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. 2015 Jan;57(Suppl 1):S160–S195.

SYMPOSIA

PMCID: PMC4333353
Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Specific Learning Disability (Sld) Clinician oriented Assessment and Certification

Thomas John1, Anoop Vincent2, Ullatil Vivek3

1Thomas Guidance Clinic Kochi, India, drthomasjohn@gmail.com, 2Dept of Psychiatry SN medical College Ernakulam Dist, 3Renai medicity hospital, Cochin, India,

E-mails: anoop.vincent@yahoo.co.in/vivekullatil@gmail.com

Keywords: SLD, assessment, certification, grade level

Background: The concept of Specific Learning Disability(SLD), popularly known as LD/Dyslexia was introduced to help a group of children who are consistently poor in academics yet are not mentally retarded. The causes and the difficulties of SLD are different. Most of them can be helped to a great extend with early intervention and individualized remedial education. Still a few students need help in the examinations. SLD is not a disability under disability act, hence its certification need not be certified in disability boards in percentge. There is a lot of confusion, criticism and misuse of SLD certificates in many states.

‘Specific Learning Disability’ refers to a heterogeneous group of conditions wherein there is a deficit in processing language, spoken or written, that may manifest itself as a difficulty to comprehend, speak, read, write, spell, or to do mathematical calculations. The term includes such conditions as perceptual disabilities, dyslexia, dysgraphia, dyscalculia, dyspraxia and developmental aphasia (PWD Bill 2012).

Based on DSM5 the presenters discuss a clinician oriented dimensional approach for SLD assessment and certification.

IQ-Achievement discrepancy mentioned for LD in DSM-IV is removed from DSM-5. Hence IQ assessment is not a mandatory in SLD assessment. The four diagnostic criteria of SLD (A to D) are to be met based on a clinical synthesis of individual’s history, school reports and psycho educational assessment (DSM-5 p67). The most reliable Psycho Educational Assessment is Grade level Assessment.

Grade level Assessment: Grade level assessment consists of tests to detect the actual grade (standard/class) of the candidate in individual subject irrespective of his/her present standard of study. All students are given promotion till 10th grade. So the academically weak students of grade 10th are at different low levels for different subjects.

Even though the cause is defect in any one or more of the six core academic skills viz, reading skill, reading comprehension, written expression, spelling, arithmetic calculation and arithmetic reasoning the effect is poor performance and consistent failure in any one or more of academic subjects. Difficulties mastering key academic skills may also impede learning in other academic skills (DSM5 p68).

Steps in SLD Assessment: Select the candidates who are more than two grades lower than the actual grade in individual subject (by school authorities).

Assessment of 6 academic skills (by school authorities/special educators/mental health professionals) which are, reading skill and reading comprehension (Dyslexia), written expression and spelling (Dysgraphia) arithmetic calculation and arithmetic reasoning (Dysalculia).

Significant impairment in any one or more of these skills can be taken as a positive sign.

Mental State Examination, assessment of other conditions like motor coordination (dyspraxia) and physical examination by respective professionals. Any long standing mental illness like depression, mania, ocd etc, and other disabilities like autism, mental retardation can cause scholastic backwardness and such cases can be included under respective disability which are better accounted.

IQ, Adaptive behavior assessment if only mental retardation is clinically suspected.

Quantification of Disability in Percentage Based on Grade Level Assessments: Since other types of disabilities are assessed and quantified in percentage of disability with respect to normal, government authorities including judiciary have started insisting for a quantification of SLD in percentage for considering child with SLD to sanction academic provisions. Since the problems related to SLD are only in the academic domains, it is not easy to quantify SLD in percentage like other disabilities notified under existing Acts. Moreover there is enough scope to suggest SLD for a student and take advantage of it in getting examination concessions. Without being aware about these facts government authorities including judiciary are insisting for a quantification of SLD in percentage in many parts of our country. So, in future, for meeting the demands of these government officials we will have to use a scale for quantifying SLD in percentage mainly based on clinical assessment rather than psychometrically Oriented approach. Validation and pilot study of such a scale is conducted by the presenters.

Just like quantification of Mental Retardation based on three domains (IQ reports, Adaptive Behavior skills and Clinical assessment), SLD can be quantified based on three domains Grade level assessment report from the school, Adaptive behavior pertaining to academics and Clinical assessment.

Percentage of Disability (SLD) = (100-GQ) + (1 to 10 points): GQ (Grade Quotient) is calculated as Assessed grade/Apparent Grade x 100. Assessed grade of a subject means the actual grade of a student in that subject with average performance without any assistance. Apparent grade means the grade on which the student is studying at present. Maximum of 10 points can be added or subtracted [ + ] by the clinician for clinical evaluation and adaptive skills specific to academics (Areas to be considered are reading accuracy, fluency, comprehension, spelling, grammar, punctuation errors, written expression, arithmetic calculation, reasoning, age, borderline intelligence, memory, attention deficit, obsessive traits, phobia and other neurotic traits, which do not account for a separate disability but definitely interfere with the academics). Each item is divided into nil, insignificant, mild, moderate and severe.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

We need to take a stand: Sexual boundaries in the doctor patient relationship in India

Sunita Simon Kurpad1, Ajit Bhide2, Alok Sarin3

1Professor and Head, Department of Psychiatry Professor, Department of Medical Ethics St. John’s Medical College Hospital, Bangalore 560 034, 2Senior Consultant and Head, Department of Psychiatry, St. Martha’s Hospital, Bangalore, 3Consultant Psychiatrist, Sitaram Bhartia Institute of Science and Research, New Delhi simonsunita@gmail.com

Background and Purpose: Violations of sexual boundaries in the doctor patient relationship are violations of the fundamental ethical code in medical practice of primum non nocere (first do no harm). Over the last few years, there has been some discussion on both non sexual as well as sexual boundary violations in certain fora in India, with the beginning of an acceptance that these violations are not an exclusively Western phenomenon.

The Medical Council of India did act on The Bangalore Declaration (a consensus document generated by a group of health professionals in order to address the issue of Nonsexual and Sexual Boundary Violations in the doctor-patient relationship in India), by incorporating this topic in the proposed new MBBS Undergraduate curriculum.

Though doctors who cross sexual boundaries are a minority, they can have devastating effects on patients, families and themselves. So, it would be a significant first step if psychiatrists and The Indian Psychiatric Society led the way, by proactively endorsing a Code of Practice on Sexual boundaries in the doctor patient relationship.

The speakers in the symposium will discuss the rationale, the essence of a proposed Code of Practice for Sexual Boundaries and the need for psychiatrists in India to take the lead on this issue.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Hallucinations and Delusions-What the Brain tells us

Anil Prabhakaran1, E.Mohandas2

1Prof & Head, Dept.of Psychiatry, Medical College, Trivandrum, drpanil@hotmail.com, 2Sun Medical & Research Centre, Trichur, Kerala, India emohandas53@gmail.com

Neurobiology of Delusions:

Delusion is a false, fixed, incorrigible pathological belief not shared by people of the same socio-cultural and educational rubric. Recent neuroimaging data provide insight into the possible functional Neuroanatomy of delusional formation.

Delusions may result from aberrations in how brain circuits specify hierarchical predictions, and how they compute and respond to prediction errors. The various hypotheses advanced include aberrant salience attribution stemming from dysregulated dopamine system and top-down dyscontrol.

Recent imaging data suggest ‘agency’ error specific activation in supplementary motor area, left cerebellum, right posterior parietal cortex (PPC), and right extrastriate body area (EBA), involvement of ventromedial prefrontal cortical networks and hyperconnectivity of default mode network in the generation of delusions.

The available evidence on neural underpinnings of delusional formation is discussed.

Neurobiology of Hallucinations

Hallucinations are perceptual experiences that occur in the absence of external sensory stimuli. The word hallucination has its roots in the Latin hallucinari or allucinari, which means ‘to wander in mind.’ David in 2004 suggested a definition of hallucination which may be relevant in non-organic states-‘A sensory experience which occurs in the absence of corresponding external stimulation of the relevant sensory organ, has sufficient sense of reality as to resemble a veridical perception, over which the subject does not feel direct and voluntary control, and which occurs in the awake state ‘

Both topological (dysfunction at specific brain locations) and hodological (emphasizing dysfunction in the connections between brain regions) models have been advanced based on the recent structural and functional imaging data. Neurostimulation techniques open further window to the neuroanatomical signature of hallucinatory phenomena.

Neuroimaging data delineate deficits in regions involved in the inner monitoring of speech and language, abnormalities in the bottom up modulation from the auditory cortex, reduced top-down modulation from cortical regions and hyperconnectivity of default mode network.

The functional Neuroanatomy of auditory cortex/auditory verbal hallucinations and visual cortex/visual hallucinations is discussed with explanations for functional, reflex and extracampine hallucinatory phenomena.

Topics:

Neurobiology of Delusions - Anil Prabhakar

Neurobiology of Hallucinations - E Mohandas

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Adverse childhood experinces and mental health

Vivek Agarwal*1, Amit Arya2, Pawan Gupta3,

1Department of Psychiatry, K.G. Medical University, 2Department of Psychiatry, K.G. Medical University, 3Department of Psychiatry, K.G. Medical University, Lucknow, India

E-mails: drvivekagarwal06@gmail.com/gpawan2008@gmail.com/11kgmu@gmail.com

Keywords: Adverse childhood experiences, neurodevelopment, mental health

Background : A normal child development involves an attainment of specific physical, cognitive, linguistic, social-emotional, and behavioral milestones across the early years. Researchers have demonstrated a strong, graded relationship between the level of traumatic stress in childhood and poor physical, mental and behavioral outcomes later in life. This later life impairment may be the result of stress induced HPA axis malfunctions and disrupted neurodevelopment. Exposure to adversity during critical developmental periods may also confer high vulnerability to particular forms of psychiatric and medical disorders. This symposium will highlight the overview of studies being done on ACE’s and its impacts on mental and physical health, impact on the process of neurodevelopment and what preventive strategies are now being researched in this area.

Topics: Adverse Childhood Experiences and Health- an overview-Vivek Agarwal

Adverse Childhood Experiences and Neurodevelopment-Amit Arya

Prevention of the impact of adverse childhood experiences-current understanding-Pawan Kumar Gupta

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Mental illness-recovery & social inclusion-insights from private practice

Abhay Vishwas Matkar*1, Nanasaheb Patil2, Swaminathg3,

1Santoolan Clinic, Hubli, India, 2Jnmc Belgaum, 3Private Clinic,

E-mails: nmpatil22@gmail.com/drswamyg@gmail.com/drabhaymatkar@hotmail.com

Keywords: Recovery, social inclusion

Background: Mental illness is defined as “a state of well being in which an individual realises his or her abilities, can cope with the normal stressors of life, can work productively & fruitfully and is able to contribute to his or her community”.

While everyone has mental health needs, many people(one in four) experience mental ill-health at some stage of life.The societal costs of poor mental health are enormous--economic performance, human & social drift, increased health & social welfare cost and above all, the issue of stigma.

Improving mental health involves coordinated action plan from many domains of society-social, legistlative, medical, education, economic etc,. Civic management, strengthening social capital, building social network & having a trust in community will help in reducing stigma.

While in the realm of private practice all the above domains maintain their uneqvivocal presence it is the heirarchy which may change with each individuals need. Important would be improvement in treatment objectives to reduce stigma & facilitate early rehabilitation. Maintaining work can be critical for those experiencing mental ill-health. Private practitioners in psychiatry are better placed to increase public awareness that people with mental health problems can work & that work can contribute to positive mental health. Stigma & social discrimination are the greatest barriers of social inclusion, quality of life & recovery of people with mental ill-health. The issue of stigma as seen in home atmosphere, educational institutes, workplace & other social areas need a relook. Guidance to employers, colleagues, family members & so also at policy level would be focused by the authors in their presentations.

In our 90 minutes of symposia we wish to address private practitioners perspective of ‘mental illness’,’recovery’&’social inclusion’. We wish to share our experience in understanding of the topic & how we have been able to integrate in our private practice. We also would share our own experience how we as psychiatrists have been able to deal with our own social exlusion & stigma.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Are mood disorders really bipolar? A theme for four pole (Quadruple) mood disorders vis: a-vis four innate (basic) emotional states.

KC Gurnani*1, 1SN Medical College Agra, India,

1952kcg@gmail.com

Keywords: Bipolar, Tripolar, quadruple mood disorder, basic emotions, anatomical localization, new diagnostic system

Objectives-1: The case for Tripolar: During the span of last couple of years it had been observed that patients suffering from bipolar mood disorders would have presented with a clinical state, being labeled herein as third pole, which would have appeared slightly different from their usual presentation of either depression or elation or mixed state. Then, it was also observed that many patients would have presented with third pole symptom complex only, as the presenting feature. Thus a patient of mood disorder would present with either depression or with elation or with this third pole symptom complex. However, these third pole symptoms have not been taken as constituting an independent identity by the scientific community.

Whereas, a close observation of a few patients had shown that over a period of years, these third pole symptoms constituted a separate identity in themselves and these would not respond to the usual treatment of depression or mania.

Methods: To test the validity of third pole, an analysis of medical data of all the patients suffering from bipolar mood disorder, which had attended the psychiatry clinic during the last six months were analyzed.

A case prototype and the symptom profile of this pole are also presented.

Results: The findings were interesting. A case for this third pole symptom complex could be easily made out in a good number of patients.

A paper related to this theme, “Identification of a new pole in mood disorders: bipolar mood disorders are tripolar mood disorders” is being presented by the author at the WPA conference being held at Madrid in Sept. 2014

Objective-2: The case for Fourth Pole: Identification of the third pole gave rise to a hypotheses: A case for circular illness, wherein there are four emotional poles. This would be keeping in line with another paper being presented by the author at the same WPA conference wherein he is putting a case for “An assessment of innate emotional states: proposition for four innate emotional states.” The objective of this paper is to identify the basic emotions with which a child is born and correlating those states with the diseased states of mood disorders. An approach of this kind may be helpful in resolving the issues concerned with anatomic localization of emotions in the brain.

With this objective in mind, case records of all the above patients were re-analyzed. Also new cases coming for the first time were analyzed.

Results: The results obtained are beyond imagination. In fact a case for this fourth pole could also be made out. The hitherto overlooked symptoms, or which are taken for granted as forming part of any psychotic disorder, stood out as if in bright sunlight. A case prototype and the symptom profile of this fourth pole are also presented.

However, critiques to this theme of understanding would come out with their theories of existing nomenclatures which had described these clinical states under the rubrics of mixed states, NOS, Schizoaffective and so on. But, however, if a classical presentation is clearly demarcated, a clear case of mood disorders having four poles can be made out.

Conclusions: Identification of this third and fourth pole gives rise to a few hypotheses:

First, if the third pole symptom complex is an independent emotional state, a case would arise wherein its place in the diagnostic and classificatory system would have to be re-assessed.

Second, this may pave way for a new direction in pursuit of better treatment modalities.

A new understanding will arise as to the causation of various psychiatric disorders and their anatomical localization in the brain.

In fact, recognition of these facts is going to change the whole face of psychiatry!

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Workshop/symposium on spirituality and meditation in mental health

Avdesh Sharma1, Sujatha Sharma2

1Mind’s Vision, India, avdeshsharma@rahat.org, 2Mind’s Vision, India

sujatha_sharma@hotmail.com

Keywords: Spirituality, Meditation, Complimentary Therapy, Mental Health

Background: The perceived causation and thus help seeking behavior of any community is based on the indigenous belief systems of that community. Belief in higher power, essence of life and role of spiritual/religious practices modified the mental health of the society. There are also many countries and populations with woefully inadequate number of mental health professionals. The indigenous belief systems and spiritual practices are being utilized by the population for these purposes.

It has been found that Meditation produces certain psychophysiological and socio-cultural changes. These include lowering of triglyceride levels in the body, achievement of lower stable heart rate, lowering of blood pressure, stable G.S.R., improved rhythm and more delta and alpha rhythms on EEG, fewer psychosomatic symptom and fewer use of prescription and non-prescription medication, better productivity at work, less man days loss and scores on interpersonal relations and self actualization. Meditation has been found to be useful in treatment and prevention of illnesses like Hypertension, Heart disease, Strokes, Migraine, Tension Headache, Autoimmune diseases like Diabetes and Arthritis which are major psychosomatic illnesses in the community. Obsessions, Anxiety, Depression and substance abuse also can be modified by spiritual practices. It is probably most useful in reducing the problems of living in normal populations.

It would be worthwhile to incorporate systems like Meditation and spiritual practices appropriately, which in some cultures are already acceptable as complimentary to psychophysiological forms of treatment. There are also many scientific discoveries happening on the role of Spirituality and Meditation in Mental health. It may not only reduce costs and burden of disease on society but also lead to holistic treatment, relapse prevention as well as growth of the individual.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Symposium on Clinical decision making

Nagesh B Pai*1, Biju Rajan2, Santosh Prabhu3

1University of Wollongong, Australia,, 2Illawarra Shoalhaven Local Health District, Australia, 3K S Hegde Medical Academy, Mangalore, India,

E-mails: nagesh@uow.edu.au / drrajanbiju@googlemail.com/santoshp@gmail.com

Keywords: evidence based Psychiatry, decison making, comorbidity, classification

Background: Clinical decision making and Intuition

Intuition is widely used in clinical decision making yet its use is underestimated compared to scientific decision-making methods. Intuition is knowing without knowing how one knows. Use of intuition in clinical practice is that it is difficult to underpin how intuition informs clinical decision-making. Strengths of unconscious processes and conscious thinking can be combined to maximize complex clinical decision-making processes to the benefit of patient situations.

Clinicians are expected to use the best available evidence in their judgments and decisions. Mental health professionals use a rapid, automatic process to recognise familiar problems instantly. Intuition could therefore involve pattern recognition, where experts draw on experiences, so could be perceived as a cognitive skill rather than a perception or knowing without knowing how. The purpose of this presentation is to gain insight into the way clinicians make decisions related to psychiatric diagnoses and interventions.

Complications with comorbidity and classification

Clinical comorbidities are increasingly recognized as the defining realities of regular clinical care. The presence of clinical comorbidities poses significant challenges to current psychiatric diagnostic systems. Since the implementation of modern psychiatric diagnostic systems and the inclusion of the multiaxial diagnostic formats, the diagnosis of comorbidity became a focus of attention for two seemingly opposite reasons. The first reason originated from one of the stated goals of these diagnostic systems, which was to improve their clinical usefulness to enhance patients’ outcome by increasing the ability to recognize and therefore treat all presenting clinical problems. The presence of clinical co morbidities poses significant challenges to current Psychiatric diagnostic systems. The prevalence of comorbidity in the community and the complex interactions that occur between the two sets of disorders should raise doubts about the manner in which we continue to deal with each entity separately. The implementation of modern psychiatric diagnostic systems with the inclusion of the multiaxial diagnostic formats, made the diagnosis of comorbidity a focus of attention for two seemingly opposite reasons. The first reason originated from one of the stated goals of these diagnostic systems: to improve their clinical usefulness, to enhance patients’ outcome by increasing the ability to recognize and therefore treat all presenting clinical problems. This development not only enhanced the potential for improved clinical care, but also highlighted the multiplicity of presenting conditions.

The second reason stems from the lack of documented diagnostic validity for most mental disorders, which raises serious questions about the nature of many forms of mental disorders comorbidity. That is whether they are an expression of a single condition or are they truly independent.

Clinical validity rather than aetiopathogenic validity may represent a key concept in considering comorbidity towards the future development of psychiatric classification systems. This presentation highlights the challenges clinicians face secondary to comorbid conditions while making clinical decisions

Is there an evidence for evidence based Practice?

Evidence based practice is neither a cookbook medicine nor a cost cutting venture. It is the integration of best evidence with best clinical knowledge to enhance the treatment of patients. Asking a right question followed by identifying the best available evidence before appraising the evidence and applying it to a give clinical situation are some of the fundamental steps in this process. This presentation focusses on steps in appraising the evidence and then illustrates how to integrate it with the clinical treatment decision. Concepts such as number needed to treat and how to use this to evaluate whether one treatment is better than another, brief discussions on systematic review and evaluation of metaanalysis will be discussed during this presentation

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Is there need for “A Forum For Teachers of Psychiatry” in India?

Mohan Isaac1, Mysore V Ashok2, Kishor M3

1The University of Western Australia, Australia, Mohan., 2St Johns Medical College, Bangalore, India, 3JSS Medical College, Mysore, India

Emails: Isaac@uwa.edu.au / drkishormd@gmail.com/drmvahok@gmail.com

Keywords: Psychiatry, Teachers, Medical colleges, Undergraduates, Postgraduates

Abstract: The number of medical colleges as well as the number of colleges offering post graduate training in psychiatry in India has substantially increased during the past two decades. Surveys of training in psychiatry in the country have shown marked variability in the way psychiatry is taught across medical colleges and universities. There is also marked variation in the number of experienced and qualified teachers interested in teaching psychiatry and resources available for optimal teaching of psychiatry. In addition, psychiatry continues to be a very stigmatizing subject. In this context, it is noteworthy that there are no opportunities or forums of teachers of psychiatry in the country to discuss issues related to psychiatry teaching and enhance teaching skills, both at the postgraduate and undergraduate psychiatry teachers’ levels.

The three presentations will review the global experiences and situation and experiences from the perspectives of postgraduate and undergraduate teachers in India to make a case for a “Forum for Teachers of Psychiatry” in India and make proposals for its organization and activities.

Topics: “Global perspectives on teaching of psychiatry and need for a forum for teachers of psychiatry”- Mohan Issac

“Teaching of psychiatry in India at a postgraduate level: Experiences and challenges” – M V Ashok

“The need for continuing “teaching skills development” – Kishor M

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Social cognition deficits in schizophrenia: the next step ahead-from theory to practice

Rishikesh V Behere*1, Naren P Rao2, Girish N Babu3

1Kasturba Medical College, Manipal, 2Indian Institute Of Science, Bangalore, 3SDM Medical College, Dharwad, India

E-mails: girisha1980@gmail.com/rvbehere@gmail.com/docnaren@gmail.com

Keywords: Social cognition, schizophrenia

Background: Social interactions are fundamental for human development and survival as they influence aspects of our everyday lives, from family relationships to caring for children to vocational achievement. Humans thus have unique set of social cognitive skills not possessed by other animals. The social cognitive abilities are so inherent and automatic that their importance are underscored by the absence of these abilities in psychiatric disorders, importantly schizophrenia. Social cognition deficits are increasingly realized as the important determinants of functional outcome in schizophrenia. The increasing realization of these deficits and their clinical importance have opened up newer avenues of clinical intervention which were hitherto unaddressed. However, despite considerable advances in treatment of psychotic symptoms of schizophrenia, significant lacunae remain in the treatment of social cognitive deficits. Conventional pharmacological treatments are largely ineffective in handling functional impairments. Further present day cognitive rehabilitative strategies have proved to be inadequate in handling social cognitive deficits. Understanding the theoretical concepts of social cognition and applying these into practice may be an important ‘next step ahead’ in achieving better functional recovery for patients with schizophrenia. This symposium will review the current advancements in understanding of concepts in social cognition and novel therapeutic approaches in addressing social cognition deficits.

Dr Girish Babu N will review current advancements in concepts of social cognition and their clinical importance in schizophrenia. He will discuss about the consensus definitions on the relevant subdomains of social cognition and their application in research studies. He would introduce the ongoing efforts by NIMH to evolve a social cognition assessment battery to provide uniform system of assessment of these deficits.

Dr. Naren P Rao will provide an overview on the neurochemical and neuroanatomical basis of social cognitive deficits and discuss the novel pharmacological treatments for these deficits. Evidence from different lines of research over the last decade have established the critical role of neuropepetides in these deficits but still translational application of this knowledge to patient care is in early stages. Recent advances in experimental pharmacological research and their potential clinical applications will be discussed.

Dr Rishikesh V Behere will discuss the approaches and modules for social cognition remediation strategies relevant to schizophrenia. Conventional neurocognitive rehabilitative strategies routinely advocated have been demonstrated to be limited in improving social cognition deficits and real world functional outcomes. Ongoing efforts at developing remediation strategies applicable to indian settings and preliminary evidence will be presented.

Topics: Is it a Stare or a Smile? - Social cognition deficits in schizophrenia and their relevance

Dr Girish Babu N,

Think out of the box: Non-Dopaminergic Novel pharmacological approaches in schizophrenia for social cognitive deficits; What works for social cognition deficits?

Dr Naren P Rao,

Teaching patients to smile again : Introducing Social cognition remediation strategies

Dr Rishikesh V Behere,

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Recent Advances in Electroconvulsive therapy: An Update

Bangalore N Gangadhar, Naveen Kumar C, Shyam Sundar, Preeti Sinha, Nilesh Shah

NIMHANS, Sion Hospital, India

E-mails: kalyanybg@yahoo.com/cnkumar1974@gmail.com/shyamsundar@gmail.com/drpreetisinha@gmail.com/dranilshah@hotmail.com

Keywords: Electroconvulsive therapy, legal, ethical, electrical

Background: Abstract for ECT symposium at ANCIPS 2015

Recent Advances in Electroconvulsive therapy: An Update

Electroconvulsive therapy (ECT) is among the oldest therapeutic modalities in psychiatry. 75 years have elapsed since the time its use started. Recently, this was commemorated with an ECT symposium at the National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore. Though it is a popular treatment choice in India, it remains one of the most controversial. One of the main reasons for ECT-related controversy is the issue of ‘unmodified ECTs’. This practice still exists in many parts of the country due to reasons such as lack of anesthetists’ support, contraindications to the use of muscle relaxants and/or anesthetics, etc. In fact, there is view that unmodified ECTs can be applied in exceptional clinical circumstances considering their relative safety and equal efficacy. Also, psychiatrists have raised concerns that mandating modification in ECT may not always be in the interest of patients. Modification adds to costs of ECT service as well. Arguably, this mode of ECT could contribute to the apparent ‘barbarism’ and is discouraged by most professional bodies. A single court judgment related to ECT in India favors modified ECT. The draft of new mental health bill 2013 calls for a total ban of unmodified ECTs in the country. Another legal aspect is related to ECT in minors. If the bill is passed as an act, prior permission of a duly constituted board is required before administering ECTs to minors. These both issues have led to a lot of debate and discussion. Further, even across the globe, ECT has been under scrutiny exemplified by the USFDA action of categorizing ECT as a separate treatment modality.

