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Psychiatric Conference
Proceedings

By Mubarak Ali

KARACHI: Prof. Masood Hameed Khan, Vice Chancellor Dow University of Health Sciences Karachi inaugurated the 20th International Psychiatric conference held at Karachi from December 26-28th, 2014.

Prof. Iqbal Afridi along with Prof. Ghulam Rasool chaired the scholarly session during the conference Mustafa Hussain from USA talked about stimulation and surgical interventions in psychiatric disorders. ECT, he stated, is still gold standard and very effective procedure. Vagus Nerve Stimulation (VNS) is an adjunctive treatment for certain types of intractable epilepsy and treatment-resistant depression. It is FDA approved and very effective treatment but very expensive. Transcranial magnetic stimulation (TMS) is a noninvasive method used to stimulate small regions of the brain. During a TMS procedure, a magnetic field generator or Coil is placed near the head of the person receiving the treatment. It produces small electrical currents in the region of the brain just under the coil via electromagnetic induction. The coil is connected to a pulse generator, or stimulator, that delivers electrical current to the coil. TMS is used diagnostically to measure the connection between the brain and a muscle to evaluate damage from stroke, multiple sclerosis, amyotrophic lateral sclerosis, movement disorders, motor neuron disease and injuries and other disorders affecting the facial and other cranial nerves and the spinal cord.TMS is also approved by FDA.


A group photograph of some senior members of the medical profession taken during the
20th International Psychiatric conference held at Karachi recently.

Epidural Cervical Stimulation Dr. Mustafa stated is used for major depression where failed response to four different antidepressants and current episode of depression lasting for one year. Deep Brain Stimulation is used for selected targets and for severe depression. Future directions are focused on surgical interventions and to potentiate neurotransmitter release. Lots of funds are required and for this Defense Advance Research Project has sanctioned fifty million US dollar, NIH forty million dollar for next five years and NSF has sanctioned twenty million dollars, he added.

Dr. Unaiza Niaz from Karachi discussed the intergenerational aspects of trauma related mental health problems among families in the Tribal area of Pakistan. She pointed out that it has long been established that armed conflicts and the subsequent mass dislocation of population results in significant psychological and social suffering. While the impact of such a situation may be acute in the short term, it also undercuts the long-term mental health and psychosocial well-being of the affected populations. This, in turn, has serious implications for social development, governance and human rights.

There are intergenerational aspects of trauma-related mental health problems among families on four decades of Afghan war. Both the Afghan refugees and the Tribal belt of Pakistan has suffered long standing trauma of war, insurgencies. A large population of IDP’s from Swat and the tribal belt of Pakistan have spread all over Pakistan since war on terror and recently following the army action against militants in the tribal areas of Pakistan Zarb-Azb. A small number of these people remained in the camps, but most of them were accommodated by their families and friends. Relocation, deprivations, traumas both physical and psychological have had toll on these families, particularly the adolescents and children.

Trauma, Dr. Uniza Niaz said effects the society badly and if not treated early will transfer to our generation. Children are facing psychiatric trauma in schools, markets streets and militancy areas. Eighty percent suicidal deaths are done by children and girls are also involved. Thousands of children suffer and until recent times little attention had been given to it. Teenagers are more susceptible to be influenced by terrorist organizations.It is important to arrange mental health programme to address selective risk groups. School based mental health programs are also important. Individual and group therapy is important particularly group therapy which is cost effective also, she added.

Dr. Saeed Farooq from Peshawar talked about improving treatment adherence in Psychosis and lessons from research for busy clinicians. Non adherence to treatment is a major challenge in all fields of medicine. It is claimed that increasing the effectiveness of adherence interventions may have far greater impact on the health of the population than any improvement in specific medical treatments. In psychotic disorders adherence to treatment is major challenge due to poor insight and cognitive impairment. Large number of trials of various psychological, social, and pharmacologic interventions has been reported. The results are mixed, but interventions specifically designed to improve adherence with a more intensive and focused approach and interventions combining elements from different approaches have shown better outcomes.

Aim for remission Dr. Saeed Farooq stated should be the first step because discontinuation of medication increases the relapse risk five folds even gap of a small period. Most effective treatment should be used. Patients who remain in remission have better adherence with treatment. If schizophrenia drugs are not working, patients should be switched to Clozapine. Clearly select drugs with optimum balance of therapeutic effects/side effects, adequate dose adjustment and treat side effects effectively. Guidelines recommended the use of LAIs especially in schizophrenia. If a schizophrenic patient is treated carefully for first two years it will make a lot of difference. My plea to the Government, Dr. Saeed said is to provide treatment of schizophrenic patients free of cost for at least first two years. A global fund for providing free medicines for schizophrenia should be provided. This will help to overcome the major structural barrier to optimum treatment adherence in resource-poor setting. Our focus should be on remission and long tern use of treatment, simplifying the treatment regimen, and the use of long-acting injections. Dr. Saeed concluded.

