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REVIEW ARTICLE  
Year : 2018  |  Volume : 60  |  Issue : 8  |  Page : 457-465
Assessment of clinical co-morbidities


Drug De-addiction and Treatment Centre, Department of Psychiatry, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India

Click here for correspondence address and email

Date of Web Publication5-Feb-2018
 

   Abstract 


A large proportion of patients with substance use disorders have clinical comorbidities, either medical or psychiatric. An initial assessment is necessary initially for prompt identification and management of any psychiatric or medical emergency, and thereafter a more detailed assessment for the comprehensive understanding of the individual. This should be done keeping in mind the goals of both immediate and long term assessment so that a comprehensive but individualized, context and culture sensitive, reality based, recovery-oriented management plan can be formulated. Assessment should consist of not only history-taking, physical and mental status examination but also laboratory and instrument based assessment as needed. During assessment, collateral reports and past medical records are valuable additions along with self-report. Since substance use disorders influence various aspects of daily life, hence medical, social, occupational, religious, spiritual, financial and legal aspects should be evaluated. Overall, the assessment needs to be diagnosis and management focused, covering the various bio-psycho-social domains relevant to the individual.

Keywords: Addiction assessment, co-morbidity, goals/factors in assessment Introduction

How to cite this article:
Basu D, Basu A, Ghosh A. Assessment of clinical co-morbidities. Indian J Psychiatry 2018;60, Suppl S2:457-65

How to cite this URL:
Basu D, Basu A, Ghosh A. Assessment of clinical co-morbidities. Indian J Psychiatry [serial online] 2018 [cited 2021 Oct 25];60, Suppl S2:457-65. Available from: https://www.indianjpsychiatry.org/text.asp?2018/60/8/457/224678





   Introduction Top


The term 'comorbidity' was first introduced by Feinstein in 1970 to refer to a 'distinct clinical entity' which occurred during the clinical course of a patient having an index illness.[1] National Institute of Drug Abuse (NIDA) in United States Research report series refers to 'comorbidity' as two disorders or illnesses which occur in the same person simultaneously or sequentially.[2] If the two conditions involved are a substance use disorder and another mental disorder then other terms are used like 'dual diagnosis', 'medically ill chemical abuser' or 'co-occurrence'.[3] The reason for such a separate designation is manifold: they are associated with poorer outcomes in various clinical domains, including increased risk of relapse, re-hospitalization, life events, suicide and violence, medical comorbidity, homelessness, family discord, economic burden and public healthcare delivery system burden.[4] Large scale epidemiological studies have shown that psychiatric disorders are present in a significant proportion of persons with substance use disorders.[5] The most common causes of mortality in severe mental illness are stroke, ischaemic heart disease, chronic obstructive pulmonary disease, and road traffic accidents; these are also associated with tobacco and alcohol use.[6],[7] Further, infections with human immunodeficiency virus (HIV), hepatitis C virus (HCV) and hepatitis B virus (HBV) are common medical conditions among persons using injection drugs.[8],[9]

In the Indian context, no national level data are available on the prevalence of clinical comorbidity; however, clinic based data show that dual diagnosis is clearly prevalent. For example, in a clinic-based study from north India, it was shown that 13.2% of the patients attending addiction services over a 11-year period have non-substance psychiatric disorders; in a clinic-based study in south India among treatment-naive first-episode psychosis, it has been shown that 20% reported any substance use disorder (except nicotine).[10],[11]

This article focuses on definitions, background, goals, and the details of primarily assessment of psychiatric comorbidities of substance use disorders, ending with two anonymized case vignettes for practical application of the principles discussed.

Definition, principles and scope

Substance Abuse and Mental Health Services Administration (SAMSHA) has described 'assessment' as the process for defining the nature of the problem and developing specific treatment recommendations for addressing the problem.[12] 'Assessment' has been conceptualized as a comprehensive, multidimensional process comprising of 12 steps ranging from initial screening, initial assessment, determination of level of care, placement and planning treatment as per structured, extensively researched and validated criteria like American Society of Addiction Medicine (ASAM) patient placement criteria (PPC).[13] An 'integrated' treatment delivery for clinical comorbidities is intended by a multidisciplinary team comprising of a qualified psychiatrist, addiction specialist, clinical psychologist, psychiatric social worker and psychiatric nurse, and there should be provision of intensive and emergency medical and psychiatric care as per the need and requirement of the individual.

