The world population is becoming older now. The boom of the elderly population comes from public health efforts to improve living conditions and prevent disease, and from improved medical interventions. People more than 65-year-old who are representing 12.9% of the population now is expected to grow to be 19% of the population by 2030. Very few numbers of diseases will have such socioeconomic burden on society in the newer world. Although Alzheimer's disease (AD) has been studied very well recently, still its exact etiopathogenesis is unknown. Currently there are no available tests for the definitive diagnosis of AD. So the clinical diagnosis of AD remains a diagnosis of exclusion. This limits the potential for early intervention. The difference between normal degenerative processes of brain and preclinical changes of AD is a gray zone and there is no particular way to distinguish between the two. Now several modalities like functional magnetic resonance imaging (fMRI), positron emission tomography (PET) scan, electrophysiological tests and cerebrospinal fluid (CSF) biomarkers for tauopathy and Aβ have shown to be promising in the development of early diagnostic tools for neurodegenerative changes and help us to differentiate between healthy aging and pathological aging. In this article we tried to discuss about the differences between pathological and physiological aging process from radiological, pathological, biochemical, and electrophysiological point of view. However, differentiating between physiological and pathological dementia still remains a challenge.

Context: Two co-morbid conditions which have been found in high proportions among treatment-seeking alcohol-dependent subjects are depression and low social support. Aim: We attempted to study both the factors simultaneously in the setting of Alcoholics Anonymous centers in Mumbai. The study intends to understand (1) if pre-existing depression affected the probability of a person abstaining from alcohol and (2) if social support affected the probability of a person abstaining from alcohol. A thorough review of the existing literature was done before initiating the study. Materials and Methods: A single-observer, cross-sectional study was conducted. Subjects with a history of alcohol dependence were included. However, those with other substances abuse and those with a history of anti-depressant usage were excluded. Questionnaires were administered. The Hamilton Depression Scale assessed depression. Similarly, social support was assessed by Social Provisions Scale by Weiss. Results: According to this study depression does not affect alcohol abstinence as the χ² test shows an insignificant result. Social support also showed a negative correlation with alcohol abstinence. Conclusion: This result is consistent with the findings of other studies such as Davidson et al. (1998). However it is not consistent with the results of the studies having a longer follow-up period. The study had some limitations primarily due to time constraints, the main one being that this study would reveal more significant results if done as a longitudinal study as opposed to a cross-sectional study. Also while interacting with subjects in a group like Alcoholics Anonymous it is important to gain the confidence of the group before obtaining confidence of the individual.

Background: Family's expressed emotion has been shown to be predictive of outcome in mental and physical illnesses in a variety of cultural settings. The relationship between caregiver burden and high level of expressed emotions has demonstrated a high level of relapse among the psychiatric patients in the West. Aim: The current study explores the relationship between caregivers' burden and level of expressed emotions by the patients with schizophrenia in Indian setting. Materials and Methods : The sample for the study consisted of totally 70 subjects comprising 35 schizophrenic patients and 35 caregivers. The schizophrenic patients who were attending the Day Care Center run by Department of Psychiatric and Neuro Rehabilitation Unit at National Institute of Mental Health and Neuro Sciences (NIMHANS) in Bangalore, India (a tertiary care center) and their primary caregivers were included. Family emotional involvement and criticism scale and The burden assessment schedule were administered to assess the expressed emotions and caregivers' burden. Carl Pearson Correlation test used to study the relationship between the variables. Results and Conclusion: The study highlighted the need for addressing expressed emotion in comprehensive psychosocial intervention plan. More attention should be paid to the needs of the caregivers in order to alleviate their burden in managing mentally ill patients.

