Background: Psychiatric advance directives have been incorporated in the Mental Health Care Act 2017 despite strong concerns about their feasibility and utility in the Indian patient population. Data on its utility in India is very scarce. Aims: To determine the possible treatment options our clients make as a part of psychiatric advance directives. Materials and Methods: Fifty consecutive individuals with severe mental illness were interviewed using a self-designed semi-structured tool to find out the possible choices they make as part of advance directives and the factors affecting their choices. Results: About 10% of the participants failed to understand the concept of advance directives. Of those who understood, 89% were willing to make advance directives, 15% refused future hospitalizations, 47% refused future electroconvulsive therapies (ECTs), and 62% refused physical restraints in future. Conclusion: The majority of the participants agreed to make advance directives. The majority of those who agreed to make advance directives refused to undergo ECTs and physical restraints in future episodes of illness. Approximately 10% of the patients could not understand the concept of advance directives.

Context: Cognitive impairments are common among patients with alcohol dependence. It may involve frontal executive dysfunction, global cognitive impairments, or both. Motivation to quit alcohol involves recognition of alcohol use as a problem. This ability may be construed as a cognitive symptom. Aims: The aim is to study the frequency of cognitive dysfunction among patients with alcohol dependence and to study the association between cognitive dysfunction and the motivation to quit alcohol. Materials and Methods: Fifty-six adult males with alcohol dependence (International Classification of Diseases-10) who had completed a course of detoxification and who did not have active withdrawal symptoms or acute medical illnesses were recruited for this study. Their cognitive functions were tested using the Montreal Cognitive Assessment (MoCA) and Frontal Assessment Battery (FAB). Their motivation levels were assessed using the Stages of Change Readiness and Treatment Eagerness Scale. Clinical details were collected using a semi-structured pro forma. Results: Global cognitive impairment (MoCA <26) was seen in 81% and frontal executive dysfunction (FAB <12) in 16% of patients. Higher MoCA and FAB scores correlated with better education, while lower FAB scores correlated with higher age. The 14 patients (25%) with good motivation did not differ in age, education, years of dependence, or MoCA or FAB scores from poorly motivated patients. FAB scores, but not MoCA, were associated with poor motivation. All nine patients with FAB <12 were poorly motivated to quit alcohol; likelihood score = 5.731, P = 0.017. Conclusions: Four-fifths of patients with alcohol dependence had global cognitive impairments after the detoxification period. One-sixth had frontal executive dysfunction. Cognitive functions were not significantly correlated with the duration of dependence. Presence of frontal executive dysfunction was associated with almost six times likelihood that the patient will be poorly motivated to quit alcohol.

Background: The role of craving in alcohol dependence and its relationship with relapse has been studied widely in the past decade. The present study was undertaken to assess the role of craving in short-term relapse of patients seeking treatment for alcohol dependence and changes in craving score at the end of detoxification and at follow-up. Materials and Methods: A total of 34 male individuals with alcohol dependence (excluding comorbid drug dependence, organic or psychiatric disorder), after detoxification and discharge, consented. No anticraving medicine, aversive or psychotherapy, was advised. They were diagnosed on the International Statistical Classification of Diseases-10 using Diagnostic Interview for Genetic Studies. Severity of Alcohol Dependence Questionnaire (SADQ) and Clinical Institute Withdrawal Assessment Scale–Alcohol-Revised (CIWA-AR) were administered at the time of admission. Penn Alcohol Craving Scale (PACS) was applied at the time of discharge and follow-up to measure craving for alcohol. Results: Out of a total of thirty patients analyzed after dropout, 21 relapsed at the end of 1 month. On comparing PACS scores between relapsed and nonrelapsed patients, the difference was significant at both time points, i.e., at discharge and follow-up (t = 4.15, P < 0.0001 and t = 4.01, P < 0.001, respectively). In the total sample, SADQ and CIWA-AR scores were positively correlated (r = 0.47, P = 0.009). PACS at discharge was compared with PACS at follow-up, of which the correlation was high (r = 0.832, P < 0.0001). Conclusion: Craving seems to be a main factor related to relapse. Its measurement with PACS can be a useful tool to predict subsequent drinking and to identify individual risk for relapse during treatment.

