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Introduction: The prevalence of psychiatric disorders among the general population is 10.6%. Primary care doctors (PCDs) are often the first contact for patients with common psychiatric disorders, but the majority of them are ill equipped to handle the same leading to symptomatic treatment. Hence, an innovative digitally driven and modular-based 1-year primary care psychiatry program (PCPP) was designed and implemented exclusively for practicing PCDs of Uttarakhand. Aim: The aim of the study was to assess the impact of this digitally driven 1-year PCPP on the general practice of PCDs. Materials and Methods: Ten PCDs were trained in the curriculum module “Clinical Schedule for Primary Care Psychiatry” which is a validated concise guideline for screening, classification, diagnosis, treatment, follow–ups, and referrals. Furthermore, they underwent training in on-site basic module (10 days); three online modules (with nil or minimal disruption in their regular clinical work) – Telepsychiatric On-Consultation Training (Tele-OCT), Collaborative Video Consultations, and weekly virtual classroom; and one public health module. In addition, PCDs underwent 10 criteria-based formative assessment including self-reports of weekly patients' audit (Primary Care Psychiatry Quotient [PCPQ]) and quarterly Tele-OCT evaluation sessions (Translational Quotient [TQ]). Results: PCPQ was 11.09% (2182 psychiatric patients of total 19,670 general outpatients) which means 11.09% of PCDs' total general consultations had psychiatric disorders, which would have been otherwise missed. Average scores obtained in first and second Tele-OCT evaluations (similar to clinical examination but in their real-time consultation) were 70.33% and 76.33%, respectively, suggestive of adequate TQ at 6 and 9 months of the course. Conclusions: One-year PCPP is shown to be effective in acquiring psychiatry knowledge, skills, and retention of skills (TQ) and also translated in providing psychiatric care in general practice with a positive impact on the delivery of primary care psychiatry.

Introduction: To mitigate the spread of the pandemic coronavirus infection (COVID-19), governments across the world have adopted “lockdowns” which have confined many individuals to their homes. This disrupts normal life routines, elements of which are important circadian cues. The pandemic is also associated with new stressors, altered roles, and uncertainties about health and economic security, which are also likely to affect sleep. The current study is an online survey of sleep experience, routines, physical activity, and symptoms of anxiety and depression, to study the alterations associated with the lockdown. Materials and Methods: The survey was conducted in early May 2020 using a questionnaire circulated through social media platforms. Questions related to demographic characteristics, current and previous sleep schedules, routine, and working patterns. Insomnia (Insomnia Severity Index - 4), Stress (Perceived Stress Scale - 4), anxiety and depressive symptoms (Patient Health Questionnaire - 4) and physical activity (International Physical Activities Questionnaire) were assessed using standardized instruments. Results: A total of 958 valid responses were received. Compared to the prelockdown period, there was a shift to a later bedtime and waking time, with a reduction in night-time sleep and an increase in day-time napping. These effects were visible across occupational groups, but mostly affected working individuals except health professionals. Sleep quality deteriorated across groups. Reductions in sleep duration were associated with depressive symptoms. Conclusions: The COVID-19 lockdown is associated with changes in sleep schedule and in the quantity and quality of night-time sleep. Although these changes are associated with elevated rates of emotional symptoms, it is unclear from these cross-sectional results, whether sleep deterioration produces psychological distress, or vice versa.

Major depressive disorder (MDD) is often linked with a number of coexisting disorders with a relation that is poorly understood. The aim of this study was to find out the role of obstructive sleep apnea (OSA) in metabolic syndrome (MS) in subjects with MDD and to develop a model for factors leading to MS.It was a cross-sectional study conducted on 119 subjects. They were evaluated on sociodemographic and clinical parameters, Berlin questionnaire, and Quick Inventory of Depressive Symptomatology. Comparisons were made using appropriate statistics. Binary logistic regression was used to find out the role of clinical parameters in the development of MS.A total of 34% with MDD had a high risk of developing OSA while 19% had metabolic syndrome. Among all clinical variables, antidepressant exposure in terms of total fluoxetine units, duration of treatment, and risk of developing OSA was found to be significantly more in patients with MS. A higher risk of OSA was found to have a higher likelihood to cause MS in patients with MDD.There is a high risk of MS and OSA in subjects with MDD. The increased risk of MS is contributed by an increased risk of developing OSA among patients with MDD. Cross-sectional design and limited generalizability are the major limitations of this study.

