Indian Journal of Psychological Medicine
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   Table of Contents - Current issue
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May-June 2017
Volume 39 | Issue 3
Page Nos. 219-387

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EDITORIAL  

Pharmacological advances in the management of sexual dysfunction p. 219
MS Reddy, M Starlin Vijay
DOI:10.4103/0253-7176.207318  
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REVIEW ARTICLES Top

Telepsychiatry in India – Where do we stand? A comparative review between global and Indian telepsychiatry programs p. 223
Subrata Naskar, Robin Victor, Himabrata Das, Kamal Nath
DOI:10.4103/0253-7176.207329  
A wide discrepancy exists in India between the existing mental healthcare repertoire and the alarmingly high burden of individuals requiring immediate attention from requisite mental healthcare services. Providing equitable mental healthcare across a vast country characterized by profound cultural variations and territorial caveats has remained a major public health concern. Against this gloomy backdrop, the emergence of distant communications technology offers solace and optimism as an ingenious approach to bridge the existing gap between clients and mental health professionals. Using inexpensive equipment and basic technical knowhow, telepsychiatry expands the scope of the discipline to distant and hazy suburbs and villages from its urban centers of excellence. The current academic endeavor intends to perform a systematic review of relevant literature from India as well as from other countries. The various models of telepsychiatry-both asynchronous and synchronous models-in practice have been elaborated on with a focus on effectiveness, feasibility and acceptability of this latest modality. A sincere attempt to chronicle the remarkable journey of telepsychiatry in India, beginning in the dawn of the 21st century to the current Indian scenario, has been made. The legal and ethical issues, along with a few words of caution and contemplation, have been briefly touched on. A set of recommendations has been provided with the hope that policy makers and administrators in the domain of mental health may benefit from them. It is anticipated that telepsychiatry will be adequately utilized in India to tackle the raging menace of inadequate mental healthcare services.
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Role of electroencephalography in the diagnosis and treatment of neuropsychiatric border zone syndromes p. 243
Sadanandavalli Retnaswami Chandra, A Asheeb, Santhosh Dash, Nikhil Retna, Karu Venkata Ravi Teja, Thomas Gregor Issac
DOI:10.4103/0253-7176.207336  
Border zone disorders involve neurological disorders with psychiatric symptoms and signs as well as psychiatric disorders with soft neurological features. This becomes a cause for great diagnostic and therapeutic concerns. We, in this paper, analyzed some of the imitators such as epilepsy, dementia, some forms of encephalitis, and pure psychiatric diseases which produce problems in decision making due to soft neurological features and the utility of electroencephalography (EEG) as a simple diagnostic tool in differentiating some of these conditions from each other as well as the therapeutic role of EEG in some of these disorders. We retrospectively took index cases which produced problems for us in decision making in the last 5 years and correlated with the final diagnosis, EEG parameters as well as literature available by PubMed search using specific key words based on the conditions identified. EEG can be normal in organic diseases and abnormal in psychiatric diseases. Typical EEG findings in neuropsychiatric syndromes point to specific diagnosis. Soft EEG changes are common in psychiatric disorders and do not indicate organicity. EEG can be used to assess efficacy and toxicity of therapeutic agents in psychiatry. Biofeedback-based training to keep the brain in particular rhythm is of use in psychiatric disorders as a pharmaco-sparing agent.
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ORIGINAL ARTICLES Top

Neurocognitive impairments in unaffected first-degree relatives of schizophrenia p. 250
Virupaksha Shanmugam Harave, Venkataram Shivakumar, Sunil V Kalmady, Janardhanan C Narayanaswamy, Shivarama Varambally, Ganesan Venkatasubramanian
DOI:10.4103/0253-7176.207335  
Background: Neurocognitive impairments of attention and executive functioning are trait abnormalities in schizophrenia, and these are considered to be endophenotypes. These deficits have been convincingly linked to prefrontal cortical functioning. In this study, we examined the cognitive performance in the domains of attention and executive functioning among first-degree relatives of Indian people with schizophrenia (high-risk [HR] patients) compared to healthy controls (HC). Materials and Methods: Siblings of patients with DSM-IV schizophrenia, HR patients (n = 17), were compared with HC (n = 30) (matched as a group for age, sex, years of education, and handedness) using the following neurocognitive tests for attention and executive function – digit span test (DST), trail making test, letter-number sequencing (LNS), and spatial span test. Results: HR patients had significantly deficient performance in attention and executive function tasks (DST-forward [P < 0.001], DST-backward [P < 0.001], spatial span-forward [P < 0.001], spatial span-backward [P < 0.001], and LNS [P < 0.001]). Conclusions: This study replicates the findings that neurocognitive deficits involving executive function task performance, attention, and working memory, which are considered as principal features in patients with schizophrenia, are also significantly present in the first-degree relatives of patients. Thus, these neurocognitive parameters can be considered as potential endophenotypes in schizophrenia.
