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Primary Care Psychiatry: A Clinician’s Companion

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 Primary Care Psychiatry: A Clinician’s Companion

EDITORS
Patley Rahul, MD
Arul Kevin Daniel David, MD
Ateev Sudhir Chandna, MD
N Manjunatha, MBBS, DPM, MD
C Naveen Kumar, DPM, MD, MAMS
Prabhat Chand, MD, DNB, MNAMS
Suresh Bada Math, MD, DNB, PGDMLE, PGDHRL, Ph.D.

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 Primary Care Psychiatry: A Clinician’s Companion

Copyright © NIMHANS, Bengaluru-560 029

Published by National Institute of Mental Health and Neuro Sciences, Bengaluru-560 029

All rights reserved. No part of this report may be reprinted, reproduced, or utilized in any form
or by any electronic, mechanical, or other means, now known or hereafter invented, including
photocopying and recording, or in any information storage or retrieval system, without
permission in writing from the editors for commercial purposes. However, this document
may be freely reviewed, freely transmitted, reproduced in part or whole, purely on a
non-commercial basis, with proper citation. This is not for sale.
Year: 2024
ISBN: 978-93-91300-65-4

NIMHANS Publication No. 257

Citation: Patley R, David AKD, Chandna AS,Manjunatha, N., Kumar, C.N., Chand, P.K.,
Math, S. B. (Eds). Primary Care Psychiatry: A Clinician’s Companion. (2024). Bengaluru
:(NIMHANS Publication No: 257), ISBN: 978-93-91300-65-4
Disclaimer- Medicine is an ever-changing science, and at the same time, the field of public
health is also evolving rapidly. The authors and the publisher of this work have checked with
sources believed to be reliable in their efforts to provide information that is complete and
generally per the standards accepted at the time of publication. However, given the possibility
of human error or changes in medical sciences and public health, neither the authors nor the
publisher nor any other party who has been involved in the preparation or publication of this
work warrants that the information contained herein is in every respect accurate or complete.
They disclaim all responsibility for any errors or omissions or the results obtained from the
use of the information contained in this work. The author/editor does not give any guarantee.
Every effort is made to ensure the accuracy of the material, but the publisher, printer, and
author will not be held responsible for any inadvertent error(s).

Correspondence:
Dr. Suresh Bada Math,
Professor & Head of Tele-Medicine Centre, NIMHANS Digital Academy and Unit-V
(Psychiatry),
Head of Forensic Psychiatry Services, Consultant, Community Psychiatry,
Department of Psychiatry, National Institute of Mental Health and Neuro Sciences,
Bengaluru – 560 029, INDIA
Email: [email protected], [email protected]
Phone: +91 080 2285/2286

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 Primary Care Psychiatry: A Clinician’s Companion

PREFACE
To achieve the aim of increasing the mental health of human resources, the NIMHANS Digital
Academy was inaugurated by the Honorable Minister for Health and Family Welfare, Govt.
of India, on 27th June, 2018. The NIMHANS Digital Academy (NDA) has helped to
consolidate and expand the tele-activities initiated at NIMHANS throughout the country. This
activity was approved as part of a larger mental health informatics initiative on 30 th April,
2018. The NIMHANS Digital Academy was started following the objectives of the Institute
in the NIMHANS Act 2012, Section 13. This is also by the National Mental Health Program.

The Diploma in Community Mental Health for Doctors was one of the courses that was
started, and it aimed at increasing mental health resources by training doctors at the
community level. To date, the course has run 40 batches and has enrolled 2093 doctors,
equipping them with skills and knowledge to help them treat and give the first line of treatment
for patients with psychiatric illness at the primary healthcare levels.
The content of this book has been curated from the feedback of all the doctors trained in the
course and resource persons, and this curriculum has been approved by the NIMHANS Digital
Academy Board of Studies (24/12/2018).
We are very hopeful that this manual will educate doctors and general practitioners and make
them feel more confident in assessing and managing psychiatric illness at the primary
healthcare level. This manual is designed to enhance theoretical and practical knowledge in
primary care management (first line of treatment) of psychiatric disorders in the community.
The manual deals with topics that help in CARE of patients with psychiatric illness at the
primary health care level.
C- Case identification

A - Assessment and first-line management

R - Referral of severe and comorbid cases
E - Evaluation and follow-up of cases

Editors
Rahul Patley

Arul Kevin Daniel David

Ateev Sudhir Chandna
N Manjunatha

C Naveen Kumar
Prabhat Chand
Suresh Bada Math

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Primary Care Psychiatry: A Clinician’s Companion

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 Primary Care Psychiatry: A Clinician’s Companion

ACKNOWLEDGEMENTS
We extend our deepest appreciation to the individuals whose unwavering commitment and
expertise have played a pivotal role in the creation and enhancement of our manual. Their
contributions have been indispensable, shaping the manual into a valuable resource for
primary care doctors.
First and foremost, our sincere gratitude goes to Dr. Pratima Murthy, Director of NIMHANS,
for her invaluable guidance throughout the manual development process. Dr. Murthy's
expertise and insights have been instrumental in refining the content, ensuring its relevance
and efficacy.
We express our gratitude to primary care doctors, namely Dr. Ashish Pundhir, Dr. Deepali
Goel, and Dr. Rini Raveendran, for their significant contributions following the completion
of the Diploma in Community Mental Health for doctors offered by NIMHANS Digital
Academy. Their thorough reviews have been instrumental in enhancing the quality of our
work.

The staff and faculty of the NIMHANS Digital Academy deserve our sincere thanks for their
unwavering support and cooperation throughout the manual creation process.
We extend our sincere appreciation to Dr Hetashri Shah, Dr Gajanana Sabhahit, Ms Gauri
Mullerpattan, Ms Sahana Nujella and Ms Nishtha Bawa, who graciously provided their
consent for the inclusion of their photographs in this manual. Your willingness to contribute
has enriched the visual content and overall quality of this resource. We thank you for your
invaluable support.
A special mention goes to Ms. Gauri Mullerpattan and Ms. Sahana Nujella for their
photography, enhancing the visual appeal of the manual. Additionally, our appreciation
extends to Dr Hetashri Shah, Dr Chandana Sabbella, Ms Gauri Mullerpattan, and Ms Sahana
Nujella for their valuable contributions and support in creating the graphic content.
Ms. Harsha, the graphic designer, deserves special recognition for her outstanding work on
the cover page design and layout. Her artistic skills have brought the manual to life.
To all contributors, whether esteemed professionals or dedicated primary care doctors, we
extend our heartfelt gratitude for their time, effort, and expertise. Their collective
contributions have elevated the guide to meet the highest standards of comprehensiveness and
practicality. We are truly thankful for their dedication to advancing mental health support in
the community, and we are confident that this guide will serve as an invaluable resource for
doctors in their essential work within primary care.

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 Primary Care Psychiatry: A Clinician’s Companion

ABOUT THE MANUAL

How was the Manual developed?

At NIMHANS, based on our experiences, we have found the hybrid mode to be the most
valuable and effective way of training doctors. We have good experience using this mode in
training mental health professionals in the states of Karnataka, Odisha, Haryana, Uttarakhand,
Bihar, and Chhattisgarh via projects like Chhattisgarh Community Mental Healthcare Tele-
Mentoring Program (ChaMP), Tele-mentoring For Rural Health Organisers of Chhattisgarh
(TORENT), and Karnataka Telemedicine Mentoring and Monitoring Program (KTM). This
training was done in batches, with each batch trained over 3-6 months. To aid, the courses
have run 40 batches and enrolled 2093 doctors, equipping them with skills and knowledge to
help them treat and give the first line of treatment for patients with psychiatric illness at the
primary health care levels. Previous DMHP training of primary care doctors was 3 to 5 days
of in-person training per year. This method failed as there was no handholding of primary care
doctors in treating, prescribing and follow-up of psychiatric disorders. Most of the patients
require treatment for many months to years. Hence, it is prudent to handhold the primary care
doctors in treating patients at the primary care level, both through online and in-person
training. This manual stems from the vast experience in training and handholding primary
care doctors and has been enriched by feedback from both primary care doctors and experts
in the field of mental health.
Who can use the manual?
The manual can be used directly by all primary care doctors across the country to provide the
first line of treatment. This manual should be used along with the Clinical Schedule for
Primary Care Psychiatry (CSP).
This manual is prepared to be used by DMHP psychiatrists to train primary care doctors.
The treatment mentioned is based on the medication availability at the primary health care
level.
How to use the manual?
This manual should be used along with online training (synchronous and asynchronous
training), completion of assignments and handholding of primary care doctors. If the users of
this manual, i.e., primary health care doctors, doubt the diagnosis, treatment, follow-up, or
any other issues, they should immediately contact their supervisor/trainer/DMHP psychiatrist.
This manual should be used under the supervision of a DMHP psychiatrist/qualified
psychiatrist for training primary care doctors in hybrid mode (online and in-person).
This manual can be freely used for educational purposes and not for any commercial purposes.
While using it for educational purposes, kindly give credits to the NIMHANS Digital
Academy.
People who want to get certified in the Diploma in Community Mental Health course can
contact NIMHANS Digital Academy.
All the chapters in the manual are linked with respective video QR codes for online
asynchronous learning.

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 Primary Care Psychiatry: A Clinician’s Companion

CONTENTS

S.No. Chapter Page No.

1 Epidemiology and Treatment Gap of psychiatric disorders in 1

Primary health care and General Population:
Dr. Patley Rahul, Dr Suresh Bada Math

2 Assessment in Psychiatry

2.1 History Taking and Psychiatric Assessment in General Practice 8

Dr. Ateev Sudhir Chandna, Dr. Rini Joseph, Dr. Patley Rahul

2.2 Clinical Schedule for Primary Care Psychiatry (CSP) 13

Dr. Patley Rahul, Dr. Narayana Manjunatha, Dr. C Naveen Kumar,
Dr. Suresh Bada Math

2.3 Communication and Counselling Skills 16

Dr. Arul Kevin Daniel David, Dr. Suresh Bada Math

3 Depressive Disorders

3.1 Classification & Assessment of Depressive Disorders 24

Dr. Tushar Panda, Dr. Rini Joseph, Dr. Patley Rahul,
Dr. C Naveen Kumar

3.2 Physical Conditions Associated with Depressive Disorders 27

Dr. Madan R, Dr. Rini Joseph, Dr. Patley Rahul

3.3 Antidepressants (Fluoxetine, Escitalopram, and Amitriptyline) 30

Dr. Nileswar Das, Dr. Shivam Gakkhar

4 Risk assessment and management of Suicide at Primary Care 34

Centre
Dr Hari Hara Suchandra, Dr Neha B Kulkarni

5. Anxiety Disorders

5.1 Anxiety Disorders 40

Dr. Prerna Keshari, Dr. Narayana Manjunatha

5.2 Somatization Disorder 45

Dr. Prerna Keshari, Dr. Narayana Manjunatha

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5.3 Obsessive Compulsive Disorder and its Treatment 49

Dr. Arul Kevin Daniel David, Dr Madhuri H Nanjundaswamy, Dr.
Lakshmi Nirisha

5.4 Low-intensity Psychological Interventions 52

Dr. Ateev Sudhir Chadna, Dr. Suresh Bada Math

5.5 Brief Intervention in a Busy Practice 57

Dr Prakyath R Hegde, Dr. C Naveen Kumar

6. Alcohol and Tobacco Use Disorder

6.1 Diagnosis of Alcohol and Tobacco use disorder 62

Dr. Gajanan Ganapati Sabhahit, Dr. Swati Ravindran

6.2 Identification & Management of Alcohol Withdrawal 67

Dr. Aishwarya John, Dr. Rini Joseph, Dr. Patley Rahul

6.3 Medications to Prevent Relapse (Anti-craving Agents) 71

Dr. Gautam Sudhakar N, Dr Madhuri H Nanjundaswamy, Dr.
Lakshmi Nirisha

6.4 Tobacco Use and Management 74

Dr. Arul Kevin Daniel David, Dr. Hari Hara Suchandra

7. Severe Mental Disorders

7.1 Schizophrenia & Psychotic Disorders 79

Dr. Sukriti Mukherjee, Dr. Nileswar Das

7.2 Antipsychotics 83
Dr. Bangalore G Kalyani, Dr. Swati Ravindran

7.3 Bipolar Disorder and Management at Primary Health Centre 87

Dr. Praveen V Raj, Dr Arpitha B K, Dr. Narayana Manjunatha,
Dr. Suresh Bada Math

8. Special Conditions

8.1 Emotional and Behavioral Disorders of the Elderly 93

Dr. Apurva Mittal, Dr P.T. Shivakumar

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8.2 Neuro-Developmental Disorders, Behavioural & Emotional 97

Disorders of Childhood
Dr. Rakesh Chander Kalaivanan, Dr. Rajendra Kiragsur
Madegowda

9 Applicability of Mental Health Care Act 2017 in Primary 105

Health Care
Dr. Prerna Keshari, Dr Madhuri H Nanjundaswamy, Dr. Suresh
Bada Math

10 Tele MANAS 14416 110

Ms Gauri Mullerpattan, Ms Sahana Nujella, Dr Patley Rahul

Appendix 113
I.Clinical Schedules for Primary Care Psychiatry v 2.4
II.Essential drugs list
III.SAD PERSONS Scale
IV.Tele MANAS poster
V.QR code to explore additional manuals published by
NIMHANS Digital Academy

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 Primary Care Psychiatry: A Clinician’s Companion

Chapter 1.1: Epidemiology of Psychiatric Disorders in Primary and General Healthcare

Settings

Health is a state of complete physical, mental, and social well-being and not merely an absence
of disease. There is no health without mental health, and most of the epidemiological studies
have shown that psychiatric disorders are quite common. Epidemiology of psychiatric
disorders helps in understanding the magnitude of psychiatric disorders and their risk factors
and in planning interventions in the community. This chapter will address the epidemiology
of psychiatric disorders within primary and general healthcare settings.
What is Primary Care?
As per the World Health Organisation (WHO), primary healthcare is a whole-of-society
approach to health and well-being centred on the needs and preferences of individuals,
families, and communities.
Pathway to Psychiatric Care in India:

Pathway to care for mental health issues in India is traditionally different than the higher
income countries, as shown in the figure below.

