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   Table of Contents - Current issue
May-June 2019
Volume 61 | Issue 3
Page Nos. 225-324

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Chatbots in psychiatry: Can treatment gap be lessened for psychiatric disorders in India p. 225
Om Prakash Singh
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Methodologies and skills in child and adolescent mental health, psychosocial care, and protection: A repository of training and intervention materials p. 226
Sheila Ramaswamy, Shekhar Seshadri
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Relative effectiveness of N-acetylcysteine and baclofen as anticraving agents in cannabis dependence – A retrospective study with telephonic follow-up Highly accessed article p. 228
Venkata Lakshmi Narasimha, Lekhansh Shukla, R P S Shyam, Arun Kandasamy, Vivek Benegal
Background: Cannabis dependence is associated with psychiatric, social, and legal consequences. Currently, there is no approved pharmacological treatment for cannabis dependence. Recent studies have reported the utility of N-acetylcysteine (NAC) and baclofen (BAC) in the long-term treatment of cannabis dependence, primarily as anticraving agents. Materials and Methods: We reviewed the records of all patients who received inpatient treatment during 2015–2017 for cannabis dependence syndrome. We included cases only if cannabis dependence was noted as the primary focus for seeking inpatient care. Data are collected up to 6 months following discharge and analyzed using Kaplan–Meier survival analysis. The time to the first use of cannabis (in days) following discharge is compared between three groups – psychosocial intervention (PSI) only, BAC in addition to PSI, and NAC in addition to PSI. Results: During the study period, 238 inpatients were diagnosed with cannabis dependence syndrome. However, cannabis dependence was the primary focus of treatment in only 72 patients. Among these patients, 29 (40.2%) received PSI only while 25 (34.8%) received BAC (mean dose = 55 mg per day, standard deviation [SD] = 2.5 mg) and 18 (25%) received NAC (mean dose = 1800 mg per day, SD = 500 mg) in addition to PSI. While 47 (62.5%) of the patients had comorbid psychiatric disorders, it was comparably distributed in the three groups. A survival analysis shows that the probability of cannabis-free survival is significantly higher in the NAC group as compared to the BAC group which is in turn higher than the PSI group (χ2 = 12.1, P= 0.002). Conclusion: The use of anticraving medications, namely BAC and NAC, may be a useful option along with PSIs in patients with cannabis dependence and requires further exploration.
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Assessment of prevalence of attention deficit hyperactivity disorder among schoolchildren in selected schools p. 232
T Golden Catherine, Nancy Grace Robert, K Kanchana Mala, C Kanniammal, Judie Arullapan
Background: Attention deficit hyperactivity disorder (ADHD) is considered the most common neurodevelopmental disorder of childhood and can continue through adolescence and adulthood. Global impairment in children with ADHD increases with increasing number of concurrent disorders. The presence of ADHD in childhood increases the likelihood of additional difficulties in academic performance, social interactions, and low self-esteem developing into adolescents and young adults. Aims: The study aims to (i) to determine the prevalence of ADHD among schoolchildren at selected schools in Kancheepuram district, (ii) to find the agreement between parent and teacher reports, and (iii) to associate the prevalence of ADHD among schoolchildren with their selected demographic variables. Settings and Design: A quantitative research approach with cross-sectional research design was adopted for the study. The study focused on primary schoolchildren from the selected schools in Kancheepuram district. Materials and Methods: Totally 3253 children aged between 8 and 11 years were enumerated from the selected six schools in Kancheepuram district after obtaining informed consent from their caregivers. The presence of ADHD was assessed using Conners' Teacher–Parent Rating Scale given to caregivers and teachers and confirmed with the Diagnostic and Statistical Manual of Mental Disorders-5 criteria for ADHD. Results: The analysis revealed the overall prevalence of ADHD to be 8.8%. The subtypes of ADHD were categorized as 124 (43.3%) for inattentive type, 124 (43.3%) for hyperactive type, and 38 (13.2%) for combined type of ADHD. Conclusion: The present study shows a high prevalence of ADHD among primary schoolchildren.
