EARLY DETECTION OF MENTAL HEALTH ILLNESSES: A COMMUNITY APPROACH

By

Dr. Vishal A. Sawant, MD, Prof & Head of Dept. of Psychiatry, Dr. R. N. Cooper Municipal Hospital.

Dr. Shailesh Umate, DNB, Lecturer, Dept. of Psychiatry, Dr. R. N. Cooper Municipal Hospital.

Schizophrenia is a chronic disorder resulting in significant social, psychological and occupational dysfunction. The Global Burden of Disease 2000 study, published in the World Health Report 2001(WHO;2000), schizophrenia is the 7^th leading cause of YLDs at global level, accounting for 2.8% of total global YLDs.

Early detection and treatment of schizophrenia reduces burden, improves functioning, reducing the chronic course. Therefore, Primary care, non-Psychiatrist doctors and the society should be aware of the need for early detection and treatment of the disorders.

Early detection can be done in the targeting etiological factors of schizophrenia, high risk population and the early community contact persons like teachers and family physicians.

HIGH RISK POPULATION:

This is target population in the community having family history of schizophrenia, especially in parents.  The vulnerability to develop schizophrenia is higher when the relationship is closer, and increases with the number of affected relatives. The vulnerability extends to development of related ‘spectrum’ disorders such as schizoaffective disorder, psychosis and certain personality disorders.

ETIOLOGICAL FACTORS:

1.Perinatal and obstetric complications The evidence that prenatal and obstetric complications are risk factors has been consistently reported. But recently, it was  found that the interaction of delivery complications and family history predicts schizophrenia in offspring. Thus, delivery complications alone were not associated with later schizophrenia.

It has been found that maternal influenza during the second trimester of gestation appears to increase risk for schizophrenia in offspring and this has been independently replicated in several countries.

2. Neurointegrative deficits-Hyperkinesis, poor concentration, motor disco-ordination, perceptual signs, and poor verbal abilities are some of the neuro-integrative deficits. These can be easily identified in children. Research findings suggest that assessing difficulties with motor coordination may be an important aid in early identification.

3. Early parental separation & Institutionalization -It is interesting to note that for children without a family history of psychiatric disorder, very early separation was associated with increased risk of psychiatric hospitalization for non-psychotic disorders. Study findings indicate that poor family environment associated with a disturbed parent is a risk factor, particularly for boys. In addition, they indicate that future psychosis may be avoided if the genetically vulnerable child experiences a positive foster placement.

4. Family functioning.- Tienari et al. (1994) found that the children who had mothers with schizophrenia but who had a positive adoptive experience were protected from later schizophrenia, while the genetically vulnerable individuals who experienced a disturbed adoptive family tended to develop the disorder. This finding suggests that a positive rearing experience can protect at-risk individuals against future psychosis.  It was also found that inconsistent parenting, over-involvement, and hostility toward the child predicted schizophrenia-spectrum outcomes.

Community contacts:

1. 1. Family physicians(GPs):

Patients of early stage psychosis are more likely to contact their family Physicians in initial period. Primary care Physicians have been identified as an important contact in the pathway to care of high risk population. Appropriate intervention at primary care level is a key factor in reducing Duration of Untreated Psychosis, distress and improving access to sustained treatment.

2.Teachers:

Most schizophrenia patients are not distinguishable from their peers in childhood. Deviant behaviors tend to become more prominent in adolescence, a time of life that may present more socially challenging situations. Studies of schizophrenia patients have shown certain behaviors such as being shy and withdrawn, having poor peer relationships and poor school performance. Some studies showed that males had more antisocial behaviors and females had more passivity and withdrawal.

In one study, teachers more frequently judged both males and females later diagnosed with schizophrenia to be emotionally labile and more susceptible to future emotional or psychological breakdown. They also more frequently rated males as disruptive, disciplinary problems, anxious, lonely and rejected by peers, and more likely to have repeated a grade, while, in contrast, they rated females as nervous and withdrawn. Individuals later diagnosed in the schizophrenia spectrum were judged by teachers and the interviewing psychiatrist to be socially withdrawn, socially anxious, passive, flat in affect, and peculiar and to have a poor prognosis.