Background: Prevalence of both domestic violence (DV) and alcohol use is reported to be high in Kerala. The prevalence of DV and psychological morbidity in spouses of alcohol-dependent males has not been studied objectively. Methods: This cross-sectional study was undertaken to study the occurrence of DV and psychological morbidity–major depressive disorder (MDD), anxiety disorders, and adjustment disorders–in spouses of alcohol-dependent males attending the de-addiction center of a tertiary care hospital in South India. Sixty consecutive cases, aged 18–55 years, were recruited after getting informed consent. They were assessed using Domestic Violence Questionnaire (DVQ), Mini International Neuropsychiatric Interview Schedule, and a questionnaire to assess adjustment disorder. The association of DV with psychological morbidities was also studied. Results: DV was reported by 41 (68.3%, 95% confidence interval [CI] = 55.0–79.7) cases. At least one psychiatric morbidity was observed in 51 (85.0%, 95% CI = 72.9–92.5) cases–MDD in 15 (25.0%, 95% CI = 15.1–38.1), anxiety disorders in 6 (10%, 95% CI = 4.1–21.2), and adjustment disorder in 32 (53.3%, 95% CI = 40.1–66.1) cases each. No statistically significant association was observed between DV and any of the psychiatric disorders. However, DVQ scores showed significant correlation with years of marriage (Pearson's r = 0.268, P < 0.05) and with stressful life events over the past 1 year (Pearson's r = 0.424, P < 0.05). Conclusions: High rates of DV and psychological morbidity were seen in spouses of alcohol-dependent males.

Background: Patients with schizophrenia hold a variety of explanatory models of illness that influence different aspects of their life including their understanding of the disease, ability to cope and sense of well-being. Aim: To study the association of explanatory models and quality of life in patients with schizophrenia. Materials and Methods: One hundred and thirty consecutive patients with schizophrenia attending a psychiatric outpatient clinic were recruited in the study and administered the Positive and Negative Symptom Scale (PANSS), the modified Short Explanatory Model Interview (SEMI) and the World Health Organization Quality of Life-BREF (WHOQOL-BREF) Scale to assess severity of psychosis, explanatory models of illness, and quality of life. Sociodemographic and clinical details of patients were also recorded. Standard bivariate and multivariable statistics were employed. Results: Higher quality of life scores were associated with better socioeconomic conditions and lower scores on negative and general psychopathology subscales of PANSS. Quality-of-life scores were significantly higher in patients who did not perceive their illness to have negative effects on the different domains of their functioning. Conclusion: Explanatory models of illness are associated with perceived quality of life in patients with schizophrenia. There is a need to focus on attitudes, perceptions and functioning, rather than symptom reduction alone, to enhance the quality of life in schizophrenia.

Background: Risperidone is one of commonly utilized antipsychotic in clinical practice. Various metabolizing enzymes effect the plasma levels of risperidone and its active metabolite and thus its clinical efficacy. So, we attempted to evaluate the relationship between CYP2D6*10 (rs1065852) and CYP2D6*4 (rs3892097) gene polymorphism and the plasma concentration of risperidone and its metabolite in patients with schizophrenia. Methodology: It was a 12-week prospective study carried out in patients diagnosed with schizophrenia. The dose of risperidone was increased weekly by 1 mg and rating of psychopathology was done using Positive and Negative Syndrome Scale (PANSS). Quantification of plasma level of risperidone and 9-hydroxyrisperidone was carried out at week 6 and 12 of treatment. The *4 and *10 alleles of CYP2D6 were genotyped and their effect on metabolism of risperidone was assessed. Results: The number of CYP2D6*4 alleles affected the plasma levels of risperidone, 9-hydroxyrisperidone at 6 weeks of treatment but not at 12 weeks. On the other hand, the number of mutated alleles for CYP2D6*10 influenced the dose corrected plasma concentration of risperidone and active moiety at 12 weeks of treatment. The ratio of plasma concentration of risperidone and 9-hydroxyrisperidone was more than one in all study participants, thus, suggesting that they were poor metabolizers of risperidone. Conclusion: The polymorphism of CYP2D6*10 affects the steady state plasma concentration of risperidone in Indian patients with schizophrenia.

