Indian Journal of Psychological Medicine
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   Table of Contents - Current issue
January-February 2020
Volume 42 | Issue 1
Page Nos. 1-103

Online since Monday, January 6, 2020

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Do asians patients require only half of the clozapine dose prescribed for Caucasians? A critical review p. 1
Michael W Jann
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Do asian patients require only half of the clozapine dose prescribed for caucasians? A critical overview p. 4
Jose de Leon, Anto P Rajkumar, Arun R Kaithi, Georgios Schoretsanitis, John M Kane, Chuan-Yue Wang, Yi-Lang Tang, Shih-Ku Lin, Kyung Sue Hong, Saeed Farooq, Chee H Ng, Can-Jun Ruan, Chittaranjan Andrade
Since 1997, studies have found that Asians need lower clozapine doses than Caucasians. Caucasians with average clozapine metabolism may need from 300 to 600 mg/day to reach the therapeutic range (350 ng/ml). Thus, serum clozapine concentration-to-dose (C/D) ratios typically range between 0.60 (male smokers) and 1.20 (female non-smokers). A 2019 systematic review of clozapine levels demonstrated weighted mean C/D ratios of 1.57 in 876 East Asians and 1.07 in 1147 Caucasians (P <.001). In Asian countries, average clozapine doses are lower than 300 mg/day. After sex and smoking stratification in 5 Asian samples with clozapine concentrations, the clozapine dose required to reach 350 ng/ml in female non-smokers ranged from 145 to 189 mg/day and in male smokers, from 259 to 294 mg/day. Thus, in Asian patients with average metabolism (with no inducers other than smoking, with no inhibitors, and in the absence of extreme obesity), the dose needed for clinical response may range between 150 mg/day for female non-smokers to 300 mg/day for male smokers. Clozapine levels may help personalize dosing in clozapine poor metabolizers (PMs) and ultrarapid metabolizers (UMs). Asian PMs may need very low doses (50-150 mg/day) to obtain therapeutic concentrations. About 10% (range 2-13%) of Asians are genetic PM cases. Other PMs are patients taking CYP1A2 inhibitors such as fluvoxamine, oral contraceptives, and valproate. Temporary clozapine PM status may occur during severe systemic infections/inflammations with fever and C-reactive protein (CRP) elevations. Asian UMs include patients taking potent inducers such as phenytoin, and rarely, valproate.
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Vitamin D and depression: A critical appraisal of the evidence and future directions Highly accessed article p. 11
Vikas Menon, Sujita Kumar Kar, Navratan Suthar, Naresh Nebhinani
Background: Growing evidence points to the role of vitamin D in the pathobiology and treatment of depression. However, the evidence is inconsistent in many aspects. The objectives of this narrative review were to evaluate the state of the evidence, synthesize the knowledge gaps, and formulate recommendations for more enhanced research in this growing area. Methods: Electronic searches of MEDLINE via PubMed, Cochrane Library, and Google Scholar databases were carried out from inception till February 2019 to identify relevant English language peer-reviewed articles. Abstracts generated were systematically screened for eligibility. Included articles were grouped under three broad themes: The association between vitamin D and depression, its biological underpinnings, and trials evaluating the efficacy of vitamin D supplementation in depression. Relevant data were extracted as per a structured proforma. Results: A total of 61 articles were included in the present review. Overall findings were that there is a relationship between vitamin D and depression, though the directionality of this association remains unclear. The association appears to be driven by the homeostatic, trophic, and immunomodulatory effects of vitamin D. Evidence from supplementation trials suggest a more robust therapeutic effect on subjects with major depression and concurrent vitamin D deficiency. Conclusion: Serum vitamin D levels inversely correlate with clinical depression, but the evidence is not strong enough to recommend universal supplementation in depression. Enriching depression treatment trials with subjects having concurrent vitamin D deficiency appears to be a potential step forward in identifying subgroups who may maximally benefit from this approach.
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Repurposing potential of ketamine: Opportunities and challenges p. 22
CS Gautam, Sonia S Mahajan, Jatin Sharma, Harmanjit Singh, Jagjit Singh
Ketamine is a noncompetitive antagonist of the N-methyl-D-aspartate (NMDA) receptor which also interacts with various other receptors that account for its myriad actions. Originally approved as a general anesthetic, it is being explored to be repurposed for numerous other indications such as depressive disorders, suicidal ideation, substance-use disorders, anxiety disorders, chronic pain, refractory status epilepticus, and bronchial asthma exacerbations. Numerous trials are ongoing for the same. The nasal spray of esketamine, a more potent S (+) enantiomer of ketamine, has been approved by the United States Food and Drug Administration (USFDA) for treatment-resistant depression along with the oral antidepressants. However, there are concerns about its safety on long term use, given its psychedelic effects and potential abuse. In this review, we discuss repurposing ketamine for potential therapeutic use and about the safety concerns related to ketamine and esketamine.