Sleep disorders often disturb sleep. Daytime symptoms of disturb sleep mimic that of depression, somatoform disorder, fibromyalgia and chronic fatigue syndrome. We are presenting a case of depression who was not responding to antidepressant therapy. Based on clinical history, diagnosis was changed to chronic fatigue syndrome and in view of prominent sleep disturbances, polysomnography was done. Based on sleep study data, diagnosis of periodic limb movement disorder was made and he was started on ropinirole, that improved his symptoms.

Literature suggests that the COVID-19 pandemic has resulted in poor sleep quality, especially among the infected population. However, literature regarding the effect of COVID-19 pandemic and SARS-CoV-2 infection on occurrence of insomnia, restless legs syndrome and dream enactment behavior is either scarce or unavailable.This study was planned to assess the effect of SARS-CoV-2 infection on the occurrence of insomnia, restless legs syndrome (RLS) and dream enactment behavior (DEB). For this cross-sectional study, a questionnaire comprising of items related to demographic details, past medical history, and information related to SARS-CoV-2 infection was distributed through social media. Insomnia was diagnosed using clinical criteria. RLS, DEB, sleep quality, depression and anxiety were assessed using a validated questionnaire. Information regarding the use of hypnotic medications was also gathered.Of the 1596 respondents, 37.2% reported disturbed sleep while insomnia was reported by 22.6% respondents. 27.3% of respondents reported RLS and 17.4% suffered DEB. The odds of insomnia were greater among males (OR = 1.27; 95% CI: 1.03-1.58;SARS-CoV-2-infection-related factors in association with environmental factors have increased the prevalence of insomnia, DEB and RLS among subjects having infection. SARS-CoV-2-associated immunological changes, hypoxia and neurotropism may play a role in occurrence of insomnia, DEB and RLS.

Background: Metabolic syndrome in individuals taking second-generation antipsychotics is thought to be mediated by antipsychotic-induced weight gain. However, recent literature challenges this notion, and theoretically, it may also be mediated through obstructive sleep apnea (OSA). This study explores the contribution of OSA in antipsychotic-induced metabolic syndrome. Materials and Methods: Forty-three participants suffering from schizophrenia spectrum disorder and major depressive disorder, taking second-generation antipsychotics were included in this study. Treatment history was taken in detail, and lifetime exposure to antipsychotics was converted to olanzapine-equivalent doses. Physical characteristics were noted. OSA was screened through the Hindi version of Berlin Questionnaire. Plasma glucose, serum total cholesterol, serum high-density lipoprotein, and serum triglyceride were measured after 12-h fasting. Adult treatment Panel-III criteria were used to diagnose metabolic syndrome. Results: Gender distribution was comparable in the study sample. About 27% had continuous illness, 25.6% of participants had metabolic syndrome, and 20.9% were at high risk for sleep apnea. Participants with and without metabolic syndrome were comparable with regard to demographic variables, duration of illness, and lifetime exposure to antipsychotics. Logistic regression depicted that OSA (odds ratio [OR] = 15.09), waist circumference (OR = 1.15), and fasting plasma glucose (OR = 1.21) increased the risk of metabolic syndrome. Conclusion: Results of the present study suggest that metabolic syndrome in participants taking second-generation antipsychotics is mediated through OSA.

Sleep disorders are common in the elderly. It is estimated that 40-70% of elderly experience chronic sleep problems. Higher rates of sleep problems are observed in those elderly with medical and psychiatric comorbidity. The comorbid disorders have additive effects on sleep disturbances, i.e. higher the number of comorbidities, higher the rates of sleep problems. Elderly subjects have initial insomnia, wake up earlier than usual, have higher time spent in bed, have nighttime awakenings, nap more, and have decreased total sleep as compared to younger adults. With increasing age lighter stages of sleep becomes more, whereas, REM and slow-wave sleep reduce; up to 6 years of age there is 2% decrease in slow-wave sleep every decade. Slow-wave sleep does not change much from 60 to 90 years of age. However, sleep efficiency, i.e. the duration of sleep relative to total time in bed, continue to decrease over time. Sleep in the elderly is fragmented, lighter and is characterized by episodes of arousals and awakenings. Certain changes in circadian physiology occur with age. They include sleeping before the desirable sleep and wake times, earlier clock hour of internal circadian time, alteration in the relationship between the internal circadian time and sleep, reduction in circadian amplitude, and reduced sensitivity to low to moderate light levels. Among the elderly, core body temperature, and cortisol and melatonin rhythms occur at an earlier time. The changes in sleep that occur with age are summarized in Table 1. However, these changes are not the common sleep complaints of the elderly population. Table 1 Sleep changes in the elderly

