Sukanto Sarkar

A cross-sectional study of prevalence and implications of depression and anxiety in psoriasis

Background: Physical and mental comorbidity is common and has significant implications for overall health outcomes. Psoriasis, a psychocutaneous disorder, is a classic example of mental-physical comorbidity. Aims: In view of the impact of socio-cultural influences on mind-body interactions and the paucity of Indian research pertaining to psychiatric morbidity in psoriatic patients, this study was undertaken to measure the prevalence of anxiety and depression in patients with psoriasis, and to correlate these with severity of psoriasis and quality of life. Materials and Methods: This cross-sectional study was conducted on 90 consecutive patients of psoriasis, over a period of 12 months, in a tertiary care centre. The Psoriasis Area and Severity Index was used to assess severity of psoriasis. PHQ-9, GAD-7 and the Perceived Stress Scale were used to screen for depression, anxiety and perceived stress respectively. The WHOQOL-BREF was used to determine the quality of life. Statistics Analysis: All analysis was performed using Microsoft Excel software and Statistical Package for Social Sciences. Results: A total of 71 (78.9%) subjects had depression and 69 (76.7%) had anxiety. Fifty one patients had significant stress. A significant positive correlation was established between psoriasis variables (severity and duration of psoriasis) and psychological variables (depression, anxiety and stress). Severity of psoriasis had a significant negative correlation with social relationships and environmental domains of WHOQOL. Quality of life was significantly worse in patients with psoriasis with comorbid anxiety/depression. Conclusion: Patients with psoriasis have a clinically significant prevalence of depression, anxiety and perceived stress. This study highlights the complex relationship between psoriasis, psychiatric comorbidity and quality of life and the need to simultaneously consider dermatological and psychological factors.

Repetitive transcranial magnetic stimulation in psychiatry

Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive and relatively painless tool that has been used to study various cognitive functions as well as to understand the brain–behavior relationship in normal individuals as well as in those with various neuropsychiatric disorders. It has also been used as a therapeutic tool in various neuropsychiatric disorders because of its ability to specifically modulate distinct brain areas. Studies have shown that repeated stimulation at low frequency produces long-lasting inhibition, which is called as long-term depression, whereas repeated high-frequency stimulation can produce excitation through long-term potentiation. This paper reviews the current status of rTMS as an investigative and therapeutic modality in various neuropsychiatric disorders. It has been used to study the cortical and subcortical functions, neural plasticity and brain mapping in normal individuals and in various neuropsychiatric disorders. rTMS has been most promising in the treatment of depression, with an overall milder adverse effect profile compared with electroconvulsive therapy. In other neuropsychiatric disorders such as schizophrenia, mania, epilepsy and substance abuse, it has been found to be useful, although further studies are required to establish therapeutic efficacy. It appears to be ineffective in the treatment of obsessive compulsive disorder. There is a paucity of studies of efficacy and safety of rTMS in pediatric and geriatric population. Although it appears safe, further research is required to optimize its efficacy and reduce the side-effects. Magnetic seizure therapy, which involves producing seizures akin to electroconvulsive therapy, appears to be of comparable efficacy in the treatment of depression with less cognitive adverse effects.

A novel approach in the detoxification of intravenous buprenorphine dependence.

Background: Opioid dependence remains a significant problem in India, and of late intravenous (IV) buprenorphine use has increased in India, especially in combination with antihistamines and benzodiazepines. Its usage has many serious consequences in the form of needle-transmitted hepatitis and HIV, which is showing an increasing trend. Buprenorphine is a partial agonist at μ-opioid receptors. In tablet form (and rarely as IV), it is widely used in the treatment of opioid detoxification. We assessed the safety and efficacy of transdermal patch of buprenorphine with week long duration of action in the treatment of detoxification of IV buprenorphine dependence in view of its many advantages. Materials and Methods: Six consecutive patients with International Classification of Diseases diagnosis of Opioid Dependence Syndrome (IV buprenorphine) were given a buprenorphine patch for treatment of withdrawal symptoms after receiving consent. Severity of opioid dependence was assessed by using Severity of Opioid Dependence Questionnaire on the day of presentation. Subjective and objective rating for opioid withdrawal was done by subjective opiate withdrawal scale (SOWS) and objective opiate withdrawal scale (OOWS) prepatch and postpatch 3rd and 7th day. Buprenorphine side effect checklist was applied on a daily basis. Results: The patients had a mean age of 30 years, of whom 83.3% are males. All were educated and 50% were currently employed. All of them had additional comorbid substance use as well as a comorbid psychiatric diagnosis. Each of them received a patch of varying dosage. The patch dose used initially was based on clinical considerations alone and was fairly adequate in controlling acute withdrawal symptoms. There is a significant improvement in SOWS and OOWS while comparing the baseline (prepatch) with 3rd and 7th day (postpatch) (P ≤ 0.05). None of the patients reported any side effect with the patch. Conclusion: This study shows that transdermal buprenorphine is safe, useful, and clinically effective, and a 7-day application may provide an alternative means of detoxification. However, the result of the study needs to be replicated in a larger sample in a clinical setting, and a control group receiving a conventional mode of treatment needs to be included.

Add-on effect of Brahmi in the management of schizophrenia.

Brahmi(Bacopa monnieri), an Ayurvedic herb has primarily been used to enhance cognitive ability, memory and learning skills. We present a case study of schizophrenia in which add-on Brahmi extracts 500 mg/day for a period of one month resulted in reduction in psychopathology without any treatment-emergent adverse effect. Although preliminary, our case study suggests therapeutic efficacy of add-on Brahmi in schizophrenia, thus opening up a new dimension of its role in alternative medicines.

