Saturday, December 17, 2011

Drinking and driving

Alcohol and driving don’t mix. In a flashback to Alex’s drug influenced joyride in A Clockwork Orange, a Pune youth bumped into four people at different points on his late night drive through the city. When chased and caught he was found to be under the influence of alcohol.

In this post we take a look at the effects of alcohol on driving. We have already discussed some of the long term effects that necessitate imposing legal age limits for alcohol consumption in order to mitigate its neurotoxic effects on the developing brain.

30mg% is the legal blood alcohol concentration (BAC) limit for driving. Limits are a safety requirement to counter the adverse effects of alcohol on driving ability. The 30mg% level is often panned as being too low. Most countries have settled at a 50mg% threshold, some at 20mg%, others (considered very liberal) at 80mg%. Lets take a look at the effects on driving at these various blood alcohol concentrations (CDC 2011).

BACEffect on driving
20mg%Visual deficits (problems with tracking of a moving object), Decline in multitasking ability (talking to a passenger while driving)
50mg%Reduced coordination, difficulty steering, increased reaction time for braking by more than a second (Siliquini 2011)
80mg%Problems with concentration, short term memory loss, reduced information processing capacity, impaired perception

How long after drinking alcohol is it safe to drive?
You need to wait at least as many hours as the ‘chota pegs’ (1oz or 30ml) you consumed. Alcohol is digested by the liver. The liver has a fixed capacity to metabolise about 8gms of alcohol in an hour. This is the amount of alcohol in 30ml of whisky, vodka, rum or gin. The equivalent dose is 250ml of beer or a glass (150ml) of wine. Each of these is considered as a ‘unit’ of alcohol.  However, consuming any quantity of alcohol within 6 hours prior to driving is associated with a doubling of the risk for a road traffic accident (Di Bartolomeo 2009). This effect of alcohol is present even at intake of 1-2 units which works out to a BAC of approximately 50mg%.

Blood alcohol levels as low as 20mg% impair driving ability under test conditions in a simulator. At 50mg% the impairments more than double the risk of an accident. The present 30mg% level may be legal but it remains impairing. Better to have a ‘designated driver’ - the person who does not drink for that particular evening. In case you want to we have already studied how to refuse alcohol.
DONT drink alcohol and drive
  1. Anthony Burgess. A Clockwork Orange. 1962. (Various publishers including Penguin)
  2. CDC. Accessed 15-Dec-2011.
  3. Stefano Di Bartolomeo Francesca Valent, Rodolfo Sbrojavacca, Riccardo Marchetti and Fabio Barbone. A case-crossover study of alcohol consumption, meals and the risk of road traffic crashes. BMC Public Health 2009, 9:316 doi:10.1186/1471-2458-9-316
  4. Roberta Siliquini, Fabrizio Bert, Francisco Alonso, Paola Berchialla, Alessandra Colombo, Axel Druart, Marcin Kedzia, Valeria Siliquini, Daniel Vankov, Anita Villerusa, Lamberto Manzoli and TEN-D Group (TEN-D by Night Group). Correlation between driving-related skill and alcohol use in young-adults from six European countries: the TEN-D by Night Project. BMC Public Health 2011, 11:526 doi:10.1186/1471-2458-11-526.

Sunday, December 11, 2011

Hope for dementia caregivers - ARDSI Conference Pune 2011

dementia caregivers training

Training for caregivers of persons with Alzheimer's disease helps address the distressing behaviours that arise in the affected person. Caregiver training also promotes wellness in caregivers by giving them the skills to  handle the relentless stress. Unfortunately most caregivers are unaware of the need or the availability of resources. The Alzheimer’s and Related Disorders Society of India (ARDSI) held its 16th conference in Nov 2011 at Pune. This significant event marked Pune’s arrival on the national dementia caregiver stage. Pune is now the 16th Indian city with an ARDSI chapter of its own. How does this help people with dementia (PwD) and their caregivers? The ARDSI Pune chapter “develops, coordinates and renders services in the field of dementia care, support, and training”.

The training aspect is particularly interesting. Conversations with caregivers at the clinic usually swing around to the day-to-day nitty-gritty of dealing with dementia, the impaired activities of daily living (ADLs) - keeping the person engaged, getting them to bathe, preventing them from wandering. Members of other fully functioning chapters whom I met at the conference animatedly discussed the caregiver training workshops and courses they held on a regular basis. These local courses are exactly what the doctor ordered - education for understanding and hands-on caregiver training.

The Dementia India Report 2010 was extensively quoted by many of the conference speakers. This document has dementia related statistics specifically for India and its states, and is an essential resource to leverage for obtain funds for dementia related activities. It also has details of services available for people with dementia - unfortunately data on support groups is as yet not available.

Caregiver training is a thrust area in dementia management. The 10/66 Dementia Research Group has developed a training package with a set of manuals, detailed instructions and a training video for caregivers and caregiver training. These are available for anyone to download after providing an email id. They provide a template that can be used by any individual or organisation involved in caring for persons with dementia.

The ARDSI conducts two geriatric care training courses; a six month certificate course and a one year post-graduate diploma course at its centre in Cochin. The number of persons with dementia in India is assessed to be 3.7 million in 2010. The ARDSI and similar courses will provide a pool of trained workers to care for the needs of people with dementia and their caregivers. This pool of personnel is not just on paper. The conference was over-booked. Extra seating had to be provided to accommodate the 100+ last minute attendees in the 400 seater main auditorium. Most of them were trainee social workers entering the field in time to meet the growing demand for their services.

  1. 10/66 Dementia Research Group. Resources for caregivers and caregiver trainers
  2. Alzheimer’s and Related Disorders Society of India (2010). The Dementia India Report: prevalence, impact, costs and services for Dementia. (Eds) Shaji KS, Jotheeswaran AT, Girish N, Srikala Bharath, Amit Dias, Meera Pattabiraman and Mathew Varghese. ARDSI, New Delhi. ISBN: 978-81-920341-0-2 

Saturday, November 12, 2011

Talk - not TV - for your toddler

No TV for babies
Turn off the television and speak to your toddler. Talking is the best thing you could do today for your child’s psychological development. Talking is an interactive process in which your child exercises a core feature of being human - communicating through speech. Your child's vocabulary is directly proportional to the amount of time you spend talking.

Talking primes your child for independence. Speech evolves through attempts to communicate needs and feelings. Infants and toddlers are driven by evolution to master this complex process. You, the parent, play a key role in this two-way interaction. Infancy and toddler-hood are stages for developing secure bonding and attachment. The child is primed to bond with the mother or caregiver. The initial bond is secured by direct contact with the caregiver - through warmth, touch and voice. A secure attachment bond enables the infant seeks to explore the environment by attempts to crawl and later walk. The exploring toddler returns often to the parent to re-experience attachment security. It is here that talking plays a crucial role in maintaining the attachment bond at a distance. The child is then able to explore the environment away from direct contact with the parent.

Your one-year-old is psychologically unable to follow or learn from video. Some parents are convinced that certain TV channels are ‘educational’ for their toddler. The ability to comprehend video arises between 18 to 24 months of age (Pempek 2010). Prior to 2 years of age TV has little or no educational impact on the child, whatever the claims by media groups vying for their ‘eyeballs’. TV programming meant for 2-year-olds delays language and vocabulary development (AAP 2011, Zimmerman 2007).

Television is not a substitute for parenting. Parents leave the TV on to distract the child while they are engaged otherwise. Television holds the toddlers attention through its series of changing visual stimuli. This visual stimulus is powerful and distracting. While interacting with parents with the TV on in the background, the toddler is forced to shift attention to the TV once every 20 seconds. Even in adolescents, background TV adversely affects mental processing, memory and comprehension. Having the TV always on in the toddlers home interferes with unstructured play time that is critical to developing problem-solving skills and creativity. Repeated research has shown no developmental benefits for television exposure in infancy (Schmidt 2009, ).

Talk to and play with your children. Television is a medium that encourages passivity. TV delays vocabulary growth and language development in toddlers. Turn off the TV.

