Background Advance directives help strike a balance between the ethical concepts of paternalism and patient autonomy in medical practice. It supports end-of-life decisions by the patient within an appropriate legal and ethical framework. This concept is still in its infancy in India and is an under-researched area. We aimed to assess the knowledge and attitudes of medical professionals on advance directives in a tertiary care teaching hospital. Methods Medical doctors from all departments were invited to participate in this survey using systematic sampling. The knowledge and attitude questionnaire was administered after obtaining informed consent. Socio-demographic and professional details were also collected. Descriptive, bivariate, and multivariate statistics were obtained using SPSS version 16.0.1. Results Our study included 391 medical doctors; 168 (43%) had good knowledge of advance directives, and 129 (33%) had a positive attitude towards them. Doctors who had completed postgraduate training in their specialty had better knowledge. Positive attitudes to advance directives were associated with greater knowledge and working in a super specialty department, while negative attitudes were associated with being more religious. Conclusion The level of knowledge and attitudes towards advance directives among medical practitioners is inadequate. While training will help improve knowledge and attitudes, other socio-cultural factors may also influence the same.

Background: Clozapine (CLZ) is the drug of choice for the management of schizophrenia that does not respond to first-line treatments. 40%–70% of patients on CLZ do not have significant improvement and require augmentation. This study aimed to identify factors associated with inadequate response to CLZ in treatment-resistant patients. Methodology: Seventy-four outpatients with a diagnosis of treatment-resistant schizophrenia on CLZ were included in the study. The Positive and Negative Syndrome Scale (PANSS) and Addenbrooke’s Cognitive Examination (ACE III) were used for assessment of the severity of psychosis and cognitive functioning, respectively. A specific pro forma for documenting sociodemographic and clinical details was also used. Results: Seventeen (22.97%) of the participants were found to have a poor response to CLZ. The majority were male with a mean age of 39.11 years (standard deviation [SD] = 9.63). The mean CLZ level was 625.53 ng/mL (SD = 398.59). The mean total PANSS score was 35.07 (SD = 3.65). Cognitive deficits were identified in 51.4% by the ACE III. Younger age at the onset of illness and poor medication adherence were found to have a significant association with inadequate response to CLZ (P < 0.05). Conclusions: Modifiable factors that contribute to CLZ resistance, such as medication adherence, must be effectively managed. Early identification of patients with an inadequate response to CLZ is essential to institute alternate pharmacological and nonpharmacological strategies that will help improve patient outcomes.

Background Medical students' attitude towards psychiatry (ATP) and mental illness will impact their choice of psychiatry as a future specialization and the quality of mental healthcare that they deliver to their patients. There is a paucity of longitudinal research on students' ATP and mental illness at different periods during medical school. We aimed to assess the attitudes of a cohort of medical undergraduates towards psychiatry and mental illness, before and after a clinical psychiatry rotation. Methods Medical students, in their second clinical year, underwent the first assessment on the 1st day of the psychiatry rotation. Socio-demographic information was collected. ATP and mental illness were assessed using the ATP-30 and the attitudes towards mental illness (AMI) scale, respectively. Assessments were repeated on the last day of the rotation and again 1 year later. Results One hundred and three medical students completed the pre- and immediate post-rotation survey questionnaire. One student withdrew consent for the 1-year assessment. There was an increase in ATP-30 and AMI scores after the rotation, and this persisted at the 1-year assessment. However, only the increase in ATP-30 scores was statistically significant. There was a significant reduction in the number of students with an overall negative attitude towards psychiatry and mental illness at 1 year. Conclusion Students generally had positive attitudes towards psychiatry and mental illness before the rotation. This improved further by the end of the rotation and persisted at 1 year of follow-up.

Background: A definite relationship has been established between epilepsy and sexual dysfunction (SD); however, this comorbidity often goes unrecognized in clinical settings. This study aimed to assess the prevalence, nature, and risk factors for SD among men with epilepsy attending a tertiary care teaching hospital. Methods: Participants were recruited from the Epilepsy clinic of a tertiary care hospital. Sociodemographic and clinical variables were recorded. The International Index of Erectile Functioning, Chinese Index of Premature Ejaculation-5, and a structured interview for DSM-5 sexual disorders diagnosis were administered to assess sexual functioning. The Revised Clinical Interview Schedule was used to assess for common mental disorders (CMD). Serum testosterone and trough antiepileptic drug levels were measured. Factors associated with SD were analyzed using bivariate and multivariate statistics. Results: One hundred and seventy men with epilepsy were recruited. The mean age was 32.68 (sd = 10.65) years, and 48.8% were currently married. Thirty-six participants (21.2%) fulfilled criteria for an SD; seventeen were diagnosed with a CMD. Older age (P < 0.001), substance use (P = 0.014), low testosterone levels (P < 0.001), and presence of CMD (P = 0.025) were associated with SD. Conclusions: Erectile disorder and premature ejaculation were the most common types of SD among men with epilepsy. Enhanced awareness regarding the prevalence and risk factors for SD among clinicians who manage patients with epilepsy is essential for appropriate preventive and intervention strategies, which can improve patient quality of life.