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Mortality in schizophrenia: A study of verbal autopsy from cohorts of two rural communities of South India p. 238
Narayana Manjunatha, C Naveen Kumar, Jagadisha Thirthalli, KK Suresha, DM Harisha, Udupi Arunachala
Background: Schizophrenia is a life-shortening disease. Although the rate of mortality of persons with schizophrenia in India is established to be more compared to that in the general population, there is a little exploration of the causes for the same. Aim: The aim of this study is to explore the causes of death in two rural cohorts of schizophrenia. Materials and Methods: In-person interviews of primary caregivers of 53 deceased persons with schizophrenia were conducted using the World Health Organization's verbal autopsy 2014 instrument. Physician-based method was used to determine the causes of death. Results: Average age of 53 deceased schizophrenia patients was 50.45 ± 13.65 years with almost equal gender ratio. Just more than two-thirds of patients were married, just more than one-third are educated up to primary school and also had no formal education each. Noncommunicable diseases (NCDs) were the most common causes of death (30, 56.6%) in this sample, followed by communicable disease (7, 13.2%), and then unnatural deaths (suicide – 8, 15%, and road traffic accidents – 3, 5.6%). Conclusions: It is the first study in India to explore the causes of death in schizophrenia. NCDs being the most common cause of death in schizophrenia suggests to the need of integration of schizophrenia care into general health care.
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Young psychiatrists' opinion on the activities of Indian Psychiatric Society: A survey under the aegis of Research, Education, and Training Foundation of Indian Psychiatric Society p. 244
Sandeep Grover, Swapnajeet Sahoo, Balachander Srinivas, Adarsh Tripathi, Ajit Avasthi
Aim: The aim of the study is to assess the opinion of young psychiatrists (aged ≤45 years) about the various scientific activities of Indian Psychiatric Society (IPS). Materials and Methods: An online survey using SurveyMonkey electronic platform was conducted. Data of 350 participants were available for analysis. Results: The mean age of the participants (spread across 115 institutes/medical colleges) was 33.61 (standard deviation [SD] – 5.32) years and their mean number of years of experience in psychiatry including the training period was 8.25 (SD – 5.5) years. About 70% of the participants (n = 243) rated the current format of the Annual National Conference of the IPS (ANCIPS) to be “good/very good,” and more than half of the participants agreed that the conferences at the zonal and state level help in enhancing the academic knowledge of the participants as well as such activities help in enhancing the social interaction among fellow colleagues. Among the various scientific sessions of the ANCIPS, workshops and guest lectures were rated as very useful by three-fifth of the participants. Regarding opinion in terms of changes required in the current format of the ANCIPS and other conferences/continuing medical educations (CMEs) being conducted by IPS, more than half to about two-third of the participants reported that having more hands-on workshops, having sessions like meet the experts, having mentorship programs, and more expert speakers from India will “definitely” be useful. Majority of the participants expressed that reduction of concurrent sessions would be definitely be beneficial. In terms of modification of ongoing activities and introduction of new activities, about two-third of the participants expressed that having IPS supported travel fellowship programs within the country and abroad, having subject/topic-focused conferences, and starting online CMEs will be definitely be useful. Conclusions: The present survey reflects that there is a need to have more subject/topic-focused conferences/CMEs, need to introduce online CME activities, reduction of concurrent sessions during the conferences and strengthening the travel fellowship programs. All these can be considered as expectations of the young generation of psychiatrists from the organization like IPS, which should be duly considered while planning future conferences and CMEs.
