Indian Journal of Clinical Psychiatry An Official Journal of Association of Clinical Psychiatry

Association of Clinical Psychiatry

http://www.ijocp.com

Volume 3 Issue 2 December 2023

ISSN – 2583-8873

IJOCP

Indian Journal of

Clinical Psychiatry An Official Journal of Association of Clinical Psychiatry

(Indian Psychiatric Society- Uttar Pradesh State Branch (IPS-UPSB))

Published by

MRI Publication Pvt Ltd.

https://myresearchjournals.com/

About the Journal

Indian Journal of Clinical Psychiatry (IJOCP) is the official journal of the Indian Psychiatric Society, Uttar Pradesh Branch. It is published biannually. It is a comprehensive journal for mental health professionals, professionals of allied disciplines, and mental health policymakers. Emerging knowledge of the highest quality in the field of psychiatry, the latest technological enhancements, and developments of psychological interventions are shared in a timely and practical manner for clinical and professional use. The journal publishes peer-reviewed original research articles; review articles; commentaries on significant articles; case reports, perspectives, view-points (opinions), and letters to the editor. All papers are peer- reviewed before publication. The journal provides immediate free access to all the published articles. The journal does not charge the authors for submission, processing or publication of the articles.

About Society

Association of Clinical Psychiatry is the newly formed branch of the Indian Psychiatric Society. The resolution for formation of the IPS UP state branch was passed in the Annual General Body meeting of the IPS- Central Zone at the IPS-Central Zonal Conference held at Agra in 2018. Subsequent to this, the application for approval of formation of this new branch was sent to the Executive council of the Indian Psychiatric Society. IPS EC approved the formation of new branch at ANCIPS 2020 held at Kolkata.

Aim and Scope

The journal is aimed to-

• Promote research and publication

in the field of psychiatry.

• Save the scientific update, knowl-

edge among the researchers and mental health professionals free of cost.

• Promote research in mental health in Northern and other parts of India.

We encourage authors to publish their research related to Mental health and allied discipline. The journal encompasses all the subspecialties of Psychiatry(Child-adolescentPsychiatry, Social Psychiatry, Neuropsychiatry, Geriatric Psychiatry, Deaddiction Psychiatry, psychosexual Psychiatry, Perinatal Psychiatry, Preventive and Forensic Psychiatry).

The journal publishes Editorials, Original Articles, Case Studies, Reviews, Correspondence, and Book Reviews, etc. pertaining to Psychiatry with the special focus on Original and Review Articles on the following:

• Clinical Research.

• Fundamental research on various

aspects of Psychiatry.

• Health promotion.

• Studies on Health Seeking Attitude

and Medico-Social aspects includ-

ing medical anthropology.

• Development of methodologies of Clinical Research Related to

Psychiatry

• Art in Psychiatry

Support Contact

Susheel Kumar editor@mripub.com

Peer Review Process

The journal follows double-blind peer review policy.

■ The IJOCP is very sensitive to pla-

giarism-related issues. The journal does not allow a similarity index of >10%. Any adoption of material (figure, diagnostic criteria, figures, etc.) from previous research work or publications needs to be produced after taking permission from pub- lisher/authors of original publication and proper credits to the original research.

■ The copyright of the published work lies with the author. However, when the author cites any published work with the journal it needs to be duly cited.

■ As the journal is a non-profit journal and does not charge the author for submission, we do not allow the published material to be used for commercial purposes without permission.

Websites:

The electronic edition of the journal is available at http://www.ijocp.com http://www.myresearchjournals.com

The manuscripts can be submitted at http://www.ijocp.com

Editorial Contact

Dr. Vipul Singh

Prof., Department of Psychiatry, GMC, Kannauj, UP, India, drvipulsingh@yahoo.co.in

Dr. Sujita Kumar Kar

Additional Professor, Department of Psychiatry, KGMU, Lucknow,

Uttar Pradesh, India drsujita@gmail.com

• Any other areas of related field etc.

IJOCP

Indian Journal of Clinical Psychiatry

Vol. 3 No. 2

ISSN – 2583-8873

Editor

Dr. Vipul Singh

December 2023

Deputy Editor

Dr. Sujita Kumar Kar

sujitakumarkar@kgmcindia.edu Associate Professor, Department of Psychiatry, King George’s Medical University, Lucknow, Uttar Pradesh, India

drvipulsingh@yahoo.co.in Professor, Department of Psychiatry, Government Medical College, Kannauj, Uttar Pradesh, India

Dr. Shivangini Singh

shivangini1103@gmail.com

Junior Resident, Department of Psychiatry, King George’s Medical University, Lucknow, Uttar Pradesh, India

Dr. Dharamveer Chaudhari

drdv8090@gmail.com Assistant Professor, Government Medical College, Kannauj, Uttar Pradesh, India

Editorial Board Members

Dr. Manoj Prithviraj. M

drmanojm@aiimsgorakhpur.edu.in Associate Professor, Department of Psychiatry, All India Institute of Medical Sciences, Gorakhpur, UP, India

Dr. Achyut Kumar Pandey

achyutpandey@bhu.ac.in Professor,

Department of Psychiatry, Institute of Medical Sciences-Banaras Hindu

University, Varanasi, Uttar Pradesh, India

Dr. Jai Singh Yadav

jsypsy@bhu.ac.in

Prof. and HOD Department of Psychiatry, IMS Banaras Hindu University, Varanasi, Uttar Pradesh, India

Dr. Vijender Singh

vijender.psy@aiimsbhopal.edu.in Professor and Head,

Department of Psychiatry, All India Institute of

Medical Sciences (AIIMS), Bhopal, Madhya Pradesh, India

Dr. Abdul Quadir Jilani

imjilani@gmail.com

Assistant Professor,

Department of Psychiatry RML Medical Institue, Lucknow, Uttar Pradesh, India

Dr. M Aleem Siddiqui

docaleem@gmail.com Professor, Department of Psychiatry, Era Medical College, Lucknow, Uttar Pradesh, India

Editorial Assistants

Dr. Akanksha Shankar

akks1420@gmail.com

Junior Resident, Department of Psychiatry, King George’s Medical University, Lucknow, Uttar Pradesh, India

Editorial

Undergraduate Psychiatry Teaching and Learning in India: A Bumpy Ride

Sujita K. Kar, Babli Kumari, Vipul Singh

Presidential Address

Pediatric Schizophrenia

Prabhat Sitholey, Shivangini Singh

Research Article

Sociodemographic Profile and Psychological Factors Influencing Deliberate Self Harm in a Tertiary Rural Health Care Setup: A Cross-sectional Study

Gaurav Pawar, Kshirod K. Mishra, Ahmed Reshamvala

Responding to Crisis: An Analysis of Psychological Reactions to the COVID-19 Pandemic through Web Survey

M L Charan, Krishan Kumar, S Novena, E V Johny, Mujiba Nazeer

Insight into Patterns of Sociodemographic and Clinical Profile of Patient attending a Newly Started Psychiatry Outpatient in an Institute of National Importance

from North India: A Retrospective Chart Review

Rashmi Shukla, Arghya Pal, Shilpi Kandwal

Case Study

Dhat Syndrome in Geriatric Population: Cultural Beliefs and Implications

Mohit K. Shahi, Ashwin J.V, Astha Singh

Atypical Presentation of Neuropsychiatric Variant of Wilson’s Disease and Clinical Improvement with Elemental Zinc Monotherapy

Simranjit Kaur, Utkarsh K. Tripathi, Abhishek Chakladar, Zaid Ahmed, Gaurav Verma, Alexander M. Alphonse, Ankan Paul

Abrupt Onset Depressive Episode in Patient with Lenticular Nucleus Infarct with Low-Risk Factors

Aleena Thomas, Mohammad Ahsan, Rashmi Shukla, Ashutosh Mishra, Arghya Pal

Levetiracetam Induced Acute Suicidal Ideations in a Patient of Juvenile Myoclonic Epilepsy

Ravikant Kumar, Rahul Mathur, Abhishek Chakladar, Anuranjan Vishwakarma

Coronavirus Disease 2019 Associated Obsessive-Compulsive Disorder: A Case Report

Ravikant Kumar, Jawahar Singh, Abhishek Chakladar

1-3

4-8

9-14

15-23

24-29

30-33 34-36

37-39

40-42 43-44

Index

Indian Journal of Clinical Psychiatry

An Official Journal of Association of Clinical Psychiatry (Indian Psychiatric Society- Uttar Pradesh State Branch (IPS-UPSB))

EDITORIAL

ISSN- 2583-8873 doi: 10.54169/ijocp.v3i02.96

Undergraduate Psychiatry Teaching and Learning in India: A Bumpy Ride

Sujita K. Kar1*, Babli Kumari1, Vipul Singh2

1Department of Psychiatry, King George’s Medical University, Lucknow, Uttar Pradesh, India. 2Department of Psychiatry, Government Medical College, Kannauj, Uttar Pradesh, India.

ARTICLE INFO

*Correspondence:

Sujita K. Kar drsujita@gmail.com

Department of Psychiatry, King George’s Medical University, Lucknow, Uttar Pradesh, India.

Dates:

Received: 20-09-2023 Accepted: 13-10-2023 Published: 08-11-2023

How to Cite:

Kar SK, Kumari B, Singh V. Undergraduate Psychiatry Teaching and Learning in India: A Bumpy Ride. Indian Journal of Clinical Psychiatry. 2023;3(2): 1-3.

doi: 10.54169/ijocp.v3i02.96

In India, there has been exponential growth in the number of MBBS seats and postgraduate seats over the past two decades. In the year 2021, there were 83,275 MBBS seats and 42,720 postgraduate seats in 554 medical colleges in

India.1,2 As of the second week of October 2023, 706 medical colleges are col- lectively providing 1,08,890 MBBS seats.3 In the same period, 331 medical insti- tutions now offer postgraduate programs in psychiatry, contributing to a total of 1,360 MD seats in psychiatry.4 The change of figures over three years gives an idea about the rapid increment in undergraduate (MBBS) and postgraduate seats in psychiatry in India.

In India, psychiatry is taught as a subject integrated with general medicine. The undergraduate subcommittee of the Indian Psychiatric Society in 1965 mentioned in its report that psychiatry teaching in India was grossly inade- quate.5 Over the next fifty years (i.e., by 2015), insignificant changes happened in undergraduate psychiatry education. This is largely attributed to the scarcity of manpower and infrastructure required for psychiatry teaching and training.5 Teaching and training of the undergraduate medical students are important for enhancing the mental health care delivery in the community.6 Strengthening undergraduate teaching is also expected to help bridge the treatment gap for patients with mental illnesses.7 To strengthen the undergraduate psychiatry training, the Indian Psychiatric Society appealed to the Medical Council of India to make psychiatry an independent subject in MBBS. However, the lack of adequate teachers in all medical colleges is a big hurdle.8 As psychiatry is not a major subject in the MBBS curriculum, most undergraduate students skip psychiatry classes and focus on other subjects. The stigma associated with mental illness also affects the perception regarding the psychiatry discipline. Many students perceive it in a stigmatizing manner.9 The way the psychiatry teachers teach psychiatry is also a matter of concern. In the present scenario, undergraduate students in medical colleges are taught psychiatry by faculty members specializing in psychiatry, senior residents, and postgraduate resi- dents. In colleges where there is a limited number of faculty members, senior residents and postgraduate residents primarily teach psychiatry.

In 2019, psychiatry was designated as a major subject in the MBBS curriculum by the All India Institute of Medical Sciences, Rishikesh (AIIMS-Rishikesh). The change included the introduction of separate examinations at the end of the

© Authors, 2023. Open Access This article is licensed under a Creative Commons Attribution-NonCommer- cial-ShareAlike 4.0 International (CC BY-NC-SA 4.0) License, which allows users to download and share the article for non-commercial purposes, so long as the article is reproduced in the whole without changes, and the original authorship is acknowledged. If you remix, transform, or build upon the material, you must distribute your contributions under the same license as the original. If your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit https://creativecommons.org/licenses/by-nc-sa/4.0/

seventh semester. They have also made a consen- sus on a comprehensive curriculum that will further address the training requirements of Indian Medical Graduates (IMGs).10 However, the MBBS curriculum for psychiatry is varied across the country.

To ensure uniformity in the curriculum, it has been suggested that the content of undergraduate lectures should contain 80% “Must-know informa- tion” and 20% “Desirable information”.11 It is import- ant to teach skills and demonstrate them through role-play as they significantly impact learning.11 It is particularly useful when the communication skills are demonstrated to the students. When under- graduate students have clinical posts in psychiatry, small group postings are often useful, which facili- tates interactive learning. It also facilitates peer-su- pervised learning. A small group of 10 to 15 students is often recommended for the clinical posting.11 In such settings, teachers can give effective feedback to individual students.

Assessment is an important component of teaching psychiatry to the undergraduates. In most medical institutes across the country, structured assessment of the students for psychiatry is not being carried out. Even in institutes that do conduct these assessments, the assessment is confined to the domain of knowledge.11 However, there is a need to assess the skills and attitudes of the students, which are important parts of learning psychiatry.11

To measure the effectiveness of teaching and learning methods as well as the clinical competence of the student, objective structured clinical exam- inations (OSCE) may be used.11,12 Researchers used various innovations in teaching to facilitate the learn- ing of psychiatry among undergraduate students.13

Recently, to strengthen the undergraduate medical curriculum in India, the National Medical Commission (NMC) suggested mandatory training of the teachers on competency-based medical curriculum (CBMC).14 Training the teachers about effective and innovative teaching methods is also likely to improve the teaching skills of the teachers and the quality of undergraduate teaching.9 The developed countries developed resource materials and guidelines for teaching undergraduate psychia- try students.15 India is lacking in this aspect. Recently, the NMC has developed certain resource materials to help psychiatry teachers augment their undergrad-

uate teaching skills, which must be widely adopted. Varying levels of expertise and available resources also hinder the effective implementation of the CBMC for undergraduate training. Consequently, the Indian Psychiatric Society has also drafted a competency-based education manual in July 2023. This manual comprises preliminary versions of spe- cific learning objectives, lesson plans, and assess- ment strategies, and it is also expected to integrate updates from the International Classification of Diseases, 11th edition (ICD-11), along with the current NMC guidelines.16 This could facilitate the adoption of a standardized curriculum throughout the country.

References

Undergraduate Psychiatry Teaching and Learning in India

6. 7.

8. 9.

Misra B. With 83,275 MBBS, 42,720 PG seats 558 Medical Colleges Operative in India: Health Minister. 2021 [cited 2021 Aug 2];Available from: https://medicaldialogues. in/news/education/with-83275-mbbs-42720-pg-seats- 558-medical-colleges-operative-in-india-health-minis- ter-80105

National Medical Commission. List of College Teaching MBBS | NMC. 2021 [cited 2021 Aug 2];Available from: https://www.nmc.org.in/information-desk/for-stu- dents-to-study-in-india/list-of-college-teaching-mbbs/ National Medical Commission. List of College Teaching MBBS | NMC. 2023 [cited 2023 Oct 12];Available from: https://www.nmc.org.in/information-desk/for-stu- dents-to-study-in-india/list-of-college-teaching-mbbs/ National Medical Commission. College and Course Search | NMC. 2023 [cited 2023 Oct 12];Available from: https://www.nmc.org.in/information-desk/college-and- course-search/

Kishor M, Isaac M, Ashok MV, Pandit LV, Sathyanarayana Rao TS. Undergraduate psychiatry training in India; past, present, and future looking for solutions within constraints!! Indian J Psychiatry 2016;58(2):119–20. Trivedi JK. Importance of undergraduate psychiatric training. Indian J Psychiatry 1998;40(2):101–2.

Gupta R, Khurana H. Challenges in Undergraduate Psychiatric Training in India [Internet]. In: Malhotra S, Chakrabarti S, editors. Developments in Psychiatry in India: Clinical, Research and Policy Perspectives. New Delhi: Springer India; 2015 [cited 2021 Aug 2]. page 593–610.Available from: https://doi.org/10.1007/978-81- 322-1674-2_31

Kar SK. Undergraduate psychiatry education in India: Where do we stand on the crossroads? Ind Psychiatry J 2015; 24: 104–5.

Masson N. Undergraduate psychiatry education: the challenges ahead: Commentary on… Teaching Medical Undergraduates. Adv Psychiatr Treat 2011;17(2):110–3.

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10. Dhiman V, Krishnan V, Basu A, Das A, Rohilla J, Rawat VS, et al. Development of psychiatry curriculum as a major subject during MBBS in India. Indian J Psychiatry 2021;63(3):290–3.

11. Manohari SM, Johnson PR, Galgali RB. How to Teach Psy- chiatry to Medical Undergraduates in India?: A Model. Indian J Psychol Med 2013;35(1):23–8.

12. Newble D. Techniques for measuring clinical compe- tence: objective structured clinical examinations. Med Educ 2004;38(2):199–203.

13. Chandran S, Sreedaran P, Pradeep J, Manohari S, Kuppili P, Kishor M. Using entertainment media to teach under- graduate psychiatry: Perspectives on the need and

14.

15. 16.

models of innovation. Arch Med Health Sci 2020;8(1):125. Kishor M, Gupta R, Ashok MV, Isaac M, Chaddha RK, Singh OP, et al. Competency-based medical curriculum: Psychiatry, training of faculty, and Indian Psychiatric Society. Indian J Psychiatry 2020;62(2):207.

El-Sayeh HG, Budd S, Waller R, Holmes J. How to win the hearts and minds of students in psychiatry. Adv Psychiatr Treat 2006;12(3):182–92.

Draft Competency Based Medical Education Manual for UG Psychiatry | Indian Psychiatric Society [Internet]. [cited 2023 Oct 13];Available from: https://indianpsychi- atricsociety.org/draft-competency-based-medical-ed- ucation-manual-for-ug-psychiatry/

Undergraduate Psychiatry Teaching and Learning in India

My Research Journals

Volume 3 | Issue 2 | 2023

Indian Journal of Clinical Psychiatry

An Official Journal of Association of Clinical Psychiatry (Indian Psychiatric Society- Uttar Pradesh State Branch (IPS-UPSB))

Pediatric Schizophrenia

Prabhat Sitholey1, Shivangini Singh2*

1Consultant Psychiatry, Lucknow, Uttar Pradesh, India.

2King George’s Medical University, Lucknow, Uttar Pradesh, India.

