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July-December 2018
Volume 27 | Issue 2
Page Nos. 159-312

Online since Friday, June 14, 2019

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EDITORIAL  

Violence: The scourge of Indian industry Highly accessed article p. 159
Kalpana Srivastava, Suprakash Chaudhury, PS Bhat, Jyoti Prakash
DOI:10.4103/ipj.ipj_25_19  
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REVIEW ARTICLES Top

Pharmacotherapy for relapse prevention of alcohol use disorder in the Indian setting: A systematic review Highly accessed article p. 163
Balaji Bharadwaj, Nivedhitha Selvakumar, Pooja Patnaik Kuppili
DOI:10.4103/ipj.ipj_79_17  
Alcohol use disorders (AUDs) is an important public health concern as estimates of the prevalence of AUD range at 4%–6% in the Indian population. Currently, there is limited literature on the pharmacotherapeutic interventions for AUD in the Indian setting. It is imperative to identify the possible variations in their effects from Western studies, and hence the current review was attempted to perform a comprehensive evaluation and critical appraisal of the methodology of the evidence on pharmacological strategies of relapse prevention of AUD in the Indian setting. A total of 18 studies were included in the review. Disulfiram was the most common pharmacological agent to be studied. The initial literature before 2000 focused primarily on disulfiram, whereas the studies in the next decade compared it to acamprosate and naltrexone and emerging interest in anticraving agents such as baclofen and topiramate had been noted over the past few years. No studies were available on newer agents such as ondansetron, selective serotonin reuptake inhibitors or formulations such as depot and implants. Deterrent agents were found to be better when compared to anticraving agents in terms of abstinence and relapse, whereas the latter were more effective for control of craving. Among the pharmacological agents studied, the greatest evidence exists for disulfiram for relapse prevention which could be due to affordability of disulfiram and social support in the Indian context. The chief methodological limitations include the lack of randomized trials and objective measures for assessing abstinence.
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Transcranial magnetic stimulation: A review of its evolution and current applications p. 172
Amit Chail, Rajiv Kumar Saini, PS Bhat, Kalpana Srivastava, Vinay Chauhan
DOI:10.4103/ipj.ipj_88_18  
Repetitive transcranial magnetic stimulation (rTMS) is a recently developed noninvasive brain stimulation method for the treatment of psychiatric and neurological disorders. Although, its exact mechanism of action is still not clear, current evidence points toward its role in causing long-term inhibition and excitation of neurons in certain brain areas. As evidence steadily grows in favor of rTMS as a therapeutic tool; there is a need to develop standardized protocols for its administration. There have been no reports of any serious side effects with rTMS, though its use is restricted in those having magnetic implants or recent adverse neurological or cardiac event. Of all the psychiatric indications of rTMS, the evidence is most robust for treatment of refractory unipolar depression. This paper reviews contemporary literature highlighting the evolution of rTMS as a diagnostic and therapeutic tool, especially in the management of treatment-resistant depression.
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ORIGINAL ARTICLES Top

Executive function in patients with schizophrenia based on socio-occupational impairment: A cross-sectional study p. 181
Delnaz Palsetia, K Chandrasekhar, MS Reddy, Avinash De Sousa, Sagar Karia
DOI:10.4103/ipj.ipj_85_18  
Background: Executive dysfunction deficit is the functionally most important cognitive deficit noted in schizophrenia. There is a dearth of Indian literature on the subject. The current study aimed at studying these executive functions in patients with schizophrenia in remission. Methodology: Sixty outpatients with a diagnosis of schizophrenia as per international classification of diseases-10 criteria; in remission as measured by Positive and Negative Syndrome Scale scores were divided into two groups using the personal and social performance scale. The patients with and without socio-occupational impairment formed the two groups. All patients were administered the Wisconsin Card Sorting Test (WCST), Stroop test, Color Trails Test 1 and 2, Phonemic Fluency (Controlled Oral Word Association Test), and category fluency (animal names test) tests and the tower of London test to ascertain deficits in executive functions. The data obtained were subjected to statistical analysis. Results: The two groups were well matched. The group with socio-occupational impairment showed a lesser number of categories completed (P = 0.001), more perseverative errors (P = 0.001), and greater percentage of the same (P = 0.001) on the WCST. Statistically significant differences between both groups were observed for scores on phonemic fluency (P = 0.012) and category fluency (P = 0.049) tests as well as the Tower of London test (P = 0.021). They also showed differences on the Stroop test and Color Trail tests, but this was not statistically significant. Conclusions: Performance on executive function tests is significantly correlated with functional outcome. It is important that future studies explore the role of these tests as a marker of socio-occupational impairment in schizophrenia.