Managing patients with treatment-resistant schizophrenia who do not respond adequately to Clozapine poses a challenge. Cariprazine, with its unique mechanism of action, may be an option for such patients. The additional benefits of using Cariprazine as an augmentation strategy include once-daily dosing, ease of titration, and a favourable side-effect profile. The report outlines the experience of six patients with treatment-resistant schizophrenia who did not respond to Clozapine. The addition of Cariprazine was tolerated by all the patients. The majority showed improvement with symptom reduction, and in some cases, the dose of Clozapine could be reduced, thereby decreasing the side-effects of Clozapine.

Introduction Mid-life cognitive function contributes to a wide range of health and social outcomes. However, there are knowledge gaps in understanding the associations of life-course growth and longitudinal cardiovascular disease (CVD) risk marker profile which are major determinants of mid-life cognition. Our study, therefore, aims to examine the relationships of size at birth, growth during infancy, childhood, and adolescence, and the cumulative burden of CVD risk factors during adulthood with mid-life cognitive performance (brain reserve and structure). Methods and analysis The study will include 1400 participants aged between 49 and 54 from the Vellore Birth Cohort (VBC). Exposures include data collected previously on serial growth measurements (height and weight) from birth to the age of 45 years, IQ measured using the Binet-Kamat battery in childhood, and CVD risk factor profile (blood pressure, plasma glucose, insulin concentrations, lipid profile), modifiable lifestyle characteristics (diet, physical activity, smoking, and alcohol use) and socio-economic status (SES) measured at mean ages 28, 41.5and 45 years. The NIMHANS Neuropsychology Battery (NNB) and Weschler Memory Scale III – Indian Edition (WMS) will be used to assess cognitive performance across multiple domains as outcomes. Anthropometry, modifiable lifestyle characteristics, and SES will be updated for the current study. A subset of 150 participants will undergo functional neuroimaging [fMRI] to quantify brain volume, white matter hyperintensities, and resting state functional connectivity. Conditional regression methods and latent trajectory models will be used to quantify changes in growth and adult cumulative CVD risk factor burden. Factor analysis will be used to reduce the dimensions of multi-domain cognitive battery tests. Ethics and dissemination The institutional ethics committees of CMC, Vellore, India, have approved the study. Findings will be shared through scientific meetings and peer-reviewed journal publications.

Background: Diabetes is a chronic medical condition which is psychologically and behaviourally demanding in nature. Persons with diabetes may be particularly vulnerable to developing mental health disorders. This study was conducted to estimate the prevalence and factors associated with common mental disorders (CMDs) in patients with diabetes and understand their explanatory models of illness. Methods: One hundred and seventy patients who attended the diabetic clinic at a secondary care hospital were recruited to participate in this cross-sectional study. Psychiatric morbidity and the individual's conceptualization of the illness were assessed using the clinical interview schedule-revised and the modified short explanatory model interview (SEMI) respectively. Socio-demographic and clinical details were recorded using a structured proforma. Results: CMDs were observed in 14.7% of the sample and were significantly associated with female gender, longer duration of diabetic illness and treatment, use of insulin and past treatment for psychiatric illness. Illness attributions included unhealthy diet, heredity, and stress, as well as punishment from God. Religious and traditional healing methods were cited as potential sources of help in addition to medical interventions and lifestyle modification. Conclusions: Diabetes can significantly impact the emotional health of an individual in addition to its myriad physical consequences. Understanding patient perspectives regarding their illness and identifying and providing appropriate interventions for those with emotional disorders are an important component of diabetes care programs.