However, the authors acknowledge the difficulty of its implementation in a low resource setting, though the basic principles of 'assessment' are still relevant, like its need to be comprehensive, individualized, readily accessible, addressing multiple treatment needs with ongoing with constant modifications.[14]

Irrespective of the facilities and setting, the three 'core' principles of clinical assessment are: a judicious combination of clinical judgment, patient self-report and collateral reports. However, laboratory investigations or collateral reports are particularly important in forensic settings, medico-legal purposes or where the patient is having absence of insight. Unlike Western societies, in the collectivistic Indian society, family is an important stakeholder in decision making.[15] In all situations of involuntary admission the rules of the new Mental Health Care Act, 2017 should be followed, which has provisions for emergency mental healthcare; but at the same time it is mandatory to undertake consent procedure at the earliest available opportunity and inform the mental health review commission or follow the advanced directives if any.[16]

Goals of a clinical needs assessment

The foremost goal in any management plan is determination of the treatment setting based upon the severity of substance use and psychiatric disorder. In this regard the quadrant model which groups both these disorders based upon severity may help to prioritize the focus.[17] The aims of treatment of dual diagnosis are:

  1. Acute psychiatric symptoms in the form of suicidality
  2. Violent behaviour/homicidality
  3. Intoxication/over-dosage/Severity of withdrawal symptoms
  4. Severity of substance dependence
  5. Associated serious medical illness
  6. Severe psychopathology
  7. Pregnancy/breast feeding
  8. Adverse psychosocial issues like psychological trauma, sexual, physical abuse


For the aforementioned conditions in-patient management is preferred. If the patient is having a psychiatric/medical emergency, then, after an initial urgent assessment, emergency care should be instituted in an intensive care setting with pending further evaluation. The goal should be personalized and modified time to time, and both short-term and long-term goal should be formulated. It needs to be remembered that the goal is not just to provide a diagnosis – rather it is a detailed assessment covering broad range of life areas, identifying environmental or situational risk factors of the co-occurring disorders or medical conditions, identifying individual supports, personal and interpersonal resources, determining the current stage of motivation, identifying the possible barriers to treatment, providing a baseline for monitoring change in treatment, formulating a realistic, culture sensitive, comprehensive treatment plan which is based upon current evidence base and at the same time acceptable to the patient, family members and treatment provider.[18]

Theoretical background

For understanding the rationale of a comprehensive assessment in clinical comorbidities, an understanding of the etiological basis is required.

Substance use in co-occurring disorders can be explained by 'self-medication hypothesis', 'affect dysregulation model' and 'addiction vulnerability model'.[19],[20] Whatever be the theoretical understanding, a multidimensional assessment as recommended by ASAM criteria may be followed in all persons with clinical comorbidities for matching assessment and treatment placement.[21] The different dimensions are:

  1. Acute intoxication/withdrawal potential
  2. Biomedical conditions and complications
  3. Emotional, behavioural, or cognitive conditions and complications
  4. Readiness to change
  5. Relapse, continued use or continued problem potential
  6. Recovery environment


In the Indian context, religion, spiritual and cultural traditions are important.[22] The focus of all such assessment is on strengths, individual skills and resources rather than deficits for an effective management plan. The basic theoretical premise as endorsed by the UK guidelines on clinical management and also the ASAM recommendations is that assessment is a continuous process ranging from initial engagement to recovery.[23]

Clinical assessment



It may be done under the following headings:

A. History

Socio-demographic and initial details – The usual details should be noted. Usually this is a routine procedure except in special situations like the homeless or for the patients brought by legal services. In the latter case, no informants might be available and as discussed before, self-report, laboratory investigations, and a thorough physical examination for indirect evidence for substance use (e.g. injection marks; parotid swelling) would have paramount importance. In all such cases physical identification marks should be recorded.[24] All such details should be carefully recorded because as per the Mental Healthcare Act, 2017, the definition of 'mental illness' includes 'mental condition associated with the abuse of alcohol or drugs' leading to disability benefits and insurance reimbursements.[25] On the other hand, in cases with severe medical comorbidities or serious mental illnesses, informants, medical records and if necessary communication with in-charge medical staff and specialists may disclose important information.

