Sunday, March 11, 2012

Bipolar disorder and hypomania - irritability and depression

hypomania-irritability-depression

Chronic unstable mood with irritability and superimposed bouts of depression is a common form of bipolar II disorder or hypomania. Persons with this pattern of illness tend to have an unstable course and stormy interpersonal relationships. They also have more irritable and hostile hypomanic episodes. The classical Bipolar II disorder or hypomania of mild elevation of mood, sharpened and positive thinking, and increased energy and activity levels is less disruptive.

Persons with this irritable type of hypomania and bipolar illness have unrealistically high expectactions of those with whom they interact; whether at the workplace, at home, or other casual day-to-day interactions. When these expectations are not met they pass on their irritation and negative mood to unsuspecting others.

There is usually a grain of truth in their version of the incident, but the growing number of incidents with various people at all levels reduces their credibility. At the workplace they are frequently in search of a new job and personally they have problems sustaining meaningful relationships.

Anger management alone is usually not effective. It needs to be combined with specific treatment for the bipolar illness. At the clinic couples and individuals come in for anger and interpersonal issues that are not resolved with counselling.

"I never realised how much my moods controlled my actions"

Treatment for bipolar disorder including hypomania hinges on medication and psychotherapy. Treatment requires patience by all parties in the therapy. Relapses are frequent when medication is stopped.
"I can see the difference when he stops his medication;
help me get him back, doctor"
It takes time for the affected person to accept he or she has hypomania or bipolar illness. The degree of realisation fluctuates during the course of therapy. Regular psychiatric review is essential to prevent relapse in bipolar illness and hypomania

Tuesday, February 21, 2012

Mental health checklists and screening tests for rampaging bus drivers

pune bus
Checklists and psychological screening questionnaires for mental illness are effective, easy to use and widely available. Pune was shocked into considering the need for mental health screening of its bus drivers after one of them wilfully killed eight people and injured 32 others. He hijacked a bus at the depot and mowed down victims in broad daylight. Amidst the protests, and outrage the Pune administration has decided that all its bus driver undergo psychological testing.

We have already looked at screening of police personnel for mental health problems, and also screening of teenagers for alcohol and drug abuse. Here we specifically examine the feasibility of regularly screening the 8600 PMPL staff and Pune bus drivers for mental health problems.

Mental illness in bus drivers

  • Mental health problems are higher for bus drivers who suffer from back pain, are dissatisfied with their jobs or undertake long-distance driving. This is more so for employees who have worked for >10 years. (Issever et al 2002)
  • Aggressive bus drivers have more anxiety, hostility, and anger. They display competitiveness when driving aggressively, and display anger at slow drivers and traffic obstructions (Galovski 2002). Aggressive drivers with Intermittent Explosive Disorder (IED) endorse more assaultiveness and resentment. They display more impatience, hostility and have an angry temperament.
  • Bus drivers have higher hospital admissions with diagnoses of mood reactions, paranoia and non-specific psychoses. (Ugesker 1989)

Ideal mental health screen

Easy to administer
it is to be conducted regularly without consuming excessive time
Culturally acceptable
anything stigmatising will be shunned
Sensitive
picks up potentially vulnerable persons
Specific
excludes those who do not have mental health problems
Easy to interpret
results should be available immediately
The aim of mental health screening is to identify individuals who require a more detailed examination. One counsellor will never be able to carry out any evaluation of 8600 staff.

Mental health checklists and screening instruments

There are already valid (test identifies persons mental illness) and reliable (results remain the same when administered by different testers and on re-testing) checklists for mental health screening. Two mental health screening instruments that satisfy many of the ideal criteria are the COOP/WONCA charts and the WHO-5 questionnaire. Both have high diagnostic accuracy for mental disorders. Specificity, sensitivity and positive predictive values range from 0.85 to 0.87 (Anything more than 0.7 is good).