PRESIDENTIAL ADDRESS

ISSN- 2583-8873 doi: 10.54169/ijocp.v3i02.99

ARTICLE INFO

*Correspondence:

Shivangini Singh

shivangini1103@gmail. com

King George’s Medical University, Lucknow, Uttar Pradesh, India.

Dates:

Received: 08-10-2023 Accepted: 20-10-2023 Published: 08-11-2023

How to Cite:

Sitholey P, Singh S. Pediatric Schizophrenia. Indian Journal of Clinical Psychiatry. 2023;3(2): 4-8.

doi: 10.54169/ijocp.v3i02.99

childhood (<13 years) or adolescence (13-18 years). It has also been defined

as Early Onset Schizophrenia (EOS- <18 years) or Very Early Onset Schizophrenia (VEOS- <13 years).2 One study suggests an onset cut-off at age 14.7 years below which schizophrenia has significantly more positive symptoms and poorer psychosocial functioning as compared to schizophrenia with better outcomes above the cut-off.3 It is agreed that onset of schizophrenia before age 12 is very rare.4 Reliable population-based incidence figures for EOS are still lacking, while males predominate in clinical samples of EOS.1

Understanding Early Onset Schizophrenia Through A Case Vignette

Y is male (born 5/12/2015), a student of Prep, the only child living with his parents and paternal grandparents. The pregnancy was uneventful, birth was normal vaginal, and he had normal typical development. He was fully vaccinated. There was no family history of psychiatric disorder. He was normal until 5 years of age when, for no apparent reason, he started running from one room to another, crying and shouting for a long time. He seemed very frightened. He was incon- solable and unstoppable. He stopped responding when addressed and asked questions. His eye contact became very less. He seemed to be looking at the void. He lost his sleep. Y then started laughing for no reason and for long time. There was no emotional connection with the family members. He was found laughing in the toilet. From his utterances, the family inferred that Y was afraid of imaginary things like a millipede, a witch, and a ‘Brahmarakshas’ (a demon). Y was afraid of going out of his home in the open. He avoided meeting people visiting his home, saying that they were demons and should be killed. He said strange things like, ‘break it, kill it, knife him’ without any reason. He would repeatedly say such phrases or sentences. He was very anxious and restless. His play, studies, and interaction with family all stopped. His daily routine was disrupted. Y became fearful of stray dogs and even of his own pet rabbit. He

Introduction

Pediatric Schizophrenia can have its onset before 18 years. It can be during

started smelling his toys and clothes. He wetted and soiled his clothes. His appetite suddenly increased, and he started shoving large amounts of food into his mouth. Y seemed unaware of his surroundings. He seemed not to recognize his parents and home. He would say, “I belong to Lucknow, Please take me home, please take me to my mother, please take me to my father,” although he was in his own home and his parents were close by. Y was taken to a ‘mazaar’ for faith healing and to a shopping mall and seeing people there, he said that they were demons and God would punish them. Y would cry and weep and say, “Don’t beat me, don’t burn me, they have killed me, I am dead, they have made my mother a kitten, don’t kill my mother, I am lost.” He would not watch TV and be fearful of it, saying that he is trapped inside it and that please he should be rescued and let out. At another time, “I have fallen into a pit and stuck there and should be helped out.” Y would be afraid of the flames of the kitchen stove, but at another time he said he himself is a big fire. When Y’s mother tried to hold and soothe him, he would scratch and bite her. Once, he tried to strangle his mother and grandfather. Y spoke of a dark woman who would kill all of them. In his lucid periods, Y was his usual affectionate self, and interacted and behaved normally with the family. But these lucid periods were short, an hour at the most, and then the psychotic symptoms returned. Y was seen by a physician and a psychiatrist. His physical examina- tion, EEG, and CT brain scan were normal. Later, a brain MRI showed bilateral peritrigonal hyperinten- sities in the cerebral hemispheres, suggesting either delayed myelination or demyelination. Neurological examination was normal and the peritrigonal hyper- intensities were thought of unclear significance. Y and his mother were seen by me through online video consultations initially. The mother was requested to make detailed videos of Y in different activities and contexts. Since Y’s speech was often unclear, the mother transcribed what he said in Hindi. The mother and Y were serially fortnightly examined online through unstructured psychiatric interviews. No special psychiatric tools were used. The initial diagnosis was non-organic psychosis and as the clinical picture became clearer, it was changed to VEOS. The mother has explained this diagnosis

and is encouraged to gather information from the specified websites and on their own. The diagnosis was devastating for the parents, and they required a lot of support and reassurance. Y was already on Risperidone 1-mg daily for ten days before PS (Dr. Prabhat Sitholey) saw him and then dose was titrated upwards in increments of 0.5 mg every 15 to 21 days till 4 mg daily and then to 5 mg daily for a month, and then to 6 mg daily and held constant. Trihexyphenidyl was required to manage extrapy- ramidal side effects at risperidone 4 mg daily dose and above. Risperidone doses were like adult doses, although these were started low and built up slowly. Little improvement was seen before the risperidone 4 mg daily dose and 3.5 months of risperidone use. Improvement was very gradual and not steady or consistent. A symptom would improve to some extent for a few days to return. This was very disap- pointing and frustrating for the parents. The mother was encouraged to take up the role of a play – an occupational therapist and a teacher. First, her role was to calm and reassure Y, look after his nutritional needs, sleep, and safety. She was then to engage him in play and other activities of daily living and get Y to regain control over his bladder and bowel and to retrain him in proper use of toilet and ablu- tions. As Y slowly started improving after about 3.5 months, he was gradually made to study at Prep level without any pressure and with a lot of encour- agement. Y had difficulty in doing even those academic tasks in language and arithmetic he could do well before his illness started. He could not pay attention. He was distracted not by anything external but by what was happening in his mind. He seemed lost. Socialization was attempted by taking him to the playground and introducing him to the children there. He was made to face and meet the visitors. At first, Y was reluctant to socialize being fearful and avoidant but gradually, he became better in this regard. Y was not able adjust and cope with his school. About a year after his treatment started, Y joined another school that was tolerant of him and accepted him as he was. As Y got better, his normal behavior started returning. He was a lot more calm. His sleep improved. His running, shouting and crying reduced. His control over his bladder and bowel improved. He started communicating better. His

Pediatric Schizophrenia

My Research Journals

5 Volume 3 | Issue 2 | 2023

talks started making sense. His mood became better and more appropriate. He was not so fearful and anxious. He started smiling and laughing mean- ingfully. Eye contact greatly improved. He started listening to his mother and obeying her. He started paying attention to the stories his mother told him. His attention and concentration became better. He would demand that he be told a story at bedtime. He would dance and recite poems. He played with his father and mother and with his peers coopera- tively and enjoyed it. Over the next few months, according to the mother, Y was about 65% improved and soon improved to about 80%. However, it did not mean that all his psychotic symptoms had been remitted. He still became anxious and fearful without any reason but for a short time and could easily be soothed and comforted. Y still said that there was a ghost under his bed but when made to check for it and not finding anything there, he was reassured. The parents were given a diagnosis of very early onset schizophrenia (VEOS). Hallucinations and non-systematized brief delusions with themes of violence, and of losing home and parents, of being precariously trapped, torture, and death were present. Disorganized behavior was present. The duration of the illness till the diagnosis of non-or- ganic psychosis was 4 months. The diagnosis could not have been a bipolar disorder with psychotic symptoms as there was no affective polarity. It could not be autism, which typically starts before age three and the symptoms have a continuous, unre- mitting course. On the other hand, Y in his lucid moments, behaved normally as before he fell ill. Y’s psychosis was not transient. The parents were encouraged to read about Y’s diagnosis on specified websites and gather information in their own way. Their questions were answered. PS told them about his experience of handling such cases before and that a good outcome can be expected with patience and regular long-term treatment.

Clinical Presentation: Selective Aspects

The core clinical features of EOS include Hallucina- tions, delusions, passivity phenomena, thought and speech disorder, reduced or inappropriate emotional reactivity, lack of volition, motor abnormalities like

posturing, mannerisms, stereotypies, and catatonic immobility or excitement are present in schizophre- nia across various age groups. It is associated with poor premorbid functioning and early developmen- tal delays, which are more frequent and severe (20%, in comparison to 10% in AOS). Impaired sociability occurs in 33% of EOS. Premorbid IQ in EOS is, on average, 80 to 85 as compared to 90 to 100 in AOS. About 33% have mental retardation.5

There is a link between self-reported isolated psychotic symptoms in childhood and later schizo- phrenia. Of those who self-report strong psychotic symptoms, 70% develop schizophrenia and 26% develop schizophreniform disorders. None of these children developed schizophrenia during adoles- cence. Therefore, it seems that isolated or atten- uated psychotic symptoms in combination with developmental impairment constitute a high-risk premorbid phenotype. A prodrome characterized by gradual social withdrawal, declining school per- formance, uncharacteristic, odd behavior and ideas, eccentric interests, change in affect and unusual and bizarre experiences is more common in schizo- phrenia than in other disorders.6 Capacity to form friendships and love relationships is very impaired. Poor outcome is predicted by premorbid social and cognitive impairments, a long first episode, long duration of untreated psychosis, and negative symptoms. Impaired social functioning and negative symptoms are strong predictors.

Neurobiology

It may be that obstetric complications are a con- sequence rather than a cause of abnormal neu- rodevelopment.7 Smaller head size at the time of birth in persons with schizophrenia may be due to defect in genetic control of neurodevelopment or else due to an earlier environmental factor such as viral exposure. Influenza and Toxoplasmosis have been implicated but the evidence is not conclusive. The mechanism in these conditions may be cyto- kines-mediated disruption of neurodevelopment that expresses as post-pubertal disruption of neu- rotransmitter functions. Childhood viral infections show an association with schizophrenia (RR = 2.1), though it is not clear whether this is a cause or consequence of schizophrenia-related deficits.8 It

Pediatric Schizophrenia

Indian Journal of Clinical Psychiatry

6 Volume 3 | Issue 2 | 2023

is hypothesized that abnormal brain development, however, caused and set in motion, whether at the micro synaptic level or at the macro level of neural networks, is expressed as neurocognitive deficits that interact with environmental risk factors to produce psychotic symptoms.9 Cross–sectional structural brain changes like reduction of total grey matter (GM), especially bilateral insula, anterior cingulate cortex, thalamus, and superior temporal cortex, irrespective of the stage of illness, are present in schizophrenia. Front insular and superior temporal changes are consistently noted and appear to be related to clinical symptoms such as hallucina- tions.10,11

These findings along with ventricular enlarge- ment, are the most robust findings. These brain changes are similarly present in EOS and AOS, supporting the continuity between them. EOS patients have a higher rate of developmental brain abnormalities than controls. Volumetric changes are associated with a number of surface anatomical properties, such as thickness, surface area, and gyr- ification. Increased gyral curvature along with sulcal thinning affecting frontal, temporal and parietal lobes are noted in EOS. In adolescent-onset schizo- phrenia, both thickness and surface area reductions are seen in the prefrontal and superior temporal cortex. White matter (WM) changes in EOS are more widespread but less consistent than in AOS. WM changes strongly suggest structural dysconnec- tivity and are present in left frontal and temporal areas and in their connections to frontal, temporal, insular, hippocampal, amygdala and occipital areas. Progressive ventricular enlargement and volume reduction occur after the onset of schizophrenia, affecting the whole brain. In EOS there is greater progressive reduction in frontal areas. But its not clear whether these changes are due to schizophre- nia or antipsychotic medication.5

Brain changes precede the onset of schizophre- nia. Present evidence suggests that a disruption of developmental trajectories during critical periods preceding and immediately after the onset of illness contributes to the diverse changes in the GM struc- ture that characterize schizophrenia. fMRI studies suggest that schizophrenia patients show ineffi- ciency in recruiting brain regions when engaging

in specific cognitive tasks. This is most apparent in the tasks that require prefrontal recruitment, where increased recruitment of areas non-relevant to the task occurs.12 In the resting state, EOS patients show abnormal time-based correlations among regions that form large brain networks. Cortical neuronal coordination, as shown by oscillatory activity, is abnormal in prefrontal GABAergic interneurons. Almost all major neurotransmitter systems are involved in schizophrenia. The most well-understood are dopaminergic and serotonergic systems.13

Glutamatergic/GABAergic systems are strongly suspected of mediating cognitive dysfunction. Cog- nitive deficits are linked to recovery and functional outcomes. Cognitive performance deficits are wide. In EOS there is a notable reduction in IQ. The biggest cognitive deficit is in executive functions, along with processing speed deficits. Verbal memory deficits are pronounced in EOS. The deficits appear early and remain static before and after the development of schizophrenia. In adolescent-onset schizophrenia, there is a decline in verbal memory along with a lesser age-related progress in learning and process- ing speed.14

Conclusion

hence, In Y’s case the premorbid development was normal, onset acute and psychosis persistent. An adult dose of risperidone of 4 mg per day was required for initiation of response.

Only partial remission in 1.3 years of treatment but a significant return of normal behavior could be obtained. It cannot be said that Y’s psycholog- ical maturity has increased since the onset of his schizophrenia. It remains to be seen whether Y will progress to full sustained recovery and catch up in his psychological development as judged by his progress in education and behavior. Whether side effects of risperidone, if any, necessitate change in medication will need to be determined. The family will need to be motivated for long-term treatment and follow-up. EOS is continuous with AOS not only in clinical picture and course but also in having similar neuropsychological deficits and neurobiolog- ical abnormalities. Western literature has shown a worse course and outcome for EOS as compared to AOS. Whether this is so in India remains to be seen.

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In view of its rarity, multicentric research should help increase knowledge about EOS.

References

1. Kendhari J, Shankar R, Young-Walker L. A Review of Childhood-Onset Schizophrenia. Focus J Life Long Learn Psychiatry. 2016 Jul;14(3):328–32.

2. Werry JS. Child and adolescent (early onset) schizophre- nia: a review in light of DSM-III-R. J Autism Dev Disord. 1992 Dec;22(4):601–24.

3. Lin A, Wardenaar KJ, Pontillo M, De Crescenzo F, Mazzone L, Vicari S, et al. Is it still correct to differentiate between early and very early onset psychosis? Schizo- phr Res. 2016 Jan;170(1):211–6.

4. Bartlett J. Childhood-onset schizophrenia: what do we really know? Health Psychol Behav Med. 2014 Jan 1;2(1):735–47.

5. Thapar A, Pine DS, Leckman JF, Scott S, Snowling MJ, Taylor EA. Rutter’s Child and Adolescent Psychiatry. John Wiley & Sons; 2015. 1098 p.

6. Larson MK, Walker EF, Compton MT. Early signs, diag- nosis and therapeutics of the prodromal phase of schizophrenia and related psychotic disorders. Expert Rev Neurother. 2010 Aug;10(8):1347–59.

7. Forsyth JK, Ellman LM, Tanskanen A, Mustonen U, Hut-

9. 10.

11. 12. 13. 14.

tunen MO, Suvisaari J, et al. Genetic Risk for Schizophre- nia, Obstetric Complications, and Adolescent School Outcome: Evidence for Gene-Environment Interaction. Schizophr Bull. 2013 Sep;39(5):1067–76.

Khandaker GM, Zimbron J, Dalman C, Lewis G, Jones PB. Childhood infection and adult schizophrenia: A meta-analysis of population-based studies. Schizophr Res. 2012 Aug;139(1–3):161–8.

Sheffield JM, Karcher NR, Barch DM. Cognitive Deficits in Psychotic Disorders: A Lifespan Perspective. Neuro- psychol Rev. 2018 Dec;28(4):509–33.

Sone M, Koshiyama D, Zhu Y, Maikusa N, Okada N, Abe O, et al. Structural brain abnormalities in schizophrenia patients with a history and presence of auditory verbal hallucination. Transl Psychiatry. 2022 Dec 22;12(1):1–7. Venkatasubramanian G. Neuroanatomical correlates of psychopathology in antipsychotic-naïve schizophrenia. Indian J Psychiatry. 2010;52(1):28–36.

Gur RE, Gur RC. Functional magnetic resonance imaging in schizophrenia. Dialogues Clin Neurosci. 2010 Sep;12(3):333–43.

Luvsannyam E, Jain MS, Pormento MKL, Siddiqui H, Balagtas ARA, Emuze BO, et al. Neurobiology of Schizo- phrenia: A Comprehensive Review. Cureus. 14(4):e23959. Frangou S. Cognitive Function in Early Onset Schizo- phrenia: A Selective Review. Front Hum Neurosci. 2010 Jan 29;3:79.

Pediatric Schizophrenia

Indian Journal of Clinical Psychiatry 8

Volume 3 | Issue 2 | 2023

RESEARCH ARTICLE

ISSN- 2583-8873 (Indian Psychiatric Society- Uttar Pradesh State Branch (IPS-UPSB)) doi: 10.54169/ijocp.v3i02.71

Sociodemographic Profile and Psychological Factors Influencing Deliberate Self Harm in a Tertiary Rural Health Care Setup: A Cross-sectional Study

Gaurav Pawar, Kshirod K. Mishra*, Ahmed Reshamvala

Department of Psychiatry, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Maharashtra, India.

Abstract

Introduction: There has been a rising trend of deliberate self-harm (DSH) in India recently. The tendency to harm oneself is associated to female sex, younger age, stressful life events and mental illnesses such as depression. Knowledge of socio-de- mographic factors and psychiatric morbidities in patients having self-harming behav- ior can be helpful in planning suicide prevention strategies.

Methods: This was a hospital-based descriptive, observational, cross-sectional study. The data was collected from 150 consecutive referrals DSH to the psychiatry OPD in Rural Tertiary Care Centre. Corresponding validated psychometric scales quantified severity of depression, and suicide intent.

Results: Most of the study population belonged to 18 to 29 years age group and most were males (n = 105, 70%). Poisoning was the most common mode of DSH (n = 133, 88.7%). Diagnosable psychiatric illnesses were found in 52 (34.6%) patients, most common being adjustment disorder (n = 25, 16.6%).

Conclusion: Our study highlights the socio-demographic, psychosocial and clinical factors present in individuals attempting self-harm.

Indian Journal of Clinical Psychiatry

An Official Journal of Association of Clinical Psychiatry

ARTICLE INFO

*Correspondence:

Kshirod K. Mishra

drkkmishra2003@ yahoo.co.uk

Department of Psychiatry, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Maharashtra, India.

Dates:

Received: 25-05-2023 Accepted: 31-08-2023 Published: 08-11-2023

Keywords:

Deliberate Self- harm, Psychosocial factors, Farmers, Organophosphorus compounds, Adjustment disorder.

