Sourav Khanra

Inpatient suicide in a psychiatric hospital: A nested case–control study

Objective: Risk factors for inpatient suicide are different from those in the general population. We examined sociodemographic and clinical variables of patients who committed suicide as an inpatient in a psychiatric hospital in India. Methods: Matched retrospective nested case–control design was adopted. Ten patients who died by suicide as inpatients between 2000 and 2013 were included, along with fifty controls, matched with respect to age, sex, diagnosis, and period of admission. Results: Suicide completers were mostly unskilled in occupation (P = 0.03), had a history of past suicide attempts (P < 0.001), shorter duration of hospital stay (P = 0.001), poorer improvement on psychopathology (P = 0.02), and were having more suicidal ideation (P = 0.02). Significantly more completers were receiving antidepressants (P = 0.04). Conclusion: This study adds to the existing sparse literature on inpatient suicides from Asia. Strength of the study was close matching between case and controls and blindedness. Limitations were retrospective design, and variations in prescription behavior and treatment decisions.

Inpatient suicide in a psychiatric hospital: fourteen years' observation

Inpatient suicide is an important issue all over the world. Patients admitted to psychiatric hospitals have increased rates of suicide in comparison to the rate in general population (Appleby et al., 2006; Hunt et al., 2007). The risk factors for suicide among inpatients are not essentially the same as the risk factors for suicide in other population groups (Powell et al., 2000). In comparison to the abundant information on inpatient suicide in Western countries, there is a paucity of data on inpatient suicide in Asia. Thus, the goal of the present study was to describe the sociodemographic and clinical factors for completed in-patient suicide and to compare those with matched living controls. This is a retrospective 1:1 matched case-control study which was undertaken at Central Institute of Psychiatry, Ranchi, India. This study pertains to 10 suicide cases that occurred at Central Institute of psychiatry, Ranchi, Jharkhand, India between the years from 2000 to 2013. For this study, each suicide case was matched with a living control based on the following criteria (in descending order of importance): (1) sex; (2) diagnoses; (3) age; and (4) admission period, from the inpatient population of the institute. Thus, a living control group consisting of 10 patients was selected. After obtaining ethical permission, data were extracted from medical case notes by one researcher and recorded. To ensure blindedness as to the case-control status of the case notes, the senior researcher obtained the medical case notes medical records section. The records were copied and to minimize information bias and to maintain blindness, information regarding the period after the censoring date (the date of death of the case) was also removed from the control’s record. Method of chart review was followed for data collection. Data were analyzed using Statistical Package of Social Sciences (SPSS) 20th version for Windows. Table 1 summarizes sociodemographic and clinical variables of patients of two groups. In parallel with other studies on inpatient suicides, schizophrenia and affective disorders were the most common diagnoses in our study (Cassells et al., 2005; Dong et al., 2005; Neuner et al., 2008; Bowers et al., 2010). In the present study a trend toward significance was observed in terms of family type and religion in line with earlier studies (Bansal et al., 2011; Ramdurg et al., 2011). All suicide completers belonged to Hindu religion whereas in control group 30% belonged to Islamic religion. In Hinduism, life is seen as a cycle and reincarnation is seen as part of this cycle. Thus, attitudes to suicide in Hinduism are more liberal and less

