Proceedings of 12th National Neuropsycon on Psychiatric Updates

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 12th National Neuropsycon at Lahore

Proceedings of 12th National Neuropsycon
on Psychiatric Updates

By Mubarak Ali

LAHORE: Many interesting scientific papers were presented during the 12th National Neuropsycon 2017 on Psychiatric Updates, held at Lahore from April 15-16, 2017. It was organized by Psychiatric Welfare Association in collaboration with Pakistan Association of Social Psychiatry, Pakistan Psychiatric Society, Psychiatry Department Continental Medical College, Lahore, Pakistan Society of Neurology, Pakistan Academy of Family Physicians, Pakistan Association of Clinical Psychologist and other sister organizations. The theme of the conference was Dignity in mental health, Psychological & Social Mental Health First aid for all. Prof. M Riaz Bhatti was the Chairman of the Organizing Committee.

Prof. Khalid Mufti along with Col. Nadeem chaired the first scientific session. Dr. Shahbaz Noor talked about Brain Stimulation Techniques. ECT he stated uses high current levels (around 800 milliamps) which induces an intentional, controlled, short-term seizure. Large magnetic coils is positioned above the scalp and directly over the desired stimulation area. Tran’s cranial Magnetic Stimulation (TMS) machine is turned on causing the magnetic coils to change polarity, producing short magnetic pulses. When these tiny but powerful pulses reach the scalp, they produce an electric current in the nearby neurons located in the brain through a process known as electromagnetic induction. In rTMS, the speed at which the magnetic coils change polarity is rapidly increased, usually switching between positive and negative polarities in just microseconds. Repetitive electromagnetic pulses creates stronger electromagnetic induction. rTMS potentially solidify longer lasting changes in the brain, whereby TMS may only induce short-term changes.


Prof. Khalid Mufti along with Prof. M. Riaz Bhatti presenting shields during the inaugural session of 
the 12th National Neuropsycon to Prof. Majid Ali Abdi, Dr. Nasir Hussain, Dr. Khalid Mehmood 
and Dr. Ishaq Sarhandi.

Talking about Deep Brain Stimulation Dr. Noor said that it is already being used to treat severe neurological conditions such as Essential Tremor, Parkinson’s disease, Tourette’s syndrome, and Dystonia. Magnetic Seizure Therapy (MST) uses magnetic pulses to stimulate a precise target in the brain’s aims to induce a seizure like ECT. So the pulses are given at a higher frequency than that used in rTMS. The goal of MST is to retain the effectiveness of ECT while reducing its cognitive side effects. A recent review article that examined the evidence from eight clinical studies found that MST triggered remission from major depression or bipolar disorder in 30-40% of individuals. Fewer memory side effects, shorter seizures, allows for a shorter recovery time than ECT. Brain stimulation therapies have an emerging role in the treatment of mental disorders. TMS has very good safety profile and is pretty safe, Dr. Noor added.


Ms. Horiya Ashgar talked about Academic Stress and its relationship with Life Satisfaction among female postgraduate students. This study was conducted at International Islamic University, Air University, and Bahria University, Islamabad on 100 female postgraduate students. The findings indicate that there is a negative significant correlation between academic stress and life satisfaction of female post graduate students. It might be because females in Pakistan have to work at home along with their studies and at this level the studies are difficult and they consume a lot of time that leads to low levels of life satisfaction. Academic stress was found to be higher in married female postgraduate students as compared to unmarried female postgraduate students. It might be because married women share more duties and responsibilities as compared to unmarried women, particularly in Pakistan and they have to tackle home, relationships and studies all together which leads to high academic stress among married female postgraduates. Life satisfaction was found to be higher among UN married female postgraduate students as compared to married female postgraduate students.

Ms. Nargas Munir, presented the findings of a study about Relationship of Learning Styles with Self Concept and academic performance of Students at Secondary Level. The target population of the study consisted of all male and female students of 10th Grade of public secondary schools of Rawalpindi and Islamabad. It was conclude that gender is strongly co-related with students’ academic performances, while self-efficacy of students has inversed co-relation with students’ academic performances and students learning styles that is visual and auditory.