  1. Academy of Pediatrics. Policy Statement. Media Use by Children Younger Than 2 Years. Council on Communications and Media. PEDIATRICS Vol. 128 No. 5November 1, 2011. pp. 1040 -1045 (doi: 10.1542/peds.2011-1753)
  2. Pempek TA, Kirkorian HL, Richards JE, Anderson DR, Lund AF, Stevens M. Video comprehensibility and attention in very young children. Dev Psychol. 2010 Sep;46(5):1283-93. 
  3. Schmidt ME, Rich M, Rifas-Shiman SL, Oken E, Taveras EM. Television viewing in infancy and child cognition at 3 years of age in a US cohort. Pediatrics. 2009 Mar;123(3):e370-5. 
  4. Zimmerman FJ, Christakis DA, Meltzoff AN. Associations between media viewing and language development in children under age 2 years. J Pediatr. 2007 Oct;151(4):364-8. Epub 2007 Aug 7. 

Thursday, November 3, 2011

Diet and mental health


Mental health and diet quality are closely linked. The food choices you made as a teenager affect the development of conduct and emotional problems that continue into adulthood. Lifestyle diseases such as heart disease, diabetes and obesity are attributed to changes in diet and exercise habits. Recently there is increasing evidence that diet and exercise also have a major influence on mental health. Dieting peaks after the festival season. This post will help you avoid the 'isms' and fads and point you in the direction indicated by current research.

A good quality diet predicts better mental health

Evaluating the quality of the complete diet provides a better and more consistent picture of nutrition status than focusing on individual nutrients like magnesium or food groups like various fatty acids (omega, polyunsaturated). A traditional diet of vegetables, fruit, meat, fish, and whole grains is associated with lower risk for depression and for anxiety disorders as compared to a "western" diet of processed or fried foods, refined grains, sugary products, and beer (Jacka 2010).

Switching to a high quality diet improves mental health

Switching to a healthy diet improves mental health. Unhealthy diets are associated with lower scores on mental health tests. The best part is that improvements in diet quality are mirrored by improvements in mental health (Jacka 2011). Also the reverse, when diet quality deteriorates psychological functioning is adversely affected.

What constitutes a high quality diet?

The quality of diet is assessed using food frequency questionnaires. Points are allotted for each type and frequency of food consumed. For example one point is allotted for each of at least two fruit servings per day, at least four vegetable servings per day; using reduced fat or skimmed milk, using soy milk, consuming at least 500mL of milk per day; using high fibre, wholemeal, rye or multigrain breads; having at least four slices of bread per day; using polyunsaturated or monounsaturated spreads or no fat spread; having one or two eggs per week, using cottage cheese, using low fat cheese. Out of a maximum possible score of 74, the average is about 33.0 (+9.0).You can get some idea of your diet quality score from this chart (Collins 2008).

Preventive psychiatry

Improving diet quality improves mental health outcomes. Especially for adolescents this is an important preventive intervention. Three quarters of all long term psychiatric illness manifest during adolescence and early adulthood (Kessler 2005) . These illness are among the most disabling. They occur with a high enough frequency to contribute a major portion of life years lost due to disability. Mental health illnesses cause long-term problems at work and at home. They usually persist over the lifetime and require medication and support at various stages. Adopting a high quality diet is an important primary preventive intervention for improved mental health - easy to implement and proven to be effective.

  1. Collins CE, Young AF, Hodge A (2008). Diet quality is associated with higher nutrient intake and self-rated health in mid-aged women. J Am Coll Nutr 27: 146–157.
  2. Jacka FN, Pasco JA, Mykletun A, Williams LJ, Hodge AM, O'Reilly SL, Nicholson GC, Kotowicz MA, Berk M. Association of Western and traditional diets with depression and anxiety in women. Am J Psychiatry. 2010 Mar;167(3):305-11. Epub 2010 Jan 4.
  3. Jacka FN, Kremer PJ, Berk M, de Silva-Sanigorski AM, Moodie M, Leslie ER, Pasco JA, Swinburn BA.A prospective study of diet quality and mental health in adolescents. PLoS One. 2011;6(9):e24805. Epub 2011 Sep 21.
  4. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, et al. (2005) Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 62: 593–602.

Sunday, October 23, 2011

Tattoos - true love will never fade

sarus crane symbol of true love
What is the motivation or psychology behind obtaining a tattoo? Tattooing as a form of decorative body art has moved out of the realm of cults and organisations into mainstream society. It is increasingly common to see patients sporting a new tattoo. "Just like that, doctor. My friends were getting one". The Pune magazines reflect this new found art form through full page articles every other week. Driving through the some parts of Pune takes you past at least three studios specialising in the art of tattooing.

Here we are concerned with the psychological aspects of tattooing. As compared to body-piercing, a tattoo is relatively permanent and more deliberate operation. For the moment set aside doubts over hygiene, HIV, and hepatitis.

10 reasons people get a tattoo

  1. Beauty, art, and fashion. Tattoos are a means of decorating the body with a permanent fashion accessory. Many tattooed individuals refer to their tattoos as a piece of art. 
  2. Individuality. A tattoo fulfils the desire to create a distinct self-identity. The symbols or words embellishing the skin creates a special message that distinguishes the person from others. The individual gains a sense of control over their appearance and identity. We see this especially in teenagers brought in by their parents.
  3. Personal narrative. Women recovering from abuse create a new understanding of the injured part of the body. They reclaim possession through the deliberate and painful procedure of body modification. Tattoos have a self-healing effect in this reclamation of the body. 
  4. Physical endurance. For some tattoos are a statement about testing their threshold for pain endurance.  
  5. Group affiliations and commitment. Body ornaments are a permanent sign of love and commitment. The wish to belong to a certain community or to show affiliation to a particular group is a common reason for getting a tattoo. 
  6. Resistance. Tattoos are a provocative protest against parents and society, especially in college students. Body modification has long been associated with subcultural movements and criminal tendencies. Until recently most studies on tattooing were done on prison populations.
  7. Spirituality and cultural tradition. Body modifications emphasise personal affiliation to cultures and their spirituality. Esoteric symbols that convey special meaning are tattooed as a permanent reminder.
  8. Addiction. Tattoos and piercings possess an addictive character through the release of endorphins. These substances are released in brain areas in association with painful penetration of the body.
  9. Sexual motivation. Tattooing is a form of expressing sexual affectations and of emphasising ones own sexuality. 
  10. No specific reason. A tattoo may be obtained impulsively on the spur of the moment. Some individuals may be under the influence of alcohol or drugs while acquiring their piece of body art.

Reasons people have a tattoo removed

People are mostly satisfied with the actual design of their tattoo.

Most want their tattoo removed for personal reasons. This occurs when the quest for uniqueness turns into stigma, negative comments, and clothes problems. Poor decision making and subsequent personal regret seem to be frequent motivations for tattoo removal.

An improved sense of self and maturity is another factor. Especially for those who obtained their tattoos for internal expectations of self-identity at an early age. Many are still trying to dissociate from the past and improve self-identity. More than 40% of persons who choose a tattoo to feel unique are disillusioned when their unique product loses its luster and excitement.

Professional/social reasons account for another third of those motivated for tattoo removal. A new job or career is a major motivation. Negative workplace attitudes toward tattoos and perceived interference for a tattooed individual’s achievement is common. There is a perception of lowered credibility, competence, and sociability that diminishes the image of tattoo wearer in the workplace.

The possession risks are more for women than for men. More than two thirds of those seeking tattoo removal are women. Society support for women with tattoos is not as strong as for men. Strong tattoo support from significant others and friends is counterbalanced by negative remarks about the tattoos from fathers, physicians, and the public. Negative responses are also documented among career-oriented women with tattoos. Women still need to deliberately think about controlling the body placement of their tattoos to avoid the possession risks and to increase their own psychological comfort.

  1. Armstrong ML, Roberts AE, Koch JR, Saunders JC, Owen DC, Anderson RR. Motivation for contemporary tattoo removal: a shift in identity. Arch Dermatol. 2008 Jul;144(7):879-84.
  2. Silke Wohlrab, Jutta Stahl, Peter M. Kappeler. Modifying the body: Motivations for getting tattooed and pierced. Body Image 4 (2007) 87–95.

Tuesday, October 11, 2011

Learning Disability - academic underachievement

learning disorder
Impaired spelling and arithmetic in Standard 3 boy with Learning Disorder

Learning Disorder (LD) is characterised by impaired acquisition of academic skills. This impairment in scholastic skills is not due to intellectual disability, physical disorders, emotional disturbances, or environmental, cultural, or economic disadvantage.

