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In a humanitarian crisis, healthcare workers are on the frontline in providing their services. Despite being crisis management personnel, healthcare workers may get exposed to occupational stress due to unprecedented circumstances, challenges in delivery of high-quality care, lack of resources, and most importantly for being at high risk to suffer from the impact of the situation itself. Therefore, it is imperative to maintain the mental health of healthcare workers on a regular basis and more so during a pandemic like COVID-19. For addressing the occupational stress in healthcare workers, a Cognitive Behaviour Therapy (CBT) based intervention is suggested, also supported by a Cochrane review, which can build/ improve/ enhance resilience, needed to shield individuals against the development of psychopathology, at the public health level in humanitarian crises. In addition to developing resilience, which will be helpful in combating anxiety, depression, somatization, and incapacitation, CBT will also help in dealing with the social isolation which has been part and parcel of COVID-19 and similar pandemic situations.

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Background  Escitalopram is widely used for the management of the major depressive disorder and generalized anxiety disorder, but there is no to very limited data available regarding efficacy and safety in Pakistani patients. This study was conducted to evaluate the efficacy and safety of escitalopram oral drops to manage the major depressive disorder and generalized anxiety disorder in a local cluster within Pakistan. Methods This prospective multicenter observational study was conducted in the department of psychiatry from August 2018 - August 2019. Eighty-five patients meeting the selection criteria were included in the study. Adolescent, adult, and geriatric patients of either gender with generalized anxiety disorder having Hamilton Anxiety Rating Scale (HAM-A) rate ≥ 10 and major depressive disorder having Montgomery-Asberg Depression Rating Scale (MADRS) rate ≥ 7 or patients with co-morbid generalized anxiety disorder (GAD), major depressive disorder (MDD) were selected for the study. We are reporting patients' improvement from baseline, response rate, and remission rate. Data analysis is performed by using SPSS version 21 (IBM Inc, Armonk, USA). Results Among enrolled patients, 42 were adolescents, 22 were adults, and 21 were geriatric. The mean age of an adolescent, adult, and geriatric patients was 14.92 ± 2.04, 44.54 ± 12.08, and 64.61 ± 3.16 years, respectively. Among enrolled patients, the mean change in a total score of HAM-A for anxiety and MADRS for depression were -10.04 ± 4.32 and -17.67 ± 14.42, respectively. At the end of the study, the remission rate and response rate for depression were 82 % and 75%, respectively. Similarly, the remission rate and the response for anxiety were 76% and 81%, respectively. Mean HAM-A and MADRS scores were significantly improved for adolescent, adult, and geriatric patients. Adverse events were reported in eight (9.41%) patients with six having gastrointestinal (GI) disturbance and two having to worsen anxiety. All reported adverse events were of mild severity.  Conclusion  Escitalopram oral drops are found effective and tolerable in reducing both anxiety and depression over the duration of study in all age groups, including adolescents, adults, and geriatrics.

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OBJECTIVE: To determine the pattern of presentations and characteristics of patients at a psychiatric emergency services facility. METHODS: The cross-sectional study was conducted in November 2016 at the Department of Psychiatry and Behavioural Sciences, Jinnah Postgraduate Medical Centre, Karachi, and comprised all patients presenting to the departmental emergency services. Data was documented on a pre designed semi-structured proforma, and analysed using SPSS 22. RESULTS: Of the 316 cases, 162(51.3%) were males and 154(48.7%) were females. The overall mean age was 30.78+/- 13.09 years (range: 8-80 years). Psychiatric emergencies comprised suicidal attempt, excitement, violence, altered sensorium, altered/ inappropriate behaviour and extrapyramidal symptoms / acute dystonia together constituting for 123(38.9%) of the total presentations, while there were 20(6.33%) cases of hysterical fits and 6(1.89%) with acute anxiety symptoms. Overall, 56(17.7%) subjects were found to have no psychiatric diagnosis, and 46(81.5%) of these were referred cases. CONCLUSIONS: Non-emergency visits constituted high percentage of emergency presentation.