Background: Insomnia is a common problem that is known to occur during depression. However, literature still debates whether insomnia is part of depression or a separate entity. Materials and Methods: Subjects presenting with depressive disorder according to DSM-IV-Text Revision criteria were recruited after seeking informed consent. Clinical interview was performed with the help of Mini International Neuropsychiatric Interview Plus. Their demographic data and depression related history were recorded. Depression severity was assessed by using Hamilton Rating Scale for Depression. Diagnosis of insomnia was made with the help of International Classification of Sleep Disorders-2 criteria. Type of insomnia, its duration, and its relationship with depressive illness were specifically asked. If any subject fulfilled criteria for more than one type of insomnia, both were recorded. Statistical analysis was done with the help of statistical package for social sciences (SPSS) version 17.0. χ² test, independent sample t test, and Pearson's correlation were performed. Results: A total of 54 subjects were enrolled in this study. Primary insomnia was seen in 40.7% cases and secondary insomnia in 58.8% cases; 27.3% subjects did not experience insomnia along with depressive disorder. In the primary insomnia category, adjustment insomnia was most prevalent (63.6%), and in secondary insomnia group, insomnia due to depressive disorder was most frequent (59.3%). Interestingly, primary insomnia often followed an onset of depressive illness (P=0.04), while secondary insomnia preceded it (c² =11.1; P=0.004). The presence of either type of insomnias was not influenced by duration of depressive illness, number of depressive episodes, and duration of current depressive episode. On the other hand, duration of insomnia was positively correlated with total duration of depressive illness (P=0.003), number of episodes (P=0.04), and duration of current depressive episode (P<0.001). Conclusion: Primary insomnia is common in subjects with depression, and it usually follows depressive illness. On the other hand, secondary insomnia often precedes the onset of depressive illness. Duration of insomnia positively correlates with duration and frequency of depressive episodes.

Context: Inhalant abuse is the deliberate inhalation of a volatile substance to achieve an altered mental state. Inhalants continue to be a poorly recognizable risk for morbidity and mortality globally. Aims: The current study explores the pattern of inhalant abuse across different year groups among the individuals seeking treatment form the de-addiction center of a tertiary care hospital. Settings and Design: The study was conducted at a tertiary care multi-specialty hospital. Materials and Methods: The current study is a chart review of the cases with inhalant abuse/dependence presenting to the clinic. All the treatment records of the de-addiction clinic were reviewed and information was gathered regarding patients with inhalant abuse/dependence. The comparisons have been made across two different year groups. The two groups were compared for various continuous and categorical variables using the independent sample t test and χ ² test/Fisher's exact test, respectively. The level of statistical significance was kept at P<0.05 for all these tests. Results: The two study groups have been found comparable for various socio-demographic and inhalant use patterns. Conclusions: The findings of the current study suggest that the pattern and parameters associated with inhalant use among those presenting to a tertiary care drug dependence center tend to remain stable.

Objectives: The present study was undertaken to test the comparative efficacy of chlorpromazine and risperidone in patients of schizophrenia in a tertiary care hospital of Maharashtra. Materials and Methods: About 100 subjects of either sex between 15 and 75 years of age were randomly assigned either chlorpromazine or risperidone. Only those patients were included who met International Classification of Diseases 10 revision criteria by World Health Organization. To avoid bias, the test drugs were coded as A and B. The study coordinator was unaware of the prescribed drugs; however, the prescribing psychiatrist knew about the drug treatment. Results: Both chlorpromazine and risperidone significantly decreased the mean score of positive and general symptoms in patients of schizophrenia. Although chlorpromazine decreased the mean score of negative symptoms, it was not statistically significant. Risperidone reduced the mean score of negative symptoms to a significant extent. The cost (Rs. 3000-4000) of risperidone was more than the cost (Rs. 700-1000) of chlorpromazine per patient per annum. The dropouts were less (25%) in the risperidone group than in the chlorpromazine group (75%). The more purchase of risperidone than of chlorpromazine was observed in our study. Conclusion: The response rates for positive and general symptoms were found to be equal for both chlorpromazine and risperidone. However, risperidone was found to be more effective than chlorpromazine in treating negative symptoms. The dropout rate was less in the risperidone group than in the chlorpromazine group. The compliance was also better in the risperidone group, even though the cost of risperidone was more than that of chlorpromazine.

