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Children constitute 40% of India’s population. Large number of children with psychiatric disorders and neurodevelopmental conditions are unable to access mental health services due to factors such as unavailability of these services in smaller urban and rural centres and lack of training for primary care providers. Given the relatively easy access to video conferencing technology, feasibility and acceptability of Telepsychiatry, there is an urgent need to invest resources and strengthen the use of Telepsychiatry for child and adolescent mental health training and serviced delivery . This viewpoint article discusses the need,scope,experiences and challenges related to use of Telepsychiatry in the area of child mental health.

Background Tic disorders (TDs) are common neurodevelopmental disorders in children and adolescents. To date, there is very scant literature on TDs in children and adolescents in the Indian setting. Aim The objectives of this study were to characterize the clinical profile, including comorbidities and pattern of medication use in the treatment of TDs, in children and adolescents. Materials and methods The present study is a retrospective chart review of children and adolescents up to age 18 years diagnosed with TD in a tertiary care center in India. Data were derived from case records of patients with a diagnosis of TD, coded as F 95 according to ICD 10, from 1st January 2014 to 31st December 2017. Results We recruited 85 subjects. The majority (95.29%, n = 81) of them were male, and the mean age of onset was 8.4 years. Chronic tic disorder was the most common subtype, followed by Tourette syndrome and provisional or transient tic disorder. Eighty patients (94%) had a comorbid disorder, with attention deficit hyperactivity disorder being the most common, followed by obsessive compulsive disorder. Eighty-two percent of patients received pharmacotherapy. Risperidone was the most frequently used medication, followed by clonidine, haloperidol, and aripiprazole. Moderate to significant improvement with medications was seen in 88% of the patients. Conclusion The present study of children and adolescents with TDs highlights very high rate of comorbidity and a favorable short-term course with medication use.

Background: Increasing rates of behavioral problems among children in India necessitates newer ways of managing them with medical and nonmedical approaches. Music add-on therapy is a method for treating mental disturbances. This study examines the effectiveness of music add-on therapy in managing children with behavioral problems. Methods and Materials: A randomized controlled design was adopted with a random allocation of 40 children (20 each in experimental and control groups) aged between 6 and 12 years with behavioral disorders as per the International Statistical Classification of Diseases and Related Health Problems (ICD)-10. After the pretest, both the groups received treatment as usual (TAU), while the experimental group alone additionally received music add-on intervention with eight Hindustani ragas for 3 weeks. As clinical outcome measures, we used the Childrens Global Assessment Scale, Nisonger Child Behavior Rating Form typical IQ (NCBRF-TIQ) version, and visual analogue scale (VAS) for a parent to monitor the behavioral improvement. Results: Children exposed to the music add-on therapy had improved score in the Children Global Assessment Scale (CGAS) and the VAS as compared with the control group (F [2,76] = 34.307, P < 0.001 and F [2,76] = 72.4, P < 0.001, respectively). Further, the NCBRF-TIQ version revealed improvement in positive social behavior (F [2,76] = 13.089, P < 0.001) and reduction in problem behaviors in the experimental group. Conclusion: Music add-on therapy is effective in improving positive social behavior and reducing problem behaviors among children.

Background Most children and adolescents in need of mental healthcare remain untreated even when services are available. This study evaluates the accuracy of a new tool, the Community Case Detection Tool (CCDT). The CCDT uses illustrated vignettes, two questions and a simple decision algorithm to support proactive community-level detection of children, adolescents and families in need of mental healthcare to improve help-seeking. Methods Trusted and respected community members in the Eastern Province of Sri Lanka used the CCDT in their daily routine. Children and families detected as potentially in need of mental healthcare based on utilizing the CCDT (N = 157, aged 6–18 years) were invited for a clinical interview by a mental health counsellor using the Mini-International Neuropsychiatric Interview for Children and Adolescents (MINI-KID). The CCDT results were compared against the results of the clinical interview. The concurrent validity and performance of the CCDT were also evaluated by comparing the CCDT outcomes against the Strengths and Difficulties Questionnaire (SDQ). Results 7 out of 10 children and families detected by community members using the CCDT were confirmed to be in need for treatment (positive predictive value [PPV] = 0.69; 0.75 when compared to the SDQ). Detections based on the family problem vignette were most accurate (PPV = 0.76), followed by the internalising problem vignette (PPV = 0.71) and the externalising problem vignette (PPV = 0.62). Conclusions The CCDT is a promising low-cost solution to overcome under-detection of children and families in need of mental healthcare. Future research should focus on evaluating the effectiveness, as well as additional strategies to improve help-seeking.

