Shivanand Kattimani

Clinical management of alcohol withdrawal: A systematic review.

Alcohol withdrawal is commonly encountered in general hospital settings. It forms a major part of referrals received by a consultation-liaison psychiatrist. This article aims to review the evidence base for appropriate clinical management of the alcohol withdrawal syndrome. We searched Pubmed for articles published in English on pharmacological management of alcohol withdrawal in humans with no limit on the date of publication. Articles not relevant to clinical management were excluded based on the titles and abstract available. Full-text articles were obtained from this list and the cross-references. There were four meta-analyses, 9 systematic reviews, 26 review articles and other type of publications like textbooks. Alcohol withdrawal syndrome is a clinical diagnosis. It may vary in severity. Complicated alcohol withdrawal presents with hallucinations, seizures or delirium tremens. Benzodiazepines have the best evidence base in the treatment of alcohol withdrawal, followed by anticonvulsants. Clinical institutes withdrawal assessment-alcohol revised is useful with pitfalls in patients with medical comorbidities. Evidence favors an approach of symptom-monitored loading for severe withdrawals where an initial dose is guided by risk factors for complicated withdrawals and further dosing may be guided by withdrawal severity. Supportive care and use of vitamins is also discussed.

Newer antipsychotics and upcoming molecules for schizophrenia.

BackgroundThe management of schizophrenia has seen significant strides over the last few decades, due to the increasing availability of a number of antipsychotics. Yet, the diminished efficacy in relation to the negative and cognitive symptoms of schizophrenia, and the disturbing adverse reactions associated with the current antipsychotics, reflect the need for better molecules targeting unexplored pathways.PurposeTo review the salient features of the recently approved antipsychotics; namely, iloperidone, asenapine, lurasidone and blonanserin.MethodsWe discuss the advantages, limitations and place in modern pharmacotherapy of each of these drugs. In addition, we briefly highlight the new targets that are being explored.ResultsPromising strategies include modulation of the glutamatergic and GABAergic pathways, as well as cholinergic systems.ConclusionsAlthough regulatory bodies have approved only a handful of antipsychotics in recent years, the wide spectrum of targets that are being explored could eventually bring out antipsychotics with improved efficacy and acceptability, as well as the potential to revolutionize psychiatric practice.

Stressful life events, hopelessness, and coping strategies among impulsive suicide attempters

Background: Suicides are among the most important causes of death in the economically productive population. Characteristics of impulsive and nonimpulsive suicide attempters may differ which would have a bearing on planning preventive measures. Aims: This study aimed to characterize the clinical and psychological profile of impulsive and nonimpulsive suicide attempters. Settings and Design: This retrospective comprehensive chart-based study was conducted at a tertiary care hospital in South India. Methods: The study utilized records of patients over a period of 3 years. An attempt was considered impulsive if the time between suicidal idea and the attempt was <30 min. Stressful life events were assessed using presumptive stressful life events scale; hopelessness was evaluated using Beck Hopelessness Scale (BHS) and coping was measured using Coping Strategies Inventory Short Form. Statistical Analysis Used: Impulsive and nonimpulsive suicide attempters were compared using appropriate inferential statistical tests. Results: Of 316 patients, 151 were classified as having an impulsive suicidal attempt (47.8% of the sample). The impulsive and nonimpulsive suicide attempters did not differ on demographic characteristics. Use of natural plant products was more common in impulsive attempters (27.2% vs. 12.7%), while physical methods like hanging was less common (0.7% vs. 7.3%). Those with an impulsive attempt were more likely to have a recent contact with a health professional (24.5% vs. 4.5%). Impulsive suicide attempters had higher scores on BHS (Mann–Whitney U = 7680.5, P < 0.001), and had recollected greater number of stressors. Conclusion: Impulsive suicide attempters differ from nonimpulsive suicide attempters in clinical features like methods of attempt, presence of hopelessness, and stressors.