 

Prof. M. Riaz Bhatti along with Dr. Ajmal Kazmi and Col Sarwar chairing a session
during the 12th National Neuropsycon held at Lahore from
April 15-16, 2017.

Prof. Azizur Rehman along with Prof. Khalid Mufti and Dr. Ishaq Sarhandi chaired the second session. Dr. Burhan A. Mustafa acted as Moderator. Dr. Sadia Hussain shared the findings of a study on Illness Perceptions in Patients of Schizophrenia completed by one hundred individuals suffering from the schizophrenia from public sectors in Lahore. Stress, family problems, lack of friends & financial worries were endorsed strongly by patients as cause of their mental illness. Patients’ perceived significant negative consequences, negative emotional response, as well as had poor understanding of their mental illness and treatment effectiveness. Patient’s perception about their own illness is predictor of their drug taking attitude and perceived social support. Perception is reality, so if we have to change our perception we have to change our reality, she concluded.

Tele Psychiatry as an educational tool- A pilot project was highlighted by Prof. M. Ishaq Sarhandi. Tele-psychiatry, he stated can be defined as the delivery of health care and the exchange of health care information for purposes of providing psychiatric services across distances. As the society has evolved into technology based society, growth has been noticed in the delivery of Psychiatric treatment. Tele Psychiatry, in the form of live interactive video conferencing is put forward as a critical tool to improve access, increase quality and reduce costs of psychiatric treatment for the last two decades. Educational Telemedicine has been used for several educational initiatives, including providing education, clinical consultation and supervision. It has successfully linked academic centers with rural areas for continuing medical education, both in North America and internationally.


TelePsychiatry, Prof. M. Ishaque stated is being used successfully for various clinical, educational, and research purposes. The technology, speed of transmission, and program structure vary widely among many clinical and Educational settings. The Educational use of TelePsychiatry include the didactic, case-based consultation and supervisory initiatives. it’s a proven fact now that TelePsychiatry is gaining ascendance not only in terms of managing the Psychiatric patients’ at their door steps even in very remote areas cost effectively, has acquired an importance for its use for the academic purpose.

Prof. Khalid Mufti, talking about psychology of electronic and print media said that Psychology holds a central Practical Position, there is close collaboration of media, technology, arts and science. As a result society is enveloped like Fish in the sea... Communication is the key to all aspect of changes, listening is the ecology of human being. It opens the door way to heart. Listening creates trust between humans. Listening creates love, it holds key to our future, both on intimate and personal level. Psychology in reality is a mixture of Psychology and spirituality. Psychology is engagement in the process of inner growth social development at the same time. Anger, power and fear are major block of communication. Attitude is most important thing, non-understanding of deep levels of communication leads to separation, misunderstanding hurting of love. Perfect love is perfect communication, he added.

Dr. Muhammad Usman Ghani talking about Frequency of depression in Hepatitis C patients stated that Pakistan is the sixth most populous country in the World with an estimated population of 166 million. In Pakistan the overall mean prevalence of depressive disorders in the community was 34%and the frequency of depression in liver disease patients is 35.3 %. The Hepatitis C virus (HCV) is a major cause of chronic liver disease and affects an estimated 180 million people worldwide. Patients receive Interferon for the treatment of Hepatitis C virus and the incidence of induced depression in patients with interferon therapy was 42%and frequency of depression without Interferon therapy was 22%.


Prof. Khalid Mufti, along with Dr. Ishaq Sarhandi, Dr. Sobia Haqqi, Dr. Bashir Ahmed and
Prof. Aziz Ur Rehman
chairing a session during 12th National Neuropsycon held at Lahore recently.