Aim and Objective: Quality of methodological and statistical parameters published in various Indian Medical Journals are usually debated in terms of appropriateness. Aim of this manuscript is to analyze and validate efficacy studies on antidepressant drugs published in Indian Medical Journals regarding quality of various methodological and statistical parameters used. Materials and Methods: An in-depth review of Efficacy studies on Antidepressant published in Indian Medical Journals was conducted. Articles were retrieved from all possible sources like Published Journals, downloaded through Pubmed, MedInd, Opengate, Medknow, and Cochrane. These studies were analyzed and validated for various methodological and statistical parameters. Descriptive statistics for various parameters with confidence interval (CI) is also reported herewith. Results : Of 32 articles reviewed, primary and secondary endpoints and sample size calculation was reported in only one article (3.1%; 95% CI, 0.5 to 15.7%). Power and CI was not reported in any of the reviewed articles. Inclusion and exclusion criteria were reported in 9 (28.3%; 95% CI, 15.5 to 45.3%) articles. Information regarding randomization was mentioned in 12 (37.5%; 95% CI, 22.9 to 54.7%) articles, whereas reporting of blinding or open label status of the study was mentioned in 21 (65.6%; 95% CI, 48.3 to 79.5%) articles. Assumptions of statistical tests were not reported in any of the reviewed articles. Statistical tests were used in only 14 (43.7%; 95% CI, 28.1 to 60.6%) articles of which 70% of were inappropriate. All studies were underpowered for small and medium effect size. Conclusion: Quality of reporting of methodological and statistical aspects of antidepressant efficacy studies published in Indian medical journals are poor and hence makes difficult to conclude on issues related to validity of these studies.

Background: In today's ultra competitive environment, students face more stress than ever - be it related to studies, examination, peer, teachers or parent's pressure. Stress is the "wear and tear" our bodies experience as we adjust to our continually changing environment. On one hand, stress compels us to action. However, it can result in feelings of rejection, anger, and depression, leading to health problems such as headaches, upset stomach rashes, insomnia, ulcers, high blood pressure, heart disease, and stroke. Materials and Methods: A cross-sectional questionnaire-based survey of 100 randomly selected students each from Medical College Engineering College and 50 Nursing College was done. For reliability, anonymity and confidentiality were maintained. Stress was measured by using stress measurement scale having 24 Yes/No questions. The questionnaire was in English and Hindi so that language would not be problem. Results: Stress as an entity is universally present among students of all three streams, irrespective of age, sex, and other variables. Students in all three streams have shown denial to existence of problems, with maximum among nursing students. Medical and Engineering students had stress level of such a degree that requires clinical attention, while none of the nursing students belonged to this category. Conclusions: There is attitude among students of turning a blind eye toward existing stress which is a serious problem and may be harbinger of serious mental and psychosocial problems.

Background: A practicing psychiatrist faces dilemmas on a number of occasions, in deciding the best course of action he/she needs to undertake while treating a patient. At times, this choice may not be in accordance with the ethical and moral principles and may in fact appear to violate patient's autonomy and rights. Aim: To study the nature of psychiatric practice by the practicing psychiatrist in the areas of admission, discharge, consent, physical restraint, electroconvulsive therapy (ECT), certification, treatment, suicide and psychotherapy. Settings and Design: Cross-sectional observational study. Materials and Methods: Forty-eight psychiatrists gave consent to participate in the study. A special proforma was prepared, which addresses the common dilemmas in the clinical psychiatric practice. All the psychiatrists were given specially designed profoma and were requested to fill the proforma with appropriate answers. Statistical analysis was done using SPSS software. Results: There were 42 male and 6 female psychiatrists. The age of the psychiatrists ranged from 28 to 65 years with a mean of 43.08 years. The mean duration of practice of these psychiatrists was 14.81΁11.07 years. Question and answers related to admission, discharge, consent, physical restraint, ECT, certification, treatment, suicide and psychotherapy are discussed. Conclusions: The present standard and practice especially in private psychiatric set-up does not confirm to the rules, recommendations, and regulations suggested by Mental Health Act 1987, Mental Health Authorities and various guidelines of practice. Indian Psychiatric Society and other professional bodies need to take steps to prepare guidelines for a good psychiatric practice.

