I jp

Honorary Editor:

Dr. Vipul Singh

drvipulsingh@yahoo.co.in

Honorary Deputy Editor:

Dr. S. K. Kar

drsujita@gmail.com

Honorary Associate Editors:

Dr. Abdul Quadir Jilani

imjilani@gmail.com

Dr. Achyut Kumar Pandey

achyutpandey575@gmail.com

Dr. M. Aleem Siddiqui

docaleem@gmail.com

Honorary Assistant Editors:

Dr. Amil H Khan

amilhayatkhan@gmail.com

Dr. Chhitij Srivastava

srivastavachitij@gmail.com

Dr. Ganesh Shankar

shankyishere@gmail.com

Dr. Manoj Prithviraj

manoprithv@gmail.com

Dr. Tapas Kumar Aich

tapas_dr@yahoo.co.in

Editorial Assistants:

Dr. Praveen Pandey

SR, KGMU Praveen@kgmcindia.edu

Dr. Dharamveer Chaudhari

SR, GMC Kannauj drdv8090@gmail.com

Dr. Akanksha Shankar

JR, KGMU akks1420@gmail.com

Dr. Shivangini Singh

JR, KGMU shivangini1103@gmail.com

Chief Advisor:

Dr. P K Dalal

docpkdalal@gmail.com

Founder President:

Dr R K Mahendru

mahendru.rk@gmail.com

Founder Vice President:

Dr. A. K. Tandon

aktandon20@gmail.com

Indian Jounal of Clinical Psychiatry

Founder Hon. Secretary:

Dr. Adarsh Tripathi

dradarshtripathi@gmail.com

Founder Hon. Treasurer:

Dr. Anil Nischal

an.kgmu@gmail.com

Founder Editor:

Dr. Vipul Singh

drvipulsingh@yahoo.co.in

ECMembers:

Dr. Ashutosh Gupta

drashutoshhkg@gmail.com

Dr. C B Madhesia

drcbmadeshia82@gmail.com

Dr. Mona Srivastava

drmonasrivastava@gmail.com

Dr. S. A. Azmi

suhailahmedazmi@gmail.com

Dr. Sandeep Chaudhary

drsandeepchoudhary70@gmail.com

Dr. Vipul Tyagi

drvipultygi@rediffmail.com

Editorial Board:

Dr. A K Agarwal

mradulanil@gmail.com

Dr. A. S. Srivastava

adya_shanker@yahoo.com

Dr. Bandna Gupta

drbandna@yahoo.co.in

Dr. Dhananjay Chaudhari

georgiondc@gmail.com

Dr. Gyanendra Kumar

gyanendra.dr@gmail.com

Dr. Harjeet Singh

dr_harjeetsingh@hotmail.com

Dr. Hemant Naidu

nadoc@outlook.com

Dr. Hemant Singh

drsinghhemant_2003@yahoo.co.in

Dr. Indira Sharma

indira_06@rediffmail.com

Dr. K C Gurnani

gurre-gowda@yahoo.com

Dr. Narottam Lal

drnarottam.lal@gmail.com

Dr. P Sitholey

psitholey@gmail.com

Dr. R. K. Gaur

drrkoyani@gmail.com

Dr. S. P. Gupta

satyapgupta@yahoo.com

Dr. Sanjay Gupta

merikushaali@gmail.com

Dr. Sarvesh Chandra

chandrasarvesh@yahoo.com

Dr. Srikant Srivastva

srikantsrivastva@kgmcindia.com

Dr. Sudhir Kumar

imhh.agra@gmail.com

Dr. Vishal Sinha

drvishalc@rediffmail.com

Dr. Vivek Agarwal

drvivekagarwal06@gmail.com

National Advisory Board

Dr Ajit Awasthi, Chandigarh drajitavasthi@yahoo.co.in

Dr Ajit Bhide, Bengaluru drajitbhide@gmail.com

Dr D. Basu, Chandigarh db_sm2002@yahoo.com

Dr B. M. Suresh, Bengaluru sureshbm@gmail.com

Dr Dayaram, Ranchi dram_cip@rediffmail.com

Dr B. N. Gangadhar, Bengaluru kalyanybg@yahoo.com

Dr Gautam Saha, Kolkatta drgsaha@yahoo.com

Dr G Prashad Rao, Hyderabad prasad40@gmail.com

Dr Hitesh Khurana, Rohtak doctorhitesh@rediffmail.com

Dr M S Bhatia, NewDelhi manbhatia1@rediffmail.com

Dr M S Reddy, Hyderabaad drmsreddy@gmail.com

Dr Nitin Gupta, Chandigarh nitingupta659@yahoo.co.in

Dr Nimesh Desai, New Delhi shrinknimesh@gmail.com

Dr O. P. Singh, Kolkatta opsingh.nm@gmail.com

Dr Prabha Chandra, Bangaluru prabhasch@gmail.com

Dr P. K. Singh, Patna pkpostline@yahoo.com

Dr Rakesh Chadda, New Delhi drrakeshchadda@hotmail.com

Dr S. K. Khandelwal, New Delhi skhandy@hotmail.com

              

i

Dr Smita Deshpande, New Delhi smitadeshp@gmail.com

Dr Sivakumar Thannapal, Bengaluru drt.sivakumar@yahoo.co.in

Dr Subhangi Parker, Mumbai psubhangi@gmail.com

Dr S. K. Padhy, Bhubaneswar susanta.pgi30@yahoo.in

Dr Shahul Ameen, Kerala shahulameen@yahoo.com

Dr Sandeep Grover, Chandigarh drsandeep2002@yahoo.com

Dr Tophan Pati, Cuttack tophanp@gmail.com

Dr T. S. S. Rao, Mysore tssrao19@gmail.com

Dr Vivek Kirpekar, Nagpur vivek.kirpekar@gmail.com

Dr Vikas Menon, Puducherry drvmenon@gmail.com

Dr Vivek Benegal, Bengaluru vbenegal@gmail.com

Dr Vihang Vahia, Mumbai vvahia@hotmail.com

Dr. Prakash B. Behere

pbbehere@gmail.com

International Advisory Board:

Dr Arun Kumar Gupta, UK Arunkumar.gupta@cntw.nhsm

Dr Anil Kumar V., UK anil.kumar@mpft.nhs.uk

Dr Anupam Bhardwaj, UK anupam.bhardwaj@nepft.nhs.uk

Dr Baldev Singh, Canada Dr Bharat Saluja, Australia

drbharatsaluja@gmail.com

Dr Dhana Ratna Sakya, Nepal drdhanashakya@yahoo.com

Dr Divik Seth, UK divikseth@yahoo.com

Dr Manoj Rajgopalachari, UK manojrajagopal@hotmail.com

Dr Mukul Sharma, UK mukul.sharma@lancashire.nhs.uk

Dr P. K. Mahapatra, UK drpkm2@gmail.com

Dr Rahul Manchanda, Canada maryellen.amaral@lhsc.on.ca

Dr Rudra Prakash, USA rudraprakash1@yahoo.com

Dr Salman Akhtar
Dr Sarvesh Singh
, Australia

sarveshdr@gmail.com

Dr Sumeet Jain, UK jainsumeet@yahoo.com

Dr Surendra Prashad Singh, UK spd@mediware.it

 

ii

Indian Jounal of Clinical Psychiatry

EDITORIAL

1. When The Whole World was Witnessing COVID-Crisis…A New Chapter Began Vipul Singh, Sujit Kumar Kar

2. The Slippery Slope of Editing : Balanced Perspectives for Initiating a New Biomedical Journal Debanjan Banerjee, T. S. Sathyanarayana Rao

PERSPECTIVE

3. A Private Psychiatric Specialty Hospital in Kanpur – Some Initial Experiences R. K. Mahendru

4. Mental Health in U.P. – Last Fifty Years A. K. Agarwal

5. A Kaleidoscopic View of Substance Use in Uttar Pradesh Pronob Kumar Dalal and Kopal Rohatgi

6. NGO’s and Their Role in Mental Health Care in India Shashi Rai, Bandna Gupta

7. Suicide in Uttar Pradesh : An Overview Shivangini Singh and Teena Bansal

REVIEW ARTICLE

8. COVID-19 Chaos and New Psychoactive Substances : New Threats and Implications Kumari Rina, Sujita Kumar Kar, Susanta Kumar Padhy

9. Mental Health Issues in Covid and Post Covid-19 Scenario: The Way Forward Tapas Kumar Aich, Amil H Khan, Prabhat Kumar Agrawal

10. Psychiatrists in The State of Uttar Pradesh : The Iconic Professionals S. C. Tiwari, Nisha Mani Pandey

11. Werther’s Effect: A Brief Review
Rakesh Yaduvanshi, Anurag Agrawal, Chinar Sharma

12. Immune-inflammatory Pathways in Somatoform-Disorders : A Theoretical Update Vikas Menon, Natarajan Varadharajan, Selvaraj Saravanan

VIEW POINT

13. Attributes of Distress Among Healthcare Workers Infected with COVID-19
Sujita Kumar Kar, Akanksha Shankar, Sudhir Kumar Verma, Parul Verma, Rahul Kumar, Suyash Dwivedi, Anand Kumar Maurya and Rajnish Kumar

14. Choosing and Publishing A Research Project
Yasodha Maheshi Rohanachandra, Raviteja Innamuri, Amit Singh, Anoop G, Guru S Gowda,
Harita Mathur, Jayant Mahadevan, Lochana Samarasinghe, Naga V S S Gorthi, Pratikchya Tulachan, Rajesh Shrestha, Rajitha Dinushini Marcellin, Samindi T. Samarawickrama, Shanali Iresha Mallawaarachchi and Shreeram Upadhyaya, Shreeram Upadhyay and Sharad Philip

ORIGINAL ARTICLE

15. Sexual Openness and Sexual Dysfunction in Indian Women: A Qualitative Approach Jyoti Mishra, Nitin Gupta and Shobit Garg

CASE REPORT

16. Cannabis Induced Psychotic Disorder in Cannabis Withdrawal During COVID-19 Lockdown : A Case Report
Dhana Ratna Shakya, Sandesh Raj Upadhaya

17. COVID-19 : Depression & Psychogenic Erectile Dysfunction Raghav Gupta, Pranahith Reddy and Kishore M.

ART & MENTAL HEALTH

18. Art & Mental health : Perspectives of The Mind Pawan Kumar Gupta and Aditya Agarwal

ABSTRACTS

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CONTENTS

FROM THE FOUNDER SECRETARY’S DESK

T he Indian Psychiatric Society (IPS), India’s largest and oldest national association of psychiatrists was established on the 7th of January 1947 in New Delhi during the Indian Science Congress. The IPS over the year grown and extended its national networks extensively all across the India. It has five major zonal branches

and around 30 state branches along with several other subsections.

The Uttar Pradesh played a key role in the IPS since its inception and many of the luminaries of the state held key positions in the IPS. Prof KC Dubey, Prof BB Sethi, Prof A K Agarwal and Prof J K Trivedi were among many other star achievers in this regard. However, the formation of the state branch was somehow kept in abeyance.

The Indian Psychiatric Society- UP State Branch (IPS-UPSB) is the newest of the state branches of India. IPS-UPSB has seen its humble beginning after a series of events 2019-20. Prof P K Dalal was elected as the Vice president cum president elect of the Indian Psychiatric society in the year 2019. He took notice that despite being such a large state and having an important place in national organization i.e. IPS, Uttar Pradesh is yet to start its state branch. Hence, Prof Dalal started efforts to establish the state branch. He requested and encouraged several members of the state for the same. He also asked the writer of this document to prepare a draft of the constitution and the bylaws for the state branch. The resolution for the establishment of the IPS UP state branch was passed at the IPS-Central Zonal Conference in Agra in 2019 during the Annual General Body meeting of the IPS-Central Zone.Several esteemed members of the state were present in the meeting including Dr P K Dalal, Dr R K Mahendru, Dr S C Tiwari, Dr S P Gupta, Dr Gyanendra Kumar, Dr Shahsi Rai, Dr Shabri Dutta, Dr Vipul Singh, Dr Hemant Naidu, Dr Sanjay Gupta, Dr Jai Prakash Narayan, Dr Anil Nischal, Dr Sachhidanand Gupta, Dr Dhananjay Choudhary, Dr Ganesh Shankar, Dr Amit Arya and Dr Adarsh Tripathi among several others. The office bearers and council members for this new state branch were proposed and elected unanimously. The resolution letter for the association was submitted to the president of IPS-Central Zone Dr S P Gupta. He presented the proposal in meeting and it was accepted in EC and AGB of theIPS-Central Zonal Conference in Agra in 2019. The president of the IPS-CZ Dr S P Gupta forwarded this resolution and proposal for the consideration to the secretary of the IPS Dr Vinay Kumar. IPS EC approved the formation of new branch at ANCIPS 2020 held at Kolkata. Indian Psychiatric Society Uttar Pradesh State Branch also known and registered as Association of Clinical Psychiatry. Association of Clinical Psychiatry is organization of psychiatrists and allied mental health professionals residing in the state of Uttar Pradesh.The society in registered under Society Registration Act (Act number 21, 1860) as Association of Clinical Psychiatry ACP via registration number LUC/ 02811/2020-2021 dated 03/09/2020. IPS-UPSB was established to promote the advancement of science of psychiatry and related disciplines, promote highest possible standard of clinical practice and ethical behavior in psychiatry in the state of Uttar Pradesh and this aims to occupy a strong and credible position for the promotion of science, newer advancements and dissemination of knowledge in psychiatry among our fellow colleagues in the state of UP.

Though, the very first year we were able to form our branch and able to register it, the world was grappling with the overwhelming and never seen before challenges of the COVID-19 pandemic. Most of the routine activities of the associations are halted or compromised due to variety of restrictions and challenges. We had our first ever-online conference of IPS- UPSB on 11-12th Dec 2021. A scholarly galaxy of national and international speakers made their presentations in the conference. We also organized a very interactive panel discussion of media persons and mental health professionals on the topic of media and mental health. About 250 delegates attended the conference on online platform. A testimony of our continued work and activism was celebrated through proving us 2nd best winner of the Best State Branch of Indian Psychiatric Society for the year 2020 at the AGB Meeting held on 30.01.2021 by national body of Indian Psychiatric Society.

However, we call for a continued togetherness and activism from all of our fellow colleagues during this challenging time. Our association aims to maintain a high standard of scientific integrity and relevance for current times. Let’s continue doing some good work for betterment of our patients, their families and society in general. As the founding honorary general secretary of the IPS-UPSB, I also appeal to all the esteemed psychiatrists of the state to become a member of this association and join hand together for the cause of psychiatry.

Long Live IPS-UP state Branch! Long Live IPS!

Dr Adarsh Tripathi

Hon Gen Secretary, IPS-UPSB

EDITORIAL

When The Whole World was Witnessing COVID-Crisis…A New Chapter Began

Vipul Singh1, Sujit Kumar Kar2

1 Associate Professor, Department of Psychiatry, Govt. Medical College, Kannauj, U.P.

2 Associate Professor, Department of Psychiatry, King George’s Medical University, Lucknow, U.P.

The COVID-19 pandemic has extended its prongs across the globe, leading to extensive mortality and morbidity.There have been 148,532 tests, 7,862 diagnosed cases, and 112 deaths for a million population in India, by mid-February 2021[1]. Despite strict monitoring, several challenges exist in the ground level, which may influence the statistics of COVID-19 related morbidity and mortality. As testing is recommended for symptomatic individuals and those who have history of contact with COVID-19 cases, asymptomatic individuals with no obvious history of contact with COVID-19 cases, are not investigated. It is difficult to estimate this number, unless every individual in the community is investigated for COVID-19. People with mild to moderate symptoms in remote places do not reach for investigation due to fear of being diagnosed with COVID-19, stigma, and unawareness. On the other hand, deaths due to suicide, severe medical morbidity in COVID-19 patients give a false impression of COVID-19 mortality. This makes the missing data of uninvestigated persons who were either infected with COVID-19 or died, more elusive.

When a mortality statistics is calculated, missing data from the numerator (the number of deaths) and the denominator (total number of diagnosed cases) both matter[2, 3]. Unless the number of COVID-19 positive cases were estimated (which is more likely to be missed as after few days the patient may become negative for the test) accurately by timely testing; the mortality rate will always remain questionable.In India, initially a larger group of the asymptomatic population were not investigated for COVID- 19, but they were regularly evaluated at their work-places for the symptoms (fever, cough, other respiratory symptoms), strictly as per the directives of the govern- ment.The Indian government has drastically improved the reporting system, increased the testing facilities, and issued strict advisories regarding COVID-testing,

Corresponding authors:

Dr. Sujit Kumar Kar Email : drsujita@gmail.com

strengthening case detections, and subsequent monitoring[4].However, during this COVID-19 pandemic the government and people of the country witnessed several unique challenges that are extremely rare and unanticipated. In the initial phase of the pandemic people were not aware of the seriousness of the COVID-19.

The pandemic affected the mental health adversely. People of all ages, genders, races and socio-economic strata encountered the challenges during this pandemic [5, 6]. Vulnerable populations (migrant workers, elderly population, commercial sex workers, children, homeless population) are affected very badly during this pandemic [5, 7, 8]. General population, during this pandemic reported anxiety, depression, sleep disturbances, difficulty in coping and paranoia related to getting infection, which significantly affected their life [6, 9, 10]. The perceived mental healthcare need among general population was high [9]. Panic buying, alterations in sexual behavior, binge watching of television or internet and addiction related challenges has also been encountered globally, including India [11–15]. Another serious mental health issue encountered during this COVID-19 pandemic was suicide. Several cases of suicide had been reported in India ranging from celebrities [16] to students [17], which was quite alarming. To mitigate the mental health issues, including suicide, the government of India had launched the national helpline number in the month ofAugust 2020 [18]. To provide mental healthcare to people at need during the COVID-19 pandemic, telepsychiatry services have been popularized and being extensively used despite certain ethical issues, dilemmas and initial reluctances [19, 20]. It has been observed that the mental healthcare needs of all groups of population are not same; hence, there is a need of person-centered care that focuses on the individual needs [21]. The mental healthcare delivery has been evolved as the pandemic progressed.

After emergence of COVID-19, there is sudden shift of focus to research on COVID-related issues, resulting in a mammoth growth in number of COVID-research.

Singh, et al.: When the whole world was witnessing COVID-crisis

Initially, most of the journals promoted fast track publication of COVID-related articles and availed the articles free of cost (open access), globally. However, this publication race resulted in lots of poor quality publications [22].

The pandemic was at its peak in late 2020. The number of cases and mortality in India due to COVID-19 was increasing in an exponential manner. The country has moved to the second position in terms of the highest number of diagnosed cases of COVID-19 in the world. During such a crisis situation, a new psychiatric society in the name of “Indian Psychiatric Society- Uttar Pradesh State Branch” was born. Uttar Pradesh, being the most populated state of the country with approximately 240 million population was not having state society on mental health for a long time. After the society was formed in the month of August 2020, it celebrated the world mental health day in the online platform and the first conference of the Indian Psychiatric Society- Uttar Pradesh State Branch was held in the online platform in the month of December 2020 (organized by the Department of Psychiatry, King George’s Medical University, Lucknow). The society has introduced a new journal in the name of “Indian Journal of Clinical Psychiatry”. This is how a new chapter began, when the whole world is going through the crisis. Academia is expanding. Research domains and scopes are expanding in mental health. More number of medical colleges and post-graduate departments of psychiatry are opening in the country. Research inclination and promotion requirements of psychiatric faculties, is resulting in more publication of research articles. There is need of more number of good quality journals to promote academic research as many predatory journals are distracting researchers by providing easy publication with a cost. To maintain the academic decorum and promote good quality research, Indian Journal of Clinical Psychiatry will continue to work.

REFERENCE

1. Worldometer. COVID-19 CORONAVIRUS PANDEMIC. Worldometer, https:/ /www.worldometers.info/coronavirus/ (2021, accessed February 15, 2021).

2. Nischal A, Prakash AJ, Singh N, et al. Understanding the variations in death rates during coronavirus pandemic and their preventive implications. Journal of Geriatric Care and Research 2020; 7: 84–88.

3. Baud D, Qi X, Nielsen-Saines K, et al. Real estimates of mortality following COVID-19 infection. The Lancet Infectious Diseases 2020; 20: 773.

4. Ministry of Health and Family Welfare, Government of India. Advisory on Strategy for COVID-19 Testing in India (Version VI, dated 4th September 2020) Recommended by the National Task Force on COVID-19, https:/

2

5.

6.

7.

8. 9. 10.

11.

12. 13. 14. 15. 16. 17. 18. 19.

20. 21. 22.

/www.mohfw.gov.in/pdf/AdvisoryonstrategyforCOVID19TestinginIndia.pdf (2020, accessed September 6, 2020).

Singh N, Gupta PK, Kar SK. Mental health impact of COVID-19 lockdown in children and adolescents: Emerging challenges for mental health professionals. Journal of Indian Association for Child and Adolescent Mental Health; 16, https://covid19.elsevierpure.com/en/publications/ mental-health-impact-of-covid-19-lockdown-in-children-and-adolesc (2020, accessed February 15, 2021).

Kar SK, Oyetunji TP, Prakash AJ, et al. Mental health research in the lower- middle-income countries of Africa and Asia during the COVID-19 pandemic: A scoping review. Neurology, Psychiatry and Brain Research 2020; 38: 54–64.

Chatterjee S, Basu S, Bhardwaj YA, et al. The Health Crisis of Marginalized Populations during COVID-19 Pandemic: Challenges and Recommendations. International Journal of Social Sciences 2020; 9: 185– 191.

Kar SK, Arafat SMY, Marthoenis M, et al. Homeless mentally ill people and COVID-19 pandemic: The two-way sword for LMICs. Asian J Psychiatr 2020; 51: 102067.

Roy D, Tripathy S, Kar SK, et al. Study of knowledge, attitude, anxiety & perceived mental healthcare need in Indian population during COVID- 19 pandemic. Asian Journal of Psychiatry 2020; 51: 102083.

Kar SK, Yasir Arafat SM, Kabir R, et al. Coping with Mental Health Challenges During COVID-19. In: Saxena SK (ed) Coronavirus Disease 2019 (COVID-19): Epidemiology, Pathogenesis, Diagnosis, and Therapeutics. Singapore: Springer, pp. 199–213.

Chatterjee S, Kar SK. Comments on “Benefits of Sexual Activity on Psychological, Relational, and Sexual Health During the COVID-19 Breakout.” The Journal of Sexual Medicine; 0. Epub ahead of print December 16, 2020. DOI: 10.1016/j.jsxm.2020.11.005.

Dixit A, Marthoenis M, Arafat SMY, et al. Binge watching behavior during COVID 19 pandemic: A cross-sectional, cross-national online survey. Psychiatry Res 2020; 289: 113089.

Arafat SMY, Kar SK, Menon V, et al. Panic buying: An insight from the content analysis of media reports during COVID-19 pandemic. Neurology, Psychiatry and Brain Research 2020; 37: 100–103.

Kar SK, Arafat SMY, Sharma P, et al. COVID-19 pandemic and addiction: Current problems and future concerns. Asian J Psychiatr 2020; 51: 102064.

Das N, Kaur A, Joseph SJ, et al. COVID-19 and Sexual Practices During the Pandemic—Do We Need to Worry? Journal of Psychosexual Health 2021; 2631831820979767.

Kar SK, Arafat SMY, Ransing R, et al. Repeated celebrity suicide in India during COVID-19 crisis: An urgent call for attention. Asian J Psychiatr 2020; 53: 102382.

Kar SK, Rai S, Sharma N, et al. Student Suicide Linked to NEET Examination in India: A Media Report Analysis Study. Indian Journal of Psychological Medicine 2020; 0253717620978585.

Ransing R, Kar SK, Menon V. National helpline for mental health during COVID-19 pandemic in India: New opportunity and challenges ahead. Asian J Psychiatr 2020; 54: 102447.

Singh Bhandari S, Joseph SJ, Udayasankaran JG, et al. Telepsychiatry: a feasible means to bridge the demand–supply gaps in mental health services during and after the COVID-19 pandemic: preliminary experiences from Sikkim state of India. Indian Journal of Psychological Medicine 2020; 42: 500–502.

Sousa A, Karia S. Telepsychiatry during COVID-19: some clinical, public health, and ethical dilemmas. Indian Journal of Public Health 2020; 64: 245–246.

Kar SK, Singh N. Person-Centered Approach to the Diverse Mental Healthcare Needs During COVID 19 Pandemic. SN Compr Clin Med 2020; 2: 1358–1360.

Kar SK, Menon V, Arafat SY, et al. Research in Mental Health During the COVID-19 Pandemic: Quality versus quantity. Sultan Qaboos University Medical Journal 2020; 20: e406.

Indian Jounal of Clinical Psychiatry

GUEST EDITORIAL

The Slippery Slope of Editing : Balanced Perspectives for Initiating a New Biomedical Journal

Debanjan Banerjee1, T. S. Sathyanarayana Rao2

1 Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, India 2 Department of Psychiatry, JSS Medical College and Hospital, JSS Academy of Higher Education and Research, Mysore, India

Since the evolutionary advent of scientific thinking, medical journals have been well-known and influential media for professional and scientific discourse within academia. Such journals have been an integral part of medical literature, comprising content relating to historical and contemporary views about diagnosis, prognosis, and medical conditions management. Starting from the Edwin Smith Papyrus (first known medical treatise) of Egypt to Yellow Emperor, China, Iliad and Odyssey, Greece to our own Charaka and Sushruta Samhitas: medical discourse has been presented in various forms which have led to the contemporary evolution of medical journals.[1] Contrary to the plethora of unauthenticated medical information and health-related news available in the modern world, published content in scientific journals has to pass through a rigorous and preferably blinded peer review process. This essentially keeps in check the content-validity and scientific relevance of published material through reviews by equally or more qualified experts in the same fields as the author, promoting revisions and suggestions to improve the manuscripts’ quality. Initiating a new medical journal (especially in the growing field of mental health) is always a challenge laden with the thin line of balance between ensuring scientific rigor and exciting content and being ‘lost’ in an endless pool of rapidly-emerging biomedical publications.

ROLE OF AN EDITOR : THE SLIPPERY SLOPE

“If you do not want to make friends, become an editor.”

Dr. H. Whitefield, Editor-in-Chief, British Journal of Urology, 1985[2]

Corresponding author:

Dr. Debanjan Banerjee
Email : Dr.Djan88@gmail.com, Ph.: 91-9535581094

Even though a completed journal issue with a great lineage of good quality papers appear glamorous and praiseworthy, the ‘behind the scenes’ efforts of an editor remain silent but potentially most challenging. Irrespective of the hierarchical organizations of editorial responsibilities (Editor-in-chief, associate editors, section editors, review editors, etc.), editing peer-reviewed medical journals is stressful and frustrating, yet in the end, a rewarding task, especially when the journal originates in a developing country. Editors are responsible and accountable for determining and finalizing content for peer-reviewed journals. As defined by the International Committee of Medical Journal Editors (ICMJE), experts need to review such journals outside the purview of the journal’s editorial board.[3] In that sense, editors’ responsibilities extend to all the authors, reviewers, readers, study participants, the broader academia, and finally to medical science itself. An optimal balance between all these stakeholders is the primary challenge and essential onus of the editor. The editorial process serves as an“intermediary function to facilitate the transmission of valid, useful knowledge while screening out poor quality, redundant, and irrelevant material.”[4] Editors keep facing a myriad of problems: balancing personal-professional boundaries, catering to the endless author correspondence, ensuring a timely yet honest peer-review, quality check for each of the publications, timeliness of the entire process, and most important, decisions to reject a paper that is often personally a bitter yet necessary experience.[5] Often, the presence of an ‘unblinded review system,’ lack of disclosures related to conflict of interest, redundant publications, fraud and plagiarism, ghost authorship, advertising, sensitive language use and stigma, absence of a declaration of patient consent and ‘rigging the Impact Factor (IF)’ are some of the critical issues especially in a new journal.[6] Pragmatically, authors’ failure to comply with instructions, inferior quality manuscripts, duplicate submissions, ‘slicing,’ ethical challenges of publication, non-availability, and varying quality of

reviewers. Lack of trained support staff, unsatisfactory copy-editing are some of the other pertinent adversities faced by scientific journals emerging from developing countries. Over time, these are compounded by the constant need to improve the journal’s standards, ensure outreach and publicity, and gain good indexing in popular databases, which are essential for the sustenance of any scientific journal in academia. Mostly, with the Coronavirus Disease 2019 (COVID-19) pandemic, a never-ending curve of research parallels the growth curve of the viral caseload. During such a global healthcare crisis which has an immense psychosocial and emotional impact, a psychiatric journal needs to disseminate real- time and accurate information which can be critical for constructive discourse building across the mental health community, facilitating understanding and management of psychiatric problems, and helping policy makers during the ongoing situation of substantial uncertainty.[7] This all the more pressurizes the editor to maintain the balance between comprehensive yet timely manuscript processing and elimination of invalid and unscientific information.

SPECIFIC VITAL RESPONSIBILITIES OF THE JOURNAL EDITOR

Towards the readers

●  Content is valid and from reputed sources

●  Factually accurate, balanced, and unbiased

●  Opinions and hypothesis differ from original research

●  Potential conflict of interest disclosed

●  Pejorative and sensitive language avoided

●  Readable with a standardised style

●  Timely and consistent publication
Towards the authors

●  Clear and standardised instructions and submission guidelines

●  Dignity

●  Timely, constructive and confidential review

●  Outreach and feedback
Towards the reviewers

●  Open to peer guidance, reviewer recognition

●  Regular discussions and obtaining suggestions

●  Discussion forum

●  Reviewer meets
4

Towards the Organisation/funding body of the journal

● Transparency in policies and advertisements
● Avoiding legal complications
● Formalize contract and employment (if applicable) ● Regular meetings and interactiveforums

EDITING A NEW JOURNAL: A CAREFUL PATH TO TREAD

Besides the hardships mentioned above, financial and resource constraints can pose a serious challenge to the editorial job in developing countries. This is of all the more concern, if the owner and editor of the journal is the same person. In today’s world where ‘every newly launched product’ is subject to evaluation and competitive ‘rat race’, publicity of naïve journals is also subject to outreach, popularity, and maintenance which needs to be at par with established journals at the same field. The former editor of British Medical Journal (BMJ), Richard Smith, high- lighted that clinicians, researchers, editors, and journalists should also seek to accept the existing shortcoming of medical journals and actively act to reform them. Most importantly, like ‘treatment guidelines’, there are no available frameworks to guide the editors for an ‘ideal editing process’.[8] As Dr Smith further mentions drawing an analogy to parenting, the process of editing is a learned skill and evolves over a period of time with multiple ‘trial- runs’ as there is no one ‘absolute right path’ to succeed. He also draws attention that less than 5% of published literature in journals with good IF are from the low and middle-income countries.[8] While the enthusiasm and efforts are praiseworthy for entrepreneurship related to new journals, a few challenges and pitfalls need to be kept in mind.

SPECIFIC CHALLENGES OF THE EDITOR WHILE STARTING A NEW SCIENTIFIC JOURNAL

Banerjee, et al.: The slippery slope of editing

● ● ● ● ● ● ●

Editorial staff training and funding
Ensuring timely peer-review and adequate reviewers Constructive feedback to the authors/reviewers Consistency and regularity of the issues
Matching the existing editing standard in the field Quality control and scientifically relevant information Outreach to the scientific community and academia

Indian Jounal of Clinical Psychiatry

●  Targeting young researchers

●  Ethical considerations for publications and plagiarism

●  Not emerging as just “another journal” in the field

●  Approximate indexing and citation

●  Meaningful contribution to the field of medical science
While performing the editorial work related to a journal launched newly in the field, the team needs to balance enthusiasm with pragmatism and reality. Many regional journals remain constricted to particular zones and areas with limited scientific appeal to the researchers, leading to unsuccessful solicitation attempts for manuscripts and eventual cessation of the journal issues. On the other hand, an overly permissive approach will lead to ‘trash publications’ that might bypass the peer-review process. Even though lucrative for young researchers, this might lower the IF, affect the citation index, and finally run the risk of that journal being considered ‘predatory’ and ultimately extinct.
Some of the common pitfalls while editing a new journal and possible consequences are listed under:

●  Excessive gap between the issues that compromises readability

●  Conflicts of financial interests if the editor owns the journal as well

●  Unclear and ambiguous instructions for the authors (reduce the contribution and interest)

●  ‘Too strict versus too permissive review process’: Lack of publishable articles versus unscientific publications

●  Opinions, viewpoints, case reports >> Original research (a proportional balance needs to be maintained)

●  Poor copy-editing (issues with grammar, spelling, and flow will compromise the quality and authenticity)

●  Internal peer-review by members of the editorial board due to lack of adequate external peer-reviewers (affects the scientific rigor)

●  Personal remarks that might be socio-politically or ideologically influenced if not adequately reviewed (can fuel controversies and ethical issues)

●  ‘Dumped publications’: in an attempt for fast publications, most manuscripts that are selected have been rejected from other journals.

●  For journals without a professional publication platform (like Elsevier, SAGE, Taylor & Francis Online, etc.): manual organization of editing work can lead to a significant delay
Indian Jounal of Clinical Psychiatry

● Poor and delayed response to the authors and reviewers: leads to reduced credibility in the scientific forum.

● Low balance between acceptance and rejection rates: a constructive feedback is necessary, especially for young researchers encouraging them to submit their work

● Excessive social publicity: runs the risk of being considered ‘casual and unscientific.’

● Editor involved in multiple roles: can lead to role-overlap and conflicts of interest

● Compromising the publication ethics (certain steps like obtaining the ISBN no., the ICJME Conflict of Interest declaration from the authors, duly signed copyright forms, and adherence to the COPE guidelines help in better indexing)

● Multiple articles from within the editorial team or by the same set of authors (which are common in new and regional journals that can markedly hamper their scientific popularity)

● Risk of slicing, duplicate publications, and plagiarism

● Increased advertising (mostly by the pharmaceutical industry) for funding which can have ethical and legal implications affecting journal maintenance.

● The distinction between a ‘scientific journal’ versus a ‘public magazine’

THE WAYS AHEAD

These pitfalls are not absolute, and as mentioned before, the ‘nitty-gritties’ of the editorial work are best appreciated by the editor himself/herself being involved in the process. Despite these challenges, the picture is not that gloomy. Medical editors of biomedical journals across the world, especially from developing nations, have made significant progress. It is all the more commendable as many researchers take up this work without any formal training and the hands-on experience serves as the best for them. Many such editors have successfully run many Indian journals that have gained global attention, good indexing, and popularity among researchers. It is important to understand that the responsibilities of editing are often added to other professional commitments of the editors and, in most cases, remain as honorary and purely of an academic interest. The most significant incentives in that case are

5

Banerjee, et al.: The slippery slope of editing

readability, fame, contribution, and acceptance of the journal among the scientific community that best meets readers, authors, and reviewers’ expectations. The professional satisfaction of editing is considered to be of immense satisfaction by many renowned editors.