Conclusions:

1. Family history of schizophrenia increases the genetic vulnerability.
2. Obstetric complications plays major role in genetically vulnerable populations.
3. Neurointegrative deficits are indicators of risk and can easily be monitored.
4. Parental separation, poor family environment and a disturbed parent is a risk factor f
5. A positive rearing experience can protect at-risk individuals against future psychosis.
6. Family Physicians can be major help for early treatment.
7. Teachers can help early detection of high risk cases

Clinical impact:

1. 1. Obstetric complications can be reduced with monitoring and so the disease impact.
2. 2. Family Physicians and teachers can be a boon for early diagnosis and intervention

APPROACH TO MALE SEXUAL DYSFUNCTION

DR PRASANNA TENDOLKAR

CONSULTANT PSYCHIATRIST AND SEXOLOGIST

The diagnosis and treatment of sexual dysfunction is an important part of medical practice. This problem presents among patients irrespective of specialty, and in primary care as well as specialist care-seekers.

Some of the myths and expectations related to male sexual functioning are:

• One must get erection whenever he desires or commands.
• One must get prolonged erection or erection till he commands.
• The penis must grow in length on command.
• One must be able to perform sexual act everyday or sometimes several times in a day.

This misplaced desire of a wonder organ has lead humankind (predominantly males) to look for artificial (medical) means to make their organs do the desired.

The most common sexual dysfunctions among male patients are—

1)      Premature ejaculation

2)      Erectile dysfunction

3)      Hypoactive sexual desire

Premature Ejaculation (P.M.E) is defined as ejaculation prior to satisfaction of the partner, which occurs in more than 50% of times that the couple has intercourse. A careful history taking is essential to establish proper diagnosis.

Treatment essentially consists of reassurance and clarifications to dispel any myths that the couple may have. “Sexual Behavior Techniques” are suggested for achieving better control of the sexual act. Some of the techniques are: Squeeze technique, stop-start technique. Medications which delay ejaculatory reflex such as Selective  Serotonin Reuptake  Inhibitors,  tricyclic antidepressants are sometimes used.

Erectile dysfunction: is defined as inability to maintain or achieve erection to perform penetration during sexual intercourse. Misconceptions about sexual functioning can lead to complaints of erectile dysfunction when no problem actually exists.

After the diagnosis is established, one has to rule out organic causes such as hypertension, diabetes, liver dysfunction, chronic debilitating illness, substance use or medication-use. When no such cause is found, a psychological cause may be suspected. Psychological Causes include depression, anxiety disorders, Relationship problems (marital disputes) and substance abuse.

If any organic problem is detected that has to be treated first. Psychological treatments include education, counseling and treatment of psychiatric disorder. Sometimes sildenafil is prescribed. This drug causes dilatation of arterial spaces in the corpora cavernosa leading to erection. Advanced treatments include locally acting papaverine injections or penile implant surgery.

Hypoactive sexual desire disorder: In this disorder patients describe decreased interest in sex, that is, decreased libido.

Sexual desire may be decreased when the patient is suffering from some other illness or is under mental or physical stress. It may be a symptom of mental illness such as depression.  Some drugs can also cause decreased libido. Sometimes relationship issues such as disputes can also cause this problem.

A thorough history can reveal the possible psychological causes, while examination and investigations can help to find the organic causes. Treatment of underlying medical and psychiatric illness is important. In drug-induced cases the offending drug may have to be reduced or replaced. Individual and couples therapy is done for some cases, to aid in recovery of sexual dysfunction.

It is important to remember that organic and psychological causes of sexual dysfunction often co-exist and both types of treatment may be required.

Sexual dysfunction is often a hidden disorder. Patients are hesitant to talk about it, and doctors may not be able to enquire about it due to constraints of space, time and lack of confidence in dealing with these issues.

The unfortunate consequences are

1. Patients believe more in myths than in facts.

2. Patients delay treatment

3. Patients visit quacks who harm or exploit them

4. Patients treat themselves by relying on friends, internet and other unreliable resources

5. Patients develop psychological complications like depression, anxiety, addiction

6. Patients develop social problems such as marital discord, infertility, antisocial behvior

As there is lot of thought given to the preventive approaches in other fields of medicine, similarly primary care interventions can reduce the burden of sexual dysfunctions in the population.

