Swapnajeet Sahoo

Relationship of depression with cognitive insight and socio-occupational outcome in patients with schizophrenia

Aim: To evaluate the prevalence of depression using different measures in patients with schizophrenia and to study the relationship of depression in schizophrenia with cognitive insight and clinical insight, disability and socio-occupational functioning. Methods: A total of 136 patients with schizophrenia were evaluated for depression, cognitive insight and socio-occupational functioning. Results: Of the 136 patients included in the study, one-fourth (N = 34; 25%) were found to have depression as per the Mini International Neuropsychiatric Interview (MINI). The prevalence of depression as assessed by Calgary Depression Scale for Schizophrenia (CDSS), Hamilton depression rating scale (HDRS) and Depressive Subscale of Positive and Negative Syndrome Scale (PANSS-D) was 23.5%, 19.9% and 91.9%, respectively. Among the different scales, CDSS has highest concordance with clinician’s diagnosis. Sensitivity, specificity, positive predictive value and negative predictive value for CDSS was also higher than that noted for HDRS and PANSS-D. When those with and without depression as per clinician’s diagnosis were compared, those with depression were found to have significantly higher scores on Positive and Negative Syndrome Scale (PANSS) positive and general psychopathology subscales, PANSS total score, participation restriction as assessed by P-scale and had lower level of functioning as assessed by Global Assessment of Functioning (GAF). No significant difference was noted on negative symptom subscale of PANSS, clinical insight as assessed on G-12 item of PANSS, disability as assessed by Indian Disability Evaluation and Assessment Scale (IDEAS) and socio-occupational functioning as assessed by Social and Occupational Functioning Assessment Scale (SOFS). In terms of cognitive insight, those with depression had significantly higher score for both the subscales, that is, self-reflective and self-certainty subscales as well as the mean composite index score. Conclusion: Our results suggest that one-fourth of patients with schizophrenia have depression, compared to HDRS and PANSS-D, CDSS has highest concordance with clinician’s diagnosis of depression and presence of depression is related to cognitive insight.

Cross-cultural and Psychological issues in Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is one of the most common functional gastrointestinal disorders encountered by gastroenterologists worldwide. Of all the etiological factors that had been postulated to explain the pathophysiology of IBS, cultural and psychological factors are unique and difficult to understand. Culture plays an important role in coloring the presentation of IBS, and many a times, it has a significant role in several treatment aspects too. Psychological aspects like personality profiles, family relationships, societal myths, and abuse in any form are equally important in the management perspectives of IBS. In this brief review, we had tried to specifically focus on these aspects in IBS and have explained the evidences in favor of these factors. Knowledge about various cross‐cultural aspects and psychological factors in patients with IBS is essential for taking an appropriate history and for undertaking a holistic approach for the management of the same. A collaborative team effort by psychiatrists and gastroenterologists could help in reducing the burden of this difficult to treat functional bowel disorder.

Clozapine induced akathisia: A case report and review of the evidence

Clozapine is a second-generation antipsychotic medication, which is mostly used in patients with treatment resistant schizophrenia. It is considered to be associated with lower incidence of extrapyramidal side-effects. Akathisia is considered to be a rare side-effect of clozapine. In this report, we describe a patient who developed akathisia while receiving clozapine and review the literature. Existing literature suggests that except for few initial reports, data suggests that clozapine is in general associated with lower incidence of akathisia compared to first generation antipsychotics. Data comparing clozapine with other atypical antipsychotics is equivocal.

Association of internalized stigma and insight in patients with schizophrenia

ABSTRACT Aim: To evaluate the association of internalized stigma with insight (clinical and cognitive insight) among patients with schizophrenia. Methods: 136 patients with schizophrenia were assessed on the Internalised Stigma of Mental Illness Scale (ISMIS), Positive and Negative Syndrome Scale (PANSS) and Beck Cognitive Insight Scale (BCIS). Clinical insight was assessed by PANSS-G12 item. Results: 38.2% of patients experienced internalized stigma. On the basis of mean scores of various domains of ISMIS, about two-fifths (41.9%) of participants reported stereotype endorsement, followed by discrimination experience (38.2%), stigma resistance (36.8%), social withdrawal (30.1%) and alienation (30.1%). Insight as assessed by PANSS-G12 item did not correlate significantly with stigma. Higher cognitive insight in the form of composite score (R-C index) and higher cognitive self-reflectiveness was associated with a higher level of stigma in all the domains except for stigma resistance. Higher stigma was associated with negative symptoms. Conclusion: The present study suggests that internalized stigma is highly prevalent among patients with schizophrenia. Clinical insight doesn’t have any association with stigma, but cognitive insight in the form of self-reflectiveness is associated with higher stigma.

Scales for assessment of depression in schizophrenia: Factor analysis of calgary depression rating scale and hamilton depression rating scale

This study aimed to evaluate the factor structure of Calgary depression rating scale (CDSS) and Hamilton Depression Rating Scale (HDRS) among patients with schizophrenia in acute and remission phase of illness by using exploratory factor analysis. For this, 267 patients with schizophrenia were assessed on CDSS and HDRS. Exploratory factor analysis of CDSS yielded 2 factor models for the whole sample, patients in clinical remission and patients not in clinical remission phase of schizophrenia. Factor analysis of HDRS yielded 3 factor models; however, there was significant difference in the factor structure between those in clinical remission and those not in clinical remission phase of schizophrenia. CDSS total score did not correlate with PANSS positive and negative subscale scores. In contrast, HDRS total score correlated positively with PANSS positive subscale score, PANSS negative subscale score and PANSS general psychopathology subscale score. To conclude, present study suggests while CDSS items separate out into 2 factors, which are stable across different stages of illness, whereas HDRS factor structure appears to be less stable across different stages of illness. Correlation analysis suggests that rating on HDRS may be affected by positive and negative symptoms of schizophrenia, whereas CDSS do not correlate with positive and negative symptoms of schizophrenia.

