natasha kate

Structure 1.0 Introduction 1.1 Learning Objectives 1.2 Aim of History Taking 1.3 Setting of the Interview 1.4 Duration of the Interview 1.5 General Principles of Interviewing 1.6 Elements of History Taking and Recording 1.7 Techniques of History Taking 1.8 Closing of Interview 1.9 Medical Records 1.10 Interviewing the Difficult Patients 1.11 Let Us Sum Up 1.12 Answers to Check Your Progress Exercises 1.13 Unit End Questions 1.14 References and Suggested Readings

This paper aims to review the available evidence for the use of clozapine and electroconvulsive therapy (ECT) in combination. Methodology Electronic searches were carried out to identify reports describing the combined use of clozapine and ECT. Forty reports including 208 patients were identified. The majority of reports were in the form of case reports and case series, with few retrospective and open-label studies. The majority of patients were aged between 18 and 65 years and diagnosed with schizophrenia or schizoaffective disorder. Most of the patients refractory to clozapine were started on ECT as an augmentation therapy; however, in some reports, both ECT and clozapine were started concurrently, and in few cases clozapine was started after ECT. In terms of effectiveness, 37.5-100% patients improved in short-term, and sustained long-term improvement (3 weeks to 24 months) was described in few studies. In terms of the side-effect profile, five patients each had delirium and tachy...

Dhat syndrome as a clinical entity has been rarely described in females. Ethnographic studies suggest that as in males, whitish vaginal discharge in females is also associated with depressive and somatic symptoms and many women with symptoms of whitish discharge attribute their depressive and somatic symptoms to the whitish discharge. In this report, we describe two female patients who presented with psychiatric manifestations also with somatic symptoms and attributed their somatic complaints to whitish vaginal discharge. In this background, we discuss whether this entity requires nosological attention and what criteria can be used to define the same.

Over the years many scales have been designed for screening, diagnosis and assessing the severity of delirium. In this paper we review the various instruments available to screen the patients for delirium, instruments available to diagnose delirium, assess the severity, cognitive functions, motoric subtypes, etiology and associated distress. Among the various screening instruments, NEECHAM confusion scale and delirium observation scale appear to be most suitable screening instrument for patients' in general medical and surgical wards, depending on the type of rater (physician or nurse). In general, the instruments which are used for diagnosis [i.e., confusion assessment method (CAM), CAM for intensive care unit (CAM-ICU), Delirium Rating Scale-revised version (DRS-R-98), memorial selirium assessment scale, etc.] are based on various Diagnostic and Statistical Manual criteria and have good to excellent reliability and fair to good validity. Among the various diagnostic instrument...

OBJECTIVE. To develop an instrument (Scale for Positive Aspects of Caregiving Experience [SPACE]) that evaluates positive caregiving experience and assess its psychometric properties. METHODS. Available scales which assess some aspects of positive caregiving experience were reviewed and a 50-item questionnaire with a 5-point rating was constructed. In all, 203 primary caregivers of patients with severe mental disorders were asked to complete the questionnaire. Internal consistency, test-retest reliability, cross-language reliability, split-half reliability, and face validity were evaluated. Principal component factor analysis was run to assess the factorial validity of the scale. RESULTS. The scale developed as part of the study was found to have good internal consistency, test-retest reliability, cross-language reliability, split-half reliability, and face validity. Principal component factor analysis yielded a 4-factor structure, which also had good test-retest reliability and cro...

The Involvement Evaluation Questionnaire (IEQ) is a comprehensive, conceptually valid and reliable means of assessing caregiver burden. However, its psychometric properties have rarely been examined in non-European settings. The aim of the present study was to evaluate the psychometric properties of an Indian translation of the IEQ (Hindi-IEQ). The European Union (English) version of IEQ was translated into Hindi and reviewed by a group of experts and caregivers for translation accuracy, cultural appropriateness, and for relevance and acceptability of items and constructs. The Hindi-IEQ was then administered to 162 primary caregivers of patients with severe mental illnesses. Eighteen caregivers completed both the English and Hindi versions to check the level of agreement between them. Another 27 completed the Hindi-IEQ twice, a week apart, to evaluate its test-retest reliability. Factor structure of the Hindi-IEQ was examined using an exploratory, principal components and factor ana...

