Indian Journal of Psychological Medicine
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   Table of Contents - Current issue
Coverpage
January-February 2017
Volume 39 | Issue 1
Page Nos. 1-104

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EDITORIAL  

Repetitive transcranial magnetic stimulation for depression: State of the art p. 1
MS Reddy, M Starlin Vijay
DOI:10.4103/0253-7176.198951  
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REVIEW ARTICLES Top

Psychotherapeutic applications of mobile phone-based technologies: A systematic review of current research and trends p. 4
Vikas Menon, Tess Maria Rajan, Siddharth Sarkar
DOI:10.4103/0253-7176.198956  
There is a growing interest in using mobile phone technology to offer real-time psychological interventions and support. However, questions remain on the clinical effectiveness and feasibility of such approaches in psychiatric populations. Our aim was to systematically review the published literature on mobile phone apps and other mobile phone-based technology for psychotherapy in mental health disorders. To achieve this, electronic searches of PubMed, ScienceDirect, and Google Scholar were carried out in January 2016. Generated abstracts were systematically screened for eligibility to be included in the review. Studies employing psychotherapy in any form, being delivered through mobile-based technology and reporting core mental health outcomes in mental illness were included in the study. We also included trials in progress with published protocols reporting at least some outcome measures of such interventions. From a total of 1563 search results, 24 eligible articles were identified and reviewed. These included trials in anxiety disorders (8), substance use disorders (5), depression (4), bipolar disorders (3), schizophrenia and psychotic disorders (3), and attempted suicide (1). Of these, eight studies involved the use of smartphone apps and others involved personalized text messages, automated programs, or delivered empirically supported treatments. Trial lengths varied from 6 weeks to 1 year. Good overall retention rates indicated that the treatments were feasible and largely acceptable. Benefits were reported on core outcomes in mental health illness indicating efficacy of such approaches though sample sizes were small. To conclude, mobile phone-based psychotherapies are a feasible and acceptable treatment option for patients with mental disorders. However, there remains a paucity of data on their effectiveness in real-world settings, especially from low- and middle-income countries.
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Barriers and challenges in seeking psychiatric intervention in a General Hospital, by the collaborative child response unit, (A multidisciplinary team approach to handling child abuse) A qualitative analysis p. 12
Vyjayanthi Kanugodu Srinivasa Subramaniyan, Anukant Mital, Chandrika Rao, Girish Chandra
DOI:10.4103/0253-7176.198957  
Child abuse is a serious criminal act against children in our country and punishable according to protection of children from sexual offenses act 2012. No one agency has the ability to respond completely to the abuse. Hence a multidisciplinary team approach was developed in India. Aim is to narrate the collaborative effort among the multiple disciplines in a general hospital to deliver child protection services and explore the barriers to integrate psychiatric services. Methodology: Members of the team were recruited from different disciplines and trained by experts. A mission statement, protocol to assess the victims and provide treatment was formulated as an algorithm. The barriers to psychiatric treatment among the stakeholders were analyzed using framework method of qualitative analysis. Results (After 20 months) the unit received 27 referrals in 20 months, 24 females, and 3 males. Age of the victims was between 8 months and 17 years. Two cases found to be physically abused. Penetrative sexual abuse was found in 23 cases, pregnant victims were 4. Most referrals were by police, trafficking found in 6 cases. Discussion: It was possible to provide multidisciplinary care to the victims and families. Recurrent themes of barriers to psychiatric treatment were stigma, victim blaming; focus on termination of pregnancy, minimization of abuse in males by stakeholders. Conclusion is collaboration needs more effort to integrate psychiatric services but can minimize the reduplication of services.
