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|Year : 2018
: 60 | Issue : 5 | Page
|Prof. K.C. Dube Award
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|Date of Web Publication||1-Feb-2018|
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. Prof. K.C. Dube Award. Indian J Psychiatry 2018;60, Suppl S4:18-21
A study of sex hormones and cognitive functioning among elderly depressed women.
Background: In India cognitive dysfunctions are often perceived as a mere “brain weakness” connected to ageing and is infrequently diagnosed by primary healthcare centers,(Patel V et al, 2001).In addition to the evidence that estrogen can affect aspects of cognitive functioning around the time of menopause, it must also be considered that the aging process itself may account for some cognitive decline independent of any hormonal effect. A study by Gibbes RB et al , found that estrogen increases choline acetyltraneferase activity in the basal forebrain and hippocampus, regions in the brain that are found to be acetylcholine deficient in patients with Alzheimer disease (AD).The apparent relationship between the menopause transition and cognitive difficulties in some women suggests that such cognitive disturbance may be related to the hormonal changes of the menopause (Yaffe K et al, 1998).
Aims and objectives: The proposed study is to ascertain possible correlation of sex hormones and cognitive functioning among elderly depressed women
Methodology: A cross-sectional,prospective study was conducted at the department of psychiatry, SMS Medical College and hospital Jaipur. 100 newly diagnosed elderly women (drug naive) fulfilling the inclusion and exclusion criteria and willing to participate in the study were recruited after informed written consent.The diagnosis of depression was made according to ICD-10. The patients detailed sociodemographic and illness characteristics were recorded.The severity of depression was assessed by Beck’s depressive inventory (BDI) and cognitive functioning with the help of Hindi Mental Status Examination (HMSE). Further all the patients were subdivided in two groups on the bases of HMSE score,either having cognitive dysfunction (dementia) or not. All the patients underwent laboratory work-up. After an overnight fasting 5 ml of venous blood sample was drawn from anticubital vein by using aseptic techniques in plain and EDTA vials.Serum separated and following investigations were performed-1.Serum estrogen(estradiol)2.Progesterone 3.TSH 4.FSH and 5.LH
Results and Conclusions: In our study significant correlation was found between depression and cognitive dysfunctions among elderly depressed women. A negative correlation of TSH and positive correlation of estrogen observed with HMSE score which were indicative of cognitive dysfunction among elderly women. No significant correlation was found with progestrerone. We conclude that estrogen and TSH are an important link between depression and cognitive functioning.
Key words: sex hormones, cognitive functioning, BDI, HMSE,menpause transition.
Study of risk factors associated with suicide attempt in patients with bipolar I disorder
Karthick Subramanian*, Vikas Menon, Vigneshvar Chandrasekaran
Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India.
Background: Suicide is the leading contributor for mortality in bipolar disorder. A history of suicidal attempt is a robust predictive marker for future suicide attempts. Personality profiles and coping strategies are the areas of contemporary research in bipolar suicides apart from clinical and demographic risk factors. However, similar research in developing countries are rare. The present study aimed to identify the risk factors associated with suicidal attempts in bipolar I disorder (BD-I).
Methods: Patients with BD-I currently in clinical remission (N=102) were included in the study. The socio-demographic details and the clinical data were collected using a semi-structured proforma. The psychiatric diagnoses were confirmed using the Mini International Neuropsychiatric Interview (MINI 7.0). The Presumptive Stressful Life Events Scale (PSLES), Coping Strategies Inventory-Short Form (CSI-SF), and Buss-Perry Aggression Questionnaire (BPAQ) were used to assess the patient’s stress scores, coping skills, and aggression, respectively. Binary logistic regression analysis was performed to identify the predictors for lifetime suicide attempt.
