Adult attention-deficit/hyperactivity disorder (ADHD) has a population prevalence of 5%. However, its prevalence is much higher in mental health and substance use treatment settings. It is associated with significant physical and psychiatric morbidity, as well as social, occupational, and legal consequences. Adult ADHD is considered to be a part of the externalizing spectrum with which it shares both homotypic comorbidity and heterotypic continuity across the lifespan. This is attributable to a shared genetic basis, which interacts with environmental risk factors such as nutritional deficiencies and psychosocial adversity to bring about epigenetic changes. This is seen to result in a lag in brain maturation particularly in the areas of the brain related to executive functioning (top-down regulation) such as the prefrontal and cingulate cortices. This delay when coupled with impairments in reward processing, leads to a preference for immediate small rewards and is common to externalizing disorders. Adult ADHD is increasingly understood to not merely be associated with the classically described symptoms of hyperactivity, impulsivity and inattention, but also issues with motivation, emotional recognition and regulation, excessive mind wandering, and behavioral self-regulation. These symptoms are also observed in other disorders which overlap with the externalizing spectrum such as oppositional defiant disorder, conduct disorder, antisocial and borderline personality disorder. It is therefore important to develop both broad-based and specific interventions to be able to target these deficits which can reduce the burden and improve outcomes.

Neurosurgery for psychiatric disorders (NPD) has been practiced for >80 years. However, the interests have waxed and waned, from 1000s of surgeries in 1940–1950s to handful of surgery in 60–80s. This changed with the application of deep brain stimulation surgery, a surgery, considered to be “reversible” there has been a resurgence in interest. The Indian society for stereotactic and functional neurosurgery (ISSFN) and the world society for stereotactic and functional neurosurgery took the note of the past experiences and decided to form the guidelines for NPD. In 2011, an international task force was formed to develop the guidelines, which got published in 2013. In 2018, eminent psychiatrists from India, functional neurosurgeon representing The Neuromodulation Society and ISSFN came-together to deliberate on the current status, need, and legal aspects of NPD. In May 2018, Mental Health Act also came in to force in India, which had laid down the requirements to be fulfilled for NPD. In light of this after taking inputs from all stakeholders and review of the literature, the group has proposed the guidelines for NPD that can help to steer these surgery and its progress in India.

Background and Aim: Treatment outcomes in bipolar disorder are highly variable, and several sociodemographic, clinical characteristics, and comorbidities play an important role. Early recognition of these factors will help the physicians to implement individualized treatment and a better clinical outcome. The present study was aimed at identifying the factors affecting treatment outcomes in bipolar disorder. Materials and Methods: All patients diagnosed with bipolar disorder as per diagnostic and statistical manual-IV criteria were included in the study. Patients were followed for 6 months from the day of enrollment. Patient demography, age at bipolar disorder was diagnosed, age at treatment was started, social habits, signs and symptoms, comorbidities, symptoms, treatment pattern, and compliance to treatment were recorded in case record form. Based on the changes in young mania rating scale and Hamilton Depression Rating Scale (HAM-D) score from baseline to last follow-up, the patients were classified as remission and non-remission. Multiple logistic regression was used to identify risk factors associated nonremission in bipolar disorder patients and calculation of odds ratio (OR). Results: The mean age of the study population was 37.6 ± 14.1 years. Out of the 121 patients, 68 (56.2%) were female. At the end of the follow-up period, 41 (33.9%) had remission, and 80 (66.1%) had nonremission. Early onset (OR: 9.77; confidence intervals [CI]: 1.77–86.01), treatment delay (OR: 6.48; CI: 1.27–32.92), treatment noncompliance (OR: 4.64; CI: 1.37–15.64), and single living (OR: 4.26; CI: 1.56–11.66) were independently associated with nonremission in bipolar disorder patients. Conclusions: Early-onset bipolar disorder, delay in treatment, treatment non-compliance, and single living adversely affect remission in bipolar disorder.