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An audit of Indian health insurance claims for mental illness from pooled insurance information bureau's macroindicator data Highly accessed article p. 254
Anusa Arunachalam Mohandoss, Rooban Thavarajah
DOI:10.4103/0253-7176.207340  
Introduction: Information on the social and voluntary insurance coverage of mental illness in India is scarce. We attempted to address this lacuna, utilizing a secondary macrodata approach for 3 years. Mental illness per se is not covered by most of existing Indian health insurance policies. Materials and Methods: Publicly available de-identified claim macrodata for all health (nonlife) insurance for Indian financial year from 2011–2012 to 2013–2014 were collected. The age group, gender, amount of claims, proportion of claims, and details of number of days of hospitalization were collected and analyzed. Descriptive statistics, Chi-square test, and Wilcoxon tests were used appropriately. P≤ 0.05 was considered statistically significant. Results: In 2011–2012, there were 2864 claims from the registered 2,591,781 members citing mental illness (0.11%) which decreased to 0.03% in 2012–2013 and marginally rose to 0.07% of all claims. The total amount of claims paid for mental illness was Rs. 51.7 millions in 2011–2012, Rs. 97.2 million in 2012–2013, and Rs. 150 million in 2013–2014. Statistically significant difference emerged in terms of age group, gender, amount and proportion of claim, and number of days of hospitalization. Conclusion: The penetration of health insurance is low and claim for mental illness remains low. The difference in patterns of age, gender, amount of claims, and number of days for mental illness provides detailed relevant information to formulate future policies.
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Regional cerebral glucose metabolism and its association with phenotype and cognitive functioning in patients with autism p. 262
BN Anil Kumar, Savita Malhotra, Anish Bhattacharya, Sandeep Grover, YK Batra
DOI:10.4103/0253-7176.207344  
Introduction: In spite of three decades of neuroimaging, we are unable to find consistent and coherent anatomical or pathophysiological basis for autism as changes are subtle and there are no studies from India. Aim: To study the regional cerebral glucose metabolism in children with autism using positron emission tomography (PET) scan and to study the behavior and cognitive functioning among them. Materials and Methods: Ten subjects (8–19 years) meeting Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for autism were evaluated on Childhood Autism Rating Scale (CARS), trail making test (TMT) A and B, Wisconsin card sorting test, Raven's progressive matrices, and PET scan. A control group of 15 matched subjects without any brain pathology or neurological disorder was similarly studied. Results: Four out of the ten patients with autism had abnormal PET scan findings, and in contrast, none of the patients in the control group had abnormal PET scan. Of the four patients with abnormality in the PET scan, two patients had findings suggestive of hypometabolism in cerebellum bilaterally; one patient showed bilateral hypometabolism in anterior temporal cortices and cerebellum, and the fourth patient had hypermetabolism in the bilateral frontal cortices and medial occipital cortices. Subjects with autism performed poorly on neuropsychological testing. Patients with abnormal PET scan findings had significantly higher scores on the “body use” domain of CARS indicating more stereotypy. Conclusion: Findings of this study support the view of altered brain functioning in subjects with autism.
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Telepsychiatry as an economically better model for reaching the unreached: A retrospective report from South India p. 271
Sydney Moirangthem, Sabina Rao, Channaveerachari Naveen Kumar, Manjunatha Narayana, Neelaveni Raviprakash, Suresh Bada Math
DOI:10.4103/IJPSYM.IJPSYM_441_16  
Aim: In a resource-poor country such as India, telepsychiatry could be an economical method to expand health-care services. This study was planned to compare the costing and feasibility of three different service delivery models. The end user was a state-funded long-stay Rehabilitation Center (RC) for the homeless. Methodology: Model A comprised patients going to a tertiary care center for clinical care, Model B was community outreach service, and Model C comprised telepsychiatry services. The costing included expenses incurred by the health system to complete a single consultation for a patient on an outpatient basis. It specifically excluded the cost borne by the care-receiver. No patients were interviewed for the study. Results: The RC had 736 inmates, of which 341 had mental illness of very long duration. On comparing the costing, Model A costed 6047.5 INR (100$), Model B costed 577.1 INR (9.1$), and Model C costed 137.2 INR (2.2$). Model C was found fifty times more economical when compared to Model A and four times more economical when compared to Model B. Conclusion: Telepsychiatry services connecting tertiary center and a primary health-care center have potential to be an economical model of service delivery compared to other traditional ones. This resource needs to be tapped in a better fashion to reach the unreached.