There is a gap between ability and application. The child may know what is asked, is able to explain it verbally, but is unable to put it down in writing. Learning Disorder could affect any of the three scholastic Rs – Reading, wRiting or aRithmetic.

Types of Learning Disability

  1. Dyslexia – is the commonest learning disability (80%). It is marked by impairment of the ability to recognize and understand written words.
  2. Dyscalculia – problems with doing math, understanding time, using money.
  3. Dysgraphia – problems with handwriting, spelling.
  4. Dyspraxia – problems with hand-eye coordination and balance, difficulties with fine motor skills.

Signs and Symptoms

Most children with a Learning Disability are not diagnosed until they are in Standard 2-3 or 7-8 years of age. Remarks like ‘can do better’ or ‘handwriting needs to improve’ are often the first warning signs to appear in the report card. Many of these children would have been the stars of their nursery or kindergarten class. The transition to assessment of written output in primary school is what unmasks the disorder. The aware teacher is able to help the parents understand and put the parents on the path to remedial teaching.

Parents should watch out for

  • Reading may be slow or there is repeated rereading or skipping of an entire section. In the lower classes the child learns to memorise and reproduce entire chapters. Later the child is unable to hold the increasing amounts of material in memory, grades plummet, and confused parents are left searching for answers.
  • Problems in copying from the blackboard or a book. This is a frequent complaint of the teacher. Classwork is left incomplete. The child tries to copy from their partner and is punished for distracting the class.
  • Poor handwriting or drawing – their exercise books are messy, with frequent scratching out and erasing. This is especially so when the child writes on blank paper. It is also a reason why the child performs poorly in exams – they just cannot write quickly enough. They run out of time before they reach the last few questions.
  • Other signs in more severe conditions
    • Reversing numbers and letters while reading or writing - For example, confusing ‘b’ and ‘d’
    • Mixing the order of letters or numbers. Writing ‘twon’ instead of ‘town’.
    • Skipping letters in spelling. The child says ‘grass’ but writes ‘gas’.
    • Forgetting words they know well.
    • Weakness in mathematics.

Conquering Learning Disorder

  • Approach a centre undertaking diagnosis of learning disabilities.
  • A complete history of the child’s birth, milestones, health and academic record
  • Physical exam to exclude problems related to vision and hearing
  • Psychometry - to demonstrate specific academic problems that are not associated intellectual disability
  • Psychiatric assessment - to address associated anxiety, phobias and depression that arise out of repeated academic failures.
  • Psychiatric assessment - to exclude or address Attention Deficit Hyperactivity Disorder (ADHD) a common comorbidity. 15-40% of children with ADHD also have dyslexia.
  • Remedial teaching is essential to overcome learning problems 

Drug treatment for dyslexia?

There is a growing body of research to show that at least in children who have both ADHD and dyslexia there are significant improvements in reading ability with ADHD medication. These improvements in reading ability are not related merely to improvements in attention. The brain systems responsible for therapeutic improvement in children with ADHD + dyslexia are probably different from those in children with ADHD alone. The finding that selective areas of working memory can be enhanced by these medications is important, as poor working memory function appears to be a mental constraint on academic learning.

  1. Schulte-Körne G. The Prevention, Diagnosis, and Treatment of Dyslexia. Dtsch Arztebl Int. 2010 Oct;107(41):718-26; quiz 27. Epub 2010 Oct 15
  2. Sumner CR, Gathercole S, Greenbaum M, Rubin R, Williams D, Hollandbeck M, Wietecha L. Atomoxetine for the treatment of attention-deficit/hyperactivity disorder (ADHD) in children with ADHD and dyslexia. Child Adolesc Psychiatry Ment Health. 2009 Dec 15;3:40..

Thursday, September 22, 2011

Stress in the festival season

festival time
Festivals as a source of stress? Festivals are meant to be a time of happiness, enjoyment and family togetherness. However for some it can be time of great stress and can adversely affect mental health. The extended festival season starts around Independence Day (15th Aug) and extends right up to New Year including Ganesh Chathurti, Dusshera, and Diwali. Vacations have a positive effect on well-being. However, these effects fade soon after resumption of work (de Bloom 2009). These four months of celebration are associated with psychological distress and mental health problems for many individuals and their families.

Festival distress

(Harion 2009)
Expectations take their toll on the family. Festivals are a prime time for couples to come in for counselling with relationship problems, problems with in-laws, siblings and their children. 'Don't we get to celebrate at least once in our own home?". They end up celebrating each in their own parental homes at Pune and Ahmedabad.

For those in the workforce it means negotiating and competing with everyone else for leave or being the only one left in the office. No one at home understands why you cannot get leave. No one understands why work-pressures and deadlines increase in the time leading up to the holiday. Financial stress also comes into the picture; cool electronics, gifts, partying and vacation trips cost.

For people with mental health problems festivals are another source of stress. Well intentioned, though ill informed relatives prevail on them to stop their medications 'they are addicting', 'why do you need to take them if you're allright?' Many are coaxed into stopping medications entirely.They relapse some time after they return to work, when the social supports are at a minimum and the beneficial effects of the vacation begin to wear off. That is also the time when they have to start paying out the EMIs. This time lag to relapse after stopping psychotropic medication is a prominent factor in non-adherence. 'But he was allright at home. It's the job that is causing stress; we are thinking of relocating'.

Fasting and sleep deprivation are associated in the run up to the festivities. In vulnerable people, especially those with mental health problems, these can play havoc with the body rhythm and with medication regimens leading to a relapse. Every religion excuses ill followers the rigours of these rituals, yet the very people who should be supporting moderation often goad their vulnerable members to comply. 'I thought he was just being lazy'.

Alcoholism is another problem that is likely to recur. It starts insidiously at the beginning of the festival season. By the time the season ends its time for another stint of 'deaddiction'. Binge drinking at parties is just another problem that requires to be addressed recurrently.

Violence and injuries in the home occur through the combination of excitement, stress, tiredness and alcohol. Pressures lead to conflict and then violence. Domestic abuse is about one-third more likely on the day of the festival than the daily average. Homicide rates are generally higher on all major holidays.

Loneliness and isolation are particular issues at festivals. The holiday season is the time of the year when our desire for social contact is most likely to outstrip what our circumstances will allow; it is into this gap that loneliness creeps (Lancet 2010). As festivals are associated with friends and family, it can be difficult for those on their own to avoid feeling lonely at this time. This is especially so for older people living alone who may have no one to spend the festive season with. The loneliness felt on the festival day is often the worst. Festivals can be a sad and nostalgic time, when the loss of a family member may become especially painful. It is often a difficult time for bereaved people. The rates of suicide are known to increase especially on New Years Day (Bridges 2004).

What to do?

Prior to the festival
  1. Communicate. Make your festival plans keeping your spouse in mind. If there were problems  last year don't expect them to disappear. ' I thought we agreed on that last year'. Putting off the discussion could ruin your festivities.
  2. Collaborate. Work together to find a solution that satisfies the needs of all parties. You may not get everything you want, but you get enough of what you want to feel satisfied. Colaboration requires respect for the needs of the other party, communication skills, patience, and creativity. Parties usually do better when they collaborate than when they compete.
  3. Watch the finances. Budget for the expenses and keep a track.
During the festival
  1. Limit your alcohol. Don't drink if you don't want to.
  2. Keep to your normal sleep-wake schedule as far as practicable. When it is disrupted return to your normal schedule at the earliest. Take some time out for exercise.
  3. Take some time off for just yourself and your family. A walk, movie or meal away from the others will contribute to a few more days of harmony.
  4. Your medication is sacrosanct. Don't negotiate on this.
Strategies for loneliness
(Masi 2010)
  1. Improve social skills: After relying on a partner to share experiences and thoughts a separation, breakup or bereavement requires relearning of skills needed to build new relationships and participate in community functions.
  2. Enhance social support: Find a listening ear – people who are lonely can find it helpful to speak to a counsellor or someone removed from their situation.
  3. Increase opportunities for social contact: Be a volunteer – many charities and organisations need help at festivals and you could spend a few hours working as a volunteer. The absence of close family need not be the end of companionship. 
  4. Address maladaptive social cognition: Loneliness can also be tackled by helping people to feel happier in their own company.
    • 'Everyone else is having a good time'. Keep busy – try to stop the festival taking over your life. Make time for enjoyable activities, such as reading, walks, joining a social club or going for a movie.
    • 'What's the point, I'm just not up to it'. Take some physical exercise – this reduces stress and enhances mood. Just getting off the sofa and getting outside should improve mood.
  5. Visit an older neighbour who lives alone if you have a little spare time on your hands over the holidays; it might be just what they need to make their holiday a happy one. 
  1. Bridges SF. Rates of homicide and suicide on major national holidays. Psychological Reports, 2004,94,723-724.
  2. de Bloom J, Kompier M, Geurts S, de Weerth C, Taris T, Sonnentag S. Do we recover from vacation? Meta-analysis of vacation effects on health and well-being. J Occup Health. 2009;51(1):13-25. Epub 2008 Dec 19.
  3. Hairon N. How christmas festivities and pressures can damage health and well-being. Nurs Times. 2008 Dec 16-2009 Jan 12;104(50-51):33-4.
  4. Masi CM, Chen HY, Hawkley LC, Cacioppo JT. A meta-analysis of interventions to reduce loneliness. Pers Soc Psychol Rev. 2011 Aug;15(3):219-66. Epub 2010 Aug 17.
  5. No authors listed. Tackling loneliness in the holidays.Lancet. 2010 Dec 18;376(9758):2042.