Background: Using digital technology to deliver mental health care can possibly serve as a viable adjunct or alternative to mainstream services in lessening the mental health gap in a large number of resource deficient and LAMI countries. Conventional models of telepsychiatric services available so far, however, have been inadequate and ineffective, as these address only a small component of care, and rely on engagement of specialists who are grossly insufficient in numbers. Aim: To describe an innovative digital model of mental health care, enabling and empowering the non-specialists to deliver high quality mental health care in remote areas. Methods: The model is powered by an online, fully automated clinical decision support system (CDSS), with interlinked modules for diagnosis, management and follow-up, usable by non-specialists after brief training and minimal supervision by psychiatrist, to deliver mental health care at remote sites. Results: The CDSS has been found to be highly reliable, feasible, with sufficient sensitivity and specificity. This paper describes the model and initial experience with the digital mental health care system deployed in three geographically difficult and remote areas in northern hill states in India. The online system was found to be reasonably comprehensive, brief, feasible, user-friendly, with high levels of patient satisfaction. 2594 patients assessed at the three remote sites and the nodal center represented varied diagnoses. Conclusions: The digital model described here has the potential to serve as an effective alternative or adjunct for delivering comprehensive and high quality mental health care in LAMI countries like India in the primary and secondary care settings.

Background: Autism spectrum disorder (ASD) is globally a major cause of childhood disability. It is estimated that in India approximately 1.7–2 million children are affected with this disorder. Early diagnosis is an important criterion to start early interventions for ASD treatment. However, for every childhood problem that receives a medical diagnosis, there is a period between a parents' first recognition of unusual symptoms and the eventual diagnosis. Several factors influence this initial symptoms recognition and final diagnosis. Aims: The present study attempts to decipher parents' perception regarding ASD and to understand the early signs of ASD recognition among parents, treatment-seeking pathways adopted their experiences and challenges in the overall process. Setting and Design: A facility-based cross-sectional study was undertaken at Bhubaneswar, Odisha. Methodology: Parents of children with ASD were recruited for this study. Seventy-six interviews were conducted, and the data were analyzed. Results: The major symptom identified by the majority of the parents was social difficulty among their children. Maximum parents had not heard about ASD before their child was diagnosed with the disorder. Parents consulted multiple professionals or traveled long distances to confirm the diagnosis. Child psychiatrists often confirmed the diagnosis and referred patients to rehabilitation centers. Conclusion: Lack of awareness, unavailability of services, and stress contributed to the delay in ASD diagnosis. There is a need for designing proper awareness and genuine center for the treatment. Similarly, referral and counter-referral mechanism is also required to be established to save delay in diagnosis and initiate prompt treatment in the field of ASD.

Background: Patients with schizophrenia were found to be less successful at emotion recognition tasks (ERTs) than healthy individuals. There is a debate surrounding whether this deficit is permanent or temporary. The current study aims to assess how emotion recognition skills are affected by treatment processes and during the course of the disease and also to determine the relation of this change with clinical assessment scales, other cognitive functions, and quantitative electroencephalography (QEEG). Materials and Methods: Twenty-four inpatients with treatment-resistant schizophrenia have been included in the study. Patients were assessed before beginning clozapine and 6 months later. During both assessments, clinical evaluation scales (Positive and Negative Syndrome Scale and Global Assessment of Functioning), Cambridge Neuropsychological Test Automated Battery (CANTAB) for schizophrenia which is used for assessment of cognitive functions were used. Electroencephalography (EEG) monitorings were performed only once before treatment. In this study, CANTAB ERT was used for emotion recognition. Results: There was no statistically significant change in the emotion recognition when the first and final ERTs were compared. There was a moderately positive relationship between emotional recognition and functioning (r = 0.65, P < 0.05). Cognitive functions such as visual memory, attention, flexible thinking, and planning were found to be in correlation with emotion recognition. Furthermore, slow waves such as delta and theta activities obtained from frontal, temporoparietal, and occipital regions were associated with emotion recognition. Conclusion: The current study supports that emotion recognition deficits are long-term stable features of schizophrenia, slow-wave electrical activity in the frontal, temporoparietal, and occipital areas in QEEG, and cognitive functions such as visual memory, attention, flexible thinking, and planning are found to be correlated with emotion recognition.

Introduction: Patients with psychosis often seek treatment at a later date after the onset of illness. There are a multitude of factors behind the treatment delay in these patients, reduction of this delay will help in better prognosis of these patients. Materials and Methods: A cross sectional study was conducted to understand the various reasons responsible for treatment delay in patients with psychosis. 25 subjects were selected by purposive sampling and their family members were interviewed. Qualitative analysis was carried out to identify various factors. Results: Reasons for treatment delay were at several levels like illness related, patient related, treatment related, family related factors. However the most common themes among these were unawareness of illness, explanatory models of illness, stigma, financial constraints. Other themes like relation of symptoms with premorbid personality, life events, absence of paternal support were also unfolded in the current study. Conclusions: There is significant delay between onset of psychosis and treatment seeking. Several factors are responsible for treatment delay in patients with psychotic illness. However they vary depending upon the socio-cultural background of the patient and their family members. Hence the interventions devised towards reducing the delay should be individualised.

