Balaji Bharadwaj

Clinical management of alcohol withdrawal: A systematic review.

Alcohol withdrawal is commonly encountered in general hospital settings. It forms a major part of referrals received by a consultation-liaison psychiatrist. This article aims to review the evidence base for appropriate clinical management of the alcohol withdrawal syndrome. We searched Pubmed for articles published in English on pharmacological management of alcohol withdrawal in humans with no limit on the date of publication. Articles not relevant to clinical management were excluded based on the titles and abstract available. Full-text articles were obtained from this list and the cross-references. There were four meta-analyses, 9 systematic reviews, 26 review articles and other type of publications like textbooks. Alcohol withdrawal syndrome is a clinical diagnosis. It may vary in severity. Complicated alcohol withdrawal presents with hallucinations, seizures or delirium tremens. Benzodiazepines have the best evidence base in the treatment of alcohol withdrawal, followed by anticonvulsants. Clinical institutes withdrawal assessment-alcohol revised is useful with pitfalls in patients with medical comorbidities. Evidence favors an approach of symptom-monitored loading for severe withdrawals where an initial dose is guided by risk factors for complicated withdrawals and further dosing may be guided by withdrawal severity. Supportive care and use of vitamins is also discussed.

Dhat syndrome: Evidence for a depressive spectrum subtype

INTRODUCTION Dhat syndrome is a condition described in the Indian subcontinent, in which patients present with concerns about loss of semen. Though this condition has been conceptualized as a culture-bound syndrome, some authors have also considered it a manifestation of depression. This calls for a closer examination of the possible genetic link between Dhat syndrome and depression. METHOD We examined the relationship between Dhat syndrome and the depressive spectrum, as conceptualized by Winokur, using a retrospective design. The case records of 46 patients with Dhat syndrome were reviewed, and patients were divided into two groups - family history positive (FH+) and family history negative (FH-) - based on the presence of depressive spectrum conditions in first degree relatives. These two groups were compared in terms of demographic variables, symptom profile and comorbidity. RESULTS The FH+ group had significantly higher rates of depressive disorders and substance use disorders (alcohol and nicotine dependence). They were also more likely to report concerns about penile size. DISCUSSION These results suggest that a subgroup of patients with the Dhat syndrome can be viewed as suffering from a depressive spectrum disorder. Dhat syndrome may be better understood as a heterogeneous group than as a single diagnostic entity. Identifying such sub-groups can help in choosing optimal treatments for patients with Dhat syndrome, such as selecting antidepressants for the group described in this study.

Long term course of bipolar I disorder in India: using retrospective life chart method.

BACKGROUND There are grounds to believe that the course of bipolar disorder may be different in tropical countries such as India when compared to temperate nations. There is a dearth of literature about the course of bipolar I disorder from India. METHODS This study was conducted in a multispecialty teaching hospital in southern India. Patients with a DSM-IV TR diagnosis of bipolar I disorder, confirmed using SCID-I, with a minimum duration of illness of 3 years were assessed. Information was gathered on demographic and clinical variables, and the life course of episodes was charted using the National Institute of Mental Health - Life Chart Methodology Clinician Retrospective Chart (NIMH-LCM-CRC). RESULTS A total of 150 patients with bipolar disorder were included. The mean age at onset of illness was 24.8 (± 8.2) years. Mania was the first episode in a majority (85%) of the cases, and was the most frequent episode in the course of the illness, followed by depression. Patients spent an average of 11.1% of the illness duration in a mood episode, most commonly a manic episode. The median duration of manic or depressive episode was 2 months. Median time to recurrence after the first episode was 21 months (inter-quartile range of 10-60 months), and was shorter for women than men. LIMITATIONS The hospital based sample from a particular region limits generalizability. Recall bias may be present in this retrospective information based study. Medical illness, personality disorders, other Axis I psychiatric disorders (apart from substance use disorder) and influence of adherence to treatment on the course of the disorder were not assessed systematically. CONCLUSIONS Bipolar I disorder among Indian patients has a course characterized by predominantly manic episodes, which is in line with previous reports from tropical countries and substantially different from that of temperate regions.

Quality of Sleep in Patients With Bipolar I Disorder During Remission.