Background: Novel atypical antipsychotics are superior to conventional antipsychotics as they significantly reduce both positive and negative symptoms of schizophrenia and have lower risk of extrapyramidal symptoms (EPS). However, these drugs have separate set of adverse drug reactions (ADRs). Therefore, this study was carried out to assess these ADRs, which can have impact on long-term compliance and achieving successful treatment. Materials and Methods: A prospective study of analysis of ADR of atypical antipsychotic drugs was carried out in the psychiatry outpatient department. Patients of psychotic disorder (any age, either sex), who were prescribed atypical antipsychotic drugs, were included. Those who were prescribed conventional antipsychotics or combinations of antipsychotics were excluded from the study. Apart from spontaneously reported ADRs, a questionnaire related to the likely ADR was used and patients' responses were recorded in the case record form. Results: Totally 93 ADRs were recorded from 84 prescriptions. Majority of the ADRs (82 out of 93) were seen with risperidone and olanzepine, as they were the commonly prescribed drugs. Weight gain, dizziness, sleep disturbance and appetite disturbance accounted for nearly 78% of the total events. With risperidone (at 4-6 mg/day) and olanzepine (at 10-15 mg/day), gastrointestinal and sleep disturbance were observed in the initial (within 7 days to 2-3 months after treatment) course of treatment, while EPS, fatigue, seizure, increased frequency of micturition and dizziness were observed after long-term (3-9 months) use. Conclusion: The present study adds to the existing information on the prevalence of adverse effects of atypical antipsychotic drugs. Role of active surveillance in post-marketing phase is also emphasized.

Background : Today's internet is a usual and common method for identifying and fulfilling unknown practices. Internet network has been prepared rapid and comfortable access to information. Internet addiction is a new and attractive subject that has been regarded as behavior-based addiction recently. Purpose : To estimate the prevalence of internet addiction and some of the related factors among medical students, Iran. Materials and Methods : An analytical cross-sectional study was conducted on 426 students selected through two-stage sampling method. Yang standard internet addiction questionnaire was used for data collection. After data entry, χ ² , t-test, and Pearson coefficient statistical tests were applied. 0.05 was considered as the significance level. Results : The overall prevalence of internet addiction was 10.8%, with moderate and severe internet addiction equal to 8% and 2.8%, respectively. Mean and standard deviation of Yang internet addiction score was calculated as 32.74±14.52. Internet addiction was associated with sex, marital status, father's job, rate of knowledge about computer and internet, and educational level (P<0.05). But it was not associated with the parents' education, residential area, field of study and level, and school of education (P>0.05). Conclusion : Because internet addiction leads to wasting of the students' leisure time and also useful time, it affects the educational situation inversely. Some measures should be taken to plan and improve the use of internet.

Context: Medically unexplained pain symptoms are common in children, and their incidence is on the rise. There is often a lack of clearly articulated pathophysiology in these patients. There is need to improve understanding about varied causes and presentations of these patients which would generate further insight in management of these patients. Documentation and detailed assessment of such children in Indian setting is not seen in literature. Materials and Methods: A series of 17 cases, 10 boys and 7 girls referred from pediatrics department is discussed, so as to categorize them in three different subgroups for management. Result and Discussion: Although there were often no overt anxiety or depressive features, some psychosocial stress which was mostly unnoticed by the child, the parents and the doctor, preceded such a pain. It was often an academic stress, familial separation or parental psychiatric illness. They were at times not able to verbalize their distress, which was revealed with the help of Children's Apperception Test (C.A.T.). They mainly had anxieties about loss of love or disapproval by parents and also fear of harm or injury. They used defence mechanisms like denial, reaction formation and repression, which were ineffective in handling the overwhelming anxiety. Most of these children had either above average or borderline intelligence. Somatic expression of emotional needs and fears in these children was managed effectively by supportive therapy and antidepressant drugs.

Context: The prevalence of psychiatric comorbidity in general hospital range from 20% to 60%. Presence of psychiatric morbidity compounds the disability and suffering in medical patients. There is a limited literature on the prevalence of psychiatric morbidity in patients admitted in the intensive care units (ICUs). Aims: The aim of the study was to estimate the prevalence and nature of comorbid psychiatric illness in the cases referred from ICUs. Settings and Design: Cross-sectional observational study. Materials and Methods: This study included all the consecutive patients referred from different ICUs to psychiatry department for consultation during the four-year period from January 1, 2000 to December 31, 2003, assessment was done by psychiatrist and diagnosis was made using ICD-10. Statistical Analysis: Descriptive statistics. Results: There were 309 (1.97%) referrals from ICUs to psychiatry department during the period of study. Among the referred patients, diagnosis of organic mental disorders was the commonest psychiatric diagnosis present in 104 (33.65%) patients followed by suicidal attempt in 101 (32.69%); anxiety disorders in 40 (12.94%); depressive disorders in 21 (6.8%); Psychotic illness in 10 (3.24%); other psychiatric illnesses in 28 (9.06%); and nil psychiatric illness in 5 (1.62%) patients. Conclusion: Prevalence of psychiatric referrals from ICUs was low. This could be due to stigma and lack of awareness among physicians. There is increased need for recognition and treatment of comorbid psychiatric illness by the treating physicians which may help to decrease morbidity and overall cost of the treatment.

