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   Table of Contents - Current issue
November-December 2020
Volume 62 | Issue 6
Page Nos. 615-753

Online since Saturday, December 12, 2020

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Psychiatry research in India: Closing the research gap Highly accessed article p. 615
Om Prakash Singh
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Mental health research on scheduled tribes in India Highly accessed article p. 617
S V. Siddhardh Kumar Devarapalli, Sudha Kallakuri, Abdul Salam, Pallab K Maulik
Background: The burden of mental illness among the scheduled tribe (ST) population in India is not known clearly. Aim: The aim was to identify and appraise mental health research studies on ST population in India and collate such data to inform future research. Materials and Methods: Studies published between January 1980 and December 2018 on STs by following exclusion and inclusion criteria were selected for analysis. PubMed, PsychINFO, Embase, Sociofile, Cinhal, and Google Scholar were systematically searched to identify relevant studies. Quality of the included studies was assessed using an appraisal tool to assess the quality of cross-sectional studies and Critical Appraisal Checklist developed by Critical Appraisal Skills Programme. Studies were summarized and reported descriptively. Results: Thirty-two relevant studies were found and included in the review. Studies were categorized into the following three thematic areas: alcohol and substance use disorders, common mental disorders and sociocultural aspects, and access to mental health-care services. Sociocultural factors play a major role in understanding and determining mental disorders. Conclusion: This study is the first of its kind to review research on mental health among the STs. Mental health research conducted among STs in India is limited and is mostly of low-to-moderate quality. Determinants of poor mental health and interventions for addressing them need to be studied on an urgent basis.
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Psychological autopsy: Overview of Indian evidence, best practice elements, and a semi-structured interview guide p. 631
Vikas Menon, Natarajan Varadharajan, Sharmi Bascarane, Karthick Subramanian, Moushumi Purkayastha Mukherjee, Shivanand Kattimani
Background: No review has been attempted, so far, on Indian psychological autopsy (PA) literature. There is also a dearth of interview guides which is at the heart of a PA procedure. Materials and Methods: Electronic searches of MEDLINE through PubMed, PsycINFO, and Google scholar databases were carried out from inception till February 2020 to identify relevant English language peer-reviewed articles from India, as well as global literature that provided information on best practice elements in PA. Abstracts generated were systematically screened for eligibility. Relevant data were extracted using a predesigned structured proforma, and a semi-structured interview guide was developed. Results: A total of 18 original articles, one case report, and three reviews/expert opinion articles which tried to give a description of PA procedure were found from India. Most Indian studies are of suicide PA (SPA), done to assess risk factors associated with suicide. There was a wide variation in reported rates of psychiatric morbidity among suicide decedents, while the other major risk factor for suicide in the Indian setting was stressful life events. An optimal approach to PA involves systematically collecting information from key informants and other sources using a narrative interviewing method, supplemented with psychological measures, and is probably best carried out within 1–6 months after the death. Conclusion: There have been limited attempts to standardize PA. Most Indian studies use SPA. We propose a semi-structured PA interview guide, suitable for both research and investigational purposes.
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Psychiatric practice: Some personal observations p. 644
Anil Kumar Agarwal
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A comparative study on the safety and efficacy of naltrexone versus baclofen versus acamprosate in the management of alcohol dependence p. 650
Arun Kumar, Arvind Sharma, PD Bansal, Mamta Bahetra, Harkamal K Gill, Rakesh Kumar
Background: The efficacy of naltrexone, baclofen, and acamprosate in the treatment of alcohol dependence has been successfully established over the past several years. The knowledge about their relative efficacies can facilitate in developing relapse prevention strategies that would give rise to a greater personal and socioeconomic benefits. Aims and Objective: To assess and compare the safety and efficacy profile of naltrexone, baclofen, and acamprosate in the treatment of alcohol dependence. In addition to this, the pattern of relapse and attitude of patients toward the treatment were also assessed. Materials and Methods: This was a prospective study carried out at a tertiary care center. It comprised of thirty alcohol-dependent patients each assigned to naltrexone, baclofen, and acamprosate group after detoxification. The patients were assessed for craving, relapse risk, and medication adherence using the respective scales and questionnaires. Results: In terms of Obsessive Compulsive Drinking Scale score decline, the decline seen in the naltrexone group (26.72 ± 13.05) was maximum, followed by baclofen and acamprosate. In terms of decreasing Advance Warning of Relapse (AWARE) questionnaire score, again naltrexone was most effective, with the maximum decline in AWARE score (64.72 ± 45.65), followed by baclofen and acamprosate. The attitude toward treatment with all the three medications was positive, as per the Hogan Drug Attitude Inventory score. Conclusion: Naltrexone was most effective in decreasing craving and drinking behavior. Baclofen showed best tolerability in terms of liver function tests and least number of side effects reported. Naltrexone group reported the least number of relapses but maximum number of side effects. Acamprosate group had the maximum dropout rate.
