Basudeb Das

Efficacy of repetitive transcranial magnetic stimulation in alcohol dependence: a sham-controlled study.

OBJECTIVE To study the anticraving efficacy of high-frequency repetitive transcranial magnetic stimulation (rTMS) of the right dorsolateral pre-frontal cortex (DLPFC) in patients with alcohol dependence. METHODS We performed a prospective, single-blind, sham-controlled study involving 45 patients with alcohol dependence syndrome (according to ICD-10 DCR), with Clinical Institute of Withdrawal Assessment in Alcohol Withdrawal (CIWA-Ar) scores <or=10. Patients were allocated to active and sham rTMS in a 2 : 1 ratio, such that 30 patients received active and 15 patients sham rTMS to the right DLPFC (10 Hz frequency, 4.9 seconds per train, inter-train interval of 30 seconds, 20 trains per session, total 10 sessions). The Alcohol Craving Questionnaire (ACQ-NOW) was administered to measure the severity of alcohol craving at baseline, after the last rTMS session and after 1 month of the last rTMS session. RESULTS Two-way repeated-measures analysis of variance (ANOVA) showed significant reduction in the post-rTMS ACQ-NOW total score and factor scores in the group allocated active rTMS compared to the sham stimulation. The effect size for treatment with time interaction was moderate (eta(2) = 0.401). CONCLUSIONS Right dorsolateral pre-frontal high-frequency rTMS was found to have significant anticraving effects in alcohol dependence. The results highlight the potential of rTMS which, combined with other anticraving drugs, can act as an effective strategy in reducing craving and subsequent relapse in alcohol dependence.

Rapid resolution of delusional parasitosis in pellagra with niacin augmentation therapy.

Pellagra is associated with low levels of vitamin B3 (niacin) and/or tryptophan and often involves other other B vitamins. Since the time Gasper Casal first described the disease in 1972, it was observed that the patients with pellagra were all poor, subsisted mainly on maize, and rarely ate fresh meat. Subsequent occurrences have been in the form of epidemic outbreaks, consequent to either introduction to maize as a major food or increased consumption of other niacin-deficient diets like Jowar (Sorgum vulgare). The virtual disappearance of pellagra as an endemic health problem in recent years can be attributed to a rise in the standard of living of farmers and diversification of the diet globally. The clinical picture is a combination of multisystem alterations typically involving gastrointestinal, skin and central nervous system abnormalities. The cardinal manifestations have been popularly known as the three Ds, which are dementia, dermatitis and diarrhea. Psychiatric manifestations are fairly common but are easily overlooked due to their non specific nature. These are commonly seen as irritability, poor concentration, anxiety, fatigue, restlessness, apathy and depression. The occurence of psychosis in pellagra is an uncommon finding, which is usually seen in advanced stages of pellagroid encephalopathy, commonly found in chronic alcoholics. Delusional parasitosis has been also reported in this condition, although the association is still controversial. We report a case of pellagra manifesting with delusional parasitosis in a man whose delusion resolved rapidly after he started niacin-augmentation therapy. This case may provide clues to the biological underpinnings of delusional parasitosis as well as niacin treatment as treatment option in similar cases.

Increased spontaneous gamma power and synchrony in schizophrenia patients having higher minor physical anomalies.

The higher frequency of minor physical anomalies (MPAs) in schizophrenia provides morphological evidence for the neurodevelopmental theory. Abnormal gamma oscillations (>30 Hz) seen in the electroencephalogram (EEG) in schizophrenia have been hypothesized to result from developmental insults. This study investigated spontaneous gamma oscillations in schizophrenia patients having higher and lower number of MPAs. Forty drug naïve/free schizophrenia patients and 20 matched healthy controls were assessed for MPAs on the Extended Waldrop Scale (EWS). All participants underwent an awake, resting 192-channel EEG recording. Spontaneous gamma spectral power and coherence were estimated in the low- (30-50 Hz) and high-gamma (51-70 and 71-100 Hz) bands. Significantly higher power was observed in high-MPA than healthy control group in low-gamma band over right frontal, parietal and temporal regions. Spectral power in the high-gamma band (71-100 Hz) was also significantly higher in the high-MPA schizophrenia subgroup than in the healthy control group over left frontal, parietal and temporal regions. Additionally, regional intra-hemispheric and inter-hemispheric coherence in the low-gamma band was significantly higher in the high-MPA schizophrenia subgroup than on the healthy control group. This study is the first to provide evidence of increased spontaneous gamma power and synchrony in schizophrenia patients having higher MPAs, supporting the idea that it may represent a distinct subgroup of schizophrenia with a neurodevelopmental basis.

