dissociative disorder unspecified type, dissociative amnesia and schizophrenia that were treated successfully. The phenomenon of autobiographical amnesia is discussed in the background of these cases.

Effect of electroconvulsive therapy on hematological parameters.

Although a complete blood count is part of the evaluation before the use of electroconvulsive therapy (ECT), there are no known hematological contraindications for the procedure. A preliminary study was done on 31 randomly selected psychiatric patients (chronic schizophrenia, n=10; acute depression, n=8; acute mania, n=6; acute psychosis, n=6; delusional disorder, n=1) receiving ECT to study its hematological effects. Blood samples were drawn just before and 0, 1 and 2 h after ECT. Hemoglobin (Hb%), total and differential leukocyte count (TLC and DLC), red blood cell (RBC) count, mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), mean corpuscular hemoglobin concentration (MCHC) and platelet count were measured on a fully automated hematology analyzer (Sysmex K-1000). Significant changes were found in TLC, percentage of polymorphs and lymphocytes, and Hb%. Changes in other parameters were not statistically significant. More such studies are needed to substantiate these observations and to understand the mechanism and implication of these effects.

Help seeking behaviour of psychiatric patients before seeking care at a mental hospital.

BACKGROUND: A wide range of professionals including psychiatrists, psychologists, general physicians, faith-healers and religious healers cater to the needs of mentally ill patients. Psychiatric facilities are available at general hospitals, office based practice and mental hospitals. Psychiatrists are preferred the least due to stigma. The present work reports on treatment options used by a group of psychiatric patients before visiting a mental hospital. AIM: To study the help seeking behaviour of patients visiting a mental hospital. METHOD: Patients attending psychiatric outpatient service at a mental hospital were asked specifically about various treatment facilities utilized by them before coming to the hospital and the reasons thereof. RESULTS: A wide range of services was used by the subjects varying from professional care to faith healers. Trust, easy availability and accessibility, recommendations by the significant others and belief in supernatural causation of illness were the important reasons for choosing a particular facility. Thus sociocultural factors appeared to influence the help seeking behaviour. CONCLUSION: A substantial number of patients suffering from severe mental disorders seek non-professional care. There is a need of studies in community to assess the help seeking behaviour of psychiatric patients and factors associated with it.