Christoday Raja Jayant Khess

The Role of Gateway Drugs and Psychosocial Factors in Substance Dependence in Eastern India

Objective: Western studies have identified the gateway patterns of substance use which lead the way from the so called “Soft Drugs” (like nicotine, etc.) to the “Hard Drugs” (like Opioids) [the Gateway hypothesis]. Nicotine and alcohol have been implicated as the most common initiating drugs in studies from different places, however, studies are lacking from this region. This study was designed to find the drugs of initiation and to understand the factors for initiation, maintenance, and relapse of these substances in persons dependent on them in Eastern India. Method: Seventy subjects with ICD 10 DCR diagnosis of substance dependence admitted consecutively in Center for Addiction Psychiatry, Central Institute of Psychiatry (CIP), Ranchi, were taken up for the study after taking written informed consent. A semi-structured questionnaire including the substance use part of Mini International Neuropsychiatric Inventory (MINI) was administered. Results: Alcohol and opioids were the most common drugs of dependence but nicotine and alcohol were found to be the most common initiating drugs in both alcohol and opioid groups. Persons dependent on opioids presented earlier for treatment, with earlier development of withdrawal symptoms and having completed lesser years of formal education, and had higher monthly incomes as compared to those dependent on alcohol. The most common psychosocial factors determining initiation and maintenance were peer pressure or curiosity. Conclusions: If adolescents and youth can be motivated to stay away even from the “gateway drugs” by targeting common initiation factors, it may lead to delay in dependence or possibly avoidance of development of dependence.

Factor analysis of positive and negative syndrome scale in schizophrenia: An exploratory study

Background: Controversy persists with regard to how best we can categorize symptomatic dimension of Schizophrenia. Aim of the study was to compute factorial dimensions in Indian subset of schizophrenic patients and to compare them with five factor pentagonal model extracted in western studies. Materials and Methods: 150 inpatients of Schizophrenia with acute exacerbation were subjected to PANSS rating within one week of admission and statistical calculation done based on exploratory factor analysis. Results: Five factors namely negative, autistic, activation, positive and depression were extracted wherein negative factors showed highest percentage of total variance supporting five factor modal of western literature Conclusion: A consensus is gradually emerging regarding symptomatic dimensions of Schizophrenia.

Atypicality in presentation of neuroleptic malignant syndrome caused by olanzapine

Neuroleptic malignant syndrome (NMS) is the most serious of acute neurological side effects produced by antipsychotic medication, characterized by hyperthermia, rigidity, altered consciousness and autonomic dysfunction, the prevalence of which varies from 0.4-1.4%. NMS is usually seen in treatment with high potency typical antipsychotics and very rarely with atypical antipsychotics. However, NMS cases have been reported with risperidone, clozapine, olanzapine and quetiapine. The presentations of NMS have often varied and we report another atypicality in presentation of NMS due to olanzapine use.

Reasons for substance use: A comparative study of alcohol use in tribals and non-tribals

Background: Consumption of alcohol has been attributed to different reasons by consumers. Attitude and knowledge about the substance and addiction can be influenced by the cultural background of the individual. The tribal population, where alcohol intake is culturally accepted, can have different beliefs and attributes causing one to take alcohol. This study attempts to examine the reasons for alcohol intake and the belief about addiction and their effect on the severity of addiction in people with a different ethnic background. Materials and Methods: The study was conducted at a Psychiatric institute with a cross-sectional design. The study population included patients hailing from the Jharkhand state, twenty each, belonging to tribal and non-tribal communities. Patients fulfilling the ICD 10 diagnostic criteria of mental and behavioral disorders due to the alcohol dependence syndrome, with active dependence, were taken, excluding those having any comorbidity or complications. The subjects were assessed with specially designed Sociodemographic-Clinical Performa, modified version of Reasons for Substance Use scale, Addiction Belief scale, and the Alcohol Dependence scale. Statistical Analysis and Results: A significantly high number of tribals cited reasons associated with social enhancement and coping with distressing emotions rather than individual enhancement, as a reason for consuming alcohol. Addiction was severe in those consuming alcohol to cope with distressing emotions. Belief in the free-will model was noted to be stronger across the cultures, without any correlation with the reason for intake. This cross-sectional study design, which was based on patients, cannot be easily generalized to the community. Conlusion: Societal acceptance and pressure as well as high emotional problems appears to be the major etiology leading to higher prevalce of substance depedence in tribals. Primary prevention should be planned to fit the needs of the ethnics.