India already has a few successfully running psychiatry journals, however that is not a hindrance to a new psychiatric journal helping to contribute more to the field. In the widely growing mental health arena, research has been rapidly emerging in biological, psychosocial, and neuropsychiatric domains that need to be published and conveyed to the global community. Any initiative in this regard is welcome. In a socio-culturally diverse nation that comprises nearly 18% of the world’s population, there will never be a dearth of good-quality scientific content for publication if professionally encouraged and given a constructive forum to flourish. With technology aiding health research in a big way over the last few decades that has gained a renewed impetus during this pandemic, most journals have transited to online forums with options of ‘online-first’ publications rather than regular time-bound issues that helps in rapid dissemination of timely research as well as bears an economic benefit. Besides the traditional principles of editorial staff training, adherence to publication ethics, adequate and timely peer-review as well as active solicitation of articles across scientific forums, few other techniques might help the editor of a freshly-mint psychiatric journal. They include a website/ online forum specifically dedicated for the journal; ‘out- of-the-box’ strategies like inclusion of video/audio abstracts, papers, author interviews; involvement of inter-sectorial research, inclusion of psychological and social sciences; first-person perspectives and opinion pieces that can be published in a blog associated with the journal; having a broad and adequate pool of peer- reviewers in each sub-section based on their expertise; pre-decided formats of publishing and ethical policies; transparent display of all the details for the authors, readers, and reviewers on the journal forum/website and finally regular meetings, feedback, and training of the editorial staff for better services. A couple of points need special mention: the involvement of students and early career researchers is extremely important and helps a journal gain immense popularity. A lot of them might be unable to find the right forum for their research, and constructive feedback from a new but scientifically rigorous journal help in their mutual improvement. A

6

separate section for these young researchers can enhance the journal’s selling points. BMJ Student (a separate but independently operating section of the BMJ) can serve as an ideal example.[9] Further, active collaboration is necessary with well-known journals, editors, and publishers for periodic trainings and workshops in editorial work, peer-review process, and journal maintenance that greatly help in learning, growth, and sharing of important insights across the editorial community which can serve as vital ‘steps’ for a journal in its adolescence.

Ultimately, editing is a fun-filled learning process, and the final fruit is always worthy! However, the challenges are practically learnt than taught. A critical balance between professionalism, personal relationships, and academic commitments is vital to guide an editor through the process, and no ‘one size fits all’. Eventually, it’s the final discretion of the editor that makes the journal a reality, and that discretion needs to come out of a “balanced and informed choice” without any attempt to possibly please everyone involved.To conclude with the words of another former editor of the BMJ, Sir Hugh Clegg ,”A medical editor has to be the keeper of the conscience of a profession and if she/she tries to come up to this idea, he/she always will be getting into trouble”.[10]

REFERENCES

Banerjee, et al.: The slippery slope of editing

1. 2.

3. 4. 5. 6.

7.

8. 9. 10.

Foster, M. http://www.st-mike.org/medicine/medicine.html. 1997 [last accessed on November 28th, 2020]

Jawaid SA. Problems of editing a peer-reviewed biomedical journal in a developing country. The Journal of Tehran University Heart Center. 2008;3(4):187-90

ICMJE. http://www.icmje.org/recommendations/. 2019 [last accessed on November 28th, 2020]

Tandon R. How to review a scientific paper. Asian journal of psychiatry. 2014 Oct 1;11:124-7

Jawaid SA. Problems faced by editors of peer-reviewed medical journals. Saudi medical journal. 2004 Jan;25(1 Suppl):S21-5

Greenberg D, Strous RD. Ethics and the psychiatry journal editor: responsibilities and dilemmas. The Israel journal of psychiatry and related sciences. 2014 Jul 1;51(3):204.

Tandon R. COVID-19 and mental health: preserving humanity, maintaining sanity, and promoting health. Asian journal of psychiatry. 2020 Jun 1.

Smith R. The trouble with medical journals. Journal of the Royal Society of Medicine. 2006 Mar;99(3):115-9.

The BMJ. https://www.bmj.com/student [last accessed on November 28th, 2020]

Jawaid SA. What medicine and medical journal editing mean to me. Men’s Sana Monographs. 2006 Jan;4(1):62.

Indian Jounal of Clinical Psychiatry

P E R S P E C T I V E

A Private Psychiatric Specialty Hospital in Kanpur – Some Initial Experiences R. K. Mahendru

Senior Practising Psychiatrist, Mahendru Hospital, Kanpur, U.P.

The modern trend throughout the world is to treat psychiatric patients in the environment in which they live to facilitate their quick return to their families and place of work. It is stated that the “establishment of a psychiatric unit in a general hospital has done more to advance than in any diagnostic or therapeutic discovery.” It is also being remarked that systemic instruction in psychiatry is non-existent in most medical colleges, and in most others, the status of psychiatry is nothing better than merely acknowledging its existence. The general hospital psychiatric units would be in a better position to provide improved treatment and teaching facilities. They would also benefit from the atmosphere of therapeutic optimism, continuity of care, day hospital treatment, and facilities of special investigations, referral, and treatment of concurrent physical diseases. With this impression, more and more psychiatric units are being opened in general hospitals to meet the country’s growing mental health requirements.

Just as psychiatric clinics in a general hospital set up have their usefulness, specialty psychiatric hospitals in the community are gaining importance in providing comprehensive psychiatric treatment facilities at the community’s doorstep.

Since the number of psychiatrists has gone up in recent years, the number of specialty psychiatric hospitals in private setup is increasing. There may be at least half a dozen big and small psychiatric hospitals in U.P. alone, ranging from a capacity of 10 to 50 beds.

The Setup: The above-mentioned psychiatric hospital in Kanpur was established in 2001 with 15 beds and a staff of two psychiatrists. The hospital was initially housed on the ground floor of a four-story building in Sarvodaya Nagar, Just 500 meters away from G.S.V.M. Medical College, Kanpur.

Corresponding author:

Dr. R. K. Mahendru
Email : mahendru.rk@gmail.com

The difficulties and the stigma of being a psychiatric hospital: Though the hospital is located in a semi- commercial area, it faced a lot of resistance and objection from the neighbors and other residents of the locality. Although from the beginning, every care was taken for adequate security of the inmates of the hospital and also the residents of the locality, the opposition to the functioning of this hospital continued. One of the hospital building floors was sealed on the complaint of a neighbor, and the resultant court case and sealing of the floor continued for several years.

The hospital staff: The hospital has three qualified psychiatrists, four general duty doctors, two trained and qualified clinical psychologists, and two dozen male and female nurses. The hospital offers 24 into 7 emergency psychiatric services round the year.

The Outpatient department (O.P.D.) : The O.P.D. of the hospital kept registering a steady growth in O.P.D. attendance. The O.P.D. caters to all sections of the society and represents the prevailing socioeconomic status of the region. The patients are drawn not only from Kanpur but also from at least a dozen neighboring districts of Utter Pradesh, such a Fatehpur, Unnao, Kannauj, Farukhabad, Etawah, Auraiya, Hamirpur and Jalaun etc.

The In-patients: The hospital started with 15 beds in 2001. It has gone up to 40 beds in 2015 with 26 general beds and 14 private rooms.

The Diagnostic break-up of the hospital patient population: The average diagnostic breakup of patients attending the hospital is shown in Table 1.

It may be seen that two-thirds of the Inpatients consist of schizophrenia, acute psychosis, and Bipolar disorders. This is entirely consistent with the trends seen in other psychiatric hospitals and general hospital psychiatric units.

Specialized treatment services: Besides conventional psychological treatment and modern pharmacotherapy,

 

Table 1: Distribution of Patient Catagories

Teaching and Training: The hospital is involved in regularly organizing various conferences, seminars, and C. M. E.s related to various psychiatry and mental health fields. The hospital is also actively engaged in providing training to A. N. M., G. N. M. and B.Sc nursing students. About a dozen nursing colleges and institutes are associated with the hospital that regularly sends their nursing students every year for psychiatric training.

The Clinical Research Setup: The hospital had a significant presence in the domain of clinical research and has conducted more than 60 multinational, multi- centric randomized controlled trials (RCTs) over a decade. The molecules studied were old and new, including quetiapine, risperidone, iloperidone, paliperidone, lithium carbonate, aripiprazole, donepezil, lurasidone, and cariprazine (not yet available in India).

Social activities: The hospital is well aware of its social responsibility towards the mentally ill and keeps doing its bit to educate the people in mental health matters and thus trying to reduce the stigma attached to mental illnesses. Organization of psychiatric relief camps, radio talks, public health lectures, and publication of mental health articles in the local press are some of the social activities regularly undertaken by the hospital.

The Future Needs: The hospital needs to be expanded further to provide the facility for long and life-long stay of patients with chronic mental disorders along with adequate rehabilitative measures.

The Implications: The general hospital psychiatric setup and the psychiatric hospital in the community can cater to the needs of all categories of psychiatric patients. A large proportion of psychiatric patients with major mental disorders in the inpatient population may be due to almost negligible psychiatric services at the government level in this biggest industrial city of the state. Further, it is definite that if the number of specialty psychiatric hospitals and general hospital psychiatric units are established, the need for a traditional mental hospital would be reduced.

Indian Jounal of Clinical Psychiatry

Mahendru : A Private Psychiatric Specialty hospital in Kanpur

S.

No.

Diagnostic Categories

Percentage

OPD

IPD

1

Schizophrenia & Other psychosis

20

50

2

Bipolar Affective Disorder

18

25

3

Major Depressive Disorder

15

5

4

Substance abuse disorders

7

5

5

Anxiety, Obsessive other Compulsive Disorder & other related disorders

25

7

6

Organic Brain Disease

6

3

7

Childhood psychiatric disorder including MR

5

2

8

Miscellaneous like epilepsy, etc.

4

3

the hospital also offers specialized psychiatric treatment in the form of Electroconvulsive Theory (E. C. T.) and rTMS procedures.

E. C. T.:- The hospital has a facility for modified E. C. T. as per prescribed international standards with the services of an anesthetist with separate treatment and recovery rooms.

rTMS:- Repetitive Transcranial Magnetic Stimulation is now available at our hospital. This is a nonsurgical, noninvasive, nonpharmacological painless technique where an electromagnetic field, roughly the strength of an M. R. I. scan, passes multiple magnetic pulses per second through the skull. These magnetic pulses stimulate the targeted areas of the underlying brain tissue to produce therapeutic changes. It is used in the treatment for certain disorders like depression, anxiety, bipolar disorders, schizophrenia, and substance abuse disorders.

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P E R S P E C T I V E

Mental Health in U.P. – Last Fifty Years

A. K. Agarwal

Former professor and Head Dept of psychiatry, K.G’s. Medical College, Lucknow.

B104/2 Nirala Nagar, Lucknow- 226020, Email : mradulanil@gmail.com

Uttar Pradesh is bigger than many countries of the world, both geographically and in population. This state consists of large Indo-Gangetic plains with Hindi as the basic language though the dialect differs in different parts. Primarily it is an agricultural society, but urbani- zation is happening amazingly fast. The cultural background is largely uniform over the state. The society is stable. Unfortunately, mental health growth has not been as robust as in some other parts of the country.The reason for this poor development is not difficult to seek. Most mental health institutions were developed in the south or eastern part of the country; therefore, not many from this state could join them.The first post- graduate teaching program came into existence in the K.G’s Medical College (KGMC) in 1971. The state did not consider the mental health of primary importance till recently. The priorities were communicable diseases and malnutrition.

HISTORY

My first encounter with an individual with mental illness was in the year 1954 when I saw a young man tied in ropes on a railway platform. This man was loudly abusing, and a crowd had gathered around him. I was fifteen-year-old and did not know what the issue was. I was told that this person is being taken to Agra for treatment. This experience was totally forgotten till I became a psychiatrist in 1965 and I could appreciate the pain of mental illness. After completing my training from All India Institute of Mental Health, Bangalore in 1965, I applied for a job in U. P. Health Services. I requested the director to allow me to work only in the area of mental health. I was informed that you are being appointed as a medical officer, and you can be posted anywhere.Why am I relating these incidents? This is to show that this state was not explicitly geared

Corresponding author:

Dr. A. K. Agarwal
Email : mradulanil@gmail.com

to develop mental health care. Similar scenes of the mentally ill lying uncared for at home and in the streets can still be seen. Even now, psychiatrists are posted as medical officers and are expected to perform duties as medical officers. They lose contact with their specialty and become ineffective both as medical officers as well as psychiatrists. There is an acute shortage of psychiatrists in the state, and we are not using even the available resources appropriately.

I joined the Department of Medicine as a lecturer in psychiatry(KGMC) in 1969. The department already had two faculty members in psychiatry. Later in 1971, an independent Department of psychiatry was carved from the department of medicine, and post-graduate training in psychiatry started. The availability of mental health training or services was very few at that time. There were three medical colleges owned by the state govt and two university-owned colleges in Varanasi and Aligarh. Psychiatric facilities were available only at Lucknow and Varanasi. There were three mental hospitals in Agra, Bareilly, and Varanasi. Except for Agra, all others were managed by non-psychiatrist. A couple of retired psychiatrists from mental hospitals were in private practice. The number of psychiatrists could not reach double figures.

The Indian Psychiatric Society asked me to organize the central zone. This zone consisted of U. P. and Madhya Pradesh. The total number in the two states was not more than twenty, and the whole conference was held in a small room. The situation has entirely changed now.

PRESENT SITUATION

The real change occurred after psychiatric post- graduation started in Lucknow. Soon after, Varanasi and Aligarh, and Agra also started post-graduate programs. Many new govt medical colleges and private medical colleges are providing post-graduate training currently.

This rapid development has led to another group of problems. There were not many trained post-graduate teachers in psychiatry. Institutions tried to fulfill the requirement of teachers by different kind of manipulations that is affecting training programs. The development of any specialty depends on the ability of persons joining it. There were three distinct phases. The first phase was in the sixties when those interested in specialty traveled long distances to do specialization. The second phase started in the seventies and continued for nearly twenty years when psychiatry was the last choice during post-graduate selections. Many senior teachers actively discouraged bright students from taking psychiatry as they felt that this specialty would not provide them the type of returns they deserved. Things started changing around 1990 when quite a few bright students started opting for psychiatry. This description does not mean that there were periods when no bright students joined psychiatry, but the ratio of the mixture had changed over a period.There are around 180 members of the Indian Psychiatric Society, and there must be another fifty who are not members, but even these numbers are too few for this state.

From its inception, psychiatry had been riddled with a conflict between biologically versus the psychologically oriented group. Though everyone accepts the multi- factorial causation of mental illnesses, the emphasis still varies. We in India have another important variable, the indigenous methods of treatments and religion-based therapies like yoga. The young clinicians are confused and often provide contradictory signals. They will prescribe a large number of medicines, provide rudi- mentary psychological help, and recommend yoga. Such advice produces conflict in patients’ minds and caregivers and often results in treatment failure. Psychiatry is an evidence-based specialty, and we should practice methods that have sound evidence. Drug treatment for various illnesses has reasonable evidence; similar evidence is also available about certain specific psychotherapies. The limitation is that these psychotherapies can be practiced by people who have been trained. Therapies like Yoga, Ayurveda, Unani are being tried by some, but there is no consensus. Till such times the consensus develops, one should refrain from using them as therapeutic tools, but they can be used as general mental health measures as per the patient’s belief system. But one must clearly specify the reason for such advice. A young man shows repetitive

10

bouts of anxiety in tough situations. If he or his family believes that prayer to god or any other such practice helps, there is no harm in trying it in the right earnest for some time. If it does not work, we revert to accepted methods. Combining the two from the start will confuse the psychiatrist as he will not know what worked.

LAW AND MENTAL HEALTH

MHCA 2017 is progressive and right based legislation, and Chapter 5 of the Act (Sec 18-28) is fully devoted to the rights of persons with mental illness (PMI). Section 28 of the Act describes the “Right to access mental healthcare,” which will be universally available. The section states that “Every person shall have a right to access mental health care and treatment” from mental health services run or funded by the appropriate government, and the government shall make sufficient provision as may be necessary, for a range of services required by PMI. Suppose the government fails to provide the right to access mental health care to everyone. In that case, it is the government’s responsibility to reimburse the costs of treatment according to the section. The range of services includes outpatient and inpatient services, free essential medicines, halfway home, sheltered accommodation, services for support of family persons of PMI, hospital, home, community-based rehabilitation services, and child and old age mental health services. Mental health services are to be integrated with the general health services at all levels, such as primary, secondary, and tertiary levels (C.L.Narayan).*Similar is the situation about The Rights of Persons with Disabilities (RPwD) Act-2016. None of the facilities envisaged in the act are available to persons with mental illness. I think it is time to encourage the mentally sick and their relatives to go to courts to avail of these facilities as provided by law.

The ground reality is that mental health service does not exist in the state. There is a district mental health program that is largely funded by the center. Mentally ill have no access to treatment near their place of stay. There are no rehabilitative services. Medicines are provided in the district mental health program and in some government hospitals. How adequate are they need to be examined? There is a need to develop a systematic mental health care program for the whole state where the sick should be able to get treatment near their homes, and rehabilitation

Indian Jounal of Clinical Psychiatry

Agarwal : Mental Health in U.P.

should be built. District mental health programs could be the nucleus for state mental health services. The district mental health program should have a twenty-bed unit in each district. This should include acute care, long term care, and rehabilitation. Patients coming from different parts of the districts should be referred back to their primary health care unit, and the follow-up treatment should be done by local health personnel. This will provide hands down training to medical officers and sensitize them to the mentally ill’s needs.

FUTURE

The future of psychiatry in U.P. will largely depend on how psychiatry’s current leadership faces the challenges. I have the following suggestions to make.

Emphasize the teaching of psychiatry both at the under- graduate and post-graduate levels. We must follow the curriculum developed by the medical council of India. This curriculum has many deficiencies, and repetitive representations could resolve these. No individual or institution should diverge from the accepted curriculum; this will bring uniformity. Many distinguished clinicians may have developed new techniques or new knowledge, but these should not be part of the curriculum till accepted by the medical council. Many teaching

institutions have a shortage of staff; this could be overcome by developing guest faculty for areas where sufficient expertise does not exist in the department. Students needto be exposed to different settings, like mental hospitals, rehabilitation centers, prisons, and research settings, not as tourists but as clinical duties.

The clinical services should be developed to provide comprehensive care for acute patients, chronic patients, and psycho-social emergencies. A partnership between private psychiatrists and state mental health services should develop.

Uttar Pradesh state branch of IPS should take the initiative to develop apsychiatric journal in Hindi, which is likely to find acceptance in the whole of Hindi heartland, e.g., U. P., M. P., Bihar, Rajasthan, Chhattisgarh, Jharkhand Uttarakhand, etc. Original thinking can only develop in one’s native language. Most of us have been trained to translate all native concepts into a foreign language, which often takes away the concept’s vital ingredient. I have emphasized it many times earlier, but re-emphasis is required to develop expertise in psycho-social management and measurements. We also need to develop primary data on psycho-social issues particular to our area.

I wish the new journal and the branch a bright future.

Agarwal : Mental Health in U.P.

Indian Jounal of Clinical Psychiatry

11

P E R S P E C T I V E

A Kaleidoscopic View of Substance Use in Uttar Pradesh

Pronob Kumar Dalal1 and Kopal Rohatgi 2

Ex-Professor & Ex-Head 1 , Senior Resident 2

Department of Psychiatry, King George’s Medical University, Lucknow, U.P

 

ABSTRACT

Substance use disorders are a rising public health problem in the state as well as the country. National level surveys have concluded that a large treatment gap exists between the population at risk, dependent individuals, and the resources available for management. Uttar Pradesh ranks higher than the national average in alcohol, cannabinoids, opioids, and sedative use and dependence. Thus, requiring a larger quantum of work to combat the issue. Tackling the initiation of substance use and management of dependence in youth is an area of particular focus that should be addressed. This article describes, how this emerging problem can be dealt with using existing policies and action plans in the state, keeping in view the lack of available resources, with recommendations for the future for better outcomes.

Keywords: Substance Use Disorders, Psychoactive substances, Narcotics, Treatment gap, Uttar Pradesh

Substance use or abuse is a public health problem affecting a magnanimous number of individuals and, in turn, their families in our country. Likewise, the general population of Uttar Pradesh indulges in the use of various psychoactive substances, with the numbers rising as the years go by, encompassing a brewing issue in recent times. These set of disorders have a significant impact on one’s personal, social and occupational spheres, including their physical and emotional wellbeing.

The recently conducted National Mental Health Survey called for immediate action and attention towards Mental Health, including Substance Use disorders, asking for integration and incorporation of the same in the government’s National and State policies and programs. Further, help from Non-Governmental Organisations and Private sectors has also been sought to make this a

Corresponding author:

Dr. Kopal Rohatgi

E-mail : kopalrohagi@hotmail.com

successful venture in the future. This article attempts to give a window into the problem at hand, including the present scenario and recommendations for the future [1-5].

SUBSTANCE USE IN UTTAR PRADESH: THE CURRENT SCENARIO

With the changing times, concern for mental health with a particular focus on substance use disorders has been growing, reflected in multiple studies conducted recently. As the availability of psychoactive substances has increased, the number of people consuming substances has also increased tremendously, leading to long-term health effects. A near increase of 60% was observed in the current mortality rate with respect to the year of 2000.The morbidity and mortality due to illicit drug use are reaching an all-time high. The lack of awareness of harmful consequences and availability of medical help paints a grim picture of the country’s drug problem [1,2].

The National Mental Health Survey, 2015-16 computed a nationwide prevalence of 22.4% of any substance use disorder, 4.6% of alcohol use disorders, 0.6% of other substances, and 20.9% for tobacco use. The highest number of people consuming substances fell in the age group of 50-59 years (29.4%). In Uttar Pradesh, any substance use had a prevalence rate of 16.4%, prevalence of alcohol use was found in 1.5%, and tobacco use in 16.1%. Thus, it can be confirmed that tobacco continues to be the most frequently abused drug in the country and Uttar Pradesh. The commonly abused substances in the state include Cannabis, Diazepam, Alprazolam, Nitrazepam, Opioid, Codeine phosphate, Charas, Spasmoproxyvon, and Heroin, ranging from 5.0% to 65.0%, the maximum being for cannabinoids. Overall, substance abuse is exhibited more by men in Uttar Pradesh, but the use of Alprazolam has been seen more in women [1,2].

A treatment gap of 90% is reported overall by the National Mental Health Survey for substance use disorders, with tobacco and alcohol use disorders at 91.8% and 86.3%, respectively. The treatment gap for the rest of the substance use disorders is 72.9%. Rates of Mental Morbidity was also calculated by this survey, which arises out of substance use nationally. This signifies a significant burden of care for drug use in the general population [1,2].

The National Mental Health Survey, Uttar Pradesh report concluded that the treatment gap for mental morbidity from substance use disorders is 95.85%. The treatment gap is 97% in tobacco use and 100% for all other substances [6]. The National Mental Health Survey also reported about the available resources in the state for the management of mental health. There are 3 Mental Hospitals, 28 medical colleges with psychiatry departments, 16 general hospitals with psychiatry units. They all have the availability of less than 0.01 mental health care facilities and 0.2 psychiatrists per 1 lakh population currently. Only 10.81% of district hospitals can provide outpatient or inpatient services. Out of the total 216 Opioid Substitution Therapy Centres (OST) in the country, only 11 are established in the state of Uttar Pradesh. Similarly, out of 29 Drug Treatment Centres (DTC) only 1 is establishedand out of 400 only 21 Integrated Rehabilitation Centres for Addicts (IRCA) centres are present in our state, even though our state tops most of the charts for substance use [6].

Indian Jounal of Clinical Psychiatry

The National Family Health Survey, conducted in 2015- 16, found that amongst the working-age group of the population (15-49 years) of the state of Uttar Pradesh, tobacco use was more prevalent in the rural areas, 8.2% vs 5.9% in women and 55.1% vs 48.2% in men (7, 8). These rates were lower than the previous survey (12.1% in women and 64.3% in men) conducted in 2005-2006, which can signify a start of a change in the general population’s mindset regarding the harmful effects of substance use and dependence. Similarly, for alcohol, lower rates of use are seen in the urban population, with 0.1% in women compared to 0.2% in the rural areas and 21.6% in men compared to 22.4% in rural areas. The total prevalence measured for alcohol use was 0.2% in women and 22.1% in men, lower than earlier rates of 0.3% and 25.3%, respectively. The survey also calculated the percentages of individuals who tried to curb or stop tobacco use in the past year, with an average prevalence of 36.6% in women and 38.7% in men [7,8].

Even children and adolescents suffer from substance use and associated problems with the prevalence of alcohol, cannabis, inhalants, and tobacco being high in this subgroup. The mean age for consumption is lowest for tobacco as 12.3 years by National Commission for Protection of Child Rights [9]. A recent study conducted in the state found that 14.3% of students had consumed substances by the age of 19 years, with 29.5% initiating use before 11 years [10]. About 35% of teens suffer from alcohol and tobacco use disorder in the state [9].

More recently, the National Survey on Extent and Pattern of Substance Use in India, 2018, conducted by the Ministry of Social Justice and Empowerment, computed the prevalence of various substance disorders and their impacted families. About 2.7% of people suffer from alcohol dependence, 0.25% from Cannabis dependence, 0.26% from Opioid dependence, 0.1 % from Cocaine, 0.18 % from Amphetamines, 0.12% from Hallucinogens, and 0.7% from inhalants, with the number of children dependent being higher, with an average of 1.17% [11]. Uttar Pradesh ranked amongst the top states to use cannabis, opioids, sedatives, and inhalants, and injectables. In Uttar Pradesh, 160 lakh people suffering from alcohol use disorder require help, which is higher than any other state. Similarly, around 10.2 lakh suffer from opioid-related problems, 28 lakhs from cannabinoids related problems, 3.5 lakh from sedative related problems,

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Dalal et al. : A Kaleidoscopic View of Substance Use

94,00 from inhalants related problems, 100,000 from injectables related problems reflecting a burden of care on the health care system [11]. Uttar Pradesh ranked highest amongst all the states in terms of use and ranking higher than the national average in alcohol use and dependence (23.8 vs 14.6 and 4.4 vs 2.7). The quantum of work (i.e.the prevalence of Harmful use and Dependence, which are understood as categories of consumption-pattern in which the individual requires professional help) required is thus higher as well (9 vs 5.2). Similarly, higher levels are seen in cannabis use and dependence (7.36 vs 2.83 and 0.50 and 0.25), opioid use and dependence (2.11 vs 2.06 and 0.25 vs 0.26), and sedative use (1.10 vs 1.08). We can therefore conclude from this data that the magnitude of the problem is large and requires prompt intervention [11].

AVAILABLE RESOURCES IN UTTAR PRADESH

The scarcity of resources catering to the problem of substance use disorders is evident in the state and the country. An immediate plan of action is needed requiring interventions at the grass-root level along with the efficient implementation ofthe existing policies and programs [3-5].

Utilising the de-addiction centres in Government hospitals with Non-Governmental organisations and supporting them has been a nation’slong haul strategy. Ministry of Health and Family Welfare of the Government of India oversees 100 drug-de-addiction centres nationwide. The Ministry of Social Justice and Empowerment has been implementing a Scheme for Prohibition and Drug Abuse Prevention since 1985-86, supporting 361 Non-Govern- mental Organisations running; 376 Deaddiction-cum- Rehabilitation Centres, De-addiction Camps, and 68 Counselling and Awareness Centres nationwide.

The individual state policy for Uttar Pradesh, like most states, is the same as the national one. The current ones are National Policy on Narcotic Drugs and Psychotropic Substances. This policy deals with the specifications of drug products such as cannabis, opium, the state governments’ role in illegal cultivations, manufacturing, and distribution of psychotropics, along with illicit trafficking. An Action plan out of the recommendations from a committee meeting in 2010 has been implemented throughout the state, including the basic principles of

14

harm reduction, supply reduction, raising awareness, and educating the general population about the ill impact of substance use disorders. The adequate management of such individuals using pharmacological and non- pharmacological interventions includes counselling sessions, motivation enhancement, and rehabilitation. The program also focuses on educating people about the ill effects and training volunteers [11].

The Drug De-Addiction Programme, under the Ministry of Health and Family Welfare, has specialised in capacity building and training. The Drug Abuse monitoring system was developed by the same in 2007 to track substance abuse patterns and monitor the individuals and profile them. This program led to the formation Of Drug Treatment Clinics, which are functional in many states, including Uttar Pradesh. This program has helped raise awareness about substance use disorders as a significant public health problem and enhanced health professionals’ capacity building. Still, a need for incorporating these initiatives is needed at the national and state levels [12].

A new program called the Anti-Drug Action Plan has been launched by the Ministry of Social Justice and Empowerment for the year 2020-2021 in 272 districts nationwide. The ministry came up with a new campaign focusing mainly on community outreach programs called a Nasha Mukt Bharat or Drug-Free India Campaign. This Action plan will generate awareness, help locate dependent individuals, increase treatment facilities and their outreach. There would be an emphasis on tackling the high risk and younger adults. Out of these 272 high-risk districts, Uttar Pradesh has predominated along with Punjab, Haryana, New Delhi, and the North East. A total of 33 districts have been selected in the state of Uttar Pradesh. The policy plans to build up Outreach and Drop- In Centres (ODIC) for affected individuals, provide screening, assessment, management, and counselling facilities, with community-based outreach programs and rehabilitation services. The policy does plan campaigns across educational institutions to raise awareness, especially amongst the youth, to refrain from substance use primarily using community-based Peer-led Intervention for Early Drug Use Prevention among Adolescents (CPLI). This new and improved Action Plan has introduced a different strategy to combat India’s Drug problem. The attention and focus have shifted from the institutional setup to the community set up, increasing the availability of said help to the community [13].

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Dalal et al. : A Kaleidoscopic View of Substance Use

A recent update on the National Action Plan for Drug Demand Reduction in April 2020, with this updated plan’s objectives including creating awareness, educating the population about substance use disorders, promoting abstinence, managing affected individuals, and rehabilitation incorporated schemes. It calls for an integration of individuals affected with disorders concurrently due to their substance use like HIV-AIDS and the address of high-risk populations like sex workers, mobile populations, youth, school dropouts, prisoners, street children, and children of the affected population with their awareness programs. The action plan also includes training teachers, paramedical staff, and counsellors using seminars, workshops, and orientation programs, thereby building capacity to fight the problem [14].

THE WAY FORWARD

Existing literature has denoted rising numbers of indi- viduals suffering from substance use disorders, and smaller sects being affected in populous states like Uttar Pradesh reflect a huge treatment demand. A national-level treatment program is needed to consider both the high prevalence and absolute magnitude of the problem for prioritisation among the states. There is a significant discrepancy between the available resources and the problematic situation, reflected in the considerable treatment gap denoted by the National Mental Health Survey, which called for an immediate cry for help [1-5].

Such individuals’ current management come under the program under the Ministries Of Social Justice And Empowerment And Health And Family Welfare, who have developed deaddiction centres, stated a need for harm and supply reduction, and capacity building. They urge non-governmental organisations’ involvement with the state government to implement the strategies at a community level. Still, due to a lack of resources, a considerable gap exists. The National Policy on Narcotic Drugs and Psychotropic substances, updated in 2012, paved a way to tackle the situation, but has its fallacies like, the term medical intervention did not list the use of opioid-based medications in treatment (exceptionally long term), and is mostly recommended only for persons with Intravenous drug abuse who could not be “convinced to undergo de-addiction” and “only as a step towards de-addiction and not otherwise.” It had

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defined the minimum standards of care to be followed by the de-addiction centres as well as provisions for their dissemination, implementation, and monitoring but, other service providers such as individual practitioners, practitioners of alternate forms of medicine, and multispecialty hospitals which can concurrently provide these services were not specified. Conclusively, it can be said that this policy encourages the use of services offered by government-supported or approved private centres, which can, in turn, mean that the availability of these services can be only through centres solely dedicated to the management of these disorders. This can also be interpreted as a lack of endorsement of integration of services for SUD in non-deaddiction settings, such as individual or a hospital/health care establishment [12].

The recent surveys, studies, and existing policies suggest a need to integrate substance use disorders and their management into the national framework for Universal Health Coverage. The focus of plans should be on greater transparency and multisectoral collaboration during policy development. Also, an updated and improved policy which carries out the following purposes of incorporation of key populations and evidence-based practices in demand and harm reduction strategies, monitoring and evaluation of prevention and treatment programs, integration of treatment services into existing health care delivery model, and their implementation can be devised [12,15].

A conducive legal and policy environment is needed to help control drug problems. In the line of recommendations by the International Narcotics Control Board (INCB), another front which is necessary to combat the drug use problem in the country are steps taken to minimise the stigma and discrimination and provide health and welfare services to people affected by substance use [12,15,16].

The challenge at hand is multifaceted. The availability of the drug, especially tobacco and alcohol (gateway drugs), is easy and large, with higher rates of dependence even in the younger subset of the population. There is a lack of rehabilitation centres, de-addiction centres, and specialists and a lack of awareness in the general public. The drug smuggling through states (in and around Uttar Pradesh) and peddling with illegal cultivation of

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Dalal et al. : A Kaleidoscopic View of Substance Use

opium and cannabis advances the situation to the deeper end. Superimposed on the stigma associated with drug users and the implications on one’s health and family are nothing short of problematic.

The Government of India has endorsed the harm reduction approach through the National Narcotic Drugs and Psychotropic Substances (NDPS) Policy, 2012 and the National AIDS Prevention and Control Policy, 2002. It reduces the risk of harm of substance use, even when complete abstinence from drugs is impossible. Successfully implemented in HIV- AIDS can be considered for substance use disorders, especially in people using injectables and opioids. It has been seen that the effectiveness of awareness generation as the predominant preventive strategy, especially in the youth, has been weak. A demand-reduction based response is another strategy to reduce the initiation of use. Educating the general population about substance use disorders as bio-psycho-social health conditions (and not just moral failings), can in turn help minimise the stigma associated with drug users and facilitate access to help [17].

Greater efficiency during the delivery of resources needs a more strategized administration. To ensure this, better cooperation and even collaboration between the Ministry of Social Justice and Empowerment and The Ministry of Health and Family Welfare is needed. Along with better utilisation of the existing resources there are other issues which may be addressed in a fruitful manner once this collaboration is successful, which includes the integration between IRCA and DMHP, setting up a governing body who will look over IRCAS, synchronising NGOSs with the available psychiatrists enlisted under the DMHP program, and so forth. The ministries of AYUSH and Youth affairs can also be cooperated to look over the youth susceptible and suffering from substance use disorders. With such cooperation setting at the national level, a similar precedent should be set at the state level as well. A collaboration between Health and family welfare and Medical education ministries is a suggestion which can lead to better utilisation of resources at the state level [18].

Substance use disorders, like opioid dependence, require specific treatment modalities with higher stress on inpatient facilities and regular monitoring services. Scaling-up of treatment services for substance use

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disorders would also require large-scale capacity-building mechanisms. This will require enhancing capacities at all levels for the professionals ranging from the medical to paramedical to social-sciences and behavioural sciences backgrounds.

This raises a poignant question at this point. What to do in the future?

RECOMMENDATIONS

Dalal et al. : A Kaleidoscopic View of Substance Use

1.

Integration of general medical and healthcare services with substance use management using outpatient clinics, a system of monitoring. This can be done by implementing governmental and non-governmental schemes by creating a broad community outreach base. This can help reduce stigma in the general population. Further, screening for other associated psychiatric illnesses and physical disorders can form a key component in promoting better outcomes in these patients in the future [1-6].