Schneiderian First Rank Symptoms and Gamma Oscillatory Activity in Neuroleptic Naïve First Episode Schizophrenia: A 192 Channel EEG Study

Objective Schneiderian first-rank symptoms (FRS) and abnormal EEG gamma activity in schizophrenia have been reported independently to have a neurodevelopmental basis. We aimed to investigate spontaneous gamma power in two groups of first episode schizophrenia patients (those who experience FRS and those who do not). Methods A comparative hospital based study having 37neuroleptic naïve male patients with schizophrenia divided into two groups-FRS(+) and FRS(-) groups based on the presence of FRS. Thirty age, sex, education and handedness matched individuals served as controls (N). All participants underwent a 192-channel resting Electroencephalography (EEG) recording. Gamma spectral power was calculated for low- (30-50 Hz) and high-gamma 1 & 2 (51-70 and 71-100 Hz) bands. Spectral power was compared between three groups using MANOVA and supplementary one-way ANOVA with Bonferroni test controlling for multiple comparisons. Linear regression was used to identifying predictor variables for FRS. Pearson correlation coefficient was computed between spectral power parameters and various clinical variables. Results Significantly higher high gamma band-1 power was observed over right frontal (p<0.05), parietal (p<0.05) and temporal (p<0.05) regions in FRS(+) than FRS(-) group and normal controls. Right parietal high gamma-1 power and paranoid cluster on PANSS significantly predicted number of FRS in total schizophrenia patients; paranoid cluster on PANSS showed significant correlation with number of FRS in FRS(+) group. Conclusion Findings of our study add to the evidence that areas contained within the hetero modal association cortex are associated with FRS. The study findings also strengthen the neurodevelopmental basis of FRS in schizophrenia.

Sporadic and familial subgroups of schizophrenia do not differ on dense array spontaneous gamma oscillatory activity

Genetic variations and developmental insults independently have been proposed to underlie aberrant gamma activity in schizophrenia. We investigated differences in spectral power in gamma (30-100Hz) frequency in patients with familial and sporadic schizophrenia. Subjects underwent resting-awake EEG recording on 192 channels. The two patient subgroups did not significantly differ in any of the gamma bands and regions. We conclude that complex gene-environment interactions are responsible for the limited power of familial-sporadic distinction in schizophrenia.

Fluvoxamine induced oculogyric dystonia and manic switch in a patient with obsessive compulsive disorder.

Fluvoxamine has a similar spectrum of adverse effects as compared to other selective serotonin reuptake inhibitors. However, fluvoxamine induced oculogyric dystonia is a rare instance in clinical practice. In this report, we present a case of obsessive compulsive disorder that developed oculogyric dystonia during the course of fluvoxamine mono-therapy and subsequently had a manic switch.

Delayed onset of clozapine-induced leucopenia.

Clozapine has been reported to cause agranulocytosis, neutropenia, and leucopenia that usually occur within 18 weeks of initiation of treatment. We report a case of delayed onset leucopenia after 11 years of treatment with clozapine, which reversed within a few days after discontinuation of medication.

Risperidone-induced mania: An emergent complication of treatment

The occurrence of manic/hypomanic switch in patients being treated with risperidone has been reported by various authors, and they have described a variety of strategies for their management. In this report, we describe two cases of induction of elevated mood symptoms in patients treated with risperidone. We propose that the emergence of these symptoms may be a complication of treatment with this drug in susceptible individuals, of which the clinicians should be aware, mainly in those diagnosed with schizophrenia and bipolar disorder. We then discuss a few findings that might be useful in the management of such cases. We thereby also propose a mechanism for such an induction.

Auditory P300 event-related potential: Normative data in the Indian population

Objective: To generate the normative data of auditory P300 event-related potential for various age groups in the Indian population. Materials and Methods: Auditory P300 event-related potentials, using the oddball paradigm, of healthy control participants in studies carried out at our institute were included to generate normative data in the age range of 10–50 years. The amplitude and latency of P300 for Fz, Cz, and Pz were selected for analysis. Results: For P300 amplitude, overall multivariate analysis of variance (MANOVA) was significant [Pillais Trace F (9/453) = 3.46, P < 0.001]. Follow-up ANOVA showed significant difference across age groups at Fz, Cz, and Pz. For P300 latency, there was a trend towards significance for overall MANOVA [Pillais Trace F (9/453) = 1.68, P = 0.09]. Follow-up ANOVA showed a trend towards significant difference across age groups at Fz only. Conclusion: Our study generated a P300 amplitude and frequency normative database at Fz, Cz, and Pz, which will serve as a reference for future studies attempting to define P300 abnormalities in various psychiatric disorders in Indian population.

Off-label psychotropics use: Isn't it now an inevitable and a “norm” in psychiatry?

Sir, “Off-label use” refers to the use of a drug outside the terms of its marketing authorization. It includes prescribing for an unlicensed indication like in unapproved indication, age group, dosage, or in unapproved form of administration. In principle, though it may not be compliant to the ethics in clinical practice, reports of off-label use of psychotropics have been widespread across clinical diagnoses and age groups. Among all medications, psychotropics are one of the most commonly prescribed for off-label purpose. A few studies from the Indian subcontinent had found that off-label use of psychotropics was seen in a significant proportion of prescriptions (up to 42%) and off-label uses were most common for indications (48.9%) followed by for dose (37.2%). Apart from the ethical and biological concerns arising from the unexpected adverse effects, off-label use also has an economic impact. In the United States, off-label use of central nervous system drugs contributes to 25%–80% of a drug’s annual sales, and off-label indications for antidepressants, anticonvulsants, and antipsychotics are expanding each year. All these drew our attention to the reasons behind the off-label prescription of psychotropics.