Journal of Psychiatrists' Association of Nepal

Child sexual abuse: Need of discussion amongst mental health experts

Pawan Sharma — 2023-10-23

Not available.

Blurred boundaries of the brain-1 (Aide-memoire for patient narrative)

Ashish Dutta — 2023-10-23

Background: This is a case series of clinical cases presenting to our Neuropsychiatry Center, who were either referred by physicians or approached to seek treatment on their own. They were receiving treatment since few years. No improvement in symptom were primary reason for referral and consultation with our team. Re-evaluation in realms of Neurology and Psychiatry depicted the missed link in diagnostic and therapeutic approaches exercised previously. The intent to reflect upon novel findings is not to undermine the effort applied in clinical evaluation by prior physicians, but to reflect few observations which may have been inadvertently missed during routine assessment. This serves as as an aide-memoire to history taking and suggestions to remain well informed and updated in our approach to service seekers.

Abstract: Symptom overlap and comorbidities are commonly encountered in clinical practice of Psychiatry or Neurology. Many neurologic disorders have psychiatric symptoms (e.g., depression in patients following a stroke or with multiple sclerosis or Parkinson’s disease), and many psychiatric disorders have been associated with neurologic symptoms (e.g., movement disorders in schizophrenia).

This overlap occurs mostly because brain is the source common for both neurological and psychiatric illness and on multiple occasion it becomes difficult to delineate the boundary, leading to diagnostic dilemmas, followed by inappropriate management strategies. Patients and family members suffer for long periods of time in trying to understand the disease phenomenon and prognosis.

In this case series, we present 3 cases of clinical interest across different framework of clinical presentation and assessment for e.g, neurological illness being managed as psychiatric illness or scenarios where both neurological and psychiatric illness coexisted but only one aspect was addressed. Re-assessment and work up by a team of neurologists and psychiatrist lead to clarification of the boundaries (at least in these cases who underwent prolonged sufferings owing to lack in clarity of pathology) with precise diagnosis generating improved outcomes in functionality and satisfaction.

The diagnosis of neuropsychiatric disorders is performed by psychiatrists through diagnostic interviews, and categorization of patients based on diagnostic and classification manual (ICD-10, DSM-5) which are syndrome/symptom based. Although this has been a standard practice, often error may occur in diagnosing illnesses falling under the wider realm of neurology and psychiatry. Some presenting symptoms may be assumed being part of neurological illness or of functional origin, or mixed states and many may be overlooked during routine clinical assessment.

Successful treatment of habit cough using suggestion therapy

Pawan Sharma — 2023-10-23

Background: Habit cough is one of the causes of chronic cough in children. Many cases do not reach the psychiatrists due to lack of specific clinical features and diagnostic tests. We present a case of 13 year old boy with habit cough who was successfully treated by suggestion therapy and lignocaine based mouth gargle as a distracter. This case highlights that suggestion therapy can be an important treatment option to this fairly common condition.

Effectiveness of group cognitive behavioral intervention in reducing test anxiety among psychology undergraduates in Kathmandu, Nepal

Khem Raj Bhatta — 2023-10-23

Background: High test anxiety negatively impacts students, affecting academic performance, well-being, focus, and retention rates. Cognitive Behavioral Therapy (CBT) is a promising approach to reducing test anxiety, and we aimed to assess the effectiveness of group-based CBT in reducing test anxiety among undergraduate students.

Material and Method: This experimental, independent two-group design enrolled 80 test-anxious participants, randomly assigning them to a control or intervention group (40 participants each). Westside Test Anxiety Scale was the primary outcome measure, and participant's feedback was collected. The intervention group received ten sessions of group-based CBT. Baseline and endline data were analyzed, and effect size was reported.

Results: Participant feedback was analyzed qualitatively. The intervention group demonstrated 16% reduction in test anxiety score from their baseline, while the control group showed only 5.54% reduction from their baseline. In contrast, the control group showed a 2-point reduction, representing a 5.54% decrease. This difference was statistically significant (effect size= -0.53), supporting moderate effectiveness. Further, scores in specific test anxiety areas, such as worry about forgetting during the study and performance after exams, showed notable improvement. Participant feedback highlighted improved stress management, self-awareness, and understanding of emotions. Suggestions incorporating visual aids and increasing interactivity for the future.

Conclusion: This study demonstrates utility of group-based CBT in reducing test anxiety among undergraduate students. A larger scale randomized controlled trial is needed to evaluate the effectiveness of group CBT in a larger population, and future studies can focus on examining the effect of group CBT delivered by non-specialists in a broader population.