How to Cite:

Pawar G, Mishra KK, Reshamvala A. Socio- demographic Profile and Psychological Factors Influencing Deliberate Self Harm in A Tertiary Rural Health Care Setup: A Cross- sectional Study. Indian Journal of Clinical Psychiatry. 2023;3(2): 9-14.

doi: 10.54169/ijocp.v3i02.71

DIntroduction

eliberate self-harm (DSH) is defined as self-poisoning, injury or attempted

suicide irrespective of the purpose of the act according to ICD-10. Deliberate

self-harm incorporates actions with no suicidal intent (but with the intent to communicate distress or relieve tension) through to suicide.2 The term “delib- erate self-harm” is preferred to “attempted suicide” or “parasuicide” because there are many non-suicidal intentions among the range of motives or causes for this act of self-harm.2 A suicide attempt is a behavior that the individual has undertaken with at least some intent to die. The behavior might or might not lead to injury or serious medical consequences. Several factors can influence the medical consequences of the suicide attempt, including poor planning, lack of knowledge about the lethality of the method chosen, low intentionality or ambivalence, or chance intervention by others after the behavior has been initiated.3 Suicide attempts are a common clinical problem prevalent in general hospitals and are 10–40 times more frequent than completed suicides.4 The

majority of suicide attempters are in young, married males and hail from rural backgrounds.5

Out of the several modes of suicide attempts viz. organophosphorus poisoning, drug overdose, drowning, jumping from heights, hanging, etc., was most common in Central and Eastern Rural India.6,7 In recent times, an increasing trend in the use of organophosphorus compounds as a method of DSH has been seen due to their easy availability as household and agricultural chemicals.7

Farmers have shown a higher prevalence of DSH compared to people working in the private or public sectors.8 Several studies report that DSH is associated with high suicide intent and depression. Family cohesion and expressiveness directly and indirectly affect suicidal ideations, hopelessness, and depression.9

Knowledge of socio-demographic and psycho- logical factors of self-harm behavior can help in improving our understanding of the behavior which may further aid in self-harm prevention.

Methodology

Tools

Socio-demographic proforma

The information about socio-demographic parame- ters (age, sex, religion, education, occupation, mode and reasons for attempt) was collected using a pre-designed format.

Beck’s suicidal intent scale10

This is a 21-item self-report Likert-type scale which measures the desire of death, preparation of suicide attempt and actual suicide desire within past seven days. Each item has minimum score of zero and maximum score of two. The scale has high internal consistency (Cronbach alpha 0.87 to 0.97). The patient’s mental state just before the attempt was enquired using this scale.

Beck’s depression inventory 11

It is a 21-item self-report questionnaire commonly used to assess the severity of depression. A value of zero to three is assigned to each item in the order of increasing severity. The standard cut-off scores available in the manual were used for analysis in the present study as follows: 0–18 minimal depression; 18–30 mild depression; 19–29 moderate depression; 30–63 severe depression.

Statistical Analysis

Data entry and cleaning was done using MS Excel software. The final data was analyzed using EPI INFO software. The categorical data was expressed in frequencies and percentages, and the contin- uous data was expressed in mean with standard deviation. The Pearson correlation test was used to assess the correlation between the quantitative variables. All inferential statistics were carried out at a confidence level of 95% with a p-value less than 0.05 being significant.

Results

A total of 158 cases of attempted suicide were referred for psychiatric assessment and manage- ment during the study period, of which 8 declined to participate giving us a sample of 150 participants. The socio-demographic factors are represented

This was a cross-sectional, observational, descriptive study conducted at a rural tertiary health care centre in central India which receives patients from eastern Maharashtra, Chhattisgarh, Madhya Pradesh and Telangana. The study commenced after obtaining the approval of the Institutional Ethics Committee and data was collected between July 2020 and December 2021 using consecutive sampling. The patients brought to the hospital with a history of DSH were first admitted to medicine depart- ment and subsequently referred to the psychiatry department after medical stabilization for evalu- ation. Informed consent mentioning all the study related information and the right to withdraw from the study was taken from all the participants. The consent also included the clauses of confidentiality and use of data for scientific purposes which was explained to the participants in their local language. All adult patients with history of DSH were included in the study after taking the informed consent. Those unable to cooperate due to acute physical or mental illness and those unwilling to participate were excluded from the study.

Demographic and Psychological factors in Deliberate Self-harm

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in Table 1. The mean age of the sample was 32.37 ± 10.81 years (Range = 18–63 years) of which 46% were between 18 to 29 years of age and 30.7% were between 30 to 39 years of age. There was a male preponderance of self-harm with male to female ratio of 2.3:1. Most common religion was Hindu (90.7%) followed by Buddhist (6.7%) among the study sample. About 39% of the participants achieved high school certification and 26.7% had a secondary school certification, while only 6% were illiterate. 58% of the participants were married, 38.7% were unmarried and almost 3% were separated, divorced or widowed. Farmers and farm laborers contributed 54% of the participants followed by homemakers (18%), 15% were students and 13% patients owned business. About 93% of the participants resided in a rural area and rest in urban area. Most of the study sample lived in a nuclear family setup (76.7%) while 23.3% belonged to a joint family. Most of the patients belonged to lower middle class of socioeconomic status (38.67%), and 20.6% of patients belonged to low of socioeconomic status.

Table 2 shows the clinical variables of the DSH patients. Most participants attempted self-harm by consuming poison (88.7%), of which 71% of the patients consumed insecticide poison, and 12% con- sumed rodenticide poison (12%). Drug overdose was found in 6% of the patients. About 11% of the study population attempted self-harm by cutting wrist, hanging, and drowning. The most common reason for attempt of self-harm was altercation with spouse (30%) followed by not able to repay the money form the money lender (29%), altercation with family members (18%), a small proportion had broken love affair, job-related stress, failure in examination and other reasons for self-harm. 65% of the study population were not diagnosed with any psychiat- ric illness. About 16.6% of patients were diagnosed with adjustment disorder, severe depression (10%), or moderate depression (8%).

Table 3 shows the severity of suicidal intent: 71.3% of the participants had low suicidal intent, 18% had medium suicidal intent and 10% had high suicidal

Table 1: Socio-demographic variables (n = 150)

Demographic and Psychological factors in Deliberate Self-harm

status intent. As per B.G.

The correlation of the severity of suicidal intent and depression is shown in Table 4. A significant positive correlation was found on correlating suicide

Prasad scale

Variables

Age Group (years)

Gender Religion

Education

Marital Status

Occupation

Living Area Type of family

Socioeconomic

18–29 years 30–39 years 40–49 years 50–59 years ≥60 years Male Female Hindu Buddhist Muslim Illiterate Primary Middle

10th

12th

Graduation

Unmarried

Married

Separated

Widow

Divorced

Farm labourer Farmer Homemaker

Self employed Student

Employed

Rural

Urban

Nuclear

Joint

Upper class

Upper middle class Middle class

Lower middle class Lower class

n(%)

69 (46)

46 (30.7) 21 (14)

10 (6.7)

4 (2.7)

105 (70) 45 (30) 136 (90.7) 10 (6.7)

4 (2.7)

9 (6)

20 (13.3) 40 (26.7) 59 (39.3) 12 (8)

1 (0.7)

58 (38.7) 87 (58)

2 (1.3)

1 (0.7)

45 (30)

36 (24) 27(18)

20 (13.33) 15 (10)

7 (4.67) 140 (93.33) 10 (6.67) 115 (76.7) 35 (23.4)

4 (2.67)

25 (16.67) 32 (21.33) 58 (38.67) 31 (20.67)

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Table 2: Clinical variables (n = 150)

Table 4: Correlation of suicide intent with depression

Pearson Correlation used; *p <0.05, R= Pearson’s correlation coefficient,

of the participants were in the young age group of 18 to 39 years (76.7%) which matched the findings of Badrinarayana et al. (2007) and Singh P et al. (2016), where the majority of the DSH attempters were under the age group of 30 years.12,13

The majority of the participants in our study were males (70%), and the male: female ratio was 2.3:1. In a research conducted by Narang et al. (2000), the ratio was 1.7:1, which is comparable to the present study. 6

A higher proportion of married participants (58%) than unmarried (38%) were found in the present study which is consistent with the findings of Sudhir Kumar et al. (2006), who found that about 70.4% of suicide victims were married.14 In contrast to the current study findings, Srivastava A et al. (2005) and Narang et al. (2000), found singles (unmarried, widowed, divorced) are more likely to attempt suicide than married people.6,15 In the Indian subcon- tinent, getting married earlier might be a reflection of tradition and culture. It may be crucial to examine the variations in stress that married people experi- ence, particularly in terms of marital conflicts.

In the present study, most participants had higher secondary certificates (39.3%), comparable to the Latha KS et al. (1996) study, which found that 54% of suicide attempters had completed high school. 5 Ray S et al. (2019), reported higher preva- lence of attempted suicide among the people who completed 10th or 12th grade.16

The current study showed that more than half of the study population were farm laborers and farmers (54%) followed by homemakers (18%), 15% were stu- dents, and 13% owned businesses. Similarly, study done by Mishra et al. (2015) found suicide attempt rates were higher than average in the Vidarbha region of Maharashtra, which is home to the majority of India’s cotton farmers.17

Most of the population lived in a nuclear family (76%) and was in rural areas (93%). According to a study by Mishra et al. (2015), living alone was found to be a significant risk factor for self harm.17 Similar

Demographic and Psychological factors in Deliberate Self-harm

Variables (Mean ± SD)

BSI Score (20.35 ± 6.87)

BDI Score (14.84 ± 9.67)

0.851

0.0001*

Variables

Mode of self- harm

Insecticide Rodenticide Phenol Turpentine Salicylic Acid

n(%)

107 (71.33) 18 (12)

5 (3.33)

1 (0.67)

2 (1.33)

9 (6)

2 (1.33)

5 (3.33)

1 (0.67) 45 (29.9) 44 (29.33)

27 (18)

17 (11.3)

4 (2.67)

2 (1.33)

11 (7.33) 14 (9.3) 136 (90.6) 28 (18.6) 122 (81.3) 98 (65.33)

25 (16.67) 12 (8)

15 (10)

Reasons for attempt

Family history of DSH

Substance use

Psychiatric Diagnosis

Drug Overdose

Cutting

Hanging

Drowning

Altercation with spouse

Demand of money from the lender

Altercation with family member

Broken Love affair Job-related stress Failure in exam Other

Yes

Not diagnosed with psychiatric illness

Adjustment disorder Moderate Depression Severe Depression

Poisoning (88.7%)

Table 3: Suicidal intent among the participants (n = 150)

Beck suicide intent scale

Low Medium High

Male n (%)

77 (51.33) 22 (14.67) 6 (4)

Female n (%)

30 (20) 6 (4)

9 (6)

Total n (%)

107 (71.33) 28 (18.67) 15 (10)

intent score with Becks depression inventory score also depicted in Figure 1.

Discussion

The present study aimed at identifying the socio-de- mographic and psychosocial factors of DSH. Most

Indian Journal of Clinical Psychiatry

12 Volume 3 | Issue 2 | 2023

Figure 1: Correlation of beck suicide intent score and beck depression inventory score

results were reported by Ebenezer and Joge (2016), who conducted research in a rural area of Madhya Pradesh and found that 69% of patients from rural agricultural households, compared to 31% of patients had urban or semi-urban upbringings.18 Index study found a majority (58.6%) of the patients belonged to the lower middle-class or lower class of socioeconomic status which is comparable to the study done by Niaz U et al. (2006), in which they found that the majority of the people in their study were from lower socioeconomic background and unemployed.19 People with low levels of education, employment opportunities, and income are more likely to experience financial stress and a sense of insecurity, which can lead to suicidal behavior.

Consumption of pesticide was found to be the most common mode of self-harm the present study which is comparable to the studies done by Sharma et al. (1998), Srivastava et al. (2004) & Gunnell et al. (2007), highlighting that easy accessibility and rela- tive low-cost of pesticides make it a preferred mode of suicide attempt.20-22

In the present study, 65.33% of the population had No diagnosable psychiatric illness. Only 34.67% of the patients had a diagnosable psychiatric illness. 16.6% of patients were diagnosed with adjustment disorder, moderate depression (8%), and severe depression (10%). In a study done by Srivastava et al. A et al. (2005), the prevalence of depressive illness was 16.6%.15 A positive correlation between depression severity and suicide attempt was found in the present study, similar to a study by Srivastava S et al. (2000).23 The most common precipitating factor for self-harm was an altercation with a spouse (29.9%) or with family members (18%), followed by a demand for money from the money lender (29%), a

broken love affair (11%), failure in examination (1.3%) and job-related stress (2.6%). These findings are comparable with the study by Ghimire et al. (2014) who found interpersonal and marital conflicts most commonly precipitate DSH.24 The most frequent cause of DSH was conflict with the spouse. In a stress-vulnerability model, Rich and Bonner et al. (1987) observed that stress accounted for 30% of the variation in suicidal thoughts because Indian society is socio-centric, and interpersonal ties are valued highly.25 Therefore, interpersonal conflict is expected to be the leading cause of suicide in males.

The index study revealed that a significant number of the agrarian population from this rural area of Maharashtra attempt suicide due to financial constraints and interpersonal conflict in the family. According to a study by Mishra et al. (2015), the cotton producer community of Maharashtra was at a high risk of committing suicide due to associated debt and a decline in economic status in that region. The financial burden and family conflicts resulting from debt in the farming community after crop failure were the main causes of suicide attempts among the study population.17

Although majority of the people did not have psychiatric diagnosis (65%), DSH might be viewed as a maladaptive coping method culminating in impulsive acts this was observed in a in study done by Bhattacharya AK et al. (2011).26

Suicide intent and depression had a positive correlation in the present study. Similar findings were reported by Thompson et al. (2005). The current study’s findings support earlier research that showed a strong link between depression and suicide conduct.27

Conclusion

Deliberate self-harm was higher in younger males due to interpersonal problems and inability to pay back the loan in time. In rural agrarian populations, easy availability of organophosphorus poisoning made it the major mode of DSH. Government reg- ulations and control policies for pesticides from sale to storage could help curb this problem. The majority of the study population did not have a diagnosable psychiatric illness, hence DSH might be viewed as a maladaptive coping method. Promoting healthy

Demographic and Psychological factors in Deliberate Self-harm

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coping mechanisms and reduction in stressors might be beneficial in preventing self-harm. Our study emphasizes the need for a complete psy- chiatric evaluation in every case of self-harm and appropriate management based on the nature of the issues.

Limitations

A small sample size, hospital setting limit the gen- eralizability of the findings of present study.

Conflicts of Interest

None.

References

1. World Health Organization. The ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines. World Health Organization; 1992.

2. Hawton K, James A. Suicide and deliberate self harm in young people. BMJ [Internet]. 2005 Apr 16;330(7496):891–4.

3. American Psychiatric Association. Desk reference to the diagnostic criteria from DSM-5. Arlington: American Psychiatric Association, 2016.

4. Dennis MS, Wakefield P, Molloy C, Andrews H, Friedman T. Self-harm in older people with depression: Compar- ison of social factors, life events and symptoms. Br J Psychiatry. 2005;186(JUNE):538–9.

5. Suresh Kumar PN. Age and Gender Related Analysis of Psychosocial Factors in Attempted Suicide Study From a Medical Intensive Care Unit. Indian J Psychiatry [Internet]. 1998;40(4):338–45.

6. Latha KS, Bhat SM, D’Souza P. Suicide attempters in a general hospital unit in India: Their socio-demographic and clinical profile – Emphasis on cross-cultural aspects. Acta Psychiatr Scand. 1996;94(1):26–30.

7. Narang RL, Mishra BP, Nitesh M. Attempted suicide in ludhiana. Indian J Psychiatry [Internet]. 2000;42(1):83–7.

8. Behere P, Behere A. Farmers′ suicide in Vidarbha region of Maharashtra state: A myth or reality? Indian J Psychi-

atry. 2008;50(2):124.

9. Dyer JAT, Kreitman N. Hopelessness, depression

and suicidal intent in parasuicide. Br J Psychiatry.

1984;144(2):127–33.

10. Beck RW, Morris JB, Beck AT. Cross validation of the

suicidal intent scale. Psychol Rep. 1974;34(2):445–6.

11. García-Batista ZE, Guerra-Peña K, Cano-Vindel A, Her- rera-Martínez SX, Medrano LA. Validity and reliability of the beck depression inventory (BDI-II) in general and hospital population of Dominican Republic. PLoS One.

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2018;13(6):1–12.

Badrinarayana, A. SUICIDAL ATTEMPT IN GULBARGA. Indian Journal of Psychiatry 19(4):p 69-70, Oct–Dec 1977. Singh P, Shah R, Midha P, Soni A, Bagotia S, Gaur KL. Revisiting profile of deliberate self-harm at a tertiary care hospital after an interval of 10 years. Indian J Psychiatry. 2016;58(3):301–6.

Sudhir Kumar CT, Mohan R, Ranjith G, Chandrasekaran R. Gender differences in medically serious suicide attempts: A study from South India. Psychiatry Res. 2006;144(1):79–86.

Srivastava A, Kumar R. Suicidal ideation and attempts in patients with major depression: Socio-demographic and clinical variables. Indian J Psychiatry. 2005;47(4):225. Ray S, Husain Z. To be, or not to be: A study of suicides in India. 2019;(93891).Munich Personal RePEc Archive. Mishra K, Gupta N, Bhabulkar S. Socio-demographic profile of suicide attempters among the rural agrar- ian community of central India. Ind Psychiatry J. 2015;24(2):185.

Ebenezer JA, Joge V. Suicide in rural central India: Profile of attempters of deliberate self harm presenting to padhar hospital in Madhya Pradesh. Indian J Psychol Med. 2016;38(6):567–70.

Niaz U, Hassan S. Culture and mental health of women in South-East Asia. World Psychiatry. 2006 Jun;5(2):118. Sharma RC. Attempted suicide in himachal pradesh. Indian J Psychiatry [Internet]. 1998;40(1):50–4. Srivastava MK, Sahoo RN, Ghotekar LH, Dutta S, Dana- balan M, Dutta TK, et al. Risk factors associated with attempted suicide : a case control study. Indian J Psy- chiatry [Internet]. 2004;46(1):33–8.