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Gender difference in affect of job applicants on completion of projective test battery for personality assessment in armed forces p. 190
Durlabh Singh Kowal, Manish Kumar Dadhwal
DOI:10.4103/ipj.ipj_23_18  
Background: Every test, whether academic or non-academic, induces an 'affect' in subjects and completion of it also produces an affect, may it be positive or negative. The projective tests are peculiar in their nature for the purpose of personality assessment and may also have a temporary or everlasting impact on the respondent's affect at the conscious level. This paper tries to investigate the affect of job applicants in armed forces on completion of projective tests. Studies have shown that women are perceived to express emotions more than men but that there were little differences in the perception of men and women's emotional experience. Aim: The aim of the study was to examine gender difference in the affect of 275 job applicants (110 male and 65 female) after completing the battery of projective tests for personality assessment in armed forces. Materials and Methods: PANAS has been used for determining the positive affect (PA), which reflects the pleasurable engagement and subjective experience of happiness whereas the negative affect (NA) subscale measures the level of subjective distress and unpleased engagement. Results: Female's average score (4.66) was greater than male (4.45) score on the 'attentive' dimension of positive affect. This difference was significant t (273) = - 2.08, P < 0.05. Male's average score (4.47) was greater than female (4.24) score on the 'active' dimension of positive affect. Conclusion: This difference was significant t (273) = 2.14, P < 0.05. Among the dimensions of the negative affect, none of them have significant difference between male and female.
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Prevalence of psychiatric morbidity among parents of children with intellectual disability Highly accessed article p. 197
Nandkisor K Tak, Brajesh Kumar Mahawer, Chandra Shekhar Sushil, Rashmi Sanadhya
DOI:10.4103/ipj.ipj_39_18  
Background: Intellectual disability is a permanent disabling condition, and caregivers are more vulnerable to develop mental illness. There is little data in developing countries, such as India, concerning about psychological issues in caregivers of intellectually disabled children. Objective: The objective of this study was to find the prevalence of psychiatric morbidity and correlation between sociodemographic factors and psychiatric morbidity in parents of children with intellectual disability. Materials and Methods: This study was carried out among 60 parents of children with intellectual disability at the outpatient Department of Psychiatry, Tertiary Care Centre, India. Parents, who fulfill the inclusion and exclusion criteria of the study, were interviewed by using semi-structured pro forma, International Disease Classification-10 criteria for mental illness, Beck Depression Inventory and Hamilton Anxiety Rating Scale, Brief Psychiatric Rating Scale, and Alcohol Use Disorder Identification Test. Results: The prevalence of depressive disorder was 28.33%, anxiety disorder was 18.33%, and other psychiatric disorders was 8.33% (psychotic disorder 3.33%, insomnia 1.66%, and alcohol use disorder 3.33%) and total psychiatric morbidity was about 55% in parents of children with intellectual disability. Conclusion: The study shows high psychiatric morbidity in parents of children with intellectual disability, and psychiatric screening should be considered among parents of children with intellectual disability.
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Study of memory changes after electroconvulsive therapy p. 201
Rajendran Akambadiyar, Pookala Shivaram Bhat, Jyoti Prakash
DOI:10.4103/ipj.ipj_42_18  
Background: Electroconvulsive therapy (ECT) is said to have few adverse effects and among them, cognitive impairment is the most significant side effect limiting its use. However, recent studies have suggested it to be due to illness rather than due to ECT, hence a need to study the memory changes following ECT. Aim: This study aimed to assess the memory changes following ECT and subsequent recovery in the short period of 4 weeks. Materials and Methods: Fifty consecutive first-episode cases of depression requiring ECT and scoring at least 27 on initial Mini–Mental State Examination were studied using Becks Depression Inventory and Wechsler Memory Scale III-Indian adaptation at baseline, after six ECTs, and 4 weeks after last ECT. Findings were analyzed using appropriate statistical methods. Results: Memory improved significantly after a course of six ECTs and further 4 weeks after the last ECT. Depression scores had dramatically reduced after a course of six ECTs. Significant correlation was found between baseline depression scores and baseline general (delayed) memory scores. Conclusions: The memory changes seen after ECT were likely to be mediated by changes in depression. Probably, ECT had no deleterious effects on memory or its negative effects were more than balanced by the changes due to improvement of depression.
