Indian Journal of Psychological Medicine
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   2011| January-June  | Volume 33 | Issue 1  
    Online since September 26, 2011

 
 
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NEW HORIZON
Utility of repetitive transcranial stimulation as an augmenting treatment method in treatment-resistant depression
Venu Gopal Jhanwar, RJ Bishnoi, MR Jhanwar
January-June 2011, 33(1):92-96
DOI:10.4103/0253-7176.85406  PMID:22021964
About 30 to 46% of patients with major depressive disorder (MDD) fail to fully respond to initial antidepressants. Treatment-resistant depression (TRD) is a severely disabling disorder with no proven treatment options; novel treatment methods like rTMS can be used as augmentation to ongoing pharmacotherapy or as a solitary method of treatment. To evaluate the utility of repetitive transcranial magnetic stimulation as an augmenting method in TRD. In an open-label study, 21 patients with DSM-IV MDD without psychotic features who had failed to respond to an adequate trial of at least 2 antidepressants were given rTMS therapy for 4 weeks, keeping the dose of pre-existing antidepressants unchanged. High-frequency (10 Hz) stimulations were delivered over left dorsolateral prefrontal cortex at intensity of 110% of patient's motor threshold. Treatment response was defined as a reduction in score on the Hamilton Rating Scale for Depression (HAM-D) from baseline to end of treatment. Secondary efficacy measures included scores on the Clinical Global Impressions-Change and -Severity scales. At the end of 4 weeks, 19 patients completed the 4-week study and were assessed. In ITT analysis, the mean HAM-D17 scores were reduced from 30.80±5.00 to 19.00±6.37 (t=8.27, P<0.001). Only four patients reported headache, but there was no discontinuation due to adverse effects. The study indicates the potential utility of rTMS as an augmenting agent in TRD. Adequately powered, randomized controlled trials are necessary to evaluate the role of rTMS in TRD.
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ORIGINAL ARTICLES
Repetitive transcranial magnetic stimulation in the treatment of depression: A randomized, double-blind, placebo-controlled trial
Anand Lingeswaran
January-June 2011, 33(1):35-44
DOI:10.4103/0253-7176.85393  PMID:22021951
Background: The efficacy of repetitive transcranial magnetic stimulation (rTMS) in the treatment of depression has never been reported as yet in the Indian literature. Aims: To study the efficacy of rTMS in the treatment of depression and to evaluate its safety and tolerability. Settings and Design: A randomized, double-blind, sham-controlled trial was conducted at the Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore. Materials and Methods: 23 patients with depression were randomized to receive either active (n=9) or sham (n=14) treatment with rTMS. Treatment consisted of six sessions of rTMS for 2 weeks (10 trains of pulses, intensity equal to motor threshold, 10 Hz frequency, train duration of 5 seconds, 1 minute inter-train duration). Response was assessed using Hamilton Depression Rating Scale (HDRS), Montgomery Åsberg Depression Rating Scale (MADRS) and Clinical Global Index (CGI). The safety and tolerability was assessed with side-effect checklist for electroconvulsive therapy. 50% reduction in HDRS scores from baseline was defined as treatment response. Outcome measures were analyzed by repeated measures analysis of variance. Chi-square test was used to analyze the categorical variables. Results: No statistical significance was seen on the baseline socio-demographic and illness characteristics (Pearson's Chi-square=0.5). Although HDRS (sham 22.0-12.4; active 22.8-12.7) and MADRS (sham 30.7-17.3; active 31.8-16.7) scores reduced by the end of 2 weeks treatment, it was not statistically significant. One patient developed manic symptoms early in the treatment. Conclusions: Treatment with rTMS did not show improvement at the end of 2 weeks. More studies with larger sample size and with higher rTMS dosages need to be done.