Gunnell D, Fernando R, Hewagama M, Priyangika WDD, Konradsen F, Eddleston M. The impact of pesticide regulations on suicide in Sri Lanka. Int J Epidemiol. 2007;36(6):1235–42.

Srivastava S, Kulshreshtha N. Expression of suicidal intent in depressives. Indian J Psychiatry [Internet]. 2000;42(2):184–7.

Ghimire S, Devkota S, Budhathoki R, Thakur A, Sapkota N. Psychiatric comorbidities in patients with deliberate self-harm in a tertiary care center. J Nepal Med Assoc. 2014;52(193):697–702.

Rich AR, Bonner RL. Concurrent Validity of a Stress– Vulnerability Model of Suicidal Ideation and Behavior: A Follow‐Up Study. Suicide Life‐Threatening Behav. 1987;17(4):265–70.

Bhattacharya AK, Bhattacharjee S, Chattopadhyay S, Roy P, Kanji D, Singh OP. Deliberate self-harm: A search for distinct group of suicide. Indian J Psychol Med. 2011;33(2):182–7.

Thompson EA, Mazza JJ, Herting JR, Randell BP, Eggert LL. The Mediating Roles of Anxiety, Depression, and Hopelessness on Adolescent Suicidal Behaviors. Suicide Life-Threatening Behav.American Association of Suici- dology. 2005;35(1):14–34..

Demographic and Psychological factors in Deliberate Self-harm

Indian Journal of Clinical Psychiatry 14

Volume 3 | Issue 2 | 2023

Indian Journal of Clinical Psychiatry

An Official Journal of Association of Clinical Psychiatry (Indian Psychiatric Society- Uttar Pradesh State Branch (IPS-UPSB))

RESEARCH ARTICLE

ISSN- 2583-8873 doi: 10.54169/ijocp.v3i02.85

Responding to Crisis: An Analysis of Psychological

Reactions to the COVID-19 Pandemic through Web

Survey

M L Charan1* IiD , Krishan Kumar1 IiD , S Novena2 IiD , E V Johny3 IiD , Mujiba Nazeer4 IiD

1Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

2Department of Clinical Psychology, School of Allied Healthcare and Sciences, JAIN University, Bengaluru, Karnataka, India. 3Government General Hospital, Thalassery, Kannur, Kerala, India.

4Department of Clinical Psychology, SRM Institute of Science and Technology, Chennai, Tamil Nadu, India.

ARTICLE INFO

*Correspondence:

M L Charan

charan.mahendran18@ gmail.com

Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

Dates:

Received: 01-09-2023 Accepted: 17-10-2023 Published: 08-11-2023

Keywords:

COVID-19 anxiety, Psychological distress, Health, Resilience, Pandemic.

How to Cite:

Charan ML, Kumar K, Novena S, Johny EV, Nazeer M. Responding to Crisis: An Analysis of Psychological Reactions to the COVID-19 Pandemic through Web Survey. Indian Journal of Clinical Psychiatry. 2023;3(2): 10-18.

doi: 10.54169/ijocp.v3i02.85

Abstract

This study investigates the psychological impact of SARS-CoV-2 on pandemic-related anxiety, health, resilience, and psychological distress in 262 participants who were measured on COVID anxiety scale, health resilience stress questionnaire, and Kessler Psychological Distress through a web-based survey using Google Forms. Data col- lection was done from May 8th to May 12th, 2020, utilizing snowball sampling via social media platforms. Results revealed the participants were experiencing relatively low anxiety levels due to COVID-19, with only a minority indicating moderate to high anxiety. While most reported high resilience, a notable segment scored lower on health. Also, negative correlations emerged between resilience and COVID-19 anxiety, while positive correlations linked psychological distress to COVID-19 anxiety. Health displayed a significant positive correlation with resilience and an inversely significant correlation with psychological distress. Unexpectedly, no significant associations were found between psychological variables and COVID-19-related epidemiological variables, indicating multifaceted influences on psychological responses beyond immediate pandemic data. Additional scrutiny demonstrated no significant psy- chological variations between regions with differing pandemic intensities and living conditions. The findings underscore the intricate nature of psychological responses, shaped by individual and contextual factors.

TIntroduction

he novel coronavirus (COVID-19) originated in Wuhan; China in 2019 was

one of the most life-threatening diseases in mankind’s history, resulting in the global pandemic 2020. Countries have made several efforts to control the spread through vaccination campaigns and public health measures. Despite that, the COVID-19 pandemic has not only posed a threat to physical health but also profoundly impacted mental well-being. In India, the pandemic has led to numerous mental health challenges, including fear and anxiety, social isolation, economic distress, and limited access to mental health services. Studies have indicated a rise in the prevalence of mental health disorders in India since the onset of the pandemic. Research consistently demonstrates a high prevalence

of anxiety symptoms during the pandemic. Studies have shown that a significant portion of the general population experiences anxiety and related psy- chological distress as a result of the pandemic.[1] Prevalence rates varied across populations and countries, indicating a substantial impact on mental health. During the initial course of COVID-19 disease spread, people started experiencing a mental phe- nomenon which was referred as COVID-19 anxiety. It usually encompassed worries about infection, health concerns, uncertainties about the future, and the social and economic impacts of the pandemic.

Many factors contribute to COVID-19 anxiety such as fear of infection, concerns about personal health and the health of loved ones, uncertainties surround- ing the virus, social isolation, economic stress, and information overload from various media sources have been identified as significant contributors.[2,3] w These factors intensified anxiety and influenced individual responses to the pandemic. Frontline healthcare workers, individuals with pre-existing mental health conditions, those with a history of trauma, and individuals facing socio-economic challenges were at higher risk for COVID-19 anxiety.[1] These groups may experience heightened anxiety due to their unique circumstances and increased exposure to pandemic-related stressors. A survey conducted during the early stages of COVID-19 reported a high prevalence of stress, anxiety, and depression among the Indian population.[4] It was identified that females, individuals aged below 35 years, history of medical or psychiatric illness, and those who had personal contact with persons with COVID-19 were significantly associated with the presence of depression, anxiety, and stress during the COVID-19 pandemic.[5] Studies have found a strong association between fear of infection and psychological symptoms in the Indian population.[6]

As this is not the first time that India has gone through an infectious pandemic rather it had faced several infectious disease outbreaks in the past such as the third Bubonic Plague Outbreak (1896- 1906), Asiatic Cholera Outbreak (1817–24), Spanish Flu Pandemic (1918–20), Chikungunya Outbreak (2006), Nipah Virus Outbreak (2018–2019). But the present-day populace never had any lived expe- riences of the infectious disease outbreaks which

had killed many as most of them occurred either centuries ago or the recent outbreaks of diseases were assumed to be not very deadly and effective treatment options were available. But, in the case of COVID-19, the extensive media coverage of COVID- 19-related deaths and the graphic images can exac- erbate the anxiety. Frequent exposure to distressing information about the pandemic through various media channels might lead to increased fear and anxiety about mortality.[7] The uncertain nature of the pandemic and the lack of control over the virus’s spread and outcomes can also contribute to death anxiety. The fear of becoming infected, the unpre- dictability of the disease’s course, and concerns about the effectiveness of preventive measures will intensify anxiety surrounding mortality.[8]

In the present study we sought to explore the associations between COVID-19 related anxiety and the various other participant characteristics and other measures such as health, resilience and psychological distress. Also, there were no previ- ous Indian studies that directly compared the dis- ease-related statistics such as the number of cases reported every day, total number cases reported, total number of deaths occurring in the participants’ state with the outcomes of the study such as COVID- 19 related anxiety, psychological distress, health and resilience. Hence, the study hypothesized that disease related statistics such as number of cases reported every day, total number cases reported, total number of deaths occurring in the participants’ state of living would significantly predict the COVID- 19 related anxiety, psychological distress, health and resilience.

Methods

Survey Description

The web-survey contained the description of study information and informed consent (including the confidentiality and data protection of the respon- dents), on agreeing the page was redirected to the data capture phase of the survey wherein the par- ticipants were asked to respond to the socio-demo- graphic details and statements of all the measures of the study. It had a total of 35 statements across

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all outcome measures of the study and it approxi- mately 25 minutes took to complete the survey. All the outcome measures of the survey were used in its original language (English).

Recruitment of the Participants

The web-based survey link was shared to the partic- ipants over social media platforms. After completion of the survey, the participants were encouraged to share the survey to others. There were no incentives given to respondents. The data collection started on 8th May 2020 and ended on 12th May 2020.

Measures

• COVID Anxiety Scale[9] – This scale was used to measure an individual’s anxiety level due to COVID-19 pandemic-related anxiety. It is a self-report measure. The CAS contains 5 items and it is rated on a 5-point scale from 0 (not at all) to 4 (nearly every day). The CAS has good internal consistency and is a reliable instrument with solid factorial and construct validity. The Cronbach’s alpha coefficient ranges from 0.84 to 0.93. The closer the CAS score to 20, then it is interpreted as subjected is experiencing more anxiety due to COVID-19.

• Health Resilience Stress Questionnaire[10] – It is a self-administered measure that measures a person’s ability to tolerate and cope with stress in relation to their health and takes only 2 to 5 minutes to complete. It consists of a series of questions that explores the individual’s physical and emotional well being, coping mechanism and social support. The HRSQ score determines the level of risk (risk category: extreme, high, moderate, low) and this determines the level of care and follow-up that should be recom- mended. Only part-A (Resilience) and part-B (Health) was used in this study. The HRSQ has good test-retest reliability, internal consistency, construct validity.

• Kessler Psychological Distress [11] – It is a self-re- ported measure that measures psychological distress in individuals aged 16 and above. It is a 10 item questionnaire and each item is scored on a 5-point Likert scale, ranging from 1 (none of the time) to 5 (all of the time). The total score

of an individual ranges from 10 (minimum score) to 50 (maximum score), with lower scores indi- cating lower psychological distress and higher scores indicating greater psychological distress. The K10 has good internal consistency and the Cronbach’s alpha coefficient ranges from 0.85 to 0.93. The K10 has good construct validity and good concurrent validity. The closer the K10 score to 50, then it is interpreted as subjected is experiencing more psychological distress.

Study Design and Participants

In this cross-sectional prospective survey, a total of 262 people participated (as shown in Table 1): 139 participants were female, and 123 participants were male. Eight participants were from the Northern Zone, which includes states such as New Delhi and Haryana. Sixteen participants were from the North Eastern zone, which includes states like Assam, Manipur, and Sikkim. The Central zone had 23 par- ticipants, covering states such as Madhya Pradesh, Uttarakhand, and Uttar Pradesh. The Eastern zone was represented by 60 participants from states like Bihar, Jharkhand, and West Bengal. The Western zone had 35 participants from states like Goa, Gujarat, and Maharashtra. The Southern zone was the most heavily represented with 120 participants, covering states like Kerala, Tamil Nadu, Telangana, and Karnataka. The state distribution of the partici- pants in this study is as follows: 61 participants from Karnataka, 48 from Bihar, 21 from Tamil Nadu, and 18 from Maharashtra and Uttar Pradesh each. There were 17 participants from Andhra Pradesh, 13 from Gujarat, 11 from Telangana, and 10 each from Kerala and West Bengal. Additionally, 7 participants were from Assam, 6 from Manipur, and 6 from Haryana. Four participants were from Goa, 3 from Madhya Pradesh, and 3 from Sikkim. Two participants were from Jharkhand, New Delhi, and Uttarakhand each. All the participants self-reported non-positive for COVID-19 at the time of response collection.

Data Pre-processing

The raw socio-demographic data which involves their current state of residence, was processed and grouped on the basis of zones using the admin- istrative guidelines released based on the States

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Reorganization Act, 1956.[12] The states of India have been grouped into six zones: Northern Zone, North Eastern Zone, Central Zone, Eastern Zone, Western Zone and Southern Zone. The COVID-19 related sta- tistic such as number of cases reported, new cases reported, number of deaths was extracted retro- spectively from various sources (including online COVID-19 statistic databases, published newspa- pers and media reports) when the analysis was performed. The spread intensity of COVID-19 was calculated using Mean ± SD of the total number of cases reported and the number of deaths occurring in every state during the time of the data collection period. The states with cases > 1 SD were labeled as high spreading regions whereas those with cases < 1 SD were labeled as low spread regions. All the other categorical (nominal) socio-demographic data was coded and used for the analysis.

Data Analysis

All the continuous data were initially subjected to assumption testing to assess its eligibility to test the hypothesis using parametric statistics. The assumption testing for normality revealed that the continuous data of the obtained measures were not normally distributed. However, the test for homo- geneity of variances for all the grouping variables considered in the analysis were found to be satisfied.

Results

Participant Characteristics

From the total participants, about 196 (75%) partic- ipants were aged between 15 to 25 years, 43 (17%) participants were aged between 26 to 35 years, 14 (5%) participants were aged between 36 to 45 years, 8 (3%) participants were aged between 46 to 55 years and 1 (0.38%) participant was aged between 56 to 61 years. The educational qualifications of the participants are as follows: 35 (14%) participants have completed their higher secondary education, 6 (2%) participants have completed a diploma course, 111 (42%) participants have completed their under- graduate degree and 110 (42%) participants have completed their postgraduate degree. The partici- pants’ living conditions during COVID-19: 229 (87%) participants were living with their family, 15 (6%)

Table 1: Participant characteristics

Psychological Reactions to the COVID-19 Pandemic

Variables

Age

15–25

26–35

36–45

46–55

56–61

Educational Qualification

Higher Secondary Diploma Undergraduate Postgraduate

N (%)

–

196 (75%) 43 (17%) 14 (5%)

8 (3%)

1 (0.38%)

–

35 (14%) 6 (2%)

111 (42%) 110 (42%)

Mean ± SD

24.67176 ± 7.280313

– – – – –

15.39313 ± 1.682121

– – – –

– – –

–

– – – – – –

Living Condition During COVID-19

With Family

In a shared accommodation

Alone

Gender Males Females

229 (87%) 15 (6%)

18 (7%)

123 (47%)

139 (53%)

Zone of Living During COVID-19

Northern Zone North-Eastern Zone Central Zone Eastern Zone Western Zone Southern Zone

8 (3%)

16 (6%) 23 (9%) 60 (23%) 35 (13%) 120 (46%)

participants were living in a shared accommodation and 18 (7%) participants were living alone during COVID-19 (Table 1).

Score Ranges, Mean and Standard Deviations for COVID-19 Anxiety, Health, Resilience and Psychological Distress

The measures’ mean and standard deviation are shown in Table 2. The quartiles were computed using the potential score ranges for each measure as no normative data was available for comparison.

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Measure

COVID-19 Anxiety

Health

Mean (SD)

2.076 (2.944) 20.713 (4.302)

50.812 (8.638)

22.824 (8.411)

Psychological Reactions to the COVID-19 Pandemic

Table 2: Score ranges, mean and standard deviations for the measures

Potential Score Range

0–20

6–30

Resilience Psychological 10–50

Distress

Participant Range Scores

0–17

6–30 14–69 10–50

1st Quartile N (%)

223 5

125

2nd Quartile N (%)

27 82

3rd Quartile N (%)

9 124

162

4th Quartile N (%)

51 64 8

14–70

COVID anxiety scale (COVID-19 Anxiety)

The overall COVID-19 anxiety scores ranged from 0–17 with a mean ± SD score of 2.076 ± 2.944. Only about 4.5% of the participants had their scores between 3rd and 4th quartiles, indicative of moderate to high anxiety due to COVID-19.

Health stress resilience questionnaire (Health and Resilience)

• For health, the participant’s scores ranged from 6–30 with a mean ± SD score of 20.713 ± 4.302. Around 33.20% of participants had a score between 1st and 2nd quartiles indicative of low health.

• For resilience, the participant’s scores ranged from 14–69 with a mean ± SD score of 50.812 ± 8.638. We found that only 13.74% of the par- ticipants scored between 1st and 2nd quartiles, indicative of low resilience.

Kessler’s psychological distress scale (Psychological Distress)

Kessler’s psychological distress scale scores ranged from 10–50 with a mean ± SD score of 22.824 ± 8.411. Only about 19.4% of the participants had their scores between 3rd and 4th quartiles, indicative of moderate to high psychological distress COVID-19 pandemic.

Correlation between COVID-19 Anxiety, Health, Resilience and Psychological Distress and Other COVID-19 Disease related Statistics

The results (Table 3) shows that resilience had a significant negative correlation with COVID-19 anxiety, r = -.176, p < 0.01. The health had a signifi- cant positive correlation with resilience, r = .420, p < 0.01. The psychological distress had a significant positive correlation with COVID-19 anxiety, r = .457,

Table 3: Pearson correlation for the various measures used in the study

CAS Pearson Coeff. RES Pearson Coeff. Health Pearson Coeff. K10 Pearson Coeff. TCC Pearson Coeff. CCSD Pearson Coeff. AC Pearson Coeff. TD Pearson Coeff. DSD Pearson Coeff.

CAS RES Health K10 TCC CCSD AC TD DSD

–

-.176** –

-.090 .420** –

.457** -.366** -.252** –

-.021 -.019 .010 -.025 –

-.030 .011 .012 -.010 .968** –

-.021 -.009 .008 -.022 .997** .973** –

-.037 -.060 -.008 -.028 .929** .840** .923** –

-.030 -.040 -.010 -.023 .940** .870** .940** .985** –

**. Correlation is significant at the 0.01 level (2-tailed). CAS: COVID-19 Anxiety Scale, RES: Resilience, K10: Kessler Psychological Distress Scale, TCC: Total Confirmed Cases, CCSD: Confirmed Cases on that Specific Day, AC: Active Cases, TD: Total Deaths, DSD: Deaths on that Specific Day

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p < 0.01. Furthermore, psychological distress had a significant negative correlation with resilience, r = -.366, p < 0.01; and health, r = -.252, p < 0.01. Contrary to our hypothesis, we did not see any relationship between the measures (COVID-19 Anxiety, Health, Resilience and Psychological Distress) and the COVID-19 related statistics (no. of cases reported, active cases, no. of deaths etc.,).

Differences in COVID-19 anxiety, health, resilience and psychological distress

The entire descriptive statistic of this analysis is illus- trated in Figures 1-3 under its respective grouping variable.