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Is serum complement C1q related to major depressive disorder? p. 659
Jing Yang, Ruibo Li, Yuanhong Shi, Siyu Jiang, Jing Liu
Background: Major depressive disorder (MDD) has a high global incidence. While the pathogenesis of depression remains unknown, accumulating evidence has implicated inflammatory changes. Aim: The aim of the study is to compare the serum complement C1q levels in patients with MDD and healthy controls. Setting and Design: The design was a case–control study. Materials and Methods: Blood samples were collected from the patients with MDD and healthy controls to assess the serum C1q levels using an immunotransmission turbidimetric method. Statistical Analysis: Differences in complement C1q levels between patients with MDD and the controls, as well as between sexes among patients with MDD and the controls, were assessed using Mann–Whitney U-test. Spearman correlations were obtained between complement C1q levels and age. Results: In total, 1016 participants (508 MDD and 508 controls) were recruited. Differences in the sex ratio (male/female among controls, 181/327; and MDD, 178/330) and age (controls, 47.0 ± 14.9 years; MDD, 46.5 ± 16.5 years) were not significant. The C1q level in the patients with MDD was significantly higher than that in the healthy controls (P < 0.05). In the MDD group, C1q level correlated significantly with age. Conclusion: Elevation of the serum complement C1q levels in MDD may support the use of C1q as a potential biomarker for diagnosing depression, but further research is needed.
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Pathways to care among patients with severe mental disorders attending a tertiary health-care facility in Puducherry, South India p. 664
Manisha Chetan Khemani, Kariyarath Cheriyath Premarajan, Vikas Menon, Jeby Jose Olickal, Mathavaswami Vijayageetha, Palanivel Chinnakali
Introduction: Pathways to care can be defined as the pathway adopted by the patient to reach the appropriate health facility. In India, health workforce related to mental health care is inadequate. Persons with mental disorders approach different types of care providers. This study describes the number, sequence of care providers visited, and time gap between providers among individuals newly diagnosed with severe mental disorders. Materials and Methods: We conducted a facility-based descriptive study in the psychiatric outpatient department of a tertiary care center in South India between April and September 2017. All patients with any of the following diagnosis; acute psychosis, depression, bipolar disorder, or schizophrenia were included in the study. Information on number and sequence of care providers visited and the reasons for preference of providers were assessed using a validated World Health Organization questionnaire. Patients seeking care was summarized as numbers. Results: Of the total 150 participants, 86 (57%) were females and the mean (standard deviation) age was 35 (11.5) years. The first point of contact were traditional healers in 52 (34.7%) participants, general hospitals in 23 (15.3%), and psychiatric services in the remaining 75 (50%). The patients with schizophrenia and bipolar disorder had greater delays in accessing psychiatric care when compared to other disorders. Median (interquartile range) number of care providers visited till the diagnosis made was 2 (1–3). The availability and recommendation by close relatives were the major reasons for the preference of traditional healers. Conclusions: One-third of patients visited traditional healers as the first point of contact and about half visited the psychiatric facilities directly.