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Catatonic schizophrenia is defined by catatonia seen either with alternating phases of stupor and motor rigidity or the extreme phase of catatonic excitement. This variant of schizophrenia has been identified with poor prognosis, mainly due to the higher association with negative symptoms and young age onset. In this paper, we illustrate a similar clinical picture of catatonic schizophrenia in two brothers, with no genetic predisposition to schizophrenia and no proximal stressors apart from the aggressive/violent behavior of their elder brother. Case presentation 1 (Patient A): An 18-year-old male from a lower socio-economic class with no previous mental health issues presented to the emergency department with complete mutism, marked psychomotor retardation, posturing along with a refusal to drink or eat, and complete lack of self-care for about two months. The diagnosis of catatonic schizophrenia was made, and the patient was started orally on aripiprazole and lorazepam. On the third day of admission, noticeable changes were observed, and in the following days, he started eating and going to the toilet while still being completely mute. After two weeks on treatment, he started responding with one-word answers. Case presentation 2 (Patient B): The biological brother of patient A, a 30-year-old male, presented on the same day with an identical history of mutism, decreased psychomotor activity, posturing along with a refusal to drink or eat, and lack of self-care for the past few months. The diagnosis of catatonic schizophrenia was made. The patient was started orally on both, olanzapine and lorazepam. He showed a quicker response to treatment with the maintenance of eye contact on the second day of treatment and started giving short answers to questions on the fifth post-admission day. We here discuss a possible genetic predisposition to catatonic schizophrenia and its initial improvement with lorazepam and subsequent treatment with olanzapine proving to be more efficacious than aripiprazole.

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OBJECTIVE: To find out the prevalence of Migraine among patients of Depressive Disorder. METHODS: A descriptive cross sectional study, conducted at Department of Psychiatry and Behavioral Sciences, JPMC, Karachi from 1st January 2014 to 30th June 2014. Total 272 patients were enrolled in the study. Depressive disorder was diagnosed as per ICD-10 criteria and Migraine headache as ICHD-2 criteria for diagnosis. RESULTS: A total of 272 patients with mean age of 31.85 ± 8.7 were enrolled. Out of 272 cases 64% were females; Out of total cases 86.4% were married. Migraine with aura was seen among 6.6% and migraine without aura was present among 26.1%. Migraine was linked more with females and married and of those having severe Depressive disorder. CONCLUSION: Migraine headache is common among depressed people, particularly females and having severe depression, so it ought to be remembered that while looking for Depressive disorder or headache the other condition must be remembered.

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OBJECTIVE: To determine the frequency of co-morbid common primary headaches among depressed patients. METHODS: This study was conducted at the Jinnah Postgraduate Medical Centre, Karachi, from July to December 2014, and comprised depressed patients. Diagnosis of depressive disorder was based on diagnostic criteria of International Classification of Diseases (10th version). For the diagnosis of common primary headaches, International Classification of Headache Disorders (2nd edition) criteria were applied. SPSS 17 was used for data analysis. RESULTS: Of the 331 participants, 129(39%) were males and 202(61%) were females. The overall mean age was 31.40±8.6 years (range: 18-50 years). Besides, 208(62.83%) participants had no headache and 123(37.16%) had common primary headaches. Of the latter, 18(5.4%) had migraine with aura, 49(14.8%) had migraine without aura and 56(16.9%) had tension-type headache. Common primary headaches were more common in females and among those having severe depressive disorder. CONCLUSIONS: The primary headache was common among outpatients with depressive disorder, predominantly tension-type headache and migraine without aura.