• Based on spread intensity

The independent sample t-test analysis indi- cated that there were no significant differences in COVID-19 anxiety between high-spread regions (1.9200 ± 2.75465) and low-spread regions (2.1390 ± 3.02177), t(260) = 0.544, p = 0.587. Similarly, there were no significant differences in resilience between high-spread regions (49.7333 ± 10.00720) and low- spread regions (51.2460 ± 8.01299), t(260) = 1.283, p = 0.201. Likewise, no significant differences were observed in health between high-spread regions (20.6800 ± 3.82792) and low-spread regions (20.7273 ± 4.48839), t(260) = 0.080, p = 0.936. The analysis also showed no significant differences in psychological distress between high-spread regions (22.1067 ± 7.75394) and low-spread regions (23.1123 ± 8.66418), t(260) = 0.874, p = 0.383.

Figure 1: Means of the measures grouped based on Spread Intensity

Figure 2: Means of the measures grouped based on Zone of Living during pandemic

Figure 3: Means of the measures grouped based on Living condition

• Based on zone of living

The one-way ANOVA results revealed there were no significant differences between zone of living and health [F (5, 256) = 1.640, p = .150]; psychological distress [F (5, 256) = 1.402, p = .224]. However, there were near marginal yet not significant differences were observed in COVID-19 anxiety [F (5, 256) = 1.929, p = .090] and resilience [F (5, 256) = 1.402, p = .224].

• Based on living condition

The one-way ANOVA results revealed no significant differences between living conditions (with family, in shared accommodation and alone) and COVID-19 anxiety, F (2, 259) = 1.758, p = .174. The same trend was observed in health [F (2, 259) = 422, p = .656], resil- ience [F (2, 259) = 1.663, p = .192] and psychological distress [F (2, 259) = .847, p = .430].

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Discussion

The statistical results presented in this study provide valuable insights into the psychological impact of the COVID-19 pandemic on individuals. To enrich our understanding of these findings, it is essential to contextualize them within the broader landscape of psychological studies conducted during the pandemic. The negative correlation between resil- ience and COVID-19 anxiety aligns with two Chinese based studies, both of which found that higher resil- ience was associated with lower pandemic-related anxiety.13,14 These studies underscore the importance of cultivating resilience to alleviate anxiety during crises. The positive correlation observed between psychological distress and COVID-19 anxiety reso- nates with the findings of one Iranian and Chinese based study,15,16 who reported a similar relationship. These studies suggest that heightened anxiety about the pandemic is closely tied to increased psychological distress, reinforcing the need for targeted psychological support measures. The positive correlation between health and resilience was consistent in two similar research conducted, both of which demonstrated a connection between physical health and psychological well-being during the pandemic.17,18 These studies highlight the bidi- rectional relationship between health and mental resilience.

The surprising lack of significant associations between the studied psychological measures and COVID-19 related data, such as the number of reported cases, active cases and deaths etc., raises important questions about the factors that contribute to individuals’ psychological responses during a pandemic. One study found that psycho- logical distress during the pandemic was not solely determined by infection rates.19 This suggests that factors beyond the immediate pandemic data influ- ence psychological responses. While these statistics provide valuable contextual information, they might not directly predict the complex emotional reactions that individuals experience. This underscores the role of individual and contextual factors that influ- ence psychological well-being beyond mere expo- sure to COVID-19 and the intensity of its spread. The lack of significant differences in psychological vari-

ables between high-spread and low-spread regions is in line with the findings of previous research.20,21 These studies demonstrate that the psychological impact of the pandemic is not solely dictated by the severity of the outbreak in a specific region, reflecting the global nature of the psychological challenges posed by the pandemic. The absence of significant differences in psychological variables across different living conditions aligns with findings of the published literature.22,1 These studies suggest that psychological responses to the pandemic are not significantly influenced by one’s immediate living situation, highlighting the universality of the psychological experience.

The cross-sectional design employed in this study captures a snapshot of participants’ psycho- logical states at a specific point in time. Longitudinal studies would offer a more dynamic understanding of how these psychological variables evolve over the course of the pandemic and its aftermath. The study relied on self-reported anxiety, health, resilience, and psychological distress measures. While these measures provide valuable subjective insights, they might be susceptible to response biases and varying interpretations. The other limitations could be it did not take the psychiatric co morbidity of the partici- pants into consideration, majority of the participants are from the age group 15 to 25, and a small sample size hence findings cannot be generalized.

Conclusion

In conclusion, when juxtaposed with the results of existing research, this study’s findings contribute to a more comprehensive understanding of the psy- chological impact of the COVID-19 pandemic. While consistent anxiety, resilience, and distress patterns emerge, the complex interplay between these vari- ables and objective data underscores the multifac- eted nature of psychological responses during crises. Moreover, the universal trends observed across different regions and living conditions empha- size the need for globally relevant psychological support strategies. As we continue to navigate the challenges of the pandemic, these insights serve as crucial guideposts for both research and practical interventions.

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Future studies could incorporate more objective measures or a combination of methods for a com- prehensive assessment. The study did not consider various contextual factors, such as government interventions, media exposure, or personal coping strategies, which could influence participants’ psy- chological responses. Exploring these contextual variables could provide a deeper understanding of the intricacies of psychological reactions during a crisis. While the study identifies associations between psychological variables, it does not delve into the effectiveness of specific interventions aimed at mitigating COVID-19-related psychological distress. Future research could explore the efficacy of various interventions, such as online counseling, mindfulness practices, or support groups.

Ethical Considerations

The confidentiality and anonymity of the partici- pants were assured for their responses. This study was conducted in accordance with the Helsinki Declaration and American Psychological Association guidelines on conducting research studies.

Data Availability

The data will be made available upon reasonable request to the corresponding author.

Author Contributions

MLC – Conceptualization, Methodology, Software, Formal analysis, Investigation, Writing – Original Draft, Writing – Review & Editing, Visualization, Project administration. KK – Validation, Resources, Supervision. SN – Software, Formal analysis, Data Curation, Writing – Original Draft, Writing – Review & Editing. EVJ – Validation, Investigation, Resources, Supervision. MN – Data Curation, Writing – Original Draft, Writing – Review & Editing.

Conflict of Interest

None.

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Indian Journal of Clinical Psychiatry

An Official Journal of Association of Clinical Psychiatry (Indian Psychiatric Society- Uttar Pradesh State Branch (IPS-UPSB))

RESEARCH ARTICLE

ISSN- 2583-8873 doi: 10.54169/ijocp.v3i02.98

Insight into Patterns of Sociodemographic and Clinical Profile of Patient attending a Newly Started Psychiatry Outpatient in an Institute of National Importance from North India: A Retrospective Chart Review

Rashmi Shukla*, Arghya Pal, Shilpi Kandwal

Department of Psychiatry, All India Institute of Medical Sciences, Raebareli, Uttar Pradesh, India.

Abstract

Background: Psychiatric disorders constitute a global public health concern. Despite advancements in mental health care, significant disparities persist in the accessi- bility and quality of services provided, particularly in under-resourced areas. There is no data on mental health from the Raebareli district of Uttar Pradesh. This study reports the initial trends in patient profiles in a newly established psychiatry outpa- tient department.

Aim: The present study was conducted to assess the sociodemographic and clini- cal profile of patients attending a newly started mental health establishment in an Institute of National Importance.

Methodology: This retrospective study analyzed case records of psychiatric patients who attended the psychiatry outpatient department from October 2020 to October 2022. Data regarding the sociodemographic profile and clinical profile was obtained. The data was analyzed using descriptive statistics as appropriate.

Results: A total of 5650 patients visited the outpatient department during the study period. The mean age of the patients attending was 37.38 years, with the majority of the patients being males (55.3%), Hindus (93.7%) and married (71.7%). The trends showed that there was rise in patients attending the centers during April and September. The most common diagnosis belonged to the group of F40, neurotic, stress-related and somatoform disorder (43.8%) disorders as per ICD 10 classification.

Conclusion: The profile of the presenting age of various disorders were in sync with the existing literature. A trend of increase in census could be seen during April and September. This study will be helpful in anticipating and planning the initiation of mental health services at a tertiary level.

ARTICLE INFO

*Correspondence:

Rashmi Shukla

drrashmikgmu06@ gmail.com

Department of Psychiatry, All India Institute of Medical Sciences, Raebareli, Uttar Pradesh, India.

Dates:

Received: 19-10-2023 Accepted: 04-11-2023 Published: 08-11-2023

Keywords:

Psychiatric, Clinical profile, Sociodemographic profile.

How to Cite:

Shukla R, Pal A, Kandwal S. Insight into Patterns of Sociodemographic and Clinical Profile of Patient attending a Newly Started Psychiatry Outpatient in an Institute of National Importance from North India: A Retrospective Chart Review. Indian Journal of Clinical Psychiatry. 2023;3(2): 24-29.

doi: 10.54169/ijocp.v3i02.98

PIntroduction

sychiatric disorders encompass a broad spectrum ranging from subclin-

ical states to more severe forms. Mental health issues can progress to a level of disorder if left untreated, which are typically identifiable, diagnosable and treatable. Certainly, psychiatric epidemiology holds a significant position within the realm of health sciences as a scientific discipline as it plays a crucial

Profile of patients attending psychiatry outpatient in an Institute of National Importance

role in understanding and addressing the patterns, causes and effects of mental health diseases in populations. There have been many epidemiolog- ical studies nationally and internationally. National mental health survey (NMHS) reported the overall weighted prevalence for any mental morbidity as 13.7% (lifetime) and 10.6% (current).1 International studies, such as the epidemiological catchment area program and the national comorbidity survey, have documented varying prevalence rates of various psychiatric disorders.2 The dynamic nature of mental disorders and methodological differences in epidemiological studies may contribute to the variability in reported rates within various studies.2 Also, this may affect health care planning, delivery and policy making.

It is evident that psychiatric disorders and sub- stance use disorders account for a substantial 13% of global burden of disease.3 The burden has seen a notable 41% increase from 1990 to 2010, primarily attributed to population growth.4 Alarmingly, a sig- nificant three-quarters of this burden lies in low- and middle-income countries, with a similar proportion lacking access to essential services due to resource constraints.5 Additionally, more than two-thirds of the total population live in rural areas in India.6 Where accessibility, availability and affordability always remains an area of concern. Although there is an increase in awareness of mental health a huge treatment gap exists, ranging from 70 to 92% for various psychiatric disorders.1

To reduce this enormous treatment gap in India there is a need of the development of effective, efficient services at the local level, which is culturally and socially acceptable and based on firm research base.7-9 In this direction to meet the need of increas- ing demand, the initiation of a psychiatry outpatient department within an institute of national impor- tance marks a significant milestone. This institute is situated on the outskirts of Raebareli town and serves nearby districts. The predominant composi- tion of this population is rural with 91% of the pop- ulation living in rural areas.10 Hence, understanding the sociodemographic and clinical characteristics of patients accessing this newly established psychia- try outpatient department (OPD) is paramount for understanding the prevalent mental health disor- ders in this region, optimizing resource allocation,

tailoring interventions and ensuring the provision of high-quality, culturally sensitive mental health care. With this background, this study endeavors to delineate the diverse profile of patients who seek care at this institute, shedding light on the initial diagnostic trends.

Material and Methods

this retrospective chart review was conducted at the All India Institute of Medical Sciences (AIIMS), Raebareli, a tertiary mental health establishment in Uttar Pradesh state in northern India. In this case records of psychiatric patients above 18 years of age, who attended the psychiatry outpatient department(OPD) of this centre from October 2020, to October 2022 were reviewed. Sociodemographic details included age, gender, religion, education status, and marital status. The clinical details col- lected include psychiatric diagnosis as mentioned in the case records made by the treating psychiatrist as per International Classification of disease (ICD10)11 criteria, any medical/psychiatric comorbidities, month of consultation and family history of psy- chiatric illness. The sociodemographic and clinical details were filled on a designed Excel sheet. All the data was collected by one of the authors to maintain uniformity of the data. The data was evaluated in the SPSS version 22. We Calculated descriptive statistics, including the mean, standard deviation and frequency distribution for all demographic and clinical variables.

The study was approved by Institute Ethics Com- mittee (AllMS Raebareli) Study/Protocol No 2023-13- IMP-4 dated 10/07/2023.

Results

The outpatient services in this institute started in October 2020. Overall, the total number of new patients who have attended Psychiatry OPD was 5650 (Figure 1). The collected data was checked for completeness. In this process, we were unable to have all the data for 985 patients. We excluded them from the analysis. We included 4665 patients in the final analysis. The mean age of the patients attending was 37.38 (15.18) years with the majority of the patients being males (55.3%), Hindus (93.7%) and

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Profile of patients attending psychiatry outpatient in an Institute of National Importance

married (71.7%)(Table 1). Overall, the most common diagnosis belonged to the group of F40, neurotic, stress-related and somatoform disorder (43.8%) disorders, followed by mood disorders (27.8%) and psychotic spectrum disorders (17.8%) as per ICD 10 (Table 2). Analyzing clinical data for a subset of 4661 patients, we observed variations in age distri- bution across different diagnostic groups. Patients with diagnoses related to organic mental disorders (F00-09) group presented at an older age (mean 64.67 years). While the younger age group is repre- sented in substance use disorder (33.33), psychotic spectrum disorders(36.62), anxiety and stress-re- lated disorders (35.15), mood disorder (39.07), per- sonality disorders (29.90) and mental retardation (26.30) (Figure 2).

The trends showed that there was rise in patients attending the center during April and September (Figure 3). When interpreted for each group of disor- der separately, the highest representation was from F40 group, followed by F30 group and F20 group (Figure 3). This trend was found to be uniform across all months of the year (Full form of ICD 10 codes is mentioned in Table 2).

Discussion

The findings from our study provide valuable insights into the patient profile and utilization patterns of the newly established psychiatry OPD, since its initiation in October 2020. A total of 5650 new patients sought services at the OPD. Notably, there was a marked increase in patient attendance over time, reflecting a growing recognition of the availability and acces- sibility of mental health services in our institute. It

Table 1: Sociodemographic profile of the patients (N = 5650)

Parameters

Age (in years)

Gender Religion

Education

Marital Status

Family History of Psychiatric Illness

Male

Female

Hindu

Muslim

Others

Illiterate

Till Primary

Till Secondary

Till graduate

Professional

Never married

Married

Divorced/ Separated

Present Absent

N (%) or Mean (SD)

37.38 (15.18)

3120 (55.3%) 2527 (44.7%) 5292 (93.7%) 344 (6.1%)

9 (0.2%)

858 (15.2%) 1825 (32.3%) 2119 (37.5%) 813 (14.4%) 35 (0.6%) 1561 (27.6%) 4053 (71.7%) 36 (0.7%)

331 (5.9%) 5319 (94.1%)

Figure 1: Distribution of patients across Calendar years (since October 2020) (N=5650)

also shows increasing awareness regarding mental health problems.12 Nevertheless, it is vital to interpret the increase in patient numbers while taking into account external factors. Specifically, the year 2020 witnessed restrictions on physical interactions due to the COVID-19 pandemic, which could have had an impact on patterns of patient attendance.13

Sociodemographic characteristics revealed mean age of patient was 37.88 years. With a slightly higher representation of males(55.3%).Which was similar to earlier conducted studies.14-16 In our sample, Hindus were over-represented, which is also supported by the district-level data that Hindus comprise of about 87.39% of the population of Raebareli.17 However, even considering this data, the mental health help-seeking was poorer in non- Hindu patients and thus further initiatives should be planned to improve access to mental health in these communities.

In our sample, increased morbidity is seen in the younger age group, similar to earlier conducted studies.14,18-20 In our study we found that patients with affective and psychotic spectrum were pre-

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Profile of patients attending psychiatry outpatient in an Institute of National Importance

Table 2: Prevalence of primary psychiatric diagnoses at first presentation according to ICD 10 (N=4661*)

Diagnosis Number of patients [n (%)]

F00-F09 161 (3.4) F10-19 195 (4.1) F20-F29 830 (17.8) F30-F39 1300 (27.8) F40-F48 2042 (43.8) F50-59 31 (0.6) F60-69 50 (1.1) F70-79 52 (1.1) TOTAL 4661

*- Excludes patients who had incomplete data or deferred diagnosis

F00 to F09: organic,including symptomatic,mental disorders

F10 to F19: Mental and behavioral disorders due to psychoactive substance use

F20 to F29: Schizophrenia, schizotypal and delusional disorders

F30 to F39: Mood (affective) disorders

F40 to F48: Anxiety, dissociative, stress-related and somatoform disorders

F50 to F59: Behavioral syndromes associated with physiological disturbances and physical factors

F60 to F69: Disorders of adult personality and behavior F70 to F79: Mental retardation

Numbers in the horizontal axis of the figure represent the months of a year. For example, 1.0 represents January month

Figure 3: Distribution of patients first presentation accord- ing to the calendar months (N=4661)

study, there was a slight predominance of males over females. This finding aligns with previous studies.14,21,22 This could be indicative of a gender bias inherent in a patrilineal family system, influencing help-seeking behavior. The gender-specific norms and other sociocultural factors may contribute to women facing additional barriers when attempting to seek help for mental health concerns.14,24

The majority of the patients had education primary and secondary. Remarkably, a substantial majority (94.1%) reported no family history. Only 5.9% of the subjects reported history of family members suffering from mental health problems. Which was lower than the findings of Shakya et al.24 This could be due to stigma or unwillingness to divulge familial information.

In our study we found neurotic, stress related and somatoform disorder (43.8 %) was the most common diagnosis followed by mood disorders (27.8%) and psychotic spectrum disorders(17.8%). This was consistent with the findings of Kameshvell,14 Regmi et al.21 and Shakya et al.24 Whereas in other studies showed schizophrenia and other psychotic disorder as main diagnostic groups.19,22 Our findings are similar to another study conducted in rural com- munity of Uttar Pradesh(India),in which about 44% of the patients were suffering from neurotic and related disorders and 9.1% from schizophrenia.25 One

Horizontal axis of the figure represents the ICD 10 F code.

Figure 2: Age-wise distribution of the patients according to their diagnosis at first presentation (N = 4661)

sented in their fourth decade which is in line with findings reported in NMHS of India.1 Earlier research has consistently highlighted a significant link between gender and mental health, often noting that the female gender is associated with a higher risk of certain psychiatric disorders. However, In our

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Profile of patients attending psychiatry outpatient in an Institute of National Importance

of the criticism of the existing literature on this area, which comprises of more of the community based studies is that these studies have been unable to tap the disorders that have relatively lesser prevalence (like sleep disorders and sexual disorders). One of the major reasons behind that is the fact the studies are conducted using pre-decided tools administered by trained staff. Our study adds valuable information in this aspect, as psychiatrists made the diagnoses in these patients after detailed interviews (and not based on semi-structured or structured tools).