B. Substance use or addiction history:

Substance users often suffer from shame, guilt, fear, distrust, hopelessness and exhibit defences characterized by denial, minimization, rationalization, projection and externalization.[26] To circumvent such obstacles, clinicians should be adept with an open ended style of interviewing, and ask questions in an honest, respectful, matter-of-fact manner with due regard to confidentiality. At no point in time should confrontation and coercive techniques be used and at all times the emphasis should be on rapport building and therapeutic alliance.[27] Interview styles will primarily depend upon important patient characteristics. A young adolescent with ADHD, conduct disorder, cannabis use in the pre-contemplation stage needs to be in interviewed differently than an elderly male with decades of alcohol use, depressive symptoms and memory loss.

Hence the patient characteristics that influence interviewing style are: 1) age, gender, legal, marital status, employment status, culture; 2) level of insight, personal explanation for nature of problem; 3) psychiatric or medical comorbidity; 4) stage in course of illness ( first treatment or relapse); 5) current phase of use (e.g. intoxicated, withdrawal, inter-episode) and 6) stage of readiness for change.

Motivation is an important parameter which is to be assessed in all patients with substance use disorders. As per Prochaska and DiClemente the usual stages of motivation for change are: pre-contemplation, contemplation, preparation, and action.[28] These stages can be determined by various instruments, which are enumerated in [Table 2]. Line of management would differ as per the stages of motivation; for example, a client in a stage of pre-contemplation should be engaged in the treatment whereas a client in the stage of contemplation can be dealt with persuasion.[29]
Table 2: Instruments related to assessment of clinical conditions and comorbidities

Click here to view


Important landmarks in the substance use history should be noted; for example, age at onset of first use, intoxication, dependence and morning use, type and nature, frequency, amount, route, consequences and complications, treatment history (including response to any particular type of therapy), period of abstinence and relapses. Treatment seeking, which often occurs in different religious/social organizations quite common in India, should be noted.

McLellan has conceptualized complications of substance use disorders in different domains like social, family, marital, occupational, financial, and legal, apart from medical and psychological domains, which are illustrated in the Addiction Severity Index, 5th edition, and this has been validated in co-occurring disorders.[30] Such details need to be explored for all the substances used. Often the patients may have recall bias, worsened by the cognitive deficits related to substance use. In those cases history taking may be aided by recalling the extent of substance use during important life-event – e.g. substance use during his marriage or first-born child. When such clues fail to yield adequate information, a timeline follow back method may be used. Though time consuming, this method may reveal useful detailed history.[31] After eliciting the history, it is useful to summarize the findings – this may help in better understanding of the history and also continuation of rapport.

Patients having behavioural addictions like gambling disorder or gaming disorder may not be forthcoming spontaneously. A detailed account of a person's daily schedule, practices, financial commitments, debts and leisure activities are required for exploring such a history.[26] For gaming addiction the nature of games, the frequency and duration of use per day should be specifically enquired.

C. Psychiatric history

Symptoms consistent with a psychiatric disorder occurring with substance use may be induced by the substances concerned, may be independent or may occur wholly during intoxication or withdrawal. Any history of onset of psychiatric symptoms before onset of substance use clinches the diagnosis. However, in the reverse situation there may be clinical dilemma. Minute details of the temporal relationship can give important clues to the diagnosis - particularly symptoms during any significant abstinence period, also the relationship between substance use and the emergence, exacerbation or regression of psychiatric symptoms. Like a person, usually an occasional user of Bhang (low-potency cannabis) shifted to Charas (cannabis resin - high potency) leading to an abrupt onset of psychotic episode.

A diagnosis of substance induced mental disorder is made when the development of the full criteria for a mental disorder occurs during or within one month of an intoxication with or withdrawal from a substance that is capable of causing a mental disorder as per Diagnostic and Statistical Manual-5 (DSM-5).[32]

A mental disorder would be considered independent of a substance if the disorder preceded the onset of severe intoxication or withdrawal, or if the mental disorder persisted for a substantial period of time (e.g. at least one month) after substance intoxication or substance withdrawal ended. The disorder typically resolves at least partially within 1 month and fully within 6 months as per International Classification of Diseases (ICD-10).[33] (see case vignette 1).