(Math SB, et al. 2010)

India also faces a scarcity of human resources, with around 8000-9000 psychiatrists, as well
as a scarcity of infrastructure, which is primarily reflected by the considerable treatment gap
that has been reported by National Mental Health Survey (NMHS) 2016, i.e., 85% for
common mental disorders and 73.6% for severe mental illnesses. As per the NMHS 2016, the
prevalence of any psychiatric disorder is 10%, which means almost 14 crores of the population
require mental health services.
The lack of adequate training in the MBBS curriculum makes it imperative to address this
issue by training Primary Care Doctors (PCD) in providing mental healthcare.

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Salient takeaway points from some selected studies on the burden of psychiatric
illnesses:
1. Most studies indicate a high prevalence of common mental disorders. Around 30%-
40% of patients visiting primary care settings have psychiatric disorders, with
depression being the most common psychiatric condition.

Disorders Prevalence in General Prevalence in Primary

Population Health Care
Overall 13.7% 47.5%
Common Mental 5.1% 35.2%
Disorders
Severe Mental Disorders 1.4% 2.6%
Substance Use Disorders 22.4% 9.5%

2. People with psychiatric disorders may experience a reduction of 10-15 years in their
Quality adjusted life-year (QALY), indicating that these conditions significantly affect
the quality of life. On the other hand, the measure of Disability Adjusted life-year
(DALY) considers both premature mortality and years lived with disability due to
psychiatric disorders. It shows that individuals with psychiatric disorders may
experience premature mortality, which means they tend to die about 10 years earlier
than those in the general population. Additionally, they also live with a substantial
burden of disability.

3. Help-seeking behaviour was noted in the Primary Health Care settings, predominantly
for symptoms of pain such as multiple body aches, headache, and medically
unexplained pain.

4. In addition to this, there has been a rampant increase in the use of substances. The
following table gives the burden of SUDs that need medical attention.

The burden of substance use (magnitude of substance use in India, 2019)

Substance use Prevalence of Dependence
Alcohol 2.9 crore (2.7%)
Cannabis 25 lakh (0.25%)
Opioids 28 lakh (0.26%)

According to the Global Adult Tobacco Survey (GATS) conducted in 2016–17, 28.6%
currently consume tobacco, either in a smoked or smokeless form.

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5. Another pressing concern within the realm of mental health is the alarming issue of
suicide. In 2021, the country reported a staggering 1.64 lakh suicides. According to
the WHO, daily, there are approximately 450 suicide deaths, and for every suicide
death, there are an estimated 20 attempted suicides, highlighting the gravity of the
situation.

6. Moreover, according to the National Mental Health Statistics (NMHS, 2016), the
prevalence of psychiatric disorders is estimated to be approximately 10%. This
suggests that in a region covered by a single primary health centre serving a population
of 30,000 individuals, at least 3,000 people may be affected by psychiatric disorders.
Emphasizing the shift of mental health treatment to primary healthcare centres is crucial
due to the potential to address these issues early, preventing an escalation of health
conditions. This approach not only reduces stigma but also offers cost-effective,
community-centred screening and intervention, promoting holistic care.

Conclusion

The presentation of patients with psychiatric disorders in primary health care varies
significantly from what can be seen in urban/mental asylum setups. There’s a complex
interplay of physical symptoms and psychological underpinnings with various social aspects
of patients.
It’s also quite evident that the current workforce is quite under-equipped and undertrained in
identifying and treating/referring a case with a psychiatric diagnosis, which contributes to the
enormous treatment gaps that have been quoted.
This underlines the need for strengthening current mental health programs with customized
training for primary care doctors in mental disorders, top-down drive with adequate and
appropriate use of technology required for the various programs to reach the grassroots.
Through training, a doctor at the Primary healthcare centre should be able to do the following:

C- Case identification of mental health disorders like Anxiety disorders, Depressive

Disorders, Alcohol Use Disorders, Nicotine Use Disorders, and Psychotic Disorders.
A-Assessment and provision of the first line of treatment and low-intensity
psychological interventions for Depressive Disorders, Anxiety Disorders, Alcohol Use
Disorders, and Nicotine Use Disorders.
R-Referral of patients to mental health institutions or psychiatrists when required.
E-Evaluation of follow-up of the case at the primary health care level.

REFERENCES
1. Nirisha, Lakshmi P.; Malathesh, Barikar C1; Jayasankar, Pavithra2; Ashwatha, Puttaswamy3;
Parthasarathy, Rajani4; Manjunatha, Narayana; Kumar, Channaveerachari Naveen; Thirthalli,

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Jagadisha2; Math, Suresh Bada. Analyzing Psychiatric Disorders from Rural Primary Health
Centers: A Clinical Epidemiological Study from a District of South India. Journal of Psychiatry
Spectrum 2(1):p 35-40, Jan–Jun 2023. | DOI: 10.4103/jopsys.jopsys_37_22
2. Gautham MS, Gururaj G, Varghese M, Benegal V, Rao GN, Kokane A, et al. The National Mental
Health Survey of India (2016): Prevalence, socio-demographic correlates and treatment gap of
mental morbidity. International Journal of Social Psychiatry. 2020 Jun 1;66(4):361–72.
3. Pothen M, Kuruvilla A, Philip K, Joseph A, Jacob KS. Common mental disorders among primary
care attenders in Vellore, South India: nature, prevalence and risk factors. Int J Soc Psychiatry.
2003 Jun;49(2):119-25. doi 10.1177/0020764003049002005. PMID: 12887046.

To gain a comprehensive understanding of primary care psychiatry, scan the QR code or click
on the topic provided for access to a concise and informative video presentation on the subject.

Primary Care Psychiatry

Chapter 1.2 Treatment Gap in Psychiatric Disorders:

The treatment gap is the difference between how many people need help for mental health
problems and how many receive that help. Failure to address these mental health disorders in
their early stages can lead to their exacerbation and increased complexity, rendering them
more challenging to treat.

According to NMHS 2016, there is a huge treatment gap for psychiatric conditions in the
country, as shown below:

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The reasons for this high treatment gap are as follows:

1. Lack of awareness about mental health problems
2. Stigma
3. Limited access to mental healthcare
4. Limited availability of medications
5. Irregular supply of medicines
6. Lack of adequate psychiatry training in the MBBS curriculum
7. Socio-cultural beliefs
8. Increased out-of-pocket expenditure for mental healthcare

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To decrease the gap, all the above issues need to be addressed at the individual, community,
and policy levels. To begin with, all the Primary Care Doctors who undergo training need to
sensitize pharmacists, social workers, religious leaders, faith healers, farmers, and other
significant members of the community.
REFERENCES
1. Kaur, A., Kallakuri, S., Mukherjee, A. et al. Mental health-related stigma, service provision
and utilization in Northern India: situational analysis. Int J Ment Health Syst 17, 10 (2023).
https://doi.org/10.1186/s13033-023-00577-8
2. Murthy, R. Srinivasa. National Mental Health Survey of India 2015–2016. Indian Journal of
Psychiatry 59(1):p 21-26, Jan–Mar 2017. | DOI:
10.4103/psychiatry.IndianJPsychiatry_102_17
3. Singh, Om Prakash. Closing treatment gap of mental disorders in India: Opportunity in new
competency-based Medical Council of India curriculum. Indian Journal of Psychiatry
60(4):p 375-376, Oct–Dec 2018. | DOI: 10.4103/psychiatry.IndianJPsychiatry_458_18

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Chapter 2.1: History and Mental Status Examination

Introduction
History-taking is the most crucial part of a psychiatric examination. It is the gold standard for
evaluation. There is no blood, laboratory, or radiological investigation that can diagnose a
psychiatric disorder definitively. The sole method for diagnosing psychiatric conditions is
through obtaining a patient's history, general physical examination, and mental status
examination. Hence, it is essential to take a detailed and comprehensive history.
It is crucial to note that the history that is collected must be kept private and confidential, the
reason being that most psychiatric disorders have a stigma attached to them.

History Taking in Psychiatry

The information can be collated from many sources such as the patient, their family, friends,
school, workplace and any medical records or documents. This is because with more sources,
the information becomes more complete, and the diagnosis gets more accurate.
Kindly follow the below-mentioned steps to obtain a good history –

1) Demographic Details – Name, age, gender, occupation, education, socio-economic status,

marital status, address, and mobile number should be collected. This is especially important
for identification purposes, and it also serves to develop a good rapport with the patient.

2) Chief Complaints – It is a record of why the patient has come to the clinic. It should be in
the patient’s own words without technical terms. Complaints should be noted chronologically
and cover only the most essential complaints, for example – poor sleep, low mood and
fearfulness.
3) Onset – Duration from the start of symptoms to the point when the condition was
diagnosed.

Acute Onset =
Diagnosable
condition 2 weeks to 1 month

Insidious Onset =
ONSET
months to years
Symptoms

Time
Start of
symptoms
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4) Course
It indicates the progression of illness.

• Episodic Illness -This is the course of illness where discrete episodes are seen with
complete recovery between the episodes. To call it an episodic illness, the period of
normalcy should be at least 2 months.
• Chronic Illness - This is a continuous illness with no period of normalcy after the
onset of the illness.

5) History of Presenting Illness (HOPI)

This must be presented in chronological order.

In the context of HOPI (History of Present Illness), it is essential to provide a detailed
description of each symptom. To do so, you can categorize each symptom using the following
aspects:

• Duration
• Context
• Frequency
• Increasing Factors
• Decreasing Factors
• Progression of Symptom
• Outcome of Symptom

In all patients, it is essential to enquire about the risk of harm to self, risk of harm to others,
and inability to take care of themselves.

Finally, associated impairment in the following needs to be investigated-

• Biological functions – sleep, appetite, hygiene, bowel & bladder function

• Occupational function
• Social function
The doctor should also check for any legal, financial, or family issues.
6) Negative History

It is essential to rule out any organicity (as mentioned in the red flag signs in the table below),
chronic illness, medication intake, substance use, other mood, anxiety, or psychotic
symptoms.

7) Medical History
Here, inquiries should be made about past or present medical illnesses, medication intake,
allergies and other chronic medical conditions.

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8) Past History
It is essential to enquire about any past psychiatric illness and, if present, what were the
number of episodes, what treatment was sought, what was the response to treatment, and the
duration of treatment.
9) Family History
Any history of medical or psychiatric illness in the family should be enquired about. The
family’s understanding of illness and attitude towards the patient should also be assessed.
Enquiry about the primary caregiver (the person who provides care to the patient) should also
be done, so that he/she can be involved in treatment.
10) Personal History
This consists of enquiring about any abnormal behavior in childhood, academic performance
during school & college, substance use history, marital history, menstrual history in females
and occupational history.
11) General Physical Examination

This consists of assessing -

◉ Nutrition/ Build/Height/Weight/Body Mass Index

◉ Vitals (Pulse, BP, RR, Temp)

◉ PICCLE – Pallor, Icterus, Cyanosis, Clubbing, Lymphadenopathy, Edema

◉ Respiratory System
Red Flag Signs of Organicity
◉ Cardiovascular System Examination
• Onset after the age of 40
◉ Abdominal Examination • Urinary incontinence
• Bowel incontinence
◉ CNS Examination • Gait disturbances
• Disorientation
• Any focal neurological signs
• Seizures
Any of the above will almost
always point towards an organic
cause!
How to do a Follow-Up?

While treating patients with psychiatric disorders, it is the duty of the primary care doctor to
follow up with the patient regularly. This is because psychiatric disorders are generally
chronic conditions and thus require long-term care. The patient should be followed up at least
once a month (can be followed up weekly or fortnightly if required). At each follow-up,
enquiry should be made about – the percentage of improvement in the patient’s condition, any
side effects of the medicine, and any risk of danger to self or others. For further details, kindly
refer to the section on Clinical Schedules in Psychiatry (CSP) (Page no. 8)

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It is prudent to send the patient for review to a psychiatrist every 6 months.

Mental Status Examination

A mental status examination is an essential tool that aids physicians in making psychiatric
diagnoses. It is analogous to the physical exam in general medicine. It's crucial for fully
understanding the patient and making a diagnosis.

Procedure
It is a series of observations and examinations at one point in time. The mental status
examination includes a historic report from the patient (past one month) and observational
data gathered by the physician throughout the patient interview. Also, additional information
can be taken from patients’ attendees and previous file records.