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Psychiatric comorbidity in patients undergoing hemodialysis p. 206
Ekram Goyal, Suprakash Chaudhury, D Saldanha
DOI:10.4103/ipj.ipj_5_18  
Background: Patients undergoing hemodialysis are under considerable physical and mental stress. Few studies indicate an increase of psychiatric morbidity in them. Aim: The aim is to study the prevalence of psychiatric comorbidity in patients undergoing hemodialysis. Materials and Methods: A total of 49 consecutive patients of chronic kidney disease undergoing hemodialysis were included in the study with their consent. The Institute Ethics Committee clearance was obtained before the start of the study. The psychiatric interview was conducted only after the dialysis procedure was over. Patients were assessed using the Schedule for Clinical Assessment in Neuropsychiatry and Hamilton rating scale for depression. Results: A total of 49 patients in the age range of 15–64 years were included in the study. Majority of the sample was males (75.5%). Out of the patients enrolled in the study group, 45% had psychiatric comorbidity which included depression (26%), adjustment disorder (12.2%), generalized anxiety disorder (2%), mixed anxiety and depression (2%), and mental and behavioral disorders due to harmful use of alcohol (2%) indicating that patients undergoing hemodialysis is more likely to have mood disorder than other psychiatric disorders. Conclusion: Patients with recent-onset dialysis are more prone to psychiatric illnesses as it has a chronic debilitating course with poor outcome leading to major lifestyle changes with occupational disturbance and consequent financial implication.
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Burnout and coping strategies among residents of a private medical college in South India: A cross-sectional study p. 213
P Sreelatha, Liji Premlal, V S. S. R. Ryali
DOI:10.4103/ipj.ipj_53_18  
Background: Burnout is evident in various professions increasingly so in the health-care field, where doctors are involved with direct interactions with dependent patients. Burnout is evident even in residents due to working in demanding and testing conditions which has a negative influence not only on their profession, but also patient care. Aims: (1) To measure the levels of burnout among the residents and (2) to assess the relationship between severity of burnout and coping strategies. Settings and Design: It is cross-sectional observational study set in a private medical college with residency program. Materials and Methods: Online self-administered questionnaire was sent to all residents, out of these, 100 residents consented and completely filled the questionnaires and were included in the analysis with a response rate of 55.6%. The questionnaire consisted of sociodemographic variables, Maslach Burnout Inventory, and Brief COPE. Results: Residents who reported burnout as high in two dimensions of emotional exhaustion and depersonalization are 31.82%. The 2nd year residents scored high on burnout measures when compared to 1st and 3rd year residents. It was observed that as the degree of emotional exhaustion and depersonalization increased from low to high, the frequency of the maladaptive coping strategies also increased. Conclusion: Based on these findings it can be concluded that burnout is frequent in residents. Further research is essential to identify the factors that contribute to burnout in residents.
