Channaveerachari Naveen Kumar

Clinical presentation of mania compared with depression: data from a geriatric clinic in India

BACKGROUND This retrospective chart review evaluated a comparison of the clinical profiles of older outpatients having mania and those with unipolar depression. METHODS The charts of elderly outpatients with mania and unipolar depression in tertiary care settings were reviewed and relevant information incorporated regarding clinical presentation, past and family history of affective disorder, treatment history and previous psychiatric and neurological history. RESULTS Charts for 30 patients with mania (23 men and 7 women with mean (+/-SD) age of 68.5(+/- 5.75 years) and 92 with depression (47 men and 45 women with mean (+/-SD) age of 68.18 (+/-6.0 years) were evaluated. Fifteen patients (50%) with manic episodes had psychotic symptoms in the form of delusions and hallucinations while only 33 (35.8%) depressed patients had psychotic symptoms. One-third of manic patients received mood stabilizers at index visit. More than half (n = 16; 53.3%) of the patients in the mania group were prescribed antipsychotic medications. On cognitive functions, patients with manic episodes scored poorly compared with those with depression. CONCLUSIONS These findings suggest that mania in the elderly is a severe form of affective disorder with respect to psychotic and cognitive symptoms. Conclusions from this study are limited due to its retrospective design. Further studies in this area are warranted.

Caregiver burden is associated with disability in schizophrenia: Results of a study from a rural setting of south India

Background: Taking care of patients with schizophrenia is a major source of burden to the family. Research on burden experienced by family members of patients living in rural communities is sparse. Methods: Data were obtained from a community intervention program for psychoses in a rural community of south India, where persons with severe mental disorders were identified, treated and followed up. As part of the program, caregivers of 245 schizophrenia patients were interviewed using the Burden Assessment Schedule. Psychopathology (Positive and Negative Syndrome Scale; PANSS), treatment status and disability (Indian Disability Evaluation and Assessment Scale; IDEAS) experienced by the patients were also assessed. Univariate and multivariate analyses were used to study the influence of different factors on the caregiver burden. Results: Level of burden had a significant direct correlation with disability (Pearson’s r = .35; p < .01) and severity of psychopathology (r = .21; p < .01). Duration of treatment had an inverse correlation with burden (Pearson’s r = −.16; p < .01). Multivariate analysis revealed that total IDEAS score (Beta = .28; t = 4.37; p ≤ .01), duration of treatment (Beta = −.17; t = −2.58; p = .01), age of the family caregiver (Beta = .15; t = 2.4; p = .02) and gender of the patient (Beta = −.13; t = −2.1; p = .04) were significant predictors of burden. The model including total IDEAS score explained 14% of variance (adjusted R2 = .139; p < .01). Conclusion: Burden experienced by family caregivers of schizophrenia patients depends on the level of disability experienced by the patient, age of the family caregivers and gender of the patient. Interventions to reduce disability of the patients may reduce the caregiver burden.

Negative symptoms mediate the influence of theory of mind on functional status in schizophrenia

We aimed to assess the relationship between social cognition, neurocognition, negative symptoms and functional status in a homogeneous schizophrenia patient group remitted from positive symptoms. Sixty patients underwent assessments of social and neurocognition dimensions recommended by expert panels. A blind rater assessed their functional status. Second order theory of mind (ToM) and negative symptoms had significant correlations with functional status. A bootstrapping analysis used to test for specific mediation models revealed that the effect of second order ToM on functioning was mediated by negative symptoms. Future studies should examine if targeted remediation of ToM improves negative symptoms and thus functioning.

Does catatonic schizophrenia improve faster with electroconvulsive therapy than other subtypes of schizophrenia

Objective. Electroconvulsive therapy (ECT) is generally recommended for treating catatonic schizophrenia. Non-catatonic schizophrenia patients also receive ECT. We compared the speed of response to ECT among patients with catatonic and other subtypes of schizophrenia. Methods and materials. Consecutive schizophrenia patients referred for ECT within 3 months of starting antipsychotic treatment were studied (19 with catatonic and 34 with non-catatonic schizophrenia). Nurses Observation Scale for Inpatient Evaluation (NOSIE-30) and Clinical Global Impression (CGI) were used to rate improvement. Referring psychiatrists stopped ECTs based on clinical impression of improvement. Total number of ECTs was taken as an indirect measure of speed of response. NOSIE-30 scores were compared using repeated measures analysis of variance. Results. Catatonic schizophrenia patients required significantly fewer ECTs to achieve clinically significant improvement. There was a significant group×occasion effect in NOSIE scores, suggesting faster response to ECT in the catatonia group (F=41.6; P<0.001). Survival analysis suggested that patients with catatonic schizophrenia required significantly fewer ECTs (one less session on an average) to achieve clinical improvement (Log-rank statistic =5.31; P=0.02). Conclusions. Catatonic schizophrenia responds faster to ECT than non-catatonic schizophrenia. However, the magnitude of the difference is modest.