Prevalence of smoking among psychiatric patients in outpatient department of tertiary care centre: A descriptive cross-sectional study

Sandesh Sharma — 2023-10-23

Background: Even though psychiatric illness is a risk factor of smoking tobacco; only few studies have been conducted to estimate the prevalence of smoking among that patient group in Nepal. Our study aims to determine the prevalence of smoking among psychiatric patients in the outpatient department of tertiary care centre.

Material and Method: A descriptive cross-sectional study was conducted in the psychiatric outpatient department of a tertiary care centre from 27th March to 27th May, 2022 following ethical approval from the Institutional Review Committee (Reference number: 577/078-079). A convenience sampling technique was used to include 398 patients, who were assessed for tobacco use behaviour using a semi-structured questionnaire and nicotine dependence using the Fagerstrom Test for Nicotine Dependence instrument. Data was collected using the “KoBo toolbox” Android mobile application and analysed using Microsoft Excel, Statistical Package for Social Sciences version 25.0, and R Studio. Point estimates and 95% confidence intervals were calculated.

Results: The prevalence of current smokers was 104 (26.13%) (21.88-30.74 at 95%CI). The prevalence of past smokers was 48 (12.06%) (9.03-15.67 at 95% CI). Nicotine dependence was present in 75(72.12%) of the 104 current smokers and 40 (83.33%) among 48 past smokers.

Conclusion: Our study found a lower prevalence of smoking among participants compared to other similar studies conducted at the national level.

Pattern of psychiatric referral in a tertiary care hospital

Ajita Paudel — 2023-10-23

Introduction: Global mental health challenges persist amidst a rising trend of patients seeking consultations with non-psychiatric specialists, driven by stigma and a lack of awareness. This study aims to study the demographic profile of patients referred to the Department of Psychiatry and Mental Health from other departments, referral sources, prevalent psychiatric disorders, and explores potential associations with co-existing physical conditions.

Material and Method: A six-month descriptive cross-sectional study (October 2022 to March 2023) was done at Birat Medical College Teaching Hospital using total enumeration sampling method. Patients referred to Psychiatry were assessed using the International Classification of Diseases, Tenth Revision, Diagnostic Criteria for Research (ICD-10 DCR). Data were analyzed with SPSS version 25, utilizing mean, standard deviation for continuous data, and frequency, percentage for categorical data. Odds ratios were computed for associations.

Results: Among 160 patients, the majority were male (55%), Hindu (90%), married (78.1%), and educated up to secondary level. Department of Medicine accounted for the highest referrals (50%) primarily for fearfulness (21.3%). Neurotic, stress-related and somatoform disorders were most common (33.1%), followed by mood disorders (28.8%). No significant association was found between psychiatric disorders and physical illnesses.

Conclusion: The Department of Medicine was the most common referring department, with neurotic stress-related and somatoform disorders being the prevalent diagnosis. Referral to Psychiatry facilitates early recognition and treatment of undiagnosed psychiatric conditions, advocating for routine practice among non-psychiatric specialists. Future research should target barriers and interventions to improve psychiatric service utilization in Consultation-Liaison Psychiatry settings.

Mental health problems, perceived stress, and internet addiction among undergraduate college students of Kathmandu, Nepal

Pawan Sharma — 2023-10-23

Introduction: The global burden of disease due to mental health problems is on a rise. One of the vulnerable groups are college going youths. The objective of the current study was to examine the frequency and pattern of mental health problems, perceived stress, and internet addiction and explore their relationship with each other among students reporting voluntarily during stress management program.

Material and method: A cross-sectional study among 139 undergraduate students was conducted as a part of a program titled "Stress, drugs and internet among college students" during orientation program for undergraduate students of a management college in Kathmandu Valley. Mental Health Screening Questionnaire (MHS), Young's Internet addiction test (YIAT), perceived stress scale (PSS) were used for mental health problems, internet addiction and stress respectively.

Results: As per mental health screening questionnaire, 64.7% (90/139) and 7.2% (10/139) participants reported somewhat difficulty and very much or extreme difficulty. There was mild internet addiction among 45.3% and moderate internet addiction among 18.7%. There was significant positive correlation of the MHS score (indicative of number of mental health problems) with the total YIAT score (ρ= 0.404, p< 0.01) and PSS scores (ρ= 0.301, p< 0.01). Also, severity of internet addiction and perceived stress levels were positively associated with each other (ρ= 0.303, p< 0.01).