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ORIGINAL ARTICLES Top

Technology addiction among treatment seekers for psychological problems: implication for screening in mental health setting p. 21
Aswathy Das, Manoj Kumar Sharma, P Thamilselvan, P Marimuthu
DOI:10.4103/0253-7176.198939  
Background: Technology usage has seen an increase among users. The usage varies from social, personal, and psychological reasons. Users are frequently using to overcome mood states as well as to manage the other psychological states. This work is going to explore the information technology use among subjects with a psychiatric disorder. Materials and Methods: A total of 75 subjects were assessed using background data sheet, internet addiction impairment index, video game use pattern, pornography addiction screening tool and screening for mobile phone use, from in-patient and out-patient setting of tertiary mental health setting. Results: It showed the presence of addiction to mobile, internet, video game, and pornography. Age was found to be negatively correlated with this addiction. Average usage time had been associated with management of mood states. The addiction to information technology had been associated with a delay in initiation of sleep. Conclusion: This work has implication for screening technology addiction among subjects seeking treatment for psychological problems and motivate them to develop the healthy use of technology.
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Personality traits in the siblings and children of patients with frontotemporal dementia: A questionnaire-based study p. 28
Suresh Kumar Korada, Sadanandavalli Retnaswami Chandra, Vivek Benegal, Meera Purushothaman, Mariamma Philip
DOI:10.4103/0253-7176.198943  
Introduction: Frontotemporal dementias (FLD) form a group of relatively young onset, male dominant dementias with significant behavioral abnormalities early in the course of the disease. Routine assessment suggested preexisting traits such as lack of empathy, self-directedness, and persistence in most of these persons even before the onset of disease. Hence, we decided the study, the siblings and children of patients for any specific traits and correlation with hexanucleotide expansion repeats if any traits were identified. Patients and Methods: A total of 35 age- and gender-matched cases and controls were included for the study as per criteria. They were screened for mental illness and cognitive dysfunction using Hindi Mental State Examination and Mini-mental State Examination. Eligible persons were given temperament and character inventory (TCI) scores for the recommended parameters. Hexanucleotide expansion was also studied in the patients, cases and controls. Results: No specific personality trait was found to have an increased correlation with siblings and children of patients with FLD in this small group using TCI scores. Conclusions: 7% of cases showed Hexanucleotide expansion suggesting a possible risk.The role of self reporting bias resulting in normal personality trait needs to be addressed in future studies.
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Cascade of traumatic brain injury: A correlational study of cognition, postconcussion symptoms, and quality of life p. 32
Rajakumari Pampa Reddy, Jamuna Rajeswaran, B Indira Devi, Thennarasu Kandavel
DOI:10.4103/0253-7176.198940  
Introduction: Traumatic brain injury (TBI) constitutes a significant burden on health care resources in India. TBI is a dynamic process which involves damage to the brain thus leading to behavior cognitive and emotional consequences. Aim: To study the cognitive profile, post-concussion symptoms (PCS), quality of life (QOL), and their correlation. Methods: A total of 60 patients with TBI were recruited and assessed for neuropsychological profile, PCS, and QOL, the correlation among the variables were analyzed. Results: The results suggest that TBI has series of consequences which is interrelated, and the study has implications for rehabilitation of TBI. Conclusion: The study highlights the deficits of cognition, and its correlation with PCS and QOL, emphasizing integrated rehabilitation approach for patients with TBI.
