Objective: Conventional antidepressants take two weeks before their therapeutic action begins. Recent studies have reported on the rapid antidepressant effect of ketamine when given as an intravenous (I.V.) infusion. Little is known about its intramuscular (I.M.) use in depression. Hence this study was conducted to compare the safety, tolerability and efficacy of I.M. versus. I.V. ketamine in Major Depression (ICD-10). Materials and Methods: It was a randomized open label parallel group study in a tertiary care teaching hospital. Study sample consisted of 27 subjects having major depression divided randomly into three groups of nine subjects each. Ketamine administered to each group in the dose of 0.5 mg/kg as an I.V. infusion, as 0.5 mg/kg I.M. or 0.25 mg/kg I.M. respectively. Depression rated on the Hamilton Depression Rating Scale (HAM-D) before the injection, two hours later, the next day, and after three days. Data analyzed using the Statistical Package for Social Sciences (SPSS). Results: Mean age of the sample was 36.81 years (SD 11.815). Two hours after the injection, HAM-D fell by 58.86%, 60.29% & 57.36% in each group respectively. The improvement was sustained for next three days. Adverse effects noticed were rare, of mild nature and transient, lasting less than an hour. Conclusions: Intramuscular ketamine in the dose of 0.25 mg/kg is as effective and safe as 0.5 mg/kg given either I.M. or I.V., substantially alleviating depressive symptoms within a few hours and sustained for 3 days.

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Context: Early intervention in specific learning disability (SpLD) results in better outcome and prevents comorbidity. Understanding the pathways is therefore important. Aims: To study and compare the pathways to care for children with SpLD and mental retardation (MR) before reaching a tertiary care center. Settings and Design, Material and Methods: A cross-sectional study was conducted for pathways to care of two groups: SpLD and MR with 50 children in each group from 8 to 16 years. MINI-KID for comorbidity and Goldberg's pathway to care instrument was used. The groups were divided into early contact (up to three carers) and late contact (more than three carers) and compared. Statistical Analysis: Data were analyzed using Statistical Packages for Social Sciences (SPSS) version 10.0 software. Results: Majority (n = 24 or 48%) of SpLD children visited "others" (teachers, neighbors, relatives, and guardians of fellow classmates) as first carer. Allopathic practitioners were the first choice for MR children (n = 31 or 62%). Six children (12%) in SpLD group and 10 of MR (20%) group have seen either traditional practitioner or healer as first carer. Maximum referral to the tertiary center in both groups was done by others (62% in SpLD and 56% in MR group). Early contacts in SpLD group belonged to younger age group (P = 0.01). While comparing both groups on the basis of early and late contact, mother's education was found to be significant in early contact group (P = 0.036) and having comorbidity was significant among late contacts (P = 0.038). Conclusions: The pathways to care for SpLD children are more or less similar to MR children whose parents recognize MR late. Both the groups visit multiple carers including traditional healers substantiating the strong belief for supernatural causation of developmental disorders in India.

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Background: Insomnia is a common sleep disorder, characterized by difficulties in sleep initiation, sleep maintenance or early morning awakening. Although polysomnography (PSG) is a standard method in the evaluation of sleep disorders, it is not recommended for routine use in the clinical assessment of insomnia. Instead, standard questionnaires could be used in the primary evaluation of insomnia. Objective: The main object of this study was to compare the type and severity of patients' subjective complaints of insomnia gathered from insomnia severity index (ISI) questionnaire with the result of their polysomnographic evaluation. Materials and Methods: In this cross-sectional study conducted during 2010-2011 in Iran, all patients in one clinic with sleep disorders were evaluated. The study consisted of self-administered questionnaires completed by participants to provide information on demographic characteristics and ISI questionnaire. After completing the questionnaire, all the participants underwent standard overnight PSG. Results: Subjects were 151 patients (47.2 ± 10.8 years old). The average ISS was 6.1 ± 4. There was a significant relationship between the subjective complaint of difficulty in sleep initiation and sleep onset latency in PSG (r = 0.5, P < 0.001). Furthermore, there was a correlation between the subjective complaint of difficulty in sleep maintenance and number of awakening in PSG (r = 0.19, P = 0.01). A low patients' satisfaction from their sleep was associated with lower total sleep time (r = -0.2, P = 0.02) and a lower percentage of rapid eye movement (REM) sleep in their PSG study (r = -0.25, P = 0.002). No relation was found between patients' satisfaction and sleep efficiency measured with PSG (r = -0.04, P = 0.6). Conclusions: Our findings suggest that objective insomnia, measured with ISI, is related with PSG variables and ISI could be a useful tool to quantify perceived insomnia severity. Further studies are needed to determine the sensitivity and specificity of this questionnaire.