Strengthening of existing schemes and policies in the state and scaling up of the resources. The change of strategy from an institutional approach to a community approach, with interventions to deliver efficient and effective prevention and treatment services as specified in the Scheme for Prevention of Alcoholism and Substance (Drugs) Abuse. The newer elements under existing policies can be increasing outreach in the community, better outpatient and inpatient facilities, including a provision of medicines delivered by qualified personnel [6].

Risk Factor Assessment, enhancing protective factors and recognising people at risk. Targeting peer groups to maintain healthier lifestyles and limit substance use initiation, with the availability of peer lead interventions and programmes [1-6].

“Biennial mental health action plan (covering severe mental disorders, common mental disorders and substance use problems) that includes specified and defined activity components, financial provisions, strengthening of the required facilities, human resources and drug logistics in a time-bound manner, including implementing legislation, coordinated Information

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2.

3.

4.

Education Communication (IEC) activities, health promotion measures, rehabilitation and other activities” as proposed by the National Mental Health Survey [1,2].

5. To prevent adolescents from initiating substance use, by reducing interest after informing about the full picture with the harmful effects of the drugs and long-term adverse consequences, with limiting availability, discourage use by educating them about the criminal and social sanctions, intervening early in adolescents at risk and treat those who are heavy users promptly. This involves the spread of awareness programs into schools and colleges to engage youth to refrain from substance use and better outcomes in the future when they become adults [11].

CONCLUSION

This article outlines how the existing policies and programmes are combating with the emerging numbers of substance users. While they seem to cater only to a portion of the current problem, a dire need for newer methods is needed to tackle the same in future. Notably, this article’s most important recommendation is to integrate resources at the grass-root level with the strengthening of older policies while targeting high-risk groups and adolescents. While applying these strategies, a factor to keep in mind will be to raise awareness and psycho-educate the general population, especially adolescents about psychoactive substances, their effects, dependence potential, and long-term consequences.

REFERENCES

1. 1. Murthy RS. National mental health survey of India 2015–2016. Indian journal of psychiatry. 2017 Jan;59(1):21.

2. Gururaj G, Varghese M, Benegal V, Rao GN, Pathak K, Singh LK, Misra R. National mental health survey of India, 2015-16: Summary. Bengaluru: National Institute of Mental Health and Neurosciences. 2016.

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3. Joseph S. Drug Demand Reduction Programme in India: Recommendations for the Future. Shanlax International Journal of Arts, Science and Humanities. 2019 Oct 1;7(2).

4. Avasthi A, Ghosh A. Drug misuse in India: Where do we stand & where to go from here?. The Indian journal of medical research. 2019 Jun;149(6):689.

5. Chadda RK. Substance use disorders: Need for public health initiatives. Indian Journal of Social Psychiatry. 2019 Jan 1;35(1):13.

6. Kar SK, Sharma E, Agarwal V, Singh SK, Dalal PK, Singh A, Gopalkrishna G, Rao GN. Prevalence and pattern of mental illnesses in Uttar Pradesh, India: Findings from the National Mental Health Survey 2015–16. Asian journal of psychiatry. 2018 Dec 1;38:45-52.

7. International Institute for Population Sciences. India national family health survey (NFSH-4), 2015-16. International Institute for Population Sciences; 2017.

8. International Institute for Population Sciences. India national family health survey (NFSH-3), 2005-06. International Institute for Population Sciences; 2007.

9. Jiloha RC. Prevention, early intervention, and harm reduction of substance use in adolescents. Indian journal of psychiatry. 2017 Jan;59(1):111.

10. Narain R, Sardana S, Gupta S. Prevalence and risk factors associated with substance use in children: A questionnaire-based survey in two cities of Uttar Pradesh, India. Indian Journal of Psychiatry. 2020 Sep 1;62(5):517.

11. Ambekar A, Agrawal A, Rao R, Mishra AK, Khandelwal SK, Chadda RK. on behalf of the group of investigators for the National Survey on Extent and Pattern of Substance Use in India (2019). Magnitude of Substance Use in India. New Delhi: Ministry of Social Justice and Empowerment, Government of India.

12. Singh Balhara YP, Singh S. Provisions for Health Sector Response to Substance Use Disorders in the Indian Policy: A Critique of the National Policy on Narcotic Drugs and Psychotropic Substances. Journal of Psychoactive Drugs. 2020 Jan 1;52(1):93-100.

13. Government of India, Department of Revenue,2019. National policy on NDPS: Department of revenue, ministry of finance, government of India. Government of India

14. Government of India,Ministry of Social Justice and Empowerment, 2020, NashaMukt Bharat, Annual Action Plan (2020-21)

15. Dhawan A, Rao R, Ambekar A, Pusp A, Ray R. Treatment of substance use disorders through the government health facilities: Developments in the “Drug De-addiction Programme” of Ministry of Health and Family Welfare, Government of India. Indian journal of psychiatry. 2017 Jul;59(3):380.

16. Singh O. Substance use in India–Policy implications. Indian Journal of Psychiatry. 2020 Mar 1;62(2):111.

17. Government Of India,Ministry Of Social Justice And Empowerment, 2020, Scheme Of National Action Plan For Drug Demand Reduction.

18. Dalal PK. Changing scenario of addiction psychiatry: Challenges and opportunities. Indian Journal of Psychiatry. 2020 May;62(3):235.

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P E E R S P E C T I V E

NGO’s and Their Role in Mental Health Care in India

Shashi Rai1, Dr. Bandna Gupta2

1Consultant Psychiatrist & Director, Sambal Drug De-Addiction and Psychiatric Centre. Chairman, Richmond Fellowship Society (India), Lucknow, U.P.
2 Additional Professor, Department of Psychiatry, King George’s Medical University, Lucknow, U.P.

Non-Government Organizations are institutions recognized by the government as nonprofit organizations, which are welfare-oriented and play a key role as service providers, activists, and researchers in various fields about human and social development. Many times NGO’s are born in response to major disasters and crisis to provide emergency relief, and after the disaster is over may continue the good work.[1] More than 10% of our population is suffering from various mental health-related problems.The paucity of treatment facilities and psychiatrists in the government sector has resulted in a huge treatment gap in mental health care. As per the survey conducted by NIMHANS in 2016, the treatment gap is to the tune of more than 84%.[2] The NGO’s have played a significant role in not only bridging this gap but have also helped in creating low-cost replicable models of care.[3]

NGOs’ role in the field of child mental health, schizophrenia,rehabilitation, care of the wandering person with mental illness,drug and alcohol abuse has been tremendous.

The NGOs’ activities include treatment, rehabilitation, community care, creating awareness,capacity building, and research works. NGOs are generally started by a leader or a group of people who are motivated for a cause, and hence they do not consider it a job but more of a commitment. Often people are skeptical about the role of NGO’s but once given the opportunity, NGOs can innovate and complement the state-run services.[4]

The NGOs have contributed significantly to the care and rehabilitation of persons with mental illness in our

country. The majority of the NGOs function in urban areas and services in a defined locality and community. The number of NGO’s are very few, which have a Pan India presence. Few mental health NGO’s have been started by the caretakers of the patients. An essential aspect of mental health NGOs is their focus on the community’s perceived needs.[3]

There are four types of mental health NGO’s working in our country –

1. Those involved in treatment care and rehabilitation 2. Community-based activities and prevention
3. Research and training
4. Advocacy and empowerment.

Empowerment of the local community and their involvement in NGO’s help the facility run for a more extended period.

There are a few primary advantages of mental health NGOs, like:

1. Ability to work in partnership – they can strike and maintain collaboration and partnership with other agencies with comparative ease than the government sector. Things have to follow a particular route and take a longer time.

2. Innovation in activities: They are more close and acceptable to the community and hence aware of their needs and provide services accordingly.[5]

Limitation of mental health NGO’s

1. Sustainability: Funding and resources could be a significant limiting factor; if the mental health NGO’s are not generating income of their own, there could be problems regarding payment of regular salary and retaining of staff.

Corresponding
Dr. Shashi Rai
email: shashi5284@rediffmail.com

author:

Rai et al. : Ngo’s And Their Role In Mental Health Care In India

2. Scope of the mental health NGO: Their functioning is limited to one city or a town. There are very few, which have a Pan India presence.[6]

List of a few important Mental Health NGO’s working in our country.

1. Sumaitrivoluntary organization –locatedin Delhi, is a crisis intervention center for depressed and suicidal patients.

2. Sanjivini Society for Mental Health – started in Delhi in 1976 as a registered nonprofit voluntary Organization – They provide free counseling services to people above 14 years and also run a rehabilitation center.

3. Saarthak – Campaign for the rights of persons with mental illness. It works for the education of children with disabilities.

4. Roshni – NGO in Delhi, which was started in 2006. It is a family support and advocacy group of family and caregivers for persons who have major mental illnesses.

5. Action for Autism – an NGO for education, charity, and advocacy which provide support and services to person with Autism and those who work with them. The National center is in Delhi. There are 22 centres in the country.

6. Minds Foundation (2010) – works to increase awareness regarding mental illness and provide access to mental health care. It has a pan India presence and follows a three-phase approach namely.

●  Educate

●  Treat

●  Reintegrate into the local community.
It started in Nizamabad and has branches in Mumbai, Vadodra and Bhavnagar.

7. Anjali Mental health rights organization- (Working in Kolkata) It works to humanize mental health and create awareness. It educates people and makes them aware of their rights with the disability.

8. Manas foundation – It started in Delhi in 2000 by a group of mental health professionals in response to their experience of the growing need for community based mental health care.

9. Sangath -It works to promote the right social, psychological, and physical health of children and adolescents.

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10. Banyan – Started in 1993, Based in Chennai and caters to mentally ill and homeless women.

11. Schizophrenia research foundation (SCARF) – A very well known mental health NGO Nationally and internationally. It was started by the first women psychiatrist in the country Dr. Sharda Menon. It provides care and rehabilitation of patients with a severe mental disorder.

12. Aasra – A Mumbai based mental health NGO which runs a 24 hours helpline service of active, non judgmental and non critical listening.

13. Ashadeep mission – Formed in 1996 in North East India to rehabilitate patients of chronic mental illness.

14. Neptunes Foundation – Mumbai based NGO which started in 2000. They work to identify homeless people with mental illness wandering the streets. They treat them and then try to unite them with their families.

15. PariPurnata halfway home-based in Kolkata and tries to help mentally ill patients to unite with their families. It provider a temporary home where patients can avail of treatment like pharmacotherapy, occupational therapy, non-formal education, and counseling.

16. Khusboo welfare society – Situated in GurgramHaryana and provides holistic care and services to people with mental illness and multiple disabilities. It runs special education schools for the disabled.

17. The Richmond fellowship society India – It is a Pan India NGO working in the field of rehabilitation of patients of chronic mental illness. In India, there are four branches at Bangalore, Delhi, Sidalgutta, and Lucknow. It was started in 1986 in Bangalore and runs various facilities like Daycare services, halfway home, long stay home, and outreach programs. The RFS is the world’slargest Global charity network concentrating on mental health.

18. Alzheimers and related disorders society of India (ARDS) – Started in Cochin and has several centers across India. It is engaged in care support and training in Dementia care.

19. Association of the mentally challenged-Based at Bangalore, their mission is to educate, train, rehabilitate intellectually challenged individuals and provide support and care.

20. Action for Mental Illness(ACMI) –It is an NGO working for advocacy for the rights of persons with mental illness and provides help regarding legal services to the mentally ill. It has a Pan India framework.

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REFERENCES

1. Thara R, Patel V. Role of non-governmental organizations in mental health in India. Indian Journal of Psychiatry. 2010 Jan;52(Suppl1):S389.

2. Gautham MS, Gururaj G, Varghese M, Benegal V, Rao GN, Kokane A, Chavan BS, Dalal PK, Ram D, Pathak K, Lenin Singh RK. The National Mental Health Survey of India (2016): Prevalence, socio- demographic correlates and treatment gap of mental morbidity. International Journal of Social Psychiatry. 2020 Mar 4:0020764020907941.

3. Murali T, Tibrewal PK. Psychiatric rehabilitation in India. Mental health care and human rights. New Delhi: National Human Rights Tribunal. 2008:197-204.

4.

5. 6.

Patel V, Thara R. Meeting the mental health needs of developing countries: NGO innovations in India. meeting the mental health needs of developing countries: NGO innovations in India. 2003. Sage Publications India Pvt Ltd.

Kalyanasundaram S, Varghese M. Innovations in psychiatric rehabilitation. InProceedings of the RF–ASPAC International Symposium (1995) at Bangalore 2000.

Murali, T., Rao,K.(2004) Psychiatric rehabilitation in India: issues and challenges, In Ed. Agarwal, S.P.(2004) Mental health –an Indian perspective1946-2003. Directorate General of Health Services, Ministry of Healthand Family Welfare, NirmanBhavan, New Delhi, Elsevier, New Delhi.152-160

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P E R S P E C T I V E

Suicide in Uttar Pradesh : An Overview Shivangini Singh1 and Teena Bansal2

1 Junior Resident, Department of Psychiatry, King George’s Medical University, Lucknow, U.P, India

2Junior Resident, Department of Psychiatry, King George’s Medical University, Lucknow, U.P, India.

 

ABSTRACT

Suicide has become a matter of growing concern in current times. The suicide rate is on the rise worldwide, and India is no exception to it. Suicide being a preventable cause of death requires more attention, early intervention, and proper strategies to deal with it. This article tries to reflect upon the status of suicide in Uttar Pradesh(U.P.), the most populous state in India, by reviewing data across PubMed, Science Direct, and Cochrane Library and incorporating national records. U.P. contributes to 3.9% of the total suicides in India. According to the 2011 census, maximum suicides in U.P. were below the age of 45years, and more females committed suicide than males. Recent data reveals that familial problems were reported as the leading cause of suicide, while hanging was the most common method. This article tries to shed some light on the recent impact of the pandemic, COVID 19, on suicide and discusses specific preventive strategies to try and fight against the rising burden of suicide in the state.

Keywords: Suicide, U.P., Epidemiology, Mental Health

INTRODUCTION

Suicide is a global phenomenon, with 1.4% deaths occurring due to suicide worldwide, with 79% deaths occurring in low and middle-income countries. While suicide is prevalent across all age groups, with one person dying of suicide every 40 seconds, it has become the second leading cause of death among people age 15-29 years of age[1]. India, a lower-middle-income company with a total youth population of 34.8%, is extremely high in suicide rates. While in 1984 around 50,000 people committed suicide (50,571, i.e. 6.8 per 100 thousand), this figure rose to 90,000 (89,195 i.e. 9.9 per 100 thousand) in 1994. The figure has now nearly reached one hundred thousand Indians dying of suicide every year, which is 20% of the world’s suicide population[2]. The National Crime Records Bureau

Corresponding author:

Dr. Shivangini Singh

E-mail : shivangini1103@gmail.com

(NCRB) has been recording an increase in the rate of suicide over the past decades, with a suicide rate of 10.4 in 2019. A total of 1,39,123 suicides were reported in the country during 2019, showing an increase of 3.4% compared to 2018, and the rate of suicides has increased by 0.2% during 2019 [3].

The prevalence of suicide is not uniform throughout the country. Interstate variability has been seen across India. The majority of suicides were reported in Maharashtra, followed by Tamil Nadu, West Bengal, Madhya Pradesh, and Karnataka. These 5 States together accounted for 49.5% of the total suicides reported in the country, while relatively lower rates were seen in the northern states[3]. Multiple factors might be responsible for this variability, like higher literacy and socioeconomic status, a better reporting system, lower external aggression, and higher expectations in the southern states [4]. However, overall, in India highest suicide rates were found in the age group of 18-30 years, with male suicide rates being higher than female, the male is to female

ratio being 70.2:29.8. A higher incidence of suicide was seen in the lower-income class(<100 thousand/annum) population, with hanging being the most common method, followed by poisoning. Familial problems accounted for the maximum number of suicides[3].

Almost 16.50% population of India, accounting for 199.8 million, resides in one of the largest states of India, Uttar Pradesh(U.P.)[5]. Since it has the highest population among all states in India, the demography and risk factors of the suicide of the state will reflect strongly upon the suicidal status of the entire nation. Currently, U.P. stands at the 27th rank when it comes to the incidence of suicide in India[3]. However, such low suicide incidence is believed to be attributed to underestimating suicide cases in U.P.[6]. Hence more studies need to be done to find the actual burden of suicide in the Northern part of India, especially in densely populated states such as U.P., as U.P. will have a significant health impact on the country’s health status. Life satisfaction and happiness majorly affect the suicidal rates of society[7]. U.P. owing to various problems like high unemployment, high poverty leading to an increased socioeconomic burden, more significant mental and physical abuse, and being the largest orthodox population along with a substantially marginalized population has several risk factors for the low quality of life and happiness index, hence, being highly predisposed to high rates of suicide.

The marginalized population has several risk factors for the low quality of life and happiness index, hence, being highly predisposed to suicide.

This article aims to get an overview of the existing data on suicide in U.P. and shed some light on the prevalence, demographic distribution, methods of suicide, risk factor, and preventive measures, if any, in U.P.

SEARCH STRATEGY

We initially conducted a broad search in online research databases (PubMed, Science Direct, and Cochrane Library) using the keyword Suicide. It helped in setting a background for the review. Then, the studies mainly consisting of Indian and state-specific data were included. We incorporated the original studies published in English along with the data collected from national records.

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PREVALENCE AND DEMOGRAPHIC DATA

U.P. with a population of 199.8 million, currently reports a suicide rate of 2.4 (Total number of suicide/Mid-year population), which is much below the national average suicide rate (10.4). On the other end of the spectrum Andaman and Nicobar islands, has the highest suicide rate of 45.5 with a population of only 0.4 million, probably owing to a more vigilant reporting system monitoring a smaller population with abundant migrants. From 2018 to 2019, U.P. has shown a variation of 12.7% in suicide rates, a rapidly increasing statistic that needs to be focussed upon. U.P. contributes to 3.9% of India’s total suicides. Kanpur, with the highest population in U.P. of 2.92 million, also has the highest suicide rate in U.P.(16.8). This is a surprising contrast as no other major city in U.P. (Agra, Allahabad, Ghaziabad, Lucknow, Meerut, Varanasi) has a suicide rate of more than 10[3].

RISK FACTORS

Risk factors can be attributed to age, gender, marital status, occupation, and psychosocial stressors. According to the 2011 census, in U.P., maximum suicides are below the age of 45 years like the rest of the country, with the maximum number of suicides being in the age group of 15-29, which also holds in accordance to the world scenario [1,3,8]. Female suicides (n = 1170) are more when compared to male suicides (n = 967), which is in contrast to the general prevalence across India, where more suicides are seen in males as compared to females [3]. However, a study conducted in Lucknow found higher suicide rates in males (56.61%) than females, 43.38% [6]. A systemic review of suicides in India showed that female suicide rates are higher under 30 years of age, but the opposite is true in over 30 years of age. In the context of the world scenario, India, in general, shows a relatively smaller gap in female to male ratio of suicide than the western world[4]. No suicides were reported in the transgender groups [3].

In U.P. majority of suicides were seen in housewives (1586 deaths) followed by daily wage workers (859 deaths), professional salaried workers (403 deaths), students (603 deaths), unemployed (581 deaths), and self-employed farmers (261 deaths). This data suggests that the females have a high propensity for suicide, reflecting upon a poor domestic environment in the

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state. As per the educational qualification, most suicides in U.P. were seen in the 10th pass population (1223 deaths) followed by the educational qualification of middle school and then no education at all. Hence, the state’s low educational status with high unemployment predisposes youth to suicide [3].

CAUSE AND METHODS OF SUICIDE

The most common cause of suicide in U.P was found to be familial problems contributing to 2208 deaths. Love affairs (370 deaths) and illnesses (318 deaths). Professional/ career problems (265 deaths) were other important causes of suicide. It is important to note that among illnesses, mental illness was the most commonly recognized cause of suicide. Similar results were found in a study conducted in U.P. where familier issues was the primary cause (29.6%) of suicide. However, the other causes recognized in the studies were slightly different from the general state scenario, with failure in examination or interview or business being the next most common cause (23.5%), followed by ill-treatment by spouse or in-laws (16.3%) and unemployment (9.2%) [9].

The primary method of suicide in India was found to be hanging (53.6%), followed by poisoning (25.8%), drowning (5.2%), and then self-immolation (3.8%) [3,10]. U.P. also showed similar statistics, with hanging being the most common method of suicide (3267 deaths). 909 suicides were due to consumption of poison, most commonly insecticide consumption, and 434 suicides were due to self-immolation [3]. A study conducted in Jhansi concluded that the most common method of suicide in females was self-immolation. In contrast, in men, the most common method was found to be getting run over by a train [11], while a study done at KGMU Lucknow concluded that poison was the most common method of suicide in both men and women [6]. Another study conducted in the western part of U.P., Meerut, focused on the most common type of poison consumed for suicide and found that Aluminium Phosphide (31.6%) was most commonly used, followed by Organophosphates (20.4%) [9].

COVID 19 AND ITS IMPACT ON SUICIDE

The COVID-19 pandemic, which has been at the level of a global health crisis for quite some time now, has

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generated fear, anxiety, depression, and stress among people. There has been a worldwide rise in psychiatric morbidity and even suicide in vulnerable individuals. A study carried out between March to May 24, 2020, presented 69 COVID-19 suicide cases from various news reports. Among which 63 were males, and the age group was between 19-65. The most common causative factors reported were fear of COVID-19 infection (n=21), followed by the financial crisis (n=19), loneliness, social boycott and pressure to be a quarantine, COVID-19 positive, COVID-19 work-related stress, unable to come back home after the lockdown was imposed, unavailability of alcohol, etc. Out of these 69 cases presented, 14 cases were from U.P [12].

Few reports like ‘Three people, including a government employee, committed suicide in the region in the past 24 hours for fear of COVID-19’, ‘On Tuesday, a farmer, who was suffering from fever and cold, committed suicide to “save his entire village from being infected,” ‘young man who had been suffering from fever and cough, committed suicide in Kanpur by hanging himself because he feared he was suffering from coronavirus.’ also support the evidence [13].

PREVENTION

Suicide needs to be tackled both at the public front and at the personal level of an individual. Currently, there are no solely dedicated government helpline numbers for suicide in India. The various NGOs that are present like “Aasra” etc., fail to have a base in all states of India including U.P. The government policies and regulations pertaining to suicide have decriminalised suicide; however, the new amendment still states that under IPC 309 attempt to suicide is a punishable offense [14]. This leads to a greater stigma within the society and under-reporting of suicide cases, depriving us of accurate data for any given region. Poor law and order in U.P. further affects the quality of suicide data collected through police reporting. Hence, newer revised government policies are needed with better implementation at the ground level. State-level strategies like SPAN (Suicide Prevention Action Network), which was implemented in Assam by NIMHANS, need to be established in U.P. as well to tackle suicide as an individual problem [15].

At the personal front, individuals need to be better prepared to deal with stress and identify suicidal ideations

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Shivangini et al. : Suicide in Uttar Pradesh

so that they can seek help at the right time as a majority of the population prone to suicides is adolescents and people <30 years of age. Awareness campaigns in schools and counselors associated with all major educational institutes should be made a priority. At work places, better stress management and coping strategies must be taught with regular mental health check-ups being added to the routine check-ups as stress directly increases the chances of poor mental health and suicide [16]. Also, at the rural level, state-level mental health programs need to be established to cover the overall rural plus urban population of U.P.

Minimal studies are available pertaining to U.P. solely. More niche studies keeping regional demographics in mind need to be done. Moreover, the data collected in India is incomplete and biased. The primary source of data collection is via NCRB (National Crime Record Bureau, which acquires data through police records that are insufficient and biased by regional law and order. A major population of India, as well as the U.P., lives in the villages where barely 25% of deaths are registered, and of that, only 10% medically certified, again reflecting poorly on the quality of data collected[17]. Another main component missing from the Indian approach to suicide is the emphasis of mental health on suicide. Studies from across the world show that 90% of suicide cases have an underlying mental disorder. However only 1.3% of these studies come from developing country with only a handful studies from India that too from cities like Bengaluru, Kolkata, etc.[18].

CONCLUSION

Suicide, a preventable tragedy, despite being a significant challenge for a developing country like India, has not received enough attention. With a diverse country like India, regional data is necessary to understand and analyze the problems associated with suicide in varied social setups. Better and more aggressive data collection needs to be done to find the actual burden of suicide in U.P. and then take the necessary specific measures to combat it.

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Patel NS, Choudhary N, Choudhary N, Yadav V, Dabar D, Singh M. A hospital-based cross-sectional study on suicidal poisoning in Western Uttar Pradesh. J Fam Med Prim Care. 2020 Jun 30;9(6):3010–4.

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Raju S, Tyagi U, Khan T. Three more corona suicides in west UP [Internet]. Hindustan Times. 2020. Available from: https:// http://www.hindustantimes.com/lucknow/three-more-corona-suicides-in-west- up/story-UMD1lLH6Nj9JRaiNuE74eN.html

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Shivangini et al. : Suicide in Uttar Pradesh

Indian Jounal of Clinical Psychiatry

REVIEW ARTICLE

COVID-19 Chaos and New Psychoactive Substances: New Threats and Implications

Kumari Rina1, Sujita Kumar Kar2, Susanta Kumar Padhy1

1Department of Psychiatry, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, Odisha, India.
E-mail id: drkumaririna@gmail.com, Ph. No: +91 9914576444
2Associate Professor, Department of Psychiatry, King George Medical University, Lucknow, Uttar Pradesh, India. E-mail id: drsujita@gmail.com, Ph: +91 9956273747

 

ABSTRACT

The new psychoactive substances (NPS) have been a challenge for control by the international regulatory measures. Parallelly, the enormous growth of darknet, has joined hands for illicit drug trafficking and marketing. COVID-19 pandemic has brought a unique opportunity for growth and herald a further shift towards online commerce and communication, which may evolve the global criminal activities through darknet, further. COVID-19 pandemic has also called for the socio-economic crisis which may divulge vulnerable group into drug-trafficking and supply chain. Amalgam of these makes situation worse, eclipsing epidemiology of NPS, further. Eventually, it also bears ill effects on health of people using it. Hence, there is a need to frame stringent policies for darknet usage and strategies to control NPS, keeping the current crisis in mind.

Keywords: New psychoactive substances, COVID-19 pandemic, darknet, legal highs, illicit drugs, drug trafficking

INTRODUCTION

New psychoactive substances (NPS) denote substances of abuse that are not subject to international control measures but mimic effects akin to controlled drugs, which may cause harm to the public health. Termed as “designer drugs”, “herbal highs”, “research chemicals” and “legal highs”, NPS have posed multi-faceted insurmountable challenges, with respect to its poor epidemiological knowledge; existing huge number and accelerated emergence rate; difficulty in identifying in biological samples and lack of standard laboratory reference sample; physical and psychological effects; marketing via crypto-markets [1]. These “legal highs” have become a legal alternative for illicit drugs. NPS

Corresponding author:

Dr. Susanta Kumar Padhy
E-mail : susanta.pgi30@yahoo.in, Ph: +91 94638 95852

have been deceiving international legislative control measures despite lumberous/ numerous efforts. Anonymity in crypto-markets and legal safety makes the trade of NPS convenient. Burgeoning information technology, especially the darknet,and globalization have revolutionized our lifestyle, including the use and trade of illicit drugs. COVID-19 pandemic has brought a new set of challenges with regards to NPS, in terms of its use and supply [2]. The pandemic paves for unique health implications due to NPS use, and tasks for policymakers from legal perspectives.

UNDERGROUND WEB COMMERCE OF NPS ‘DARKNET’: THE MYSTERIOUS ‘BERMUDA TRIANGLE’ FOR NPS SALE

Internet is a major platform for NPS distribution.3Broadly, worldwide webs can be surface web (which is readily available to the general public and indexed by standard

search engines such as Google, Mozilla Firefox, etc.) and the dark web or darknet (which refers to encrypted online content that is not searchable by conventional search engines, and cannot be accessed without an adept software, like Tor, Freenet and I2P) [4,5]. Surface websites (for ex: a version of Firefox) often provide listings of ‘.onion’ addresses or bundles of software to download, and access dark net markets [6].

The Dark Web is anonymous and cannot demarcate between criminals and ordinary users.It is a matter of debate whether online anonymity on dark web should be maintained inspite of the illegal activities (like cyber- attacks, hacking, drug trafficking) that it enables.4 With its discovery in 2011, the anonymous trade of illicit drugs, including NPS, is progressing through hidden- web drug marketplaces (crypto-markets). The ban of first online crypto-marketplace Silk Road (with fascinating innovative technology to hide internet user activities) in Europe and United States, sprang around 45,000 dark websites [7-8]. The situation is smoldered by the huge number of NPS, with the rapid rate they emerge and number of vendors, across the globe. The 2015-16 CASSANDRA project, where data collection was done bimonthly, revealed that overall, both the numbers of individual NPS and vendors escalated to 94% and 72%, respectively [9]. NPS possibly begin from the darknet and later migrate to the open web [10]. Customarily, drugs on the darknet are purchased using digital non-identifying form of money, cryptocurrency such as bitcoin [8].

NPS SALE-SECRETS AND BEGUILING RISE OF INTERNET AND DARKNET DURING COVID-19 PANDEMIC: A GRUELING COMBINATION

During the first quarter of 2020, average broadband consumption expanded to 47%, 402.5 GB from 273.5 GB, during the same quarter of 2019 [11]. The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) analyzed three darknet markets (Agartha, Cannazon and Versus) activities during the same time revealed that regular consumers stocked up drugs, anticipating market disruption and lockdown, akin to other consumables. Cannazon, a market devoted to cannabis products, had an increased business and traded 1.6 metric tons, which is approximately EUR 4.3 million over three months of the lockdown. It indicated

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awanedurge for the synthetic drugs like MDMA, commonly used in creational settings. However, few countries like Netherlands were trading the drugs on offers and discounts [12]. The menu proffered “Corona Lock Down Survival Pack”. The contents listed masks, gloves, hand sanitizers, cannabis and a variety of NPS [13].

POSSIBLE FEARED NPS RELATED RAMI- FICATIONS DURING AND POST-COVID-19 PANDEMIC ERA

Rina et al. : COVID-19 chaos and New Psychoactive Substances

1.

Drug use: India and China manufacture NPS in bulk. These are imported to Europe and elsewhere, where they are processed, packaged and sold. The street- level drug-dealers are also involved in such trading [14]. United Nations News reported of surge in prices of illegal drugs in many regions of the world [15]. Moreover, many darknet narcotics purchasers remained largely confined to their homes, with more free time and fewer opportunities for face-to-face transactions. Behavioral addiction like internet addiction and usage of NPS often, co-exist. This might have resulted in an increased NPS sale and consumption during the pandemic while buyers are spending more time online at home [16]. Online retailers have deciphered a unique opportunity from this pandemic, and may herald a further shift towards online commerce. This shift is indicated by a recent report which claim a massive spike in narcotic business after COVID-19 lockdown restrictions ease in India [17].

Masking epidemiological data: Crypto-markets pose a challenge for law enforcement with regards to illicit drug trade due to anonymity and sophisticated security [18]. Moreover, drug manufacture, processing and trafficking are designed to escape legal authorities. Consumers are often unaware of their NPS usage, and seek treatment services. This makes learning exact NPS epidemiological data arduous.

Drug supply:COVID-19 containing measures have a mosaic impact on drug supply chain. COVID-19 and lockdown has impeded NPS manufacture, either due movement inhibition to workplace, spread of contagion and disease suffering or quarantine. Due to overall paucity of drug, manufacture concluded with hiked rate and decrease purity. Eventually, users diverted to alternative substances (for example, from heroin to synthetic opioids like fentanyl) and/or approaching

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2.

3.

drug treatment (benzodiazepines, buprenorphine, etc.).

Territories with stringent shut down had decreased drug seizures (eg; Italy and Central Asia). Countries with lenient lockdown and probably marching drug trafficking (Islamic Republic of Iran and Morocco) and postal services (like Nigeria) had more seizure [2]. Access to internet, empty time and more time being spent online, may result in people with adventurous and novelty seeking personality, to buy NPS for recreation, via darknet.

4. Health implications: NPS have been marketed to large populations, apart from targeted ones, such as psychonauts, clubbers, life-style users and gym-visitors (in food supplements or pre-workout booster) [19-20]. For marketing, Phenibut is described as to ‘improves mood, induce relaxation, enhance sexual desire’ [21]. NPS use may cause acute and chronic health effects (respiratory, cardiovascular, transmission of blood-borne diseases like HIV, Hepatitis B and C, neuro-psychiatric problems, dependence and death), depending upon the user characteristics, dose, route of administration and adulteration [22-28].
Anticipated lockdown led to stockpiling of preferred drug. Availability of substantial amount of drug, addicted to could cause accidental overdose. The risk of drug overdose may be higher among those injecting drugs with COVID-19 infection [15]. Due to price hike and drug unavailability might had abrupt and dangerous withdrawal.17Increased contamination with poor knowledge could have caused deleterious health effectsor overdose.Possible deficit of sharing injection equipment may carry higher risk of spreading diseases like HIV/AIDS, hepatitis C and COVID-19 itself [15].

5. Social-economic problems: NPS is known to worsen social issues at workplace, with partners or family, housing problems and legal problems [29]. The economic crisis sprouted by the pandemic may metamorphosize drug markets. This could engage more people, especially vulnerable and socio-economically dis- advantaged, in illicit drug marketing or trafficking organizations. The learning from the economic crisis of 2008, reminds that economic crisis and consequent reductions in drug-related budgets may end-up in escalated substance use, more use of low-priced drugs and injectables and hence, increased risk of harm [30].

6. Increasing crime,offences and challenges for legal system: Drug trafficking usually camouflage legal trading to reach consumers. The Indian Financial Hack-

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2020 reports at least 50 lakh CVV and credit card dumps on the darknet. These stolen credit and debit card details are sold online. The recent escalation in One Time Password frauds may be ascribed to increased darknet activity during lockdown [31]. The organized criminal groups involved in drug trafficking has switched from their usual illicit activities by emerging crime linked to the COVID-19 pandemic; for example, cybercrime and trafficking in falsified medicines.30Drugs such as GHB and Rohypnol are well-known for date- rape and robbery [32]. Overall, criminal activities mayrise due to the pandemic. Banning substances altogether may be intuitively effective, but has its unintended consequences too. Although adequate legal provisions are there for use of substances in research, restrictive scheduling may discourage researchers for conducting substance related (like NPS) research [33]. Banning of a particular NPS also results in the development of alternative substances [34].

7. Services and policies:The economic decline caused by the COVID-19 could, in the medium-term, increment drug production, trafficking and use [30]. Since beginning of this decade, role of stakeholders, including policy makers, practitioners and researchers, has been emphasized for regular evidence-based data on new substances, use pattern, the possible harms they may cause, and policy strategies to reduce the harms. This task becomes grueling during this pandemic, as we are already facing a mankind crisis of multi-dimensional nature [35]. A possible solution can be framing stringent terms and conditions for darknet usage.