COOP/WONCA

The COOP/WONCA measures six core aspects of functional status: physical fitness, feelings, daily activities, social activities, change in health and overall health through six charts. The charts have been successfully used in illiterate populations, and have guidelines for translation where required. The average time for completion is less than five minutes. One-time assessment with the COOP/WONCA Charts is a valid and feasible option for screening for mental disorders at the primary care level.

WHO-5

The WHO-Five Well-being Index (WHO-5) is a set of 5 questions that can be used when six charts are too much.

A mental health check is most acceptable as part of the regular or annual ‘health check’. Those who score above the cut-off are taken up for detailed assessment by a psychiatrist or other mental health professional. No additional man-power is required. The process will not cost in crores. Our roads will be safer.
We need to use available checklists and screening tests for early detection of mental illness in Pune’s bus drivers.
References
  1. Galovski T, Blanchard EB. Psychological characteristics of aggressive drivers with and without intermittent explosive disorder. Behav Res Ther. 2002 Oct;40(10):1157-68. 
  2. Issever H, Onen L, Sabuncu HH, Altunkaynak O. Personality characteristics, psychological symptoms and anxiety levels of drivers in charge of urban transportation in Istanbul. Occup Med (Lond). 2002 Sep;52(6):297-303. 
  3. Joao Mazzoncini de Azevedo-Marques, MD, PhD1 and Antonio Waldo Zuardi, MD, PhD. COOP/WONCA Charts as a Screen for Mental Disorders in Primary Care.  Annals of Family Medicine 9:359-365 (2011) doi: 10.1370/afm.1267
  4. C. van Weel, C. K├Ânig - Zahn, F.W.M.M. Touw - Otten, N.P. Van Duijn, B. Meyboom - de Jong. Measuring functional status with the COOP/WONCA charts: a manual. Northern Centre of Health Care Research 1990. ISBN 90 72156 33 1 
  5. WHO. WHO-Five Well-being Index (WHO-5) Accessed 17-Feb-2011 
  6. Ugeskr Laeger. Psychiatric admissions among city bus drivers. A prospective study. Ugeskr Laeger. 1989 Jan 30;151(5):302-5. 

Tuesday, January 31, 2012

Dyslexia - Difficulty with Reading, Maths & Spelling


dyslexia LD testing


Difficulty with reading, spelling and maths is rampant among Indian students. Two recent reports have highlighted this academic underachievement. The academic infrastructure is definitely a major contributor. However, unrecognised dyslexia or other learning disability also needs to be considered by every concerned parent and enlightened teacher. We have already discussed the management of dyslexia. Here we underline the urgent need for action.

India ranked 72nd of 73 countries in a comparative international survey (PISA) of 15-year-old students. All students were assessed on the same test for knowledge and skills in reading, mathematical and scientific literacy. A sample of more than 5000 students from 200 Indian schools were assessed in this program. In none of these categories did more than 17% of Indian students scored above baseline levels as compared to 81% of students from OECD countries (US, UK, Australia etc).

15-year-olds scoring above baseline 

Test India China OECD avg
Reading 11-17 % 95.3% 81%
Mathematics 12-15% 94.5% 75%
Science 11-16% 96.3% 82%

The Annual Status of Education Report (2010) paints an equally dismal picture.
Reading ability
  • Only half the students in Class 5 can read the Class 2 text
Maths
  • Only a third of Class 1 children can recognise numbers 1-9
  • Only a third of Class 3 students can do subtraction in two digits
  • Only a third of Class 5 students can do simple division
  • A third of Class 8 students could not use a calender

This may be a scathing indictment of our education system, but it also reflects the presence of unrecognised Learning Disorder in our students. Learning Disorder affects 5-10% of students worldwide. Learning Disorder manifests in varying combinations and severity of difficulty with reading, spelling and arithmetic.