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Drug utilization study of psychotropic drugs in outdoor patients in a teaching hospital
KG Piparva, DM Parmar, AP Singh, MV Gajera, HR Trivedi
January-June 2011, 33(1):54-58
DOI:10.4103/0253-7176.85396  PMID:22021954
Background: Psychotropic drugs have had a remarkable impact in psychiatric practice. However, their utilization in actual clinical practice, effectiveness and safety in real life situation need continuous study. Materials and Methods: A prospective cross sectional study was carried out for 6 months. Patients of all ages and both sexes were included in the study while in-patients, referred patients and patients of epilepsy were excluded. Using World Health Organization basic drug indicators, the prescribing pattern was analyzed. Results: The numbers of psychotropic drugs prescribed per patient were 2.96. Anti-anxiety drugs (82.83%) were most frequently prescribed psychotropic drugs in various psychiatric disorders. Usage of antipsychotic drugs was in 70.15% cases. Atypical antipsychotic drugs (43.83%) were prescribed more frequently than the typical antipsychotic drugs (26.32%). Prescribing frequency of selective serotonin reuptake inhibitors (36.66%) was more than the tricyclic antidepressant (21.96%) and atypical antidepressant drugs (1.83%) in major depression. Use of mood stabilizers was restricted only to bipolar mood disorders. Central anticholinergic drug was co-prescribed in as many as 88.15% patients receiving antipsychotic drugs. Conclusion: Anti-anxiety drug (Benzodiazepine (BZD)) usage was extensive in various psychiatry disorders. Rational use of BZD requires consideration/attention to dose and duration of usage as well as drug interactions with other psychotropic drugs. Routine use of central anticholinergic drug along with atypical antipsychotic drugs also, could not be justified.
  3 2,675 205
CASE REPORTS
A giant trichobezoar causing rapunzel syndrome in a 12-year-old female
Nadeem Ul Nazeer Kawoosa, Babar Rashid Zargar
January-June 2011, 33(1):77-79
DOI:10.4103/0253-7176.85401  PMID:22021959
Bezoar is a tightly packed collection of undigested material that is unable to exit the stomach. Most bezoars are of indigestible organic matter such as hair-trichobezoars; or vegetable and fruit-phytobezoars; or a combination of both. Trichobezoars commonly occur in patients with psychiatric disturbances who chew and swallow their own hair. In very rare cases, the Rapunzel syndrome hair extends through the pylorus into the small bowel causing symptom and sign of partial or complete gastric outlet obstruction. A case report of trichobezoar in the stomach causing Rapunzel syndrome in a 12-year-old female is reported.
  2 10,055 71
ORIGINAL ARTICLES
Stress and social support
Shadiya Baqutayan
January-June 2011, 33(1):29-34
DOI:10.4103/0253-7176.85392  PMID:22021950
Background: This is an experimental study and it discusses the effectiveness of social support in managing academic stress among students. Aim: The purpose of this study is to understand the importance of social support in managing stress. Materials and Methods: Simple random sampling was assigned to a number of 120 students, equally divided into an experimental and a control group. Classes on social support as coping mechanisms were given to the experimental group only. The accumulated data were then analyzed, descriptive statistics were used to interpret and evaluate the prevalence of academic stress, and social support. Correlation analysis was employed in the examination of the relationship between stress and social support. Results: The findings of this study indicate that there are significant differences between the experimental group and the control group in relation to stress and social support. Eventually, the experimental group proved to cope with academic stress better than the control group, and they were satisfied with their academic performance during the experimentation. Conclusion: Hence, it is highly advisable to encourage the students to use social support as coping mechanisms.