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Caregivers' perspectives on disclosure, care, and treatment among pediatric HIV/AIDS patients in South India: A qualitative study p. 219
Sonali Sarkar, Kalaiselvi Selvaraj, Sriram Krishnamurthy, Abyramy Balasundaram, Subitha Lakshminarayanan
DOI:10.4103/ipj.ipj_54_16  
Background: Rollout of antiretroviral therapy (ART) has helped to achieve the increased life span among pediatric HIV patients. The psychosocial aspects of parents or caregivers can affect the treatment adherence in children and the disease outcome. Aims and Objectives: This study aims at understanding the perspectives on disclosure of HIV status, stigma, antiretroviral treatment, and compliance among caregivers of children attending ART clinic in South India and to explore the barriers to treatment-seeking behavior. Materials and Methods: This facility-based qualitative study was carried out among caregivers of pediatric HIV patients <15 years of age. In-depth interview was conducted on caregivers after informed consent in the absence of the child, focusing on stigma, disclosure of HIV status to children, adherence, and coping strategies followed by the parents. The complete interviews were transcribed in English, and content analysis was done to identify the emergence of codes. Interview was conducted among mothers of affected child. The disease status of the children was known only to the parents and not to the children themselves (excepting one) or siblings. Parents intended to keep it confidential for the affected children as long as possible. Nevertheless, to maintain adherence and to prevent disclosure of HIV status, mothers traveled to this ART center from very far places, medical records were hidden, and tablets were removed from the strips and said to be medicines for energy and protection. Conclusion: Mothers of HIV-positive children faced many difficulties to prevent the disclosure of the diagnosis from the affected children and others, which is not very conducive to adherence to the ART regimen. Effective disclosure strategies to manage this emotionally vulnerable group are an urgent need.
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Psychiatric morbidity in children of alcoholic parents p. 226
Himanshu Mansharamani, Pradeep S Patil, Prakash B Behere, Deepak Mansharamani, Amit Nagdive
DOI:10.4103/ipj.ipj_57_17  
Context: Children of alcoholics (COAs) are children who have grown up in families in which either one or both parents are alcoholic. The interplay of several factors such as environmental, cognitive, and genetic vulnerability has been linked to the psychopathology among COAs. Aims: To assess psychiatric morbidity in COAs and to compare these children with the children of nonalcoholic parents. Setting and Design: This cross-sectional study was conducted on children of outpatients and inpatients of a tertiary health-care center in Central India, for 18 months. Subjects and Methods: A total of 100 children, fifty children of alcoholic parents and fifty children of nonalcoholic parents between the age groups of 4 and 14 years, were assessed using childhood psychopathology measurement schedule. Statistical Analysis Used: Statistical analysis was done by using descriptive and inferential statistics using Chi-square test and Student's unpaired t-test. SPSS version 22.0, were used for statistical analysis, and P < 0.05 was considered as level of significance. Results: Most of the children were in the age group of 8–11 years. Depression and anxiety were found to be statistically significant (P < 0.05) in COAs than in children of nonalcoholics. Whereas, there was no difference (P > 0.05) for low intelligence and behavioral problems, conduct disorder, psychotic symptoms, special symptoms, physical illness, emotional problems, and somatization. Conclusions: Thus, there is a high need to address the stress to children of persons with substance abuse. Early detection of psychiatric morbidities in such children and appropriate intervention can produce beneficial changes in such children.
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The utility of modified version of sentence completion test for children and adolescents p. 231
Adarsh Kohli, Soumya Jhanda, Susanta K Padhy
DOI:10.4103/ipj.ipj_63_18  
Introduction: Sentence completion test (SCT) is a projective test used widely by clinicians and psychologists to explore the needs, inner conflicts, fantasies, attitudes, aspirations, adjustment difficulties, and sexual abuse in the children and adolescents. Aim: The aim of the study is to modify the existing SCT (Form S) for children and adolescents and to corroborate with clinical history. Methodology: A pilot testing was done on 35 children and adolescents who were referred to the Department of Clinical Psychology section for evaluation of conflicts after a detailed evaluation by psychiatrist(s). The clients were administered both the unmodified and the modified SCT. The information obtained was compared between (i) unmodified and the modified SCT and (ii) between clinical history and modified SCT. The psychologist was blind to the assessment of the patient done at the time of workup by a psychiatrist. The two information were analyzed. Descriptive analysis was carried out. Results: The modified version of SCT gave more comprehensive information on all areas of the patient's life compared to older version. The information obtained corroborated with the clinical history explored by the psychiatrist. This test can be administered with ease and can yield detailed information in a wide range of stress-related and neurotic disorders, which can be utilized for clinical case management. Conclusion: The modified SCT may better complement clinical history in eliciting comprehensive information on psychosocial issues and better formulation of management plan.
