An eminent psychiatrist with about four decades of clinical experience in the field of Psychiatry; received his masters from Christian Medical College, Vellore. He served in many prominent positions for Indian Association of Private Psychiatry, Indian Association of Biological Psychiatry, Asian Network of Bipolar Disorders and Asian association of neuro- psychopharmacology and was editor of Indian Journal of Psychological Medicine for about a decade. He is currently the secretary of Society for Bipolar Disorders, India.
He did his diploma and masters from Christian Medical College, Vellore. He is currently the assistant editor of Indian Journal of Psychological Medicine. While practicing general psychiatry, he specially focuses on mood disorders, sexual medicine.
Dr. Swetha Reddy received her master’s degree in psychiatry from The National Board of Examinations, New Delhi. Along with general psychiatry, she has special interests in mood disorders and OCD
She is a health psychologist, graduated from Center for Health Psychology, University of Hyderabad. She intensively works with patients suffering from mood and anxiety disorders.
She is a graduate in psychology possessing professional and therapeutic skills in counseling and administering neuro-psychological assessments. She perused her master’s degree in clinical psychology with specialization in neuro- psychology at The University of Texas At Tylor, USA.
She is a trained counselor from Christian Counseling Centre Vellore, with experience of supervised counseling in grief from Christian Medical College, Vellore. She has masters in clinical psychology from IGNOU and masters in family and marriage counseling from Osmania University.
BD is a major psychiatric disorder affecting about 1% of population, with equal risk in males and females, with first episode of illness occurring at 15-30 years age in about 40%.
Bipolar Disorder (BD) is The Most Unique Disorder, one and only one of its kind in the Diagnostic literature of science of Medicine, with clinical symptom profile of opposite poles (“Depression” with extreme sadness, dullness & “Mania” with extreme happiness and enthusiasm) described under one single entity of a Disorder! No other disorder in Medical Science has this polar variation of symptomatic presentational structure, under a single diagnostic entity!!!
For many reasons, it may take years to diagnose bipolar disorder. As an example, a person may have multiple episodes of depression which is treated with the diagnosis of Recurrent Depressive Disorder. Perfectly correct. Later, may be after many years, if the patient develops a manic episode the diagnosis gets revised as Bipolar Disorder.
1. RECOVERY: Symptomatic recovery of the current episode - of any polarity, any degree of severity, any duration, at any age – is the immediate goal. Patient must recover from the current episode (a norm in about 80-90% patients). Minimal Polypharmacy is the chosen path. Patient’s complete recovery from the present episode has two important spin offs – 1. Short term - Patient is asymptomatic 2. Long term – cementing a belief in the success of the treating clinician’s therapeutic skills and laying the foundation for a satisfactory Therapeutic Alliance. This facilitates better compliance, one of the essential components in the Prophylaxis of BD!
2. REINTEGRATION: Aided by Symptomatic recovery, attainment of Premorbid Functional status is the next goal. Two important road blocks are a) Adverse Event profile of the medications prescribed and b) Cognitive impairment, which need to be minimised with a personalised therapeutic strategy.
3. RECURRNCE Prevention (Prophylaxis): This needs to be based on an individualized long term therapeutic strategy depending on the episodes - frequency, severity, acuteness of onset, suicidality, hospitalization risk, disability….Long term effective prophylaxis (no future episodes) is the desired goal, but seemingly difficult in the real life clinical practice! Prophylaxis, we opine, is to be need based, clinician advised, compliance determined with patient’s concurrence!
4. COMORBIDITY (Dual Diagnosis): Large number of patients with BD also suffer from other psychiatric disorders like OCD, Panic disorder, Phobias, Personality Disorders, and Substance abuse, with varying severity. Effective treatment of these comorbid conditions also should be taken up with concomitant pharmacotherapy and supportive counseling.
5. COLLABORATIVE Care: Recovery being the rule, patient in the euthymic state along with the caregivers should be involved to participate in psychoeducation sessions.
