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The paper examines 1037 publications on bipolar disorder (BD) during the years 2000-19 from India, as listed in the Scopus database. India's publications constituted 2.27 % share of global output (45,624 publications) in the study period of 20 years. India does not figure in the top 10 countries in terms of research output on BD. The number of publications on BD from India increased from 13 in 2000 to 107 in 2019, registering 14.44 % annual average growth, higher than world's growth of 6.02 %. India's 10-year cumulative publications increased from 264 during 2000-09 to 773 during 2010-19, registering 192.8 % absolute growth, much higher than world cumulative growth of 63.27 %. India's publications on BD averaged citation impact per paper of 14.24, which decreased from 25.38 to 10.43 from 2000-09 to 2010-19. Maximum numbers of papers from India on BD were published by researchers from National Institute of Mental Health and Neurosciences, Bangalore (222 papers),Post Graduate Institute of Medical Education and Research, Chandigarh(118 papers), and AII India Institute of Medical Sciences, New Delhi (79 papers). Lady Harding Medical College, New Delhi (36.20 and 2.54), Schizophrenia Research Foundation, Chennai (27.45 and 1.93), and King George's Medical University, Lucknow (25.21 and 1.77) were the most significant organizations in terms of citation per paper and relative citation index. Maximum number of papers were published in Indian Journal of Psychiatry (101 papers), followed by Asian Journal of Psychiatry (88 papers) and Indian Journal of Psychology Medicine (34 papers)., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Abstract: In this commentary, we critique the Indian government's decision to approve endoxifen for the treatment of acute mania among adults., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

The development of the Diagnostic and Statistical Manual-5 (DSM-5) has been an exhaustive and elaborate exercise involving the review of DSM-IV categories, identifying new evidence and ideas, field testing, and revising issues in order that it is based on the best available evidence. This report of the Task Force of the Indian Psychiatric Society examines the current draft of the DSM-5 and discusses the implications from an Indian perspective. It highlights the issues related to the use of universal categories applied across diverse cultures. It reiterates the evidence for mental disorders commonly seen in India. It emphasizes the need for caution when clinical categories useful to specialists are employed in the contexts of primary care and in community settings. While the DSM-5 is essentially for the membership of the American Psychiatric Association, its impact will be felt far beyond the boundaries of psychiatry and that of the United States of America. However, its atheoretical approach, despite its pretensions, pushes a purely biomedical agenda to the exclusion of other approaches to mental health and illness. Nevertheless, the DSM-5 should serve a gate-keeping function, which intends to set minimum standards. It is work in progress and will continue to evolve with the generation of new evidence. For the DSM-5 to be relevant and useful across the cultures and countries, it needs to be broad-based and consider social and cultural contexts, issues, and phenomena. The convergence and compatibility with International Classification of Diseases-11 is a worthy goal. While the phenomenal effort of the DSM-5 revision is commendable, psychiatry should continue to strive for a more holistic understanding of mental health, illness, and disease. [ABSTRACT FROM AUTHOR]

The article presents abstracts on psychiatric problems which include metabolic syndrome in subjects with bipolar disorder, depression and coping skills in relation to violence against women and study of metabolic syndrome in patients of dementia.

Background: In recent years there has been significant coverage of mental health in Indian newspapers; the media can play a significant role in perpetuating as well as reducing stigma towards people with mental illness. This paper analyses the content, context and type of newspaper coverage of various mental health disorders in English language newspapers in India between 2016 and 2021. Methods: A detailed analysis was performed on a sample of articles about mental illness in a range of English language Indian newspapers. Results: Depression was the most prevalent topic amongst the articles followed by anxiety, schizophrenia and bipolar disorder. Our study describes a wide range of use of mental health disorders in various newspapers. All diagnoses were generally described in a criminal context like homicide, sexual assault and other crimes. Over time newspaper coverage of mental illness has become less stigmatising. Further exploration of non-English medium newspapers is required to fully understand the extent of the role of print media in perpetuating unhelpful stereotypes of people with mental illness in India. [ABSTRACT FROM AUTHOR]