Introduction: Prevalence rates of Substance Use Disorders (SUDs) in patients with schizophrenia are reported to be about twice of that of the general population. Co-morbid SUDs in these patients can affect the natural course of the illness, quality of life and treatment compliance. Increased rates of hospital admissions, longer duration of inpatient stay, more severe psychopathology, increased rates of criminal activity and violent behaviour have also been reported in this group of patients. Data from the region on substance use in patients with schizophrenia is sparse. Aim: To study the prevalence of SUD’s in patients with schizophrenia and the risk factors associated with SUD’s and patient Explanatory Models (EM) regarding the same. Materials and Methods: The present cross-sectional study was conducted in the Psychiatry Outpatient Clinic at Christian Medical College, Vellore, Tamil Nadu, India, from November 2016 to May 2017 in 103 consecutive patients with schizophrenia. Symptom severity was assessed using the Positive and Negative Symptom Scale (PANSS), substance use patterns with the Drug Abuse Screening Test (DAST), Alcohol Use Disorders Identification Test (AUDIT) and Fagerstrom’s Test for Nicotine Dependence (FTND) and patient EMs for substance use with a semistructured questionnaire. Socio-demographic and clinical details were also recorded. Data was analysed using Statistical Package for Social Sciences (SPSS) software version 16.0.1. Chi-square test and the student’s t-test were used to assess the significance of association for categorical and continuous variables respectively. The Pearson’s correlation coefficient was employed to assess the statistical significance of the association between two continuous variables. A p-value <0.05 was considered as statistically significant. Results: The mean age of the participants was 37.54 years. The majority of the participants were males (n=60, 58.3%), 62 (60.2%) were married, 97 (94.2%) were literates and 54 (52.4%) participants were employed. The prevalence of substance use was seen in 30 (29.1%) participants. Nicotine was the most common substance of abuse (n=21, 20.4%) followed by alcohol (n=19, 18.4%). Male gender, being employed and a family history of substance use were factors significantly associated with any substance use with p-values 0.001, 0.001 and 0.01, respectively. Patient’s explanations for the use of the nicotine included the feeling of relaxation it produced (n=13, 61.9%), and feeling more energetic and active (n=12, 57.1%). Making one more relaxed and social (n=14, 73.7%) was the most common patient explanation for alcohol use. Conclusion: Alcohol and nicotine were common substances of abuse among the participants in this study. It is useful to understand patient’s explanations for substance use in order to develop effective intervention programmes tailored to the individual patient’s beliefs.

Background: The COVID-19 pandemic has overwhelmed the health-care infrastructure in the country. The steadily increasing number of cases and workload, inadequacy of healthcare infrastructure, and perceived lack of support contribute to psychological stress among health-care workers (HCWs). Aims: This cross-sectional survey estimated the prevalence and factors associated with depressive, anxiety, and stress symptoms among HCWs during the COVID-19 pandemic at a tertiary care hospital in South India. Methodology: Randomly chosen HCWs who provided informed consent were recruited to the study and administered the Depression Anxiety and Stress Scale-21, Clinical Interview Schedule-Revised, and the revised stigma scale to assess for depressive, anxiety, and stress symptoms, common mental disorders, and stigma, respectively. Sociodemographic details were also recorded. Bivariate and multivariate statistics were obtained. Results: One hundred and twenty-seven participants completed the survey questionnaire. The overall prevalence of significant depressive, anxiety, and stress symptoms was 31.5%, 26%, and 16.5%, respectively. Depressive symptoms were associated with younger age, being single, presence of medical illness in the family, current nicotine, and alcohol use. Anxiety symptoms were associated with younger age, being single, and working in a clinical area with potential for exposure to COVID-19 patients. The presence of children at home was associated with lower depressive or anxiety scores. Nearly 15.7% of the participants had a primary psychiatric diagnosis. Conclusions: HCWs are at risk of experiencing psychological distress during the ongoing COVID-19 pandemic. Our findings suggest that a supportive environment is essential to protect and promote the psychological well-being of HCWs during and after the outbreak. Early psychological interventions for those who require it can prevent long-term sequelae in this vulnerable group.