Background: Benzodiazepines (BDZs) have been the treatment of choice for alcohol withdrawal syndrome (AWS); however, they are associated with several side effects and also have abuse potential. In some studies, the use of baclofen has been effective in reducing symptoms of alcohol withdrawal symptoms. Aim: The objective of this study was to compare the efficacy of baclofen and benzodiazepine (lorazepam) in reducing symptoms of AWS. Materials and Methods: It was a single-center, randomized, open-label study. Patients with alcohol dependence syndrome were enrolled in the study and randomized into two groups using computer-generated random table number. Baclofen (experimental group, 10 mg three times a day) and BZDs (control group, lorazepam, 8–12 mg/day in divided doses) were orally administered for reducing symptoms of alcohol withdrawal. Both groups received Vitamin B1 (100 mg/day through intramuscular route) and psychotherapeutic interventions. The severity of alcohol dependence was assessed by using the Severity of Alcohol Dependence Questionnaire, and alcohol withdrawal was assessed with the Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar). Results: Sixty-six patients were randomized (baclofen n = 34, benzodiazepine (BZD) group n = 32). Two patients (one patient in each group) had complicated withdrawal symptoms and were dropped from the final analysis. There was a significant reduction in alcohol withdrawal symptoms in both groups. There were no significant differences in CIWA-Ar scores between the two groups. Both the drugs were well-tolerated. Conclusion: Baclofen and lorazepam are comparable in efficacy and tolerability in reducing symptoms of AWS.

Background: Tobacco use is a major global public health threat for all countries and no form of tobacco use is safe. Pictorial warnings covering 40% area of tobacco products are made mandatory from May 31, 2009 in India. The present study was aimed to investigate the awareness and attitude toward pictorial warnings on tobacco products among age 15 years and above population in field-practice area. Materials and Methods: A total of 1064 individuals were selected by systematic random sampling. A model containing the pictorial warnings were shown to the study subjects, and data were collected by semi-structured questionnaire. Data was analyzed using SPSS 20 and statistical tests used were Chi-square test. Significance level set at P ≤ 0.05. Results: Of the 1064 individuals participated in the study, 53.9% were male and the mean age of the study population was 31.24 ± 5.8. Nearly 45.8% reported using tobacco in some form and all of them were males. 51.3% of both males and females reported that they never came across antitobacco messages (pictorial warnings). 71.2% believed that the size and position of pictorial warnings on tobacco products were not sufficient to understand the harmful effects of tobacco. There was statistically significant difference between different age groups in their responses to the aforementioned questions. Conclusion: The results of present study demonstrate that the need for pictorial warnings on tobacco products to be more clear and explanatory since there is little point in having pictorial warnings when the prime purpose of having them is not being served.

Background: The biochemical basis of depression has been related to blood–brain barrier (BBB) allowing/restricting a number of components to enter the brain milieu from the peripheral plasma milieu. S100B has been associated with BBB damage and is used as a marker of its integrity. Several studies have reported that depressive patients have increased levels of S100B in serum and cerebrospinal fluid. Materials and Methods: Forty-two confirmed cases of depression, 13–25 years of ages were recruited from the Department of Psychiatry, All India Institute of Medical Sciences during the period from January 2013 to June 2014 along with 42 healthy controls of comparable age and sex. Psychometric evaluation of the patients and controls was done to assess the severity of depression using Beck's Depression Inventory-II and Hamilton Depression Rating Scale. Medical assessment and laboratory investigations were done. Serum S100B levels were measured using Sandwich ELISA. The results obtained were statistically analyzed. Results: Levels of serum S100B were significantly elevated in patients with major depression as compared to controls. Significantly higher levels of S100B were seen only in females as compared to their healthy counterparts. Serum S100B was higher in depressed participants with the recurrent disorder than those with single episode. No correlation of levels of this marker was seen with clinical severity of the patients. It was found that with increased duration of illness for which the patient was being treated with antidepressants, the patients had higher levels of S100B. Conclusions: Serum S100B can be used as a biomarker of depression.

