Prabhat Chand

Substance use and addiction research in India

Substance use patterns are notorious for their ability to change over time. Both licit and illicit substance use cause serious public health problems and evidence for the same is now available in our country. National level prevalence has been calculated for many substances of abuse, but regional variations are quite evident. Rapid assessment surveys have facilitated the understanding of changing patterns of use. Substance use among women and children are increasing causes of concern. Preliminary neurobiological research has focused on identifying individuals at high risk for alcohol dependence. Clinical research in the area has focused primarily on alcohol and substance related comorbidity. There is disappointingly little research on pharmacological and psychosocial interventions. Course and outcome studies emphasize the need for better follow-up in this group. While lack of a comprehensive policy has been repeatedly highlighted and various suggestions made to address the range of problems caused by substance use, much remains to be done on the ground to prevent and address these problems. It is anticipated that substance related research publications in the Indian Journal of Psychiatry will increase following the journal having acquired an ‘indexed’ status.

Treatment of dual diagnosis disorders.

Purpose of review Treatment of dual diagnosis [co-occurrence of a substance use disorder (SUD) in patients with mental illness] poses several challenges for mental health professionals. This article seeks to review the recent advances in dual diagnosis treatment with respect to pharmacotherapy and psychosocial approaches. Recent findings Atypical antipsychotics are commonly used for comorbid schizophrenia and SUD. Whereas there is no difference between risperidone and olanzapine, clozapine appears to have a distinct advantage in reducing psychotic symptoms as well as substance abuse (including smoking). There is emerging evidence that quetiapine is beneficial in dually diagnosed patients, particularly using alcohol, cocaine and amphetamine. A combination of naltrexone and sertraline was found to be effective in patients with depressive disorder and alcohol dependence. Effectiveness of atomoxetine is yet to be established in patients with comorbid adult attention-deficit/hyperactivity disorder with respect to decrease in substance abuse. Integrated intervention is the choice of treatment for patients with dual diagnosis. Summary In spite of the high association between substance use and psychiatric disorders, there is a surprising paucity of studies related to treatment and outcome. A few well-designed studies have been recently published and more studies of this nature are required in order to address the challenges posed in the treatment of dual disorders.

Dissociative and conversion disorders: defining boundaries

Purpose of review Although dissociative disorders have been described and diagnosed for some time, their aetiology, pathogenesis, phenomenology and management continues to arouse debate. It is only in recent times that researchers have made some progress by integrating trauma related theories with more contemporary cognitive theories and neurobiology. Recent findings Dissociation as a phenomenon is reported to occur in a variety of disorders. This widespread occurrence has contributed to a better understanding of dissociation. An expansion of this concept may have contributed to the loss of its original significance. Recent studies in the field of dissociation that pertain to its aetiology, pathophysiology, neurobiology and management are critically reviewed. Summary Dissociative disorder is conceptually a difficult disorder to study. Apart from exposure to trauma, certain primary personality attributes may contribute to the propensity to develop dissociative disorder. Recent advances in functional neuroimaging facilitated by enhanced knowledge in the neural representation of body state have helped to improve our understanding of dissociation. There is confusion over the use of various terms such as sexual abuse and physical abuse in explaining causality. Current classificatory systems have not been found suitable when applied across cultures. In spite of all of these limitations, there has been recent progress toward a better understanding of dissociative disorders.

The implications of medication development in the treatment of substance use disorders in developing countries.

Purpose of review To enquire as to how applicable are the latest developments in pharmacotherapy of substance use disorders (SUDs) to patients in developing countries. We review the latest literature regarding the magnitude of the problem in developing countries. We then present a review of recent developments in pharmacotherapy of SUDs, especially from developing countries. Finally, we discuss the barriers that prevent patients in developing countries from benefiting from these developments. Recent findings The problem of SUDs is increasing in developing countries and there is a severe shortage of manpower to manage it. Disulfiram, naltrexone and acamprosate are useful in treating alcohol dependence, and likewise methadone and buprenorphine in treating opioid dependence. Strategies of matching patients to medications and combining the medications have shown promise. There is a parallel benefit of reduction in the risk of HIV spread among injecting drug users. However, many barriers prevent an average patient with SUD from benefiting from these developments. Conclusion Medication treatment can improve the outcome of SUDs. Research in this field is catching up in developing countries. However, due to issues of availability, affordability, manpower and governmental policies, a large number of patients in these countries are unable to benefit from recent developments. Urgent efforts are required to fill this gap between research and practice.

Mania as a presenting symptom of Wilson's disease.

Objective: Wilsons disease commonly presents with neurological or hepatic manifestations. When it presents with only psychiatric symptoms, or with extrapyramidal symptoms secondary to neuroleptic exposure, the diagnosis of underlying Wilsons disease may be missed. Methods: An 18-year-old boy presented to the psychiatric clinic with a manic syndrome and high propensity for extrapyramidal symptoms to neuroleptic. Initial examination revealed splenomegaly and pancytopenia. Subsequent detection of Kayser–Fleischer ring and typical biochemical findings confirmed the diagnosis of Wilsons disease. Results: While the psychiatric symptoms came under control with lithium carbonate, extrapyramidal symptoms continue to persist even after neuroleptic withdrawal. Pancytopenia thought to be due to hypersplenism persists, and patient has developed features of liver cirrhosis. Treatment with zinc and folic acid has been started, and the patient is under evaluation for treatment with penicillamine. Conclusion: The psychiatrist needs to recognize that Wilsons disease can uncommonly present with isolated psychiatric symptoms, including mania. Early and severe extrapyramidal symptoms secondary to neuroleptic exposure in an adolescent age group warrants a detailed evaluation to rule out underlying neuropsychiatric conditions.