  2 4,659 147
REVIEW ARTICLES
Management of bipolar depression
Jae Seung Chang, Kyooseob Ha
January-June 2011, 33(1):11-17
DOI:10.4103/0253-7176.85390  PMID:22021948
Patients with bipolar disorder spend more time in a depressed than manic state, even with individualized treatment. To date, bipolar depression is often misdiagnosed and ineffectively managed both for acute episodes and residual symptoms. This review attempts to summarize the current status of available treatment strategies in the treatment of bipolar depression. For acute and prophylactic treatment, a substantial body of evidence supports the antidepressive efficacy of lithium for bipolar disorders and its antisuicidal effects. Among numerous anticonvulsants with mood-stabilizing properties, valproate and lamotrigine could be first-line options for bipolar depression. Due to receptor profile, mood-stabilizing properties of second-generation antipsychotics have been explored, and up to date, quetiapine and olanzapine appear to be a reasonable option for bipolar depression. The usefulness of antidepressants in bipolar depression is still controversial. Current guidelines generally recommend the cautious antidepressant use in combination with mood stabilizers to reduce the risk of mood elevation or cycle acceleration. Results from clinical trials on psychosocial intervention are promising, especially when integrated with pharmacotherapy. Most patients with bipolar depression need individualized and combined treatment, although the published evidence on this type of treatment strategy is limited. Future studies on the utility of currently available agents and modalities including psychosocial intervention are required.
  2 3,550 142
Management of bipolar II disorder
Michael M.C Wong
January-June 2011, 33(1):18-28
DOI:10.4103/0253-7176.85391  PMID:22021949
Bipolar II disorder (BP II) disorder was recognized as a distinct subtype in the DSM-IV classification. DSM-IV criteria for BP II require the presence or history of one or more major depressive episode, plus at least one hypomanic episode, which, by definition, must last for at least 4 days. Various studies found distinct patterns of symptoms and familial inheritance for BP II disorder. BP II is commonly underdiagnosed or misdiagnosed. Making an early and accurate diagnosis of BP II is utmost importance in the management of BP II disorder. The clinician should have this diagnosis in mind when he is facing a patient presenting with mood problems, particularly unipolar depression. Quetiapine and lamotrigine are the only agents with demonstrated efficacy in double-blind RCT. Although the evidence for the use of lithium in long-term therapy is largely based on observational studies, the many years of close follow-up, comparatively larger subject numbers, and 'harder' clinically meaningful with bipolar disorder outcomes measures, enhance our confidence in its role in treating BP II. With respect to short-term treatment, there is some limited support for the use of risperidone and olanzepine in hypomania and for fluoxetine, venlafaxine and valproate in treating depression. The current clinical debate over whether one should use antidepressants as monotherapy or in combination with a mood stabilizer when treating BP II depression is not yet settled. There is a need for large, well-designed RCTs to cast more definitive light on how best to manage patients with BP II disorder.
  2 3,548 109
Measurement of autism: A review of four screening measures
Nishalie Fernandopulle
January-June 2011, 33(1):5-10
DOI:10.4103/0253-7176.85389  PMID:22021947
Using a key word search on electronic databases, two relevant journals and relevant review references, four measures of autistic symptoms (Childhood Asperger Syndrome Test, Autism Behavior Checklist, Social Communication Questionnaire, Social Responsiveness Scale) were reviewed with reference to their ability to discriminate the three major components of autism and measure across the whole spectrum of autism. None of the reviewed measures were able to effectively tap into and differentiate between all points on the spectrum. Further work is required to assess the sensitivity of the measures to independence between domains. The development of a measure sensitive to symptom change/continuity across development may be useful.
  2 4,093 122
CASE REPORTS
Delayed onset, protracted delirium and aspiration pneumonitis associated with a combination of clozapine and electroconvulsive therapy
N Manjunatha, GS Ram Kumar, R Vidyendaran, K Muralidharan, JP John
January-June 2011, 33(1):80-82
DOI:10.4103/0253-7176.85402  PMID:22021960
Few studies reported the efficacy and safety in combination of clozapine and electroconvulsive therapy (ECT) in schizophrenia; systematic studies are lacking. Side effects like seizure, and confusional state are reported. Authors report two cases of delayed onset/protracted delirium with ECT and clozapine in schizophrenia, one of whom developed aspiration pneumonitis possibly due to clozapine hyper-salivation. Delirium improved with stopping of ECT and clozapine. Clozapine monotherapy restarted to previous dosages in both cases without recurrence of delirium. Authors recommend for careful monitoring for delirium in ECT augmentation on high dose clozapine. Unilateral ECT may be preferred for augmenting clozapine.