Another important trend we noticed was rise in patients attending the services during April and Sep- tember. When interpreted for each group of disorder separately, the highest representation was from F40 group followed by F30 group and F20 group. This trend was found to be uniform across all months of the year. This could be explained as few psychiatric disorders can occur in seasonal pattern, especially with the onset of summer and winter. A study con- ducted by Avasthi et al., highlight distinct seasonal trends in psychiatric diagnosis. It has reported peak of mood disorders during winter months.26

Conclusion

Overall our findings provide an overview of patient profile and utilization patterns at newly established psychiatry OPD. These insights are crucial for tai- loring services, optimizing resource allocation and planning targeted interventions to address the diverse mental health needs of the community we serve. Also, it shows that awareness is increasing regarding mental health issues.

Limitations

It was a single centre, retrospective study which limits its generalizability. For a subset of patients complete data could not be retrieved, potentially introducing selection bias.

early intervention and prevention efforts. Tertiary psychiatry care was not available in this part of the region earlier. Hence, this study can form the basis of larger population-based studies that should be performed henceforth to garner a better idea about the epidemiology of psychiatric disorders.

Ethical Approval

The study was approved by the Institute Ethics Committee (AllMS Raebareli) Study/Protocol No 2023-13-IMP-4 dated 10/07/2023.

Funding

This is a completely researcher-initiated study without any external funding whatsoever.

Acknowledgment

None.

Conflicts of interest

There are no conflicts of interest. The authors whose names are listed above certify that they have no affiliations with or involvement in any organization or entity with any financial interest.

Authors contribution

Dr RS-Conceptualization, supervision, data collec- tion, writing the manuscript, review and editing. Dr AP: Analysis of data, writing, and review of manu- script. Ms SK-Data collection, editing and review of the manuscript. All the authors confirm that all of them have contributed in the conception of design; analysis, interpretation of data; drafting of the article; critically revisiting the article for important intellec- tual inputs; and approval of the final version. Manu- script has been read and approved by all the authors.

References

Implications

1. 2.

Murthy RS. National mental health survey of India 2015–2016. Indian journal of psychiatry. 2017 Jan;59(1):21. Math SB, Srinivasaraju R. Indian Psychiatric epidemio- logical studies: Learning from the past. Indian journal of psychiatry. 2010 Jan 1;52(Suppl1):S95-103.

Press WH, Geneva S. The global burden of disease: 2004

The study provides knowledge about initial trends in a newly established OPD patient profile. The fact that early age of presentation in anxiety and stress-related disorders underscores the need for

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update. World Health Organization. 2008.

4. Patel V, Chisholm D, Parikh R, Charlson FJ, Degenhardt L, Dua T, Ferrari AJ, Hyman S, Laxminarayan R, Levin C, Lund C. Addressing the burden of mental, neuro- logical, and substance use disorders: key messages from Disease Control Priorities. The Lancet. 2016 Apr

16;387(10028):1672-85.

5. WHO World Mental Health Survey Consortium. Preva-

lence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys. Jama. 2004 Jun 2;291(21):2581-90.

6. “Census of India 2011: Uttar Pradesh District Census Handbook – Rae Bareli, Part A (Village and Town Direc- tory)” (PDF). Census 2011 India. pp. xiii–xv, 5–10, 17–8, 28–65, 74, 90, 108, 125, 142, 158, 168, 185, 202, 219, 244, 262, 288, 306, 331, 348, 365, 37V5, 393, 410, 427, 573–92.

7. Eaton J, McCay L, Semrau M, Chatterjee S, Baingana F, Araya R, Ntulo C, Thornicroft G, Saxena S. Scale up of services for mental health in low-income and middle-in- come countries. The Lancet. 2011 Oct 29;378(9802):1592- 603.

8. Jacob KS. Repackaging mental health programs in low-and middle-income countries. Indian Journal of Psychiatry. 2011 Jul;53(3):195.

9. Ng C, Chauhan AP, Chavan BS, Ramasubramanian C, Singh AR, Sagar R, Fraser J, Ryan B, Prasad J, Singh S, Das J. Integrating mental health into public health: The community mental health development project in India. Indian journal of psychiatry. 2014 Jul;56(3):215.

10. Chandramouli C. Census of India 2011: rural urban dis- tribution of population. Registrar General and Census Commissioner, Ministry of Home Affairs: New Delhi. See http://censusindia. gov. in/2011-prov-results/paper2/ data files/India/Rural_Urban_2011. pdf. 2011.

11. World Health Organization. The ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines. World Health Organization; 1992.

12. Foulkes L, Andrews JL. Are mental health awareness efforts contributing to the rise in reported mental health problems? A call to test the prevalence inflation hypoth- esis. New Ideas in Psychology. 2023 Apr 1;69:101010.

13. Singh D, Pandey R, Yadav GS, Agrawal PK, Khan AH, Aich TK. A study report on the effect of COVID-19 pandemic in providing in-and-out-patient psychiatric services in a level-3 COVID hospital. Indian Journal of Psychiatry. 2023 Sep 1;65(9):961-V5.

14. Kameshvell, Rajin S, Raj Kumar P. Morbidity pattern among patients attending a private psychiatric

15. 16.

17. 18.

19.

20. 21.

22.

23. 24. 25.

26.

clinic – A cross sectional study. Sch J App Med Sci 2016;4(9D):3462–3466.

Reddy VM, Chandrashekar CR. Prevalence of mental and behavioural disorders in India: A meta-analysis. Indian journal of psychiatry. 1998 Apr;40(2):149. Venkatesh BK, Thirthalli J, Naveen MN, Kishore kumar KV, Arunachala U, Venkatasubramanian G, Subbakrishna DK, Gangadhar BN. Sex difference in age of onset of schizophrenia: findings from a community-based study in India. World psychiatry. 2008 Oct;7(3):173.

“Table C-01 Population by Religion: Uttar Pradesh”. censusindia.gov.in. Registrar General and Census Com- missioner of India. 2011

Khattri JB, Godar ST, Thapa P, Ramesh K, Chakrabortty PK, Thapa BB. Socio-demographic characteristics and diagnostic profile of patients attending psychiatric OPD of a private hospital in western region of Nepal. Nepal journal of medical sciences. 2012;1(1):15-8.

Jaju S, Al-Adawi S, Al-Kharusi H, Morsi M, Al-Riyami A. Prevalence and age-of-onset distributions of DSM IV mental disorders and their severity among school going Omani adolescents and youths: WMH-CIDI findings. Child and Adolescent Psychiatry and Mental Health. 2009 Dec;3:1-1.

Soren S, Bhutto ZA, Kumari P. A socio-demographic study of patients attending DMHP, Dumka. Eastern J Psychiatry. 2008;11:9-13.

Regmi SK, Khalid A, Nepal MK, Pokhrel AK. A study of socio-demographic characteristics and diagnostic profile in psychiatric outpatients of TUTH. Nepalese J Psychiatry. 1999;1(1):26-33.

Shrestha NM, A prospective analysis of 300 cases attending outpatient clinic in Mental Hospital. In: Pro- ceedings of the Workshopon National Mental Health Planning, Kathmandu; 1987. pp. 47–73.

Baker KA, Dwairy M. Cultural norms versus state law in treating incest: A suggested model for Arab families. Child abuse & neglect. 2003 Jan 1;27(1):109-23.

Shakya DR. Psychiatric morbidities among mentally ill wives of Nepalese men working abroad. Industrial psychiatry journal. 2014 Jan;23(1):52.

Dube KG. A study of prevalence and biosocial variables in mental illness in a rural and an urban community in Uttar Pradesh—India. Acta Psychiatrica Scandinavica. 1970 Dec;46(4):327-59.

Avasthi A, Sharma A, Gupta N, Kulhara P, Varma VK, Mal- hotra S, Mattoo SK. Seasonality and affective disorders: a report from North India. Journal of affective disorders. 2001 May 1;64(2-3):145-54.

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Indian Journal of Clinical Psychiatry

An Official Journal of Association of Clinical Psychiatry (Indian Psychiatric Society- Uttar Pradesh State Branch (IPS-UPSB))

CASE STUDY

ISSN- 2583-8873 doi: 10.54169/ijocp.v3i02.78

Dhat Syndrome in Geriatric Population: Cultural Beliefs and Implications

Mohit K. Shahi*, Ashwin J.V, Astha Singh

King George Medical University, Lucknow, Uttar Pradesh, India.

Abstract

This case series examines Dhat syndrome in the geriatric population, considering its association with cultural beliefs prevalent in the Indian Sub-continent. Dhat syndrome involves anxiety about the perceived loss of semen in young individuals and is less reported in older individuals. Cultural norms surrounding masculinity and sexual functions contribute to feelings of shame and guilt in affected geriatric individuals, impacting mental health and overall well-being. The series emphasizes the necessity of cultural competence in mental health care, urging personalized and customized interventions to address the unique needs of older adults experiencing Dhat syn- drome. Two illustrative cases highlight the complexities and challenges associated with the disorder in the geriatric context, warranting further research and heightened cultural sensitivity to improve mental health outcomes in this vulnerable population.

Introduction

The geriatric population, comprising individuals aged 65 years and older, is growing worldwide.1 With the aging process, unique physical and psycho- logical health challenges arise. Among these challenges, cultural beliefs and traditional perspectives significantly shape the understanding and manifesta- tion of various health conditions, including psychological disorders.2 One such culturally influenced psychological disorder observed in older adults is “Dhat syndrome.” This case series explores the manifestation of Dhat syndrome in the geriatric population, emphasizing the profound impact of cultural beliefs on its presentation, perception, and implications for mental health care. By examining the interplay between cultural norms and psychological well-being, valuable insights can be gained to inform culturally competent and tailored interventions, ultimately improving mental health outcomes in this vulnerable population.

Dhat syndrome is a culturally bound syndrome prevalent in South Asian countries, including India, Pakistan, Sri Lanka, and Bangladesh.3 It is character- ized by a preoccupation with anxiety about the loss of semen, perceived as a vital fluid through sexual activities or involuntary emissions such as nocturnal emissions, urination, or defecation. Although predominantly observed in young

ARTICLE INFO

*Correspondence:

Mohit K. Shahi

dr.mohit.shahi@ kgmcindia.edu

King George Medical University, Lucknow, Uttar Pradesh, India.

Dates:

Received: 10-07-2023 Accepted: 24-09-2023 Published: 08-11-2023

Keywords:

Dhat syndrome, Geriatric population, Cultural beliefs, Mental health care.

How to Cite:

Shahi MK, Ashwin JV, Singh A. Dhat Syndrome in Geriatric Population: Cultural Beliefs and Implications. Indian Journal of Clinical Psychiatry. 2023;3(2): 30-33.

doi: 10.54169/ijocp.v3i02.78

men, evidence also suggests its occurrence among older men.3,4

Cultural beliefs and traditional practices signifi- cantly influence the manifestation and presentation of Dhat syndrome in older adults.5 In many South Asian cultures, semen is considered a vital essence and a symbol of masculinity and vigor. The loss of semen is often associated with feelings of weakness, fatigue, and a decline in physical and mental health. Moreover, sexual functions are intertwined with the perception of masculinity and societal honor, adding stigma and shame to any sexual dysfunction or per- ceived loss of vital fluids.5,6

In the geriatric population, cultural beliefs about aging and sexuality intertwine with understanding Dhat syndrome.7 As older men experience age-re- lated changes in sexual function, such as decreased libido, erectile dysfunction, and nocturnal emissions, cultural norms may amplify anxiety and distress related to perceived semen loss.8 Geriatric individ- uals become more susceptible to developing or exacerbating Dhat syndrome due to the confluence of age-related sexual changes and deeply ingrained cultural beliefs surrounding masculinity and sexual potency.9

Dhat syndrome in the geriatric population sig- nificantly affects mental health and overall quality of life. Older adults with this condition often expe- rience shame, guilt, and inadequacy, leading to increased levels of anxiety, depression, and social withdrawal. These psychological disturbances can further exacerbate physical health issues, worsen cognitive function, and contribute to a decline in overall well-being.10,11

Given the profound influence of cultural beliefs on the expression and perception of Dhat syndrome in the geriatric population, mental health care pro- fessionals must approach diagnosis and treatment with cultural competence. It is crucial for healthcare providers to acknowledge and understand cultural norms surrounding masculinity, sexuality, and aging to establish a therapeutic alliance with their older patients.12

Dhat syndrome in the geriatric population is an important research area requiring cultural sensitivity and awareness. Understanding the cultural beliefs that influence the presentation and interpretation

of this psychological disorder is critical for providing effective mental health care to older adults in South Asian communities. By recognizing the impact of cultural norms, healthcare professionals can tailor their interventions to address the unique needs of older adults experiencing Dhat syndrome, thereby promoting better mental health outcomes and enhancing the overall quality of life in this vulnerable population.

Case 1

A 65-year-old male with a rural background, formal education up to class 7th, and a farmer by occupation visited the psychiatric Outpatient Department (OPD) with multiple complaints. He is a known case of hypertension. The patient reported experiencing generalized weakness, anxiety, impaired sleep, erectile dysfunction and premature ejaculation. In the past, there were no reported instances of psychiatric illness; however, five years ago, he had a history of left-sided hemiparesis (weakness on one side of the body). The patient attributes his weakness to semen loss, linking his erectile dysfunction and premature ejaculation to masturbation. During the counseling session, the patient was informed about the misconceptions regarding semen loss and its connection to weakness. He was also provided guidance on Kegel exercises, which can be beneficial for addressing some of his sexual issues.

Case 2

A 65-year-old male, retired from a government job, sought medical attention at the psychiatry OPD with a range of complaints. He reported experi- encing on/off low mood, anxiety, weakness, and difficulty sleeping. Additionally, he had concerns about semen loss before urination and defecation, which he believed to be the cause of his weakness and nocturnal emission of semen. In night falls. The patient’s medical history includes hypertension and diabetes, which are managed with appropriate medications. During the counseling session, the patient was reassured and provided with accurate information regarding semen loss and nocturnal emission of semen. He was educated about the normal physiological processes related to these occurrences and how they are not directly linked to

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weakness or other health issues. The importance of avoiding unnecessary worries and misconceptions was emphasized to reduce anxiety and improve overall mental well-being. As part of the treatment plan, we decided to initiate low-dose selective serotonin reuptake inhibitor (SSRI) therapy. Tab Escitalopram 5 mg/day was prescribed to address the patient’s low mood.

Additionally, the patient was encouraged to con- tinue managing his hypertension and diabetes as per the prescribed medications and lifestyle mod- ifications. Overall, a comprehensive approach was taken to address the patient’s physical and mental health concerns, focusing on accurate education, medication management, and regular follow-up to ensure optimal care and improvement in his overall quality of life.

Discussion

The presented case series sheds light on the unique psychological disorder known as Dhat syndrome, which is observed less frequently in the geriatric population and previous research revealed that Dhat syndrome is more prevalent in the young adult population.13 The cases highlighted the impact of cultural norms surrounding masculinity, sexuality, and aging on the presentation and perception of Dhat syndrome, thereby offering valuable insights for mental health care professionals, particularly psychiatrists.

In both cases, we observed how cultural beliefs significantly influenced the patients’ perspectives on their symptoms. The first case revealed a rural background with limited formal education, where misconceptions about semen loss and its con- nection to weakness and sexual dysfunction were prominent. The patient attributed his generalized weakness and sexual issues to semen loss, demon- strating the pervasive influence of cultural beliefs on health-related perceptions. The counseling session focused on dispelling these misconceptions and providing appropriate guidance on managing sexual concerns.

The second case demonstrated the impact of cultural norms on an older individual’s perception of semen loss. The patient’s belief that semen loss before urination and defecation caused his

weakness and night falls exemplified how deeply ingrained cultural beliefs surrounding semen as a vital essence can lead to distress and anxiety in the geriatric population. In this case, the counseling session successfully reassured the patient by pro- viding accurate information about the physiological processes, which helped alleviate his anxiety and improve his mental well-being.

Culturally competent mental health care is crucial when addressing Dhat Syndrome in the geriatric population.14 Healthcare professionals, especially psychiatrists, must be sensitive to cultural norms’ influence to build a strong therapeutic alliance with older patients.11 Understanding cultural beliefs and their implications can facilitate the implementation of personalized and customized interventions, pre- cisely targeting the specific requirements of older adults afflicted with Dhat Syndrome, thereby pro- moting better mental health outcomes.15

One of the limitations of this case series is that it includes a small sample size, which may limit the generalizability of the findings to other cultural contexts. Additionally, the role of cultural factors in the etiology and progression of Dhat Syndrome warrants further investigation, emphasizing the need for future research in this area.

Conclusion

Dhat Syndrome in the geriatric population presents unique challenges, influenced significantly by cultural beliefs and traditional perspectives. By rec- ognizing the impact of cultural norms on symptom expression and perception, mental health care pro- fessionals can design targeted interventions that address the specific needs of older adults with Dhat Syndrome. Culturally competent care is essential in providing effective support and improving mental health outcomes for this vulnerable population. Further research is necessary to deepen our under- standing of the complex interplay between culture and mental health in the context of Dhat Syndrome among older adults.

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MS. Phenomenology and beliefs of patients with Dhat syndrome: A nationwide multicentric study. Interna- tional Journal of Social Psychiatry. 2016 Feb;62(1):57-66. KAR SK, Singh A. Person centered management approach for the Dhat syndrome. International Journal of Person Centered Medicine. 2016;6(4).

Grover S, Gupta S, Mehra A, Avasthi A. Comorbidity, knowledge and attitude towards sex among patients with Dhat syndrome: A retrospective study. Asian Journal of Psychiatry. 2015 Oct 1;17:50-5.

Sagar R, Pattanayak RD, Garg R, Chavan BS, Arun P, Roelandt JL, Daumerie N, Defromont L, Caria A, Bastow P, Kishore J. Stigma and community intervention: Has enough been done. J Ment Health Hum Behav. 2014 Jan 1;19:1-3.

Khan N. Dhat syndrome: Physical and psychological implications. Unpublished Doctoral Thesis Submitted to University of Health Sciences, Lahore, Pakistan. 2008 Apr.

Newlands RT, Brito J, Denning DM. Cultural consider- ations in the treatment of sexual dysfunction. Handbook of Cultural Factors in Behavioral Health: A Guide for the Helping Professional. 2020:345-61.