Results: One hundred and two patients (Males=49, females=53) with BD-I were included for the study. Thirty seven subjects (36.3%) had a history of suicide attempt. On binary logistic regression analysis, the odds ratios (OR) for predicting a suicide attempt were highest for positive family history of suicide (OR 11.45, 95% Confidence Interval (CI):1.15-114.40, p=0.038), followed by presence of psychiatric co-morbidity (OR 3.24, 95% CI:1.13-9.32,p=0.029), lower scores on problem focused disengagement (OR 0.71, 95% CI: 0.56-0.90,p=0.005), and increased verbal aggression as per BPAQ (OR 1.11, 95% CI: 1.00-1.24).
Discussion: The study sample reflected the high incidence of suicidal behaviours in patients with BD-I. The findings reiterate that genetic loading, psychiatric comorbidities and poor coping strategies can significantly worsen the suicide risk.
Conclusions: Clinicians should exert caution while evaluating BD-I patients with a family history of suicide, multiple psychiatric diagnoses, poor coping skills, and verbal abusiveness.
Keywords: Bipolar-I, suicide
Structured pathway of non-pharmacological methods for managing patients with dementia in a tertiary care hospital
Nisha Mani Pandey, SM Tripathi, Bhupendra Singh, S.C. Tiwari
Department of Geriatric Mental Health, King George’s Medical University, Lucknow, India.
Background: Management of a patient with dementia (PwD) is a difficult task. There is hardly any pharmacological intervention with high level of efficacy. Further, side effects of commonly prescribed drugs for managing behavioural and psychological symptoms of dementia (BPSD) are also reported to be high. Alternatively, non-pharmacological methods (NPM) are well accepted, appreciated and encouraged to be used as first line treatment for managing PwDs [1-3].
Objectives: Primary objective: To assess the impact of non-pharmacological methods (NPM) in managing PwDs. Secondary Objective: To develop structured pathway of NPM for managing PwDs.
Methodology: To develop the NPM intervention strategies, a structured proforma has been developed. This proforma is based on the research outcome as well as experiences of the multi-disciplinary team (MDT). After obtaining all basic information from the patient/ their care givers, needed assessments were done by the concerned team member to identify and rate the level of severity of the problem and the type of NPM strategies to be used. A realistic goal is set and periodic assessments are done to note outcome of the applied procedures. Applied NPM includes dietary, psychological, social , occupational, physical exercises, recreational as well as spiritual methods. Psycho-eduaction sessions are held with caregiver.
Results: A total of 42 PwDs and their caregivers were assessed. Each of the subjects were assessed at baseline and at the end. Significant improvement in attitude of caregivers and management of PwDs were noted.
Discussion: Our findings reveal that proper sessions of psycho-education Along with appropriate NPM strategies lead to increased functionality, reduce caregivers’ burden and ensures dignified life to the PwDs.
Conclusion & Implication: No negative impact of NPM was found. It is a cost-effective approach and therefore, should be implemented to ensure dignified life to elderly mentally ill.
Key Words: non-pharmacological methods (NPM), structured pathway, multi-disciplinary team (MDT), patients with dementia.
- Barton C, Ketelle R, Merrilees J, Miller B. Non-pharmacological Management of Behavioral Symptoms in Frontotemporal and Other Dementias. CurrNeurolNeurosci Rep. 2016 Feb;16(2):14.
- Sachdeva A, Kumar K, Anand KS. Non Pharmacological Cognitive Enhancers – Current Perspectives.J ClinDiagn Res JCDR.2015 Jul;9(7):VE01-VE06.
- Alves J, Magalhães R, Machado Á, Gonçalves ÓF, Sampaio A, Petrosyan A. Non-pharmacological cognitive intervention for aging and dementia: Current perspectives. World J Clin Cases WJCC. 2013 Nov 16;1(8):233–41.