Plasma homocysteine levels in depression and schizophrenia in South Indian Tamilian population

Context: Hyperhomocysteinemia has been associated with psychiatric diseases in non-Indian populations. Objectives: We aimed to determine if total plasma Homocysteine (Hcys) is associated with schizophrenia or depression in South Indian Tamil patients and if so, to correlate their severity and phenomenology to Hcys levels. Settings and Design: 40 patients each with schizophrenia and depression and 40 healthy controls were recruited from the psychiatry department of a quaternary referral centre. Association between Hcys and psychiatric disorders was determined using a Case- control design. Hcys levels were correlated with age, gender and severity and duration of the disease by appropriate statistical methods using SPSS17. Materials and Methods: Schizophrenia and depression were defined using ICD10 DCR version. Severity of depression was assessed by Hamilton Depression Rating Scale and that of schizophrenia using Positive and Negative Schizophrenia scales (PANSS). Hcys levels were determined using automated chemiluminiscence immunoassay (74-76). Statistical Analysis: Differences between the mean values of plasma homocysteine levels among schizophrenia, depression and control groups were compared using analysis of variants. The association between the severity and duration of schizophrenia and depression and the plasma homocysteine levels were determine using Pearson correlation. Conclusions: In Tamilian population, schizophrenia and depression are associated with total plasma Hcys levels which correlated with the duration and severity of psychosis.

Relationship between matrix metalloproteinase-9 and oxidative stress in drug-free male schizophrenia: a case control study.

Abstract Background: Deregulation of synaptic plasticity and oxidative stress are reported to play a crucial role in the pathogenesis of schizophrenia. Matrix metalloproteinase-9 (MMP-9) is an extracellular protease involved in regulation of synaptic plasticity. Malondialdehyde (MDA) is a marker of lipid peroxidation which is elevated in schizophrenia. Earlier studies have reported polymorphism of MMP-9 and its association with schizophrenia. The present study was designed to assess the serum levels of MMP-9, MDA and total antioxidant status (TAS) and their association in schizophrenia. Methods: A total of 40 cases and 40 controls were included in the study. Serum MMP-9, MDA and TAS were estimated in all the subjects. Disease severity was assessed using Positive and Negative Syndrome Scale (PANSS). Results: MMP-9 and MDA were significantly increased and TAS were significantly reduced in schizophrenia cases compared to controls. MMP-9 was positively correlated with MDA (r=0.353, p=0.025) and negatively correlated with TAS (r=−0.461, p=0.003). TAS was significantly correlated with total (r=0.322, p=0.043) and negative symptom scores (r=0.336, p=0.034). Higher MMP-9 levels were associated with previous exposure to antipsychotics (p=0.032). Conclusions: MMP-9 and oxidative stress were increased and correlate well with each other in schizophrenia cases. Though total oxidant status showed positive association with disease severity, MMP-9 and MDA were not associated with the severity of the disease.

Treating children with attention-deficit/hyperactivity disorder and comorbid epilepsy

Attention-deficit/hyperactivity disorder (ADHD) is one of common neurodevelopmental disorder often comorbid with epilepsy. There are no existing guidelines on how to manage these two conditions when they are comorbid. To identify relationship between epilepsy and ADHD and to know role of antiepileptics and safety of stimulant like methylphenidate in such conditions from existing literature, we searched articles published in clinical journals available online between 1990-2010, with these key words in medline:children, epilepsy, seizure, comorbid, ADHD, treatment. Relevant abstracts were further selected for their focus on current topic. Cross references were extracted. Finally relevant articles that included original research articles, reviews and abstracts of non-english literature were used. Children with epilepsy may manifest with symptoms of ADHD. Children with ADHD may develop epilepsy. Some antiepileptics like phenobarbitone, gabapentin, topiramate may not be helpful in controlling behavioral symptoms of ADHD. Stimulants are the main stay of pharmacotherapy for ADHD but there is risk of decreasing seizure threshold in children with comorbid epilepsy especially when their epilepsy is not well controlled. Existing evidence is not in favor of screening children with ADHD for EEG abnormality before starting stimulant therapy.

Long term course of bipolar I disorder in India: using retrospective life chart method.