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A study of physical anhedonia as a trait marker in schizophrenia p. 235
Shobit Garg, Christoday R. J. Khess, Sumit Khattri, Preeti Mishra, Sai Krishna Tikka
DOI:10.4103/ipj.ipj_65_17  
Background: Inability to define the heritable phenotype might be a reason for failure to replicate results in psychiatric genetics. Hence, the use of a candidate symptom approach to identify more homogeneous forms of diseases among affected individuals and subclinical traits among first-degree relatives (FDRs) may increase genetic validity. The objective of the present study was to determine whether physical anhedonia can be used as a marker for individuals at risk of schizophrenia. Materials and Methods: Physical anhedonia scores (measured using Revised Physical Anhedonia Scale [rPAS]) were compared across thirty remitted schizophrenic patients, thirty of their unaffected FDRs, and thirty healthy controls. We compared anhedonia scores among the three main groups using one-way ANOVA. Results: Physical anhedonia (rPAS) scores of the schizophrenic patient group were significantly higher than that of their FDRs and controls both, and physical anhedonia (rPAS) scores of FDRs were significantly higher than that of healthy controls (F = 115.33, P < 0.001). The subgroups did not differ on various other clinical characteristics. Conclusion: Our data suggest that physical anhedonia is a candidate symptom for schizophrenia.
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Evaluation of treatment of psychiatric morbidity among limb amputees p. 240
Sojan Baby, Suprakash Chaudhury, Tejvir Singh Walia
DOI:10.4103/ipj.ipj_69_18  
Background: The sudden jolt of becoming an amputee brings with it the realization of loss of independence and self-built psychological and physical security. Advances in the field of prosthesis give the individual hope for better future, but the presence of psychological morbidity is a hurdle to be crossed in the road to satisfactory rehabilitation. Aim: This study aimed to assess the psychiatric morbidity in amputees and the response to treatment. Materials and Methods: One hundred newly amputated soldiers were assessed by means of clinical interview, General Health Questionnaire, Impact of Event Scale, Hospital Anxiety Depression Scale, McGill Pain Questionnaire, and Dallas Pain Questionnaire. Individuals were treated with appropriate medications and psychotherapy, and response to treatment was assessed. Results: Psychiatric disorders were diagnosed in 66% including adjustment disorders (40%), depressive episode (20%), and posttraumatic stress disorder (6%). Phantom sensation and phantom pain were noted in 72% and 64% of participants, respectively. More psychiatric disorders and phantom sensation were found in the early months after amputation. Psychiatric morbidity was associated with negative body image, distressing pain, and restriction of activities of daily life. Treatment produced complete remission of symptoms in 65.15% of individuals suffering from psychiatric disorders and statistically significant reduction in the scores of psychiatric rating scales. Conclusions: There is a high prevalence of psychiatric morbidity among amputees. Psychiatric treatment produces significant improvement in the psychological well-being of amputees and underlines the need to focus on the psychological rehabilitations of the amputee apart from physical rehabilitation.
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Burden of caregiving and its impact in the patients of acute lymphoblastic leukemia p. 249
Rina Kumari, Adarsh Kohli, Pankaj Malhotra, Sandeep Grover, Alka Khadwal
DOI:10.4103/ipj.ipj_75_18  
Aim: This study aims to study the caregiver burden and its correlates among the caregivers of adolescent and adult patients of acute lymphoblastic leukemia (ALL). Materials and Methods: Sixty caregivers of patients with ALL were assessed on Family Burden Interview Schedule (FBI), Caregiver Strain Index, multidimensional aspect of perceived social support scale, Cognitive–Behavioral Avoidance Scale, ways of coping checklist, and General Health Questionnaire. Results: Caregivers of patients with ALL reported high caregiver burden (FBI objective burden score – 21.77; subjective burden score – 1.83). Among the domains of FBI, the highest burden was seen in the form of financial burden closely followed by disruption of family leisure. Caregivers of male patients and those belonging to higher socioeconomic status reported higher level of objective burden. Caregiver burden was higher among caregivers who reported lower perceived social support, who more often used avoidance and escape as coping and less often used planful problem solving. Higher caregiver burden is associated with higher psychological morbidity. Conclusion: Caregivers of patients with ALL experience high level of caregiver burden and it is associated with lower social support and more often use maladaptive coping strategies.
