Research on clinical aspects of bipolar disorder: A review of Indian studies.

Background: Bipolar disorder is one of the severe mental disorders that are associated with significant morbidity of the patients. Despite advancements in our understanding about the disorder, it remains a challenging proposition to treat bipolar disorder, largely since the prophylactic treatment of the disorder requires assessment of complex clinical algorithms. The revisions of the classificatory systems have also changed the conceptualization of the disorder. In this background, we conducted a review of the Indian studies conducted on the clinical aspects of bipolar disorder. Methods: A narrative review was conducted with focus on the literature published from India. The databases searched included PubMed, Scopus, and Google Scholar, and articles published over the last 15 years by Indian authors were included for this review. Results: In our review, we could access a substantial volume of research published from India. We could identify studies that catered to most of the relevant themes in bipolar disorder including epidemiology, etiology, comorbidities, stigma, disability, clinical course, cognitive profile, pathways to care, and recovery. Conclusion: The research trajectory was in line with the research conducted elsewhere in the world. However, certain dissimilarities in terms of focus could also be observed. The possible reason behind this deviation could be the difference in clinical need and unique challenges faced in the management and rehabilitation of patients in bipolar disorder in Indian scenario.

Mental health stigma and its relationship with mental health professionals - A narrative review and practice implications.

The extent and magnitude of the mental health stigma are enormous, with substantial clinical and social implications. There is a complex relationship between mental health stigma and mental health professionals (MHPs); MHPs can be anti-stigma crusaders, victims of stigma, and even a source of stigma. Unfortunately, literature is scarce talking about the relationship between stigma and MHPs. Hence, the current review aims to bridge the existing gap in the literature on various aspects of stigma and the role of MHPs. For the current review, we ran a search in PubMed and Google Scholar databases; we restricted our study to records focusing on the interplay of mental health stigma and the MHPs, published during 2012-2022, in English, and having a full text available. We found that MHPs (psychiatrists, psychologists, and psychiatric nurses) can also be the recipients of the stigma. The stigma faced by the MHPs is determined by the negative stereotypes set by the media, or medical students, or other health professionals; the marginal position of psychiatry in the health system; difficult-to-treat mental disorders; MHPs' own experience of stigma; and the attitude or beliefs of various caders of the MHPs, their professional experience, and expertise in managing various mental health conditions. Notably, MHPs can also be a source of stigma (stigmatizers). MHPs need to be sensitized concerning this, and the anti-stigma interventions must incorporate this aspect of stigma. Novel interventions, such as digital-based programs, should be used instead of traditional anti-stigma programs in order to decrease stigma around mental health issues and make anti-stigma initiatives more appealing and scalable. To address the issues of stigma, there has to be more communication between MHPs, other health professionals, service users, and policymakers.

A prospective study of suicidal behavior in young patients of depressive episodes with hidden bipolarity exposed to selective serotonin reuptake inhibitor.

Background: Treatment of depressive episodes in young patients is challenging owing to several reasons such as poor diagnostic stability and atypical presentation. Evidence regarding treating such patients with antidepressants such as selective serotonin reuptake inhibitor (SSRI) is not clear. Methods: Fifty patients aged 10-24 years diagnosed with depressive episodes and drug-free for at least 3 months were rated on Beck's Depression Inventory (BDI), The Mood Disorder Questionnaire (MDQ), and Beck Scale for Suicidal Ideation (BSS). The scores of BSS and BDI were compared across four timeframes (weeks 0, 2, 4, and 6) for MDQ-positive and negative patients by using the generalized estimating equations model. Results: Patients who were MDQ-positive (11 patients) tended to score higher on BDI (at weeks 2 and 4) and BSS (at weeks 2, 4, and 6) as compared to MDQ-negative patients (39 patients). After being started on SSRI, MDQ-positive patients showed a poorer response as compared to the other group. The small sample size and short follow-up duration were the major limitations. Conclusions: Close clinical monitoring with regular follow-up during antidepressant initiation is recommended to reduce the risk of suicidality.

Understanding the epidemiology of substance use in India: A review of nationwide surveys.

Substance use is a public health concern on a global and national levels. There is a scarcity of nationally representative systematic research on the epidemiology of substance use in India. This narrative review aims to discuss the various large epidemiological surveys providing data on substance use in India. Attempts have been made to extract data pertaining to special population groups as well.