Epidemiology of comorbid substance use and psychiatric disorders in Asia.

Purpose of review Studying comorbidities between substance use disorders (SUDs) and psychiatric disorders in different regions is important from public health and heuristic perspectives. In this study we review recent studies conducted in Asian countries on these comorbidities. Recent findings Comprehensive and methodologically sound studies conducted with focus on comorbidity between SUDs and psychiatric disorders are few and far between in Asian countries. Studies differ widely in their focus and methodological rigor. Some studies from China, Japan and Taiwan report fairly low rates of comorbidity of SUDs, particularly with illicit substances, among individuals with psychiatric disorders. Similar findings exist for rates of psychiatric disorders among those with SUDs. Recent research is lacking in several Asian countries on the issue of comorbidity. Summary Interesting regional differences exist in the rates of comorbidity both across the Asian countries and between these countries and the west. Genetic and socio-cultural differences may be responsible for these differences. Methodologically sound, multicenter studies, involving several Asian countries, specifically examining the epidemiology of comorbidity between SUDs and psychiatric disorders, will have the potential to provide useful insights in this regard.

Clinical correlates and predictors of perceived coercion among psychiatric inpatients: A prospective pilot study

BACKGROUND The current Mental Health Care Bill (MHCB) -2013 in India advocates least restrictive alternatives (LRA) in psychiatric treatment. However, we have little evidence on patients perspectives of coercion and LRA. METHODOLOGY This was a hospital-based prospective pilot study. 170 subjects chosen by computer-generated random number sampling were screened. In 83 eligible subjects, all assessments including coercion assessment were completed within 3 days of admission and in 75 subjects reassessment was done within 3 days of discharge. RESULTS Perceived coercion as measured by the MacArthur Perceived Coercion Scale (MPCS) decreased significantly from 3.72±1.98 at admission to 1.77±1.8 (<0.001) at discharge. This was accompanied by significant increase in global functioning, insight score (from 1.5±1.0 to 3.8±1.1; p<0.001) and as well as decrease in symptom severity (CGI-S) (from 5.9±1.1 to 1.8±1.9; p<0.001). Coercion is predicted by family type, employment status, socio economic status, severity of illness and level of insight. 87% patients reported that their admission was justified even though many felt coerced during hospital stay. CONCLUSION Coercion is a dynamic state and changes with treatment and care. Clinical care may result in an improvement in global functioning, insight as well as in reduction in severity of illness consequently leading to less coercion. During the time of discharge, majority of patients reported that their admission was justified, even though they felt coerced during hospital stay and agreed for treatment against their will within a safe, standardised coercive practice.

A randomized double-blind comparison of fluoxetine augmentation by high and low dosage folic acid in patients with depressive episodes

BACKGROUND Though encouraging evidence exists for the use of folic acid as an augmenting agent to antidepressants, evidence regarding its optimal dosage is lacking. METHODS Forty-two female out-patients with moderate (with or without somatic syndrome) or severe depressive episodes (without psychotic symptoms) diagnosed as per ICD-10 criteria, were randomized in a double-blind fashion to receive either 20 mg fluoxetine and a relatively low dose folic acid (1.5 mg/day; n=23; Group I) or 20 mg fluoxetine and high dose folic acid (5 mg/day; n=19; Group II). Primary outcome measures were weekly changes of scores on Hamilton Depression Rating Scale (HDRS) and Beck Depression Inventory (BDI) for 6 weeks. RESULTS Group II patients showed greater improvement in both HDRS [Mean (SD) baseline HDRS score=21 (2.3) for group I and 20.0 (1.4) for group-II; time X group interaction effect: p=0.01] and BDI [Mean (SD) baseline BDI score=25.1 (5.2) for group-1 and 23.1 (2.7) for group-II; time X group interaction effect: p=0.01]. With regard to HDRS, 7 (36.8%) group II patients remitted compared to 2 (8.7%) group I patients (p=0.03); 9 (47.4%) patients of group II responded when compared to 6 (26.1%) from group I (p=0.15). When BDI was considered, 5 (26.3%) group II patients remitted when compared to 2 (8.7%) from group I (p=0.13); 10 patients (52.6%) from group II responded when compared to 5 (21.7%) from group I (p=0.04). No adverse effects were noted in either group. LIMITATIONS Lack of a placebo arm and small sample size. CONCLUSION Compared to folic acid 1.5 mg/day, augmentation with 5 mg/day may be more beneficial in female patients with depressive episodes taking fluoxetine 20 mg/day.