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Alcohol, harmful use and dependence: Assessment using the WHO Alcohol Use Disorder Identification Test tool in a South Indian fishermen community p. 259
A Manoj Kumar, Gomathi Ramaswamy, Marie Gilbert Majella, Balaji Bharadwaj, Palanivel Chinnakali, Gautam Roy
DOI:10.4103/ipj.ipj_82_15  
Background: Fishermen have a high burden of alcohol-related morbidity. The Alcohol Use Disorder Identification Test (AUDIT) is used to classify individual to have harmful use of alcohol and probable alcohol dependence. Hence, this study was conducted among fishermen in a selected fishermen community in Puducherry, South India, to (a) assess the proportion of harmful alcohol use and probable dependence to alcohol among alcohol users using AUDIT tool and (b) find the sociodemographic factors associated with harmful alcohol use and probable dependence among alcohol users. Materials and Methods: A community-based cross-sectional study was carried out among the fishermen above 18 years of age in a selected “fishing hamlet.” A house-to-house survey was conducted to identify the fishermen. A semi-structured questionnaire was used to obtain sociodemographic details. AUDIT tool was administered by interviewer to those fishermen who used alcohol in the past 1 year. Data were entered and analyzed using EpiData software. The proportion of harmful use of alcohol and probable dependence among alcohol users was expressed as percentage. Chi-square test was used to find association between sociodemographic factors with harmful use of alcohol and probable dependence. Results: Of 304 fishermen included in the study, 241 (79%) reported alcohol use in the past 1 year. Of 241 alcohol users, four-fifths (82%) had some formal education and two-thirds (67%) had monthly income <3000 INR. “Harmful use” of alcohol was noted in 76.8% (95% confidence interval [CI]: 71.1%–81.7%) and probable alcohol dependence in 12.4% (95% CI: 8.9%–17.2%). None of the individual characteristics of alcohol users were associated with either harmful use of alcohol or probable dependence. Conclusion: Among fishermen who use alcohol, eight out of ten have harmful use of alcohol. There is a need to screen for alcohol-related disorders among fisherman and adopt brief intervention strategies to counter problems of harmful use of alcohol.
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Study to determine the prevalance of substance use and factors associated with it, in first-episode of psychosis p. 264
Navdeep Banyal, Debajyoti Bhattacharyya, Prateek Yadav
DOI:10.4103/ipj.ipj_86_18  
Background: Psychoactive substance use occurs commonly in patients with psychotic disorders. Aim: This study aimed to determine the prevalence of substance use in first-episode psychotic patients and to evaluate the association between substance use and various sociodemographic variables. Materials and Methods: This was a cross-sectional study, and symptomatic first-episode, treatment-naive psychosis patients were included (n = 79). A semi-structured pro forma was used for the evaluation of sociodemographic and clinical characteristics. The patients were then interviewed for use of any psychoactive substance in their lifetime. In each case, the history was corroborated by a family member or a caregiver. Wherever required, a second interview was conducted. Results: The mean age at the onset of psychotic disorder for substance users was 36.09 years and for nonusers was 35.50 years. Almost three-fourth of the patients reported the use of at least one substance in their lifetime. Alcohol use was reported by 40.50% of patients, tobacco by 55%, and cannabis by 8.86%. It was significant in patients who were diagnosed with schizophrenia, acute and transient psychotic disorder, persistent delusional disorder, and unspecified nonorganic psychotic disorder. Conclusion: The results show a high prevalence of psychoactive substance abuse compared to the prevalence in the general population. This has tremendous significance in the management of such illness, which is known to impact the prognosis adversely.