Further, the postgraduate training in ECT in the country is far from satisfactory. Many centers do not have formal training in ECTs while others have cursory courses. Issues such as electrical aspects including dosimetry and electrode placements, on-the-table procedures, adverse effects of ECT, ethical and legal issues and use of ECT in special populations are generally not covered in ECT training. Even psychiatry textbooks do not comprehensively cover these aspects.

Since the last ECT symposium at ANCIPS (Chandigarh), the above-mentioned aspects have got research attention both in India and abroad. For example, the clinical and cognitive superiority of bi-frontal ECTs for schizophrenia patients, altering electrical parameters in order to elicit seizures, effects of different pulse-widths on the symptomatic and cognitive outcomes are recent developments. Also, notable research has occurred with ultra-brief pulse ECTs. We now have more definitive information about the nature and extent of cognitive deficits induced by ECT. We also have a simple and useful scale to measure and monitor the cognitive adverse effects both during and after stopping the course of ECTs.

In the backdrop of all the above-mentioned professional and scientific developments, there is a need for us to update ourselves. Accordingly, we propose to conduct a symposium at ANCIPS 2015. We plan to cover the following aspects of ECT practice

  1. Ethical and Legal issues related to ECT - BN Gangadhar

  2. On-table procedures and complications - Naveen Kumar C

  3. ECT in special populations - Shyam Sundar

  4. Adverse effects of ECT with a focus on cognitive deficits - Preeti Sinha

  5. Electrical aspects of ECT - Nilesh Shah

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Substance Use Disorders in Children and Adolescents: A Burgeoning Epidemic

Amit Garg, Pallavi Sinha, Shailesh Jha, Pankaj Kumar, Deepak Kumar

IHBAS, India,

E-mails: drgargamit@yahoo.com/pallavisinha0102@gmail.com/dr.shaileshk.jha@gmail.com/drpankajkumar13@yahoo.co.in/deepsrivastav@gmail.com

Keywords: Substance use disorder, adolescent, interventions

Background: Objective- To discuss the growing use of licit and illicit substance use in children and adolescents and related disorders.

Children and adolescents are an important resource for future of a country. Those aged between 10 and 19 years of age constitute 22.8% of population and those aged 5-9 years comprise another 12.5% of population in India. Use of tobacco, inhalants, alcohol, and other substances among children and adolescents is a public health worry in several parts of India. The childhood and adolescent years are important shaping years of life during which the child procure academic, cognitive, social and life skills. Any substance abuse at this age is likely to interfere with the normal child development and may have a lasting impact on the future life. Current research suggests that substance use in adolescence leads to abnormalities in brain functioning, including poorer neurocognitive performance, white matter quality, changes in brain volume, and abnormal neuronal activation patterns. Early initiation of substance use is usually associated with a poor prognosis and more serious impact on health, education, familial or social relationships. Substance use may lead to behavioral problems, relationship difficulties and may cause disruption in studies, and at times, anti-social behaviors e.g. lying, stealing etc.

Juvenile crime and its recidivism have its roots in poverty, dysfunctional homes, school dropouts and substance use. Most studies conducted in juvenile homes report 60-90% of juveniles with behavioural and substance use disorders.

In a study from India majority of sample children reported lifetime use of a variety of substances. Tobacco (83.2%) and alcohol (67.7%) were the most common substances ever used followed by cannabis (35.4%), inhalants (34.7%), pharmaceutical opioids (18.1%), sedatives (7.9%) and heroin/smack (7.9%). Use of injectable substances was reported by a significant proportion (12.6%). The gateway substance appeared to have an early onset before the use of illicit substances. The mean age of onset was lowest for tobacco (12.3 years) followed by onset of inhalants (12.4 years), cannabis (13.4 years), alcohol (13.6 years), proceeding then to use of harder substances -opium, pharmaceutical opioids, heroin (14.3-14.9 years) and then finally use of substances through injecting route (15.1 years).

Treatment interventions have mainly focussed on Prenatal care and mandatory parenting classes, Early identification of children at risk, Stress reduction and remediation for damaged systems and Targeted treatment, e.g., cognitive neurorehabilitation, psychiatric evaluation and treatment, etc but the most successful strategies employed is cognitive behavioral therapy that focus on refusal skills, or cognitive control and to decrease risky behaviors.

One of the challenges in addiction-related work is the development of biobehavioral markers for early identification of risk for substance abuse and/or for outcomes assessments for interventions/treatments. The findings underscore the importance of considering individual variability when examining complex brain-behavior relations related to risk-taking and impulsivity in developmental populations. Further, these individual and developmental differences may help explain vulnerability in some individuals to risk-taking associated with substance use and, ultimately, addiction.

Sub topics:

  1. Adolescent brain and substance use: An overview-Deepak Kumar

  2. Inhalant and smokeless tobacco use in adolescents: New ‘Gateway’ drugs?-Pallavi Sinha

  3. Substance use pattern in juvenile delinquents-Pankaj Kumar

  4. Novel treatment approaches for adolescent substance use disorders- Shailesh Jha

  5. Translating research to practice in adolescent substance use disorders-Amit Garg

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Euthanasia and psychiatry: curious paradox

Rachana Pradeepkumar Pole1, Indla Rama Subba Reddy2

1Saoji Tupkari Hospital, 2VIMHANS, India

E-mails: pradnyapole@gmail.com/indlas1@rediffmail.com

Keywords: Euthanasia, controversies, psychiatry

Objectives: Euthanasia and permissiveness towards it has been a matter of debate for decades. Many countries which have recently legalized euthanasia have made it mandatory to take opinion of two psychiatrists before executing the measures to death.

To discuss the various aspects of euthanasia, role of psychiatrists in granting the right to die along with the apparent discordance of opinion between the caretakers and policy makers, we intend to conduct a symposium on this much debated yet a bit neglected area in psychiatry.

Description: The topic euthanasia invokes very strong polarized arguments. Opinions vary according to country, race, religion and also the religiosity of the people. Apart from the ethical and moral issues involved euthanasia also raises more important questions about its possible abuse, effect on the natural process of death and bereavement and the possibility of supercedence of the medical science over a person’s own desire.

Empowerment of medical science has brought up a most frightening yet very real question staring in face of medical professionals and general population- a question of making the right choice between continuing the ongoing medical care or terminating it, one of the most difficult choices between life and death.

The countries like Australia have made a psychiatric referral mandatory before granting death. In several other countries psychiatric opinion is sorted on the request of physician. This brings psychiatrists into a very problematic position of ‘gatekeeper’ for euthanasia.

Recent studies have indicated that many psychiatrists have reported the reluctance to certify mental competence and absence of depression based on one clinical examination.

In this symposium, we wish to throw light on recent research conducted by us and the studies so far on the issue, some case vignettes, role of psychiatrist in this challenging situation, controversies surrounding it and the political neglect.

Speakers will cover following topics

  • (1)

      Euthanasia-The controversies, Research, Case vignettes and Medicolegal aspect.

  • (2)

     The two poles-Caretakers and Policymakers take on euthanasia.

  • (3)

     Psychiatrist as gatekeeper for euthanasia.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Salvador Minuchin’s Structural Family Therapy

Madhao Gajananrao Raje*1, Praveen Khairkar2, Neena Narula3

1Mahakali Hospital, 2MGIMS, Sevagram, Wardha, India

E-mails: anumanraje@yahoo.com/pravinkhairkar@mgims.ac.in/pravinkhairkar@mgims.ac.in

Keywords: Cultural impact, family mental health, Structural family therapy, salvador Minuchin, Joining, Re-framing, Unbalancing, Enactment

Background: Aim: To deal with cultural impact over family-health.

Introduction: Revolutionary change has taken place in today’s Indian family structure1. Change in Family structure affects functioning of family, which invariably affect family members. E.g. loneliness of elderly, female’s increased vulnerability to violence/mishaps.

Increased expression of anger, delinquency, social distrust, are increasing day-by-day as a result of non-conducive & changed family structure1.

Children around whom family/market revolves have changed significantly, evidenced by increased cases of ODD, Conduct disorders, & psychologically symptomatic children2 in today’s Indian family.

Around 1920, Salvador Minuchin, son of Jewish family in Argentina faced similer scenario of treating disruptive children of low socio-economic-family who were affected by impact of cultural disarrey while he was practising at Philadelphia. Since then, Focus of psychotherapy changed from ‘intra-psychic conflict’ to ‘family interaction’ leading to correction of dysfunctional family.

Principles of Model: (1) Family: family is an open, living system, can be affected by society to undergo change. (2) Presenting problem – Problem is partial indicator of structure of family transaction. So therapist focuses to change structrue of family transaction. (3) Process of therapeutic change- come alive when relative position of family members change. E.g. proximity of husband-wife increases in view of relative proximity of mother-son.

Methodology: Therapist role – (i) active. (ii) Neutral.

Tools of therapy

  • (1)

    Joining technique: Therapist joining, maintainance of therapeutic relations.

  • (2)

    Technique of Disequilibrium: Enactment, boundary making, reframing, punctuation, unbalancing.

Boundary making: Is supposed to bring great impact in Indian scenario.

Reframing: can be applied to most of the indian families in trouble.

Case study: To elaborate tool.

Conclusion: An active therapist proactively facilitates change in family’s structural dysfunctional interaction. Corrected family structure brings symptomatic relief which lasts long.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Biomarkers, Where Do We Stand

Vikash Dixit*1, Payal Sharma2, Atul Dyandeo Dhage3

1,2L.T.M.M.C. & G.H., India, drvikasdixit@gmail.com, 3Regional Mental Hospital, Ratnagiri, Maharastra, India

E-mials: drvikasdixit@gmail.com/drvikasdixit@gmail.com

Keywords: Biomarker, genetics

Objectives: Psychiatry for long time has been criticized for subjectivity of its diagnosis based on DSM/ICD. Biomarkers will lay foundation of a new classification system based on genetics, imaging and cognition which will increase accuracy and objectivity.

To address this issue and to show recent research done by experts in these areas we have planned a symposium.

Description: It is a long cherished dream of the medical profession to be able to individually tailor diagnosis and treatment for every patient. This dream of personalized medicine could come true with the help of biomarkers.

Biomarker is “a biologic feature that can be used to measure the presence or progress of disease or the effects of treatment, better understanding of pathogenesis and pathophysiology of disorder.” Its estimation predicts the high risk individuals, improves the accuracy of diagnosis and prognosis and tells whether a drug will be effective in a particular individual or not.

These potential biomarkers can be divided into three primary categories:

  1. Protein-based

  2. Imaging-linked

  3. Genetic

As psychiatric disorders are of multifactorial etiology and heterogeneous in expression biomarker research for psychiatric disorders requires a more complex approach, incorporating a multiplicity of clinical, socio-environmental, molecular, neuroimaging and neurophysiological findings associated with a psychiatric disorder.

These tests are quite expensive, their reliability is yet to be ascertained and there are lots of ethical concerns, it might lead to discrimination, selective abortion, and ill treatment.

Topics

  • (1)

    Introduction to biomarkers- what is biomarker? Why it is needed in psychiatry? - vikash dixit*

  • (2)

    Types of biomarkers and its association with various psychiatric conditions.- payal sharma2

  • (3)

    Potentials, pitfall and clinical implication of biomarkers.- Atul dyandeo dhage3

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Life Skills Education For School Students The Kerala Experience

Arun B Nair*1, Ullatil Vivek2, Jithu V P3

1Medical College Thiruvananthapuram, India, 2Renai medicity hospital, 3Medical College Kozhikode, India,

E-mails: arunb.nair@yahoo.com / vivekullatil@gmail.com/arunb.nair@yahoo.com

Keywords: Life Skills, School Students, Kerala Experience

Background: Life skills are a group of abilities which every person should imbibe in order to face new and difficult situations in life. It helps to improve psychosocial competence and enhance assertiveness so that a person can abstain from unhealthy practices like substance abuse, aggression, unhealthy sexual behaviour and abuse. UNICEF has pointed out that adolescence is the key period to develop life skills in an individual. WHO has listed a group of 10 life skills, which have to be imparted to children and adolescents in a structured way.

Since most of the available life skills education modules are city based and having high western influence, it is important to develop new modules which are culturally appropriate and addresses the local issues pertaining to every state. The state council for education and research and training, Government of Kerala attempted to develop a module suitable for training school students of Kerala. The module which was to be in Malayalam was supposed to contain separate modules for each class from std 1 to 12.

A high level meeting of psychiatrists, paediatricians, teachers and education experts was convened to form a core committee to design the module. The committee identified eight different areas including self-safety, personal hygiene, environmental hygiene, social responsibility, nutrition, growth and development etc. which are important in the development of a child. Structured group activities and role plays utilising the 10 like skills are employed to impart a clear awareness to students, regarding how to handle various real life situations. The modules-separate ones for each class from std 1-12-addresses various issues including sexual abuse, developing good friendships, career guidance, substance abuse, and assertiveness. The module has been implemented in pilot basis in 20 schools in Kerala based on the results of which it will be extended to the whole public education sector in the state.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Prevention of Divorce in Married Women with Mental Illness

Abhishek Pathak, Avdesh Sharma, CP Rabindranath MS Bhatia and Shruti Srivastava, Indira Sharma,

Senior Resident, NIMHANS, Bangalore, Consultant Psychiatrist, Consultant Psychiatrist, Madurai, GTB Hospital, Shahdara, Delhi Former Prof & Head, Dept Psychiatry, IMS, BHU, Varanasi

Background: Divorce/separation of women with mental illness is a major social problem which adversely affects the clinical outcome and rehabilitation of women with mental illness

Introduction: Separation or divorce of women with mental illness is a major social and legal problem. It adversely affects the clinical outcome and rehabilitation of women with mental illness. Many more women than men with mental illness are abandoned by their husbands. Women with less severe forms of illness such as conversion disorder are also sometimes abandoned. The problem is largely due to stigma for mental illness. Often the clinician’s priority is treating mental illness, but the family’s the priority is prevention of dissolution of marriage.

Community level programs of mental health education: Separation or divorce of women with mental illness, especially those with severe mental illness, is a major social and legal problem. Mental health education should focus on: 1. Modern medical treatment has significantly improved the outcome of mental disorders. 2. In the modern era gender discrimination is not acceptable. If parents want their daughters with mental illness to be accepted and integrated into their husbands’ families; the same norms should apply for daughter-in-laws with mental illness. Likewise, if wives can accept and continue marital relations with husbands having mental illness, husbands can also do the same. 3. Good behavior of husband/family members improves the outcome of mental illness and hostile behavior worsens the prognosis. 3. Marriage and mental illness are not incompatible as many women with mental illness have been accepted and integrated into their husbands’ families 4. Women with mental illness need sympathy and care. They should not be abandoned and punished for no fault of theirs. 5. The main problem is stigma and not mental illness. The solution is family support and prompt treatment of mental illness.

Role of patients and families: Most parents are aware about the problems that their daughters with mental illness could face if the history of previous illness is revealed or symptoms of mental illness appear, yet they marry their daughters often without disclosing the history of mental illness prior to marriage. After marriage patients / family members adopt several measures to prevent dissolution of marriage such as: denial of mental illness; attributing the mental symptoms to cruelty meted out to the women for want of dowry or gifts from parents; taking psychotropic medication secretly; the woman telling lies (that the medicines are for headache or some other ailment), when caught taking medicines; parents supplying psychotropic medication to the patient secretly; unplanned pregnancies; making complaints to the police under the Dowry Prohibition Act, Protection of Women from Domestic Violence Act or Of Cruelty by Husbands and Relatives of Husband (498A IPC); and filing petitions in courts etc. These methods may at times prevent dissolution of marriage, but at other times worsen the situation. There is a need to debate on what is in the best interest of women with mental illness and their families.

Role of clinicians: When dealing with women with mental illness the clinician’s dilemma is that whereas his/her priority is treatment of mental illness, the families’ priority is preservation of the institution of marriage. The clinician faces many problems such as: parents of the women may pressurize him to conceal the truth (past history of mental illness) from the husband; may exaggerate or fabricate complaints against the in-laws and husband so that a charge of cruelty and reaction to it by wife is made, rather than of mental illness. Husband may ask for details of mental illness of the woman with so that he go for a divorce suit. The main role played by the clinician is to convey that: 1. The medical needs of the woman should receive top priority, the environment should be warm and supportive and mental illness in the woman should be treated promptly. 2. Decision for separation or divorce should not be taken during the acute phase of the illness. 3. Divorce can only be taken in accordance with the law of the country. The decision on whether to, and how much to disclose, about mental illness of the woman, to the husband by the clinician needs further discussion.

Role of judiciary: The laws relating to marriage have put restrictions on marriage of persons with mental illness to a lesser or greater extent. As per the Hindu Marriage Act a person with a mental disorder, which is recurrent, which makes the person incapable of giving a valid consent, or unfit for marriage or the procreation of children, is not entitled for a marriage. The diagnostic category of mental illness is not specified. Consequently, many people assume that marriage with a person with any mental illness is unjustified and voidable. This has led to the abandonment of many women with mental illness even before the initiation of court proceedings. The Dowry Prohibition Act (DPA), the Protection of Women from Domestic Violence Act (PWDVA) and Of Cruelty by Husbands and Relatives of Husband (498A IPC) are often used by families of women with mental illness to prevent dissolution of marriage rather than against dowry/violence per se. In the judgements of various matrimonial disputes it is evident that often the one party had a mental illness, but often due attention was not paid to the same. The judicial system can play a positive role by: 1. Proposing amendments to 1) remove mental illness from the conditions of Hindu Marriage Act and 2) provision for mental health assessment and treatment of the perpetrator and/victim in the code of civil procedure in cases filed under DPA and PWDVA. 2. Sensitivity regarding presence of mental illness in persons involved matrimonial disputes. All suspected cases should have mental health assessment and necessary treatment after which resumption arguments can take place.

Topics:

Introduction: Abhishek Pathak

Community level programs of mental health education: Avdesh Sharma,

Role of patients and families: CP Rabindranath

Role of clinicians: MS Bhatia and Dr Shruti Srivastava,

Role of judiciary: Indira sharma

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Delirium in clinical practice

Umesh Sureshrao Nagapurkar, BSV Prasad

Sujata Birla Hospital, India,

E-mails: umeshanjali@gmail.com / bsvprasad2@gmail.com

Keywords: delirium, diagnosis, management, clinical practice

Background: Delirium is an acute state of confusion marked by sudden onset, fluctuating course, inattention, and at times an abnormal level of consciousness. Delirium is extremely common but can be challenging to diagnose. It can often be triggered by an infection, operation or a new drug. Delirium can lead to longer stays in hospital, bed pressure sores, and may increase the risks of dementia and death.

Its manifestations range from acute agitation, which accounts for less than 25% of all cases, to the much more common but less frequently recognized hypoactive, or quiet, variant.. Approximately one third of patients aged 70 years or older admitted to the general medical service of an acute care hospital experience delirium: One half of these are delirious on admission to the hospital; the other half develops delirium in the hospital. Postoperative delirium rates among seniors range from 15% to 25% after elective surgery, such as total joint replacement, to over 50% after high-risk procedures, such as hip fracture repair and cardiac surgery. Among patients of any age admitted to intensive care units (ICUs), the prevalence of delirium may exceed 75% and the cumulative incidence of delirium at the end of life is reported to be as high as 85%.

Delirium is a serious disturbance in a person’s mental abilities that results in a decreased awareness of one’s environment and confused thinking. The onset of delirium is usually sudden, often within hours or a few days.

Delirium can often be traced to one or more contributing factors, such as a severe or chronic medical illness, medication, infection, surgery, or drug or alcohol abuse.

Taking good history of symptoms from relatives/caregivers or hospital staff is very important for a clinician to make an accurate diagnosis.

The signs and symptoms of delirium appear over a short period of time, from a few hours to a few days. They often fluctuate throughout the day, so a person may have periods of no symptoms.

Primary signs and symptoms include Reduced awareness of the environment, Poor thinking skills (cognitive impairment), Behavior changes

Delirium may last only a few hours or as long as several weeks or months. If factors contributing to delirium are addressed, the recovery time is often shorter.

The degree of recovery depends to some extent on the health and mental status before the onset of delirium. People with dementia, for example, may experience a significant overall decline in memory and thinking skills. People in better health are more likely to recover fully.

People with other serious, chronic or terminal illnesses may not regain the levels of thinking skills or functioning that they had before the onset of delirium. Delirium in seriously ill people is also more likely to lead to: General decline in health, Poor recovery from surgery, Need for institutional care, Increased risk of death

Diagnosis of delirium usually depends on good medical history, mental status examination, Physical and neurological exams, relevant tests and the identification of the possible contributing factors.

The first goal of treatment for delirium is to address any underlying causes or triggers — by stopping use of a particular medication, for example, or treating an infection. Treatment then focuses on creating the best environment for healing the body and calming the brain.

Prevention

The most successful approach to preventing delirium is to target risk factors that might trigger an episode. Hospital environments present a special challenge — frequent room changes, invasive procedures, loud noises, poor lighting and lack of natural light can worsen confusion.

There are various clinical guidelines describing methods of preventing, identifying, diagnosing and managing delirium. A few guidelines focus on preventing delirium in people identified to be at risk, using a targeted, multi-component, drug-free intervention that is tailored for each individual.

Considering importance of delirium in clinical practice, office practice as well as hospital, indoor set up(in GHPU, ICU etc), we intend to present importance of identifying, diagnosing, managing delirium with 4-5 case presentations. After presenting theoretical aspects of pathophysiology & etiology, how to diagnose delirium using clinical skills, relevant tests would be discussed with practical tips.

Aim of this symposium to sensitize audience esp, PG students & clinicians regarding delirium. To use check lists, guidelines to diagnose & manage patient with delirium, present protocols for management so that it can be implemented in clinical practice. Also highlighting their follow ups & outcomes (with help of case vignettes). Not to forget are medicolegal issues related to delirium, would also be discussed with practical inputs. Plan to present relevant survey of mental health professionals & physicians involved in treating delirium regarding, frequent causes, management & prognosis, so that we could generate data which would have important implications in management of delirium in clinical practice. At the end interactive discussion with audience regarding practical issues in managing delirium would be encouraged which would be mutually beneficial.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Life And Its Possibilities: Part 3 - Your Child And You

Venkatesh Ramachandran: Psymed

N.Rangarajan – Psymed Professor, T Nagar, Chennai

Emial: lakshran2006@gmail.com/pszmedclinic@gmail.com

“Man often becomes what he believes himself to be.
If I keep on saying to myself that I cannot do a certain thing, it is possible that I may end by really becoming incapable of doing it.
On the contrary, if I have the belief that I can do it, I shall surely acquire the capacity to do it even if I may not have it at the beginning.” M.K. Gandhi

As part of series of workshops: Life and its possibilities, this part brings out burning issues between you and your child. This is workshop aimed at parents and the qualities they want to their children to imbibe. We set about collecting data from family, friends, class mates, colleagues, well-wishers, patients, care takers, hospital staff, and our social networks to put forward the most wanted qualities to teach your child.

Here we set about practical ways to help you teach your children to learn these qualities. We also address burning issues like anger in children and ways to limit set and positively channelize this negative emotion in Children.

We should believe we can do it with our children and help them acquire the capacity of these qualities setting the stage for our children to grow into a responsible good human being.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Symposium on Liaison Psychiatry ‘Scope of sub-specialities within Liaison Psychiatry’

Phani Prasant Mulakaluri1, Ajay Verma Macharouthu2, Keshav Rao Devulapally3

1Chetana Hospital, India,2NHS Ayrshire & Arran, United Kingdom,3Chetana Hospital, India,

E-mails: drphani@gmail.com/ajayverma.macharouthu@nhs.net/dkrao@hotmail.com/apandurangi@mcvh-vcu.edu

Keywords: Liaison Psychiatry, Old age Psychiatry, Adult Psychiatry, Child Psychiatry

Background: Symposium on Liaison Psychiatry

‘Scope of sub-specialities within Liaison Psychiatry’

Liaison Psychiatry is a young and developing sub-specialty. Liaison Psychiatry is sometimes known as Psychological Medicine or Consultation-Liaison Psychiatry.

Liaison Psychiatry teams provide the psychiatric service for general or acute hospitals (and occasionally other types of hospital). We work at the interface of physical health and mental health. Liaison Psychiatrists are often treating people who are severely unwell, and have to balance people’s need for psychiatric treatment against their need for physical treatment.

Most Liaison Psychiatrists treat ‘working age adults’ (18-65yrs) and many also see and treat older adults. Increasingly some new consultant posts have been developed for specialist Older Adult Liaison Psychiatrists, and there are a very small number of specialist Child and Adolescent Liaison Psychiatrist posts.

Working in Liaison Psychiatry: If you specialize in Liaison Psychiatry, you are likely to be based in a general or acute hospital, rather than in a psychiatric hospital.

You will need to feel confident assessing people across the whole range of psychiatric diagnoses, and until you arrive at work in the morning you won’t know which patients (with which diagnoses) are going to be referred to you. This makes the work interesting, varied and challenging.

Compared to other psychiatric sub-specialties, in Liaison Psychiatry there is a relatively greater emphasis on assessment, and less emphasis on providing ongoing treatment. If you like a diagnostic challenge, you like working in a hospital, and you enjoy the more acute aspects of psychiatric practice, then Liaison Psychiatry may be a career for you.

Common procedures/interventions: Most Liaison Psychiatrists provide a service across three broad areas of the hospital:

  • The Emergency Department

  • Hospital wards

  • Liaison Psychiatry outpatient clinics

In the Emergency Department we work closely with Emergency Medicine consultants and other clinicians to assess and treat people who have presented acutely with psychiatric disorders. This ranges from acute psychoses to deliberate self-harm and drug & alcohol disorders, and undiagnosed patients who appear to be suffering from an acute mental disorder. Calmness, efficiency and decision-making are key attributes here.

On the hospital wards we treat a wide range of psychiatric disorders, some of which may have arisen as a result of a physical health problem. In other cases the psychiatric disorder may have led to the health problem, or the two problems may be coincidental. Most Liaison Psychiatrists will treat some older adults, where skills in assessing and managing confusional states and dementia are also important, as well as finding the right treatment for someone who may have multiple physical health problems and may be taking an array of medication. We need to consider the person’s home setting, safety and independence as well as making decisions about medication and follow-up.