India has a considerable skilled manpower deficit in the area of child and adolescent mental health, given its population and their needs. To address this deficit, in the recent past, various centres in India have begun specialty training in the field of child and adolescent psychiatry with the lead being taken by the National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore. This is a welcome step in the right direction. However, specialty training of this nature cannot exist in a vacuum. There is a need for a comprehensive and cohesive child and adolescent mental health policy which must include adopting certain standards in training in the various sub-specialties of child and adolescent mental health. From this national policy, provisions must be made for a spectrum of care from specialized tertiary care to high-quality community-based care. Dedicated, skilled mental health professionals who will impart training at the highest level as well help train a cadre of specialists (psychiatrists, pediatricians) and non-specialists with various degrees of exposure and training in the field of child and adolescent mental health are the need of the hour to have a stepped model of care. This will go a long way in ensuring effective and equitable distribution of the sparse human resources. Similar issues may operate in other low- and middle-income countries and thus the discussion may be relevant to such populations as well.

Background: Anxiety spectrum disorders are the most prevalent psychopathology among children and adolescents. Qualitative research in childhood anxiety disorders can provide valuable insights regarding interventions. The objectives of this study were to examine the child's perspectives on the subjective experience of concerns, the impact of the symptoms on socioacademic functioning, and the process of recovery with interventions. Methods: Children and adolescents aged 6–16 years, presenting with any subtype of anxiety spectrum disorder as per International Classification of Diseases and Related Health problems, 10th Revision (ICD-10) Diagnostic Criteria for Research, were included. Convenience sampling was used, and 30 children fulfilling inclusion and exclusion criteria were selected. An interview guide with simple questions to facilitate response was used, at the baseline and 12th week of follow-up, to generate a written narrative account of the experience of concerns, the impact of symptoms, and the treatment process. Children received treatment as usual, which included a workbook-based cognitive behavioral intervention. Results: Content analysis was done using 30 baseline and 20 follow-up narratives. Clustering of themes were done. Themes related to the recovery process reflected perceived improvement in academic performance and competence, apart from the improvement in symptoms. There were more themes in favor of cognitive interventions. Conclusion: Children's narratives highlight the importance of cognitive interventions for anxiety disorders.

Since many years, the concept of recovery in mental illness has been discussed from different perspectives of the patient, family and mental health professionals. In the literature there are numerous definitions of what recovery means. A persistent theme in mental health recovery literature is that a concise definition of recovery is hard to determine. It is acknowledged that recovery means different things to different people, and that not every view of recovery will fit with every person’s belief system. This article aims to identify the meaning of recovery in the published literature among persons with Schizophrenia.

AimsThe primary objective of the study is to assess the clinical course and functional outcome of comorbid mood disorders in children and adolescents with Intellectual Disability [IDD]Method53 children and adolescents with varying levels of severity of IDD presenting with comorbid mood disorders diagnosed using Kiddie Schedule for Affective Disorder and Schizophrenia-DSM-5 version [KSADS] were recruited by convenient sampling with the exclusion of autism spectrum disorders. Vineland Social Maturity Scale [VSMS] is used to quantify the severity of ID. Developmental Behaviour Checklist-Parent [DBC-P] version is used to measure psychopathology, Clinical Global severity of illness [CGI-S] to quantify the clinical improvement, and Developmental Disabilities Children's Global Assessment of Severity [DD-CGAS] to assess functional improvement. Prospective naturalistic follow-up was done with assessment points at baseline, 1, 3- and 6-month timeline.Result40 patients were followed up for 6 months period. Overall significant improvement is observed in the dependent variables like CGI, DDCGAS, and DBC-P from baseline to 3 months and then a plateau of improvement from 3 to 6 months. The diagnostic breakup of mood disorders is mania [N = 19], Depression [N = 12], and mixed affective state [N = 9]. Patients with mania had significant improvement in DBC score [F = 12.69, p < 0.001 in repeated measures ANOVA], DDCGAS [p < 0.001], and CGI score [p < 0.03] with an overall remission rate of 42.10% over 6 months period. Patients with depression had significant improvement in DBC score [F = 15.48, p < 0.001], DDCGAS, and CGI score [p < 0.001] with an overall remission rate of 41.7%. None of the patients with mixed affective states had clinical remission with no significant improvement observed in any of the dependent variables measuring course and outcome.ConclusionComorbid psychiatric disorders in children and adolescents with IDD have a guarded prognosis compared to mood disorders in neurotypical children. Comorbid ADHD and caregiver stress majorly influenced the course and outcome in the current study.