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Correlates and management of comorbid anxiety disorders in schizophrenia p. 271
Chandra Kiran, Suprakash Chaudhury
DOI:10.4103/ipj.ipj_66_17  
Background: Only a few studies have examined the treatability of anxiety disorders in schizophrenia, even though it is generally accepted that in the absence of schizophrenia, the anxiety disorders are safely and effectively treatable. Aim: The aim of this study was to study the relation of anxiety disorders with the positive and negative symptoms of schizophrenia and the effect of treatment of different anxiety disorders in schizophrenia patients. Materials and Methods: The study was carried out on inpatients of a tertiary care psychiatric hospital using a purposive sampling technique. The schizophrenia patients were evaluated for psychopathology and the presence of anxiety disorder at baseline. After being prescribed with antipsychotic medication in a suitable dose for 8 weeks, they were followed up at monthly intervals for the course of both schizophrenia and anxiety disorders. Thereafter, an selective serotonin reuptake inhibitor (SSRI) was also prescribed to the schizophrenia patients with comorbid anxiety disorder, and the patients were again followed up for a period of 8 weeks to assess the progress of schizophrenia and anxiety disorder. Results: The prevalence of anxiety disorder in 93 schizophrenia patients included in the present study was 45.16%. The most common comorbid anxiety disorders in schizophrenia patients were panic disorder (18.27%), social anxiety disorder (9.68%), obsessive-compulsive disorder (8.60%), and agoraphobia (6.45%). Schizophrenia patients with anxiety disorder had a significantly higher positive score of the Positive and Negative Symptom Scale for Schizophrenia (PANSS) and a significantly lower score on the negative scale and the general psychopathology scale of the PANSS, as compared to the scores of the schizophrenia group without anxiety disorders. Schizophrenia patients with anxiety disorders responded well to the combination of SSRIs and antipsychotics but not antipsychotics alone. Conclusions: Comorbid anxiety disorders are common in schizophrenia. Schizophrenia patients with anxiety disorders differ significantly from those without anxiety disorders in their basic psychopathology. These anxiety disorders are quite responsive to the SSRIs but not to antipsychotics alone. Further, there is a shorter duration of illness in schizophrenia patients with anxiety disorders as compared to schizophrenia patients without anxiety disorders assigning a prognostic significance to the presence of comorbid anxiety disorders in schizophrenia.
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The sociocultural factors and patterns of help-seeking among patients with mental illness in the sub-Himalayan region p. 279
Suneet Kumar Upadhyaya, Chintan M Raval, Devendra Kumar Sharma
DOI:10.4103/ipj.ipj_95_14  
Context: Selection of first help in psychiatric illnesses depends on various sociodemographic and environmental factors. In integrated societies like India careers also contribute in deciding help-seeking behavior of psychiatric patients. In this study, we explored these factors and the role of education of decision maker, i.e., person who is final authority in deciding the course of management. Aims: This study aims to study sociocultural factors and patterns of help-seeking behavior of psychiatric patients in rural sub-Himalayan region. Settings and Design: A cross-sectional study conducted in a tertiary care teaching hospital. Subjects and Methods: Factors affecting help-seeking behavior such as age, sex, education, occupation, income, accessibility to psychiatric treatment, expenses on faith healers and general practitioners, and education of “decision maker were assessed. Statistical Analysis Used: Data were analyzed with GraphPad InStat, using appropriate statistical tests. Results: In this study of 250 patients, psychiatrists were chosen as first help by 98 (39%), faith healers by 84 (34%), and general medical practitioners (GMPs) by 68 (27%) patients. Mean “years of education” of patients in psychiatrist group, faith healer group, and GMP group were 9.98, 8.81, and 7.99, respectively (P = 0.08). Mean “years of education” of decision makers for these groups were 11.64, 8.36, and 10.93, respectively (P < 0.001). Time required in reaching psychiatric facility form the residence of patient was maximum in those who consulted faith healers first compared to those who consulted psychiatrist (P < 0.001) or GMP (P < 0.01). Expenses on faith healers were significantly high compared to GMPs (P < 0.001). Conclusions: Psychiatrists, faith healers, and GMPs were equally chosen as first help for psychiatric illness. Education of decision maker and accessibility affect help-seeking behavior significantly. Faith healers were more expensive than GMPs.