The Liaison Psychiatry outpatient clinic reflects the patient group served by the hospital. Liaison Psychiatrists usually offer treatment for patients with medically unexplained symptoms, as well as common mental disorders (anxiety and depression) that may arise from or worsen a person’s physical symptoms.

Programme

Old-age liaison psychiatry service -

‘From Consultation to Integration’: The development of a Mental Health Liaison Service for Older People in General Hospitals - Ajay Verma Macharouthu,

General Adult Liaison Psychiatry service

Experiences of a Liaison psychiatrist in India: Phani Prasant

Child & Adolescent liaison psychiatry service: Working with children & Adolescents in a gebral hospital setting – UK perspective Keshav Rao Devulapally

Post-Graduate Psychiatry Training in USA: Raghu (Nyapati) Rao, Joel J Silverman, Anand K. Pandurangi, Antony Fernandez,

  1. Professor & Chair of Psychiatry, Nassau University Medical Center, East Meadow, NY

  2. Professor & Chair of Psychiatry, Virginia Commonwealth University, Richmond, VA

  3. Professor & Vice Chair of Psychiatry, Virginia Commonwealth University, Richmond, VA

  4. Clinical Professor of Psychiatry, Virginia Commonwealth University and McGuire Veterans Administration Medical Center, Richmond, VA

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Post-Graduate Training in Psychiatry in USA

AIMS: To provide an overview of the training program, core competencies, and elective opportunities in the residency training program in USA.

Materials & Methods: Paul Summergrad will provide introductory remarks on the psychiatric needs of the community and current status of the psychiatric workforce in USA, and the role of APA.

Nyapati Rao will present the evolution of psychiatric GME, the milestones, development of core competency goals, and the inclusion of professionalism as a core competency. He will also discuss the dimensions of professionalism as applied to psychiatric practice.

Joel Silverman will discuss the infrastructure, faculty and continuous quality improvement processes in psychiatry residency programs, the challenges of funding and the role of public and private support.. Anand Pandurangi will present elective and research opportunities in psychiatric GME and provide a personal perspective on the strengths and weaknesses of Psychiatry residency in USA and India.

Antony Fernandez will discuss the role of diverse training sites in enriching the learning of residents. He will also compare the training models in India, UK and USA from his personal experience.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Mental Illness: Recovery and Social Inclusion: An Indian Perspective

Fiaz Ahmed Sattar, Kiran Kumar K, Rohini T, Mohammed Munnawar Hussain

Vydehi Institute of Medical Sciences & Research Center, India

E-mails: fiazahmedsattar@gmail.com/drkiran.psychiatry@gmail.com/drrohinimd@gmail.com/munnawar1986@gmail.com

Keywords: Mental illness, Recovery, Social inclusion

Background: In recent years social inclusion has emerged as a prominent concept in discussions about social disadvantage. Of all the disadvantaged groups in society, the mentally ill are the most socially excluded. Social inclusion following recovery is a noble idea but not a simplistic concept. It is tied up with political and professional discourses around mental health care and treatment.

Objectives: To discuss and debate the current Indian perspectives in the area of Recovery and Social inclusion in patients suffering from mental illness.

Overview: Recovery and Social Inclusion can be intricately linked through an individual’s experience of mental illness. Everyone who experiences mental health problems faces the challenge of recovery, i.e. rebuilding a meaningful and valued life; they face the task of living with and growing beyond, what has happened to them. Although recovery is a personal journey based on the idea of resuming a ‘normal’ life despite illness or disability, this can be either significantly hampered or enhanced by social experiences, by being involved and participating in the same civic, social and leisure opportunities as others do. Recovery, in the sense used here, does not necessarily mean ‘clinical recovery’; rather, it is concerned with ‘social recovery’, the idea of building a life beyond illness, of recovering one’s life, without necessarily achieving clinical recovery. There is a substantial body of literature that focuses on aspects of social inclusion for people with mental health problems. It is interesting to note that the concept of social inclusion has become an increasingly popular concept to use when focusing on issues of disadvantage. Studies on specific areas such as unemployment, housing, and education, are increasingly reported as studies of social exclusion, and studies of interventions designed to improve aspects of people’s lives are described as programmes to promote social inclusion. Social inclusion is a worthy goal of mental health services, but its attainment requires extensive social change. Within services, structures, systems and the balance of power between clinician and patient will have to be re-examined. Beyond services, social exclusion is perpetuated by public prejudice, by far-reaching discrimination and by the association between mental illness and other indicators of deprivation.

Speakers and Topic: In a country likeIndia, with vast socio-cultural and ethnic background and with a huge burden of mental illness; the mental health professionals faces a unique challenge of Social inclusion of a mentally ill person. Here we shall discuss these aspects with special relevance to an Indian perspective.

  1. F.A.Sattar: “From Social Exclusion to Social Inclusion: A Paradigm shift”

  2. Rohini T: “The concept of Recovery: Moving beyond treatment and cure”

  3. Kiran Kumar K: “Social Inclusion: The construct and its contents”

  4. Munnawar Hussain: “Challenges and future opportunities- An Ideal Scenario”

Conclusion: A socially inclusive approach should be a key driver for the practice of individual mental health professionals and for the working and culture of mental health services in the 21st century. Psychiatrists must play a leading role in this.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Behavioral and psychological symptoms of dementia (bpsd): Management skill development

Sarvada Chandra Tiwari, Nisha M Pandey

1King George’s Medical University, India

E-mails: sarvada1953@gmail.com/nmpandey@gmail.com

Background: Behavioral and psychological symptoms of dementia (BPSD) are those symptoms which are often distressing for both care givers and professionals. It consists of disturbed emotions, mood, perception, thought, motor activity, and altered personality traits. The spectrum of BPSD may include aggression, agitation, and/or restlessness, screaming, pacing and repetitive motor activity, anxiety, depression, psychosis (delusions and hallucinations), repetitive vocalization, cursing and swearing, sleep disturbance, shadowing (following the care givers closely), sun downing, wandering, inappropriate sexual behavior, hoarding. It is reported that 76% of nursing home admitted patients with dementia exhibit BPSD. In community, among clinically diagnosed dementia patients approximately one-third suffer with BPSD. Another study reports, around 90 per cent of people with dementia experience aggression, agitation and psychosis (delusions and hallucinations).

Because of varying and overlapping phenomenology, it often becomes difficult to differentiate and diagnose the symptoms correctly. Further, for both professionals and caregivers it is often quite difficult to manage BPSD. Therefore, before initiating/providing any sort of treatment, one needs to diagnose the symptoms and signs correctly and also to identify the benefits and risks of treatments as well. Management strategies should be adopted using an ABC approach that focuses on Antecedents, Behaviors, and Consequences. In this workshop four important BPSD symptoms namely- aggression, wandering, inappropriate sexual behavior and repetitive behavior will be taken up. The process of their diagnosis and management modules will be discussed.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

“School mental health in india”: Good practices models towards inclusion in schools

Jitendra Nagpal1, Divya Singhal Prasad2, Pooja Jaitly2, Astha Sharma2, Diksha Sachdeva2

1Institute of Child Development & Adolescent Health, Moolchand Medcity, 2Expressions India, India,

E-mails: poojashivamjaitly@gmail.com/astha12sharma@gmail.com/divyasprasad1973@gmail.com/jnagpal10@gmail.com/dikshasachdeva2010@gmail.com

Keywords: Children, Adolescent, Mental Health, Inclusion, Disability

Background: Children are the most important assets of any country and the most important human resource for overall development. In India, Children and adolescents constitute 40 % - 44 % of over 1200 million population.

Schools are one of the settings outside the home where children can acquire new knowledge and skills to grow into productive and capable citizens, who can involve, support and help their communities to grow and prosper. The school plays a crucial role in the development of cognitive, linguistic, social, emotional and moral functions and competencies in a child. However, in the contemporary system of education, schools have seriously marginalized and compromised on their role in guiding and regulating the psychological development of children with disabilities. According to National Census of India (2011), children and adolescents with disability in age group of 5 years to 19 years are 3.36%. World Bank Report (2007) highlighted that 38 per cent of the children with disabilities in the age group 6-13 years are out of school. It is now widely acknowledged that to achieve the goal of universal education in India and in order to fulfil provisions laid out in the Right of Children to Free and Compulsory Education (RTE) Act, 2009 (Ministry of Human Resource Development, 2009) the education of children with disabilities cannot be put on the back burner.

A Health Promoting School is a setting where education and health programmes create a “health promoting”, environment that in turn “promotes learning for all”. Inclusion or the education of children with disabilities in regular classrooms must be adopted both as an ideology and as a practical solution to support the Education for All, and to meet the needs of children with disabilities. Inclusion aims at integrated development of children with special needs through mainstream schooling. It upheld the aim of ‘education for all’ by suggesting some foundational changes in programmes and policies of nations. Through inclusive education children with disabilities remain on a path that leads to an adult life as a participating member of society. Meeting all their needs together increases their ability to achieve academic and physical growth to their potential, and it enhances their overall quality of life.

The symposium envisages to highlight the School’s Emerging Potential for Promoting Mental Health and Inclusion.

  • Schools have profound influence on children, their families and the community.

  • Schools can act as a safety net, protecting children from hazards that affect their learning, development and psychosocial well-being.

  • In addition to the family, schools are crucial in building or undermining self-esteem and a sense of competence.

  • School mental health programmes are effective in improving learning, mental well-being, and channelizing management of mental disorders.

  • Young peoples’ ability and motivation to stay in school, to learn, and to utilize what they learn is affected by their mental well-being.

  • School infrastructure and environment should be disabled friendly Schools should have special educators in schools on a regular basis.

  • Make further recommendations to encourage mental health professionals to establish good practices in schools.

  • School counselors and their profile needs a revisit for enhancing role and responsibility.

  • Pre-service & in-service training programmes for teachers and counselors.

  • Teachers have often received some training in developmental principles. This makes them potentially well qualified to execute the philosophy of inclusive education in schools.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Cognitive behaviour therapy in adolescent mental health

Manju Mehta, Rajesh Sagar, Usha Naik, Paakhi Srivastava

All India Institute of Medical Sciences (AIIMS), India

E-mails: naikusha@gmail.com / drmanju.mehta@gmail.com/rsagar29@gmail.com/paakhisrivastava@gmail.com

Adolescence (11-19 years age) has been recognised as a period of turmoil. This is a transitional stage characterized by biological, psychological and interpersonal changes. At present many adolescent have to face high competition, unrealistic expectations and multiple distractions. It is not surprising that different types of psychological problems are manifested during adolescence.

There is increase in cases of aggression-both physical and verbal - and other behavioural problems among adolescents.. Psychological intervention is becoming the need of the hour. Rise in the number of adolescents involved in cases of sexual violence, bullying, suicide etc has led to a need to help adolescents by mental health practitioners across the country. Not just the early years, but the entire adolescent period needs psychosocial support - though only 3-12% need help for various diagnosed mental disorders, 25% need help for adjustment problems and almost 40% need help in developing life-skills and competencies to learn to deal with their problems effectively

Cognitive behavioural therapy helps to bring changes in patterns of thinking, feeling and behaviour. in an individual. CBT empowers adolescents to improve psychosocial competence and to build resilience. Psychological empowerment is an adolescent’s cognitive state characterized by a sense of perceived control, competence, and goal internalization.

The symposium will focus on the following topics

Magnititude of mental health problems in Adolescents: Usha Naik

Empowering Adolescents through CBT: Manju Mehta

Computer Assisted CBT: Paakhi Shrivasatava

Effectiveness of CBT in Adolescent Mental Health: Rajesh Sagar

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Somatoform Disorder: Current Understanding & Management

Manu Arora*1, Samir Praharaj2, Shahul Ameen3

1Assistant Professor, Department of Psychiatry, Government Medical College, Jammu, J & K, India, 2Assistant Professor, Department of Psychiatry Kasturba Medical College, Manipal, Karnataka, India, 3Psychiatrist, St. Thomas Hospital, Changanacherry, Kerala, India,

E-mails: samirpsyche@yahoo.co.in/drmanu2004@rediffmail.com / shahulameen@yahoo.com

Keywords: Somatoform disorders, etiology, pharmacotherapy, psychotherapy

Background: This symposium will discuss the current understanding of somatoform disorder and its relevance in Indian context. The symposium aims to bridge research and bedside practice. Discussions will focus on the pathophysiology, non-pharmacological treatment approaches and evidence-based pharmacotherapy.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

“Doc ! I am not getting good sleep.”: Is a sleeping-pill enough?

Ravi Gupta1, Atul Ambekar2, Alka Subramanyam3, Arshad Hussain4, Vaibhav Dubey5

1Himalayan Institute of Medical Sciences, India, 2All India Institute of Medical Sciences, New Delhi, India, 3TNMC & Nair Hospital, Mumbai, India, sleepdoc. Email: ravi@gmail.com atul.ambekar@gmail.com/alka.subramanyam@gmail.com/arshadtina@gmail.com/dr.vaibhavdubey@gmail.com, 4GMC, Srinagar, India,5Peoples Medical College, Bhopal, India

Keywords: Sleep, Insomnia, Restless legs Syndrome, Sleep Apnea, ADHD, elderly, PTSD, Opioid

Background: Recent classification systems, DSM-5 and International classification of sleep disorders-3 have brought a new understanding towards insomnia. Based upon the recent clinical evidences, these systems have described insomnia as a disorder rather than just a symptom of any psychiatry disorder. In other words, the dichotomy of primary and secondary insomnia has been removed and it has been considered as “Insomnia Disorder” and “Chronic insomnia” in DSM-5 and ICSD-3 respectively. This change has been brought because the evidences indicate that insomnia even when occurring with psychiatric disorders, often runs an independent course, if not adequately treated.

A number of opioid abusers and patients during opioids withdrawal complain of sleep problems that meet the criteria for insomnia. These patients are often given benzodiazepines but they are usually ineffective. It is known that opioids can induce central sleep apnea (CSA) which often clinically presents as poor quality sleep. Moreover opioid withdrawal leads to the Willies Ekboms Disease/Restless legs syndrome (WED/RLS) and may persist for a long time. Prescription of psychotropics further worsens this situation.

PTSD patients often have flashbacks and hyperarousal. Flashbacks can appear in dreams and worsen the sleep quality. Many of these patients are afraid of getting asleep because of nightmares. Hyperarousal further worsens the situation.

Elderly subjects have advanced sleep phase and they may present as ‘terminal insomnia’. In addition, medical morbidities interfere with their sleep, e.g., CHF, Parkinsons Disease etc. They are at a higher risk for Obstructive sleep apnea (OSA) and REM sleep behavior Disorder (RBD). These disorders often present as poor sleep quality. Sleeping pills and other psychotropics may worsen the situation.

It has been long known that ADHD children have poor sleep. However, recent evidences suggest that children who have sleep disorders e.g., Willies Ekboms Disease/Restless legs syndrome and obstructive sleep apnea (OSA) have poor quality sleep. Unlike adults, in whom poor nighttime sleep presents as excessive daytime sleepiness, children become hyperactive and present as ADHD. Hence, it is important to rule out sleep disorders before starting therapy for ADHD.

  1. Insomnia in Psychiatric Disorders: A symptom or a disorder? Ravi Gupta

  2. Sleep Problems during opioid Abuse and withdrawal: Can a sleeping pill improve it? Atul Ambekar

  3. Sleep and PTSD: What to look for? Arshad Hussain

  4. Sleep complaints in elderly: looking beyond insomnia! Alka Subramanyam

  5. Sleep problems and ADHD: Chicken or the egg? Vaibhav Dubey

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Proposal for workshop for MRCPsych exam in India

Jyothirmayi Kotipalli1, Sayed Aqeel Hussain2

1Private, 2Institute of Mental Health Neurosciences, Kashmir, India,

E-mail: jyodoctor@gmail.com sayedaqeel@gmail.com

Keywords: MRCPsych examination India

Background: proposal for workshop for MRCPsych exam in india

The process of revalidation and the job prospect in UK following pass of MRCPSYCH exam.

In order to increase the man power at secondary care level, The Royal College of Psychiatry has proposed to conduct MRCPsych exam in India from 2015.

They have made eligibility criteria easy and it will create an opportunity for psychiatrists to work in UK, share their experience and work and have an opportunity to work in Uk even for short period of time which can be facilitated by Locum agencies, one of which will be part of workshop to interact and provide advice about the process and job opportunities in UK.

A joint presentation will be given about the process of MRCPsych examination in India, to have valuable feed back about the practicalities and the process of MRCpsych exam, the type of support the Psychiatrists would like to have with regards to preparation for MRCPsych examination.

The second component would be about the process of revalidation and how to collect evidence for successfully getting revalidated by GMC UK despite working in India or partly in UK.

The eligibility criteria includes two years experience of psychiatry in a psychiatry hospital followed by a letter of recommendation by the HOD.

The workshop will provide an excellent opportunity to get valuable feedback from psychiatrists from all over India and from various sub specialities and colleges which will be fed back to Royal College of Psychiatry in order to make the launching of MRCPsych in India a valuable contributor towards providing good quality psychiatric services and increase opportunity to share research, experience and workforce between two countries.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Mental Health Literacy in India

Bhaveshkumar Manharlal Lakdawala1, Mahemubin S Lahori2, Suneet Kumar Upadhyaya3, Naresh Nebhinani4

1Dept. of Psychiatry, Assoicate Professor and Head, GMERS Medical College and General Hospital, Gandhinagar, Gujarat, 2Assistant Professor, 3Associate Professor and Head, 4Assistant Professor, Dept. of Psychiatry, AIIMS, Jodhpur, Rajasthan, India

Keywords: Mental Healh Literacy, Knowledge, Attitude, Stigma, India

Outline of Symposium

Objectives: The term “mental health literacy” refers to knowledge and beliefs about mental disorders which aid their recognition, management or prevention. The objectives of this symposium are (1) To understand what is Mental Health Literacy and its Indian status (2) Recent Research and work on Mental Health Literacy in India and (3) What needs to be done to improve Mental Health Literacy

Description: Mental health literacy includes the ability to recognize specific disorders; knowing how to seek mental health information; knowledge of risk factors and causes, of self-treatments, and of professional help available; and attitudes that promote recognition and appropriate help-seeking.

Many studies have shown that negative attitudes towards mental illness are widespread. Several studies report that stigma is universal and involve not only lay persons but also various health professionals including psychiatrists, nursing personnel and health workers. Stigma and Discrimination is associated with mental illness and the same expressed by mental health professionals as well as the general public, results in the underuse of mental health services. The main strategies for addressing psychiatric stigma and discrimination focus on protest, contact and education.

This symposium is divided into the followings subsections (1) Status of Mental Health Literacy in India (2) Mental Health Literacy in College students and Nursing Staff in India (3) Attitude Towards Mental Illness in Paramedical Professionals and Junior Doctors (4) Ways of Improving Mental Health Literacy

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

High resolution electroencephalography in psychiatry: principles and clinical implications

Shamsul Haque Nizamie*1, Nishant Goyal2, Sai Krishna Tikka3

1Central Institute of Psychiatry, 2Central Institute of Psychiatry, 3Central Institute of Psychiatry, India,

E-mails: sh.nizamie@gmail.com/psynishant@gmail.com/cricsai@gmail.com

Keywords: High resolution eeg, cognitive neurosciences, psychiatry

Background: Conventionally recorded scalp Electroencephalography (EEG) has matchless temporal resolution, but it has only modest spatial resolution. Low spatial resolution is due to blurring of electrical fields as it conducts through the skull and scalp layers, the head volume conductor effect. Number of electrodes used for recording was initially extended from 21 to 74 in order to facilitate superior brain source localization by reducing spatial blurring. Presently, even higher number of channels is being used by researchers. Use of EEG acquisition systems with 128 channels is common and 256 channel EEG systems are commercially available too. Accordingly, there is a shift from international 10-20 system of electrode placement to 10-05 system. With development of high-resolution EEG, advancements have transpired not only in device technology, but also in analysis methods and software. To further enhance source localization, data obtained from higher number of EEG channels is integrated with more realistic three-dimensional structural models of the head and brain surface derived from magnetic resonance images (MRIs). These Three-dimensional EEG imaging methods offer an economical alternative to otherfunctional brain imaging modalities. There is vast research on traditional EEG in psychiatry and consistent abnormalities have been reported in various psychiatric disorders. Presently, more and more studies on high resolution EEG on psychiatric population are published. How different and how much more advantageous high resolution EEG is over conventional EEG in understanding the pathophysiology of various psychiatric disorders shall be discussed along with advances in EEG techniques and contribution of Indian research in this field.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Value based practice and Recovery oriented service delivery

R. Srinivasa Murthy,

Bangalore.

smurthy030@gmail.com

The theme of the Conference, ‘Mental illness-recovery and social inclusion’ Is at times not only at the national level but at the international level. It is a privilege for me to address three aspects of the Conference theme, namely recovery, service delivery and value based practice by psychiatrists.

All over the world there is focus on the need for universal and quality mental health care. Examples of recent documents addressing this issue are: ‘Global Mental health from policy perspective(ODI, Nov 2014); ‘Global Mental Health’(Lancet Dec 2014); ‘A weight on my mind’(PHFI,2012); ‘Treated worse than animals’(HRW, Nov 2014); and ‘National Mental Health Policy’(GO India, Oct 2014).

The concept of recovery is a recent development. This concept is the outcome of the majority of the persons with mental disorders moving from institutional settings to the community. This shift resulted in greater recognition of disability, quality of life, burden on the family/community and the process of reintegration into community life (recovery).

The current knowledge about the recovery from mental disorder has the following components: (i) short duration of illness at first treatment;(ii) co-morbid substance use; (iii) good initial response to treatment; (iv)continuous and complete treatment; (v) wide range of services to support the person with disorder and their family; (vi) community support including non-discrimination; and (vii) ensuring human rights of individuals.

In India, all the seven areas are compromised. There is evidence of long delays in seeking care, both a reflection of the limited services and the lack of knowledge in the community. The treatments are cross-sectional and not completed by a large majority of people, even after they seek care from recognised psychiatric facilities. Community facilities and attitudes do not facilitate social inclusion. There are only beginnings of awareness of human rights of the individuals with mental disorders. The only area we seem to be doing well, at present, is the low co-morbid substance abuse in patients.

The presentation covers the 7 areas both in terms of service delivery and at the level of individual psychiatrist towards value based practice.

In conclusion, towards the goal of recovery there is need for well thought out and planned interventions at the level of individual psychiatrists and the service delivery system at the level of services, families, community, public awareness and legislation.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Right To Information Act 2005 in the context of Mental Health Care: Experiences

Nimesh Desai, Vijender Singh, Rajesh Kumar, Pankaj Kumar

Institute of Human Behaviour and Allied Sciences (IHBAS) Dilshad Garden Delhi, India

E-mails: ngd1955@rediffmail.com/dearfrien@gmail.com/kartavyarajesh2003@rediffmail.com/drpankajkumar13@yahh.co.in

Keywords: confidentiality, fiduciary relationship, right to information

Background: Right to Information Act 2005 has been a welcome step in empowering people by getting access to the information contained in the files. People often seek information related to patients’ clinical details also. The clinical information is available to treating clinicians in a fiduciary relationship between a doctor and patient. The same information if disclosed may jeopardize the said fiduciary relationship. The issues are even more complex in the context of Mental Health Care. Information provided by the patient during “fiduciary relationship” (doctor-patient relationship) shall be treated as privileged communication which is a confidential information shared by the patient which cannot be disclosed as per the code of ethics of professional secrecy unless the disclosure of such information is required by the Court of Law. The section 8 (1) (e) of the RTI Act, 2005 indeed is supportive of such a policy view. If the information is related to some matter subjudice, it may be that court may ask for that information and same will be submitted to the court.

Table 1.

Recovery in individuals with mental disorders in India

graphic file with name IJPsy-57-160-g001.jpg

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The information contained in Psychiatry case record files in very sensitive and personal to the patient. These files also contain information provided by significant others. So any disclosure of clinical information may harm the interests of patient as well as significant others around him. There is no harm in disclosing the factual information related to the case, but before any disclosure of clinical information certain guiding principles should be followed. current symposium will ddiscuss ethical dilemmas, administrative solutions and certain policy issues concerning confidentiality of psychiatry case records, third party disclosure and comptenecy for information disclosure along with IHBAS experience.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

The Novel pathway for Community Mental Health: The Sankalpa Model

Abhiruchi Chatterjee, Abir Mukherjee, Sarbani Dasroy

Iswar Sankalpa, India

abhiruchichatterjee@gmail.com

Background: Mental illness, homelessness and deinstitutionalization:

Homelessness is one the core problem in case of major psychiatric illnesses. 11% prevalence of schizophrenia in homeless persons. Non institutional care of homeless mentally ill was practiced in India all through the ages. The self-sufficient village community used to give shelter to the patients who wandered off from their families. The asylum concept was popular in Europe, where the community used to feel safe to keep their ‘unwanted, dangerous, and unproductive’ mentally ill in closed institutions. In the current perspective with the introduction of NMHP, the community Psychiatry became functional in India. Though due to multiple issues the outcome remained far from successful.

Inception of concept and services of Iswar sankalpa: Iswar Sankalpa started in 2007 with the hope of reaching out to the ‘forgotten’ and ‘untouchable’ population — that of the homeless persons with psychosocial disabilities on the streets of Kolkata. IS’s flagship project ‘Naya Daur’ is a unique community based outreach programme for the homeless mentally ill. IS initiated their novel shelter programme for the homeless women with psycho-social disabilities in 2010. With their newest programme IS turned its focus to integrate mental health services with primary health care. In this venture called Urban Mental Health Programme (UMHP) IS got Kolkata Municipal Corporation (KMC) as its partner and started mental health service in two ward health units since 2012.

Difficulties and Challenges: At different time and circumstances various difficulties and challenges made the organization more adaptive and resilient. Challenges were faced from the clients, community, government authority, funders and also the disease itself.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Sleep disorders: What a psychiatrist should know.