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Technological addictions in attention deficit hyperactivity disorder: Are they associated with emotional intelligence? p. 670
Gamze Yapça Kaypakli, Özge Metin, Dilek Altun Varmiş, Perihan Çam Ray, Gonca Gül Çelik, Canan Kuygun Karci, Ayşegül Yolga Tahiroğlu
Background: The impaired regulation of emotional responses has significant social consequences for patients with attention deficit hyperactivity disorder (ADHD) and can be thought to increase the risk for technological addictions. Aim: Ditto objective of the present research is to investigate the relationship between technological addictions and trait emotional intelligence (EI) in adolescents with ADHD. Methods: This cross-sectional study was conducted in 150 treatment-naïve adolescents with ADHD, aged 12–18 years. The sociodemographic information form, the Emotional Quotient-Inventory: Youth Version (EQ-i: YV), Internet Addiction Test, Smartphone Addiction Scale, and Conners' Parent Rating Scales were used for data collection. Results: The findings revealed that ADHD-C and female patients have lower mean stress management scores on EQ-i: YV. Patients who have smartphone addiction (SA)/problematic internet usage have lower total EI and stress management scores. The oppositional, hyperactivity, and DSM-total scores were negatively correlated with stress management scores. Intrapersonal and stress management scores were negatively correlated to SA symptoms. Conclusion: The stress management dimension was the strongest factor related to ADHD and technological addictions. In adolescents with ADHD, stress management may be the key factor to cope with daily problems. Therefore, the interventions to develop EI can be a therapeutic option in ADHD and technological addictions.
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Telomere length and 8-hydroxy-2-deoxyguanosine as markers for early prediction of Alzheimer disease p. 678
Dalia H Abou-Elela, Rawhia H El-Edel, Amr S Shalaby, Mariam A Fouaad, Ahmed A Sonbol
Background: Becoming shorter by each cell division, telomere length (TL) is regarded as a marker of cellular aging. Relative TL (T/S) depends on the quantitation of telomere hexamer repeat copy number normalized to autosomal single-copy gene copy number. TL is influenced by several factors, including oxidative stress (OS) and inflammation. This study aimed to investigate the possible role of TL and OS as markers for Alzheimer's disease (AD). Materials and Methods: One hundred and eighty participants were categorized into three groups. Group 1: Included 60 patients with AD. Group II: included 60 age-matched nondemented subjects. Group III (pregeriatric group): included 60 healthy controls with their ages ranging between 30 and 60 years. TL was determined by the quantitative Real time-PCR method, plasma levels of 8-OHdG by enzyme-linked immunosorbent assay, and total antioxidant capacity (TAC) by colorimetery. Results: In comparison to the other two groups, patients with AD showed shortened TL, increased plasma 8-OHdG concentration, and decreased TAC. The sensitivity of T/S ratio to predict AD was 86.67%, whereas the specificity was 96.67%. The sensitivity of 8-OHdG to predict AD was 96.67%, whereas the specificity was 86.67%. Conclusion: AD is associated with shortened TL and increased OS as manifested by decreased TAC and increased serum 8-OHdG. T/S and 8-OHdG could be used as early predictors for AD.
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Effectiveness of Rajyoga meditation as an adjunct to first-line treatment in patients with obsessive compulsive disorder p. 684
Kiran Mehta, Shivangi Mehta, Harsh Chalana, Harjot Singh, Richa Ghay Thaman
Background: Yoga is a set of mental, physical, and spiritual practices with its origin in ancient India. The renewed interest in Yoga has led to the exploration of its benefits in a variety of psychiatric disorders such as schizophrenia, depression, and anxiety disorders. There is a dearth of literature on the effect of yoga in obsessive compulsive disorder (OCD) in the Indian context. Aim: The present study was conducted to find out the efficacy of Rajyoga meditation (RM) as an adjunct to the first-line treatment in the treatment of OCD. Materials and Methods: Patients with OCD (diagnosed according to Diagnostic and Statistical Manual of Mental Disorders fifth edition) were divided into two groups – (i) The meditation group (MG), which included 28 patients and (ii) The nonmeditative group (NMG), which included 22 patients. MG practiced RM protocol for 3 months duration in addition to the pharmacological treatment. The NMG continued on pharmacological management as usual. The symptomatology was assessed at baseline and 3 months using the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS). Results: At 3 months, both groups demonstrated improvement in symptoms. The improvement in MG was statistically significant with a change of 9.0 ± 3.16 in Y-BOCS and a 49.76 ± 9.52% reduction in symptoms. Improvement scores of NMG were also statistically significant with a change of 3.13 ± 2.59 in Y-BOCS and 18.09 ± 14.69% reduction in symptoms. MG showed significantly more improvement in Y-BOCS scores (49.76 ± 9.52) as compared to NMG (18.09 ± 14.69) using the student's paired t-test (P < 0.001). Conclusion: The present study suggests that the RM is an effective adjunctive therapy to reduce obsessions and compulsions in patients with OCD.
