Indian Journal of Psychological Medicine
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   Table of Contents - Current issue
January-February 2019
Volume 41 | Issue 1
Page Nos. 1-101

Online since Friday, January 4, 2019

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A year on: The changes we introduced and the common mistakes encountered Highly accessed article p. 1
Shahul Ameen, Samir Kumar Praharaj, Vikas Menon
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A critical look at the methodology of epidemiological studies p. 6
Sandeep Grover, Samir Kumar Praharaj
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Predominant polarity in bipolar affective disorder: A scoping review of its relationship with clinical variables and its implications p. 9
Arghya Pal
Background: Bipolar affective disorder (BPAD) is an episodic psychiatric disorder that is associated with considerable morbidity. Psychiatrists have found it difficult to treat the disorder owing to the variety of presentation and variety of challenges in clinical decision-making. To guide the clinicians, the concept of predominant polarity (PP) in BPAD has become important. This review was conducted to understand the definition, epidemiology, relationship with sociodemographic and clinical parameters, and implications of PP in BPAD. Methodology: The review was conducted after selecting 17 original research studies from PubMed using appropriate search terms. Results: There is no consensus definition of PP. Epidemiological data showed varied results, although most common PP demonstrated in most studies was depressive polarity. The relation between sociodemographic and clinical parameters also lacked uniformity, although certain patterns could be identified in their relationships. The implications of PP in diagnostics, treatment, and classificatory system are discussed. Conclusion: PP in BPAD conveys clinically important information that aids a clinician in decision-making. Further studies are required so that we can understand the neurobiological underpinning of the concept.
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Expressed emotion research in India: A narrative review p. 18
Anvar Sadath, Ram Kumar, Magnus Karlsson
Background: Expressed emotion (EE) is detrimental to patients with schizophrenia, mood disorders, eating disorders and many other psychiatric and neurological disorders. However, majority of the EE literature is generated from the west, and the results of those studies may have limited application in Indian setting. Hence, we conducted this review with the main aim of understanding EE research in India and its potential role in the course and outcome of psychiatric disorders and other chronic illnesses. Methods: Using keywords, we performed searches of electronic databases (PubMed, IndMed, PsychInfo, Science-Direct and Google Scholar) and internet sources and a manual search in the bibliography of the retrieved articles to identify potential original research articles on EE in India. Results: As per the selection criteria, 19 reports of 16 studies were included and reviewed. The sample size of the EE studies ranged from 20 to 200, and majority of the studies were conducted in psychosis/schizophrenia, followed by obsessive compulsive disorder and epilepsy. Although high EE was found in most of the studies, the impact of EE on illness outcome is not well explored and only two studies examined the relationship between EE and relapse. Discussion and Conclusion: There is a dearth of studies on EE, especially its relationship with relapse or clinical outcomes in the Indian context. We recommend more studies in these areas which may be helpful for clinical decisions and advancement of context knowledge in EE.
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Mental disorders in ethnic community: A prevalence study from thakali community of Nepal p. 27
Devavrat Joshi, Pawan Sharma, Ananta P Adhikari, Praveen Bhattarai, Mohan R Shrestha, Basudev Karki
Introduction: Mental disorders are common and major source of disability around the world. Though Nepal lacks national data on the prevalence of mental disorders, many studies have been conducted in specific groups of people. The Thakali community is one of the indigenous communities of Nepal. We aim to look at the prevalence of mental disorders in this group. Materials and Methods: This is a cross-sectional study with multiphasic sampling conducted in the Thakali community in six distinct geographical regions of Nepal. The first stage was a household survey done by field researchers using screening questionnaires to detect a probable diagnosis of mental disorders. The second stage was detailed clinical assessment and diagnosis (ICD-10) by two independent psychiatrists. Results: Among the 917 participants, after the first phase, a probable diagnosis (as per the screening questionnaire) was found to be 12.5%. After the psychiatrists' assessment and addition of already diagnosed cases, the prevalence was 6.1%. In both the cases, prevalence of alcohol use disorder was comparatively higher (34.8% and 31.9%, respectively). Conclusion: Despite many shortcomings, this study has provided an estimate of the prevalence and pattern of mental disorders among an indigenous Nepalese community. We emphasize the need of validation of tools for Nepal and estimation of prevalence at the national level.
