Karthick Subramanian

Diagnostic Masking and Overshadowing in Intellectual Disability—How Structured Evaluation Helps

PROBLEM Comorbid psychiatric diagnoses tend to be underdiagnosed in patients with intellectual disability. Diagnosing anxiety disorders in such patients can pose challenges, in particular with regard to obsessive and compulsive disorder (OCD). METHODS We present the case of an adolescent diagnosed with intellectual disability with poor expressive language skills who presented with nonspecific mood and behavioral symptoms, not improving with routine clinical evaluations and treatment. A structured assessment was done to decipher the psychopathology. FINDINGS The structured evaluation was able to diagnose OCD, and the treatment response was accentuated, bringing about a significant reduction in patient and caregiver distress. Psychosocial interventions through nurses played a significant role. CONCLUSIONS The case highlights the need for a systematic assessment of patients with intellectual disability to arrive at reliable diagnoses and to plan appropriate treatment strategies.

Risperidone-induced adverse drug reactions and role of DRD2 (−141 C Ins/Del) and 5HTR2C (−759 C>T) genetic polymorphisms in patients with schizophrenia

Objective: To determine the adverse drug reaction (ADR) profile of risperidone and their association with dopamine (DRD2 − 141 C Ins/Del/rs1799732) and serotonin receptor (5HTR2C −759 C>T/rs3813929) gene polymorphisms in patients with schizophrenia. Materials and Methods: The study was conducted among 289 patients who were diagnosed with schizophrenia and were on treatment with risperidone (4–8 mg/day)-based therapy for a minimum of 4 weeks. Genotyping was carried by real-time quantitative polymerase chain reaction. All the patients were observed for the occurrences of ADRs during the study. Changes in prolactin levels and body weight were analyzed for a subgroup of 102 and 97 patients, respectively. Results: Risperidone-induced extrapyramidal symptoms (EPSs) were seen in 36.7% of patients. Among them, tremors were the most common symptom 31.8%. Risperidone-induced hyperprolactinemia and weight gain were seen in 87.2% and 53.6% in subgroup patients. Adverse effects such as sedation, gastrointestinal effects, and amenorrhea were seen in 9.7% (28/289), 5.1% (15/289), and 6.1% (7/114), respectively. Occurrence of DRD2 − 141 Ins/Del and Del/Del polymorphisms were significantly associated with increased prolactin levels in response to risperidone (odds ratio [OR] = 10.45; 95% confidence interval = 1.29–84.89,P = 0.004). No such association was observed with 5HTR2C (−759 C>T) polymorphism. Weight gain and EPS were not associated with the above genetic polymorphisms. Conclusion: Hyperprolactinemia, weight gain, and EPSs (>36.7%) were common adverse effects of risperidone. DRD2 – 141C Ins/Del and Del/Del polymorphisms were significantly associated with increased prolactin levels (OR = 10.45) in response to risperidone.

Psychiatric presentations heralding Hashimoto's encephalopathy: A systematic review and analysis of cases reported in literature

Hashimotos encephalopathy (HE) may often present initially with psychiatric symptoms. These presentations are often variable in clinical aspects, and there has been no systematic analysis of the numerous psychiatric presentations heralding an eventual diagnosis of HE which will guide clinicians to make a correct diagnosis of HE. This systematic review was done to analyze the demographic characteristics, symptom typology, and clinical and treatment variables associated with such forerunner presentations. Electronic databases such as PubMed, ScienceDirect, and Google Scholar databases were searched to identify potential case reports that described initial psychiatric presentations of HE in English language peer-reviewed journals. The generated articles were evaluated and relevant data were extracted using a structured tool. We identified a total of forty articles that described 46 cases. More than half of the total samples (54.4%) were above the age of 50 years at presentation. The most common psychiatric diagnosis heralding HE was acute psychosis (26.1%) followed by depressive disorders (23.9%). Dementia (10.9%) and schizophrenia (2.2%) were uncommon presentations. Antithyroid peroxidase antibodies were elevated in all patients but not antithyroglobulin antibodies. Preexisting hypothyroidism was absent in majority of cases (60.9%). Steroid doses initiated were 500–1000 mg of intravenous methylprednisolone for majority (52.1%) of patients while oral steroid maintenance was required for a significant minority (39.1%). Psychiatric manifestations of HE may be heterogeneous and require a high index of clinical suspicion, especially in older adults. A range of clinical and treatment variables may assist clinicians in making a faster diagnosis and instituting prompt and effective management.