Background and Goals: Sleep disturbances have been noted not only during affective episodes in bipolar disorder, but also between affective episodes. The goal of this study was to assess and identify determinants of sleep quality in patients with bipolar I disorder. Methods: This cross-sectional study enrolled patients with bipolar disorder who were currently in remission. Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI). Mood symptoms were evaluated using the Young Mania Rating Scale (YMRS) and the Hamilton Depression Rating Scale (Ham-D). Adherence was assessed using the Medication Adherence Rating Scale. Results: The mean age in the sample (N=103) was 37.4 years; 44.7% of the sample were men. On the basis of PSQI scores, 41 patients (39.8%) were poor sleepers. Poor sleepers had significantly higher Ham-D scores (mean score of 1.8 vs. 0.9, P=0.012) and higher rates of medication nonadherence (36.6% vs. 11.3%, P=0.002). The relationship between Ham-D scores and sleep quality did not remain significant when the sleep-related items on the Ham-D were removed. Logistic regression analysis suggested that medication nonadherence was the only independent predictor of poor sleep quality in this study. Conclusions: A significant proportion of patients with bipolar disorder who are in remission have sleep problems that seem to be independent of core symptoms of depression.

Frequency and correlates of tardive dyskinesia in Indian patients with type I bipolar disorder

BACKGROUND Patients with Bipolar Disorder (BD) may have higher risk of Tardive Dyskinesia (TD). Theories for TD include inflammatory or oxidative stress and altered iron metabolism. The current frequency and clinical and biochemical correlates of TD in BD needs exploration. OBJECTIVES To assess: (1) the frequency of TD in BD; (2) clinical correlates of TD in BD; (3) oxidative stress markers, inflammatory markers and hepcidin in TD in BD. MATERIALS & METHODS In this cross-sectional study, 170 patients with BD were assessed for clinical characteristics using structured assessments. Inflammatory and oxidative markers like Interleukin-6 (IL-6), high sensitivity C-Reactive Protein (hsCRP), malondialdehyde (MDA), Total Antioxidant Status (TAS) and hepcidin were assessed by ELISA. RESULTS Frequency of TD was 10.6% (95%C.I.=6.4%-16.2%). Compared to patients without TD, patients with TD were older (F=0.340;p=0.000), had more episodes of illness (U=962.5;p=0.044) higher rates of medical comorbidity (X2=6.924; p=0.009*), antipsychotic exposure (U=592.5;p=0.000), typical antipsychotic exposure (U=756.5;p=0.001) and cognitive deficits (F=1.129;p=0.001). The biomarkers levels did not differ between the groups. Hepcidin levels correlated with Abnormal involuntary Movements scale (AIMS) score (r=0.213;p=0.006). Patients treated with lithium were more likely to have TD, but also had greater exposure to antipsychotics than patients on valproate. CONCLUSION About one-tenth of patients with BD-I have TD. The presence of TD is associated several clinical characteristics such as age, exposure to typical antipsychotics and chronicity of illness. Hepcidin was associated with greater severity of dyskinetic movements and needs further exploration.

DRESS syndrome: Addressing the drug hypersensitivity syndrome on combination of Sodium Valproate and Olanzapine

A case of an adolescent with symptoms of Mania, who developed Drug Reaction with Eosinophilia and Systemic Symptom (DRESS) syndrome on exposure to combination of oral Olanzapine and Sodium Valproate is presented. We have attempted to highlight the atypical presentation of DRESS syndrome in this patient as well as management difficulties in patient who develops DRESS syndrome with the conventional psychotropic medication. Hence, it is necessary for mental health professionals to be vigilant about this life threatening drug reaction associated with high morbidity and mortality, thus ensuring prompt diagnosis and management.

What happens to episode duration and cycle length over the course of bipolar disorder

Objectives: Published scientific literature on cycle acceleration over the course of bipolar disorder has been equivocal. The present analysis aimed to find whether episode duration and cycle lengths become shorter over the course of bipolar disorder with predominantly manic polarity. Methods: The present study comprised 150 patients diagnosed with bipolar I disorder using SCID-I for DSM-IV TR. The course of illness was charted according to the NIMH Life Chart Methodology – Clinician Retrospective Chart (NIMH – LCM CRC). Spearman correlation was used to assess the relationship of episode duration and cycle length with the number of episodes. Results: The mean age of the sample was 37.8 years and the average duration of illness was 13.4 years. Unipolar mania comprised 52.7% of the sample. The episode duration and the cycle length decreased with increasing number of episodes (r=−0.245, p<0.001 & r=−0.299, p<0.001 respectively). Conclusion: The present study suggests that over the course of bipolar I disorder, cycle length and episode duration become shorter.