A prospective hospital-based study on C-reactive protein as a response predictor of antidepressant treatment in drug naïve patients with major depressive disorder.

Background: C-reactive protein (CRP) is an acute phase reactant that is implicated in the pathogenesis of major depressive disorder (MDD), due to its role in the execution of various important neurological events, including neurogenesis, mediation of neural plasticity, and synaptic transmission. Aims: This study was conducted to determine the relationship between the level of CRP to remission rates after antidepressant therapy. Methods: Fifty patients of first episode MDD with no past history of antidepressant exposure and other medical comorbidity were recruited after obtaining consent for Escitalopram therapy. The CRP levels of the patients were evaluated on the day of recruitment and depressive symptoms were monitored using Montgomery-Asberg Depression Rating Scale at weeks 0, 3, 6, and 12. The patients with low (≤10 mg/l) and high (>10 mg/l) CRP levels were compared for time taken to achieve remission using Kaplan-Meier survival analysis. Results: The Kaplan-Meier survival analysis showed a significantly higher proportion of patients with low CRP levels attained remission than patients with higher CRP levels (Log-rank = 7.594; dF = 1; P = 0.006). The age, compliance to pharmacotherapy, and disability did not significantly affect the remission rates of the patients. Conclusion: Our study confirms that higher levels of CRP can lead to poorer remission rates in patients with MDD after antidepressant therapy and can predict treatment resistance.

A domain-agnostic MR reconstruction framework using a randomly weighted neural network.

Purpose: To design a randomly-weighted neural network that performs domain-agnostic MR image reconstruction from undersampled k-space data without the need for ground truth or extensive in-vivo training datasets. The network performance must be similar to the current state-of-the-art algorithms that require large training datasets. Methods: We propose a Weight Agnostic randomly weighted Network method for MRI reconstruction (termed WAN-MRI) which does not require updating the weights of the neural network but rather chooses the most appropriate connections of the network to reconstruct the data from undersampled k-space measurements. The network architecture has three components, i.e. (1) Dimensionality Reduction Layers comprising of 3d convolutions, ReLu, and batch norm; (2) Reshaping Layer is Fully Connected layer; and (3) Upsampling Layers that resembles the ConvDecoder architecture. The proposed methodology is validated on fastMRI knee and brain datasets. Results: The proposed method provides a significant boost in performance for structural similarity index measure (SSIM) and root mean squared error (RMSE) scores on fastMRI knee and brain datasets at an undersampling factor of R=4 and R=8 while trained on fractal and natural images, and fine-tuned with only 20 samples from the fastMRI training k-space dataset. Qualitatively, we see that classical methods such as GRAPPA and SENSE fail to capture the subtle details that are clinically relevant. We either outperform or show comparable performance with several existing deep learning techniques (that require extensive training) like GrappaNET, VariationNET, J-MoDL, and RAKI. Conclusion: The proposed algorithm (WAN-MRI) is agnostic to reconstructing images of different body organs or MRI modalities and provides excellent scores in terms of SSIM, PSNR, and RMSE metrics and generalizes better to out-of-distribution examples. The methodology does not require ground truth data and can be trained using very few undersampled multi-coil k-space training samples.

A Prospective Observational Study on Changes in Intraocular Pressure and Iridocorneal Angle Following the Use of Escitalopram and Amitriptyline.

Background: Depression has emerged as one of the prime morbidities affecting professional and personal lives worldwide. Antidepressants are one of the mainstays of management of depressive episodes. Although antidepressants are considered a safe class of drugs, the studies examining the effects of antidepressant prescription on intraocular pressure (IOP) have shown a propensity to increase IOP, but not consistently. This study aimed to compare the changes in IOP and iridocorneal angle in drug-naïve patients with depressive episodes prescribed escitalopram or amitriptyline. Methods: Overall, 109 patients were recruited, of which 53 were prescribed amitriptyline and 56, escitalopram. A comparison of IOP and the iridocorneal angle at weeks 0, 4, and 8 was done using a two-way repeated-measures analysis of variance (two-way RM analysis of variance). Results: Patients initiated on escitalopram tended to show a higher rise in the IOP (left eye-[F = 3.27; P = 0.04]; right eye [F = 2.47; P = 0.08]). No difference was found in the iridocorneal angles in any of the four quadrants across both eyes. Conclusions: Escitalopram use had an association with an increase in IOP. While initiating patients on antidepressants, clinicians should be aware of this possibility, which can lead to ocular emergencies, and obtain a proper history of ocular morbidities.