Thursday, September 15, 2011

Diagnosing Alzheimer's Dementia

Alzheimer's Disease amyloid plaques and neuro-fibrillay tangles in brain tissue
Microscopic picture of the brain showing amyloid plaques and
 neurofibrillary tangles first seen by Alois Alzheimer in 1907

The diagnosis of Alzheimer's disease became headline news when the defence counsel of a prominent citizen of  Pune stated they were awaiting results of his brain MRI to finalise the diagnosis of dementia. Recently a patient's medication was stopped when his neuro-physician declared there were 'no plaques on MRI so it is not a case of Alzheimers'. The caregivers returned to me when his behaviour problems recurred.

Dementia including that of the Alzheimer's type is a clinical diagnosis (Grand 2011). Dementia is characterised by a triad of
  1. Progressive deterioration of mental processes (cognitive abilities)
  2. Behavioural and psychological symptoms of dementia (BPSD)
  3. Difficulties carrying out day-to-day activities (activities of daily living or ADL).  
Alzheimer's Disease is commonest dementia after 65 years of age Alzheimer's dementia has an insidious onset, and progresses gradually and inexorably. This natural course is a key differentiator Alzheimer's from other forms of dementia. Dementia is suspected when a caregiver of an elderly person, or sometimes a person with a family history of dementia, becomes concerned about problems with memory. The diagnosis is purely clinical. No laboratory test or imaging (including MRI) is required to diagnose Alzheimer's disease. These investigations can only help differentiate the other forms of dementia when those are suspected.

Memory problems are a core feature of the disease. These manifest as
  • Difficulty recalling details of recent events (forgets he has already dropped his grandchild to school), personal conversations, or specific elements of a task she is performing (eg, preparing a meal)
  • Asking the same question multiple times while denying repeated questioning
  • Tendency to make up events to fill memory gaps and to give inaccurate responses to questions (what he had for breakfast)
Other common cognitive concerns that could indicate dementia of the Alzheimer or any other type
  • Disoreintation to time and place. As the illness progresses orientation worsens to include problems identifying familiar places, family members, or other well known people.
  • Difficulties with activities of daily living (ADL). Problems with dressing or using common utensils
  • Language impairments resulting in decreased conversational output, word-finding difficulties, and limited vocabulary.
  • Visuo-spatial dysfunction manifest as impaired driving ability, and getting lost
  • Problems with mathematical calculations impair ability to use money and balance finances.
  • Impaired judgement in novel situations (difficulty planning a vacation).
Behavioural and psychological symptoms (BPSD)
  • Depression occurs in up to 50% of individuals with Alzheimer's Dementia, and may be attributed to awareness of cognitive changes
  • Lack of feeling or emotion (apathy) is associated with significant caregiver distress
  • Psychosis generally occurs later in the disease course. Delusions are predominantly paranoid in nature, with fears of personal harm or mistreatment, theft of personal property (usually related to financial matters), and marital infidelity. Hallucinations are less common than delusions, and tend to be visual.
  • Other behavioural symptoms include agitation, wandering, and sleep disturbances.

Diagnosis of Alzheimer's Disease is based on 
  1. Detailed history to identify memory deficits, and other cognitive symptoms and assess their impact on the individual and family.
  2. A thorough clinical exam (mental status examination) confirms the impairments in memory and cognition, and delineates the behavioural and psychiatric symptoms that cause caregivers concern. This usually includes using validated and standardised screening pencil and paper tests. 
  3. Psychological testing confirms and quantifies the impairments across various areas of brain function (memory, language, visuo-spatial), assesses the treatment response, and documents progression of the illness with time.

Laboratory tests including MRI only differentiate Alzheimer's disease from other disorders such as subdural haematoma, brain tumour, hydrocephalus, and dementia associated with vascular disease. Magnetic Resonance Imaging (MRI) has no other clinical utility in Alzheimer's disease. These tests are not required or mandated by any classification system including that of the WHO (ICD) or the National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer’s Disease and Related Disorders Association (NINCDS-ADRDA).

Amyloid plaques, and neurofibrillary tangles are the hallmark of Alzheimer's disease and are required for a definitive diagnosis. These were first discovered by Alois Alzheimer in 1907.  His slides were rediscovered in 1992 and 1997. The rediscovered images show the classical pathological signs of the disease named after him. Amyloid plaques and neurofibrillary tangles are seen on microscopic examination of brain tissue using special staining techniques or by electron microscopy. Therefore the only way to obtain a definitive diagnosis of Alzheimer's disease is to obtain a brain tissue sample by biopsy or on autopsy. No MRI, however advanced can detect plaques.
For the purpose of treatment a probable diagnosis using bedside techniques of history and clinical examination is all that is required to diagnose Alzheimer's disease.

  1. Dickerson BC. Advances in quantitative magnetic resonance imaging-based biomarkers for Alzheimer disease. Alzheimers Res Ther. 2010 Jul 6;2(4):21.
  2. Graeber MB, Kösel S, Egensperger R, Banati RB, Müller U, Bise K, Hoff P, Möller HJ, Fujisawa K, Mehraein P. Rediscovery of the case described by Alois Alzheimer in 1911: historical, histological and molecular genetic analysis. Neurogenetics. 1997 May;1(1):73-80.
  3. Grand JH, Caspar S, Macdonald SW. Clinical features and multidisciplinary approaches to dementia care. J Multidiscip Healthc. 2011;4:125-47. Epub 2011 May 15.
  4. McKhann G, Drachman D, Folstein M, Katzman R, Price D, Stadlan EM. Clinical diagnosis of Alzheimer's disease: report of the NINCDS-ADRDA Work Group under the auspices of Department of Health and Human Services Task Force on Alzheimer's Disease. Neurology. 1984 Jul;34(7):939-44.

Thursday, September 8, 2011

Parental supervision of children and adolescents

parental supervision and injuries in children with high intensity behaviour
Parental supervision protects boisterous children from injury:
More time unsupervised corresponds to more injury 
“To my parents we were just two girls in the bedroom”. What exactly was going on? Without adequate supervision the parents of this teenager never found out; the memories returned to haunt her in adulthood. Studies comparing children with and without parental supervision show that lax parental supervision is associated with injury in toddlers and preschoolers; conduct problems in school going children; and road accidents, addictions, gambling and sexual risk taking in teenagers.

Parental supervision has three dimensions (Gitanjali 2004)
  1. Attention - watching or listening 
  2. Proximity - within or beyond reach 
  3. Continuity - constant, intermittent, or not at all 

Two factors determine the degree to which a child would be left unsupervised (Morrongiello 2008)
  1. Parent’s conscientiousness - the more conscientious the parent more the supervision
  2. Child’s propensity for risky behaviour - the more impulsive and sensation seeking the child the more likely the child will be kept in direct view. 

Distinguishing adequate from neglectful supervision is not straight forward. The consequences of lower levels of supervision are not uniform for all children. The consequences depend to a great extent on child attributes. For children with high sensation seeking, even close supervision is not adequate to prevent injury. For children who are high in behavioural control, even not supervising does not elevate risk of injury.