Dr. Shahin Hussain from Karachi talking about Psychiatry in east said that there is tremendous stigma of psychiatry in Pakistan; there is dearth of psychiatrists, lot of unethical practices even ECT is given without anesthesia. We have treated about twenty thousand patients during last thirteen year free of cost at Markaz-e-Nafsiyat and all these patients has been to Peers, Faqeers and Alams before coming to us. Most of them around 33 years of age had stress. Majority of patients were Urdu speaking, low level of education, married and low income. Depression was the major problem and most prescribed drugs were antidepressants. Schizophrenia was the most common diseases. What we need to do is to have more trained psychiatrist, at least one clinic free per week, institutional training for psychologists, awareness programs, ECT without anesthesia should be stopped to improve the stigma of psychiatric illness, she added.

Prof. Rizwan Taj from Islamabad talked about National Mental Health Policy and stated that only 0.4 % of total health budget is given to mental health. At government level it is not a priority. Recently aLiver Transplant Center was established and millions of rupees were spent but after the death of two patients this facility has been abandoned. This shows the priority of the government. Billions of rupees have been spent in other areas showing no results. Now a day’s governmenthas changed its attitude after the recent Peshawar incident. Gilgat Biltastan, FATA, have no psychiatrist they travel all the way to Islamabad. Outside Quetta have no facility. We have failed to provide the facilities to the poor. Insecurity, poverty and unemployment, disasters, earthquakes floods have further aggravated the situation. There are 520 psychiatrists and 3000 psychiatry beds in Pakistan. Tertiary care Centers have no specialized services for mentally ill besides poor funding of PHC and it is weak link of health. Chief Minister Punjab is taking step to ensure presence of GP’s in PHC. Only 20% population of Pakistan is productive and serving the remaining 80% Dr. Rizwean Taj concluded.

Dr. Afraz Zaman from Australia spoke about mental health services and pointed out that mental diseases are the disease of young age. Diagnosis is done by observation, detection is late. Patients have increased use of antipsychotics. Research in heart diseases, cancer has helped to outcome improvement but psychiatry has done nothing in this regard.

Dr. Nasir Sayeed from Lahore addressing the participants said that we all know that psychology practice in Pakistan is founded on the Western model. We are five hundred psychiatrists but do not have a consensus in one thing. Awareness is the only remedy. All stakeholders have to sit and collaborate with each other. Inter sectoral collaboration between psychologists physiatrists and media is the need of the hour, he added.

Earlier Prof. Niaz Maqsood along with Prof. Munir Himarani chaired a session on Adult Psychiatry. Dr. Hina Javed from Aga Khan University talked about assessing the significance of spiritualty in management of patients. People it was stated, have strong belief in spiritualty which helped them to cope the mental disorders. Spirituality, she stated, has potentially positive role in psychiatric rehabilitation and recovery. Kiran Dossani and Sualeha Shekhani presented the preliminary findings of views of mental health professionals regarding the effects of mental illness on marriages in Pakistan. Support for couples, psycho education and further study of the subjects is needed to assess the effects of mental illness on marriages.

Prof. Imran Ijaz Haider presented the finding of a study conducted to check the reliability of the ICD-10 International Personality Disorder Examination (Urdu Translation).Study was conducted at the outpatient department of Fatima Memorial Hospital Lahore from April 2012 to March 2013. Patients considered to have a personality disorder by a psychiatrist were initially screened by the IPDE screening questionnaire. Those who scored positive on screening were evaluated in a detailed interview using IPDE. Two interviewers conducted the interviews simultaneously, to ensure inter-rater reliability. For translation, permission was taken from World Health Organization. Linguistic equivalence was assessed through back- translation and conceptual equivalence through opinion of mental health experts.The final Urdu draft was obtained after incorporating modifications suggested by experts following a feasibility study.

Out of 30 enrolled patients, 25(83.3%) were females. Majority of patients had more than one personality disorder. Most prevalent personality disorder was emotionally unstable borderline type with a phi correlation of 0.831, followed by emotionally unstable impulsive type and anankastic personality disorder with phi correlations of 0.930 and 0.867, respectively, for definite cases. Urdu translation of IPDE is a reliable tool to screen and diagnose personality disorders in population of Pakistan, he concluded.

Dr. Wajid Ali Khanzada talked about attitude of girls medical students towards psychiatry. He conducted a study in 2011-2012 on n eight six students. They showed positive response towards Psychiatry as specialty but Psychiatry was not a part of their mainstream medical sciences. There positive attitude of the postgraduate students can help to improve the mental health of the patients. During discussion it was pointed out that parents asked the psychiatrist that their daughter has mental illness, should we marry her? It is a difficult question to answer, because people will never disclose it prior to marriage. Psychiatrist should know what we have to say to the parents. It should be a uniform statement in this regard, because spectrum is very wide. As psychiatrist we should not play our role as decision maker, we should educate the parents and final decision should be there. Motivational education is lacking in our conferences and psychiatry is at the last of our priority. Efforts should be made for social support of the patients besides development of psychiatry, he added.

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