How and when to use psychotropic drugs in psychodermatology

A significant number of patients coming to dermatologists have psychiatric symptoms as predisposing, precipitating, and perpetuating factors. Assessment and treatment of these conditions is complex. However, looking at the number of patients with these problems, dermatologist needs to be well versed with an assessment of these patients and use of some of the psychotropic drugs. Some such drugs are discussed here along with a discussion about the decision to use them. Benzodiazepines such as clonazepam and lorazepam, doxepin, selective serotonin reuptake inhibitor like fluoxetine, escitalopram, and low dose of antipsychotics like risperidone, haloperidol, and olanzapine are discussed. As the patients are often reluctant to visit a psychiatrist, a dermatologist needs to help in allaying the initial anxiety and to provide understanding about the psychiatric conditions and available options for treatment. In long term, liaison with a psychiatrist can be established and joint treatment by both consultants can be continued

Insights into psychosocial problems of primary caretakers of patients with schizophrenia in India

Context: Schizophrenia affects 1%–1.5% of the population of the world. The illness commonly affects young population disturbing and disrupting the patient as well as his family. Research has demonstrated increased physical and mental health morbidities among these caretakers. Aims: The aim of this study was to explore various stresses and social problems faced by caretakers due to patient's schizophrenia. Settings and Design: A qualitative study of the distress experienced by primary caretaker of schizophrenia patients was undertaken at a tertiary hospital in an urban Indian setting. Methods: Relatives of 30 patients were assessed for their physical, psychological, and social problems. Their narratives of distress caused by patients' illness were recorded as verbatim and analyzed qualitatively manually. Statistical Analysis: Manual qualitative and quantitative analysis. Results: Caretaker was a parent in 72.3% of the cases. Distress due to blaming by relatives for not bringing up the child carefully was reportedly experienced by most parents, especially the mothers. Local cultural setting plays a huge influence in these highly personal and sensitive concerns. Social stigma, anxiety about illness, anger, and resentment were commonly reported. Conclusions: These insights into suffering of the caretakers of people suffering from schizophrenia in current local setting need to be considered and addressed as essential part of the management of Schizophrenia

Children with Medically Unexplained Pain Symptoms: Categorization and Effective Management

Context: Medically unexplained pain symptoms are common in children, and their incidence is on the rise. There is often a lack of clearly articulated pathophysiology in these patients. There is need to improve understanding about varied causes and presentations of these patients which would generate further insight in management of these patients. Documentation and detailed assessment of such children in Indian setting is not seen in literature. Materials and Methods: A series of 17 cases, 10 boys and 7 girls referred from pediatrics department is discussed, so as to categorize them in three different subgroups for management. Result and Discussion: Although there were often no overt anxiety or depressive features, some psychosocial stress which was mostly unnoticed by the child, the parents and the doctor, preceded such a pain. It was often an academic stress, familial separation or parental psychiatric illness. They were at times not able to verbalize their distress, which was revealed with the help of Children′s Apperception Test (C.A.T.). They mainly had anxieties about loss of love or disapproval by parents and also fear of harm or injury. They used defence mechanisms like denial, reaction formation and repression, which were ineffective in handling the overwhelming anxiety. Most of these children had either above average or borderline intelligence. Somatic expression of emotional needs and fears in these children was managed effectively by supportive therapy and antidepressant drugs

Original Article - Evaluation of functional impairment in psoriasis

Background: Psoriasis is a chronic disease, the course of which is punctuated by exacerbations and remissions. The impact of a chronic, relapsing, and disfiguring disease such as psoriasis on occupational, social, and other areas of functioning is substantial and needs attention. Aim: The purpose of this study was to assess the level and nature of functional impairment in psoriasis. Methods: Forty-three consecutive patients attending the dermatology clinic of a rural hospital were studied for psychiatric comorbidity and the level of functioning, using a semistructured questionnaire. Results: Psoriasis affected social functioning of 48% patients, led to decreased work efficiency in 51.1%, and to subjective distress at work in 62.8% of patients. Stress in home environment and interpersonal relationships was reported by 69.8%. Social and occupational functioning worsened with increasing severity of psoriasis after 1-year duration of illness. Patients complaining of pruritis frequently had anxiety disorders. Psychiatric comorbidity was detected in 67.4% cases. Conclusion : Substantial proportion of patients suffered deterioration of functioning, especially with increasing duration of illness. Thus, timely attention by dermatologists is needed in order to limit the disability caused by psoriasis. To achieve this, liaison with psychiatrist would be crucial along with illness education and emotional support

A comparative study of psychosocial morbidity in stable versus unstable vitiligo

Context: Vitiligo is a cosmetically disfiguring condition especially in dark-skinned individuals, thereby adversely affecting their quality of life (QOL). Studies have reported higher psychiatric morbidity in patients with vitiligo, but a comparative study between patients with stable and unstable vitiligo has not been reported. Aims: To compare the psychiatric morbidity, perceived stress, and QOL in patients suffering from stable versus unstable vitiligo. Settings and Design: This was a clinical observational, cross-sectional liaison study conducted over a period of 2 years and included 100 consecutive patients with vitiligo, who came for treatment to the dermatology clinic of a tertiary care hospital. Materials and Methods: A dermatologist clinically assessed the patients and calculated their vitiligo area severity index score and dermatology life quality index. A psychiatrist evaluated the patients on the basis of the perceived stress scale (PSS), hospital anxiety and depression scale (HADS), and clinically established diagnosis using International Classification of Diseases (ICD-10). Statistical Analysis: The aforementioned variables between the two groups were compared using chi-square test and independent t test. Results: High psychiatric morbidity (65%) was reported in patients with vitiligo, with adjustment disorder being the most common morbidity. The most common reported stress was grief or emotionally significant loss. Psychiatric morbidity, scores on HADS, and PSS were significantly higher in patients with unstable vitiligo in comparison to patients with stable vitiligo. The quality of life (QOL) was mildly affected among the patients in both the groups. Conclusions: There is higher psychiatric morbidity in patients with unstable vitiligo along with a worse QOL in comparison to those with stable vitiligo. Patients with vitiligo should be assessed for stability as well as psychiatric morbidity, because it will have significant management implications

Stresses and Disability in Depression across Gender

Depression, though generally episodic, results in lasting disability, distress, and burden. Rising prevalence of depression and suicide in the context of epidemiological transition demands more attention to social dimensions like gender related stresses, dysfunction, and their role in outcome of depression. Cross-sectional and follow-up assessment of men and women with depression at a psychiatric tertiary centre was undertaken to compare their illness characteristics including suicidal ideation, stresses, and functioning on GAF, SOFAS, and GARF scales (N=107). We reassessed the patients on HDRS-17 after 6 weeks of treatment. Paired t-test and chi-square test of significance were used to compare the two groups, both before and after treatment. Interpersonal and marital stresses were reported more commonly by women (P<0.001) and financial stresses by men (P<0.001) though relational functioning was equally impaired in both. Women had suffered stresses for significantly longer duration (P=0.0038). Men had more impairment in social and occupational functioning compared to females (P=0.0062). History of suicide attempts was significantly associated with more severe depression and lower levels of functioning in case of females with untreated depression. Significant cross-gender differences in stresses, their duration, and types of dysfunction mandate focusing on these aspects over and above the criterion-based diagnosis