  1 1,753 45
Munchausen syndrome masquerading as bleeding disorder in a group of pediatric patients
Srivani Sridharan, Deepak Shukla, Ritambhara Mehta, Rajat Oswal
January-June 2011, 33(1):86-88
DOI:10.4103/0253-7176.85404  PMID:22021962
This short communication is about Munchausen's syndrome in a group of pediatric patients and co morbid Munchausen's syndrome by proxy. A 7-year-old girl presented with spontaneous bleeding from forehead, eyes and scalp. The girl was investigated thoroughly by pediatricians at a tertiary care hospital in western India for all possible bleeding disorders, but there was no conclusive diagnosis. After two days, cases with similar complaints were reported among children residing in the same locality and with similar socioeconomic background. All of them were investigated in detail for possible causes of bleeding but nothing came out. There was a media reporting of the cases as a mysterious bleeding disorder. At this point of time, an expert opinion from the psychiatrist was demanded. Covert video surveillance and series of interviews revealed Munchausen's syndrome and possible Munchausen's syndrome by proxy. An in-depth literature review with special reference to Munchausen's syndrome was carried out to come to a final conclusive diagnosis.
  1 2,003 55
LETTERS TO EDITOR
Is chronic mania a distinct clinical entity?
Gurvinder Pal Singh, KC Jindal
January-June 2011, 33(1):97-98
DOI:10.4103/0253-7176.85407  PMID:22021965
  1 1,188 49
ORIGINAL ARTICLES
Effectiveness of bifrontal ECT in practice: A comparison with bitemporal ECT
Biju Viswanath, Janardhanan C Narayanaswamy, Jagadisha Thirthalli, BN Gangadhar
January-June 2011, 33(1):66-70
DOI:10.4103/0253-7176.85398  PMID:22021956
Background: Bifrontal (BF) placement of electrodes in electroconvulsive therapy (ECT) has emerged as an alternative option to the conventional bitemporal (BT) and right unilateral electrode placement in view of fewer cognitive adverse effects. However, the results have been contradictory in terms of clinical efficacy. Materials and Methods: We studied the records of all patients referred for ECT between the months of August 2008 and July 2010 (n=1575). One hundred and five of these patients had received BF-ECT. These records were compared with the records of 105 patients who received BT-ECT. For each patient who received BF-ECT, the very next person posted for BT-ECT was taken as the control. All patients received bilateral ECTs at 1.5-times the threshold stimulus dose. The number of ECTs administered, duration of hospital stay after ECT initiation, seizure threshold and failure to achieve adequate seizures were compared. Two raters who achieved good inter-rater reliability assessed the initial severity using the clinical global impression scale and clinical improvement using a Likert scale. Results: The speed of response, as assessed by the number of ECTs received and the duration of hospital stay after ECT initiation was similar in the two groups. In addition, both groups were comparable in terms of clinical improvement scores on the Likert scale. BF-ECT patients also had a significantly higher seizure threshold, which remained significant in spite of controlling for age. This study is chart based, with its inherent limitations. Standard outcome measures were not used. Cognitive adverse effects were not studied. Conclusions: BF-ECT performed similar to BT-ECT with regard to therapeutic efficacy. Given the consistent results of the former, with fewer cognitive side-effects, the findings of the present study support BF-ECT as the first line for electrode application.