CONCLUSION & FUTURE DIRECTION

The COVID-19 pandemic has brought multiples challenges, one of them being drug use. This pandemic may result in change in availability and pattern of drug use. Number of people involved in the drug trafficking may rise. Socio-economic down-gradation puts socially- disadvantaged individuals at risk of drug use and get involved in drug-trafficking or supply chain. Darknet being anonymous and out of judicial jurisdiction, sets an easy platform for illicit drug market. Therefore, it demands attention for establishing stringent terms and conditions. India is a hot bed for manufacture of NPS and supplies substances across the globe. There is a need to frame and implement policieskeeping these in mind, especially in India. To effectively control the increasing

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Rina et al. : COVID-19 chaos and New Psychoactive Substances

use of NPS during this COVID-19 pandemic, following domains need to be addressed in future research:

●  Burden of NPS use (country and region specific)

●  Vulnerability factors for NPS use

●  Loopholes in cyberspace that facilitates NPS marketing

●  Lacunae in the existing policies to control NPS trafficking

●  Innovative strategies for control of manufacturing, selling and transport of NPS
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31. Sanjiv D. During pandemic, cyber attackers leverage Darknet | Mangaluru News – Times of India. Jul [cited 2020 Nov 15]; Available from: https://timesofindia.indiatimes.com/city/mangaluru/during- pandemic-cyber-attackers-leverage-darknet/articleshow/77055815.cms

32. Club drugs: review of the “rave” with a note of concern for the Indian scenario – PubMed [Internet]. [cited 2020 Nov 12]. Available from: https://pubmed.ncbi.nlm.nih.gov/21727657/

33. Griffin OH, Lee Miller B, Khey DN. Legally High? Legal Considerations of Salvia divinorum [Internet]. Vol. 40, Journal of Psychoactive Drugs. 2008 [cited 2020 Nov 12]. p. 183–91. Available from: https:/ /pubmed.ncbi.nlm.nih.gov/18720668/

34. Leffler AM, Smith PB, de Armas A, Dorman FL. The analytical investigation of synthetic street drugs containing cathinone analogs. Forensic Sci Int. 2014 Jan 1;234(1):50–6. Available from: https:// pennstate.pure.elsevier.com/en/publications/the-analytical-investigation- of-synthetic-street-drugs-containing

35. EMCDDA–Europol 2013 Annual Report on the implementation of Council Decision 2005/387/JHA | http://www.emcdda.europa.eu [Internet]. [cited 2020 Nov 12]. Available from: https://www.emcdda.europa.eu/ publications/implementation-reports/2013_en.

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REVIEW ARTICLE

Mental Health Issues in Covid and Post Covid-19 Scenario: The Way Forward

Tapas Kumar Aich1, Amil H Khan2, Prabhat Kumar Agrawal3

1Professor and Head, Department of Psychiatry, BRD Medical College, Gorakhpur, UP 2Associate Professor, Department of Psychiatry, BRD Medical College, Gorakhpur, UP 3Assistant Professor, Department of Psychiatry, BRD Medical College, Gorakhpur, UP

 

ABSTRACT

The coronavirus pandemic has been spreading around the globe over the last eleven months now. More than 54.5 million people have been infected worldwide, and 1.3 million of them have died due to the disease as of November 15, 2020. India’s corona virus case tally rose to 8.8 million (6380 per million infected), and the number of deaths rose to 1.29 lacs (94 per million deaths) as of November 15, 2020.

India and many other countries have gone through various lockdown periods with a devastating outcome. Millions of households suffered, and millions of laborers have lost their job during this period. There has been a significant impact on the financial, occupational, social, environmental, intellectual, and emotional wellbeing of our people, more so, on the fragile and vulnerable groups like the elderly, disabled, migrants, refugees, homeless, women, children, girls and adolescents.

The present write-up is divided into two broad headings. First, a general narrative is there on various health issues in Covid and post-Covid-19 scenario. The next part of the essay will be focussed on mental health issues in Covid and post-Covid-19 scenario. Finally, this review summarises the present Covid-19 pandemic,highlighting the importance of World Mental health day and world mental health week themes in the prevailing scenario.

Keywords: Covid-19 pandemic, Post covid-19 scenario, Mental health in Covid pandemic

INTRODUCTION: THE COVID-19 PANDEMIC

The coronavirus pandemic has been spreading around the globe over the last eleven months now. More than 54.5 million people have been infected worldwide, and 1.3 million of them have died due to the disease as of November 15, 2020[1]. India’s coronavirus case tally rose to 8.8 million (6380 per million infected), and the number of deaths rose to 1.29 lacs (94 per million deaths) as of November 15, 2020[2].

Corresponding author:

Dr. Tapas Kumar Aich Email : tapas_dr@yahoo.co.in

This rapidly increasing number of infections and deaths around the world have made the COVID-19 pandemic one of the greatest health and illness-related challenges to human existence since World War-II. Of late, a few western countries and regions are going through the second wave of the pandemic, and experts are predicting the same for our country also in the coming months. The only silver lining in this bleak scenario is that daily infection in India has come down to less than 50 thousand, and recovered patients have out-numbered the new cases daily. The recovery rate increased to more than 90%, and the death rate reduced to less than 1.5% [2].

We have seen the various preventive measures are taken worldwide, including our country, vary from complete

Aich et al. : Mental Health Issues In Covid And Post Covid-19 Scenario

to partial lockdowns of countries, states, regions, or smaller localities. These measures have had a significant impact on the economy, society, household, and individual level. Especially affected are fragile and vulnerable groups like the elderly, disabled, migrants, refugees, homeless, women, children.

We all know the basic definition of health as given by WHO (1948) as “health is a state of complete physical, mental, and social wellbeing and not merely the absence of disease or infirmity”[3]. A little modification is added to this later by WHO (1984) as that “health is a resource for everyday life, not the objective of living”[3]. In an article, the Lancet (2009) defined health as ‘the ability of a body to adapt to new threats and infirmities’[4]. This definition is especially relevant today as the world combats one of its biggest transformative challenges, the COVID-19 pandemic.

The National Wellness Institute’s definition of health and wellness as follows: “Wellness is the active process of becoming aware of, and making choices towards, a healthy and fulfilling life.” It has described various dimensions of wellness, including financial, occupational, social, environmental, intellectual, physical, spiritual, and emotional wellness[5]. A detailed discussion of all these factors is beyond the scope of the present article. We will be focussed on emotional wellness, understanding one’s feelings and coping effectively with stress, paying attention to self-care, relaxation, stress reduction, and the development of inner resources and strength. We have seen these health and wellness have been severely impacted by the ongoing COVID-19 pandemic.

The topic will be discussed in three broad groups: (i) first, a general narrative will be given on various health issues in Covid, and post-Covid-19 scenario; (ii) next, a special brief narrative will be there on mental health issues in Covid and post Covid-19 scenario; (iii) and finally, the way forward, keeping in view of this year’s theme of World Mental Health Day/week ‘Mental Health for All: Greater Investment – Greater Access’.

GENERAL HEALTH ISSUES IN COVID AND POST COVID-19 SCENARIO

We all have heard PM Narendra Modi’s first broadcast to the entire nation during the first lockdown period

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with the slogan “Jaan hai to jahaan hai” there is a world out there only if you stay alive. In other words, it is the survival that is a precursor, a pre-requisite to having a life [6]. This thought of survival is dominating and will dominate the thinking of most people around us, before all other things or activities in the days and months to come. Health has become an important theme in common man’s daily lives. Precaution and prevention of illness have started dominating the thoughts of common people. Social distancing has become the new mantra, during the first partial lifting of lockdown, with PM Modi’s new slogan “do gaz ki doori mask hai zarooribecoming a must while interacting socially[7].

The use of masks, gloves, hair nets, no contact deliveries, hand-washing, and sanitizers has become a daily habit of our citizens. The new health lexicon for the common public’s lips now is isolation, quarantine, containment, etc. Prime Minister’s next slogan follows “jaan bhi jahaan bhi,” and though some of the cautions got diluted by this, now onwards health sensitivities amongst common people got ingrained sharp and strong[8].

Dr. Anthony Fauci, the director of the National Institute of Allergy and Infectious Disease in the US, said, probably, “we should never shake hands again.” “Maybe the world will embrace the Indian ‘namaste’ or the Japanese ‘ojigi’ (bow)” [9]. The doctor will be no longer the only source of information on health; they will come into the picture only at a much later stage of the health trip. More and more people are turning to a variety of digital platforms to understand their health problems and concerns. Google has become the number one destination for health queries. Most searched items on Google at the onset of the pandemic are ‘loss of smell,’ ‘yoga at home,’ plasma therapy,’ etc. So, Search and self- awareness has and will become a critical part of the health and wellbeing of the common public in the times to come.

The Aarogya-Setu app has been made compulsory by the government for its employees [10]. It has become a must for travel, and health Passports are becoming mandatory for travel. Building immunity has become the new mantra with many home remedies, magic formulae, wonder foods, immune supplements are flooding the market and being tried in the quest to strengthen the body against infections. Prevention through various alternate medicines, especially Ayurveda,

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Aich et al. : Mental Health Issues In Covid And Post Covid-19 Scenario

has become the talk of the town. In Ayurveda, there are concepts of “Dinacharya” – daily regimes and “Ritucharya” – seasonal regimes to maintain a healthy life. Ayurveda advocates drinking warm water and the daily practice of ‘yogasana’, ‘pranayama’ and ‘meditation’to boost one’s innate immunity[11].

Thus the ‘life style health is a new consciousness’ now- a-days. COVID-19 has forced a significant lifestyle change, especially when billions around the globe forced into lockdowns. We are choosing a more vegetarian diet, opting for less travel, indulging more in meditation, and giving more quality ‘me’ time for ourselves[12]. During the post-COVID-19 scenario, “occupational health” will demand more attention; occupational safety and health will take on even greater importance. But in our country, where 90 percent workers work in the private and unorganised sector and are forced to work in cramped and unhealthy workplaces, it will be a herculean task to address occupational health issues[13].

Telemedicine is surging and will surge further in the post-COVID-19 period. The corona crisis acted as the trigger for large-scale trial and acceptance of telemedicine. Patient acceptance, physician cooperation, and legal and liability issues have all got fast-forwarded. With social distancing is now a universal norm, the general public will insist more and more on new technologies that don’t force them to visit hospitals or clinics. So, tele- medicine is here to stay and expected to grow at a faster rate in coming months [14].

Healthcare cost is expected to cost higher in the days and months to come, and health insurance will cover less and will cost more. In the post-COVID-19 scenario, the cost of treatment of the viral infection may run into lakhs of rupees. In a worse scenario, many private hospitals are turning back the Covid infected patients while government hospitals are over-full and ill-equipped. In the coming days, health insurance covers will see significant changes due to this pandemic outbreak, and the insurance premiums are expected to see sharp hikes of 25-40 percent during renewals [15]. The disease is and will be debilitating for those infected, both financially and physically.

MENTAL HEALTH ISSUES IN COVID AND POST COVID-19 SCENARIO

Many epidemiologists opine mental illness will be the

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‘next wave’ as a sequalae to COVID-19 pandemic [16]. Covid-19 resulted a sudden and stark change in the way people live their lives. As we are returning to some semblance of normality, we are faced with the long- term impact this pandemic will have on mental health. COVID-19 pandemic is leading to mass unemployment, depleted social safety nets, starvation, increase in gender- based violence, homelessness, loan defaults, and millions more population slipping into poverty [17].

In India, at-risk populations include 150 million people with pre-existing mental health issues, Covid-19 survivors, those who are quarantined, frontline medical workers, young people, differently abled people, women, workers in the unorganized sector, the millions of migrants returning home, and the elderly, esp., with comorbid physical illnesses [19].

This post-Covid landscape is a fertile breeding ground for chronic stress, anxiety, depression, alcohol dependence, and deliberate self-harm, leading to an overall significant rise in morbidity and mortality through suicide linked to mental health [20]. Each one of us reacts differently to stressful situations borne out of the COVID-19 pandemic and subsequent lockdown. How we respond to this stress depends on our background, our social support from family or friends, our financial situation, our health and emotional background, the community we live in, etc.

Signs and symptoms of stress overload include emotional symptoms like anxiety and agitation, depression or general unhappiness, moodiness, irritability, or anger, feeling overwhelmed, loneliness, and isolation. Cognitive symptoms of stress include memory problems, inability to concentrate, poor judgment, seeing only the negative, constant worrying, etc. Physical symptoms of stress include chest pain, rapid heart rate, breathlessness, tremulousness, dry mouth, diarrhea or constipation, nausea, dizziness, etc. Behavioral symptoms of stress include sleeping too much or too little, withdrawing from others, procrastinating or neglecting responsibilities, using alcohol, cigarettes, or drugs to relax, and various nervous habits (e.g., nail biting, pacing) [21].

Healthy ways to cope with stress arising due to the COVID-19 lockdown scenario is briefly as follows: (i) contact a health professional before you start any self-

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Aich et al. : Mental Health Issues In Covid And Post Covid-19 Scenario

treatment for COVID-19, (ii) know where and how to get treatment and other support services and resources, including counseling or therapy (in person or through telehealth services), (iii) take care of your emotional health-It will help you think clearly and react to the urgent needs to protect yourself and your family, (iv) take breaks from watching, reading, or listening to news stories, including those on social media. Hearing about the pandemic repeatedly can be upsetting, (v) take care of your body: Take deep breaths, stretch, or meditate, (v) eat healthy and well-balanced meals, exercise regularly, get plenty of sleep, avoid drugs and alcohol use, (vi) make time to unwind. Try to do some other activities you enjoy, (vii) connect with others. Talk with people you trust about your concerns and how you are feeling, (viii) connect with your community- or faith-based organizations. While social distancing measures are in place, consider connecting online, through social media, or by phone or mail [22].

Reaction to severe stress and adjustment disorders secondary to Covid-19 infection may result in acute stress disorder, post-traumatic stress disorder (PTSD), or adjustment disorder. A detailed discussion of these disorders is beyond the scope of this essay. Similarly, this pandemic has seen an increase in frequency and severity of various anxiety and depressive disorders and substanceabuse disorder.

Suicide needs a special mention here.Every year one million people commit suicide, accounting for about 2 percent of total global mortality. This means, globally, one person commits suicide every 40 seconds [23].

As per the report of Suicide Prevention India Foundation, rural India is expected to be particularly susceptible to suicide due to the influx of migrant workers and also because it is home to the at-risk farming community. The reverse migration of millions of day workers to their villages is also fertile ground for deterioration of mental health scenario in rural India [24]. News of suicides poured in from India and the world over, during this lockdown and subsequent period. During two months of devastating lockdown in USA, doctors at one California clinic said they’d seen more suicides than Covid-19 deaths [25].

Warning signs of suicide help us to answer the critical

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question what is our patient doing (observable signs) or saying (expressed symptoms) that elevates his or her risk to die by suicide in the next few minutes, hours, or days? Higher-level warning signs are threats of harming or killing self, seeking means, such as access to weapons or pills, talking or writing about death, dying, or suicide, and giving away personal belongings. Lower-level warning signs are various symptoms of depression like hopelessness, rage, anger, seeking revenge, acting reckless or engaging in risky activities, feeling trapped, increased alcohol or drug use, with- drawing from friends, family, society, anxiety, agitation, insomnia, hypersomnia and dramatic changes in mood [26,27].

Suicide prevention measures include removal of access of instruments of suicide. Treat sleep disturbances and Insomnia, as insomnia is a well-established suicide risk factor. Provide adequate social support; as we know, social support is a well-established suicide protective factor. It also promotes belonging, provides appraisal, nurtures self-esteem, and allows for tangible support. Close buddy watch to be followed, another member at home, hostel, usually a close relative or friend, is assigned to constantly monitor the at-risk member [27].

Child and adolescent mental health: According to UNESCO, by April 2020, schools were suspended in 188 countries. Over 90% of enrolled students, about 1.5 billion young people, worldwide are now completely or partially disconnected from education. Approximately 10% to 20% of all young people experience mental health problems.We can expect this number is likely to increase significantly in the days and months to come in this corona pandemic period. Many children and young people are struggling with lockdown experience. They are missing the security that school, friends, and normal activities used to provide them.Managing their lives online and meeting study demands has become impossible for some. Teachers witness student’s distress more and more, and these teachers will need to be trained so as to support their students appropriately and refer, if neces- sary. Isolation and confinement at children and adolescent age group and staying at home for extended periods dramatically changes their normal daily and social routines [28].

There is an increased risk of different types of addictions in the children like misuse of the internet,online

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Aich et al. : Mental Health Issues In Covid And Post Covid-19 Scenario

gaming,social media, and use of recreational drugs and alcohol. Such behaviours increase depression, anxiety and stress among secondary school students.

What we can do to help our loved one with a mental illness in present scenario? If we know someone with a mental illness, now is the time to step up and make sure we are helping them in whatever way we can. Reach out—be it via video, phone, text, or social media— to check in and be an active part of their support group. Now that lockdown period is over, reach out to the needy one physically. Reach out with the intention of letting them know that we are there and wanting to know how they are. Tell them we have been thinking about them and genuinely ask how they are doing. Remember that, this simple act of connecting with another human being can be life-saving.

EPILOGUE : World Mental Health Day is observed on October 10 every year. Theme for this year’s World Mental Health Day is ‘Mental Health for All: Greater Investment – Greater Access’ [29]. The goal is to help raise mental health awareness around the world and to put all our efforts in support of mental health. The first World Mental Health Day was observed on October 10, 1992. ‘Kindness’ announced as the new theme for Mental Health Awareness Week 2020, in response to the coronavirus outbreak. In a Joint press release by the World Health Organization, United for Global Mental Health and the World Federation for Mental Health on World Mental Health Day, on October 10 highlighted following things: (i) mental health is one of the most neglected areas of public health, (ii) close to 1 billion people are living with a mental disorder (iii) Approximately 3 million people die from the harmful use of alcohol per year and (iv) one person dies from suicide every 40 seconds. And now, the COVID-19 pandemic has infected billions of people around the world, which is having a further effect on the mental health of people. So, we’re potentially facing a post- COVID-19 mental illness tsunami. COVID-19 reminded us that mental health is no longer just a question of individuality. It is formed by relationships and livelihoods that allow us to belong to the society and to contribute to it. Recovery will require that we restore the socio- economic parameters of good mental health (e.g., food, shelter, adequate income, social connection, etc.), empower local communities to support vulnerable individuals and families, encourage each of us to recognize our own distress and take responsibility for our mental health.

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A post-COVID-19 landscape will, probably, be a fertile breeding ground for an increase in chronic stress, anxiety, depression, alcohol dependence, and self-harm. UN Secretary-General Antonio Guterres urged governments, civil society and health authorities to urgently address mental health needs arising from the coronavirus pandemic [31]. He said, ‘After decades of neglect and under-investment in mental health services, the Covid- 19 pandemic is now hitting families and communities with additional mental stress’. ‘Rather than hurtling toward a post-Covid mental health crisis, this pandemic must be used as an opportunity to evaluate the current provision of mental health services. This means giving mental health services the long-overdue parity, we have desperately needed, to ensure we move forward for the better31.Tony Bates, professor of psychology, aptly said ‘Covid-19 has not only shaken us up but it has also opened our eyes. We became kinder, more aware of how fragile we are, clearer about our values and appreciative of people whose services we previously took for granted’.

Key recommendations, we can think of, to deal with post-Covid-19 mental health care demand are (i) The world is following the concept of universal health coverage. An integral part of UHC must be mental wellbeing. Ability to mental health care should not be denied to anyone because they are disadvantaged or live in a remote area (ii) according to WHO Mental Health Atlas (2017), mental health expenditure is less than 2% of global median of government health expenditure. This scenario has to change for the better, (iii) at least, double mental health spending over next 5-year planning period, (iv) ensure access to mental health services at PHC level, (v) patients with pre-existing mental health conditions, should get the care urgently, and finally, (vi) recruit, train and place of mental health staffs on priority basis at PHC level.

Finally, our Prime Minister Mr Narendra Modi aptly said during his last ‘Man ki Baat’radio-broadcast, “Jab tak dawai nahi, tab tak dhilahi nahi”. We should not lower our guard, till an effective medication, an effective vaccine is available to us [32].

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REVIEW ARTICLE

Psychiatrists in The State of Uttar Pradesh: The Iconic Professionals

S. C. Tiwari1, Nisha Mani Pandey2

1 Corresponding Author, Professor (Retd.) & Founder Head, Dept. of Geriatric Mental Health, King George’s Medical University UP, Lucknow. 2/38 Vipul Khand, Gomti Nagar, Lucknow. Email : sarvada1953@gmail.com
2Associate Professor (Non-medical Research), Dept. of Geriatric Mental Health, King George’s Medical University UP. Email:nishamani@kgmcindia.edu

“Most of the important things in the world have been accomplished by people who have kept on trying when there seemed to be no hope at all.”

Psychiatry, over years, is gradually getting its well-deserved recognition in the country, especially in the state of Uttar Pradesh.The credit goes to the concerted efforts of the professionals of the area who have worked hard to develop and sustain the field. They have remained consistently involved in establishing its various branches as well as strengthening the super/ sub specialities of Psychiatry. During the current pandemic, the need for mental health care was felt to be a primary concern. In this crisis, these professionals offered assistance through the newly formed Association of Clinical Psychiatry, Indian Psychiatric Society, Uttar Pradesh Branchand contributed towards an article to the inaugural issue of the ‘Indian Journal of Clinical Psychiatry’. In this manuscript, we strive to acknowledge the contributions of the psychiatrists of Uttar Pradesh in the field of mental health, who have worked tirelessly 24*7 to promote the subject as well as its sub/ super speciality in the state. We have tried to elaborate upon and pen down some of the phenomenal contributions/ stories of these great pioneers. Some of these icons are in our memory and some are guiding, supervising and helping us for developing and expanding the mental health related services further. Keeping this in the mind, with help of various websites and through personal contacts, present manuscript was prepared. Information related to these legends have been collected from various webpages and articles, we apologise for any missing information.

Corresponding author:

Dr. S. C. Tiwari
Email : sarvada1953@gmail.com

̄ Dale Carnegie

We would like to start with recounting the life of Dr. Kalika Chand Dube popularly known as KC Dube, who was born in 1913, in a district of Madhya Pradesh i.e. Hoshangabad. Dr. Dube joined the Agra Mental Hospital in 1957 as the Superintendent and made history by conducting the largest epidemiological study in Psychiatry with his colleagues between 1961 to 1967 (1). In the history of psychiatry, this is a landmark study sponsored by the Indian Council of Medical Research “A pilot investigation of incidence of mental diseases in India”. In the literature of psychiatry,this study has been quoted across the world including India. Another achievement of this great person was the recognition of the Mental Health Unit of Agra as one of the only field research centresfor International Pilot Study of Schizophrenia (IPSS) in the entire South Asia [1]. The study was conducted for 11 years at 9 centres of the world and has been published in year 1973 and 1979 subsequently in 2 volumes by the World Health Organization. With ample of publications in national as well as international journals he has been received many awards and fellowships too. He was one of the active members of the Indian Psychiatric Society (IPS) since its beginning and helped to upgrade the society in many ways; he had been President of the society twice. His work in the field given the recognition to psychiatry not only in the state of Uttar Pradesh but decided the fate of the subject in the country.

Prof. Brij Bhusan Sethi, popularly known as Dr. B.B. Sethi, was another pioneering psychiatrist in the state of Uttar Pradesh. He shaped how psychiatric practice is perceived in the state. Prof. Sethi did his medical graduation in 1956 from King George’s Medical College-

Tiwari et al. : Psychiatrists in the State of Uttar Pradesh: the Iconic Professionals

KGMC (now known as King George’s Medical University-KGMU), Lucknow. Thereafter, he did his postgraduation i.e. M.Sc. Psychiatry from USA and was awarded the Diploma of American Board of Psychiatry and Neurology. In December, 1966 he joined KGMC as a faculty in the department of medicine and with his concerted efforts, extensive vision and professional zeal he started the department of psychiatry in the premises of the then KGMC. By 1971,a separate Department of Psychiatry was established in KGMC. He had been recipient of many awards and fellowships including a membership of the Royal College of Psychiatry in 1972 and a fellowship in 1976. He had been awarded the prestigious National B.C. Roy Award by Govt. of India for developing a specialty in medical discipline; Dr. D.L.N. Murthy Rao Oration Award was also conferred on him. As a member of Central Health Committee, Ministry of Health and Family Welfare, Government of India, he had been one of the planners of national mental health programme. Along with these, he had held many other distinguished academic positions in institutes like Indian Council of Medical Research;was an editorial member of Biological Psychiatry; a panellist in Council of Science and Technology, Medical Council of India;inspector as well as founder editor of the Indian Journal of Social Psychiatry [2]. Between 1976-1984 he was also the editor of Indian Journal of Psychiatry and during his editorship the journal had several innovative features, wider circulation and global recognition. He was an enthusiastic and committed researcher too. In a narration by Prof. Trivedi, he reveals “since the beginning of his academic career Prof.Sethi devoted his energies ……and was one of the pioneers to conduct epidemiological studies in mental health and biological psychiatry and psychopharmacology. He was principal investigator in more than two dozen research projects sponsored by ICMR, WHO and Council of Science of Technology”. It was heard by many of Professor Sethi’ juniors/ student including the first author that he was very meticulous and the word ‘no’ was not in his dictionary, he never liked an incomplete mission and he was a hard task master full of energy.In later stage of his life, he was the Director of Mental Health Services in Napier, New Zealand during 1995- 1996 and left for his heavenly abode on May 8th, 1996.

Prof. Narendra Nath Wig known as NN Wig was one of the foremost Indian psychiatrists of India. His medical education (graduation and post- graduation in medicine)

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was from KGMC, Lucknow and then he gained a double diploma in Psychological Medicine from England and Scotland. In 1991, he was honoured by the Royal College of Psychiatrists, London, with the highest award of the Honorary Fellowship [3]. Though Dr. Wig did not practice in Uttar Pradesh after his postgraduation but he took up numerous activities, which guided us in many ways. He developed the Primary Mental Health Care model for India and for many other countries.He was well-known for helping his patients and their families towards developing coping strategies for mental health issues. He was also a strong advocate for local, cultural issues and championed advocacy for women’s mental health. He never believed in looking back; his continuous effort was to look forward to ensure that the benefits of modern scientific psychiatry became available to all sections of the population in India, and that those services become more relevant in terms of Indian cultural needs [4].

Prof. Anil Kumar Agarwal known as Dr. A.K. Agarwal did his medical graduation from KGMC Lucknow in 1961 and Post-graduation in Psychiatry from All India Institute of Medical Sciences, New Delhi. He has been registrar and lecturer at AIIMS from July 1965 to July 1969 and then joined KGMC in 1969 as faculty in the department of psychiatry and headed the department during 1986-88 and 1989-1999.In September 1999 Professor Agarwal superannuated. However, till date, he is a practicing psychiatrist and a renowned and appreciated mental health professional who is continuously involved in taking care of mentally ill persons. He has been president of Indian Psychiatric Society in 1994; Editor, Indian Journal Psychiatry for four years; Chairperson, Ethics committee for six years. He is also the President of Richmond Fellowship Society (INDIA), Lucknow branch and is the Chairman of Richmond Fellowship Society National Board, taking care of schizophrenic patients by providing them with modern psychosocial treatment. For his noble work and publications, he has been awarded by many organizations. He has been president of the IPS in 1994; Editor, Indian Journal of Psychiatry (IJP) for four years; Chairperson, Ethics committee for six years. There are around 120 articles published by him in renowned national/ international journals. He has authored four books and is the editor of two. His area of interest is to provide treatment and support to chronically ill psychiatric patients.

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Tiwari et al. : Psychiatrists in the State of Uttar Pradesh: the Iconic Professionals

Dr. R. K. Mahendru is a former Professor and Head, Psychiatric Division, GSVM Medical College, Kanpur. He was first to obtain a MD in Psychiatry in 1971 from KGMC Lucknow. He has won the Central Zone Oration Award by the Indian Psychiatric Society in 1986 and has been the President and Secretary of Central Zone Branch of Indian Psychiatric Society as well. He has published many scientific papers in various national and international journals and written several articles on psychiatry and mental health in various magazines and newspapers. He was a part of the Executive Council of the IPS as a Direct Member and has successfully organized several national level CME programs and two central zone conferences, the first in 1983 and the second in 2000. The annual national conference of the Indian Psychiatric Society organized by him in Kanpur in Jan’1997 was a grand success. The national level mid- term CME programme of Indian Psychiatric Society held at Khajuraho in Sept’2004 was another memorable event organized by him. He has also won the prestigious Amit Bohra Oration Award at the national IAPP conference held at Kolkata in 2016 and delivered his popular lecture on ‘Spirituality in Everyday Life’. Dr.Mahendru has attended many national and international conferences and had presented various lectures and research papers.In Oct. 2019 he attended the 11th SAARC International Psychiatric conference held in Colombo, Sri Lanka and presented his paper on spirituality. Dr.Mahendru is closely associated with IIT Kanpur and has been a regular guest speaker in IIT Kanpur on various topics related to psychiatry and mental health.

Prof. Narottam Lal popularly known as Dr. Lal Joined the then KGMC, Lucknow as a Faculty of Psychiatry in July, 1972 and remained there till 2003. He retired as the Professor & Head of Psychiatry in 2003. He was a Nodal Officer in the National Mental Health Program for the Govt. of India and founder Professor and Head of the Dept. of Psychiatry, ERA’s Lucknow Medical Collage, Lucknow.At ERA’s, he also served as the Dean and Chief Medical Superintendent and remained between 2003 to 2009. He is a consultant psychiatrist with more than 40 years of experience in handling and treating adult and geriatric patients. He was also associated with a special program run by Govt. of India at Ramakrishna Mission Sevasram Lucknow (Vivekananda Polyclinic and Institute of Medical Sciences Lucknow is a part of it) called Youth Counseling and positive thinking for youths as part of the celebration of 150th birth anniversary of Swami Vivekananda Youth Counseling Centre at Lucknow [5].

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Prof. Prabhat Sitholey, a renowned child and adolescent psychiatrist, is a practicing consultant psychiatrist at presentin Lucknow. Dr.Sitholey graduated from GSVM Medical College in 1971 and obtained MD (Psych) from the then King George’s Medical College (KGMC), Lucknow in 1975. Afterwards,Dr.Sitholey joined the department as a faculty and in due course of time became the Professor. He became the Head of Psychiatry twice i.e. during 2000-2001 and 2002-2008. He superannuated in 2010. Dr Sitholey obtained his training in child and adolescent psychiatry from England and is a very popular child and adolescent psychiatrist. His works have been published in national and international journals and cited in international textbooks on child and adolescent psychiatry. He was the Founding Fellow and President of the Indian Association for Child and Adolescent Mental Health and President of the IPS Central Zone. He has been the Chairperson of the IPS Child and Adolescent Psychiatry Specialty Section. He has been the recipient of various awards including Commonwealth Medical Fellowship Award for training in Child and Adolescent Psychiatry in England; PPA Oration Award of Indian Association for Child and Adolescent Mental Health; IPS Central Zone Oration Award; Marfatia Best Paper Award of Indian Association for Child and Adolescent Mental Health.

Prof. Jitendra Kumar Trivedi was amongst one of the most eminent psychiatrists of the country. He was an adorable individual with many abilities par excellence in academics, research, leadership and wisdom. He completed his medical graduation in 1973,and post- graduation in 1977 from the then KGMC. In 1978, he joined the department of Psychiatry, KGMC, as faculty. He was the Head of the Department between November 2008 to March 2009; since March 2009 to September 2013, he served the department as a contractual professor and gave his services to psychiatry department for about 35 years. He was a psychiatrist of international repute and an ideal teacher and researcher. He was one of the pillars of the department who took the department on national and international heights [6,7]. Kallivayalil and Dalal (2013) report that formation of SAARC Psychiatric Federation(SPF) was one of his lasting contributions when he was President of Indian Psychiatric Society. One of his students describes him a “charismatic, disciplinarian, eminently fair, honest to the point of bluntness, punctual, hard-working and dedicated to the cause of psychiatry” [7]. His unfortunate, untimely sad demise created a vacuum in the world of psychiatry.

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Prof. Indira Sharma did her graduation in 1972 and completed her post-graduation (psychiatry) in 1977 from the then KGMC and served Dept. of Psychiatry, Banaras Hindu University (BHU), Varanasi. Prof. Sharma served BHU for more than 3 decades and became the head of the department on rotation basis. After superannuation she served BHU as an emeritus professor too. She served many societies as President like;IPS, SPF, Indian Association of Child & Adolescent Mental Health, IMA- BHU (twice)and published many articles in National & International Journals (including 2 books and 17 chapters). Her research interests include- cognitive remediation of geriatric population, social and legal issues in married women with mental illness, mental illness and marriage- social and forensic aspects etc.[8].

Prof. Harjeet Singh joined KGMC in year 1967, for medical graduation and joined the Dept. of Psychiatry in 1974. He became a faculty in the department in 1980 and for 5 years he worked in child psychiatry. He had an interest in Community Psychiatry and he had taken an initiative to train physicians of Lucknow and has given training to of psychiatry to 50 General Physicians of Lucknow. He was the nodal officer for District Mental Health Programme, Raebareli sponsored by the Govt. of India. He has supervised 25 MD theses as the Chief Guide and 75 research publications are in his name. He has presented 150 Research papers in national/ international conferences. According to Dr. Singh, he has participated in various drug trials – Nomifexin, Amoxetine, Centpropazine etc. He served the Department of Psychiatry as the Head during 2009-10 and superannuated in 2010. Till date he is a practicing consultant and gives free services to mentally ill, poor patients.

The present Head of Department of Psychiatry, KGMU, Lucknow and the president of the IPS Prof. Pronob Kumar Dalal known as Dr.PK Dalal has also worked hard at upgrading the mental health status of residents of Uttar Pradesh. In 1979, after admission in MBBS in the then KGMC, he successively went forward and completed his MD (Psychiatry) in 1984; and did senior residency in 1984-85. He became a faculty member in January 1986 in the Department of Psychiatry, KGMU. He became professor in April, 1999 and since 2010 he has been the Head of the Department. He did extensive work in the field of de-addiction; the credit to run the de-addiction clinic in the department goes to Prof Dalal.

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He acknowledges everyone’s effort to sustain mental health and believes in the virtue of gratitude. Under his headship and guidance, M.D. Psychiatry seats were increased from 6 to 12, and he is the one who took initiative to start various programs/ courses/ Centres namely Manpower Development Program of Government of India; RCI Recognized Clinical Psychology course; NCI Recognized Diploma in Psychiatric Nursing; District Early Intervention Centre (DEIC); Drug Treatment Centre (DTC) and Opioid Substitution Therapy Centre (OST). He did many state and national level research projects. He has around 140 publications under his name; he has attended 17 international and more than 100 national conferences and seminars. He is also a member of different professional bodies. As the president of IPS, he took the initiative to start Foundation Day of the society and also started the UP State Branch of the IPS. He has been the recipient of many honours and awards including the Honorary fellowship of World Association of Psychiatry (2020).