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OBJECTIVE: To determine the frequency of different motivating factors to quit opioid use. METHODS: The descriptive, cross-sectional study was conducted at the Department of Psychiatry and Behavioural Sciences, Jinnah Postgraduate Medical Centre, Karachi, from August 2012 to February 2013, and comprised opioid users. Demographic data was collected through a semi-structured questionnaire whereas motivational factor was assessed through a self-designed proforma. A motivational factor questionnaire was developed after a pilot study. In this questionnaire, different intrinsic and extrinsic factors were categorised into four types, i.e. biological, psychological, social and religious factors. SPSS 17 was used for data analysis. RESULTS: Of the 157 participants, 148(94.3%) were males and 9(5.7%) were females. The overall mean age was 31.83±8.99 years (range: 14-57 years). The mean age of onset of using opioids was 25.79±7.17 years (range: 13-40 years). The mean duration of using opioids was 5.29±3.72 years (range: 1-20 years). Besides, 141(90%) patients were under the age of 45 years. Strong social factors included feeling of inability to care for family among 122(77.7%) participants, embarrassment in society 107(68.2%), and family pressure by parents/ spouse/ children 94(59.9%). CONCLUSIONS: Family and social factors were found to be the main source of motivation for a person to quit substance abuse.

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OBJECTIVE: To assess gastrointestinal symptoms among depressed patients presenting in an outpatient psychiatric clinic. METHODS: All consecutive and consenting cases of depressive disorder presenting to the clinic from Jan' 02 to Dec' 05 were inducted in the study. A descriptive study was carried out in a clinical setting at the Neuro-Spinal Medical Institute, Karachi, Pakistan. The assessment was based on detailed history, physical examination, mental state examination and filling of semi structured proforma designed for this purpose. For diagnostic purpose WHO classification ICD-10 criteria was used. RESULTS: A total of 1165 (Male: 56%, Female: 43.2%) patients were assessed. The age ranged from 6 to 90 years for male and 5 to 80 for females with p-value of 0.001. Majority were married. Their educational status revealed that 20.4% of males and 45.1% females were illiterate. The most frequently reported gastrointestinal symptom was decreased appetite (67.7%) followed by constipation (57.7%) and diarrhoea (42.3%). Other reported symptoms included abdominal pain, vomiting, gas, indigestion and nausea in order of frequency. In males 13.7% and 12.7% females had suffered for > 10 years before seeking psychiatric consultation. Surprisingly, about 26.3% of the patients had previously pursued alternative modes of treatment (homeopathic, faith healers and hakeems). CONCLUSION: Somatic symptoms manifesting as gastrointestinal symptoms are common in patients with depressive disorder. Awareness about such an association is essential and will be useful for primary care physicians and gastroenterologists for establishing early diagnosis and management, thus avoiding unnecessary investigations in patients with poor resources.

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OBJECTIVE: To determine the gender based response to fluoxetine HCl medication in relation to tryptophan metabolism in depressed patients. DESIGN: A comparative, analytical study. PLACE AND DURATION OF STUDY: Clinical Biochemistry and Psychopharmacology Research Unit, Department of Biochemistry, University of Karachi during the year 2002 to 2003. SUBJECTS AND METHODS: Sixteen adults depressed patients who were not having any other major comorbidity were selected from the outpatients department of local psychiatric clinic for the study. They were subjected to a semi-structured interview for associated clinical characteristics and diagnosis of depression according to ICD-10 criteria. A control group of normal health male and female individuals was identified for comparison with the depressed group. All the depressed patients were treated with fluoxetine hydrochloride (Prozac 20 mg/day) for four weeks. Healthy individual's data was compared with the depressed group and evaluated for gender based response to fluoxetine HCl medication. RESULTS: Significant decreases were found in total tryptophan concentrations (33 %, p<0.01,56%, p<0.01) in depressed male and female patients respectively, in contrast, serum cortisol levels were increased by 68% and 98% in male and female depressed patients respectively as compared to healthy controls. Significant increases (23%, p<0.05) in albumin levels were found in females only. Four weeks treatment of male and female depressed group by Fluoxetine HCL (Prozac) 20 mg/kg/day, increased serum total tryptophan concentrations significantly by 32% (p<0.05) in males and by 83% (p<0.01) in females. Serum-free tryptophan concentrations were increased by 22% (p<0.05) in males only. In contrast serum cortisol concentrations were decreased by 31% (p<0.01) and 45.35% (p<0.01) in males and females respectively. CONCLUSION: Increases in tryptophan and decreases in cortisol concentrations were greater in females which may contribute to better response of the drug in females.

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