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An impact of a digitally driven primary care psychiatry program on the integration of psychiatric care in the general practice of primary care doctors p. 690
Erika Pahuja, Thamaraiselvan Santhosh Kumar, Fareed Uzzafar, Narayana Manjunatha, Channaveerachari Naveen Kumar, Ravi Gupta, Suresh Bada Math
Introduction: The prevalence of psychiatric disorders among the general population is 10.6%. Primary care doctors (PCDs) are often the first contact for patients with common psychiatric disorders, but the majority of them are ill equipped to handle the same leading to symptomatic treatment. Hence, an innovative digitally driven and modular-based 1-year primary care psychiatry program (PCPP) was designed and implemented exclusively for practicing PCDs of Uttarakhand. Aim: The aim of the study was to assess the impact of this digitally driven 1-year PCPP on the general practice of PCDs. Materials and Methods: Ten PCDs were trained in the curriculum module “Clinical Schedule for Primary Care Psychiatry” which is a validated concise guideline for screening, classification, diagnosis, treatment, follow–ups, and referrals. Furthermore, they underwent training in on-site basic module (10 days); three online modules (with nil or minimal disruption in their regular clinical work) – Telepsychiatric On-Consultation Training (Tele-OCT), Collaborative Video Consultations, and weekly virtual classroom; and one public health module. In addition, PCDs underwent 10 criteria-based formative assessment including self-reports of weekly patients' audit (Primary Care Psychiatry Quotient [PCPQ]) and quarterly Tele-OCT evaluation sessions (Translational Quotient [TQ]). Results: PCPQ was 11.09% (2182 psychiatric patients of total 19,670 general outpatients) which means 11.09% of PCDs' total general consultations had psychiatric disorders, which would have been otherwise missed. Average scores obtained in first and second Tele-OCT evaluations (similar to clinical examination but in their real-time consultation) were 70.33% and 76.33%, respectively, suggestive of adequate TQ at 6 and 9 months of the course. Conclusions: One-year PCPP is shown to be effective in acquiring psychiatry knowledge, skills, and retention of skills (TQ) and also translated in providing psychiatric care in general practice with a positive impact on the delivery of primary care psychiatry.
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Tapentadol, the new kid on the block in India: Is it time to worry? p. 697
Debasish Basu, Tathagata Mahintamini, Abhishek Ghosh, Fazle Roub, BN Subodh, SK Mattoo, Ajit Avasthi
Background and Objectives: Large-scale prospective case series of tapentadol abuse or dependence in India is not available. Hence, we aimed to study the prevalence and profile of tapentadol users in a treatment-seeking population. Materials and Methods: The study had prospective and retrospective arms. We collected 8-month prospective data by face-to-face interviews (n = 70) and 8-year retrospective data from case notes (n = 26) with either tapentadol misuse/abuse or dependence in patients attending a de-addiction center. Results: The prevalence of tapentadol abuse or dependence was 25% among the pharmaceutical opioid users. Concurrent use of other opioids was seen in >80% of participants of both the arms. Major sources of tapentadol were chemists (without a prescription) (53%) and doctors (prescriptions) (40%). Patients in the tapentadol dependence group had a significantly higher dose, duration, and pharmaceutical opioid use. Conclusion: India needs awareness promotion, training, availability restriction, and provision of treatment for tapentadol abuse or dependence.
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Body-focused repetitive behaviors in school-going children and adolescents and its relationship with state-trait anxiety and life events p. 703
Swati Sailly, Roshan Vitthalrao Khanande, Sanjay Kumar Munda, Varun Shantilal Mehta
Background: Body-focused repetitive behaviors (BFRBs) are nonfunctional self-injurious behaviors. BFRBs fall under obsessive–compulsive and related disorders (OCRDs) and co-occur with anxiety disorders. Aim: The current study plans to assess the presence of BFRBs in schoolchildren and adolescents and find its relationship with state-trait anxiety and significant life events. Materials and Methods: The study identified twenty-one students with BFRBs using the Modified Habit Questionnaire. Along with the 21 matched healthy controls, both the groups were evaluated on the State-Trait Anxiety Inventory for Children (STAIC) and Life Event Scale for Indian Children (LESIC). Results: The study group scored significantly high on STAIC state score (P = 0.004), trait score (P= 0.014), and total score (P = 0.020). On five life events, the study group reported significantly high on stress. Conclusion: The study reports the presence of BFRBs in schoolchildren; state-trait anxiety and significant life events have a significant association with BFRBs.