If your child has difficulty reading, spelling or in mathematics
  • Have them assessed for dyslexia or other learning disability
  • The earlier remedial teaching is instituted the more likely the child is to benefit
  • Identification of dyslexia or learning disability entitles your child to waivers at the 10th and 12th board exams.

The Right of Children to Free and Compulsory Education Act (RTE) of 2009 lays down the duties of government, local authorities and parents; the responsibilities of schools and teachers; and the norms for schools. These norms include the number of teachers, buildings, minimum teaching hours, teaching aids, library, and recreational equipment. However, the teaching to be done is not mentioned and nor is it monitored. Rote learning is emphasised. Students fail to acquire basic reading, writing and calculation skills that are required to continue learning as adults.

Don't just wait for the government 
Act NOW to secure your child's place in a global future

References:
  1. ASER 2010 - Rural. Annual Status of Education Report (Rural)Date of publication: January 14, 2011
  2. Maurice Walker. PISA 2009 Plus Results: Performance of 15-year-olds in reading, mathematics and science for 10 additional participants. ACER Press. Victoria. 2011.  ISBN: 978-1-74286-067-1
  3. The Right of Children to Free and Compulsory Education Act (RTE). 

Sunday, January 15, 2012

Recovery from mental illness

recovery from mental illness
Recovery to meaningful functioning after even severe mental illness is the present standard of care in mental health treatment. Recovery is made possible by medications that are now widely available at a reasonable cost. Planning and persistence with treatment need to be ensured to achieve a quality recovery.

Recovery from mental disorders is a process of change through which individuals
  1. improve their health and wellness
  2. live a self-directed life
  3. strive to reach their full potential
The road to recovery from mental illness has four components that together give meaning to life.
1. Health
Overcoming or managing the disease and living in a physically and emotionally healthy way.
Start with the basics - medication, meals, sleep and exercise. Establishing routines for these basic health tasks are essential for recovery of function. Medication is the corner stone on which recovery is nurtured. In the absence of medication frequent relapses and recurrences disrupt basic functions that protect the individual from the illness producing effects of daily stressors.
2. Home
A stable and safe place to live.
In daily practice we see persons with the most severe mental illnesses putting aside their disturbing thoughts, controlling their behaviours and getting back to school or work; while others with a milder illness are unable to leave their preoccupations and move ahead with life. Trusting relationships are quite often what they lack. Trust makes the home feel safe.
3. Purpose
Meaningful daily activities, such as a job, school, volunteerism, family caretaking, or creative endeavors, and the independence, income and resources to participate in society.
A person needs something to recover to. Amazing recovery can be sustained in a supportive job environment. Some bosses give this support naturally. It may be it is in their outlook; they see the illness as just one aspect of the persons identity. Vice versa, others with good symptom recovery without stigmata are unable to function in a hostile work place, and are unable to integrate with society  and lead meaningful lives.
4. Community
Relationships and social networks that provide support, friendship, love, and hope.
From volunteering at the community bookshop to joining a local football team; community interactions bring many otherwise isolated individuals into useful contact with others. These valued interactions are based on a personal identity which is not connected to their mental illness.
Recovery is a process towards achieving ones potential. The first small steps result in giant gains. Without them the individual is unable to reach any level of meaningful recovery. The first step for persons with serious mental illness is medication. Without medication, recovery from serious mental illness is long-drawn, stigmatising, and characterised by frequent relapses. Medication is the pillar around which recovery is fostered. A supportive home, work-place and community further augments this process. Recovery from severe mental illness is a process, it does not happen overnight, but for those who stay the course it brings the meaning back to life.

References
  1. SAMHSA’s Definition and Guiding Principles of Recovery – Answering the Call for Feedback
     Accessed 04-Jan-2012

Saturday, December 17, 2011

Drinking and driving

drinking-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
References
  1. Anthony Burgess. A Clockwork Orange. 1962. (Various publishers including Penguin)
  2. CDC. http://www.cdc.gov/motorvehiclesafety/pdf/BAC-a.pdf. 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.