Whether or not children comply with their parents’ requests to behave in safe ways is a complex interaction of parenting style, attachment style,  and child temperament. The level of supervision necessary to ensure a child’s safety should finally be based on the child’s characteristics. The only reliable maxim is that the time children could be safely left unsupervised generally increases with child age.

Parental supervision of an adolescent differs from supervising a younger child (DeVore 2005). Direct parental observation gradually gives way to indirect parental ‘‘monitoring’. This indirect supervision involves ongoing communication between parents and adolescents about the adolescents’
  • Whereabouts
  • Friends they are with
  • Schedule to return home
  • Contact information enabling parents to directly communicate with adolescents. 
Effective supervision entails active participation of the adolescent, and honest communication between adolescent and parents.

Parental monitoring buffers negative peer influence. Strong peer attachments and increasing independence from the family is a normal part of adolescent development. Unfortunately, youth whose peers engage in high-risk behaviour are at high risk for the development of similar behaviours. Not only are high levels of monitoring protective, low levels of parental monitoring have been associated with numerous risk behaviours.

More unsupervised time is associated with more sexual activity in youth (Cohen 2002). In one urban study more than half of sexually active youth had sex at home after school. For boys, sex and drug-related risks increase with amount of unsupervised time. Trust and communication did not predict decreases in problem behaviour as strongly as did monitoring. Parental monitoring may be particularly protective for high-risk young urban adolescents; those who spend a significant amount of non-school time unsupervised. 

  1. Cohen DA, Farley TA, Taylor SN, et al. When and where do youths have sex? The potential role of adult supervision. Pediatrics 2002; 110:e66 
  2. DeVore ER, Ginsburg KR. The protective effects of good parenting on adolescents. Curr Opin Pediatr. 2005 Aug;17(4):460-5. 
  3. Gitanjali S, Brenner R, Morrongiello BA, Haynie D, Rivera M, Cheng T. The role of supervision in child injury risk: Definition, conceptual, and measurement issues. Journal of Injury Control & Safety Promotion 2004;11(1):17-22. 
  4. Morrongiello BA, Klemencic N, Corbett M. Interactions between child behavior patterns and parent supervision: Implications for children’s risk of unintentional injury. Child Development 2008;79(3):627-638.  

Tuesday, August 30, 2011

Treating Depression

wild grass and moths
Depressed mood or sadness lasting two weeks or more requires treatment. We all feel depressed, sad, or ‘blue’ occasionally. Moods and feelings change in response to events in our external environment. Usually depressive feelings or sadness last for a day or two; longer in case of loss or bereavement. However, if these feelings of sadness and hopelessness persist for more than 2 weeks and interfere with daily life, it indicates a clinical depression.
Depression is the fourth highest contributor to the global burden of disease. 
Clinical depression is a treatable illness. Many people never seek treatment due to lack of awareness, lack of access to mental health care, ignorance, or shame.

Signs and Symptoms

The hallmark of Clinical Depression is a pervasive depressed mood. This depressed mood is not responsive to positive events. There is associated slowness of thinking and movement; and there are thoughts related to guilt, self-blame, hopelessness and suicide . These features of constitute the classical triad of symptoms for the diagnosis of Clinical Depression. For a more formal diagnosis some or all of the symptoms below are used
  1. Persistent sadness. Frequent crying, irritability, ‘emotional outbursts’
  2. Slowing of movement and thoughts
  3. Feelings of guilt - ‘I shouldn’t have done that’, ‘it is all my fault’
  4. Worthlessness - ‘I haven’t achieved anything’, ‘I let my parents down’, ‘what I do has no value’
  5. Hopelessness - ‘What’s the point?’, ‘I don’t see things getting better’
  6. Thoughts of dying and suicide - ‘I would be better off dead’
  7. Loss of interest in activities and hobbies that were once pleasurable
  8. Difficulty concentrating, remembering details, making decisions
  9. Insomnia, early morning wakefulness, excessive sleeping.
  10. Change in appetite – appetite loss or overeating.
  11. Fatigue, lethargy, decreased energy
  12. Headache, cramps or digestive problems that are not relieved by treatment

How is depression treated?

The first step to treatment is to visit a psychiatrist. Your psychiatrist is the only mental health professional qualified to prescribe medication and provide psychotherapy. Your psychiatrist will take a detailed history of your symptoms, and will ask you to complete some questionnaires to assess their severity. He will also do a physical examination and may get some tests done (thyroid disorders and blood glucose related problems can cause similar symptoms).

The treatment of depression rests on two pillars
  1. Pharmacotherapy (medication)
  2. Psychotherapy (counselling, CBT)
Medication (pharmacotherapy) is required for moderate and severe depressions. Formal psychotherapy is started later once concentration and thinking improve. Your psychiatrist will prescribe an appropriate antidepressant. Antidepressants are not addicting. Side effects if any occur during the initial phase of treatment, they should not make you feel worse. Antidepressants must be taken for 4-6 weeks before they have a full effect. Later you should continue the medication even if you are feeling better to prevent a relapse. Suddenly stopping antidepressants can precipitate a relapse. Medication should be tapered gradually under your doctor’s supervision. If you follow your doctor's advice regarding follow up visits your treatment will be optimal.

Psychotherapy alone may be used in mild depression. Usually it is combined with medication for moderate and severe depressions. Psychotherapy is of two types:
  1. Cognitive Behaviour Therapy (CBT) identifies self-defeating, ‘negative thoughts’ and behaviours that perpetuate clinical depression in a vicious cycle. Your therapist then works with you to replace these thoughts and behaviours with ‘positive’ ones to help you recover from the illness.
  2. Interpersonal Therapy (IPT) helps people understand and work through troubled relationships that may be at the root of depression or making it worse.

How can I help a friend or family member who is depressed?

  1. Listen carefully.
  2. Offer support, understanding and encouragement.
  3. Never dismiss feelings, but point out realities and offer hope.
  4. Encourage them to go out for walks, outings and other simple activities. Don’t push too hard but keep trying.
  5. Make sure they keep appointments with the psychiatrist and stay in therapy.
  6. Never ignore suicide comments
    • Gently correct blatantly ‘negative’ thoughts. Help the person form an action plan to resolve the problem
    • DON'T LEAVE THEM ALONE until they OK the plan. 
    • Accompany them to a known responsible person or a doctor or mental health professional. You could save a life.

What can I do when I am depressed?

  1. Stay active. Exercise; go out for a movie, or any event you previously enjoyed.
  2. Eat regular meals. Don’t skip them even if you are not hungry.
  3. Go to bed at a regular time. Don’t wait until you are extremely tired so you can get sleep. Insomnia is the first symptom to respond to antidepressant medication
  4. Set realistic goals for yourself.
  5. Break up large tasks into smaller ones and do what you can.
  6. Spend time with others, confide in a trusted friend or relative.
  7. Postpone important decisions such as getting married/divorced, changing jobs until you are feeling better.
  8. Do not wait too long to get treatment.
  9. Expect your mood to improve gradually. Sleep and appetite will improve before your mood changes.
  10. Keep your appointments with your psychiatrist and do not stop your medication suddenly.

Monday, August 15, 2011

Rejection and aggression - the fury of the scorned male

rejection and aggression

Rejection experienced in an intimate relationship can trigger unexpected aggression with sometimes fatal consequences. A working woman in Pune was stabbed to death in her home when she spurned the marriage proposal of a good friend. Another 17 year-old girl from Hadapsar was stabbed in the stomach for rebuffing the overtures of a relative. Why would a man assault a woman after professing his love to her? Many instances of aggression arise from events where an individual perceives he is not sufficiently loved or valued in the context of an intimate relationship.

People differ in their readiness to perceive and react to rejection. The desire to belong is a basic human need. Some maintain equanimity while others over-react in ways that harm their relationships and their well-being. Hostility and aggression are among the most destructive reactions to rejection. Low self-esteem, depression, jealousy, self-neglect and a breakdown of daily routine are other painful outcomes of being rejected. Social rejection is the strongest predictor of violence in adolescents (Surgeon General 2001). This association between rejection and aggression is also repeatedly shown in social experiments.