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Comparison of maternal stress and psychiatric morbidity among mothers of children having psychiatric disorders and those of typically developing children p. 707
Nupur Shashank Mahatme, Anil Kakunje, Ravichandra Karkal
Introduction: Motherhood is regarded to be stressful, but when the child has a psychiatric illness, the mother is affected more than the father since she is the primary caregiver. She gets affected not only emotionally but also psychologically. Increasing severity of stress in mothers may lead to negative outcome on a child's care. Aims: The aim of this study was to evaluate the stress levels in mothers of children diagnosed with psychiatric disorder and to study the association between children having a psychiatric disorder and the psychiatric morbidity in their mothers. Materials and Methods: This was a case–control study with a total of 150 participants, in which 75 consecutive mothers of children were diagnosed with any psychiatric illness using ICD-10 criteria and compared to 75 mothers of typically developing children. The study was approved by the Institutional Ethics Committee. The Parental Stress Scale and the Mini-International Neuropsychiatric Interview-Plus questionnaire were used for assessments. Results: The study showed statistically significant stress scores (49.54) in mothers having children diagnosed with psychiatric illnesses as compared to scores (30.98) in mothers of normally developing children. Psychiatric morbidity in cases (n = 58; 77.3%) was statistically significant as compared to controls (n = 23; 30.6%). Depression and anxiety were among the most common psychiatric morbidities evaluated, and the highest was for mothers having children with severe mental retardation. Conclusion: In all children with psychiatric disorders, mothers have to be screened for psychiatric morbidity to prevent, detect, and manage it at the earliest.
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Knowledge about obstructive sleep apnea among medical undergraduate students: A long way to go! p. 713
Ridhima Wadhwa, Ashita Jain, Kaustav Kundu, Naresh Nebhinani, Ravi Gupta
Objective: The aim is to study the knowledge and attitude of medical undergraduate students regarding obstructive sleep apnea (OSA). Materials and Methods: This cross-sectional study involved 324 medical undergraduate students in clinical semesters. Knowledge and attitude regarding adult OSA were assessed using the obstructive sleep apnea knowledge and attitude (OSAKA), and to evaluate the same about childhood OSA, OSAKA-KIDS was used. Results: Results showed that the study population was not informed about OSA among adults as well as kids. Most of the participants could recognize that snoring was a common symptom of adult OSA but failed to identify the association between childhood OSA and hyperactivity. The participants had a good knowledge about the pathophysiology of OSA. More than 80% of students reported that OSA is an important disorder and that these patients should be identified. Conclusion: Medical undergraduates are poorly informed about OSA.
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Psychopathology, perceived social support, and coping in survivors of adult sexual assault: A cross-sectional hospital-based study p. 718
Pranav U Pohane, Suyog Vijay Jaiswal, Vihang N Vahia, Deoraj Sinha
Background: Adult sexual assault (ASA) is often associated with negative mental health consequences. The psychological needs of ASA survivors are overlooked while the legal and social needs focused on. Methodology: It is a cross-sectional study. The ASA survivors who came for medical evaluation were included in the study after obtaining consent. Fifty ASA survivors were interviewed for the study. Psychopathology, perceived social support, and coping mechanisms were assessed during interview using especially designed semi-structured pro forma. Results: The mean age of participants was 25.6 ± 7.2 years. Forty-one of 50 survivors suffered from major depressive disorder or posttraumatic stress disorder or both with 33 expressing suicidal ideas. Maximum social support was perceived from family and least from significant others such as health-care workers, police, and judiciary. Problem solving and expressive action are associated with better perceived social support by family as well as friends. Conclusion: Depression and suicidal ideas among majority the survivors of ASA highlight the mental devastation the sexual assault causes to a woman. Although family is primary social support to them, health-care workers and law enforcement officials are not perceived as supportive toward the survivors. Routine mental health assistance and empathetic approach by all parties involved in the management of survivors are needed in these cases.