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Use of mobile phone technology to improve follow-up at a community mental health clinic: A randomized control trial p. 276
Gaurav Singh, Narayana Manjunatha, Sabina Rao, HN Shashidhara, Sydney Moirangthem, Rajendra K Madegowda, B Binukumar, Mathew Varghese
DOI:10.4103/0253-7176.207325  
Background: Mobile phone technology is being used worldwide to improve follow-ups in health care. Aim: Aim of the study is to evaluate whether the use of mobile technology will improve or not the follow-up of Indian patients from a community mental health center. Materials and Methods: Patients or caregivers having mobile phones and consenting for study were enrolled, and sociodemographic and clinical details of patients were taken. Participants were randomized into two groups (short message service [SMS] vs. non-SMS group). At first intervention level, a SMS was sent to SMS group (not in non-SMS group) 1 day before their appointment. At second-level intervention (voice call level), patients from both groups who missed their first appointment were given a voice call requesting them to come for follow-up, and the reasons for first missed appointments (MA) were also elicited. The effect of these two intervention levels ( first SMS for SMS group and next voice calls for both groups) on follow-up was evaluated. Results: A total of 214 patients were enrolled in the study. At first SMS intervention level of SMS group (n = 106), 62.26% of participants reached appointment-on-time (RA), while in the non-SMS/as usual group (n = 108), 45.37% of patients RA. The difference of these groups is statistically significant. At second-level intervention (voice call), 66 of 88 (another 15 were unable to contact) were came for follow-up consultation within 2 days of MA. Distance and diagnosis of alcohol dependence were significantly associated with MA. Social reasons were most common reasons for first MA. Conclusion: The use of mobile phone technology in an outpatient community psychiatric clinic improved follow-up significantly.
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Prediction of risk for boys' involvement in drug use based on levels of self-evaluations in Russia p. 281
Svetlana N Islamova, Rafael Sh Islamov
DOI:10.4103/0253-7176.207322  
Background: Adolescents often experiment with drug use, which can impact on their health and well-being and increase the probability of problem drug use. Yet, not enough is known about which psychological indicators is related with the initiation of drug use among young adults and have predictive power. Materials and Methods: Participants in this study were 311 boys (school and college students) aged 15–17. Data were collected in the towns of Moscow region. A modified version of Dembo-Rubinstein test was used to assess the self-evaluation (SE). A questionnaire and detection of drugs in urine were used to identify drug users. Binary logistic regression analysis based on SE with the inclusion of interactive effects between predictors was used for prediction of drug use. Results: Drug users, compared to nondrug users, are characterized by lower actual SE of health, happiness, success in learning, mind and desired SE of appearance, and higher desired SE of relationships with friends. The developed nonlinear regression model for prediction of boys' involvement in drug use among young boys in the towns of Moscow region has a sensitivity of 82.7% at a specificity of 79.0%. Conclusions: Dembo-Rubinstein test of SE is a sensitive measure to identify boys at risk of involvement in drug use. Application of the regression model based on SE may contribute to the useful solution in preventing any onset of early drug use.
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Prevalence of depression among school-going adolescents in an Urban Area of Bihar, India p. 287
Kunal Kishor Jha, Satyajeet Kumar Singh, Santosh Kumar Nirala, Chandramani Kumar, Pragya Kumar, Neeraj Aggrawal
DOI:10.4103/0253-7176.207326  
Introduction: Depression is one of the under-recognized health problems in adolescents. Emotional instability resulted from childhood to adulthood transition makes adolescents vulnerable to depression. Aims: The aim of the study was to explore the prevalence of depression and its associated sociodemographic factors among school-going adolescents. Materials and Methods: This cross-sectional study was undertaken from January 2016 to June 2016 in adolescents studying in 9–12th standard from forty schools located in an urban area of Patna, Bihar. The self-administered questionnaire of Beck's Depression Inventory II was utilized to assess the prevalence of depression. Statistical analysis was done with Pearson's Chi-square test using SPSS software version 21.0. Results: Among the 1412 selected students, the prevalence of depression was found to be 49.2%, wherein the prevalence of severe depression was 7.7%. The overall prevalence of depression was significantly (P < 0.001) higher among girls (55.1%) than boys (45.8%). The prevalence of depression was found to be higher among students belonging to minorities (Buddhism, Jainism, etc.) (63.3%, P < 0.001). Elder students were found to be more depressed than younger students. Depression was found to be statistically significantly associated with gender and religion (P < 0.005). Guilty feeling (69.48%) was one of the most prominent clinical factors associated with depression followed by pessimism (58.14%), sadness (56.52%), and past failure (55.81%). Conclusions: Mental health is one of the most neglected aspects of our society. There is a need to increase awareness about depression among teachers and parents to identify and help depressed adolescents in the school.