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Prevalence of depression in an urban geriatric population in Marathwada region of Western India p. 32
Mamta S Rathod, Jagannath V Dixit, Akhil D Goel, Vikas Yadav
Background: Depression is a common problem in the elderly but is often undetected and ignored as a medical problem, leading to poor quality of life. This community-based study was conducted to know the burden and risk factors of depression among the elderly. Subjects and Methods: The survey was done in 2015 in Maharashtra, India as a part of an initiative addressing community mental health needs of the elderly. Total 400 elderly, aged 60 years and above, were selected through a house-to-house survey, using probability proportional to size method, and interviewed for depression using Major Depression Inventory Scale (MDI Scale), and other potential risk factors using a pretested questionnaire. Results: A total of 16.75% elderly had depression. Increasing age (Spearman's rho = 0.112, P = 0.026), illiteracy (OR = 2.23; 95% confidence interval, CI 1.22–4.07), lack of sleep (OR = 2.97; 95% CI 1.73–5.09), and leisure time spending alone (OR = 0.57, 95% CI 0.34–0.98) were found to be associated with depression. However, on multivariate analysis, only sleep duration <6 h was found to be associated [AOR = 2.6; 95% CI 1.4–4.6]. Conclusions: There is a considerable burden of depression in the elderly, reemphasizing the need for regular screening for this disorder and its risk factors.
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Prevalence and correlates of current alcohol use among bhutanese adults: A nationally representative survey data analysis p. 38
Kinley Wangdi, Tshering Jamtsho
Background: Alcohol-related ailments are among the 10 leading causes of morbidity and mortality in Bhutan. The objectives of this article were to determine the prevalence and explore the correlates of current alcohol use among Bhutanese adults. Materials and Methods: This is a retrospective study of secondary data from the National Health Survey 2012 of Bhutan. The outcome variable of interest was current alcohol use. The questionnaire was developed following the World Health Organization (WHO) STEPwise approach to Surveillance (STEPS) of noncommunicable diseases. Univariate and multivariate logistic regression was performed to identify the correlates of current alcohol use. The prevalence of current alcohol use was 30.9%. The correlates of current alcohol use were male sex [adjusted odds ratio (AOR) = 1.85; 95% confidence interval (CI) 1.47–2.36], widowhood (AOR = 2.92, 95% CI, 1.22–6.99), and chewing betel quid >20 times per week (AOR = 2.07, 95% CI, 1.08–4.03). Primary (AOR = 0.67, 95% CI, 0.50–0.91), high (AOR = 0.52, 95% CI, 0.38–0.71), and university (AOR = 0.46, 95% CI, 0.29–0.73) educated participants were less likely to be current alcohol users when compared with those who had no education. Compared with unskilled workers, services and sales workers were less likely to use alcohol regularly (AOR = 0.64, 95% CI, 0.49–0.82). Homemade alcohol Ara was the most common drink. Conclusion: The national prevalence of current alcohol use in Bhutan is higher than the national average in the WHO South-East Asia Region. Prevention should target the correlates and limit the availability of locally home-brewed Ara.
