Prescription pattern of antidepressants in five tertiary care psychiatric centres of India

BACKGROUND & OBJECTIVES

Limited data are available on prescription patterns of the antidepressants from India. We studied antidepressants' prescription pattern from five geographically distant tertiary psychiatric care centers of the India.

METHOD

In this cross-sectional study, all patients who attended outpatients department or were admitted in the psychiatry wards at Lucknow, Chandigarh, Tiruvalla, Mumbai and Guwahati on a fixed day, who were using or had been prescribed antidepressant medications, were included. The data were collected on a unified research protocol.

RESULTS

A total of 312 patients were included. Mean age was 39±14.28 yr and 149 (47.76%) were females, 277 (87.5%) were outpatients. Among the patients receiving antidepressants, 150 (48.1%) were of diagnoses other than depression. Diabetes mellitus 18 (5.78%) was the most common co-morbid medical illness. A total of 194 (62.2%) patients were using selective serotonin reuptake inhibitors (SSRIs) with escitalopram 114 (36.53%) being the most common antidepressant used. Overall, 272 (87.18%) patients were using newer antidepressants. Thirty (9.62%) were prescribed more than one antidepressant; 159 (50.96%) patients were prescribed hypnotic or sedative medications with clonazepam being the most common (n=116; 37.18%).

INTERPRETATION & CONCLUSIONS

About half of the patients with diagnoses other than depression were prescribed antidepressants. SSRIs were the most common group and escitalopram was the most common medication used. Concomitant use of two antidepressants was infrequent. Hypnotic and sedatives were frequently prescribed along with antidepressants.

Twelve-month prevalence and treatment gap for common mental disorders: Findings from a large-scale epidemiological survey in India

BACKGROUND

Common mental disorders, such as mood, anxiety, and substance use disorders, are significant contributors to disability globally, including India. Available research is, however, limited by methodological issues and heterogeneities.

AIM

The present paper focuses on the 12-month prevalence and 12-month treatment for anxiety, mood, and substance use disorders in India.

MATERIALS AND METHODS

As part of the World Health Organization World Mental Health (WMH) Survey Initiative, in India, the study was conducted at eleven sites. However, the current study focuses on the household sample of 24,371 adults (≥18 years) of eight districts of different states, covering rural and urban areas. Respondents were interviewed face-to-face using the WMH Composite International Diagnostic Interview after translation and country-specific adaptations. Diagnoses were generated as per the International Classification of Diseases, 10^th edition, Diagnostic Criteria for Research.

RESULTS

Nearly 49.3% of the sample included males. The 12-month prevalence of common mental disorders was 5.52% - anxiety disorders (3.41%), mood disorders (1.44%), and substance use disorders (1.18%). Females had a relatively higher prevalence of anxiety and mood disorders, and lower prevalence of substance use disorders than males. The 12-month treatment for people with common mental disorders was 5.09% (range 1.66%-11.55% for individual disorders). The survey revealed a huge treatment gap of 95%, with only 5 out of 100 individuals with common mental disorders receiving any treatment over the past year.

CONCLUSION

The survey provides valuable data to understand the mental health needs and treatment gaps in the Indian population. Despite the 12-month prevalence study being restricted to selected mental disorders, these estimates are likely to be conservative due to under-reporting or inadequate detection due to cultural factors.

Prevalence and prescription of antidepressants in depression with somatic comorbidity in Asia: the Research on East Asian Psychotropic Prescription Patterns study

Background:

Depression is often comorbid with chronic somatic diseases. Few previous studies have investigated the prevalence of somatic diseases in depression or the prescription pattern of antidepressants in comorbidly depressed patients in Asia. This study aimed to investigate the prevalence of somatic comorbidity (SC) in depression and compared the prescriptions of antidepressants in depressed patients with and without SC.

Methods:

A total of 2320 patients treated with antidepressants in 8 Asian countries were examined, and a diagnosis was based on the International Classification of Disease, 10^th revision. We listed 17 common chronic somatic diseases. Patients’ socio-demographic and clinical characteristics and psychotropic drug prescriptions were recorded using a standardized protocol and data collection procedure.

Results:

Of the patients examined, 1240 were diagnosed with depression and 30% of them (n = 375) had SC. The most common comorbid condition was diabetes (23.7%). The patients with SC were more likely to seek help at a general hospital (74.7% vs. 47.2%), and had a higher incidence of symptoms involving sadness, disturbed sleep, and poor appetite. Noradrenergic and specific serotonergic antidepressant was prescribed more for patients with SC than for those without SC (30.4% vs. 22.9%).

Conclusions:

SC is common in depressed Asian patients. It is important to strengthen the recognition of depression, especially in general hospitals and when patients report some somatic discomfort. It is also a matter of urgency to establish evidence-based guidelines for the use of new antidepressants in depressed patients with SC.

Use of electroconvulsive therapy for Asian patients with schizophrenia (2001-2009): Trends and correlates

AIMS

Little is known about electroconvulsive therapy (ECT) use in Asian inpatients with schizophrenia. This study examined trends of ECT use for schizophrenia patients in Asia between 2001 and 2009 and its independent demographic and clinical correlates.

METHODS

Data on 6761 hospitalized schizophrenia patients (2001 = 2399, 2004 = 2136, and 2009 = 2226) in nine Asian countries and territories were collected by either chart review or interviews during a 1-month period. Patients' sociodemographic and clinical characteristics, prescriptions of psychotropic drugs and ECT use were recorded using a standardized protocol and data-collection procedure.

RESULTS

The frequency of ECT was 3.3% in the whole sample; rising from 1.8% in 2001 to 3.3% in 2004 and 4.9% in 2009 (P < 0.0001). However, this increased trend was driven solely by increased ECT use in China (P < 0.0001), and the inclusion of India in the 2009 survey. There were wide inter-country variations: 2001, 0% (Hong Kong, Korea) to 5.9% (China); 2004, 0% (Singapore) to 11.1% (China); 2009, 0% (Hong Kong) to 13.8% (India) and 15.2% (China). Multiple logistic regression analysis of the whole sample revealed that patients receiving ECT were less likely in the 35-64-year age group, had shorter length of current hospitalization and fewer negative symptoms, and were more likely to receive second-generation antipsychotic medications compared to those who were not treated with ECT (R(2)  = 0.264, P < 0.001).

CONCLUSIONS

ECT use for schizophrenia has increased over the past decade in China, being low/relatively stable in other Asian countries/regions. Reasons for substantial variations in ECT frequency in Asia require further study.

QTc prolongation in schizophrenia patients in Asia: clinical correlates and trends between 2004 and 2008/2009

OBJECTIVE

Little is known about the pattern of QT interval (QTc) prolongation in Asian patients with schizophrenia. This study examined trends of QTc prolongation in schizophrenia inpatients in six Asian countries and territories between 2004 and 2008/2009 and its independent demographic and clinical correlates.