Does gender influence electroconvulsive therapy sessions required across psychiatric diagnoses? A 5-year experience from a single center

Context: There is a paucity of systematic data reflecting the practice of electroconvulsive therapy (ECT) from developing countries. Aim: We aimed to identify the number of ECT sessions required to yield response and gender diffeferences in the number of sessions across various diagnostic categories. Setting and Design: A record-based study from a teaching cum tertiary care hospital in South India. Subjects and Methods: Case records of patients who received modified ECT from January 2011 to January 2016 were reviewed. The sociodemographic details and ECT-related data were collected. Psychiatric diagnoses were ascertained as per the International Classification of Diseases, 10th Revision criteria. Statistical Analysis Used: Kruskal–Wallis test and Mann–Whitney U-test. Results: Among 148 patients, 82 (55.4%) had mood disorder (bipolar disorder and recurrent depressive disorder), 43 (29.1%) had schizophrenia, and 22 (14.9%) had other acute and transient psychotic disorders (ATPDs). Patients with mood disorders, schizophrenia, and other ATPD received 7.3 (± 3.8), 9.7 (± 6.1), and 5.4 (± 2.0) ECT sessions, respectively, to achieve response. There was no gender difference in the number of sessions received. Conclusion: Our findings show that number of ECT sessions required to yield response may be disorder-specific. Gender does not influence the ECT dose requirement. Variations in ECT parameters across settings may limit the generalizability of results.

History of Lifetime suicide attempt in bipolar I disorder: its correlates and effect on illness course

Abstract Objectives: To identify the prevalence and correlates of bipolar I patients with a lifetime history of suicide attempt. Materials and methods: Bipolar I disorder was diagnosed in 150 patients as per DSM-IV-TR criteria. Their lifetime suicide risk was assessed using the Columbia Suicide Severity Rating Scale. NIMH retrospective Life Chart Methodology was used to chart the illness course. Medication Adherence Rating Scale (MARS) and Pittsburgh Sleep Quality Index (PSQI) were used to assess the recent adherence and subjective sleep quality, respectively. The suicide attempters were compared with non-attempters on individual variables. Results: Around 23% had a positive lifetime history of suicide attempt. They were predominantly female, had an index (first ever) episode of depression, spent more proportion of time being ill, especially in depressive or mixed episode phase. Comorbid substance use disorder along with suicidal attempts was seen only in males. Suicide attempters displayed poor medication adherence attitudes for medications taken during the past week and reported impaired sleep quality for the previous month. Conclusions: A positive history of lifetime suicide attempt was significantly associated with a worse course of bipolar I disorder. Effective treatment of depressive episodes, addressing non-adherence, substance use and sleep problems can reduce the suicide risk in such patients. Retrospective design of the study and recall bias are some of the limitations.

Cost-of-treatment of clinically stable severe mental lilnesses in India

Background and Aims: The cost-of-treatment studies can help to make informed decisions while planning health-care services. This study is aimed to assess direct costs of outpatient treatment of four common chronic severe mental illnesses in a tertiary care hospital in South India. Methods: The patients with ICD-10 diagnoses of schizophrenia, unspecified nonorganic psychosis, bipolar disorder, and recurrent depression were recruited by purposive sampling from a government teaching hospital in South India. The total cost-of-treatment to the patient and the hospital was computed for each disorder as a percentage of the per-capita income of an individual patient. Results: The study comprised a total of 140 patients. The average monthly total cost-of-treatment was Indian Rupees (INR) 770 (95% confidence interval of 725 to 815), or approximately US

Converging neurobiological evidence in primary polydipsia resembling obsessive-compulsive disorder

12.8. The monthly total cost-of-treatment was INR 720 for schizophrenia, INR 750 for unspecified nonorganic psychosis, INR 830 for bipolar disorder, and INR 790 for recurrent depression, with no significant differences between groups. On an average, 22.8% of total cost-of-treatment was borne by the patient, and the rest by the hospital. The patients spent a median of 12% of their per-capita income on treatment related to direct costs. Conclusions: Despite substantial government subsidies, patients do incur some expenses in treatment of chronic psychiatric illnesses. The attempts to reduce treatment and travel costs can facilitate psychiatric care to larger number of individuals.