At ABC we have taken a conscious, though debated, decision not to initiate medication for Prophylaxis at First episode itself – Controversial conceptual therapeutic paradigm shift, which is blamed as a “Mistaken Kindness” approach…
ABC differs with (with due respects and apologies to) several algorithms and protocols in the prophylactic management strategy, reasons being:
1. The long term course of BD, at least in about a third of patients, is “random and chaotic” and it is nearly impossible to predict the next episode’s onset, polarity, and severity…
2. Therapeutic effectiveness of “mood stabilisers”, but for Lithium, has “lacunae in their evidence” and the approved medications are therapeutically “unsatisfactory in the day to day clinical experience”
3. Adverse events of medication is one of the significant reasons impeding a patient attaining functional recovery.
And so at ABC the Therapeutic Strategy for Prophylaxis of BD remains
1. Need based
2. Compliance Determined
3. Collaborative concurrence with patient and caregivers
And also at ABC we take a liberal approach in the prescription of Antidepressants, mostly SSRI, in the treatment of Bipolar Depression…
1. Considering the evidence of suicide prevention benefit of antidepressants. It is documented that 15% of patients with BD end their lives with suicide. Evidence for suicide prevention efficacy of Quetiapine and Lamotrigine is not well documented.
2. Treatment of comorbid disorders like OCD, OCPD, Panic, Phobia and other Anxiety disorders (> 50% of patients with BD have comorbidity) for which SSRI are the drug of choice. Untreated co morbid disorder adds to the disability in BD. Hence the need, for early and correct diagnosis of co morbid disorder and also effective pharmacotherapy and counseling.
Pharmacotherapy of BD is riddled with controversies on several DOs and DON’Ts, and effective treatment of BD is a fine Art of Therapeutics!
Major Depressive Disorder (MDD): This is the most common of all the mood disorders affecting about 5% of the population, twice as common in females, in about 30-40% starting in the age group of 15-30 years, the predominant symptom being feelings of sadness. Sad mood lasting for most of the time in the day, most of the days in a week for at least two weeks is the requirement for the diagnosis. Inability to experience pleasure, loss of interest, insomnia, loss of appetite, negative thoughts, inferiority feelings, hopeless and helpless, dullness, lethargy, pains and aches all over the body are some common symptoms. Anxiety is a common comorbidity. Suicide is a major and real risk, with about 15% ending their lives with self harm.
Sadness is a normal emotional response to loss; depressive disorder is a disorder like any other medical illness, often occurring without context. Stress can lead to sadness, we all know; but depressive disorder can exaggerate and magnify a minor stress and make the person experience it as seriously disturbing! No one is immune from developing depressive disorder, similar to Diabetes, Typhoid etc. Incidence of depressive disorder seems to be on the increase in the population in a similar way as is happening with diabetes. Genetic vulnerability, Brain neurotransmitter dysfunction play a major role in the causation of Depressive Disorder and psychosocial stress can be the last straw! Whatever may the causative factor, the final common pathway in depression could be the “serotonergic dysfunction” which is amenable to SSRI, to a large extent in a majority of patients.
There are several types of Depressive disorders – Recurrent Depressive disorder, Psychotic Depression, Bipolar Depression, Postpartum Depression, Melancholia etc. In Melancholia the characteristic features are – 1. Waking up at around 2-3 am (Late insomnia) 2. Symptoms typically are severe in the mornings and becoming better by evening hours (diurnal variation).
Often patients present with numerous body aches and pains without expression of sad mood, for fear of stigma.
About 50% patients have only one episode of Depressive disorder; the rest of 50% having multiple episodes in their life time. The episodes are curable in a significant group.
Treatment is generally with SSRI antidepressants and counseling. At ABC we routinely follow a protocol of SSRI monotherapy, along with counseling which usually is for about 3- 4 sessions at our clinic. A small dose of benzodiazepine is added for relief of anxiety and for better sleep, which is generally stopped after the first few months. Important point to note is that in a majority it takes about 3-4 weeks for the patient to experience significant relief from depression. As on today this is a major short coming of the antidepressant medication.