  1 1,678 58
CASE REPORTS
Visual hallucinations in mania
Arindam Chakrabarty, MS Reddy
January-June 2011, 33(1):71-73
DOI:10.4103/0253-7176.85399  PMID:22021957
Visual hallucinations occur in a wide variety of neurological and psychiatric disorders, including toxic disturbances, drug withdrawal syndromes, focal central nervous system lesions, migraine headaches, blindness, schizophrenia, and psychotic mood disorders. Visual hallucinations are generally assumed to characteristically reflect organic disorders and are very rare in affective disorders. Here, we present a case of visual hallucinations in a young female with bipolar illness during the manic phase.
  - 1,957 59
Intense suicidal thoughts and self-harm following escitalopram treatment
Farooq Khan, Morris Bernadt
January-June 2011, 33(1):74-76
DOI:10.4103/0253-7176.85400  PMID:22021958
In a minority of depressed patients, treatment with an antidepressant drug appears to initiate intense suicidal thoughts and actions. We describe this phenomenon in a 52-year-old woman treated with escitalopram. She did not experience this when treated with six other antidepressants, which were not Selective Serotonin Reuptake Inhibitors. Clinicians need to warn patients and their relatives of the risk that intense suicidal thoughts may develop after an antidepressant drug is started and encourage them to seek help immediately should this occur.
  - 1,435 52
Obsessive compulsive disorder with bipolar mood disorder: A rare comorbidity in India
Bindu Annigeri, Rajesh Raman, Rashmi Appaji
January-June 2011, 33(1):83-85
DOI:10.4103/0253-7176.85403  PMID:22021961
Obsessive compulsive features occurring in mania have been well documented. Though there have been some studies on obsessive compulsive disorder (OCD) comorbid with mania in the western countries, there are very few case reports and studies in India. Our aim is to report one such case here, who presented with OC features which are not typical of the symptom cluster of the OCD commonly seen with mania in earlier reports. Also, the comorbidities in OCD should be recognized as this can have important diagnostic and therapeutic implications.
  - 2,317 119
A unique case of pica of adult onset with interesting psychosexual aspects
Suddhendu Chakraborty, D Sanyal, R Bhattacharyya
January-June 2011, 33(1):89-91
DOI:10.4103/0253-7176.85405  PMID:22021963
Pica has been considered as the ingestion of inedible substances or atypical food combinations. Pica has been reported widely in pediatric age group and often found to be co existing with obsessive compulsive or major depressive disorder. Reports of pica in elderly age group are relatively uncommon and rarely does it have an adult onset. In this article we present a case of adult onset pica. A young lady with unusual sensation in her abdomen was found to consume iron nails over years and there was history of dyspareunia since her marriage three months back. On query it was known that the lady is having same sex relationship over years. There unique conglomeration of cultural, psychodynamic and physiological determinants which together is responsible for this unusual habit of this lady. Moreover the onset of the disease at a late age and different psychodynamic issues make the case all the more interesting. Whether the pica is an eating disorder or obsessive compulsive disorder is still controversial. Pica has been mentioned in Diagnostic and Statistical Manual IV TR. The present case report warrants the need to look into this entity more closely with regards to its occurrence and etiology.