Resting state oscillatory power and functional connectivity in schizophrenia: A high-resolution EEG study
Sai Krishna Tikka1, Jose Cortes-Briones2, S Haque Nizamie3, Vinod Kumar Sinha3, Deepak Cyril D’Souza2
1Department of Psychiatry, AIIMS, Rishikesh, Uttarakhand, India, 2Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA., 3Consultant Senior Psychiatrist, Ranchi, Jharkhand, India
Study venue: Data was collected at Central Institute of Psychiatry, Ranchi, India and data was processed at Yale University School of Medicine, New Haven, USA
Background: Brain function depends critically on oscillations. Studying oscillatory activity within brain-networks is a major emphasis in understanding neuroscience of schizophrenia.
Objectives: To determine whether the oscillatory properties of the brain are abnormal in schizophrenia patients.
Material and Methods: Resting EEG was collected under eyes closed condition (5 minutes) from 40 symptomatic schizophrenia subjects (SCZs) and 15 healthy controls (HCs) using a 256-channel Geodesic EEG System. EEG data was pre-processed to remove artifacts and sLORETA source analysis was performed. Average delta-band power was obtained for the reconstructed EEG sources (15000 vertices) using a fast Fourier transform. To estimate connectivity between regions of interest (ROIs – Brodmann areas), global signal (principal component explaining most of the variability) of each ROI was obtained and delta-band inter-ROI time-delayed (to reduce volume conduction effects) phase-locking value (dPLV) was obtained. Psychopathology was assessed using PANSS.
Power at sources (vertices) and inter-ROI PLVs were compared between SCZs and HCs and t-maps were obtained. Permutation tests using the t-max statistic were used to determine multiple comparison-corrected sources and inter-ROI PLVs. Subsequently, regression analysis was conducted to characterize correlations with any specific psychopathology scores.
Results: The analyses showed a widespread increase in delta-band power and inter-ROI connectivity in SZC patients compared to HCs. Neither delta-band power nor inter-ROI connectivity was significantly correlated to psychopathology scores.
Conclusions: We find that EEG delta oscillations in schizophrenia patients show well-replicated abnormalities. Increased power and connectivity of resting delta oscillations during symptomatic phase of the illness may infer a direct causal relationship with overall disease process.
Keywords: EEG, schizophrenia
Brief Intervention to Reduce Substance Use in Class C Male Hospital Employees: A Randomised Controlled Trial
Background: Substance use in workplace is linked to risk of accidents, injury, poor health, absenteeism, and negative effects on the workplace atmosphere. Existing research focuses on alcohol related harm, while workplace use of other substances has been neglected. There are no randomised controlled studies of brief interventions in Indian hospital settings.
Aim: To evaluate the efficacy of WHO ASSIST-linked Brief Intervention (ALBI) for reducing risky patterns of substance use in Class C male workers at a tertiary-care hospital in North India.
Material and methods: The study was conducted in two phases. In Phase-I a random list of 400 employees was generated from the entire pool of Class C male hospital workers. Data on the ASSIST risk categories (mild, moderate, and severe) was generated from Phase I. In Phase-II moderate and high risk subjects (‘screen-positive’ by ASSIST score) were randomised into Intervention and Control groups with 35 screen-positive subjects in each group. The Intervention group was given a structured session as per ALBI protocol, while the control group was given a 30-minute general talk on health related consequences associated with substance use. The subjects were compared on ASSIST score, WHOQOL-BREF, RCQ and Motivation to seek treatment at baseline and at 3-month follow up.
Results: The percentage of ‘screen-positive’ subjects for different substances was: tobacco-28.6 %, alcohol-24 %, and cannabis-6.9 %. The inferential analysis showed that ALBI recipients had significant reduction of ASSIST scores for all risky use of substance compared to the control group (p<0.001). Changes in motivation toward action stage were documented significantly more in intervention group than in the control group. Participants receiving ALBI were significantly improved across WHOQOL-BREF parameters and more motivated to seek treatment compared to the control group.
Conclusion: The screening and ALBI were effective in: reducing substance use, increasing motivation to change and improving the QOL of the subjects at workplace setting.
Keywords: ASSIST, brief intervention, psychoactive substances, hospital employees, class C workers, screening, randomized controlled trial.