Pharmacological Prevention of Posttraumatic Stress Disorder: A Systematic Review

Introduction. Various interventions, both psychological and pharmacological, have been studied for their efficacy in preventing posttraumatic stress disorder (PTSD) following trauma exposure. However, the preventive effect of pharmacotherapy has not been systematically assessed. Methodology. A systematic review of all clinical trials of drug therapy to prevent PTSD, available through the PubMed and EMBASE databases, was conducted. This included an assessment of each study’s quality. Results. A total of 13 studies were reviewed. The drugs examined in these papers included propranolol, hydrocortisone, serotonin reuptake inhibitors, gabapentin, omega-3 fatty acids, and benzodiazepines. There was marked heterogeneity across studies in terms of quality, study populations, and methodology. Analysis of the outcomes revealed preliminary evidence for the efficacy of hydrocortisone, particularly in critical care settings. There was no consistent evidence to support the use of other drugs to prevent PTSD. Discussion. There may be a limited role for hydrocortisone in preventing the development of PTSD in specific settings. Results with other drugs are inconsistent. Further large-scale studies should assess the efficacy of these approaches in other contexts, such as natural disasters, and the time frame within which they should be used.

Aripiprazole for acute mania in an elderly person.

New-onset bipolar disorder is rare in the elderly. Symptom profile is similar to that in young adults but the elderly are more likely to have neurological co-morbidities. There are no case reports of elderly mania being treated with aripiprazole, an atypical antipsychotic. A 78-year-old gentleman presented to us with symptoms suggestive of mania of 1 months duration. He had similar history 3 years ago and a family history of postpartum psychosis in his mother. There were no neurological signs on examination and work-up for an organic etiology was negative except for age-related cerebral atrophy. He improved with aripiprazole and tolerated the medications well. The use of psychotropic medications in the elderly is associated with side-effects of sedation, increased cardiovascular risk, and greater risk of extra-pyramidal side-effects. The use of partial dopaminergic antagonists like aripiprazole may be useful in the balancing of effects and side-effects.

Cognitive functions among recently detoxified patients with alcohol dependence and their association with motivational state to quit

Context: Cognitive impairments are common among patients with alcohol dependence. It may involve frontal executive dysfunction, global cognitive impairments, or both. Motivation to quit alcohol involves recognition of alcohol use as a problem. This ability may be construed as a cognitive symptom. Aims: The aim is to study the frequency of cognitive dysfunction among patients with alcohol dependence and to study the association between cognitive dysfunction and the motivation to quit alcohol. Materials and Methods: Fifty-six adult males with alcohol dependence (International Classification of Diseases-10) who had completed a course of detoxification and who did not have active withdrawal symptoms or acute medical illnesses were recruited for this study. Their cognitive functions were tested using the Montreal Cognitive Assessment (MoCA) and Frontal Assessment Battery (FAB). Their motivation levels were assessed using the Stages of Change Readiness and Treatment Eagerness Scale. Clinical details were collected using a semi-structured pro forma. Results: Global cognitive impairment (MoCA < 26) was seen in 81% and frontal executive dysfunction (FAB < 12) in 16% of patients. Higher MoCA and FAB scores correlated with better education, while lower FAB scores correlated with higher age. The 14 patients (25%) with good motivation did not differ in age, education, years of dependence, or MoCA or FAB scores from poorly motivated patients. FAB scores, but not MoCA, were associated with poor motivation. All nine patients with FAB < 12 were poorly motivated to quit alcohol; likelihood score = 5.731, P = 0.017. Conclusions: Four-fifths of patients with alcohol dependence had global cognitive impairments after the detoxification period. One-sixth had frontal executive dysfunction. Cognitive functions were not significantly correlated with the duration of dependence. Presence of frontal executive dysfunction was associated with almost six times likelihood that the patient will be poorly motivated to quit alcohol.