About 14.2% of women in the general Indian population and 4.8% in Delhi use tobacco but its use among women with Major Mental Illness (MMI) in developing countries has not been adequately studied. We assessed tobacco use in women with MMI in a tertiary care psychiatry outpatient department through a cross-sectional, observational study, with sample size of at least n= 77 each for schizophrenia-SZ, bipolar disorder-BD and Recurrent Depressive Disorder-RDD. Fagerstrom Test for Nicotine Dependence (FTND) both for smoke and smokeless tobacco were applied along with a subset of questions from Global Adult Tobacco Survey 2016. After diagnosis and referral by the treating psychiatrist and written informed consent, in our total sample of 321 women participants, lifetime use of tobacco was reported by 14.64%. Of all those who had ever used tobacco, 12.14% used it currently as well. As for diagnosis, those with BD (16.25%) used tobacco most frequently followed by SZ (14.18%) and RDD (6%). The FTND score was higher for schizophrenia indicating greater dependence. Tobacco use among women with MMI was thrice as common as women in general population of Delhi State, with smoke and smokeless tobacco use being equally prevalent, a grave cause for concern and intervention., Competing Interests: Declaration of Competing Interests The authors declare NO conflict of interest. The content of this manuscript is solely the responsibility of the authors. This paper is an expanded version of BK's presentation at the Annual National Conference of the Indian Psychiatric Society 2019 where it was shortlisted for the Bhagwat Award., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Bipolar disorder and schizophrenia share some key symptoms which lead to misdiagnosis, especially on initial presentation. In this study, we have considered two categories of patients belonging to schizophrenia and bipolar disorder with (i) total duration of illness (TDI) less than or equal to 2 years and (ii) TDI greater than 2 years. We statistically test the difference between the severity of symptoms of the two groups as measured by their respective psychiatric rating scales using (or score tests), likelihood ratio and permutation tests for both categories of patients. The unknown parameters are estimated using maximum likelihood, moments by Cran and Bayesian estimation. It is observed that there exists a significant difference between the two disorders for patients in second category based on real and simulated data. Further, performance of statistic is compared on the basis of p-value and power performance with the other two methods. A new weight suggested in this paper is found to be as efficient as the previous weight based on simulation study. A retrospective data of 108 patients diagnosed with schizophrenia and bipolar disorders is collected from Lady Hardinge Medical College & Smt. S.K. Hospital, New Delhi, India for the calendar year 2013–2014. [ABSTRACT FROM AUTHOR]

Background: Bipolar disorder is one of the severe mental disorders that are associated with significant morbidity of the patients. Despite advancements in our understanding about the disorder, it remains a challenging proposition to treat bipolar disorder, largely since the prophylactic treatment of the disorder requires assessment of complex clinical algorithms. The revisions of the classificatory systems have also changed the conceptualization of the disorder. In this background, we conducted a review of the Indian studies conducted on the clinical aspects of bipolar disorder. Methods: A narrative review was conducted with focus on the literature published from India. The databases searched included PubMed, Scopus, and Google Scholar, and articles published over the last 15 years by Indian authors were included for this review. Results: In our review, we could access a substantial volume of research published from India. We could identify studies that catered to most of the relevant themes in bipolar disorder including epidemiology, etiology, comorbidities, stigma, disability, clinical course, cognitive profile, pathways to care, and recovery. Conclusion: The research trajectory was in line with the research conducted elsewhere in the world. However, certain dissimilarities in terms of focus could also be observed. The possible reason behind this deviation could be the difference in clinical need and unique challenges faced in the management and rehabilitation of patients in bipolar disorder in Indian scenario. [ABSTRACT FROM AUTHOR]

Psychiatric rehabilitation is to assist disabled people in developing the emotional, social, and cognitive skills required to live, learn, and work in the community with the least amount of professional assistance. The goal of the current case study revealed that support from family, friends, community, treating mental health professionals, and drug compliance contributes to the recovery. Many persons with mental illness will experience disability which becomes a barrier to regular follow-up. The needs of severely disabled people are often neglected or not met adequately by mental health professionals, family, and the community. They do not understand what is happening in the community and the home environment. Therefore, the current case study made an effort to know the actual situation of mentally disabled people in their home environment and evaluated psychiatric rehabilitation needs. A case study was presented in detail with findings of the home visit and the strengths and weaknesses of the home visit from a social work perspective. The case study concludes that community attitude; the economic burden was one of the leading causes of barriers to psychiatric rehabilitation in India. [ABSTRACT FROM AUTHOR]