Subhash Bhatia, Shashi Bhatia, Sriram Ramaswamy, Venkata Kolli

Creighton University School of Medicine, United States

E-mails: subhash.Bhatia@va.gov / shashiBhatia@creighton.edu/sriramRamaswamy@creighton.edu / kollivb@googlemail.com

Keywords: community mental health, Iswar sankalpa

  1. Describe the neurobiology of sleep.

  2. Distinguish sleep disorders and their presentation across the life span.

  3. Apply pharmacological and behavioral interventions in the management of sleep disorders and promote healthy sleep.

Sleep is an active physiological process with distinct stages essential for normal brain functioning. Sleep-related problems have a prevalence of 30-40% in the general population and up to 60% in psychiatric patients. Sleep disorders often exacerbate comorbid psychiatric conditions and are associated with poor treatment outcomes in psychiatric patients. The physiological changes in sleep cycle across the life span and their varied presentation in psychiatric patients pose challenges to diagnosis and successful treatment.

During this interactive workshop, we will initially review the neurobiology of sleep and changes in sleep architecture across the life span. Building on this background, we will review common sleep disorders encountered by psychiatrists. We will highlight changes in DSM-5 diagnostic criteria for sleep disorders. We will focus on insomnia, hypersomnia’s, narcolepsy and parasomnias. We will review the effect of psychiatric disorders and psychotropic medications on sleep architecture. We will appraise evidence-based strategies for the management of sleep related problems encountered by psychiatrists and measures to promote healthy sleep habits.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Medical evaluation in patients with schizophrenia.

Kirpekar Vivek, Bhave Sudhir, Tadke R, Gawande S, Faye A, Vivek C Kirpekar, Sudhir H Bhave, Rahul Ramdas Tadke, Sushil D Gawande, Abhijeet D Faye

NKP Salve Institute of Medical SCiences & Lata Mangeshkar Hospital, India

E-mails: rahultadke@gmail.com/vivek.kirpekar@gmail.com/shbhave@gmail.com/rahultadke@gmail.com/sushil.gawande@rediffmail.com/dr.abhifaye@yahoo.co.in

Keywords : Medical evaluation, schizophrenia

Abstract: It’s a well known fact that persons with schizophrenia are more vulnerable to have physical illnesses and they have up to 20% shorter life expectancy than the general population. Because of the very nature of their psychiatric disorder there is likely hood of neglect towards own self-care, inability to understand and report the physical-symptoms which otherwise would have got reported and resultant delay in the identification and treatment of the physical ailments. Their poor dietary habits, disturbed daily routine, lack of proper physical exercises, additional comorbid substance-use and in many cases altered sleep cycle makes them more vulnerable to a host of metabolic and systemic illnesses. In addition to this they are at-risk of developing metabolic and other side-effects of the long term pharmacotherapy. Thus, physical health monitoring or systematic medical evaluation becomes essential in this patient population to prevent any further morbidity and mortality.

In this symposium authors will discuss about the concept and need of medical evaluation in patients with schizophrenia. There will be detailed discussion on the clinical examination in them and how to plan and chart evaluation. All necessary investigations which are needed at baseline will be discussed indepth along with need for consultation with other specialties. Then the authors will speak on the monitoring of physical-health of the patients in follow up or maintenance phase including those specific for the pharmaco-therapies going on and share the updates available in the medical literature. In the end there will be guidance on dos and don’ts related to medical evaluation.

At the end of the symposium the participant delegates will be able to get idea about various clinically relevant aspects of medical evaluation in patients with schizophrenia, the minimum necessary evaluation which should be periodically carried out and roles of various investigations in acute as-well-as in maintenance phase.

Topics: Introduction, Concept and need:Sushil Gawande

Clinical Examination: Vivek Kirpekar

Investigations at baseline: Abhijeet Faye

Evaluation in follow up or maintenance phase: Rahul Tadke

Dos and don’ts: Sudhir Bhave

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Aggression and Cognitive Impairment

Mina Chandra, Kuljeet Singh Anand, Manish Kandpal, Srikant Sharma

Department of Psychiatry, PGIMER & Dr RML Hospital, New Delhi, India

E-mails: minasaxena@gmail.com/kuljeet_anand@rediffmail.com/drmanishkandpal@yahoo.com/prachillb@gmail.com

Keywords: aggression, cognitive impairment, dementia, mental retardation

Background: Aggression is commonly seen in neuropsychiatric disorders and is often attributed to psychotic disorders, personality disorders and substance use.

However aggression in the setting of cognitive impairment — Mental Retardation and Dementia. - is extremely common. The prevalence of aggression in Mental Retardation is between 10-20% and in dementia is between 30-50%. 96 % of subjects with Dementia will exhibit aggression at some time in the course of their illness often in the advanced stages (Keene 1999). Aggression as a symptom is associated with significant caregiver burden, excessive disability, risk to health and safety of self and others and higher rates of institutionalization.

Yet aggression in the context of cognitive impairment is often neglected as the caregivers attribute the aggressive behavior to be a component of cognitive deficit not amenable to any intervention. Factors like social stigma, service delivery issues and lack of awareness also play a role in subjects with cognitive impairment being brought for management only when the behavior becomes unmanageable or Results in serious harm to self or others.

Hence Aggression by subjects with cognitive impairment is an important unmet need and requires the attention of all mental health professionals.

Topics:

  • Cognitive Impairment: Salient Aspects - K.S.Anand,

  • Aggression: Salient Aspects- Manish Khandpal,

  • Aggression & Mental Retardation - Srikant Sharma,

  • Aggression & Dementia - Mina Chandra

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

ADHD & comorbidity: diagnostic issues and its management

Dr Jayanthini V*1, Dr Shanthi Nambi2, Aravind Vaithiyam3

1Jayanthini Psychiatry Hospital, India,, 2Institue Of Child Health Chennnai, India,3Ram Psychiatry Hospital Madurai, India,

E-mails: Shanthi.Nambi@Gmail.Com/Jayanthini@Yahoo.Com/Drvkaravind@Gmail.Com

Keywords: ADHD, Comorbidity, Internalizing symptoms, Drugs

Background: Attention — deficit hyperactivity disorder (ADHD) is an early — onset, highly prevalent neurobehavioral disorder, with genetic, environmental, and biologic etiologies, that persists into adolescence and adulthood in a sizable majority of afflicted children of both sexes. ADHD is characterized by behavioral symptoms of inattention, hyperactivity, and impulsivity across the life cycle and is associated with considerable morbidity and disability. The new DSM 5 criterion makes narrower definition of childhood ADHD.

Comorbidity is a distinct clinical feature of ADHD in children. Although its etiology remains unclear, emerging evidence documents its strong neurobiologic and genetic underpinnings. Approximately 54% to 67% of children and adolescents diagnosed with ADHD meet the criteria for ODD; 20% to 56% of children and adolescents diagnosed with ADHD meet the diagnostic criteria for CD; 25% to 33% of children and adolescents diagnosed with ADHD meet the diagnostic criteria for somatization disorders, and 40% of children and adolescents with ADHD have some form of a learning disability.

Children with inattentive ADHD type are more likely to display internalizing Symptomatology, learning disorders and speech & language problems compared with those with hyperactive/impulsive or combined subtypes. Children who display comorbid features often show more serious levels of impairment, often challenging treatment which includes multimodal form of treatment with medications, parents or family focused strategies, child interventions at home and school. Treating ADHD and comorbidity with pharmacological drugs is a challenging task due to the fluctuating symptoms. Drug intervention from western studies differs from Indian continent and ramification of medicines is needed.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

The need & challenges associated with developing community self-help groups for Mental Health

Ramasubramanian Chellamuthu1, Sanjay Gupta2

1State Nodal Officer, Mental Health Program, Tamil Nadu, India, dr.ramasubramanian@gmail.com, 2IMS, BHU, Varanasi, India, guptavaranasi@hotmail.com

In psychiatric disability the worst sufferers are the family members. They are frustrated and dejected. The interpersonal relationship between husband and wife is strained and they exhibit depressive features. Their children have poor scholastic performance, often absenting themselves from school and also become victim of child labour and targets of anti social elements.

By keeping this in mind, we have mobilized the social support through awareness building activities such as street plays, distribution of pamphlets & home visits. For further support to the families, Care Givers Association was formed by family members of the mentally disabled and they met once in a month. They discussed issues relating to family problems in care giving and also they advocated and lobbied with Government agencies and they felt the need to start income generating programmes as it will be an answer to the economic burden they were facing and this lead to the formation of SHGs.

The Self Help Group, a group of women (mothers and care givers) belonging to the families of persons with Mental Disabilities form a federation. They used to collect monthly subscription and operate their accounts in the bank. Every month, they used to meet and discussed about the illnesses of their family member, savings, credit activities and receive training in entrepreneurship. The families benefited by this Micro Economic Development Activities are encouraged to establish the income generating activities. The Self Help Group movement has changed the attitude of the family members towards their mentally ill person because of economic independence. It also reduced the family burden and improved the quality of life of the persons with mental illness.

On the whole, the Self Help Group Movement has brought the hope and confidence in the life of the persons with mental illness. For a developing country like India with the population 120 million, with 3% of serious psychiatric morbidity, with limited manpower, with poor infrastructure facility, the only alternative to address this situation of the community is Self Help Group Movement.

Even though, there is an acute need for this movement, there is no guidelines and also there is no scientific evaluation to assess the efficacy of the Self Help Group concept.

Keeping this in mind, we have proposed the symposium to study the need and challenges associated with developing Community Self Help Groups for Mental Health.

The speakers who are having rich experiences in this field are expected to share their expertise and their interaction is going to give more insight about this Self Help Group Movement.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

CBT in OCD for clinicians

Vishal Indla*1, Manjiri Deshpande2

1Vijayawada Institute Of Mental Health and Neuro Sciences, 2Nair Hospital, India,

E-mails: vishalindla@gmail.com/drmanjirideshpande@gmail.com

Keywords: OCD, CBT

Objective: This symposium aims to discuss the phenomenology and non-pharmacological management of OCD.

Description: OCD is a common condition that psychiatrists come across very often. It has a prevalence of around 3-4%, affecting both males and females and can at times have a childhood onset. Left untreated, can be very disabling. Meta-analysis has repeatedly proven superiority of combination of cognitive behavior therapy and pharmacotherapy over pharmacotherapy alone. However, in routine practice, due to either time constraints or insufficient training in this field, cognitive behavior therapy is ignored.

This symposium attempts to cover the various CBT techniques clinicians can use to combat OCD.

Topics: Phenomenology and basic principles of CBT in OCD Vishal Indla

Nuts and bolts of doing CBT with specific examples - Manjiri Deshpande

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Fifty Shades of Grey: Alcohol and Drug Policy Options for India

Debasish Basu1, Vivek Benegal2, Atul Ambekar3

1PGIMER Chandigarh, 2NIMHANS Bangalore, 3AIIMS New Delhi, India

E-mails: db_sm2002@yahoo.com/vbenegal@gmail.com/atul.ambekar@gmail.com

Keywords : Alcohol; Opioids; Cannabis; Policy; India

Background: Alcohol-related problems are a major contributor to ill health in India, contributing to more than sixty communicable and non-communicable disorders; to psychological burden and to social and economic cost. The combined burden on health due to alcohol related disorders is equal to the burden attributable to problems due to water and sanitation (population-attributable fraction for mortality-risk at 5%) and greater than that due to tobacco-related mortality (4%) and hypertension (3%).

The reduction of the health burden of alcohol-related diseases and its attendant social costs in India requires the application of a broad spectrum of measures. A considerable body of evidence shows that the most effective alcohol policies are those that combine measures addressed at the whole population — in particular aimed at decreasing availability — as well as targeting vulnerable or disadvantaged groups which face the greatest risk of harm.

Evidence notwithstanding, the implementation of a public health strategy to reduce the impact of alcohol related problems is hampered by a number of factors: both alcohol production-sales and health are state subjects and defy attempts to generate a national consensus. Multiple attempts to generate a national policy on alcohol which is sensitive to public health concerns have been repeatedly unsuccessful. Even a draft policy generated by the Specialty Section of the Indian Psychiatric Society in 2012 evoked little interest in generating support. The Ministry of Health is currently in the process of drafting a National Alcohol Policy and the time is therefore ripe to re-examine the elements which should go into it with a view to generate evidence and support for the policy document and its future deployment.

Opioids have been the reasons why nations fought wars with each other. Ironically, opioids have also been responsible for bringing about international cooperation long before the United Nations came into existence. The basic principle behind the international drug regulatory framework remains achieving a balance between control of illicit abuse and easy access to legitimate scientific and medical use. Over the years however - in the zeal displayed behind the ‘War on Drugs’ - the balance tilted too heavily towards a discourse of crime and punishment and thus drugs (especially opioids) came to be seen as national security concerns. The failure of war on drugs to bring about any reduction in prevalence of drug use and its simultaneous success in creating a huge black economy, making access to health services difficult for millions of patients and in general spreading misery in the mankind is forcing the world community to take a fresh look on the policy options for dealing with opioids. There are lessons here for India as well.

Cannabis, the most widely used illicit drug in the world, has gained the dubious distinction of also being the most widely debated illicit drug in the world as far as policies to regulate its use are concerned. The classical position — starting from its inclusion as a ‘narcotic’ drug in 1961 Single Convention and maintained in the Indian NDPS Act 1985 — has been an overall prohibitionist policy, in tune with the ‘War on Drugs’ ethos promulgated by the USA in the 1970s. It is now generally accepted that this hardcore prohibitionist policy has not been successful, and that other (often called ‘softer’) policy options are worth looking into. These options range from decriminalization of personal use of small quantities to unrestricted legalization (free trade and free use) models. No option is perfect, and every option comes with its benefits as well as costs. Thankfully for cannabis (and its users), a variegated menu of such options already exist and have been tried in many countries (such as Netherlands, Spain, Portugal, Australia and New Zealand, the latest and most drastic being Uruguay) and sub-national areas such as Colorado and Washington in the USA. The minimum common denominator of all these policies has been decriminalization. India too needs to have a fresh look at its cannabis policy, keeping in view its historical use of cannabis products since several millennia, its socio-cultural ethos, and its own unique needs and strengths. We argue that decriminalization of personal use is a must, along with measures to control its production and supply on a mass scale, but not at par with other ‘harder’ drugs such as heroin. There has been enough of useless and expensive policing, vote-bank politics, and the cacophonic poltergeist that creates only noise but does not consider the light of evidence. The time has come to try out another shade of grey!

Topics: Alcohol Policy: Once more unto the breach dear friends! —Debasish Basu

Opioid Policies: Persistent Pain in the Neck - Vivek Benegal

Cannabis Policy: Policing, Politics, and Poltergeist — Atul Ambedkar

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Nicotine, Psychopathology, and Antipsychotics: Relation with Cotinine and CHRNA7 Genetic Polymorphism

Navoneela Bardhan, Shyamanta Das, Dipesh Bhagabati, Sangeeta Datta1, Mauchumi Saikia Pathak, Chimanjita Phukan, Sashibha Barman

Gauhati Medical College Hospital, 1NEMCARE Hospital, Guwahati, Assam, India.

E-mails: navo11610@gmail.com/dr.shyamantadas@gmail.com/dbhagabati@gmail.com/drsangeetadatta@gmail.com/mauchumip@gmail.com/chimanjitaphukan@gmail.com/sashibha@gmail.com

Keywords: Schizophrenia. Tobacco. Genetic Markers.

Background: Nicotine, a natural ingredient derived from tobacco leaves (Nicotiana tabacum) is the principal tobacco alkaloid. It occurs to the extent of about 1.5% by weight in the commercial cigarette tobacco and comprises about 95% of the total alkaloid content. The majority of nicotine in tobacco is the levorotatory (S)-isomer where as (R)-nicotine is only about 0.1-0.6% of total nicotine content.

Absorption of nicotine is pH dependent and occurs across biological membranes. Nicotine is a weak base with a pKa of 8.0. Nicotine does not rapidly cross membranes in ionised states as occurs in acidic environments. High levels of nicotine reach the brain in 10-20 s after a puff, faster than with intravenous (IV) administration. This rapid rise in nicotine levels makes smoking the most reinforcing and dependence producing form of nicotine administration. Nicotine binds to brain tissues with high affinity, and the receptor binding capacity is increased in smokers compared with non-smokers. Increase in the binding is caused by a higher number of nicotinic cholinergic receptors in the brain of the smokers.

Nicotine is extensively metabolized by the liver. About 70-80% of nicotine is converted to cotinine in humans. Exposure to nicotine is indicated by the presence of cotinine in biological fluids. Cotinine has a long half-life and therefore, it has been used as a biomarker for daily intake, both in smokers and in those exposed to passive smoking. There is a high correlation among cotinine concentrations measured in plasma, saliva, and urine, and measurements in any of these fluids can be used as a marker of nicotine intake. An optimal plasma or saliva cotinine cut-point of 15 ng/ml or a urine cotinine of 50 ng/ml discriminates smokers from non-smokers.

More than 60% of patients with schizophrenia are current smokers. Smoking stimulates dopaminergic activity in the brain by two distinct mechanisms. First, nicotine stimulates central nicotinic cholinergic receptors, resulting in the release of dopamine and serotonin. Second, monoamine oxidase (MAO) activity is decreased by cigarette smoke, thus further increasing brain dopamine concentration.

Patients of schizophrenia who smoke are more likely to have an earlier age of onset of schizophrenia, higher severity of schizophrenia, have lower school performance, have poorer premorbid adjustment, a greater number of hospitalizations and require higher doses of antipsychotics compared with non-smoking patients of schizophrenia. During adolescence, subjects that will develop schizophrenia have a higher hazard of starting smoking than normal controls, even before the onset of prodromal symptoms.

Interactions of nicotine with antipsychotic drug pharmacokinetics are common since majority of patients with schizophrenia smoke. Compared to non-smokers, olanzapine and clozapine concentrations are decreased in smokers. It is estimated that with a daily consumption of 5 cigarettes, induction of olanzapine metabolism occurs sufficiently.

There is also evidence supporting the hypothesis that there might be a significant genetic difference between those patients of schizophrenia who smoke and those who do not smoke. For example, the proportion of 113-bp allele of the D15S1360 marker in the α-7 nicotinic receptor gene (CHRNA7), which encodes for the α-7-nicotinic receptor was increased in patients with schizophrenia who smoked. This receptor is thought to mediate nicotinic effects on cognitive processes including attention and memory. Additional evidence of the involvement of nicotinic receptor system in the pathophysiology of schizophrenia comes from postmortem studies indicating a decrease in the number of α7 nicotinic receptors in the brains of patients with the disease. Mutation screening of CHRNA7 from schizophrenia and control individuals identified promoter polymorphisms associated with schizophrenia.

The CHRNA7 gene is located on chromosome 15q13-14, a region linked with schizophrenia. The CHRNA7 gene has a partial duplication of exons 5-10, including the intervening introns (CHRFAM7) that map approximately 0.5Mb proximal to the full-length CHRNA7 gene. The chromosome 15 markers which are spaced at intervals of approximately 10 cM over the entire chromosome and 2±5 cM for the region surrounding the α-7 nicotinic cholinergic receptor subunit gene (CHRNA7).

At Gauhati Medical College and Hospital (GMCH), Guwahati, Assam, India, Department of Psychiatry in collaboration with Departments of Biochemistry and Microbiology has developed a study protocol, which has been approved by the Institutional Ethical Committee. The study aims to compare the severity of psychopathology between nicotine users and nonusers of patients with schizophrenia, as well as to compare the efficacy of olanzapine versus amisulpiride in nicotine users. It also aims to study the correlation of cotinine levels with change in psychopathology. Assessment of genetic polymorphism in the CHRNA7 gene is also planned.

In our study, we have planned to include males between 18-60 years of age, suffering from first episode schizophrenia with duration of illness more than 1 month and less than 2 years and giving a written informed consent. We have planned to exclude patients with history of substance abuse other than tobacco, comorbid medical, surgical, and neurological illness, family history of psychiatric illness.

Tools to be used in the study include the tenth revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) criteria, the Fagerstorm Test for Nicotine Dependence Fagerstorm (FTND), the Brief Psychiatric Rating Scale (BPRS), the Positive and Negative Syndrome Scale (PANSS) for schizophrenia, cotinine estimation in urine/serum by chemiluminescence and genotyping of polymorphism in CHRNA7 gene by polymerase chain reaction (PCR).

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

E Learning: Moving towards a Technologically Advanced and Progressive Psychiatry!

Darpan Kaur1, Prasad G Rao2, Naresh Nebhinani3, Kishor M

1Assistant Professor, Department of Psychiatry, MGM Medical College, Navi Mumbai, India,, 2Director, Schizophrenia and Psychopharmacology division, Asha Hospital Hyderabad, India, prasad40@gmail.com, 3Assistant Professor, Department of Psychiatry, AIIMS-Jodhpur, Rajasthan, India, drnaresh_pgi@yahoo.com, 4Assistant Professor, Department of Psychiatry, JSS Medical College, Mysore, Karnataka, India., India, drkishormd@gmail.com E-mails: prasad40@gmail.com/drnaresh_pgi@yahoo.com / drkishormd@gmail.com

Keywords: e-learning, psychiatry, medical education, facebook, twitter, skype, e-prescription, moodle learning, virtual classroom, e-psychotherapy

Background: Background: E learning has made significant advancements in various sectors of education ranging from international schools to IITs and IIMs. E learning is also called Internet based learning. The Medical Education Unit of each medical college is encouraged to include E Learning in its Faculty Development Programmes. Internet has started reshaping education. Education and training forms one of the largest sectors of the economy in most countries E-learning refers to use of technologies based on health care delivered on distance and covers areas such as electronic health, tele-health, telematics, telemedicine, tele-education, etc. There are various technologies and communication systems from standard telephone lines to the system of transmission digitalized signals with modem, optical fiber, satellite links, wireless technologies, etc. E-learning as a part of tele-education has gained popularity in the past decade; however, its use is highly variable among medical schools and appears to be more common in basic medical science courses than in clinical education. Hence the need for the workshop for psychiatrists! E learning principles can be applied to clinical practice, interactive training programs and research based training in psychiatry.

Aims of the Workshop: This workshop is intended for technologically savvy psychiatrists and allied mental health professionals who wish to be well armoured for the upcoming generation!
Topics covered in the workshop
E Learning and Medical Education in Psychiatry
E learning, Distance Education and online courses in psychiatry, psychology and psychotherapy
Virtual Classroom and Moodle based learning
Webinars, E platforms and videoconferences
Skype Consultation in Psychiatry
E prescription and e psychotherapy
Emails, Chats, Whatsapp and newer Apps in Psychiatry
Facebook, Twitter and Blogs in Psychiatry
E Campaigns for mental health promotion
E learning (Hype) - The future lies in it!
E learning in Practice (Critique) - Pit falls, Alarms and Cautions
Overall Description of workshop: The workshop shall aim to disseminate knowledge and provide skills for e learning. Use of Live demos, videos, online presentations shall be provided via internet and learning based technologies in the above described subsections.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Topic : Advances in Psychiatry: looking forward

Kshirod K. Mishra, Jyoti Prakash, N Chandrasekhar, Kalpana Sriastava

Professor and Head, Department of Psychiatry, MGIMS, Sevagram, Professor Psychiatry, Armed Forces Medical College, Pune, Psychiatrist, Military Hospital, Tejpur, Scientist F & Clinical Psychologist, Armed Forces Medical College, Pune.

E-mails: drkkmishra2003@yahoo.co.uk

Objective: We would like to critically analyse the recent advances in the investigative and therapeutic paradigm in the field of psychiatry.

Brief Description: Over the years we have seen lot of progress in the field of Psychiatry & psychology which has led the evolution of the subject from unknown to known, functional to biological and stigmatized malady to yet another acceptable morbidity. Is this the end of road or greater opportunity lies further ahead? Will the geometric progression of the science and technology lead to metamorphosis the management of mentally ill? We would hereby discuss some technological innovation likely to affect the psychiatry in future. Topic discussion will give us better appreciation of the psychiatric sciences and appreciations of the tool for the future.

Topics: Nanotechnology & psychiatry - Kshirod K. Mishra,

Optogenetics in Psychiatry - Jyoti Prakash,

Genetic engineering & psychiatry - N Chandrasekhar,

Virtual reality & psychiatry - Kalpana Sriastava

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Perception of emotion in schizophrenia

Kaberi Bhattacharya, Gargi Dasgupta, Nitu Mallik

Medical College and Hospital, Kolkata, India

E-mails: bkaberi.acharyya@gmail.com/gdasguptain@gmail.com/nitu@gmail.com

Keywords: perception emotion schizophrenia

Background: Introduction: Emotion is a hard term to define. When we speak of emotions, we usually refer to (a) subjective feelings, (b) the physiological basis of such feelings, (c) effect of emotion on perception, thinking and behavior (d) the motivational properties of certain emotions, and (e) expression of emotion in language, facial expression and gesture. Facial expressions are probably the most important nonverbal way in which emotions are manifested. Studies have shown that facial expression of certain primary emotion can be judged accurately by people of diverse cultures. This supports the view that expression of certain primary emotion can be innate or inborn

Brain and emotion: Emotion may be thought of as comprising of three components: physiological arousal, behavior and conscious experience. According to early theories conscious experience is the result of feedback to the cortex about bodily arousal and behavior. The hypothalamus is critically important for the activation and organization of autonomic and endocrine components of emotion. It also organizes certain emotional behavior. Recent research has shown that the amydala is central to conditioned fear; it organizes sensory input into fear response, executed by central nucleus of amygdala. Cortical processes can modulate amygdala activity.

Emotion perception in schizophrenia:It is generally agreed that schizophrenia patients show a markedly reduced ability to perceive and express facial emotions. Previous studies have shown, however, that such deficits are emotion-specific in schizophrenia and not generalized. Three kinds of studies were examined: decoding studies dealing with schizophrenia patients’ ability to perceive universally recognized facial expressions of emotions, encoding studies dealing with schizophrenia patients’ ability to express certain facial emotions, and studies of subjective reactions of patients’ sensitivity toward universally recognized facial expressions of emotions. A review of these studies shows that schizophrenia patients, despite a general impairment of perception or expression of facial emotions, are highly sensitive to certain negative emotions of fear and anger. These observations are discussed in the light of hemispheric theory, which accounts for a generalized performance deficit, and social-cognitive theory, which accounts for an emotion-specific deficit in schizophrenia

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Fresh insights into neurobiology

Philip John1, Johann Philip1, Varghese Punnoose2

1Peejays Child Guidance Clinic, The Neurocenter, Cochin, 2HOD and Professor of Psychiatry, Govt Medical College, Kottayam. Emails : Peejays@the Neurocenter/peejaycl@gmail.com

Keywords: Biological Psychiatry Symposium

Background and Objectives: The objective of this Symposium of Biological Psychiatry is to switch clinical perceptions, from `Behaviour Disorders’ to `Brain Disorders’. Exponential advances in genetics and molecular biology and applying them to investigate developmental disorders in children have provided robust evidence for this paradigm shift.