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Factors associated with depression among school-going adolescent girls in a District of Northern India: A cross-sectional study p. 46
Mukesh Shukla, Siraj Ahmad, Jai Vir Singh, Nirpal Kaur Shukla, Ram Shukla
Context: Depression among adolescents, especially among girls, is a rising public health problem worldwide. It has been associated with a profound negative impact on their physical, social, and mental well-being. Aim of the Study: To ascertain the factors associated with depression among school-going adolescent girls in district Barabanki of Uttar Pradesh. Settings and Design: School-based cross-sectional study. Subject and Methods: The study was conducted among 2187 school-going adolescent girls (10–19 years) in Barabanki district from September 2016 to September 2017 using multistage sampling. Sociodemographic characteristics such as age, residence, family background, and socioeconomic status were assessed through direct interview of the adolescent girl, with its reconfirmation from school records. Eleven-item Kutcher Adolescent Depression Scale was used for assessment of depression. Statistical Analysis Used: Probability (P) was calculated to test for statistical significance at 5% level of statistical significance. Association between risk factors and depression was determined using bivariate analysis followed by multivariate logistic regression. Results: The prevalence of depression was found to be 39.7%. Multiple logistic regression revealed that depression was significantly higher among those residing in rural areas [odds ratio (OR) 3.32; P < 0.001], those in early and mid-adolescent age group (OR 2.51; P < 0.001), those studying in private schools (OR 3.22; P < 0.001), and those with Hindi as the medium of instruction (OR12.50; P < 0.001). Depression was also found to be significantly higher among those whose mothers were educated up to primary (OR 3.19; P < 0.01) or up to intercollege (OR 1.59; P < 0.001) when compared with illiterate mothers. Similarly, depression was found to be more common among those girls whose fathers were educated up to intercollege (OR 1.29; P < 0.05) or were graduate and above (OR 1.58; P < 0.001). Conclusion: A significant proportion of school-going adolescent girls were suffering from depression, which reflects the need for reinforcement and strengthening of school-based mental health screening programs. Parents, teachers, and community health workers should work as a team to deal with the problem in a more effective way.
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Magnitude of mental morbidity and its correlates with special reference to household food insecurity among adult slum dwellers of Bankura, India: A cross-sectional survey p. 54
Sanjay K Saha, Parthapratim Pradhan, Dibakar Haldar, Baisakhi Maji, Widhi Agarwal, Gautam N Sarkar
Background: Mental disorders cause considerable morbidity and disability, and there is ample evidence that mental disorders are positively associated with household food insecurity. Methods: A cross-sectional survey was conducted for a period of 2 months at Bakultala slum of Bankura town involving 152 people of ≥18 and ≤60 years of age selected using simple random sampling technique to estimate the prevalence of mental disorders and to find out its correlates. Information pertaining to socio-demographics and household food security (HHFS) and “ potential psychiatric case” were collected through a house to house interview of the head of the household, using predesigned questionnaire, Bengali version of self-reporting questionnaire, and 6-item household food security scale (HFSS). Results: In total, 45% of the study participants belonged to food unsecured households. Overall, 21% of the respondents were identified as “potential psychiatric case,” which was found to be associated with higher age, illiteracy, divorcee female, and people living in households without food security. Conclusion: Study results reflecting high prevalence (21%) of “potential psychiatric case” with various correlates such as age, sex, education, marital status, and HHFS among the slum dweller of Bankura town may be helpful in formulating policies for combating mental health morbidities.
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Stressful life events and relapse in bipolar affective disorder: A cross-sectional study from a tertiary care center of Southern India p. 61
Sivin P Sam, A Nisha, P Joseph Varghese
Background: Bipolar affective disorder (BAD) is a severe mental illness which results in serious lifelong struggles and challenges. The full impact of stressful life events (SLEs) on the course of BAD is poorly understood. Materials and Methods: A cross-sectional study was conducted on 128 consecutive patients with BAD currently admitted with a relapse. Our objectives were (1) to estimate the proportion, type, and timing of preonset SLEs in relapsed BAD patients and (2) to study the association between SLEs and selected clinical variables in this group. Semi-structured proforma, Young Mania Rating Scale, Hamilton Rating Scale for Depression, Presumptive Stressful Life Events Scale, and Brief Psychiatric Rating Scale were used. Statistical analysis was done using R software for Windows. Results: About 69.5% (89/128) of patients reported preonset SLEs – among which 50 (56.2%) had mania and 39 (43.8%) had depression. Conflict with in-laws and financial problems were the commonly reported SLEs. The mean duration between SLEs and the relapse was 19.73 ± 4.8 days. BPRS score was significantly high in subjects with preonset SLEs (P = 0.022). No significant association was detected between SLEs and the type of episode during relapse (P = 0.402). Conclusion: This study emphasizes the significance of SLEs in the relapse and longitudinal course of BAD. Understanding the association of SLEs and relapse in BAD will help in predicting further relapses and developing newer pharmacological and nonpharmacological measures targeting this aspect, thereby maximizing both symptom reduction and quality of life in patients with BAD.