Singh AK, Kant S, Abdulkader RS, Lohiya A, Silan V, Nongkynrih B, Misra P, Rai SK. Prevalence and correlates of sexual health disorders among adult men in a rural area of North India: An observational study. Journal of family medicine and primary care. 2018 May;7(3):515.w

Geriatric Dhat Syndrome

My Research Journals

Volume 3 | Issue 2 | 2023

Indian Journal of Clinical Psychiatry

ISSN- 2583-8873 (Indian Psychiatric Society- Uttar Pradesh State Branch (IPS-UPSB)) doi: 10.54169/ijocp.v3i02.81

Atypical Presentation of Neuropsychiatric Variant

of Wilson’s Disease and Clinical Improvement with

Elemental Zinc Monotherapy

Simranjit Kaur, Utkarsh K. Tripathi, Abhishek Chakladar*, Zaid Ahmed, Gaurav Verma, Alexander M. Alphonse, Ankan Paul

Department of Psychiatry, Varun Arjun Medical College and Rohilkhand Hospital, Banthra, Shahjahanpur, Uttar Pradesh, India.

An Official Journal of Association of Clinical Psychiatry

CASE REPORT

ARTICLE INFO

*Correspondence:

Abhishek Chakladar avcal89@gmail.com

Department of Psychiatry, Varun Arjun Medical College and Rohilkhand Hospital, Banthra, Shahjahanpur, Uttar Pradesh, India.

Dates:

Received: 22-08-2023 Accepted: 01-10-2023 Published: 08-11-2023

How to Cite:

Kaur S, Tripathi UK, Chakladar A, Ahmed Z, Verma G, Alphonse AM, Paul A. Atypical Presentation of Neuropsychiatric Variant of Wilson’s Disease and Clinical Improvement with Elemental Zinc Monotherapy. Indian Journal of Clinical Psychiatry.2023;3(2):34-36. doi: 10.54169/ijocp.v3i02.81

Introduction

Wilson’s disease has been referred to as “the great masquerader” because it has a plethora of clinical manifestations based on the organ system involved.1 Current understanding is that neuropsychiatric WD develops after

years of subclinical hepatic dysfunction.1 Neurologic dysfunction typically begins at approximately 20 years of age but can present earlier or later.2 In WD, the predominant neurologic manifestations (60%) are dysarthria, tremor and ataxia, followed by dystonia (15%) and parkinsonism (11%).3,4 In WD, pure psychiatric presentations are typically seen in patients in their teens. However, symptoms are often non-specific and frequently misdiagnosed as behavioral problems.5 Therefore, in many cases, when the clinical suspicion is low, the diagnosis of Wilson’s disease is often delayed or missed.

Case Report

A 13-year-old male child, studying in the eighth standard, belonging to a Muslim joint family of lower socioeconomic status presented with fearfulness, restless- ness, irritability and crying for no apparent reason, decreased food intake and sleep, along with seeing indescribable images for two months. The onset of the symptoms was sub-acute and the course was continuous and steady; during this course, the patient had sought treatment from a local practitioner, and the details were unavailable. During the physical examination, there was rigidity in both upper limbs and in the trunk; there was a lack of facial expressions with obliteration of both nasolabial folds. Mental state examination revealed rest- lessness and inability to sit at a place throughout the examination; there was poverty of speech with the decrease in rate, tone and productivity; the effect was blunt. The patient was well-orientated with respect to time, place and person. The BPRS score at the time of the first evaluation was 45, and the Modified Simpson Angus Scale (MSAS) score for extra-pyramidal symptoms was 25, indi- cating a severe degree of movement disorder. A provisional diagnosis of acute transient psychotic disorder, with a possibility of drug-induced extra-pyramidal

Clinical improvement of neuropsychiatric variant of Wilson’s disease with zinc monotherapy

Table 1: Diagnostic scoring system for Wilson’s disease

Clinical and laboratory presentation

Points

Present in the index case

Present (2 points) MRI brain was normal

0.15 g/L (1 point)

Absent

Not done (invasive procedure was avoided).

85.41 microgram; 1.7 times of upper limit of normal (1 point)

Not done as the facility of genetic analysis is not available in the study centre

tion. The patient was further investigated for serum ceruloplasmin, 24 hour urinary copper and urine ceruloplasmin levels. Although serum ceruloplas- min and urinary ceruloplasmin levels were within normal limits, the 24 hour urinary copper was 85.41 μg, which was 1.7 times the upper limit of the normal range (Normal reference range: 3–50 μg per day/24 hours of urine sample). On the basis of Leipzig criteria (Table 1) (score = 4), a diagnosis of Wilson’s disease was made. The patient was started on an oral dose of elemental zinc 50 mg per day and observed for a period of 2 weeks. At the end of two weeks the MSAS score decreased to 13, and the BPRS score was 32. During this period of two weeks, tablet pro-

Kayser-Fleischer ring

Present 2 Absent 0

Neurologic symptoms or typical abnormalities

of MRI brain

Severe 2 Mild 1 Absent 0

Serum ceruloplasmin (g/L)

Normal (>0.2) 0 0.1–0.2 1 <0.1 2

Coomb’s negative hemolytic anaemia

Present

Absent 1

Liver copper (in the absence of cholestasis)

>5 x ULN (>4 micromol/g)

0.8–4 micromol/g 2 Normal (<0.8 micromol/g) 1 Rhodamine positive granules* -1

24-hour urinary copper (in the absence of acute hepatitis)

Normal 0 1–2 x ULN 1 >2 times ULN 2

Mutation analysis

Mutations detected on both chromosomes Mutation detected on a single chromosome 1 Mutation absent 0

TOTAL SCORE:

4 or more: Diagnosis established

3: Diagnosis possible; more tests needed 2 or less: Diagnosis very unlikely

symptoms, was made. Treatment was started with oral trihexyphenidyl 2 mg twice daily, built up to 2 mg thrice daily, and quetiapine 25 mg once daily for movement disorder and behavioral symptoms, respectively. Even after 1-week of treatment, the extra-pyramidal symptoms persisted with MSAS score of 20 and a BPRS score of 42. At this stage, an organic cause for the symptoms was considered. Complete blood count with erythrocyte sedimen- tation rate, thyroid function tests, liver function tests, renal function tests and MRI were normal. A possibility of Wilson’s disease was considered and an ophthalmology referral revealed the presence of K-F (Kayser-Fleischer) ring by a slit lamp examina-

My Research Journals

Volume 3 | Issue 2 | 2023

Clinical improvement of neuropsychiatric variant of Wilson’s disease with zinc monotherapy

methazine 25 to 50 mg daily was used for sedation and the patient was kept free of antipsychotic. Sub- sequently, the opinion of a neurologist was sought from higher centre when it was decided that there was no need to consider a chelating agent and the patient can be continued on 50 mg of elemental zinc daily. Currently, the patient is free of any behavioral disturbance and there is no movement disorder. The patient is on regular monthly follow up with the treating team.

Discussion

The threshold for clinical suspicion of Wilson’s disease should be high in patients presenting with the first episode of unspecified psychosis and/or movement disorder, and they should be investigated accordingly. Although brain magnetic resonance imaging findings are abnormal6 in patients with a neurologic variant of Wilson’s disease, our patient had a normal brain MRI study. The current treatment guidelines for Wilson’s disease recommend copper chelation therapy for up to 5 years, followed by main- tenance therapy with zinc when they are clinically well, with stable hepatic function and normal serum and urinary copper levels.7 Zinc is typically reserved for maintenance treatment, but it has been used as first-line therapy for asymptomatic or pre-symptom- atic patients.8 However, in our patient, as there was no evidence of copper deposition in the brain and the 24-hour urinary copper was less than twice the upper limit of normal, it was clinically decided to use zinc as the first line of management. Zinc also has a lower propensity to cause neurologic deterioration compared to chelating agents; however, lifelong medical supervision (in the form of monitoring of liver function tests and copper level estimation for the next five years after the initial diagnosis and

subsequently depending on the individual case) is of utmost importance in the management of such patients.9

Conflict of Interest

The authors declare no conflict of interest with regard to this manuscript

References

2. 3.

4. 5.

6. 7. 8. 9.

Sean Cleymaet, Katsuko Nagayoshi, Edward Gettings & Justin Faden (2019): A review and update on the diagnosis and treatment of neuropsychiatric Wilson disease, Expert Review of Neurotherapeutics, DOI: 10.1080/14737175.2019.1645009

Merle U, Schaefer M, Ferenci P, et al. Clinical presen- tation, diagnosis and long-term outcome of Wilson’s disease: a cohort study. Gut. 2007; 56:115– 120. Członkowska A, Litwin T, Dzieżyc K, et al. Characteristics of a newly diagnosed Polish cohort of patients with neurological manifestations of Wilson disease evaluated with the Unified Wilson’s Disease Rating Scale. BMC Neurol. 2018; 18:34.

Hedera P. Wilson’s disease: A master of disguise. Par- kinsonism Relat. Disord. 2019.

Carta M, Mura G, Sorbello O, et al. Quality of Life and Psychiatric Symptoms in Wilson’s Disease: the Rele- vance of Bipolar Disorders. Clin. Pract. Epidemiol. Ment. Health. 2012; 8:102–109.

Sinha S, Taly AB, Ravishankar S, et al. Wilson’s disease: cranial MRI observations and clinical correlation. Neu- roradiology. 2006; 48:613–621.

Roberts EA, Schilsky ML. Diagnosis and treatment of Wilson disease: An update. Hepatology. 2008; 47:2089–2111.

Brewer GJ, Dick RD, Johnson VD, et al. Treatment of Wil- son’s disease with zinc: XV long-term follow-up studies. J. Lab. Clin. Med. 1998; 132:264– 278.

Linn FHH, Houwen RHJ, van Hattum J, et al. Long- term exclusive zinc monotherapy in symptomatic Wilson disease: Experience in 17 patients. Hepatology. 2009;50:1442–1452

Indian Journal of Clinical Psychiatry 36

Volume 3 | Issue 2 | 2023

Indian Journal of Clinical Psychiatry

An Official Journal of Association of Clinical Psychiatry (Indian Psychiatric Society- Uttar Pradesh State Branch (IPS-UPSB))

CASE REPORT

ISSN- 2583-8873 doi: 10.54169/ijocp.v3i02.90

Abrupt Onset Depressive Episode in Patient with Lenticular Nucleus Infarct with Low-Risk Factors

Aleena Thomas1, Mohammad Ahsan1, Rashmi Shukla1, Ashutosh Mishra2, Arghya Pal1*

1Department of Psychiatry, All India Institute of Medical Sciences, Raebareli, Uttar Pradesh, India. 2Department of Neurology, All India Institute of Medical Sciences, Raebareli, Uttar Pradesh, India.

ARTICLE INFO

*Correspondence:

Arghya Pal

drarghyamb@gmail. com

Department of Psychiatry, All India Institute of Medical Sciences, Raebareli, Uttar Pradesh, India

Dates:

Received: 16-09-2023 Accepted: 12-10-2023 Published: 08-11-2023

How to Cite:

Thomas A, Ahsan M, Shukla R, Mishra A, Pal A. Abrupt Onset Depressive Episode in Patient with Lenticular Nucleus Infarct with Low-Risk Factors. Indian Journal of Clinical Psychiatry. 2023;3(2): 37-39.

doi: 10.54169/ijocp.v3i02.90

To the Editor,

Post-stroke depression has been well-researched over the last few decades. Despite advances, it remains a poorly understood entity and till now, a repli- cable and valid model explaining the etiology of post-stroke depression remains

elusive. This is alarming considering the fact that the prevalence of post-stroke depression has been estimated to be around 18 to 33% of patients suffering from stroke in various studies.1 Post-stroke depression is often associated with changes in the expression of the monoamine receptors and alteration in the receptor sensitivity.2 A number of studies have attempted to recognize clinical and neuro-anatomical correlates that can predict the development of post- stroke depression in patients suffering from stroke.3–5 The most replicated risk factor that has been postulated for post-stroke depression include a history of mental disorder, higher stroke severity, higher post-stroke physical disability, higher cognitive impairment, and poorer social support.3,4 However, here we present a case of post-stroke depression with few of the predictive factors being present.

Mr. M, a 69-year-old male presented to the outpatient clinic with complaints of low mood, crying spells and anhedonia for the last 2 weeks. As corroborated by the family, Mr. M was his usual self until the night before and the change in the presentation was sudden as apparent the next morning. Mr. M appeared sad for no apparent reason, clumsy in carrying out daily activities like self-care and dressing and developed facial deviation to one side. No other symptoms like gait changes, urinary and/or fecal incontinence or sensory changes were noted at the time.

Over the initial days, Mr. M remained aloof and was also found to have decrease in speech productivity and found it challenging to express himself, along with restricted vocabulary. His appetite during this time was reduced by about 75% and total duration of sleep was also decreased by about 50%. During interactions, Mr. M would be tearful and low in mood but denied any self-harm ideations.

In 3 days post onset, CT head was found to be normal, and symptomatic treatment was prescribed. With no noticeable improvement in the following 10 days, he was brought to our outpatient clinic for further management. An eval-

uation revealed no past personal or family history of psychiatric illnesses. He also had no history of other medical comorbidities like hypertension, diabetes mellitus or dyslipidemia. Mr. M had a history of nic- otine dependence for the last 40 years, predomi- nantly using bidis (tobacco rolled in leaf). He was also using alcohol in a non-dependent pattern for the last 15 years, and predominantly using country-made liquor. Since the onset of the symptoms, he had stopped taking either of the substances. Sensory and motor examination of the nervous system was mostly normal, except for deviation of the face to the right side.

The plantar responses on each side were flexor. His cognitive testing revealed features of aphasia. He presented with a depressed mood and ideas of helplessness, though the evaluation was hampered by paucity of speech. The patient scored 15/15 on the Glasgow Coma Scale, and scored 2 on the Modified Rankin Scale, signifying ‘Slight disability; unable to carry out all previous activities, but able to look after own affairs without assistance’. The National Institutes of Health Stroke Scale (NIHSS) rating was 4 denoting minor stroke. The depressive symptoms of the patient were evaluated using the Hamilton Depression Rating Scale and the score was found to be 12 (denoting mild depression). The patient was tested for his cognitive functioning with Montreal Cognitive Assessment (MoCA) and the score was found to be 15/30, signifying severe cognitive impair- ment. Due to high degree of suspicion a neurological insult because of abrupt onset of depressive symp- toms with focal neurological signs and cognitive symptoms, magnetic resonance imaging (MRI) of the brain was performed, which showed evidence of infarct in the region of the left lenticular nucleus (Figure 1). Based on the obtained information, the diagnosis of major depressive disorder, secondary to infarction of the left lenticular nucleus, was made according to the Diagnostic and Statistical Manual 5th edition. The patient was initiated on Escitalopram (10 mg) for the depressive symptoms and post- stroke measures included initiation on Atorvastatin (10 mg) and Aspirin (75 mg), after consultation with Neurology. The patient was discharged after one week, when the HAM-D score was 10 and the MoCA score was 19.

Figure 1: Image on the left is the computed tomographic image of the brain done on the 3rd day of the onset of the symptoms and image on the right is the diffusion weighted image of the brain done on 14th day of the onset of symptoms.

Strokes involving the various regions of basal ganglia have been repeatedly implicated for post-stroke depression in various studies.1,6 In our patient, we also found that the afflicted region was the lentiform nucleus. Still, we decided to report this case because we felt that there were some critical learning points from this case. Firstly, in this case, the onset of symptoms was abrupt, which is rela- tively rare even in cases of secondary depression (depression due to other medical causes). Though there was certain overlap with cognitive symptoms, the manifestations of the depressive symptoms were clear (as manifested by depressive cognition, decreased appetite and sleep and low mood) in this case. Previous studies on this topic reported that symptoms are highest within the first 3 months of stroke, but an abrupt onset (<48 hours) is relatively rare.7 Secondly, most of the existing literature shows a positive correlation with the severity of stroke and degree of disability. In our case, however, the patient had a minimal disability and the severity of the symptoms were mild. Finally, though a sus- picion of cerebro-vascular accident was very high during the initial workup, the initial CT images were inconclusive. It was during the later MRI scans that the diagnosis could be established. A valid question that arises in this context is the overlay between post-stroke depression and post-stroke cognitive impairment. Current evidence does suggest that the cognitive profile of patients with post-stroke depres- sion is worse than patients who do not develop depression following stroke.8–10 Cognitive impair-

Depressive episode in patient with stroke

Indian Journal of Clinical Psychiatry

38 Volume 3 | Issue 2 | 2023

ment can be seen in about 35 to 87% patients of with post-stroke depression.10 There has been attempts to find neurological correlates of depression and cog- nitive impairments and it was found that cognitive impairment in post-stroke depression is commoner in patients having lower years of education, higher age and left-sided lesions (vs right sided lesions).8 We believe that this case goes on to show that the importance of detailed clinical evaluation, including emphasis on history taking can avoid many unin- tended clinical misdiagnoses. In case of high clinical suspicion one can go for regional cerebral blood flow (rCBF) measurement to assess brain function in neuropsychiatric disorders. For example, single photon emission brain CT is a reliable method for the measurement of rCBF. We were not able to go for it due to limited resources. It is an investigation worth considering in such types of cases.

References

1. Medeiros GC, Roy D, Kontos N, et al. Post-stroke depres- sion: A 2020 updated review. Gen Hosp Psychiatry 2020; 66: 70–80.

2. Guo LH, Wang S, He R. Poststroke Depression. Stroke 1995; 9: 230–231.

4. 5.

7. 8.

10.

Chen Y-M, Chen P-C, Lin W-C, et al. Predicting new-on- set post-stroke depression from real-world data using machine learning algorithm. Front Psychiatry 2023; 14: 1195586.

Hackett ML, Anderson CS. Predictors of Depression after Stroke. Stroke 2005; 36: 2296–2301.

Ladwig S, Werheid K, Südmeyer M, et al. Predictors of post-stroke depression: Validation of established risk factors and introduction of a dynamic perspective in two longitudinal studies. Front Psychiatry; 14. Epub ahead of print 2023. DOI: 10.3389/FPSYT.2023.1093918/ FULL.

Espárrago Llorca G, Castilla-Guerra L, Fernández Moreno MC, et al. Post-stroke depression: an update. Neurol (English Ed 2015; 30: 23–31.

Robinson RG, Jorge RE. Post-Stroke Depression: A Review. Am J Psychiatry 2016; 173: 221–231.

