One in three adults in India uses tobacco, a highly addictive substance in one or other form. In addition to prevention of tobacco use, offering evidence-based cessation services to dependent tobacco users constitutes an important approach in addressing this serious public health problem. A combination of behavioral methods and pharmacotherapy has shown the most optimal results in tobacco dependence treatment. Among currently available pharmacological agents, drugs that preferentially act on the α4 β2-nicotinic acetyl choline receptor like varenicline and cytisine appear to have relatively better cessation outcomes. These drugs are in general well tolerated and have minimal drug interactions. The odds of quitting tobacco use are at the very least doubled with the use of partial agonists compared with placebo and the outcomes are also superior when compared to nicotine replacement therapy and bupropion. The poor availability of partial agonists and specifically the cost of varenicline, as well as the lack of safety data for cytisine has limited their use world over, particularly in developing countries. Evidence for the benefit of partial agonists is more robust for smoking rather than smokeless forms of tobacco. Although more studies are needed to demonstrate their effectiveness in different populations of tobacco users, present literature supports the use of partial agonists in addition to behavioral methods for optimal outcome in tobacco dependence.
Cessation; cytisine; tobacco dependence; varenicline
Tobacco is a leading cause of disease and premature death. Most of the smokers visit a doctor for various health related ailments and thus such clinic visits provide many opportunities for interventions and professional tobacco cessation advice.
The primary aim of the following study is to assess the physician practices, perspectives, resources, barriers and education relating to tobacco cessation and their perceived need for training for the same. The secondary aim is to compare the physician's cessation practices from patient's perspective.
Settings and Design:
A descriptive study was conducted in a hospital attached to Medical College in Mysore city, Karnataka.
Materials and Methods:
Information about doctor's practices, perspectives and their perceived need for training in tobacco cessation were collected using pre-structured self-administered Questionnaire, which were distributed in person. Patient's practices and perspectives were assessed using a pre-structured Oral Questionnaire.
Almost 95% of physicians said that they ask patients about their smoking status and 94% advise them to quit smoking, but only 50% assist the patient to quit smoking and only 28% arrange follow-up visits. Thus, they do not regularly provide assistance to help patients quit, even though 98% of the physicians believed that helping patients to quit was a part of their role. Only 18% and 35% of the physicians said that Undergraduate Medical Education and Post Graduate Medical Education respectively prepared them very well to participate in smoking cessation activities.
Tobacco cessation requires repeated and regular assistance. Such assistance is not being provided to patients by attending doctors. Our medical education system is failing to impart the necessary skills to doctors, needed to help patients quit smoking. Reforms in education are needed so as to prepare the physician to effectively address this problem.
Karnataka; Mysore; physician's practices and perspectives; smoking; tobacco; tobacco cessation
Antidepressants hold the center stage in the treatment of depression in current clinical practice. However, it is also well-known that the treatment response and dosage requirement are influenced by ethnic variations. Although many efficacy studies have evaluated the efficacy of antidepressants, there is lack of systematic reviews and meta-analysis of the existing literature from India.
To systematically review the efficacy of treatment of depression in the Indian context.
Materials and Methods:
We searched PubMed, Psychinfo, Medknow and Google scholar to identify studies published in peer-reviewed English language journals. All controlled trials from India evaluating the clinical efficacy of antidepressants, electroconvulsive therapy (ECT), and repetitive transcranial magnetic stimulation (rTMS) for management of depression were evaluated. Data were extracted using standard procedures and risk of bias was evaluated. Effect sizes were computed for the individual studies.
Effect sizes were computed from 35 clinical trials. Overall, medications were superior to placebo for treatment of depression (mean effect size (ES) of 0.87, confidence intervals (CI of 0.71-1.02). The effect was greatest for tricyclic antidepressants (ES of 1.00, CI of 0.80-1.21) followed by monoamine oxidase inhibitors (ES 0.54, CI of 0.40-0.67). ECT was superior to antidepressants (ES 0.32, CI of − 0.21 to 0.86) and active rTMS was found to be superior to sham rTMS with mean effect size of 0.74 (CI 0.39-1.08). Risk of bias was found to be considerable. However, the review literature suggests that most of the studies have not been powered adequately and have been limited to small sample sizes.