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Pathways to care for patients with Bipolar-I disorder: An exploratory study from a tertiary care centre of North India p. 68
Anamika Sahu, Vaibhav Patil, Sumedha Purkayastha, Raman Deep Pattanayak, Rajesh Sagar
Introduction: Understanding the pathways to psychiatric care is important from a public health perspective. Only a few Indian studies have focused on this, particularly for severe mental disorders. The present study was planned to assess it in patients with Bipolar-I disorder (BD-I). Materials and Methods: Sixty-four patients with DSM 5 diagnosis of BD-I and their caregivers were included. A semi-structured interview proforma was used to gather information. Results: Psychiatrists were the first care provider in 43.8% of the cases, followed by traditional faith healers (32.8%) and general physician/neurologists (17.2%). The median duration of untreated bipolar disorder (DUB) was 21 days (1 day to 152 months). Relatively long DUB (3.5 ± 3.5 years) was found for 17.2% of the sample. The median duration of the first contact with a psychiatrist was 45 days and the interval between the contact with the first care provider and a psychiatrist was 90 days (1 day to 151 months). At the time of first treatment seeking, 64% of patients and caregivers had poor awareness regarding psychiatric treatment. Conclusions: Patients with BD-I seek help from psychiatrists, faith healers or other medical practitioners for multiple reasons. There is a need to sensitise the community and various service providers about early identification and optimum management of BD-I.
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Illness perception of anxiety patients in primary care in Singapore p. 75
Chee Khong Yap, Mei Yin Wong, Kok Kwang Lim
Background: The majority of people with anxiety tend to seek help in primary care. Patients' illness perception regarding their own anxiety can influence the assessment, treatment processes, and outcomes. This cross-sectional study explored possible relationships between patients' illness perception of their anxiety and the severity of their anxiety. Materials and Methods: Ninety-five patients with anxiety were recruited at two primary care clinics in Singapore. Their responses to the generalized anxiety disorder-7 (GAD-7) and illness perception questionnaire mental health (IPQ-MH) were examined with Spearman's rho correlation coefficients and multiple regression analyses. Results: Four illness perception subscales, i.e., consequences (rs = 0.23), personal control (rs= –0.27), coherence (rs= –0.22), and biological (rs = 0.34) significantly correlated to anxiety (P < 0.05). A multiple regression analysis identified that attribution to biological factors (β = 0.348, P =0.001) and attribution to personal control (β = -0.262, P =0.008) were significantly associated with anxiety. Conclusions: Interventions for anxiety reduction in primary care can be enhanced with methods that promote (1) patients' awareness of the reasons for their anxiety beyond mostly bodily ones to include psychosocial ones and (2) patients' confidence in their own capacity to influence their recovery.
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Sexual dysfunction among men in rural Tamil Nadu: Nature, prevalence, clinical features, and explanatory models p. 81
KS Vivekanandan, P Thangadurai, J Prasad, KS Jacob
Background and Aim: There is a dearth of community data on nature, prevalence, clinical features, and explanatory models related to sexual dysfunction among men, particularly from rural India. This study attempted to examine different aspects of male sexual dysfunction and misconceptions in the community. Materials and Methods: Villages in Kaniyambadi Block, Vellore district were stratified, and four were randomly selected. Men living in these villages were recruited for the study. The following instruments were administered: (i) International Index of Erectile Function, (ii) Chinese Index of Premature Ejaculation (iii) Short Explanatory Model Interview, and (iv) Revised Clinical Interview Schedule. The data were analyzed using standard bivariate and multivariate statistics. Results: A total of 211 men were recruited. The majority were middle-aged (mean 40.73 years), literate (84.8%), married, and with children (72%), from nuclear families (99.6%), followed the Hindu religion (87.7%), reported satisfaction with their marriage (51.2%), had a single sexual partner (99.5%), and practised contraception (88.2%). A minority reported erectile dysfunction (29.9%), premature ejaculation (19.4%), and depression/anxiety (30.8%). Erectile dysfunction was associated with single marital status (P < 0.001), premature ejaculation (P < 0.001), worry about nocturnal emission and loss of semen (P < 0.02), and punishment by God as causal beliefs (P < 0.001). Premature ejaculation was associated with diabetes mellitus (P < 0.05), alcohol use (P < 0.05), anxiety and depression (P < 0.01), guilt about masturbation (P < 0.001), and belief that nocturnal emission is causal (P < 0.001) and erectile dysfunction (P < 0.05). Conclusion: Sexual misconception and dysfunction in men are significant problems in rural communities in India. They mandate the need for sex education in schools and the empowerment of physicians in primary and secondary care to manage such problems.
