Muhammad Hassan Majeed

Mindfulness-based interventions for chronic pain: Evidence and applications

Chronic pain is estimated to occur in from 5.5% to 33% of the worlds adult population (Gureje et al., 1998). Chronic pain is frequently treated with opiates, which has produced an opiate addiction crisis (Dowell et al., 2016). Several non-pharmacological treatment alternatives can help manage chronic pain. There is moderate evidence that mindfulness-based interventions (MBIs) such as meditation, yoga, and stress reduction lower the perception of pain, increase mobility, improve functioning and well-being. By integrating MBIs and other therapeutic interventions in a multi-disciplinary pain management plan, clinicians can improve treatment outcomes and potentially decrease pain-related medication utilization.

Psychotherapeutic interventions for chronic pain: Evidence, rationale, and advantages

Background Long-term use of opioids to treat chronic pain incurs serious risks for the individual—including misuse, abuse, addiction, overdose and death—as well as creating economic, social, and cultural impacts on society as a whole. Chronic pain and substance use disorders are often co-morbid with other medical problems and at the present time, primary care clinicians serve most of this population. Primary care clinicians would benefit from having alternatives to opioids to employ in treating such patients. Method We electronically searched different medical databases for studies evaluating the effect of nonpharmacological treatments for chronic pain. We describe alternative approaches for the treatment of chronic pain and cite studies that provide substantial evidence in favor of the use of these treatments. Results Cognitive behavioral therapy, acceptance and commitment therapy, and mindfulness-based programs have well-documented effectiveness for the treatment of chronic nonmalignant pain. Integration of such behavioral health therapies into primary care settings may optimize health resources and improve treatment outcomes. Conclusion Evidence-based psychotherapy for chronic pain has established efficacy and safety and improves quality of life and physical and emotional functioning. Such interventions may be used as an alternative or adjunct to pharmacological management. Chronic opioid use should be reserved for individuals undergoing active cancer treatment, palliative care, or end-of-life care.

International Medical Graduates and American Psychiatry: The Past, Present, and Future

In recent years, the percentage of non-US citizen international medical graduate (IMG) physicians matched for positions in psychiatry residency programs declined by half [1]. In 2017, there were a total of 1495 post-graduate year 1 (PGY-1) psychiatry positions in the National Residency Matching Program (NRMP) match; 137 positions were secured by visa-requiring IMGs (9.2%) [2]. This contrasts with 2008, when 1069 PGY-1 psychiatry positions were available and 201 were secured by visa-requiring IMGs (18.8%) [3]. This decline reflects the challenges faced by such applicants (Fig. 1). Conversely, the number of visa-requiring psychiatry applicants has increased. There has been an increase in the number of psychiatry applicants from US allopathic schools, likely displacing IMGs. Moreover, the recent presidential executive order that suspended the entry of nationals from six Muslim majority countries, if allowed to stand, may cause the number of IMG candidates matching in psychiatry to further decline [4]. In 2014, the NRMP published match outcome data which showed 227 applicants from these countries were successfully matched across all disciplines [5]. According to Dr. William Pinsky, president and CEO of the Education Commission for ForeignMedical Graduates (ECFMG), approximately 850 applicants participating in the match of 2017 were from countries affected by the executive order [6]. Psychiatry and psychology departments in academic institutions in the USA have a long history of providing opportunities for IMGs. A large group of IMG psychiatrists arrived in the US post-World War II from a destabilized Europe. Eminent and influential psychiatrists immigrated to the USA and enhanced the quality and breadth of psychiatric education and care. The psychoanalytic movement was in its ascendancy in the USA and was strengthened by this influx of psychiatrists from other nations. In subsequent decades, the American Psychiatry Association (APA) became a true multinational organization and currently represents physicians from almost 150 countries. The APA acknowledged the significant presence and vital contribution of IMGs as early as 1972 when the APA annual meeting was dedicated to the services of IMGs and called them “another of APA’s neglected minorities.” IMGs trained in the USA are extremely influential and actively advance psychiatry in the USA and the world. In the last three decades, three APA presidents were IMGs. Several IMGs have made outstanding and enduring contributions to contemporary American psychiatry by playing important roles as leaders, academicians, researchers, and editors of peer review journals in psychiatry. The decline in IMGs in US residency programs represents a significant loss to the global psychiatry community since many non-US citizen IMG psychiatrists bridge the gap in education, clinical research, and development between the USA and their native countries [7]. In addition to IMG contributions to education and scholarship, IMGs provide an invaluable resource in the provision of care to the underserved. Most IMGs are admitted to the USA for residency training on J-1 visas sponsored by the ECFMG. After graduation, if they wish to continue to stay in the USA, most elect to work for at least 3 years in a visa waiver program in a medically underserved area, known as a Health Professional Shortage Area. Even in the absence of visa * Muhammad Hassan Majeed Hassan.Majeed@iCloud.com