Conclusion: There is significant burden of mental health problems, stress and problematic internet use among the undergraduate students in Nepal. There is also a significant positive correlation of the MHS score (indicative of number of mental health problems) with the Young’s internet addiction test score and perceived stress scale scores.

Burnout and mental health problems among health care workers during second wave of Covid-19 pandemic: A hospital based cross sectional study

Nirajan Bhattarai — 2023-10-23

Background: Large number of healthcare workers exposed to COVID-19 might be at increased risk of developing mental and psychological disorders. This study aimed to find out the prevalence of burnout, depression, anxiety and stress and its correlates.

Methods: This was hospital based cross-sectional study using printed Questionnaire conducted during second wave of COVID-19. Total 96 healthcare workers participated in this study. Depression Anxiety Stress Scale (DASS-21) and Copenhagen Burnout Inventory (CBI) were used to measure study variables. Multivariable logistic regression analysis was done to determine the associate factors.

Results: The symptoms of depression, anxiety and stress were found to be 31.3%, 40.6 % and 14.6 % respectively. Doctors were 5.2 and 6 fold more likely to experience anxiety and depression respectively. The prevalence of personal, work, and client-related burnout were 43.7%, 31.3% and 14.6% respectively. Younger healthcare workers (HCWs) less than 27 years were 3.5 fold more likely to develop personal burnout. Healthcare workers who had worked for more than 100 hours/week were 5 times more likely to experience personal burnout. Doctors and nurses were 7.9 and 3.5 times more likely to develop work related burnout. Personal, work and client related burnout were significantly correlated with anxiety.

Conclusion: This study finds considerate proportion of burnout, depression, anxiety and stress among HCWs. Doctors and younger HCWs with increased working hours had high level of these symptoms. Early identification of mental health disorders and awareness intervention could increase the efficiency and quality of care.

Recent advances in the treatment of attention deficit hyperactivity disorder in children: A narrative review

Omkar Dhungel — 2023-10-23

Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder characterized by age inappropriate levels of inattention, and or impulsivity and hyperactivity. Often arising in childhood, ADHD can also be chronic in nature, frequently continuing through adolescence and beyond, at least at the level of impairment. The early accurate diagnosis of the condition is possible based on clinic settings, clinicians’ expertise; and the context at which screening and evaluation of this population for ADHD is done. ADHD is an etiologically complex neurodevelopmental disorder that begins early in life and has heterogeneous clinical manifestations encompassing a broader spectrum of psychopathology. This underscores the importance of early accurate diagnosis so that effective treatments can be started that significantly reduces immediate and long-term psychosocial burdens. Effective ADHD
treatments are available and cognitive neuroscience is rapidly expanding, however there is a significant gap between empirical evidence and clinical practice. Multimodal and multidisciplinary treatment strategies are the best approach in the treatment, but there is a significant gap between the knowledge and practice, such that evidence-based treatments are often not implemented in the community settings. How we implement such in our clinical practice helps us to advocate and advance towards more effective ADHD treatments. There is growing scientific progress in understanding the causes and treatment of ADHD. Knowledge about the evidence-based recent advances in the treatment helps mental health professionals to advocate for the effective approaches to treat ADHD, with minimal unwanted side effects.

Exploring the role of nutrition in mental health: A narrative review

Neeti Bhat — 2023-10-23

Global burden of disease 2020 indicates that unipolar depression contributes the second most to increased DALY (disability-adjusted life years) worldwide, but it wasn't even on the top fifteen list in the 1990s. While some mental health problems may warrant pharmacological intervention, non-drug lifestyle behaviors also popularly known as lifestyle medicine and mental health tools present a promising avenue for mitigating depressive symptoms. Lifestyle psychiatry, a growing field pertains to lifestyle pillars such as diet, physical activity, stress, and sleep and their role in psychiatric disorders. Nutrition, a fundamental core in lifestyle medicine, presides over virtually all chronic diseases. Describing nutrition and mental health is challenging, and studies of their interactions are even more complex. Nevertheless, gut microdata are critical to understanding this relationship. Thus, this narrative review aims to unravel the role of nutrition in the context of selected mental disorders. Simultaneously, it aims to empower practitioners and readers of Nepal to make informed lifestyle decisions regarding their nutritional choices. Additionally, it seeks to play as well as play a contributory role in the advancement of nutritional psychiatry as a discipline.