Background: Smartphone addiction is known as nomophobia (NMP) which is a fear of not using mobile phone. More researches are available regarding NMP among the students of various professions. However, till date, to the best of our knowledge, there is no literature available on the impact of NMP on the academic performance among students pursuing physiotherapy course (SPPC). Aim: To determine the impact of NMP among SPPC. Materials and Methods: An online cross-sectional survey was conducted by using Google Form platform utilizing validated NMP questionnaires (NMP-Q). A self-reported questionnaire regarding demographic data, information regarding smartphone use, last academic performance, and presence of musculoskeletal disorders was collected. A total of 157 students participated in this survey. Google Form automatically analyzed the collected data. Results: The mean age of students was 22.2 ± 3.2 years; among them, 42.9% were male and 57.1% were female. Nearly 45% of students have been using smartphone for >5 years and 54% students have musculoskeletal disorders during their prolonged smartphone use. The mean NMP score with 95% confidence interval was 77.6 (72.96–82.15). There exists an inverse relation between the NMP scores (NMPS) and student's academic performance and no significant difference between NMP scores, P = 0.152. Conclusion: NMP among the SPPC have been established. There might be a negative impact between NMP and academic performance.

Context: Almost 1/5^th of the adolescent population suffers from mental morbidity. In older adolescents, clinical challenges are accompanied by unique psychosocial and developmental needs. Recent legislations in India – the Mental Health Care Act, 2017 and the Juvenile Justice Act, 2015 – mandate specific arrangements and provisions for evaluation and treatment of children and adolescents. A separate inpatient Adolescent Psychiatry Center (APC) was started at National Institute of Mental Health and Neurosciences, Bangalore, in 2016. Aims: (a) The aim of this study is to present the need for, development, infrastructure and workforce at APC; (b) to describe clinical profile of adolescents admitted to APC and (c) to identify clinical and psychosocial challenges in the management of older adolescents. Setting and Design: The paper covers consecutive inpatient admissions over the first 7 months of APC. Materials and Methods: Data were gathered from a review of hospital records, staff meetings, and case files. Statistical Analysis: Qualitative data, such as clinical management challenges, are summarized under major emergent themes. Quantitative data are summarized as means with standard deviations and frequencies with percentages. Results: Males, from urban, nuclear family background constituted the majority admissions. Family stressors and risk behaviors were prevalent. Unique clinical challenges included – risk behaviors, issues related to autonomy, conflict with family and conflict with the legal system. Conclusions: Older adolescents need to be treated in an environment appropriate to their age and developmental stage. Restructuring of spaces, routines, and creative inputs to interventions strategies must be made for healing environments for youngsters. APC could be a model for the development of other similar centers.

Context: Tobacco will cause one billion deaths in the 21^st century. The use of tobacco causes dependence both psychological and physical. Aims: To find out the level of nicotine dependence and it correlates among adolescents. Settings and Design: A community-based, cross-sectional, observational study was conducted in the Burdwan town, West Bengal, among 1354 adolescent tobacco users. Materials and Methods: Data were collected by direct interview using a pretested, predesigned, semistructured schedule containing the Fagerström Test for Nicotine Dependence (FTND) questionnaire. Statistical Analysis: Pearson's Chi-square test, Student's unpaired t-test, one-way analysis of variance, Pearson's product-moment correlation coefficient, and multivariable linear regression were used. All the statistical analyses were performed using SPSS version 19.0. Results: The mean FTND score was significantly higher among adolescents aged >15 years, males, Hindu, tobacco users from joint family, who belonged to lower socioeconomic status, who started using tobacco at the age of 10–12 years, using tobacco for ≥5 years, who were not married, were illiterate, working, and not aware of the injurious effect of tobacco to health. Conclusions: A suitable individualized approach should be used for those who want to quit tobacco depending on their FTND score.

Leukocytoclastic vasculitis (LCV) may be secondary to drugs, underlying infection, collagen vascular disorders, or malignancy. Drug-induced vasculitis contributes to 10% of vasculitic skin lesions cases usually developing within 7–21 days of treatment initiation. The present case highlights a report of LCV in a 59-year-old male with a history of paranoid schizophrenia on clozapine therapy. The report upsurges the need to promote awareness and expedite diagnosis and treatment of drug-induced LCVs.

Progressive facial hemiatrophy or Parry–Romberg syndrome is a rare disorder of unknown etiology which is characterized by atrophy of the one side of the face and various neurological complications. Clinical overlap is sometimes seen with linear scleroderma or en coup de sabre. We present such a case that manifested clinically with partial epilepsy and novel psychiatric complaints of agoraphobia.