Nivedhitha Selvakumar

A qualitative analysis of explanatory models in medically unexplained physical symptoms presenting to a tertiary health care psychiatric facility in South India.

Background: Knowledge about subjective perceptions and explanatory models has the potential to inform clinical evaluation and lead to development of patient-friendly treatment models in medically unexplained physical symptoms (MUPS). Aim: To collect qualitative data about explanatory models in MUPS. Methods: A cross-sectional observational study was done among patients with MUPS presenting over a 2-year period to a specialty psychosomatic clinic. The Short Explanatory Model of Illness interview was used to gather qualitative data about explanatory models which were subsequently recoded using standard manuals. Results: A total of 123 subjects were evaluated. The nature of symptoms was most commonly reported as ‘non-specific’ (n = 102, 82.9%) but of moderate to severe intensity (n = 87, 73.8%). Getting cured or showing improvement was the most common expectation from treatment (n = 58, 47.9%). Moderate to severe impact of symptoms was reported on work output (n = 100, 84%), emotional life (n = 85, 71.4%) and physical mobility (n = 59, 49.1%). A considerable proportion was either dissatisfied (n = 61, 50%) or frankly unhappy (n = 38, 31.4%) with treatment received. Conclusion: There is a need to re-calibrate the clinical approach to people with MUPS to enhance treatment satisfaction. Our findings could assist in evolving culturally sensitive conceptualizations of illness and in developing patient-centred models for therapy in MUPS patients.

A Cross-sectional Analysis of Patterns and Predictors of Medication Adherence in Bipolar Disorder: Single Center Experience from South India

Objective Our objective was to determine patterns and predictors of medication adherence in bipolar disorder. Methods Between August 2015 and December 2016, we recruited 160 patients with a diagnosis of bipolar disorder as per International Classification of Diseases-10: Clinical Descriptions and Diagnostic Guidelines. The diagnosis was further confirmed by using the MINI International Neuropsychiatric Inventory. All of them were currently in remission (confirmed by standard measures) and on stable dosing of medication for at least a year. Medication adherence was assessed using Tamil validated version of Morisky Medication Adherence Scale. Patients were dichotomized into low adherence (<6) and high adherence (≥6) groups and compared on various socio-demographic and clinical variables. Results Majority of the sample (n=97, 60.6%) demonstrated low adherence to treatment regimen. Being employed and having spent greater number of days in hospital were predictive of higher medication adherence (odds ratio [OR] 2.78, 95% confidence interval [CI] 1.019–7.585; and OR 1.02, 95% CI 1.003–1.037, respectively). Fewer number of lifetime depressive episodes and positive drug attitudes demonstrated trend level positive association with high medication adherence. Conclusion Non-adherence to prescribed medications is a common problem in bipolar disorder. Interventions targeting vocation, medication focused psychoeducation and promotion of positive drug attitudes are likely to enhance medication adherence in this group.

Therapeutic effects of mobile-based text message reminders for medication adherence in bipolar I disorder: Are they maintained after intervention cessation?

Mobile phone short messaging service (SMS) reminders may be a low-cost method for promoting medication adherence. Our objective was to determine whether text SMS reminders improve medication adherence in patients with bipolar I disorder even after discontinuation of the intervention. Participants were stable adult bipolar I disorder outpatients on maintenance medication who were randomized to receive treatment as usual (TAU; n = 70) or TAU plus twice-weekly medication reminders by SMS (n = 62) for 3 months. Rater-blinded assessments of medication adherence, treatment attitudes, and quality of life (QoL) were obtained at baseline, at the 3-month intervention endpoint, and at a 3-month post-intervention follow up during which both groups received TAU. Intent-to-treat analyses were conducted on the full randomized sample. The clinical trial protocol was registered with the Clinical Trials Registry of India (CTRI) (CTRI/2016/07/007101). The SMS intervention improved medication adherence and attitudes towards medication at the end of the treatment phase; these benefits were maintained for medication adherence but not for attitudes towards medication at the end of the follow-up phase. The SMS intervention did not improve QoL outcomes. These findings indicate that biweekly SMS reminders improve medication adherence and the benefits persist for at least 3 months after the SMS reminders are discontinued. The SMS reminders do not affect attitudes towards treatment or QoL.