Continuing Dr. Usman said that it is observed that depression occur in many medical illnesses. Depression in patients with hepatitis C mainly complains of multiple somatic pain, generalized weakness, low mood and loss of interest. A study was conducted in liver clinic of Fuji Foundation Hospital Rawalpindi and department of psychiatry Fauji Foundation Hospital. Duration of study was 6 months from 23rd November, 2011 to 23rd May, 2012. One hundred fifty patients were included in the study. It showed that the frequency of depression was significantly higher in patients with Hepatitis C. All patients of hepatitis C should be screened for depression. A well-designed population based study is required to know the association of HCV and depression so that management of hepatitis C and depression is taken into account, to achieve maximum quality of life in patients, Dr. Usman concluded.


Talking about future of Cognitive Behaviour Therapy (CBT) in Pakistan, Dr Bashir Ahmad said that about 35-40 percent patients do not respond to antidepressant medication, some develop side effects, some people simply do not like medication and CBT is an intervention for this group of patients. Cognitive Behavior Therapy is an effective intervention across a wide range of psychiatric disorders. It has proven efficacy in the management of depression, panic anxiety, OCD, social anxiety, PTSD, personality disorders and psychosis. Its goal is to change patterns of thinking or behavior that are behind people’s difficulties and so change the way they feel. Maudsley’ and NICE guidelines recommend CBT as effective alternative interventions, in some psychiatric conditions even as a first line treatment. Unfortunately, in Pakistan we don’t have proper CBT services and lack of trained people, he added.

Continuing Dr. Bashir said that it is our mission to make available the best evidence based psychological intervention to people across the country by excelling in the field of Cognitive Behavior Therapies. To train at least 200 professionals in the next 5 years not only to provide CBT services to patients but also become master trainers. Psychiatry Department Khyber Teaching Hospital organized numerous CBT training courses and workshops for psychologists and psychiatrists. In 2013 and 2014 intensive eight weeks training courses were organized for the staff working in psychiatry department Khyber Teaching Hospital Peshawar. Psychiatry Department started a six months certified training course, affiliated with Khyber Medical University Peshawar. We plan to start a one year diploma course from January 2018 and also trying to get both the courses recognized from the PMDC and to make these courses convenient to participants all over the country. The Future of CBT in Pakistan is bright, he added.


Depression in Adolescents- DSH & Risk Management was the topic of presentation by DR S. M. Ahmad. Incidence of suicide he stated is the 2nd most important cause of death after accident. Adolescents are too proud to admit to problems and death would be a better option for them. Cognitively immature, unable to consider alternatives, act impulsively to eliminate a problem by the only action they can conceptualise. Its Prevalence is 5 – 8 % and 2% develop Bipolar Disorder. Symptoms of Depression includes, Irritability, social withdrawal, low mood, reduced interest in pleasurable activities, loss of sleep /hypersomnia, loss of weight/ weight gain, Poor attention and concentration. It requires multidisciplinary approach and power of assessment, he added.

Prof. Muhammad Riaz Bhatti talking about Schizophrenia treatment and compliance issues said that up to 80% of patients with psychotic disorders fail to comply with their medication regimen at some point during the course of their treatment. In schizophrenia, it is estimated that up to 50% of out-patients and 20% of in-patients are not compliant with prescribed medication. Olanzapine has been demonstrated to be effective in the treatment of patients with schizophrenia. The orally disintegrating formulation of olanzapine may provide an alternative for no adherent patients. The Olanzapine orally disintegrating formulation was developed as an alternative oral formulation to standard oral tablets. Orally disintegrating olanzapine formulation are freeze-dried, fast-dissolving oral formulation that rapidly disperses on contact with saliva.Orally disintegrating olanzapine had more rapid absorption, earlier measurable plasma concentrations, and higher plasma values of olanzapine after one hour compared with patients given standard olanzapine tablets. Orally disintegrating olanzapine has an equivalent bioavailability to standard olanzapine tablets, Prof. Bhatti added.