BACKGROUND There are grounds to believe that the course of bipolar disorder may be different in tropical countries such as India when compared to temperate nations. There is a dearth of literature about the course of bipolar I disorder from India. METHODS This study was conducted in a multispecialty teaching hospital in southern India. Patients with a DSM-IV TR diagnosis of bipolar I disorder, confirmed using SCID-I, with a minimum duration of illness of 3 years were assessed. Information was gathered on demographic and clinical variables, and the life course of episodes was charted using the National Institute of Mental Health - Life Chart Methodology Clinician Retrospective Chart (NIMH-LCM-CRC). RESULTS A total of 150 patients with bipolar disorder were included. The mean age at onset of illness was 24.8 (± 8.2) years. Mania was the first episode in a majority (85%) of the cases, and was the most frequent episode in the course of the illness, followed by depression. Patients spent an average of 11.1% of the illness duration in a mood episode, most commonly a manic episode. The median duration of manic or depressive episode was 2 months. Median time to recurrence after the first episode was 21 months (inter-quartile range of 10-60 months), and was shorter for women than men. LIMITATIONS The hospital based sample from a particular region limits generalizability. Recall bias may be present in this retrospective information based study. Medical illness, personality disorders, other Axis I psychiatric disorders (apart from substance use disorder) and influence of adherence to treatment on the course of the disorder were not assessed systematically. CONCLUSIONS Bipolar I disorder among Indian patients has a course characterized by predominantly manic episodes, which is in line with previous reports from tropical countries and substantially different from that of temperate regions.

Association between prolactin and thyroid hormones with severity of psychopathology and suicide risk in drug free male schizophrenia.

BACKGROUND Hormonal deregulation is associated with suicidal risk in various psychiatric disorders. Thyroid hormones and prolactin play a role in the pathophysiology of schizophrenia. The present study aimed to analyze thyroid hormones and prolactin levels in patients with schizophrenia, and to explore its association with disease severity and suicide risk. METHODS Thirty-eight cases and 38 controls were included in the study. Serum thyroid hormones and prolactin were estimated in all the subjects. Disease severity was assessed using the Positive and Negative Syndrome Scale and suicidal ideations were assessed using the Columbia Suicide Severity Rating Scale. RESULTS Serum prolactin (p=0.004) and free T4 (p=0.029) were significantly elevated in the schizophrenia group as compared to controls. Serum prolactin was significantly associated with higher negative symptom scores (r=0.418, p=0.008), but not positive symptoms or general psychopathology of schizophrenia. Thyroid hormones were not associated with disease severity scores. Suicidal ideas were more common in schizophrenia patients with higher free T4 (p=0.011). CONCLUSION Prolactin and free T4 were increased in patients with schizophrenia as compared to controls. Suicidal ideation was associated with increased free T4, but not prolactin levels.

Ethical Issues Relating to Faith Healing Practices in South Asia: A Medical Perspective

Despite growing access to modern medicine, faith healing practices still continue to be prevalent in South Asia. Faith healing practices include a wide range of activities like performing elaborate rituals, recommending amulets, suggestion for wearing specific rings, branding with rods, chaining in temples, exorcism of jinn and ghosts, animal sacrifices and others. In this paper, faith healing practices are evaluated on the principles of medical ethics using specific examples. The principle of autonomy, beneficence, non-maleficence and justice are explored. The authors draw inference that while some practices may be unacceptable and should be curtailed, the overall institution of faith healing might be useful for some people.

Association of neurotrophins, inflammation and stress with suicide risk in young adults

BACKGROUND Stress, anxiety and various neurobiological changes have been postulated to be associated with increased suicidal ideation. Hence, this study was undertaken to evaluate the serum concentrations of neurotrophins, inflammatory markers and stress concentrations as predictors of suicidal risk among young adults. METHODS This cross-sectional study was conducted in a tertiary care referral center in South India from March 2014 to February 2015. We recruited 42 suicide attempters and 42 age- and gender-matched healthy controls. The serum concentrations of neurotrophins (BDNF and NT-3), inflammatory markers (hs-CRP and IL-6) were assessed. Stress severity was assessed by Presumptive Stressful Life Events scale (PSLE) and Daily Hassles and Uplifts Scale-revised (DHUS-R). Psychological distress and Suicide risk was assessed using Hospital Anxiety and Depression Scale (HADS) and Mini International Neuropsychiatric Interview (MINI) respectively. RESULTS Suicide attempters tend to show significantly lower concentrations of neurotrophins and significantly higher concentrations of inflammatory markers. We observed significant negative correlation of neurotrophins with inflammatory markers, stress, and suicide risk. In multivariate linear regression model, hs-CRP [adjusted β=0.333, p<0.0001], PSLE [adjusted β=0.133, p=0.029], DHUS-R [adjusted β=0.159, p=0.018] emerged as independent predictors of suicide risk (R(2)=0.76). CONCLUSION Our results suggest that inflammation and stress scores have a moderate association with suicidal ideation.