Various interventions at primary care can be;

a)      Sex education in schools and colleges

b)      Sex education modules for teachers and parents

c)      Workshops for primary care physicians

d)      Using media for education and displacing myths

The initiation of sex education of any individual begins in childhood from his or her parents, child tends to imbibe the values carried the parents. The observation of parental interaction plus the sex determined grooming by the parents lays the foundations for the sexual identity of the individual. Hence it is the parents who are the crucial sex educators for the children. Thus of various interventions mentioned enhancing parental counseling abilities is the most important intervention.  Primary care physicians have to assist the community by giving proper factual information to dispel myths, whenever necessary. In addition, one must be sensitive to sexual needs of the patient and give legitimate importance to the timely diagnosis and treatment of sexual dysfunction.

BIPOLAR  DISORDER

Dr. Malik Merchant

Consultant Psychiatrist

Bipolar disorder is a mental illness that is characterised by repeated episodes in which the patient’s mood and activity levels are significantly disturbed. This disturbance may consist of an elevation in the mood and activity called ‘mania’ or ‘hypomania’; or lowering of mood and decreased activity levels called ‘depression’.

They are different from the normal ups and downs that everyone goes through from time to time because these are independent of external causes, or out of proportion to the stressors. The mood changes remain persistent and cause dysfunction in various domains such as damaged relationships, poor job or school performance, and even suicide. The condition has a high rate of recurrence and if untreated, it has an approximately 15% risk of death by suicide.

Symptoms of Bipolar Disorder.

Bipolar disorder is not easy to spot when it starts. Following are the common symptoms:

Symptoms of mania or a manic episode include:

Symptoms of depression or a depressive episode include:

Mood Changes A long period of feeling “high,” or an overly happy or outgoing mood Extremely irritable mood, agitation, feeling “jumpy” or “wired.” Behavioral Changes Talking excessively/very fast, jumping from one idea to another, having racing thoughts Increasing goal-directed activities, such as taking on new projects Being restless, active Sleeping little Being intrusive Demanding fancy articles, foods, etc Having an unrealistic belief in one’s abilities Taking part in a lot of pleasurable, high-risk behaviors, such as spending sprees, impulsive sex, and investments.

Mood Changes Feeling low and depressed, which is pervasive A long period of feeling worried or empty Loss of interest in activities once enjoyed. Behavioral Changes Feeling tired or “slowed down” Having problems concentrating, remembering, and making decisions Being restless or irritable Getting negative thoughts about most things decreased sleep, appetite and libido Thinking of death or suicide, or attempting suicide

Sometimes, a person with severe episodes of mania or depression has psychotic symptoms such as hallucinations or delusions. People with bipolar disorder may abuse alcohol or substances, have relationship problems, or perform poorly in school or at work.

What causes bipolar disorder?

Researchers are learning about the possible causes of bipolar disorder. Many factors likely act together to produce the illness. Bipolar disorder tends to run in families. For any person, the genetic risk of developing bipolar disorder is directly proportional to the number of relatives having this disorder and the degree of closeness of the relationship with the affected relative/s.

But genes are not the only risk factor for bipolar disorder. A person with vulnerability to develop bipolar disorder, may precipitate onset by several environmental factors. Psychological stress, substance abuse and medication use are some of the factors associated with onset of this disorder.

Brain-imaging studies are helping scientists learn what happens in the brain of a person with bipolar disorder. Some imaging studies and psychological studies have shown that the brains of people with bipolar disorder differ from the brains of healthy people or people with other mental disorders. Thus, bipolar disorder is a real biological disorder. However, these differences are not yet so clear as to be used for purpose of diagnosis.

How is bipolar disorder treated?

Proper treatment helps most people with bipolar disorder gain better control of their mood swings and related symptoms. Because bipolar disorder is a lifelong and recurrent illness, people with the disorder need long-term treatment to maintain control of bipolar symptoms. An effective maintenance treatment plan includes medication and psychotherapy for preventing relapse and reducing symptom severity.

Medications

The choice of medication depends on the phase of the illness. Sometimes, during an acute manic phase many patients require involuntary admission.