Continuing Prof. Riaz Bhatti said that rates of partial compliance with antipsychotic treatment increase over time with discharge from an inpatient facility in patients with schizophrenia. Strategies to help maintain compliance includes Psycho-education of patients, families and careers, regular contact between patients caregivers, effective medication with few side effects, use of long-acting injectable formulations. The need for earlier recognition, intervention, and future prevention of partial compliance by clinicians is essential to successful treatment of our patients with schizophrenia, he concluded.

Prof. I. A. K Tareeen along with Dr. Shahid Noor and Wajid Ali Akhunzada chaired third session. Dr. Rana Mozammil talked about satisfaction of outpatients and inpatients with psychiatric services at Allama Iqbal Memorial Hospital, Sialkot. Satisfaction of patients, it was stated, plays a pivotal role in improving the delivery of care by the health services and to reform the system. Most of the outpatients and inpatients were satisfied with the psychiatric services. Elderly patients were more satisfied than the younger patients. Other demographic variables like gender, marital status, education and economic status did not influence the satisfaction.


Prof. I.A.K Tareen who Chaired the third session along with Porf. Mazhar Malik and Porf Riaz Bhatti
during
12th National Neuropsycon are photographed with presenters of the session and some participants.

A Survey of Knowledge, Attitude and Perceptions about ADHD among Pediatric Residents in Lahore, was discussed by Dr. Fajar Raza. There is a dire need of emphasis on educational courses. Certain knowledge gaps were identified which contribute to under-recognition of disorder and adversely affects lives of many children. It should be incorporated in post-graduate curriculum to develop early confidence in screening and management skills.

Dr. Mahwish Khalid talked about Prevalence of Depression of Hepatitis C in Rahim Yar Khan, which she stated is 23.8%. No data on prevalence of depression associated with Hepatitis C is present. A study was conducted to find the prevalence of depression in patients with Hepatitis C. One hundred seventy patients of Hepatitis C registered in Hepatitis Clinic of medicine department Sheikh Zayed Medical College and Hospital Rahim Yar Khan, were included in the study. High frequency of Depression among Patients of Hepatitis C were observed and patients were referred to the Psychiatrist. Prevention and intervention to minimize Psychiatric disorders is needed, she concluded.

Dr. Sobia Haqqi presented the findings of study participated by one hundred seventy one students to quantify the levels of empathy amongst medical students in the first year and final year of the medical curriculum in Ziauddin Medical University in Karachi. There was no significant difference in the level of empathy between first year and final year medical students, however it was observed that female exhibited higher level of empathy than male, she added.

Dr. Sarmad Mushtaq talked about Prevalence of Depression among Ischemic Heart Disease Patients. Depression, she stated is high in number among cases of IHD as in every 3rd case develops it and significantly associated with female gender & duration of IHD lasting for more than three months.

Dr. Ayesha Sarwar discussed Self-harm and Risky Behavior. Self-harm, she said is much more common than suicide. Girls attempt more often than Boys. There is an increased risk of suicide in individuals who self-harm to the extent that self-harm is found in 40–60% of suicides. The risk of suicide after deliberate self-harm varies between 0.24% and 4.30% (at least 10 times the risk in the general population). Common forms of self-harm are self-poisoning (often medication overdose, self-injury are the most common methods of self-harm. Other behaviors including burning, scratching, banging or hitting body parts, interfering with wound healing and hair-pulling. Every year approximately 2,000 teens commit suicide. Self-harm is a behavior that is linked to an increased risk of suicide. Self-harm should not be ignored and appropriate help should be provided to them Dr. Ayesha concluded.


Dr. Rafia Rafique talked about Stigma, Social Support and Psychological Well- Being in Patients with HIV. It is a stigma, or social discrediting and devaluation associated with HIV which remains a significant barrier to efforts aimed curbing the HIV epidemic throughout the World. HIV stigma may have strong associations with health and well-being, however social support from family, friends and others can buffer these negative effects. Prof. Dr. Aziz-ur-Rahman spoke about Psychosocial Stress & Trauma Factors. Risk factors for PTSD includes lower level of education, previous trauma, general childhood adversity, psychiatric history, childhood abuse and family psychiatric history. More exposure to violence was associated with greater scores of PTSD and depression, he added.