To the Editor: Modafinil is a wakefulness-promoting agent used for the treatment of various sleep disorders like narcolepsy, obstructive sleep apnea, and shift work sleep disorder. Over the years it has gained popularity among prescribers due to its wakefulness-promoting efficacy and presumably lower abuse potential and has been used in the treatment of various fatigue syndromes, treatment-resistant depression, and attention-deficit/hyperactivity disorder.1,2 There is a controversy with regard to the abuse potential of modafinil, with some authors suggesting that it has low abuse potential and others suggesting that it has psychoactive and euphoric effects and leads to alterations in mood, perception, thinking, and feelings, all of which are seen with other central nervous system stimulants.1,2 The data with regard to its use in toxic doses are also limited.3–6 In our search, we could find no report of modafinil abuse or dependence in the literature. We report a case of a patient who used modafinil in supratherapeutic doses in a pattern that conformed with drug dependence. Case report. Mr A, a 53-year-old man diagnosed with schizoaffective disorder (DSM-IV criteria) for the last 33 years along with tobacco and benzodiazepine dependence syndrome (currently abstaining), presented with a history of excessive use of modafinil. Exploration of his history revealed that, 3 years prior, he consulted a psychiatrist for symptoms of fluctuating sadness of mood, lethargy, and sedation and was started on tablet modafinil, 50 mg/d, which was later increased to 100 mg/d along with tablet sertraline, 50–100 mg/d, and tablet amisulpride, 100 mg/d. The addition of modafinil made the patient feel fresh and active, and after 4–5 months modafinil was increased to 200 mg/d at the request of the patient. Over the next year, he started self-medicating with modafinil, taking 1 or 2 tablets (100–200 mg) in the afternoon or evening to overcome his boredom and fatigue, having felt a strong desire to take the same. On days when he would not take modafinil, he had strong craving and urge to do so, felt that something was missing in his life, and became irritable, felt weak, and had difficulty in concentrating on the work at hand. Over the next year, his intake of modafinil increased to 1,500–2,000 mg/d in order to experience the desired effect; he consumed 100–200 mg every 1–4 hours. Later, due to heavy doses of modafinil, he would have slurring of speech and poor attention and concentration. He continued to take modafinil against the advice of family and treating psychiatrists and would indulge in doctor shopping if he had difficulty in getting a prescription for modafinil or procuring it. With the available information, an additional diagnosis of modafinil dependence syndrome (per DSM-IV criteria for substance dependence disorder) was considered. He was counseled to taper off the dose of modafinil and was given benzodiazepines to manage the symptoms of withdrawal. The usual recommended dosage of modafinil is 200 mg/d. The previous reports of the use of modafinil in supratherapeutic or toxic doses did not describe continuous intake of the higher doses over the period.3–6 In the case reported here, the patient took 1,500–2,000 mg of modafinil per day for about 1 year. The intake of modafinil followed the typical pattern of drug dependence, which indicates its abuse potential. To conclude, our case suggests that modafinil has abuse potential and hence it should be prescribed cautiously and clinicians should be aware of its abuse potential. There is a need for further systematic studies to evaluate its abuse and dependence potential.

Delirium tremens is a common presentation in tertiary care hospitals. Severe and/or refractory delirium tremens is not as common, is potentially lethal, and requires intensive management. Usually delirium tremens responds to management with standard doses of benzodiazepines. Limited literature is available, however, for the management of refractory delirium tremens. We describe a case of refractory delirium tremens in which the patient was successfully managed with a combination of high doses of lorazapam, midazolam, and phenytoin.