Diagnosing other co-occurring disorders may be a challenge at times. For example, co-morbid attention deficit hyperactivity disorder (ADHD) history can only be explored with a patient about the patients' childhood and in adulthood about symptoms of inattention (e.g. lack of sustained activity, forgetfulness, poor organizational skills), hyperactivity, impulsivity (e.g. frequent job changes, easily frustrated and interrupting others).[34]

Medical history

This should be given particular emphasis. A patient with severe alcohol dependence may have physical complications of almost all the organs ranging from head to foot.[35] Even apparently innocuous medical findings like proximal muscle weakness may lead to difficulty in performing day to day activities, thereby impairing quality of life.[36] Since sexually transmitted diseases, blood borne infections are very common in substance users particularly among people who inject drugs (PwID), hence relevant symptoms should be enquired (see case vignette 2).[37]

[Table 1] enumerates the medical conditions commonly comorbid with substance use disorders.
Table 1: Some important medical complications of common substances

Click here to view


Note: The medical complication list is not comprehensive and is intended for only an overview.

Family history

Recent biological research has shown that that not only individual disorders but also 'comorbidity' runs in families – hence constructing a detailed genogram is important. For example, 'sensorimotor gating' is an endophenotype which predisposes one to tobacco smoking and also to schizophrenia.[38] Similarly, the gene related to the α7 receptor subunit CHRNA3-CHRNA5-CHRNB4 makes an individual vulnerable to carcinogens in tobacco and lung cancer.[39]

Substance use disorders may lead to significant family, marital conflicts, intimate partner violence and influence on children, which may be aggravated by comorbid psychiatric illnesses. Critical comments, co-dependence, enabling behaviour are quite common in families with dual diagnosis.[40] There is evidence of the efficacy of family interventions in the Western countries in dual diagnosis.[41] Hence this may be applicable to Indian families given the richness of family support in India.

Personal history

Birth, early development and childhood history are important in delineating the genesis of both substance use disorder, psychopathology, externalizing and internalizing symptoms, and personality disorders like borderline personality disorder. Therapists desirous of constructing a psychological formulation may need further details of childhood history, coping skills, cognitive distortions ways and means of dealing with or reacting to life-events or adversity. Many patients having history of sexual abuse in childhood require a sensitive approach and detail exploration may be done spanning over several sessions.

For performing occupational interventions, it may require details of past working experience, functional assessment and history regarding competence in relevant neurocognitive domains. This is also important from the disability assessment point of view. History of sexual exposure, practices and high risk sexual behaviours should be noted in all individuals. For women menstrual, obstetric history and substance use during pregnancy should be noted.

Personality and temperament

The temperamental characteristics which make one vulnerable to substance use should be assessed, like high impulsivity, low frustration tolerance and reward dependence.[42] Apart from this, individuals with an abnormal behaviour pattern pervasive and clearly maladaptive to a broad range of personal and social situations that started in adolescence, persisted into adulthood, often preceded substance use and are diagnosed as comorbid personality disorder. This is important because persons with severe mental illness like schizophrenia may have temperamental traits which as per the 'affect dysregulation model' may be predictors of substance use.[43]

Examination

A detailed physical assessment in the first presentation is often difficult because of lack of co-operation on behalf of the patient due to intoxication/withdrawal or lack of insight. However, assessment of vitals should be done initially and thereafter detailed physical examination on the next available opportunity. Important findings like nasal perforation, needle stains, body piercing, tattooing, needle marks, stigmata of chronic liver disease can give important clues to associated substance use.[44] Any physical sign suggestive of a self-harm attempt (e.g. wrist slashing) should always be noted. Importance of the medical examination lies in the fact that currently the commonest cause of mortality in developed countries among persons with severe mental illness and substance use disorders is medical illnesses.[6]

Whatever be the level of cooperativeness, mental status examination (MSE) is mandatory. If a formal one is not possible then Kirby's method may be useful.[45] Alterations in general appearance, speech, mood, affect, thought process, content, memory, orientation, cognition, insight and judgment should be noted. Such examination should be done repeatedly since physical and mental status may change dramatically during different stages of substance use (e.g. withdrawal/intoxication) and with any concurrent medical and psychiatric illnesses.