Children with autism spectrum disorder (ASD) have unique characteristics such as impairments in communication and social interaction. The impact of these characteristics constitutes a challenge to other children in the family. Most of the researchers in the field of developmental disability have focused on the parents and not on the siblings. The purpose of this article is to review the current literature related to psychosocial interventions for siblings of children with ASD. The primary electronic data search was carried out in PubMed database, Scopus, Google scholar, ProQuest, EBSCOhost, and Psych NET. All the searches yielded a total of 891 titles. After screening for necessary inclusion criteria, eight studies were included in the final review. All studies reported positive impacts on sibling relationship quality, understanding about autism. Furthermore, these effects were maintained from post intervention to follow-up. Review findings imply that there was a significantly positive impact on target children after participating intervention program. Implications for both research and practice are discussed.

India has got a new mental health legislation, the Mental Healthcare Act in 2017 (MHCA). Compared to its predecessor the Mental Health Act of 1987, this act was purported to be more patient centric and rights based. Considering the significant burden of child and adolescent mental health problems in the community, it is essential to understand what this new act means for the mental healthcare of young people. This article presents sections of the act relevant to children and adolescents. We look at the provisions in the context of changes from the earlier act, concordance with other Indian legislations and with mental health legislations in other parts of the world.

Delay in the diagnosis and early intervention for Autism spectrum disorders has been observed across cultures and within the same cultural context. With the current evidence base for early intervention there is a need for greater awareness for early recognition, evaluation and intervention. This brief report discusses the average age at recognition to initiation of intervention and possible ways to address delay. Since early intervention programs for ASD results in favourable outcome, it would be good practice to routinely screen children at first consultation and initiate intervention in any child suspected to be 'At Risk' for ASD.

PurposeTo assess the psychiatric diagnoses and outcome in children with psychogenic non-epileptic seizures (PNES).MethodologyThis hospital based observational study was performed on 44 children aged

Aims and objectives The use of electroconvulsive therapy (ECT) in children and adolescents is a controversial issue. This study was done to examine the pattern and practice as well as the outcome of electroconvulsive therapy administered to children and adolescents admitted to a tertiary care centre. Methodology A 10 year retrospective chart review of all children and adolescents (up to 16 years of age) admitted in the Child and Adolescent Psychiatry Centre, National Institute of Mental Health and Neurosciences (NIMHANS) who had received at least 1 session of ECT was done. Information regarding diagnosis, reasons for prescribing electroconvulsive therapy, details regarding the procedure and outcome variables was collected from the records. Clinical Global Impressions (CGI) scale rating of the severity of illness and improvement seen were done by 2 trained psychiatrists independently. Results 22 children and adolescents received electroconvulsive therapy over 10 years. There were an equal number of boys and girls. All received modified ECT. Most patients who received electroconvulsive therapy were severely ill. Catatonic symptoms 54.5% (12) were the most common reason for prescribing electroconvulsive therapy. It was efficacious in 77.3% (17) of the patients. Electroconvulsive therapy was relatively safe, and most experienced no acute side effects. 68.2% (15) who were on follow up and did not experience any long term side effects due to the electroconvulsive therapy. Conclusions Electroconvulsive therapy has a place in the acute management of severe childhood psychiatric disorders. Further long term prospective studies are required.