Objectives Bilateral extracapsular or total orchiectomy (BEO) for prostate cancer is presumed to have psychological consequences after the surgery due to perception of an empty scrotum. Bilateral subcapsular orchiectomy (BSO) was designed to preserve perception of palpable testes. We compared the patients' satisfaction and genital perception following BEO and BSO. Materials and methods Prostate cancer patients eligible for androgen deprivation therapy who opted for orchiectomy were enrolled in prospective randomized study. Patients with bleeding disorder or uncorrected coagulopathy, poor performance score, and psychiatric problems were excluded. Outlook to life and own health in-general, overall satisfaction to the procedure and genital perception was evaluated using modified Fugl-Meyer questionnaire (FMQ) which was administered before and after 3 months of the surgery. Patients were randomized to BEO and BSO groups at the time of surgery using block randomization. Primary outcome was to compare the genital perception of testicular loss and patients' satisfaction to BSO and BEO. Secondary outcomes included testosterone and PSA control, operative time, and complications. Results Total 35 patients were enrolled in each group which was comparable. There was no difference in PSA control at 3 months. Mean operative time and blood loss were significantly lesser in BEO group. FMQ score at 3 months did not show significant difference. Majority of the patients in both groups were satisfied with procedure and the aesthetic value of scrotum after surgery. However, 84% in BSO group did not feel that testes were removed on self-examination, as compared to 28% in BEO group. Majority patients in both groups did not report physical or psychological discomfort from change in scrotal content. Conclusions Results showed that patients' satisfaction and genital perception following BSO and BEO were similar. Feeling of remaining intrascrotal contents after BSO did not had added psychological advantage in terms of perception of genitalia.

BACKGROUND:Men with infertility experience significant distress, however research on psychiatric morbidity among this group is limited. Literature on explanatory models of infertility, which influence help seeking behaviour is also scarce.OBJECTIVES:The aim of this cross-sectional study was to assess the prevalence and factors associated with psychiatric morbidity among men with infertility, their quality of life, and explanatory models regarding infertility.MATERIALS AND METHODS:One hundred and thirty-five consecutive males who attended the reproductive medicine outpatient clinic in a tertiary care hospital were recruited after obtaining informed consent. Psychiatric morbidity, quality of life and explanatory models were assessed using the Clinical Interview Schedule - Revised, Fertility Quality of Life scale and modified Short Explanatory Model Interview respectively. Socio-demographic and clinical details were recorded using a structured proforma.RESULTS:Common mental disorder (CMD), observed in one third of the sample, was associated with longer duration of infertility and treatment, family history of psychiatric illness, sexual dysfunction, and past psychiatric illness in spouse. Presence of CMD was associated with lower quality of life scores. Participants held simultaneous and multiple explanatory models for infertility.CONCLUSION:Men with infertility experience psychological distress that can further impair their quality of life. They should be offered support and psychosocial interventions as they undergo infertility treatment.

Sir, Laryngeal dystonia (LD) is a functionally specific disorder of the afferent-efferent motor coordination system producing action-induced muscle contraction. Respiratory dystonia is a rare form of LD, which can result in respiratory distress. It characteristically disappears with sleep and does not alter the patient's voice during speech. A paradoxical vocal fold movement during inspiration with early adduction preventing air intake at the end of inspiration is the considered pathology.[1] Tardive dystonia (TDt) is estimated to occur in 1%–4.0% of patients on dopamine receptor-blocking agents.[2] Frequent among patients on conventional neuroleptics, they are increasingly being reported with second-generation antipsychotic agents as well. This report describes a case of tardive respiratory dystonia in a young male with schizophrenia while on risperidone. A 20-year-old single male with no family history of neuropsychiatric illness presented with 4 years of schizophrenia characterized by social and occupational dysfunction, persecutory and referential delusions, and auditory hallucinations. Routine tests were normal. Positive symptoms were remitted with risperidone (6 mg/day), while some negative and cognitive symptoms remained. Trihexyphenidyl (2 mg/day) was commenced when extra-pyramidal symptoms developed. Nine months later, the patient reported with blepharospasm and episodic feelings of suffocation. These lasted several minutes during which he felt choked and unable to breathe, they remitted spontaneously, were absent during sleep, and did not affect speech. There were no specific precipitating factors for these episodes. They had been progressively increasing in frequency and duration, and he did not report any change in voice. Mental status examination did not reveal delusions or hallucinations. Physical examination did not reveal focal neurological deficits. In view of respiratory distress, the patient was referred for an urgent ear, nose, and throat (ENT) evaluation. Examination excluded inflammatory, neoplastic, and traumatic changes in the larynx and vocal cords. Stroboscopy revealed intermittent LD during vocalization. Neurological evaluation for secondary causes for dystonia including a work-up for Wilson's disease and magnetic resonance imaging brain were unremarkable. A diagnosis of tardive LD – respiratory type and tardive blepharospasm was made. Quetiapine was commenced and gradually increased to 600 mg/day. Risperidone was discontinued. Trihexyphenidyl was increased to 6 mg/day, and clonazepam was added (0.75 mg/day). With these changes, the episodes of suffocation and blepharospasm resolved within 2 weeks. There was no re-emergence of psychotic symptoms. Tardive LD is a rare but life-threatening complication of antipsychotic medications.[34] The unusual presentation could result in a misdiagnosis of an anxiety attack. Early ENT evaluation helped establish the diagnosis in this patient. Criteria to diagnose antipsychotic-induced TDt include exposure to more than 3 months of the drug, exclusion of secondary causes of dystonia, and negative family history for dystonia.[5] Risk factors for TD in this patient were the long duration of illness, prominent negative symptoms, early development of extrapyramidal side effects, and concomitant use of anticholinergics. Remedial measures include the addition of benzodiazepines, an increase in the dose of anticholinergics, and a change of antipsychotic medication. Clinician awareness regarding this unusual side effect will help in early detection and better patient outcomes. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