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Catechol-O-Methyltransferase Val158Met and brain-derived neurotrophic factor Val66Met gene polymorphisms in paraphilic sexual offenders p. 253
Mujgan Cengiz, Esma Cezayirli, Burcu Bayoglu, Hizir Asliyuksek, Nese Kocabasoglu
Background: Child sexual abuse (CSA) is an important problem worldwide. The reason of sex abuse is considered as multifactorial. Genetic contribution reported by recent studies is a significant evidence for this pathologic behavior. Catechol-O-Methyltransferase (COMT) is an enzyme in the metabolic inactivation of catecholamine and substances containing catecholamines such as dopamine, epinephrine, and norepinephrine. COMT polymorphism causes functional changes in COMT enzyme activity. Brain-derived neurotrophic factor (BDNF) is a neurotrophic factor usually synthesized from central nervous system neurons. With the effect of BDNF, dopamine and serotonin play important roles on neurogenesis, survival, and synaptic plasticity. Aim: This study aims to examine COMT Val158Met (rs4680) and BDNF Val66Met (rs6265) polymorphisms in CSA. Settings and Design: This was a case–control study. Materials and Methods: Seventy paraphilic child sexual abuser patients and seventy age- and gender-matched healthy controls participated in this study. COMT Val158Met and BDNF Val66Met polymorphisms were genotyped by real-time polymerase chain reaction assay. Results: COMT Val158Met genotype frequencies were determined as GG 31.4%, GA 45.7%, and AA 22.9% in patients; GG 24.3%, GA 45.7%, and AA 8.6% in controls; and exhibited a positive relationship between the groups (P = 0.018). BDNF Val66Met genotype frequencies were determined as GG 77.1%, GA 21.4%, and AA 1.4% in patients; GG 65.7%, GA 31.4%, AA 2.9% in controls; and no significant relationship was observed between the groups (P = 0.317). Conclusions: This research investigated COMT (Val158Met) and BDNF (Val66Met) in paraphilic child sexual offenders. A positive relationship was found for COMT gene; however, no significant relation was observed for BDNF gene between paraphilic sexual offenders and controls.
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Comparison of efficacy of ketamine versus thiopentone-assisted modified electroconvulsive therapy in major depression p. 258
Amit Jagtiani, Hitesh Khurana, Naveen Malhotra
Background: It is well known that depression improves faster with electroconvulsive treatment (ECT) than with antidepressant medications. N-methyl-D-aspartate-receptor antagonists (ketamine) have been shown to have rapid antidepressant effects when given as an intravenous infusion. Faster recovery with ECT is likely when used with ketamine as anesthetic. Aim: The aim of the study is to compare the outcome of modified electroconvulsive therapy (MECT) in major depressive disorder patients undergoing MECT with ketamine versus thiopentone anesthesia. Materials and Methods: Sixty hospitalized patients (age: 18–45 years) with major depressive disorder (Diagnostic and Statistical Manual of Mental Disorders-IV Text Revision) were randomly allocated to either of the two MECT groups (30 patients each) receiving ketamine or thiopentone as anesthetic agent. The participants were assessed on a weekly basis on Hamilton Rating Scale for Depression (HAM-D) and Beck Depression Inventory (BDI). Results: Ketamine group required significantly lesser number of MECT sessions for achieving remission and had rapid improvement in HAM-D and BDI scores compared to the thiopentone group. Furthermore, the stimulus intensity required to elicit seizures was significantly less and seizure duration was longer in ketamine group compared to the thiopentone group. Conclusion: The use of ketamine for anesthesia led to rapid recovery from depressive symptoms and seems to be a better option for depressive patients, especially when a rapid response is desired.
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Internet addiction and daytime sleepiness among professionals in India: A web-based survey p. 265
Lokesh Kumar Singh, K Hari Hara Suchandra, Amrit Pattajoshi, Spoorthy Sai Mamidipalli, Huma Kamal, Sharda Singh, Bhoomika Sachacher, Varun Mehta
Background: The likelihood of the relation between Internet overuse and comorbid psychiatric conditions is on the rise. However, sleep disturbances are common psychiatric symptoms associated with internet overuse. Our objective was to examine the association of Internet overuse with excessive daytime sleepiness, sleep problems in professionals from India. Materials and Methods: This was a web-based cross-sectional study through a predesigned questionnaire which included various professional groups. The information included in the questionnaire was sociodemographic details, Young's internet addiction test (IAT) and Epworth sleepiness scale (ESS). Results: About 1.0% of total sample population had severe internet addiction whereas 13% were in the range of moderate internet addiction and the mean score on IAT was found to be 32 (standard deviation [SD] = 16.42). The mean duration of total night time sleep (5.61 ± 1.17) is significantly lower in participants with moderate and severe internet addiction (6.98 ± 1.12) compared to those with no and mild internet addiction. The mean scores of ESS were significantly higher in individuals with moderate and severe addiction (M = 10.64, SD = 4.79). We found that sleepiness while in 5 of the situations such as driving a car (χ2 = 27.67; P < 0.001), sitting and reading (χ2 = 13.6; P = 0.004), traveling in a car (χ2 = 15.09; P = 0.002), afternoon rest time (χ2 = 15.75; P = 0.001), and postlunch quiet time (χ2 = 24.09; P < 0.001), predicted membership to moderate-to-severe internet addiction, even after controlling for the confounding effects of age and gender. Conclusions: This study shows an association between Internet overuse, excessive daytime sleepiness, and other sleep problems. Clinicians should be proactive and conscious in scrutinizing the patients for internet addiction and its consequences.