Now some information about the first author – Prof. Sarvada Chandra Tiwari popularly known as Dr. S.C. Tiwari.After completion of his post-graduation in psychiatry in year 1982 from KGMC, he served the department of psychiatry as chief resident and senior research officer till September 1985 and then joined the department as faculty in October, 1985.In his professional career of more than 3 decades, he has contributed, achieved and added several feathers to the cap on the subject of Mental Health in the Medical University, State of Uttar Pradesh and the country. He has many firsts to his credit; Founder President, Indian Association for Geriatric Mental Health”(IAGMH) (2004); Founder Head, Department of Geriatric Mental Health (2005), first to start a course – DM (Geriatric Mental Health) (2010) from the mother subject Psychiatry; Healthy Ageing Clinic in 2010, National Centre for Geriatric Electro- convulsive Therapy. Sixteen “Care Giver’s Guide” with different 16 mental health and other problems was developed by him for care givers of elderly patients. He is the first Indian who received “WHO Rafaelson Fellowship Award in Psycho-pharmacology in 1988” and “II place IPA/Bayer Award in Psychogeriatrics in 1999” from International Psychogeriatric Association, USA. The “Socio-Economic Scale” developed by him and his team, is being used for urban/rural research studies all over the country and abroad. Similarly, recognizing his work and efforts, during the 8th Foundation

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Tiwari et al. : Psychiatrists in the State of Uttar Pradesh: the Iconic Professionals

Day of the Department in 2013,the then Hon’ble Chief REFERENCES Minister established the “Advance Centre for

Research,Training and Services in Ageing and Geriatric Mental Health”which is another milestone.

Psychiatry is a field emerging out of stigma in the Indian society. These psychiatrists have devoted their lives to the betterment of the general population. They have been pioneers and should be celebrated for what they have achieved.

1. 2.

3. 4.

5. 6.

7. 8.

Jain R. Dr. K. C. Dube (1913-2005). Indian J Psychiatry. 2010;52(6):143–4.

Trivedi JK. B.B. Sethi (1932 – 1996). Indian J Psychiatry. 2010;52(6):179–82.

Wig NN. Brief biodata: Dr. N. N. Wig. Mens Sana Monographs; 2005.

Khandelwal SK. The joy of mental health: Some popular writings of Dr N.N. Wig (Chatrath, K.J.S.). Indian J Psychiatry. 2006;48:207–8.

Lal N. Psychiatrist Dr. Narottam Lal.pdf.

Kallivayalil R, Dalal P. Prof. J. K. Trivedi. Indian J Psychiatry. 2013;55(4):311.

Tripathi A. Late Prof. J. K. Trivedi: A teacher affects eternity. Mens Sana Monogr. 2014;12(1):1.

Sharma I. Indira Sharma, MBBS, MD, MAMS, PhD – Openventio Publishers.

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REVIEW ARTICLE

Werther’s Effect: A Brief Review

Rakesh Yaduvanshi 1, Anurag Agrawal2, Chinar Sharma3

1 Associate Professor, Department of Psychiatry, Rohilkhand Medical college and Hospital, Bareilly.
2 Associate Professor, Department of Psychiatry, Integral Institute of Medical Science and Research, Lucknow. 3Junior Resident, Department of Psychiatry, Rohilkhand Medical College and Hospital, Bareilly.

 

A B S T R A C T

Suicide by a prominent public figure often leads to extensive, sensational media coverage. There are always concerns about whether such reporting has any influence on further suicides. Durkheim, Lester, Phillips,and other researchers had a different saying on imitative suicides. Various anecdotal shreds of evidence, studies, and meta-analyses now established media portrayal of suicide as an independent risk factor of further suicides in society. Philips termed this phenomenon as the “Werther effect” after the main character in Goethe’s novel “The sorrows of young Werther.” In this review, we discuss the Werther effect, its postulated mechanism, some statistical considerations, the group at risk, and essential variables of this phenomenon, along with recent media guidelines.

Keywords: Werther effect, publicized suicide, imitative suicide

INTRODUCTION

Every individual is an essential building block of our soci- ety. Hence, whenever a life is lost prematurely to suicide, it is a personal tragedy and a devastating loss to a family and society. India has one of the highest reported deaths due to suicide worldwide [1]. NCRB data shows an in- crease in suicide by 3.6% and 3.5% in 2018 and 2019, re- spectively, compared to the previous years [2].

It is hard to ignore the association between a widely publicized celebrity suicide and an increase in suicidal thoughts, attempts, and rates thereafter. [3,4,5] A recent suicide by a famous Indian film actor and its media coverage prompts us to review this association.

Corresponding author:

Dr. Rakesh Yaduvanshi
Email : rakeshyaduvanshi@rocketmail.com

EVIDENCE

Probably the first documented evidence of this asso- ciation came after the publication of Goethe’s novel Die Leiden des Jungen Werthers (The Sorrows of Young Werther) in 1774. Goethe’s novel became very popular and was read widely in Europe. Young men in many European countries mimicked Werther’s main character by dressing, but many of them imitated Werther’s manner of death. Though the novel’s influence on suicides was never conclusively demonstrated, the book was banned in many places, including Italy, Leipzig, and Copenhagen [6]. Similar phenomenon also occurred in Italy after the U. Foscolo’s work “The Jacopo Ortis Last Letters” (The Last Letters of Jacopo Ortis) in 1802 [7].

Durkheim, in 1897, rejected any such association, especially at the national level. He believed that these suicides were only precipitated by prior suggestions, and these people would have committed suicide eventually [8].

Lester (1972) analyzed seven studies and concluded

that the effect of suggestion on suicides is equally challenging to document and rule out [9].

David Phillips analyzed suicide stories publicized in the newspapers in Britain and the United States between 1947 to 1968 and observed an associated immediate increase in the number of suicides. He termed this increase in suicides as “the Werther effect” after Goethe’s hero and attributed this effect to the influence of suggestion. Highly publicized suicides, front-page coverage, and suicides by prestigious public figures are more likely to be imitated. Contrary to Durkheim’s rejection of the Werther effect on the national level, Philips believed that the Werther effect is manifested nationally and sometimes on an international level. Philips concluded that publicized suicide stories not only precipitate some suicides and also create others [6].

Later on, in 1985 and 1989, Phillips and his colleagues also found the rise in fatal car accidents along with suicides after a well-publicized suicide.He considered these accidents a form of suicide and leveled these accidents as “covert imitation” while explicit suicide was termed as “overt imitation” [10].

After the suicide of Indian actor Sushant Singh Rajput on June 14, 2020, there occurred an increase in suicide- seeking keywords related search on the internet from different parts of India. Many instances of copycat suicides were also reported suggesting Werther’s effect [11].

STATISTICS

Since Phillips’s study, many studies have been conducted in different parts of the world to find Werther’s effect’s statistical impact.

In the five months following the death of the international celebrity Robin Williams by suicide on August 11, 2014, deaths by suicide increased by 9.85% in the United States [12].

A recent Indian study found a significant proportion (> 5%) of subsequent suicides after SSR’s suicide was linked to celebrity suicide [13].

Michiko Ueda in Japan analyzed the daily suicide counts

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in Japan from 1989 through 2010 using the Poisson regression model on 109 celebrity suicides and. On average, the total number of suicides increased by 4.6% on the day of media reports, and this increase lasted for about ten days [14].

After controlling for humidity, temperature, seasonal variation, calendar year, and unemployment rate, Cheng et al. found a marked increase in the number of suicides (relative risk =1.17, 95% CI 1.04–1.31) in 4 weeks after media reporting of suicide by famous male television actor in Taiwan. In another study, Cheng et al. interviewed suicide attempters within two months after the suicide by the television actor mentioned above. They found that 89.2% of suicide attempters reported exposure to publicized suicide. About 25% of the exposed suicide attempters reported an influence of the media reports on their subsequent suicide attempts [4,5].

One meta-analysis of 10 studies published in 2012 found an increase in suicide rates (suicides per 100, 000 population) by 0.26 in the month after a publicized celebrity suicide [15].

Another meta-analysis of 31 studies, published in 2020, reported that suicides increased by 8-18%in the next month of media reporting of celebrity suicide. The risk of suicide by the same method increases by 18-44% after reporting of the method of suicide [16].

DURATION OF EFFECT

Most of the studies assumed this imitation effect to be short term and assessed the short-term (mostly 2 to 4 weeks) effect only [6,17]. Schmidtke and Schaller called media reporting of suicide as a natural advertisement of suicide and feared that it might “sow the seeds of suicide in the distant future” [18]. A population-based household survey in Hong Kong revealed that celebrity suicide might lead to long-term effects on people’s suicidal ideation other than well-known short-term effects [3].

FACTORS/ VARIABLES

There are overwhelming shreds of evidence that imitative suicides have a “dose-response” relationship.The amount of publicity given to the news and the prominence of the placement (front page, in large headlines) of the

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newspaper’s story is closely related to the increase in suicidal behavior [6].

A meta-analysis by Stack et al. 2005, showed that compared to studies based on non-celebrity suicides, those based on celebrity suicides were 5.27 times more likely to report an imitation effect. High-profile celebrities were associated with a more considerable (6.3% in the 10-day post-report period) increase in the number of suicides [14].

Among different types of celebrities, only suicide of celebrities from entertainment and politics was found to have a significant imitative effect [17]. Kim et al. 2013 found the longer Werther effect band for entertainment celebrities thanpoliticians and attributed it to more significant and positive frames of media coverage [19]. In Japan, suicides of politicians and economic elites evoked a larger imitation than after the deaths of entertainment celebrities [14].

Adverse life events also increase the likelihood of suicide following a celebrity suicide [20].

Both retrospective and prospective studies identified pre- existing mental illness as a risk factor for subsequent suicides following celebrity suicide [3,20]. However, a study from India found persons without mental illness to be at a higher risk of suicide following celebrity suicide [13].

Cheng et al. 2007, after controlling the variable, found temperature as the most salient factor and held it res- ponsible for higher suicides during spring to summer. [5,21].

An individual’s thinking is also an essential factor. A study says that having less reason for living, a greater level of anxiety symptoms, and more irrational values enhance the suicidogenic effect of celebrity suicide. On the other hand, positive thinking after a celebrity suicide, less impulsivity, and having health problems are predictors of not having severe suicidal ideation [3].

GROUPS AT RISK

Some studies reported the most significant effect of a publicized celebrity suicide on teenagers, while others found those belonging to the same age group as the

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celebrity at greater risk [5,22-24]. Similarly, some studies found females to be more commonly affected by the Werther effect. Some find the same gender more vulnerable, and some didn’t find any gender-specific impact in some celebrity suicides [5,13,18,24-26].

The age gender-specific effect is a complex interaction rather than a simple linear stimulus-response relationship. Age group and gender of celebrity’s admirers is also an important consideration while studying Werther’s effect. These people are more likely to identify with celebrity’ behavior [5].

MECHANISM

First of all,the media report of celebrity suicide makes its influence much more far-reaching than it would have been otherwise. Further increased media coverage of suicide leads to the normalization of suicide as an acceptable way of coping with problems.27 Romanticized and sensationalized reporting about celebrities make the people see suicide as a glamorous ending, with the victim getting attention and sympathy that they never got in life.

Werther effect can also be explained by the concept of behavioral or social contagion. Some people might have a pre-existing motivation to perform a specific behavior, but they have internal restraints against performing it. Publicized suicides provide them a model to imitate, which results in the reduction of internal restraints [28]. Suicidal thoughts are a common occurrence, and media reports of suicide can negatively influence many vulnerable people [29].

Specific stories promote “differential identification” in specific individuals if they find themselves similar to the deceased celebrity in certain aspects [30]. Higher imitative suicides in similar age and sex group provide evidence for identification [24]. Increase in suicides by the same method as that of a celebrity suggests that information transfer about the method might increase the same method’s cognitive availability [16].

PAPAGENO EFFECT

The Papageno effect is named after a lovelorn character in Mozart’s 18th-century opera “The Magic Flute,”

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wherein the character plans his suicide. At the last minute, his attempt is prevented by three boys who remind him of alternatives to suicide. [31]

Philips predicted that the suicide rate should decrease if more publicity is given to an alternative to suicide [6]. Research also says that not all reporting on suicide is associated with increases in suicides. Media reports might help prevent suicides if they feature positive coping in adverse circumstances, stories of hope, and healing [32,33]

This effect can be seen after the suicide of singer and guitarist Kurt Cobain. Coverage of Cobain’s suicide in the area focused largely on suffering to his family after Cobain’s death, treatment for mental health problems, and suicide prevention. As a result of this, the local suicide rate declined in the following months. [34]

MEDIA GUIDELINES

Following the implementation of media guidelines, Austria noted a significant decline in suicide rates after celebrity suicide.35This encouraged media guidelines for reporting about suicide by the World Health Organization and other countries. In general, these guidelines attempt to reduce sensationalism and prevent content that may be a trigger or prompt suicides in vulnerable individuals. Inclusion of preventive information (e.g., suicide helpline) is also recommended. 36

On September 13, 2019, the Press Council of India released guidelines on suicide reporting, based on WHO media guidelines.37It states that stories about suicide must NOT be placed prominently and unduly repeated. It must NOT sensationalize or normalize suicide or present suicide as a constructive solution to problems. Explicit description of suicide method, details of site/ location, and use of photographs, video footage, or social media links are also strictly prohibited.38However, adherence to this guideline is far from ideal in India.11

CONCLUSION

Werther effect is a well-documented phenomenon, and media portrayal of celebrity suicide act as an independent risk factor. However, this effect is probably smaller but significant enough to warrant special attention. Media

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reports spread the news to a large number of people rather quickly. The normalization of suicide by such reports, identification with a celebrity by some indi- viduals,and information about suicide methods often results in imitative suicides. The risk of these copycat suicides is highest during the short term, but sometimes suicidal thoughts may last longer. These suicides have a “dose-response” relationship with the amount of publicity given to the news. Certain individuals, such as individuals with adverse life events, pre-existing psychiatric disorders, are at higher risk than others. Implementation of media guidelines in Austria and a resultant decrease in suicide rates encouraged other countries, including India, to adopt these guidelines. However, there is still a deficit in following these guidelines. Efforts should be made to enhance quality research in this area, to sensitize media personals, and strict compliance of media guidelines must be ensured.

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14. Michiko Ueda, Kota Mori, Tetsuya Matsubayashi. The effects of media reports of suicides by well-known figures between 1989 and 2010 in Japan. International Journal of Epidemiology, 2014, 623–629

15. Niederkrotenthaler T, Fu K, Yip PSF et al. Changes in suicide rates following media reports on celebrity suicide: a meta-analysis. J Epidemiol Community Health 2012; 66:1037–42.

16. Niederkrotenthaler T et al. Association between suicide reporting in the media and suicide: systematic review and meta-analysis. BMJ. 2020; 368: m575.

17. Stack S. Celebrities and suicide: a taxonomy and analysis, 1948– 1983. Am Sociol Rev 1987;52:401–12.

18. Schmidtke A, Schaller S. The role of mass media in suicide prevention. In: Hawton K, Heeringen K, eds. The international handbook of suicide and attempted suicide. New York: Wiley, 2000:675–97.

19. Kim, J-H., Park, E-C., Nam, J-M., Park, S., Cho, J., Kim, S. J., Choi, J. W., & Cho, E. (2013). The Werther effect of two celebrity suicides: An entertainer and a politician. PLoS ONE, 8(12): e84876. https:// doi.org/10.1371/journal.pone.0084876

20. Hawton, K., Harriss, L., Appleby, L, Juszczak, E., Simkin, S., McDonnell, R., Amos, T., & Kiernan, K. (2000). Effect of death of Diana, Princess of Wales on suicide and deliberate self-harm. The British Journal of Psychiatry, 177: 463–466. https://doi.org/10.1192/ bjp.177.5.463

21. Lee HC, Lin HC, Tsai SY, Li CY, Chen CC, Huang CC. Suicide rates and the association with climate: a population-based study. J Affect Disord 2006;92:221–26.

22. PHILLIPS, D. & L.L. CARSTENSEN. 1986. Clustering of teenage suicides after television news stories about suicide. N. Engl. J. Med. 315: 685–689

23. GOULD, M.S., K. PETRIE, M. KLEINMAN, et al. 1994. Clustering of attempted suicide: New Zealand national data. Int. J. Epidemiol. 23: 1185–1189.

24. Yip, P. S. F., Fu, K. W., Yang, K. C. T., Ip, B. Y., Chan, C. L., Chen, E. Y., Lee, D. T., Law, F. Y., & Hawton, K. (2006). The effects of a celebrity suicide on suicide rates in Hong Kong. Journal of Affective Disorders, 93(1–3): 245–252. https://doi.org/10.1016/ j.jad.2006.03.015e.g

25. Myung, W., Won, H-H., Fava, M., Mischoulon, D., Yeung, A., Lee, D., Kim, D. K., & Jeon, H. J. (2015). Celebrity suicides and their differential influence on suicides in the general population: A national population-based study in Korea. Psychiatry Investigation, 12(2): 204. https://doi. org/10.4306/pi.2015.12.2.204

26. Park, J., Choi, N., Kim, S. J., Kim, S., An, H., Lee, H. J., & Lee, Y. J. (2016). The impact of celebrity suicide on subsequent suicide rates in the general population of Korea from 1990 to 2010. Journal of Korean Medical Science, 31(4): 598– 603. https://doi.org/10.3346/ jkms.2016.31.4.598

27. Niederkrotenthaler T, Reidenberg DJ, Till B, Gould MS. Increasing help-seeking and referrals for individuals at risk for suicide by decreasing stigma: the role of mass media. Am J Prev Med 2014;47(Suppl 2):S235-43. 10.1016/j.amepre.2014.06.010

28. WHEELER, L. 1966. Toward a theory of behavioral contagion. Psychol. Rev. 73: 179–192.

29. Lipari R, Piscopo K, Kroutil LA, Kilmer Miller G. NSDUH data review: suicidal thoughts and behavior among adults – results from the 2014 national survey on drug use and health. Substance Abuse and Mental Health Services Administration, 2015. https://www.samhsa.gov/ data/sites/default/files/NSDUH-FRR2-2014/NSDUH-FRR2-2014.pdf.

30. STACK, S. 1990. Divorce, suicide, and the mass media: an analysis of differential identification, 1948–1980. J. Marriage Fam. 52: 553– 560.

31. Sisask, Merike; Värnik, Airi (2017-01-04). “Media Roles in Suicide Prevention: A Systematic Review”. International Journal of Environmental Research and Public Health. 9 (1): 123–138.

32. Niederkrotenthaler T, Till B. Effects of suicide awareness materials on individuals with recent suicidal ideation or attempt: online randomised controlled trial. Br J Psychiatry 2019. 10.1192/bjp.2019.259

33. Till B, Arendt F, Scherr S, Niederkrotenthaler T. Effect of educative suicide prevention news articles featuring experts with vs without personal experience of suicidal ideation: a randomized controlled trial of the Papageno effect. J Clin Psychiatry 2018;80:17m11975. 10.4088/ JCP.17m11975

34. Jobes D.; Berman A.; O’Carroll P.; Eastgard S. (1996). “The Kurt Cobain suicide crisis: Perspectives from research, public health and the news media”. Suicide and Life-Threatening Behavior. 26 (3): 260– 271

35. ETZERSDORFER, E. & G. SONNECK. 1998. Preventing suicide by influencing mass-media reporting. The Viennese experience 1980– 1996. Arch. Suicide Res. 4: 67–74.

36. World Health Organization. Preventing Suicide: A Resource for Media Professionals-Update 2017. Reference No WHO/MSD/MER/17.5. Geneva, Switzerland: World Health Organization; 2017.

37. Guidelines Adopted by PCI on mental illness / reporting on suicide cases [press release]. HTTP:// presscouncil.nic.in/WriteReadData/ Pdf/PRtennineteentwenty.pdf, 13th September 2019 2019.

38. Lakshmi Vijayakumar. Media Matters in suicide – Indian guidelines on suicide reporting. Indian J Psychiatry. 2019 Nov-Dec; 61(6): 549– 551.

Yaduvanshi et al. : Werther’s Effect

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REVIEW ARTICLE

Immune-inflammatory Pathways in Somatoform-Disorders : A Theoretical

Update
Vikas Menon1, Natarajan Varadharajan2, Selvaraj Saravanan3

1Additional Professor, 2Senior Resident and 3Junior Resident, Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry-605006, India

ABSTRACT

Somatoform disorders are comprised of conditions where patients have multiple somatic symptoms without any underlying medical explanation for the causation of such symptoms and cause significant psychosocial distress. These somatic complaints often occur in major depression and chronic fatigue syndrome where involvement of immune-inflammatory pathways has been described, which suggests their possible involvement in somatoform disorders. This stimulated research and lead to unravelling the possible role of mechanistic pathways like cell-mediated immunity and subsequent inflammation, the involvement of TRYCAT (tryptophan catabolite), and oxidative/nitrosative stress pathways in somatoform disorders. In this review, we attempt to provide an overview of the three possible pathways elucidated to date as a precise understanding of the biological underpinnings has profound implications in stimulating further research in these poorly understood group of disorders.

Keywords: somatoform disorders, somatization, inflammation, immunity, autoimmunity

INTRODUCTION

Nearly a decade ago, Rief and others published their pioneering work documenting the relationship between the inflammatory response system and somatization and comparing it with major depression. While they found some evidence for immune-inflammatory system activation in somatization syndrome, they also found key differences in activation patterns; patient with somatoform disorder showed decreased concentration of CD8 + T-lymphocytes and IL-6 and raised levels of some anti-infammatory markers (Clara cell protien CC-16) [1]. These changes are relatively stable over time. [2]

Corresponding author:

Dr Vikas Menon
Email: drvmenon@gmail.com ORCiD ID: 0000-0001-8035-4658

Subsequently, a credible body of evidence has established common biological underpinnings between depression, somatization, and specific symptom syndromes such as chronic fatigue syndrome.[3–5] This has led to some authors rechristening the term psychosomatic disorder as a “physio-somatic” disorder.[6] These observations are strengthened by clinical observations of frequent co-morbidity and symptom overlap between depression and somatoform disorders; the common underpinning mechanism here may be immune-inflammatory challenges and perturbations.[1]

Traditionally, the origins of somatoform disorder have been attributed to a combination of cognitive and environmental factors; these include adverse childhood experiences [7], and cognitive misinterpretation or cata- strophizing of symptoms.[8] However, it is increasingly becoming clear that physiological aberrations may drive, or at least augment, the non-specific symptoms in somatoform disorders. Insights from cognitive neural

science such as somatosensory amplification and psycho- neuroimmunological perspectives are now recognized as key to answering questions such as why some people develop unexplained somatic symptoms and why some ‘amplify’ or ‘catastrophize’ their symptoms more than others.[9,10]

Against this background, we sought to provide an overview of the major evidence based immune- inflammatory pathways implicated in the pathobiology of somatoform disorders. We do not aim to provide an exhaustive coverage of immune-inflammatory aberrations in somatoform disorders; instead, what we focus on is the mechanistic pathways that may link inflammation and somatoform disorders. The goal of the review was to improve our understanding of biological basis of somatoform disorders which may potentially identify novel treatment targets to ameliorate somatic symptoms and resultant distress.

METHODS

We performed an electronic search of MEDLINE through PubMed and Google scholar databases till April 2020 to identify relevant articles on inflammation and somatoform disorders. We used random combination of the following MeSH or free text terms for PubMed search;somatoform disorder*, somatization disorder, medically unexplained syndrome, hypochondriasis, somatic symptom disorder, illness anxiety disorder, Briquet syndrome, pain disorder, inflammation, neurogenic inflammation, inflammation mediators, cellular immunity, humoral immunity. Additionally, the reference list of the articles generated were hand searched to identify additional studies.

We included English language articles published in peer reviewed journals. Articles were included, regardless of their type (original article, reviews, editorials, and commentaries), as long as they discussed the biological basis of the association between inflammation and somatoform disorders. Based on these criteria, a total of 19 articles were included in the present review. Since this was a narrative overview of the topic of interest, we neither computed effect estimates nor performed a risk of bias assessment of included studies.

We examined the full text of the studies shortlisted for inclusion to identify the relevant mechanistic links or pathways discussed therein. The biological links mainly

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included three distinct, yet, inter-connected mechanistic pathways; cell-mediated immune activation and resultant inflammation, stimulation of TRYCAT (tryptophan catabolite) pathway, and triggering of oxidative/nitrosative stress pathways. Accordingly, the results are discussed under these headings.

RESULTS

Contribution of TRYCAT pathway

Normally, dietary tryptophan is metabolized chiefly via two pathways; by the smaller pathway into serotonin and melatonin (key for mood regulation) and by the larger TRYCAT pathway, sequentially, into multiple neuroregulatory compounds such as kynurenine, kynurenic acid, quinolinic acid, and nicotinamide. The latter pathway is preferentially activated during systemic inflammation and consequent activation of indoleamine 2,3 dioxygenase (IDO) or tryptophan 2,3 dioxygenase (TDO).[11]

This activation of the TRYCAT pathway is germane to the genesis of somatization symptoms. The Kyn/KYNA as well as the Kyn/tryptophan ratios, crucial to determining the net neuroregulatory effects, are increased in somatization compared to depression and healthy controls. Further, plasma tryptophan and kynurenic acid, which has neuroprotective as well as anti-nociceptive effects, is decreased in somatization compared to depression.[12,13] These data support notions of perturbations in the TRYCAT pathway in somatization disorder and that these perturbations are qualitatively different from what is observed in depression.[11,12]

TRYCAT activation, together with tryptophan depletion, has been linked particularly to the onset of pain and fatigue. The depletion of tryptophan has been linked to the resurgence of depressive symptoms in remitted individuals.[14] Simultaneously, it has also been associated with nociceptive effects in a wide range of medical conditions. Increased Kyn/KYNA ratio, a representing TRYCAT activation, impacts nociception in two ways. Whereas Kyn enhances pain and gut motility (which may also lead to IBS-like symptoms), KYNA has anti-nociceptive effects exerted through NMDAR antagonism and G-protein couple receptor 35 activations. These processes are further accentuated by systemic inflammation which sensitizes NMDAR as well as activates the IDO pathway which in turn increases

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Menon et al. : Inflammation in somatoform disorders

TRYCAT products, such as kynurenine/quinolinic acid with “depressogenic/somatogenic” potential.

Indeed, increased IDO activity and resultantly decreased serotonergic functioning has been associated with altered gut motility and increased pain sensitivity, both of which are cardinal symptoms of irritable bowel syndrome.[15] The female preponderance of somatoform disorders could be due to increased IDO responsiveness.[16,17]

Cell-Mediated Immune Activation and Inflammation

Systemic inflammation may also underlie the wide- ranging sleep disturbances noted in fibromyalgia and chronic fatigue syndrome. Sleep and systemic inflam- mation seem to share a reciprocal relationship with a decrease in sleep leading to elevations in pro-inflammatory cytokines, which further impairs sleep time. Cytokine alterations may also impair normal sleep physiology and architecture, altering normal NREM and REM durations. Sleep disturbances may also cause fatigue and malaise, both central to sickness syndrome. Thus, immune activation and inflammation may underpin key somatic symptoms such as pain, sleep, and fatigue [18].

Somatosensory amplification

Findings from animal studies suggest that exogenously administered cytokines can result in a heightened nociceptive experience induced by a peripheral stimulus. This suggests that peripheral pain sensations can be amplified in the brain, consequent to cytokine-dependent sensitization.[10] A plethora of studies have consistently demonstrated increased levels of systemic and central inflammation in depression, another condition with heightened pain experience. But few studies have examined this issue in somatoform conditions [19].

In this regard, using a case-control design, Euteneuer and others reported a novel finding of elevated levels of neopterin in people with somatization syndromes compared to healthy controls as well as major depression. Neopterin is a pteridine compound, known to be produced by monocytes activated by IFN-y, a known pro-inflammatory cytokine. Consequently, neopterin is an indirect marker of IFN-y activity. Persistent elevations of IFN-y stimulate dorsal horn neurons in the spinal cord, thus amplifying bodily sensations through central

48

sensitization. Increased IFN-y can also enhance pain perception by downstream effects such as IDO and TRYCAT activation, which alters kyn/KYNA ratio and heightens pain experience as explained in the preceding section [20].

These immune-inflammatory pathways are part of a larger, integrated stress response matrix in the body that also involves the hypothalamo-pituitary-adrenal axis and autonomic nervous systems that underpin normal brain and body responses to different types of stress such as pain, arousal, emotional or psychological trauma. The stress system model of FND emphasizes the sensitization effects of early life stressors which may prime the brain-body stress system to trigger abnormally exaggerated responses to subsequent life stressors [21]. During this process, aberrant functional connectivity between the components of the stress response matrix may provide a biological substrate for amplification of normal body sensations, provoking distress, and impairment. Very few studies, though, have systematically examined this proposition [22].

The above mechanisms provide a neurobiological basis for the somatosensory amplification model of Barsky and colleagues, a popular approach employed in traditional CBT models for somatization [23]. However, it also legitimately questions the current taxonomical position of somatoform disorders, traditionally understood as physical symptoms in the “absence” of a corresponding medical basis.

Role of oxidative/nitrosative pathways

Normally, there is a balance in the body between stress- induced free radicals and anti-oxidant compounds that prevents oxidative stress and damage. Following stress, the resultant inflammatory pathway cascade produces an outpouring of reactive oxygen radicals; such as peroxides and superoxides. Owing to the direct cellular damage they induce via lipid peroxidation, such pathways may be pertinent to the genesis of physical symptoms such as muscular fatigue and pain [24,25].

Indeed, there is now credible evidence for increased oxidative stress in chronic fatigue syndrome. However, the exact mechanisms linking oxidative damage to specific physical symptoms, such as fatigue, in other words, a pathway phenotype is less clear. Researchers have

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Menon et al. : Inflammation in somatoform disorders

proposed an exaggerated IgM response against fatty acids and markers of oxidative stress in the muscular system such as malondialdehyde which may be central to muscle fatigue. Vindicating the role of oxidative stress further, studies have found that muscular fatigue can be delayed in exercising individuals by pre-medicating with N-acetyl cysteine, a known anti-oxidant compound [26].

Other mechanisms proposed include IgM and IgG- mediated autoimmune reactions that target neuro- transmitters such as serotonin. Increased serotonin auto- immunity is closely tied to cytokine-mediated immune activation as well as triggering of the TRYCAT pathway, leading to further depletion of serotonin. This may have implications for pain perception. In two related case- control studies, the authors found evidence for nitrosative stress in chronic fatigue syndrome and postulated that it may be a common biological pathway that explains the clinical overlap between CFS and MDD. Specifically, the authors found evidence for IgM mediated immune response against proteins which then undergo chemical modification and become immunogenic on account of nitrosative and oxidative damage. The neoepitopes generated during this process of protein modification may trigger an IgM response [27,28].

Evidence for disrupted oxidative balance with net oxidant stress has also been shown in a case-control study of subjects with DSM-5 defined somatic symptom disorder. Interestingly, the authors noted that their findings may not fully reflect brain oxidant status as only serum samples were studied and recommend cerebrospinal fluid- based studies in the future [24].

Put together, there is emerging evidence for oxidative and nitrosative stress in somatoform disorders which must be considered preliminary due to the limited literature. Unanswered questions that may be worth further investigation are whether it is possible to delineate oxidative stress biomarker signatures for different subtypes of somatoform disorders, use these markers as a predictor of treatment response and whether and to what extent there is a role for antioxidants in the treatment of somatoform disorders [28].

CONCLUSION

Signalling of peripheral and central immune-inflammatory

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pathways, in response to different types of stressors, may underlie a host of somatic symptoms such as pain, fatigue and insomnia commonly seen in somatoform disorders. The immune-inflammatory pathways described above are a result of cross-sectional studies in patients with somatoform disorders and hence, longitudinal studies are needed for better understanding and to delineate the complex interplay between the three mechanistic pathways which will foster novel therapeutic targets for the treatment of this difficult to treat the disorder.

REFERENCES

1. Rief W, Hennings A, Riemer S, Euteneuer F. Psychobiological differences between depression and somatization. J Psychosom Res. 2010 May;68(5):495–502.

2. Krause D, Stapf TM, Kirnich VB, Hennings A, Riemer S, Chrobok A, et al. Stability of Cellular Immune Parameters over 12 Weeks in Patients with Major Depression or Somatoform Disorder and in Healthy Controls. Neuroimmunomodulation. 2018;25(1):7–17.

3. Kuppili PP, Selvakumar N, Menon V. Sickness Behavior and Seasonal Affective Disorder: An Immunological Perspective of Depression. Indian J Psychol Med. 2018;40(3):266–8.

4. Lee C-H, Giuliani F. The Role of Inflammation in Depression and Fatigue. Front Immunol [Internet]. 2019 Jul 19 [cited 2020 Nov 14];10. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC6658985/

5. Pedraz-Petrozzi B, Neumann E, Sammer G. Pro-inflammatory markers and fatigue in patients with depression: A case-control study. Sci Rep. 2020 Jun 11;10(1):9494.

6. Anderson G, Berk M, Maes M. Biological phenotypes underpin the physio-somatic symptoms of somatization, depression, and chronic fatigue syndrome. Acta Psychiatr Scand. 2014 Feb;129(2):83–97.

7. Hotopf M. Childhood experience of illness as a risk factor for medically unexplained symptoms. Scand J Psychol. 2002;43(2):139– 46.

8. Hiller W, Rief W, Brähler E. Somatization in the population: from mild bodily misperceptions to disabling symptoms. Soc Psychiatry Psychiatr Epidemiol. 2006 Sep;41(9):704–12.

9. Barsky AJ, Wyshak G, Klerman GL. The somatosensory amplification scale and its relationship to hypochondriasis. J Psychiatr Res. 1990;24(4):323–34.

10. Dimsdale JE, Dantzer R. A Biological Substrate for Somatoform Disorders: Importance of Pathophysiology: Psychosom Med. 2007 Nov;69(9):850–4.

11. Anderson G, Maes M, Berk M. Inflammation-Related Disorders in the Tryptophan Catabolite Pathway in Depression and Somatization. In: Advances in Protein Chemistry and Structural Biology [Internet]. Elsevier; 2012 [cited 2020 Nov 5]. p. 27–48. Available from: https:/ /linkinghub.elsevier.com/retrieve/pii/B9780123983145000027.

12. Maes M, Galecki P, Verkerk R, Rief W. Somatization, but not depression, is characterized by disorders in the tryptophan catabolite E (TRYCAT) pathway, indicating increased indoleamine 2,3-dioxygenase and lowered U S kynurenine aminotransferase activity. 2011;10.

13. Maes M, Rief W. Diagnostic classifications in depression and

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somatization should include biomarkers, such as disorders in the tryptophan catabolite (TRYCAT) pathway. Psychiatry Res. 2012 Apr;196(2–3):243–9.

14. Booij L, Van der Does W, Benkelfat C, Bremner JD, Cowen PJ, Fava M, et al. Predictors of mood response to acute tryptophan depletion. A reanalysis. Neuropsychopharmacol Off Publ Am Coll Neuropsychopharmacol. 2002 Nov;27(5):852–61.

15. Grover M, Camilleri M. Effects on gastrointestinal functions and symptoms of serotonergic psychoactive agents used in functional gastrointestinal diseases. J Gastroenterol. 2013 Feb;48(2):177–81.