Context: Early intervention in specific learning disability (SpLD) results in better outcome and prevents comorbidity. Understanding the pathways is therefore important. Aims: To study and compare the pathways to care for children with SpLD and mental retardation (MR) before reaching a tertiary care center. Settings and Design, Material and Methods: A cross-sectional study was conducted for pathways to care of two groups: SpLD and MR with 50 children in each group from 8 to 16 years. MINI-KID for comorbidity and Goldberg's pathway to care instrument was used. The groups were divided into early contact (up to three carers) and late contact (more than three carers) and compared. Statistical Analysis: Data were analyzed using Statistical Packages for Social Sciences (SPSS) version 10.0 software. Results: Majority ( n = 24 or 48%) of SpLD children visited others (teachers, neighbors, relatives, and guardians of fellow classmates) as first carer. Allopathic practitioners were the first choice for MR children ( n = 31 or 62%). Six children (12%) in SpLD group and 10 of MR (20%) group have seen either traditional practitioner or healer as first carer. Maximum referral to the tertiary center in both groups was done by others (62% in SpLD and 56% in MR group). Early contacts in SpLD group belonged to younger age group ( P = 0.01). While comparing both groups on the basis of early and late contact, mother's education was found to be significant in early contact group ( P = 0.036) and having comorbidity was significant among late contacts ( P = 0.038). Conclusions: The pathways to care for SpLD children are more or less similar to MR children whose parents recognize MR late. Both the groups visit multiple carers including traditional healers substantiating the strong belief for supernatural causation of developmental disorders in India.

There is a recent trend of increase in diagnosis of Autism Spectrum Disorder in India. Till date, there are few retrospective and prospective Indian studies with limited sample sizes ranging from 16 to 94 children. With this background, we planned a retrospective chart review of all new cases of Autism Spectrum Disorder for a period of 1 year in our tertiary care child psychiatry centre.Objectives of this study were to compare the sociodemographic and clinical profile of children below and above 3 years of age and between those who were self-referred versus those referred by professionals.Out of a total of 1957 case records, 201 children (10.3%) were diagnosed with Autism Spectrum Disorder. Male to female ratio was 4:1.2. Mean age of consultation was significantly higher in males. Seventy six percent had a comorbid disorder with Intellectual disability, Attention Deficit Hyperactivity Disorder and Epilepsy being the most common comorbidities. Most caregivers (92.5%) recognized symptoms by 3 years of age. Presenting complaint of poor social response was more prevalent in children3 years and co-morbidities in children above 3 years. Presenting complaint of speech delay was more common in children who were referred by professionals when compared with those who were self-referred.There is a need to sensitize parents and professionals for early intervention and to standardize protocols for assessment and intervention.

Background and need for the study Identification and management of aggression is a major mental health priority in hospitalised patients. However, no such studies have been done in child and adolescent in-patients in India. Objectives To study the clinical and demographic features; characteristics of the aggression and methods employed to manage aggression in child and adolescent in-patients. Materials and methods Child and adolescent in-patients between the ages of 4 and 16 years who were aggressive were included. The tools used were the MINI-International Neuropsychiatric Interview (M.I.N.I) KID, Overt Aggression Scale (OAS), Children's Global Assessment Scale (CGAS), and a Semi-structured interview regarding each aggressive episode. Results 31 patients displayed aggressive behaviour out of the 131 patients who were admitted during the study period. Aggressive acts were more common in males, those with academic difficulties, who had a past history of aggression, with suicidal ideation or suicidal attempts. Aggression occurred across diagnostic categories but a significant proportion was diagnosed to have Disruptive Behaviour Disorders either as a primary diagnosis or as comorbidity. 90.6% were on psychotropic medication prior to admission. Around 2/3rd of aggressive episodes occurred in the evening and family members (85.7%) were the most common targets of aggression. Conclusion There are a few factors that can possibly help identify and predict aggression in children and adolescents in a hospital setting. More research is required to understand aggression in clinical settings.