Although there is some data from India with respect to efficacy of antidepressants, most of the trials have been of shorter duration have been inadequately powered. The available data support the superiority of antidepressants over placebo and that of ECT over antidepressants.
Antidepressants; efficacy; India
Management of behavioral problems in children with intellectual disabilities (ID) is a great concern in resource-poor areas in India. This study attempted to analyze the efficacy of behavioral intervention provided in resource-poor settings.
This study was aimed to examine the outcome of behavioral management provided to children with ID in a poor rural region in India.
Materials and Methods:
We analyzed data from 104 children between 3 and 18 years old who received interventions for behavioral problems in a clinical or a community setting. The behavioral assessment scale for Indian children with mental retardation (BASIC-MR) was used to quantify the study subjects’ behavioral problems before and after we applied behavioral management techniques (baseline and post-intervention, respectively). The baseline and post-intervention scores were analyzed using the following statistical techniques: Wilcoxon matched-pairs signed-rank test for the efficacy of intervention; χ2 for group differences.
The study demonstrated behavioral improvements across all behavior domains (P < 0.05). Levels of improvement varied for children with different severities of ID (P = 0.001), between children who did and did not have multiple disabilities (P = 0.011).
The outcome of this behavioral management study suggests that behavioral intervention can be effectively provided to children with ID in poor areas.
Behavioral assessment scale for Indian children with mental retardation; behavioral problems; community-based rehabilitation; India; intellectual disabilities; multiple disabilities; tribal population
Hyperhomocysteinemia has been associated with psychiatric diseases in non-Indian populations.
We aimed to determine if total plasma Homocysteine (Hcys) is associated with schizophrenia or depression in South Indian Tamil patients and if so, to correlate their severity and phenomenology to Hcys levels.
Settings and Design:
40 patients each with schizophrenia and depression and 40 healthy controls were recruited from the psychiatry department of a quaternary referral centre. Association between Hcys and psychiatric disorders was determined using a Case- control design. Hcys levels were correlated with age, gender and severity and duration of the disease by appropriate statistical methods using SPSS17.
Materials and Methods:
Schizophrenia and depression were defined using ICD10 DCR version. Severity of depression was assessed by Hamilton Depression Rating Scale and that of schizophrenia using Positive and Negative Schizophrenia scales (PANSS). Hcys levels were determined using automated chemiluminiscence immunoassay (74-76).
Differences between the mean values of plasma homocysteine levels among schizophrenia, depression and control groups were compared using analysis of variants. The association between the severity and duration of schizophrenia and depression and the plasma homocysteine levels were determine using Pearson correlation.
In Tamilian population, schizophrenia and depression are associated with total plasma Hcys levels which correlated with the duration and severity of psychosis.
Depression; plasma homocysteine; schizophrenia
In low and middle-income countries, about 80% of those who need mental health services do not receive them. Reasons for this have not been systematically studied. In this qualitative study, we explored this issue in a rural community of South India among schizophrenia patients.
Materials and Methods:
Patients who had never sought psychiatric treatment despite long-standing psychotic illnesses were identified as part of a community intervention program. In-depth interviews were conducted with patients’ caregivers to understand factors preventing them seeking psychiatric treatment. Interviews were audio-recorded and transcribed. Reasons cited by family members were listed and grouped into factors based on themes. Interview process was iteratively followed till no new factor emerged. Sixteen caregivers were thus interviewed.