That, indeed, is the reason why the most dramatic changes in DSM-5 have been in Neuro-developmental Disorders. Based on such evidence, ADHD and ASD have been legitimately brought under the same rubric in classification.

The highlight of the presentation will be to link the cardinal Clinical Features of ASD and ADHD to their probable Neurobiology, as understood today. Multipronged pharmacological and non-pharmacological strategies get to be based on targetting neural circuits for management.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Stigma and Mental illness: Perspectives and Prevention

Roy Abraham Kallivayalil1, Mohan Isaac2 Rakesh Chadda3 Harischandra Gambheera4 Varghese P Punnoose5

1Pushpagiri Institute of Medical Sciences, Thiruvalla, Kerala, 2University of Western Australia, Australia, 3All India Institute of Medical Sciences, New Delhi, India, 4Colombo University, Sri Lanka, 5Medical College Kottayam,

E-mails: roykalli@gmail.com/mohan.isaac@uwa.edu.au/drrakeshchadda@gmail.com/hgambheera@gmail.com/vargheseppunnoose@yahoo.com

Keywords: Stigma, mental illness, prevention, obstacles, NGOs, interventions, perspectives

Background: Stigma is one of the major obstacles faced by mental health professionals. This is especially so in India and many of the South Asian countries. Mental illness, HIV/AIDS, leprosy and venereal diseases are in the fore-front of stigmatized illnesses. The persons suffering from them face exclusion and discrimination in several walks of life. They do not get the social support they badly require. Besides, they and their families face uncertainty or despair. Not only mental illnesses but also the institutions which cater to them are sometimes stigmatized, leading to further deterioration in the upkeep of these centres.

Stigma is a like a curse on the sufferer, devaluing them in the eyes of the society. Compared to the West, anti stigma efforts in South Asia are less organized and lacking adequate penetration. However there is a growing awareness, stigma is one of the major impediments in providing mental health care. It is probably the most significant obstacle to recovery and rehabilitation, especially in the less resourced countries. There have been some good examples, where General Hospital Psychiatry Units and NGOs are working together, especially from Kerala, India. Other South Asian countries including Srilanka have renewed their efforts to fight stigma. The various dimensions of stigma should be studied and interventions need proper structure with flexibility. All these will be discussed in the following presentations:

  1. Stigma: Emerging Perspectives : Mohan Isaac

  2. Stigma as Obstacles to Recovery and Rehabilitation: Rakesh Chadda

  3. General Hospitals and NGOs working together against stigma: Roy Abraham Kallivayalil

  4. Stigma Prevention: Experience from Srilanka: Harischandra Gambheera

  5. Anti-Stigma Interventions: Structure and Dimensions: Varghese P Punnoose

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Dhat syndrome: Trapped by culture, spanked by myth but struggling for right place

Sujit Kumar Kar*1, Prerna Kukreti2, Rasmin Achalia3, Om Prakash4

1King George’s Medical University, Lucknow, U.P, India, drsujita@gmail.com, 2Institute of Human Behaviour & Allied Sciences, New Delhi, India, dearfrien@gmail.com, 3Government Medical College, Aurangabad, Maharastra, India, rashminachalia@gmail.com, 4Institute of Human Behaviour & Allied Sciences, Dilshad Garden, New Delhi, India, drjhirwalop@yahoo.co.in

Keywords: Dhat syndrome, Nosological status, non-pharmacological management

Background: Dhat syndrome is introduced to the diagnostic system decades back. It was the Indian contribution to current psychiatric diagnostic systems. It is a culture bound syndrome prevalent in the South Asian sub-continent. The conservative Asian culture that holds the myths related to sexuality over generations together has a strong influence on the mental health wellbeing. Despite of modernization and urbanization globally, the myths related to sexuality are still persisting and attributing in the causation of Dhat syndrome. The prominent symptoms of Dhat syndrome are anxiety, depression, multiple somatic complaints as well as sexual symptoms. Pharmacological treatment (antidepressants) may improve the anxiety and depressive symptoms but resolution of Dhat syndrome needs prompt psychological and psycho-educational intervention. Migration and mixing of cultures may be responsible for the Dhat syndrome’s violation of cultural boundaries. The symposium addresses issues related to Dhat syndrome and its current nosological status.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Are we using clozapine enough?

Sandeep Grover*1, Susanta Kumar Padhy2, Naresh Nebhinani3

1,2PGIMER, Chandigarh, 3AIIMS, Jodhpur, India.

E-mails: drsandeepg2002@yahoo.com, susanta.pgi30@yahoo.in, drnaresh_pgi@yahoo.com

Keywords: Clozapine, schizophrenia, treatment resistant schizophrenia, prescription practice

Background: Treatment resistance in schizophrenia (TRS) is highly prevalent. Significant number of TRS patients will show improvement with clozapine. However data from various countries suggest that clozapine is often underutilized by the psychiatrists, because of the fear of the side effects and the needs for regular monitoring.

Aim of the Symposium: This symposium will focus on the usefulness of clozapine, attitude and practices of psychiatrists about its use and adverse-effects.

Effectiveness of clozapine: The first speaker will discuss the evidence of efficacy and effectiveness of clozapine in TRS patients. Evidence suggests that about 60% of patients with TRS will show improvement with clozapine. Evidence suggests, compared to other antipsychotics the effectiveness of clozapine increases with time with 6 months to 3 years period required for symptom stabilization, reduction in hospitalization rates, suicide attempts, functioning and overall quality of life.

Attitude towards and Practice of clozapine by psychiatrists: The second speaker will discuss the attitude and practices of psychiatrists with regard to use of clozapine. Studies from the West suggest that over the years there is reduction in the prescription rates of clozapine and over the years there is reduction in the delay in initiation of clozapine. In general evidence suggests that many psychiatrists are not comfortable in using clozapine.

Evidence base and experience of clozapine use in India: The third speaker will focus on the evidence base about use of clozapine in India. There are few studies from India which have evaluated the effectiveness of clozapine. However the meagre data suggests that clozapine is useful in patients with TRS. Multiple case reports suggest the association of clozapine with multiple side effects, but systematic studies evaluating the incidence of various side effects are few in number.

How we can use clozapine more will be discussed in the end.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Psychopharmacology of violence in the mentally disordered: Evidence & Practice from United Kingdom and India.

Callum Ross, Samrat Sengupta, Nitin Gupta, Mrigendra Das

Broadmoor Hospital, West London Mental Health NHS Trust., United Kingdom E-mails: callum.ross@wlmht.nhs.uk, sengupta@wlmht.nhs.uk, nitingupta659@yahoo.co.in, das@btinternet.com

Keywords: Psychopharmacology, schizophrenia, personality disorder, violence, forensic, agitation

Background: Most patients with mental illness are not violent; however, there is a higher prevalence of violence in forensic patients with schizophrenia and personality disorder. Psychopharmacology plays an important role in the management of violent behaviour in schizophrenia and to an extent in personality disorder and is an under researched area.

We present a symposium on the evidence base and our experience of management of serious violence in schizophrenia and violent disorder. The multi-national presenters are consultant forensic psychiatrists in Broadmoor Hospital- A UK high security hospital hospital and an Associate Professor of Psychiatry from Government Medical College Chandigarh who previously worked in the UK. High security hospitals treat patients who have committed serious offences, have severe psychiatric conditions and therefore pose the highest level of risk to others such that they can not be managed in other security settings. Typically, the commonest diagnosis is schizophrenia followed by personality disorder.

The presenters from UK will discuss the psychopharmacological management of high risk forensic patients, discuss the evidence base and report on their experience and research from Braodmoor Hospital. This will cover use of typical antipsychotics, depot antipsychotics, and newer generation antipsychotics and in particular focus on the use of clozapine. The presentation will discuss augmentation strategies and the use of other psychotropics as augmentors including mood stabilisers and other unique strategies. The presenter from India will discuss rapid tranquillisation in agitation & violence and compare practice in India to the UK. The attendees will have a good overview of the clinical approach to the management of a violent mentally disordered patient.

Topics: Setting the scene-Epidemiology and presentation of serious violence in schizophrenia & personality disorder- Mrigendra Das,

Psychopharmacology in the management of Personality disorder- the evidence and practice in a UK high secure hospital.- Callum Ross,

Psychopharmacological approaches and use of ECT in the management of the violent treatment resistant schizophrenia patient. — Samrat Sengupta,

Rapid tranquillisation in agitation and violence: Practice in India and the United Kingdom - Nitin Gupta,

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Managing attention deficit hyperactivity disorder in preschool age

Deepak Moyal*1, Bhavuk Garg2, Sumit Kumar Gupta3, Uday Kumar Sinha4, Deepak Kumar5

1IHBAS, India, 2IHBAS, India, 3IHBAS, India, 4IHBAS, India, 5IHBAS, India.

E-mails: deepak.moyal@gmail.com, bhavuk.garg@gmail.com, Drsumit@aol.in, dr_uday@yahoo.com, srivastav.deep@gmail.com

Keywords: Preschool ADHD, identification, management

Introduction: Deepak Moyal

Presentation of ADHD in preschool children: Bhavuk Garg

Update for pharmacological management: Sumit Kumar Gupta

Non-pharmacological management: Uday Kumar Sinha

IHBAS experience: Deepak Kumar

Background: With increasing awareness, more and more number of children are being diagnosed with ADHD at an earlier age. In absence of any approved medication and nuances of clinical presentation, ADHD in preschool children becomes challenging. However, there are leads from emerging evidences with regard to clinical management of ADHD in preschool children. The evidence coupled with insights from clinical experience of one of the busiest Child and Adolescent Psychiatry Clinic in India may help expert audience to generate practical strategies to deal with this challenge.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Innovative models of service delivery

Padmavati Ramachandran, Mangala R, T C Ramesh Kumar, Lakshmi Venkataraman

Schizophrenia research foundation, India

E-mails: padmavati@scarfindia.org, drmangla@yahoo.com, rameshkumar@scarfindia.org, lakmesridhar@yahoo.com

Keywords: Innovations, mental health services

Background: Innovative models of service delivery

Majority of people with mental illnesses do not receive treatment of any kind and the reasons are very many. Poor understanding of the illness, lack of knowledge about available treatment options and stigma attached to mental illness and mental health services are some of them. Negative attitudes and beliefs toward people who have a mental health condition are common and can be a major reason for delay in seeking treatment.

Psychiatric services have been delivered through General Hospital Psychiatry Units, Government run Institutes of Mental Health, Public Health Centres with Psychiatry Units, Private Psychiatrists and Private Psychiatric Hospitals and through Non Government Organizations. Despite this there is a gap in the services being provided making it necessary to utilize other services to deliver mental health care.

This symposium will focus on role of SCARF which is a three decade old NGO working in the field of mental health based at Chennai in implementing alternate models of service delivery through Telepsychiatry, controlled trial using lay health workers to deliver mental health services in the community and the public — private partnership in delivering health care. It will also deal with creating awareness to enhance knowledge about mental health issues, capacity building by training of general practitioners, community level workers and members of the community at large as there is a definite need to reduce treatment delay and ensure engagement with services. It becomes the responsibility of mental health professionals to promote awareness about mental health issues amongst the people, because they understand the need and impact better.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Recent updates in anxiety disorder management

Anil Nischal, Anuradha Nischal, Manu Agarwal, Sujit Kumar Kar, Diwakar Sharma

King George Medical University, Up, Lucknow, India,

E-mails: an.kgmu@gmail.com, nischal.anuradha@gmail.com, drmanuagarwal7@gmail.com, drsujita@gmail.com, diwakar.dr@gmail.com

Keywords: Anxiety disorder, non-pharmacological treatment

Background: Anxiety disorders are common psychiatric disorders frequently encountered in day to day clinical practice. In the recent decades there is increased diagnosis of anxiety disorders, important reasons being increased mental health awareness leading to increased reporting, increased day to day life stress and many more. For the management of anxiety disorder, various treatment modalities have been used. Introduction of selective serotonin reuptake inhibitors has brought a revolutionary change in the management of anxiety disorders and it has almost replaced the tricyclic antidepressants.

Evidences are also in favor of non-pharmacological techniques like — cognitive behavior therapy, mindfulness based therapy, relaxation therapy, biofeedback methods, autogenic training and applied relaxation. Research is also going on regarding effectiveness of various biological and brain stimulation techniques in anxiety disorder.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Exploring the Cannabis-Psychosis link: Genes, Brain, and the environment

Debasish Basu, Subodh B.N., Abhishek Ghosh

PGIMER Chandigarh, India

E-mails: db_sm2002@yahoo.com, drsubodhbn2002@gmail.com, ghoshabhishek12@gmail.com

Keywords: Cannabis, psychosis, genetics, neuroscience, environment

Background: For over a century now, attempts have been made to explore, establish and explain the link between cannabis and psychosis. This question is more than esoteric; on the contrary, it has profound implications for diagnosis, therapy, prevention…..and at a more basic level, for our understanding of the interactions between genes and environment and how it can impact the brain and behaviour.

Aims of this symposium: The questions asked and discussed in this symposium, roughly in this order, are: Is there a link between cannabis and psychosis? If so, what is the strength of the association? What is the direction of the association? What is the nature of the association? What are the brain substrates of the association, in terms of neuroanatomy, neurophysiology and neurochemistry? Are genes involved in this association? Which ones? How? And finally, how can genes and environmental factors interact to make one cannabis using individual more vulnerable to psychosis than another?

Speakers with individual topics: The lead speaker will introduce the theme. The first speaker, in his talk titled “Exploring the LINK of the cannabis-psychosis link”, will dwell upon the first four of these questions, up to the nature of the cannabis-psychosis link. The second speaker, in his talk titled “Exploring the BIOLOGY of the cannabis-psychosis link”, will deal with the intriguing questions of biology, brain substrates, and genes involved in the link. The final speaker, in his talk titled “The cannabis-psychosis link: a unique opportunity to study gene-environment interactions”, will highlight the recent spate of studies unraveling the mystery of why only a few cannabis using individuals develop lasting psychosis and most others do not. He will also summarize the entire symposium key points and ponder over the therapeutic and preventive implications.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Mobile based mental health programme for rural India

Pallab K Maulik, Siddhardha Devarapalli, Sudha Kallakuri

George Institute for Global Health, India

E-mails: pmaulik@georgeinstitute.org.in, sdevarapalli@georgeinstitute.org.in, skallakuri1@georgeinstitute.org.in

Keywords: Mobile based, mental health service, common mental disorders, disadvantaged community, low and middle income countries, global mental health

Background: Common mental disordes like depression, anxiety, stress and suicidal risk affect one in four individuals as per community based studies from India and the burden of such is very high. However, due to the lack of trained mental health professionals, especially in rural settings few get adequate mental health care. On the other hand mobile phone usage is very high in India.

Objectives: To develop and evaluate the feasibility, acceptability and preliminary effectiveness of a multifaceted primary healthcare worker intervention utilising a mobile device based electronic decision support system to improve the identification and management of individuals> = 18 years with common mental disorders (CMD).

Methods: The study will be conducted across two different sites - rural and scheduled tribe villages. It will include 10 villages of the West Godavari district of Andhra Pradesh and about 25 other scheduled tribe villages of the same district. Two key phases are — development of the intervention that will enable suitably trained ASHAs and primary-care doctors to identify and manage CMD in the community; and conduct of a large pilot study to evaluate this intervention utilising quantitative and qualitative methods.

Results: The study will be discussed and experiences from the stages of mobile application development and stigma awareness campaign material development will be shared.

Conclusion: Overall the study should provide an innovative method of provising basic but evidence based mental health care to disadvantaged communities in low resource settings.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

How to deliver Methadone Maintenance Treatment (MMT) for Opioid Dependence

Atul Ambekar, Anju Dhawan, Rajkumar Lenin Singh, Ravindra Rao

National Drug Dependence Treatment Centre (NDDTC), AIIMS, New Delhi, India

E-mails: atul.ambekar@gmail.com, dranjudhawan@gmail.com, leninrk@yahoo.com, drrvrao@gmail.com

Keywords: Methadone, OST, Opioid dependence

Background: Workshop Proposal

Abstract: Methadone is the most widely used agent worldwide for the purpose of agonist maintenance treatment / opioid substitution therapy (OST). In India, Methadone has been launched in the recent past and hence clinical experience with using Methadone as an agent for OST has been limited. Moreover the unique operational issues involved in the service-delivery for Methadone Maintenance Treatment (MMT) present certain specific challenges. Since, this treatment modality is now being scaled-up in India, it will be useful for all the psychiatrists to be familiar with the clinical practice guidelines for using Methadone as an agonist maintenance agent.

Delivered by the facilitators with first-hand clinical experience of prescribing and dispensing methadone as well as managing the operational aspects of service delivery, the proposed workshop will enhance the capacities of all the participants in (a) understanding the conceptual basis of OST, (b) the unique pharmacological properties of Methadone, (c) induction, maintenance and discontinuation of methadone, (d) specific clinical situations and ways to address them and (e) managing the operational aspects of service delivery. The highly interactive workshop aims to enhance the knowledge, skills and attitudes of various mental health professionals, including trainees as well as senior psychiatrists.

Topics :

  1. “Overview of Opioid Substitution Therapy (OST) with special focus on Methadone”: Anju Dhawan,

  2. “Clinical Practice Guidelines for MMT: Induction, Stabilization, Discontinuation”: Atul Ambekar,

  3. “Clinical Practice Guidelines for MMT: Managing Side effects and common clinical challenges”: R. K. Lenin Singh,

  4. “Implementation and Programme Management issues in MMT”: Ravindra Rao,

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Current Scenario Of Non Adherence In Schizophrenia And A Way Ahead

Akshada Sabnis, Anil Rane, Ashish Srivastava, Veerappa Patil

Institute of psychiatry and human behaviour, Bambolim, Goa, India

E-mails: ashadasabnis@gmail.com, dranilrane@gmail.com, ashishsri1977@rediffmail.com, veeru3984@gmail.com

Keywords: Non-adherence, schizophrenia

Background: Adherence to treatment is poor in patients with both physical and psychiatric disorders especially severe mental disorders. Schizophrenia is one of the severe mental illnesses with most debilitating long standing course, requiring lifelong health care and supervision. Majority of these patients relapse and attempt suicide even with treatment. Poor adherence further aggravates the severity and leads to frequent cause of relapse and hospitalisation. The rate of medication non-adherence has seen to range between 20-76% in the patients with schizophrenia. Non-adherence to treatment continues to be a significant barrier to the outcome and quality of life. The predictors of the non-adherence are spread across various clinical and patient profiles. With multiple understandings of the non-adherence its need of the hour to have common understanding and what is the way out. When is the patient said to be non-adherent, what are the various factors responsible, what can be done to improve the same are various questions which linger when dealing with such patients. The studies which are done across the world, will they hold well in our practice and the research vacuum in India to improve our patient care remains a big problem. The symposium aims to highlight some of these issues and suggest practises that may hold good in our scenario.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Psychiatric aspects of Parkinsonian disease: An overview

Vishal Dhiman, Akhilesh Sharma, Rohit Verma

Institute of Human Behavior & Allied Sciences (IHBAS), Delhi, India

E-mails: vishaldhiman102@gmail.com, drakhileshsharma@gmail.com, rohit.aiims@gmail.com

Keywords: Parkinson disease; Consultation liaison psychiatry

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Trajectory of Attention deficit hyperactivity disorder across the life span- Focus on psychological and psychiatric issues in young adulthood

Shankar Kumar*1, Gopal Das C M2, Kasthuri Pandiyan1, Chandrashekar Hongally1

1Bangalore medical college and research institute, India, 2Basaveshwara Medical college, chitradurga, India, E-mails: shankarkjs@gmail.com, drgopaldascm@gmail.com, drkasthurip@gmail.com, chanag61@gmail.com

Keywords: Attention deficit disorder, adulthood, sexual behavior, comorbidities

Background: Attention deficit disorder (ADD), unlike previous thinking, does not just limit its manifestations to childhood. A large body of evidence now says that ADD continues into adulthood and is associated with multiple psychosocial and psychiatric problems.

Objectives: This symposium will target the following objectives-

  1. Association of ADD with psychosocial adversities in young adulthood- troubled interpersonal relationships, employment difficulties, risky driving, risky sexual behaviour. A comprehensive review of available literature will be done, also with presentation of studies done at our institute on ADHD and risky sexual behavior and HIV.

  2. Presentation of psychiatric comorbidities with ADD- Focus on unique features of the comorbidities which will aid the clinician to suspect ADD. Substance use disorders, Mood disorder, eating disorder comorbidities will be discussed. A quote of our study on eating behaviour abnormalities in adult females with ADD will be done.

  3. A comprehensive literature review on modalities of management and benefits of treatment of ADD in adulthood will be done.

Proposer & Moderator: Brig RC Das, Chairman Military Psychiatry Specialty Section; Indian Psychiatric Society.

Topic : Do present diagnostic system needs a paradigm shift?: A debate.

Objective: A critical evaluation and analysis of present classificatory system; its advantages, pitfalls and the conclusion thus drawn.

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Brief Description : Our classificatory system like any pay commission has a decadal pattern of change with group of psychiatrist liaise and modify to bring out a newer version of classification like Pentium or intel. Does this change suggest dynamist or momentum to keep abreast with scientific advent or is it born out of mere acceptance or rejection of certain phenomology as a disorder; by the psychiatrist, clientele or the law. Does putting a similar thing together is better than putting different things separately? Is the typological classification somehow restrictive to the biological renaissance? With this debate, we would exercise our higher order thinking to analyse how good the tool is as well as how to use it well.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Systematic Review of Mental Health Research in Scheduled Tribe Areas in India

Siddhardha Devarapalli, Sudha Kallakuri, Pallab K Maulik

George Institute for Global Health, India

E-mails: sdevarapalli@georgeinstitute.org.in, skallakuri1@georgeinstitute.org.in, pmaulik@georgeinstitute.org.in

Keywords: Mental health research, systematic review, low and middle income countries, tribal population, India

Background: The burden of mental illness in tribal popualtions in india is not known clearly and mental health research specifically including such poplations is also limited.

Objectives: The systematic review will be conducted to identify mental health research on scheduled tribe populations in India and to collate such data to inform future studies involving such communities.

Methods: Different health related databases will be searched using systematic search strategies and the studies will be assessed for quality. After a thorough qualitative assessment, all quantitative data will be generated and tabulated.

Results: The data will be presented using well defined sub-groups and tables, and inferences will be drawn from such.

Conclusion: The review should provide a comprehensive idea about the burden of mental illness in scheduled tribe communities as per current literature, availability of mental health services and quality of such services. Overall, it will provide an understanding of the gaps in knowledge and will help develop future mental health research involving such communities.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Suicide prevention: One world connected

Suneet Kumar upadhyaya1, kishor M2, Naresh Nebhinani*3, Darpan Kaur4

1GMERS medical college, Patan, Gujarat, India, 2J.S.S. Medical College, Mysore, India, 3AIIMS, Jodhpur, Rajasthan, India, 4M.G.M. Medical College, Navi Mumbai, India.

E-mails: dr_suneet12@yahoo.com, drkishormd@gmail.com, drnaresh_pgi@yahoo.com, darpan.kaur@rediffmail.com

Keywords: Suicide, prevention, connectedness

Background: Suicide is a major public health problem. The psychological pain that leads each of these individuals to take their lives is unimaginable. Their deaths leave families and friends bereft, and often have a major ripple effect on communities.

Every year, over 800,000 almost people die from suicide; this roughly corresponds to one death every 40 seconds. The number of lives lost each year through suicide exceeds the number of deaths due to homicide and war combined. Worldwide mental disorders are a major risk factor for suicide.

Connectedness is crucial to individuals who may be vulnerable to suicide. Studies have shown that social isolation can increase the risk of suicide and, conversely, that having strong human bonds can be protective against it. Reaching out to those who have become disconnected from others and offering them support and friendship may be a life-saving act.

Connectedness and collaboration between services is also important at this level in preventing suicide. The right service or individual clinician must be available.

Subtopics:

  1. Suicide scenario in India- Suneet Kumar Upadhyaya.

  2. Suicide prevention services in India: Experience and challenges- Kishor M.

  3. Role of connectedness: Evidence and practice- Naresh Nebhinani.

  4. The way foreward- Darpan Kaur.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Headache: A clinical approach for neuropsychiatrist

Debadatta Mohapatra*1, Sidharth Soumyadarsan Pattnaik2, Jayprakash Russell Ravan3

1AIIMS Bhubaneswar, India, 2,3KALINGA Institute Of Medical Sciences, India

E-mails: 2000debee@gmail.com, sidharth.pattnaik90@gmail.com jpr_219@yahoo.co.in

Keywords: Headache, protocol based approach

Background: Headache is one of the most common complaints among patients presenting to the outpatient department. The evaluation, diagnosis, and treatment of headache can be rather cumbersome and at times quite challenging for even the most seasoned medicine specialists, oto-laryngologist, psychiatrists, neurologist. The purpose of this article is to provide a simplified approach to diagnosing headache which aims at providing a prompt and appropriate referral. Not only does this save patients from avoidable pain and expenditure, it also provides lead time in certain cases which ultimately makes a difference in the outcome. Headache may be primary, where headache itself is the sole disorder, or secondary, where headache is due to some under lying cause[2]. Primary headache includes migraine, tension type, cluster, and headache due to coughing, straining, exercise, sexual activity. Secondary includes headache due to infections, injuries, vascular disorders, CSF pressure abnormalities, benign paroxysmal vertigo or glaucoma, addiction, substance abuse, drug withdrawal and sleep disorders. The approach of a physician should be to take a detailed history of the headache which includes its type, location, intensity of pain, aggravating and relieving factors, duration, course and other associated features. On the basis of information, the next step is to ask the patient certain leading questions so as to determine whether it’s a case of primary or secondary headache. Arriving at this conclusion is very necessary to assess the further plan of management. And the referral is also determined at this stage. Following a set guideline saves time and prevents confusion. A case of secondary headache may need a neurological, ophthalmology, ENT or psychiatric evaluation depending on the information gathered by a detailed history and examination. Ultimately, such an approach would lead to either the patient being diagnosed at one’s own level or provide the patient an appropriate referral.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Rehabilitation at the Sakalawara Community Mental Health Center using a multidisciplinary approach

Sabina Rao, Sydney Moirangthem, Prasanthi Nattala, Paulomi Sudhir

National Institute of Mental Health and NeuroSciences, India

E-mails: sabinarao@yahoo.com, sydmoir@gmail.com, paidi89@gmail.com paulomi.sudhir@gmail.com

Keywords: Rehabilitation at the Sakalawara Community Mental Health Center using a multidisciplinary approach

Introduction: Ever since mental illnesses have evolved into the top ten of non-communicable diseases list by the World Health organization, the focus on mental illnesses, in general, has increased. Studies have repeatedly shown that rehabilitation of the chronically mentally ill consistently can improve outcomes1. Studies also indicate symptomology and diagnostic criteria are poor predictors of future work performance2, interventions such as life skills education can improve the impairments experienced by those with chronic mental illness3. Research has also shown that pre-vocational training is not more effective than supported employment4.