Byline: T. Sudhakar, G. Rao, P. Prasuna, K. Vijay Sagar Introduction Since the introduction of conventional anti-psychotics in the treatment of various psychotic disorders in late 1950's the quest for better molecules continued. The reasons for the betterment resulted in the introduction of second generation antipsychotics (SGA's) which are supposed to be more patient friendly with lesser extra pyramidal symptoms lesser chances of inducing tardive dyskinesia and better impact on affective, cognitive and negative symptoms of the schizophrenia. The initial enthusiasm about SGA's within 5 yrs had settled down towards skeptical optimism to control the unwanted and potentially endangering metabolic side effects. Among the newer drugs except for Aripriprazole and to some extent Ziprasidone all other drugs produce significant weight gain and predispose the individual for hyperglycemia and hyperlipedemia. They also produce significant day time drowsiness which interferes with patients daily occupational activities. The land mark study on antipsychotic efficacy, safety and tolerability namely CATIE study had clearly shown that 74% of the patients discontinued the treatment before 18months of trial. Intolerability was one of the major reason for the discontinuation, weight gain & metabolic effects with Olanzapine was established in phase II, part of the study. However, the trend for metabolic syndrome is also noticed with Clozapine, Risperidone, Olanzapine and to some extent with Quetiapine, Ziprasidone. The other major side effect that discourages the patient to continue the treatment is daytime drowsiness. Though with dose titration this side effect can be minimized, most of the patients do not continue, because day time drowsiness interferes with their daytime work performance. So, to improve the compliance with atypical antipsychotics and to give the patients a better quality of life, it becomes imperative that we should find various strategies including pharmacotherapy and diet control. Modafinil is a novel, non amphetamine psycho stimulant though it is not a typical sympathomimetic amine and has only weak affinity for dopamine uptake carrier site. It also acts on anterior hypothalamic nucleus and adjacent area. It is currently being promoted for excessive daytime sleepiness that occurs in Narcolepsy and also sleep apnoea. In 5% of cases it is known to produce anorexia and increase the alertness. In this, study we are making an attempt to explore whether, a non amphetamine drug like modafinil for reducing daytime drowsiness, would be of any utility in preventing daytime drowsiness associated with atypical antipsychotics. As this drug also has got anorexia and weight loss as adverse events, it would be worth while to see, whether add on therapy of modafinil with atypical especially Olanzapine, Risperidone, Clozapine (widely prescribed atypicals in India) would in anyway influence the daytime sleepiness, weight gain, hyperglycemia & hyperlipidemia. Review of Literature Atypical Anti Psychotics Versus Conventional Antipsychotics. Conventional antipsychotic agents which have been the mainstay of treatment in Schizophrenia and other psychotic disorders for over forty years have a number of limitations. This had prompted a search for new agents with greater efficacy and fewer side effects. So the serotonin dopamine antagonists (SDA) (Janssen et al ,1988) came into the practice which is at present the mainstay of treatment in patients with schizophrenia and other psychoses. But atypical antipsychotics are also not without side effects. Atypicality mainly refers to infrequent occurence of extrapyramidal syndromes in clinical setting. During recent years, it was found that akathisia is still common and tardive dyskinesia is also not uncommon with atypical drugs as earlier thought. Hence Second Generation Anti psychotics would be a better name that was suggested for this group of drugs. …

To study the clinical features of children with history of sexual abuse.A chart review of 40 children (16 years) with history of Child Sexual Abuse (CSA) evaluated at the Department of Child and Adolescent Psychiatry at NIMHANS during a three year period.52.5% (N=21) of the children came from broken families. The most common form of abuse was contact penetrative (67.5%) followed by contact non-penetrative abuse (30%). Seventy-Five percent (N=30) had a psychiatric diagnosis at baseline and 37.5% of these children had comorbidities. The commonest diagnoses were Depressive Disorder (35%) followed by Stress related disorders--PTSD and Acute Stress Disorder (25%). Children abused multiple times were more likely to have psychiatric illness following CSA. Children abused by multiple perpetrators were more likely to have depression, psychiatric comorbidity and more prone to exhibit sexualized behaviour. Sixty five percent of children did not follow up 8 weeks after the initial consultation.Psychiatric morbidity is high in the population of children with history of CSA. It is necessary to assess the risk factors, circumstances of abuse along with psychiatric morbidity in order provide flexible and tailor made interventions for this population. In order to ensure the best possible care for these families, focused and time limited intervention that respect the needs of the child and addresses the ground realities of the circumstances of the family and the health system are the need of the day.

Pervasive refusal syndrome is described as a condition comprising varying degrees of refusal across several domains; social withdrawal; resistance to treatment and is potentially life threatening with no detectable organic cause. Female predominance, refusal to eat with low weight, body image distortion, depressive features, premorbid personality issues similar to eating disorders have been noted, with 67% cases having complete recovery. In this paper, we describe what is probably the first case reported from India, of a child, who presented with neuropsychiatric symptoms, and treated with electroconvulsive therapy along with medications, but, sadly had a fatal outcome.