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Resting state quantitative electroencephalogram power spectra in patients with depressive disorder as compared to normal controls: An observational study p. 30
Jnanamay Das, Shailly Yadav
Introduction: A significant number of quantitative electroencephalogram (qEEG) studies indicate that increased spectral activities distinguish patients with depressive disorder from control subjects. But they did not yield consistent findings in the delta, theta, alpha, or beta bands. Methods: A total of 30 drug-naïve or drug-free subjects with a depressive episode or recurrent depressive disorder were compared with 30 age, sex, education, and handedness-matched healthy controls using qEEG power spectra in six frequency bands (delta, theta, alpha, beta, slow beta, and fast beta) and total activities separately. Spectral analysis was performed on a section of 180 s of qEEG digitized at the rate of 512 samples/s/channel, and absolute powers were log-transformed before statistical analysis. Results: Statistically significant differences between the patients and normal controls were found in the delta and the total bands, while Structured Interview Guide for the Hamilton Depression Rating Scale ( SIGH-D) score predicted the fast beta spectral power at the left temporal region. In the entire region of the brain, in the theta band, lesser absolute spectral power was found in patients than normal controls, whereas in the fast beta band, it was greater. In other bands, greater powers of spectral activities were found in patients than normal controls consistently in the parietal and occipital regions. Conclusion: Various findings of qEEG absolute power spectra could demonstrate a difference between the patients with depressive disorder and the normal controls independently and efficiently. However, all the differences collectively showed stronger evidence. The findings may steer future studies to differentiate the patients with depressive disorder from controls.
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Depression outcome expectancy in primary care in Singapore: Symptom severity as a mediating determinant p. 39
Shannon Chin, Kokkwang Lim, Chee Khong Yap, Meiyin Wong
Background: Depression has been identified as the most common mental illness in Singapore. To address this growing concern, the current study focused on the population within the primary care setting since depression has been demonstrated to be highly prevalent in these patients. This study examined the possible predictors of outcome expectancy based on illness perception and depression severity. Methods: One hundred and one adult patients with depressive symptoms in primary care were recruited for a cross-sectional study. Positive outcome expectancy was measured using the Depression Change Expectancy Scale, and illness perception was measured using the Illness Perception Questionnaire Mental Health. Depression severity was derived from the Patient Health Questionnaire-9 scores extracted from the participants' medical records. Regression and mediation analyses were applied to explore possible predictors of positive outcome expectancy. Results: Regression analysis demonstrated that symptom severity, and specific dimensions under illness perception (i.e., perception of chronicity, perception of personal control, and perception of treatment control) were the most significant predictors of positive outcome expectancy. Mediation analysis found that symptom severity partially mediated the relationship between perception of chronicity and positive outcome expectancy. Conclusions: Pharmacotherapy, interventions from allied health professionals, and psychotherapeutic interventions (e.g., strategies from positive psychology, solution-focused therapy, and strengths-based cognitive behavioral therapy) that aim to directly alleviate depressive symptoms as well as improve the perceptions of chronicity, personal control, and treatment control could potentially enhance treatment benefits in primary care patients with depression.
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Sexual dysfunction in women with depression: A hospital-based cross-sectional comparative study p. 46
R Mrinalini Reddy, R Arul Saravanan, Samir Kumar Praharaj, M Thirunavukarasu
Background: There is a need to explore the sexual functioning of women with depression as one part of sexuality is that it helps in developing an intimate emotional and physical relationship with another person, and this relationship may serve as a buffer against life stresses. Our aim was to study the prevalence and types of sexual dysfunction in depressed women patients and to compare them with non-depressed women. Materials and Methods: A total of 270 participants who attended a teaching hospital were selected for the study – 135 cases and 135 controls. Sociodemographic and clinical details were collected. Mini International Neuropsychiatry Interview (M.I.N.I), Hamilton Depression Rating Scale (HAM-D), Arizona Sexual Experiences (ASEX) scale, and Female Sexual Functioning Index (FSFI) scale were used. Sexual dysfunction was assessed in both groups. Results: Among the cases, 47.40% had mild depression, 44.44% had moderate depression, and 8.15% were severely depressed. On the ASEX, 46.66% of the cases had sexual dysfunction, while it was only 8.89% among the controls. The difference in sexual dysfunction among cases and controls was statistically significant. Using the FSFI, 40% of the cases had female sexual dysfunction (FSD), and it was only 11.1% in controls. Conclusion: Sexual dysfunction was more common in females with clinical depression than in those without depression. Numerous factors can operate in the causation of FSD. This study underlines the importance of screening females with depression for FSD, for its early diagnosis and management.