Our team proposes to conduct a symposium on Rehabilitation of chronically mentally Ill individuals in a community setting, at ANCIPS 2015, focussing on the following issues:

  1. The need for such a Center for rehabilitation of the mentally Ill in an open non-restrictive setting, under a government run Institute.

  2. Use of a multidisciplinary approach in the rehabilitation of such patients.

Rationale for choosing the above topic: There are a few rehabilitation centres across the country that cater to the rehabilitation of chronically mentally ill individuals. These centres are usually run by Non-Government organizations. Research clearly indicates that a subsection of chronically mentally ill need some form of rehabilitation to help them integrate back into society. The rehabilitation Center at Sakalawara, Bangalore, Karnataka is directly run by a Central Government controlled Hospital System, in this case, the National Institute of Mental Health and Neuro Sciences(NIMHANS). Other than providing multiple services to individuals at a low cost, this centre can cater to those individuals that are below the poverty line.

Areas that would be focused: The need for such a centre in the heart of the community.

Role of multi-disciplinary team of Psychiatry, Nursing, Clinical psychology & Psychiatric social work in the setting

Format of the Symposium:

  • Medication management and adjustments in consultation with the primary treating team.

  • Management of acute exacerbations.

  • After hours interpersonal conflict resolution, support.

  • Case presentations.

  • Community meetings.

  • Medication administration and monitoring vital parameters.

  • Monitoring of the structured schedule for patients from morning till night.

  • Health education to patients and families on relevant topics.

  • Participating in social skills training, training in daily living skills.

Improvement both psychological and socio-occupational functioning in the following ways:

  • Psychological assessments help in determining the needs and targets of each patient.

  • Focus on enhancing socio-occupational functioning through improvements in cognitive functions, social skills, problem solving and coping skills.

  • Specific cognitive and behavioural strategies to address maintaining factors.

Improve the psychosocial functionality of the patients and the family members in the following ways:

  • systematic assessment of patient’s functionality using WHO’s International Classification of Functioning (ICF) (WHO,2001)

  • Based on the assessment, psychosocial formulation and planning

  • Group Therapy

  • Day outs

  • Job Placements

  • Follow up of discharged patients

Topics: Psychiatry: Sabina Rao and Sydney Moirangthem

Nursing: Prasanthi Nattala,

Clinical Psychology:. Paulomi Sudhir,

Psychiatric Social Work:. Aravind Raj,

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Lives less understood: A socio-cultural approach to understanding mental health needs of people with non-normative gender sexual preference.

Debashis Chatterjee*1, Ujjaini Srimani2, Ranjita Biswas3

1Mon Foundation, India, 2Consultant Psychiatrist, India, 3Jadavpur University, India.

E-mails: c.dev59@gmail.com, srimaniujjaini@gmail.com, ranjitabsws@gmail.com

Keywords: Homosexuality, transgender, IPC 377

Background: The symposium would like to highlight mental health issues of two important categories of people with the objective to initiate discussion on how the mental health fraternity can respond more effectively to the emerging voices of the LGBT community in this country.

The first paper would discuss about various aspects of understanding homosexuality through some true stories of joint suicides by lesbian women. Homosexuality is normal and natural. This has been proven beyond doubt by years of scientific research all over the world, but even today, more than four decades after deletion of homosexuality from the list of diseases by American Psychiatric Association in 1973, followed by WHO in 1990, this still remains a matter of controversy. We, the mental health professionals in India, seem to be, sometimes still ambivalent while dealing with the issue of alternative sexuality and sexual practices in our day to day clinical practice. In a society where homosexuality is still not acceptable, significant emotional distress in the lives of individuals with homosexual orientation is also very common. Few important factors that need rethinking are our age-old socio-cultural beliefs (myths?), individual prejudices and lack of information on their lives that often leads the medical fraternity putting the onus of dysfunction and distress on individuals ignoring other social factors leading to the distress. The dearth of literatures and research work on this issue further reinforces our silence. In the meantime many of the homosexual people have committed suicide either alone or along with their partners silently; only some of the news about their death reach us through the media. The review of the available leading newspapers reports on lesbian suicide in West Bengal and some other parts of the country, from the archive maintained by an NGO, named Sappho for Equality, an organization based in Kolkata, working with and for LBT (Lesbian, Bisexual and Transgender) women, points towards some important socio-cultural factors that led to these unfortunate deaths. An alarming fact is lack of functional and sensitive mental health services, especially in rural areas. Moreover The IPC 377, that criminalizes alternative sexual acts, is also a matter of concern for the human rights and mental wellbeing of the troubled individuals. All these make us rethink about the roles and responsibilities of the mental health professionals to reach out to the people with alternative sexualities.

The second paper would focus on transgender persons and their unmet health needs. The Supreme Court has given a verdict on 15.04.14 ordering all the states of India to take pro-active steps towards social inclusion of the transgender persons by considering them as OBC and raising awareness to make educational institutes, work places, health sectors and society at large more gender-sensitive. Increasingly, transsexual people are approaching mental health professionals for sex transition processes. However, we are yet to evolve our own standardized protocol for the same. Discussing about the concept of sex gender continuum and stating about the current scenario of gender-transition services of our country which is lacking far behind the actual need of this population, the paper would highlight upon the immediate necessity for research work in this area and the roles and responsibilities of mental health professionals to move towards more gender-sensitive health care services in our country.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Changing perspectives of psychiatric residential care facilities-the scarf experience

Mangala R, Hema Tharoor, Aarthi Ganesh

Schizophrenia Research Foundation, R 7/A, North Main Road, Anna Nagar West, Chennai-101, India

E-mails: drmangla@yahoo.com, hematharoor@scarfindia.org, aarthi@scarfindia.org

Keywords: Psychiatric residential facility, psychosocial rehabilitation, Elderly patients

Background: Mental health resources are inadequate to meet the growing needs in our country. Non availability of sufficient hospital beds has been compensated to a large extent by families and to some extent by private and nongovernmental organizations. Though treatment of psychiatric disorders has moved away from institutional management to community based care in recent times, the need for residential facilities seems to be increasing for several reasons like care-giver’s being aged, absence of family members, small family size to name a few.

Schizophrenia Research Foundation (SCARF) is a three decade old NGO based in Chennai and has been providing residential services for over 25 years now. It has three residential centres with a combined bed capacity of 150 with over 85% occupancy at any given time.

The symposium will focus on the various aspects of residential care. It will include the various reasons families seek admission into residential facility, the profile of patients admitted, social, legal and other issues involved in admitting patients into the facility. It will also focus on the challenges in running a residential care facility, management of patients in the residential centres including medical and psychosocial rehabilitation and taking care of people with special needs especially the elderly.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Pediatric Obsessive Compulsive Disorder is it any different from adults?

Vinod Sinha, Sujit Sarkhel, Varun Mehta, Roshan Khanande

Central Institute of Psychiatry, India,

E-mails: vinod_sinhacip@yahoo.co.in, sujitsarkhel@gmail.com, vs_mehta@yahoo.co.in, roshankhanande@gmail.com

Keywords: Obsessive compulsive disorder, OCSDs, Treatment

Overview: Obsessive compulsive disorder (OCD) is found to be common in children and adolescents with a prevalence rate of 2 - 4 % and males being more affected than females. The mean age of onset is between 7.5 - 12.5 years with a bimodal peak in childhood and adulthood. Children are highly secretive about their symptoms due to which it remains undiagnosed for a long time. The higher prevalence of only compulsions, aggression, harm, religious and sexual obsessions differentiate them from adult onset OCD. The exacerbation or worsening of previously present tics/obsessions with neuropsychiatric symptoms is also one of the distinct presentations of the disorder. The co-morbidity with Attention Deficit Hyperactivity Disorder, Tourette Syndrome, Separation anxiety disorder presents a distinct challenge for treatment. The clinical course is also affected by the developmental period as the nature of the obsessions and compulsions change over time. Pediatric OCD tends to have a chronic course with early age of onset and frequently persisting till adulthood in majority of children with co-morbid psychiatric illness and poor initial treatment response being the predictors of poor prognosis. The combination treatment of selective serotonin reuptake inhibitors (SSRIs) with Cognitive Behaviour Therapy (CBT) remains the treatment of choice.

Phenomenology of pediatric OCD (pOCD): OCD in ICD 10 & DSM 5 is defined as repetitive thoughts and/or rituals that are unwanted and which interfere significantly with function or cause marked distress. In general, the symptoms in children & adolescents mirror to those in adults but at times they are influenced by their developmental period. Thus, obsessive fear of loss or harm to loved ones and the presence of hoarding compulsions is found to be more common in children with religious/moral and sexual obsessions being more often reported in adolescents. Rituals such as reassurance seeking and verbal checking from family members have been found to be present in both children and adolescents. One third of patients report certain stimuli that trigger their rituals and the avoidance of these triggers protects them from obsessive – compulsive symptoms. Some may report “microepisodes” of OCD before developing full blown symptoms. Some childe lack belief into the senselessness of their thoughts at times extending to a delusional intensity.

Obsessive Compulsive spectrum disorders (OCSDs): The obsessive compulsive spectrum disorders are a set of disorders that have repetitive thoughts and behaviours like those in OCD. These include body dysmorphic disorder, eating disorders, impulse control disorders (e.g. trichotillomania), hoarding disorder, neurological disorders with repetitive behaviours (e.g. Tourette’s syndrome) & behavioral addictions. These are found to be less common in children and adolescents than adults. There is also a special subgroup of behaviours known as body focused repetitive behaviours (BFRBs) that refer to a group of problematic, destructive and nonfunctional behaviours directed towards the body. The children engage in “harmless” nervous habits that do not cause them distress but have a range of physical and psychological sequelae. Many of the behaviors in OCSDs are not preceded by obsessions, less ego dystonic and often produce gratification. They are less responsive to SSRIs and behavioral interventions are the main modalities of treatment.

Treatment of pOCD: Before starting treatment a thorough psychosocial assessment with identification of co-morbid conditions is essential for a successful management. Similar to adults, treatment of pOCD involves Cognitive behavior therapy (CBT), family intervention and medication. CBT is the only psychological therapy found to be effective in children & adolescents. The combination of CBT with medication has been found to have the greatest efficacy. The Selective serotonin reuptake inhibitors (SSRIs) remain the first-line medication for pOCD like in adults. Up to 50% children show a partial response where augmentation strategies are effective whereas switching to another SSRI, augmentation with CBT have proven useful in non-responders. The recommended treatment period is a minimum of six months after full remission. Novel augmentation trials with stimulants, glutamate antagonists, N – acetyl cysteine and St. John’s wort have been tried but none have been recommended for routine use.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Digitalizing Psychiatrists’ Clinics

Vihang Vahia, Sanjay Phadke, K. K. Mishra,

Professor Emeritus of Psychiatry, Cooper Hospital and Medical College, Mumbai, Consultant Psychiatrist Breach Candy and Lilavati Hospitals, Mumbai.

Neuroscience Fellow (Germany), Consultant Neuropsychiatrist, Deenanath Mangeshkar Hospital and Jehangir Hospital, Pune

Convener, IPS Task Force Clinic Software Development, Psychiatry Alcohol and Drug De-addiction Center, MGIMS, Sevagram, Wardha, Chairman, IPS Task Force Clinic Software Development

The Ministry of Health and Family Welfare (MoHFW) published “Recommendations on Electronic Medical Records Standards in India” in the year 2013. The ultimate aim of the MoHFW is to be able to produce life time Electronic Health Records of every citizen of India. This ambitious project does not have a specifically designed protocol for mental health. The IPS had actually proposed the notion of digitalizing medical records at its annual CME in the year 2001. The interest was rekindled by the MoHFW notification. In the month of March, 2014, IPS set up the present Task Force to formulate EMR for Psychiatry.

This presentation is aimed at introducing the first draft of a Clinic Software for Psychiatry. It is designed for use of standalone psychiatrist’s clinics, teaching institutions and service institutions in public, corporate and private sectors. The President Elect and the Task Force hope to provide this software complimentary to the members of the IPS and hope that eventually it will be a platform for secured and protected sharing of clinical information, research and mutual learning. Intended benefits of attending this presentation: Participants will get to learn the significance and operation of this software.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Beyond ‘The Usual’: Amphetamine Type Stimulants (ATS) & Newer Psychoactive Substances (NPS)

Yatan pal singh balhara, Rakesh Lal

AIIMS, New Delhi, India.

E-mails: ypsbalhara@gmail.com, ypsbalhara@gmail.com

Keywords: Addiction, Amphetamine Type Stimulants (ATS), Newer Psychoactive Substances (NPS)

Background: Psychoactive substance (alcohol and other drugs) use has been identified as a leading contributor to morbidity and mortality globally. In Indian context, tobacco, alcohol, cannabis and opioids have been identified as the most common drug being abused. This has been corroborated by the studies from across the country including the National Survey.

However, over the past few years it has been increasingly thought that drug use scene in the country has changed. Increased realization of problem associated with use of inhalant is an example of this. Many other psychoactive substances have also been identified and reported across the globe (including India) over the past decade or so. To put the issue in perspective, today these newer psychoactive substances outnumber the psychotropic and narcotic substances identified in the three major international conventions on narcotics and psychotropic substances.

It is time we look beyond ‘The Usual’ and discuss these new psychoactive substances in scientific forum. This will help us (mental health professionals) be better prepared for days ahead.

The current symposium will focus on Amphetamine Type Stimulants (ATS) & Newer Psychoactive Substances (NPS).

Amphetamine Type Stimulants (ATS): The first presentation will focus on Amphetamine Type Stimulants (ATS). Problem of ATS misuse is on the rise. Earlier believed to be one of the secondary drugs with use restricted to certain parts of the country, its use is being encountered from different regions of the country. Misuse of ATS is associated with significant psychological and physical morbidity. The presentation will focus on changing patterns of use of ATS globally including India. It will also discuss issues such as neurobiological underpinnings of ATS use, its effects and adverse effects, and management approach.

Newer Psychoactive Substances (NPS): As stated above the number of newer psychoactive substances has outnumbered the psychotropic and narcotic substances identified in the three popular conventions on narcotics and psychotropic substances. This presentation will focus on the salient features of these NPS. It will include epidemiology of use of NPS, salient features of NPS, effects and adverse effects associated with their use and challenges associated with their regulation.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Partnership In Wellness And Recovery: An Evidence-based Practice For Family Psycho-education

Rekha Vaishnav*1

1Supportive Housing in Peel, CANADA, Canada.

E-mail: r_d_vaishnav@yahoo.com

Keywords: Family Psycho-education: An Evidence-based Practice

Background: This workshop will be based on the significance of Family Psycho-education as a key component of recovery in the mental health profession. The author will share her own success in developing a unique support group for the family members of individuals who are diagnosed with complex psychiatric illness.

As a part of a professional role as a Social Worker of an Assertive Community Treatment Team, the author was involved in promoting and implementing projects to increase awareness and understanding of family members and assisting them with enhancing their coping skills to deal with the issues of complex care. This psycho-educational family support group was able to create a safe environment where members had an opportunity to share and exchange their ideas and discuss the challenges in care. Sessions were developed to incorporate the unique needs of family members to manage the complex illness of their loved-ones and become better partners in their wellness. This group was conducted annually and represented by the family members from diverse communities of Canada. Members who attended the series of 10 workshops gained information on various diagnoses, treatment modalities, and community resources. Members had an opportunity to share and exchange their ideas with others, learn new coping skills, and improve their problem solving and crisis management skills. Members were given an opportunity to interact with the professionals from different disciplines of ACT throughout the series. This group was able to create a foundation for a future support network for family members.

As Recovery encompasses personal, emotional, physical, social, vocational and spiritual aspects of an individual who is being recovered, the most essential components of this complex process can be: Clinical care, hope, support from family members, community involvement, empowerment, access to resources, a healthy life style, positive interpersonal relationships, motivation and encouragement. In the absence of these elements it becomes almost impossible for an individual to reach the last stage of recovery which is a stage of Interdependence/awareness where the individual relies on self and others in a mutual exchange of beneficial support, services and resources. The author intends to focus on how family members can become a better partner in the process of Recovery.

In the ANCIPS workshop, the author will make a presentation on the summary of the Evidence-based Psycho-educational Support Group which will include information on the conception of group, outreach, contents of workshops, results of pre and post questionnaire and feedback summaries. The author will also provide information on the ACT Model which is a unique service delivery system implemented in over 4 major countries of the world.

Target Audience: Social Workers, Addiction Specialists, Occupational Therapists, Peer Support Specialists, Registered Nurses in Psychiatric Sectors, Mental Health Clinicians, Family Members of Patients, Researchers, Psychiatrists

Learning Outcomes:

  • Participants will learn about the ACTT model and how it helps to establish partnership and collaboration in multidisciplinary teams.

  • Participants who are mental health professionals will learn about the benefits of providing evidence-based services to families.

  • Participants who are mental health professionals will learn how to formulate a unique support group for families and significant others.

  • Participants who are mental health professionals will learn about the partnership in wellness and recovery.

  • Participants who are family members will learn about the significance of education and awareness around treatment and how to foster recovery.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Management of Attention Deficit Hyperactivity Disorder (ADHD) across the Life Span

Shroff Manohari, Ravindra Baburao Galgali, Vijaya Raman, Vidya Sathyanarayanan, Johnson R Pradeep

St. John’s Medical College Hospital, India

E-mails: smmanohari@yahoo.com, rbgalgali@yahoo.com, vraman12@yahoo.co.uk, vidyasnarayanan@gmail.com, drjohnsonpradeep@gmail.com

Keywords: ADHD, Across life span, Pharmacological management, Psychological management

Management of Attention Deficit Hyperactivity Disorder (ADHD) across the Life Span.

ADHD is a neurodevelopmental disorder where the core symptoms present in different ways through the lifespan.

Identification of the disorder needs a high level of suspicion. Discerning ADHD from co-morbid illness is also a challenge.

Though the core symptoms are the same through the life/different ages, management of the same problem has to be tailored to the developmental stages/age.

This symposium will focus on identifying nuances in how ADHD presents in children, adolescents, young adults and older adults with special emphasis on distinguising differential diagnosis. We will highlight the intricacies of pharmacological and psychosocial management in children and adults. The management of the disability and impairment in various spheres of functioning across the lifespan will be addressed.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Safety issues in Psychiatry Practice

Amitabh Saha, A S Saxena, Kalpana Srivastava

Classified Specialist Psychiatry, Command Hospital Southern Command, Pune, India.

E-mails: sahaing@gmail.com, faujipsychiatrist@yahoo.co.in, kalpanasrivastav@hotmail.com

Objective: To understand, analyze and standardize safety practices in various psychiatric treatment settings.

Brief Description: Mental health hold special caution in care as apart from address safety issues for individual from external factors they have to be safeguarded from the worst risk, the devils of their own mind. Be it a protected but stifled inpatient environment to open and risky outpatient setting; safety is paramount and measures required though different; but important. This topic will also deliberate on relevant safety issues in special context viz. care of mentally retarded, rape victim etc. Topic discussion will give us better appreciation of the existing practice and requirements for the future.

Safety issues in inpatient management — Amitabh Saha,

Safety issues in outpatient management — A S Saxena,

Safety issues in special cases: MR, rape victims — Kalpana Srivastava.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Recovery oriented Services: Success stories and Lessons learnt

T Sivakumar*1, Sailaxmi Gandhi2, Avinash Waghmare3, Abhishek Pathak4

1Psychiatric Rehabilitation Services, Department of Psychiatry, NIMHANS, Bangalore, India, 2Department of Nursing, NIMHANS, Bangalore, India,, 3Department of Psychiatry, Smt. Kashibai Navale Medical College, Pune., India, 4Psychiatric Rehabilitation Services, Department of Psychiatry, NIMHANS, Bangalore, India,

E-mails: drsivakumar_mmc@yahoo.co.in, sailaxmi63@yahoo.com, aveevaa@gmail.com, drpathak7@rediffmail.com

Keywords: Recovery, Psychiatric Rehabilitation, NIMHANS, India

Background: The long-term outcome of patients with psychiatric disorders is likely to be better with rehabilitation inputs. In India, there is paucity of psychiatric rehabilitation facilities. With the advent of recovery oriented practice, there is a felt need for a model applicable to our country. Psychiatric rehabilitation services (NIMHANS) has been a pioneer in the field for over the last 50 years. A range of services including occupational therapy, cognitive remediation, social skills training, recreation, and NGO/employer liaison are provided for clients in OPD, daycare and inpatient settings. A formal teaching programme on psychiatric rehabilitation for students of behavioural sciences is being developed. Students are trained in making a rehabilitation assessment and plan road to recovery. Various strategies like role plays, caregivers’ programmes, NGO visits and family recreation activity are used to sensitize students.

Topics

  1. ‘Road to recovery’: the journey of a client: Dr Sailaxmi Gandhi.

  2. Evolving a teaching programme for psychiatric rehabilitation: Dr Avinash Waghmare.

  3. Transition from traditional to recovery oriented practice: Dr Abhishek Pathak.

  4. Recovery oriented services: Opportunities & Challenges: Dr T Sivakumar.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Issues in the Management of Psychiatrically ill Homeless Women

Manoj Kumar, Kavita Nagpal

1Institute of Human Behaviour and Allied Sciences, India

E-mails: drmanoj_k73@rediffmail.com, kvnagpal2010@gmail.com

Keywords: Homeless, Psychiatricaly ill, women

Background: There are gender differences in the prevalence of psychiatric disorders with certain disorders more common in females as compared to males. Women also have specific time periods in their life cycle during which they are especially vulnerable to develop mental illnesses. Presence of psychiatric illness increase the risk of becoming homeless and homelessness render women vulnerable to further medical and psychiatric morbidities. Apart from certain common risks factors and adversities which may be shared by both genders, certain specific issues may be seen in mentally ill homeless women rather than men in similar situation. Homeless women may be more prone to have illness ranging from nutritional deficiencies to skin infections to psychiatric morbidity like deliberate self harm attempts and suicidal ideation and are prone to use drugs and alcohol to cope with the illness. These homeless women are also prone to have increased rates of physical and sexual violence and develop sexually transmitted diseases and pregnancy. Working in liaison with Obstetrics department may be required for regular antenatal evaluation and delivery services in such pregnant women with mental illness. Periodic consultation and active collaboration with Pediatric specialty is useful to cater to the needs of developing child. Keeping both mother and child in the same setting is likely to enhance mother child bonding which can be a stepping stone for good parenting. Rehabilitation of such women can also be a difficult task and require collaboration with a multidisciplinary team including psychiatric social worker. So in this symposium we aim to discuss issues and challenges which are pertinent in the management of psychiatrically ill homeless women.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Late onset depression: Challenges challenges in diagnosis and treatment

Srinivas Suribhatla*1

1Leicestershire Partnership NHS Trust, United Kingdom,

E-mail: srinivas.suribhatla@leicspart.nhs.uk

Keywords: Depression in elderly

Background: Depression is a common disorder in older people and the prevalence differs in different settings. Prevalence of depression is increased by 3 to 7 fold in people with other co-morbid physical health problems.

Objectives and Methods: The talk will begin by reviewing literature on the epidemiology of depression and differences in the aetiology, presentation and outcomes of people who first suffer a depressive episode after the age of 55.

Results and Conclusions: The differences in presentation amongst other things make depression more difficult to accurately diagnose in elderly patients. We will also examine the concept of dysexecutive syndrome and Vascular depression during depression and challenges in choosing and treating with antidepressant medication.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Issues in Child and adolescent substance use

Anju Dhawan, Biswadip Chatterjee, Yatan Pal Singh Balhara, Rachna Bhargava

All India Institute Of Medical Sciences, India

E-mails: dranjudhawan@gmail.com, biswadip.c@gmail.com, ypsbalhara@gmail.com rachnabhargava@gmail.com

Keywords: Child and adolescent, substance use, risk factors

Background: Substance use among children is a rising public health concern in a country like India, where adolescents comprise about 20% of the total population. It interferes with normative age appropriate development and makes children more vulnerable to several health and psychosocial consequences. There is limited international and Indian data on the extent of the problem and the resources available. However, recently National Commission for Protection of Child Rights (NCPCR) has come up with the nationwide study on pattern, profile and correlates of child substance use, which was conducted by NDDTC, AIIMS.

Multiple factors like curiosity among the age-group, peer pressure, low perception of harm, migration, poverty, street life are some of the factors that are related to substance use in children. Issues specific to street children like acceptability among peer-groups and need for security from the drug-using peers and elders add to increased vulnerability to substance use and hampers treatment-seeking among these children. Psychiatric comorbidities like Attention Deficit and Hyperkinetic Disorder (ADHD) and conduct disorders are also commonly associated with substance use among this age group. All the above risk factors are typically associated with this age groups and rarely seen in adult substance users. Further, the severity of dependence, range of substance used, and the knowledge and perception of harm is much lower in this age group which poses challenge in their treatment. Further, the lack of safety data of the pharmacological medications commonly used in older age group limits their usage in this population. The psychological management remains the mainstay of treatment in this age group. Involvement of family members and management of associated psychiatric comorbidity is essential. Further, as the population remains mostly hidden from the conventional treatment set up there is a need for the capacity building at community level to identify and bring them in treatment. Further, there is also a need to thrust research in all aspects of in this area.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Degree of burnout among emergency healthcare workers and factors influencing level of burnout

Shyamanta Das, Sashibha Barman, Sangeeta Datta, Navoneela Bardhan, Marami Baishya, Bornali Das, Sakhee Bujarbarua, Anjana Devi, Dipesh Bhagabati

Gauhati Medical College Hospital, Guwahati, Assam, India

E-mails: dr.shyamantadas@gmail.com, sashibha@gmail.com, drsangeetadatta@gmail.com, navo11610@gmail.com, maramibaishya@gmail.com, bornali.d@rediffmail.com, sakhee.bujarbarua@yahoo.com, sashibha@gmail.com dbhagabati@gmail.com

Keywords: Depersonalisation, Health personnel, Psychiatry.