METHOD

Data on 3482 hospitalized schizophrenia patients (2004 = 1826 and 2008/2009 = 1656) in six Asian countries and territories were collected by either chart review or interviews during a 1-month period. Patients' sociodemographic and clinical characteristics, prescriptions of psychotropic drugs, and QTc interval were recorded using a standardized protocol and data collection procedure.

RESULTS

The frequency of QTc prolongation (>456 ms) was 2.4% in the whole sample, decreasing from 3.1% in 2004 to 1.6% in 2008/2009 (p = 0.004) with wide intercountry variations. However, this decreased trend was driven by decreased QTc prolongation detected in China and Hong Kong (both p-values < 0.05). Multiple logistic regression analysis of the whole sample revealed that patients having more likely to have an illness lasting longer than 5 years and received antipsychotics classified as list-1 drugs according to the Arizona Centre for Education and Research on Therapeutics. Compared with 2004, patients in 2008/2009 were less likely to have QTc prolongation. Thioridazine caused QTc prolongation most frequently (odds ratio (OR) 4.4; 95% confidence interval (CI) 1.2-15.2), followed by sulpiride (OR 2.4; 95% CI 1.3-4.5), clozapine (OR 2.4; 95% CI 1.4-4.2), and chlorpromazine (OR 1.9; 95% CI 1.07-3.5).

CONCLUSIONS

Frequency of QTc prolongation was low in Asian patients with schizophrenia. QTc prolongation in schizophrenia decreased in China and Hong Kong between 2004 and 2008/2009 but increased in Taiwan over the same period, remaining low in the other countries.

The reliability and validity of the MATRICS functional assessment battery

OBJECTIVES

The Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) initiative was designed to encourage the development of cognitive enhancing agents for schizophrenia. For a medication to receive this indication, regulatory agencies require evidence of improvement in both cognition and functional outcome. Functional capacity measures typically used in clinical trials as intermediate measures of functional outcome must be adapted to fit different cultural contexts for use internationally. We examined the psychometric properties of the MATRICS Functional Assessment Battery (MFAB), comprised of 2 subtests from the UCSD Performance-based Skills Assessment (UPSA) and one from the Test of Adaptive Behavior in Schizophrenia (TABS) that were rated by experts in a previous study to be the most appropriate functional capacity assessments across different cultural contexts.

METHOD

Four sites in India administered the MFAB, a brief version of the UPSA, the MATRICS Cognitive Consensus Battery, measures of symptomatology, and a measure of global functional outcome to 141 individuals with schizophrenia at a baseline assessment and at 4 weeks later.

RESULTS

Test-retest reliability based on the intraclass correlation coefficient was significantly better for the UCSD Performance-Based Skills Assessment-Brief (UPSA-B). Pearson correlation coefficients over time were not significantly different for the 2 measures. Only the MFAB was significantly correlated with functional outcome as measured by the Specific Levels of Functioning Scale.

CONCLUSIONS

The psychometric properties of the MFAB and UPSA-B were similar. The MATRICS scientific board chose to translate the MFAB into multiple languages for potential use in studies of novel medications seeking an indication for improving cognition in schizophrenia.

Welcome biological breakthroughs, supply psychosocial insights

Human behaviour, emotions, and cognition are complex to understand and explain. It is even more difficult to understand the basis for abnormal behaviour, disturbed emotions, and impaired cognitions, something mental health professionals are trying for long. In these pursuits, psychiatry has traversed through eras of humours, witchcraft, spirits, psychoanalysis, and gradually deviated from other medical specialities. Now, with recent biological breakthroughs like advances in psychopharmacology, neuroimaging and genetics, increasingly more emphasis is being given to the biological model of psychiatric disorders. These new biological models have given a more scientific appearance to the speciality. It has also revolutionised the management strategies and outcome of many psychiatric disorders. However, this rapid development in biological understanding of psychiatry also leads to a new wave of reductionism. In an attempt to deduce everything in terms of neurons, neurochemicals, and genes, can we neglect psychosocial aspects of mental health? Patients' personality, expectations, motives, family background, sociocultural backgrounds continue to affect mental health no matter how much 'biological' psychiatry gets. Biological and psychosocial approaches are not mutually exclusive but complementary. Integrating them harmoniously is the skill psychiatry demands for comprehensive understanding of mental and behavioural disorders.

Preventive psychiatry: Concept appraisal and future directions

Preventive psychiatry is a branch of psychiatry that aims at health promotion, protection from specific mental illnesses, early diagnosis, effective treatment, disability limitation and rehabilitation. Prevention of neuropsychiatric illnesses as compared to other illnesses is particularly important as they run a chronic course and cause substantial disability. Preventive measures have been found to be effective in reducing incidence and disability in a wide range of mental illnesses such as depression, psychosis, anxiety and conduct disorders. The need of the hour is to translate advances in our understanding of mental illness into effective intervention programmes for the prevention of mental illness and the promotion of positive mental health.

Electroconvulsive therapy pre-treatment with low dose propofol: comparison with unmodified treatment

BACKGROUND

Whilst electroconvulsive therapy (ECT) is routinely administered under anesthesia in developed nations, in many developing countries, ECT is still administered unmodified. This practice has attracted considerable scrutiny with calls to ban unmodified ECT. However, there are no affordable alternatives for many poor, acutely ill psychiatric patients. We evaluated whether administration of intravenous propofol 0.5 mg/kg for sedation by the ECT psychiatrist just prior to otherwise unmodified treatment improved acceptance of and reduced anxiety surrounding the treatment.

METHOD

We conducted an open label trial at The King George's Medical University in Lucknow, India. Forty-nine patients received propofol pre-treatment and 50 patients received unmodified treatment as usual.

RESULTS

Socio-demographic profiles, diagnoses and clinical responses were comparable. Patients who received propofol experienced less anxiety monitored by the State-Trait Anxiety Inventory just prior to ECT (p < 0.001), and had a more favorable attitude towards treatment assessed by an established questionnaire (Freeman and Kendell, 1980). Propofol patients were less likely to experience post-ictal delirium monitored by the CAM-ICU (p = 0.015) and had fewer cognitive side-effects on the MMSE (p = 0.004). There were no adverse events associated with propofol administration.

CONCLUSION

Whilst unmodified ECT should never be used when modified ECT under anesthesia is available, we have found low dose propofol can be safely administered by the ECT psychiatrist to sedate patients pre-treatment who would otherwise receive completely unmodified treatment. The intervention was associated with reduced anxiety and a more positive attitude towards ECT, without compromising efficacy. A randomized double blind controlled study is necessary to confirm these benefits.

Common use of high doses of antipsychotic medications in older Asian patients with schizophrenia (2001-2009)

OBJECTIVE

This study aimed to examine the use of high doses of antipsychotic medications (≥600 mg/day chlorpromazine equivalent) in older Asian patients with schizophrenia and its demographic and clinical correlates.

METHOD

Information on hospitalized patients with schizophrenia aged ≥50 years was extracted from the database of the Research on Asian Psychotropic Prescription Patterns study (2001-2009). Data on 2203 patients in six Asian countries and territories, including China, Hong Kong, Japan, Korea, Singapore and Taiwan, were analyzed. Socio-demographic and clinical characteristics and antipsychotic prescriptions were recorded.