Baccaro A, Wang YP, Candido M, et al. Post-stroke depression and cognitive impairment: Study design and preliminary findings in a Brazilian prospective stroke cohort (EMMA study). J Affect Disord 2019; 245: 72–81. Tu J, Wang LX, Wen HF, et al. The association of dif- ferent types of cerebral infarction with post-stroke depression and cognitive impairment. Medicine (Balti- more); 97. Epub ahead of print 1 June 2018. DOI: 10.1097/ MD.0000000000010919.

Terroni L, Sobreiro MFM, Conforto AB, et al. Association among depression, cognitive impairment and exec- utivedysfunction after stroke. Dement Neuropsychol 2012; 6: 152.

Depressive episode in patient with stroke

My Research Journals 39

Volume 3 | Issue 2 | 2023

Indian Journal of Clinical Psychiatry

An Official Journal of Association of Clinical Psychiatry (Indian Psychiatric Society- Uttar Pradesh State Branch (IPS-UPSB))

CASE STUDY

ISSN- 2583-8873 doi: 10.54169/ijocp.v3i02.94

Levetiracetam Induced Acute Suicidal Ideations in a Patient of Juvenile Myoclonic Epilepsy

Ravikant Kumar1, Rahul Mathur2, Abhishek Chakladar3*, Anuranjan Vishwakarma2

1 Department of Psychiatry, National Drug Dependence Centre, All India Institute of Medical Sciences, New Delhi, India. 2Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India.

3Department of Psychiatry, Varun Arjun Medical College and Rohilkhand Hospital, Shahjahanpur, Uttar Pradesh, India.

ARTICLE INFO

*Correspondence:

Abhishek Chakladar avcal89@gmail.com

Department of Psychiatry, Varun Arjun Medical College and Rohilkhand Hospital, Shahjahanpur, Uttar Pradesh, India

Dates:

Received: 28-09-2023 Accepted: 15-10-2023 Published: 08-11-2023

How to Cite:

Kumar R, Mathur R, Chakladar A, Vishwakarma A. Levetiracetam Induced Acute Suicidal Ideations in a Patient of Juvenile Myoclonic Epilepsy. Indian Journal of Clinical Psychiatry. 2023;3(2): 40-42. doi: 10.54169/ijocp.v3i02.94

Introduction

The US Food and Drug Administration (FDA) approved levetiracetam as an antiepileptic drug (AED) in 1999. After nine years, the FDA released a post- marketing statement describing an increased risk of suicide (0.43%) in patients taking AEDs, including levetiracetam.1 Levetiracetam is a second-generation AED that has shown clinical effectiveness in generalized and partial epilepsy syndromes as monotherapy and adjunctive treatment.2 The recommended starting dose of levetiracetam is 500 mg twice daily and it can be titrated by 1,000 mg every 2 weeks as needed to a maximum dose of 3,000 mg daily.3 The most common side effect of levetiracetam was found to be sedation at 10.7%, while mood disturbance was found in 4.8% of patients.4 A possible association has been reported between the use of levetiracetam and suicidality.5 We here describe the case of a patient with a history of juvenile myoclonic epilepsy without any family history or past history of psychiatric illness being treated with levetiracetam, who developed acute onset of suicidal ideations when the dose of levetiracetam was increased, which subsided in a span of five days when levetiracetam was gradually stopped and sodium valproate was introduced. To the best of our knowledge, this is one of the very few case reports from India that demonstrates the temporal association of levetiracetam with acute onset of suicidal ideations in the absence of other risk factors for AED-induced suicidal behavior.

Case Report

Mr. S, 25 an old male from a Hindu nuclear family of middle socioeconomic status, presented to the neurology outpatient department with a history of seizure disorder. There was no family history or past history of any psychiatric illness. He was previously diagnosed as juvenile myoclonic epilepsy and was on levetiracetam 2 gm per day in divided doses on which he was maintaining seizure-free. There was no history of prior head injury and MRI scan of the brain was normal. The patient developed three episodes of breakthrough seizures (semiology suggestive of generalized seizures, witnessed by family members) on levetiracetam 2 gm in a span of seven days. Family members ensured com-

pliance to medications. The consultant neurologist increased the dose of levetiracetam to 3 gms per day in a span of 2 weeks for better control of seizures. Three days after taking levetiracetam at 3 gms per day in divided doses, the patient started remain- ing irritable for most of the time during the day, developed anhedonia, easy fatigability, decreased appetite, decreased attention and concentration and pessimistic views about the future along with suicidal ideations. At this point, he was referred to the psychiatrist and he was admitted in view of active suicidal ideations. Hamilton Depression Rating Scale (HAM-D) and Hamilton Anxiety Rating Scale (HAM-A) were applied along with the Beck Scale for Suicidal Ideations (BSS) to estimate the severity of depression, associated anxiety, and suicidal ide- ations, respectively. The scores on HAM-D, HAM-A and BSS came out to be 22, 14 and 23, respectively, indicating mild anxiety and severe depressive episodes. Since the onset of suicidal ideations was temporally correlated with the escalation of the dose of levetiracetam, the drug was stopped and sodium valproate was introduced after consultation with a neurologist. In view of the severe depressive episode, escitalopram was started and maintained at 10 mg. Five days after levetiracetam was stopped, the suicidal ideations had decreased significantly, which correlated with a score of 5 on BSS. There was significant improvement in the mood and biological functions, which correlated with score of 12 on HDRS. On day 5 of stopping levetiracetam, the HAM-A score was 11. The patient was subsequently discharged on sodium valproate 1250 mg and escitalopram 10 mg and on follow-up he maintained seizure free on the same medications. There was no evidence of any mood symptoms during follow-up till 6 months, and escitalopram was tapered and stopped.

Discussion

Levetiracetam potentiates gamma-aminobutyric acid and modulate Ca++ channels/K+ currents and SV2A (a synaptic protein) involved in vesicle exocy- tosis.6 Apart from sedation and mood symptoms, it is known to develop behavioral symptoms such as nervousness (3.8%), hostility (2.3%), anxiety (1.8%) and emotional lability (1.7%) in clinical trials.7 These factors although could contribute to increased sui-

cidality, but none of them are directly associated. Levitracetam can exert negative effects on mood and cognition due to lack of serotonergic proper- ties.8 Inhibition of glutamatergic neurotransmission by antiepileptic drugs has also been hypothesized as the pathophysiology of mood and behavioral disorders, but the effects of levetiracetam on the glutamatergic system still remain unknown.9 The risk factors that contribute to suicidal behavior in patients with epilepsy on antiepileptic drugs (includ- ing levetiracetam) include temporal lobe epilepsy, surgically treated epilepsy, post-ictal psychosis, past and/or current history of mood and anxiety disorders, prior suicide attempts, family history of mood disorders complicated by suicide attempts and treatment-refractory epilepsy.10

Our case highlights the direct influence of levit- racetam on suicidality with the exclusion of seizure and comorbid psychiatric disorders. Our findings suggest the possibility that suicidality induced by levitracetam was related to depression rather than anxiety. Suicidality and behavioural disturbances can be precipitated in patients on antiepileptic drugs, but this does not appear to have a “class effect”.5 Although levetiracetam-induced psychi- atric adverse effects are not considered to be dose related,11 but this case suggests that rapid titration of dose may be an important factor in developing suicidal behavior. Larger prospective studies will be needed to further validate our findings. At this time, monitoring depressive symptom scales for patients taking antiepileptic drugs, especially levetiracetam seems to be beneficial.

References

Levetiracetam induced acute suicidality in a case of juvenile myoclonic epilepsy

1. 2.

Mula M, Bell GS, Sander JW. Suicidality in epilepsy and possible effects of antiepileptic drugs. Curr Neurol Neu- rosci Rep. 2010 Jul;10(4):327–32.

Surges R, Volynski KE, Walker MC. Is Levetiracetam Different from Other Antiepileptic Drugs? Levetirace- tam and its Cellular Mechanism of Action in Epilepsy Revisited. Ther Adv Neurol Disord. 2008 Jul;1(1):13–24. Betts T, Waegemans T, Crawford P. A multicentre, dou- ble-blind, randomized, parallel group study to evaluate the tolerability and efficacy of two oral doses of leve- tiracetam, 2000 mg daily and 4000 mg daily, without titration in patients with refractory epilepsy. Seizure. 2000 Mar;9(2):80–7.

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4. Nicolson A, Lewis SA, Smith DF. A prospective analysis of the outcome of levetiracetam in clinical practice. Neurology. 2004 Aug 10;63(3):568–70.

5. Siamouli M, Samara M, Fountoulakis KN. Is antiepilep- tic-induced suicidality a data-based class effect or an exaggeration? A comment on the literature. Harv Rev Psychiatry. 2014;22(6):379–81.

6. Crepeau AZ, Treiman DM. Levetiracetam: a comprehen- sive review. Expert Rev Neurother. 2010 Feb;10(2):159–71.

7. Cramer JA, De Rue K, Devinsky O, Edrich P, Trimble MR. A systematic review of the behavioral effects of leveti- racetam in adults with epilepsy, cognitive disorders, or an anxiety disorder during clinical trials. Epilepsy Behav.

8. 9.

10. 11.

2003 Apr;4(2):124–32.

Kalinin VV. Suicidality and Antiepileptic Drugs. Drug- Safety. 2007 Feb 1;30(2):123–42.

Perucca P, Mula M. Antiepileptic drug effects on mood and behavior: molecular targets. Epilepsy Behav. 2013 Mar;26(3):440–9.

Esang M, Santos MG, Ahmed S. Levetiracetam and Sui- cidality: A Case Report and Literature Review. Prim Care Companion CNS Disord. 2020 Jul 30;22(4):19nr02502. Kaufman KR, Bisen V, Zimmerman A, Tobia A, Mani R, Wong S. Apparent dose-dependent levetiracetam-in- duced de novo major depression with suicidal behavior. Epilepsy & Behavior Case Reports. 2013 Jan 1;1:110-2.

Levetiracetam induced acute suicidality in a case of juvenile myoclonic epilepsy

Indian Journal of Clinical Psychiatry

Volume 3 | Issue 2 | 2023

Indian Journal of Clinical Psychiatry

An Official Journal of Association of Clinical Psychiatry (Indian Psychiatric Society- Uttar Pradesh State Branch (IPS-UPSB))

CASE REPORT

ISSN- 2583-8873 doi: 10.54169/ijocp.v3i02.95

Coronavirus Disease 2019 Associated Obsessive- compulsive Disorder: A Case Report

Ravikant Kumar1, Jawahar Singh2, Abhishek Chakladar3*

1National Drug Dependence Centre & Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India 2Department of Psychiatry, All India Institute of Medical Sciences, Bhatinda, Punjab, India.

3Department of Psychiatry, Varun Arjun Medical College and Rohilkhand Hospital, Shahjahanpur, Uttar Pradesh, India.

ARTICLE INFO

*Correspondence:

Abhishek Chakladar avcal89@gmail.com

Department of Psychiatry, Varun Arjun Medical College and Rohilkhand Hospital, Shahjahanpur, Uttar Pradesh, India.

Dates:

Received: 05-10-2023 Accepted: 11-10-2023 Published: 08-11-2023

How to Cite:

Kumar R, Singh J, Chakladar A. Coronavirus Disease 2019 Associated Obsessive-compulsive Disorder: A Case Report. Indian Journal of Clinical Psychiatry. 2023;3(2): 43-44.

doi: 10.54169/ijocp.v3i02.95

To the editors,

Distressing obsessions and repetitive compulsions characterize obses- sive-compulsive disorder (OCD). Usually, OCD responds well to pharma- cotherapy, cognitive behavioral therapy, or a combination of both.1 Due to

the pandemic of the Coronavirus disease 2019 (COVID-19), strict preventive measures, lockdowns, and quarantines during COVID-19 had a wider social impact, which caused significant mental health problems. Many studies have highlighted the worsening of OCD symptoms during the COVID-19 pandemic. We are reporting a case of a young adult who had gone through severe distress during the COVID-19 pandemic and developed syndromal OCD. To the best of our knowledge, this is the first case reporting new-onset OCD as an adverse outcome of COVID-19-associated stress.

A 26-year-old unmarried male, with no past history or family history of psychiatric illness or any childhood traumatic experience had a well-adjusted premorbid personality. His RTPCR test for COVID-19 was negative. Complete blood count, liver function test, kidney function test, and thyroid function tests were within normal limits. The patient provided written consent for this case writing. Due to the pandemic, International borders were closed and global agencies were looking for treatment and other containment measures to control the spread of the virus. The World Health Organisation (WHO) recommended social distancing and hand hygiene as precautionary measures to prevent ofthe spread of the virus. The patient reported excessive worries about health and illness related to COVID-19 for 2.5 months. Initially, he started to have difficulty getting sleep. He reported that whenever he would think about COVID-19, he started to have palpitations, dry mouth, restlessness, and sweating, which would subside on its own in 10 to 15 minutes. After 15 to 20 days of these symptoms, the patient started to keep track of worldwide cases of COVID-19. He started to be more particular about his hand hygiene and he would avoid touching unneces- sary things. Gradually after one month of these symptoms, the patient started having repetitive intrusive thoughts of dirt and contamination and had to wash

his hands multiple times a day. He acknowledges these thoughts as his own, excessive, distressing, and useless. He would try to resist these repetitive thoughts but could not succeed, and at the same time, he started to have anxiety and restlessness. Anxiety and restlessness would be relieved by com- pulsive washing. He started to spend more time on each wash than the recommended (20 seconds) by WHO, in the whole day he would spend three hours washing and cleaning his hands. The patient gradually started to spend more time washing his hands. He also started to spend one hour every day and spend time in bathing, which was more than his usual self. Based on the Diagnostic and Statistical Manual of Mental Disorder Fifth Edition (DSM-5), he was diagnosed with OCD and his Yale-Brown Obses- sive Compulsive Scale (Y-BOCS) was 24, suggesting severe OCD. On Depression and Anxiety Stress Scale (DASS),the patient showed mild depression, moderate anxiety, and severe stress. There was no history of fever/sore throat or associated hoarding behavior before or during all these symptoms. When the patient started to have significant distress and difficulty in his routine work, he consulted a local psychiatrist. There, he was started on Clomipramine 25 mg, and with it he was having excess sedation. Later, he visited the psychiatry outpatient depart- ment of our institute in September 2020, when regular outpatient services were started following Government directives. He was started on fluoxetine, which was gradually increased to 80 mg/day over one month and subsequently, Clomipramine was subsequently stopped. After two months of treat- ment, the patient showed gradual improvement in symptoms and his Y-BOCS score was reduced to 10, after which he resumed his duty. During follow-up periods at one and three months, he was maintain- ing well. At present, the patient is on Fluoxetine 60 mg as the only psychotropic medication and he is maintaining free of any obsessive-compulsive symptoms.

The COVID-19 pandemic has created a lot of dis- tress and mental health problems in the population. Acute stress can cause obsession in both healthy as well as in persons with pre-existing psychiatric illness.1-3 Similar findings have been reported during Severe Acute Respiratory Syndrome, Middle East

Respiratory Syndrome, and Influenza4 outbreaks. Prolonged exposure to stressful conditions can also increase the risk of adverse mental health out- comes like OCD.3 The index case had gone through severe stress, which signifies its role in the causation of OCD. According to the stress diathesis model, stressful conditions can lead to different effects in different individuals.5 Through the “stress-diathesis” model, stress can impact corticostriatal and limbic circuitry, leading to the development of OCD.1 This is the first case that shows COVID-19-associated stress-induced OCD. However, the possibility of unknown pre-existing vulnerability factors cannot be excluded. Also, stress could have been contrib- uted by fear of getting the infection and strict lock- down, which OCD may have further aggravated.

During the pandemic, OPD services were tempo- rarily suspended, so it could have delayed the diag- nosis and treatment of mental illnesses. Secondly, poor awareness and stigma associated with illness might have prevented patients from seeking help. So, physicians have to be more vigilant during and after such pandemics. Timely psychiatry consulta- tions will help in the early diagnosis and treatment of illnesses. The health authorities must strengthen the public mental health services to address the adverse impact of the pandemic.

References

COVID-19 associated obsessive compulsive disorder

4. 5.

Adams TG, Kelmendi B, Brake CA, Gruner P, Badour CL, Pittenger C. The role of stress in the pathogenesis and maintenance of obsessive-compulsive disorder. Chronic Stress. 2018 Feb;2:2470547018758043.

Zaccari V, D’Arienzo MC, Caiazzo T, Magno A, Amico G, Mancini F. Narrative review of COVID-19 impact on obsessive-compulsive disorder in child, adolescent and adult clinical populations. Frontiers in psychiatry. 2021 May 13;12:575.

Benatti B, Albert U, Maina G, Fiorillo A, Celebre L, Girone N, Fineberg N, Bramante S, Rigardetto S, Dell’Osso B. What happened to patients with obsessive compulsive disorder during the COVID-19 pandemic? A multicentre report from tertiary clinics in northern Italy. Frontiers in Psychiatry. 2020 Jul 21;11:720.

Banerjee D. The other side of COVID-19: Impact on obsessive compulsive disorder (OCD) and hoarding. Psychiatry research. 2020 Jun;288:112966.

Ingram RE, Luxton DD. Vulnerability-stress models. Development of psychopathology: A vulnerability-stress perspective. 2005 Jan;46(2):32-46.

Indian Journal of Clinical Psychiatry 44

Volume 3 | Issue 2 | 2023

Guidelines for Authors

Type of article

1. Editorial

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We encourage researchers, academicians, clinicians and students to contribute scientific articles for the Indian Journal of Clinical Psychiatry (IJOCP).

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pocketbook: Pregnancy and childbirth. Chiches- ter (England): John Wiley & Sons; 2008.

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Puri S, O’Brian MR. The hmuQ and hmuD genes from Bradyrhizobium japonicum encode heme‐ degrading enzymes. J Bacteriol [Internet]. 2006 Sep [cited 2012 Aug 2];188(18):6476‐82. Available from: http://jb.asm.org/cgi/content/ full/188/18/6476?view=lo ng&pmid=16952937. doi:10.1016/j.psychsport.2009.03.009

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■ Butler SW. Secrets from the black bag. London (GB): The Royal College of General Practitioners; 2005.

■ Cheers B, Darracott R, Lonne B. Social care practice in rural communities. Sydney (AU): The Federation Press; 2007.

■ Hofmeyr GJ, Neilson JP, Alfirevic Z, Crowther CA, Gulmezoglu AM, Hodnett ED et al. A Cochrane

References