Mantosh Dewan

Withdrawal-emergent dyskinesia in a patient on risperidone undergoing dosage reduction.

A 23-year-old, white male with history of paranoid schizophrenia developed a withdrawal-emergent dyskinesia during a dose reduction of risperidone. The implications of this with regard to future risk of tardive dyskinesia (TD) and the potential association of risperidone with TD are discussed.

Treating common psychiatric disorders associated with attention-deficit/hyperactivity disorder

Attention-deficit/hyperactivity disorder (ADHD) often occurs along with other psychiatric disorders, with estimated comorbidity rates of 50 – 90%. Comorbidity greatly influences presentation, diagnosis and prognosis, complicates treatment and significantly increases the morbidity and disease burden of ADHD. Commonly co-occurring psychiatric disorders are disruptive behavior disorder, anxiety, depression, bipolar disorder and substance use disorders. This article provides a brief review of effective strategies for treating the most common psychiatric disorders associated with ADHD. This paper also discusses knowledge gaps in the understanding of treatment of comorbid disorders associated with ADHD, and directions for future research.

Gabapentin's Effect on Agitation in Severely and Persistently Mentally III Patients

OBJECTIVE: To study the effects of adjunctive gabapentin on agitation in severely and persistently mentally ill (SPMI) inpatients. METHOD: Eleven chronic SPMI inpatients on stable psychotropic medication regimens were evaluated before and after the initiation of adjunctive gabapentin for six months. The following psychometric tests were used: Brief Psychiatric Rating Scale (BPRS), Corrigan Agitated Behavior Scale (CABS), and Clinical Global Impression (CGI)–Severity. Data collection was accomplished via retrospective chart review. An internal reliability check indicated that a chart review BPRS is significantly predictive of one performed face-to-face. RESULTS: Statistically significant reductions were found at six months for each assessment instrument (p > 0.05, two-tailed). BPRS scores were reduced from 40.6 to 33.2, CABS from 34.4 to 25.0, and CGI—Severity from 5.9 to 5.3. The bulk of the BPRS reduction was accounted for by several subscores exclusive of those assessing affective/anxious symptomatology. Adverse effects were minimal. Two patients were discharged 12 and 17 months after implementation of gabapentin. CONCLUSIONS: Adjunctive gabapentin appears to be associated with a reduction in agitation in chronically hospitalized SPMI patients. Controlled, prospective trials are needed before any definitive conclusion can be drawn regarding the role of gabapentin in the treatment of this group of patients.

Catatonic Syndrome: Importance of Detection and Treatment with Lorazepam

BACKGROUND A resurgence of interest has led to renewed attempts to clarify the concept and treatment of catatonia. METHOD A large prospective study was conducted to estimate the incidence of catatonic syndrome in 138 consecutive psychiatric patients admitted to a general hospital in India, to demarcate the common symptom presentations and its response to intravenous benzodiazepines. Patients were screened using the Bush Francis Catatonia Screening Instrument. Patients with two or more signs on the Instrument were subsequently administered intravenous lorazepam and their response was rated on the Bush Francis Catatonia Rating Scale. RESULTS Catatonic syndrome was found in 11% of patients with a wide variety of diagnoses, especially schizophrenia. Mutism (87.5% incidence) was the most common symptom. A significant proportion (93%) of these patients showed a marked immediate response to lorazepam, with 75% showing sustained improvement. CONCLUSIONS Catatonic syndrome is common, often undiagnosed, and quickly responsive to treatment, irrespective of the diagnosis. It needs to be identified and actively treated with benzodiazepines to minimize distress, and facilitate diagnosis and treatment. Most patients also need additional treatment for the underlying psychiatric condition.

Psychiatric morbidity following motor vehicle crashes: a pilot study from India

Background. Motor vehicle crashes can result in significant posttraumatic psychiatric morbidity. While the psychological impact of major disasters has been extensively studied in developing nations, psychological distress resulting from personal disasters such as road traffic crashes is sadly lacking. Method. Thirty inpatients who had been involved in a motor vehicle crash, either as a driver, passenger, or pedestrian, were assessed for psychiatric morbidity using the Hospital Anxiety and Depression Scale and the Impact of Events Scale. We also studied the influence of various sociodemographic factors and peritraumatic emotional experiences on the development of psychological symptoms. Results. Of the 30 patients, 57% had anxiety or depressive symptoms, 30% had an anxiety or depressive disorder, and 20% had posttraumatic stress disorder. It was also observed that peritraumatic emotions seemed to determine the type and severity of psychiatric symptoms that patients experienced. Conclusions. This study found that more than half of the victims of motor vehicle crashes in the sample suffered from some form of psychiatric morbidity. With rising industrialization and motorization in developing countries, the number of victims of motor vehicle crashes is bound to increase. Adequate attention to psychiatric interventions in the provision of emergency and trauma services could help prevent significant disability.