Instrument based assessment

Instrument based assessment is mostly used in the research parlance and seldom done in routine clinical practice, but may be quite useful particularly in clinically challenging situations and in inpatient settings. Instruments used in dual diagnosis patients are for diagnostic purpose, withdrawal assessment, severity assessment, assessment of motivation for change in substance use behaviour, assessment for suicidality, cognitive and personality assessment, as shown in [Table 2]. This table is not a comprehensive account of all instruments; rather, it summarizes the most commonly used instruments in Indian setting.[46] Most of the instruments are suitable for research purpose and rarely used in routine clinical practice. Only some of them, like Beck Depression Inventory, Beck Anxiety Inventory and Brief Psychiatric Rating scale, have been validated among dual diagnosis patients.[47] Psychometric properties need to be established for most of the instruments in dual diagnosis patients.

One of the most important instruments useful in patients with dual diagnosis is the Psychiatric Research Interview for Substance and Mental Disorders (PRISM), which differentiates primary disorders, substance-induced disorders and the expected effects of intoxication and withdrawal.[48] The PRISM assesses the following disorders - substance abuse and dependence, pathological gambling, primary and substance induced mood, anxiety and psychotic disorders, eating disorders, personality disorders, pathological gambling and attention deficit hyperkinetic disorder, which have been included in DSM-5. It takes one hour to administer and has excellent reliability and validity and assesses lifetime and current psychiatric symptoms and disorders.[49] However, it is not suitable for routine clinical purpose.

Laboratory assessment

Laboratory assessment has become an integral part of the overall clinical assessment.[18] It may help in understanding the true extent of medical complications. This may be complementary to patient report or family report with regard to substance use but is particularly useful in cases with medico-legal issues or unreliable/inadequate history. Laboratory findings may help in psychosocial interventions also. For example, while performing motivational enhancement if a client is reluctant to undergo treatment then feedback regarding any worsening of biochemical parameter may be useful.[27] At times a seemingly healthy individual may be screened for high gamma glutamyl transferase, raised mean corpuscular volume or altered carbohydrate deficient transferrin may point to an undisclosed alcohol use disorder.[50]

The choice of laboratory investigations should depend upon the clinical context and the availability of laboratory services. In a chronic cannabis user with daily intake of cannabis, urine can yield traces of tetrahydrocannabinol (THC) for weeks up to a month – a negative urine report can practically rule out cannabis induced psychopathology.[51] However, one should be cautious about any false negative or positive results. All women of reproductive age should be assessed to rule out pregnancy by performing appropriate tests.

Case Vignettes

(The following are not original cases but clinical description of typical cases presenting to PGIMER Chandigarh, and managed by a multidisciplinary team)

Clinical Scenario 1 [Middle aged gentleman with alcohol use]

Mr X is a 45 year old married male, educated up to graduation, working as an office-assistant, belonging to middle socio-economic status, with family history of alcohol dependence in elder brother, past history of severe depressive episode without psychotic symptoms at the age of 20 years, which remitted with treatment within a few months. However, the mood symptoms led to the onset of alcohol use leading to dependence within 2 years. Thereafter, he continued drinking about 8 units of alcohol per day leading to significant socio-occupational dysfunction. Six months back, the sudden death of his elder son precipitated heavy alcohol intake – now drinking about 18-20 units per day along with depressive symptoms and suicidal ideation.

Assessment: On presentation, the psychiatrist elicited the preliminary history; physical examination revealed mild jaundice, parotid enlargement, hepato-splenomegaly and moderate withdrawal symptoms, with a Clinical Institute of Withdrawal Assessment score (CIWA-Ar) of 12. Hindi Mental Status Examination score was 28 and transient suicidal ideation without any plans – assessment was done with Beck Suicidal Ideation scale. MSE revealed sadness of mood, worthlessness and hopelessness. In view of multiple clinical comorbidities and complications, the patient was admitted for further management with due consent in an 'action' stage of motivation. Upon admission, all the requisite investigations for medical comorbidities were sent and a management of alcohol withdrawal and nutritional supplementation was started with liaison with medical specialty. Thereafter, a diagnostic clarification was performed with the help of PRISM. The focus was mostly on the inter-relationship between depression and substance use, any significant abstinence attempt and abstinence period were studied carefully.