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Psychiatric morbidity, cultural factors, and health-seeking behaviour in perinatal women: A cross-sectional study from a tertiary care centre of North India p. 52
Shweta Goyal, Bandna Gupta, Eesha Sharma, Pronob K Dalal, Yashodhara Pradeep
Background: Poor mental health of the mother affects her physical health and the neonate's health and development. Studies from Southern India place different estimates of perinatal mental ill-health. Cultural variables affect health-seeking behaviour and are thus important to study in perinatal women with psychiatric morbidity. Methods: A total of 281 perinatal women were screened on Edinburgh Postnatal Depression Scale (EPDS), Perinatal Anxiety Screening Scale (PASS) and Mini International Neuropsychiatric Interview version 6.0 (MINI), assisted with a clinical interview to identify psychiatric illnesses. The cultural formulation interview (CFI) of DSM-5 was applied on perinatal women having psychiatric illnesses and their caregivers. Results: A psychiatric diagnosis was present in 10.3% of perinatal women. Depression and anxiety disorders were seen in 7.12% and 1.41%, respectively. Marital discord (P < 0.0001), psychosocial stressors (P < 0.0001), and past history of psychiatric disorder (P < 0.001) were significantly higher in perinatal women with a current psychiatric diagnosis. On CFI work-related stress, the gender of the infant, low education and conflict across generations were identified as the negative aspects of the culture associated with psychiatric illness during and after pregnancy. Religion and social support were the major coping strategies, while stigma and financial problems were the major barriers to help-seeking. Conclusion: The high prevalence of psychiatric disorders and the strikingly low help-seeking are noteworthy. These findings can help in planning treatment and prevention programs for timely detection and intervention for perinatal psychiatric disorders.
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Short-term impact of hematopoietic stem cell transplantation on psychiatric morbidity and quality of life in hematological malignancies in adults p. 61
Deeksha Elwadhi, SK Khandelwal, Lalit Kumar, Atul Sharma
Background: Hematopoietic stem cell transplantation (HSCT) is an established treatment for a number of malignancies. Quality of life (QOL) is an important marker for assessing arduous treatment modalities. Diagnosis of cancer, HSCT, and the physical and psychosocial sequelae of the intensive treatment lead to a deficit in the QOL of the recipient. This study aimed to assess the impact of HSCT on psychiatric morbidity and QOL in patients with hematological malignancies. Methods: A longitudinal pre-post study was conducted at a cancer research center. Thirty patients with hematological malignancies were assessed at three different time points for psychiatric symptoms and QOL. Sociodemographic and clinical variables were collected using a semi-structured questionnaire. Comprehensive psychopathological rating scale was used to assess the psychiatric symptoms. WHO QOL Bref and cancer-specific European Organisation for Research and Treatment of Cancer Quality of life Questionnaire (EORTC-QLQ) were used to measure the quality of life.Results: The mean (SD) age of the sample was 42.3 (12.8) years, with 24 males and 6 females. Most patients reported anxiety and depressive symptoms, reaching a peak at 3 week post-HSCT. The maximum deficit in QOL scores was seen at 3 weeks, with further improvement at 3-month post-transplant. Conclusions: HSCT leads to an increase in symptoms and a decrease in QOL during the acute phase. In the long run, it leads to improvement in physical and psychological wellbeing, with improvement in QOL. The recent surge in the long-term survivors of the procedure calls for further research in this direction so as to aid in their full recovery.