Adequacy of Pain Control in Patients With Advanced Cancer in Pakistan

Purpose: Pain is highly prevalent in advanced cancer and requires aggressive management. However, pain management in cancer is minimally investigated in Pakistan. This cross-sectional study explores the adequacy of pain management in patients with advanced stage cancer in Pakistan. Method: From January 2017 to May 2017, a cross-sectional study was conducted at Mayo Hospital, Lahore, Pakistan. A total of 218 patients with cancers were interviewed, and 136 patients with pain ≥5 on a Numerical Rating Scale for pain were included in the study. Demographic of patients and clinical characteristics of tumors were also evaluated. Results: Only about one-third of the patients with advanced cancer reported adequate pain management. Chi-square test, χ2 (1, n = 136) = 33.038, P < .05, indicated that pain scores were inversely associated with pain control; inadequate pain control was observed in patients with higher pain score and vice versa. Of the 55.88% of patients who were prescribed morphine, only 6 patients were compliant with treatment recommendations. Most patients were prescribed nonopioid medications and tramadol and codeine, which are weak opioid medications. Conclusion: The rate of undertreatment of cancer pain in Pakistan is alarming. Inadequate clinicians’ training, patients’ and caregivers’ beliefs, lack of availability of opioid medications, and socioeconomic factors are some of the barriers to effective pain control. A multidisciplinary team approach is necessary to follow the World Health Organization pain ladder guidelines for the treatment of cancer pain.

Primary genetic dystonia and first episode of psychosis

Australian & New Zealand Journal of Psychiatry, 52(3) persistent pancytopenia and a mildly reduced calcium. A brain magnetic resonance imaging (MRI) described early atrophic cerebral changes and a prominent pituitary gland. Her symptoms responded to a gradually titrated 800 mg of quetiapine. The physical examination and medical history raised the suspicion of an organic cause. Genetic testing revealed a 22q11 deletion. No other cases of 22q11 deletion were found in the immediate family members. 22q11 deletion syndrome is also known as Di George syndrome, and while it is a recognised cause of psychosis with up to 25% of patients developing schizophrenia, it is typically diagnosed in childhood following physical health complaints (McDonaldMcGinn et al., 2013). Interestingly, this patient had not presented to paediatric services and did not have a learning disability diagnosis, but instead was diagnosed with 22q11 deletion syndrome following contact with the early intervention in psychosis team during her first psychotic episode. This is an unusual presentation, and psychiatrists should consider such organic causes of psychosis. Minor facial anomalies are the commonest finding in 22q11 deletion syndrome, and it was this that alerted the team to the possible diagnosis (Cohen et al., 1999). Making this diagnosis is crucial to ensure physical complaints are addressed in addition to optimal psychiatric management. Knowledge of the ongoing physical health problems, such as pancytopenia and possible cardiac anomalies, is important when considering antipsychotic therapy (Fung et al., 2015). Consideration should be given to how psychiatric services access and counsel for possible genetic abnormalities. Declaration of Conflicting Interests

When the mind hurts the heart: spontaneous coronary artery dissection after acute stress

Certain psychiatric illnesses are predisposing factors for cardiovascular diseases such as myocardial infarction (MI), angina and arrhythmia, or, in some cases, sudden death.1 Stress from acute grief is known to trigger Takotsubo cardiomyopathy.2 Severe stress is a well-recognized precipitating factor for spontaneous coronary artery dissection (SCAD) in individuals without any known classic risk factors for atherosclerotic coronary artery disease.3 It is important to diagnose and treat SCAD in patients who present with chest pain under acute stress. We present a case that lacked the classic risk factors for atherosclerotic disease but where the patient developed acute MI from SCAD in a setting of acute stress disorder. A 48-year-old female with a clinical history significant for gastro-esophageal reflux disease, came to the Emergency Department (ED) with intermittent, atypical chest pain that was radiating to her left arm for the previous three days. She reported multiple recent stressful events causing acute stress disorder. She presented with severe anxiety, irritable mood, insomnia, and dissociative symptoms. She lacked any classical risk factors for cardiovascular diseases. In the ED, her initial electrocardiogram (ECG) showed ST-elevation MI in inferior leads (Figure 1), with a repeat ECG showing resolution of ST elevation. Her troponin was elevated. Her coronary angiography showed dissection in mid to distal parts of the left anterior descending artery. Her echocardiogram showed normal left ventricular systolic function. She was diagnosed with myocardial infarction secondary to SCAD. She was conservatively managed with dual antiplatelet and beta-blocker therapy. She was subsequently discharged home to participate in cardiac rehabilitation and a follow-up with a psychiatrist.

Effect of relocation after a natural disaster in Armenia: 20-year follow-up

BACKGROUND This study is a 20-year follow-up of individuals relocated from their home after the devastating earthquake in Armenia in 1988. METHODS Ninety-seven subjects who were exposed to the earthquake and thirty-seven subjects who were not exposed to the earthquake were administered the Symptom Checklist-90-R (SCL 90) and the UCLA PTSD Reaction in 2008. The exposed subjects comprised three groups: subjects who stayed in the earthquake city; those who relocated and returned; and a group who left permanently but were visiting family at the time of the study. RESULTS The Stayed group had significantly higher scores on the SCL-90-R when compared to the other three groups. The Stayed group and the Relocated group had significantly higher scores for partial and full PTSD than the Left group and the comparison group. CONCLUSION Permanent relocation to another country where one is able to start a new life in a safe environment provides the best adaptation for recovery when the destruction and delay in reconstruction lasted as long as it did in Armenia.