Lithium continues to be a main drug in mood disorders despite risks associated with high blood levels of lithium and introduction of a number of mood stabilizers. Therapeutic drug monitoring (TDM) is a norm while using lithium. The present paper reports analysis of a retrospective audit of TDM of lithium over a period of 4 years. A retrospective serum lithium estimation data of 4 years were analyzed for drug levels, reasons for request, and correlation of levels with dose and side effects. Of 4359 requests received during the study period, about 80% were for routine monitoring and about 3% each were for adverse effects and relapse or irregular treatment. Twelve percent of the requisition forms were incomplete and therefore could not be analyzed. Out of requests of TDM for adverse effects, lithium levels were above therapeutic range (>1.2 mmol/L) in 17%, subtherapeutic (<0.6 mmol/L) in 23%, and within therapeutic range (0.6-1.2 mmol/L) in 60% cases. Thirty percent of the requisitions for routine monitoring had lithium levels in subtherapeutic range and 7% were above therapeutic range. TDM for lithium is necessary in clinical practice, and this study further confirms the need for TDM, as lithium levels remain below or above the therapeutic range in a substantial number of cases. Regular lithium level monitoring helps in uncovering unsuspected poor compliance and for better clinical management.

Despite having a large chunk of human population, Asian countries face shortage of mental health professionals. There is further shortage of doctors dealing with special groups of population like the children, the elderly, and the medically ill. However, in this era of super-specializations, are the basic principles of general psychopharmacology being forgotten? Dealing with child population is different and often more difficult than adult population but are management guidelines for the two populations vastly divergent? A close look at this paints a different picture. Psychotherapies applied in adults and those in children and adolescents are disparate owing to cognitive, social, emotional, and physical immaturation in children and adolescents. But the drugs for the treatment of pediatric psychiatric disorders are mostly similar to those prescribed for adults (case in point -bipolar disorders, obsessive compulsive disorder, schizophrenia). Rather than focusing energy on propagating the differences in assorted subgroups of population, honing of skills regarding intricacies of psychopharmacology is required to be emphasized. Detailed history taking, careful evaluation of the patient, sound diagnostic formulation, and prescribing medications which are tailor made to the patient will all go a long way in ensuring a functional recovery of the patients irrespective of the group they belong to. [ABSTRACT FROM AUTHOR]

Aim: This study aimed to evaluate the disability and its correlates in persons with Bipolar Disorder during the remission phase. Materials and Methods: As part of the multicentric study, 773 patients with bipolar disorder, currently in clinical remission, were evaluated for disability on the Indian Disability Assessment Evaluation Scale. Results: About one-fifth of the participants had some level of disability in the domain of self-care, one-third had some level of disability in the interpersonal domain, one-fourth had some level of disability in communication and understanding, and a maximum proportion (43.7%) had some disability in the domain of work. Overall, about one-fifth (18.4%) were considered to have a benchmark disability (i.e., disability >40%). In terms of correlates, those with a disability had a short duration of current remission, a higher number of manic and mixed episodes, a higher mean number of total episodes, spent more time in the episodes, had lower severity of the depressive episodes, higher residual depressive and manic symptoms, had overall higher manic affective morbidity, had a higher level of cognitive deficits, and had poorer insight. Conclusion: A significant proportion of patients with bipolar disorder have disability in work domain, and the presence of residual symptoms of either polarity are associated with higher level of disability. [ABSTRACT FROM AUTHOR]

To evaluate the risk factors associated with lifetime suicide attempts in bipolar disorder (BD) patients. 773 BD patients with a duration of illness of at least ten years, currently in clinical remission, were evaluated for suicidal attempts in their lifetime. Those with and without lifetime suicide attempt(s) were compared for various demographic and clinical risk factors. 242 (31.3%) patients had a history of at least one lifetime suicide attempt. Compared to those without lifetime suicide attempts, those with suicidal attempts were less educated, were more often females, spent more time in episodes, and had a significantly more number of total episodes (in the lifetime, first five years of illness, and per year of illness), had significantly more number of total depressive episodes (in the lifetime, first five years of illness, and per year of illness), spent more time in depressive episodes, had more severe depressive episodes, more often had depression as the first episode in the lifetime, spent more time in mania/hypomania/mixed episodes, had higher residual depressive and manic symptoms, more often had rapid cycling affective disorder pattern in the lifetime, use of cannabis in dependence pattern, had poorer insight into their illness and had a higher level of disability (especially in three out of the four domains of Indian disability evaluation assessment scale). About one-third of the patients with BD have at least one-lifetime suicidal attempt, and those with suicide attempts usually have a poorer course of illness. [ABSTRACT FROM AUTHOR]