The silent epidemic: Death by suicide among physicians.

Suicidal deaths among physicians have been on a steady rise in the past few decades, despite being a part of the healthcare system, training for early identification and easy access to treatment services. While there is no doubt that this warrants concern at individual, institutional, and community levels, physician suicide remains an under-researched topic. We examine the correlates of suicidal deaths among physicians along with risks and protective factors conferred to physicians as a population and emphasize the need for preventive and risk-reduction initiatives that are specifically tailored for physicians and the healthcare provider community.

Relationship of obstructive sleep apnea with major depressive disorder and development of metabolic syndrome.

Objective: Major depressive disorder (MDD) is often linked with a number of coexisting disorders with a relation that is poorly understood. The aim of this study was to find out the role of obstructive sleep apnea (OSA) in metabolic syndrome (MS) in subjects with MDD and to develop a model for factors leading to MS. Methods: It was a cross-sectional study conducted on 119 subjects. They were evaluated on sociodemographic and clinical parameters, Berlin questionnaire, and Quick Inventory of Depressive Symptomatology. Comparisons were made using appropriate statistics. Binary logistic regression was used to find out the role of clinical parameters in the development of MS. Results: A total of 34% with MDD had a high risk of developing OSA while 19% had metabolic syndrome. Among all clinical variables, antidepressant exposure in terms of total fluoxetine units, duration of treatment, and risk of developing OSA was found to be significantly more in patients with MS. A higher risk of OSA was found to have a higher likelihood to cause MS in patients with MDD. Conclusion: There is a high risk of MS and OSA in subjects with MDD. The increased risk of MS is contributed by an increased risk of developing OSA among patients with MDD. Cross-sectional design and limited generalizability are the major limitations of this study.

Evaluation of the effectiveness of yoga in management of premenstrual syndrome: a systematic review and meta-analysis.

Aim: The management of Premenstrual Syndrome (PMS) is still evolving due to the modest effect sizes of the available treatment modalities. Yoga as therapeutic intervention in PMS has been gathering interest amongst researchers. The current manuscript reviews the evidence surrounding yoga in PMS.Methods: This manuscript was a systematic review and meta-analysis evaluating the effectiveness of yoga on the total scores and sub-domains of PMS after studies were identified using a pre-defined selection criterion after a search in PubMed, Google Scholar, Scopus and Web of Science. Both quantitative and qualitative analysis of the accumulated data was performed. Overall, 14 studies were identified for the review, 11 of which were used for the purpose of quantitative analysis.Results: The studies were heterogenous in terms of the design, yoga regimes, nature of interventions and tools used for outcome measures. It was found that yoga was beneficial in the management of PMS. This benefit was also seen when all the sub-domains of PMS were individually examined except physical sub-domain.Conclusion: Though there were certain limitations in our review like heterogeneity in studies, possibility of publication bias and restrictive selection criterion; it supported that yoga can be beneficial in patients with PMS.

A review and experimental evaluation of deep learning methods for MRI reconstruction.

Following the success of deep learning in a wide range of applications, neural network-based machine-learning techniques have received significant interest for accelerating magnetic resonance imaging (MRI) acquisition and reconstruction strategies. A number of ideas inspired by deep learning techniques for computer vision and image processing have been successfully applied to nonlinear image reconstruction in the spirit of compressed sensing for accelerated MRI. Given the rapidly growing nature of the field, it is imperative to consolidate and summarize the large number of deep learning methods that have been reported in the literature, to obtain a better understanding of the field in general. This article provides an overview of the recent developments in neural-network based approaches that have been proposed specifically for improving parallel imaging. A general background and introduction to parallel MRI is also given from a classical view of k-space based reconstruction methods. Image domain based techniques that introduce improved regularizers are covered along with k-space based methods which focus on better interpolation strategies using neural networks. While the field is rapidly evolving with plenty of papers published each year, in this review, we attempt to cover broad categories of methods that have shown good performance on publicly available data sets. Limitations and open problems are also discussed and recent efforts for producing open data sets and benchmarks for the community are examined.

Management of Chronic Insomnia Using Cognitive Behavior Therapy for Insomnia (CBT-I) During COVID-19 Pandemic: Does One Shoe Fit All?

