Natasha Kate

Relationship of caregiver burden with coping strategies, social support, psychological morbidity, and quality of life in the caregivers of schizophrenia

AIM To evaluate the relationship of caregiver burden as assessed by using Hindi Involvement Evaluation Questionnaire (IEQ) with coping strategies, social support, psychological morbidity, and quality of life of caregivers of patients with schizophrenia. Additionally, the relationship of caregiver-burden with sociodemographic variables, and clinical variables, including severity of psychopathology and level of functioning of patients, was studied. METHODOLOGY The study included 100 patients with schizophrenia and their caregivers recruited by purposive random sampling. RESULTS Among the four domains of IEQ, highest number of correlations emerged with tension domain. Tension domain had positive correlation with the caregiver being single, time spent in caregiving per day, and use of avoidance, collusion, and coercion as coping strategies. Additionally, tension domain was associated with poor quality of life in all the domains of WHO-QOL Bref and was associated with higher psychological morbidity. Worrying urging-I domain of IEQ correlated with frequency of visits, higher use of problem focused coping and poor physical health as per the WHO-QOL Bref. Worrying urging-II domain of IEQ had positive correlation with higher level of positive symptoms, lower level of functioning of the patient, younger age of caregiver, caregiver being unmarried, and higher use problem focused and seeking social support as coping strategies. Supervision domain of IEQ correlated positively with lower income, being an unmarried caregiver, from an urban locality and non-nuclear family. Supervision domain was associated with poor physical health as assessed by WHO-QOL Bref. CONCLUSION Caregiving burden, especially tension is associated with use of maladaptive coping strategies, poor quality of life and higher level of psychological morbidity in caregivers.

Positive aspects of caregiving in schizophrenia: A review.

Schizophrenia is a severe mental illness which is associated with significant consequences for both the patients and their relatives. Due to chronicity of the illness, the relatives of patients of schizophrenia have to bear the main brunt of the illness. Studies across the world have evaluated various aspects of caregiving and caregivers such as burden, coping, quality of life, social support, expressed emotions, and psychological morbidity. In general the research has looked at caregiving as a negative phenomenon, however, now it is increasingly recognised that caregiving is not only associated with negative consequences only, also experience subjective gains and satisfaction. This review focus on the conceptual issues, instruments available to assess the positive aspects of caregiving and the various correlates of positive aspects of caregiving reported in relation to schizophrenia. The positive aspect of caregiving has been variously measured as positive caregiving experience, caregiving satisfaction, caregiving gains and finding meaning through caregiving scale and positive aspects of caregiving experience. Studies suggests that caregivers of patients with schizophrenia and psychotic disorders experience caregiving gains (in the form of becoming more sensitive to persons with disabilities, clarity about their priorities in life and a greater sense of inner strength), experience good aspects of relationship with the patient, do have personal positive experiences. Some of the studies suggest that those who experience greater negative caregiving experience also do experience positive caregiving experience.

Relationship of quality of life with coping and burden in primary caregivers of patients with schizophrenia

Background: Very few studies have evaluated the quality of life (QOL) of caregivers of schizophrenia patients. The aim of this paper is to study the QOL, including the spirituality, religiousness and personal beliefs (SRPB) facets, of primary caregivers of patients with schizophrenia using the WHOQOL-BREF and WHOQOL-SRPB scales. Additionally an attempt was made to study the relationship between QOL with coping and burden in caregivers. Method: One hundred primary caregivers of patients with schizophrenia completed the WHOQOL-BREF and WHOQOL-SRPB scales. They were also assessed on the Family Burden Interview Schedule and Coping Checklist. Results: There were no significant associations of clinical variables and perceived burden with any of the WHOQOL-BREF domains and various WHOQOL-SRPB facets. There was a significant positive correlation between WHOQOL-BREF and various facets of WHOQOL-SRPB. There was a significant negative correlation between coercion as a coping strategy and the spiritual strength facet of WHOQOL-SRPB. Seeking social support as a coping strategy had a negative correlation with all domains of WHOQOL-BREF, whereas avoidance and use of problem-focused coping had no correlation with any of the domains of WHOQOL-BREF. Collusion as a coping skill had a negative correlation with the domains of physical health, social relationships and environment and the total WHOQOL-BREF score. Coercion as a coping strategy had a negative correlation with the general health and environment domains of WHOQOL-BREF. Conclusions: Findings of the present study suggest that there is a positive correlation between WHOQOL-BREF domains and WHOQOL-SRPB facets, which indicates that SRPB forms an integral component of the concept of QOL. Further, the QOL of caregivers is influenced by the coping skills used to deal with stress arising due to a patient’s illness.