This study aimed to evaluate the prevalence of unipolar mania (UM) in a group of patients of bipolar disorder (BD). Additionally, effort was made to evaluate the demographic, clinical and treatment related factors, which distinguish subjects of UM from BD. Seven hundred and seventy-three patients with BD, of at least 10 years duration, recruited from 14 General Hospital Units of tertiary care centers from India were evaluated for UM. The prevalence of UM, varied from 5.4% to 20.3%, depending on the definition used. With the most stringent definition of ≥4 episodes of mania and at least 5 years of follow-up, the prevalence of UM was 5.4%. Compared to patients of BD, who have episodes other than mania too, those with UM had lower proportion of patients with lifetime history of suicide attempts, spent less time in the episodes in their lifetime and had lower severity of residual depressive and manic symptoms. Further, compared to those with episodes other than mania too, those with UM had higher number of manic episodes per year of illness, had higher proportion of patients who had more than five episodes in the lifetime and had higher proportion of those with at least one episode with psychotic symptoms in the lifetime. The present study suggests that a small proportion of patients with BD have UM course and this runs a different clinical course compared to that seen in patients with traditionally recognized as BD. [ABSTRACT FROM AUTHOR]

The clinical features and course of bipolar disorder differ between women and men; however, studies are limited in Indian population. The objective of this study was to identify gender differences in patients with bipolar disorder. This was a cross-sectional, hospital-based observational study conducted over a period of 25 months. The sample consisted of 110 males and 90 females with a diagnosis of bipolar disorder according to ICD-10 Diagnostic Criteria for Research. Socio-demographic and clinical details were collected using semi-structured proforma. All patients were evaluated on Mini International Neuropsychiatric Interview Plus, Presumptive Stressful Life Events Scale and Clinical Global Impression. Sample consisted of 55% men and 45% women. The total number of episodes was similar between genders, however, the number of manic episodes (p = 0.004) was significantly more in males and the number of depressive (p = 0.003) and mixed episodes (p = 0.018) were significantly more in females. Majority of males had first episode of mania, whereas, first episode in females were mostly depressive (p < 0.001). Comorbid physical disorders were seen in 61.1% females and 40% males. Bipolar disorder subtype, episode types and number varied across gender. Co-morbid hypothyroidism, migraine, and obesity are seen more often in women and substance use was higher in men. [ABSTRACT FROM AUTHOR]

Background: Gaps in lithium-related knowledge among bipolar disorder (BD) patients on lithium prophylaxis may pose safety concerns and could adversely influence attitudes to lithium. Objective: To assess the lithium-related knowledge and attitudes among patients with BD. Materials and Methods: This was a cross-sectional, observational study assessing euthymic, adult outpatients with BD on lithium prophylaxis (≥1 year) using a semi-structured pro forma, lithium questionnaire for knowledge, lithium attitude questionnaire (LAQ), and medication adherence rating scale (MARS). Results: Descriptive analysis revealed several deficits in knowledge, including lack of critical safety information or need for periodic blood tests. Lower knowledge group had significantly more negative attitudes. Favorable attitude toward lithium (lower LAQ score) was significantly associated with the number of psychiatric follow-ups in the last year and MARS score. Conclusion: There were critical deficits in lithium-related knowledge among the patients. Lower lithium knowledge was associated with negative lithium attitudes. Educative interventions should be delivered periodically to regular lithium users. [ABSTRACT FROM AUTHOR]