Introduction: Antepartum anxiety and depression are two of the most common risk factors for the development of postpartum depression. Women are at a higher risk of developing depression and suffering from mental disorders during pregnancy and the postnatal period. Psychopathological symptoms during pregnancy have physiological consequences for the fetus, such as impaired blood flow leading to low birth weight, as well as cognitive delay and behavioral problems. Objectives: To screen antenatal women for common mental health disorders and to determine the factors associated with mental health disorders during pregnancy. Methods: A cross-sectional study among 208 pregnant mothers in the third trimester attending the antenatal clinic at a Government Maternity Home in a low-income urban area of Bengaluru was conducted using clinical interview schedule-revised (CIS-R) questionnaire as a screening tool for detecting the presence of mental morbidity. Data collected were analyzed using SPSS version 16. Results: In the study population, 12 (5.8%) screened positive for antepartum mental morbidities, of which depression was the most common. 3.8% of all women screened positive for depression, with 15.4% demonstrating depressive symptoms. Overall, 82 (39.4%) had the presence of one or more psychological symptoms, including fatigue, irritability, anxiety, and problems with sleep and concentration but scored less than the CIS-R cutoff score of 12. Factors associated with the presence of antepartum mental morbidities included poor relationships with their spouse, poor/satisfactory relationship with siblings or in-laws, as well as the desire to have a male child. Conclusion: In the study population, 12 (5.8%) screened positive for antepartum mental morbidities. Considering the effects on quality of life for these women as well as poor fetal outcomes associated with maternal mental morbidity, it is important to include screening and treatment of mental morbidity as a part of routine antenatal care.

Background: Psychiatric disorders are ubiquitous and affect not only adults but also children and adolescents. The age factor plays an important role in the pattern of these psychiatric disorders. The objective of our study was to find the pattern of psychiatric morbidity in children and adolescents at the child and adolescent outpatient service of a tertiary care hospital. Materials and Methods: A semi-structured questionnaire was used to record the sociodemographic status. The state of mental health and psychiatric morbidity was assessed after a thorough clinical assessment. Intelligence quotient was assessed by a clinical psychologist as and when needed. All the diagnoses were made on the basis of Diagnostic and Statistical Manual of Mental Disorders, 4^th Edition, Text Revision criteria. Results: A total of 529 patients were included. Most patients belonged to the age group of 6–16 years (70.5%). Boys (67.9%) outnumbered girls. Most of the patients were from rural background (56.7%) and from nuclear families (53%). Attention-deficit hyperactivity disorder (31%) and mental retardation (29%) were the most frequent diagnoses, followed by pervasive developmental disorders (10%). Comorbidity was present in about 18% of our patients. Conclusion: The child psychiatry is gaining acceptance, and children and adolescents with minor mental health issues are being identified and referred for specialized services.

Context: In India, psychiatrist is an important point of helpseeking for sexual complaints. A detailed sexual history can go a long way in understanding sexual difficulties. In this background, there is inadequate information on the difficulties that psychiatry postgraduate trainees experience while taking a sexual history as part of a routine mental health evaluation. Aims: The aim was to study the difficulties experienced by postgraduate psychiatry trainees while taking sexual history as a part of routine mental health evaluation. Setting: This study was conducted in an Indian medical college general hospital psychiatry setting. Materials and Methods: This is a qualitative study using focus group discussions and in-depth interviews with postgraduate psychiatry trainees. Statistical Analysis: Content analysis was used to identify direct and latent themes. Results: Thematic saturation was achieved with 17 participants. Major themes of difficulties that emerged included trainee-related factors such as gender and sociocultural background of the trainee; patient-related factors such as age, gender, and sexual orientation; setting-related factors; and language-related difficulties. Conclusions: Specific and regular training in taking a sexual history is essential in addressing the difficulties faced by postgraduate psychiatry trainees in India.