Stevens-Johnson syndrome progressing to toxic epidermal necrolysis with haloperidol and carbamazepine combination

Carbamazepine and other anticonvulsants are commoner cause of severe adverse cutaneous drug reactions such as erythema multiforme, toxic epidermal necrolysis (TEN), and Stevens–Johnson syndrome (SJS). We report a case of SJS rapidly progressing to TEN with a combination of haloperidol and carbamazepine in a patient with bipolar affective disorder. The pathophysiological mechanism underlying this reaction is discussed.

Effect of Olanzapine on Clinical and Polysomnography Profiles in Patients with Schizophrenia

Acute and short-term administration of olanzapine has a favorable effect on sleep in schizophrenia patients. This study aimed to clarify the effect of olanzapine on polysomnographic profiles of schizophrenia patients during the acute phase of illness after controlling for previous drug exposure. Twenty-five drug-naïve or drug-free schizophrenia patients were assessed at baseline and after six weeks of olanzapine treatment on Brief Psychiatric Rating Scale (BPRS), Positive and Negative Syndrome Scale (PANSS), and Udvalg for Kliniske Undersogelser (UKU) side-effect rating scale and a whole-night polysomnography; fifteen patients completed the study. There was a significant reduction in all psychopathological variables with maximum reduction in PANSS total, BPRS total, and PANSS positive scores. A significant increase in total sleep time (TST), sleep efficiency (SE), nonrapid eye movement (NREM) stage 1 duration, stage 3 duration, stage 4 duration, and stage 4 percentage of TST, number of rapid eye movement (REM) periods, REM duration, and REM percentage of TST was observed. REM latency at baseline inversely predicted the reduction in BPRS total and PANSS total and positive scores. In summary, short-term treatment with olanzapine produced significant improvement in clinical and polysomnography profiles of patients with schizophrenia with shorter REM latency predicting a good clinical response.

Higher Impulsivity and HIV-Risk Taking Behaviour in Males with Alcohol Dependence Compared to Bipolar Mania: A Pilot Study

To study the association of impulsivity, high-risk behaviours and incidence of HIV infection in patients with alcohol dependence and bipolar mania. This was a cross-sectional hospital-based pilot study and the sample consisted of male patients divided into three groups: 25 patients with alcohol dependence and 25 with bipolar mania as per ICD-10 Diagnostic Criteria for Research and 25 normal controls. Severity of Alcohol Dependence Questionnaire (SADQ) and Young Mania Rating Scale (YMRS) were administered on alcohol dependent and bipolar patients, respectively. All three groups were rated on Barrett’s Impulsivity Scale (BIS) and HIV Risk-taking Behaviour Scale (HRBS). None of the patients tested positive for either HIV 1 or 2. BIS motor impulsivity, BIS total score and HRBS total score were significantly higher in alcohol dependent patients as compared to bipolar mania patients. In the Alcohol dependent group, BIS score significantly correlated with education years, age of onset of alcohol use and SADQ, whereas, HRBS total score significantly correlated with SADQ scores. In the bipolar mania group, BIS significantly correlated with YMRS, and total number of episodes, whereas, there was no significant correlation of HRBS total score with any clinical variable. The findings of this pilot study underscore the link between alcohol use disorder and the impulsive behaviours that can lead to HIV infection, and highlight that those risks are higher for individuals with alcohol dependency than for individuals with bipolar disorder.

Multimodal hallucinations in a visually impaired elderly female: Is it a variant of Charles Bonnet syndrome?

Charles Bonnet Syndrome (CBS) is a common cause of visual hallucinations seen in elderly people with visual impairment. Well-formed visual hallucinations in clear consciousness with preserved insight are commonly reported in literature. We report a case of CBS having multisensory hallucinations. An elderly patient with visual impairment fulfilling the criteria of CBS presents with various modalities of hallucinations viz. visual, auditory and tactile hallucinations improved completely with low dose of antipsychotics. Atypical features are common in CBS and thus often make it difficult to diagnose this condition.

Risk factors for the development of delirium in alcohol dependence syndrome: Clinical and neurobiological implications

Introduction: Alcohol withdrawal delirium (AWD) or delirium tremens (DT) is associated with severe complications and high mortality. Prospectively identifying patients with increased risk of developing DT would have important preventive and therapeutic implications. Thus, the present study aimed to identify clinical risk factors predicting the development of DT. Materials and Methods: The study was a cross-sectional quasi-experimental one with equivalent control group, conducted at a tertiary hospital from August 2014 to May 2015. Forty adult male inpatients, diagnosed with DT, were compared with forty age- and sex-matched inpatients in alcohol withdrawal state without delirium. Assessments were done using confusion assessment method, Clinical Institute Withdrawal Assessment of Alcohol Scale, and Mini–Mental Status Examination. For group comparisons, Pearsons Chi-square test and independent sample t-test were used; logistic regression was applied to identify predictors followed by receiver operating characteristic curve analysis. Results: Heavy drinking (P = 0.005; odds ratio [OR]: 1.17, confidence interval [CI]: 1.05–1.31), continuous pattern of drinking (P = 0.027; OR: 4.67, CI: 1.19–18.33), past history of delirium (P = 0.009; OR: 552.8, CI: 4.88–625.7), alcohol-induced psychosis (P = 0.002; OR: 74.6, CI: 4.68–1190), and presence of cognitive deficits (P = 0.044; OR: 12.5, CI: 1.07–147.3) emerged as strong predictors of AWD. Conclusion: The risk factors found can be easily evaluated in a clinical setting for physicians to readily identify patients at risk for developing DT and plan intensive therapies for them. At a neurobiological level, patients with preexisting brain neurotransmitter disturbances are at greater risk for developing DT.