BACKGROUND:There is a growing body of literature on the high prevalence of sexual dysfunction in patients with psychotic disorders. However, most studies have focused on medication-related sexual side effects.MATERIAL AND METHODS:Consecutive males with a diagnosis of acute psychosis or schizophrenia who were either drug-naïve or drug-free for six months were recruited to the study after obtaining informed consent. Sociodemographic and clinical data, psychopathology (using Positive and Negative Syndrome Scale), and sexual functioning (using The International Index of Erectile Functioning and DSM-IV TR criteria) were assessed. Bivariate and multivariate statistics were obtained.RESULTS:One hundred males were recruited. The overall prevalence of sexual dysfunction by DSM IV-TR criteria in this population was 17%. The factors that were associated with sexual dysfunction were older age and later age of onset of illness. The rate was higher on excluding those who said that they were not sexually active (25%).CONCLUSIONS:Sexual dysfunction may be found in patients with psychotic disorders even prior to commencing antipsychotic medications. It is possible that this is contributed to by several factors including the disease process. Assessment of sexual function in these patients will help in early identification and appropriate management.

BACKGROUND:Indian society is considered to have conservative attitudes regarding sex and is ambivalent about the concept of sex education. Previous reports suggest that a considerable proportion of Indian youth have inadequate sexual knowledge and hold a variety of sexual misconceptions. Methodological flaws limit the generalizability of some earlier studies.AIMS:This study assessed knowledge and attitude toward sexual health and common sexual practices among college students in Tamil Nadu.METHODOLOGY:A total of 952 students from seven randomly selected colleges in Vellore district of Tamil Nadu participated in the survey. The survey questionnaire contained 51 questions on knowledge and attitude toward sexual health and common sexual practices and incorporated items from standardized questionnaires and additional questions suggested by a multidisciplinary group who work in the field.RESULTS:Two hundred seventy-five students among those who completed the survey were women. Higher knowledge scores were associated with older age, male gender, being from a rural background, pursuing non-science streams, and being in postgraduate courses. Nonconservative attitudes were associated with older age, male gender, enrollment in non-science disciplines, discomfort with the family environment, and a religious family background.CONCLUSIONS:Sexual knowledge is inadequate and sexual misconceptions were widely prevalent in the population studied. School-based comprehensive sex education programs, which have been demonstrated to be effective in improving sexual health, could be used to deal with these lacunae in sexual health knowledge and attitudes.

In many parts of the world family members are the primary caretakers of persons with mental illness. The chronic stress associated with being a caregiver for an individual with schizophrenia can result in a variety of emotional responses, influenced by religion, spirituality and different styles of coping. The aim of this study was to assess patterns of coping, and spiritual and religious beliefs among caregivers of patients with schizophrenia. Consecutive patients with schizophrenia and their caregivers attending an outpatient clinic were recruited. Patients were rated on the Positive and Negative Symptom Scale. The Royal Free Interview for Religious and Spiritual Beliefs, Modified Jalowiec Coping Scale and General Health Questionnaire-12 were administered to caregivers. Socio-demographic details of carers and clinical details of patients were recorded. Caregivers of patients with schizophrenia were found to cope in a variety of ways; the most useful and frequently used was the optimistic style of coping. While religious beliefs had an influence, factors significantly associated with coping included caregiver education and employment and patient psychopathology. Providing support to carers of patients with schizophrenia and enhancing their coping is an essential part of quality clinical care. Spirituality and religion can serve as a positive coping strategy.