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A cross-sectional study to assess disability and its correlates among treatment seeking individuals with alcohol use disorders p. 40
Yatan Pal Singh Balhara, Shalini Singh, Tamonud Modak, Siddharth Sarkar
DOI:10.4103/0253-7176.198941  
Background and Objectives: Alcohol use is a major risk factor for global disease burden, and excessive use leads to disability in the individual. This study aimed to assess the disability and its correlates among individuals with alcohol use disorders (AUDs). In addition, it assessed the quality of life measures in this population group. Methodology: A cross-sectional study on a sample (N = 62) from among treatment seekers for alcohol dependence. Diagnostic and Statistical Manual, Fifth Edition (DSM-5) criteria were used to assess disorder severity. The WHO Disability Assessment Schedule (WHODAS) 2.0 and World Health Organization Quality of Life-BREF were used to assess disability and quality of life, respectively. Descriptive statistics, correlation analysis, and linear regression analysis were used for comparative assessments. The level of statistical significance was kept at P < 0.05 for all the tests. Results: DSM-5 diagnosis of the individuals suggested a high severity of substance use disorder as an average of 8.8 (±1.8) criteria were fulfilled. WHODAS 2.0 revealed maximum disability in the domains of “participation in the society,” “household and work-related activities” and “cognitive functioning.” The quality of life measures indicate poor physical health, reduced work capacity, and cognitive dysfunction. A negative correlation was seen between the social dimensions of disability (getting along) and quality of life measures of psychological health (P = 0.026) and social relationships (P = 0.046), work domain of disability schedule and physical health score on quality of life evaluation (P = 0.001). Older age had greater impairment in the work domain (P = 0.040), and unemployment was associated with higher disability (P = 0.001). Unemployment and duration of alcohol use were the independent predictors of greater disability. Conclusions: Disability assessment using WHODAS 2.0 shows significant impairment in individuals with AUDs that is negatively correlated with quality of life measures.
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Sociodemographic correlates of unipolar and bipolar depression in North-East India: A cross-sectional study p. 46
Kamal Narayan Kalita, Jyoti Hazarika, Mohan Sharma, Shilpi Saikia, Priyanka Patangia, Pranabjyoti Hazarika, Anil Chandra Sarmah
DOI:10.4103/0253-7176.198949  
Introduction: Early diagnosis and management of depression is important for better therapeutic outcome. Strategies for distinguishing between unipolar and bipolar depression are yet to be defined, resulting improper management. This study aims at comparing the socio-demographic and other variables between patients with unipolar and bipolar depression, along with assessment of severity of depression. Materials and Methods: This cross sectional study was conducted in a tertiary care psychiatry hospital in North-East India. The study included total of 330 subjects selected through purposive sampling technique from outpatient department after obtaining due informed consent. Mini-International Neuropsychiatric Interview (M.I.N.I.) version 6.0 and Beck Depression Inventory (BDI) were applied. Statistical Package for Social Sciences (SPSS) version 16.0 was applied for analysis. Results: Bipolar group had onset of illness at significantly younger age with more chronicity (32.85 ± 11.084). Mean BDI score was significantly higher in the unipolar depressive group. Conclusion: Careful approach in eliciting symptom severity and associated socio demographic profiles in depressed patients may be helpful in early diagnosis of bipolar depression.
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Prevalence of depression and associated factors among diabetic patients at Mekelle City, North Ethiopia p. 52
Tilahun Belete Mossie, Gebreselassie Hagos Berhe, Gebremedhin Haile Kahsay, Minale Tareke
DOI:10.4103/0253-7176.198947  
Background: Coexistence of mental health problems on diabetes mellitus can result in poor management of the illness, poor adherence to treatment, and low quality of life. Therefore, it is highly crucial to assess these problems; thus we carried out this study with the aim of determining the prevalence of depression and identifying related factors among diabetic patients at city of Mekelle, North Ethiopia. Methods: Hospital-based cross-sectional study was employed among 264 diabetic patients, and participants were selected through systematic random sampling technique. We used local language versions of Beck Depression Inventory-II, Beck Anxiety Inventory, and Morisky 8 Item Medication Adherence Scale to assess the levels of depression, anxiety, and medication adherence, respectively. Socio-demographic and clinical factors were also assessed. We accomplish data entry, cleaning, and analysis through Statistical Package for Social Sciences window 20; also the level of significance was determined using adjusted odds ratio (OR). Results: The prevalence of depression among diabetic patients is 17% (95% confidence interval [CI]: [12.9%, 21.6%]). In addition, 28% and 18.2% has low medication adherence and comorbid anxiety, respectively. We identify anxiety disorder (AOR = 10.52, 95% CI: [4.56, 24.28]), poor medication adherence (AOR = 4.38, 95%CI: [1.98, 9.64]), and coexistence of other physical illness (AOR = 3.04, 95% CI: [1.11, 8.34]) as risk factors for depression. Conclusions: Depression is a common mental health problem among diabetic patients which is related to poor treatment adherence coexistence of other physical illness and anxiety disorder. This emphasizes to formulate a mechanism for early detection and appropriate intervention.