The patient’s appearance, behaviour, speech, thought, mood, perception, and cognitive
functions are systematically studied.

Components
1) General appearance and behaviour – It is a general observation of how the patient
appears throughout the interview and how they behave towards the clinician.

2)Psychomotor activity – Psychomotor activity is defined as motor/physical activity that is

secondary to or dependent on a psychic component and is mostly non-goal-directed.
Psychomotor activity can be increased in conditions like mania or decreased in conditions like
depression and must be noted as such.
3) Speech – This can be assessed by asking the patient to give a speech sample by asking an
open-ended question and writing down the patients verbatim. (example – “tell me about your
favourite movie”). The clinician can then comment on whether speech is normal or abnormal
in terms of amount and content.
4) Thought – The following are important abnormalities in thought-

• Delusions – these are false fixed beliefs that have an unexplainable origin and are beyond
the patient’s socio-cultural background.
• Depressive cognitions – these include the patient expressing thoughts that there is no hope
for them in the future (hopelessness), that they are a person who is ‘useless’ and has no
value (worthlessness), that no person can help them out of their current situation
(helplessness).
• Suicidal ideas/death wishes – these should be described in terms of the intensity &
frequency of these thoughts, any plan for attempting suicide that the patient might have
made, and any help the patient has sought. It also includes any attempts done in the past
month (kindly refer to a psychiatrist if present).

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5) Mood – Continuous and sustained emotion colours the perception of the external world. It
is commented on subjectively by the patient as sad, anxious, tense, happy, etc., and objectively
judged by the clinician as ‘affect’ being euthymic(normal), dysphoric(sad), or anxious.

6) Perception – Perceptual abnormalities like hallucinations are described here.

Hallucinations are perceptions without any external stimuli. These can be of the following
types- auditory, visual, tactile, gustatory, or olfactory. While describing hallucinations, the
experience of the patient should be recorded verbatim. An important distinction is that
hallucinations should be present only when the patient is awake and is in clear consciousness.

7) Cognitive Functions – A brief cognitive function test can be done. The patient’s orientation
can be checked by asking them the current time, which place they are in, and the identification
of people accompanying them. Attention and concentration can be tested by asking the patient
to tell the days of the week backwards, the months of the year backwards, or count back from
20 to 1.
Assessment of memory includes recent memory, which can be assessed by asking the patient
to recall what they had for their last meal or how they came to the hospital today, as well as
remote memory, which can be tested by asking the patient the year of their birth and other
such autobiographical information. Finally, insight of the person into the illness, i.e.,
awareness of having an illness, can be commented on as present, partially present, or absent.

Take Home message:

Taking a thorough patient history, general physical examination and mental status
examination are the most important aspects of a psychiatric evaluation. It's the primary
way to diagnose psychiatric disorders because there are no blood tests or other
investigations for it. Hence, a detailed history is essential.

Scan the QR code/Click on the topic below to learn more about clinical assessment in
Psychiatry:

Clinical Assessment in Psychiatry (CSP)

Chapter 2.2: Clinical Schedules for Primary Care Psychiatry (CSP)

As the presentation of psychiatric illnesses is high in the community, and there is limited time
and resources for doctors in primary care settings, the National Institute of Mental Health and
Neuro Sciences (NIMHANS) has developed the Clinical Services Program (CSP) manual. It

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 Primary Care Psychiatry: A Clinician’s Companion

is a validated, all-in-one,12-page manual that covers the identification, diagnosis, and first-
line management of psychiatric disorders in general practice.
The manual can be used in 5 minutes in busy practice of the Outpatient Department (OPD)
for adult patients.
The illnesses covered under the CSP are the most common psychiatric illnesses – (TAPSAD)
T – Tobacco Use Disorders

A – Alcohol Use Disorders

P - Psychosis

P – Panic Disorder
S – Somatisation Disorder
A – Anxiety Disorder

D – Depressive Disorder
A high index of suspicion must be kept for patients who are on analgesics, multivitamins,
benzodiazepines, and those with vague or unusual symptoms, and the CSP must be used
proactively for them.

When to Refer the Patient?

• When they become dangerous to self or others

• When you observe worsening of symptoms or no improvement after 4 weeks
• When the patient experiences unmanageable side effects of medicines

Primary Care Taxonomy

Management Prescription
Screener
Guidelines Guidelines

1) Screener/Case Record Form

This has demographic details and the guiding path. The guiding path states that if the
symptoms and physical examination do not point towards a known medical illness and the

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 Primary Care Psychiatry: A Clinician’s Companion

symptoms have been present for more than two weeks, then the 21-item General Screening
Questionnaire is to be used. The first three questions are general inquiries about sleep,
appetite, and interest in daily work. The subsequent questions are specific to seven specific
psychiatric disorders. These questions cover the patient's family's reports and the doctor's
clinical judgment. The last question is related to psychiatric emergencies, and psychological
first aid must be given to the patient, who should then be immediately referred. Behavioural
observation must also be documented here, which refers to the patient's behaviour towards the
doctor and their family members during the interview. Finally, this section contains a box with
the diagnosis and further treatment plan.
2) Management Guidelines
This includes -

Diagnostic Guidelines – The CSP manual includes diagnostic criteria for all seven
disorders mentioned earlier. If a patient shows positive symptoms on the screener,
these diagnostic guidelines can be used to make a diagnosis.

Investigation Guidelines - There are no diagnostic tests for psychiatric disorders. The
investigations aim to rule out medical conditions or monitor the side effects of
medicines.

Treatment Guidelines - The manual provides general treatment guidelines for each
condition, including guidelines for counselling. Counselling should be brief and cover
the medical nature of the illness, the need for medication, follow-up, and a healthy
lifestyle. Specific drugs and their doses are also provided. Additionally, there is a
section on managing side effects. For patients with comorbid medical conditions, the
manual advises avoiding polypharmacy and to "begin low, go slow," meaning starting
with the lowest possible dose.
Follow-up Guidelines – The first follow-up (2 weeks) is used to assess side effects,
while subsequent follow-ups (4 weeks and onward) are used to evaluate the
effectiveness of the treatment.

IMPROVEMENT

NO YES

Is patient taking medicines How much improvement?

properly?

NO YES <50% >50%

Improve intake Refer Increase dose Continue same

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 Primary Care Psychiatry: A Clinician’s Companion

3) Prescription Modules
This contains the prescription for each disorder, including the medicines and the doses. It
also mentions counselling and follow-up guidelines.

When should a Neurology referral be made:

• Disorientation
• Seizures
• Urinary & Bowel incontinence
• Gait disturbances
• Focal neurologic deficits

Scan the QR code/ click on the topic to get more information on the method of using the
Clinical Schedules for Primary Care Psychiatry:

Clinical Schedules for Primary Care Psychiatry (CSP)

Chapter 2.3: Communication and Counselling Skills

Counselling involves a professional relationship that helps individuals, families, and groups
achieve mental health, wellness, education, and career goals. The aim of counselling is
empowering patients to find solutions and develop the skills to solve their problems.
Communication skills are at the core of counselling. The two essential elements of effective
communication skills are rapport and empathy.
Rapport is a harmonious and accordant relationship between the patient and the healthcare
provider, characterized by trust, empathy, and mutual responsiveness.
Empathy is the ability to share the psychological and emotional state of another person as if
you were able to sense their private world. It includes being non-judgemental and trying to
see the world from other’s perspectives. Understanding the patient's emotions, behaviour, and
thoughts and responding to them in a way that they feel like the doctor has comprehended
their issue is what empathy is all about in a clinical setting.
An empathetic person possesses certain qualities, such as:

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 Primary Care Psychiatry: A Clinician’s Companion

1. Open-mindedness: To comprehend other people's emotions, one must set aside one’s
own opinions, biases, and attitudes.
2. Imagination: Ability to picture the circumstances, ideas, and feelings of others.
3. Commitment: Striving to comprehend the feelings and thoughts of others.
4. Understanding and accepting of oneself: Empathy for others can be developed by
understanding one’s own beliefs and values.

Being sympathetic only addresses the patient's emotions and feelings, whereas empathy
enables the counsellor to comprehend the client's thoughts and point of view. The
differences between the two are elucidated below:

Aspect Empathy Sympathy

Emotional Establish a deep emotional connection with Acknowledges the patient's

Connection the patient by putting oneself in their shoes, emotions without necessarily
attempting to feel what they feel. experiencing them personally;
focuses on offering comfort and
support.

Focus Centers on the patient's experience, Centers on the doctor's feelings

emotions, and perspective, aiming to and desire to alleviate the patient's
validate their feelings and provide suffering may not fully grasp the
understanding. patient's experience.

Non-judgemental Maintaining a non-judgmental and non- It may unintentionally convey a

Attitude critical stance allows the patient to express sense of pity or condescension,
themselves freely without fear of judgment. which can be perceived as
judgmental.

Active Listening Actively listens to patients, validates their It tends to offer reassurance,
emotions, and responds with reflective sympathy, and solutions rather
statements or open-ended questions. than active listening and
understanding.

Communication Uses phrases like "I can see how you might Uses phrases like "I'm sorry you're
Style be feeling" or "I understand this must be going through this" or "I feel bad
difficult for you" to reflect the patient's for you" to express sympathy and
emotions. compassion.

Skills for communication include:

1. Active listening
2. Verbal and non-verbal communication
3. Attending
4. Responding
5. Paraphrasing and
6. Summarizing

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 Primary Care Psychiatry: A Clinician’s Companion

Active Listening
Active listening involves techniques to make the person being listened to feel heard and
understood. The four essential rules of active listening are:

1. To seek to understand before seeking to be understood

2. Be non-judgmental
3. Give undivided attention to the speaker
4. Use silence effectively
Differences between active and passive listening:

• When someone listens passively, they merely hear what the speaker says and do not
give any feedback.
• Receiving, interpreting, and responding to the speaker's message are all parts of
listening.

Components Active Listening Passive Listening

Receiving + +
Interpreting + -
Responding + -
Effective Communication + -

Verbal Communication
It includes:

• Speaking in a language that the client can understand

• Repeating the client's narrative in different words, clarifying the client's statements
• Effectively explaining, summarizing, and addressing the main message
• Using encouraging phrases
• Providing appropriate information for the client's age

Open-ended questions are essential for verbal communication, as they allow the client to
explain themselves in detail and understand their problems better. Examples of open-ended
questions include:
"How can I help you?" & "Tell me more about it,"

Open-ended questions are important because they encourage the person being questioned to
pause, consider, and reflect on their thoughts, feelings, and opinions. They also give the person
control of the conversation rather than the person asking the questions.

Nonverbal Communication
It includes all aspects of communication that are not represented through words, such as

• Facial expressions

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 Primary Care Psychiatry: A Clinician’s Companion

• Gestures
• The tone of voice and
• Body language.
It is essential to be aware of nonverbal communication and use it appropriately to build trust
and rapport with patients.
Nonverbal communication also includes silence, which can be a powerful tool in
communication. Silence can be used to allow emotional responses, express suppressed
emotions, and create a sense of comfort in the counselling session.
Responding

Responding and reflecting are also crucial for communication and should be used at the right
time, such as when the client raises a concern or is unsure about something that was said.
However, responding should be avoided when the client or counsellor is tired, stressed, or
anxious. Reflective feelings, reflecting meanings, and probing are different types of
responding and reflection.

• Reflective feelings involve reflecting the client’s feelings back to the client.
• Reflecting meanings involves clarifying the client's statements
• Probing involves asking for more details in a non-judgmental way
Paraphrasing

Paraphrasing is a way to demonstrate understanding and can be used to reinforce, clarify,

highlight, or double-check the information.
When to use it?

● When you have a hypothesis regarding the client's condition

● When there is a conflict in the client's decision-making
● When the client has given you a lot of information, and you are perplexed

There are four steps in effective paraphrasing:

● Listen and recall

● Determine the message's content
● Rephrase the client's key phrases and concepts
● Perception check is usually a brief question, e.g., “It sounds like...”; “Let me see if I
understand this.”

Summarizing
Summarizing is a way to make feelings more understandable, connect the client’s message
components, assess progress, and set the pace of a session.
Purpose of Summarizing
● To make feelings more understandable for the client and the helper/counsellor.

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 Primary Care Psychiatry: A Clinician’s Companion

● To connect several client message components.

● To assess the work that has been done thus far.
● To conclude a meeting by tying together the key points of the conversation.
● A session's conclusion.

Displaying Communication Skills- How to Show Empathy:

Skills Instruction Example

Active Listening Pay full attention to the person “I can see you’re feeling
speaking, maintain eye contact, and upset. Please take your
avoid interrupting. Show that you time and share what is
are genuinely interested in what bothering you.”
they have to say.

Non-verbal Use open body language, maintain a • Maintaining good

Communication warm and approachable demeanour, eye-to-eye contact
and employ appropriate facial during the
expressions and gestures to convey conversation
empathy. • Nodding frequent
• Offering a genuine
smile

Reflective Listening Repeat what the person said in your "It sounds like your
own words to show that you've workload has been
understood their feelings and overwhelming and is
thoughts. taking a toll on you,
right?"

Asking open-ended Encourage the person to share more "Tell me more about
questions about their experiences and what's been on your mind
emotions by asking questions that lately."
cannot be answered with a simple
"yes" or "no."