This chapter reviews the Indian research on efficacy and effectiveness of antipsychotics in management of schizophrenia, other treatment related issues, caregivers related issues, course and outcome of schizophrenia and studies evaluating the special population. Most of the available studies have evaluated the efficacy of typical antipsychotics and suggest that these are more efficacious than placebo. In recent time, some of the studies have also evaluated the short-term efficacy of atypical antipsychotics in management of acute phase of schizophrenia. Some of the studies have also specifically evaluated the side effects of antipsychotics. Other studies have tried to understand treatment compliance, factors associated with relapse and attitude towards medications. One of the major areas of interest in recent times has been evaluation of prevalence of metabolic syndrome (MS). As family members form an integral part of treatment, research has also focused on issues such as caregiver burden, coping, social support, quality of life, experience of caregiving, needs of patients as perceived by the caregivers, positive aspects of caregiving and family intervention. Research in psychosocial rehabilitation of schizophrenia and related areas is sparse. Studies evaluating the course and outcome of schizophrenia suggests that overall the outcome of schizophrenia is better in Indian setting when compared with developed countries.

In medically ill patients the term 'somatic symptoms' is used to understand those symptoms which cannot be fully understood in the light of existing medical illness(es). These include a number of physical symptoms and also certain clinical syndromes such as irritable bowel syndrome, fibromyalgia, and chronic fatigue syndrome among others. However, it is increasingly recognized that such patients have larger degrees of psychological morbidities, especially depressive and anxiety disorders, and have disproportionately elevated rates of medical care utilization, including outpatient visits, hospitalizations and total healthcare costs. In view of this psychological morbidity, significant distress and functional impairment, the role of the consultation-liaison psychiatrist is prominent in the management of these patients. A consultation-liaison (CL) psychiatrist is expected to be part of the primary care team to manage patient with unexplained SS, and at the same time is expected to guide colleagues to practice a patient-centred approach to improve the outcome of patients with such symptoms. The clinical work of a CL psychiatrist involves evaluation of patients with medically unexplained symptoms for probable psychiatric disorders and treatment of psychiatric morbidity and also management of patients without psychiatric morbidity. Management strategies include reattribution, cognitive behaviour therapy and antidepressants, with each strategy showing varying degrees of success.

ABSTRACTBackground: Very few studies from India have studied the phenomenology of delirium. The aim of the present study was to study the phenomenology as measured using the Delirium Rating Scale-Revised-98 (DRS-R98), the associated etiologies and the outcome of delirium among the elderly participants seen by the consultation-liaison psychiatric service in India. In addition, an attempt was made to study the factor structure of symptoms using principal components analysis.Methods: The case notes of 109 elderly patients referred to psychiatry liaison services were reviewed.Results: The mean age of the sample was 73.35 years (SD: 7.44; range 65–95 years) and two-thirds of the sample had hospital emergent delirium. The mean DRS-R98 severity score was 18.77 and the DRS-R98 total score was 24.81. In 15 patients the DRS-R98 scores were in the subsyndromal range. Among the various symptoms present, most patients had sleep-wake cycle disturbance, disturbance in orientation, attention and sh...

Only a few studies have evaluated the similarities and differences between clinicians' and caregivers' rating of burden of caring for a person with chronic mental illness. To compare clinician-rated and caregiver-rated burden in a population of patients with either schizophrenia or bipolar disorder, using two different scales to measure caregiver burden. Caregivers of patients with schizophrenia (n = 65) or bipolar disorder (n = 57) completed the Hindi version of the Involvement Evaluation Questionnaire (Hindi-IEQ) by themselves. Clinicians rated the burden on the Family Burden Interview Schedule (FBI) based on semi-structured interview with the same caregivers. Both total objective and subjective burden on the FBI (clinician ratings) demonstrated significant positive correlations with the total Hindi-IEQ (caregiver ratings) scores. Most areas of burden on the FBI correlated positively with the tension and the worrying-urging II subscales, as well as the total Hindi-IEQ scores. According to clinicians, a significantly higher percentage of caregivers of patients with schizophrenia were experiencing a moderate to severe degree of subjective burden; objective burden in this group was also significantly higher in the domains of effect on the mental health of caregivers. Contrastingly, caregivers of patients with bipolar disorder judged burden to be higher in this group than schizophrenia. There were many areas of agreement as well as some significant discrepancies between clinicians' and caregivers' assessment of burden in this population of patients. This suggests that a comprehensive evaluation of burden should include assessments by both clinicians and caregivers of patients.