Background: Presleep thoughts may vary between patients of insomnia with or without depression. They are important for cognitive behavior therapy for insomnia (CBT-I), but they have never been systemically examined in Indian population. Materials and Methods: Patients with insomnia (>1 month) who were willing to undergo CBT-I were included in this study after obtaining informed consent. They were requested to fill a sleep diary and return after 15 days. At the time of intake, diagnosis of depression and anxiety disorders was made according to Diagnostic and Statistical Manual - IV-Text Revision. They were encouraged to provide information regarding presleep thoughts through open-ended and then, close-ended questions. Dysfunctional attitudes and beliefs about sleep were assessed with Hindi version of “dysfunctional beliefs and attitudes scale-brief version”. Hindi version of “insomnia severity index” was used to assess the severity of insomnia. Subjects were divided into two-groups - insomnia without depression (I) and insomnia with major depressive disorder (I-MDD+). Statistical Analysis: It was done with the help of SPSS v 21.0. Descriptive statistics was calculated. Proportions between groups were tested with Chi-square analysis and categorical variables were compared using independent sample t-test. Results: This study included a total of 63 subjects, out of which 60% were women. Mean age of the whole group was 41.7 ± 11.8 years. About 40% of all the subjects were diagnosed as having I-MDD+. Forty-one percent of the subjects had clinically significant anxiety. Both groups - I and I-MDD+ had comparable proportion of female subjects (χ2 = 0.002; P = 0.96) and there was no difference regarding precipitating factors for insomnia (χ2 = 0.97; P = 0.61). They were also comparable with regards to sleep-related measures, themes of presleep thoughts, and dysfunctional beliefs and attitudes about sleep and insomnia severity. Major themes of presleep thoughts included family issues and health issues. Only a small proportion had recurrent thoughts related to insomnia and its consequences. Conclusion: Insomnia is a co-morbid illness with depression and it needs to be separately addressed during therapy. CBT-I should include the element of problem-solving technique, especially when we are dealing with the Indian population.

Background: The COVID-19 pandemic has led to a complete shut-down of the entire world and almost all the countries are presently in a “lockdown” mode. While the lockdown strategy is an essential step to curb the exponential rise of COVID-19 cases, the impact of the same on mental health is not well known. Aim: This study aimed to evaluate the psychological impact of lockdown due to COVID-19 pandemic on the general public with an objective to assess the prevalence of depression, anxiety, perceived stress, well-being, and other psychological issues. Materials and Methods: It was an online survey conducted under the aegis of the Indian Psychiatry Society. Using the Survey Monkey platform, a survey link was circulated using the Whatsapp. The survey questionnaire included perceived stress scale, Patient Health Questionnaire-9, Generalized Anxiety Disorder-7, Warwick-Edinburgh Mental Well-being Scale to assess perceived stress, anxiety, depression, and mental well-being, respectively. The survey link was circulated starting from April 6, 2020 and was closed on April 24, 2020. Results: During the survey, a total of 1871 responses were collected, of which 1685 (90.05%) responses were analyzed. About two-fifth (38.2%) had anxiety and 10.5% of the participants had depression. Overall, 40.5% of the participants had either anxiety or depression. Moderate level of stress was reported by about three-fourth (74.1%) of the participants and 71.7% reported poor well-being. Conclusions: The present survey suggests that more than two-fifths of the people are experiencing common mental disorders, due to lockdown and the prevailing COVID-19 pandemic. This finding suggests that there is a need for expanding mental health services to everyone in the society during this pandemic situation.

Objective: The aim is to study the knowledge and attitude of medical undergraduate students regarding obstructive sleep apnea (OSA). Materials and Methods: This cross-sectional study involved 324 medical undergraduate students in clinical semesters. Knowledge and attitude regarding adult OSA were assessed using the obstructive sleep apnea knowledge and attitude (OSAKA), and to evaluate the same about childhood OSA, OSAKA-KIDS was used. Results: Results showed that the study population was not informed about OSA among adults as well as kids. Most of the participants could recognize that snoring was a common symptom of adult OSA but failed to identify the association between childhood OSA and hyperactivity. The participants had a good knowledge about the pathophysiology of OSA. More than 80% of students reported that OSA is an important disorder and that these patients should be identified. Conclusion: Medical undergraduates are poorly informed about OSA.