Cultural Sensitivity Be aware of cultural differences and "I want to make sure we
demonstrate respect for diverse respect your cultural
beliefs and practices. values. Can you tell me if
there are any specific
beliefs or preferences we
should consider in your
care?"

Shared Decision- Involve the person in decisions "Let's discuss your

Making related to their care or situation. treatment options

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 Primary Care Psychiatry: A Clinician’s Companion

Explain options, risks, and benefits together. Your input is

clearly. important in making the
right choice for you."

Emotional Support Offer comfort and reassurance, and "I'm here to offer
connect the person with additional emotional support.
support, such as counselling or Please don't hesitate to
support groups. reach out if you need
someone to talk to or
have questions."

Self-Care Ensure you take care of your well- • Taking regular

being to prevent burnout and breaks away from
maintain the capacity for empathy. work
• Having defined
working hours
• Seeking
psychosocial
support for oneself
where necessary

COURSE OF CLINICAL INTERVIEW

Open ended question

Using the effective communication

skills

Closed end questions

Summaziation and closing notes

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 Primary Care Psychiatry: A Clinician’s Companion

Behaviours to be Avoided in Counselling

In counselling, it is vital to avoid certain behaviours that can be unhelpful to the client.

• Advice-giving should be avoided if the problem has not been fully understood or the
patient is not ready to listen. However, in a crisis, advice can be used more liberally.
• Lecturing and preaching should also be avoided as they can create a power struggle
between the patient and the doctor.
• Excessive questioning should be avoided, and verbal interactions should include
statements, observations, encouragement and questions.
• Other non-helpful behaviours to avoid include being dismissive, blaming, interrupting,
storytelling, and yawning.
These behaviours can create communication barriers and can impede the effectiveness of the
counselling session.
Primary care doctors need to have good communication and counselling skills to help patients
with their mental health issues effectively. By understanding and utilizing empathy, rapport,
and various communication techniques, doctors can build trust and effective relationships with
their patients and empower them to find solutions and improve their mental health.

REFERENCES
1. Robertson, K. (2005). Active listening: more than just paying attention. Australian Family
Physician, 34(12). https://search.informit.org/doi/10.3316/informit.366629010280498
2. Wiseman, Theresa. (1996). A concept analysis of empathy. Journal of Advanced Nursing.
23. 1162 - 1167. 10.1046/j.1365-2648.1996.12213.x.
3. Hess, Ursula. (2016). Nonverbal Communication. Encyclopaedia of Mental Health.
10.1016/B978-0-12-397045-9.00218-4.
4. Weller SC, Vickers B, Bernard HR, Blackburn AM, Borgatti S, Gravlee CC, et al. (2018)
Open-ended interview questions and saturation. PLoS ONE 13(6): e0198606.

Scan the QR code/ click on the topic to watch a video on Communication skills:

Communication skills

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Primary Care Psychiatry: A Clinician’s Companion

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 Primary Care Psychiatry: A Clinician’s Companion

Chapter 3.1 Classification and Assessment of Depressive Disorders

Depressive disorders are a common and leading cause of disability worldwide. These
disorders are characterized by a persistently low mood, loss of interest in pleasurable
activities, easy fatiguability and other behavioural symptoms. These symptoms usually last
for at least two weeks to months. Depression is different from normal sadness which occurs
in day-to-day life, both qualitatively and quantitatively. Normal sadness is brief and short-
lasting whereas depression is long-lasting.

This chapter aims to provide primary care doctors with a basic understanding of the
assessment and classification of depressive disorders.

Diagnosing depressive disorders in the primary care settings:

Cardinal features of depression:

• Feeling sad/low for most of the time in a day and all settings (home, work/school/ in
social settings)
• Loss of interest or pleasure in most activities (particularly in previously enjoyable
activities)
• Tiredness most of the day in a week
• Irritability or restlessness
• Death wishes / Suicidal ideas
• Early morning awakening
• Changes in appetite and weight.

These symptoms must be present for most days for at least two weeks.
The following things must be kept in mind while assessing for depression:

• These symptoms must be pervasive for at least 2 weeks, i.e., they should be present
for most of the time. It should not be transient.

• Co-morbid chronic medical conditions must to be assessed while assessing for

depression.

Classification of Depressive Disorders:

Depressive disorders can be classified into several types, including:

• Single-episode depressive disorder

o Depressive episode occurring for the first time or one single episode of
depression in the person’s lifetime.
• Recurrent depressive disorder

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 Primary Care Psychiatry: A Clinician’s Companion

o This is characterized by a history of two or more depressive episodes separated

by at least several months without significant mood disturbance.
• Dysthymic disorder/Chronic low depression
o This is characterized by persistent low mood, lasting at least two years.

Epidemiology in the primary care settings:

"In primary healthcare settings in India, approximately 14 -20 out of every 100 people
experience depression, as revealed by a study."

Normal sadness can be easily mistaken for depression. However, the following points can
help to differentiate them:

Sadness Depression
Normal human emotion which is Abnormal emotional state
contextual/temporary
Often, the temporary response to a specific Often persists for weeks to months and is not
event/trigger solely linked to trigger
Usually, it doesn’t impair daily functioning. Significant decline in a person's ability to
function

Another condition which is commonly misdiagnosed as depression is grief. Grief is the normal
response to the loss of a loved one.

Grief Depression
It tends to come in waves Continuous sadness
Triggered by the reminders of their loss Not solely linked to a trigger
Mixed with moments of positivity Negative thoughts and emotions
Not significantly impact a person's self- Low self-esteem
esteem

When to Refer (Red Flag Signs):

• Recent suicide attempt
• Voicing out of suicidal thoughts, ideas or plans
• Severe agitation
• Risk of harm to others
• Unable to take care of themselves
• No response to treatment after 4 weeks
• Special population e.g., pregnancy, elderly, children

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 Primary Care Psychiatry: A Clinician’s Companion

Management and Follow-Up

After the initial assessment and diagnosis, primary care doctors should provide appropriate
treatment options and follow-up care.

Medication

Treatment Psychotherapy

Lifestyle Changes
Yoga
Meditation

Medications commonly used to treat depressive disorders include selective serotonin

reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), and
tricyclic antidepressants. In addition, primary care doctors should provide support and
education to the patient and their family and monitor their progress over time.
Take home points

1. Depressive disorders are widespread and lead to personal distress and social-
occupational issues.
2. Primary care physicians are crucial in detecting and addressing these disorders.
3. Treatment typically includes medication, psychotherapy, and lifestyle adjustments.
4. Consistent follow-up and progress monitoring are essential components of care.

References:
1. World Health Organization (2019). International Statistical Classification of Diseases and Related
Health Problems (11th ed.). https://icd.who.int/

2. National Mental Health Survey of India, 2015-16: Mental Health Systems. Bengaluru, National
Institute of Mental Health and Neuro Sciences, NIMHANS Publication No.130, 2016.

3. Shidhaye, R., Gangale, S. & Patel, V. Prevalence and treatment coverage for depression: a
population-based survey in Vidarbha, India. Soc Psychiatry Psychiatr Epidemiol 51, 993–1003
(2016). https://doi.org/10.1007/s00127-016-1220-9

Scan the QR code/ click on the topic to learn more about Depression.

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 Primary Care Psychiatry: A Clinician’s Companion

Chapter 3.2 Chronic Medical Conditions Associated with Depression

Depression is a common co-occurring disorder in patients with chronic medical conditions. It

can be challenging for primary care doctors to distinguish between symptoms caused by
chronic medical conditions and those caused by co-morbid depression. For example,
symptoms such as fatigue, anorexia, and weight loss can be mistaken for depression when
they are caused by a medical illness such as diabetes, hypertension, chronic kidney disease,
ischemic heart disease, cancer, arthritis, etc.
Furthermore, it is essential to note that depression and anxiety often occur alongside other
medical disorders and can worsen biological, social, and occupational functioning and
decrease adherence to prescribed treatments. They are also associated with adverse health
behaviours and can increase mortality.

How to diagnose?
Depressive Disorder due to another medical condition is diagnosed when:

• There is a clear episode of depression.

• A definite medical condition diagnosed by either symptoms/or investigations.
• There is significant distress and difficulties in functioning.

Aetiology
Depression can occur through two pathways: psychological and biological.
Medications used to treat several chronic medical conditions have also been reported to cause
depression.
The following are the commonly used medications at the primary care level that can cause
depression.

• Beta-Blockers
• Angiotensin Receptor Blockers
• Angiotensin-converting enzyme Inhibitors
• Calcium Channel Blockers
• Anti-Obesity Drugs
• Steroids

Prevalence of Depression in Primary Health Care Settings:

The prevalence of depressive disorder varies depending on the age of the patient,
stage/severity, and duration of the medical condition.

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 Primary Care Psychiatry: A Clinician’s Companion

Depressive symptoms are common in people with chronic medical illnesses, ranging from
15% to 50%, depending on the specific condition.

Medical condition Prevalence

Cancer patients 12-16%
Cardiovascular disease patients 3-48%
Diabetes 15-23%
Respiratory conditions 12-40%
Neurological disorders like stroke, 15-50%
Parkinson's, and Alzheimer's

Management
Assessment:

To screen for depression associated with a medical illness, primary care doctors can ask
patients these simple questions:
1) Have they been feeling down/depressed/hopeless in the past month?

2) Have they experienced little or no interest/pleasure in activities they previously enjoyed?

3) Are they getting tired easily?
If either answer is "yes," further questioning is necessary to meet the criteria for major
depression. If the answer is "no’ to all the three questions, the patient is unlikely to have
depression.
Treatment:

Educating the patient and family members about depression and its symptoms is the first step
in managing comorbid depression with chronic medical conditions. A primary care doctor
can spend a few minutes assessing the knowledge of caregivers about the illness, explaining
the condition, and assuring the patient and caregivers that they can relieve distress and
improve functionality with adequate compliance with pharmacological management. This
initial assurance or counselling can help patients and caregivers prepare for further
interventions.
Treatment of depression in medically ill patients should involve a combination of
pharmacological and counselling interventions. Antidepressant medication is effective in
treating depression in patients with medical illnesses. It is important to note that the dose and
duration of treatment may need to be adjusted for patients with comorbid medical conditions.

In addition to pharmacological factors, it is crucial to address any modifiable risk factors for
depression, such as lack of exercise, disturbed sleep, and lack of exposure to daylight. A
healthy lifestyle, including regular exercise and a balanced diet, can help improve mood and
overall health.

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 Primary Care Psychiatry: A Clinician’s Companion

Take home points

1. Depression often accompanies chronic medical conditions.
2. Primary care doctors are vital in identifying and managing such patients.

3. Treatment involves a mix of medication and therapy and addressing modifiable risk factors.
4. This comprehensive approach can enhance the quality of life of patients with chronic
medical conditions.

REFERENCES
1. Gold, Stefan M.; Köhler-Forsberg, Ole; Moss-Morris, Rona; Mehnert, Anja; Miranda, J.
Jaime; Bullinger, Monika; Steptoe, Andrew; Whooley, Mary A.; Otte, Christian
(2020). Comorbid depression in medical diseases. Nature Reviews Disease Primers, 6(1), 69–
. doi:10.1038/s41572-020-0200-2

2. Wang, J. et al. Prevalence of depression and depressive symptoms among outpatients: a

systematic review and meta-analysis. BMJ Open 7, e017173 (2017).

3. The American Psychiatric Association Publishing Textbook of Psychosomatic Medicine and

Consultation-Liaison Psychiatry, Third Edition, Edited by James L. Levenson, M.D. (2019)

Scan the QR code/ click on the topic to watch video on Medical Conditions Associated
with Depression:

Medical Conditions Associated with Depression

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 Primary Care Psychiatry: A Clinician’s Companion

Chapter 3.3 Antidepressants: Focus on Escitalopram, Fluoxetine, and Amitriptyline

Antidepressants are the first-line treatment for depression, especially in India. Despite several
effective options, less than one-fifth of affected individuals receive treatment. This chapter
discusses antidepressant medications for primary care doctors in the community, focusing on
escitalopram, fluoxetine, and amitriptyline, which are relatively safe and are easily available
at the primary care level.
Antidepressants:

Antidepressant drugs inhibit the reuptake of monoamines, restoring chemical balance and
treating depression. They are prescribed for several psychiatric and non-psychiatric
conditions, including major depressive disorder, generalized anxiety disorder, migraine,
tension headache and neuropathic pain. Selective serotonin reuptake inhibitors (SSRIs) are
the safest and most used antidepressants.
Prescribing Principles:

• The onset of therapeutic action is delayed, usually four weeks.

• The adequate trial is 6-8 weeks at a therapeutic dose.
• If there is no response, increase the dose or change the medication.
• Continue treatment until all symptoms are resolved.
• Do not stop the medication immediately after remission to prevent relapse.
• Continue medicine at least-
• One year for a single episode,
• Two years to lifelong for second and subsequent episodes

Individual Antidepressants
Escitalopram
Escitalopram is a selective serotonin reuptake inhibitor (SSRI) antidepressant medication.