Background: Haloperidol is highly effective against the positive symptoms of schizophrenia, but is less effective against the negative symptoms. It also produces marked extrapyramidal symptoms. The newer atypical antipsychotics are believed to have an equal efficacy with a favourable side-effect profile. Aim: We assessed the effects of risperidone and haloperidol in patients with schizophrenia to compare their clinical efficacy and side-effect profile. Methods: A double-blind, randomized, prospective, comparative trial with a parallel treatment design of 6 weeks' duration was undertaken on 46 drug-naive schizophrenics to compare the efficacy and adverse effects profile of risperidone and haloperidol. Results: The study showed no difference in the positive and negative subscale scales on the Positive and Negative Syndrome Scale (PANSS). However, risperidone was found to have an edge over haloperidol in improving the general psychopathology as well as in bringing about global improvement. Conclusion: Of the two drugs, the adverse effect profile of risperidone is better, with less need for the use of antiparkinsonian medication.

A B S T R A C T A majority of adolescents in India, who are at risk for depression, do not receive treatment or receive it when the psychopathology has become entrenched and chronic. The present pilot study was an endeavor to assess the felt needs of adolescents vis-a ` -vis the difficulties and stressors experienced by them. For this purpose, 300 students across three schools were screened using standardized measures. Another objective of the study was to develop and test a school-based Coping Skills Program to address adolescents at-risk for depression. Schools were sequentially assigned to intervention or control conditions; students of index (n = 13) and control (n = 6) groups were assessed at baseline, postintervention, and 3 months follow-up. At post-intervention for the index group, all outcomes measures except coping skills—including depressive symptoms, negative cognitions, academic stress, and social problem-solving—showed change in the expected direction, this difference assuming significance at follow-up. The program was rated positively by students using anonymous feedback and there was low to nil perceived stigmatization. Results are discussed in the context of need for such intervention programs in India, and future scope of research involving larger samples.

Women and children with psychotic disorders in developing countries may be vulnerable and have considerable social disadvantages. Gender disadvantage has implications for all health outcomes including mental illnesses. In the more relevant gender-related context we discuss several important issues which affect women with schizophrenia, namely stigma, caregiver burden, functional outcome, marriage, victimization and help-seeking. The fi ndings indicate that there are variations in clinical and functional outcomes and age of onset of illness between different regions. Drug side effects, such as metabolic syndrome appear to be quite common, adding to disease burden in women from developing countries. Victimization and coercion may contribute to poor quality of life and health concerns such as STIs and HIV. Stigma among women with schizophrenia appears to play a major role in help-seeking, caregiver burden and issues such as marriage and parenting. Gender-sensitive care and practices are few and not well documented. Research in the area of psychoses in children and adolescents from LAMI countries is sparse and is mainly restricted to a few clinic-based studies. More research is needed on organic and medical factors contributing to childhood psychoses, pathways to care, help-seeking, and impact of early detection and community care. Part I: Introduction When one discusses the concept of gender in the context of mental illness among women it is important to defi ne what we mean by the terms gender and sex. ‘ Sex ’ refers to the biological and physiological characteristics that defi ne men and women, while ‘ gender ’ refers to the socially constructed roles, behaviours, activities, and attributes that a given society considers appropriate for men and women. In this review on women and schizophrenia in low and middle income (LAMI) developing countries, while we have tried to focus on certain specifi c issues that are related to the female sex and schizophrenia, much of the discussion focuses on gender and how it shapes the schizophrenia experience. Gender disadvantage has implications for all health outcomes including mental illnesses. The many reports on better outcomes for schizophrenia among women sometimes fail to take into account those women who suffer gender-related disadvantage that might not contribute to symptom outcome but have an important role in functional outcome and recovery. In literature, gender disadvantage is synonymously referred to as gender discrimination, gender inequality, and gender disparities. These include poverty, limited access to resources such as nutrition, education, employment, healthcare, child gender preference, workplace harassment, migration and exposure to disasters. In this review we deliberately focus on two issues related to schizophrenia and biological sex, namely age of onset and antipsychotic-related metabolic syndrome. These two topics were chosen because of the slight variations in fi ndings between the developed and developing world related to the former and the important healthcare implications of the latter. In the more relevant gender-related context we discuss several important issues which affect women with schizophrenia, namely stigma, caregiver burden, functional outcome, marriage, victimization and help-seeking.

