Karishma Kulkarni

Clinical Presentation and Course of Persistent Delusional Disorder: Data From a Tertiary Care Center in India.

OBJECTIVE Despite its long history as a psychiatric diagnosis, little is known about the sociodemographic and clinical profile of persistent delusional disorder (PDD) or its subtypes, treatment response, and outcomes, particularly in India. We examined the clinical characteristics and course of PDD in patients presenting to a tertiary neuropsychiatry center in India. METHOD A retrospective chart review of patients diagnosed with PDD (ICD-10) between January 2000 and May 2014 was conducted. Sociodemographic and clinical data including age at onset, total duration of the illness, clinical symptoms and treatment, hospitalizations, occupational functioning, and follow-up were extracted from the files. The study was approved by the institute ethics committee. RESULTS The sample (N = 455) consisted of 236 men and 219 women. The mean age at onset was 32.36 ± 10.47 years. The most common delusion was infidelity (n = 203, 44.6%) followed by persecution (n = 149, 32.7%). Hallucinations were present in 78 (17.1%), depressive symptoms in 187 (41.1%), and comorbid substance dependence in 61 (13.4%) subjects; 141 subjects (31.0%) had a family history of mental illness. Follow-up data were available for 308 subjects, of whom 285 (92.5%) reported good compliance with medication. Of the subjects, 163 (52.9%) showed a good response to treatment. The diagnosis of PDD remained unchanged in 274 of 308 subjects (88.9%). CONCLUSION In our center, PDD appears to be uncommon and has a near-equal gender representation. Infidelity was the most common delusion, which is in contrast to the reported literature. The diagnosis of PDD appears to be stable with good response to atypical antipsychotics if compliance can be ensured.

Feasibility and utility of tele-neurorehabilitation service in India: Experience from a quaternary center

Background: Neurological rehabilitation service in developing countries like India is a great challenge in view of limited resources and manpower. Currently, neurological rehabilitation with a multidisciplinary team is limited to a few major cities in the country. Tele-neurorehabilitation (TNR) is considered as an alternative and innovative approach in health care. It connects the needy patients with the health-care providers with minimum inconvenience and yields cost-effective health care. Aim: The aim of this study was to study the socioclinical parameters, feasibility, and utility of TNR services in India. Methodology: A retrospective file review of TNR consultations provided through Telemedicine Center at a quaternary hospital-based research center in south India between August 2012 and January 2016. Results: A total of 37 consultations were provided to the patients belonging to four districts of Karnataka. The mean age of the patients was 34.7 (±19.5) years, 23 (62.1%) were aged between 19 and 60 years, and 31 (83.8%) were male. Thirty-one patients (83.8%) had central nervous system-related disorders such as stroke, cerebral palsy, and tubercular meningitis with sequelae or neuromuscular disorders such as Guillain–Barre Syndrome and Duchenne muscular dystrophy. Twelve patients (32.4%) were advised to consult higher centers in the vicinity, and the rest was referred to the district hospital. Conclusion: The findings suggest that TNR services are feasible, effective, and less resource intensive in delivering quality telemedicine care in India. More clinical studies are required to elucidate its full utility at different levels and in different parts of the country.

Course and naturalistic treatment seeking among persons with first episode mania in India: A retrospective chart review with up to five years follow-up

BACKGROUND An understanding of the early course of Bipolar Disorder (BD) can contribute towards developing timely interventions. First episode mania (FEM) determines a diagnosis of bipolarity, and therefore, onset of BD-I. We investigated the course of BD-I over a five-year period after FEM by retrospective chart review. METHODS Charts of patients diagnosed with FEM in 2008 (n = 108) were reviewed. Data was extracted about FEM and subsequent course up to 5 years, for those who came for follow-up during this period. The factors influencing course were evaluated with statistical analyses including logistic regression and survival analysis. RESULTS The mean age at onset of BD was 26 ± 9.2 years and mean age at FEM was 27.1 ± 9 years. 41 (38%) patients had previous depression. Patients who returned for at least one follow-up were 60/108 (55.6%), with 54 (90%) of them experiencing another mood episode following FEM. Most recurrences occurred between 6 months to 1 year after FEM, with manic episodes occurring two-three times as frequently as depressive episodes. Good adherence to treatment was a predictor of fewer hospitalizations [B = -0.61; t = -3.1; p = 0.004]. LIMITATIONS The study was limited by its retrospective design and high number of dropouts. CONCLUSION The five-year course after FEM showed twice the number of manic compared to depressive recurrences, irrespective of when the recurrence occurred. Consistent with earlier reports from India, BD-I appears to be mania-predominant, even early in the course. This has significant implications in planning maintenance treatments.

A study on collaborative telepsychiatric consultations to outpatients of district hospitals of Karnataka, India

INTRODUCTION The Indian National Mental Health Survey (NMHS) of 2015-2016 has estimated 13.7% lifetime and 10.6% point prevalence for mental illnesses. It has identified that the treatment gap for mental illnesses ranges between 70% and 92%. Tele-Psychiatric consultations could be an alternative and innovative approach to bridge this gap in low resource settings. AIMS To study the sociodemographic and clinical profiles of patients who have received collaborative Tele-Psychiatric consultations across district hospitals in Karnataka, India. METHODOLOGY We performed a retrospective review of case files of patients who have received collaborative Tele-Psychiatric consultations from January 2013 to June 2017 through video-conferencing. A total of 139 consultations were provided to patients in the state of Karnataka. RESULTS The mean age of the sample is 31 (±15.5) years. 61.8% were male and 79.8% were aged more than 18 years. In total, 25.9% of them had schizophrenia and other psychotic disorders, 14.4% had mental retardation, 13.7% had a mood disorder and 14.4% had a substance use disorder. 67.6% of patients had been advised pharmacotherapy, 7.9% had been advised rehabilitation along with pharmacotherapy and 24.4% were advised further evaluation of illness and inpatient care at a higher centre. CONCLUSION Collaborative tele-psychiatric consultations to district hospitals from an academic tertiary care hospital can be feasible and are likely to benefit patients from rural areas. There is a need for more studies to elucidate their acceptability by patients, caregivers and professionals.

