Guru S. Gowda

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.

High doses of Baclofen as suicide attempt in patients with alcohol use disorders - A serious concern

Baclofen is increasingly being used as an off label anti-craving agent in alcohol use disorders in various parts of the world. The lack of proper recommendations regarding the dosage has important implications for safety in clinical management. In this context, we report two patients who were started with Baclofen as an anti-craving agent, and later developed serious complications following acute self inflicted overdose. We also highlight the important mechanisms of such complications and precautions that needs to be exerted while prescribing.

Perceived coercion in persons with mental disorder in India : A cross-sectional study

Background: Little is known about how patients in India perceive coercion in psychiatric care. Aims: To assess perceived coercion in persons with mental disorder admitted involuntarily and correlate with sociodemographic factors and illness variables. Materials and Methods: We administered the short MacArthur Admission Experience Interview Questionnaire to all consecutive involuntary psychiatric patients admitted in 2014 in Mysore, India. Multivariate linear regression was used. Results: Three hundred and one patients participated. “Perceived coercion” subscale scores increased with female gender, nuclear family status, Muslim and Christian religion, lower income, and depressive disorder. It decreased with former coercion, forensic history, and longer illness duration. Drug use increased total scores; the extended family item decreased them. “Negative pressure” increased with male gender, extended family, lower income, forensic history, and longer illness duration. Conclusions: The study shows perceived coercion is a reality in India. Levels of perceived coercion and the populations affected are similar to high-income countries.

Sociodemographic and clinical profiles of homeless mentally ill admitted in mental health institute of South India: ‘Know the Unknown’ project

Objectives: A significant number of homeless mentally ill (HMI) patients without any personal, family or other identification details represent a unique problem in the psychiatric services of developing countries like India in the context of legal, humanitarian and treatment issues. These patients pose challenge to the mental health professional in diagnosis and management. Aims: To study the sociodemographic and clinical profiles of HMI patients admitted under psychiatry. Methods: We performed a retrospective chart review of ‘HMI’ patients from 1 January 2002 to 31 December 2015, who were admitted to the Department of Psychiatry at National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India. Sociodemographic and clinical profiles of the patients were analyzed by descriptive statistics. Results: Mean age of the sample was 34.6 years (±12.21 years), 42 (53.8%) were females, 74 (94.9%) were registered as Medico Legal Case and 53 (80.8%) were admitted under reception order issued by a magistrate. HMI patients brought by police were 32 (41.0%), by the public were 32 (41.0%) and 14 (18.0%) by nongovernmental organization /ambulance/social worker. In total, 51 (65.4%) of them had schizophrenia and other psychotic disorders, 24 (30.8%) had mental retardation and 23 (29.5%) had a comorbid substance use disorder. The mean Clinical Global Impression severity at admission was 5.07 (±1.7), and the mean duration of inpatient care was 15 weeks. Anemia and malnutrition were found in 34 (43.6%) and 25 (32.1%) patients, respectively. Conclusion: This study shows that schizophrenia, comorbid mental retardation and substance use disorder are common causes of admission of HMI patients in psychiatry. It is an emerging problem, which needs urgent interventions, and there is a need for an efficient system, guidelines and collaboration with government and nongovernmental agencies.

Unknown patients and neurology casualty services in an Indian metropolitan city: A decades experience