Rejection triggers behaviours internalised during interactions with parents during infancy and early childhood. Based on these interactions children form certain expectations regarding the satisfaction or rejection of their needs. When childhood needs are met sensitively and consistently the child forms secure expectations. When childhood needs are met with rejection the child forms a pattern of insecure expectations involving doubts and anxieties. These repeated early interactions determine the individuals attachment style - the communication pattern exhibited in close relationships.

Aggression is first learned during infancy as a response to separation from the mother. The purpose is to reunite with the mother and discourage future separation. Adults who are socially immature respond to separation from a loved one with shouting, crying, and throwing or smashing objects. Again the purpose is to protect the relationship. Men with a fearful or preoccupied attachment style are more likely to be jealous, violent and abusive in intimate relationships. This tendency to violence increases when the relationship is threatened. Males with a fearful attachment style are anxious about gaining their partners approval and at the same time are fearful of being rejected by them. These males are more likely to attribute negative intent to their partners. This combination of internal conflict and external blame makes men with a fearful attachment style respond to rejection with aggression (Leary 2006).

Jealousy is the precursor of aggression in many close relationships. Jealousy occurs when people believe that another person does not sufficiently value their relationship because of the presence or intrusion of a third party. Men who are abusive have higher interpersonal jealousy. Abused women and the men who abuse them report jealousy as the most common precursor to violence. Among both men and women, intimate violence is often provoked by real or imagined infidelity (Leary 2006). We have already discussed jealousy in the context of the family.

Rejection-sensitivity is a personality characteristic associated with aggression elicited by rejection in love and romance. People high in rejection sensitivity (Downey 1996)
  1. Anxiously expect rejection by significant people in their lives.
  2. Readily perceive intentional rejection in the ambiguous or insensitive behaviour of their new partner.
  3. Over-react to rejection

Gender differences (Downey 1996) dictate that men with high rejection sensitivity manifest jealousy in the face of perceived rejection. Their consequent attempts to control their love object’s interactions with other males leads to further dissatisfaction in the relationship. When they are not successful in this they respond with rage - the common fallout of jealousy. Females react to perceived rejection with hostility and withdrawal of support. Both gender reactions lead to dissatisfaction with the partner and subsequent breakup of the relationship. If taken to an extreme, the jealousy in the rejection sensitive male can lead to fatal consequences for object of his affections.

Despite these negative experiences rejection sensitive people are repeatedly drawn to intimate relationships. The new relationship is viewed as an opportunity for acceptance. Initially they work hard to ingratiate themselves with their partner. However, the inevitable transient negativity, insensitivity, or preoccupation triggers the deeply ingrained anxieties and expectations of rejection. The person over-reacts to minor and ambiguous signals from the love object and starts the cycle of dissatisfaction in the relationship.

Rejection sensitivity is deeply ingrained in the personality. An intimate partner or a therapist can alter the expectancies and anxieties about rejection. It is possible for the rejection sensitive person to develop better conflict resolution skills. But only when there is a high degree of motivation in the rejection-sensitive person and a skilled, and nurturing partner.

  1. Özlem Ayduk, Anett Gyurak, and Anna Luerssen. Individual differences in the rejection-aggression link in the hot sauce paradigm: The case of Rejection Sensitivity. J Exp Soc Psychol. 2008 May 1; 44(3): 775–782. doi: 10.1016/j.jesp.2007.07.004
  2. Downey G, Feldman SI. Implications of rejection sensitivity for intimate relationships. J Pers Soc Psychol. 1996 Jun;70(6):1327-43.
  3. Leary MR, Twenge JM, Quinlivan E. Interpersonal rejection as a determinant of anger and aggression. Pers Soc Psychol Rev. 2006;10(2):111-32.
  4. Office of the Surgeon General. (2001). Youth violence: A report of the Surgeon General. U.S. Department of Health and Human Services. 

Sunday, July 31, 2011

Brain effects of cellular phone use

EEG changes with cellular phone radiation
Mobile phone induced EEG changes
Cellular phones affect the brain to cause injury and death through inattention and reaction time delays. Cellular phone radiations also induce abnormal changes in brainwaves. Here we are not concerned with the potential for death due to the cancer generating properties of GSM radiation. We are concerned with the direct and immediate adverse effects of cellular phone conversations.

Cellphones continue to kill their users in Pune. At least two people died crossing the Hadapsar railway tracks while engrossed in conversation. One of them was oblivious to shouting onlookers warning him of the oncoming train. Another cell-bewitched user fell off his eighth-floor balcony while conversing. And of course cellphone use while driving continues to kill despite the ban. All this is besides the cancer risk that the WHO (2011) is unable to disregard.

How distracting is a cellphone conversation?

Any extraneous demand on attention will distract from performance on an ongoing task. If the task itself is critical, as in driving, distractions can be lethal. Even hands-free cellphone conversations while driving cause attention lapses and slow down reaction time (McCartt 2006). These effects are seen in drivers across gender and age groups. The surest way to verify that a crash occurred during mobile phone use is to check billing records. Using this method crashes leading to personal or property damage are found to be four times more common during mobile phone use. When there is a higher mental load in the mobile phone conversation problems with attention and reaction time are magnified (Lin 2006).

The stream of media reported mobile phone related deaths during the performance of everyday tasks highlights the much neglected aspect of non-driving related mobile phone injuries. Pedestrians conversing on a mobile phone cross the road more slowly, are less likely to look for traffic, and take more risks in the face of oncoming traffic (Neider 2010). Pedestrians are less likely to cross a road successfully while using a mobile phone than while listening to music on an iPod. These effects are more pronounced in adolescents.

The risk of injury is related to the need to shift the focus attention from the task on hand to the conversation. Conversing on a mobile phone takes up a significant amount of mental processing ability. Mobile phone conversations increase reaction times and reduce accuracy on task performance. These impairments increase with increasing complexity of the task being interrupted. One can only imagine the effect of a mobile phone interruption on the outcome of an ongoing medical procedure.

Do cellular phone generated electromagnetic waves interfere with brainwaves?

Intriguingly, GSM microwave radiation interacts with and distorts brainwaves. This effect can be directly measured and recorded on an electro-encephalogram (EEG). Electromagnetic fields emitted by cellular phones cause a slowing of brain waves (delta waves) that is not seen in healthy adults during normal wakefulness. These changes persist for up to ten of minutes after the mobile phone is switched off. Children are more vulnerable to these effects as microwave absorption is greatest in an object the size of a child’s head. This radiation also penetrates the thinner skull of an infant with greater ease (Kramarenko 2003).

Brainwaves normally discharge asynchronously when attention is drawn to an event in the environment. This event related de-synchronisation is altered by mobile phone electromagnetic fields. This affects tasks involving memory, especially in children (Krause 2000, 2006). Cellphone radiofrequency waves have a dose dependent effect on tasks attention, concentration and short term memory. Reaction speed decelerates with increasing GSM field intensity. These effects are more pronounced when the responding hand and side of radiation exposure are taken into account (Luria 2009).

These dose dependent radiation effects are also seen when cellular phone use also alters brainwave patterns (spindle activity) during slow-wave sleep. These effects are long lasting, and indicate a non-thermal effect. The thalamus, a part of the brain that processes sensation, is responsible for generating sleep spindle activity and may be especially susceptible to cellphone radiation (Regel 2007).