Prof. Mazhar Malik discussed the findings of Research on Asian Psychotropic Prescription Patterns (REAP). It is an International Collaborative Research on Psychotropic Drug Prescription Patterns' in Asian Countries. The longest and the largest international collaboration in research in the field of psychiatry in Asia. Started in 2001 and still continuing. REAP has more than 200 psychiatrists from 40 leading psychiatric institutions of 10 countries in Asia. In the past 10 years, REAP has succeeded in forming a research network of Asian psychiatric institutions. Most of the institutions participated in REAP studies are the leading research centers in respective countries and areas. REAP group involves many eminent psychiatrists from all over Asia. The goal of REAP has been to improve prescription patterns of psychotropic drugs in those participated Asian countries.

Prof. Riaz Bhatti along with Dr. Akhunzada, Col. Nadeem and Dr. Nasir Hussain chaired the fourth session. Dr. Syed Aysha Sheeraz speaking at the occasion said that there is increase in anxiety due to changes in life style. Pakistan is male dominated society and majority wish to have fist male baby. Community educational programmes in Pakistan should be initiated besides home based training of post partial complications.

Dr. Nadeem Ahmed talking about music therapy and mental health said that music therapy is an interpersonal process in which the therapist uses music and all of its facets-physical, emotional, mental, social, aesthetic, and spiritual to help clients to improve or maintain their health. Music therapists use music to enhance social or interpersonal, affective, cognitive, and behavioural functioning. It is effective at reducing muscle tension and anxiety, and at promoting relaxation, verbalization, interpersonal relationships, and group cohesiveness. This can set the stage for open communication and provide a starting place for non-threatening support and processing symptoms associated with or exacerbated by trauma and disaster. It helps to Reduce muscle tension, improved self-image/increased self-esteem, decreased anxiety/agitation, increased verbalization, enhanced interpersonal and recognize and cope with traumatic triggers.

Prof. M. Ishaque Sarhandi presented findings of a study regarding depression among migrant workers in Al-Qasim, Saudi Arabia. The Kingdom of Saudi Arabia (KSA) has been largely dependent on migrant labor since the oil boom to the extent that one third of its current population consists of migrant workers. Workers usually live in crowded sub-standard conditions, eat all types of food without any health consideration, get inadequate sleep, and often lack access to healthcare. Furthermore they are less likely to utilize the healthcare system compared to nationals One notable health hazard of migration is the deterioration of mental health, which has been implicated to suicide and more serious diseases like schizophrenia. The extreme climate and the hot and dry weather in KSA add another dimension to difficult living conditions. A cross-sectional study was conducted among 400 migrant workers in a selected company at Al-Qasim, Saudi Arabia. Depression prevalence was 20%, he added.

Dr. Ajmal Kazmi discussed Psychiatric Rehabilitation Practices. Psychiatric Rehabilitation also known as Psychosocial Rehabilitation is a comprehensive strategy for meeting the needs of persons with severe and persistent mental illness. It refers to efforts to restore individuals to optimal state of constructive activity, community integration, improved quality of life and recovery. Goals of Psychiatric Rehabilitation includes recovery, maximum community integration and improved quality of life. We at Kerwane-Hayat, Karachi, and Dr. Ajmal Kazmi stated have introduced psychiatric rehabilitation facility in collaboration with University of Medicine and Dentistry in New Jersey. It is 15 Week Web-based Training WebCT distance learning platform, it has Weekly SKYPE lecture/discussion. Final project involved in-depth study of 5 evidence-based practices and the feasibility of their introduction at Kerwane-Hayat, Karachi. We have trained 55 people and only five are left with us and others are serving in various parts of the country and abroad. We should set goals for our patients because meaningful goals for a patient is very important, He added.