Schizophrenia with comorbid idiopathic parkinson's disease: A difficult clinical management scenario

Comorbidity of idiopathic Parkinsons disease (IPD) and schizophrenia is an uncommon and rare scenario, which often poses a difficult and challenging situation for management. Both the disorders have completely opposite pathophysiology and treatment of one disorder with available pharmacological agents can pose a threat to the other disorder. The situation becomes graver and risk of adverse side effects increases when an individual presents at a later age with both these disorders along with compromised physical and mental health. Of all the available psychopharmacological agents, clozapine has been found to be quite helpful for the management of psychosis without deterioration of existing movement problems of Parkinsons disease. In this case report, we present the case of a 60-year-old female with long-standing paranoid schizophrenia for the last 30 years, who later developed IPD and discuss the various management issues encountered during her treatment.

Treatment compliance and noncompliance in psychosis: Methodological issues

Indian Journal of Psychiatry Volume 59, Issue 3, July-September 2017 401 2. Farmer KC. Methods for measuring and monitoring medication regimen adherence in clinical trials and clinical practice. Clin Ther 1999;21:1074-90. 3. Mullard A. Do you want chips with that? Nat Rev Drug Discov 2015;14:735-7. 4. Morisky DE, Green LW, Levine DM. Concurrent and predictive validity of a self-reported measure of medication adherence. Med Care 1986;24:67-74. 5. Fialko L, Garety PA, Kuipers E, Dunn G, Bebbington PE, Fowler D, et al. A large-scale validation study of the medication adherence rating scale (MARS). Schizophr Res 2008;100:53‐9. Ideally, a study on compliance should assess compliance using more than one method, and operationalization of compliance on continuous rather than categorical measures should be preferred.

Valproate-induced hyperammonemic encephalopathy in an elderly patient with bipolar disorder

Hyperammonemia is a rare side effect of valproate, diagnosis of which requires a high level of clinical suspicion. We describe a case of 57-year-old man, suffering from bipolar affective disorder, who had multiple physical comorbidities (diabetes mellitus, benign prostatic hyperplasia, hydroureteronephrosis, and chronic kidney disease) and was on sodium valproate 1500 mg/day along with risperidone 6 mg/day, who developed delirium when the dose of sodium valproate was increased from 1500 mg/day to 2000 mg/day. In view of use of high doses of valproate, hyperammonemia was suspected, and on investigations, patient was found to have high ammonia levels (159 μmol/l). He was managed conservatively with stoppage of valproate and syrup lactulose. To conclude this case depicts that use of high doses of valproate can lead to hyperammonemia, especially among those with chronic medical illnesses.

Thrombocytopenia Associated with Olanzapine: A Case Report and Review of Literature

There is limited literature on olanzapine-associated thrombocytopenia. In this report, we present a case of a 32-year-old female, suffering from persistent delusional disorder who had thrombocytopenia (46,000/mm3) with the use of olanzapine 25 mg/day, 6 weeks after starting medication. Blood film did not reveal any evidence of any dysplastic cells, disturbance in the count of other cell lines, and autoimmune workup including antinuclear antibodies and anti-neutrophil cytoplasmic antibodies were found to be negative. Given no other etiology, olanzapine was gradually tapered, and platelet counts were monitored. Reduction in the dose of olanzapine led to an improvement in platelet counts which reached the normal range after complete stoppage of olanzapine. In view of continued psychotic symptoms, she was started on clozapine and which was gradually increased to 200 mg/day with biweekly monitoring of total platelet counts before each increment in the dose of clozapine. Thrombocytopenia did not recur with use of clozapine. With clozapine, her psychosis improved by nearly 60%. A review of literature revealed only eight case reports supporting the association of olanzapine and thrombocytopenia.

Auditory P300 event related potentials in acute and transient psychosis—Comparison with schizophrenia

BACKGROUND Limited biological research data are available on acute and transient psychotic disorder (ATPD) vis-à-vis schizophrenia. P300 event related potentials (ERP) have been extensively studied as an important neurophysiological parameter in schizophrenia. However, no P300 ERP studies comparing the two disorders are available. We compared auditory P300 ERP in patients remitted from ATPD with schizophrenia in remission and biologically unrelated healthy controls. METHODS In this case-control study design, 25 subjects remitted from ATPD were age-/gender-matched with healthy controls and patients with schizophrenia in remission. Clinical assessment and auditory P300 ERP (amplitude and latencies at central and parietal sites, reaction time) were recorded. The ERP parameters were compared across the three groups. RESULTS All three groups showed significant differences in P300 amplitudes and latencies at central and parietal sites. Schizophrenia group differed significantly (p<0.001) from the ATPD group in all the P300 parameters. The ATPD group was found to have lower Pz latency (p<0.05) and lower mean reaction time (p<0.001) as compared to healthy controls. CONCLUSION The results suggest that P300 could easily distinguish between ATPD and schizophrenia in remission, thus neurophysiologically differentiating the two disorders. Lower P300 latency and reaction time, which indicate hyper-arousability, distinguished ATPD from normal controls, with implications for a better understanding of ATPD.