Background: The phenomenon of hospital readmission of the psychiatric patient has been a matter of concern ever since the concepts of deinstitutionalization and community care of these patients have been emphasized. There are pieces of evidence from the literature that the readmission rate has been increasing substantially. The role of psychiatric hospitals has shifted dramatically. Inpatient programs are now focused on acute stabilization, leaving most treatment to community based providers. Aim: Aim of the study is to assess the psychosocial aspects of rehospitalization of psychiatric patients namely Bipolar Affective Disorder and Schizophrenia and difference between both the groups. Methods: On the basis of purposive sampling 100 rehospitalized (50 Bipolar Affective Disorder and 50 Schizophrenia) patients were taken from inpatient IMH, Rohtak. The socio-demographic data sheet was filled-up for assessment of sociocultural aspects, social support questionnaire was administered for the assessment of the level of social support and attitude questionnaire was applied on the caregivers for assessment of the level expressed emotion. Results: Most of the re-hospitalized Schizophrenia patients face a high level of expressed emotion and poor social support in comparison to Bipolar Affective Disorder patients. Conclusion: Finding of the study illustrate that high expressed emotion and poor social support are associated with rehospitalization. [ABSTRACT FROM AUTHOR]

Background: Estimates of psychiatric morbidity in the community will help service development. Participation of trained nonspecialist health-care providers will facilitate scaling up of services in resource-limited settings. Aims: This study aimed to estimate the prevalence of priority mental health problems in populations served by the District Mental Health Program (DMHP). Settings and Design: This is a population-based cross-sectional survey. Materials and Methods: We did stratified cluster sampling of households in five districts of Kerala. Trained Accredited Social Health Activists (ASHAs) identified people who had symptoms suggestive of schizophrenia or bipolar disorder. Clinicians evaluated the information collected by the ASHAs and designated individuals as probable cases of psychosis or noncases. Screening instruments such as General Health Questionnaire-12, CAGE questionnaire, and Everyday Abilities Scale for India were used for identifying common mental disorders (CMDs), clinically significant alcohol-related problems, and functional impairment. Results: We found 12.43% of the adult population affected by mental health conditions. We found CMD as most common with a prevalence of 9%. The prevalence of psychosis was 0.71%, clinically significant alcohol-related problems was 1.46%, and dementia and other cognitive impairments was 1.26%. We found informant-based case finding to be useful in the identification of psychosis. Conclusions: Mental health problems are common. Nonspecialist health-care providers can be trained to identify psychiatric morbidity in the community. Their participation will help in narrowing the treatment gap. Embedding operational research to DMHP will make scaling up more efficient. [ABSTRACT FROM AUTHOR]

Management of bipolar during pregnancy and postpartum is very challenging. The treating clinicians have to take into account various factors like current mental state, longitudinal history of the patient, past history of relapse while off medication, response to medication, time of pregnancy at which patient presents to the clinician, etc. The choice of drug should depend on the balance between safety and efficacy profile. Whenever patient is on psychotropic medication, close and intensive monitoring should be done. Among the various mood stabilizers, use of lithium during the second and third trimester appears to be safe. Use of valproate during first trimester is associated with major malformation and long‑term sequalae in the form of developmental delay, lower intelligence quotient, and higher risk of development of autism spectrum disorder. Similarly use of carbamazepine in first trimester is associated with higher risk of major congenital malformation and its use in first trimester is contraindicated. Data for lamotrigine (LTG) appears to be more favorable than other antiepileptics. During lactation, use of valproate and LTG is reported to be safe. Use of typical and/atypical antipsychotic is a good option during pregnancy in women with bipolar disorder. [ABSTRACT FROM AUTHOR]

Background: Only a few studies have evaluated the similarities and differences between clinicians' and caregivers' rating of burden of caring for a person with chronic mental illness. Aim: To compare clinician-rated and caregiver-rated burden in a population of patients with either schizophrenia or bipolar disorder, using two different scales to measure caregiver burden. Methodology: Caregivers of patients with schizophrenia (n = 65) or bipolar disorder (n = 57) completed the Hindi version of the Involvement Evaluation Questionnaire (Hindi-IEQ) by themselves. Clinicians rated the burden on the Family Burden Interview Schedule (FBI) based on semi-structured interview with the same caregivers. Results: Both total objective and subjective burden on the FBI (clinician ratings) demonstrated significant positive correlations with the total Hindi-IEQ (caregiver ratings) scores. Most areas of burden on the FBI correlated positively with the tension and the worrying-urging II subscales, as well as the total Hindi-IEQ scores. According to clinicians, a significantly higher percentage of caregivers of patients with schizophrenia were experiencing a moderate to severe degree of subjective burden; objective burden in this group was also significantly higher in the domains of effect on the mental health of caregivers. Contrastingly, caregivers of patients with bipolar disorder judged burden to be higher in this group than schizophrenia. Conclusions: There were many areas of agreement as well as some significant discrepancies between clinicians’ and caregivers’ assessment of burden in this population of patients. This suggests that a comprehensive evaluation of burden should include assessments by both clinicians and caregivers of patients. [ABSTRACT FROM AUTHOR]