RESULTS

The frequency for high-dose antipsychotic medications was 36.0% overall, with 38.4% in 2001, 33.3% in 2004 and 36.0% in 2009. Multiple logistic regression analysis of the whole sample showed that compared to patients receiving low-medium antipsychotic doses, those on high doses had a longer illness duration (odds ratio (OR): 2.0, 95% confidence interval (CI):1.2-3.3, p = 0.008), were more likely in the 50-59-year group (OR: 0.95, 95% CI: 0.94-0.97, p < 0.001), more often had current positive (OR: 1.5, 95% CI: 1.2-1.8, p < 0.001) or negative symptoms (OR: 1.3, 95% CI: 1.03-1.6, p = 0.03), and more commonly received antipsychotic polypharmacy (OR: 5.3, 95% CI: 4.1-6.7, p < 0.001). Extrapyramidal symptoms (p = 0.25) and tardive dyskinesia (p = 0.92) were not more frequent in the high-dose group.

CONCLUSIONS

High doses of antipsychotic medications were used in more than one third of older Asian patients with schizophrenia. The reasons for the frequent use of high antipsychotic doses in older Asian patients warrant further investigation.

Sociodemographic and clinical profile of homeless mentally ill inpatients in a north Indian medical university

Homeless mentally ill (HMI) persons are a highly vulnerable and socially disadvantaged population, deprived of even the basic minimal human rights. Data on HMI in India is scarce. This retrospective chart review aimed to evaluate socio-demographic, socio-cultural and clinical profile of HMI patients, and to study reasons of homelessness and outcome related variables in these patients. One hundred and forty homeless persons were admitted to the department of psychiatry of a north Indian medical university from February 2005 to July 2011. Of these, one hundred and twenty-seven (90.7%) had psychiatric illness and six had only intellectual disabilities. The majority of HMI persons were illiterate/minimally literate, adult, male, and from low socioeconomic and rural backgrounds. Most of the patients (55.7%) had more than one psychiatric diagnosis. HMI had considerably high rates of co-morbid substance abuse (44.3%), intellectual disabilities (38.6%) and physical problems (75.4%). Most (84.3%) were mentally ill before leaving home and 54.3% left home themselves due to the illness. Most HMI responded to the treatment. After treatment of mental illness, it was possible to reintegrate about 70% of the patients into their families. Families were willing to accept and support them. Untreated/inadequately treated mental illness was the most common reason for homelessness. Easily accessible treatment and rehabilitation facilities at low cost can improve the plight of such patients. Further research in this area is required.

Assessment of cognition in non-affected full biological siblings of patients with schizophrenia

BACKGROUND

Schizophrenia is a devastating psychotic illness which is like the most mental disorders, shows complex inheritance; the transmission of the disorder most likely involves several genes and environmental factors. It is difficult to judge whether a particular person without schizophrenia has predisposing factors for the said disease. A few studies have shown the relative sensitivity and reliability of cognitive and psychophysiological markers of brain function as the susceptibility factors for schizophrenia which may aid us to find people with an increased risk of complex disorders like schizophrenia. The present work is an exploration on cognitive impairments in unaffected siblings of patients suffering from schizophrenia with a framework to explore why a mental disorder occurs in some families but not in others.

MATERIALS AND METHODS

This is a single point non-invasive study of non-affected full biological siblings of patients with schizophrenia, involving administration of a battery of neuropsychological tests to assess the cognitive function in the sibling group and a control group of volunteers with no history of psychiatric illness. The control group was matched for age, gender, and education. The siblings were also divided on the basis of the type of schizophrenia their siblings (index probands) were suffering from and their results compared with each other.

RESULTS

The siblings performed significantly poorly as compared to the controls on Wisconsin card sorting test (WCST), continuous performance test (CPT), and spatial working memory test (SWMT). The comparison between the sibling subgroups based on the type of schizophrenia in the index probands did not reveal any significant difference.

CONCLUSION

These findings suggest that there is a global impairment in the cognition of the non-affected siblings of patients of schizophrenia. Cognitive impairment might be one of the factors which will help us to hit upon people who are predisposed to develop schizophrenia in the future.

Use of clozapine in older Asian patients with schizophrenia between 2001 and 2009

BACKGROUND

To date there has been no large-scale international study that examined the use of clozapine in older patients with schizophrenia. This study examined the use of clozapine and its demographic and clinical correlates in older patients with schizophrenia in East Asia during the period between 2001 and 2009.

METHOD

Information on 1,157 hospitalized patients with schizophrenia aged 50 or older in five East Asian countries and territories (China, Hong Kong, Korea, Singapore and Taiwan) was extracted from the database of the Research on Asian Psychotropic Prescription Patterns (REAP) project. Socio-demographic and clinical characteristics and prescription of psychotropic medications were recorded.

RESULTS

Clozapine was prescribed for 20.6% of the pooled sample; 19.0% in 2001, 19.4% in 2004 and 22.9% in 2009. Multiple logistic regression analysis of the whole sample revealed that patients taking clozapine had a longer duration of illness, more negative symptoms and were less likely to receive first generation antipsychotic and anticholinergic drugs, but more likely to report weight gain compared to those not receiving clozapine. Compared to those in other sites, older patients in China were more likely to receive clozapine.

CONCLUSIONS

The prescription of clozapine for older Asian schizophrenia inpatients has remained at a stable level during the past decade. The appropriateness of use of clozapine in China needs to be further explored.

Adjunctive antidepressant prescriptions for hospitalized patients with schizophrenia in Asia (2001-2009)

INTRODUCTION

Little is known about the prescription patterns of adjunctive antidepressants in Asian schizophrenia patients. This study aimed to examine trends in the use of antidepressants and their demographic and clinical correlates in the treatment of schizophrenia in Asia between 2001 and 2009.

METHODS

A total of 6,761 hospitalized schizophrenia patients in nine Asian countries and territories were examined: 2,399 in 2001, 2,136 in 2004 and 2,226 in 2009. Patients' socio-demographic and clinical characteristics and prescriptions of psychotropic drugs were recorded using a standardized protocol and data collection procedure.

RESULTS

The proportion of antidepressant prescription was 6.8% in the whole sample; 5.3% in 2001, 6.5% in 2004 and 8.7% in 2009. There were wide inter-country variations at each survey ranging from 0.9% in Hong Kong to 15.3% in Singapore in 2001; from 1.9% in Korea to 15.4% in Singapore in 2004; and from 2.7% in Japan to 22.0% in Singapore in 2009. Multiple logistic regression analysis of the whole sample revealed that patients on antidepressants were younger, more likely to receive benzodiazepines and have significant extrapyramidal side-effects and less likely to have significant positive symptoms.

DISCUSSION

Unlike findings in Western countries, adjunctive antidepressant prescription for schizophrenia was not common in Asia. The frequency of antidepressant prescription varied among countries and territories, suggesting that a host of clinical and socio-cultural factors played a role in determining antidepressant use in Asia.