Prevalence of tobacco use among young adult males in India: a community-based epidemiological study.

Background: Prevalence of tobacco use in India is reaching alarming proportions, despite efforts by both World Health Organization (WHO) and Government of India (GOI) in controlling it. Part of the problem has been lack of available data on tobacco use in various groups. Although Global Youth Tobacco Survey (GYTS) and National Family Health Survey (NFHS) III have focused on adolescents and adults, respectively, data on use among young adults is lacking. Another limitation has been the use of the questionnaire method to determine tobacco use which may not reveal exact prevalence. This study aimed to explore the prevalence of tobacco use among young adult males in Ranchi, as confirmed by serum cotinine levels. Methods: Five-hundred male students were selected through systematic randomized process to represent 5 universities in Ranchi. After informed consent, the students were administered Tobacco and Other Substance Use questionnaire and then subjected to urine Rapid Nicotine Test to improve sensitivity and biologically confirm prevalence. All tobacco users then were administered Fagerstroms Scale for Severity of Nicotine Dependence. Results and Conclusion: Biologically confirmed prevalence of tobacco use among male students was 55.6%, revealing high degree of prevalence in this age group. Predominant form of tobacco use was cigarettes (78%) followed by khaini (20%) and gutkha (2%), showing that most young adults use cigarettes possibly due to the ‘cool image’ associated with it. Seventy-seven percent of all tobacco users want to quit, thereby giving a strong opportunity to carry out cessation services in this group. There was higher mean Fagerstroms Scale for Severity of Nicotine Dependence (FTND) score in smokers (6.7 ± 2.2) compared to chewers (4.6 ± 2.5), revealing higher severity of dependence among smokers than chewers.

Insight in schizophrenia and its association with executive functions

Background: Lack of insight or awareness of illness is most frequently observed in patients with schizophrenia, and it influences treatment compliance. It has been hypothesized that the frontal dysfunction may explain poor insight in schizophrenia. Aim: The purposes of the study were to assess the degree of insight in schizophrenia and to examine the association, if any, between the degree of insight and executive functions in patients with schizophrenia. Materials and Methods: In this pre-post study, 30 patients of both sexes diagnosed to have schizophrenia were assessed with the Scale to Assess Unawareness of Mental Disorder and Wisconsin Card Sorting Test (WCST). They were assessed once at the time of admission and then at the time of their discharge. Results: The study revealed that 70% of the subjects possessed poor awareness of mental disorder. There was significant improvement of insight over time. The degree of insight was significantly associated with the performance on WCST 2nd assessment. WCST scores were able to explain 42% of the variance in insight. Conclusion: Majority of schizophrenic patients possess poor insight. This poor insight is significantly associated with poor executive function. Hence poor insight may have a cognitive etiology.

Why is alcohol excluded and opium included in NDPS act, 1985?