16. Maes M, Leonard BE, Myint AM, Kubera M, Verkerk R. The new “5- HT” hypothesis of depression: cell-mediated immune activation induces indoleamine 2,3-dioxygenase, which leads to lower plasma tryptophan and an increased synthesis of detrimental tryptophan catabolites (TRYCATs), both of which contribute to the onset of depression. Prog Neuropsychopharmacol Biol Psychiatry. 2011 Apr 29;35(3):702–21.

17. Bonaccorso S, Marino V, Puzella A, Pasquini M, Biondi M, Artini M, et al. Increased depressive ratings in patients with hepatitis C receiving interferon-alpha-based immunotherapy are related to interferon-alpha-induced changes in the serotonergic system. J Clin Psychopharmacol. 2002 Feb;22(1):86–90.

18. Irwin MR. Inflammation at the Intersection of Behavior and Somatic Symptoms. Psychiatr Clin North Am. 2011 Sep;34(3):605–20.

19. Nakao M, Barsky AJ. Clinical application of somatosensory amplification in psychosomatic medicine. Biopsychosoc Med. 2007;1(1):17.

20. Euteneuer F, Schwarz MJ, Hennings A, Riemer S, Stapf T, Selberdinger V, et al. Psychobiological aspects of somatization syndromes: Contributions of inflammatory cytokines and neopterin. Psychiatry Res. 2012 Jan;195(1–2):60–5.

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Kozlowska K. A stress-system model for functional neurological symptoms. J Neurol Sci. 2017 Dec;383:151–2.

Perez DL, Barsky AJ, Vago DR, Baslet G, Silbersweig DA. A Neural Circuit Framework for Somatosensory Amplification in Somatoform Disorders. J Neuropsychiatry Clin Neurosci. 2015 Jan;27(1):e40–50.

Barsky AJ, Ahern DK, Bauer MR, Nolido N, Orav EJ. A Randomized Trial of Treatments for High-Utilizing Somatizing Patients. J Gen Intern Med. 2013 Nov;28(11):1396–404.

Kabadayi Sahin E, Caykoylu A, Senat A, Erel O. A comprehensive study of oxidative stress in patients with somatic symptom disorder. Acta Neuropsychiatr. 2018 Dec 18;1–6.

Bagis S, Tamer L, Sahin G, Bilgin R, Guler H, Ercan B, et al. Free radicals and antioxidants in primary fibromyalgia: an oxidative stress disorder? Rheumatol Int. 2005 Apr 1;25(3):188–90.

Medved I, Brown MJ, Bjorksten AR, Murphy KT, Petersen AC, Sostaric S, et al. N-acetylcysteine enhances muscle cysteine and glutathione availability and attenuates fatigue during prolonged exercise in endurance-trained individuals. J Appl Physiol Bethesda Md 1985. 2004 Oct;97(4):1477–85.

Maes M, Mihaylova I, Kubera M, Leunis J-C. An IgM-mediated immune response directed against nitro-bovine serum albumin (nitro- BSA) in chronic fatigue syndrome (CFS) and major depression: evidence that nitrosative stress is another factor underpinning the comorbidity between major depression and CFS. Neuro Endocrinol Lett. 2008 Jun;29(3):313–9.

Maes M. Inflammatory and oxidative and nitrosative stress pathways underpinning chronic fatigue, somatization and psychosomatic symptoms: Curr Opin Psychiatry. 2009 Jan;22(1):75–83.

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VIEW POINT

Attributes of Distress Among Healthcare Workers Infected with COVID-19

Sujita Kumar Kar1, Akanksha Shankar2, Sudhir Kumar Verma3, Parul Verma4, Rahul Kumar5, Suyash Dwivedi6, Anand Kumar Maurya7 and Rajnish Kumar8
1Associate Professor, Department of Psychiatry, King George’s Medical University, Lucknow, U.P, India.
E-mail: drsujita@gmail.com

2Junior Resident, Department of Psychiatry, King George’s Medical University, Lucknow, U.P, India. E-mail:akks1420@gmail.com
3Associate Professor, Department of Medicine, King George’s Medical University, Lucknow, U.P, India. E-mail:sudhirkgmu@gmail.com

4Associate Professor, Department of Dermatology, Venerology and Leprosy, King George’s Medical University, Lucknow, U.P, India. E-mail: parulverma6@gmail.com
5Additional Professor, Department of Pharmacology, King George’s Medical University, Lucknow, U.P, India.
E-mail: rahulkgmu@gmail.com

6Senior Resident, Department of Psychiatry, King George’s Medical University, Lucknow, U.P, India. E-mail: suyash.dwivedi19@gmail.com
7Junior Resident, Department of Pharmacology, King George’s Medical University, Lucknow, U.P, India. E-mail: dranand150@gmail.com

8Junior Resident, Department of Orthopedics, King George’s Medical University, Lucknow, U.P, India.

E-mail: rajnishkmr214@gmail.com

Over the past year, the world has witnessed the devastating effect of COVID-19. As of by 5th January 2021, a total of 84,233,579 confirmed cases and 1,843,293 confirmed deaths had been reported globally, with a mortality rate of 2.188% [1]. As per an earlier report (by the first week of May 2020), more than 90,000 healthcare workers (HCWs) are infected with COVID-19 globally [2]. As the pandemic progressed, there is exponential increase in the number COVID infected HCWs, globally. By the first week of September 2020, only the American region accounted for 570,000 COVID infected HCWs with 2500 deaths among HCWs [3]. It indicated that the global figure of COVID infected HCWs to be huge by this time.

There is no central registry in India that documents the number of healthcare workers infected or died because of COVID-19 [4]. As there is a substantial increase in several COVID-19 cases and a more significant number of HCWs are involved in care, the number of infected HCWs is expected to rise, leading to a more significant mortality rate among HCWs [2]. Due to poor reporting

Corresponding author: Dr. Akanksha Shankar E-mail: akks1420@gmail.com

and limited coverage of testing, the data reported in official portals reflect the tip of the iceberg [2,5]. Research data from the Netherlands report that nearly 1% of the HCWs involved in COVID-care are found to be COVID positive [6]. Of these infected individuals, only 3% had a history of contact with COVID-19 patients. However, the scene is expected to be drastically different if the infection rate is evaluated among the HCWs in developing countries with limited resources involved in the direct care of COVID-19 patients.

The World Health Organization (WHO) had appealed to all the governments, organizations, agencies, and the global community to adopt appropriate cautionary measures for the utmost safety and protection of HCWs [5]. Stress and burnout levels among healthcare workers were high before the pandemic, which has further increased due to obvious reasons. During the COVID- 19 pandemic, HCWs involved in COVID patients’ care face stigma, discrimination, violence, psychological trauma, physical exhaustion, and burnout [5]. The challenges faced by the HCWs infected with COVID- 19 are enormous. Physical health issues are objective and easily identifiable, but mental health issues are often subjective and remain under-evaluated. A recent syste- matic review and meta-analysis revealed that the HCWs

 

Kar et al. : Attributes of distress among healthcare workers infected with COVID-19

Figure 1: Attributes to distress among HCWs dealing with COVID-19 patients

Figure 2: Word cloud showing the characteristics of an HCW to combat distress during COVID-19

 

undergo significantly higher psychological distress than the general population in the context of COVID-19 [7].Evidence support that HCWs during this COVID-19 pandemic experience – stress, anxiety, depression, adjustment disorder, moral injury, acute stress reaction, post-traumatic stress disorder, burnout, somatic symptoms, and sleep disturbances [7-11]. Negative impacts were increased by the perceived stigma of family members and the community. Incidences like asking doctors and HCWs to vacate their homes and not allowing them to step in their own apartment, considering them to be the carrier of infection, further increased the stress level despite taking all the precautions during their duties [12]. Various challenges met by the HCWs, attribute to distress (Figure 1).

Experiencing guilt, fear of transmitting infections to closed ones, and anticipating feared consequences are potential attributes to distress in HCWs 10. During this pandemic, it is vital that the HCWs understand what stress seems like, take the initiative to enhance their resilience and cope with stress, and know where to go if they needed support13.

To combat the distress related to healthcare delivery during the COVID-19 pandemic, the HCWs should be self- sustainable. Various characteristics in an HCW (as shown in figure 2) may improve the self-sustainability. Among the contrasting socio-cultural environment, coping mecha-

52

nisms differed and tended to vary among doctors, nurses, and other HCWs14. While we cannot fully alleviate stress in the healthcare community, environmental modifications can improve working practice15. The HCWs involved in COVID-care have the right to avail several occupational healthcare benefits like – appropriate treatment service, rehabilitation, insurance, honorarium, and compensation 5. The commitments and sacrifice of the HCWs during this healthcare crisis should not be ignored. Addressing the mental healthcare needs of HCWs engaged in COVID-care and those infected with COVID-19 is highly essential. It will help in motivating the HCWs to continue their uninterrupted and self-less service.

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WHO. WHO Coronavirus Disease (COVID-19) Dashboard, https:// covid19.who.int (2021, accessed 5 January 2021).

Reuters. Over 90,000 health workers infected with COVID-19 worldwide Read more at: The Economic Times, 5 June 2020, https:// economictimes.indiatimes.com/news/international/world-news/over- 90000-health-workers-infected-with-covid-19-worldwide/articleshow/ 75578439.cms?utm_source=contentofinterest&utm_medium=text&utm_ campaign=cppst (5 June 2020, accessed 19 July 2020).

PAHO. COVID-19 has infected some 570,000 health workers and killed 2,500 in the Americas, PAHO Director says, https://www.paho.org/ en/news/2-9-2020-covid-19-has-infected-some-570000-health-workers- and-killed-2500-americas-paho (2020, accessed 1 May 2021).

PTI. No Central Data on Health Workers Who Died, Tested Positive During COVID Duty: Govt. The Wire, 19 September 2020, https:// thewire.in/government/centre-data-health-workers-died-infected-covid-19 (19 September 2020, accessed 10 January 2020).

World Health Organization. WHO calls for healthy, safe and decent

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Kar et al. : Attributes of distress among healthcare workers infected with COVID-19

working conditions for all health workers, amidst COVID-19 pandemic, https://www.who.int/news-room/detail/28-04-2020-who-calls-for-healthy- safe-and-decent-working-conditions-for-all-health-workers-amidst-covid- 19-pandemic (2020, accessed 19 July 2020).

6. Bergh MFQK den, Buiting AGM, Pas SD, et al. Prevalence and Clinical Presentation of Health Care Workers With Symptoms of Coronavirus Disease 2019 in 2 Dutch Hospitals During an Early Phase of the Pandemic. JAMA Netw Open 2020; 3: e209673–e209673.

7. Luo M, Guo L, Yu M, et al. The psychological and mental impact of coronavirus disease 2019 (COVID-19) on medical staff and general public – A systematic review and meta-analysis. Psychiatry Res 2020; 291: 113190.

8. Barello S, Palamenghi L, Graffigna G. Burnout and somatic symptoms among frontline healthcare professionals at the peak of the Italian COVID-19 pandemic. Psychiatry Res 2020; 290: 113129.

9. Greenberg N, Docherty M, Gnanapragasam S, et al. Managing mental health challenges faced by healthcare workers during covid-19 pandemic. BMJ; 368. Epub ahead of print 26 March 2020. DOI: 10.1136/bmj.m1211.

10. Walton M, Murray E, Christian MD. Mental health care for medical staff and affiliated healthcare workers during the COVID-19 pandemic. Eur Heart J Acute Cardiovasc Care 2020; 9: 241–247.

11. Yang L, Yin J, Wang D, et al. Urgent need to develop evidence- based self-help interventions for mental health of healthcare workers in COVID-19 pandemic. Psychol Med 2020; 1–2.

12. Sharma NC. Doctors, nurses face stigma over coronavirus, asked to vacate rented homes. mint, https://www.livemint.com/news/india/ doctors-nurses-face-stigma-over-coronavirus-asked-to-vacate-rented- homes-11585074366997.html (2020, accessed 27 December 2020).

13. CDC. Coronavirus Disease 2019 (COVID-19). Centers for Disease Control and Prevention, https://www.cdc.gov/coronavirus/2019-ncov/ hcp/mental-health-healthcare.html (2020, accessed 27 December 2020).

14. Cabarkapa S, Nadjidai SE, Murgier J, et al. The psychological impact of COVID-19 and other viral epidemics on frontline healthcare workers and ways to address it: A rapid systematic review. Brain BehavImmun – Health 2020; 8: 100144.

15. Markovitz S. Six Design Strategies To Reduce Healthcare Worker Stress During The Coronavirus Pandemic. Forbes, https:// http://www.forbes.com/sites/coronavirusfrontlines/2020/07/08/six-design- strategies-to-reduce-healthcare-worker-stress-during-the-coronavirus- pandemic/ (accessed 27 December 2020).

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53

VIEW POINT

Choosing and Publishing A Research Project

Yasodha Maheshi Rohanachandra1, Raviteja Innamuri2, Amit Singh3, Anoop. G4, Guru S Gowda5, Harita Mathur6, Jayant Mahadevan7, Lochana Samarasinghe8, Naga V S S Gorthi9, Pratikchya Tulachan10, Rajesh Shrestha11, Rajitha Dinushini Marcellin12, Samindi T. Samarawickrama13, Shanali Iresha Mallawaarachchi14 and Shreeram Upadhyaya15, Shreeram Upadhyay16 and Sharad Philip 16

1Senior Lecturer, Department of Psychiatry, University of Sri Jayewardenepura, Sri Lanka, yasodha@sjp.ac.lk
2Assistant Professor, Department of Psychiatry, Christian Medical College, Vellore, India, drravitejainnamuri@gmail.com 3Assistant Professor, Department of Psychiatry, King George’s Medical University, Lucknow, U. P. 4AssistantSurgeon,KeralaGovernmentHealthServices,CommunityHealthCentre,Arookutty, dranoopg@gmail.com 5Assistant Professor, National Institute of Mental Health And Neuro Sciences, Bengaluru, India, drgsgowda@gmail.com 6SeniorResident,V.M.M.CandSafdarjungHospital, haritamathur@gmail.com
7Assistant Professor of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, India jayantmahadevan@gmail.com
8Senior registrar in Psychiatry, North Western Mental Health, The Royal Melbourne Hospital, Australia, lnpsamarasinghe@gmail.com
9 Psychiatry fellowship doctor, old age psychiatry liaison team, Cumbria, Northumberland Tyne and Wear NHS foundation trust, Newcastle , nvsaisudhagorthi@gmail.com 10AssociateProfessor,MaharajgunjMedicalCampus,InstituteofMedicine,Nepal, prats38@gmail.com
11Lecturer, Department of Psychiatry and Mental Health, Lumbini Medical College and Teaching Hospital(LMCTH), KathmanduUniversity(K.U),Nepal, rajesh694111@gmail.com
12Consultant Psychiatrist, National Institute of Mental Health, Sri Lanka, rajithadinushini@yahoo.co.in
13Senior Registrar in Child and Adolescent Psychiatry, Lady Ridgeway Hospital for Children, Colombo, Sri Lanka samindi1982@gmail.com
14 Senior Registrar in Psychiatry, Ministry of Health Sri Lanka, Sri Lanka, shani2400@yahoo.com
15 Senior Resident, Department of Psychiatry and Mental Health, Institute of Medicine, Tribhuvan University Teaching Hospital, Nepal, upadhyayashreeram@gmail.com
16 Senior Resident in Psychiatry, National Institute of Mental Health And Neuro Sciences [NIMHANS], Bengaluru, India

A B S T R A C T

 

Early Career Psychiatrists (ECP) may need to undertake research as part of their training, institutional expectations or for their academic advancement. Choosing a research project, deciding on the appropriate study design, applying for funding and writing up their findings may all be challenging to an ECP due to inadequate formal training in research and lack of experience. In this article, the authors have examined the relevant literature sources for recommendations and guidelines to choosing and publishing a research project and have added insights and learning gleaned during the ‘Early Career Psychiatrist Leadership and Professional skills workshop’.

Key take away: It is prudent to cautiously explore and experiment with the guidelines and learnings listed here to suit the Early Career Psychiatrist (ECP) style. We believe that these gleanings can benefit other medical professionals with relevant modifications.

Keywords: Early Career Psychiatrist, Early Career Psychiatrist Leadership and Professional skills workshop

Corresponding author:

Dr. Sharad Philip

Email : sharadphilipdr@gmail.com

INTRODUCTION

Rohanachandra et al. : Choosing and publishing a research project
information and the time and effort invested in the study

Research is an important building block for most academic careers. One of the main goals of education in psychiatry should be to encourage individuals in the early stages of their careers to conduct research[1]. Research collabo- ration is vital for an Early Career Psychiatrist (ECP) because it will improve communication, the sharing of competence and production of new scientific knowledge, leading to novel treatment methods and services. Research not only provides a deeper understanding of scientific topics within the specialty, it also helps an individual to develop analytical, conceptual and critical thinking skills that extend beyond the research project itself. Research may also be an expectation of a training program or of a supervisor. Getting experience in research early in training enables ECPs to balance research time as well as clinical work, and might have an impact on their professional choices [2].

Conducting research can be challenging for many ECPs, especially at the start of their career. Research requires time and commitment and the results are often not guaranteed. Training programmes often give priority for clinical teaching rather than research. Previous literature shows that less than one third of residency programmes in Psychiatry offer formal research training and this may even be lower in the Asian region [3]. Thus, young psychiatrists often do not feel competent in carrying out a research projects or getting their work published.

Therefore, in this article, we discuss about how to decide on a research project, how to write a research proposal and how to get your research published, with special focus on how choosing the correct title for your paper can help in publication of your paper. This is based on the proceedings of the Eighth Leadership and Professional Skills Course for Early Career Psychiatrists conducted by the Dr Ramachandra N Moorthy Foundation for Mental Health & Neurological Sciences, Bangalore, at the National Institute of Mental Health and Neuro Sciences (NIMHANS) in January 2020.

DECIDING ON A RESEARCH TOPIC

Deciding on the research question is vital in the final outcome of a study. If the research question is not well-defined, the research is unlikely to provide useful

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would be wasted.

A research question has been defined as “the uncertainty that the investigator wants to resolve by performing a study”. A clinician may encounter several opportunities to develop research questions in their everyday clinical practice [4]. The research question may be based on an observation or a clinical experience. For example, a psychiatrist who has observed that some patients with depression respond better to cognitive behaviour therapy (CBT) than others, may question what factors contribute to the effectiveness of CBT, which may be the basis of a research question. Alternatively, some ECPs may decide to select a research topic for a learning experience, to get experience in an area which they have not been exposed to in the past. Or else, a research question may be identified through a literature review. A literature review may reveal gaps in knowledge in the existing literature. Certain areas may not have been studied or may only have been studied in limited settings. Such gaps in knowledge may serve as an appropriate research question [4]. The discussion section of many scientific articles identifies the current gaps in knowledge in the topic and suggests areas for further research [5]. These can be useful in identifying an appropriate research question. Finally, discussions with colleagues may also provide important insights into possible research areas. It is a good practice to keep a research notebook to write down research questions that you encounter during your clinical practice or while reading research articles. This will aid you in identifying the best research question from a list of possible research areas [6].

Selecting an area that you are interested in is of utmost importance. Research can be time consuming, prolonged and exhausting. Therefore, unless you are enthusiastic about the topic under study, it may be difficult to sustain motivation to complete the research in the long haul.

Another fact that needs to be considered when choosing a research topic is that whether you have time to conduct the research alongside your clinical work. Studies that may take up a lot of your time or those that may need to be done over a long period may not be suitable for an ECP with multiple roles and responsibilities.

If a research project is not published, it might as well

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never have been done, because nobody will know about its results. Therefore, the likelihood of getting published needs to also be considered when choosing a research project. It is suggested that any research question should pass the “so what” test [5]. If the answer to this question is useful, meaningful and has implications for improve- ment of patient care, the research is more likely to be published. A good research topic should be narrowly focused and clearly define and an important part of a broad-ranging complex problem. A young researcher may become over-enthusiastic and try to incorporate too many research questions in a single study, which may make the study less feasible. If the initial research question is broad, it can be broken down into smaller questions [6] which can then be addressed in separate studies. Prior to deciding on a research topic, it is also important to assess your own resources, in terms of both capabilities and time you can dedicate for the research. The opportunity the research will provide for national or international collaboration should also be considered. A research project needing inter disciplinary and international collaboration is likely to provide new scientific knowledge with greater translational impact. Furthermore, the role of research may differ among different institutions and departments. Therefore, it would be wise to be aware of the priority that research takes within your department and the potential for support [5]. Furthermore, the research topic should be harmonious with your supervisors’ wishes and be within the expertise of the supervisor. If not, a co-supervisor maybe needed to fill in the gaps of knowledge [7]. For early career psychiatrists, lack of funding has also been identified as a major barrier in conducting research. Therefore, the opportunities for funding should also be considered when choosing a research project [8]. ECPs may have to choose their topic to correspond with the available funding resources or may need to fund their projects themselves. If self-funding is required, the cost of conducting the research needs to be kept in mind when deciding on the research topic.

The ethical aspects of the study should also be considered when deciding on a research topic. In many resource limited developing countries, there is often no clear distinction between the healthcare provider and the research clinician and patient care is often integrated with clinical research. This may potentially result in subordination of patient care for research, therapeutic misconception and inappropriate inducement [9].

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Therefore, ethical implications of the study should be considered and input from the local ethics committees and institutions should be consulted prior to commence- ment of a research.

The feasibility of finding the study population should also be considered when selecting a research topic. If the study process requires participants to answer long questionnaires, include multiple visits to the hospital or requires participants to undergo numerous investigations, participants are unlikely to consent to be a part of the study [10].

Table 1 – Factors to consider when choosing a topic for your research

●  Area of interest

●  Focused on a prevalent and important problem

●  Yields useful information

●  Provides opportunity for collaboration

●  Narrowly focused

●  Feasible in terms of your time and capabilities

●  Whether multidisciplinary involvement in needed

●  Funding

●  Ethically acceptable

●  Feasibility in finding the study population

●  Publishable

DECIDING ON THE STUDY DESIGN

The research question is the basis of choosing the study design. In other words, the study design should be appropriate to answer the particular research question.

Examining previous literature to identify methods that have previously succeeded answering similar research questions is helpful in deciding the type of study design. The language used in the research question is also helpful in identifying the type of study design. Tully et al has suggested that if a research question starts with “how many” or “how often”, this suggests prevalence or an incidence of a problem is assessed, which suggests that a descriptive epidemiological study design would be

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Rohanachandra et al. : Choosing and publishing a research project

suitable. If the question starts with “why”, this may indicate that a deeper understanding of the topic is needed, which suggests that a qualitative study design would be most applicable. Finally, if the research question aims at answering “what is the impact of a particular experience or intervention”, this indicates that a causal relationship is sought between two variables and a comparative study design is needed [6].

PITCHING FOR FUNDING

With the recent change in research policies there is an increased demand for funding and stiff competition among research and health organizations to obtain funding opportunities. Fundraising for research may be a daunting task for an ECP, due to their limited experience, lack of strong research background and inadequate administrative training. The first step in applying for a research grant is selecting the appropriate research team. If the reviewers feel that the team of researchers does not have the skills or workforce to execute the planned activities, it may lead to rejection of the proposal [11]. Current mental health research policies emphasize the need for higher degree of interdisciplinary and interagency collaboration. Therefore, when choosing your research team, you should ensure that your team of collaborators has the professional experience in the area of the project, leadership skills, networking and management skills needed to execute the planned activities.

Once you have your research team, the next step is searching for available funding options. If your initial research topic does not comply with currently available grant options, you may choose to wait for a further grant opportunity to become available, adapt the project in order to fit current funding requirements, or expand the search for funding options [11].

When preparing the research proposal, it should be done in accordance with the detailed instructions stated by the funding body. Careful reading of such instructions may avoid your funding proposal being rejected for not complying with the donor’s requirements.The proposal should start with giving the background information about the evidence currently available, the current gaps in knowledge and how your research plan to address these gaps. Next, the goals and objectives of the project

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should be clearly stated. This should be followed by a detailed methodology, describing the study participants, study instruments, data collection and analysis. The description of the methods should be in sufficient detail to make the reader understand who (of the team members) is going to do what (project activity) at any given point [11]. References about the study instruments and procedures should be provided where ever appropriate, to demonstrate the scientific soundness of the study. The expected outcomes and results of the project should be highlighted and should correspond to your aims and objectives. The methods of evaluating the project performance should also be stated. Plans to address any drawbacks or unexpected outcomes should also be discussed. The financial aspects have to be carefully considered and a detailed budget and financial plan should be presented. Avoid both overestimation and underesti-mation of finances as it can give the impression that the financial plan is unsound. The plan for dissemination of results as well as benefits of the project to the applicant, the applicant’s institution, participants and the community should be emphasized. Strategies to maintain sustainability of the product should also be included. The roles and responsibilities of each of the team members should be stated. Their professional experience, skilled compe-tencies and previous success with similar projects should be highlighted, to reassure the reviewers that the team members are capable of executing the planned activities. If there is any evidence to support the feasibility of the project (e.g. pilot studies, or previous similar studies done in other settings), they should be included. Finally, the ethical aspects of the research should always be included.

Presentation of the research proposal itself is crucial in deciding whether the proposal will be accepted. First, know your audience. The audience will consist of experts in your field as well as generalists with exposure to your field of study. The ultimate goal of the presentation is to convince the evaluators that your project is worth doing and the team members are capable of carrying it out. Generally, the presenter should change in accordance with the change of the topic being presented. However, changing speakers can distract the audience. Therefore, these shifts should be kept minimal. It is also important for other team members not to interrupt the speaker. The presenter should appear respectful to the reviewers and should present the proposal with emotion and devotion. Once the proposal is presented, be prepared

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to respond to the questions and feedback of the reviewers. Be flexible and modify your proposal incorporating the reviewer feedback and resubmit your proposal.

EFFECTIVE WRITING AND GETTING YOUR PAPER PUBLISHED

Once you have chosen the appropriate journal, the next step is publishing your manuscript. For an article to be published it needs to have good scientific validity as well as being well written. Manuscripts that cover significant, timely and prevalent issues, are well designed, have practical implications and which are well written are more likely to be accepted for publication [12]. If the manuscript fails to make a significant contribution to knowledge, has methodological flaws, outdated literature reviews, inappropriate or incomplete statistics and are difficult to follow, they are more likely to be rejected [13]. While some of the deficiencies can be corrected through the review process, certain deficiencies such as insignificant topics and inappropriate designs are unlikely to be improved.

When writing the manuscript, it is vital to adhere to the author guidelines of the particular journal. The sentences should be kept short, a spell check should be run and for authors whose first language is not English, it is useful to get the manuscript proofread by a native English speaking person [14,15]. Usually, a manuscript will need to be revised several times before it is ready for submission.

The title of the manuscript should be considered carefully, as this will affect how the paper appears on search engines. The tile predicts content and condenses the paper’s content in a few words, reflects the tone or slant of the piece of writing, captures the readers’ attention and helps to differentiate the paper from other papers of the same subject area. Ideally, the title of your manuscript, seen in isolation should give a full yet concise and specific indication of the work reported. A title should be concise but informative and should contain information about the type of study (e.g. clinical trial, case report, meta-analysis etc..) [16], but should not exceed 10-12 words.Care should be taken to ensure that the title does not make more claims than what your paper conveys. The introduction should be brief and should include an explanation why the research question

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is important, the gaps in the current knowledge about the topic and how your study is going to bridge this knowledge gap [16]. The methodology should be clearly described in a way that the study can be easily replicated by another investigator [15]. The results should provide answers to the research question and should parallel the methods section. The results that need to be highlighted can be included as figure or tables, but care should be taken for these not to be a repetition of the text. The discussion should include a recap of your major findings, how these compare with the existing literature, strengths and limi- tations of your study and a strong take home message [16].

Once you have submitted your manuscript your article will be reviewed and you will be informed with a decision. The goal of the reviewers and editors is to improve the quality, readability and credibility of your manuscript. Therefore, you need to take all reviewer comments into consideration when revising your manuscript. Do not be discouraged if your manuscript gets rejected. 70% of the rejected manu- scripts ultimately get published in another journal [17]. Therefore, use the reviewer comments to rewrite the article and submit to alternative journal [16]. Though the process is arduous; patience, persistence, utilization of available resources with guidance of mentors can result in publication, which helps to boost confidence and career of an ECP [18, 19].

CONCLUSION

Research is an inevitable part of an ECP, but formal training and experience in research is lacking in psychiatry training programs. Success of a research starts with choosing the right research topic, which is of an area of interest, feasible, ethical, cost effective and publishable. Funding opportunities may be limited for an ECP and lack of experience may make applying for a research grant challenging for an ECP. Learning the fundamentals of writing and presenting a research grant proposal will improve an ECP’s confidence in applying for research grants. No research is completed without publishing the results. Therefore, skills in effective writing should also be mastered by ECPs.

Acknowledgements: We gratefully acknowledge the Dr Ramachandra N Moorthy Foundation and the Association to Improve Mental health Programs for graciously funding and conducting the 8th Annual

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Rohanachandra et al. : Choosing and publishing a research project

Leadership and Professional Skills for Early Career Psychiatrists workshop from SAARC nations. It was held in Bangalore at the National Institute of Mental Health And Neuro Sciences (NIMHANS) from January 30 to February 1, 2020. We were mentored and taught at the workshop by Prof Norman Sartorius, Prof Mohan K Isaac, Prof Santosh K Chaturvedi and Prof Pratima Murthy, who were assisted by Dr Arun Kandasamy and Dr Krishna Prasad M. We thank Dr Shalini Naik and Dr Chithra K who coordinated the logistics. We also express our heartfelt thanks to the host institution – NIMHANS and its administration for all the facilities extended.

REFERENCES

1. Dellis A, Skolarikos A, Papatsoris AG. Why should I do research? Is it a waste of time? Arab journal of urology. 2014;12(1):68-70.

2. Torous J, Padmanabhan J. Research by residents: obstacles and opportunities. Asian Journal of Psychiatry. 2015;13:81-2.

3. Simmons M, Barrett E, Wilkinson P, Pacherova L. Trainee experiences of Child and Adolescent Psychiatry (CAP) training in Europe: 2010– 2011 survey of the European Federation of Psychiatric Trainees (EFPT) CAP working group. European child & adolescent psychiatry. 2012;21(8):433-42.

4. Macfarlane MD, Kisely S, Loi S, Looi JC, Merry S, Parker S, et al. Getting started in research: Research questions, supervisors and literature reviews. Australasian Psychiatry. 2015;23(1):8-11.

5. Kwiatkowski T, Silverman R. Research fundamentals: II. Choosing and defining a research question. Academic emergency medicine. 1998;5(11):1114-7.

6. Tully MP. Articulating questions, generating hypotheses, and choosing study designs. The Canadian journal of hospital pharmacy.

2014;67(1):31.

7. Cheung G, Friedman SH, Ng L, Cullum S. Supervising trainees in research: what does it take to be a scholarly project supervisor? Australasian Psychiatry. 2018;26(2):214-9.

8. Siskind D, Parker S, Loi S, Looi JC, Macfarlane MD, Merry S, et al. How to survive in research: advice for the novice investigator. Australasian Psychiatry. 2015;23(1):22-4.

9. Laman M, Pomat W, Siba P, Betuela I. Ethical challenges in integrating patient-care with clinical research in a resource-limited setting: perspectives from Papua New Guinea. BMC medical ethics. 2013;14(1):29.

10. Stone P. Deciding upon and refining a research question. Palliative medicine. 2002;16(3):265-7.

11. Fiorillo A, Volpe U, Bhugra D. Psychiatry in Practice: Education, Experience, and Expertise: Oxford University Press; 2016.

12. Bordage G. Reasons reviewers reject and accept manuscripts: the strengths and weaknesses in medical education reports. Academic medicine. 2001;76(9):889-96.

13. McKercher B, Law R, Weber K, Song H, Hsu C. Why referees reject manuscripts. Journal of Hospitality & Tourism Research. 2007;31(4):455- 70.

14. Audisio RA, Stahel RA, Aapro MS, Costa A, Pandey M, Pavlidis N. Successful publishing: How to get your paper accepted. Surgical Oncology. 2009;18(4):350-6.

15. Chernick V. How to get your paper accepted for publication. Paediatric respiratory reviews. 2012;13(2):130-2.

16. Fisher PG, Goodman DM, Long SS. Getting published: A primer on manuscript writing and the editorial process. The Journal of Pediatrics. 2017;185:241-4.

17. Bhargava P, Agrawal G. From the Editor’s Desk: A systematic guide to revising a manuscript. Radiology case reports. 2013;8(1):824.

18. Abramson EL, Paul CR, Petershack J, et al. Conducting Quantitative Medical Education Research: From Design to Dissemination. Acad Pediatr. 2018;18(2):129-139. doi:10.1016/j.acap.2017.10.008

19. Radford DR, Seath RJG, Davda LS, Potts G. Research dissertation to published paper: the journey to a successful publication. Br Dent J. 2020;228(10):791-794. doi:10.1038/s41415-020-1539-1

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ORIGINAL ARTICLE

Sexual Openness and Sexual Dysfunction in Indian Women: A Qualitative Approach

Jyoti Mishra1, Nitin Gupta2 and Shobit Garg3

1MSc, MPhil, PhD, Clinical Psychology, GMCH, Chandigarh 2MD, Consultant Psychiatrist, Chandigarh
3MD, DPM, SGRRM&HS, Uttarakhand

A B S T R A C T

 

Introduction: With regard to sexual divergences, man and woman are different in terms of its openness. Citing continued sexual dominance by male partners and traditional mindset of the Indian society, women barely express their sexual needs (or relationship demands) influencing the overall functioning of the women’s health. So, the present study aims to explore the sexual openness in Indian women via qualitative approach.

Methodology: Qualitative analysis and purposive sampling was used. 5 healthy females (age range of 35- 44 years) who were able to establish a relationship and express her sexual life experiences accompanying their husband (having sexual dysfunction) were included. Focused qualitative assessment via interview was conducted. Subjects were asked to narrate their experiences in four major headings:Participants knowledge of sexuality; sexual relationship between the couple; impact of illness on her and her desire for the sexual relationship.

Results: Qualitative semi-structured interviews were conducted with guiding questions depending upon the written narratives of the participant.Findings of this exploratory study demonstrate that the participants were under significant stress because of their husbands’ sexual problems.

Conclusion: Our qualitative study concludes that sexual issues are prevalent in spouses of males with sexual dysfunction andneeds empathetic evaluation for sexual openness.

Keywords: Sexuality, openness, relationship, society

INTRODUCTION

A healthy and satisfying sex life is an important component of overall wellbeing for a woman. Multiple studies have shown a strong positive association between

Corresponding author:
Dr Shobit Garg
email address: shobit.garg@gmail.com

sexual function and health-related quality of life (1, 2).The World Health Organization (3) defines overall sexual health as “a state of physical, emotional, mental and social well-being in relationship to sexuality; it is not merely the absence of disease, dysfunction or infirmary. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence.”

Mishra et al. : Sexual Openness and sexual dysfunction in Indian Women

On historical analysis of the status of women in India, the role of her is far away of what she desires and everything seems imposed. Husband and wife, though, contributing to the maintenance of the family,have a clear division of labour based on sex. The sex roles of a person consist of the behaviour that is socially defined and expected of that person because of his or her role as a male or female. In India’s male-dominated tradition, the paradigms in myths, rituals, doctrines, and symbols are masculine [4].