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Need and learnings from having psychiatry as major subject during medical graduate examination p. 723
Anindya Das, Vijay Krishnan, Vishal Dhiman, Jitendra Kumar Rohilla, Vikram Singh Rawat, Aniruddha Basu, Ravi Gupta, Ravi Kant
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The need, scope, challenges, and potential solutions for enhancing addiction psychiatry training in India p. 728
Richa Tripathi, Shalini Singh, Roshan Bhad
Addictive disorders have become increasingly common in India. The health consequences of addictive disorders are immense, and the need for specialized addiction treatment and training far exceeds the capacity and human resources that currently exist. At the same time, increasing demand and treatment gap, need for specialized care, and the emerging sector of medical tourism in the country open avenues for superspecialty training in addiction psychiatry as an attractive career option for Indian psychiatrists. Human resource development and capacity building in the addiction psychiatry field in India is the need of the hour. In the present article, we describe the existing scenario and challenges related to addiction psychiatry training among postgraduate psychiatry trainees and psychiatrists in India and scope for the future.
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Aphagia in frontal lobe syndrome following traumatic brain injury: Delightful lessons from olanzapine treatment p. 732
Fatimah Ahmedy, Jiann Lin Loo, Mazlina Mazlan
A case of persistent aphagia in frontal lobe syndrome after traumatic brain injury (TBI) with successful use of olanzapine to improve the eating disorder is presented. A 20-year-old man suffered a severe TBI with right frontal intracerebral haemorrhage At four-month post-TBI, he had agitation, concurrent apathy with constant refusal for oral swallow despite gustatory sensory stimulation, hence the needs for nasogastric tube (NGT) feeding. He was diagnosed with frontal lobe syndrome and prescribed olanzapine 5mg daily that was optimised to 10mg due to worsened aggression. One month later, the aggression reduced with gradual improvement in oral intake. Percutaneous enterogastrostomy (PEG) tube insertion was cancelled and the NGT was sucessfully removed. Olanzapine prescription in this case improved aggression and aphagia simultaneously. Although olanzapine is proven beneficial and surgical intervention for long-term enteral feeding was avoided in this case, its usage requires judicious judgement.
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Nightmares with mirtazapine - A case report p. 734
Anjana Rao Kavoor, Sayantanava Mitra
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Survey on women's mental health awareness among medical undergraduates and postgraduates p. 735
Supriya Agarwal, Sameeksha Rathi, Navroz Khosla
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Acute dystonic reaction due to a combination of chloroquine and doxycycline in an emergency psychiatry setting p. 736
Hrishikesh B Nachane, Ajita S Nayak
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Pregabalin dependence p. 738
Akashdeep Singh, Ajeet Sidana, Abhinav Agrawal, Priti Arun
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Cannabis-induced hallucinosis syndrome: A rare case report p. 739
Akashdeep Singh, Ajeet Sidana, Abhinav Agrawal, Priti Arun
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A rare case of dicyclomine and mefenamic acid abuse fulfilling criteria of dependence syndrome p. 740
Santosh Kumar Sinha, Shyla Dhiman, Ajeet Sidana
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Life threatening opioid withdrawal syndrome due to inadvertent naltrexone administration and lifesaving result by clonidine p. 742
Jayanta Kurmi, Hasina Anjuman Choudhury
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A rare association of lithium carbonate with blepharospasm: A case report p. 743
Ajay Kumar, Sandeep Grover
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Reasons for not following up in patients with psychiatric illnesses: A telephonic cross-sectional study p. 745
Swarna Buddha Nayok, Sathyanarayana Malleshwara Thimmaiah
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Comparison of cost-effectiveness of long-acting depot injection antipsychotics and oral antipsychotics in patients with schizophrenia in a rural community in South India p. 747
Vijaya Raghavan, Aishwarya Gonzalez Cherubal, Sujit John, R Padmavati
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Knowledge about confidentiality among medical students from a tertiary care teaching hospital in South India p. 749
Himalni Padmanaban, Manjula Simiyon, Pradeep Thilakan, K Ravichandran
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Medical Council of India module on pandemic management: Neglecting mental health training a major lacuna p. 750
Bheemsain Tekkalaki, M Kishor
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Erratum: Stereotypical linear purpura of the upper limbs: A report of three cases of a rare psychocutaneous disorder and review of the literature p. 752

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Erratum: Study of white matter abnormalities in elderly patients with major depressive disorder p. 753

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