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Assessment of cotinine in urine and saliva of smokers, passive smokers, and nonsmokers: Method validation using liquid chromatography and mass spectrometry p. 270
Priyamvada Sharma, Niharika Sane, Shravanthi D Anand, P Marimutthu, Vivek Benegal
Background: Self-report does not provide complete information about tobacco smoke exposure among users and is not relevant for secondhand exposure detection. Biochemical screening for primary metabolite of nicotine would be useful to validate the smoking status and exposure to secondhand smoke. Aims and Objectives: This study was designed to evaluate the performance of a sensitive and rapid method to verify smoking status among smokers, passive smokers, and nonsmokers by quantification of cotinine in saliva and urine using liquid chromatography and mass spectrometry. Materials and Methods: Cotinine (urine and saliva) levels were measured in 98 participants out of which active users (smoked tobacco users; n = 56) and persons exposed to tobacco smoke (passive smokers; n = 15). Values obtained were compared with nonusers (nonsmokers; n = 27). A simple, rapid, and sensitive method was developed and validated for this purpose. With minimal sample preparation, the current analytical procedure showed a wide detection range (1.1–1000 ng/mL) which made it suitable for analyzing various biological matrices. Results: The mean cotinine levels of urine for smokers, passive smokers, and nonsmokers were 1043.7, 36.63, and 13.6 ng/ml, respectively, while in saliva, it was 327.39, 18.31, and 9.53 ng/ml, respectively. Conclusion: Analysis of variance showed that cotinine levels (urine and saliva) of smokers were significantly higher levels than passive smokers and nonsmokers (P < 0.01). Similarly, passive smokers also had significantly higher cotinine levels (urine and saliva) than nonsmokers (P < 0.001).
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Depression in caregivers of patients with breast cancer: A cross-sectional study from a cancer research center in South India p. 277
Sreeja Sahadevan, Vasudevan Namboodiri
Context: Existing literature suggests an alarming rate of depression in cancer caregivers, which is comparable to or even higher than in patients themselves. There are no studies on depression among caregivers of breast cancer from India. Aims: The aim is to study the prevalence and determinants of depression in caregivers of breast cancer. Settings and Design: This is a cross-sectional study of 384 patient-caregiver dyads at a cancer research center in South India. Materials and Methods: Based on the International Classification of Diseases, 10th Revision Diagnostic Criteria for Research depression was diagnosed, and the severity of depression was assessed using the Hamilton rating scale for depression. A semi-structured pro forma was used to collect the clinical data under patient, caregivers, and care characteristics. Results: The prevalence of depression in caregivers was 52.5%. Among them, 35% had mild depression, 16% had moderate depression, and 2% had severe depression. Spousal caregivers, those who resided with the patient, those providing financial support and those with noncaring domestic responsibilities appeared as vulnerable determinants in univariate analysis. However, multivariate analysis did not support the same. Conclusion: Depression is common among caregivers of patients with breast cancer. There is a need for focused interventions for this group, which may improve the outcome of the patient as well.