• Use - It is commonly used in the treatment of major depressive disorder, obsessive-

compulsive disorder, and generalized anxiety disorder.
• Dose - The initial dose is 10mg/day and can be gradually increased to a maximum of
20mg/day for community settings by the general physician. It can be taken in the
morning or at bedtime.
• Formulation - Escitalopram is available in 5mg, 10mg, 15mg, and 20mg tablets.
• Side Effects - Escitalopram has the least chance of side effects and drug interactions
among all the selective serotonin reuptake inhibitors. Common side effects include
nausea, decreased appetite, and sexual dysfunction.
Fluoxetine
Fluoxetine is the longest-acting SSRI antidepressant medication.

• Use - It is approved for the treatment of Major Depressive Disorder, Obsessive

Compulsive Disorder.

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 Primary Care Psychiatry: A Clinician’s Companion

• Dose - It has a starting dose of 20mg/day and a maximum dose of 40mg/day for GP in
primary care settings. It is usually taken in the morning.
• The formulation is available in 10mg, 20mg, and 40mg capsules and tablets.
• Side Effects - Common side effects include nausea, decreased appetite, and sexual
dysfunction. It also has the highest chance of drug interactions among all selective
serotonin reuptake inhibitors.

Amitriptyline
Amitriptyline is a tricyclic antidepressant medication.

• Use - It is used to treat depression and chronic pain conditions such as neuropathic
pain, fibromyalgia, headache, and low back pain.
• Dose - The initial dose is 10mg/day and can be gradually increased to a maximum of
50mg/day for GP in primary care settings. It is usually taken in the night.
• The formulation is available in 10mg, 25mg, and 50mg tablets.
• Side Effects - It can cause side effects such as constipation, dry mouth, nausea,
sedation, and weight gain. Baseline ECG and body weight/BMI should be taken before
starting treatment and monitored regularly. It is to be avoided in the elderly and
patients with cardiac disorders and seizures.

Points to Convey While Counselling Patients before Starting Antidepressants

Depression is a real medical issue: Depression is a medical condition that affects mood
and emotions.
Antidepressants restore balance: Medication helps balance chemicals in the brain,
improving mood.
Benefits take time: It may take a few weeks to feel better, but the medication can reduce
symptoms and improve daily life.
Possible side effects: Some may experience mild side effects like nausea or drowsiness,
which usually go away quickly.
Regular follow-up is essential: Regular check-ins help monitor progress and make any
needed adjustments.
Don't stop abruptly: Avoid stopping the medication suddenly and talk to me if you want
to discontinue it.
Healthy coping strategies: Exercise, good sleep, and talking to loved ones can complement
the medication's effects.
Seek immediate help: If you have thoughts of self-harm or suicide, reach out for
emergency support.
These medicines don’t have addiction (habit-forming) properties.

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Take home points

1. Antidepressants are the main treatment for depression at the primary care level.

2. When prescribing antidepressants, it's important to consider factors like delayed onset of
therapeutic action, adequate trial duration, dose adjustments, and the duration of treatment
based on the episode type.

3. Common Antidepressants include

- Escitalopram: Used for major depressive disorder. Starts at 10mg/day with a maximum
of 20mg/day for GP in primary care settings.
- Fluoxetine: Effective for major depressive disorder. Begins at 20mg/day with a
maximum of 40mg/day for GP in primary care settings.
- Amitriptyline: Used for depression and chronic pain, starting at 10mg/day and going up
to a maximum of 50mg/day for GP in primary care settings. Requires monitoring,
especially in elderly patients and those with cardiac issues or seizures.

REFERENCES

1. Gururaj G, Varghese M, Benegal V, Rao GN, Pathak K, Singh LK, et al (2016). National Mental
Health Survey of India, 2015-16: Summary. Bengaluru, National Institute of Mental Health and
Neuro Sciences, NIMHANS.
2. Stahl SM. (2020). Prescriber’s guide: Stahl’s essential psychopharmacology. Cambridge
University Press.
3. Manjunatha, N, Kumar, C, Math SB, Thirthalli J. (2020) Clinical Schedules for Primary Care
Psychiatry (CSP), version 2.3 (COVID-19). Bengaluru, National Institute of Mental Health and
Neuro Sciences, NIMHANS.
4. Taylor DM, Barnes TR, Young AH. (2021). The Maudsley prescribing guidelines in psychiatry.
John Wiley & Sons.

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Definitions

• Suicide is a self-initiated, potentially injurious behaviour with the intent to die, leading
to the death of the individual (1). Many stakeholders are involved in managing suicide.
It is as equally a social concern as it is a medical concern.
• A suicide attempt is a self-initiated potentially injurious behaviour with the intent to
die having a non-fatal outcome.
• Deliberate self-harm is a self-initiated injurious behaviour without intent to die and
having a non-fatal outcome.

Burden of Suicide
In India, according to the 2021 NCRB data, the suicide rate has exhibited a steady rise over
the years, reaching 12 per lakh population in 2021, up from 9 per lakh population in 2017.
This increase amounts to an annual increment of 1 per lakh population. Globally, in 2021, the
World Health Organization (WHO) reports that more than 1 out of every 100 deaths can be
attributed to suicide,(6) and a significant 58% of all suicides occur before individuals reach the
age of 50. (4) Every day, there are 450 deaths by suicide; every 45 seconds, there is a death by
suicide. The NCRB data also highlights the alarming 70% rise in student suicides from 2011,
amounting to 36 suicides per day in India, most attributed to failure in examinations.
Assessment of Suicidal Risk

Recognizing warning signs for suicide is crucial, as it provides insights into the distress
someone might be experiencing. These signs are not always obvious and can be easily missed,
but they should never be ignored. It's essential to pay attention to these signs when they are
unusual or more severe than before. Here are some essential verbal and behavioural warning
signs:

• Talking about ending life: When someone expresses thoughts like, "Sometimes I feel
like I just want to die," it's a clear indication of their emotional pain.
• Talking about guilt or sin: It could reflect their internal struggles if someone discusses
feeling guilty or having committed a sin.
• Expressing hopelessness: If someone talks about having no reason to live or feeling
hopeless, it suggests they are grappling with despair.
• Feeling trapped or in pain: Expressions of feeling trapped or unbearable emotional or
physical pain can signal significant distress.
• Being a burden to others: If someone talks about being a burden to those around them,
it might indicate they perceive themselves as causing difficulties.
• Changes in substance use: Increased alcohol consumption or use of other substances
might signify an attempt to cope with emotional pain.
• Eating pattern changes: Significant shifts in eating habits, whether eating less or more
than usual, may be related to emotional difficulties.

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• Social isolation: Withdrawal from family and friends, especially if the person was
previously outgoing, could cause significant emotional turmoil.
• Extreme anger or revenge: Expressing intense rage or talking about seeking revenge
may signal inner turmoil and distress.
• Mood swings: Sudden and extreme mood swings, such as crying spells or
hyperactivity, might point to emotional instability.
• Preparatory behaviours: If someone starts giving away belongings or collecting
potentially harmful substances like medicines or pesticides, it may indicate they are
considering suicide.

Risk factors for suicide

S – Sex: 1 if male; 0 if female; (more females attempt, more males succeed)

A – Age: 1 if < 20 or > 44
D – Depression: 1 if depression is present

P – Previous attempt: 1 if present

E –Ethanol abuse: 1 if present
R – Rational thinking loss: 1 if present

S – Social Supports Lacking: 1 if present

O – Organized Plan: 1 If the plan is made and lethal

N – No Spouse: 1 if divorced, widowed, separated, or single

S – Sickness: 1 if chronic, debilitating, and severe
Guidelines for action with the SAD PERSONS scale at the primary care level (Refer to
Appendix III for SAD PERSONS Scale) (4)

Total points Proposed clinical action

0 to 2 Send home with follow-up

3 to 4 Close follow-up; Referral to high centre

5 to 6 Referral to high centre for hospitalization

7 to 10 Referral to high centre for hospitalization

Protective factors

◼ Person has a desire to get better

◼ Person is willing to get help

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◼ Strong sense of responsibility towards their family members (parents, children; spouse)

◼ Strong affection and bond with any or all family members

◼ Having good support from family, friends, and colleagues

◼ Ability to resolve problems and difficulties in relationships

◼ Previous positive and helpful experience from care-providing services

◼ Easy local availability of help providing hospitals

◼ Access to support from counsellors and doctors

◼ Cultural and religious beliefs that discourage suicide

Steps in managing suicide:

1. Approach and Initial Inquiry:

• Express concern and indicate care: Approach the person showing warning signs with
empathy and concern.
• Normalize the discussion: Begin with normalizing questions that discuss suicide as a
common mental health issue to create a comfortable environment.
• Encourage sharing: Use open-ended questions like "I've noticed..." or "You seem..."
to encourage the person to express their distress.
2. Risk and Protective Factors:

• Systematic inquiry: Ask about risk factors (e.g., mental illness, substance use, past
suicide attempts) and protective factors (e.g., family support, coping skills).
• Explore relationship and life stressors: Inquire about relationship problems, work
stress, financial issues, and recent life events that could contribute to distress.
• History of self-harm: Ask if they've engaged in self-harming behaviours in the past
and the outcomes of those situations.
3. Inquiring About Suicidal Thoughts:

• Passive and active thoughts: Ask about any thoughts of wanting to be dead (passive)
or actively planning to end one's life (active).
• Normalizing approach: Use phrases like "Sometimes when people feel disturbed..." to
make the discussion more comfortable.
• Frequency, duration, and intensity: Inquire about how often they have these thoughts,
how long they last, and the intensity of their feelings.
4. Suicidal Intent and Lethality:

• The intent behind the attempt: Understand the intentionality of their actions, whether
seeking attention, escape, or a serious desire to die.
• Lethality assessment: Assess the degree of harm resulting from the self-injury, the ease
of rescue, and the need for medical intervention.
5. Follow-Up and Support:

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• Establish a safety plan: Collaborate on a crisis plan, including strategies for coping,
confidante contact, and crisis helpline numbers.
• Encourage follow-up: Schedule regular visits or check-ins, involve family or support
systems, and ensure they have access to necessary resources.
6. Immediate Hospitalization:

• If the person is medically unstable, ensuring their physical well-being precedes the
assessment.
• Conduct a formal suicide evaluation when the person is conscious and responsive.
• Refer for higher centre for further management of psychiatric illness.

Immediate Intervention:

• Assessment: Thoroughly assess the person's risk factors, including dynamic

(fluctuating) and static (unchanging) factors.
• Active Listening: Listen attentively, validate concerns, and be non-judgmental to
encourage open expression of thoughts and feelings.
• Instilling Hope: Offer support, instil hope, and assure that problems can be resolved
with time. Provide practical help and referrals.
• Crisis Plan: Develop a personalized crisis plan, including distraction techniques,
physical activities, confidante contact, and helpline numbers.
• Safety Net: Reduce access to lethal means, identify a confidante, and assure
accessibility to healthcare professionals. Follow up to ensure safety.

Referral:

• Risk Assessment: Determine risk level (high, moderate, low) based on risk factors
• Crisis Plan: Formulate a crisis plan, including productive activities, confidante contact,
and professional help.
• Referral Process: Arrange referral to a mental health facility based on risk level.
Maintain communication, follow-up, and support after referral.

Take home points

1. Suicide is a social concern as well as a health concern
2. Attempting suicide/suicidal thoughts is a cry for help
3. Every individual who has either a suicide idea/ non-suicidal self-injurious (NSSI)
behaviour/suicide attempt must be treated equally and seriously
4. Every case of suicide attempt must be referred to a psychiatrist for detailed evaluation
5. Stigma remains one of the main barriers to treatment seeking, which must be broken by
increasing awareness
6. Social causes of every suicide must be managed during the treatment process with the help
of the social work department.

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REFERENCES

1. Silverman MM, Berman AL, Sanddal ND, O’Carroll PW, Joiner TE. Rebuilding the Tower of Babel:
A Revised Nomenclature for the Study of Suicide and Suicidal Behaviors Part 1: Background,
Rationale, and Methodology. Suicide Life Threat Behav. 2007 Jun;37(3):248–63.

2. adsi2021_Chapter-2-Suicides.pdf [Internet]. [cited 2022 Dec 27]. Available from:

https://ncrb.gov.in/sites/default/files/ADSI-2021/adsi2021_Chapter-2-Suicides.pdf

3. Van Orden KA, Witte TK, Cukrowicz KC, Braithwaite S, Selby EA, Joiner TE. The Interpersonal
Theory of Suicide. Psychol Rev. 2010 Apr;117(2):575–600.

4. Hockberger RS, Rothstein RJ. Assessment of suicide potential by non-psychiatrists using the sad
person score. J Emerg Med. 1988 Mar 1;6(2):99–107.