Public awareness of male sexual dysfunction has dramatically increased over the past years and changing cultural attitudes fuelled by publicity campaigns. The overall outcome of men with sexual dysfunction depends a lot on participation in treatment of their partners/ spouses. However, psychosexual functioning of female spouses has received scant attention as if it is taboo for a female to open herself up in-terms of sexual relation- ship. Despite this growing attention, the impact of these disorders on the female partner is not well understood [5]. Women in India are still under the table when it comes to sexual openness. So, the aim of the present study is to explore the sexual openness in Indian women via narrative review.

METHODOLOGY Subjects

In the current study, qualitative analysis and purposive sampling was used. The participants in this study included 5 females accompanying their husband who were consulting psychosexual and marital clinic of GMCH-32, Chandigarh. The Inclusion criteria were: being married females (any age), willing to consent to participate, being able to establish a relationship and express her sexual life experiences. The exclusion criteria included: any severe medical and psychiatric morbidity [General Health Questionnaire (GHQ-12 <3)].

Procedure

Data collection consisted of a focused qualitative assessment and interview. The female participants (wives of males having sexual dysfunction consulting the marital psychosexual clinic of GMCH-32, Chandigarh) were screened out with the help of General Health Questionnaire (GHQ-12). And were subsequently selected for the

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qualitative study. Out of 5 participants 1 data was collected via email as the participant was not living in Chandigarh but had consulted in GMCH-32 before. The socio-demographic details were detailed followed by noting of their written narratives. They were told to write their experiences in four major headings: Participants knowledge of sexuality; sexual relationshipbetween the couple; impact of illness on her and her desire for the sexual relationship.Duration of the assessment varied from 90-120 min, depending on the participants’ interest. The assessment has been completed in one or two sittings.Qualitative semi-structured inter- views were conducted with guiding questions depending upon the written narratives of the participant. Then the narration was analysed with the help of qualitative analysis.

Data Analysis

Female participants were given four open ended themes. The written sample and qualitative interview (in terms of guided questions from the written sample) were transcribed verbatim.

RESULTS

Socio-demographic characteristics of the participants

A total of five healthy females (wives of patients with sexual dysfunction) participated in the study within the age range of 35-44 years. All the participants were from urban background. Of 5 females 2 were post graduates, 2 graduates and 1 was high school passed. All the participants were married with total duration ranging from 7-21 years of marriage. Of 5 participants; 3 couples were coming from nuclear family and 2 from extended family and all participants were from middle socio-economic status.

Themes

The four broad themes in which the study findings are presented include participant’s knowledge of sexuality; sexual relationship between the couple; impact of illness on her; and her desire for the sexual relationship.

a. Her knowledge of sexuality
Initially the knowledge of sexuality has been explored

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among the female participants.They have been asked to write about what they feel about the term sexuality. Following statements have been taken from the participants.

1. Sexuality means making your partner happy. Ye ladies ke liye abhi bhi mushkil hai zahir karna. Bahot saare mann mein sawal aate hai ki kya shochenge mere bare mein. Khud ke mann mein bhi kai baar aata hai ki mai aisi nahi hu. Mere mann mein aise galat khayal nahi aane chahiye. Aisa nahi hai ki ladies ko initiate nahi karna chahiye bus pata nahi aisa kya hai mann main jo rokta hai. Aisa nahi hai ki iski vajah se mujhe koi problem aati hai per main khush hu (Mrs. R).

2. I feel shy, unable to confront what I want. I believe man should initiate rather than a female. Though sometimes I do initiate but that becomes very difficult. I sometime feel I should not have initiated (Mrs. A).

3. Sexual relationship is an integral part between a husband and a wife. It strengthens the relationship and creates happiness. It requires consent of both the partners. Healthy sexual relationship does not put burden and gives wing to life (Mrs. S.).

4. Ye zindgi ke liye bahot zaruri aur ahem hissa hai. Per jitna ek aadmi iise zahirr kar sakta hai utna ek aurat nahi (Mrs. J).

5. Sexual relationship is not that important but it is more important of how much we share our responsibility (Mrs. D).

b. Sexual relationship between the couple

1. Sexual satisfaction of husband is very important. Isse unka mann khush rehta hai aur humari pariwarik zingdgi bhi khush rehti hai. Unko pasand nahi aata hai jab mai koi aisi jeez karu shararik sambhand ke duaraan jo mai chahti hu. Per shaadi ke itne samay ke baad mujhe ab aadat ho gae hai. Ab koi pareshanni nahi aati (Mrs. S.).

2. We had a very good sexual relationship before his illness. He almost always initiated but I hardly did. It is difficult to express the desire. I usually hide my expression and prefer to have sexual contact in the darkness. I hardly had orgasm in the day time. (Mrs. R)

3. We have a very limited sexual contact. For my husband, it is very important but for me sexual contact should be limited and should not be everything. Because of this reason we frequently had fights. (Mrs. D).

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4. We share a very good sexual relationship. I am very shy in nature but I like when he initiates. (Mrs. A).

5. Meri zindgi ka ye ek ahhem hissa hai. Mai bhi bahot baar shuruwaat karti hu kuyuki mera maanana hai ki pade likhe hone ke baad agar hum ye na smajhe ki hume kya chiye to phirr jeevan ka kya fayada. Mere pati bhi insmein mujhe samjhne mein mera sahyog karte hai. (Mrs. J).

c. Impact of illness on her

1. Our sexual relationship was very healthy before his illness (ED). We used to enjoy and cuddle each other. Our family was a happy family but now he becomes irritable on trivial issues. I wanted to share his feeling of pain but he does not share. Suppose if I try to ask, he does not say anything and goes to sleep by saying I’m tired and does not explain further. I don’t initiate after that (though I always wanted…). Sometimes I feel like have extra-marital affair because I am a human being and also have a desire but my conscience does not allow me to do so (Mrs. S.).

2. Ye tension mai apne aap ke alwa aur kisis se bhi share nahi kar sakti, na hi apni behan se aur na hi apni maa aur friends se. Akhir kya batau, ye koi kehne waali baat thode hi hai. He denies that it is a psychological problem and says “doctors ko nahi pata, kya mai ye jaan ke ker raha hu. We always end up fighting”. I always ask him to share what he is feeling but he hardly does by saying nahi kuch nahi. He now remains irritable and that makes me more irritable (Mrs. A).

3. Inki beemari ka meri zindgi pe bahot jada asar hua hai. Kaafi dukhi aur akela mehsoos karti hu. Oer main haar nahi maani aur inke illaz ki koshish ki aur inhe motivate bhi kia hai maine. Per bahot baar mujhe khaalipan lagta hai (Mrs. J).

4. It is very frustrating for me. I am unable to focus on my household activities and other family responsibilities. I feel as if I am ill. Because of his problem I am also suffering (Mrs. R).

5. Ismein koi do rai ani hai ki inki bimari ka humari shaadishuda zindgi pe bahot asar hua hai. Ab to umare beech mein jo rishte bannte the vo bhi nahi hota. Iski vajah se kai baar mera maann udaas rehta hai per mai apne aap ko samjha kar baaki kaamo mein apna mann laga leti hu (Mrs. D)

* Dissatisfaction from life (from all the participants).

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Mishra et al. : Sexual Openness and sexual dysfunction in Indian Women

d. Her desire

1. Hope he can share what he feels. It has been told by the doctor that we have to work together to overcome the problem but he does not follow by saying ye practice hum kab tak karenge. Mujhe laqgta nahi hai ki mai thik ho paunga. Vo ye nahi samjhne ki koshish kar rahe hai ki maim kya chahti hu aur mai bol bhi nahi paaati hu. Mann mein khayaal dusra sambandh banane ka bhi karta hai (Mrs. S.).

2. Mai batana chahti hu ki mai kya chahti hu per ye bahot mushkil hai. Aisa nahi hai ki mujhse roka jata hai bus ander se ye awaj nai aati ki mera bhi bolna zaruri hai. Bus mai ye chahti hu ki ye pehle jaise ho jaaye aur jiasa ye karte the waisa hi kare. Jo bhi ye karte hai mujhe acha lagta hai (Mrs. A).

3. In order to talk, I require a space and time. We are most of the time surrounded by our kids and also with in- laws. This also creates frustration in me. Many a times i feel i don’t have life and space to express or be free. I can’t tell this to my husband also as indirectly whenever I tried to say he becomes angry by saying they are my parents (Mrs. R).

4. I want to go out alone with him where no one is there to bother or disturb us ((Mrs. J.).

5. We share a good bond. Hum khush rahe aur apni responsibilities ko ace e nibaye aur pooja path mein apna dyaan laaye. (Mrs. D).

DISCUSSION

This study set out to explore the level of sexual openness in Indian women. The important findings from the study were in terms of what understanding they have by the term sexuality; what kind of relationship they share with their spouse; impact of illness on her and her desire as a female.Findings of this exploratory study demonstrate that the participants were under significant stress because of their husbands’ sexual problems.

On her knowledge of the sexuality: All the participants knowledge were coloured by the environmental factor, where the sexuality means pleasing the male partner and their satisfaction. Knowledge of sexuality in India is mainly affected by various psycho-social factors. Psychological components like performance anxiety, depression; social factors like upbringing, cultural norms and expectations have an important role. Also other

Indian Jounal of clinical Psychiatry

confounding factors are quality of current and past relations and financial stressors [6, 7]. Exploring literature, in a developing country like India, modern Hindu cultures even today contain a general disapproval of the erotic aspect of married life, a disapproval that cannot be disregarded as a mere medieval relic. Many Hindu women, especially those in a higher caste, do not even have a name for their genitals. Though the perception of modern Indian women is transforming, many of them still consider the sexual activity a duty, an experience to be submitted to, often from a fear of abuse [8].

Sexual relationship between the couple: Almost all the participants share healthy sexual relation with the partner except one participant where the religious values and sharing responsibilities was more important than having frequent sexual contact. However, all the statements of the female participants about healthy sexual relation were before the illness of the partner, which has affected their life significantly. Multiple factors contribute to the quality of sexual relationship between the couple and there are number of variables that are correlated to sexual satisfaction [9, 10, 11]. These factors may include personal experiences like how often one reaches orgasm during sex, the experience of the sexual partner like how consistently a partner has an erection during sex, or relationship related aspects of sexuality like how often a couple has sex or how openly sexual matters are discussed [9,12].

Impact of illness: Illness has a significant impact onto the healthy spouses’ mental health.They feel more frustrated when their spouses don’t share what they feel. And also when wives don’t come up with what they want by hiding their emotions. They stated that despite not having any illness they suffer more than their spouses. Spouses of men with erectile dysfunction (ED) have significantly lower levels of marital (and sexual) satisfaction, poor quality of life and higher levels of psychiatric symptoms than controls [13]. Derogatis and colleagues [14] were the first ones to report that female partners of men with a sexual dysfunction had lower sex drive and more restricted sexual activity, as compared to women whose partner did not report sexual dysfunction. Similarly in these circumstances, lower sexual arousal, lubrication and orgasm frequency has also been reported [15].

Her desire: All the participants desired to live a healthy 63

Mishra et al. : Sexual Openness and sexual dysfunction in Indian Women

sexual life. However, they didn’t come up with what REFERENCE they actually want.Studies reported that sexual satis-

faction has been less well studied than sexual function. For most Indian women, sex is primarily about satiating the male desire, towards achievement of the male orgasm. The female orgasm is a mythical concept much like the unicorn. Few men take the effort to pleasure their partners to orgasm – few women dare tell their partners what pleasures them enough to help them climax [5].

Some women may initially report no sexual concerns when first questioned, but if provided with a supportive listening environment, a clearer picture of precipitating and maintaining factors may emerge. For example, one female participant initially reported that her main problem is that she requires longer time during sexual contact. However, on further discussion, she reveals that her male partner is having difficulty maintaining erections, but she is hesitant to discuss what she desires during sexual activity. These issues may be readily amenable to improvement with psycho-educational and psycho- therapeutic interventions or counselling. An important limitation of the study is limited sample size and cross sectional nature of the evaluation.

Future direction

Current study gives us an opportunity to understand how sexual dysfunction affects both the partners.Women might not be talking openly about female sexual desire yet, but they’re taking baby steps towards acknowledging that it exists. A holistic, bio-psychosocial approach is necessary to guide research and clinical care regarding women mental health in this area. Therefore, future research should focus on understanding the changes occurring not only in men suffering from sexual dysfunction but also towards their healthy spouses.

CONCLUSION

Our qualitative study concludes that sexual issues are prevalent in spouses of males with sexual dysfunction and needs empathetic evaluation for sexual openness. Holistic management would help in attenuating marital and sexual related problems.

64

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Biddle AK, West SL, D’Aloisio AA, Wheeler SB, Borisov NN, Thorp J. Hypoactive sexual desire disorder in postmenopausal women: quality of life and health burden. Value Health. 2009 Jul-Aug;12(5):763- 72. doi: 10.1111/j.1524-4733.2008.00483.x. PMID: 19192259.

Ventegodt S. Sex and the quality of life in Denmark. Arch Sex Behav. 1998 Jun;27(3):295-307. doi: 10.1023/a:1018655219133. PMID: 9604118.

World Health Organization, (WHO). Defining sexual health: Report of a technical consultation on sexual health. World Health Organization. Geneva, Switzerland.2006. p. 35.

Mahajan PT, Pimple P, Palsetia D, Dave N, De Sousa A. Indian religious concepts on sexuality and marriage. Indian J Psychiatry. 2013 Jan;55 (Suppl 2):S256-62. doi: 10.4103/0019-5545.105547. PMID: 23858264; PMCID: PMC3705692.

Women’s Web. When Women Dare Not Speak Of Desire. 2013. Extracted from http://www.womensweb.in/articles/talking-about-female- sexual-desire/.

Rosen RC, Barsky JL. Normal sexual response in women. Obstet Gynecol Clin North Am. 2006 Dec;33(4):515-26. doi: 10.1016/ j.ogc.2006.09.005. PMID: 17116497.

Althof SE, Leiblum SR, Chevret-Measson M, Hartmann U, Levine SB, McCabe M, Plaut M, Rodrigues O, Wylie K. Psychological and interpersonal dimensions of sexual function and dysfunction. J Sex Med. 2005 Nov;2(6):793-800. doi: 10.1111/j.1743-6109.2005.00145.x. PMID: 16422804.

Kakar, S. Intimate relations: Exploring Indian sexuality. Chicago, IL: University of Chicago Press. 1989.

Yucel D, Gassanov MA. Exploring actor and partner correlates of sexual satisfaction among married couples. Soc Sci Res. 2010; 39: 725-738.

Stulhofer A, Ferreira LC, Landripet I. Emotional intimacy, sexual desire and sexual satisfaction among partnered heterosexual men. Sex Relatsh Ther, 2014; 29: 229-244.

Schmiedeberg C, Schröder J. Does Sexual Satisfaction Change With Relationship Duration? Arch Sex Behav. 2016 Jan;45(1):99-107. doi: 10.1007/s10508-015-0587-0. Epub 2015 Aug 6. PMID: 26246315.

Theiss J. Modeling Dyadic Effects in the Associations Between Relational Uncertainty, Sexual Communication, and Sexual Satisfaction for Husbands and Wives. Communic Res. 2011; 38: 565-584.

Avasthi A, Grover S, Kaur R, Prakash O, Kulhara P. Impact of nonorganic erectile dysfunction on spouses: a study from India. J Sex Med. 2010 Nov;7(11):3666-74. doi: 10.1111/j.1743- 6109.2009.01647.x. PMID: 20059659.

Derogatis LR, Meyer JK, Gallant BW. Distinction between male and female invested partners in sexual disorders. Am J Psychiatry. 1977 Apr; 134(4): 385-90. doi: 10.1176/ajp.134.4.385. PMID: 842724.

Cayan S, Bozlu M, Canpolat B, Akbay E. The assessment of sexual functions in women with male partners complaining of erectile dysfunction: does treatment of male sexual dysfunction improve female partner’s sexual functions? J Sex Marital Ther. 2004 Oct-Dec; 30(5):333-41. doi: 10.1080/00926230490465091. PMID: 15672601.

Indian Jounal of Clinical Psychiatry

CASE REPORT

Cannabis Induced Psychotic Disorder in Cannabis Withdrawal During COVID- 19 Lockdown : A Case Report

Dhana Ratna Shakya1, Sandesh Raj Upadhaya2

1Professor, Department of Psychiatry, BP Koirala Institute of Health Sciences, Dharan, Nepal

2Junior Resident, Department of Psychiatry, BP Koirala Institute of Health Sciences, Dharan, Nepal

 

A B S T R A C T

In the light of genetic predisposition, cannabis may act as a trigger for psychosis in a predisposed individual who otherwise do not develop psychotic symptoms if he/she abstains from the substance. Usually, cannabis- induced psychosis occurs during heavy use and during intoxication. There are only a few reported cases when psychotic symptoms occurred during cannabis withdrawal state. We report a 20-year-old man who had a brief episode of psychosis upon cannabis withdrawal due to the circumstance arising in the aftermath of COVID-19 lockdown following the regular heavy pattern.

Keywords: Cannabis induced psychotic disorder, COVID-19, lockdown, adult

INTRODUCTION

Cannabis is one of the most widely cultivated, trafficked and abused illicit drugs in the world. [1] The generic term cannabis is used to indicate the several psychoactive preparations of the plant Cannabis sativa with Delta-9- tetrahydrocannabinol (THC) as the major psychoactive ingredient. Smoking cannabis is taken as a pleasant and non-threatening experience for most people as opposed to the people who experience adverse reaction, feeling opposite to that. The feeling of high, pleasure and mystical experience by the user not only depends upon the potency of cannabis, the route of intake, smoking technique and dose but also upon the individual’s personality and the current emotional state before the drug use and previous drug experience. The features/ adverse reaction of substance induced psychosis associated with smoking of cannabis may include: anxiety, fear, tachycardia, dyspnea, crying, suspiciousness, paranoid ideas, dissociation, derealization, delusion and auditory hallucination [2,3]. Cases of induced psychosis

Corresponding author:

Dr. Dhana Ratna Shakya Email : drdhanashakya@yahoo.com

are somewhat reported from the countries where there is long-term access to cannabis of high potency and the episodes of psychosis are referred to as ‘hemp insanity’[2]. Cannabis withdrawal symptoms such as anxiety, irritability, tremor of an outstretched hand, sweating and muscle aches usually begin 10 minutes to 48 hours after its last use and these are brief lasting from several hours up to seven days. [4,5] There have been limited cases of psychosis reported in relation to cannabis withdrawal and studies are lacking to show the relationship between cannabis withdrawal and the onset of psychosis [6].

The government of Nepal decided to impose the lockdown from March 24, 2020, after the slow initial rise of COVID-19 cases [7]. We report a case of excessive use of local Cannabis in an adult male during lockdown due to COVID-19 who later developed the cannabis-induced psychotic disorder upon its withdrawal on account of decreased availability of local cannabis following COVID-19 lockdown.

CASE PRESENTATION

A 20-year-old unmarried Hindu male, from low middle

 

Shakya et al. : Cannabis induced psychotic disorder in cannabis withdrawal during COVID-19 lockdown

socioeconomic status, studied up to secondary edu- cation, working as a bus conductor; with a history of unspecified psychosis (self-muttering behavior, suspi- ciousness and delusion of persecution) in his uncle; with well-adjusted premorbid personality; was brought by his brother to our hospital because of his abnormal behavior at home. As per information collected from his peer circle, he had history of on-off use of Pregastar (Pregabalin 75mg), Decolic Tablet [(Diazepam 2mg) + (Dicyclomine 20mg)] and Spasmo-Proxyvon plus [(Dicyclomine (10mg) + Paracetamol/Acetaminophen (325mg) + Tramadol (50mg)]. A pattern of the use was all the drugs taken 2-3 tablets/day if available, for 4 years. He occasionally used to drink locally distilled alcohol with his friend circle for recreational purposes. He had a history of tobacco use in the form of smoking and Ganja (cannabis) use for the last 4 and 3 years respectively. He had been regularly using tobacco in the form of smoking cigarette 5-10 sticks/day; with intense craving and feeling restless, irritable and difficulty in sleeping if he didn’t smoke. For the last two months, he had increased smoking to 15 sticks per day and could not resort back to previous years.

Prior to the lockdown, for last three years, he used to take marijuana/Ganja in the form of smoking joints, shared among friends 2-3 times per day in 2-3 days gap and 8-9 times during weekends. For the last 3 months, after the lockdown started in March 24, 2020, the patient had been staying at his uncle’s home, frequently going out of the house and meeting his friends. He had been using locally available marijuana in larger amounts in the form of a water gun bong and sticks sharing among the friends. He expressed that he was high (euphoria) most of the time and felt less worried about contracting the virus during the sharing of cannabis. The patient felt that his thoughts were sometimes moving quickly and time was passing very slowly as if he was traveling in another parallel universe. In between, he would also use spasmo-proxyplus and pregabalin which increased to 5- 6 tablets orally due to unavailability of the other drugs. As per the patient, the additive effect of the drug would make him feel less anxious and more craving for cannabis. Due to the Nepal-India border close down, the oral drug was not available for the last 1 month, but, there was an adequate local supply of marijuana to the patient by his peer circle. So, he continued smoking the marijuana. He would feel restless, headache, pain in the abdomen, decrease in appetite and difficulty sleeping;

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and these symptoms would go away after smoking cannabis. He would spend most of the time acquiring cannabis and would feel satisfied only after consuming cannabis in greater amount. As the government imposed more restrictions on movement amid the slow initial rising cases of COVID-19 and stock of cannabis went down, the patient had decreased the amount of marijuana use for the last 5 days before the presentation to the emergency department (E.D.).

After decreasing the use of marijuana, he started appearing irritable, anxious and complaining of headache and decrease in appetite. He started closing the door and staying alone most of the time, moving here and there in his room. He used to express that his activities were being monitored and the camera was kept all around his room. He would frequently run away from the house, expressing that some magic might cast upon him. He had to be locked up at home for 2 days by family members. He was taken by his family members to the local traditional faith healer where appearing irritable, he expressed that he would kill the faith healer with a weapon. His last cannabis use was 3 days prior to the presentation when he was found self- muttering, appearing irritable and suspicious. He would sleep only for 3-4 hours and appear energetic in the morning. There was no abnormal finding on neurological examination. Mental state examination showed anxious, irritable affect, abnormalities in thought content as delusion of reference (being monitored) and delusion of persecution (intruders planning to kill him). Sensorium was intact, judgment was impaired and insight about the illness was absent. As the patient was difficult to control at home, amid lockdown, patient was brought to our emergency department and admitted to the psychiatric ward on July 21, 2020 with a provisional diagnosis based on the ICD- 10, ‘Cannabis dependence with Cannabis induced psychotic disorder, Tobacco Dependence Syndrome, Opioid, Benzodiazepine and Alcohol use’. Differential diagnosis was: Acute and transient psychotic disorder. The patient was tranquilized with haloperidol 10mg and promethazine 50mg injection. A baseline investigation was sent from the E.D. Blood investigation parameters were within normal limits. Neuroimaging was suggested but later deferred due to the patient’s financial condition. The patient was kept on olanzapine 7.5mg/day and lorazepam 4mg/day. The patient reached to premorbid level within 36 hours after admission. There was no referential or paranoid ideation. The patient accepted that these delusions of being monitored and intruders planning to kill him had not been

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Shakya et al. : Cannabis induced psychotic disorder in cannabis withdrawal during COVID-19 lockdown

real and acknowledged these symptoms were due to substance use. Eventually, the drug was tapered off in 4 days and the patient was discharged 7 days post-admission after psychoeducation and motivational interviewing to quit substance. He was abstinent from cannabis and was doing fine in 6 months follow-up.

DISCUSSION

Seen with SARS and now with COVID-19, one of the coping strategies used by an individual to disengage from a stressor is the use of the substance.[8,9] Our patient was also busy obtaining and consuming cannabis; he had used this negative coping strategy to overcome the fear of pandemic. Our patient was using Ganja in the form of smoking joints and bong (water gun) which is obtained from the smaller upper leaves and flowering tops of the female plants. There were features of craving, spending his free time in searching and obtaining cannabis and features of withdrawal (such as: restlessness, headache, abdominal pain, insomnia, decreased appetite) and relief after consuming cannabis in the last three months which fulfills the criteria for dependence as per the ICD-10 for cannabis [5]. A study by D’Souza et.al. showed that the use of cannabis in healthy individuals may produce a wide range of transient psychiatric symptoms including schizophrenia-like positive, negative, and cognitive symptoms, alteration of perception, euphoria and anxiety [10]. A diagnosis of substance-induced psychotic disorder was made as there

are: (a) onset of psychotic symptoms during or within two weeks of substance use; (b) persistence of the psychotic symptoms for more than 48 hours; (c) duration of the disorder not exceeding six months. It shouldn’t be a manifestation of a drug withdrawal state with delirium [5]. Our patient experienced predominantly schizophrenia-like symptoms: the delusion of persecution and delusion of reference with some mood pictures like irritability, decreased need for sleep, increased energy following decreasing the use of cannabis. This pattern of decreased use suggests that the delusion and mood symptoms were linked to this period of cannabis use [11]. Our case had a family history of psychosis in a second-degree relative (uncle) making him genetically vulnerable. In this case; there was a clear temporal relationship of psychotic episode with marijuana use. First, the symptoms developed in the background of prolonged marijuana use and the symptoms appeared after decreasing the amount of marijuana use (during withdrawal state) due to shortage of the supply during lockdown period. Second, the patient’s symptoms resolved completely within 5 days of abstinence of the marijuana and there were no residual psychotic/ mood symptoms noticed after improvement during hospital stay. And, the sensorium was intact in our patient which rules out cannabis withdrawal state with delirium.

The following table can help differentiate between primary psychosis and cannabis-induced psychotic disorder (CIPD). [2,5,12] (Table.1)

Table 1 : Comparison of Cannabis induced psychosis and indipendent psuchosis

Cannabis induced

Independent psychosis

Symptoms appear during or immediately after cannabis use (a substance known to cause)

Symptoms usually appear before substance use

Symptoms resolve after cannabis abstinence

Symptoms persist despite discontinuation of use

Psychotic symptoms fleeting in nature

Symptoms are frank and persistent

Urine toxicology- usually positive

Positive in comorbid cases

Insight about the symptoms and illness- partially present

Insight about the symptoms and illness- partial or usually absent

Trial of antipsychotics may/ may not improve the symptoms

Trial of antipsychotics markedly improves the symptoms

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Shakya et al. : Cannabis induced psychotic disorder in cannabis withdrawal during COVID-19 lockdown

There has been criticism regarding the existence of CIPD as these symptoms are regarded as a sign of underlying psychopathology and difficult to differentiate from schizophrenia. Long term follow-up data regarding existence of cannabis psychosis is lacking and the study regarding same is also inconclusive whether cannabis aggravates or precipitates psychosis in genetically vulnerable individuals. However, critics believe that the use of cannabis can produce psychosis and it is usually short-lived; with complete remission [13]. Sometimes, accurate histories may not be obtainable but a treating physician should be alerted of the possibility of cannabis- induced psychosis during withdrawal in cases resembling acute psychosis-like symptoms. Usually, patients with CIPD are treated on an outpatient basis and those who are admitted also have short hospital stays. Long-term follow-up of such patients is also essential prognostically. The diagnosis of CIPD is entertained not only during acute intoxication but also upon withdrawal which will ensure the timely and appropriate management of the disorder. In the Current COVID-19 pandemic context, substance-related disorders like this might present to the psychiatric service [14].

CONCLUSION

Our case report highlights the fact that cannabis use can trigger psychosis in genetically predisposed healthy individuals even during the withdrawal period with no prior history of mental illness. Careful history and examination are essential to rule out psychotic disorder as the overdiagnosis will lead to overtreatment with antipsychotics and mood stabilizers in such cases. Abstinence from cannabis and long-term follow-up for early intervention if independent disorder occurs in the presence or absence of cannabis is important from a management perspective. The current COVID-19 pandemic might pose various local contextual dynamics in the course of substance use disorders including cannabis.

KEY CLINICAL MESSAGE

We present a case of cannabis dependence, with genetic loading in his second-degree relative, who presented with the psychosis while decreasing the amount of consumption of the cannabis due to unavailability of local cannabis during lockdown following the heavier

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use and the resolution of the psychotic symptoms when he abstained from the substance for five days.

LIST OF ABBREVIATIONS

CIPD : Cannabis Induced Psychotic Disorder ICD : International Classification of Disease WHO : World Health Organization

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Indian Jounal of Clinical Psychiatry

CASE REPORT

COVID-19 : Depression & Psychogenic Erectile Dysfunction

Raghav Gupta1, Pranahith Reddy2 and Kishore M.3

1Psychiatry Resident, JSS Medical College And Hospital , Mysuru, Email id- raghavrajindergupta14@gmail.com 2 Psychiatry Resident,JSS Medical College And Hospital , Mysuru, Email id- pranahith@gmail.com
3Associate Professor of Psychiatry, JSS Medical College, JSSAHER, Mysuru, Email id- kishorem@jssuni.edu.in

TO THE EDITOR,

COVID19 outbreak is a pandemic and global health emergency that directly impacts the physical and mental health of the global population. Commonly reported mental health problems due to COVID-19 are depression, anxiety, insomnia, loneliness,boredom,avoidance, defence responses, and maladaptive behavior [1]. During the height of the COVID-19 outbreak, overall sexual activity, frequency, and risk behavior declined significantly among men and women in China [2]. Sexual disorders are rarely reported during COVID-19; however, they compromise equally psychosocial health and quality of life. Here, we report Psychogenic Erectile Dysfunction with depression presented during COVID-19 to tertiary care general hospital.

A 31-year-old male, studied up to 10th class, migrant daily wage worker from lower-middle socioeconomic status, married for 18 months, from urban area presented with the chief complaint of difficulty of erection for last six months. Informed consent from the patient was taken, and the patient reported that he was well for nearly one year after marriage. The patient-reported that his married life was alright and his wife was pregnant three months after marriage but had an abortion due to unexplained reason in her eighth month of pregnancy. This event coincided with the lockdown in India in early April 2020. After the abortion, they continued sexual intercourse, but the patient initially had a decrease in interest along with erection difficulty. Problem with erection, the frequency increased progres-sively and worsened during the lockdown period. The patient lost his work in the meantime. After losing work due to the COVID-19 pandemic, the patient complained of stress, staying idle at home throughout the day with the family’s financial crisis, leading to a loss of interest in daily

Corresponding author:

Dr Kishor M
Email : kishorm@jssuni.edu.in, Ph.: 9686712210

activities. Even when he had a desire for sexual intercourse, he had erection difficulty. The patient tried using sildenafil citrate from the chemist shop without any consultation, but symptoms persisted. The patient developed a feeling of guilt and sadness. He began to feel tired and fatigued whenever he tried to have sexual intercourse, and fatigue persisted even on the next day. Sleep and appetite were normal. Spouse corroborated history. On physical & genital examination, no abnormalities were detected.The patient was investigated; a complete blood count and lipid profile was done, which came out to be normal. The patient had a high score on the HAM-D (Hamilton Rating Scale for Depression). The patient was diagnosed with Psychogenic Erectile dysfunction with Moderate depression. He was prescribed a Selective Serotonin Reuptake Inhibitor (SSRI) Tab. Sertraline 50 mg once a day. He was educated, and supportive psychotherapy was given. Follow up was advised. He reported significant improvement after 15 days.

This case has to be understood based on the complex interaction of COVID-19 pandemic, depression, and Erectile Dysfunction. Erection in males has physiological and psychological aspects responding to emotional stimuli controlled by the brain’s limbic system. Erectile Dysfunction is a recurrent and persistent inability to have/maintaining sufficient penile erection for satis- factory sexual intercourse [3]. Psychiatric illnesses like anxiety, depression, excessive stress, etc., can cause psychogenic erectile dysfunction where an imbalance in neurotransmitters like noradrenalin is involved [4]. COVID 19 pandemic has also played a significant role in causing severe stress in individuals beyond health and economic factors, further affecting sexual wellbeing and intimacy among couples. Social isolation and the fear of getting COVID-19 infection have greatly affected relationships and couples living separately for various reasons. During COVID-19 lockdown, increased stress was recorded with frequent interpersonal conflicts, hostility, poor communication, impatience, lack of privacy, and negative perceptions, further affecting the wife-husband relationship [5].

Gupta et al. : COVID-19: Depression &Psychogenic Erectile Dysfunction

Patients being migrant workers may have faced much uncertainty about changing situations like economic crisis, fear about intimacy, safe sexual practices to prevent transmission of the virus, and misconceptions circulating in social media. Adding to this patient’s wife had a termination of pregnancy due to the fetus’ non-viability, which is a major traumatic event for a young couple causing significant distress. In depression, the patient can develop decreased self-esteem and negative thoughts, leading to decreased libido or performance anxiety, causing a decreased erection. Depression also affects the HPA axis (Hypothalamo-Pituitary-Adrenal), leading to increased catecholamines leading to insufficient cavernosal muscle relaxation. Anxiety further increases the patient’s focus on the firmness of erection leading to self-consciousness and cognitive distraction during the act, and the patient further develops a fear of the next sexual encounters. Sexual dysfunction in one partner affects the couple as a whole, causing significant distress and interpersonal issues, further aggravating the problem.

When erectile dysfunction (ED ) coexists with anxiety and depression, mood disorder treatment should be prioritized. Treating with antidepressants, preferably Selective Serotonin Reuptake Inhibitor (SSRI) and non-

pharmacological management include psychoeducation to the couple, supportive psychotherapy, couple therapy is beneficial [6]. Lifestyle modifications like aerobic activity, weight loss, dietary changes, yoga, meditation, and quittingsubstance use are useful. Maintaining social distance, using a face mask, frequent hand washes while being at work, risk reduction counseling, and safe sexual practices with known partners will help sexual wellbeing during the COVID-19 pandemic.

REFERENCES

1. 2.

3. 4. 5.

6.

Talevi D, Socci V, Carai M, Carnaghi G, et al. Mental health outcomes of the COVID-19 pandemic. RivPsychiatr. 2020;55(3):137-44.

Li W, Li G, Xin C, Wang Y, et al. Challenges in the Practice of Sexual Medicine in time of COVID-19 in China. J Sex Med 2020;17:1225- 1228

Rew KT, Heidelbaugh JJ. Erectile dysfunction. American family physician. 2016;15;94(10):820-7.

Yafi FA, Jenkins L, Albertsen M, Corona G et al. Erectile dysfunction. Nature reviews Disease primers. 2016; 4;2(1):1-20

Lopes GP, Vale FB, Vieira I, da Silva Filho AL et al. COVID-19 and sexuality: reinventing intimacy. Archives of Sexual Behavior. 2020;49(8):2735-8.

Banerjee D, Rao TS. Sexuality, sexual well being, and intimacy during COVID-19 pandemic: An advocacy perspective. Indian journal of psychiatry. 2020;62(4):418.