Prescription pattern of mood stabilizers for bipolar disorder at a tertiary health care centre in north India

BACKGROUND

Mood stabilizers are drugs used to steady/balance the mood, and are also used to manage symptoms of aggression and impulsivity. There is disparity in prescription pattern across the globe.

AIM

The aim of this study was to observe prescription pattern of mood stabilizers for the treatment of bipolar disorder with or without psychotic symptoms.

MATERIALS AND METHODS

A sample of 100 adult patients was selected to participate in the study. First 5 patients of bipolar disorder with or without psychotic symptoms from twenty out-patient departments of various consultant psychiatrists of Department of Psychiatry (C.S.M. Medical University, Lucknow) were included in the sample. A written informed consent was obtained and survey method was adopted to conduct the study.

RESULTS AND CONCLUSION

Lithium was found to be the most frequently prescribed mood stabilizer, sodium valproate ranked second while carbamazepine was least frequently prescribed.

Common use of anticholinergic medications in older patients with schizophrenia: findings of the Research on Asian Psychotropic Prescription Pattern (REAP) study, 2001-2009

OBJECTIVE

This study surveyed the use of anticholinergic medications (ACMs) in older Asian patients with schizophrenia and examined its demographic and clinical correlates.

METHOD

A total of 1452 hospitalized patients with schizophrenia aged 55 years or older in nine Asian countries and territories were surveyed between 2001 and 2009. The cross-sectional data of patients' socio-demographic and clinical characteristics and the prescriptions of antipsychotic drugs and ACM were recorded using a standardized protocol and data collection procedure.

RESULTS

The frequency of ACM prescription was 64.6% in the pooled sample, with 72.4%, 61.9%, and 59.5% in 2001, 2004, and 2009, respectively. Multiple logistic regression analysis of the whole sample revealed that patients on ACM had a higher dose of antipsychotic medications, and were more likely to have extrapyramidal side effects and receive first-generation antipsychotic medications.

CONCLUSIONS

Anticholinergic medications were frequently used in older Asian patients with schizophrenia. Considering the potential side effects of ACM, the rationale for their widespread use in this patient population should be revisited.

Use of first- and second-generation antipsychotic medications in older patients with schizophrenia in Asia (2001-2009)

OBJECTIVE

This study examined the prescribing patterns of several first- (FGAs) and second-generation antipsychotic (SGAs) medications administered to older Asian patients with schizophrenia during the period between 2001 and 2009.

METHOD

Information on hospitalized patients with schizophrenia aged 65 or older was extracted from the database of the Research on Asian Psychotropic Prescription Patterns (REAP) study (2001-2009). There were no older patients in Thailand, therefore data on 467 patients in eight Asian countries and territories including China, Hong Kong SAR, India, Japan, Korea, Malaysia, Singapore, and Taiwan were analysed. Cross-sectional socio-demographic data, clinical characteristics and antipsychotic prescriptions were assessed using a standardized protocol and data collection procedure.

RESULTS

Of the 467 patients, 192 patients (41.1%) received FGAs only, 166 (35.5%) received SGAs only and 109 (23.3%) received a combination of FGAs and SGAs. Of the FGAs, haloperidol was the most commonly used (31.3%; mean 9.4 ± 6.7 mg/day), followed by chlorpromazine (15.4%; mean 126.4 ± 156.4 mg/day) and sulpiride (6.6%; mean 375.0 ± 287.0 mg/day). Of the SGAs, risperidone was the most commonly used (31.5%; mean 4.5 ± 2.7 mg/day), followed by olanzapine (13.1%; mean 13.6 ± 6.5 mg/day), quetiapine (7.3%; mean 325.0 ± 237.3 mg/day) and aripiprazole (1.9%; mean 17.6 ± 7.7 mg/day).

CONCLUSIONS

FGAs and higher doses of certain SGAs (risperidone, olanzapine and quetiapine) were still commonly dispensed to older Asian patients with schizophrenia. Considering older patients' reduced tolerability of potentially severe side effects associated with FGAs and higher doses of certain SGAs, continuing education and training addressing the rational use of antipsychotics in this population is clearly needed.

Suicide and antidepressants: what current evidence indicates

The documented efficacy and long-term benefit of antidepressants in patients with recurrent forms of severe anxiety or depressive disorders support their use in those individuals with these disorders, who experience suicidal thoughts or behavior. In general, it is assumed that antidepressants are beneficial for all symptoms of depression, including suicidality. However, some evidence suggests that Selective Serotonin Reuptake Inhibitors [SSRIs] may cause worsening of suicidal ideas in vulnerable patients. Systematic reviews and pooled analysis of experimental, observational, and epidemiological studies have investigated the use of SSRIs and their association with suicidality. Taking account of the methodological limitations of these studies, the current evidence fails to provide a clear relationship between their use and risk of suicidality in adults. However, in children and adolescents, there appears to be a bit of increased risk of suicidal ideations and attempts, but not of completed suicides. This risk can be anticipated and managed clinically. Clinicians are, therefore, advised to maintain a close follow-up during the initial treatment periods and remain vigilant of this risk. This advisory, however, should not deter clinicians from the use of effective dosages of antidepressants for a sufficient period of time, in every age group of patients, when clinically needed, and if found suitable otherwise.

Neurocognitive dysfunction in patients with obsessive compulsive disorder

OBJECTIVE

Although a dysfunctional prefrontal-striatal system is presupposed in obsessive-compulsive disorder (OCD), this is not unequivocally supported by neuropsychological studies. This study aims to study the neurocognitive dysfunctions in OCD patients, compared to controls; to study the variations in neurocognitive deficits with the duration of illness, as well as, the severity of the disease.

METHOD

Thirty OCD patients were compared with thirty, age and education matched control subjects on computer based tests measuring executive functions, vigilance and spatial working memory.

RESULTS

OCD patients performed poorly on all the neuro-cognitive parameters as compared to controls. The severity of illness had a positive correlation with poorer performance on CPT. There were no significant correlations between duration of illness and any parameters of cognition.

CONCLUSION

The results suggest that OCD patients perform significantly worse on cognitive measures than controls. This is consistent with their poorer functional outcome. The results further indicate that on the basis of severity OCD patients are qualitatively distinguishable in neuropsychological terms, given their difference in the profiles of cognitive impairment.

Adjunctive mood stabilizer and benzodiazepine use in older Asian patients with schizophrenia, 2001-2009

OBJECTIVE

This study surveyed the use of adjunctive mood stabilizers (MS) and benzodiazepines (BZD) in older Asian schizophrenia patients and examined their demographic and clinical correlates.

METHOD

Information on hospitalized schizophrenia patients aged 55 years or more were extracted from the database of the Research on Asian Psychotropic Prescription Patterns (REAP) study. A total of 1,452 patients from 9 Asian countries and territories was included in the study. The patients' sociodemographic and clinical characteristics and the prescriptions of antipsychotics, MS and BZD were recorded using a standardized protocol and data collection procedure.