Objectives: A large number of unknown patients without any personal, family, or other identification details represent a unique problem in the neurological emergency services of developing countries like India in a context of legal, humanitarian, and treatment issues. These patients pose a diagnostic and management challenge to treating physicians and staff. There are sparse data on these patients. The objective of this study was to know the clinical, socio-demographic, and investigational profile of “unknown” patients. Materials and Methods: We did retrospective chart review of all “Unknown” patients from January 2002 to December 2011, who was admitted under Neurology Emergency Service at a Tertiary Care Neuropsychiatry Center in South Indian Metropolitan City. Clinical and sociodemographic characteristics and clinical outcome of the sample were analyzed. Results: A total of 151 unknown patients were admitted during the 10 years. Out of these, 134 (88.7%) were males with the mean age of 43.8 ± 14.8 years and 95 (63%) were aged >40 years. Among them, 147 (97.4%) were from the urban vicinity, 126 (83.6%) were brought by police and 75 (49.7%) were registered as medico-legal cases. Out of these, only 3 (2%) patients had normal sensorium, whereas 101 (66.9%) presented with loss of consciousness. Forty-one (27.2%) unknown patients had a seizure disorder, 37 (24.5%) had metabolic encephalopathy, 26 (17.2%) had a stroke, 9 (6%) had neuro-infection, and 17 (11.3%) had a head injury. Deranged liver functions were seen in 65 (43%), renal derangement in 37 (24.5%), dyselectrolytemia in 42 (27.8%), and abnormal brain imaging finding in 95 (62.9%) patients. Furthermore, there were 14 (9.3%) deaths. Conclusions: Our findings demonstrate seizures, metabolic causes, and neuro-infections were the primary reasons for admission of unknown patients to neuro-emergency service. This novel Indian study data show the common causes of admission of unknown patients in neurology. This pattern can be useful to guide the approach of healthcare providers in India.

Resurgence of catatonia following tapering or stoppage of lorazepam – A case series and implications

The resurgence of catatonia following tapering of lorazepam is a common clinical phenomenon. However, there is limited evidence on the relationship between tapering method of lorazepam and resurgence of catatonic state. We report seven (0.6%) such patients who were found to have resurgence of catatonia. The mean age is 35.7 years; five of them had schizophrenia and other psychotic spectrum disorders. Five of them had resurgence within one week of stoppage, and three of them had multiple resurgences and required maintenance treatment with lorazepam. So gradual tapering and maintenance treatment with lorazepam might be effective in preventing resurgence of catatonia.

Involuntary admission and treatment experiences of persons with schizophrenia: Implication for the Mental Health Care Bill 2016

BACKGROUND Involuntary admission and treatment experiences may affect the attitude of patients toward subsequent treatment and further outcomes. This issue has received relatively less research attention in persons with schizophrenia from developing countries. METHODOLOGY In this hospital based prospective observational study, involuntary admission, treatment and coercion experiences among 76 persons with schizophrenia, admitted under special circumstances of Mental Health Act -1987 were studied. Demographic, clinical and assessments related to coercion experiences were completed within 3days of admission. In 67 subjects, a reassessment was done just before discharge. RESULTS Mean (SD) age was 33.1 (±11.5) years, 47.8% (n=32) were males and 32.8% (n=22) were married. 92.5% (n=62) had absent insight at admission. Mean CGI Severity score at admission was 6.27 (±0.53). Mean (SD) score on MacArthur Perceived Coercion Scale at admission was 4.04 (±1.61). This reduced to 2.43(±1.91) [p<0.001]. This reduction correlated significantly with improvements in global functioning (r=-0.40, p <0.001), insight level(r=0.26, p<0.001) and as well as symptom severity(r=0.36, p<0.001). At discharge, 70% (n=47) patients reported that their involuntary admission was justified. CONCLUSION Perceived coercion in schizophrenia though common clinical phenomena, it is a dynamic state which reduces over course of treatment. At Discharge, majority reported that their admission was justified, even though they were admitted involuntarily. The study underlines the need for a standardized rule of conduct based coercive practice in psychiatry.