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ART & MENTAL HEALTH

Art & Mental health : Perspectives of The Mind

Pawan Kumar Gupta1 and Aditya Agarwal2

1Additional Professor, Department of Psychiatry, King George’s Medical University, Lucknow, U.P.

2 Junior Resident, Department of Psychiatry, King George’s Medical University, Lucknow, U.P.

  

Corresponding author:

Dr. Pawan K Gupta
Email : gpawan2008@gmail.com

From a tiny insect crawling through the centre of the image to a humongous bat flapping its wings right through the art, it is our fickle minds that make sense out of what objectively is nothing but colours spread over paper. Made famous by Hermann Rorschach by using it for psychoanalysis, klecksography is the art of creating images out of random inkblots by merely folding the piece of paper[1,2]. The artwork (shown above) uses the same technique, but instead of monochrome, multiple contrasting colours have been used to create a vivid, dream like image. It may just be plain colours for someone, and for someone else, it may be an abstract work of art that takes her to a place of bewilderment, making her ponder over the deeper meaning of life. Forests, venation of leaves, lakes, angel wings, a human in a yoga pose, peacock, caves, seashell, multiple objects, and creatures become visible as our minds put into use its tendency to find meaningful patterns everywhere. As Klaus Conrad termed it, Apophenia is a unique trait in humans that has evolutionarily helped us survive by recognizing danger patterns early on[3].More interestingly, for an observer of human behaviour like us psychiatrists, this provides a perspective of an individual’s hidden self. Almost like a window opening up to an astonishing view of the mind. A view filled with subtle traits of personality, clues into past experiences, and particulars of behaviour. This is where

a psychiatrist’s scientific, structured mind and a free- flowing, fantasizing imagination of an artist come together. A combination that is unusual to see in our very restricted lives, but its amalgamation is what makes us palpate the humanness within us. Art, in all its forms, has played multiple roles throughout human history. A treat to the eyes of the spectator it is. A key to unlock hidden emotions for the painter. For a stressed mind, a therapeutic session for the relief it is. With their different viewpoints, art and psychiatry may although seem a bit far off. It is in paintings like the one shown above; one can notice the point of their submergence. A holy dip into this sea of abstraction can wash away and clean our minds to reveal the real soul of ours.

REFERENCES

Art & Mental health : Perspectives of the mind

1- 2-

3-

Teles RV. Hermann Rorschach: From klecksography to psychiatry. Dement Neuropsychol. 2020;14(1):80-82. doi:10.1590/1980- 57642020dn14-010013

Eschner, K. (2017, November 8). Hermann Rorschach’s Artistic Obsession Led to His Famous Test. Smithsonian Magazine. https:/ /www.smithsonianmag.com/smart-news/hermann-rorschachs-artistic- obsession-led-his-famous-test-180967088/

Ellerby ZW, Tunney RJ. The Effects of Heuristics and Apophenia on Probabilistic Choice. AdvCogn Psychol. 2017;13(4):280-295. Published 2017 Dec 31. doi:10.5709/acp-0228-9

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ABSTRACT

Metabolic derangements with olanzapine and risperidone in schizophrenia spectrum and other psychotic disorders: A prospective 24-week study

Praveen Rikhari1*, Ashutosh Kumar2
1Postgraduate resident (3rd year),2Assistant Professor and Head, Department of Psychiatry, S N Medical College, Agra *Corresponding author : praveenrikhari@gmail.com

BACKGROUND

Metabolic derangements are common with antipsychotic medications leading to increased morbidity and mortality due to diabetes mellitus, stroke, and cardiovascular events in schizophrenia spectrum and other psychotic disorders as these require long term treatment.

AIMS AND OBJECTIVES

We aimed to study the metabolic derangements with olanzapine and risperidone. The prevalence of metabolic syndrome and its predictors were evaluated.

METHODS

A 24-week follow-up study was done at S.N. Medical College, Agra. Patients aged 18-65 years who were antipsychotic free for the prior 3 months and met DSM- 5 criterion for schizophrenia spectrum and other psychotic disorders were enrolled after written informed consent. I.D.F. criteria was used to define metabolic syndrome. Anthropometric measurements and biochemical investigations were done at baseline and 24 weeks. A total of 65 patients were included in the study, and 45 completed the study. Out of these, 30 received olanzapine, and 15 received risperidone.

RESULTS

Statistically significant changes occurred in weight, B.M.I., T.G.s, HDL, systolic, and diastolic blood pressure with both drugs. Waist circumference and fasting plasma glucose were significantly increased only with olanzapine. Comparison between groups revealed significantly greater increase in HDL with olanzapine than risperidone. 9(20%) patients, 7(23.33%) from olanzapine group and 2(13.33%) from risperidone group developed metabolic

syndrome, the difference between them being insignificant. Baseline T.G.s predicted emergent metabolic syndrome.

CONCLUSION

Both olanzapine and risperidone cause metabolic derangements and clinicians should bear this in mind while prescribing.

Correlation of biochemical derange-ments with severity of alcohol use disorder

Akhilesh Kumar Sharma1*, Ashutosh Kumar 2
1Postgraduate resident (3rd year),2Assistant Professor and Head, Department of Psychiatry, S N Medical College, Agra *Corresponding author : akhileshdraks@gmail.com

BACKGROUND

Biochemical derangements are seen commonly in patients of alcohol use. Identification of alcohol use and its impact is an important social and clinical objective for which various biochemical parameters have been utilized -serum enzymes, hematological parameter, and serum protein being predominant.

AIMS AND OBJECTIVES

The aim of our study was to study the biochemical derangements occurring in patients with alcohol use disorder and find out its correlation with the severity of alcohol use disorder.

METHODS

This study was undertaken at S N Medical College, Agra. The patients between the age of 18-60 years who fulfilled the diagnostic criterion for alcohol use disorders according to DSM-5 and without any chronic illness were enrolled in the study after taking written informed consent. The biological parameters were assessed at baseline, and the severity of alcohol dependence was assessed using the SADQ scale.

RESULTS

Statistically significant differences were found between

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the values of hemoglobin, mean corpuscular volume, aspartate aminotransferase(SGOT), alanine aminotrans- ferase (SGPT), gamma glutamyl transferase, total protein and globulin with the severity of alcohol dependence (SADQ score), but not for albumin.

CONCLUSION

We concluded that there is a significant correlation between various biochemical parameters and severity of alcohol dependence (SADQ score).

A comparative study of stress and depressive symptoms among undergraduate medical students of different professionals

Jyoti Prakash1*, Achyut Kumar Pandey2, Amit Singh3, Pankaj Sureka4, Abhinav Pandey5
1Junior resident, 2Professor, Ex Junior resident, 4 Associate Professor, 5Ex Senior residentDepartment of Psychiatry, IMS BHU Varanasi

*Corresponding author:mauryajpgsvm@gmail.com

BACKGROUND

Medical students are exposed to tremendous pressure, leading to stress, depression, and other psychiatric disorder at increasingly higher rates. The stress and depression can affect their learning and leads to poor quality of life. The students of different professional may have differing reasons for being under stress and in depression. Assessing stress and depression in students of different professionals may provide better insights and help policymakers plan appropriate interventions.

AIMS AND OBJECTIVE

This study was conducted to measure and compare the prevalence and severity of stress, various aspects of life affected by stress, and depressive symptoms among medical students of various professional years.

METHODS

A cross-sectional study was conducted from February 2018 to January 2019 on 150 undergraduate medical students (50 each from 1st, 2nd, and 3rd professional Years) of a medical institute in Northern part of India. Mini International Neuropsychiatric Interview (MINI

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version 5) to screen for depression, Student’s Stress Dimension Questionnaire (SSDQ) to assess for stress prevalence and severity and to find the various aspects of life affected by stress and Hamilton depression rating scale (HAM-D) was used to measure the severity of depressive symptoms.Chi-square test and one-way analysis of variance (ANOVA) were used to make the group comparisons.

Results: Overall severe stress and depressive symptoms were present in 66.7% and 52% of the participants respectivly. The three groups also differed significantly in the total score of SSDQ (H=13.664, p<0.000) HAM- D (H=11.352, p<0.000), with first professional students having higher scores than second and third professional students. Domain wise comparison also showed a higher prevalence and severity of impaired domains in first professional students.

Conclusions: Special care must be taken with students admitted to medical schools. Interventions addressing stress and depression should be initiated from the first professional students itself.

Demographic and clinical profiles of patients attending teleconsultation O.P.D. at BRD medical college, Gorakhpur

Deepa Singh1*, Gaurav Yadav 2,Richa Pandey3, Ajeet Chaudhary4, Amil Hayat Khan 5
1,2,3,4Junior resident, 5Associate Professor, Department of Psychiatry, BRD Medical College, UP

*Corresponding author:deepasingh20122017@gmail.com

BACKGROUND

The emergence of the COVID 19 pandemic affected each and every service sector in our country, including the health care delivery sector.

AIMS AND OBJECTIVES

The present study aims to analyze the demographic and clinical profiles of patients attending our teleconsultation O.P.D. over a period of 3 months.

METHODOLOGY

The study was carried out at the psychiatry O.P.D. of Nehru Hospital at BRD Medical College, Gorakhpur,

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UP. All the cases that were registered for the teleconsultation for a period of 3 months (from 01 August 2020 to 31 October 2020) were included in the present study. A total of 404 patients were registered during the period. One hundred and ten patients were either not reachable over phone or referred to other departments for symptoms unrelated to Psychiatry. Thus, a total of 294 patients were included in the present study.

RESULT

Out of 294 patients, 182 patients were male and the rest 112 were female patients. The majority (258) were adults (18 to 60 years), 24 of them were in child and adolescent age group, and rest 12 patients were more than 60 years old. Diagnostic distribution was as follows: 45 patients were of anxiety disorders, 26 patients were Bipolar Affective disorders, and 69 were depressed patients. Sixty-three headache patients were there, and 47 cases were of psychotic patients.

CONCLUSION

The common patients attending teleconsultation services during COVID-19 were adults, males, with mood or

anxiety disorders.

Impact of COVID 19 on psychopathology: A case series study

Rajon Jaishy1*, Mona Srivastava 2
1*Junior resident,2 Professor, Department of Psychiatry, IMS BHU Varanasi
*Corresponding author : rajonjaishylfc@gmail.com

BACKGROUND

COVID19 pandemic is associated with an increase in the number of patients with S.M.I. (severe mental illness) severe mental illness. Previously diagnosed patients with S.M.I. have shown vivid presentation to psychiatric services with symptomatology incorporating coronavirus and COVID related beliefs into thepsychopathology.

AIMS AND OBJECTIVES

To understandand document the impact of the pandemic on the psychopathology of mentally ill individuals.

Indian Jounal of Clinical Psychiatry

Methods

A cross-sectional compilation of cases since the opening of the O.P.D. services of I.M.S., B.H.U. in August 2020 after the nation wide lockdown till 25 Nov’2020.

RESULTS

10 cases (5 cases with psychotic symptoms and 4 cases with obsessive compulsive /anxiety related symptoms and 1 case of dissociative trans disorder due to coronavirus ) ,6 new cases (3 psychotic spectrum ,2 obsessive compulsive spectrum and 1 dissociative possession disorder ) and 4 were already diagnosed cases (3 psychotic spectrum and 1 obsessive compulsive spectrum ) and 1 case had delusional parasitosis. All the patients had shown COVID related themes in their psychopathology.

CONCLUSION

We may now be witnessing an increasing number of COVID-related psychopathology in severe mental illnesses in people due to the pandemic.These presentations highlight the impact of socio-cultural factors on the psychopathology of mentally ill individuals.

Adverse childhood experiences and substance abuse in young adults: A correlational study

Dileep Kumar Maurya 1*, Mona Srivastava2 1Junior resident,2Professor & Head, Department of Psychiatry, Institute of Medical Sciences, B.H.U., India *Corresponding author: dkm012imsbhu@gmail.com

BACKGROUND

Individuals who have Adverse Childhood Experiences (A.C.E.s) tend to have more physical and mental health problems as compared to adults who do not have A.C.E.s. Individuals who have A.C.E.s can be more susceptible to disease development through both differences in physiological development and adoption and persistence of health-damaging behaviors.

AIMS AND OBJECTIVES

Abstract

 

1.

To assess the amount and extent of adverse childhood experiences in the study population.

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2. To find pattern extent of substance use in young adults.

3. To assess the correlation between the adverse childhood experiences and the amount of substance use in the study population.

METHOD

This was a Case-control Cross-sectional comparative analysis depending upon inclusion and exclusion criteria. Each group consisted of 60 participants and were assessed on Dysfunctional Analysis Questionnaire (D.A.Q.), General Health Questionnaire (GHQ-12), A.C.E. International Questionnaire (ACE-IQ)

RESULTS

In case group, prevalence of Tobacco was 85%, alcohol 86.7%, Cannabis 20%, opioid 18.3%, and sedatives 11.7%. Mean GHQ-12 score in Case 9.05 and in Control 0.600, Mean D.A.Q. in Case 150.6 and Control 55.8% and Mean ACE-IQ in case 3.53and in control 0.850.

CONCLUSION

The present study shows that the number of adverse childhood experiences is highly associated with the development of health-risk behaviors, which, as well as other factors, can influence behavioral and health outcomes in adulthood.

A study report on the effect of COVID -19 pandemic on the outpatient attendance at the department of psychiatry in a level three COVID-19 hospital

Gaurav Singh Yadav 1*, Deepa Singh 2, Richa
Pandey3, Shudanshu Chandel4, Tapas Kumar Aich5 1,2,3Junior resident, 4Senior resident Department, 5 Professer and Head Department of Psychiatry, BRD Medical College,

Gorakhpur, UP

*Corresponding author :drgarrybrd@gmail.com

INTRODUCTION

During the COVID-19 pandemic BRD Medical College was declared to function as a level three COVID-19 treatment center. This decision has lead to the complete

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closure of all O.P.D. services at the Nehru Hospital, BRD Medical College, Gorakhpur.

AIM

The present study aims to analyze the effect of the COVID-19 pandemic at our psychiatry O.P.D. from April to October, 2020.

METHODOLOGY

The study was carried out at the psychiatry O.P.D. of Nehru Hospital, BRD Medical College. All the cases that were reported through emergency O.P.D. from April 2020 till October 2020 were included in the study. Teleconsultation O.P.D. started on 28 April 2020. All the cases of teleconsultation O.P.D. were also included in this study. Thus, the final data analyzed is the combination of emergency O.P.D. and teleconsultation O.P.D. Data available from these 7 months (April to October 2020) has been compared with the psychiatry O.P.D. attendance of the same period of the previous year (April to October 2019). Data thus received is subjected to simple statistics like frequencies and percentages.

RESULTS

From April to October this year, we have a total of 1249 patients registered either through emergency or teleconsultation O.P.D. During the same period last year, 22859 patients attended our psychiatry O.P.D. Thus, there was almost a 94.5 percent fall in O.P.D. attendance in comparison to the previous year. The drop was maximum in month of April (more than 99% drop). Attendance gradually improved over the last 6 months but still drop was approximately 90% in the month of October in 2020 compared to the previous year.

CONCLUSION

COVID-19 pandemic resulted in a significant decline in out-patients consultation for mental health services in tertiary care centers.

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Abstract

 

How COVID 19 pandemic has affected admission rate of patients in psychiatry ward of BRD medical college, 7 month study

Richa Pandey 1*,Gaurav Singh Yadav 2,Deepa Singh3, Prabhat Agarwal4
1,2,3Junior resident, 4 Assistant Professor, Department of Psychiatry, BRD Medical College, Gorakhpur, UP *Corresponding author:dr.richapandey20@gmail.com

BACKGROUND

COVID-19 was declared a pandemic by WHO on 30 January 2020 and has disrupted the routine hospital services globally. With the increasing number of cases Government of India had imposed a complete lockdown on 25 March 2020, which was subsequently lifted gradually over time. Inpatient attendance in our psychiatry ward at the B.R.D. Medical College has also been affected significantly.

AIMS AND OBJECTIVES

The present study aims to analyze the effect of the COVID-19 pandemic at our psychiatry I.P.D.

METHODOLOGY

The study was carried out at the psychiatry ward of our Nehru Hospital, BRD Medical College. Study included all the cases admitted from the month of April to October 2020 in our psychiatry ward, either through the emergency, teleconsultation services, or those referred from other departments. Admission data of these 7 months period (April-October2020) has been compared with the psychiatry I.P.D. attendance of the same period of the previous year (April-October2019). Data thus received is subjected to simple statistics like frequencies and percentages.

RESULTS

During the study period this year, a total of 53 patients were admitted this year. During the comparable period 2019, a total of 216 patients were admitted. Thus, there is a drop of at least 75.46% in admission rate compared to the previous year. In comparison to the previous year the percentage of females admitted was more than that of males.

Indian Jounal of Clinical Psychiatry

CONCLUSION

COVID-19 pandemic resulted in a significant decline in inpatients (hospitalizations) for mental health care in tertiary care centers.

Socio-demographic profile of patients with Pulmonary Tuberculosis associated with psychiatric co-morbidities

Authors:Simran Sharma1*,
Rakesh Yaduvanshi2, Abhinav Kuchhal3
1Junior resident, 2Associate Professor,3Assistant professor, Department of Psychiatry, Rohilkhand Medical College and Hospital, Bareilly
*Corresponding author:simrnsharmaa@gmail.com

BACKGROUND

Tuberculosis (T.B.) is an infectious disease caused by Mycobacterium Tuberculosis and is one of the leading cause of mortality worldwide. Presence of various psychiatric co-morbidities can impact treatment of tuberculosis, and identifying and treating them can increase cure rates of tuberculosis.

AIM AND OBJECTIVES

The aim of the study is to assess the psychiatric co- morbidities and their relationship with socio-demographic variables in patients of pulmonary tuberculosis.

METHODS

A total of 120 patients diagnosed with pulmonary tuberculosis from the department of respiratory medicine were assessed for the presence of psychiatric co- morbidity using Mini International Neuropsychiatry Inventory (MINI).

RESULT

Overall psychiatric co-morbidities were found in 54 (45%) patients out of 120. The frequency of co-occurrence of different types of psychiatric disorders was as following: depression 22.5%, social phobia 9.2%, panic disorder 7.5%, obsessive compulsive disorder 5.8%, generalized anxiety disorder 4.2%, alcohol dependence 2.5%, suicidality 1.7%. Among socio-demographic parameters,

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Abstract

  

marital status and educational level were associated with psychiatric co-morbidities in pulmonary tuberculosis patients. Psychiatric co-morbidities were found to be more in singles and patients with lower educational level.

CONCLUSION

Psychiatric co-morbidities were found to be a common problem with pulmonary tuberculosis. The results of this study are in line with many different research works both in India and abroad. A proper address of this issue is important for the management, better outcome, and policymaking in patients with pulmonary tuberculosis.

A Study of Psychological stress and burden on caregivers of schizophrenic patients

Ekaansh Sharma 1*, Rakesh Yaduvanshi2, Abhinav Kuchhal3
1Junior resident, 2,3Associate Professor, Department of Psychiatry, Rohilkhand Medical College and Hospital Bareilly, U.P.

*Corresponding author:pamky_dp@yahoo.com INTRODUCTION

Schizophrenia is a chronic severe mental illness which not only affects patients but also causes significant burden and stress to the caregivers. India definite lacks studies, exploring caregiver burden and psychological stress.

OBJECTIVES

To assess psychological stress and the burden on caregivers of schizophrenic patients.

MATERIALS AND METHODS

The study sample included 52 patients with a diagnosis of schizophrenia and their caregivers, randomly selected from the patients coming to the O.P.D. of two tertiary care centers in Bareilly, as per inclusion and exclusion criteria. Burden Assessment Schedule and General health questionnaire-12 were used for the study.

RESULTS

Our study also shows that 42.31% of caregivers experienced severe burden. Caregivers of patients with

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low levels of education reported greater burden.Parents and spouses reported a moderately higher level of burden, but siblings reported the highest level of burden.Parents had greater psychological stress as compared to spouses and siblings. Caregivers with higher psychological stress found to have a heavier caregiving burden.

CONCLUSION

Caregivers of schizophrenic patients suffered from a significant burden. It thus becomes important to plan interventions that would reduce their burden of care and thus improving their psychological well-being.

Online gaming amid COVID-19 Lockdown in India

Gunjan Joshi 1*, Ginni Sharma 2
1,2Clinical psychology (Trainee)
King George’s Medical University, Lucknow, U.P. *Corresponding author : gunjanj051011@gmail.com

BACKGROUND

Nationwide lockdown imposed in India in response to Coronavirus Pandemic has caused 1.3 billion people to stay at home. With the excessive time spent at home it is natural for people to use the internet for different purposes. Apart from using the internet for entertainment, online gaming has become one of the popular leisure activities irrespective of age, gender, and culture.

AIMS & OBJECTIVES

This study attempted to assess the use and motivation of online gaming amongst adult population in India amid the COVID-19 pandemic lockdown.

METHOD

An online survey was conducted using a structured questionnaire using non-probability snowball sampling. Two hundred seventeen participants took part in the survey.

RESULT

A total of 70.5% of people reported an increase in time spent playing online games during the lockdown. Out

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of these, 16.9% reported playing it provided them a platform to connect and interact with others, 17.6% reported increased competence, 5.2% reported playing online due to perceived behavioural control, 18.9% reported playing as it alters anxiety and negative emotions, 13.7% played due to social acceptance, 13.7% played to reduce boredom and 20.9% reported playing due to novelty seeking and fun. Moreover, in this study 64.1% of people were identified as normal gamers, 17% as engaged gamers, 11.7% as problematic gamers, and 7.2% as addicted gamers. Their purpose of gaming varied amongst different users. Normal gamers reported highest on novelty seeking, engaged gamers on the platform to connect and interact with others, problematic gamers, and addicted gamers on altered anxiety and negative emotions.

CONCLUSION

It is concluded that the purpose of playing online during lockdown is dependent on various factors like interaction and connectedness with other players, increasing competence, autonomy and perceived behavioural control, alters anxiety and other negative emotions, novelty seeking and too much idle time.

Assessment of Drug Dependence in the Geriatric Age Group in Eastern UP.

Jitesh Kumar Gupta1*, Achyut Kumar Pandey2,Pradeep Kumar3
1Junior resident,2Professor,3Senior Resident , Department of Psychiatry, IMS BHU Varanasi, U.P.

*Corresponding author : jiteshguptakgmu@gmail.com

BACKGROUND

There are several bio-psychological & social factors contributing to substance abuse. These factors could differ in different socio-demographic status. This study provides important information regarding different Psychosocial factors in Geriatric people contributing to substance abuse, which would help in planning better psychosocial intervention fitting to Geriatric population.

AIMS AND OBJECTIVES

This research aimed to study the demographic and clinical profile of elderly subjects (60 years) presenting to a

Indian Jounal of Clinical Psychiatry

drug addiction center in IMS BHU Varanasi.

METHODS

All patients with SUD and without any comorbid physical or mental illness were included in the study. Patients aged more than 60 years and were applied DAST, S.D.S., C.P.S., S.D.S. & AUDIT and applying using SPSS software.

RESULTS

Prevalence of tobacco 97.5%, alcohol 22.5%, cannabis 5% and benzodiazepine 7.5%. The majority of the elderly were below 75 years of age (95%), married (77.5%), Hindu (87.5%), and from rural background (80%). All the patients were male, and the majority have a positive family history of substance abuse (82.5%).

CONCLUSION

The present study has tried to delineate various psychosocial factors which are important in term of substance abuse. Thus, it can help in an optimal psychosocial intervention which is patient-centric.

Role of rTMS in management of Obsessive- Compulsive symptoms in patients of Schizophrenia

Aditya Agrawal1*, Mohita Joshi2, Sujit Kumar Kar3, Vivek Agarwal4
1,2Junior resident,3Associate Professor,4Professor Department of Psychiatry, King George’s Medical University, Lucknow, Uttar Pradesh, India *Corresponding author : adiagrawal3697@gmail.com

BACKGROUND

Prevalence of Obsessive-Compulsive Symptoms in Schizophrenia is around 30% and up to 12-14% patients meet the diagnostic criteria of Obsessive-Compulsive Disorder (OCD). The presence of OCD in schizophrenia is associated with a poor prognosis of the illness. Sometimes, Obsessive-Compulsive Symptoms can be antipsychotic induced for which dose reduction of antipsychotic agent to minimum effective level or switching to different antipsychotic can be done. However, if it persists, it can be treated with anti-obsessional drugs,

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Abstract

  

psychotherapy, or newer treatment modalities like repetitive transcranial magnetic stimulation (rTMS).

AIMS AND OBJECTIVES

Efficacy of rTMS in management of Obsessive- Compulsive symptoms in patients of Schizophrenia.

METHODS

A total of 4 patients of Schizophrenia with OCD, who were well maintained on antipsychotic medications for Schizophrenic symptoms, but shown minimal improvement in OCD. symptoms even after adequate dosage and duration with anti-obsessional drugs were included in the study. Written informed consent was taken. Baseline Y-BOCS score was assessed before starting the sessions. The protocol chosen was: 1Hz, 60 Pulses/trains, 20 trains with the inter-train interval being 5 seconds. A total of 20 daily sessions of rTMS over the Supplementary motor area with above-mentioned protocol were given. Y-BOCS at the end of 20 sessions was again assessed, and results were analyzed.

RESULTS

Patients had shown a reduction in the symptom severity of OCD. after completion of rTMS therapy. The symptom reduction ranges between 24% to 29% from the pre-TMS level. None of the patients reported any adverse effects to TMS during the course of therapy.

CONCLUSION

In the management of treatment-refractory obsessive- compulsive symptoms in schizophrenia, add-on rTMS can be auseful modality.

Clinical profile of the patients seeking tele- medicine services during pandemic period in the Psychiatry Department of a teaching hospital

Ved Prakash Gupta1*, Shravan Kumar2, SAAzmi3 1*Juniorresident,2SeniorResident, 3Professor Department of Psychiatry, Jawaharlal Medical College Aligarh Muslim University, Aligarh, Uttar Pradesh, India *Corresponding author : dr.vedgupta2k11@gmail.com

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BACKGROUND

The Covid-19 pandemic is a major health crisis affecting several nations with over 65 million cases and 1.5 million conformed deaths reported till date. Such widespread outbreaks are associated with adverse mental health consequences. Mental health has a significant impact on public health and contributes to a substantial part of the disability of a general population.

AIMS AND OBJECTIVES

The aim of this study was to evaluate the clinical profile of the patients seeking tele-medicine services during the pandemic period.

METHODS AND MATERIALS

A total of 205 patients who attended telemedicine in a teaching hospital were selected for study, and clinical details were collected.

Results

Among the cases 27% had depression, 11% had anxiety disorder, 6% had mixed depression and anxiety, 8% had schizophrenia and related disorder, 2.5% had bipolar affective disorder and related disorder, 6% had OCD., 1.5% substance abuse, 1.5% had insomnia, and 6% had headache.

CONCLUSION

This study concluded that most of the consultations sought during the COVID-19 pandemic were from patients falling under the depression and anxiety spectrum of psychiatric disorders.

A cross-sectional study to assess the co- dependency, anxiety, depression and family burden among the caregivers of patients with opioid dependence syndrome”

Sanju Pant1*, Sudha Mishra2, Sujit Kumar Kar3
1 M.Sc. Nursing 2nd Year Student, 2Assistant Professor,KGMU College of nursing King George’s Medical University Lucknow

3Associate Professor, Department of Psychiatry, King George’s Medical University Lucknow U.P *Corresponding author : sanju.pant63@gmail.com

Indian Jounal of Clinical Psychiatry

Abstract

  

BACKGROUND

A substance user in the family affects nearly all facets of family life. This results in traumatic events that affect the lives of caregivers and impose a huge psychological strain on them.

AIMS & OBJECTIVE

This study aims at assessing the co-dependency, anxiety, depression, and family burden among caregivers of patients with opioid dependence syndrome and their association with them

METHOD

A cross-sectional study of caregivers was conducted and resulted in 132 respondents. The assessment of variables was accomplished by using MINI 6.0, Span Fischer co-dependency scale, Patient health Questioner- 9, Generalized Anxiety Disorder -7, and Family Burden Interview Schedule who were attending the OPD, OST clinic and inpatient at the Department of Psychiatry, KGMU, Lucknow.

RESULT

Most caregivers reported a severe co-dependency (50%), severe anxiety (75.60%), moderately severe depression (54.54%). All participants reported a more burden (100%).The effect on mental health in family burden had a higher mean score (1.68±0.47) among all.A positive correlation was found among co-dependency and anxiety (0.216), co-dependency and depression (0.205), co- dependency and family burden (0.300), anxiety and depression (0.300), anxiety and family burden (0.271) and depression and family burden (0.151).

CONCLUSION

The present study found that there is a significant association among depression, anxiety, co dependence, and burden. Therefore, it is important to alleviate the impact and plan better treatments.

Smartphone addiction and quality of sleep in medical students of a tertiary care teaching hospital of North India.

Indian Jounal of Clinical Psychiatry

Surobhi Chatterjee1*, Sujit Kumar Kar2
1MBBS Final year student, 2 Associate Professor, Department of Psychiatry, King George’s Medical University, Lucknow
*Corresponding author : surochat98@gmail.com

INTRODUCTION

Smartphone addiction is congenial today more than ever. Medical students who are already sleep-deprived can have detrimental health effects due to smartphone overuse.

OBJECTIVE

To study smartphone addiction and quality of sleep among medical students along with background variables.

METHODOLOGY

This cross-sectional study was conducted on 224 medical students from August-October 2019 using a self-administered questionnaire consisting of four parts – Socio-demographic characteristics, general health questionnaire (GHQ-12), smartphone addiction scale- short version (SAS-SV), and Pittsburgh sleep quality index (PSQI). Pearson correlation coefficient was used to correlate the scores.The data was interpreted using SPSS software version 23.The study was initiated only after receiving approval from the Institutional Ethics Committee.

RESULT

The prevalence of smartphone addiction was found to be 33.33% in females and 46.15% in males. 63.39% were poor sleepers as assessed by their PSQI Scores, and 62.05% reported poor health status as per their GHQ scores. Though the length of smartphone use (in years) among female medical graduates was found to be significantly higher (p=0.013) than their male counterparts, SAS-SV scores reveal that male students (45.3%) were more addicted to smartphones. 43% of them get anxious in a network deficient area, whereas 39% of female students felt guilty over excessive smartphone use.One hundred seventy-eight students (79.46%) also reported the use of smartphones in risky situations.A positive and statistically significant correlation (at p<0.05) was observed between overall PSQI scores, SAS-SV Scores and GHQ Scores.

81

Abstract

 

CONCLUSION

The study delineates the importance of regulating smartphones’ usage as they were associated with physical problems, risky behaviors, and behavioral changes. It also highlights the importance of regulating students’ usage in their formative years to decrease its impact on their decision-making capabilities as clinicians.

Developmental trajectory of dissocial personality disorder: Attribution of adverse childhood experience

Mishkat Fatima1*, Niyati Narang2,
Kritika Chawla3, Ankita Saroj4
1,2 MBBS Student, 3, 4 Post-graduate resident Department of Psychiatry,King George’s Medical University, Lucknow, U.P
*Corresponding author : mf.fatima466@gmail.com

INTRODUCTION

Dissocial or anti-social personality disorder is a pervasive pattern of disregard for and violation of others’ rights that begins in childhood and early adolescence and continues into adulthood. It is more common in males, with prevalence rates ranging from 0.2% to 3.3%. Adverse childhood experiences have a significant attribution in the development of dissocial personality disorder.

AIMS AND OBJECTIVES

To discuss the developmental trajectory of dissocial personality in the index case.

METHOD

A young adult male who was earlier diagnosed as a case of oppositional defiant disorder in the first decade of his life was hospitalized for evaluation and management of his psychiatric illness.

RESULT

History revealed that the patient was an adopted child with authoritarian parents and a history of child abuse. The patient was diagnosed with oppositional defiant disorder in the first decade of his life. He started

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substance use at 12 years of age. He was also involved in gambling, theft, and duping his friends and neighbors to earn money and spend it on leisure. He had been irritable and aggressive by nature and got into frequent quarrels, but he claimed to enjoy all these as a part of life. On further evaluation, he showed traits of low tolerance to frustration, impulsivity, irritability, aggressiveness and defiance of rules. History and psychometric findings are suggestive of dissocial personality disorder.

CONCLUSION

Adverse childhood experiences, strict parenting, and poor psychosocial support seem to be responsible for the development of dissocial personality disorder in the index case.

Listeners Abode: An Analysis of Experience

Saurabh Tandon1*, Ashutosh Jaiswal2, Mona Srivastava3 1,2 MBBS 2nd Year Student, 3 Professor and Head

Department of Psychiatry, IMS BHU, Varanasi *Corresponding author : saurabhtandon876@gmail.com

BACKGROUND

Mental health disorders are most commonly associated with the innate shame and hesitation to share and open up. Depression and anxiety disorders are commonly related to feelings of loneliness and helplessness, but the shame associated with seeking help means most people suffer in silence.

AIMS & OBJECTIVES

Our aim is to offer a non-judgmental and non-threatening innovative positive emotional chat support program.

METHODS

A website named “Listeners Abode” was launched by the MBBS batch of 2018 under the mentorship of the Department of Psychiatry. This website is free and accessible to all individuals who need a safe place to voice their thoughts. The website has volunteers from the MBBS UG students, who have been trained to offer a platform to listen.

Indian Jounal of Clinical Psychiatry

Abstract

  

RESULTS

In about 1.5 months, the website has catered to more than 150 chats with the help of 15 trained volunteers. 30.4% of respondents felt that they needed a good listener & 31.3% felt that if they talk about their feelings with a stranger, it will help them overcome their anxiety. Five people were suggested to seek professional help.

The encouraging response to the website underlines the significance of the need to reach out to individuals for emotional support .

Anxiety in college students in COVID-19 Lockdown over Academic losses

Sagar Rai1*, Zareen Akhtar2, Kaushal Kishor Singh3 1,2,3 MBBS Student, King George’s Medical University, Lucknow, Uttar Pradesh
*Corresponding autho r : sagarrai.2257@gmail.com

BACKGROUND

COVID Lockdown was a sudden unexpected hit to educational institutions due to which the educational and placement cells could not decide what to do, and hence all academic activity of students went off. In the initial phases, it was like vacations for the students, which they enjoyed. However, pending courses, lack of practical exposure, canceling interviews, canceling internships created chaos for college students.

METHODS

This was a cross-sectional study intended to measure anxiety among students due to academic loss during the COVID-19 lockdown. In this study, we employed General Anxiety Disorder Scale- 7 and asked students to answer the question in accordance with their academic losses in the Google forms. The survey was conducted during the first three months of the COVID pandemic— the initial phase.

AIMS AND OBJECTIVE

To identify the prevalence of anxiety among graduates of different disciplines in COVID Lockdown.

RESULTS

We got 514 responses, and we selected 507 students for the study. Almost 25% of students reported moderate to severe levels of anxiety scores. This calls for psychological support and assistance by the institution’s student welfare committees.

CONCLUSION

The health care students group had relatively low anxiety levels compared to technical students and other field students. Health care students can be the first choice to join the Corona Warrior Forces if it becomes needful.

Abstract

 

Indian Jounal of Clinical Psychiatry

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