Does withdrawal seizure occur in opioid dependence syndrome? A case series

PROSOPAGNOSIA IS A neuropsychological syndrome characterized by difficulty in recognizing human faces or facial expressions, without elemental visuospatial deficits. Individuals with this syndrome often feel distressed in everyday life. Cases of prosopagnosia caused by cerebrovascular events or neurodegenerative disease have been described. Here we describe a case of prosopagnosia, probably developmental in origin, in which the patient was referred to the outpatient psychiatric service. Developmental prosopagnosia is gradually becoming known mainly through the mass media or Internet, but patients are rarely referred to psychiatric services despite significant distress. The present patient gave informed consent to publish this letter. A 23-year-old Japanese man was refereed to the outpatient psychiatric service at Niigata University Hospital by a contact physician at his workplace. The patient was suspected of an autism spectrum disorder (ASD) because of his communication difficulty at work, although the physician did not find any evidence to support it at the initial interview. Physical examination, screening imaging, urine and blood tests showed no significant medical and neurological conditions. He was psychologically distressed but was not diagnosed as having any DSM-IV disorders. He described difficulty, however, in memorizing the faces of several colleagues and supervisors at his office in a telecom company even though he had been working with them for at least a few years. The difficulties had been present from his childhood to date, thus he managed to cope using various strategies to identity individuals: hairstyle, physical constitution, clothes, voice tone, characteristic speech and desk position in the office. The results of visual perception test for agnosia were as follows. The patient successfully answered all tests with regard to object recognition, primary visual function and recognition of symbols. Checking the center of lines was 6% to the left, showing no evidence of hemispatial neglect. In contrast, the errors in face recognition were significant as compared to the norm: famous face naming (100%), famous face pointing (69%) and perception of facial expression (17%). Additional deficits in unknown face discrimination (75%), unknown face matching (50%), perception of gender (75%) and perception of age (63%) suggested an apperceptive type of prosopagnosia. Individuals with developmental prosopagnosia rarely visit the mental health clinic unless they have comorbid psychiatric conditions. With increasing public attention on developmental disorders, the present patient was suspected of having ASD, which is also characterized by deficits in non-verbal communication used for social communication, including a total lack of facial expression and/or poor understanding of that. Although there is a superficial similarity between difficulty in interpersonal communication and some autistic features, as evidenced by the autism-spectrum quotient (31 points), the present patient suffered mainly from prosopagnosia, and his social–emotional reciprocity and ability to develop and maintain relationships was not impaired. Developmental prosopagnosia should be listed as a rare neuropsychiatric condition in the differential diagnosis of ASD.

Clinical correlates of enlarged cavum septum pellucidum in schizophrenia: A revisit through computed tomography

Like prevalence of abnormal cavum septum pellucidum in patients of schizophrenia remains controversial, its role in clinical outcome, duration of illness and effect on treatment remains less understood as well. Our study examined clinical correlates of enlarged cavum septum pellucidum in schizophrenia. A total of 139 patients diagnosed with schizophrenia during the year 2012 and 2013 were taken for the study. We compared them in respect to the presence and absence of enlarged cavum septum pellucidum. We found 16 patients with enlarged cavum septum pellucidum and were compared with those without enlarged cavum septum pellucidum for socio-demographic and clinical variables. We also correlated these clinical variables with dimension of cavum septum pellucidum. We found statistically significant increased current age and duration of illness in patients with enlarged cavum septum pellucidum. The implications of these findings are discussed with possible confounding effect of current age on neuroimaging. No meaningful correlation was found. No difference in clinical variables was found. Retrospective design and use of computed tomography were limitation of our study.

Off-label psychotropics use: Isn't it now an inevitable and a “norm” in psychiatry?

Sir, “Off-label use” refers to the use of a drug outside the terms of its marketing authorization. It includes prescribing for an unlicensed indication like in unapproved indication, age group, dosage, or in unapproved form of administration. In principle, though it may not be compliant to the ethics in clinical practice, reports of off-label use of psychotropics have been widespread across clinical diagnoses and age groups. Among all medications, psychotropics are one of the most commonly prescribed for off-label purpose. A few studies from the Indian subcontinent had found that off-label use of psychotropics was seen in a significant proportion of prescriptions (up to 42%) and off-label uses were most common for indications (48.9%) followed by for dose (37.2%). Apart from the ethical and biological concerns arising from the unexpected adverse effects, off-label use also has an economic impact. In the United States, off-label use of central nervous system drugs contributes to 25%–80% of a drug’s annual sales, and off-label indications for antidepressants, anticonvulsants, and antipsychotics are expanding each year. All these drew our attention to the reasons behind the off-label prescription of psychotropics.

Does opioid and ketamine “codependence” exist?