Supernatural beliefs, aetiological models and help seeking behaviour in patients with schizophrenia

Background: Few studies have evaluated the supernatural beliefs of patients with schizophrenia. This study aimed to study the personal beliefs, aetiological models and help seeking behaviour of patients with schizophrenia using a self-rated questionnaire. Materials and Methods: Seventy three patients returned the completed supernatural Attitude questionnaire. Results: 62% of patients admitted that people in their community believed in sorcery and other magico-religious phenomena. One fourth to half of patients believed in ghosts/evil spirit (26%), spirit intrusion (28.8%) and sorcery (46.6%). Two-third patients believed that mental illness can occur either due to sorcery, ghosts/evil spirit, spirit intrusion, divine wrath, planetary/astrological influences, dissatisfied or evil spirits and bad deeds of the past. 40% of the subjects attributed mental disorders to more than one of these beliefs. About half of the patients (46.6%) believed that only performance of prayers was sufficient to improve their mental status. Few patients (9.6%) believed that magico-religious rituals were sufficient to improve their mental illness but about one-fourth (24.7%) admitted that during recent episode either they or their caregivers performed magico-religious rituals. Conclusion: Supernatural beliefs are common in patients with schizophrenia and many of them attribute the symptoms of mental disorders to these beliefs.

Delirium in elderly people: a study of a psychiatric liaison service in north India.

BACKGROUND Very few studies from India have studied the phenomenology of delirium. The aim of the present study was to study the phenomenology as measured using the Delirium Rating Scale-Revised-98 (DRS-R98), the associated etiologies and the outcome of delirium among the elderly participants seen by the consultation-liaison psychiatric service in India. In addition, an attempt was made to study the factor structure of symptoms using principal components analysis. METHODS The case notes of 109 elderly patients referred to psychiatry liaison services were reviewed. RESULTS The mean age of the sample was 73.35 years (SD: 7.44; range 65-95 years) and two-thirds of the sample had hospital emergent delirium. The mean DRS-R98 severity score was 18.77 and the DRS-R98 total score was 24.81. In 15 patients the DRS-R98 scores were in the subsyndromal range. Among the various symptoms present, most patients had sleep-wake cycle disturbance, disturbance in orientation, attention and short-term memory impairments, fluctuation of symptoms, temporal onset of symptoms and a physical disorder. Principal components analysis identified three factors which explained 43.5% of variance of symptomatology and it yielded a three-factor structure. Endocrine/metabolic disturbances were the commonest associated etiological category with delirium. The mean hospital stay after being referred to psychiatry referral services was 8.89 days, after which delirium improved in 58.7% of cases. The mortality rate during the inpatient stay was 16.5%. CONCLUSIONS Results suggest that the symptoms of delirium as assessed by DRS-R98 separate out into a three-factor structure. Delirium is commonly associated with metabolic endocrine disturbances and about one-sixth of the patients die during the short inpatient stay.

Symptom profile of delirium in children and adolescent--does it differ from adults and elderly?

OBJECTIVE The objective was to evaluate the phenomenology, etiology and outcome of delirium in children and adolescents (8-18 years of age) seen in a consultation-liaison psychiatric service in India. Additionally, an attempt was made to compare the phenomenology with adult and elderly patients with delirium. METHOD Thirty children and adolescents (age 8-18 years) diagnosed with delirium by the consultation-liaison psychiatry team were rated on the Delirium Rating Scale-Revised-98 (DRS-R-98) and compared with DRS-R-98 data on 120 adults and 109 elderly patients. RESULTS The commonly observed symptoms in children and adolescents with delirium were disturbance in attention, orientation, sleep-wake cycle disturbances, fluctuation of symptoms, disturbance of short-term memory and motor agitation. The least commonly seen symptoms included delusions and motor retardation. Compared to adults, children and adolescents had lower frequency of long-term memory and visuospatial disturbances. Compared to the elderly, children and adolescents had higher frequency of lability of affect. For severity of symptoms, compared to adults, the children and adolescents had lower severity of sleep-wake disturbances, abnormality of thought, motor agitation, orientation, attention, short-term memory, long-term memory and visuospatial abilities. When compared to elderly patients, children and adolescents had higher severity of lability of affect and lower severity of language disturbances, short-term memory and visuospatial abilities. CONCLUSIONS In general, phenomenology, of delirium in children and adolescents (age 8-18 years) is similar to that seen in adults and elderly patients.

Combined use of clozapine and ECT: a review

Objective This paper aims to review the available evidence for the use of clozapine and electroconvulsive therapy (ECT) in combination. Methodology Electronic searches were carried out to identify reports describing the combined use of clozapine and ECT. Results Forty reports including 208 patients were identified. The majority of reports were in the form of case reports and case series, with few retrospective and open-label studies. The majority of patients were aged between 18 and 65 years and diagnosed with schizophrenia or schizoaffective disorder. Most of the patients refractory to clozapine were started on ECT as an augmentation therapy; however, in some reports, both ECT and clozapine were started concurrently, and in few cases clozapine was started after ECT. In terms of effectiveness, 37.5–100% patients improved in short-term, and sustained long-term improvement (3 weeks to 24 months) was described in few studies. In terms of the side-effect profile, five patients each had delirium and tachycardia and only four patients were described to have prolonged seizures. Overall, the combination was considered effective and safe. Conclusion There is evidence for the effectiveness and safety of the clozapine–ECT combination and it should be used in patients with treatment-resistant schizophrenia who do not respond to clozapine.