Substance use disorders among treatment naïve first-episode psychosis patients.

OBJECTIVES To examine the prevalence of substance use among treatment naïve patients with first episode psychosis presenting to a psychiatry outpatient clinic in India. METHODS The study sample consisted of 139 first episode treatment naïve patients with psychosis from in and around Bangalore, a city in South India. Self as well as informant-reported data on type, use and duration of substance use as well as the severity of psychotic symptoms were collected using structured instruments. Urine toxicology screen was also conducted for six common drugs of abuse. Breath alcohol analysis was performed in all patients. RESULTS Acute and transient psychosis was the most common diagnosis (42.4%). Overall, 20% of the population reported current substance use disorder (excluding nicotine). Current alcohol dependence was diagnosed among 17.3%, whereas cannabis dependence in 3.6%. Life time as well as current use of cannabis was less than 6%. While one patient reported inhalant abuse none reported use of amphetamine or opioids. There was very high concordance between reported drug use and urine toxicology screen. CONCLUSION The use of illicit drugs is substantially less among first episode drug naïve patients with psychosis in an Indian urban clinical setting compared to rates reported from developed countries like North America, Canada and UK.

Correlates of baclofen effectiveness in alcohol dependence

Alcohol dependence is a global concern. Baclofen has shown promise as an anti-craving agent but its efficiency remains to be settled. We reviewed 549 male cases diagnosed with alcohol dependence who received Acamprosate (201) or Baclofen (348). ‘Time to first drink’ was compared between two groups and multiple regression analysis was done in baclofen group to identify correlates of effectiveness. There was a significant difference in outcome measure between Baclofen (M = 4.44, SD = 3.75) and Acamprosate group (M = 3.73, SD = 2.19); t (547) = 2.45, P = 0.01. Initial regression analysis with six predictor variables (average daily alcohol units, current age, age at onset of dependence, family history, duration of dependence and dose of baclofen in mg/day) showed significant correlation of outcome variable with only two predictor variables — dose of baclofen and average daily intake. Using the hierarchical method it was found that ‘dose of baclofen’ and ‘average alcohol intake’ explain a significant amount of variance in ‘time to first drink’. [F (1, 345) = 182.8, P < 0.001, R2 = 0.52, R2adjusted = 0.51]. This information can be used to select patients in long term longitudinal studies and may explain variable results seen in clinical trials of baclofen done earlier.

High doses of Baclofen as suicide attempt in patients with alcohol use disorders - A serious concern

Baclofen is increasingly being used as an off label anti-craving agent in alcohol use disorders in various parts of the world. The lack of proper recommendations regarding the dosage has important implications for safety in clinical management. In this context, we report two patients who were started with Baclofen as an anti-craving agent, and later developed serious complications following acute self inflicted overdose. We also highlight the important mechanisms of such complications and precautions that needs to be exerted while prescribing.

Problem drinking among male inpatients in a rural general hospital

The study was carried out in a 550-bed teaching hospital in Kolar, a rural district of southern India. All consecutive admissions of adult male patients admitted during the study period were evaluated within 4 days of their admission to the respective wards. During the study period of two months, there were 311 new admissions of which 252 (81.02%) patients consented to participate in the study. The history of alcohol and tobacco use was collected from every respondent. The current drinkers i.e. drinking during the past one year were screened with AUDIT (Alcohol Use Disorders Identifi cation Test)(1). Persons scoring 8 or more on the AUDIT were considered as “problem drinker”(1).Those who has scored positive on the fi rst item were interviewed in detail to assess severity of use and dependence as per DSM IV(4).

Benzodiazepine and “Z-Drug” Dependence: Data From a Tertiary Care Center

Objective To examine the clinical characteristics and course of benzodiazepine and �Z-drug� dependence in patients presenting to a tertiary deaddiction center in southern India. Methods Case files of 950 inpatients admitted between January 2007 and January 2014 who reported benzodiazepine or Z-drug use were reviewed. Patients (n = 170) with an ICD-10 diagnosis of mental and behavioral disorders due to the use of sedatives or hypnotics-dependence syndrome currently using substance (F13.24) were included in this study. Results Alprazolam (n = 86, 50.6%), nitrazepam (n = 40, 23.5%), and zolpidem (n = 19, 11.2%) were the most commonly reported drugs of abuse. Alcohol dependence was present in 37 subjects (21.8%) and opioid dependence in 41 subjects (24.1%). Comorbid psychiatric illness was diagnosed in 67 patients (39.0%). Only 28 patients (16.5%) had sedative dependence with no other substance use disorder. Conclusion High comorbidity occurs in this group of patients. Outcome varies significantly (P < .05) between sedative-dependent only and multiple-substance�dependent patients. High attrition should be addressed through follow-up and tracking mechanisms.