Decoding post partum depression challenge to motherhood: A study from perinatal psychiatric service out- patient department from rural Maharashtra.
Aim & Objectives: According to WHO, maternal mental health problems are considered major public health challenge, especially in developing countries. Despite its serious consequences and amenity to treatment, post partum depression (PPD) often remains unrecognized. Author aims to describe cases of patients with PPD with emphasis on its phenomenology, culture- specific risk factors and management.
Methodology: Twenty patients referred to perinatal psychiatry services of psychiatry department in one year and diagnosed with PPD were assessed retrospectively. Patient’s symptoms were evaluated using Edinberg’s Post-partum Depression Scale (EPDS). Data was tabulated and analysed using Microsoft excel.
Results: Mean age of the patients was 25 years and majority were primigravida (60%). Half of the patients had significant psychosocial stressors. Most common mode of delivery was operative (60%), a quarter had pregnancy complications and poor obstetrics outcome. Mean duration of presentation was 4 months post partum. Seven patients had disruption in breast feeding and thoughts to harm baby and of suicide were reported by one patient each.
In management, only two patients needed admission and electro- convulsive therapy. Rest of patients showed good improvement with psycho-pharmacological and psycho-therapeutic interventions except three, who dropped out of treatment.
Discussion: PPD is the most common psychiatric disorder observed in the postpartum period (11-26%). Biological changes, psychosocial stressors along with risk factors contributes to etio-pathogenesis of PPD. Untreated PPD can have adverse effect on health of the mother, infant, mother- infant bonding, overall development of infant and increases chances of future relapses.
Conclusion: PPD is disturbing but treatable. Occurrence of symptoms anytime till 1 year post partum makes screening and diagnosis difficult. In resource scarce country like India, innovative perinatal care can be planned using involvement and training of field workers, nurses, relatives, primary health care professionals, gynaecologists and paediatricians for timely screening, referral and management of PPD.
Utilization of tramadol for maintenance treatment of opioid dependence: Yet another option?
Siddharth Sarkar, Rakesh Lal, Mohit Varshney, Saurabh Kumar, Yatan Pal Singh Balhara
Department of Psychiatry and NDDTC, AIIMS, New Delhi.
Aims/objectives: Existing opioid substitution therapies have certain limitations which necessitate the exploration of alternative options for maintenance of patients with opioid use disorders. The present study presents the experience of utilization of tramadol for long term maintenance treatment of patients with opioid dependence.
Methodology: This cross-sectional observational study used a structured interview to gather data. Patients with opioid dependence who received tramadol for a period of more than 6 months were recruited. Outcome was assessed in terms of self-reported abstinence while being on tramadol.
Results: One hundred and two participants were recruited in the study. The mean age of the sample was 41.3 years and all were males. Abstinence to extraneous opioids was reported by 58.8% of the sample. The median dose of oral tramadol at which abstinence was achieved was 350mg/day. Users of natural opioids (raw opium or poppy husk) at the time of treatment seeking had higher rates of achieving abstinence.
Discussion and conclusion: Tramadol may be a possible alternative option for the maintenance treatment of opioid dependence in selected individuals, especially in situations where regulatory constraints limit the use of other opioid substitution agents. Further evidence is required to establish its efficacy as a prominent agent in opioid substitution treatment.
The Impact of Attention Deficit Hyperkinetic Disorder on Residual Symptoms in Bipolar Disorder
Soumya Jhanda1, Savita Malhotra2, Sandeep Grover3
1Senior Resident, Department of Psychiatry, PGIMER Chandigarh, 2Former Dean and HOD, Department of Psychiatry, PGIMER Chandigarh, 3Professor, Department of Psychiatry, PGIMER Chandigarh
Aim: This study aimed to evaluate the impact of comorbid Attention Deficit Hyperkinetic Disorder (ADHD) on residual symptoms among patients with Bipolar disorder (BD).