5. Reddi VSK, Muliyala KP, Manjunatha N, Kumar CN, Math SB, Gangadhar BN. Handbook on Suicide
Prevention. A Practical Guide for Primary Healthcare Workers. Bengaluru: NIMHANS, 2020

6. One in 100 deaths is by suicide, https://www.who.int/news/item/17-06-2021-one-in-100-deaths-is-by-

suicide (accessed 13 November 2023)

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 Primary Care Psychiatry: A Clinician’s Companion

Chapter 5.1 Anxiety Disorders

Anxiety is a feeling of unease and worry that is not clearly linked to a specific threat. It can
create tension and cause the body to react with autonomic symptoms like palpitations,
trembling, hyperventilation, etc. Anxiety is a general sense of concern, while fear is a response
to a known, specific danger. The patient usually presents with unusual symptoms and might
not be able to verbalize anxiety symptoms.
In some cases, anxiety is a normal and helpful response that helps people recognize potential
problems. However, when anxiety becomes too intense and persistent, it can disrupt daily life
and become a disorder. Anxiety disorders are characterized by excessive and irrational anxiety
that causes significant impairment. These conditions can last long and seriously impact a
person's quality of life.
EPIDEMIOLOGY
The NMHS India 2015-2016 found that about 2.57 out of every 100 adults had anxiety
disorders. Women aged 40-59 and those living in big cities were at a higher risk.
In another study, among adult patients at general healthcare clinics, about 5 out of every 100
had an anxiety disorder.

ETIOLOGY OF ANXIETY DISORDERS

Anxiety disorders are caused by the complex interplay of biological and environmental
factors. Biological factors include abnormal genes and dysregulation in the neurotransmitter
systems like epinephrine, nor-epinephrine, serotonin, dopamine, and GABA. Social factors
include difficult life experiences, being raised in a dysfunctional family, childhood trauma,
etc.
COMMON SIGNS AND SYMPTOMS OF ANXIETY DISORDERS
These symptoms are common to all anxiety disorders. However, their presentation may vary
according to the sub-type of the anxiety disorder. For example, in generalized anxiety
disorder, symptoms are present continuously, while in panic disorder, they may be present
episodically.
1)Physical Manifestations

• Motor Manifestations – Tremors, restlessness, twitching of muscles

• Autonomic Manifestations – Palpitations, sweating, flushes, dizziness, choking
sensation, dry mouth, constriction in the chest, diarrhoea, blurring of vision
2)Psychological Manifestations

• Cognitive Manifestations- poor concentration, distractibility, hyperarousal,

vigilance, negative thoughts
• Perceptual Manifestations – a sense of unreality of atmosphere
• Emotional Manifestations - vague sense of apprehension, fearfulness, inability to
relax, irritability, feeling like something bad will happen (feeling of impending doom)

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• Other Manifestations – insomnia(initial), increased sensitivity to noise, exaggerated

startle response

COMMON PRESENTING COMPLAINTS OF PATIENTS WITH ANXIETY

DISORDERS

Generalized Anxiety Disorder: headache, sleep disturbances

Panic Disorder: giddiness, sudden breathing difficulty/chest discomfort, fear of death
Agoraphobia: fear and avoidance of situations like going in a lift, crowded place, confined
places, etc
Social Anxiety Disorder: fear and avoidance of going to a gathering, speaking in a group,
stage presentation, etc
Phobia: fear and avoidance of blood, injections, lizards, spiders, etc
The signs and symptoms of anxiety described above are additional to the core and may be
encountered in any of the five anxiety disorders described above.

DIAGNOSTIC CRITERIA OF DIFFERENT ANXIETY DISORDERS

The core criteria of the subtypes of anxiety disorders are described below.

1. GENERALISED ANXIETY DISORDER(GAD)

An experience of excessive and uncontrollable anxiety/tension/worries/nervousness with
no apparent reason or for trivial reasons for many months (often for ˃ 6 months). In GAD,
the anxiety and excessive worries (preoccupation) are surrounding day-to-day activities &
mundane events. The characteristics of these anxiety/tension/worries/nervousness
are:

1. Generalized in nature, usually involving several aspects of life like family, health,
finances, or work. Worry may revolve around events like a family tragedy, ill health,
job loss, or accidents, even when there are no apparent signs of trouble.
2. Persistent (present throughout the day)
3. Free-floating anxiety (means anxiety does not have an obvious cause/without
pinpointing any source of worry/anxiety. Rather, the anxiety moves freely without
being connected to one cause/source of anxiety)
4. There is a chronic tendency to worry, and symptoms may last for months. The patient
may always feel on edge.

2. PANIC DISORDER
The characteristics of an attack of severe anxiety or fear (panic attack) are as follows:

1. Repetitive (more than one attack)

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2. Spontaneous (sudden onset without any reasons) and

3. Unpredictable

These panic attacks are usually associated with

• Sudden onset of palpitations, chest pain, difficulty breathing/choking sensations,

dizziness, dry mouth, and feelings of unreality.
• Secondary fear of dying, losing control or going mad.
• A fear of anticipation of another attack (‘anticipatory attack’) leading to avoidance of
certain situations where these attacks may have previously occurred.
• Abrupt beginning, reaching a peak in minutes, and resolution in 10-20 minutes.

However, a panic attack that is not spontaneous and predictable could be an anxiety attack
as a part of GAD/Depressive disorder but may not be panic disorder per se. It is essential to
rule out any organic conditions in such presentations.

3. AGORAPHOBIA
Agoraphobia is characterised by irrational and excessive fear of situations in which escape is
perceived as difficult, resulting in marked disturbance in daily functioning. These situations
may include fear of travel in public transportation, fear of open spaces, enclosed spaces,
crowded places, standing in line, or being alone. They may engage in safety behaviours to
avoid the above situations. E.g., not stepping outside the home on holidays as streets might be
more crowded, etc.

4. SOCIAL PHOBIA
It includes being irrationally afraid of others judging them or paying too much attention to
how they are seen in social causes a marked disturbance in daily functioning. This may include
situations like conversation or meeting with unfamiliar people, performing in front of others
like giving a speech, etc. They may engage in behaviours that may result in avoidance of the
above situations.

5. SPECIFIC PHOBIA
Irrational and excessive fear of a specific object or situation causes a marked disturbance in
daily functioning. This may include fear of flying, heights, animals, receiving an injection, or
seeing blood. They may engage in behaviours that may result in avoidance of the above
situations or objects.
Summary of Pathognomonic Features of Anxiety Disorders

The anxiety and excessive worries (preoccupation) around Generalized Anxiety

day-to-day activities & mundane events. Disorder
Abrupt onset, episodic anxiety with an impending sense of Panic Disorder
death

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Excessive anxiety about a situation from which easy escape is Agoraphobia

not available leads to avoidance
Excessive anxiety in a social situation leads to avoidance Social Anxiety Disorder
Irrational anxiety of Specific objects or situations with Phobia
avoidance

INVESTIGATIONS
For a patient with one or two episodes of panic attacks, ECG, blood sugar level and thyroid
function tests are advisable to rule out an organic cause. The investigations may not be
necessary for patients with a long-standing history consistent with the above-described
symptomatology.

COURSE OF ANXIETY DISORDERS

About one-third of patients will have complete resolution of symptoms, a third will have a
chronic illness, while another third will have a relapsing and remitting course of illness.

TREATMENT

The treatment for anxiety disorders includes both pharmacotherapy and

counselling. However, in the Indian scenario, pharmacotherapy is the first line of treatment
due to a lack of resources and limited expertise.

• PHARMACOTHERAPY
Selective Serotonin Reuptake Inhibitors (SSRIs) like Escitalopram and Fluoxetine are the
mainstay of treatment. Benzodiazepines are simultaneously added for immediate relief of
physical symptoms, as SSRIs may take up to 3-4 weeks for action. Benzodiazepines like
diazepam can be used for short-term (2-3 weeks). Benzodiazepines should not be used beyond
2-4 weeks as they have addiction potential.
For detailed guidelines on how to start and continue medicines, kindly refer to CSP v2.4 Page
number 4-7 (Appendix I)

• COUNSELLING
- Patients and relatives need to be educated that anxiety can have physical symptoms
like shortness of breath and chest pain.
- Educate about the medical nature of the illness. Specific information needs to be
provided in case of panic attacks that are not life-threatening.
- Educate that medication may only bring out improvement in part. Engagement in
activities/hobbies, engaging with friends, lifestyle changes like exercising, and a
healthy diet are important in accomplishing complete improvement.

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- Educate that treatment may last for a term of 9-12 months, and one-third of the patients
may have a relapsing and remitting course.
- Teach relaxation methods like breathing exercises and progressive muscular
relaxation.
- Educate about complete abstinence from any substance use as it may worsen anxiety.
- Yoga and meditation are also advisable in mild to moderate cases.

Take Home Points

1. Anxiety is a vague sense of unease and tension, while fear is a response to a known
external threat. Anxiety can be normal but becomes a disorder when it's excessive and
persistent.
2. The prevalence of anxiety disorders in the Indian adult population is around 2.57 out
of every 100 people. Risk factors include gender, age group (40–59), and urban living.
3. Anxiety disorders result from a complex interplay of biological and environmental
factors.
4. Treatment: Escitalopram/Fluoxetine + Diazepam + Counselling
5. Probable duration of Treatment: Escitalopram/Fluoxetine for 9 -12 months,
Diazepam for initial 2-4 weeks

REFERENCES
1. Nirisha PL, Jayasankar P, Manjunatha N, Kumar CN, Math SB, Thirthalli J. DESCRIPTIVE
ANALYSIS OF PSYCHIATRIC DISORDERS FROM RURAL PRIMARY HEALTH
CENTRES: A CLINICAL EPIDEMIOLOGICAL STUDY. Indian Journal of Psychiatry.
2022 Mar;64(Suppl 3):S531.
2. A Short Text Book Of Psychiatry by Dr. Niraj Ahuja, 7 th Edition
3. Khambaty, M., & Parikh, R. M. (2017). Cultural aspects of anxiety disorders in
India. Dialogues in Clinical Neuroscience, 19(2), 117-
126. https://doi.org/10.31887/DCNS.2017.19.2/rparikh

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 Primary Care Psychiatry: A Clinician’s Companion

Chapter 5.2 Somatization Disorder

Somatization Disorder is often found in lower socio-economic groups, especially in remote

and rural areas. It is characterised by multiple unexplained physical (somatic) symptoms,
significantly affecting patients' day-to-day activities. Somatisation is also associated with lost
workdays, especially for daily wage workers, and unnecessary expensive medical tests.
Raising awareness about this disorder across healthcare levels can help reduce its economic
impact on patients and the healthcare system.

EPIDEMIOLOGY

In primary healthcare settings in India, the prevalence of somatization disorder is 13.5%, and
key risk factors include being female, having lower education, and having lower
socioeconomic status.

ETIOLOGY

People with this disorder often have a low tolerance for physical discomfort. They can
unintentionally exaggerate physical sensations, even turning mild discomfort into pain. These
physical/somatic symptoms worsen during stressful life situations.

SIGNS AND SYMPTOMS OF SOMATISATION DISORDER

These patients present with various physical complaints without a physical explanation, as
evidenced by a detailed physical examination. The signs and symptoms often do not have any
neurological basis or easily identifiable medical cause.

These symptoms may be single, multiple, or variable physical symptoms that often change.
The focus is on bodily symptoms and expecting relief from them. They may interpret the
bodily symptoms as disproportionately life-threatening. Persistent attribution to medical
illness despite medical reassurance is noted.

The following list includes the most common symptoms

• Pain symptoms at multiple sites (such as abdomen, back, chest, dysmenorrhea,

dysuria, extremities, head, joint, and rectal) are often present.
• Gastrointestinal sensations (pain, belching, regurgitation, vomiting, nausea, etc.).
• Abnormal skin sensations (itching, burning, tingling, altered temperature sensations,
numbness, soreness, blotchiness etc.)
• Persistent unexplained pain at one site e.g. persistent headache

These are often expressed dramatically with gestures and may be accompanied by multiple
help-seeking behaviours. The expression usually has terms and phrases from the local
language that are a culturally acceptable, for instance, “gas is getting into the head.”, “electric

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sensations throughout the body”, “complete twisting of the body”, “feeling of

tingling/numbness”(which does not follow the nerve distribution pattern).

For a definite diagnosis of somatization disorder

• Symptoms of the illness explained above present for at least 6 months
• Doctor shopping - The patient often repeatedly visits the same doctor or several
doctors and may request multiple investigations like MRI and CT scans or may be
persistent for some form of treatment like “saline drip.” There may be requests for
ECG, often confusing shortness of breath and retrosternal heartburn for heart attack.
• There will be some degree of social and family dysfunction. The symptoms usually
worsen during stress.

DO NOT MAKE DIAGNOSIS OF SOMATISATION DISORDER AFTER THE AGE OF

40 YEARS (usual onset is in the 2nd and 3rd decade)

INVESTIGATIONS

No mandatory investigation is advised. The goal is to check for other medical issues that might
be causing the symptoms, as somatization disorder often involves many unclear symptoms.
Medical disorders which present with multiple vague symptoms, like hypothyroidism,
infections, diabetes, hypertension and carcinomas, must be ruled out. Baseline blood
investigations like complete blood count, liver function test, renal function test, and CRP may
be ordered for new patients. The investigations may not be necessary for patients with a long-
standing history consistent with the above-described symptomatology.

COURSE AND PROGNOSIS

About one-third of patients will have a complete resolution of symptoms, a third will have a
chronic illness, and another third will have an episodic course of illness. Somatization
disorders are often chronic and difficult to treat, having a significant impact on the quality of
life of an individual.

TREATMENT

The treatment for Somatization Disorder includes both pharmacotherapy and counselling.

➢ PHARMACOTHERAPY

Tricyclic Antidepressants (TCAs) are the mainstay of treatment. Low-dose TCAs

Amitriptyline (starting dose 12.5mg to maximum dose 50mg for GP) are preferred for
somatization disorder. However, the side effects of TCAs should be monitored, especially
with comorbid medical illnesses and in old patients.