Aims and Objectives: Translation of the Insomnia Severity Index from English to Hindi and Validation of the Hindi version. Materials and Methods: The translation process of the Insomnia Severity Index was initiated after obtaining due permission from the author of the original version of the same. Translation was carried out by using standard translation procedures, such as combined translation, decentering, and pretest method. The final version of the Insomnia Severity Index in Hindi was finally validated. A randomly selected sample size of 65 subjects was enrolled for the purpose of validation and testing the reliability of Hindi version of the Insomnia Severity Index. Insomnia was present in 45 subjects and they constituted the insomnia group. The rest 20 subjects did not have insomnia and were included in the control group. The Hindi version of the Insomnia Severity Index was applied to both the groups. Results: The total sample constituted of 50.8% males and 49.2% females. The mean age in the control group was 30.8±8.3 years and that in the insomnia group was 40.3±4 years (t=3.04; P=0.001). The translated version of the Insomnia Severity Index showed a reliability of 0.91 (Cronbach's α=0.91). This was not just simple translation, but many of the words were changed to adapt it for the local population. Conclusion: The Hindi version of the Insomnia Severity Index is a valid and reliable tool that can be administered for the assessment of severity of insomnia.

Background: Does cognitive screening rule out impairment of different cognitive functions of older adults in India? This study is an attempt to explore these issues. Materials and Methods: Study sample consisted of 89 Mixed version of Mini Mental State Examination and Hindi Mental State Examination (Mixed MMSE) negative older adults aged ΃60 years. Subjects giving informed consent for the study were recruited using inclusion/exclusion criteria from a randomly selected ward of urban Lucknow as consecutive series. Semi-structured proforma of sociodemographic details and Mixed MMSE were administered. Subjects scoring above 23 on Mixed MMSE and not having any significant physical illness in past one year which affects the activity of daily living were considered as normally aging older adults. These normally aging older adults (89) were further assessed on Brief Cognitive Rating Scale to identify level of cognitive functioning on different domains. Appropriate statistical test was used for data analyses using Statistical Package for Social Sciences (SPSS) 12.0 version. Results: Maximum normally aging older adults (51.7%) has mild level of objective dysfunction in "orientation" followed by "concentration" (22.5%). Significantly (P<0.05) higher number of normally aging males had objective dysfunction in "orientation" and in "functioning/self-care" in comparison with females. Similarly, significantly (P<0.05) higher number of subjects aged 70 years or more had subjective dysfunction on "recent and past memory" in comparison with those in 60 to 69 years of age. Conclusion: Normally ageing subjects had objective cognitive dysfunction in the areas of "orientation" and "concentration" and "functioning/self care." It was found in more older adults with increasing age.

Objective: Some persons attempt suicide with a strong intention to die and some are not. Presently, no distinctive grouping has been done on the basis of the suicidal intention, though there is a significant variation in the psycho-socio-demographic profile, suicidal ideation, and intent within the persons making suicidal attempt. The aim of our study was to find the psycho-socio-demographic profile, suicide intent in survivors of suicide attempt, categorizing them by suicide intent, and finally to define the deliberate self-harm (DSH) group. Materials and Methods: It was a cross-sectional study. Two hundred patients who survived suicide attempt were evaluated by a psychiatrist. The data were recorded for sociodemographic variables, psychiatric disorder, suicide intent, and lethality of suicide attempt. Grouping was done by using suicide intent as the determining dimension. The DSH group was defined by psycho-socio-demographic characteristics of the patient. Results: The mean age of the DSH group was 26.72 years, mostly females (50.5%), semiskilled workers (43.43%) and housewives (32.32%), from nuclear family (60.6%) with no psychiatric disorder (35.35%). Most of them attempted a nonlethal suicide attempt (87.87%) by organophosphorus poisoning (87.87%). Conclusions: The DSH group is a distinct group among suicide attempters, having different psycho-socio-demographic characteristics.

