Yasir Hassan Rather

Duloxetine in treatment of refractory chronic tennis elbow: Two case reports

IntroductionTennis elbow is a common musculoskeletal disorder; management options include physiotherapeutic, medical, surgical, and other forms of intervention. Some patients remain symptomatic despite best efforts. We present two patients who did not respond to medical and surgical treatments, and whose symptoms were relieved with duloxetine. This is the first report on the use of duloxetine to treat tennis elbow.Case presentationTwo mentally healthy young Asian women aged 32 and 27 years, each with tennis elbow of about 18 months duration continued to suffer pain despite treatment with analgesics, local steroid injections, physiotherapy, cryotherapy, ultrasound, and surgical release, among other interventions. Both showed substantial improvement within 4 to 6 weeks of receiving monotherapy with duloxetine 60 mg/day. Both were pain-free with continued treatment at a 6-month follow-up.ConclusionDuloxetine may be a useful treatment option in patients with chronic tennis elbow, even those who have failed conventional medical, physiotherapeutic, surgical, and other forms of management.

Effects of switching from olanzapine to aripiprazole on the metabolic profiles of patients with schizophrenia and metabolic syndrome: a double-blind, randomized, open-label study

Background Patients with schizophrenia suffer high rates of metabolic derangements on some antipsychotic medications that predispose them to cardiovascular diseases. Keeping this fact in mind, we planned this open-label study to see the effect on various metabolic parameters after switching stable schizophrenia subjects, who had developed metabolic syndrome on olanzapine, to aripiprazole. Methods Sixty-two patients with schizophrenia who were stable on olanzapine and were fulfilling modified National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP-III) criteria for the presence of metabolic syndrome were enrolled on the study. Patients were randomly assigned either to switch to aripiprazole or to stay on olanzapine, on a 1:1 basis. Cross-tapering over a period of 1 month was done while switching patients to aripiprazole. Laboratory assessment for metabolic parameters was done at baseline, 8 weeks, and 24 weeks after enrollment; efficacy assessment was done using the Positive and Negative Syndrome Scale (PANSS) at baseline and 24 weeks, the Clinical Global Impressions severity subscale (CGI-S) at baseline, and the Clinical Global Impressions improvement subscale (CGI-I) at 24 weeks. Results All parameters of metabolic syndrome (waist circumference, blood pressure, triglyceride level, fasting blood glucose, and high-density lipoprotein cholesterol) kept deteriorating in the stay group, compared with a continuous improvement in the switch group over time. At the end of the study, 26 patients (100%) from the stay group and 15 patients (42.8%) from switch group met the modified NCEP ATP-III criteria for presence of metabolic syndrome (P<0.001). There were no statistically significant differences between groups in psychopathology changes as measured by the PANSS total score and CGI-I scores. Conclusion Clinically stable patients with schizophrenia who are taking olanzapine and who have evidence of metabolic syndrome can be successfully switched to aripiprazole, with improvement in various parameters of metabolic syndrome and without any significant change in efficacy measures.

The Association between Adult Mental Health Problems andChildhood Trauma: A Retrospective Community Based Study fromKashmir

Background: The association between retrospectively reported childhood adverse experiences and psychiatric morbidity in adulthood is documented in several community surveys and clinical samples. But the long term outcome studies from South Asian countries are almost non-existent even though the frequency and the extent of childhood traumatic experiences in this part of the world are considerably high. Methods: It was a retrospective community-based study done in various areas of Kashmir Valley (Jammu and Kashmir, India) which were selected randomly. Those fitting criteria for the study were further evaluated using MINI International Neuropsychiatric Interview which is a well-validated short structured Diagnostic and Statistical Manual ? Text Revision (DSM IVTR) based diagnostic interview. Results: 18.2% (572 of 3137) of total sample population had suffered a traumatic event between age 5 to 17 years (M>F). A considerable number (42.6%) of the traumatized cases had a DSM IV diagnosis in the long-term follow-up (F>M), out of whom 47.4% had a significant morbidity at >5 yrs and 38.7% at >10 yrs (p<0.007). Post- traumatic Stress Disorder (PTSD) & Major Depressive Disorder (MDD) formed the majority of diagnosis (24.4% & 15.3% respectively).Both PTSD and MDD were seen 10 years after trauma and beyond. Conclusion: Post trauma morbidity is significantly chronic and long-lasting. MDD and PTSD form the majority of the morbidities present. Both MDD and PTSD may develop very late after the traumatic event. People with trauma may need long-term psychiatric screening, care and help.

Are health care systems insensitive to needs of suicidal patients in times of conflict? The Kashmir experience

Suicide and attempted suicide is an important health issue and the number of people who die of suicide exceeds that of conflicts. Kashmir has been suffering from a low intensity war since last 20 years in which thousands have been killed or injured. There has been phenomenal increase in cases of psychological disorders along with suicide and and suicide attempters. Suicide in a conflict zone is viewed with indifference due to focus on the physical part of trauma. Difficulties faced by the suicidal patient and his attendants are seldom highlighted. 1408 patients who reported to emergency room for suicide attempt from 2000 to 2008 were taken for the study. All the patients underwent the hospital protocol for poisoning management. Patients were subjected to detailed psychiatric evaluation and questions were specifically asked about the difficulties encountered during management. Most of the cases were females with 92.11% belonging to the Muslim religion. 76.20% cases were from a rural background. 32.5% had been referred because of the lack of specific antidotes. Forty-three percent required arrangement of transportation by their own family members. Fifty-seven percent had been stopped for security checks along the way. Seventy-three percent felt that the attitude of the staff hostile. Twenty-three percent of patients had to share a bed. Almost all patients were questioned by security agencies within the hospital. More than 68% patient reported hostility amongst their neighbors. Suicidal poisoning is a significant health problem in Kashmir and management of these cases is fraught with difficulties across the spectrum of health care. Educating the doctors at primary care about first aid, improvement in community services followed by long term resolution of the conflict would go some way in alleviating the difficulties faced by a suicidal patient and his family in a conflict zone.