RESULTS

The frequency of MS prescription was 26.7% in the pooled sample, with 25.5% in 2001, 26.9% in 2004 and 27.7% in 2009. The corresponding figures for BZD were 20.7%, 20.2%, 18.4% and 23.1%, respectively. Multiple logistic regression analysis of the whole sample revealed that patients on MS were younger and more likely to be men and to have extrapyramidal side effects (EPS) and a longer duration of illness. Compared to patients in China, those in Japan were more likely to receive MS, while Korean patents were prescribed less MS. In contrast, there were no significant sociodemographic or clinical correlates of BZD use. Compared to patients in China, their Korean and Singaporean counterparts were more likely to be on BZD.

CONCLUSIONS

The use of MS and BZD is not uncommon in older Asian patients with schizophrenia. Given the paucity of empirical data on the efficacy of these agents in individuals with schizophrenia of any age and concerns about added side effects in older patients in particular, the rationale for the prescription of these agents in this population warrants further examination.

Psychological aspects of widowhood and divorce

Despite advances in standard of living of the population, the condition of widows and divorced women remains deplorable in society. The situation is worse in developing nations with their unique social, cultural and economic milieu, which at times ignores the basic human rights of this vulnerable section of society. A gap exists in life expectancies of men and women in both developing and developed nations. This, coupled with greater remarriage rates in men, ensures that the number of widows continues to exceed that of widowers. Moreover, with women becoming more educated, economically independent and aware of their rights, divorce rates are increasing along with associated psychological ramifications. The fact that widowed/divorced women suffer from varying psychological stressors is often ignored. It has been concluded in various studies that such stressors could be harbingers of psychiatric illnesses (e.g., depression, anxiety, substance dependence), and hence should be taken into account by treating physicians, social workers and others who come to the aid of such women. A change in mindset of the society is required before these women get their rightful place, for which a strong will is needed in the minds of the people, and in law-governing bodies.

What psychiatry means to us

Psychiatry has come up as one of the most dynamic branches of medicine in recent years. There are a lot of controversies regarding concepts, nosology, definitions and treatments in psychiatry, all of which are presently under a strict scanner. Differences are so many that even the meaning of psychiatry varies amongst individual psychiatrists. For us, it is an art to practice psychiatry and give the patient what he needs. Still, it should be practiced with great caution and utmost sincerity towards the patient, based on scientific knowledge and not to be guided by individual conceptions alone. Ethics in psychiatry forms an integral part of its basic concept and meaning, and a tight balance should be maintained between professional advancement and patient benefit. In recent years, the scope of psychiatry has enlarged considerably, with wide ranging influences from Sociology, Anthropology and Philosophy on the one hand, and Neurology and Medicine on the other.

Clozapine use in schizophrenia: findings of the Research on Asia Psychotropic Prescription (REAP) studies from 2001 to 2009

OBJECTIVE

Optimizing treatment and outcomes for people with schizophrenia requires understanding of how evidence-based treatments are utilized. Clozapine is the most effective antipsychotic drug for treatment-refractory schizophrenia, but few studies have investigated trends and patterns of its use over time internationally. This study examined the prescription patterns of clozapine and its demographic and clinical correlates in Asia from 2001 to 2009.

METHOD

Clozapine prescriptions were collected in a sample of 6761 hospitalized schizophrenia patients in nine Asian countries and regions using a standardized protocol and data collection procedure.

RESULTS

Overall, the proportion of patients receiving clozapine prescriptions was stable across the three surveys from 2001 to 2009, ranging from 14.5% to 15.9%. However, the rates and patterns observed within different regions and countries at each survey differed considerably. Clozapine use decreased significantly over time in China, while it increased in Korea and Singapore. Multiple logistic regression analysis revealed that patients taking clozapine were significantly younger, had a higher dose of antipsychotic drugs in chlorpromazine equivalents, were more likely to be female, had fewer extrapyramidal symptoms, and had more negative symptoms, admissions and weight gain in the past month than those not receiving clozapine.

CONCLUSION

The variability in overall rates and changes in prescription rates over time in these samples suggest that factors other than psychopharmacological principles play an important role in determining the use of clozapine in schizophrenia in Asia.

Antipsychotic polypharmacy in inpatients with schizophrenia in Asia (2001-2009)

OBJECTIVE

This study aimed to identify trends in the use of antipsychotic polypharmacy (APP) and their demographic and clinical correlates in the treatment of schizophrenia in Asia between 2001 and 2009.

METHOD

A total of 6,761 schizophrenia inpatients in 9 Asian countries and territories were examined; 2,399 in 2001, 2,136 in 2004, and 2,226 in 2009. Patients’ socio-demographic and clinical characteristics and prescriptions of psychotropic drugs were recorded using a standardized protocol and data collection procedure.

RESULTS

The proportion of APP prescription decreased from 46.8 % in 2001, to 38.3 % in 2004, and increased to 43.4 % in 2009, with wide intercountry variations at each survey. Multiple logistic regression analysis of the whole sample revealed that patients on APP were younger, had a higher dose of antipsychotics in chlorpromazine equivalents, and more severe positive and negative symptoms. They were also more likely to receive depot and fi rst-generation antipsychotic drugs.

CONCLUSIONS

The frequency of APP prescription varied between countries and territories, suggesting that a host of clinical and socio-cultural factors played a role in determining APP use in Asia. To resolve the discrepancy between treatment recommendation and clinical practice, regular reviews of prescription patterns are needed.

Depression in patients of myocardial infarction--a cross-sectional study in northern India

OBJECTIVES

To assess the prevalence of major depressive disorder and subsyndromal depression in patients with first episode of myocardial infarction (MI) and to compare the socio-demographic, clinical and coronary risk factors in patients with and without depression.

METHODS

Patients of acute MI (n = 101) attending OPD at 4 to 6 weeks after the index event were the subjects. Diagnoses of Major Depressive Disorder were established according to Diagnostic and Statistical Manual for Mental Disorders fourth edition Test Revision (DSN-IV-TR) criteria. Schedule for Affective Disorder and Schizophrenia changed version modified for Bipolar disorder (SADS-CB) was applied to detect cases with depressive symptoms not amounting to major depressive disorder (sub-syndromal). It was a single point cross sectional study.

RESULTS

No depressive symptoms (Group-A) were found in 56 patients (55.4%). Major Depressive Disorder (Group-B) was found in 24 patients (23.8%) and subsyndromal symptoms (Group-C) in 21 patients (20.8%). Sociodemographic and clinical variables were similar amongst three groups except, more patients in Group-C were from nuclear family (p = 0.01) and were educated (p = 0.03). More patients in Group-B had hypertension (p = 0.001), diabetes (p = 0.03) or were overweight (p = 0.02) as compared to Group-A. Similarly higher number of Group-C patients had hypertension (p = 0.04), diabetes (p = 0.01) and were current smokers (p = 0.01) as compared to Group-A.

CONCLUSION

Unrecognized and untreated major depressive disorder and sub-syndromal symptoms were frequent in patients of MI. Established coronary factors were more commonly present in these groups as compared to no depressive symptom group. This emphasizes the need for routine screening for depression in post MI phase in our population.