Mood stabilizing medications are usually the first choice to treat bipolar disorder. In general, people with bipolar disorder continue treatment with mood stabilizers for years. Except for lithium, many of these medications are anticonvulsants. Anticonvulsant medications are usually used to treat seizures, but they also help control moods. These medications are commonly used as mood stabilizers in bipolar disorder: The mood stabilisers are lithium, sodium valproate, carbamazepine, oxcarbazepine and lamotrigine. Gabapentin, topiramate, and levatiracetam are sometimes prescribed.

Atypical antipsychotic medications like olanzapine and quetiapine are also used to treat symptoms of bipolar disorder. Often, these medications are taken with other medications. Risperidone  and Aripiprazole are other atypical antipsychotics that may also be prescribed for controlling manic or mixed episodes.

Antidepressant medications are sometimes used to treat symptoms of depression in bipolar disorder. People with bipolar disorder who take antidepressants often take a mood stabilizer too.

Psychotherapy

In addition to medication, psychotherapy, can be an effective treatment for bipolar disorder. It can provide support, education, and guidance to people with bipolar disorder and their families.

Electroconvulsive Therapy (ECT)— In certain patients, modified electroconvulsive therapy is the treatment of choice. The indications are:

1. Severe symptoms
2. Non responders
3. Patients with poor physical condition such as those who have starved themselves, etc
4. Patients where rapid relief is required and medications may not be feasible-pregnancy and post partum
5. Acutely suicidal patients

ECT has received unjustified notoriety among patients as well as doctors. Modified ECT is a safe, humane and effective procedure. In fact, it deserves respect as a life-saving modality along the lines of use of a defibrillator. ECT may cause some side effects like confusion, disorientation, and short term memory loss. These are short-lived and completely reversible and cause no lasting dysfunction.

Treatment of bipolar disorder is more effective when people work closely with a doctor and talk openly about their concerns and choices. Keeping track of mood changes and symptoms with a daily life chart can helps to assess a person’s response to treatments. Sometimes one needs to change a treatment plan to make sure symptoms are controlled most effectively. A psychiatrist should guide any changes in type or dose of medication.

FROM ADDICTION TO  FREEDOM

DR. KARTHIK RAO, MD.DPM,

Consultant Psychiatrist : BSES MG Hospital.

Director : Vishwas, Mind Care Institute of Mental  Health and Behavioral Science

We all know  the effect of addiction on our organs like alcohol on  liver or cigarette smoking on lungs. But the real devastation is  in psychological,  occupational, financial, family and social functioning of the patient. Management  of such patients is akin to fighting multiple wars of independence with many wins and defeats in between, which we term as remissions and relapses.

The prevalence of substance use disorders is as follows: alcohol=2.9-82.5%, sedatives=3.5-53%, nicotine=5-25%,  cannabis=1.9-33%, opiates=0.04-.0.1%.  Also  30- 46% of all substance abusers  are  also  suffer from  other psychiatric disorders which make abstinence difficult, making the prognosis even more worse. These patients  are said to  have   dual diagnosis.

CAUSES

They are multi factorial i.e. genetics, brain reward pathway pathology (dopamine) for craving, external / internal  cues. Similar disorder in genetic tree is  seen commonly  . Enabling- co-dependence behavior is seen in family memeber loke mother or wife who almost encourages subtance use. Personality Disorders which are more prone to have substance disorders are  antisocial , dependent and  avoident

INDIVIDUAL SUBSTANCES:

Nicotine-Depndence;

Patients can present mainly with physical presentations like COPD- chronic cough, Breathlessness, hypertension, ,  Coronary spasm , Tiredness, bad breath,  Loss of taste and smell, hyperacidity. Nicotine is an addictive Stimulant, thus common reasons expressed for consumption are like  releasing  tension,  craving, pleasure, to socialize, break from work, projecting a cool, macho & sophisticated identity. As  part of the psychodynamics, patients will unconsciously  deny the possibility of medical problems due to the addiction. Withdrawal  symptoms  gradually reduce in two weeks. They can suffer from insomnia, restless, anxiety, depression and recurrent craving

Alcohol

Beer, country liquor, whisky, vodka  are common forms which are abused with gradually increasing quantity and frequency. Withdrawal symptoms include tremors, lack of sleep, restlessness, hallucinations, rum fits, delirium. Alcohol has many effect on body namely on the gastric, liver, heart, CNS (memory, co-ordination) and peripheral nerves causing both temporary and permanent damage.