Walk and talk is a bad idea

  1. Robert Baan, Yann Grosse, Béatrice Lauby-Secretan, Fatiha El Ghissassi, Véronique Bouvard, Lamia Benbrahim-Tallaa, Neela Guha, Farhad Islami, Laurent Galichet, Kurt Straif, on behalf of the WHO International Agency for Research on Cancer Monograph Working Group. Carcinogenicity of radiofrequency electromagnetic fields. The Lancet Oncology, Volume 12, Issue 7, Pages 624 - 626, July 2011 doi:10.1016/S1470-2045(11)70147-4
  2. Kemker BE, Stierwalt JA, LaPointe LL, Heald GR. Effects of a cell phone conversation on cognitive processing performances. J Am Acad Audiol. 2009 Oct;20(9):582-8.
  3. Kramarenko AV, Tan U. Effects of high-frequency electromagnetic fields on human EEG: A brain mapping study. Intern. J. Neuroscience, 113:1007–1019, 2003 DOI: 10.1080/00207450390220330
  4. Krause CM, Sillanmäki L, Koivisto M, Häggqvist A, Saarela C, Revonsuo A, Laine M, Hämäläinen H.  Effects of electromagnetic fields emitted by cellular phones on the electroencephalogram during a visual working memory task. Int J Radiat Biol. 2000 Dec;76(12):1659-67.
  5. Krause CM, Björnberg CH, Pesonen M, Hulten A, Liesivuori T, Koivisto M, Revonsuo A, Laine M, Hämäläinen H. Mobile phone effects on children's event-related oscillatory EEG during an auditory memory task. Int J Radiat Biol. 2006 Jun;82(6):443-50.
  6. Lin CJ, Chen HJ. Verbal and cognitive distractors in driving performance while using hands-free phones. Percept Mot Skills. 2006 Dec;103(3):803-10.
  7. Luria R, Eliyahu I, Hareuveny R, Margaliot M, Meiran N. Cognitive effects of radiation emitted by cellular phones: the influence of exposure side and time. Bioelectromagnetics. 2009 Apr;30(3):198-204.
  8. McCartt AT, Hellinga LA, Bratiman KA. Cell phones and driving: review of research. Traffic Inj Prev. 2006 Jun;7(2):89-106.
  9. Mark B. Neider, Jason S. McCarley, James A. Crowell, Henry Kaczmarski, Arthur F. Kramer. Pedestrians, vehicles, and cell phones. Accident Analysis and Prevention 42 (2010) 589–594
  10. Regel SJ, Tinguely G, Schuderer J, Adam M, Kuster N, Landolt HP, Achermann P. Pulsed radio-frequency electromagnetic fields: dose-dependent effects on sleep, the sleep EEG and cognitive performance. J Sleep Res. 2007 Sep;16(3):253-8.

Tuesday, July 26, 2011

Discrimination of psychiatrically ill persons by hospitals

Healthcare discrimination of mentally ill persons
Discrimination of mentally ill persons by hospitals
A young woman with psychiatric illness was refused admission at a leading tertiary care hospital in Pune. The reason - “mentally unstable patients are known to cause harm not only to themselves but to others as well. The hospital lacks facilities and infrastructure for catering to psychiatric patients.” A similar unwritten policy of denying inpatient care on grounds of psychiatric illness exists in at least one other large corporate hospital in Pune.

We have already stressed the importance of access to healthcare for persons with mental illness. We will now further explore the stereotype of harm in mental illness. The stigma associated with this stereotype has an adverse impact on timely delivery of healthcare to persons with psychiatric illness.

Are mentally ill persons likely to harm other hospital inpatients?

Hospital and healthcare settings have the highest levels workplace related violence across all industry sectors (CDC 2002).  The place where patient perpetrated violence is most likely to occur is the Emergency or Casualty department not the wards (Farooq 2009). Patients of all categories mostly attack staff or junior doctors - the ones they are in regular and direct contact with. In most cases violence is perpetrated by arrogant patient attendants not the patients themselves, whatever their diagnosis. For the rest violence is a result of unacceptable staff behaviour, and dissatisfied patients or attendants. It is rare for patients of any diagnosis to physically attack and harm each other in a hospital. Even in acute inpatient psychiatry units violence towards other patients or staff is less than 3% of total incidents of violence (Biancosino 2009). So much for psychiatric illness being “known to cause harm”.

Are patients with psychiatric illnesses the only ones that harm other patients? At the height of the swine-flu scare in 2009 no patient suspected of having the disease was denied treatment or admission. Yet swine-fly is known to be highly contagious and lethal. Special protocols and facilities were drawn up and earmarked overnight. So the potential for harm is not the overriding factor in denial of treatment.

Patients with psychiatric illness require minimal investigation, and respond rapidly to cheap and effective medication. Return on investment may be what it is all about. Psychiatrically ill pateintsdo not make much money for a hospital. It is more lucrative to provide skewed facilities for a liver transplant that would require weeks of ICU care, extensive investigation and invasive procedures. It would also make news for all the right reasons.

Mental illness accounts for 80-90% of completed suicides. Serious suicide attempts by poisoning or jumping result in emergency hospital admissions. Treatments would entail stay in the Intensive Care Unit, utilisation of the Operation Theatre, mechanical ventilation, and extensive monitoring and investigations. All this translates into large cash transactions over a short period of time. No hospital administrator would deny admission to these critically ill patients - ethical considerations, policy and stigma not withstanding.

Is it really possible to exclude patients with psychiatric illness from the hospital healthcare system?

The dichotomy between soma and psyche, physical and mental is artificial. This was formally enunciated in Para 1 of the WHOs Alma-Ata declaration (1978) and is the accepted definition of health for medical students since decades. Psychiatric and somatic illnesses coexist with and impact eachother. Ignoring this interaction is adversely affecting the outcomes of chronic illnesses like diabetes, heart disease, cancer and respiratory disease. The World Mental Health Day 2010 document specifically evaluates the evidence and stresses the urgent need to integrate mental heatlhcare for these chronic illnesses which account for 60% of the worlds deaths.

Walk into any hospital ICU and you will see at least one delirious patient strapped to the bed with physical restraints. Psychological aspects of critical illness are given the short shrift only because the mindset is one of discrimination and disrespect for the individual. Psychiatric and physical health problems do not exist in isolation. Their physical basis and vice versa cannot be excluded by artificial dichotomies.

Is it desirable to treat persons with mental illness in a general hospital setting?

Integration of mental healthcare delivery with existing facilities is a major thrust of the WHO (2008). Hospitals need to provide an accessible and acceptable location for treatment of acute exacerbations of mental health disorders in the same way that they currently do for physical health disorders. This would also enable access to services for physical health problems that arise during the inpatient stays of persons with mental health problems.

Deinstitutionalisation of psychiatric and mental health care has been stressed as a human right since the mid 20th century. A step in this direction for Pune's hospitals would be to draw up and implement guidelines to prevent and manage hospital violence. These guidelines already exist (CDC 2002, OSHA 2004).

  1. Biancosino B, Delmonte S, Grassi L, Santone G, Preti A, Miglio R, de Girolamo G; PROGRES-Acute Group. Violent behavior in acute psychiatric inpatient facilities: a national survey in Italy. J Nerv Ment Dis. 2009 Oct;197(10):772-82.
  2. CDC. Violence - occupational hazards in hospitals.  DHHS (NIOSH) Publication No. 2002–101. April 2002
  3. J Farooq, A Mustafa, D Singh, GH Yattoo, A Tabish, GJ Qadiri. Violence in hospitals. Journal of the Academy of Hospital Administration, Volume 21, No. 1 & 2 Jan-June & July-December 2009; 16-20
  4. Occupational and Safety Health Administration. Guidelines for preventing workplace violence for health care and social service workers. 2004. Publication no. OSHA 3148-01R
  5. Soliman AE, Reza H. Risk factors and correlates of violence among acutely ill adult psychiatric inpatients. Psychiatr Serv. 2001 Jan;52(1):75-80.
  6. World Federation for Mental Health (WFMH). Mental health and chronic physical illness - the need for continued and integrated care. World mental health day. 10 October 2010.
  7. World Health Organisation (WHO) Declaration of Alma-Ata. International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September 1978
  8. WHO/Wonca.  Integrating mental health into primary care: a global perspective. World Health Organisation and World Organization of Family Doctors (Wonca). 2008.

Saturday, July 16, 2011

Inclusive education for children with autism in Pune

inclusive education for children with autism and developmental disabilities
Inclusive Education
Inclusive education for children with autism and other developmental disabilities is now approaching reality in Pune. Nine children with autism appeared for the Maharashtra 10th standard (SSC) board exam. The accommodations and waivers granted to these students reflect an infusion of the fresh breath of inclusion into the corridors of the board of education .

Sarva Shiksha Abhiyan (SSA) in Maharashtra

The Education for All Movement, the central government’s flagship SSA, seeks to ensure that every child, including those with special needs, is provided an elementary education. As far as disability is concerned the SSA has adopted a zero rejection policy. It provides for universal access to infrastructure and curricula in schools. Maharashtra is at the forefront of this scheme. In all 380000 teachers from Maharashtra attended workshops on inclusive education through the SSA. 414277 children with special needs were identified and 380723 enrolled under the SSA in Maharashtra as of Jun-2009, . Of these about 9000 children were provided a home-based education.