Background: Subclinical depression in adolescents constitutes a risk factor for future clinical depression and hence warrants examination. However, there is a paucity of research that documents subclinical depression among adolescents in India. Objectives: (a) To investigate the prevalence of subclinical depression in urban school-going adolescents; (b) to investigate the problems and felt needs of these adolescents; (c) to examine depression-related variables; and (d) to examine the relationships between socio-demographic and depression-related variables. Materials and Methods: Eight hundred adolescents (ages 13–18 years) of English-medium schools of Bangalore city were assessed using standardized self-report measures. Results: Academic difficulties were the most frequently reported problem, followed by interpersonal issues. Of the sample, 18% adolescents were identified as endorsing subclinical depression. Adolescents in the present study scored higher on measures of depression and negative cognitions than their Western counterparts. In addition, girls were found to be at higher risk for experiencing depressive symptoms and negative cognitions, lower social problem-solving skills, and more problematic interpersonal relationships as compared to boys. Conclusion: Identification of subclinical depression constitutes an important goal, as it places an adolescent at risk of considerable vulnerability and impairment.

Migraine is a primary headache disorder. It includes transient aura symptoms that occur before the headache phase. Auditory hallucinations are very infrequently reported as part of migraine and are a very rare presentation. We report a 15-year-old nonpsychotic adolescent boy who has had migraine and auditory hallucinations for the past 6 years, and it worsened over the last 2 months, which was closely correlated with the severity, frequency, and duration of episodes of symptoms. The auditory hallucinations and the migraine attacks disappeared together under prophylaxis with tab. topiramate. This report suggests the possibility of auditory hallucinations as an acoustic aura in migraine attacks.

Dear Editor: Among cholinestcrase inhibitors, rivastigmine is an acetylcholinesterase and butyrylcholinesterase inhibitor that is widely used in treating Alzheimer's and subcortical vascular dementias, owing to its beneficial pharmacodynamic property. Combined with antipsychotics, rivastigmine has been found effective in improving negative schizophrenia symptoms (1,9). We report a case of residual schizophrenia with predominant negative symptoms that responded to rivastigmine and risperidone. Case Report Mrs J is an Indian woman, aged 45 years, with residual schizophrenia (according to ICD-10 criteria) of 6 years' duration. She was treated with risperidone and maintained on 6 mg daily. She presented with marked psychomotor retardation, passivity, lack of initiative, poverty of speech, and poor facial expression. With strong family support, she had maintained good drug compliance and responded to risperidone, which completely controlled her positive symptoms. She developed the presenting complaints during the prior 18 months, despite regularly taking an antipsychotic. Using the clinical interview, patient observation, and additional informant information, we evaluated her baseline negative symptom complex according to the Scale for the Assessment of Negative Symptoms (SANS, 2). We also evaluated her performance in Instrumental Activities of Daily Living (IADL, 3) and on the Satisfaction with Life Scale (SWLS, 4). Further, we administered neurocognitive tests: the Halstead-Reitan Battery (5) for psychomotor speed, attention, and scanning; the Rey Auditory Verbal Learning Test (6); and the Wechsler Memory Scale-Third Edition (7) for learning and memory. We started the patient on rivastigmine tartrate 1.5 mg twice daily, titrated at monthly intervals to reach a maximum of 6 mg daily in 2 months' time and maintained along with risperidone 6 mg daily. A second SANS evaluation, done after 4 weeks of drug therapy, showed 10% improvement in negative symptoms. The combined treatment of antipsychotic and rivastigmine continued for 6 months, at which time the patient was reassessed. Wc found a notable drop of 41% from her baseline SANS score. Similarly, her baseline IADL and SWLS scores improved by 36% and 28%, respectively. Neuropsychological tests measured after 6 months showed appreciably better cognitive functions, which were directly related to the improvement in her quality of life. Discussion The neurotransmitters implicated in the pathogenesis of schizophrenia are dopamine, serotonin, glutamate, and acctylcholinc. …

A case of juvenile-onset bipolar affective disorder with a childhood history of attention-deficit hyperactivity disorder (ADHD) is presented. As the patient was refractory to treatment with mood stabilizers, clozapine was given, which succeeded in achieving remission. The disorder's natural history needs further study. Data also need to be collected for optimal pharmacotherapeutic guidance.