Psychosocial risk factors and clinical profile associated with attempted suicide in young adult and adolescent patients in conflict zone-Kashmir

Background: Several efforts have been made in the past to study psychosocial risk factors and clinical profile associated with attempted suicide, but only few have addressed the issues of youth in a conflict area Kashmir. Aims: To study psychosocial risk factors and clinical profile associated with attempted suicide in young adult and adolescent patients in conflict zone-Kashmir. Material and Method: It was a hospital-based study in which 200 young adults and adolescent patients who were admitted following unsuccessful suicide attempts to the emergency and referred to Department of Psychiatry, Govt. Medical College, Srinagar, Jammu and Kashmir, India. Selected patients were subjected to Mini International Neuropsychiatric interview (MINI) and International Personality Disorder Examination (IPDE) for evaluation of symptoms and diagnosis. Subjects of age less than 15 years and more than 34 years have been excluded. Results: Majority of the suicide attempters 65% were < 24 years of age with adolescent over represented in the sample (Mean = 21.24 ± 4.66), females were 58%, low socioeconomic status (86%), oral agents (most common method) was used by 84%, 64% had expressed suicidal or death wishes before act and 72% made an impulsive attempt. Eighty-two percent of the suicide attempters were suffering from some psychiatric illness at that time. Out of which 40% had mood disorder with predominance of major depressive disorder, 15% had personality disorders, and 9% had posttraumatic stress disorder. Conclusion: Knowledge of clinical phenomenology may assist in identification and early intervention of youth who are at high risk. Overall, findings indicate a strong and immediate relationship between suicide attempt and psychiatry morbidity.

Genetic Approaches-Investigating Psychiatry

Rational and logical answers have been the basis of all the sciences. Many questions in the understanding of psychiatric psychopathology and symptoms are rationally understood and a lot more are revealing due to the development of modern investigative techniques. Genetic factors are under active and extensive research for better understanding of psychiatric illnesses. And these approaches have undergone a paradigm shift in the recent times. From basic molecular genetics to the pharmacogenetics, a lot many tools are in the kitty of the investigators. The study of theses genetic factors, development of genetic techniques, vis-a-vis the interaction with other factors is an active area of interest.

Role of Amisulpride Augmentation in Treatment Resistant Major Depressive Disorder: An Open Label Study from North India

Background: About 60% patients with major depressive disorder do not achieve a sufficient response to standard antidepressant therapy and about two-thirds of patients receiving initial antidepressant medication do not achieve remission. Various strategies are being employed to counter this problem. Studies have shown that atypical antipsychotics, augmented to antidepressants for major depressive disorder patients, produced higher response and remission rates. The data regarding the augmentation of antidepressants with amisulpride is very scarce as compared to other atypical antipsychotics. Objective: To evaluate whether augmentation with amisulpride is effective and tolerable in patients of major depressive disorder (MDD) who did not respond significantly to adequate trials of standard antidepressants. Methodology and Results: In our open label 6 weeks study, amisulpride was added to baseline antidepressant medication of treatment resistant patients of major depressive disorder. A total of 112 patients enrolled in the study with a mean age of 39.37 years out of which 83% completed the study. Over a period of 6 weeks, 71% patient showed response and 40% patient remitted (p<0.001) with a mean amisulpride dose of 135.31 mg/day. The mean decrease in HAM-D17 score was 16.17 points. There was more than 2 point change in mean CGI-S score from base line to endpoint. Common adverse effects were akathisia (4.64%), sleep disturbances (10.71%), restlessness (5.36%) and extrapyramydial side-effects (4.64%). Conclusion: Augmentation of antidepressant drugs with low doses of amisulpride seems to be effective and tolerable in patients of major depressive disorder who do not respond adequately to standard antidepressant medications.

ADHD presenting as recurrent epistaxis: a case report

Epistaxis is an important otorhinolaryngological emergency, which usually has an apparent etiology, frequently local trauma in children. Here we present a case report wherein the epistaxis was recalcitrant, and proved to have a psychiatric disorder as an underlying basis. The child was diagnosed with Attention Deficit/Hyperactivity Disorder, hyperactive type, which led to trauma to nasal mucosa due to frequent and uncontrolled nose picking. Treatment with atomoxetine controlled the patients symptoms and led to a remission of epistaxis.

P02-180 - Complicated grief in families of enforced disappearances

Objective To determine incidence of complicated grief in the families of enforced disappearance in the conflict torn Kashmir valley. Complicated GRIEF is a recently identified symptom complex marked by continued separation distress and bereavement related accompanying traumatic distress. Methods A total of 100 family members who were recruited from a workshop conducted by department of psychiatry and MEDICENS SAN FRONTIERS with family members of enforced disappearances were screened by psychiatrists. Results COMPLICATED GREIF was very prevalent, 79% screened positive for complicated grief, PTSD was present in 30% of screened, 41% met criteria for major depressive disorder, 38% neither met criteria for major depressive disord: er nor PTSD, even though everybody who met criteria for PTSD had major depressive disorder as comorbidity. Conclusion COMPLICATED GRIEF is a important diagnosis in this subgroup of population and results into significant distress and dysfunction and hence warrants attention.