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Adverse drug reactions and their impact on quality of life in patients on antipsychotic therapy at a tertiary care center in Delhi p. 293
Shalini Chawla, Shankar Kumar
DOI:10.4103/0253-7176.207332  
Context: Adverse drug reactions (ADR) due to antipsychotic therapy have significant impact on a psychiatric patient's quality of life. Few studies have been conducted in India to monitor adverse drug reactions due to antispsychotics and none has been done to determine their impact on quality of life. Aims: The present study was conducted to monitor ADRs due to antipsychotics and ascertain the impact of ADRs on quality of life. Settings and Design: This prospective observational study was conducted in the psychiatry outpatients department in New Delhi for 1 year. Patients and Methods: A total of 224 patients enrolled were followed up for a period of 3 months. ADRs were monitored using the standard form of the Central Drugs Standard Control Organization and causality was determined using the Naranjo algorithm. The WHO Quality of Life BREF (WHOQOL-BREF) scale was used to study the effect of ADR on the quality of life. Statistical Analysis Used: The data were entered and analyzed using the statistical software SPSS 17.0. Unpaired t-test was used to compare the quality of life of patients who encountered ADRs and those who did not. P < 0.05 was considered statistically significant. Results: Of the total 224 patients, 38 adverse drug events occurred. Adverse drug events were mostly with risperidone (10), followed by olanzapine (8) owing to high usage. Majority of the events were classified as probable (34). The occurrence of adverse drug events decreased the scores on physical and psychological domain scores of WHO-QOL BREF at 3 months compared to baseline. Conclusions: The study provides information on the existing incidence of ADRs in the setup with an established pharmacovigilance center. The nature of ADRs correlates with the prevalence pattern of usage of atypical antipsychotics. Clinicians need to weigh benefit versus the impact on quality of life while prescribing antipsychotics.
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Evaluation of antioxidant status, high sensitivity C-reactive protein, and insulin resistance in male chronic opiate users without comorbidities p. 299
Purvi Purohit, Naresh Nebhinani, Praveen Sharma
DOI:10.4103/0253-7176.207330  
Background: There is a paucity of data on frequency of metabolic syndrome (MS), insulin resistance (IR), and oxidative stress in Indian opiate users without comorbidities. Objectives: To determine the influence of opiate use on frequency of MS, homeostasis model assessment for IR (HOMA-IR), high-sensitivity C-reactive protein (hs-CRP), and oxidative stress in opiate-dependent male patients without comorbidities. Methods: Participants (n = 120) were grouped as controls (Group I), pure opiate dependents (Group II), opiate + tobacco dependents (Group III), and tobacco dependents (Group IV) with a minimum of 1-year dependence participated in the study. Participants were evaluated for anthropometric parameters, blood pressure (BP), fasting blood sugar, insulin, HOMA-IR, lipid profile, hs-CRP, and total antioxidant status (TAS). Frequency of MS was determined based on modified Adult Treatment Panel-III. The data were analyzed using one-way ANOVA, multiple regression by SPSS 21. Results: Frequency of MS in opiate dependents was higher than control. There was a significant difference in serum insulin, HOMA-IR, and TAS levels of the study groups. Multiple regression analysis showed dependence years, body mass index, waist-hip ratio, systolic blood pressure, diastolic blood pressure (DBP), HOMA-IR, and hs-CRP to be significant independent predictors of TAS in Group II and III patients with MS after adjusting for age and education years. TAS and DBP significantly predicted hs-CRP after adjusting for age and education years in Group II and III patients with MS. No such relation was seen in Group I and IV. Conclusions: Chronic opiate-dependent males without comorbidity are a unique group that shows low-grade inflammation, oxidative stress, and prevalence of MS predisposing them to future risk of cardiovascular diseases.
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Adverse drug reaction monitoring in a tertiary care psychiatry setting: A comparative study between inpatients and outpatients p. 306
Tejaswi Gummadi, Virupaksha Shanmugam Harave, Lakshmi Narayan Aiyar, Saraswathy Ganesan RajaLekshmi, Radhika Kunnavil
DOI:10.4103/0253-7176.207328  
Background: Psychotropic medications are the mainstay of treatment in psychiatric disorders and are associated with ADRs which affect the compliance and treatment course. Previous studies have looked at the frequency, profile of ADRs and their management aspects. However, the systematic comparison between IP and OP was lacking even though there is a prescription pattern difference. Hence this study was aimed to compare the proportion, pattern, severity and resolution of ADRs once detected. Methods: This is a hospital based, prospective follow up study done in the psychiatry ward and outpatient setting for a period of 6 months. A total of 491 patients (200 IP, 291 OP) who received psychotropics were monitored in the study. UKU side effect rating scale was used to detect ADRs, WHO – UMC scale for causality, Modified Hartwig and Siegel Scale to assess severity of ADR and CDSCO suspected ADR form for reporting it. Results: Out of 491 patients who were recruited for the study, 83 patients developed ADRs (34 IP, 49 OP, P = 0.963). The mean number of ADRs per patient was found to be higher in IP (IP-2.17±1.14, OP-1.65±1.12, P-0.01). Severe ADRs were observed to be higher IP (IP-67.64%, OP-38.7%, P-0.014) which was statistically significant. There is no statistically significant difference in distribution of ADRs across all age groups (P-0.475). Conclusion: The study results emphasises the need for active pharmacovigilance so that ADRs are detected and managed at the earliest, hence reducing the morbidity and improving compliance. There is also need for systematic long term, multicentric study to further examine and correlatethe observations of our study.