Clinicians’ versus caregivers’ ratings of burden in patients with schizophrenia and bipolar disorder

Background: Only a few studies have evaluated the similarities and differences between clinicians’ and caregivers’ rating of burden of caring for a person with chronic mental illness. Aim: To compare clinician-rated and caregiver-rated burden in a population of patients with either schizophrenia or bipolar disorder, using two different scales to measure caregiver burden. Methodology: Caregivers of patients with schizophrenia (n = 65) or bipolar disorder (n = 57) completed the Hindi version of the Involvement Evaluation Questionnaire (Hindi-IEQ) by themselves. Clinicians rated the burden on the Family Burden Interview Schedule (FBI) based on semi-structured interview with the same caregivers. Results: Both total objective and subjective burden on the FBI (clinician ratings) demonstrated significant positive correlations with the total Hindi-IEQ (caregiver ratings) scores. Most areas of burden on the FBI correlated positively with the tension and the worrying-urging II subscales, as well as the total Hindi-IEQ scores. According to clinicians, a significantly higher percentage of caregivers of patients with schizophrenia were experiencing a moderate to severe degree of subjective burden; objective burden in this group was also significantly higher in the domains of effect on the mental health of caregivers. Contrastingly, caregivers of patients with bipolar disorder judged burden to be higher in this group than schizophrenia. Conclusions: There were many areas of agreement as well as some significant discrepancies between clinicians’ and caregivers’ assessment of burden in this population of patients. This suggests that a comprehensive evaluation of burden should include assessments by both clinicians and caregivers of patients.

Bupropion-induced hyponatremia

Although hyponatremia has been reported with the use of various antidepressants, the association of hyponatremia with bupropion has been limited to two case reports. In this case report, we present the case of a 75-year-old man who developed hyponatremia with the use of bupropion, which improved with stoppage of bupropion.

Dependence on supratherapeutic doses of modafinil: a case report.

To the Editor: Modafinil is a wakefulness-promoting agent used for the treatment of various sleep disorders like narcolepsy, obstructive sleep apnea, and shift work sleep disorder. Over the years it has gained popularity among prescribers due to its wakefulness-promoting efficacy and presumably lower abuse potential and has been used in the treatment of various fatigue syndromes, treatment-resistant depression, and attention-deficit/hyperactivity disorder.1,2 There is a controversy with regard to the abuse potential of modafinil, with some authors suggesting that it has low abuse potential and others suggesting that it has psychoactive and euphoric effects and leads to alterations in mood, perception, thinking, and feelings, all of which are seen with other central nervous system stimulants.1,2 The data with regard to its use in toxic doses are also limited.3–6 In our search, we could find no report of modafinil abuse or dependence in the literature. We report a case of a patient who used modafinil in supratherapeutic doses in a pattern that conformed with drug dependence. Case report. Mr A, a 53-year-old man diagnosed with schizoaffective disorder (DSM-IV criteria) for the last 33 years along with tobacco and benzodiazepine dependence syndrome (currently abstaining), presented with a history of excessive use of modafinil. Exploration of his history revealed that, 3 years prior, he consulted a psychiatrist for symptoms of fluctuating sadness of mood, lethargy, and sedation and was started on tablet modafinil, 50 mg/d, which was later increased to 100 mg/d along with tablet sertraline, 50–100 mg/d, and tablet amisulpride, 100 mg/d. The addition of modafinil made the patient feel fresh and active, and after 4–5 months modafinil was increased to 200 mg/d at the request of the patient. Over the next year, he started self-medicating with modafinil, taking 1 or 2 tablets (100–200 mg) in the afternoon or evening to overcome his boredom and fatigue, having felt a strong desire to take the same. On days when he would not take modafinil, he had strong craving and urge to do so, felt that something was missing in his life, and became irritable, felt weak, and had difficulty in concentrating on the work at hand. Over the next year, his intake of modafinil increased to 1,500–2,000 mg/d in order to experience the desired effect; he consumed 100–200 mg every 1–4 hours. Later, due to heavy doses of modafinil, he would have slurring of speech and poor attention and concentration. He continued to take modafinil against the advice of family and treating psychiatrists and would indulge in doctor shopping if he had difficulty in getting a prescription for modafinil or procuring it. With the available information, an additional diagnosis of modafinil dependence syndrome (per DSM-IV criteria for substance dependence disorder) was considered. He was counseled to taper off the dose of modafinil and was given benzodiazepines to manage the symptoms of withdrawal. The usual recommended dosage of modafinil is 200 mg/d. The previous reports of the use of modafinil in supratherapeutic or toxic doses did not describe continuous intake of the higher doses over the period.3–6 In the case reported here, the patient took 1,500–2,000 mg of modafinil per day for about 1 year. The intake of modafinil followed the typical pattern of drug dependence, which indicates its abuse potential. To conclude, our case suggests that modafinil has abuse potential and hence it should be prescribed cautiously and clinicians should be aware of its abuse potential. There is a need for further systematic studies to evaluate its abuse and dependence potential.