Content analysis brought out 75 reasons, which were further grouped under the following 15 factors [n (%)]: Lack of awareness about the illness: 15 (93.75%); lack of family support: Nine (56.25%); religious attributions: Nine (56.25%); financial constraints: Six (37.5%); family dynamics: Seven (43.75%); family's tolerance: Seven (43.75%); lack of insight: Five (31.25%); families resilience: Four (25.0%); community beliefs regarding mental illnesses: Four (25%), and others. In each patient, a complex interplay of several of these factors precluded the family from seeking psychiatric treatment.
In addition to the well-known factors, many hitherto less-understood factors (e.g., families’ conflicts, dynamics, resilience and acceptance, and community support, etc.) were identified which prevented patients and their families from seeking treatment. These findings have important policy implications.
Factors; qualitative study; rural community; schizophrenia; treatment access
Absence of normal posterior alpha rhythm is an indirect indicator of seizure disorder.
Materials and Methods:
Study group consists of 116 child and adolescent patients in the age range of 5-17 years, with established history of seizure disorder. Follow-up cases of seizure disorder formed first comparison group, patients with a history of pseudo-seizures formed second comparison group and patients with a history of headache formed the third comparison group.
In significant 48.3% (56) patients within the study group there was no visible alpha rhythm. Whereas, this absent alpha rhythm criteria was seen in only 11.2% (4) patients in first and 15% (8) patients in second and in only 6.1% (2) patients in third comparison groups.
Absent alpha rhythm- a criterion seems to have a certain amount of specificity for electroencephalograms (EEGs) with seizure disorder patients. Presence of seizure activity and absence of alpha activity in EEG significantly correlated to each other (Significant at < 0.01 level). Absent alpha rhythm appears to be a state marker rather than a trait marker of seizure disorder.
Absent alpha; adolescent seizure disorder; alpha rhythm
Schizophrenia is a severe mental disorder that elicits feelings of strangeness and discomfort, which may create stigma and lead to the social exclusion of the mentally ill and of the people relating with them. In the past decade, there has been an increase in the number of research studies on attitudes toward mental disorders.
Materials and Methods:
An instrument was developed to assess the attitude of primary caregivers on home care of schizophrenics. This article describes the development of a Likert scale, the Caregivers Attitude Scale on Home Care of Schizophrenics CASHS, which is a 31-item self-reported instrument that quantifies three aspects of home care, that is, attitude towards patient, towards treatment, and towards social interaction. The steps involved in its development are the review of literature, development of items, content validation, translation and language validity, pretesting, and reliability.
After establishing the content validity, the CASHS was pretested with five subjects. To establish the reliability of the CASHS, 21 primary caregivers were recruited through purposive sampling technique. In order to measure the stability between scores obtained, a test-retest reliability was computed using Karl Pearson correlation coefficient and the r value was 0.78. The internal consistency was measured using Cronbach's alpha and item-total correlation and the r value was 0.789. The item discrimination analysis was also computed and the value was of above 0.35. These statistical measurements indicate that the CASHS was reliable.
The CASHS is a valid and reliable tool that can be utilized for assessing the attitude of primary caregivers on home care of schizophrenics.
Attitude scale; home care; item analysis; primary caregivers; schizophrenia
Shared or induced obsessive compulsive disorder (OCD) is not yet a distinct diagnosis in classification of psychiatric disorders. In fact, though recognized as a diagnostic category, shared or induced psychotic disorders are rare and most of the literature is based on the case reports.
Materials and Methods:
We are reporting three case studies manifested with shared or induced OCD (cases with obsessive symptoms that were shared from the primary case in their family).
All the cases were treated considering shared or induced OCD as psychopathology. Response to treatment modalities in first and second case and poor response to treatment in third case is suggestive of shared or induced OCD as a distinct entity. It is different from shared psychosis in many ways.
Shared or induced OCD is a distinct diagnosis. Greater awareness about this entity among mental health professionals is needed.