Background: The term burnout was first used to describe the feeling of failure and exhaustion that can be observed in social workers that worked in institutions, and it was the result of immoderate requirements of energy, effort, and qualifications. Burnout is a state of physical, mental, and emotional exhaustion that often results from a combination of very high expectation and persistent situational stress. It describes a state of depletion of a person’s resources, particularly energy due to excessive demands made on him as a result of which the individual becomes apathetic and impassive towards his work and other aspects of his life. It has dysfunctional repercussions on the individual and adverse effects on the organisation. It may reflect in a continued dissatisfaction with the situation, ranging from mild boredom to severe depression, irritation, exhaustion, and physical ailment. The experience of too much pressure and very few sources of satisfaction can develop into a feeling of exhaustion leading to burnout.

Unfortunately most of the studies on burnout in nursing have been conducted in Europe and United States. There are few studies from Asian countries. The socio-cultural background of Indian healthcare workers varies widely from their western counterparts. Finding predictors of burnout relevant in an Indian setting should have important policy implications in human resource management in this sector in similar developing countries. A health workforce crisis is crippling health service delivery in many low-income countries. High-income countries with high salaries and attractive living conditions are drawing qualified doctors and nurses from poorer countries to fill gaps in their own human resources pool. This migration of skilled labour is depleting human capital in many developing countries. The human resource crisis in India is acute.

Although burnout in large organisations has been examined in many studies, in general there has been a lack of concentration on healthcare workers and on hospital settings, especially in India. In addition, there are relatively few studies investigating burnout among Indian healthcare workers. To the best of investigators’ knowledge, there is a paucity of such work in this field in the state of Assam. Moreover, with the increasing complexities and the changing patterns of society, the stress in the environment leading to burnout is increasing day by day. Study of burnout and factors influencing it will therefore enable us to find out suitable ways to reduce stress among healthcare workers and thereby improving the quality of health care.

Therefore, the Departments of Psychiatry and Emergency Medicine (EM) of Gauhati Medical College Hospital (GMCH), Guwahati, Assam, India have designed this study to identify degree and factors that influence burnout among emergency healthcare workers in hospital with the objectives of examining the degree of burnout reported by healthcare workers of EM; finding out the relationship between burnout and demographic variables; exploring factors that may influence the level of burnout among healthcare workers working in EM.

Doctors, nurses, and other healthcare workers who are working in ED of GMCH will constitute the population. For the purpose of present study, 62 numbers of healthcare workers will be selected. The sample size was calculated from past experience of a study conducted among nurses of the Maternity Department (MD) of GMCH in 2014. Random sampling method will be adopted for selecting the samples in the present study. Healthcare workers who will be available during the data collection period (from September 2014 to August 2015) and who are willing to participate in the study will be included in the study.

Demographic proforma is prepared to gather the background information regarding the participations under study. It consists of eight items. Variables are socio-demographic data, e.g. age, sex, religion, marital status, years married, education, children, and number of children. Factors influencing level of burnout consists of 12 items. These are travelling time to work, working hours per week, doctor/doctor conflict or nurse/nurse conflict, nurse/doctor conflict, availability of doctors/nurses to work with, lack or inadequate nursing personnel, poor wages, too frequent night duties, inadequate security during night duties, job status, years in current job, and additional work.

It was evident from the literature review that because of the very nature of the type of data required to be analysed to assess level of burnout and factors that may influence the level of burnout among health care workers, standardised tools are essential. After an extensive literature search, authors found that Maslach Burnout Inventory (MBI) is the golden scale for assessing burnout. MBI is subdivided into three sections: emotional exhaustion, depersonalization, and personal achievement.

MBI contains 22 items which are answered as never, a few times per year, once a month, a few times per month, once a week, a few times per week and every day. Emotional exhaustion contains seven items. Depersonalisation contains seven items. Personal achievement contains eight items. A high score in the first two sections and a low score in the last section may indicate burnout.

The inventory was translated from English into local language Assamese by an expert not related to this study. It was later back-translated into English by another independent expert, not acquainted with the original version. The back-translation was subsequently compared with the original version by a psychiatrist for conceptual equivalence of the items. Necessary finer adjustments were made to convey the correct information to the participants.

The reliability of the scale was established by data collected from ten staff nurses, who are working in MD of GMCH. The reliability has been drawn by using Split-Half Spearman Brown Formula. Reliabilities of emotional exhaustion, depersonalisation, and personal achievement are 0.88, 0.79, and 0.86, respectively, which are highly reliable, and the tool can be used for main study.

Ethical clearance from the Institutional Ethical Committee is obtained. Informed consent will be obtained from participants. Data analysis will be planned on the basis of objectives of the study using statistical methods of descriptive and inferential statistics.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Predictors and Identifiers in Alcohol Use Disorders. Early detection model for high risk of 1) dependence and abuse, 2) delirium tremens and 3) relapse

Devavrat G Harshe, Aditi Acharya, Rucha Sule

Lokmanya Tilak Medical College and Municipal General Hospital, India

E-mails: devavrat.harshe@gmail.com, adtacharya@yahoo.co.in, rusu1010@gmail.com

Keywords: Alcohol, predictors, biomarker, relapse, delirium tremens

Background: Alcohol use disorders (AUD) impart a substantial burden on the patient as well as the caregivers. Each phase of the illness viz. 1) The dependence phase, 2) The detoxification phase and 3) Relapse prevention phase carries with it a vast array of problems.

AUD’s just like other substance use disorders are unique among all psychiatric diagnoses. The severity of illness, treatment and the recovery depends largely on biological factors as well as personality factors, motivation, resilience and coping strategies.

Thus, it becomes vital to identify those patients:

  1. With a more severe pattern of consuming alcohol.

  2. With a high risk for a severe alcohol withdrawal.

  3. With a high risk of developing delirium tremens.

  4. With poorer predictors of motivation.

  5. With high risk of relapse.

Objectives: The symposium is aimed at discussing the current research on predictors and identifiers for consumption, detoxification and relapse. It will also discuss the possibility and role of customized therapeutic models for AUD.

The speakers will discuss:

  1. Patterns of alcohol consumption. Predictors of high risk for alcohol use disorders.

  2. Predictors of a severe course of alcohol withdrawal. Predictors of delirium tremens.

  3. Predictors of relapse in AUD after detoxification.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Insanity Defence : Past, Present and Future

Channaveerachari Naveen Kumar, Suresh Bada Math, Sydney Moirangthem

NIMHANS, India cnkumar1974@gmail.com

Keywords: Insanity defense

Introduction: Our team proposes to conduct a smposium on Forensic Psychiatry at ANCIPS 2015, focussing on the following issues: (a) History of, assessments related to and caselaws related to Insanity defence and (b) Psychiatrist handling issues related to ‘Insanity Defence’ as an expert witness in the court of law (through mock trial approach)

The existence of Insanity Defence became clear after McNaughton rules which was the sequel of a reaction to the acquittal in 1843 of Daniel M’Naghten on the charge of murdering Edward Drummond, whom M’Naghten had mistaken for British Prime Minister Robert Peel. A panel of judges was asked by the House of Lords, a series of hypothetical questions on the defence of insanity. The principles expounded by this panel have come to be known as the M’Naghten Rules. The rules so formulated has become a standard test for criminal liability in relation to mentally disordered defendants in common law jurisdictions ever since, with some minor adjustments. The insanity defense is recognized in many countries of the world including India.

Insanity Defence is volalized in IPC-Section 84: “Nothing is an offence which is done by a person who, at the time of doing it, by reason of unsoundness of mind, is incapable of knowing the nature of the act, or that he is doing what is either wrong or contrary to law”.

Under Section 84 IPC, a person is exonerated from liability for doing an act on the ground of unsoundness of mind if he, at the time of doing the act, is either incapable of knowing (a) the nature of the act, or (b) that he is doing what is either wrong or contrary to law.

According to section 84, acts done by an unsound person is not an offence. But the main question behind this section is who is a sound person and who is unsound? From a clinical standpoint, even a person under the influence of drugs is an unsound person, but legal stand point is much more narrower. If medical perspective is taken into account, then any person under the influence of drugs commits a crime and can take a plea of sec 84. This would create chaos in the society.

Basically there are three faculties that law recognizes in human mind:

  1. Emotional.

  2. Will.

  3. Cognitive.

Indian law only recognizes Cognitive faculty which means, he is incapable of knowing the nature of the act, or that he is doing what is either wrong or contrary to law. Incapacity is different from potentiality and incapacity of mind to differentiate what is wrong/Right is Unsoundness.

The concept of Insanity defence is a very basic one in forensic psychiatry and also one of the most important and necessary one. Our team, using innovative approaches, aims to help participants gain a clear understanding of this particular issue. At the end of the symposium, participants are likely to have a clear understanding of the Section 84 IPC and also the skills required to handle Section 84 IPC as an expert witness in the court of law.

Rationale for choosing the above topic: There is an almost complete lack of structured training in forensic psychiatry for post-graduates in India and no opportunities for further specialisation in this area. This workshop attempts to impart core competencies in the area through innovative training approaches. The goal of the program is to enable psychiatrists to understand and to liaison effectively with the legal system. Major strength of this symposium lies in teaching the pragmatic skills of performing evaluations and critical thinking about this topic. Participants will witness mock testimony and also role play of experts in teaching courtroom skills.

Areas that would be focused: Insanity defence: Past, present and future. Assessments related to Insanity defence- using a case presentation format· Recent updates on Section 84, IPC· Competencies for collaboration- drafting responses and psychiatrist as expert witness (through practicum and role play).

Format of symposium:

  • History of Insanity defence — Sydney M,

  • Assessments related to Insanity defence issues: Naveen Kumar C,

  • Section 84, IPC: Recent case laws from the honb’le Supreme Court of India: Suresh BM,

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Tricks of managing Bipolar Disorder

Devashish Konar*1, Debjani Bandopadhyay2, Om Prakash Singh3

1Mental Health Care Centre, Kolkata, India, 2Mansij, Burdwan, India, 3Nil Ratan Sarkar Medical College, India,

E-mails: debjanib_231@rediffmail.com, devkon59@yahoo.com, opsingh@india.com

Keywords: Bipolar Disorder

Background:

  1. When mood is high: Dr. Debjani Bandopadhyay Consultant Psychiatrist, Manasij, Burdwan

  2. When mood is low: Dr. Devashish Konar Consultant Psychiatrist, Mental Health Care Centre, Kolkata

  3. When mood is mixed on rapidly cycling: Prof Om Prakash Singh Nil Ratan Sarkar Medical College, Kolkata.

Over the last two decades, Bipolar Disorder has gained its due share of attention in the mindscape of psychiatrists.

That the treatment is tricky and mismanaging is not uncommon came into the awareness of psychiatrists. Extra attention and intelligent decision making on the basis of evidences available is the key to success in care of Bipolar Disorder.

When the mood is high: You really have a good choice of drugs for manic and hypomanic phase of Bipolar Disorder. Selecting the right kind of medication and ensuring drug intake remains the corner stone of challenges in treatment.

When mood is low: Treatment remains difficult because of the severity of the condition, loss of work days, suicide risk and chance of switching. Rampant use of antidepressants in case of Bipolar has to be restrained. Awareness in general practioners, family physicians, and other specialists has to be created.

When mood is mixed or rapidly cycling: They constitute the most difficult situations for treatment. Here treatment options are still not so satisfactory. One has to negotiate the best possible combination for individual patient.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Dementia Caregiving: Experience, Burden and Interventions

Om Prakash*1, Charles Pinto2, Pallavi Sinha3, K. S. Shaji4

1Institute of Human Behaviour & allied Sciences (IHBAS), New Delhi, 4Government Medical College, Trissur, Kerala, India,

E-mails: drjhirwalop@yahoo.co.in, charlespinto@yahoo.com, pallavisinha0102@gmail.com drshajiks@gmail.com

Keywords: Dementia, caregiving, burden of care, interventions

Background: Caring for a person with dementia poses special challenges With the numbers of dementia patients predicted to increase by more than 300% in India, China, and the Asia-Pacific region between 2001 and 2040, dementia caregiving is clearly becoming a significant public health issue. With minimal facilities for institutional or trained care, the majority of the burden for caregiving falls on the family. The effects of being a family caregiver lead to high rates of burden and psychological morbidity. Behavioural and psychological symptoms in dementia (BPSD) further contribute to the difficulties faced by caregivers on a day-to-day basis. Multi-component intervention strategies aimed at improving caregiver management strategies would help increase caregiver competency and decrease patient problem behavior. This symposium addresses the issues related to dementia caregiving- experiences, burden and interventions.

Subtopics

  1. Family caregiving for older persons with Dementia: an overview- Om Prakash.

  2. Impact and challenges in Dementia caregiving- Charles Pinto.

  3. Burden and Quality of Life in Dementia caregivers: An Indian perspective- Pallavi Sinha.

  4. Psychological interventions for dementia caregivers- K.S. Shaji.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Enhancing emotional intelligence: Hands on workshop

Ravindra Mukund Kamath, Alka Anand Subramanyam

TNMC & Bylnair Ch. Hospital, India

E-mails: ravindrakamath@hotmail.com, alka.subramanyam@gmail.com

Keywords: Emotional intelligence

Emotional intelligence (EI)has been spoken about often and has garnered much importance in the 21st century. Today parents are teaching children and curricula are being modified to enhance “people skills” and training for children. Similarly, adults in corporate offices and the business sector are being groomed to enhance their PR or soft skills.

So, emotional intelligence is nothing but awareness of emotions- of oneself and others in the environment; and thereby achieving control of any situation by awareness and control of one’s emotions. This leads to a win-win situation for all.

As mental health professionals it becomes imperative for us to understand emotions in our patients, other professionals and with each other. This will lead to a more beneficial doctor-patient relationship and less burn out in mental health Professionals, themselves.

This is a hands on workshop, with limited registration for 30 individuals. Registration is free but compulsory. A questionnaire will be distributed online prior to the workshop to the registered candidates, and the analysis will be discussed to bring out (a)aspects of EI, (b)how to enhance one’s EI and (C) it’s role in day to day life-both personal and professional.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Mindfulness based hypnotherapy for neurotic disorders

Shaunak Ajinkya*1, Deepali S. Ajinkya2

1MGM Medical College, Navi Mumbai, India, shaunaka@hotmail.com, 2Master Your Mind Institute of Clinical Hypnosis, Mumbai, India, drdeepasa@yahoo.com

Keyword: Mindfulness, Hypnotherapy, Hypnosis, Neurotic Disorders

Background:Hypnosis is an artificially induced trance-like state characterized by deep relaxation, increased suggestibility, and constriction of peripheral awareness with increase in focal concentration on the task at hand. It was first utilized by Anton Mesmer in 1775, who called it Animal Magnetism. The word “Hypnosis” was coined by James Braid from Greek word ‘hypnos’ meaning sleep. Freud noted that patients who had encountered psychosocial adversities benefitted from hypnosis and abreaction.

Mindfulness is an intentional, accepting, non-judgmental focus of one’s attention on one’s own thoughts, emotions and sensations occurring in the present moment. The term ‘Mindfulness’ is derived from Pali word ‘Sati’, an essential element of Buddhist meditative practices. ‘Sati’ means a conscious awareness or skillful attentiveness. Mindfulness is the skill that allows us to be less reactive to what is happening in the moment and develop a non-judgmental acceptance of it. Integration of Mindfulness into mainstream psychotherapy seems to stem from the pioneering work of Kabat Zinn – the Mindfulness Based Stress Reduction (MBSR) Program.

Mindfulness and hypnosis work in complementary ways. Mindfulness helps the client be in the moment and accept the unpleasant feelings making it easier for the client to take the corrective suggestions provided under hypnosis so that the client can correct the inappropriate strategies and achieve positive results.

Objectives: To help mental health professionals know the basics of mindfulness-based hypnotherapy which they can use as effective additional therapeutic tool for patients with neurotic disorders.

Brief Description: The facilitators are internationally certified clinical hypnotherapists. The workshop will be mix of didactic presentations, demonstrations and group practice.

Contents of Workshop:

Brief history of hypnosis

Laws & Stages of hypnosis

What is mindfulness-based hypnotherapy?

Advantages over traditional hypnotherapy

Demonstration of mindfulness-based hypnotherapeutic session.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Dhat Syndrome: Newer Perspectives

Ajit Avasthi*1, T SS Rao2, Sandeep Grover3

1PGIMER, India, drajitavasthi@yahoo.co.in, 2JSS Medical College, India, tssrao19@yahoo.com, 3PGIMER, India, drsandeepg2002@yahoo.com

Keyword: Dhat syndrome, culture bound syndrome

Rationale for the symposium: This symposium will focus on the recent developments in understanding the clinical manifestation and management of Dhat syndrome.

Subtopics

Dhat Syndrome – Cultural Perspective (TSS Rao)

The term Dhat syndrome originated from the word ‘Dhatu’, which means an important elixir which constitutes the body. It was first described in Indian context by Wig in 1960. The clinical picture included “severe anxiety and hypochondriasis”. Patients with this disorder are usually preoccupied with the excessive loss of semen by nocturnal emissions. This presentation will discuss the cultural beliefs and other cultural factors associated with Dhat syndrome.

Dhat Syndrome – Multicentric study (Ajit Avasthi)

This presentation will focus on the phenomenology of Dhat syndrome. Although there are many studies on Dhat syndrome, the clinical description is heterogeneous with regards to associated beliefs, reasons for passage of Dhat, situations in which patient experiences Dhat and the consequences of Dhat. The existing literature also suggests variation in the prevalence of various psychological and somatic symptoms. This presentation will also provide a glimpse of the findings of multicentric study on Dhat syndrome.

Dhat Syndrome – is there a female variant (Sandeep Grover)

In the existing literature, the clinical description of Dhat syndrome is mainly limited to males. However, ethnographic studies, studies in patients presenting with non-pathological vaginal discharge and few case reports suggest the existence of similar syndrome in females too. This presentation will focus on the existence of female equivalent of Dhat syndrome.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Pornography: Is it relevant to psychiatrists?

Indla Ramasubba Reddy, Mohit Sharad Sholapurkar, Vishal Indla Reddy

VIMHANS Hospital, Vijayawada, Andhra Pradesh, India, indlas1@rediffmail.com, docsholapurkar@gmail.com, vishalindla@gmail.com

Keyword: Pornography, sexuality

Objectives: Overall there is much gain in the percentage of the population seeking access to pornography. Consumption of it may be stimulating as well as may lead to development of ill effects such as aggression, paraphilias, violence, sexual crimes and other behavioral changes.

To address this issue and to show recent research done by us in these areas we have planned a symposium on this neglected and untouched subject in the field of psychiatry.

Description: Form of pornography consumption has been constantly in the process of change. When mobile phones and internet facilities were not widely available, porn Literature/magazine / photos were used very commonly. With the advancement in technology, more audio visual forms of porn material started getting available and easily accessible. There are many studies conducted on the issue overseas whether porn consumption leads to any hazards and a few studies show rather positive side of porn consumption in form of variation and better communication with the partner in the act of making love, increase in libido and sexual performance etc.

We wish to throw light on current patterns of pornography consumption, some case vignettes and applications in psychiatry, future research directions.

Speakers will cover following topics

  • (1)

    Pornography Consumption: Past and Present

  • (2)

    Pornography Consumption and Sexuality ? How are they related ?

  • (3)

    Some opinions about pornography consumption from general population.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Nutritional deficiencies complicating the presentation of delirium in acute alcohol withdrawal: a case series from a rural psychiatric setup

Johann Alex Ebenezer*1

1Department of Psychiatry, Padhar Hospital, India, johannebenezer@gmail.com

Keyword: nutritional deficiencies, delirium, alcohol withdrawal

Background: Chronic alcohol use is known to be associated with several micro-nutrient deficiencies. The reasons for this association include both direct effects of alcohol on absorption as well as the generally poor dietary habits of alcohol dependent patients. Much of the available literature and management protocols have tended to focus on thiamine (vit B1)deficiency and its related neuropsychiatric manifestations like Wernicke-Korsakoff syndrome and peripheral neuropathy. However, other micro-nutrient deficiencies are also described, including niacin (vit B3), riboflavin (vit B2) and cyanocobalamin (vit B12). Since B vitamin deficiencies frequently occur concurrently, it is possible that many of these are under-diagnosed in routine clilnical practice.

Cases: The author presents a series of two inpatient cases in the department of Psychiatry at a rural mission hospital. Both were men with chronic alcohol dependence who presented with complicated withdrawal delirium and were managed with standard treatments for delirium tremens including high dose benzodiazepines and routine neurovitamin supplementation. Both, however, had prolonged delirium and cognitive abnormalities despite resolution of other withdrawal symptoms. Both patients were found to have subtle signs and symptoms of micro-nutrient deficiencies, and neuropsychiatric symptoms resolved completely when appropriate doses of supplementation were initiated. One was found to have a combination of thiamine deficiency and nutritional anemia (iron and B12/folate deficiency) and the other had niacin deficiency (pellagra).

Discussion: Delirium is most commonly multifactorial, and any atypical or prolonged presentations of delirium tremens should alert psychiatrists to the possibility of co-exisitng conditions. Nutritional deficiencies are often missed, and are an easliy treatable co-morbidity. Misdiagnosis or inadequate supplementation can also lead to severe morbidity and even mortality. Although a lot of attention (rightly) is given to thiamine, other deficiencies should also be considered when clinically appropriate.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

The canvas of mind: Eat, Pray and Love

Bikram Dutta*1, Virendra Vikram2, T Madusudan Madhusudan3

1Command Hospital Central Command, Lucknow, India, bikram_dutta06@yahoo.com, 2Military hospital Jhansi, India, virvik@gmail.com, 3Command Hospital, India, kalpanasrivastava@hotmail.com

Keyword: Eat, Love and pray

Background: Inspired by a literary work by Elizabeth Gilbert we thought to have some more insight and exercise on the same title. While the character of Julia Robert travels across the world to understand the importance of these things in life; we would rather explore our expanse of mind and territory of knowledge to understand how these simple things of life do affect us immensely; in a positive or an adverse manner. From newer correlates in the dimension of eating disorder; sync of prayer and well being to the longing of love; this topic will unravel all dimensions.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

High Risk Behavior in Adolescence: Neurobiology, Intervention and legal issues

Jayaprakash Russell Ravan, Seema Parija, Siddharth Shankar Dash, Sidharth Soumyadarsan Pattnaik

Kalinga Institute of Medical Sciences, India, jpr_219@yahoo.co.in, drseemaparija@gmail.com, sid.dash@yahoo.co.in, sidharth.pattnaik90@gmail.com

Keywords: Adolescent Health, High Risk Behavior, Addiction, Legal issues

Background: Title Of The Symposium- High Risk Behavior In Adolescence: Neurobiology, Intervention, Legal Issues.

Objective Of The Symposium - Adolescent Age Is A Post Pubertal State. During This Period Many Hormonal Changes Occur Not Only In Soma But Also In The Brain.

So This Age Group Is Vulnerable For High Risk Behaviors Such As Promiscuity, Substance Abuse, Rta, Deliberate Self Harm, Teenage Pregnancy, College Drop Outs And Delinquent Behaviors. There Is Growing Consensus That Healthy Development In Adolescence Contributes To Good Mental Health And Can Prevent Mental Health Problems.

Hence A Young Psychiatrist Should Be Trained For The Necessary In Depth Assessment. Possible Multimodal Intervention Strategies Are Required To Be Developed And Discussed For The Benefit Of Our Adolescent Patient In Crisis.

Last But Not The Least The Issues Of Human Rights, Privileges, Other Legal Aspects Pertaining To Adolescent Health Need To Be Addressed And Discussed In Depth.

So In Conclusion The Symposium On Adolescent Mental Health Will Give An Insight Related To The Neurobiology, Assessment, Intervention For This Special Group Of Clients And Possibly Advocating A Subspeciality In Every Medical College And Hospitals.

Topics To Be Presented In The Symposium:

  1. Neurobiology Of Adolescent Brain And Behavior By Dr Sidharth S Pattnaik, Kims Bhubaneswar

  2. Pattern Of High Risk Behavior In Adolescents In Rural And Urban India By Dr Jayprakash R Ravana, Md Cmc Vellore

  3. Approach, Assesment And Intervention Of Adolescent In Crisis By Dr Seema Parija, Afmc Pune

  4. Legal Issues Rights And Privileges Of Adolescents By Dr Siddharth S Dash, Dmrt Ipgmer And Sskm Kolkata.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Critical Evaluation and Management of a Hyperactive Child in a Clinical Setup

Kshirod Kumar Mishra*1, Kishor Gujar2, Jyoti Prakash3, Vivek Kirpekar4

1Mahatma Gandhi Institute of Medical Sciences, India, drkkmishra2003@yahoo.co.uk, 2Consultant, Psychiatrist, YCM Hospital, Pune, India, gujarkishor9@gmail.com, 3AFMC, Pune, India, drjyotiprakashpsy@yahoo.com, 4NKPSIMS, Nagpur, India, vivek.kirpekar@gmail.com

Keywords: Hyperactive child, ADHD

Background: Every hyperactive child brought to a Child guidance clinic or a referred for the Psychiatric evaluation and management may not be ADHD per se. Selecting a medication, when to start and for how long is the difficult discussion for clinician. What behavioral therapy work well at what setup needs to be discussed. In spite of best of management certain percentage of children (20-25%) continue to have ADHD in the Adulthood. We intend to throw light in this dark area with recent development in this field through symposium cum workshop module.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

The challenges for a young psychiatrist in the community

Pavitra Ks*1, Shubrata Ks2, Adithya Pandurangi3

1Sridhar Neuropsychiatric Centre, India, pavitraks2011@gmail.com, 2Subbaiah Institute Of Medical Sciences, Shimoga, India, shubhrataks@gmail.com, 3Dharwad Institute Of Mental Health And Neurosciences, India, pandurangi.aditya@gmail.com

Keywords: Young psychiatrist, community, mental health care

Background: The challenges for a young psychiatrist in the community are many. More and more doctors are taking up psychiatry as their specialty. But few of them stay back in India and very few in smaller cities and rural areas.