Indian experiences with International Classification of Mental and Behaviour Disorders-10: Pathway for ICD-11

BACKGROUND

International Classification of Mental and Behavioural Disorders (ICD)-10 has been serving its purpose in the spheres of diagnosing psychiatric patients, research, and education since long. With ICD-11 is on the horizon, this is the right time to assess issues in the application of these guidelines in routine clinical practice.

AIM

In this study, an effort was made to find out day-to-day difficulties in application of ICD-10.

MATERIALS AND METHODS

A total of 130 patients attending for the first time the outpatient Department of Psychiatry, CSMMU, Lucknow, were taken as sample for the present study. The "provisional diagnosis", which was made after the usual assessments on a single day at the clinical setting was recorded. The selected patients were later assessed in detail and a "final diagnosis was recorded for these patients. The diagnoses were matched with ICD-10 and rated on a five-point scale.

STATISTICS

The direct count and percentage analysis was done.

RESULTS

Results show that 67.69% "provisional diagnosis" were fully matched, while 8% and 5% diagnosis had no match and some match, respectively with the "final diagnosis". There were also some cases that had significant match (1.5%) and almost match (17.69%).

CONCLUSION

In a busy clinical setting, the focus of the clinicians is more on management and accurate diagnosis based on ICD-10 may be ignored.

The low frequency of reported sexual dysfunction in Asian patients with schizophrenia (2001-2009): low occurrence or ignored side effect?

OBJECTIVE

The purpose of the study was to evaluate the frequency of reported sexual dysfunction (SD) in schizophrenia and its associations with sociodemographic and clinical variables in selected Asian countries.

METHODS

A total of 5877 schizophrenia patients in nine Asian countries and territories were examined between 2001 and 2009. The patients' sociodemographic and clinical characteristics, prescription of psychotropic drugs, and drug-induced side effects were recorded using a standardized protocol and data collection. SD was evaluated as "present" or "absent" according to the clinical judgment of experienced psychiatrists.

RESULTS

The frequency of reported SD in the whole sample in women and men was 3.0%, 0.8%, and 4.6%, respectively, with variations across study sites. In the multivariate analyses, male sex, more second-generation antipsychotics, benzodiazepines, and antidepressants were independently associated with higher likelihood of reported SD, whereas negative symptoms had an inverse association with reported SD.

CONCLUSIONS

The results of this study indicate that SD was seldom recorded as a side effect by Asian psychiatrists while treating patients with schizophrenia. It is unclear whether the low prevalence of reported SD compared with Western data is real or whether the results are being insufficiently recognized.

Indian psychiatry, research and Asian countries

Asia has some of the largest conglomerations of human populations and also the fastest growing economies of the world. About 23% of the world's population lives in the South Asian region, and one-fifth of psychiatrically ill patients in the world live in this part of the world. Despite vast cultural, religious, geographical, and political diversities, the factors influencing mental health remain the same throughout this wide region, as highlighted at the recently concluded Asian summit, where the slogan, 'One vision, one identity, one community,' was launched. Thus, the need to strengthen regional cooperation in the field of mental health has always been felt. This article highlights facts about influence of Indian Psychiatry research as well as of some Asian countries in the world psychiatry and vice versa.

The geriatric population and psychiatric medication

With improvement in medical services in the last few years, there has been a constant rise in the geriatric population throughout the world, more so in the developing countries. The elderly are highly prone to develop psychiatric disorders, probably because of age related changes in the brain, concomitant physical disorders, as well as increased stress in later life. Psychiatric disorders in this population may have a different presentation than in other groups and some of psychopathologies might be mistaken for normal age related changes by an unwary clinician. Therefore the need of the day is to train psychiatrists and physicians to better recognize and manage mental disorders in this age group.

Rapid urbanization - Its impact on mental health: A South Asian perspective

Rapid increase in urban population as a proportion of total population is resulting in rapid urbanization of the world. By the end of 2008, a majority of the world's population will be living in the cities. This paradigm shift in the dynamics of human population is attracting attention of demographers, sociologists, scientists, and politicians alike. Urbanization brings with it a unique set of advantages and disadvantages. Though it is driving the economies of most of the nations of the world, a serious concern regarding the impact of urbanization on mental health is warranted. The impact of urbanization on mental health in South-Asian countries needs to be examined. These countries by virtue of their developing economies and a significant proportion of population still living below poverty line are particularly vulnerable and tend to have a higher burden of diseases with an already compromised primary health care delivery system. The range of disorders and deviancies associated with urbanization is enormous and includes psychoses, depression, sociopathy, substance abuse, alcoholism, crime, delinquency, vandalism, family disintegration, and alienation. Thus, it is a heterogenous mix of problems and categorizing them to one particular subtype seems daunting and undesirable. Urbanization is affecting the entire gamut of population especially the vulnerable sections of society - elderly, children and adolescents, and women. Rapid urbanization has also led to creation of "fringe population" mostly living from hand to mouth which further adds to poverty. Poverty and mental health have a complex and multidimensional relationship. Urban population is heavily influenced by changing cultural dynamics leading to particular psychiatric problems like depression, alcoholism, and delinquency. Judicious use of resources, balanced approach to development, and sound government policies are advocated for appropriate growth of advancing economies of South-Asian region.

Neurocognition in first-degree healthy relatives (siblings) of bipolar affective disorder patients

AIM

Cognitive deficits have been presupposed to be endophenotypic markers in bipolar disorder, but few studies have ascertained the cognitive deficits in healthy relatives of bipolar disorder patients. The aim of the present study was to assess the cognitive functions of first-degree relatives of patients with bipolar disorder and compare them with healthy controls.

METHODS

Ten first-degree apparently healthy relatives of patients with bipolar disorder were compared with 10 age- and education-matched control subjects on computer-based cognitive tests.

RESULTS

As compared to the control group, the relatives group performed significantly poorly on tests for executive function and vigilance, while on the test for working memory the performance was not significantly different on most of the parameters.

CONCLUSIONS

Executive functioning and vigilance could be potential markers of the endophenotype in bipolar patients.

Cognitive functions in euthymic state of bipolar disorder: an Indian study

INTRODUCTION

It has recently been observed that some cognitive deficits in bipolar disorders persist even after the subsidence of active symptoms. The authors aim to study the cognitive functioning of patients with bipolar disorder, currently in euthymia and compare them with normal healthy controls.

METHODS

Fifteen patients having bipolar-I disorder and currently in euthymia were compared with fifteen age- and education-matched controlled subjects. Cognitive assessments were done using three computer-based tests, i.e., Wisconsin's Card Sorting Test (WCST), Spatial Working Memory Test (SWMT), and Continuous Performance Test (CPT).

RESULTS

Euthymic bipolar patients showed significant deficits in executive functions. Subtle deficits were present in attention and working memory that were not statistically significant.

CONCLUSIONS

Executive deficits may be trait markers in bipolar disorder and may have clinical implications in patient rehabilitation.