Byline: Saddichha. Sahoo, N. Manjunatha, Baxi. Sinha, C.R.J. Khess The Problem Different forms of alcohol have been used in various human societies at least since the beginning of recorded history. As part of the contemporary dynamic of globalization, there has also been an increased use of drugs, which has now reached mammoth proportions. The use of both licit drugs such as alcohol and tobacco and illicit drugs such as cannabis, cocaine and opioids has been acknowledged to have multiple consequences to health, society and economy. According to estimates made by the World Health Report,[sup] [1] at least ten thousand million people throughout the world regularly use alcohol and about 13.5 million people use opioids. In India too, the problem is slowly increasing and it is estimated that 75 million people are alcohol users and nearly three million are opioid users, of which a majority require medical treatment and rehabilitation.[sup] [2] A number of other psychoactive substances are being added daily to the present list of psychotropic substances. The entire issue is complex and multifaceted requiring both health measures and efforts to control trafficking / smuggling and manufacture of these drugs. There is a need for the reduction in the demand of drugs of addiction, both legal and illegal, which may otherwise lead to numerous health, family and societal consequences. To combat this, the Government of India formulated the Narcotic Drugs and Psychotropic Substances (NDPS) Act, 1985,[sup] [3] which provides the current framework for drug abuse control and sale in this country. Essentially, the Act deals with supply reduction activities of psychotropic substances namely, cannabis, cocaine and opium. However, the absence of alcohol in the list of psychotropic substances is surprising given the fact that mental health professionals consider alcohol to be a psychoactive substance leading to various social, legal, economic and medical complications ranging from gastritis to withdrawal seizures and delirium tremens.[sup] [4] The Reasons The reasons for not including alcohol in the NDPS Act are many, the important ones being (a) prevailing social acceptance even for frequent self-induced intoxication;[sup] [5] (b) the high revenues earned by the Government on the sale of alcoholic beverages; (c) prevalence of illicit and locally brewed undistilled forms of alcohol is very high in society and (d) there may be differences in the clinical course of alcohol dependence contrary to other drugs like opium which have been included in NDPS. The last reason is what can be corrected through systematic clinical studies, which have not been conducted until now. The Solution Our study We therefore aimed at evaluating the reasons for inclusion of opium and exclusion of alcohol from NDPS by comparing and contrasting the course of dependence for both substances. We recruited consecutively admitted patients of ≥18 years of age for treatment of dependence in our Centre for Addiction Psychiatry, Central Institute of Psychiatry, Ranchi, India with International Classification of Diseases-10-Diagnostic criteria for research (ICD-10-DCR) diagnosis of alcohol dependence syndrome or opioid dependence syndrome and obtained their written informed consent. We excluded other comorbid psychiatric disorders, substance dependence or general medical conditions requiring additional treatment. We administered the SSAGA-II[sup] [6] (Semi-Structured Assessment for the Genetics of Alcoholism-II) test to all our subjects after detoxification. SSAGA II is a poly-diagnostic instrument, which was designed to assess the physical, psychological and social manifestations (in other words, in terms of the criteria of ICD-10-DCR dependence). After the interview, data was transferred to the ICD-10 tally sheets of the respective alcohol or opioid sections of SSAGA-II. We considered the earliest age of any items of respective criteria of ICD-10-DCR dependence which was taken as the age of first onset of respective criteria of dependence. …

Assessment of Mood and Affect by Mental State Examination in Different Cultural Contexts

Serby [11] reported a study on New York psychiatry trainees (n = 99) concerning the conceptualization of mood and affect. In this context, we decided to compare the responses to similar sets of questions in the Central Institute of Psychiatry (CIP), Ranchi, India, with some modification by adding 4 more items of the sign/ symptom dimension and including 1 more response, ‘not sure’, to the existing ‘true’ and ‘false’ choices for each item. Terms/ phrases which were deemed ambiguous were rephrased with consensus. The final version of the questionnaire (in English) consists of 18 items arranged in 9 pairs as in the original study [11] and was discussed with experienced psychiatrists to improve the validity. The questionnaire has been designed in such a manner that the answer of each odd-numbered item is inevitably the opposite of the following even-numbered item, e.g. the preferable answer for item number 1 is ‘true’, while for item 2 it is ‘false’, and so on. Any combination of answers other than as above is therefore considered to include contradictory responses. The study was approved by the Institutional Review Board of the CIP, Ranchi, India. The final questionnaire was administered to all psychiatry trainees (junior residents), pursuing a postgraduate (DPM/ MD) course in psychiatry at the CIP and they were invited to participate in the study. After informed consent, the trainees were requested to mark 1 response (either ‘true’ or ‘false’ or ‘not sure’) for each item. The completed questionnaire was The assessment of mood and affect is a vital part in the Mental Status Examination, which is a cornerstone of psychiatric assessment [1] and also helpful in the management of different psychiatric disorders. Karl Jaspers describes affect as a momentary emotional perturbation and mood as a more prolonged emotional state that influences all aspects of the mental state [2] . The German original of Jasper’s concepts [3] has retained some of its genuine flavor after translation and the subsequent literatures have added subtle complexities to these concepts. With the globalization of medicine, psychiatrists trained in various countries (India and other Asian regions where English is often not their first language) may provide care in other areas like the USA, Canada and Australia. Hence, it is worthwhile to compare the conceptualization of different terms of the Mental Status Examination by the trainees of different countries . Currently the conceptualization of the terms ‘mood’ and ‘affect’ is somewhat contradictory between textbooks. Some authors refer to mood as an internal, subjective and sustained emotional state usually reported by patients and affect as an external, objective, visible, moment-to-moment emotional state which should be observed by an examiner [4, 5] . In other words, mood is a self-reported symptom, whereas affect is a physical sign noted by some authors [6, 7] . However, some authors refer to mood has both a subjective and an objective component [8–10] . Received: September 6, 2007 Accepted after revision: January 15, 2008 Published online: July 19, 2008