Neuroleptic malignant syndrome (or malignant extrapyramidal autonomic syndrome): Time to revisit diagnostic criteria and terminology?

Neuroleptic malignant syndrome (NMS) is an uncommon but potentially life-threatening adverse reaction to medications having dopamine receptor–blocking properties, also referred to as ‘neuroleptics’. Although most reported cases of NMS implicate antipsychotics as the offending agent, there have also been many reports about its occurrence with agents traditionally considered to be non-neuroleptics (Berman, 2011). In this scenario, we feel that continued retention of the term NMS may not only be scientifically inaccurate but also detrimental to clinical practice as clinicians may lower their guard against this serious complication when initiating non-neuroleptic agents. A new term with less implications for presumed etiology of such a condition may have better clinical utility. Furthermore, standard diagnostic criteria mention elevated temperature (>39°C) as a core diagnostic criteria of NMS while also recognizing the heterogeneous nature of its presentation (American Psychiatric Association [APA], 2013). However, there have been prior reports highlighting atypical presentations of NMS, wherein the patients remained afebrile throughout the course of this reaction (Menon et al., 2016). Such presentations not only challenge the theoretical underpinnings of NMS but also question the wisdom of having separate core and additional criteria. Although a couple of aberrant observations may not necessarily invalidate diagnostic criteria for NMS, or for that matter, any medical condition, the serious and potentially life-threatening nature of NMS demand that criteria be carefully recalibrated so as to minimize medical errors. There is a need to re-conceptualize NMS as a spectrum of clinical manifestations with no presentation being a sine qua non for diagnosing the syndrome. Considering these issues, we propose an alternate term ‘Malignant Extrapyramidal Autonomic Syndrome’ (MEAS), which may better capture the underlying myriad manifestations of this condition while remaining noncommittal about the nature of the offending agent. The latter will encourage clinicians to remain watchful for this adverse reaction when initiating a wide variety of agents and not just antipsychotics. This will, doubtless, facilitate early and accurate diagnosis of the condition which is of paramount importance to avoid potentially lethal sequelae including death. We hope that our observations trigger a debate on the terminology and criteria of NMS so as to make its diagnosis faster and easier thereby facilitating prompt intervention to hasten its resolution.

The forgotten entity of cycloid psychosis

A classic case of Cycloid Psychosis descriptive of “Anxiety Elation” subtype as described by Leonhard with polymorphic presentation of anxiety, elation, perplexity, delusions and hallucinations is presented. We have attempted to highlight the nosological limitations as well as the treatment implications considering the lack of guidelines for management in such cases. We have further discussed the need for validating the entity of Cycloid Psychosis highlighting the differences shared with Schizophrenia and Bipolar Disorder. This case illustrates the need for reporting on Cycloid Psychosis especially from Indian setting where it is found to be common yet under reported.

Black hairy tongue (Lingua villosa nigra) in a young male precipitated by Lithium

Black hairy tongue (BHT), or eponymously “Lingua villosa nigra”, is an acquired, benign and reversible condition characterised by hypertrophy, elongation and defective desquamation of the filiform papillae typically seen on the dorsum of the tongue. (Lawoyin and Brown, 2008; Poulopoulos et al., 2008). Though a benign condition, its appearance may be alarming to the patient and family. In this report, we describe the development of black hairy tongue in a young male precipitated by lithium. A 20 year old male with no significant past history of psychiatric or medical illness was admitted to our ward with a diagnosis of mania with psychotic symptoms for control of acute disturbance. His baseline Young Mania Rating Scale (YMRS) score was 32. Physical examination and blood work-up was within normal limits. The patient was managed with a combination of Table Chlorpromazine 800 mg and Table Lorazepam 12 mg/day. Table Trihexyphenidyl 6 mg/day was added to control treatment emergent extrapyramidal symptoms. Following inadequate response to this combination for two weeks, Table Lithium was started at 600 mg and increased to 1050 mg/day to obtain desired serum levels (0.9 meq/L). Two weeks later, there was remarkable improvement in manic symptoms and the YMRS score had dropped to seven. At this point, the family members apprehensively complained of a blackish discoloration of the tongue. Examination revealed a black plaque measuring 2.5 cm x 1.5 cm