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Impact of balloon mitral valvotomy on quality of life and psychiatric morbidity in patients with severe mitral stenosis p. 285
Nipun Verma, Rajesh Vijayvergiya, Sandeep Grover
DOI:10.4103/ipj.ipj_76_18  
Objectives: To evaluate the quality of life (QoL), psychiatric comorbidities in patients with rheumatic heart disease-mitral stenosis (RHD-MS), and the impact of balloon mitral valvotomy (BMV) on the QoL and psychiatric morbidity. Materials and Methods: Fifty consecutive patients of RHD-MS were evaluated for QoL and psychiatric morbidity prior to BMV and at 3 months after the procedure. Results: The mean age of the study sample was 34.9 years (standard deviation, 11.1 years). At baseline assessment, majority (94%) had New York Heart Association Class II/III symptoms and QoL scores below average, that is, 50. About two–fifth (19 out of 50) of the patients had one or more psychiatric comorbidity, that is, depression (32%), anxiety (16%), and somatoform disorder (12%). Those with psychiatric comorbidity had poor QoL scores in social, emotional, and mental subscales (P < 0.05) at the baseline. At 3-month follow-up, there were significant improvement in symptoms and transmitral pressure gradients (P < 0.05), QoL scores (P < 0.05), and psychiatric comorbidities (P < 0.05) after BMV. Improvements in QoL were irrespective of the baseline psychiatric comorbidity. Conclusions: High prevalence of psychiatric illness and poor QoL scores were observed in patients with RHD-MS. BMV significantly improves the QoL and psychiatric comorbidities.
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CASE REPORTS Top

Psychosis in a case of encephalomalacia p. 293
Jnanamay Das, Shailly Yadav
DOI:10.4103/ipj.ipj_19_17  
We report an adult female who had changes suggestive of encephalomalacia in bilateral temporal and basifrontal region in the magnetic resonance imaging of the brain but presented with psychiatric symptomatology suggestive of psychosis instead of neurological manifestations. Encephalomalacia is softening of the brain tissue which may lead to the brain changes and present with varied clinical manifestations. Most of the cases reported previously were in infants and children and almost all of them were related to neurological disorders. However, cases with psychiatric symptomatology were rarely reported, that too in adults. The authors discussed the psychiatric symptom profile, their management and emphasized the importance of imaging of the brain and its association with psychiatric manifestations.
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Local complications of pentazocine abuse: Case report and review p. 296
Subodh Kumar, Suprakash Chaudhury, Subhas Soren, Jayati Simlai, Ranju Kumari
DOI:10.4103/ipj.ipj_53_17  
The skin is the tissue most commonly affected by intravenous drug addiction with pentazocine. The present article attempts to review the adverse effects of injecting drug use along with one case report of cutaneous complications of injection pentazocine abuse underlining the need for early identification, management, and above all prevention. It also provides credence to the fact that pentazocine abuse is common in paramedical staff, and easy accessibility of pentazocine injection can easily lead to serious complications.
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Hashimoto's encephalopathy in a pregnant female: A diagnosis in disguise p. 302
Shri Ram Sharma, Nalini Sharma, Debjit Roy
DOI:10.4103/ipj.ipj_63_17  
While Hashimoto's encephalopathy (HE) is quite rare, it is also likely that there are many more undiagnosed sufferers. Because it is little known and its symptoms are primarily neurological, it is easy to misdiagnose or overlook and the symptoms frequently lead to mistaken neurological diagnoses. We report a case of a 21-year-old female diagnosed with HE at 6 months of gestation. She was successfully treated. HE is a neuropsychiatric disorder of exclusion. As a good response can be obtained with corticosteroid therapy, early diagnosis and treatment is very beneficial for patients. To the best of our knowledge, there is no such report in the literature.
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The overlap between poststroke and vascular depression: A case study p. 305
Yogender Malik, Subho Chakrabarti
DOI:10.4103/ipj.ipj_69_17  
Depression associated with cerebrovascular disease (CVD) is common among the elderly. Two major types are described, including poststroke depression (PSD), which occurs following a clinically apparent stroke and vascular depression (VaD) which results from silent cerebral infarctions or lacunar infarcts mainly in the subcortical regions. Although PSD and VaD have been regarded as distinctive types of depression, there appears to be a great degree of overlap between them. The case of an elderly patient with late-onset depression is presented to highlight this overlap.
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COMMENTARY Top

Geopolitical determinants of health Highly accessed article p. 308
Albert Persaud, Pookala Shivaram Bhat, Antonio Ventriglio, Dinesh Bhugra
DOI:10.4103/ipj.ipj_71_18  
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LETTER TO EDITOR Top

The hippocampus and executive functions in depression: Comments on the article p. 311
Vigneshvar Chandrasekaran, Vikas Menon
DOI:10.4103/ipj.ipj_39_16  
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