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Adult attention deficit hyperactivity disorder in patients with substance use disorders: A study from Southern India p. 59
Suhas Ganesh, Arun Kandasamy, Ubahara S Sahayaraj, Vivek Benegal
DOI:10.4103/0253-7176.198945  
Context: Externalizing disorders of childhood characterized by attention deficit hyperactivity disorder (ADHD), conduct disorder and oppositional defiant disorder are well known to predispose an individual to experiment with substances at an early age and the later lead to the development of substance use disorders (SUD). ADHD, a developmental disorder, persists into adulthood in about two-thirds of the cases. Aims: In the present study, we aimed to explore the prevalence of ADHD and its subtypes in treatment-seeking patients with SUD in an outpatient setting. Secondarily, we also aimed to compare the ADHD scores in the early onset and late onset subtypes of SUD.Subjects and Methods: Adult ADHD self-report scale symptom checklist was administered in 240 patients with SUD. The prevalence of ADHD and the difference in scores in early onset and late onset dependent groups of SUD patients were calculated.Statistical Analysis: Independent sample t-test was used to calculate the mean differences, and Chi-square test was used to calculate the difference in the proportion of cases screening positive across subgroups. Results: Among the 240 patients with SUD, 135 (56.25%) screened positive for “likely ADHD” and 52 (21.7%) for “highly likely ADHD.” The scores on the inattention domain and the prevalence of “likely ADHD” were significantly higher among the early onset group. Conclusions: The results are in agreement with similar studies of larger samples performed worldwide. Routine screening for ADHD in the treatment-seeking patients with SUD will enable the early detection and management of this highly comorbid condition.
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Psychological adaptation to alteration of body image among stoma patients: A descriptive study p. 63
Umesh Jayarajah, Dharmabandhu Nandadeva Samarasekera
DOI:10.4103/0253-7176.198944  
Background: Creation of an ostomy leads to significant change in the body image of the patient. However, adaptation to this alteration of body image is necessary for rehabilitation following surgery. The objective of this study was to identify the factors that influence adaptation to altered body image. Materials and Methods: An analytical cross-sectional study was conducted among 41 ostomy patients who were treated at a single tertiary care unit. Body image disturbance questionnaire (BIDQ) was used to assess the perception of body image. Data were analyzed using independent samples t-test (unpaired), Chi-square test, and Spearman's correlation. Results: In our study, the mean BIDQ score was 2.22 (standard deviation ± 0.88). The body image disturbance was significantly associated with younger age (P < 0.05). The prevalence of body image disturbance was significantly higher among overweight patients (P < 0.05). Males had a higher BIDQ score than females. Those who had temporary stoma had significantly higher BIDQ score (P < 0.05). Those who felt depressed or had thoughts of self-harm soon after surgery had significantly high body image disturbance score (P < 0.05). There was a significant negative correlation with the perception of self-efficacy and body image disturbance (P < 0.01). There was no significant association between body image disturbance and the diagnosis, type of surgery, or time duration after surgery. Conclusions: Poor adaptation to alteration of body image was associated with younger age, overweight, and temporary stoma. Individuals at risk of poor adaptation should be identified before surgery and counseled before surgery, after surgery, and during follow-up visits.