© 2017 Indian Journal of Social Psychiatry | Published by Wolters Kluwer Medknow Dear Sir, There are several case reports of ketamine dependence in the literature. Furthermore, recent research has shown the therapeutic use of ketamine beyond anesthesia in opioid-dependent patients for reducing perioperative pain[1] and to reduce opioid withdrawal symptoms.[2] A recent case report demonstrated successful use of opioid receptor antagonist naltrexone for ketamine dependence.[3] Taken together, these intuitively raise the possibility of pharmacodynamic proximity between opioid and ketamine beyond common risk factors. We here present a case of opioid and ketamine codependence in a health worker. Moreover, we raise the possibility that ketamine dependence might be in part determined by past opioid dependence in particular.

Mirtazapine Is Effective in Steroid Withdrawal Syndrome Related Depression: A Case Report

Steroid withdrawal syndrome (SWS) following steroid dependence is becoming a common clinical condition. It may be associated with body image disorder. Though selective serotonin reuptake inhibitors (SSRIs) are found to be effective SWS associated depression, data for this clinical condition is limited. We present a case of SWS associated with body image disorder which improved with mirtazapine. Mirtazapine might be better option than SSRIs in this subgroup of patients for its noradrenergic property and better gastrointestinal profile. More research should explore its efficacy in this clinical condition.

Datura and Psychiatry: A Short Reappraisal

Citation: Khanra S and Raja C. Datura and Psychiatry: A Short Reappraisal. J Drug Abuse. 2016, 2:1. The effect of Datura on mental health and subsequent use of it by general population is well known for decades. Whether as an involuntary or voluntary ingestion, robust literature exists indicating its potential to be used as a psychoactive substance. The genus Datura consists of several species with similar physical and psychological effects. They are D. stramonium (Gimson Weed), D. sauveolens (Angel’s Trumpet) [1]. Since antiquity, D. stramonium has been used for religious purposes throughout the world and also for witchcraft in medieval Europe. Sixty four major and minor tropane alkaloids have been found in D. stramonium. Among major ones are hyoscyamine and scopolamine. Other typical minor alkaloids found are tigloidin, aposcopolamine, apoatropine, hyoscyamine N-oxide, scopolamine N-oxide 17-20, 6a-ditigloyloxytropane and 7-hydroxyhyoscyamine [2, 3].

Prevalence and Characteristics of Cavum Septum Pellucidum in Schizophrenia: A 16 Slice Computed Tomography Study

Objective: Several significant midline abnormalities including cavum septum pellucidum (CSP) have been reported in schizophrenia. However, not all studies were able to replicate similar findings. Furthermore, very few of them were conducted with large samples. Methods: CSP was identified and graded with 16 slice computed tomography (CT) machine in 138 patients of schizophrenia and 64 controls. Results: We found 21.0% of patients in schizophrenia group had abnormal CSP compared to only 9.4% in control group (P = 0.047). Grade III was most frequent type (19.6%) in schizophrenia group. Conclusions: Our study adds to the existing literature suggesting abnormal CSP may reflect neurodevelopmental process in schizophrenia. The strength of our study was larger sample size. Limitations were use of CT, male predominance in schizophrenia group, the inclusion of nonpsychiatric patients in control group.

An Unusual Case of Delirium after Restarting Clozapine

Clozapine is a gold standard medication and drug of choice in refractory schizophrenia. Among many of its fatal side effects, delirium is less reported and inconsistently recognized by clinicians. We here present a case of delirium which emerged during retreatment with clozapine in a patient of paranoid schizophrenia. A patient diagnosed with paranoid schizophrenia, was restarted on clozapine after he left medications and became symptomatic. He was delirious on 22nd day after clozapine was restarted. Clozapine was stopped and the patient was managed with standard treatment for delirium. After one week interval, clozapine was restarted. Delirium was not noted till 6 weeks of his hospital stay. Clozapine induced central anticholinergic toxicity or clozapine induced seizure might cause delirium in index case. Limited literature exist delirium with clozapine. Clinicians must have high index of suspicion to detect delirium during clozapine therapy. More researches should focus to explore the association between delirium and clozapine.