Cognitive functions in stable schizophrenia & euthymic state of bipolar disorder

BACKGROUND & OBJECTIVES

Some cognitive deficits in schizophrenia and bipolar disorders persist after the subsidence of active symptoms. We carried out this study to assess and compare the cognitive functioning of patients with stable schizophrenia and bipolar disorder.

METHODS

Fifteen each of stable maintained schizophrenic patients and euthymic bipolar-I patients attending outpatient clinic in a tertiary care psychiatric hospital in north India were included in the study as also equal number of age and education matched control subjects. Cognitive assessments were done using Wisconsin's Card Sorting Test (WCST), Spatial Working Memory Test (SWMT) and Continuous Performance Test (CPT).

RESULTS

Stable schizophrenia patients performed poorly on all the neurocognitive parameters as compared to both controls and bipolar euthymic patients. Euthymic bipolar patients showed significant difference on executive functions with normal controls. Patterns of cognitive disturbances in tasks of executive function are similar in both groups but are quantitatively more marked in schizophrenia.

INTERPRETATION & CONCLUSIONS

Our results showed that stable schizophrenia patients performed significantly worse on cognitive measures than patients of euthymic bipolar disorder which was consistent with their poorer functional outcome. The results further indicated that stable schizophrenia and euthymic bipolar disorders may be distinguished qualitatively in neuropsychological terms with different profiles of cognitive impairment.

Depression among women in the South-Asian region: the underlying issues

BACKGROUND

The condition of women in third-world countries continues to be dismal. They are constantly exposed to such circumstances which make them prone to sufferings. These sufferings bear an irreparable brunt upon the mental health condition of females which are presented as greater psychological problems in terms of depressive disorders. The impact, in turn is felt by the society as a whole which lags behind due to the huge burden. This study is presented to highlight the various factors affecting the presentation of women in the region.

METHODS

This is a review of studies in which various issues pertaining to presentation, course, and outcome of depression among women in South-Asian region are discussed. The studies were chosen from Internet-based search.

RESULTS

The various factors affecting the problems can be grouped into: social milieu, reproductive health factors, and biological milieu.

LIMITATIONS

This study incorporates various studies which were undertaken at different time durations; hence, its finding cannot be reproduced in an exact sense. It is worth mentioning that these factors need to be studied comprehensively for better health care.

CONCLUSION

This study gives an indication of specific health care needs of women in the region which are to be customized as per local needs and cultural sanctions.

Culturally-sensitive complaints of depressions and anxieties in women

BACKGROUND

Current classifications of Mental Disorders are centered on Westernized concepts and constructs. "Cross-cultural sensitivity" emphasizes culturally-appropriate translations of symptoms and questions, assuming that concepts and constructs are applicable.

METHODS

Groups and individual psychiatrists from various cultures from Asia, Latin America, North Africa and Eastern Europe prepared descriptions of main symptoms and complaints of treatment-seeking women in their cultures, which are interpreted by clinicians as a manifestation of a clinically-relevant dysphoric disorder. They also transliterated the expressions of DSM IV criteria of main dysphoric disorders in their cultures.

RESULTS

In many non-western cultures the symptoms and constructs that are interpreted and treated as dysphoric disorders are mostly somatic and are different from the Western-centered DSM or ICD systems. In many cases the DSM and ICD criteria of depression and anxieties are not even acknowledged by patients.

LIMITATIONS

The descriptive approach reported here is a preliminary step which involved local but Westernized clinicians-investigators following a biomedical thinking. It should be followed by a more systematic-comprehensive surveys in each culture.

CONCLUSIONS

Westernized concepts and constructs of mental order and disorders are not necessarily universally applicable. Culturally-sensitive phenomena, treatments and treatment responses may be diversified. Attempts at their cross-cultural harmonization should take into consideration complex interactional multi-dimensional processes.

An open-label multicentric study of the tolerability and response to escitalopram treatment in Indian patients with major depressive disorder

To evaluate the tolerability and response to escitalopram in Indian patients with major depression, over an 8-week open-label multicentric study was carried out among 18-65 years old Indian patients suffering from DSM IV major depressive disorder with Montgomery-Asberg depression rating scale (MADRS) total score> or =22. Patients received a fixed dose of escitalopram 10 mg daily for 2 weeks, followed by flexible dose of 10 to 20 mg daily for 6 weeks. Patients were evaluated for depression and rated on MADRS score and clinical global impressions-severity (CGI-S) and--improvement (CGI-I) scores. They were monitored for treatment-emergent adverse effects. A total of 119 patients were enrolled and 103 completed the trial. There was a decrease from baseline in the MADRS total score after one week of treatment continuing until 8 weeks. By week 8, 76.9% patients had responded to treatment (> or =50% or more reduction of MADRS total score). A similar pattern of improvement to that seen with the MADRS total score was seen with CGI-S and CGI-I scores. Escitalopram was well tolerated, with only 2 patients (1.7%) withdrawing from the study due to adverse events. There were no serious adverse events.

Regional cooperation in South Asia in the field of mental health

The South Asian region accounts for around one fourth of the world population and one fifth of psychiatrically ill patients in the world. The region lacks mental health policies and infrastructure. Issues like community care, trained manpower, patient satisfaction and better legislation have been a focus of attention in recent years. As this region is fast developing, cooperation is needed in the field of mental health to keep pace with the other areas. Cooperation is needed to develop culturally acceptable forms of psychotherapy and new technologies for delivery of mental health services. Another area of potential cooperation is the development of a classification of mental disorders that is more informative in our setting. The development of a mental health programme and its inclusion at various levels of health care delivery has also gained precedence. As most of countries in the area have limited financial resources, the funds are to be used in the most cost-effective manner, and for this a greater collaboration amongst the countries is needed. New research needs to be undertaken in the area especially to meet the local requirements and to understand diseases in a regional perspective, but research cannot be fruitful if regional cooperation is lacking. To enhance the cooperation in mental health, world bodies like the WPA will need to come forward and bring all the countries at a common platform. The WPA has done commendable work in this regard and has always extended support to the regional bodies to uplift the mental health in this region.

Cognitive deficits in psychiatric disorders: Current status

Cognition denotes a relatively high level of processing of specific information including thinking, memory, perception, motivation, skilled movements and language. Cognitive psychology has become an important discipline in the research of a number of psychiatric disorders, ranging from severe psychotic illness such as schizophrenia to relatively benign, yet significantly disabling, non-psychotic illnesses such as somatoform disorder. Research in the area of neurocognition has started unlocking various secrets of psychiatric disorders, such as revealing the biological underpinnings, explaining the underlying psychopathology and issues related to course, outcome and treatment strategies. Such research has also attempted to uproot a number of previously held concepts, such as Kraepelin's dichotomy. Although the range of cognitive problems can be diverse, there are several cognitive domains, including executive function, attention and information processing, and working memory, which appear more frequently at risk. A broad range of impairment across and within the psychiatric disorders are highlighted in this oration. The oration summarizes the studies investigating cognitive processing in different psychiatric disorders. I will also discuss the findings of my own research on neurocognitive deficits in mood disorders, schizophrenia, obsessive-compulsive disorder, somatoform disorder, including studies on 'high-risk' individuals. Tracing the evaluation of neurocognitive science may provide new insights into the pathophysiology and treatment of psychiatric disorders.