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Psychosocial factors associated with relapse in patients with alcohol dependence p. 312
Kailash Sureshkumar, Shabeeba Kailash, Pronob Kumar Dalal, Murali Mohan Reddy, PK Sinha
DOI:10.4103/0253-7176.207337  
Introduction: Despite the recent developments in the biology of addiction, a significant part of relapse and its management is still influenced by psychosocial factors and the interplay between them. This study aims at finding the extent of association of various psychosocial factors with relapse in patients of alcohol dependence. Materials and Methods: It is a cross-sectional study of two groups of alcohol dependence patients: abstinence (n = 31) and relapse (n = 35). Demographic, clinical, and psychosocial variables were compared between the two groups. Statistical analyses were aimed at finding the extent of association between various factors and relapse. Results: Demographic variables such as family history of substance dependence (odds ratio [OR] =2.09; confidence interval [CI] =0.74–5.90) and past history of ≥2 relapses (OR = 2.71; CI = 0.83–8.87) were associated with relapse in alcohol dependence. Clinical variables such as younger age of onset of dependence (Mean difference = −3.93; 95% CI = −7.66 - −0.21; P = 0.038) and shorter time to develop dependence (Mean difference = −3.08; 95% CI = −5.53 -−0.63; P = 0.014) were significantly associated with relapse. Of the psychosocial variables, coping behavior (OR = 6.54; CI = 1.17–36.74) had the highest association with relapse followed by relapse precipitants (OR = 1.42; CI = 1.16–1.74). Conclusion: Coping behaviors to adverse situations have greater association with relapse among psychosocial variables than the number of high-risk situations a patient experiences. Interventions targeted at improving coping skills can help patients stay abstinent.
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Do life events and social support vary across depressive disorders? p. 316
Savitha Soman, Shripathy M Bhat, KS Latha, Samir Kumar Praharaj
DOI:10.4103/0253-7176.207334  
Background: Social support and life events moderate the expression of depression though studies have shown contradictory results. The objective was to study the stressful life events and perceived social support in patients with adjustment disorder, first-episode depression, and recurrent depressive disorder (RDD). Subjects and Methods: One hundred and forty-six patients aged 18–60 years with adjustment disorder, first-episode depression, or RDD according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision were evaluated using the presumptive stressful life events scale and Multidimensional Scale of Perceived Social Support. Results: There was no difference in mean number of total life events and subgroups as well as perceived stress score in the past 1 year between the groups. There was no difference in the perceived social support scale total score, as well as from family and friends, across the three groups. However, the mean perceived social support from significant others in those with RDD was lower as compared to those with adjustment disorder. Conclusion: Stressful life events do not differ in adjustment disorder, first-episode depression, and RDD. Furthermore, the perceived social support was similar across the three groups, except for perceived social support from significant others, which was less in those with RDD.
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The phenomenology and treatment response in catatonia: A hospital based descriptive study p. 323
Sarada Prasanna Swain, Sushree Sangita Behura, Manoj Kumar Dash
DOI:10.4103/0253-7176.207338  
Background: Literatures regarding clinical symptomatology and treatment response of catatonia are very few. Objective: To assess onset, clinical profile, diagnostic break up, treatment response and outcome in patients diagnosed as Catatonia, reported to a tertiary care hospital. Methods: The present study was a cross-sectional descriptive study conducted in indoor of Mental Health Institute (Centre of Excellence), S.C.B. Medical College, between March 2015 to March 2016. A total of 34 patients were included in the study who reported at outdoor department of Mental Health Institute with catatonic symptoms. All patients admitted in inpatient department were routinely assessed through a detailed semi-structured interview. The diagnosis of catatonia was made if the patients present with three or more symptoms out of twelve symptoms fulfilling the criteria of DSM-5. All the patients were assessed through Bush-Francis Catatonia Rating Scale. They were initially given parental lorazepam at the doses ranging from 4-12 mg per day as per requirement. Patients who did not respond to lorazepam trial were given ECT. Results: The patients were predominantly presented with retarded symptoms of catatonia such as staring, mutism, withdrawal, posturing and negativism. Schizophrenia and other psychotic spectrum disorders were more commonly presented as catatonia as compared to mood disorders. Younger age group patients were mainly responded to lorazepam only, whereas older age group patients responded to both ECT and lorazepam. Conclusion: This study has came out with very important insights in the age of incidence, phenomenology, clinical profile, source of referral, diagnostic break up and treatment response with lorazepam and ECT in catatonic patients following mental disorder.