Three young psychiatrists within 10 years of their post graduate degree, and currently practicing in smaller cities will discuss three important aspects of the challenges for young psychiatrists in going out of institutions and bigger cities.

Working in the community involves multiple responsibilities for a psychiatrist-education, advocacy, media responsibility, collaboration, leadership and legal issues. The first speaker will speak on these and give practical guidelines for an effective management of these roles.

The second talk will cover the tasks for the psychiatrist as a clinician who has to develop good clinical services and ensure delivery of care to mentally ill. The talk will cover the requirement of multidisciplinary liaison, knowledge of different areas of psychiatry and training mental health personnel from the community.

The third speaker will speak on the importance and the ways to conduct evidence based research while working in the community mental health care. The talk will discuss the innovative ways to conduct research in these settings, learning from this research to help one to improvise over the clinical practices.

The symposium’s focus is to elicit a brain storming regarding these important challenges and then to arrive at a set of practical solutions which a young psychiatrist can follow to help mentally ill in a better way.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Training the trainee before training: focus on fragile foundation in psychiatry during undergraduate period

Virupaksha Shanmugam Harve, Sundarnag Ganjekar

M S Ramaiah Medical College, India, virupaksha.hs@gmail.com, drbsnake@gmail.com

Keywords: Undergraduate, training, psychiatry

Background: Workshop aims to Identify lacunae in undergraduate psychiatry training as reported by undergraduate students, interns, and faculties at Medical college teaching hospital. What MCI says about undergraduate psychiatry teaching? What is actually happening at ground level. How psychiatrists working at medical colleges create an interest in their undergraduates so that they can take up psychiatry as their profession?

Background: Psychiatry is still considered as a pseudoscience. Stigma associated with psychiatry is very high even among the medical professionals. Though there is high psychiatric comorbidities among patients attending general hospitals it is rarely identified and treated properly. Medical professionals find it difficult to identify common psychiatric conditions associated with chronic medical/surgical conditions. One of the reason for such a neglect is not giving much importance to undergraduate psychiatric training. This is also one of the reason why undergraduates do not choose psychiatry as their postgraduate subject. There is need to instill the interest in undergraduates psychiatry training vis a vis cardiology, neurology.

Material And Method: A short survey was conducted among various strata of medical professionals (undergraduates, interns, postgraduates and consultants) to understand their views about psychiatry and psychiatry training for undergraduates.

the workshop will also discuss how faculties working at medical colleges teach psychiatry to their undergraduates, help to change in MCI policies, and encourage upcoming graduates to take up psychiatry as their profession.

Workshop will specially focus on the skills and methods which can be practiced to make psychiatry more interesting.

Utilize feedback from Ug students to refine the MCI UG curriculum.

Results and Discussions: will be discussed in workshop. (report of study and the attendance aspects of our hospital)

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Psychotherapy and its role in mental illness recovery

Dinesh Sinha*1

1NHS, United Kingdom, sdanes@gmail.com

Keywords: Psychotherapy, recovery, psychological, interventions

Background: Mental illness is often defined by its chronic relapsing and remitting nature for many disorders. Additionally, there can be marked differences between the effect of an illness on different people, which has led to a lot of interest in the concept of resilience. The author works in a busy hospital based service delivering a range of psychological and psychotherapeutic interventions for patients across a wide range of diagnosis and presentations.

Using relevant links to references and clinical vignettes, the aim is to explore the role of psychotherapy in recovery. In this context, we will discuss the theoretical and research basis for the role of resilience building and its connections with psychological change. Psychotherapy can help in building emotional resilience and well being within patients, which can break the cycle of recurrent episodes requiring intervention and promote recovery. Finally, attention will be drawn to the need for psychological fluency and knowledge for all psychiatrists.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Integrated Online Video Consultation & Prescription System

Jyothirmayi Kotipalli1, Hemanth Kumar Satyanarayana*2

1HelloPsych, India, jyodoctor@gmail.com, 2Imaginate Software Labs Pvt Ltd, India, hemanth@imaginate.in

Keywords: Video, Tele-Psychiatry, Electronic Health Records, Internet, Online Consultation

Background: Mental health care is often construed as a topic of taboo or is otherwise plainly ignored. One of the major mental health disorders - Depression continues to be the second largest spreading disease in the world and is expected to become the first largest in few years. With the stigma associated with mental health, dearth of easy modes of access to psychiatrists and psychologists, one can understand that the stats mentioned above can’t be wrong. Similarly addiction to drugs, alcohol, etc is increasingly prevalent. We intend to solve these problems at a faster rate through HelloPsych by providing faster and cheaper access to mental health advice with experts.

HelloPsych is a proprietary telemedicine technology platform that enables people to consult with professionals in the field of mental health care, remotely through video channels, from the confines of their private surroundings. To a patient, it is the comfort of being able to connect to an available expert immediately when in need of help and also pay instantaneously via a credit card. To the expert psychiatrist or psychologist, it is the luxury of being able to serve the patient on the go via a handheld or a PC with a fast internet and front facing camera and still not missing out on the element of direct face-to-face contact with the patient. The revolutionary aspect is not just the inbuilt live video feature but the scheduling functionality of the system that identifies doctors available and match them with a consultation requesting patient based on their subject of interest and followup.

Our first users have been a couple of patients who couldn’t attend direct consultation with a couple of doctors present in the system. They have comfortably used the system and paid for via credit card. Moreover, we see a growing demand for online consultation requests.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Counteracting stigma through media -a community experience

Pavitra KS*1, Shubrata KS2, Harisha Delanabettu3

1Sridhar Neuropsychiatric Centre, India, pavitraks2011@gmail.com, 2Subbaiah Institute of Medical Sciences, Shimoga, India, shubhrataks@gmail.com, 3K.V.G Medical College, Sulya, India, harishad@gmail.com

Keywords: stigma, mental health care, community

Background: Stigma remains one of the most important barriers to seek mental health care early in the period of mental illness.The stigma is not only associated with the illiterate and poor people but also the educated and financially well off alike.The methods to counteract stigma need to be innovative and should be evaluated periodically for their efficacy and revised accordingly.

This symposia will have three speakers talking on three different aspects of stigma. The first talk will discuss the different ways we find stigma in the community and their hindrance to mental helath care. The cultural aspects unique to Indian rural and cultural settings will be given special emphasis.

The second talk will cover the media’s influence in increasing stigma against mental illness and mental health professionals. It will discuss in detail of the effective use of the media –print, mass communication and social media to enhance mental health awareness and treatment issues.

The third speaker will speak on the basis of the experiential narratives of psychiatrists working in the community. the talk will lead to a discussion on various innovative methods to remove stigma ensuring an improved access to mental health care in all settings across the country.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Stigma and Mental illness: Perspectives and Prevention

Roy Abraham Kallivayalil*1, Mohan Isaac2, Rakesh Chadda3, Harischandra Gambheera4, Varghese P Punnoose5

1Pushpagiri Institute of Medical Sciences, Thiruvalla, Kerala, India, roykalli@gmail.com, 2University of Western Australia, Australia, mohan.isaac@uwa.edu.au, 3All India Institute of Medical Sciences, New Delhi, India, drrakeshchadda@gmail.com, 4Colombo University, Sri Lanka, hgambheera@gmail.com, 5Medical College Kottayam, India, vargheseppunnoose@yahoo.com

Keywords: Stigma, mental illness, prevention, obstacles, NGOs, interventions, perspectives

Background: Stigma is one of the major obstacles faced by mental health professionals. This is especially so in India and many of the South Asian countries. Mental illness, HIV/AIDS, leprosy and venereal diseases are in the fore-front of stigmatized illnesses. The persons suffering from them face exclusion and discrimination in several walks of life. They do not get the social support they badly require. Besides, they and their families face uncertainty or despair. Not only mental illnesses but also the institutions which cater to them are sometimes stigmatized, leading to further deterioration in the upkeep of these centres.

Stigma is a like a curse on the sufferer, devaluing them in the eyes of the society. Compared to the West, anti stigma efforts in South Asia are less organized and lacking adequate penetration. However there is a growing awareness, stigma is one of the major impediments in providing mental health care. It is probably the most significant obstacle to recovery and rehabilitation, especially in the less resourced countries. There have been some good examples, where General Hospital Psychiatry Units and NGOs are working together, especially from Kerala, India. Other South Asian countries including Srilanka have renewed their efforts to fight stigma. The various dimensions of stigma should be studied and interventions need proper structure with flexibility. All these will be discussed in the following presentations:

  1. Stigma: Emerging Perspectives: Prof Mohan Isaac (University of Western Australia)

  2. Stigma as Obstacles to Recovery and Rehabilitation: Prof Rakesh Chadda (Delhi)

  3. General Hospitals and NGOs working together against stigma: Prof Roy Abraham Kallivayalil (Thiruvalla)

  4. Stigma Prevention: Experience from Srilanka: Prof H Hambheera (Colombo)

  5. Anti-Stigma Interventions: Structure and Dimensions: Prof Varghese P Punnoose (Kottayam)

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Bridging the service gap – From Memory clinics to Comprehensive Care

Soumya

Alzheimer’s Disease and other forms of Dementia are as much a problem in India as in the rest of the world. According to the Dementia India Report (2010) there are 3.2 lakh people suffering from the disease and this number is set to rise exponentially in the coming years. Despite the increasing prevalence, dementia is only minimally represented in our health care program.

In the last few decades the population demographics have also changed. There is a rural to urban shift as well as a break down in the joint family system. In the absence of care facilities such as day care, respite care and quality institutional care, we seem to be ill equipped to deal with this epidemic.

In this scenario there was a real need to merge the existing service gap so that patients and caregivers could access everything under one roof. This was the philosophy on which the Nightingales Centre for Ageing and Alzheimer’s (NCAA) was developed in 2010. NCAA is India’s first comprehensive care facility providing memory clinic assessments, daycare, short term, long term care, training and support to caregivers. The three storeyed, 86 bed facility has been designed taking into account the specific physical health and cultural needs of patients in India.

In the nearly 5 years since its existence, over 1500 patients have been assessed in the outpatient clinic and short term care has been provided to about 600 patients. Patients and caregivers have been coming from all parts of the country in search of quality dementia care that is compassionately and professionally delivered.

Over these years we found that there was still a large proportion of patients who were not able to access this service both because of geographical constraints and financial.

In May 2014, a teledementia enabled centre with 36 residential beds was set up in Kolar. The use of technology increased the reach of specialised care and also considerably cut down the cost of care.

As of now, the cure for dementia eludes us and as the awareness about this disease increases so does the concern about being affected by it in the future.

The Nightingales Trust Bagchi Centre inaugurated in October 2014 looks at life style modification with the help of physiotherapy and cognitive exercises delivered through a structured and tailor made program to minimise risk and hopefully delay the onset of dementia.

Through our various innovative and need based projects we hope to reach out to more dementia patients and their caregivers and do our bit to reduce the suffering associated with this disease.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Aetiology Of Insanity: British Perceptions And Labelling

Manikarnika

Most of the histories of madness in colonial India have pondered on the intersection of race, class and power, while the language of madness as a determinant of medical aetiology has been largely overlooked. This paper examines the works of colonial administrators and other medical personnel such as Alexander Overbeck Wright, G.W Ewens, T.A Wise and the like whose treatises on insanity are considered as representative texts of this convention. Here I seek to explore what extent the description of madness in medical and semi-medical texts written were informed by prevalent ideological attitudes and reproduced European hegemonic concepts. Additionally government reports are studied to arrive at an understanding of British perceptions and conceptions about insanity among their colonial subjects. By studying the ideological assumptions underlying history of insanity in the Indian subcontinent, descriptions of case notes and diagnostic prescriptions, this paper unpacks the discursive praxis of madness among the medical administration in colonial India.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Challenges in treatment of refractory Obsessive Compulsive Disorder: A case report and review of literature.

Sambhu Prasad1,*, Shashi Kant Khanna2, Om Prakash3

1Senior Resident, 2Junior Resident, 3Associate Professor of Psychiatry, Department of Psychiatry, Institute of Human Behaviour & Allied Sciences, Dilshad Garden, New Delhi, India; sambhu3011@gmail.com

Obsessive compulsive disorder (OCD) is a chronic disorder, currently recognized as one of the most common psychiatric disorders as well as one of the most disabling of all medical disorders. OCD is characterized by high rates of partial and/or absent response to standard, recommended treatments. We present a case 23-year-old male with mixed OCD, insidious onset and of waxingand waning course. He had been tried on several antiobesessional drugs such Fluoxetine, Fluvoxamine, Clomipramine, Sertaline, Paroxetine, Escitalopram at adequate dose and duration. He also had been treated with combination and augmentation with low dose of several antipsychotic drugs together with psychotherapy at adequate period. There was no complete remission in symptoms at any point of time of illness despite his symptoms went on deterioriating (YBOCS remain at highest score 32-38). There was brief psychotic episode during the course of treatment with marked deterioration in biological functioning for which MECT (sessions =19) given. His psychotic spells subsided but there was no improvement in obsessional symptoms. In view of gross dysfunction and failure of all usual modalities, treating team is thinking of other noble treatment such as rTMS/psychosurgery. The presentation will discuss the options of treatment of refractory OCD and newer development in this area.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Substance Abuse – Models of Care, Relapse Prevention, and Recovery

Debasish Basu

Drug De-addiction & Treatment Centre, Department of Psychiatry, Postgraduate Institute of Medical Education & Research, Chandigarh. db_sm2002@yahoo.com

Substance use disorders are multifactorial and biopsychosocial in nature. Models of care are also diverse in their philosophy, orientation, settings and goals. Within the traditional professional realm, models can be acute vs. chronic, community vs. residential, detoxification vs. rehabilitation, incentive vs. disincentive based, pharmacological vs. psychosocial, abstinence vs. harm reduction, among others. All have their advantages and disadvantages, but the current consensus appears to be toward endorsing a chronic care model, more community oriented, focused on rehabilitation and incentive based with a combination of pharmacological and psychosocial modalities. Relapse is an integral feature of substance use disorders, hence no addiction treatment package should be complete without addressing and tackling the issue of relapse. Along with pharmacoprophylactic measures, there are a number of psychosocial approaches including contingency management, cognitive behavioral therapies, and more recently mindfulness-based relapse prevention. Of these, Marlatt and Gordon’s Relapse Prevention Therapy derived from cognitive-behavioral principles has received maximum attention over 30 years and hence this will be discussed in some details. The eventual goal and aspiration, however, is to go beyond relapse prevention and focus on non-substance related outcomes as well, ultimately resulting in restitution of the personal holistic health of the substance user and reintegration with society as a useful citizen. This long-term process (rather than event) constitutes recovery from addiction. Recovery, though a lofty and idealized abstraction, has become recently very popular in various countries’ drug control agenda and policy, due to a combination of historical, social and political factors. The issue of long-term indefinite opioid substitution therapy versus time-limited therapy with abstinence as the final goal has been hotly debated within the context of recovery from addiction. This controversy will be analyzed, ending with a reconciliatory roadmap.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Female Sexuality

T S Sathyanarayana Rao1, Mrugesh Vaishnav2

1Professor, Department of Psychiatry, JSS Medical College and Hospital, JSS University, Mysore, tssrao19@yahoo.com, 2Director, Samvedana Hospital & Research Institute, Consultant FPAI- SECRT, Ahmedabad. drmrugesh@rediffmail.com

Key words: Female sexuality, sensate focus exercises, classification

Sexuality is one of the major determinants of quality of life is an established fact. However, compared to male, sexual problems in female are most often difficult to quantify or qualify as a physical problem. The issues span sexual response, role of anxiety and guilt and associated inhibition and other relational matters. The simplistic classification propounded by ICD 10 has not stood the test of time and there is a rethink on all the matters related to desire and arousal, orgasm and issues related to pain and penetration. This rethink is reflected in the newer classification in DSM 5. The presentation looks into all these nuances and its implication in the management of female sexual dysfunctions.

The sub topics:

  1. Common problems but complex issues -. Mrugesh Vaishnav.

  2. Practical Management including sensate focus exercises – T S Sathyanarayana Rao

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Mental Illness: Institutionalisation…Recovery… Social inclusion…The Journey…

Dr. Vinod K. Sinha

Professor of Psychiatry, Central Institute of Psychiatry Ranchi, Ranchi cipranchi@hotmail.com

Keywords: Institutionalisation, recovery, social inclusion

In the 19th and early 20th century, asylums were the main form of care for patients with severe mental illness. Patients’ lives were dictated by institutional routine and isolated from the wider society for an extensive period of time.

However, due to the widespread civil rights movement and the right to receive treatment in the least restrictive environment possible, advances in antipsychotic drugs and alternative care in community, the process of de-institutionalisation has evolved over the last 70 years. Since then, the roles of psychiatric hospitals have changed, and millions of long-stay patients have been discharged from psychiatric hospitals all over the world. Nevertheless, inpatient psychiatric hospital services are still considered an essential type of care in psychiatry today, as community care may not be suitable for all patients, especially those with acute mental illness and a lack of support.

The effects of deinstitutionalization vary across countries based on their health care and social welfare systems as well as the specific features of national traditions, socio-cultural context, and the level of available resources. Thus, the responsibility of facilitating the recovery of patients with mental illness and their inclusion in the main stream society has shifted from psychiatric hospitals to the community at large.

Recovery, however, is not a new concept within mental health, although in recent times, it has come to the forefront of the policy agenda and is being increasingly debated within mental health discourse as a consequence of de-institutionalisation. It appears to have a multitude of meanings, being an idea, a movement, a philosophy, a set of values, a paradigm, and a doctrine for change. The term is being used in a number of ways by the mental health sector, including as a way to describe an individual’s personal journey from illness to wellness. In community setting recovery is closely linked to social inclusion which is the extent to which people are able to exercise their rights and participate, by choice, in the ordinary activities of citizens in the society in which they reside.

Promoting opportunity and social inclusion means getting the basics right: making sure that people have access to the material resources and supports they need—things such as money, food, housing, transport, physical health care, personal safety. However, it also involves going beyond mere survival and should be about enabling people to make the most of their lives, accessing those activities, roles, and relationships that they value.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

We need to take a stand: Sexual boundaries in the doctor patient relationship in India

1Sunita Simon Kurpad, 2Ajit Bhide,3Alok Sarin

1Professor and Head, Department of Psychiatry Professor, Department of Medical Ethics St. John’s Medical College Hospital, Bangalore 560 034 simonsunita@gmail.com, 2Senior Consultant and Head, Department of Psychiatry, St. Martha’s Hospital, Bangalore, 3Consultant Psychiatrist Sitaram Bhartia Institute of Science and Research New Delhi

Background and Purpose

Violations of sexual boundaries in the doctor patient relationship are violations of the fundamental ethical code in medical practice of primum non nocere (first do no harm). Over the last few years, there has been some discussion on both non sexual as well as sexual boundary violations in certain fora in India, with the beginning of an acceptance that these violations are not an exclusively Western phenomenon.

The Medical Council of India did act on The Bangalore Declaration (a consensus document generated by a group of health professionals in order to address the issue of Nonsexual and Sexual Boundary Violations in the doctor-patient relationship in India), by incorporating this topic in the proposed new MBBS Undergraduate curriculum.

Though doctors who cross sexual boundaries are a minority, they can have devastating effects on patients, families and themselves. So, it would be a significant first step if psychiatrists and The Indian Psychiatric Society lead the way, by proactively endorsing a Code of Practice on Sexual boundaries in the doctor patient relationship.

The speakers in the symposium will discuss the rationale, the essence of a proposed Code of Practice for Sexual Boundaries and the need for psychiatrists in India to take the lead on this issue.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Treatment Gap in Mental Health

K. S. Shaji

Professor of Psychiatry, Govt Medical College, Thrissur, Kerala. drshajiks@gmail.com

Most people with mental health problems do not get the treatment they need. Treatment gap refers to the proportion of individuals who require mental health care, but do not receive treatment. The treatment gap in mental health care exists across the world and is especially huge in low and middle income countries (LMIs). We need to identify the barriers leading to the treatment gap and develop strategies to overcome them. Scaling up of services would require a different kind of knowledge, often referred to as implementation science and generated by operational research. We need to invest in operational research.

The World Health Organization (WHO) has developed an intervention guide for diagnosis and management of common mental health problem as part of the Mental Health Gap Action Program (mhGAP). These evidence informed interventions can be delivered by trained non-specialist health care providers and will help in scaling up of mental health services in the community, primary and secondary care settings of LMIs. We need to closely examine the usefulness of these interventions in India, especially in the setting of the District Mental Health Program (DMHP). Embedding operational research to the DMHP would help to understand the issues and challenges during its implementation. Programme to Implement Mental Health Care (PRIME) is a consortium of research institutions and Ministries of Health in five countries in Asia and Africa (Ethiopia, India, Nepal, South Africa & Uganda)with partners in the UK and the World Health Organization (WHO). It is important that we take active collaborative role in evaluating and scaling up of mental health services and link up with global initiatives in this direction. While doing so we must recognize the important role of research in informing and guiding service development

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

WPA Section on Human Sexuality Symposium

T.S. Sathyanaryana Rao, Vihang N Vahia, Ajit Avasthi

Professor, Department of Psychiatry, JSS Medical College and Hospital, JSS University, Mysore, tssrao19@yahoo.com, consultant Psychiatrist, Breach Candy Hospital eelavathy Hospital and Harkishandas HospitalMumbai. vvahia@hotmail.com, Professor, Department of Psychiatry, Postgraduate Institute of Medical Education & Research, Chandigarh 160012 (India) drajitavasthi@yahoo.co.in

Sexualities: Waking up the Sleeping Beauty, Dressing up the classification.

The classification of sexual dysfunctions and disorders have always been a major concern for the clinicians and researchers. Many different words are used to refer to the usual and unusual inclinations and behaviors and we need to make a sense out of these terms and their diverse and sometimes overlapping meanings. Different authors, scientists, psychologists and psychiatrists have used the terms, nosology, classification and usage in many idiosyncratic ways. Many issues, either in diagnosis or classification are currently determined to a great extent by historical socio-cultural influences, current traditions and available limited evidence - based data.

The current symposium under the banner of Human Sexuality Section of World Psychiatric Association looks at the meanings and issues related to terminologies, International classificatory efforts of historical importance and the available evidences for existing classificatory systems and makes an effort to look at the future from the socio-cultural perspective.

The symposium will be presented in the following sub - titles:

Looking into Current ‘Premature’ Nosologies - Dr. Vihang N Vahia

Covering ICD 10 and DSM 5 Perspectives

WPA attempts to scale the ‘Peak’ - Dr. T S Sathyanarayana Rao

Looks at the pros and cons of the WPA Classification of sexual disorders and emphasizes that it is indeed a great step forward in the current scenario.

Indian Sexualities: “Foreplay or after play” - Dr. Ajit Avasthi

An effort would be made to direct and analyze existing classifications, in addition to looking at the classification from the Indian context. The dilemma whether to follow and tread the accepted line or to plough a new path will be the area of discussion.

In the end, the symposium makes a point to look into the past and the current perspectives, and attempts to look beyond to improve or improvise or device a whole new system keeping in mind Indian ethos and milieu in mind.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

WPA Section on Psychiatry in Developing Countries Symposium: Ethical Issues in Psychiatry

Chair: E Mohandas & Russel D’Souza

Russel D’Souza Ethical Issues in Psychiatry-UNESCO perspective

Mohandas E Informed Consent-What does it mean?

Rajesh Nagpal Ethical Dilemmas in Drug deaddiction Clinics

Abstract

Ethical issues in Psychiatry are many. On one hand issues concerning informed consent and confidentiality are a matter of debate. On the other human right issues and the ethical principles regarding research loom large. Real world issues in India compared with what is ideal from a UNESCO perspective are discussed.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S160–S195.

Surgery for psychiatric disorders: Update and guidelines

Paresh K. Doshi

Director of Neurosurgery, Jaslok hospital and research centre, Mumbai. pareshkd@gmail.com

The World health organization defined psychosurgery as “selective surgical removal or destruction of nerve pathways for the purposes of influencing behaviour.” The modern era of psychiatric disorders surgery (PDS) started following the work of Egaz Moniz and Alemida Lima, for which they won Nobel prize. From 1930-1960 there was a widespread use of PDS, however, with the advent of newer drugs, surgery took a breather. In 1990s, deep brain stimulation (DBS) surfaced as a newer technique to modulate neural functions. This, combined with better understanding of psychiatric disorders, renewed the interest in PDS. DBS is a reversible treatment as compared to earlier lesional surgeries and it also offers the benefit of titrability by way of adjustment of stimulation parameters. Bart Nuttin, from Belgium initiated the study of anterior capsule stimulation for OCD. His encouraging initial experience led to a multicentre study which evaluated 26 patients of OCD. This study with a follow-up ranging from 3-36 months showed that 20/26 patients had improved outcome. During the same time Lozano and Mayberg stimulated subcallosal cingulate gyrus to control depression. They found >50% reduction in depression score in 55% of patients and 35% of patients experienced remission at the end of twelve months.

We also had a similar outcome results in the patients undergoing lesional and DBS surgeries at the Jaslok hospital, Mumbai.

The world society of stereotactic and functional neurosurgery took note of the renewed interest and decided to set up a task force for drawing the guidelines for PDS. The first meeting was convened in Shanghai in 2011. After a detailed analysis of available literature, personal experiences of the experts across the world, psychiatrists and moral ethicists inputs a comprehensive guideline was published this year in the Journal of neurology, neurosurgery and psychiatry. This guideline has been endorsed by several organizations including World Psychiatric Association.

I plant to discuss the evolution, current status, indications, selection criteria and outcome of psychiatric disorders, in my presentation. As a member of the World society task force, I was closely involved with drawing of the above guidelines and will present them before the Indian psychiatric society.

Articles from Indian Journal of Psychiatry are provided here courtesy of Wolters Kluwer -- Medknow Publications

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