Protocol for MDD at ABC is –
Visit 1 – initial evaluation and diagnosis, starting on antidepressant medication
Visits 2 to 4 – Counseling sessions, Psychoeducation, Titration of drug dosage (within a period of 7-10 days)
Visits 5 & 6 – between 4-8 weeks. Remission can be expected around this period
Visits 7 to 10 - (in those patients who recovered) frequency of visits at 1-2 month intervals. We down titrate the medication in about 9-12 months based on the levels of improvement
In patients with Psychotic Depression, Chronic depression, Recurrent depression, Bipolar depression etc – Protocols vary with some modifications
REGULAR MEDICATION, about 8 hours of Sleep - are the general suggestions to patient
Education about the Suicidal Risk, Biological reasons as the causative factors, need for empathic support – are the points for caregivers
Good compliance to medication and Good family support systems are essential.
SSRI Antidepressants are reasonably safe medicines without any major serious short term and long term adverse events in a majority of patients. But as we all know, no medication can be counted as absolutely safe!
In a majority of patients, after recovery from MDD, life can be as “Normal” as any other average human being!
Depressive Disorder – Let us talk, Let us treat….Bring back the smiles…Reintegrate into the society as another well-functioning human!
DMDD is a new diagnostic entity included in depressive disorders along with MDD. Probably indicating that significant irritability and situation related anger outbursts can be a varied presentation of depressive mood, especially in childhood!
Episodic outbursts of anger along with chronic underlying temperament of irritability being present continuously for a period of at least 12 months, with onset before the age of 10 years.
Management generally includes counseling to the adolescent along with parental counseling, and a small dose of medication, where required, for shorter durations
DMDD is of particular importance while considering the differential diagnosis of childhood onset BD.
PMDD is a somewhat severe variant of Premenstrual Syndrome (PMS) presenting with severe mood swings and physical symptoms, affecting about 3-4% of women in the reproductive age group. PMDD can disrupt relationships and disturb work. Some women experience severe depression, irritability and tension; misunderstanding by the spouse can lead to marital disharmony. PMDD is a cyclical, hormone based mood disorder with complete resolution of symptoms with the onset of menstruation. Hormones, antidepressants and several alternative therapy strategies have been tried with varying success. Insight into the problem, counseling, relaxation and family support should be of great help
Repetitive Thought or Action
Again, again and again and again – is OCD
“Doubt” is the core feature of OCD
• Affects 2-3 % of the population
• Usually starts around the age of 15 years
• Genetic vulnerability Predisposes; Neurochemical imbalance causes; Stress triggers OCD
Obsessions are unwanted Repeated thoughts, images, impulses – not being clean, not done perfectly, not conveyed clearly, may harm my child, “bad” thoughts on religion, thought ruminations…
Compulsions are Repetitive Actions - Cleaning / Checking / Counting…for example washing hands 3 or 3x3 or 3x9 times or such magical number of times…extremes of cleanliness, orderliness, punctuality…
The Patient: Imagine a teenage girl brushing her teeth for 20 minutes, washing hands 33 times, taking 90 minutes for bathing, has to wear this particular coloured dress only on this day of the week, has to check the door lock thrice every time, touch the college bus tyre nine times before getting in, can not use the college toilet as it is dirty, has to sit cross legged in a specific place in her bedroom before retiring to sleep….an example of a patient with typical OCD symptoms
The Struggle: Person affected is well aware of the illogicality, irrationality and absurdity of the thought; makes serious and continuous effort to control it, but finds himself miserably failing to stop the thought or action. The struggle to control this irrational thought and action generates tremendous anxiety; and inability to stop leaves helplessness and depression. Relatives are mostly at a loss to understand this struggle and their misguided remarks lead to anger outbursts or depressive withdrawals. Suicides are not uncommon.
Treatment: OCD responds to treatment that includes a combination of medicines, counseling, family support, behavior therapies, relaxation and life style modifications. Neuro modulatory procedures like r TMS, TDCS are tried in resistant patients. Highly satisfactory response is possible and treatment is long term.