Background: Empathy is a desirable quality in every clinician. It is a crucial determinant of patient–physician communication and relation. There are very few existent Indian studies on empathy of medical students and its correlates. Aim: The aim of the study was to assess empathy level of medical students and its correlates. Methodology: It was a cross-sectional, hospital-based, analytical observational study conducted from July to November 2017. In total, 249 undergraduate medical students of a medical college of Kolkata were interviewed with a structured schedule. The schedule comprised of the sociodemographic questionnaire, career satisfaction, future career choice, and Jefferson Scale of Empathy. Results: The mean empathy score was 98.5 ± 12.5. Third-semester students had higher empathy scores (102.4 ± 12.4) compared to fifth (97.2 ± 12.9) and seventh semester (95.0 ± 10.9) students. The difference between the mean scores of different semesters was statistically significant. Female students were more empathic than male students. In the multivariable linear regression model, sex, semester, residence, career satisfaction, future career choice, and current place of living were significant predictors of empathy scores. Conclusion: Empathy level of medical students of our study was quite low compared to other studies conducted outside India. Empathy eroded with semester, which supports earlier pieces of evidence in this regard.

In this case series, we report three cases of alopecia associated with use of methylphenidate for ADHD (Attention deficit hyperactivity disorder), that reversed with discontinuation of methylphenidate.

Papillon–Lefèvre syndrome (PLS) is an autosomal recessive disorder that presents with palmoplantar hyperkeratosis and childhood-onset progressive loss of all dentition. Mental retardation is the only neurodevelopmental disorder reported with this condition till date. We report the first ever case in the literature of PLS presenting with psychotic depression and suicidal intention. A 40-year-old, never married, unemployed woman presented for psychiatric consultation and was given an International Classification of Diseases version 10 diagnosis of severe depression with psychotic symptoms. Physical examination warranted dermatological and dental evaluation before electroconvulsive therapy (ECT) could be administered. She was diagnosed with PLS and pseudoainhum by the skin and dental specialists. Karyotyping study was normal, and histopathology of the palmar tissue showed hyperkeratinization. She was treated with ECT, duloxetine and olanzapine, and she achieved full remission of her depression. She was prescribed oral retinoids and emollients for the skin disorder, and there was a good improvement. The dental prosthesis was fixed, and she was able to eat and feel better than before. Early diagnosis of this condition and rehabilitation would be important in improving wellbeing.

Clozapine is superior to all other antipsychotics in treatment-resistant schizophrenia. However, metabolic side effects are common while treating patients with clozapine. Administering clozapine in a patient who already is diabetic involves careful weighing of risks and benefits. Here, we report our experience of starting clozapine in a known diabetic patient. Clozapine was started in a patient with treatment-resistant psychosis in view of suicidal risk. Her diabetes mellitus was under good control with oral medications. After initiation of clozapine, blood sugars increased several fold within few days. Blood glucose continued to increase even with high doses of insulin and insulin infusion. Finally, blood sugars came under control only after discontinuation of clozapine. Precautionary measures while initiating clozapine in a diabetic patient are suggested – close monitoring of blood sugar during the initial few days and intensive intervention if blood sugar levels increase. Discontinuation of clozapine should also be kept in mind as a last resort.

Lithium induced primary hyperparathyroidism is an uncommon endocrine side effect of long term lithium therapy. We studied the case of a 67-year-old female patient on long term lithium therapy for bipolar affective disorder, who developed resistant hypercalcaemia and parathyroid adenoma which required parathyroidectomy. Furthermore, the effect of chronic lithium therapy on parathyroid glands and serum calcium levels, its pathogenesis, and management were reviewed. Periodic monitoring of serum calcium levels in patients on long term lithium therapy should be practiced. Surgical removal of the affected parathyroid gland is an effective treatment modality in selected patients with resistant hypercalcaemia and parathyroid adenoma and/or hyperplasia. However, regular post-operative follow up is needed for early identification of recurrence in such patients.

A recent study found that maternal antenatal depressive symptoms were associated with adverse infant general health outcomes and that gestational age, birth weight, and breastfeeding did not mediate the observed relationship. The authors suggested that antenatal depression can have a harmful effect on infant health through disturbed fetal programming driven by maternal symptoms and behaviors that influence the maternal and hence the fetal internal environment. The authors implied that interventions to diagnose and treat maternal depression can have a protective effect against disturbances in infant health. However, because of the observational nature of the study, cause–effect relationships cannot be conclusively stated. This is especially so because there were many confounds that the authors did not consider. The present article provides examples and explanations of how inadequately measured, unmeasured, and unknown confounds can explain observed relationships between explanatory and outcome variables, thereby negating cause–effect interpretations of study findings. It is important to minimize confounding when conducting observational studies, and this can only be done by comprehensively listing and efficiently measuring potential confounders in advance.