Deoxyribonucleic acid (DNA) integrity plays a significant role in cell function. There are limited studies with regard to the role of DNA damage in bipolar affective disorder (BP). In the present study, we have assessed DNA integrity, conformation, and stability in the brain region of bipolar depression (BD) patients (n=10) compared to age-matched controls (n=8). Genomic DNA was isolated from 10 postmortem BD patients' brain regions (frontal cortex, Pons, medulla, thalamus, cerebellum, hypothalamus, Parietal, temporal, occipital lobe, and hippocampus) and from the agematched control subjects. DNA from the frontal cortex, pons, medulla, and thalamus showed significantly higher number of strand breaks in BD (P<0.01) compared to the age-matched controls. However, DNA from the hippocampus region was intact and did not show any strand breaks. The stability studies also indicated that the melting temperature and ethidium bromide binding pattern were altered in the DNA of BD patients' brain regions, except in the hippocampus. The conformation studies showed B-A or secondary B-DNA conformation (instead of the normal B-DNA) in BD patients' brain regions, with the exception of the hippocampus. The levels of redox metals such as Copper (Cu) and Iron (Fe) were significantly elevated in the brain regions of the sufferers of BD, while the Zinc (Zn) level was decreased. In the hippocampus, there was no change in the Fe or Cu levels, whereas, the Zn level was elevated. There was a clear correlation between Cu and Fe levels versus strand breaks in the brain regions of the BD. To date, as far as we are aware, this is a new comprehensive database on stability and conformations of DNA in different brain regions of patients affected with BD. The biological significance of these findings is discussed here. [ABSTRACT FROM AUTHOR]

Background: Obsessive compulsive disorder (OCD) is a psychiatric disorder that often tends to run a chronic course. The lifetime prevalence of OCD is around 1-3%, which is twice as prevalent as schizophrenia and bipolar disorder. Aim: To asses the family burden, quality of life (QoL) and disability in patients suffering from at least moderately ill OCD and then to compare them with schizophrenia patients of comparable severity. Settings and Design: We recruited 70 consecutive subjects (OCD - 35, schizophrenia - 35) who met study criteria between March 2005 and March 2006 from the psychiatric services of the National Institute of Mental Health and Neuro Sciences, Bangalore, India. Materials and Methods: The severity of illness was rated using the Clinical Global Impression-Severity (CGI-S). Instruments used in the current study were the Family Burden Schedule, the World Health Organization (WHO) QoL (Bref) and the WHO - Disability Assessment Schedule (DAS). Statistical Analysis: The Fisher's exact test/chi-square test was used to compare categorical variables and the independent sample t test was used to analyze continuous variables. Analysis of covariance (ANCOVA) was used to compare the groups after controlling for potential confounding variables. Pearson's correlation was used for correlation analysis. Results: Overall family burden, financial burden and disruption of family routines were significantly higher in schizophrenia patients compared to OCD although the groups did not differ with respect to other domains of family burden. On the WHO QoL, OCD patients were comparable to schizophrenia patients with respect to the psychological and social domains. On the WHO - DAS, both the groups were similar in all the domains except getting around. Conclusion: Severe OCD is associated with significant disability, poor QoL and high family burden, often comparable to schizophrenia. Therefore, there is an urgent need to increase the sensitivity among healthcare professionals to recognize and treat OCD. [ABSTRACT FROM AUTHOR]

Mental health interventions in low and middle income countries, with limited resources of human and other resources, requires that they be viewed from multiple viewpoints. This applies to the issue of covert medication, which on the face should not be practiced at all, in an ideal care situation. In India, it would be better to consider the use of covert medication, in differing situations and with the varying levels of involvement of patients and their families in a planned manner and with an open approach. Such an approach could meet the care needs of patients as well as protect the rights of the patients. [ABSTRACT FROM AUTHOR]