The impact of depressive symptoms on the clinical presentation of Persistent Delusional Disorder

BACKGROUND Our aim was to investigate the influence of depressive symptoms on the clinical presentation of Persistent Delusional Disorder (PDD). METHODS We have previously conducted a retrospective review of patients diagnosed with PDD (n = 455). We divided this sample into two groups according to the presence or absence of co-morbid depressive symptoms - a subsample of PDD with depressive co-morbidity (PDD + D; n = 187) and a subsample of PDD without depressive co-morbidity (PDD only; n = 268). RESULTS PDD + D group had a significantly younger age at onset of PDD. The PDD + D group received significantly more antidepressants but had similar response and adherence rates. CONCLUSIONS The presence of depressive symptoms in 41% of the study population did not appear to influence the clinical presentation or response to treatment.

Risperidone versus olanzapine in the acute treatment of Persistent Delusional Disorder: A retrospective analysis

There is a dearth of prospective trials studying treatment response in Persistent Delusional Disorder (PDD) to guide clinical practice. Available retrospective data indicate good response to second-generation antipsychotics (SGAs). We selected the data of patients prescribed either olanzapine or risperidone from a retrospective chart review of PDD (n=455) at our centre. We compared the two groups olanzapine (n =86) versus risperidone (n =280) on dose, drug adherence, response and adverse effects. The two groups were comparable on socio-demographic and clinical characteristics of PDD. There was no statistically significant difference between the two groups on adherence (>80%) and response to treatment (>52% good response). Olanzapine was effective at lower mean chlorpromazine equivalents than risperidone. Logistic regression analysis identified shorter mean duration of illness, good adherence and absence of substance dependence as predictors of good response to both drugs. Our study indicates that acute PDD responds well to treatment with both risperidone and olanzapine, provided adherence can be ensured. In the absence of specific treatment guidelines and randomized controlled trials for PDD, our analysis reaffirms the efficacy of SGAs.

Investigating The Role Of One-Carbon Metabolism Pathway In Complicated Alcohol Withdrawal States

Background Complicated withdrawal states in alcohol dependence syndrome (ADS) include alcohol withdrawal seizures (AWS) and delirium tremens (DT) and are associated with significant medical and psychiatric morbidity. Existing evidence suggests that in patients with chronic ADS, the associated deficiency of vitamin B12 and folic acid could lead to hyperhomocysteinemia through the inhibition of methionine synthase (MS) and methylene tetrahydrofolate reductase (MTHFR) enzymes of the one-carbon metabolism pathway. Hyperhomocysteinemia has been found to be associated with complicated alcohol withdrawal especially withdrawal seizures (AWS). The common variant of the MS A2756G gene has been found to be associated with lower plasma homocysteine levels. The homozygote variant of the MTHFR A1298C gene results in partial loss of enzyme activity. Thus, it may be worthwhile to study the above SNPs in patients with complicated alcohol withdrawal states and correlate the findings with plasma homocysteine, vitamin B12 and folate levels. Methods In our study, we aimed to investigate the association of MTR A2756G (responsible for the MS enzyme) and MTHFR A1298C polymorphisms with complicated withdrawal states i.e. AWS and delirium tremens (DT). We also measured levels of plasma homocysteine, vitamin B12 and folate in these patients. The sample consisted of a total of 150 male patients with ADS of which 84 patients had simple withdrawal state (SWS), 30 patients had DT and 36 patients had AWS. Assessments included a general physical examination, biochemistry panel, a complete blood count, assays of plasma homocysteine, vitamin B12 and folate along with genotyping for the MTR A2756G and MTHFR A1298C polymorphisms. Results There was no difference in the mean age at onset of dependence (SWS - 28.2 ± 5.7; DT - 28.2 ± 4.6; AWS - 27.9 ± 5, F = 0.03, p = 0.9). However, there was a significant association between the mean daily units of alcohol consumed and complicated alcohol withdrawal states. (SWS - 13.6 ± 3.7; DT - 19.8 ± 3.9; AWS - 17.1 ± 4.9, F = 27.8, p The study also found no differences in the serum homocysteine levels (SWS – 0.91; DT – 0.91; AWS – 0.88 nmol/ml, t = 0.9, p = 0.6), vitamin B12 levels (SWS – 274; DT – 265; AWS – 230 pg/ml, t = 1.2, p = 0.5), and folate levels (SWS – 99.3; DT – 99.1; AWS – 98.2 pg/ml, t = 2.4, p = 0.1). Although vitamin B12 and folic acid levels fell in the lower end of the normal range, no deficiency states were observed. No association was found between levels of plasma homocysteine, vitamin B12 & folic acid levels and complicated alcohol withdrawal states. No significant differences were found between the groups with respect to haematological and biochemical parameters examined. The two groups did not differ significantly with respect to genotype frequency of the SNPs examined (MTHFR A1298C and MTR A2756G). Discussion Our study finds that it is the quantity of alcohol consumed in a day that is associated with complicated withdrawal states with frequent heavy drinkers more likely to have severe withdrawal. It would be worthwhile to explore this further as no clear genetic risk factors emerged. The study was limited by its sample size, the use of cross-sectional sampling method and the exclusion of female patients from the study. However, it is one of the first studies to examine these SNPs in a south Indian population. The role of the one-carbon metabolism pathway in these states remains an important area of research with numerous possible treatment implications.