Methods: Patients aged 13-40 years with history of BD with ADHD (N=30) were compared to patients with BD without ADHD (N=69) for presence of residual affective symptoms during the remission phase of illness.
Results: As compared to those without ADHD, patients of BD with ADHD had higher level of residual depressive symptoms in the form of total Hamilton Depression Rating Scale (HDRS) score (p≤0.001). Those with BD with ADHD had higher severity of depressed mood (p≤0.001), guilt (p=0.03), suicidal behavior (p=0.001), early insomnia (p=0.01), impairment in work and activities (p=0.01) and somatic anxiety (0.03) on the HDRS. In terms of manic symptoms, higher severity was noted only for the symptom of irritability (p=0.04) on the Young Mania Rating Scale (YMRS) in the BD with ADHD group.
Conclusions: Comorbid ADHD has negative impact on outcome of BD in terms of increased severity of sub-syndromal symptoms that can negatively affect functionality.
Key Words: Bipolar disorder, attention deficit
Neurobiological correlates of suicidal behavior and sleep quality in remitted bipolar I patients
Vigneshvar Chandrasekaran1, Karthick Subramanian1, Venkatalakshmi Penchilaiya1, Siddharth Sarkar2, Shivanand Kattimani1, Hanumanthappa Nandheesha3
1Department of Psychiatry, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, 2Department of Psychiatry and NDDTC, All India Institute of Medical Sciences, New Delhi, 3Department of Biochemistry, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, India
Objectives: About 25-50% of Bipolar Disorder-I (BD-I) patients attempt suicide and are more likely to have further attempts during their lifetime. Sleep disturbances in interepisode period is associated with increased risk of suicidal behaviors. Altered biomarker levels such as low Brain Derived Neurotrophic Factor (BDNF) and higher Matrix Metalloproteinase-9 (MMP-9) have been implicated in suicidal patients. The current study evaluates for biomarker specificity in BD-I patients who had made lifetime suicide attempts and those who had poor sleep Quality in a section of south Indian population.
Methodology: BD-I patients in remission (n=25) were recruited after confirming the diagnosis with Structured Clinical Interview for DSM-IV-TR (SCID-I). The illness course was retrospectively computed using the National Institute of Mental Health Life Chart Methodology (NIMH-LCM). Suicidal behavior and subjective sleep quality were assessed using the Columbia Suicide Severity Rating Scale (C-SSRS) and the Pittsburgh Sleep Quality Index (PSQI) respectively. Serum BDNF and MMP-9 levels were correlated with suicidal behavior and sleep quality.
Results: About 20% of the sample had a history of suicide attempt and about half the study population (48%) were poor sleepers. MMP-9 levels had significant positive correlation with history of suicide attempts. BDNF levels did not reveal any significant correlation with suicidal behavior or sleep quality.
Discussion: Prevalence rates of suicide attempts in the study population are comparable with contemporary research findings. Nearly half the remitted patients were poor sleepers, implicating the role of circadian rhythms in pathophysiology of BD. Though BDNF levels did not correlate with suicide, elevated MMP-9 levels reiterate its role in suicide similar to previous studies. No association could be made out between biomarker levels and sleep quality.
Conclusion: Increased levels of MMP-9 could reflect the lifetime suicide risk in BD-I, whereas biomarker levels were not associated with sleep quality during remission. Such findings need replication in studies with a larger sample size.
Keywords: Bipolar, suicide
Comparison of Neurocognitive domains in patients with Schizophrenia with and without co-morbid Obsessive Compulsive Disorder
Swapnajeet Sahoo*, Sandeep Grover, Ritu Nehra, Subho Chakrabarti, Ajit Avasthi
Department of Psychiatry, PGIMER, Chandigarh
Background: Neurocognitive deficits have been well documented in patients with schizophrenia. Research has shown that a significant proportion of patients with schizophrenia have co-morbid obsessivecompulsive symptoms/disorder (OCS/OCD). However, the impact of OCS/OCD on various neurocognitive domains in patients with schizophrenia is less understood.