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People with depressive illness often have symptoms of overt or suppressed anger. Those with anger traits face exaggerated problem during symptomatic period of depression. Pharmacological management helps in control of depressive and anxiety symptoms, but rarely address anger symptoms. Non-pharmacological management like cognitive-behavioral therapy (CBT) is effective in depression as well as in anger management, but is not used frequently in anger associated or exacerbated by depression. We present the case of a 27-year-old male suffering from moderate depressive episode with associated anger outburst. He underwent CBT, which resulted in a significant decrease in anger symptoms as well as in severity of depression.

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Myxedema madness is a very rare but established entity. A psychotic patient having hypothyroid features should always be evaluated regarding same. A 30-year-old female without known significant past medical history had, for the past one and half year, continuous persecutory and referential delusions; second and third person auditory hallucinations, facial puffiness and Brief Psychiatric Rating Scale (BPRS) score of 41 on admission. Her thyroid profile was: Thyroid stimulating hormone - 63.71 mIU/L, Free tri iodo threonine (FT3) - 2.1 pg/ml, free tetra iodo thyronine (FT4) - 0.6 ng/ml with normal ultrasound-thyroid. Patient was started on thyroxin 100 μg with a low dose risperidone 2 mg. Risperidone was withdrawn over a week and the patient was discharged on thyroxin alone with BPRS score of 8 and absence of delusions and hallucinations.

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Bereavement reactions are associated with numerous physical and mental complications. Atypical bereavement reactions have been described but their place in the classificatory system has not been established. We present the case of an eighty-year-old woman who came with the belief that her deceased son was alive. We discuss the diagnostic dilemma she posed and conclude that it may be difficult to differentiate atypical bereavement from other psychiatric illnesses.

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Although frequently underdiagnosed, several epidemiological studies have estimated the prevalence of restless legs syndrome (RLS) in western countries at 5-15% of the general population. The diagnosis is usually made on a clinical basis, according to the criteria established by the international RLS study group. There are case reports of transient RLS in opiate withdrawal. We describe three opiate (dextropropoxyphene (DPP)) dependent young male patients; two of them had DPP intoxication/withdrawal seizure developing RLS during opiate withdrawal. However, their RLS persisted even after the remission of other withdrawal symptoms. Thyroid function test, hemogram, serum ferritin were normal in all of them. The cases responded well to a treatment with ropinirole. Hence, there might be a causal association, which required further well-designed studies to substantiate. The sleep disturbances and use of benzodiazepines can be minimized by increasing clinician's sensitivity to diagnose RLS.

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Neuroleptic malignant syndrome is an acute, life-threatening medical complication caused by antipsychotics. It is commonly seen with typical antipsychotics and very rare with atypicals. Cases have been reported with quetiapine also, but this case is of special interest because it occurred in patient who was stable on maintenance quetiapine 200 mg/day for last 5 years.

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Olanzapine, a 2 ^nd generation antipsychotic, is in use in the clinical practice for nearly a decade and a half now. It is classified as a category C drug with very few reports of its toxic effects on the fetus. In general, the risk benefit analysis warrants its use in pregnancy. We report a case of microcephaly and anopthalmos associated with the use of olanzapine in pregnancy. Although a causal role cannot be unequivocally proven, it calls for larger studies to explore this issue.