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Stress and its social determinants – a qualitative study reflecting the perceptions of a select small group of the public in Sri Lanka p. 69
Buddhika Senanayake, Sumudu Indika Wickramasinghe, Sisira Edirippulige, Carukshi Arambepola
Background: Exposure to stress, especially for prolonged periods, can result in physical and mental disorders. To attribute causality to its associated disease profile, social determinants need to be identified at the population level. The objective of this study was to explore perceptions regarding stress and its probable social determinants, among a purposeful cohort of the public from Colombo district, Sri Lanka. Methods: A qualitative study using focus group discussions (FGDs) was conducted among adults. Purposive sampling was used to recruit 8--10 participants into homogenous groups. Data were collected until information saturation. A semistructured FGD guide was used to facilitate the discussions. Content analysis methods were used to analyze data. Results: Six FGDs consisting of 59 participants were conducted. Participants included primary healthcare workers, community members, village leaders, private and public sector employees, unemployed individuals, homemakers, self-employed persons, slum dwellers, and persons from affluent communities. Three main themes emerged: social, economic, and cultural factors. Social factors consisted of four sub-themes: social role or status, generation gap, disability, and unsafe environment. Economic factors included three related subthemes: poverty, unemployment, and job insecurity. Cultural factors included three subthemes: superstitious beliefs, religion and caste, marriage and dowry. Conclusion: Elements regarding stress and its social determinants among the public in Sri Lanka seem to be an amalgam of interconnected sociocultural and economic factors. However, addressing these social determinants in isolation (at an individual level) may not be feasible, as most causes appear to be outside the scope of the individual.
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Perceived stress and its epidemiological and behavioral correlates in an Urban Area of Delhi, India: A community-based cross-sectional study p. 80
Ruchira Pangtey, Saurav Basu, Gajendra Singh Meena, Bratati Banerjee
Background: Increasing stress has been recognized as a major public health problem in the developing world accelerated by an ongoing demographic, economic, and sociocultural transition. Our study objectives were to validate a Hindi version of the 10-item Perceived Stress Scale (PSS-10) and to also assess the extent of perceived stress and its correlates among an adult population in an urban area of Delhi. Methodology: A community-based cross-sectional study was conducted in an urban resettlement colony of Delhi among 480 adult subjects aged 25--65 years, during the period from January to December 2015. The PSS-10 was translated into Hindi and validated in the study population. Data was analyzed using IBM SPSS Version 25. Results: A total of 243 (50.6%) men and 237 (49.4%) women were enrolled. The scale had an acceptable level of internal consistency (Cronbach's alpha = 0.731). A principal component analysis was run on the PSS-10 data, based on which a three-component structure was accepted, which explained 61% of the total variance. The mean PSS score was 19.25 (SD = 4.50) years. Perceived stress was highest in the 35--50 age group. On multivariate analysis, low socioeconomic status and a white-collar occupation were found to be associated with increased perceived stress (P < 0.001)Conclusion: A high burden of perceived stress exists in residents of a low-income urban population in India.
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Preoperative anxiety in adult patients undergoing day care surgery: Prevalence and associated factors p. 87
Meghna Jiwanmall, Stephen A Jiwanmall, Aparna Williams, S Kamakshi, Lovisal Sugirtharaj, K Poornima, Kuruthukulangara S Jacob
Background: There is a paucity of data related to anxiety levels in patients undergoing day care surgery in India.Methods: Preoperative anxiety was assessed using Amsterdam Preoperative Anxiety and Information Scale (APAIS) 1 day before surgery and on the day of surgery, and the patients were categorized as cases (APAIS score ≥13) and controls (APAIS score <13). Sociodemographic characteristics, clinical features, and fears associated with anesthesia and surgery were also noted. Results: Out of the 399 patients recruited, 58.1% experienced significant preoperative anxiety. The fear of needles (P = 0.002), fear of waking up during the surgery (P < 0.001), and the patient's need of additional information regarding anesthesia and surgery (P < 0.001) were significantly associated with preoperative anxiety. Conclusion: A significant proportion of patients scheduled for day care surgery have preoperative anxiety. A preanesthetic workup of a patient with adequate clarification about their doubts and fears related to anesthesia and surgery is recommended to bring down the level of anxiety.
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Reaching the unreached: Insights on psychological interventions beyond the clinic–walls p. 93
Seema Mehrotra
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Chlorpromazine-induced drug reaction with eosinophilia and systemic symptoms syndrome p. 99
Shayanth Manche Gowda, KG Vijay Kumar, K Shilpa
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Sample size and its importance in research p. 102
Chittaranjan Andrade
The sample size for a study needs to be estimated at the time the study is proposed; too large a sample is unnecessary and unethical, and too small a sample is unscientific and also unethical. The necessary sample size can be calculated, using statistical software, based on certain assumptions. If no assumptions can be made, then an arbitrary sample size is set for a pilot study. This article discusses sample size and how it relates to matters such as ethics, statistical power, the primary and secondary hypotheses in a study, and findings from larger vs. smaller samples.
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