Speed of response to threshold and suprathreshold bilateral ECT in depression, mania and schizophrenia

BACKGROUND Bilateral electroconvulsive therapy (BLECT) is useful in affective disorders and schizophrenia. Studies on electrical dose during BLECT are sparse. The Royal College of Psychiatrists recommends the use of electrical dose at 50-100% above seizure threshold. We studied the impact of change of BLECT practice from using threshold-level to 1.5 times threshold-level electrical dose in patients with depression, mania and schizophrenia. METHOD Data of 100 consecutive inpatients who received BLECT at threshold-level was compared with that of 101 who received BLECT at 1.5 times threshold-level. Patients in the two groups were comparable in sociodemographic and clinical details. In all patients ECT was stopped after patients had shown clinical improvement. Number of ECTs required to achieve improvement and the number of inpatient days after the start of ECT formed the outcome measures. RESULTS Overall, there was no significant difference between the groups in the outcome variables. However, when diagnoses were considered separately, patients with mania who received threshold-level needed about 2 more ECT sessions (t=2.6; p=0.01) and stayed for about 10 more days as inpatients (t=2.4; p=0.03) than those who received 1.5 times threshold-level BLECT. LIMITATIONS The study is chart-based, with its inherent limitations. Standard outcome measures were not used. Cognitive adverse effects were not studied. CONCLUSIONS Patients with schizophrenia and depression treated with BLECT at 1.5 times threshold-level electrical stimulus require similar number of ECT sessions as with threshold-level. However, patients with mania show clinical improvement with significantly fewer ECT sessions if treated at suprathreshold stimulus.

Karnataka state telemedicine project: Utilization pattern, current, and future challenges

Background: The Telemedicine Network Project in the state of Karnataka was introduced in the year 2001. This is a value added service from the health department of the government of Karnataka. There is no data on its utilization pattern or its future challenges. This study was conducted from a nodal center in order to understand the above two issues. Materials and Methods: We used a 51-item survey questionnaire that captured data on infrastructure, technical aspects, and connectivity parameters, tele-consultations including emergency services, human resources, and coordination aspects both at the client as well as the nodal centers. Results: Services are operational in 25 district hospitals across the state for the past 3.3 (2.1) years. Space was ear-marked across all the client centers. Back-up power supply was present only in 10 (40%) of the client centers. Quality of satellite connection was acceptable in 18 (72%) centers. Approximately, 3.0 (1.8) phone calls had to be made to the nodal centers to obtain one appointment. Monthly maximum and minimum cases done over the past 2 year period were reported as 58.2 (66.2) and 13.5 (16.2) respectively. Each consultation lasted for 26.1 (13.9) min. Tele-consultation advices from nodal centers were carried out completely in only 9 (36%) centers. Only in 13 (52%) client centers, did doctors keep up with appointment regularly. All technicians reported that the training they received was inadequate. 16 (64%) technicians were asked to do works that were not pertaining to telemedicine. 19 (76%) technicians had frequently felt insecurities about their jobs. Conclusions: The telemedicine service has been largely under-utilized and has failed to deliver the promise in Karnataka state. At present, the obstacles reflect both inherent limitations in the technology and also improper use of human resources. Successful implementation of the given recommendations may in the long run help optimal utilization and reach all end-users.

Cognitive deconstruction of parenting in schizophrenia: The role of theory of mind

Objective: Schizophrenia patients experience impairments across various functional roles. Emotional unresponsiveness and an inability to foster intimacy and display affection may lead to impairments in parenting. A comprehensive cognitive understanding of parenting abilities in schizophrenia has the potential to guide newer treatment strategies. As part of a larger study on functional ability in schizophrenia patients, we attempted a cognitive deconstruction of their parenting ability. Methods: Sixty-nine of the 170 patients who participated in a study on social cognition in remitted schizophrenia were parents (mean age of their children: 11.8 ± 6.2 years). They underwent comprehensive assessments for neurocognition, social cognition (theory of mind, emotion processing, social perception and attributional bias), motivation and insight. A rater blind to their cognitive status assessed their social functioning using the Groningen Social Disabilities Schedule. We examined the association of their functional ability (active involvement and affective relationship) in the parental role with their cognitive performance as well as with their level of insight and motivation. Results: Deficits in first- and second-order theory of mind (t = 2.57, p = 0.01; t = 3.2, p = 0.002, respectively), speed of processing (t = 2.37, p = 0.02), cognitive flexibility (t = 2.26, p = 0.02) and motivation (t = 2.64, p = 0.01) had significant association with parental role dysfunction. On logistic regression, second-order theory of mind emerged as a specific predictor of parental role, even after controlling for overall functioning scores sans parental role. Conclusions: Second-order theory of mind deficits are specifically associated with parental role dysfunction of patients with schizophrenia. Novel treatment strategies targeting theory of mind may improve parenting abilities in individuals with schizophrenia.