Opioid

Heroin=brown sugar,  codeine and even  abuse of prescription drugs like buprenorphine,  dextroprpoxyphene. They are very addictive at a very early stage and one of the most difficult to treat.

Cannabis

Bhang, charas,  marihuana/ ghanja  are smoken in cigarettes, chillums and pipes. They are called the gateway drugs as they are used to  experiment by  the youth and may allow them  to try opiods and other recreational drugs

Cocaine and  Hallucinogens

These drugs can cause a person to go into Bad Trips where they may experience hallucinations. They can get hyperthermia , dehydration and seizures

Newer addictions

Internet- pornography, video and mobile  gaming and  gambling are equally damaging addictive behavior.

PATH TO  FREEDOM –TREATMENT ASPECTS

Motivation tips

We can advise them  to  make a list of harmful result( stick to bathroom) and a similar list of advantages( stick to mirror) and use of imagery of positive & negative outcomes of treatment and addiction respectively. We can also encourage our patients to make a public announcement to  friends and relatives about their quitting of substance and follow the following rules like – take Rewards involving  outdoor activities and  avoid other substance abusers. They can be given – auto suggestions like I am an ex-smoker,  smoking is poisonous for my body, I need by body to live, I will protect my body from harm.

Treatment  Setting :

This can be initiated in:

1)      nursing home-general, psychiatric

2)      rehabilitation: Vishwas, Mind Care Institute, Sevadhan, Kripa, NARC,BMC (Therapeutic community)

Detoxification

The term is misleading, as it suggests that it includes an elimination of toxin, but  actually it is treatment of withdrawal symptoms.

Medication for nicotine withdrawal include Clonazepam for anxiety and Lorazepam- sleep .Anti- craving agents like Bupropion (150mg) and Varenicline (champix) are to  be given  in  the log run.  For temperory measures like in  hospital  admission, replacement therapies like Nicotine gum (2- 4mg), Nicotine patch can  be used.

The drug of choice in alcohol withdrawal  is benzodiazepine like diazepam 5-10mg tds or lorazepam1-2mg tds if liver damage. Along with this, thiamine-oral, IV100mg for  preventing Wernicke encephalopathy. Disulfiram is used at a dosage of 250-500mg/day after a written, informed consent about the alcohol –disulfiram reaction and an alcohol challenge test as aversion therapy.However, disulfiram can have  side- effects like hepatic, sexual and  memory problems.

Medications  used in withdrawal of opiod withdrawal are opiod substitutes like dextropropxephene, buprenorphine and benzodiazepines.Later naltrexone a opid receptor blocker can be used .

Psychotherapy

It helps to  increase motivation, teach  coping skill, reinforce with reward sobriety, improve interpersonal  functiong and solidify  gains of abstienence. Individual psychotherapy  is used to treat the faulty defense mechanisms like denial, minimization, rationalization and projection. Group  therapy  helps in  identify,  acceptance,  role modelling,  positive peer pressure, discipline, hope,

Family Therapy

We need to incorporate indian  context with  intact family concepts to psycho-educate and  encourage support  of all the family members. Also this is to deal with abnormal family dynamics like  co-dependence and teach the importance of healthy family rituals. The special problems of  children of alcoholics like ADHD, conduct disorders and childhood depression and learning disbilities are identified and treated

Self-Help Approach:

Alcohol anonymous(AA) , Narcotic anonymous(NA), AL Anon for family,ALTeen for children which use  the philosophy of the Twelve traditions and the Twelve steps to help in the rcovery of the patient. these  groups are non- religious but held in various churches and other locations throught the country on  a voluntary basis by people who  are trying to help each other to recover.

Relapse Prevention Plan

These can include various stratergies  like deep breathing, talking to friend or call over friend and  other healthy ways to seek pleasure like music, hiking. These steps need to  be rehearsed and applied when  the craving comes . As the saying goes try again  and again till you succeed

When to Refer:

One should remember that those patients who are having severe withdrawal, recurrent  use, co morbidity, medical complications and high suicide risk should be referred to  speciality centres for further management.