Methods: 40 patients with schizophrenia and comorbid OCD (Group-I) were compared with 39 patients with schizophrenia without OCD (Group-II) and were assessed on Trail making test A and B (TMT-A/B), Controlled Oral Word Association test (COWA), Stroop test and Tower of London (TOL). Psychopathology was assessed by using Positive and Negative syndrome Scale (PANSS). Severity of OCD was assessed by using Yale-Brown Obsessive Compulsive Scale (Y-BOCS).
Results: Compared to patients without comorbid OCD, those with comorbid OCD had more severe cognitive deficits, with medium to large effect sizes. Significant differences were noted in the domains of processing speed (TMT-A; p-0.018), verbal fluency (COWA;p <0.001), cognitive flexibility (TMT-B;p-0.006) and in executive functioning (TOL- 2 moves,3 moves and 4 moves problems). There was significant associations in Group I Y-BOCS total score with the domains of verbal fluency (perseveration words, p -0.006, variant words,p-0.036), cognitive processing and selective attention (Stroop score,p-0.04) and executive functioning (significance noted in 2 moves problems only). However, no significant correlations emerged between YBOCS severity score and Group II neurocognitive domains.
Conclusions: Co-morbid OCD in schizophrenia is associated with more neurocognitive impairment as compared with schizophrenia without OCD. Accordingly, more intensive interventions must be carried out to address the neurocognitive deficits in patients of schizophrenia with OCD.
Keywords: Schizophrenia/obsessive-compulsive disorder/neurocognitive deficits
Haematological abnormalities among patients receiving Clozapine
Sandeep Grover, Anish Shouan, Subho Chakrabarti, Ajit Avasthi
Department of Psychiatry ,Postgraduate Institute of Medical Education and Research, Chandigarh
Background: Clozapine has been associated with neutopenia. However, clozapine can also cause other haematological side effects. Other haematological side effects which have been noted with clozapine include thrombocytopenia, thrombocytosis, eosinophilia, and leukocytosis etc. Most of the data about other haematological side effects in patients receiving clozapine is limited to case reports, case series and occasional small sample size studies.
Aim of the study: To evaluate the incidence of clozapine induced haematological side effects among patients receiving clozapine.
Method: Data of 331 patients who were on clozapine for duration varying from 1 month to 22 years, with a mean duration of clozapine therapy being 52.96 (45.18) months were reviewed for haematological abnormalities.
Results: Majority of the patients were males (N=157; 56.8%), single (n=219; 66.2%), Hindu (n=242; 73.1%), residing in urban locality (n=223; 67.4%) and unemployed (n=289; 87.3%). Most of the patients (n=207; 93.7%) were diagnosed with psychotic disorders, mainly schizophrenia. These patients were receiving clozapine in a dose range of 12.5 mg – 600 mg/day, with a mean dose of 212.08 (102.43) mg/day at the time of review of their records. About one-sixth (N=55; 16%) of patients developed at least one incidence of eosinophilia (eosinophil count > 6%), and 8.2% (N=27) experienced one incidence of thrombocytopenia (platelet count < 1, 00,000 cmm3) and 7 patients developed at least one incidence of anaemia (haemoglobin level < 10 mg%) during the clozapine therapy. Only 2 patients developed neutropenia. Mean dose (mg/day) at which haematological side-effects occurred were as follows: 155.68 (100.23) mg/day for eosinophilia; 193.98 (148.93) mg/day for thrombocytopenia; 78.57 (22.49) mg/day for anaemia. All these abnormalities were observed in more than one serial haemogram. In a small proportion of patients, clozapine was discontinued due to the haematological abnormalities and in other patients no other cause for these abnormalities could be ascertained. These abnormalities normalized on its own in subsequent follow-up.
Conclusion: Clozapine is associated with benign haematological abnormalities and most of these normalize with time.
Key Words: Clozapine, hematological
Source of Support: None, Conflict of Interest: None