Dr. Wajid Ali Akhunzada presented the findings of a study regarding job satisfaction of employees working in Khyber Girls Medical College Peshawar. Majority of employees have been affected by symptoms of poor mental health. Almost 77% say that they have experienced symptoms of poor mental health at some point in their lives and 29% have been diagnosed with mental health condition. About 62% of employees attributed their symptom of poor mental health and said that work was a contributing factor. There is dire need to take a preventive approach to creating a work environment that promotes mental wellbeing he concluded.


Prof. Mazhar Malik along with Dr. Ajmal Kazmi presenting certificates to Dr. Muhammad Babar Kahn and
Dr. Athar Javed in Epilepsy session during the 12th National Neuropsycon held at Lahore, recently.

Dr. Fatima Saleem talking about antidepressant treatment for postnatal depression said that it is not well studied because of the risk antidepressants passing on newborns during lactation. Treatment is largely by social support and psychological interventions. SSRI’s are significantly more effective than placebo in postnatal depression. Ms. Abeer Naseem talked about relationship between work stress and aggression among employees of the Resource Group. Dr. Urooj Zafar talking about depression among substance users said that substance abuse itself may induce depression. It may be theorized that those who predispose towards depressive symptomatology due to either reason are more inclined towards the substance use. There is a significant association between substance use and depression and moderate depression present for at least one year.

Talking about cognitive dysfunction in depression, Dr. Sadaf Rashid said that it is a common symptom of depression that can be easily identify but is often overlooked. It is a clinically heterogeneous disorder. Ultimate goal of treatment in depression is to full functional recovery which should be our goal. Vortioxetine is a new novel antidepressant with additional benefits in cognitive symptoms of depression, she concluded.

Session on Epilepsy

 Prof. Mazhar Malik along with Dr. Ajmal Kazmi and Dr. Nasir Hussain chaired this session. Dr. Athar Javed from Lahore discussed the diagnosis of epilepsy. It is not a new disease, it is as old as humanity. Ibne Sine first used the world epilepsy. Diagnosis of epilepsy, he stated is clinical, obtaining an eye witness account is critical. EEG is an aid to diagnosis but need clinical correlation. Neuro imaging is required in partial epilepsies to diagnose structural abnormalities of the brain. Video EEG monitoring is gold standard for diagnosis of psychogenic non epileptic seizures. Routine EEG should not be used to exclude a diagnosis of epilepsy. Its diagnosis remain clinical and witness account of video of the attack is most important for diagnosis. EEG is aid to diagnosis and must be correlated clinically. All patients above the age of 18 years should have neuroimaging, he added,

Dr. Muhammad Babar Khan from Rawalpindi talking about management of Epilepsy said that EEG is one of the most significant investigative procedure in the diagnosis of epilepsy, is often misunderstood and misused. Top diagnostic procedure provides in vivo visualization of structural causes of epilepsy. Genetic testing has become available for a growing number of hereditary disorders associated with epilepsy. The treatment of epilepsies will change but their correct diagnosis will always be the golden rules. One in ten people will have seizures and we have very few trained epileptologists. Medical Treatment of first seizure is controversial and in 16-62% of unprovoked seizures will recur within five years relapse rate may be reduced by anti-epileptic drugs. Treatment may be considered if a patient has abnormal imaging, abnormal neurological exam and abnormal EEG.

The mortality associated with status epileptics Dr. Babar stated is around 10%, increasing to more than 20% when it becomes refractory. The longer the GTC-SE Lasts, the harder it is to treat and greater the morbidity and mortality. The risk of brain damage increases progressively if continues GTC-SE persists for more than 30 minutes and particularly after one or two hours. Immunotherapy for generalized onset Tonic colonic seizures includes Valproate, topramate. One should not change the drug during pregnancy, The AED should be administered at the lowest dose and lower plasma level that protects against tonic-clinic and complex partial seizures. If there is a family history of neural tube defects, both valproate and carbamazepine should be avoided, unless a patient’s seizures cannot be controlled.

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