A Roadmap for Observership Programs in Psychiatry for International Medical Graduates

ObjectiveInternational medical graduates (IMGs) constitute a significant proportion of the psychiatric workforce in the United States. Observership programs serve an important role in preparing IMGs for U.S. residency positions; yet there are limited resources with information available on establishing these observerships, and none specific to psychiatry. In this article, authors present a roadmap for observership programs in psychiatry for IMGs.MethodThis article draws on the experience of the IMG committee of the Group for Advancement of Psychiatry in establishing observership programs.ResultsAuthors highlight the benefits of observership programs to IMGs, psychiatry departments, and the U.S. medical system as a whole. The different components of an observership program are presented, along with core competencies that need to be acquired. The authors discuss challenges that observership programs may encounter as well as recommendations for overcoming them.ConclusionObservership programs provide a unique opportunity to integrate IMGs into the U.S. medical system. This article provides a framework for establishing such programs in a way that will optimize their benefits and avoid potential pitfalls. Drs. Hamoda and Sacks contributed equally to this article and are hence co-1st authors.

Psychiatric Complications of Malaria: A Case Report

This article reviews the psychiatric complications of malaria. A case of malaria infection is described. The diagnoses, treatment, and neuropsychiatric complications of acute and chronic malaria infection are discussed. The treatment of malaria and its complications are summarized.

Prophylaxis of antipsychotic-induced extrapyramidal side effects in east Indians: cultural practice or biological necessity?

Objective: Although still controversial, as early as 1989, the World Health Organization recommended that antipsychotic agents should be initiated without routinely adding anticholinergic drugs prophylactically. However, combined treatment with antipsychotics and anticholinergic agents is the norm in India. The goal of this study was to investigate whether Indians are more susceptible to extrapyramidal side effects (EPS) or if the practice of routinely adding an anticholinergic agent to an antipsychotic is overly cautious and wasteful. Method: 75 consecutive patients started on conventional antipsychotics were repeatedly evaluated over 2 months on a standardized EPS scale, the abbreviated Simpson-Angus scale. Results: Of 71 subjects who completed the study, 68 (96%) suffered EPS while receiving 2–13 mg/day of haloperidol equivalents, with 70% of EPS present by day 5 and 90% by day 10. The most common symptoms were tremor (49%), cogwheel rigidity (40%), and acute dsytonic reaction (34%). Routine clinical care detected 49% of the EPS, patients volunteered a complaint 19% of the time, and relatives reported EPS in 7% of patients. Conclusion: Since patients of Indian origin are prone to suffer EPS when taking conventional antipsychotic drugs, initial prophylaxis with antiparkinson agents should perhaps be more carefully considered on a routine basis. Even among atypicals, agents with the least potential to cause EPS should be favored. In all patients treated with antipsychotics, it is imperative to ask directly about and carefully examine for EPS, because few patients will volunteer their complaints.

Somnambulism Precipitated by Selective Serotonin-Reuptake Inhibitors

Objective: To report a case of somnambulism (sleepwalking) potentially precipitated by selective serotonin-reuptake inhibitors (SSRIs) in an HIV-positive woman. Case Summary: A 34-year-old HIV-positive white woman without a prior history of somnambulism began sleepwalking following treatment for depression with two different SSRIs. The sleepwalking episodes disappeared completely with a reduction of the dosages of the SSRIs and began again when the dosages were increased. Discussion: Somnambulism has been associated with psychoactive drugs that affect the physiology of sleep, awareness, arousal, and memory. A biologic plausibility is supported by the fact that SSRIs alter electroencephalogram and sleep patterns and may be prone to precipitating somnambulism in susceptible individuals. Because people who sleepwalk may not be aware of their actions during such episodes, there is a potential for injury if this adverse effect were to occur. Conclusions: Given the widespread use of SSRIs, clinicians should be aware of the possibility that somnambulism may occur with this class of drugs.

Evaluation and Feedback

This chapter reviews the educational, cultural, and linguistic factors that contribute to international medical graduate physicians’ perceptions of feedback and self-assessment as high-risk behaviors. Lack of exposure in medical school to feedback, limited role modeling of self-reflection, and an emphasis on certain cultural values all contribute to a high level of anxiety about the feedback process. This anxiety can be interpreted by faculty as disinterest or lack of motivation. Functioning in a second language can impact relationships with patients and supervisors’ assessment of residents’ capabilities.