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Depressive symptoms are common in neurological diseases, at times posing dilemma in organic or functional origin. Cerebrovascular disease may predispose, precipitate, or perpetuate some geriatric depressive syndromes that resemble primary depressions both clinically and therapeutically in about half of the patients following acute stroke. Terson's syndrome is the direct occurrence of vitreous hemorrhage following subarachnoid/subdural hemorrhage, often overlooked in the acute setting. Autosomal dominant (adult) polycystic kidney disease may be associated with berry aneurysms and hypertension, and may lead to intracranial bleeds. We report an unusual case of organic depression and Terson's syndrome in a 50-year-old female with polycystic kidney disease and hypertension, following anterior communicating artery aneurysmal subarachnoid bleed with bilateral subdural extension. Management included anti-hypertensives, antiepileptics, neodymium: YAG laser photocoagulation, and aneurysmal clipping.

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Background: Despite a large body of evidence, the issue of differences in adherence and continuation of treatment with first-generation antipsychotics (FGAs) and second-generation antipsychotics (SGAs) in schizophrenia remains unresolved. This study compared adherence and continuation of treatment between patients on SGAs and FGAs and examined the influence of several socio-demographic and clinical variables on adherence in the two antipsychotic groups. Materials and Methods: Two groups, one of 40 patients with schizophrenia on SGAs and the other with 30 patients on FGAs, were compared on clinician-rated and patient-rated measures of adherence over 6 months; a 3-month period prior to intake and a 3-month follow-up period. Mean scores on these measures and the proportion of adherent/non-adherent patients was estimated for both groups. Results: The two groups did not differ in the 3-month period prior to intake. Over the subsequent 3 months of follow-up, a-fifth of the patients on FGAs became non-adherent, while about 10% of those on SGAs became more adherent. These differences in continuation rates resulted in patients on SGAs being rated as significantly more adherent at the end of this 3-month follow-up period and over the entire 6 months of the study. Differences in adherence and continuation rates between the two groups were primarily driven by the differences between olanzapine and the FGAs. Supervision of treatment by relatives emerged as the only consistent determinant of adherence, but explained only 8% of the variance. Conclusions: Patients on certain SGAs, notably olanzapine, are more likely to continue with their treatment that those on FGAs.

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Background: Substance abuse is one of the major health challenges across the globe. Adolescents are among the most affected. This study aims to examine the reasons for initiation, maintenance of harmful use of substances and abstinence among adolescents and young adults by comparing the users and non-users. Materials and Methods: Accordingly, 40 users and 40 non-users of substances, aged 15-24 years were selected through convenient sampling method. Results: It was found that most of the users had initiated substance abuse during 15-18 years of age, with peer influence, curiosity and sense of growing being the major reasons for the same. 'Feel good' and socialization were the main reasons for maintenance. The non-users never gave into substances because of personal values, awareness of the impact on health and family values. Both users and non-users had specific personal reasons for their respective behaviors. Conclusions: Young population would use substance for various psychosocial reasons despite knowing the harmful effects of substance. These findings have specific implications for preventive programs.

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Objective: Factitious disorder is amongst the more intriguing but less-studied psychological disorders. Studies from different parts of the world have reported of varying prevalence rates. Here, we try to study the prevalence of factitious disorder in a specific sample of patients attending a neuropsychiatric center in India. Materials and Methods: We did a retrospective review of our institute's database for cases with a diagnosis of factitious disorder in the 10-year duration from 2001 to 2010. We reviewed the available clinical and socio-demographic data. Results: Of the 81,176 patients seen in the 10-year duration, only 8 patients had been assigned the diagnosis of factitious disorder, leading to a prevalence rate of 0.985 per 10,000 patients in this sample. Most of the patients were lost to follow-up; hence. Conclusion: Factitious disorder remains highly underdiagnosed in developing countries like India. Mental health professionals need to be more aware and inquisitive about this particular disorder, so that they do not miss the diagnosis.