Few studies have evaluated the supernatural beliefs of patients with schizophrenia. This study aimed to study the personal beliefs, aetiological models and help seeking behaviour of patients with schizophrenia using a self-rated questionnaire. Seventy three patients returned the completed supernatural Attitude questionnaire. 62% of patients admitted that people in their community believed in sorcery and other magico-religious phenomena. One fourth to half of patients believed in ghosts/evil spirit (26%), spirit intrusion (28.8%) and sorcery (46.6%). Two-third patients believed that mental illness can occur either due to sorcery, ghosts/evil spirit, spirit intrusion, divine wrath, planetary/astrological influences, dissatisfied or evil spirits and bad deeds of the past. 40% of the subjects attributed mental disorders to more than one of these beliefs. About half of the patients (46.6%) believed that only performance of prayers was sufficient to improve their mental status. Few patients (9.6%) believed that magico-religious rituals were sufficient to improve their mental illness but about one-fourth (24.7%) admitted that during recent episode either they or their caregivers performed magico-religious rituals. Supernatural beliefs are common in patients with schizophrenia and many of them attribute the symptoms of mental disorders to these beliefs.

Most of the psychiatry practice in India is guided by the western concepts of mental health and illness, which have largely ignored the role of religion, family, eastern philosophy, and medicine in understanding and managing the psychiatric disorders. India comprises of diverse cultures, languages, ethnicities, and religious affiliations. However, besides these diversities, there are certain commonalities, which include Hinduism as a religion which is spread across the country, the traditional family system, ancient Indian system of medicine and emphasis on use of traditional methods like Yoga and Meditation for controlling mind. This article discusses as to how mind and mental health are understood from the point of view of Hinduism, Indian traditions and Indian systems of medicine. Further, the article focuses on as to how these Indian concepts can be incorporated in the practice of contemporary psychiatry.

Quetiapine is an atypical antipsychotic which has been shown to have greater relative affinity for 5-HT(2A) receptors than for D(2) receptors, due to which it is thought to lead to lower incidence of extrapyramidal symptoms (EPS). However, over the years literature in the form of case reports have accumulated which shows that quetiapine can lead to akathisia, especially in subjects prone to develop EPS. In this study, we report the case of a 22-year-old female who developed akathisia with quetiapine 150 mg/day, which subsided with reduction in dose. We have also reviewed the existing literature with respect to akathisia with quetiapine.

Although hyponatremia has been reported with the use of various antidepressants, the association of hyponatremia with bupropion has been limited to two case reports. In this case report, we present the case of a 75-year-old man who developed hyponatremia with the use of bupropion, which improved with stoppage of bupropion.

Tardive syndromes are among the most debilitating side effects associated with use of antipsychotics. In this case series we present 5 cases of drug induced tardive syndromes, who had not responded to many of the other therapeutic measures but responded to clozapine. The response rate with clozapine varied from 50% to 100% and the response was seen by week 3 in most cases. Over the long term follow-up of as long as 6 years the response to clozapine was sustained. In two cases clozapine could be stopped.

This study evaluated caregiving experience in the caregivers of patients with schizophrenia within the framework of the stress-appraisal-coping model. By purposive random sampling, 100 Indian patients with schizophrenia and their primary caregivers were assessed. The patients were assessed on Positive and Negative Symptom Scale (PANSS). Caregivers completed the Scale for Positive Aspects of Caregiving Experience (SPACE), Involvement Evaluation Questionnaire (IEQ), Family Burden Interview (FBI) Schedule, Coping Checklist, Social Support Questionnaire, and General Health Questionnaire (GHQ-12). Path analysis showed that psychological morbidity is mainly determined by subjective experience of burden, which in turn is significantly influenced by severity of psychopathology, time spent per day (in hours) in caregiving and the coping strategies used. Although coping strategies and PANSS do influence objective burden, objective burden itself has no influence on the level of psychological morbidity. Total PANSS score has no direct influence on subjective burden, but acts indirectly through total time spent in caregiving and coping. Caregiver's gain in positive experiences on SPACE scale positively influences subjective burden. The present findings suggest that better control of patients' symptoms would lead to less demand on the caregivers in the form of time and strain on coping abilities and would thus reduce subjective burden and psychological morbidity in the caregivers.