  - 1,503 69
EDITORIAL
"Comorbid" Insomnia
MS Reddy, Arindam Chakrabarty
January-June 2011, 33(1):1-4
DOI:10.4103/0253-7176.85388  PMID:22021946
  - 2,060 118
LETTERS TO EDITOR
Extended course of repetitive trans-cranial magnetic stimulation therapy and a complicated case of obsessive-compulsive disorder
Ram Jeevan Bishnoi, Venu Gopal Jhanwar
January-June 2011, 33(1):98-99
DOI:10.4103/0253-7176.85408  PMID:22021966
  - 1,156 38
ORIGINAL ARTICLES
Depression and suicide publication analysis, using density equalizing mapping and output benchmarking
BH Vogelzang, C Scutaru, S Mache, K Vitzthum, David Quarcoo, DA Groneberg
January-June 2011, 33(1):59-65
PMID:22021955
Background: Depression is a major cause of suicide worldwide. This association has been reflected by numerous scientific publications reporting about studies to this theme. There is currently no overall evaluation of the global research activities in this field. Aim: The aim of the current study was to analyze long-term developments and recent research trends in this area. Material and Methods: We searched the Web of Science databases developed by the Thompson Institute of Scientific Information for items concerning depression and suicide published between 1900 and 2007 and analyzed the results using scientometric methods and density-equalizing calculations. Results: We found that publications on this topic increased dramatically in the time period 1990 to 2007. The comparison of the different Journals showed that the Archives of General Psychiatry had the highest average citation rate (more than twice that of any other Journal). When comparing authors, we found that not all the authors who had high h-indexes cooperated much with other authors. The analysis of countries who published papers on this topic showed that they published papers in relation to their Gross Domestic Product and Purchasing Power Parity. Among the G8 countries, Russia had the highest male suicide rate in 1999 (more than twice that of any of the other G8 countries), despite having published least papers and cooperating least with other countries among the G8. Conclusion: We conclude that, although there has been an increase in publications on this topic from 1990 to 2006, this increase is of a lower gradient than that of psoriasis and rheumatoid arthritis.
  - 2,553 64
Psychological distress among patients with epilepsy
Asma Khalid, Naeem Aslam
January-June 2011, 33(1):45-48
DOI:10.4103/0253-7176.85394  PMID:22021952
Background: Epilepsy is a disorder of the brain characterized by recurrent seizures which are physical reactions to sudden, usually brief, too much electrical discharges in a group of brain cells. Psychological distress often accompanies epilepsy. It badly affects the disease and the treatment outcome. Whereas, familial social support is a positive factor. The objective of the present study was to see the difference of Psychological distress among the patients of Epilepsy; the comparisons on the variables of the study were made between gender, age, marital status, education, socio-economic status and type of Epilepsy. Materials and Methods: Sample comprised of 50 patients with epilepsy. These participants were divided into three subgroups according to their ages that are children, adolescence and adults. Patients were taken from hospitals Islamabad and Muzaffarabad (AJK). Results: The result showed that psychological distress is higher among male patients with generalized epilepsy and among those who are un-married, un-educated, having low socioeconomic status and lower familial social support. Conclusion: It can be concluded that psychological distress is common co morbidity in patients with epilepsy. During treatment, Counseling to the patients and the family can better help in coping with distress during their illness.
  - 1,778 73
Disability in patients with bipolar and recurrent depressive disorder in remission: A comparative study
Deenu Chacko, K.T.P Dayal Narayan, KS Prabhavathy
January-June 2011, 33(1):49-53
DOI:10.4103/0253-7176.85395  PMID:22021953
Background : To compare the disability among patients with bipolar disorder and recurrent depressive disorder in remission. Settings and Design : Cross-sectional study of outpatients. Materials and Methods : Patients in the remission phase of the illness were taken for the study. Disability assessment was done using Indian Disability Evaluation and Assessment Scale. Treatment compliance was measured using medication adherence rating scale. Statistical Analysis : Between group comparison. Results : A total of 40 patients were included in the study, 25 in bipolar and 15 in recurrent depressive disorder group. There was no difference between the groups in the domain of self care. The bipolar patients had more impairment in interpersonal activities than recurrent depressive disorder (RDD) group, this difference was statistically significant (P =0.004). The bipolar patients had more impairment in communication and understanding (P =0.009) and in work (P =0.011). The mean total score for disability was more for bipolar patients (P =0.0001). The total duration of illness had significant influence on communication and understanding, work, and total disability scores. The total number of episodes significantly influenced the impairment in interpersonal activities, communication and understanding, work, and total disability scores. The impairment in self care was significantly associated with the total number of psychotic episodes (P =0.0013). No significant relation was found between treatment compliance and disability. Conclusions : The patients with mood disorders had significant disability even during the periods of remission. The impairment was more for the bipolar patients compared with the RDD patients.
  - 1,962 88
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