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Gender, life events, and depression: An exploratory study p. 330
Subahani Shaik, Ravi Philip Rajkumar, Vikas Menon, Siddharth Sarkar
DOI:10.4103/0253-7176.207339  
Context: Literature is inconsistent about the role of gender in mediating the relationship between life events and depression. Aim: Our objective was to explore gender differences in patterns and frequencies of stressful life events before onset of a depressive episode. Setting and Design: Cross-sectional study at a tertiary care center. Subjects and Methods: One hundred patients fulfilling Diagnostic and Statistical Manual of Mental Disorders fourth edition criteria for current major depression (50 males and 50 females) were recruited for the study. Structured instruments were used to assess psychiatric comorbidity, episode severity, and stressful life events. We compared the number and frequency of stressful life events between genders and their relationship with demographic and clinical variables. Statistical Analysis Used: Mann–Whitney U-test and Chi-square test. Results: Women with depression were older, more likely to be married (P < 0.01), had lower rates of comorbid panic disorder (P < 0.01) and nicotine dependence (P = 0.016) compared to men. Total stress scores and median number of stressful events in the year before onset of depression were significantly lower in women (P < 0.01). Getting married, job or property-related stressors, and breakup of friendship were more commonly reported stressors among males while more females reported dowry-related issues before symptom onset. In stratified analysis, these gender differences continued to hold good only in those with comorbid dysthymia. Conclusion: There appears to be a sex-specific effect of certain life events on depression. Comorbid dysthymia may play an important role in mediating this differential stress sensitivity across genders.
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The mood spectrum and temperamental instability in unipolar and bipolar disorder p. 336
Manish Kumar, Pradeep Kumar Saha, Anwesha Mondal
DOI:10.4103/0253-7176.207343  
Background: The current categorical split of mood disorders in bipolar (BP) disorders and depressive disorders has recently been questioned. The presence of a significant number of manic/hypomanic symptoms in patients with recurrent unipolar depression seems to challenge the traditional dichotomy of unipolar-BP disorder. Two highly unstable personality features, i.e., the cyclothymic temperament (CT) and borderline personality disorder, have been found to be more common in BP disorder than in major depressive disorder. Aim: The aim was to assess the distributions of the number of mood spectrum, CT, and borderline personality items between two groups. Finding no bimodal distribution (a “zone of rarity”) of these items would support a continuity between the two disorders. Methods: Forty euthymic BP disorder patients and forty unipolar depression patients were administered the Structured Clinical Interview for the Mood Spectrum, which assesses lifetime symptoms, traits, and lifestyles that characterize threshold and subthreshold mood episodes. CT was assessed using Temperament Evaluation of Memphis, Pisa, Paris and San Diego-A relative to CT and borderline personality trait (BPT) was assessed using Structured Clinical Interview for DSM Disorders II personality questionnaire relative to BPT. The distribution of the number of CT and BPT items was studied by Kernel density estimate. Result: Patient with recurrent depression endorsed manic/hypomanic items though less than BP group. However, the Kernel density estimates distributions of the number of hypomanic/manic items, CT and BPT items in the entire sample had a normal-like shape (i.e. no bimodality). Conclusion: Normal-like curves in the distributions of mood symptoms, number of CT and BPT items in the entire sample, suggest significant amount of overlap of these characteristic in both the groups. Using the bimodality approach, continuity between BP and major depressive disorder (MDD) seems to be supported, questioning the current categorical splitting of BP and MDD based on classic diagnostic validators.
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Comparative study of psychiatric manifestations among Type I and Type II diabetic patients p. 342
Rupesh Chaudhary, Pankaj Kumar, Akhil Chopra, Sandeep Chabbra, Parminder Singh
DOI:10.4103/IJPSYM.IJPSYM_35_17  
Background: Anxiety and depressive disorders belong to the most common psychiatric disorders worldwide. They are generally seen in individuals who suffer from chronic diseases, such as diabetes mellitus (DM). The prevalence of depression among diabetics ranges from 8.5% to 32.5%, while that for anxiety it is up to 30%. In this study, we try to compare the mental health problems faced by those with Type I and Type II DM. Materials and Methods: Fifty patients diagnosed with Type I diabetes (T1D) and Type II diabetes each presenting to Medicine and Endocrinology Department were assessed with Hamilton Depression Rating Scale (HAM-D) for depression and Hamilton Anxiety Rating Scale (HAM-A) for anxiety. Patients were assessed on sociodemographic profile, duration of illness, type of treatment and then the data were analyzed on different domains. Results: On the assessment of patients with HAM-D a total of 38% with T1D were found to be depressed, and 42% patients with Type II diabetes had depression. Similarly, on assessment of anxiety with HAM-A, a total of 44% with T1D had anxiety. In patients with Type II diabetes, a total of 34% patients suffer from anxiety. Conclusion: The study concludes that Type I and Type II are slightly different in terms of associated psychiatric illnesses. In those with psychiatric illness, they do less well in terms of improving their overall diabetes control. The wider implication is that all the patients with diabetes should be regularly assessed for psychological problems. There needs to be greater psychological/psychiatric support available to intensive diabetes clinics.