Disability assessment in mental illnesses using Indian Disability Evaluation Assessment Scale (IDEAS)

BACKGROUND & OBJECTIVE

Psychiatric disorders cause disability in individuals and pose significant burden on their families. In most of the cases residual disability and poor quality of life continue even after disability evaluation in patients with chronic mental illness in very important. The present study was undertaken to assess and compare the disability in patients with schizophrenia and obsessive-compulsive disorder (OCD) using Indian Disability Evaluation Assessment Scale (IDEAS).

METHODS

Patients diagnosed to have schizophrenia and OCD with mild severity of illness were included in the study. Indian Disability Evaluation Assessment Scale (IDEAS) was applied. Disability was assessed in these patients on all domains of IDEAS.

RESULTS

Majority of the patients with schizophrenia were from rural areas whereas most of the patients with OCD were from urban background. There was comparable disability in the patients with schizophrenia with duration of illness in the range of 2-5 yr and >5 yr. Significant disability in work and global score was seen in patients of obsessive-compulsive disorder with duration of illness >5 yr. Patients with schizophrenia had significantly higher disability in all domains than patients with OCD.

INTERPRETATION & CONCLUSION

Schizophrenia causes greater disability than obsessive-compulsive disorder in patients. These illnesses affect all areas of daily functioning leading to greater disability, and thus increasing the burden on the family, pose greater challenge for the rehabilitation of patients and their inclusion in the mainstream of the family and society. Further studies on a larger sample need to be done to confirm the finding.

Suicide: an Indian perspective

Suicide, as an issue, has attracted the attention of society since time immemorial. Its situation in India and the socio-demographic variables have been discussed along with management profile. The education of physicians and general practitioners in suicide prevention has been stressed.

Better mental health care for older people in India

Demographic aging will soon lead to a sudden increase in the number of older people with dementia and depression in India. We need to develop services to meet the mental health needs of the aged in the population. Geriatric Psychiatry section of IPS has initiated a process of consultations to address this emerging public health issue. Health professionals involved in the care of older people with mental health problems took part in focus group discussions Their opinion and suggestions regarding development of psychogeriatric services and research were gathered. Urgent action is needed to improve the existing low levels of public awareness about mental health problems of older people. Home based care needs to be supported through formal services in the community. If sensitised properly clinicians, can be more effective in managing depression and dementia at primary care level. Research initiatives can be facilitated by networking of researchers and active efforts at dissemination of important research findings. Community health workers could be trained to identify and provide help to older people with mental health problems and their carers. Community outreach programmes for elderly could be particularly relevant in the rural areas where as development of clinic based psycho-geriatric services may be feasible in urban settings. Good research can influence and shape policies which in turn can result in better mental health care for older people.

Depression in general clinical practice

Worldwide currently about 340 million people suffer from depression. If not treated, it leads to increased morbidity and mortality. Risk factors include female sex, young age, lower socio-economic study, separated or divorced, positive family history, stressful life events, certain medical illness and so on. Aetiology lies on genetic factors, biochemical abnormality and personality and environmental factors. Clinical features lie on cardinal and other common symptoms. Depression usually starts before 40 years of age, average duration of one episode being 3-9 months. Treatment consists of a variety of psychotherapeutic approaches, pharmacotherapy and electroconvulsive therapy. A clinician may start therapy with low dose SSRIs which is considered as 1st line drugs. To educate patients about anti-depressants is very important.

Escitalopram Versus Citalopram and Sertraline: A Double-Blind Controlled, Multi-centric Trial in Indian Patients with Unipolar Major Depression

The present randomized, double blind, parallel group, controlled, multi-centric trial was designed to evaluate the efficacy and tolerability of escitalopram in comparison with citalopram and sertraline in the treatment of major depressive disorder. Outpatients (N=214) with an ongoing/newly diagnosed ICD-10 major depressive episode and a Hamilton Rating Scale for Depression (HAM-D) score of > 18 were randomly assigned to citalopram, 20-40 mg/day (74 patients), escitalopram, 10-20 mg/day (69 patients) and sertraline, 50-150 mg/day (71 patients), for a 4-week double-blind treatment period, with dosage adjustment (after 2 weeks of treatment) according to the response to treatment. Clinical response was evaluated by the 17 items HAM-D and the Clinical Global Impression (CGI) scales, which were recorded at baseline and at weekly intervals. Tolerability was evaluated by observed/spontaneously reported adverse changes in laboratory parameters (baseline and after 4 weeks). Response rate was defined as a decrease in HAM-D score by 50% from baseline and remission rate was defined as a HAM-D score of < 8. Response rate at the end of two week were 58% for escitalopram (10mg/day), 49% for citalopram (20mg/day) and 52% for sertraline (50-100mg/day). Response rate at the end of four week were 90% for escitalopram (10-20mg/day), 86% for citalopram (20-40mg/day) and 97% for sertraline (100-150mg/day). The Remission rates at the end of four weeks were 74% for escitalopram, 65% for citalopram and 77% for sertraline. Adverse experiences were reported by 45% of patients in escitalopram group, 58% patients in citalopram and 56% patients in the sertraline group. Additionally, there were lesser dropouts and lesser requirement for dose escalation in escitalopram than in citalopram and sertraline group. In conclusion Escitalopram, the Senantiomer of the citalopram is a safe and effective antidepressant in the Indian population. It has potentially superior efficacy than citalopram and a comparable efficacy to sertraline with fewer side effects than both citalopram and sertraline.

Urban mental health services in India : how complete or incomplete?

The information about Urban Mental Health Services has been nearly nonexistent in India, although the developed countries have been focusing on programmes for "Healthy Cities". The initiative taken as part of the WHO-ICMR Pilot Project on Urban Mental Health Services, with a public health perspective is being shared. The objectives of the Health Services Research (HSR) Arm of the project were to study the distribution and the availability of tertiary Mental Health Services, availability of human resources, average service load, mental health service gap, and perceptions of the users and the service providers, regarding the barriers in accessibility of mental health services, unmet service needs and strategies for improvement.The Research Methods involved Mapping Exercises with estimation of Service Loads and Qualitative Research Methods (QRM) like In-Depth Interviews (IDIs), Key Informant Interviews (KIIs), Free Listing and Focused Group Discussions (FGDs). The results indicate uneven availability of mental health services, human resource deficit specially for non-medical mental health professionals and mental health service gap (82% to96%). The average service load in the specialist mental health services is largely carried by the Govt. sector (half to two thirds), followed by the private sector (one third to half), with only a small portion by the NGO sector. The average mental health service load in the primary care general health services is largely carried by the private sector, with significant contribution from the non-formal service providers. The barriers to access, unmet needs and possible strategies as perceived by the community, users and service providers have been identified. The findings are discussed in the context of the mental health programmes and the public policy issues. The implications of the conclusions which suggest that Urban Mental Health Services are far from complete are highlighted.