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Early diagnosis and intervention for autism spectrum disorder: Need for pediatrician–child psychiatrist liaison p. 87
Harshini Manohar, Preeti Kandasamy, Venkatesh Chandrasekaran, Ravi Philip Rajkumar
Background: Early interventions in children with autism spectrum disorder (ASD) reduce progressive symptom development. Delay in diagnosis and initiation of ASD-specific interventions is observed across settings. This study aimed to assess the trends in time to diagnosis and treatment initiation in a tertiary care pediatric setting. Methodology: Families of children with ASD (n = 50) were assessed, and details regarding age at first symptom recognition, medical consultation, receiving the diagnosis, and initiation of treatment were collected, in addition to detailed clinical assessment. Results: About 70% of families met a pediatrician for initial concerns, and 20% received a diagnosis of ASD from the first-contact pediatrician. The mean age at initial symptom recognition was 22.22 ± 9.47 months, whereas the first consultation was 27.22 ± 10.83 months. The mean age at initiation of ASD-specific interventions was 36.58 ± 10.2 months, amounting to an overall delay of 14.38 months from initial symptom recognition to treatment initiation. The time delay in our study is found to be lesser compared with similar studies across settings. Discussion: Pediatricians have a significant role to play in early diagnosis and care of children with ASD in close liaison with child psychiatry teams. Improving awareness, routine screening, and prompt referral of children “at-risk” for ASD are imperative. Initiating ASD-specific interventions in pediatric or primary care settings is an effective alternative to curtail the delay in treatment initiation.
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Psychiatrist's perspective: Invited commentary on “Early diagnosis and intervention for autism spectrum disorder: Need for pediatrician–child psychiatrist liaison” p. 91
Varghese P Punnoose
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Comments on “leisure time physical activity and risk of developing depression among the youth of Kangra District, Himachal Pradesh, India” p. 93
Satish Suhas, Rahul Kumar Chakravarty, Ramdas Ransing, Naresh Vadlamani, Chittaranjan Andrade
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Authors' responses to the comments on “leisure time physical activity and risk of developing depression among the youth of Kangra District, Himachal Pradesh, India” p. 94
Mitasha Singh, Piyush Sharma, Des Raj, Shailja Sharma, Ankush Kaushal, Sunil K Raina
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Comments on “prevalence and predictors of abuse in elderly patients with depression at a tertiary care centre in Saurashtra, India” p. 95
Jitendra Rohilla, Charan S Jilowa, Akash Kumar, Mrinal Jha, Khwaja Khayyam
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“I stopped hearing voices, started to stutter” – A case of clozapine-induced stuttering p. 97
Sachin Nagendrappa, Vanteemar S Sreeraj, Ganesan Venkatasubramanian
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Multiple testing and protection against a type 1 (false positive) error using the Bonferroni and Hochberg corrections p. 99
Chittaranjan Andrade
In a given study, if many related outcomes are tested for statistical significance, one or more outcomes may emerge significant at the P < 0.05 level not because they are truly significant in the population but because of chance. The larger the number of statistical tests performed, the greater the risk that some of the significant findings are significant because of chance. There are many ways to protect against such false positive or Type 1 errors. The simplest way is to set a more stringent threshold for statistical significance than P < 0.05. This can be done using either the Bonferroni or the Hochberg correction. Using the Bonferroni correction, 0.05 is divided by the number of statistical tests being performed and the result is set as the critical P value for statistical significance. Using the Hochberg correction, the P values obtained from the different statistical tests are arranged in descending order of magnitude, and each P value is assessed for significance against progressively more stringent levels for significance. The Bonferroni and Hochberg procedures are explained with the help of examples.
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Erratum: Comments on “specific learning disabilities: Issues that remain unanswered” p. 101

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