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CASE REPORTS Top

Postherpetic neuralgia presenting as delusional parasitosis: A case series p. 347
Shailendra Mohan Tripathi, Priti Singh, Nisha Mani Pandey
DOI:10.4103/0253-7176.207347  
Delusional parasitosis (DP) or Ekbom's disease is a rare psychiatric condition where the sufferers have a firm-fixed belief of insects crawling over their skin. The condition may be primary monosymptomatic hypochrondrical delusion or secondary to an underlying psychiatric or organic condition. We present two cases of elderly men presenting with classical symptomatology of DP, which is found to be secondary to postherpetic neuralgia following an acute episode of shingles or herpes zoster infection. One patient responded to a combination of antipsychotic, olanzapine, and pregabalin, used for neuropathic pain, and the other patient responded completely with medications used for neuropathic pain only without any antipsychotic use.
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Cabergoline-induced mania in a patient of pituitary microadenoma p. 350
Satyakam Mohapatra, Mihir Ranjan Nayak
DOI:10.4103/0253-7176.207314  
Cabergoline, a dopamine agonist agent, is commonly used in the treatment of hyperprolactinemia, Parkinson's disease, restless leg syndrome, and antipsychotic-induced prolactin elevation. It is generally well tolerated as compared to other dopamine agonist agents due to its more selective D2 receptor agonistic effect. We present a case of a 25-year-old female who developed manic episode, following the use of cabergoline for treatment of pituitary microadenoma. We suggest that physicians should carefully screen patients before initiating cabergoline therapy and at-risk patients may benefit from more frequent monitoring and cessation of therapy at the earliest safe juncture.
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Hypokalemia with trifluoperazine at therapeutic dose p. 352
Sajjadur Rehman, Dhruba Jyoti Chetia
DOI:10.4103/0253-7176.207315  
This case report outlines a rare presentation of hypokalemia with therapeutic doses of trifluoperazine in a patient with schizophrenia. Although there was comorbid diabetes mellitus in the patient, its effect was ruled out subsequently. On recovery, rechallenge with trifluoperazine resulted in the same effect at a milder level. No cardiac abnormalities were detected with the presentation. Naranjo adverse drug reaction probability scale reported definite relation with the drug.
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Online methods of managing auditory hallucinations: A new trend to understand psychopathology p. 354
Manoj Kumar Sharma, Poornima Mahindru
DOI:10.4103/0253-7176.207316  
Treatment seekers use various coping methods to reduce the distress associated with auditory hallucinations. With the increase use of technology, the technology means are also in use to manage the auditory hallucination. The current report documents the implications of technology means for the management of auditory hallucinations. The user was assessed using clinical interview, internet addiction test, problematic online gaming questionnaire, and screening questions for technology addiction. It showed the use of technology to manage the auditory hallucinations. Psychotherapy work revealed a reduction in their use of technology means at follow-up. It implies to evolve the therapeutic use of technology means and development of alternative therapeutic means to manage the auditory hallucinations.
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Sleeping beauty syndrome: A case report and review of female cases reported from India p. 357
Naresh Nebhinani, Navratan Suthar
DOI:10.4103/0253-7176.207319  
Kleine–Levin syndrome (KLS), also called “Sleeping beauty syndrome” is a rare, disorder predominantly reported in adolescent males, characterized by recurrent episodes of hypersomnia and to various degrees, hyperphagia, cognitive disturbances, and hypersexuality. Here, we are reporting a case of a middle-aged female, with 16 years delay in diagnosing KLS, poor response to most of the psychotropics, except good response to a combination of lithium, sertraline, and modafinil for last 12 months and also reviewing other female cases with KLS reported from India.
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Rumination disorder: An unexplained case of recurrent vomiting p. 361
Bhaktishree Raha, Swapanjit Sarma, Pradeep Thilakan, Zarine Maria Punnoose
DOI:10.4103/0253-7176.207323  
Rumination disorder or rumination syndrome is an infrequent clinical presentation reported in infants and young children as well as adults worldwide. Studies calculating prevalence and etiological considerations are very few, and the scientific literature mostly consists of anecdotal case reports and series. Awareness of this clinical entity is obscured by presentations mimicking upper gastrointestinal disorders, mostly recurrent vomiting. The repetitive, voluntary, habitual nature of this disorder is vulnerable to be missed out if not looked for specifically in the history. Here lies the importance of increasing the awareness about diagnosis of this disorder and the need to operationalize treatment guidelines for this disorder which has long-term physical, psychological, and economic consequences if not treated early in its course.