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A cross-sectional study to assess the association between major depression and inflammatory markers in patients with acute ischemic stroke p. 283
Hasan Huseyin Kozak, Faruk Uǧuz, İbrahim Kılınç, Ali Ulvi Uca, Osman Serhat Tokgöz, Figen Güney, Nejla Özer
Background: Increased interest in the relationship between affective disorder and long-term health consequences has generated recent examinations of depression and stroke. Observations suggest that depressive disorder is associated with abnormal physiological and immunological responses and a resultant increase in inflammatory markers. Given the high prevalence of stroke and associated costs for the community, it is important to understand the mechanisms that may impact on the outcome to achieve the best possible prognosis. Aims: The view that inflammatory factors contribute to depression is predicated on findings that circulating cytokines and other inflammatory factors are increased in depressed patients. Therefore, it has been hypothesized that inflammation could be one of the mechanisms by which depression increases risk for ischemic stroke. Our aim was to determine whether there is any relationship between major depression and tumor necrosis factor-alpha (TNF-α), interleukin-1 beta (IL-1β), IL-18, brain-derived neurotrophic factor (BDNF), and neuron-specific enolase (NSE) in patients with acute ischemic stroke (AIS). Study Design: This was as a cross-sectional design. Materials and Methods: This study has a cross-sectional design, and it was conducted in Necmettin Erbakan University, the Meram Faculty of Medicine in Konya, Turkey, between 2014 and 2015. Fifty-three AIS patients admitted to the hospital within the first 24 h after stroke onset were recruited. Major depression was ascertained by means of the structured clinical interview for the diagnostic and statistical manual of mental disorders, Fourth Edition/Clinical Version. The enzyme-linked immunosorbent assay was used to measure the serum levels of TNF-α, IL-1 β, IL-18, BDNF, and NSE at admission. Results: A total of 53 patients with a mean age of 65.9 years were recruited. Of these patients, 17 (32.1%) had major depression. Depressive and nondepressive patients had similar demographical and clinical features. There was no significant statistical difference between depressive and nondepressive patients with AIS with respect to levels of TNF-α, IL-1 β, IL-18, BDNF, and NSE. Conclusion: This study suggests that in patients who have experienced AIS, there is no significant relationship between major depression and basal proinflammatory cytokines (TNF-α, IL-1 β, IL-18), BDNF, and NSE.
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Sample attrition rate of a community study: An analysis of Lucknow urban and rural elderly follow-up over a period of 9 years p. 290
Bhupendra Singh, Nisha Mani Pandey, RK Garg, Neera Kohli, Kausar Usman, GG Agarwal, Sarvada Chandra Tiwari
Background: Longitudinal/ follow-up studies of older adults are a tough task as sample attrition rates due to mortality and other factors may be high in this particular group. However, such studies are very much needed to assess the outcome of health status as well as explore preventive, protective, interventional aspects, as well as risk factors. Given this, a follow-up study was planned and carried out. Aim: To discuss the rate of sample loss as well as the reasons over 9 years. Methods: An Indian Council of Medical Research (ICMR) supported follow-up study of urban and rural elderly was done during June, 2016–May, 2017; these subjects were studied in 2007-09 through two independent ICMR supported studies. Similar methodology and assessment tools were applied in these studies. During follow-up a semi structured proforma was developed to get the information of study cohort, obtained data was analyzed and presented applying percentage statistics. Results: The sample attrition rate was reported to be comparatively high in urban 52.1% (n= 633) cohort than their rural counterparts 36.3% (n= 457). Conclusion: Over a period of 9 years chances of cohort loss due to mortality is about 32%–35%.
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Measuring reliability and validity of “Stressometer®”: A computer-based mass screening and assessment tool for evaluation of stress level and sources of stressors p. 295
Sandeep Vohra, Angela Swilley Kelling, Mrinal Mugdh Varma, Anand Prakash, Divyani Khurana
Introduction: It is essential to develop tools that can identify stress manifestation, source of stressors, and suffering in an effort to bridge the treatment gap and enhance behavioral health in the developing world. To that aim, the Stressometer® (SOM) was developed as a comprehensive scale of stress and behavioral health for use around the world. Materials and Methods: A validation study of the Stressometer® (SOM) was undertaken with a sample in India that included a nonclinical group and a group of patients at a clinic in New Delhi. For validation purposes, participants were also administered three currently validated scales, including Perceived Stress Scale, Stress Overload Scale (SOS), and Depression Anxiety Stress Scale (DASS). Results: The Stressometer® (SOM) was found to be reliable and had high correlations with established scales. Conclusion: Stressometer® (SOM) is a valid and reliable, computer based mass screening tool for evaluation of stress level and sources of stress. Overall, Stressometer® (SOM) creates a robust measurement of stress and behavioral health that is likely culturally neutral and thus has universal applicability. A scale such as this one is ideal for use in the developing world to help bridge the treatment gap created and enhance behavioral health, especially in those suffering.