What happens to episode duration and cycle length over the course of bipolar disorder

Compulsive water drinking can have phenomenological and pharmacotherapeutic similarities with obsessive-compulsive disorder (OCD). Substantiating neurobiological evidence is lacking for such an association. We report a patient who was referred with a diagnosis of primary polydipsia with no signs of organic pathology in structural neuroimaging. However, positron emission tomography revealed basal ganglia hypometabolism indicating that primary polydipsia with compulsive water drinking is neurobiologically related to OCD. The diagnostic complexities displayed by primary polydipsia and the use of systematic evaluation with supporting neuroimaging evidence in reaching a reliable diagnosis are discussed. The neurobiological evidence will foster the treatment decisions for starting anti-OCD measures when clinicians encounter patients with primary polydipsia exhibiting compulsive patterns of drinking. Nevertheless, such findings need to be replicated in future studies with a larger sample size.

Current adherence attitudes can reflect the course and outcome of bipolar disorder-type I

Objectives: Published scientific literature on cycle acceleration over the course of bipolar disorder has been equivocal. The present analysis aimed to find whether episode duration and cycle lengths become shorter over the course of bipolar disorder with predominantly manic polarity. Methods: The present study comprised 150 patients diagnosed with bipolar I disorder using SCID-I for DSM-IV TR. The course of illness was charted according to the NIMH Life Chart Methodology – Clinician Retrospective Chart (NIMH – LCM CRC). Spearman correlation was used to assess the relationship of episode duration and cycle length with the number of episodes. Results: The mean age of the sample was 37.8 years and the average duration of illness was 13.4 years. Unipolar mania comprised 52.7% of the sample. The episode duration and the cycle length decreased with increasing number of episodes (r=−0.245, p<0.001 & r=−0.299, p<0.001 respectively). Conclusion: The present study suggests that over the course of bipolar I disorder, cycle length and episode duration become shorter.

Role of stressful life events and kindling in bipolar disorder: Converging evidence from a mania-predominant illness course

Bipolar disorder (BD) is regarded as a severe mental illness, and various factors seem to influence its course and outcome namely substance use, life events and medication adherence (Bates et al., 2010; Lingam and Scott, 2002). Adherence in BD is influenced by many factors including social support systems and positive therapeutic relationships (Col et al., 2014; Teter et al., 2011). Studies evaluating such factors in developing regions like India are relatively rare. Hence, we assessed adherence attitudes in remitted patients with BD type I (n = 109) diagnosed using the Structured Clinical Interview for DSM-IV-TR Patient Version (SCID-I/P) (First et al., 2001). The illness course was retrospectively charted using the National Institute of Mental Health-Life Chart Methodology Clinician Retrospective Chart (NIMH-LCM-CRC) (Roy-Byrne et al., 1985). A Young Mania Rating Scale (YMRS) score <7 and a Hamilton Depression Rating Scale-17-item version (HDRS) score <8 confirmed remission status (Hamilton, 1960; Young et al., 1978). The adherence attitudes were evaluated using the Medication Adherence Rating Scale (MARS) which is a 10-item self-rated instrument in yes/no format with two items in reverse scoring. Scores 5 imply non-adherence (Thompson et al., 2000). The illness severity and outcome was measured using the Clinical Global Impression-Bipolar (CGI-BP) scale (Spearing et al., 1997). Among the sample, 24 (22%) had ‘poor’ adherence and were classified as ‘non-adherent’ group, with 85 in the ‘adherent’ group. The two groups were compared on demographic and clinical characteristics using appropriate parametric and non-parametric inferential statistics. Non-adherent patients exhibited greater sub-syndromal manic symptoms and had a shorter duration of the illness. However, they had spent a higher proportion of time being symptomatic. Their illness was more severe as per CGI-BP. There were no significant differences between the two groups along the socio-demographic lines. Regarding the MARS items, it was found that the nonadherent patients were ‘careless’ about taking the medication (91.7%) while the adherent patients were ‘confident’ regarding medications (85.9%).