Purpose: Insomnia is a highly prevalent disorder that is seen across all age groups causing significant morbidity to the patients. Its prevalence has further risen during COVID-19 pandemic. It is widely acknowledged that untreated insomnia can lead to significant health risks and socio-occupational dysfunction. Methods: A narrative review was conducted following focused search of databases. Results: Available guidelines mention two different approaches for the management of insomnia-pharmacological and non-pharmacological. Non-pharmacological therapies like multicomponent cognitive behavior therapy for insomnia (CBT-I) have been advocated for the management of acute as well as chronic insomnia in the literature as it has been found efficacious and useful. Multiple variants of CBT-I, e.g., digitally delivered CBT-I, brief CBT-I have been tested during pandemic owing to closure of clinics. However, there are certain issues to be considered while choosing CBT-I as therapy. For example, like other forms of psychotherapies, is there a need for assessing the candidature of patient before administering CBT-I; is CBT-I free of adverse effects as commonly thought; is CBT-I more efficacious than hypnotics; and at last, how to manage cases that are not candidate for CBT-I. Conclusion: This narrative review addresses the scientific robustness of evidence for issues related to adherence, efficacy and adverse effects of non-pharmacological therapies. Available literature suggests that data related to adherence and efficacy of CBT-I suffer from methodological shortcomings and careful selection of patient is important for the successful therapy. At the same time, attempts have been made to shed light to the areas where CBT-I can be helpful in the management of insomnia.

Management of chronic insomnia using hypnotics: a friend or a foe?

Epidemiological studies suggest that 10-15% adults meet the present criteria for the diagnosis of insomnia disorder; however, there may be geographical variations. Untreated insomnia disorders have a number of adverse health consequences in addition to economic burden caused by it. Available guidelines mention that CBT-I should be preferred over hypnotics. However, several patients of chronic insomnia are not candidate for CBT-I and for them, hypnotics are the only answer. This paper reviews the literature to answer following questions: What is the current understanding regarding place of hypnotics for in management of insomnia disorder? How many patients misuse or abuse hypnotics, especially benzodiazepines, as commonly believed? Do we have data from human studies regarding low-dose benzodiazepine dependence? What does hypnotics produce-withdrawal insomnia, rebound insomnia or end of dose phenomenon? Are adverse effects of benzodiazepines worse than other psychotropic medications? Is prescription of hypnotics more troublesome than untreated insomnia disorder? Available literature suggests that there is an unreasonable negative bias attached to the use of hypnotics. Only a sub-set of patients who are prescribed hypnotics, meet the criteria for "dependence" in long term. Other patients either discontinue it (as insomnia remits) or change to occasional use (since insomnia may be relapsing remitting disorder), or continue using it in low dose (since insomnia reappears as hypnotics are discontinued, similar to increase in blood sugar after hypoglycemics are discontinued). Meta-analysis shows that adverse effects of hypnotics are comparable to that of other psychotropic medications. Considering the consequences and risks associated with untreated insomnia disorder, even long-term use of hypnotics is justified, however with the careful watch that patients are not increasing the dose. This approach is especially important in geographical areas where trained CBT-I therapists are not available.

Role of Transcranial Direct Current Stimulation in the Management of Alzheimer's Disease: A Meta-analysis of Effects, Adherence and Adverse Effects.

Transcranial direct current stimulation (tDCS) is a form of novel brain stimulating method that has attracted interest owing to its relative inexpensiveness and ease of administration. It has been evaluated in many studies for its effectiveness in improving cognitive symptoms in Alzheimer's disease (AD). However, our understanding regarding its efficacy and the most effective way of administering tDCS (in terms of lead placement to achieve response and prevent harmful consequences) is still evolving. The current meta-analysis was conducted to resolve the above issues. A search using appropriate keywords and medical subject headings was conducted on PubMed, Scopus and DOAJ database. Studies were analysed on pre-defined inclusion and exclusion criteria. Finally 11 studies were included for quantitative analysis from 1,021 obtained from initial search. All the studies included were methodologically of high quality, though an asymmetrical funnel plot raised the possibility of publication bias. tDCS was found to significantly improve the scores on cognition as compared to sham. Anodal tDCS was found to be significantly beneficial in this regards, whereas cathodal and dual stimulation were not. There were no significant difference in the number of drop-outs and adverse reaction in tDCS and sham group. The quality of evidence that we have reviewed in this study is robust. tDCS, particularly anodal tDCS is an effective treatment modality in AD. It is well tolerated in patients with AD. However, further studies are warranted to probe the role of tDCS in other domains of AD.