Beyond elementary school it is up to the state education boards to ensure access to further education. For this the Central Board of Secondary Education (CBSE) initiated accommodations and waivers in 2009. This year for the first time, 9 students with autism from Pune division and 10 students from Mumbai appeared for the Maharashtra SSC 10th standard board exams. Lets look at why this is a significant social event.

Modern education of children with disability traces its history to Jean-Marc Itard a French physician. On the cusp of the 18th and 19th centuries Itard attempted to educate Victor, a feral child discovered in the forests of Aveyron. Although Itard himself judged his work with Victor a failure, this renowned experiment marked the first time that anyone considered the possibility that persons with disabilities could be educated.

Edouard Seguin (mid 1800s), a French educator, developed a method for teaching children with intellectual disability in order for them to take their rightful place in the societies of their day. The early training schools were based on these concepts. The schools were small and homelike with 8 to 10 residents. The original goal was the return of children to their families after a period of intervention.


Despite these early efforts, it was later concluded that educational and therapeutic approaches had failed. Persons with intellectual disability were scapegoated and regarded as the root cause of many social problems. Institutionalisation and segregation into special schools became the principal means of ‘protecting’ intellectually disabled persons from society and also for ‘safeguarding’ society against the social ill thought to be caused by an expanding population of defectives (Jackson 1999).


Lloyd Dunn (1968), a special educator, declared that most children with mental retardation could be "mainstreamed" in classes with typically developing age-mates. He questioned the need for segregated special education classes for most children with mental retardation. He highlighted the lack of evidence to show that children with mild mental retardation learn any better in special education classes than in regular classes. Lloyd Dunn pointed out that educational techniques had advanced sufficiently to allow the effective schooling of most children with retardation alongside other typical children.


Wolf Wolfensberger (1972), a scholar, activist and prolific author in the field of development disabilities extended the idea of normalization to the service delivery system itself. He called on all residences, schools, and other services for persons with retardation to be as normative as possible. Parent and professional advocacy groups also fought hard for legislative and legal victories to decrease the size of large institutions.


Inclusive education seeks to overcome every barrier - physical and academic- to ensure the child is educated with their peers (Sigafoos 2003). It stresses the importance of peer interaction in the final outcome for the child who is to enter into the adult world on a level playing field. To this end academics is given a secondary role. The child is supported for all physical needs to enable participation in the classroom experience with their peer group. Academic difficulties are addressed by a remedial teacher or special educator attached to the class who helps the child in parallel with the regular curriculum. The child may be learning at a level many grades below the rest of the class but has the benefit of meaningful social interaction.

It has taken 200 years for the vision of Itard to reach the SSA, the national inclusive education program. The universal principles of justice, fraternity, and equality secured for all citizens by the constitution are driving us to ensure children with autism and other disabilities are educated alongside their peers. That is why nine children with autism have appeared for a board exam in Pune. That is why this is a significant social event.

  1. CBSE. Amendments/Additions in Examination Bye Laws. 2009
  2. Dunn L M. Special education for the mildly retarded—is much of it justifiable? Except. Child. 35:5-22, 1968.
  3. Jackson, Mark. Mental Retardation In: A century of Psychiatry. Ed. Hugh Freeman. London: Harcourt Publishers, 1999.
  4. Sigafoos, Jeff, Michael Arthur, and Mark O'Reilly. Challenging Behaviour and Developmental Disability. London: Whurr Publishers, 2003.
  5. SSA, Inclusive education. Accessed 04-Jul-2011
  6. SSA. Kolkotta National Workshop. Accessed 04-Jul-2011

Thursday, June 30, 2011

Neurotoxic effects of alcohol on the adolescent and young adult brain

(or why the 25 year age-bar on alcohol consumption could be reasonable)

Does alcohol have specific neurotoxic effects on the adolescent or young adult brain? This question is the only important one for deciding whether the 25 year age-bar on alcohol consumption in Maharashtra is justifiable. While the debate rages two students from the premier medical college of India drowned in an alcohol fuelled swimming pool misadventure, and in an unrelated incident on the same night five inebriated youths were arrested for disturbing the peace in a residential area. We have seen how to recognise problem alcohol drinking in teenagers, and how to refuse alcohol. This article probes the specific effects of alcohol on the maturing brain.


Alcohol is a neurotoxin. It distorts the normal architecture of the developing brain. This distortion starts during pregnancy when imbibed maternal alcohol crosses the placenta into the foetus. In the foetus alcohol acts on the specially vulnerable immature insulating cells (oligodendroglia) of the brain. The child is born with Fetal Alcohol Syndrome, characterised by irreversible mental retardation, a small head, small stature and facial abnormalities. Because the exact amount of alcohol required and the most vulnerable periods of pregnancy have not been definitively established all pregnant women are advised to abstain from any use of alcohol.


By the second year of life the number of connections between brain cells (synapses) are at a maximum. These synapses are gradually reduced to the adult number (synaptic pruning). This process is controlled by immature excitatory (glutamate) receptors in the synapses. These receptors differ from adult ones by allowing quicker and longer excitation. Immature glutamate receptors are vulnerable to the effects of alcohol. Their over-stimulation distorts synaptic pruning (Johnston 1995).


In adolescence there is a rapid growth of gray matter and the formation of new connections (proliferation) in the brain. Elimination of some synaptic connections (pruning) enables the adolescent or young adult brain to change in response to environmental demands. Stability of these connections is enhanced through insulation of neuronal fibres (myelination). Myelination increases the overall speed of information processing within the brain. These maturational processes are critical for cognitive development. They are all adversely affected by alcohol (Guerri 2010).
These adverse effects specifically impact the frontal lobes of the brain and are highly associated with level of intelligence. In addition the brain area essential for working memory (hippocampus) is preferentially damaged by alcohol (De Bellis 2000). Gender effects render female adolescents more vulnerable than males to these alcohol effects.
The reward system of the brain is responsible for motivation and learning. The immature reward system has an adolescent-specific vulnerability for alcohol and drug addiction. Early exposure to alcohol sensitises the brain regions involved in drug addiction and alters gene expression in the brain reward regions (nucleus accumbens).
The pattern of brain electrical activity changes during the transition from adolescence to adulthood. Alcohol also has a premature aging effect on brain electrical activity during wakefulness and sleep. Animal models have shown that even brief exposure to alcohol in adolescence can cause long lasting changes in brain electrical activity. These changes place the adolescent at a high risk for later substance abuse and addiction (Ehlers 2010).


Alcohol differentially impairs the young persons judgement and motor skills. The evidence for this is so robust that some administrations have placed a lower legal blood alcohol level limit on drivers less than 21 years old (Hingson 1994). This differential susceptibility to alcohol has been shown to persist up to 30 years of age when a specific impact is seen on frontal lobe functions related to driving skills (Domniques 2009).

Whether the authorities considered the neurotoxic effects of alcohol while imposing the 25 year age-ban on alcohol consumption is a moot point. However, educating adolescents and youth regarding these adverse alcohol effects should be the duty of every parent.

  1. De Bellis MD, Clark DB, Beers SR, Soloff PH, Boring AM, Hall J, Kersh A, Keshavan MS. Hippocampal volume in adolescent-onset alcohol use disorders. Am J Psychiatry. 2000 May;157(5):737-44.
  2. Domingues SC, Mendonça JB, Laranjeira R, Nakamura-Palacios EM. Drinking and driving: a decrease in executive frontal functions in young drivers with high blood alcohol concentration. Alcohol. 2009 Dec;43(8):657-64.
  3. Ehlers CL, Criado JR. Adolescent ethanol exposure: does it produce long-lasting electrophysiological effects? Alcohol. 2010 Feb;44(1):27-37.
  4. Guerri C, Pascual M. Mechanisms involved in the neurotoxic, cognitive, and neurobehavioral effects of alcohol consumption during adolescence. Alcohol. 2010 Feb;44(1):15-26.
  5. R Hingson, T Heeren, and M Winter. Lower legal blood alcohol limits for young drivers. Public Health Rep. 1994 Nov-Dec; 109(6): 738–744.
  6. Johnston MV. Neurotransmitters and vulnerability of the developing brain. Brain Dev. 1995 Sep-Oct;17(5):301-6.