Context: Migraine and tension type headache (TTH) are two most common types of primary headaches. Though the International Classification of Headache Disorders-2 (ICHD-2) describes the diagnostic criteria, even then in clinical practice, patients may not respect these boundaries resulting in the difficulty in diagnosis of these pains. Materials and Methods: This cross-sectional study involved 50 subjects in each of the two groups – migraine and TTH – after screening for the inclusion and exclusion criteria. Diagnosis was made according to the ICHD-2 criteria. Their clinical history was taken in detail and noted in a semi-structured performa. They were examined for the presence of a number of factors like pericranial tenderness and muscle parafunction. Statistical analysis was done with the help of SPSS v 11.0. To compare the non-parametric issues, chi-square test was run and continuous variables were analyzed using independent sample t test. Results: In general, migraineurs had progressive illness (χ2=9.45; P=0.002) with increasing severity (χ2=21.86; P

Sleep disorders are common, still we have limited data regarding the prevalence and management of sleep disorders from India. Although the systematic research is limited from our country, still case reports from Indian population suggest that we see all kinds of sleep disorders. Prevalence of various sleep disorders is shown in Table 1. Table 1 Prevalence of various sleep disorders in general population

Background: Restless legs syndrome (RLS) is known to be associated with depression. We hypothesized that RLS in depression is linked to the severity, duration, and frequency of depressive episodes. Materials and Methods: Subjects fulfilling DSM-IV-TR criteria of depressive disorders were included in this study after seeking informed consent. Using structured interview of MINI-Plus their demographic data and history were recorded. Severity of depression was assessed with the help of HAM-D. Insomnia was diagnosed following ICSD-2 criteria. RLS was diagnosed according to IRLSSG criteria. Descriptive statistics, Chi-square test, independent sample t test and MANOVA were computed with the help of SPSS v 17.0. Results: RLS was reported by 31.48% of sample. There was no gender difference in prevalence of RLS ( X 2=0.46; P=0.33). There was no difference in the age , total duration of depressive illness and number of depressive episodes between RLS and non-RLS groups (F=0.44; P=0.77; Wilk's Lambda=0.96). The HAM-D score was higher in the non-RLS group ( P=0.03). Onset of RLS symptoms was not related to onset of depressive symptoms. Conclusion: RLS is prevalent in depressive disorder. However, onset of RLS is unrelated to age and number or duration of depressive disorders.

Rumination syndrome is known to exist in infants and mentally retarded adults since long time. In past few years, some reports appeared that showed its existence in adult patients also. It is frequently confused with the intractable vomiting in adults and misdiagnosis leads to delay in appropriate management. We are here describing the case of a female patient with rumination syndrome where specific points in the history delineated the presence of this illness and helped in appropriate management. The patient became symptom free soon after the diagnosis was reached.

Background: The present study was designed to assess whether subjective sleep patterns differ between: (i) depressed patients and controls, and (ii) between subjects with different severity of depression. Based on available literature, it was hypothesized that sleep patterns must be different between the above mentioned groups. Materials and Methods: This study included 60 subjects with major depressive disorder and 40 subjects in the control group. Subjects with sleep disturbance secondary to any other factor, e.g ., medical illness, environmental factors, other psychiatric illness etc, were not included in the study. Depression severity was assessed in the subjects with depression with the help of Beck Depression Inventory II. Subjective sleep complaints were noted in the presence of a reliable informant, preferably bed partner. All the information was recorded in a semistructured performa. Statistical analysis was done with the help of SPSS v 11.0. The Chi square and Fisher exact tests were used for categorical variables; independent t-test and one way ANOVA were applied for numerical variables. Ordinal variables were analyzed using Mann Whitney U and Kruskall-Wallis tests. Results: Depression and control groups were similar in age ( P = 0.32) and gender ( P = 0.14) distribution. Subjects in the depression group had lesser total sleep time ( P = 0.001), longer sleep latency ( P = 0.001), frequent awakenings ( P = 0.04), greater wake-after-sleep onset and offset times (both P = 0.001), lesser sleep efficiency, and tended to wake up early (Mann Whitney U = 913.5; P = 0.05). Subjects with severe depression were different from the mild and moderate groups with regards to total sleep time ( P = 0.002), night-time sleep ( P = 0.007), and sleep efficiency ( P = 0.001) even when the three groups were comparable in age. Conclusion: Depression is associated with sleep disturbances, not only qualitatively, but also quantitatively. Sleep disturbance arises only after a critical level of depression is reached, and depression of varying severity may selectively affect different sleep parameters.