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Comparison of effect of antidepressants on psychomotor functions p. 69
Pranjali P Mendhe, Samidh P Shah, Mira K Desai, Minakshi N Parikh
DOI:10.4103/0253-7176.198946  
Objective: The comparison of the effect of antidepressants on psychomotor functions in patients with endogenous depression. Materials and Methods: This prospective interventional study was carried out at a tertiary care teaching hospital on 95 literate patients with newly diagnosed endogenous depression matching inclusion and exclusion criteria. Patients were prescribed either desvenlafaxine (50 mg) or fluoxetine (40 mg) or sertraline (50 mg). Psychomotor functions were assessed by digit letter substitution, six letter cancellation, choice reaction time, hand steadiness and flicker fusion test at the baseline 1st month and 3rd month. Efficacy of drugs was also measured by Hamilton rating scale for depression. Data were analyzed by using ANOVA and P < 0.05 was considered as statistically significant. Results: A total of 95 patients were enrolled. Fluoxetine, desvenlafaxine, and sertraline were prescribed in 32, 32, and 31 patients, respectively. At the end of 3 months, a significant improvement in psychomotor functions was observed in patients treated with sertraline (P < 0.05), while desvenlafaxine-treated patients did not show any significant change in any of the tests. Surprisingly, fluoxetine-treated patients showed deterioration in all psychomotor tests (P < 0.05). Hamilton rating score improved at the end of 3 months treatment as compared to baseline. Most commonly observed adverse reactions in all three drug groups were nausea (n = 20), dizziness (n = 3), headache (n = 20), and diarrhea (n = 3). Conclusion: Sertraline significantly improves psychomotor function as compared to desvenlafaxine while fluoxetine impairs.
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Specific learning disabilities and psychiatric comorbidities in school children in South India p. 76
Shailaja Bandla, Gowri Devi Mandadi, Anand Bhogaraju
DOI:10.4103/0253-7176.198950  
Background: Specific learning disabilities (SLDs) are an important cause of academic underachievement in children and are also associated with comorbidities like attention deficit hyperactivity disorder (ADHD) which further have an impact on the child's education. Aims: To estimate the prevalence and psychosocial profile and psychiatric comorbidities in children with SLD in two settings, i.e., on special (remedial) education and schools and to compare the findings with normal children. Materials and Methods: This study was carried out in schools situated in urban and semi-urban areas and special education schools. A total of 96 children were chosen for the study. After taking informed consent from the parents, the details about socioeconomic status, family, developmental history, and school history of the children were collected on a semi-structured pro forma and then the children were screened for SLD. They were administered colored/standard progressive matrices and Malin's intelligence scale for assessing their intelligence quotient and NIMHANS SLD index and developmental psychopathology checklist to study psychopathology. Chi-square test and ANOVA were done. Results: The prevalence of SLD in schools is found out to be 6.6%. There was a significant association with prematurity, cesarean section, delayed speech, and family history of SLD. Among comorbidities of SLD, association with ADHD alone has been found to be significant. Conclusion: The most common type of SLD is combined type comorbid with ADHD. There is a need for early identification of learning disabilities in schools so that with early recognition and remedial intervention children can be helped with to cope with studies.
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CASE REPORTS Top

An interesting case report of hematohidrosis p. 83
Anu Rita Jayaraman, P Kannan, V Jayanthini
DOI:10.4103/0253-7176.198953  
Hematohidrosis or hematidrosis is a rare condition in which a human being sweats blood. Psychogenic cause is found to be the most frequent cause among other causes such as systemic disease and vicarious menstruation. This is a case report of a 10-year-old girl with oozing of blood from intact skin of scalp. Underlying intense fear secondary to psychosocial stressor was identified and a provisional diagnosis of mixed anxiety and depressive disorder was made. Pharmacotherapy and psychotherapy were followed by complete remission. It was inferred from this experience that hematohidrosis is a treatable condition if the underlying cause is correctly identified.
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Multimodal hallucinations in schizophrenia and its management p. 86
Vijaya Kumar, Virupakshappa Bagewadi, Dayanand Sagar, Shivarama Varambally
DOI:10.4103/0253-7176.198955  
A cluster of symptoms including hallucinations characterizes schizophrenia. Hallucinations that occur in more than one modality simultaneously and emanate from a single source are called multimodal hallucinations (MMHs). The occurrence of simultaneous hallucinations as the major manifestations of a psychiatric disorder often was dismissed as factitious disorder or malingering. Conversely, MMHs have been reported in severe mental disorders including schizophrenia. Here, we report MMH in two patients of treatment-resistant schizophrenia and its successful management with clozapine. The significance of MMH on the course, prognosis, and treatment resistance of schizophrenia needs to be elucidated. Further systematic research is needed to address these issues.