Induced obsessive compulsive disorder; obsessive compulsive disorder; shared obsessive compulsive disorder
Marchiafava Bignami disease is a rare toxic disease seen mostly in chronic alcoholics, resulting in progressive demyelination and necrosis of the corpus callosum. Initially it was thought to be specific to individuals in central Italy, consuming large amounts of Chianti red wine; however, alcoholic beverages worldwide are presently implicated. In our case series of two cases, locally made “illicit” liquor (Mahuwa Alcohol) could be the causative factor. In radiological point of view typically the corpus callosum is affected, with involvement of the body, genu, and splenium in order of occurrence. Occasionally the entire callosum may be also involved. Clinical presentation varies from case to case.
Corpus callosum degeneration; mahuwa alcohol; Marchiafava Bignami disease in India
Stimulant prescriptions are routinely used to treat Attention Deficit Hyperactivity Disorder. Reports of psychiatric symptoms that have occurred include euphoria, delirium, confusion, toxic psychosis, and hallucinations. Here, authors report two cases of Attention Deficit Hyperactivity Disorder who were prescribed methylphenidate. Both children developed suicidal ideation that abated after discontinuing the drug. There were no depressive symptoms reported along with it, and the ideation could not be explained on the basis of impulsivity either.
Attention deficit hyperactivity disorder; children; methylphenidate suicidal ideas
Cannabis is a known risk factor for schizophrenia, although the exact neurobiological process through which the effects on psychosis occur is not well-understood. In this review, we attempt to develop and discuss a possible pathway for the development of psychosis. We examine the neurobiological changes due to cannabis to see if these changes are similar to those seen in schizophrenic patients the findings show similarities; however, these mere similarities cannot establish a ‘cause-effect’ relationship as a number of people with similar changes do not develop schizophrenia. Therefore, the ‘transition-to-psychosis’ due to cannabis, despite being a strong risk factor, remains uncertain based upon neurobiological changes. It appears that other multiple factors might be involved in these processes which are beyond neurobiological factors. Major advances have been made in understanding the underpinning of marijuana dependence, and the role of the cannabinoid system, which is a major area for targeting medications to treat marijuana withdrawal and dependence, as well as other addictions is of now, it is clear that some of the similarities in the neurobiology of cannabis and schizophrenia may indicate a mechanism for the development of psychosis, but its trajectories are undetermined.
Cannabinoid system; cannabis; psychosis; schizophrenia; transition to psychosis
Although generally regarded as a disease of young adults, schizophrenia does occur in older ages. Doubts have been raised about the validity of diagnosing schizophrenia in very old age. We have described herein a rare and unique case of a woman who had onset of “schizophrenia” as per ICD-10 and DSM-IV-TR criteria at the age of 100 years. We have discussed about the validity of diagnosing schizophrenia in older age.
Paraphrenia; schizophrenia; very late onset schizophrenia like psychosis
Body dysmorphic disorder is an under-recognized chronic problem that has been established as an independent diagnostic entity. Its clinical features, comorbidity, course, and prognosis have been studied in detail. But, the issue of its psychotic and non-psychotic variants and the question of dimensional or categorical method of classifying this disorder still pose a diagnostic dilemma. This case report tries to highlight this issue.
Body dysmorphic disorder; delusional subtype; non-delusional variant
Nicotine in tobacco smoke causes not only pathophysiological changes in the smoker's body, but also develops tolerance to its own action with repeated use. Repeated exposure to nicotine develops neuroadaptation of the receptors, resulting in tolerance to many of the effects of nicotine. Pharmacotherapies for smoking cessation should reduce withdrawal symptoms and block the reinforcing effects of nicotine without causing excessive adverse effects. All forms of nicotine replacement therapy (NRT) – gum, patches and inhaler – and bupropion are safe and effective for increasing smoking cessation rates in the short and long-term use. Combination NRT (more than one therapy) may be indicated in patients who have failed monotherapy.
Nicotine replacement therapy; smoking cessation; varenicline