In this case, since the mood symptoms persisted despite the patient being abstinent in the in-patient care for more than a month, a subsequent diagnosis of an independent depressive episode was considered.

Further evaluation of past history and personality revealed that the patient had neurotic traits from childhood, low self-esteem and anxious preoccupation. After a detailed assessment with International Personality Disorder Examination (IPDE), a diagnosis of anxious avoidant personality disorder was considered. Finally, the psychologist in charge constructed a cognitive behavioural formulation and started cognitive behaviour therapy along with pharmacotherapy. Cognitive assessment after a month of abstinence revealed no significant cognitive deficit. The in-charge social work professional formulated a management plan for further follow-up and aftercare services including family sessions and aftercare services.

Clinical Scenario 2 [Young adult with injection drug use]

A 22-year old male, unmarried, educated up to primary school, belonging to low socio-economic status, unemployed, with family history of natural opium dependence in father and grandfather, presented with history of externalizing symptoms, particularly being too restless, overactive, with history of frequent bullying, fights in childhood, oppositionality, fearlessness and callous unconcern for the plight of family members. He was also an experimenter, interested in rash driving, adventure sports. From early adolescence he was exposed to substances like alcohol and tobacco, cannabis and engaged in gang activities, fights and involved in sexual indiscretions from late adolescence. At 20 years of age he started taking heroin, quickly moved from chasing, snorting to intravenous use with needle sharing leading to stealing, peddling and finally developed fever, weight loss and presented to primary health services from where he was referred to addiction treatment services after initial detoxification. There is also a history of incarceration under NDPS act, 1985 – though in prison he continued injecting.
Table 3: Algorithm for management of clinical co-morbidities

Click here to view


Assessment: On presentation the psychiatrist assessed him for medical complications with particular focus on blood and sexually transmitted illnesses. He was particularly screened for HIV, HCV, HBsAg and VDRL with due consent. He was found to be HIV-1 seropositive and was liaised with Anti-retroviral therapy (ART) clinic and related counselling services.

On presentation he was found to have significant opioid withdrawal and nicotine dependence as assessed by Clinical Opioid Withdrawal Scale (COWS) and Faegerstrom Test for Nicotine Dependence (FTND), leading to his management with buprenorphine based opioid substitution therapy (OST). Since the person was not willing for in-patient management, he was managed as an outpatient. He was assessed with ASRS (Adult ADHD Self-report Scale), and ADHD diagnostic instrument (Wender Utah ADHD scale). IPDE had suggested dissocial personality disorder.

Psychologist in charge made a formulation where the externalizing traits, early drug exposure, positive family history, and lack of disciplining in childhood led to the development of substance use disorder and drug subculture, lack of prison harm reduction services and poor knowledge about safe injection practices, which unfortunately led to contracting HIV. The psychiatric social worker liaised with ART, medical specialties and this led to retention in services and continuation of both treatments.


   Summary and Conclusion Top


  • Clinical comorbidities are very common in substance use disorder.
  • The clinician needs to pay attention to both the medical and psychosocial needs.
  • Assessment needs to be a judicious combination of clinical judgment, patient self-report and collateral reports.
  • Basic principles of assessment are that it should be comprehensive, individualized, readily accessible, addressing multiple treatment needs with ongoing constant modifications.
  • Comprehensive assessment should range from engagement, screening and need to be recovery oriented.
  • Immediate focus of the assessment should be on emergency medical and psychiatric symptoms.
  • History-taking should include history of substance use, psychiatric history, medical history, family history, personal history, temperament and personality assessment.
  • Comprehensive assessment should focus on long-term issues including retention in services and aftercare in a culture sensitive manner acceptable to all stakeholders.
  • Medical examination and mental status examination should be done repeatedly to rule out rapidly changing nature of substance use disorder.
  • Laboratory evaluation and instrument based assessment are corroborative.
  • The assessment needs to multidimensional, ideally addressing not only the biopsychosocial but also spiritual and religious aspects.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Correspondence Address:
Debasish Basu
Professor, Drug De-addiction and Treatment Centre, Department of Psychiatry, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/psychiatry.IndianJPsychiatry_13_18

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  [Table 1], [Table 2], [Table 3]



 

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