Inpatient suicide in a psychiatric hospital: A nested case–control study

Objective: Risk factors for inpatient suicide are different from those in the general population. We examined sociodemographic and clinical variables of patients who committed suicide as an inpatient in a psychiatric hospital in India. Methods: Matched retrospective nested case–control design was adopted. Ten patients who died by suicide as inpatients between 2000 and 2013 were included, along with fifty controls, matched with respect to age, sex, diagnosis, and period of admission. Results: Suicide completers were mostly unskilled in occupation (P = 0.03), had a history of past suicide attempts (P < 0.001), shorter duration of hospital stay (P = 0.001), poorer improvement on psychopathology (P = 0.02), and were having more suicidal ideation (P = 0.02). Significantly more completers were receiving antidepressants (P = 0.04). Conclusion: This study adds to the existing sparse literature on inpatient suicides from Asia. Strength of the study was close matching between case and controls and blindedness. Limitations were retrospective design, and variations in prescription behavior and treatment decisions.

Clinical course of development of alcohol and opioid dependence: what are the implications in prevention?

In India, it is estimated that 75 million people are alcohol users and nearly 3 million are opioid users.(1) Of these, there has been a noted prevalence of 19.78-21.4%(2) of alcohol use and 5% of alcohol dependence in Indian population.(3) The prevalence of opium use in India has also been increasing and it is now considered to be a ’party drug’ or ’relaxation drug’. Several studies have described the prevalence of opium abuse to be 1.51-2%(3,4) although a recent study notes it to be around 0.4%.(2) Yet, there is a concerning increase in the social acceptance of alcohol even for frequent self-induced intoxication and easier access to ’hard drugs’ like opioids is now responsible for driving adolescents toward substance use and a trend is being noted toward lower ages of onset of both alcohol and opioid use. Even though opium use is generally frowned upon, alcohol use is widely accepted. There is, therefore, an urgent need for reduction in the demand of drugs of addiction, both legal and illegal, which may otherwise lead to numerous health, family and societal consequences. One of the ways this can be made possible is by identifying and preventing the development of dependence in both alcohol and opioid users. This study is therefore aimed at: Studying the clinical course of development, in terms of ages, order of onset and duration of criteria of ICD-10 dependence, of both alcohol and opioid dependence. Comparing and contrasting the two substances to evaluate differences if any, to formulate a strategy for primary prevention. Materials and Methods Consecutively admitted patients of ≥18 years of age for treatment of dependence in the period of August 2005 to May 2006 in Centre for Addiction Psychiatry, Central Institute of Psychiatry, Ranchi, India with ICD-10 DCR(5) diagnosis of alcohol dependence syndrome or opioid dependence syndrome (made by a senior resident/senior consultant) and giving written informed consent were recruited for the study. Subjects with other co-morbid psychiatric disorders/substance dependence/general medical condition and with MMSE score <24 and were excluded from the study. All the subjects participated in the personal face to face interview after medically supervised withdrawal using alcohol or other drug (opioid) section of SSAGA-II(6) (revised in 1997) according to individual diagnosis of patient. The details of this instrument and the methods have been given in an earlier paper.(7) Since it was a retrospective recall study, questions were framed individually to trigger the recall with reasonable accuracy using anchor questions to memorable events, tagging the questions with specific examples and defining the technical terms.(8) All ratings were done by an investigator blind to the diagnosis and current status of the subjects. The data were statistically analyzed by means of T-test for descriptive variables and the Chi-squared test for categorical variables.