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Background: The aim of the present study was to evaluate the effect of risperidone in patients afflicted by autistic disorder especially with regards to its three core symptoms, including "relating to others", "communication skills", and "stereotyped behaviors" based on Childhood Autism Rating Scale (CARS). Materials and Methods: An 8-week open-label study of risperidone for treatment of autistic disorder in children 4-17 years old was designed. Risperidone dose titration was as follow: 0.02 mg/kg/day at the first week, 0.04 mg/kg/day at the second week, and 0.06 mg/kg/day at the third week and thereafter. The outcome measures were scores obtained by CARS, Aberrant Behavior Checklist (ABC), and Clinical Global Impression-Improvement (CGI-I) scale. Results: Fifteen patients completed this study. After 8 weeks, CARS total score decreased significantly, (P=0.001). At the end of the study, social interactions and verbal communication skills of the patients were significantly improved (P<0.001, P=0.03, respectively). However, stereotypic behaviors did not show any significant change in this study. Increase in appetite and somnolence were the most reported side effects. Conclusion: This study suggests that risperidone may be an effective treatment for the management of core symptoms of autistic disorder.

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Background: The complex interaction of human, vehicle and environmental factors along with a lack of sustainable preventive programs has contributed to the "silent epidemic" of traumatic brain injuries (TBI). TBI poses a grave threat to the quality-of-life (QOL). Aim: The aim of the present study was to examine the effects of neurofeedback in QOL in patients with TBI. Materials and Methods: Pre- and post-interventional study design was adopted. Sixty patients, 30 in the intervention group (IG) and 30 in waitlist group with the diagnosis of TBI in the age range of 18-49 years were assessed on QOL scale, after obtaining the informed consent. Patients in the IG were given 20 sessions of alpha-theta neurofeedback training (NFT), 5 sessions / week. Statistics Analysis: Descriptive statistics, Spearman's correlation, Mann-Whitney and Chi-squared test was used. Results and Conclusion: Patients in the IG showed statistical improvements in QOL post post-neurofeedback. Results are encouraging for the incorporation of NFT into treatment programs for patients with TBI in improving QOL.

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Context: Mechanism of action of electroconvulsive therapy (ECT) is unclear. Anticonvulsant action of ECT has also been one among the hypothesized mechanisms. Anticonvulsant effect may manifest during ECT in at least two ways (a) increased seizure threshold (b) decrease in seizure duration. In depression, increased seizure threshold has been shown to be associated with better antidepressant response. However, relationship between seizure duration and antidepressant activity has been inconsistent. These issues are not investigated in conditions other than depression. Aims: We examined seizure duration over the course of ECT in schizophrenia patients. Settings and Design: Material for this analysis was obtained from a clinical trial examining the differential efficacy of bifrontal ECT (BFECT) versus bitemporal ECT (BTECT) in schizophrenia patients. As a part of study 122 schizophrenia patients who were prescribed ECT were randomized to receive either BFECT or BTECT. Subjects and Methods: Final analysis was conducted on data from 70 patients, as the rest of the data either had artifact or there was a significant change in medication status. Electroencephalogram seizure duration was noted in each session for these patients. Results: Seizure duration declined significantly from second ECT to 6 ^th ECT (repeated measures analysis of variance F = 4.255; P = 0.006). When separate analysis was conducted for BTECT and BFECT patients the decline in seizure duration from 2 ^nd to 6 ^th ECT was significant only with BFECT (F = 3.94; P = 0.014) and not with BTECT (F = 0.966; P = 0.424). Conclusions: Better anticonvulsant effects with BFECT may explain the better therapeutic observed with BFECT in schizophrenia as well as mania in our earlier studies.