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Assessment and management of pediatric depression p. 300
Suravi Patra
Pediatric depression is difficult to identify and manage because of complex nature of the disorder. Psychological and cognitive developments impact the clinical presentation and often make assessment tenuous. In addition, the disorder is often associated with multiple biological, psychological, and environmental risk factors, which need thorough assessment. Clinical presentation varies from subsyndromal depression to depression with psychotic features. Although diagnostic criteria for depression remain the same for children; deciphering symptoms need specialized clinical training. This article discusses identification and assessment of depression in the pediatric population. Specialized interviewing techniques pertaining to assessment in this unique population are discussed. Evidence-based guidelines for management of pediatric depression in terms of both pharmacotherapy and psychotherapy are also enumerated. Choice of medication based on multiple parameters with available evidence base is discussed. Treatment planning and continued evaluation on long-term basis are also elaborated.
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Haloperidol-related neutropenia p. 307
Ebru Sahan
Phenothiazines like antipsychotics have been known to cause neutropenia, but this has been reported very rarely with haloperidol. A 20-year-old male patient admitted to emergency service (emergency room) with shortness of breath, chest pain, and anger. He was diagnosed with pneumonia and prescribed moxifloxacin. After 2 days with antibiotic, he readmitted. Left lung pneumothorax was detected, and thorax computerized tomography was requested. However, he opposed and beated one of the hospital officials. The diagnosis of manic episode due to antibiotic moxifloxacin was considered. The tube thoracostomy had to be done, and antibiotic therapy was stopped. Haloperidol 10 mg/day and biperiden 4 mg/day injections were administered because he continued to resist medical interventions. After haloperidol, his leukocyte count decreased. He responded well to filgrastim (Neupogen) and blood transfusions, so a drug-related cause of neutropenia has been suspected. He was switched from haloperidol to quetiapine 300 mg twice a day. His white blood cell count returned to normal levels.
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Risperidone as an effective choice for obsessive–compulsive symptoms and tardive dyskinesia in an Indian quadragenarian with schizo-obsessive disorder p. 311
Ajita S Nayak, Heena H Merchant, Hrishikesh B Nachane, Aditya R Anvekar
Tardive dyskinesia (TD) is a chronic, stigmatizing side effect of typical and atypical antipsychotics that is often debilitating for the patient and resistant to treatment. Obsessive–compulsive symptoms (OCS) may arise at any stage of schizophrenia ranging from prodrome to posttreatment and carry a poor prognosis. Management of both the conditions is a challenging and often fatiguing task for the treating physician. We report a case of schizo-obsessive disorder in an Indian quadragenarian who had developed TD with olanzapine and had failed to show improvement with clozapine and quetiapine. The patient improved dramatically with risperidone. Our findings corroborate with previous literature which has shown risperidone to be effective in treatment of TD and obsessive symptoms, possibly due to its action on the serotonergic system. The authors conclude that risperidone is an effective choice to treat TD and comorbid OCS in patients with schizophrenia.
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Blood urea levels associated to antidepressant drug treatment: Role of nitrogen and nitric oxide p. 314
Roberto Lozano, Reyes Marín, María-Jesús Santacruz, Alberto-José Frutos
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Rapidly progressive dementia in a case of progressive multifocal leukoencephalopathy p. 315
Partha Pratim Daimary, Soumitra Das, Seshadri Sekhar Chatterjee, Rammohan Krishnapillai
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A case of pathological gambling p. 316
Neha Sharma, Anindya Kumar Gupta, T Hannah Jane
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Escitalopram-induced extrapyramidal symptoms p. 318
Pattath Narayanan Suresh Kumar, Arun Gopala Krishnan, Rohith Suresh
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Integrating mental health into primary care for addressing depression in a rural population: An experience from North India p. 319
MA Bashar, Aseem Mehra, Arun K Aggarwal
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Golden Brown Jubilee: 25 Years of Trainspotting by Irvine Welsh p. 322
Ashutosh Ratnam
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