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For detailed guidelines of management for somatization, please refer to CSP v2.4, page
number 2-9.
➢ COUNSELLING

• Validate the presence of an illness. Convey the message that he/she has an illness, but
not life-threatening. Never convey he/she has no illness.
• Patients may not accept medications if their symptoms are labelled to be
psychological. Try to steer the conversation from “purely mental” or “purely physical”
to “mental as well as physical.”
• Listen, validate, and empathize. Avoid repeated reassurance.
• Educate about the nature of the illness. Symptom exacerbation after a fight can be
explained. Frequent follow-up for brief counselling of about 10-20 minutes to discuss
life situations may alleviate symptoms to a significant extent.
• Educate that treatment may last for a longer period (2 years), and one-third of the
patients may have a relapsing and remitting course.
• Try to shift focus from physical symptoms to other areas of functioning like work,
other leisurely activities, and sleep. Educate that medication may bring out 50-60%
improvement. Rest improvement is dependent on mood-enhancing activities.
• Engagement in mood-elevating activities of their personal choice contributes to
accomplishing complete improvement. Advise to include healthy lifestyle activities
like walking, exercising, playing, and other entertaining activities. Teach about
prioritizing when overwhelmed with multiple chores and timelines.
• Identification and treatment of other comorbid medical conditions go hand in hand.
• Yoga and meditation are helpful.

WHEN TO REFER:

• No improvement with Amitriptyline 50 mg after 1 month of treatment

• They are persistently requesting for investigations.
• Change in the clinical picture from the initial presentation
• The onset of symptoms after 40 years of age

Take Away Points

- Somatization disorder primarily impacts women, particularly those from lower

socioeconomic backgrounds, and imposes a significant financial burden on affected
individuals.
- It often co-occurs with conditions such as depression, anxiety, and substance use, which
should be considered in treatment.
- In India, Tricyclic Antidepressants (TCAIs) are the primary treatment. Treatment
typically involves a combination of pharmacotherapy and counselling for effective
management.

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REFERENCES

1. Chander KR, Manjunatha N, Binukumar B, Kumar CN, Math SB, Reddy YJ. The prevalence
and its correlates of somatization disorder at a quaternary mental health center. Asian journal
of psychiatry. 2019 Apr 1;42:24-7.

2. Nirisha PL, Jayasankar P, Manjunatha N, Kumar CN, Math SB, Thirthalli J. DESCRIPTIVE
ANALYSIS OF PSYCHIATRIC DISORDERS FROM RURAL PRIMARY HEALTH
CENTRES: A CLINICAL EPIDEMIOLOGICAL STUDY. Indian Journal of Psychiatry.
2022 Mar;64(Suppl 3):S531.

3. A Short Text Book Of Psychiatry by Dr. Niraj Ahuja, 7 th Edition

Scan the QR code or click on the topic below to learn more about Somatization:

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 Primary Care Psychiatry: A Clinician’s Companion

Chapter 5.3: Obsessive-compulsive Disorder and its treatment

Introduction:

Obsessive-Compulsive Disorder (OCD) is a chronic and distressing mental health condition

characterized by unwanted and recurring thoughts (obsessions) that lead to repetitive
behaviours or mental acts (compulsions), which are aimed at alleviating the distress caused
by these thoughts.

Epidemiology in the General Population:

OCD is a highly prevalent mental disorder worldwide. According to the National Mental
Health Survey 2016, the prevalence of OCD in India is approximately 0.8%. Interestingly,
studies in primary care settings in India have indicated lower prevalence rates compared to
Western studies.

OCD in Primary Health Care (PHC) Population:

In primary care settings, identifying OCD can be challenging due to patients' limited ability
to express their obsessions and compulsions. However, initial assessment is crucial in
recognizing potential cases. The following mnemonic can aid in evaluating obsessive thoughts
and behaviours:

D Disturbing, Distressing
thoughts/behaviours
O Own thoughts/behaviours
Repetitive, Intrusive, Distressing
I Intrusive thoughts
R Repetitive thoughts/behaviours
S Senseless thoughts/behaviours

When suspecting OCD, primary care assessment can start with broad questions:

• Do certain thoughts or images repeatedly intrude your mind despite efforts to suppress
them?
• How do you attempt to counter these thoughts?
• Do you feel compelled to perform certain actions repeatedly, even if you don't want
to?
• Do these actions seem reasonable or excessive to you?

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Clinical Features and Common Presentations of OCD:

OCD is characterized by distressing obsessions and compulsions that significantly interfere
with daily functioning. Some common obsessions and their corresponding compulsions
include:

DIMENSIONS OBSESSION COMPULSION

CONTAMINATION Concerns about dirt, germs Washing, Cleaning

PATHOLOGICAL DOUBT Concerns about uncertainty Checking, Repeating

HARM RELATED Concerns about harm Checking

UNACCEPTABILITY Intrusive, aggressive, sexual Praying, Mental rituals

or religious thoughts

Comorbid Conditions and Suicidality:

OCD frequently co-occurs with other mental disorders like depression, dysthymia, and
anxiety disorders. Suicidality can affect nearly 40% of individuals with OCD, emphasizing
the importance of thorough evaluation.
Management:

Pharmacological Treatment:
Selective Serotonin Reuptake Inhibitors (SSRIs) are the first-line pharmacological treatment
for OCD.

Higher doses of SSRIs are required for OCD compared to depression. Referral to a psychiatrist
is recommended for management.
At the primary care level, initiating SSRIs at a lower dose and referring to a specialist after
failure of 4 weeks trial.
Maximum Doses of SSRIs for OCD at the primary health care level:
Fluoxetine: 20 mg (minimum) – 40 mg (maximum for GP)

Escitalopram: 10 mg (minimum) – 20 mg (maximum for GP)

Non-Pharmacological Treatment:
Psychoeducation is vital, conveying that OCD is treatable and requires long-term medication
and psychotherapy.
Cognitive Behavioural Therapy (CBT) is the most effective psychotherapy for OCD,
significantly reducing symptoms in both adults and children.

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Primary care physicians should refer suspected OCD cases to mental health professionals for
comprehensive evaluation and treatment.
Take Away Points

- Obsessive-Compulsive Disorder (OCD) is a chronic mental health condition

characterized by distressing obsessive thoughts and corresponding compulsive
behaviours.
- OCD is treated with a combination of pharmacological and non-pharmacological
approaches. Selective Serotonin Reuptake Inhibitors (SSRIs) are the primary
medications, and cognitive-behavioural therapy (CBT) is effective for psychotherapy.
- Medicines might be required for a longer duration (2 or more years)
- Suspected cases of OCD should be referred to mental health professionals for
comprehensive evaluation and treatment, given the complexity of the disorder.

REFERENCES

1. Fernández de la Cruz L, Rydell M, Runeson B, D'Onofrio BM, Brander G, Rück C,

Lichtenstein P, Larsson H, Mataix-Cols D. Suicide in obsessive-compulsive disorder: a
population-based study of 36 788 Swedish patients. Mol Psychiatry. 2017 Nov;22(11):1626-
1632. Doi 10.1038/mp.2016.115. Epub 2016 Jul 19. PMID: 27431293; PMCID:
PMC5658663.
2. Veldhuis, J., Dieleman, J. P., Wohlfarth, T., Storosum, J. G., van Den Brink, W.,
Sturkenboom, M. C. J. M., & Denys, D. (2011). Incidence and prevalence of “diagnosed
OCD” in a primary care, treatment seeking population. International Journal of Psychiatry in
Clinical Practice, 16(2), 85–92. doi:10.3109/13651501.2011.617454
3. Reddy YC, Rao NP, Khanna S. An overview of Indian research in obsessive-compulsive
disorder. Indian J Psychiatry. 2010 Jan;52(Suppl 1): S200-9. Doi 10.4103/0019-5545.69233.
PMID: 21836679; PMCID: PMC3146215.
4. Recognizing and managing OCD in primary care, bpacnz, July 2022. Available

Click on the topic or Scan the QR code below or to learn more about OCD:

Obsessive Compulsive Disorder

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 Primary Care Psychiatry: A Clinician’s Companion

Chapter 5.4: Low Intensity Psychological Interventions(LIPI)

Introduction

Low-Intensity Psychological Interventions (LIPI) are simplified, evidence-based treatments

that non-specialists in primary care can give. They are termed ‘Low intensity’ as they require
less training, resources, and time as compared to traditional psychological interventions.

Due to the high rate of mental illness in the community, as evidenced by the 2016 NMHS
survey (which found a prevalence of 10.6% in India) and a shortage of mental health
professionals, LIPI interventions are necessary. Additionally, primary care doctors have
limited time, so LIPI, which is short-term, is ideal.
LIPI can be provided in various forms, such as brief individual therapies (not lasting more
than six sessions), brief group therapies (involving family members), and providing the patient
with self-help material or links to internet resources. However, in this module, we will
describe brief individual therapies.

Many studies prove that low-intensity psychological interventions work well for various
mental health problems in different places. The World Health Organization (WHO) has also
recognized the effectiveness of these interventions and has developed a manual on low-
intensity psychological interventions for common mental health disorders.

Ideal Candidates for LIPI – (MSD)

1) Mild to Moderate intensity of symptoms

2) Specific clinical problems (for example, anger outbursts, stress, sleep disturbances)

3) Depression and anxiety, which are highly prevalent

Contraindications for LIPI -

1. Children & Adolescents (<16 years) and elderly patients (>65 years)
2. Past history of suicidal attempts, recent self-harm attempt, or suicidal attempt
3. Forensic or criminal involvement
4. Patients who are recently unemployed, have had recent major relationship loss, and
are expressing significant hopelessness.
5. Patients who have severe intensity symptoms of mental illness.

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Steps in Administering LIPI

Before beginning to administer LIPI, it is essential to remember ABC –
• Active Participation from the patient is a prerequisite for any psychological
intervention.
• Building rapport which means creating an environment where a patient feels
informed and in control of his/her treatment, is crucial for the patient to participate
fully.
• Choosing an appropriate problem & patient, as has been described above.

If all these requirements are met, the LIPI can be initiated in the following way -
1) Explain the purpose & structure of the LIPI ( 1-2 sessions)

At the start, the patient should be given clear information about each step of the LIPI, they
need to be informed about the time-limited nature of the intervention, and most importantly,
they need to be informed of the need for active participation.

The patient must also be given general counselling. They must be told in clear, understandable
terms about the nature of the illness, the treatment options, and the long-term prognosis.
Lifestyle modifications such as a healthy diet, regular exercise, and maintaining a routine must
be explained. The patient and the family’s emotions and distress should be enquired about &
given positive validation.

2) Assessment (1-2 sessions)

This is one of the most important steps. It is the process by which the doctor can understand
the patient’s current problems, decide the modality of treatment, link problems with the goals
of the patient, and make a structured treatment plan.

Assessment can be done using the 5 ‘W’s approach –

What – What occurs during the problem? What improves or worsens it?
Who – Who specifically causes the problem? Who improves or worsens the problem?
Where – Where does the problem happen? Where does it not happen?

Why – Why does the patient think the problem occurs? (i.e., their understanding)
When – When is the problem most likely to happen? When is the problem least likely to
happen?

Also, it should be made sure in the assessment to include OPD -

Onset– How did it start? What triggers the problem each time?
Progress – Has it increased in intensity? Is it causing problems in the daily life of the patient?

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Duration – How long has it been happening? Once starting, how long does the problem last?
Always make sure to assess for suicidal risk. In case it is present, refer to a psychiatrist
at the earliest.

At the end of the assessment, the doctor can give his formulation, i.e., his conceptualization
of the problems, to the patient. This will not only help the patient better understand their illness
but also serve as a glimmer of hope that their problems can be solved.

3) Psychological Tools & Techniques (3 sessions)

Based on the assessment, the psychological tools and techniques to be used for each patient
can be individualized and initiated.
The following table is a brief summary of some commonly used techniques –

Life style modifications

Technique Method

Stress • Yoga
Management • Breathing retraining techniques (Deep Breathing techniques) to
Techniques reduce hyperventilation
• Muscle Relaxation techniques – Ask the patient to focus on
sequentially tensing and relaxing muscles of each part of the
body
Sleep Hygiene • These are techniques to improve sleep in patients with
insomnia. This works on the principle of promoting behavioural
& environmental changes which increase sleep and reduce
factors in the environment that decrease sleep.
• The basic principles are
o Ask the patient to keep a regular sleep schedule of going
to bed and waking up
o Patients should have a relaxing bedtime routine – They
should turn off the television and mobile phone during
bedtime. They should only use the bed for sleeping.
They can take warm baths before bedtime.
o The patient’s bedroom should be dark, cool, and with
less noise
o The patient should avoid any daytime napping
o Patients should not have big meals at night-time. They
should avoid caffeine/alcohol after the evening.
o The patient can use deep breathing or muscle relaxation
techniques at night while lying on the bed.
Problem- • This consists of teaching patients some skills to effectively
Solving solve problems rather than worrying about adverse outcomes.
Techniques

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• It teaches patients flexible ways of thinking, which consist of

generating many solutions to the problem and evaluating each
solution's positives and negatives.
• A patient can be asked to
o Identify a problem in detail; it’s maintaining factors and
goals
o List all possible solutions
o Evaluate the advantages & disadvantages of the top 5
solutions
o Decide on a solution write down what steps they will
take, and fix a timeline to implement each step
o Implement the solution
o Judge the effectiveness and then decide whether a new
plan might be needed to address the problem better
Anger • These are techniques by which patients can learn to control or
Management reduce the intensity of their anger. These consist of
• Reverse Counting from 20 before saying anything
• Deep breathing exercises
• Punching pillows in their bedroom – taking out anger on
non-living things
• Taking a 5-10-minute walk before responding
• Mentally challenging oneself before responding – ‘What is
the source of anger? What is the degree of my anger? What
is the other person’s role in the situation? How would I want
to be treated if the other person felt like me?’
• Leave the situation where they are being provoked
• Write out a response in their diary before saying it orally

4) Termination of LIPI (1 session)

The last session consists of –

• Summarizing all the previous sessions

• Revising goals
• Making the patient aware of what they have achieved till now and how they can
achieve much further in the time to come
• Addressing any anxiety, fear, or sadness, the patient may feel on terminating sessions.