Genital self mutilation is a rare and a severe form of self-injurious behavior usually described in psychotic disorders, with delusions and hallucinations. It has been ascribed to sexual conflicts, Body image distortions, Internalized aggression, and suicidal intent. This phenomenon has been described in schizophrenia, affective psychosis, alcohol intoxication, and personality disorders. The present case genital self mutilation in a case of alcohol withdrawal state complicated by delirium is reported.

A 36-year-old male from an urban middleclass family with strained relationship among family members was referred from a corporate hospital for further management of psychological problem. As he was attempting suicide repeatedly, Electroconvulsive Therapy (ECT) was planned. After preoperative assessment and preparation, modified ECT was done with thiopentone and 0.5 mg/kg of suxamethonium. Apnea following suxamethonium was prolonged for 2 hours. Subsequent enquiry revealed that patient was treated for organophosphate poisoning and was on ventilator support for 15 days. This was concealed by the relatives. On searching patient previous records, Butyrylcholinesterase levels were very low, i.e., 350 u/l (normal reference range is 5 500 - 12 500 u/l). Prolonged suxamethonium apnea should be anticipated in patients with recent history of organophosphate poisoning; it is advisable to estimate the levels of butyrylcholinesterase and avoid suxamethonium in patients with low enzyme levels.

Kleine-Levin syndrome (KLS) and idiopathic hypersomnia (IH) are primary sleep disorders of unknown etiologies, which often run a chronic course. The common core symptoms of these syndromes are hypersomnolence and sleep drunkenness, with periodic hypersomnolence and hyperphagia being the prominent symptoms of KLS. Psychiatric manifestations are common to both and include irritability, depression, apathy, inattention and poor concentration. Both disorders are diagnosed clinically and no specific laboratory investigation is available to confirm the diagnosis. We present a case highlighting the overlapping of the symptoms of KLS and IH, producing a complex clinical picture.

Games have been introduced as a means for studying cross-cultural differences and societies. This paper presents a case study in analogous games played by children in two different countries with two different cultures - Iran and the United States. Four examples are presented to demonstrate that games played by Iranian children are subject to less objectivity in their rules. Therefore, nonobjectivity may be a phenomenon that has roots in the society and the many differences between the two societies may very well be the results of this fundamental difference. If the presence of objectivity in childhood game rules could be, in actuality, indicative of objectivity in social and civil interactions in the everyday lives of the people, the direction of causality remains to be established. In other words, it remains unclear whether the games influence the culture or are influenced by the mandates of the society.

B12 acts as a cofactor in synthesis of neurotransmitters such as serotonin and dopamine, thus B12 deficiency affects mood, emotions and sleeping and can lead to psychiatric disorders. Psychiatric manifestations of B12 deficiency are varied. They seldom precede anemia. We want to present a case of B12 deficiency which was presented with obsessive compulsive disorder.

Conventionally, antipsychotics are used to treat schizophrenia due to predominant dopamine antagonist activity. The use of various types of Benzodiazepines (BZDs) in the treatment of Schizophrenic symptoms like agitation and psychotic excitement in general and control of florid psychotic symptoms such as hallucinations and delusions in particular is well known. However, the use of BZDs, specifically in remission of paranoid schizophrenia, is not reported so far. Here, we are reporting a case of an elderly female patient with chronic paranoid schizophrenia showing short-term remission in paranoid symptoms with injectable lorazepam.

Acyclovir, a commonly used antiviral drug can rarely result in neuropsychiatric complications especially in elderly. We for the first time report acyclovir associated hypomania in an elderly woman. Our report suggests that acyclovir is a risk factor for mood episode in vulnerable individual and one need to be cautious while using antiviral agents in patients with psychiatric disorders.

Culture-bound syndrome is a broad rubric that encompasses certain behavioral, affective and cognitive manifestations seen in specific cultures. These manifestations are deviant from the usual behavior of the individuals of that culture and are a reason for distress/discomfort. This entitles these manifestations for a proper labeling and subsequent management. However, the available information and literature on these conditions suggest that at least some of them are/have been more widely prevalent than being considered. This article presents a case for possible relabeling and inclusion of these conditions in the mainstream diagnostic systems based on the example of the dhat syndrome- a culture-bound syndrome from India. These conditions could be relabeled as functional somatic syndromes.