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Background: Youth indulgence themselves in various aggressive behaviors leading to significant psychosocial dysfunctions. The present study assesses the prevalence of aggression among youth and to assess the risk factors of aggression among youth. Materials and Methods: Anger Data sheet, Resilience Scale and Buss-Perry Aggression Scale, were administered on 5476 participants using survey design. Data was collected from different communities (college, residential, apartments and workplace) of Bangalore, Jammu, Indore, Kerala, Rajasthan, Sikkim and Delhi. 47% were female and 53% were male. The mean age of the sample was 20.2 years. Comparative analysis was carried out by Pearson correlation coefficient and Chi-square was also carried out. Results: About 17.7% of the youth has high mean aggression score on Buss-Perry Aggression Scale. Males have high mean score on aggression than females. Males experienced more verbal aggression, physical aggression and anger than females. Younger age group (16-19 years) experienced more aggression than older age group (20-26 years). The risk factors of the youth aggressions were identified as physical abuse in childhood, substance abuse such as alcohol and tobacco, negative peer influence, family violence, academic disturbance, psychological problems attention deficit-hyperactivity disorder, suspicious, loneliness, mood disturbance, negative childhood experience and TV and media. Conclusion: The study document, the presence of correlates of risk factors of aggression among youth and implies usages of management strategies to help them to handle aggression.

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Hippocampal deficits are an established feature of schizophrenia and are complementary with recent evidences of marked allocentric processing deficits being reported in this disorder. By "Cognitive mapping" we intend to refer to the concepts from the seminal works of O'Keefe and Nadel (1978) that led to the development of cognitive map theory of hippocampal function. In this review, we summarize emerging evidences and issues that indicate that "Cognitive mapping deficits" form one of the important cognitive aberrations in schizophrenia. The importance has been placed upon hippocampally mediated allocentric processing deficits and their role in pathology of schizophrenia, for spatial/representational cognitive deficits and positive symptoms in particular. It is modestly summarized that emerging evidences point toward a web of spatial and cognitive representation errors concurrent with pronounced hippocampal dysfunction. In general, it can be stated that there are clear and consistent evidences that favor the cognitive mapping theory in explaining certain deficits of schizophrenia and for drawing out a possible and promising endophenotype/biomarkers. Further research in this regard demands attention.

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Pet assisted therapy (PAT) is a form of complementary psychosocial intervention used in the field of mental health and disability. The form of therapy has the potential to augment the other forms of psychotherapies and pharmacotherapy. This article is an overview of history and clinical origins of PAT, classification and therapy models, scientific basis, the current use in specific disorders, preventive and diagnostic role as well as the potential risks among children and adolescents with mental health needs with a special focus on the Indian needs. A systematic electronic search strategy was undertaken to identify the intervention effectiveness of PAT in MedLine (PubMed), cochrane database of systematic reviews, high-wire press and Google Scholar. We augmented our electronic search with a search of additional articles in reference lists of retrieved articles, as well as a hand search available journals that were not indexed in any electronic database in consultation with colleagues and experts. To qualify for inclusion, studies were required to meet predetermined criteria regarding study design, study population, interventions evaluated and outcome measured to reduce the publication bias.

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Pain is a commonly experienced complaint in the general population. It aims to determine the occurrence of pain complaints among the general population as well as the clinical group. The sample for the current study was drawn from the ongoing study on development of NIMHANS Screening tool for psychological problems. It includes males and females (119 males and 110 normal and 200 males and 100 clinical subjects) above age 18 years. Subjects were assessed on the question related to frequent experience of body ache and headache in the past one week in an individual setting. Data was analyzed using percentage scores. It indicate that 27% (16% in females and 11% in male) experience pain in the normal group, whereas in clinical categories, 14.5% of anxiety disorder (9.5% in females and 5% in males), 13.9% of depression (8.9% in females and 5% in males), 17.9% of obsessive compulsive disorder (OCD) (8.5% in females and 9.4% in males) and 13.9% of substance users reported pain in last seven days. It implies the need for sensitization among professionals and general population to identify pain complaints.

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