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Atomoxetine induced hypomania in a patient with bipolar disorder and adult attention deficit hyperactivity disorder p. 89
Vijaya Kumar, Shivarama Varambally
DOI:10.4103/0253-7176.198954  
Comorbidity of bipolar disorder (BD) with attention deficit hyperactivity disorder (ADHD) is frequent. The management of comorbid ADHD and BD is complicated by the risk of induction of (hypo) mania by the medications used for ADHD treatment. Earlier reports in children and adolescents with ADHD-BD suggest that the possibility of (hypo) mania induction is low when atomoxetine is used along mood stabilizers or antipsychotics. Here, we report induction of hypomania by atomoxetine when used for the treatment of comorbid ADHD in a BD patient while on prophylactic treatment with mood stabilizers. This report indicates that atomoxetine carries the risk of induction of (hypo) mania even in stabilized BD patients. Clinicians should closely monitor such patients for (hypo) mania symptoms.
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Feasibility of online neuromodulation using transcranial alternating current stimulation in schizophrenia p. 92
Vanteemar S Sreeraj, Vandita Shanbhag, Hema Nawani, Venkataram Shivakumar, Dinakaran Damodharan, Anushree Bose, Janardhanan C Narayanaswamy, Ganesan Venkatasubramanian
DOI:10.4103/0253-7176.198937  
Abnormalities in resting and event-related brain oscillations are known to be associated with cognitive deficits in schizophrenia. Transcranial alternating current stimulation (tACS) modulates these rhythms across the neuronal circuits and could have a potential therapeutic role in psychiatric disorders. In this report, we describe, for the first time, application of online tACS in a schizophrenia patient with working memory deficits. This case report supports the feasibility and potential utility of online tACS in schizophrenia, which needs further systematic research.
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Severe tardive dystonia on low dose short duration exposure to atypical antipsychotics: Factors explored p. 96
Nilanjan C Chandra, Shabina A Sheth, Ritambhara Y Mehta, Kamlesh R Dave
DOI:10.4103/0253-7176.198938  
Tardive dystonia (TD) is a serious side effect of antipsychotic medications, more with typical antipsychotics, that is potentially irreversible in affected patients. Studies show that newer atypical antipsychotics have a lower risk of TD. As a result, many clinicians may have developed a false sense of security when prescribing these medications. We report a case of 20-year-old male with hyperthymic temperament and borderline intellectual functioning, who developed severe TD after low dose short duration exposure to atypical antipsychotic risperidone and then olanzapine. The goal of this paper is to alert the reader to be judicious and cautious before using casual low dose second generation antipsychotics in patient with no core psychotic features, hyperthymic temperament, or borderline intellectual functioning suggestive of organic brain damage, who are more prone to develop adverse effects such as TD and monitor the onset of TD in patients taking atypical antipsychotics.
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Dissociative motor disorder p. 99
Arya Jith, Dinesh Narayanan
DOI:10.4103/0253-7176.198952  
Conversion disorders are more prevalent in childhood and adolescence, especially in females. They are usually associated with stressors and symptoms usually reflect a means to avoid the stressor, or also with a primary and secondary gain. This case report involves a similar situation where a young girl was treated successfully with diazepam, therapeutic nerve conduction study, and behavioral psychotherapy.
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LETTERS TO EDITOR Top

Ecological momentary interventions delivered by smartphone apps: Applications in substance use treatment in indian scenario p. 102
Arpit Parmar, Pragya Sharma
DOI:10.4103/0253-7176.198942  
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Clozapine use in adolescents p. 103
Samir Kumar Praharaj
DOI:10.4103/0253-7176.198948  
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