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Olanzapine-induced neuroleptic malignant syndrome p. 364
Pradeep Kumar Saha, Abhijit Chakraborty, Avik Kumar Layek, Aritra Chakraborty
DOI:10.4103/0253-7176.207320  
Neuroleptic malignant syndrome (NMS) is a life-threatening adverse effect usually seen with typical antipsychotic drugs. Rarely, NMS can occur with atypical antipsychotics also. A 19-year-old male diagnosed as a case of acute and transient psychotic disorder developed NMS, following the treatment with an atypical antipsychotic, olanzapine 20 mg/day. The patient was diagnosed NMS, an offending agent olanzapine was immediately withdrawn, and prompt treatment by maintaining hydration and giving bromocriptine produced recovery.
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Multimodal hallucinations in a visually impaired elderly female: Is it a variant of Charles Bonnet syndrome? p. 366
Sukanto Sarkar, Eswaran Subramanium, Kirti Nath Jha
DOI:10.4103/0253-7176.207331  
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.
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Converging neurobiological evidence in primary polydipsia resembling obsessive-compulsive disorder p. 369
Karthick Subramanian, Tess Maria Rajan, Vikas Menon, Ravi Philip Rajkumar
DOI:10.4103/0253-7176.207327  
Compulsive water drinking can have phenomenological and pharmacotherapeutic similarities with obsessive-compulsive disorder (OCD). Substantiating neurobiological evidence is lacking for such an association. We report a patient who was referred with a diagnosis of primary polydipsia with no signs of organic pathology in structural neuroimaging. However, positron emission tomography revealed basal ganglia hypometabolism indicating that primary polydipsia with compulsive water drinking is neurobiologically related to OCD. The diagnostic complexities displayed by primary polydipsia and the use of systematic evaluation with supporting neuroimaging evidence in reaching a reliable diagnosis are discussed. The neurobiological evidence will foster the treatment decisions for starting anti-OCD measures when clinicians encounter patients with primary polydipsia exhibiting compulsive patterns of drinking. Nevertheless, such findings need to be replicated in future studies with a larger sample size.
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“Radio inside my head”: A curious case of early onset “stuck song syndrome” or obsessive-compulsive disorder with predominant musical obsession p. 373
Subrata Naskar, Robin Victor, Kamal Nath, Hasina Anjuman Choudhury
DOI:10.4103/0253-7176.207333  
Musical obsessions also called “stuck song syndrome” is a topic of limited research. It is among the most poorly understood and rare phenomenology. There are only a few cases reported across the world which describes it. Subjects usually present with complaints of continuous play of a musical tune in the head which the subject is unable to remove. Because of its similarity in presentation with auditory musical hallucination, it presents a diagnostic dilemma to the clinician. Here, we present the case of a 25-year-old man who presented with this particular phenomenon, and the approach we took to manage it.
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LETTERS TO EDITOR Top

Comment on: Dance-like movements in obsessive compulsive disorder p. 376
Pooja Yudhishthir Palkar, Anand Ajit Kumthekar
DOI:10.4103/0253-7176.207317  
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Premature ejaculation: A redundant entity in the era of somatic symptom disorder? p. 377
Arghya Pal, Rudraprasad Acharya
DOI:10.4103/0253-7176.207324  
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Reasons of disciplinary discharges from a tertiary care de-addiction setting in India p. 378
Siddharth Sarkar, Yatan Pal Singh Balhara, Abhinav Tewari, Jawahar Singh, Namita Gautam
DOI:10.4103/0253-7176.207321  
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Is low body mass index a risk factor for postinjection delirium/sedation syndrome? p. 380
Zarine Maria Punnoose, Parthasarathy Ramamurthy, Susan Solomon
DOI:10.4103/0253-7176.207342  
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Bipolar in women: Any gender-based difference? p. 381
Ahmed Naguy
DOI:10.4103/0253-7176.207345  
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Pimozide: An old wine in a new bottle! p. 382
Ahmed Naguy
DOI:10.4103/IJPSYM.IJPSYM_400_16  
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Shared or induced obsessive compulsive disorder: A case report with critical review p. 384
Snehil Gupta, Sathya Prakash, Pratap Sharan
DOI:10.4103/IJPSYM.IJPSYM_435_16  
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Smartphone app for management of mental disorder: Comment on usefulness in specific case of posttraumatic stress disorder p. 385
Sora Yasri, Viroj Wiwanitkit
DOI:10.4103/IJPSYM.IJPSYM_104_17  
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Baclofen and back pain: A paradoxical phenomena p. 386
Soumitra Das, Adesh Agrawal
DOI:10.4103/IJPSYM.IJPSYM_60_17  
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