Staff and caregiver attitude to coercion in India

Objectives: The objective of this study was to assess attitudes of Indian psychiatrists and caregivers toward coercion. Materials and Methods: The study was conducted at the Department of Psychiatry, Krishna Rajendra Hospital, Mysore, India. Staff Attitude to Coercion Scale (SACS), a 15-item questionnaire, was administered to self-selected psychiatrists across India and caregivers from Mysore to measure attitudes on coercion. Data were analyzed using descriptive statistics and investigating differences in subgroups by means of Chi-square test, Students t–test, and analysis of variance. Reliability of the SACS was tested in this Indian sample. Results: A total of 210 psychiatrists and 210 caregivers participated in the study. Both groups agreed that coercion was related to scarce resources, security concerns, and harm reduction. Both groups agreed that coercion is necessary, but not as treatment. Older caregivers and male experienced psychiatrists considered coercion related to scarce resources to violate patient integrity. All participants considered coercion necessary for protection in dangerous situations. Professionals and caregivers significantly disagreed on most items. The reliability of the SACS was reasonable to good among the psychiatrists group, but not in the caregiver group (alpha 0.58 vs. 0.07). Conclusion: Caregivers and psychiatrists felt that the lack of resources is one of the reasons for coercion. Furthermore, they felt that the need on early identification of aggressive behavior, interventions to reduce aggressiveness, empowering patients, improving hospital resources, staff training in verbal de-escalation techniques is essential. There is an urgent need in the standardized operating procedure in the use of coercive measure in Indian mental health setting.

Mephentermine dependence syndrome – A new emerging trend of substance use

Mephentermine is a b-adrenergic agonist, which has the direct positive chronotropic effect. It is used as vasopressor during spinal anaesthesia. It is structurally closely similar to methamphetamine. It is available as an oral and parenteral formulation. Its misuse is reported to improve physical performance and bodybuilding in young athletes. However, scarce literature data are available on the harmful use, dependence and induced psychosis. Currently, World Anti-Doping Agency (WADA) has prohibited use of mephentermine in competitive sport games (WADA, 2011). Mr. A, a 25-year-old man, underwent initial structured assessment and revealed premorbid dissocial and impulsive personality traits. Early onset ADS was noticed in his brother and father, and he presented to us with a 3-year history of mephentermine use. He started using the following unsolicited advice, mephentermine use, from a gym-instructor to improve his bodybuilding while working out at a gym. He perceived happiness, increased physical strength, multimodal auditory-visual and sometime tactile vivid hallucinations and increase in muscle mass. Its initial irregular use became regular in the next 2 months and the daily use increased from 60 to 300 mg/day. Intravenous self-administration (termin – 30 mg/ml), currently his average use, was 300 mg/day; the last usage being 1-month back. Since the last 2 years, he fulfilled ICD-10 criteria for mephentermine dependence syndrome by meeting four out of six criteria. In addition, the patient also had the harmful habit of cannabis and alcohol usage – currently abstinent for 6 months – and nicotine dependence syndrome – active use. Since 21⁄2 years the patient is also having delusion of persecution, reference, thought broad casting, insertion, blocking, somatic passivity, first/third person auditory hallucinations and running commentary of his actions, with multiple suicidal attempt of impulsive type, and associated with altered biological, sociooccupational dysfunction.

Correlates of High-Risk and Low-Risk Alcohol Use among College Students in Kerala, India

ABSTRACT This study describes the prevalence and correlates of alcohol use among college students in Ernakulam, Kerala State, India. A total of 5784 students from 58 colleges selected by stratified random sampling completed a questionnaire incorporating standardized instruments. The prevalence of lifetime alcohol use was 21.4% with a male predominance. Among users, low-risk, hazardous, and dependent use were 80.2%, 18.3% and 0.9% respectively. Initiation was mostly with friends (45.3%). Both low-risk and high-risk alcohol users (hazardous and dependent users), in comparison to abstainers, had higher odds of being older, non-Muslim, having a part-time job, using other substances, and exposure to sexual abuse. Students who reported low-risk use also had an urban background, more severe psychological distress and suicidal thoughts, while high-risk users had attention deficit hyperactivity disorder (ADHD) symptoms. Students who reported high-risk use compared to low-risk users had higher odds of having a part-time job, tobacco use, and ADHD symptoms. Alcohol use among college students is common, with both low- and high-risk drinking associated with significant morbidity. This study highlights the need to promote public health policies to target and prevent all patterns of alcohol use among young people.