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REFERENCES
1)A Clinician’s Guide to Low-Intensity Psychological Interventions (LIPIs) for Anxiety and
Depression [Internet]. WAPHA. [cited 2022 Dec 1]. Available from:
https://www.wapha.org.au/about-us/our-priorities/mental-health/lipimanual/

2) Thinking Healthy [Internet]. [cited 2022 Dec 1]. Available from:

https://www.who.int/publications-detail-redirect/WHO-MSD-MER-15.1

Click on the topic or Scan the QR code below or to learn more about LIPI:

LIPI

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Chapter 5.5: Brief intervention for substance use

Brief intervention (BI) is a short, focused counselling approach to reduce harm from substance
use disorders, like alcohol and tobacco, in a busy practice. It's based on motivational
interviewing (MI), which is the idea that behavior change is a process that needs motivation.
BI is patient-centered and can be done in primary or community care.

BI is mainly for people with hazardous, harmful, or mild to moderate substance use. For those
with severe dependence, it is better to refer the patient to a mental health professional.
Evidence shows BI decreases drinking days, heavy drinking, average amount of alcohol used
and hospital visits.
To do BI, screen the person for substance use (type and quantity of alcohol used), understand
their motivation, and identify their needs. Create a personalized plan using the FRAMES
technique, and be non-judgmental and supportive.
Kindly remember relapse is the norm in substance use. Prepare yourself, the patient and your
family for relapse and to start treatment again as soon as there is a lapse.

Stages of change by Prochaska and DiClemente (1983):

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The models of brief intervention for alcohol and tobacco use are FRAMES and 5 As,
respectively.

FRAMES:

Components Definitions Examples

F Feedback Personalized and meaningful “You’ve scored 16 on the screening
feedback on the pattern of use, test, which indicates that you are at
existing or potentially harmful high risk of harm from drinking.”
effects, and, when available,
laboratory parameters. “Your liver functions are deranged
greatly, and quite possibly, it is due
to excessive alcohol intake.”

R Responsibility Emphasis on the need for “What you do with the information
change in substance use being I give is up to you.”
the individual's personal “How concerned are you about
responsibility. your LFT reports.”

A Advice Professional opinion, clear and “Considering your family history of

precise with no beating around addiction, you should moderate
the bush. your drinking behaviour.”

“Best way to reduce the risk of

liver disease is to stop alcohol
completely.”

M Menu of Various treatment options Keeping a diary of use

options available, the pros and cons of Activity Scheduling
each, and the best suited for the Drinking with Food
individual Identifying high-risk situation
Attending Counseling
Info on Treatment Centres

E Empathy Understanding and “You have tried stopping multiple

acknowledging the person's times before, it must be important
feelings and experiences. to you.”

“I know this process can be

confusing. Let's see if we can solve
this together.”

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S Self-efficacy Helping the person to believe in “I appreciate that you agreed to

their ability to change their come for the next session to work
substance use. on this. You are very courageous to
manage these stressors.”
5 As:
Ask: screening for tobacco use.
Advise: provide specific, personalized advice to quit.
Assess: assessing the person's willingness to make
Assist: provide support and assistance with pharmaceutical or non-pharmaceutical
interventions such as Nicotine Replacement Therapy (NRT) or behavioural therapy.
Arrange: scheduling follow-up appointments or referrals to specialized treatment services if
needed.

Take away points

1. Brief Intervention (BI) is a short, patient-centered counseling approach used in
primary or community care to reduce harm from substance use disorders, like alcohol
and tobacco.
2. It's important to recognize that relapse is a common occurrence in substance use. Be
proactive in readiness—both yourself and the patient, along with their family,
acknowledging the possibility of relapse and the need to promptly resume treatment
in the event of a lapse.
3. BI is most effective for people with hazardous, harmful, or mild to moderate substance
use. Severe cases may require referral to a specialist.
4. Evidence supports that BI can reduce drinking days, heavy drinking, average alcohol
consumption, and hospital visits.
5. When conducting BI, screen for substance use, understand motivation, and tailor the
intervention using the FRAMES technique or the 5 As model, depending on the
substance, all while being empathetic and supportive.

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REFERENCES
1. National Drug Dependence Treatment Centre [Internet]. Google My Maps [cited 2022 Nov
24]; Available from:
https://www.google.com/maps/d/viewer?mid=1VvJZVcy9uc2XyidRQrGh6V80u8A
2. Edwards G, Orford J, Egert S, Guthrie S, Hawker A, Hensman C, et al. Alcoholism: a
controlled trial of “treatment” and “advice.” J Stud Alcohol 1977;38(5):1004–31.
3. Miller WR, Sanchez VC. Motivating young adults for treatment and lifestyle change. In:
Alcohol use and misuse by young adults. Notre Dame, IN, US: University of Notre Dame Press;
1994. page 55–81.
4. Screening, Brief Intervention, and Referral to Treatment (SBIRT) [Internet]. [cited 2022
Nov 24]; Available from: https://www.samhsa.gov/sbirt
5. Prochaska JO, DiClemente CC. Stages and processes of self-change of smoking: toward an
integrative model of change. J Consult Clin Psychol 1983;51(3):390–5.
6. Five Major Steps to Intervention (The “5 A’s”) [Internet]. [cited 2022 Nov 24]; Available
from: https://www.ahrq.gov/prevention/guidelines/tobacco/5steps.html

Click on the topic or scan QR code below to watch a video on Brief intervention:

Brief intervention

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Chapter 6.1 Diagnosis of Alcohol and Tobacco Use Disorder

Alcohol and Tobacco use is highly prevalent in the Indian population, and this has a big impact
on health and quality of life. Habit-forming substances are drugs or medications which, on
using over a period of time, can cause the person to become addicted. That is, the person
continues to use it despite its harmful consequences to his health and his functioning (studies,
job), and to his family relationships.

Epidemiology for substance use disorders:

Around 15% of people aged 10 to 75 drink alcohol in India, which means approximately 16
crore individuals. Among them, men are much more likely to drink (about 27.3%) compared
to women (1.6%). Out of the 16 crore drinkers, around 5.7 crore face problems due to alcohol,
and about 2.9 crore are dependent on it, according to the National Survey on Magnitude of
Substance Use in India (2019).

Risk Factors for Substance Use Disorder:

Both genetic and environmental factors play a role in the development of substance use
disorder. Substance use disorder is often influenced by factors like family, school, community,
economic and peers.

Diagnosing Substance Use Disorders:

There are specific criteria, mentioned in diagnostic books like ICD 11, that need to be fulfilled
to diagnose dependence or opine that a person is addicted to a habit-forming substance(s).
This includes a pattern of recurrent episodic or continuous substance use with where the
person has trouble controlling their use which is shown by 2 or more of following -
● Loss of control over substance use: Taking larger quantities of substances or for a
longer duration than what was initially planned.
● Salience: They start to prioritize drinking alcohol more than anything else in their life,
like taking care of their health or doing daily tasks, and they keep drinking even when
it causes health problems or negative consequences.
● Craving: A strong irresistible desire to take the substance.
● Physiological features which suggest brain adaptation -
1. Tolerance: The need to take more amount of the substance to experience
pleasure (Commonly described as ‘high’ or ‘Kick’), which was previously
possible with lower doses.

2. Withdrawal symptoms: When not taking or consuming the substance, the

person starts developing physical symptoms (ex: in alcohol, they can develop
tremors, sweating, worry, and sleep disturbances) or psychological symptoms
(feeling restless). Other withdrawal symptoms could be severe such as seizures
(commonly known as Fits) and confusion (not being able to identify time, place,
person, or memory problems). If such scenarios occur, please refer them to a
hospital immediately.

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3. Repeated use of substance to prevent withdrawal symptoms

The diagnosis may be made if use is continuous (daily or almost daily) for at least 3 months.
ALCOHOL:

✔ Alcohol is one of the commonly used and licit psychoactive substances.

✔ The prevalence of Alcohol Dependence Syndrome is 3.3% at the primary health care
level.(3)
✔ The acute and chronic effects of alcohol consumption on a person’s health depend on
two factors-
o (1) The amount of alcohol consumed and
o (2) The drinking pattern

✔ There are various patterns of alcohol consumption. These include:

● Social drinking: Occasionally drinking when it is socially appropriate. This

pattern of drinking does not usually cause any adverse consequences.
● Problem drinking: This pattern of drinking involves drinking alcohol in excessive
quantities, and having occasional problems but no physical symptoms of
dependence.
● Harmful drinking: This pattern of drinking leads to negative physical, mental,
and/or social effects.
● Alcohol dependence: In this pattern of alcohol consumption, there are
physiological, psychological, and behavioural changes that result in the person
giving excessive importance and priority to alcohol consumption as compared to
other essential activities in his life.

Alcohol consumption in a harmful or dependent pattern is associated with multiple

physical, mental, and social problems.

Withdrawal symptoms in Alcohol

● These are symptoms that are seen in a dependent person when the amount of alcohol
consumption is less than the usual amount or is completely stopped, abruptly.
● These symptoms are usually seen 6-8 hours after the last intake of alcohol.
● Some patients with severe dependence start consuming alcohol early in the morning
as an ‘eye opener’ in order to avoid withdrawal symptoms
● The common withdrawal symptoms that are seen in alcohol dependence are sleep
disturbance, restlessness, irritability, tremors, increased heart rate, increased blood
pressure, sweating, etc.
● In severe cases, people with alcohol withdrawal may experience hallucinations
(hearing voices or seeing things without the presence of any actual stimulus),
disorientation (the person becomes confused and unaware of his surroundings), or
seizures (fits).

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● ‘Delirium tremens’ – This is a serious and life-threatening complication of alcohol

withdrawal. It is characterised by sudden onset of disorientation and tremors. This is
a medical emergency and the patient should be immediately referred

Severe withdrawal symptoms(especially delirium tremens) could be potentially life-

threatening. All cases of complicated withdrawal should be immediately referred to a doctor
(preferably a secondary or tertiary care hospital)

Red Flag Signs of Alcohol use:

• Daily consumption of alcohol
• Consistently increasing use of alcohol
• Complications after stopping alcohol use
• Harm to others or self after drinking
• Difficulty in walking, memory difficulties, visual difficulties due to alcohol
use (Wernicke-Korsakoff syndrome)

TOBACCO

Tobacco is another commonly used substance that is legal to use across the globe.
Unfortunately, the number of deaths due to tobacco consumption is way more than any other
psychoactive substance. Tobacco is available in various forms. They can be classified into
either smoking (e.g., beedis, cigarettes, chillum, hookah, etc.) or chewable (gutka, khaini,
snuff, mishri, betel quids) products.
Tobacco consumption in either form is associated with several harmful physical
consequences. These include the following:

● Cancer of various organs like lungs, oesophagus, stomach, mouth, head & neck, etc.
● Respiratory problems like infections, asthma, emphysema, etc.
● Diabetes mellitus
● Hypertension
● Heart disease
● Stroke

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Steps to follow:

Step 1 : Establish rapport with the patient

• If the person refuses to talk or take help, do not force them.

• Request politely to answer a few questions.
• Check for any immediate medical issues - if present refer to nearest
hospital; if no medical issues then, encourage them to come back.

Step 2 : Patient agrees to take help - Assessment for Addiction

• Are you drinking alcohol heavily or regularly?

• Do you have any difficulty falling asleep without alcohol?
• Do your hands/body parts tremble whenever you abruptly reduce or stop
using alcohol?

NOTE: IF YES TO ANY OF THE ABOVE 2 QUESTIONS THEN IT

IS LIKELY TO BE ALCOHOL ADDICTION

• Check for any diffculties currently - if withdrawal (shaking of hands,

sleep disturbances, wanting to take alcohol present - then refer to nearest
health facility if patient is in the community)

Step 3 : Intervention

• Encourage abstinence, if not then focus on harm reduction- minimize use.

• Encourage to seek help from friends and family.
• Engage in other activities to distract from substance use.
• Discuss how to handle craving:
• Delay the use of substance
• Distract: engage in activities and home, indoor games.
• Discuss with friends and family about substance use.
• When craving occurs – Drink water or eat some food – a full tummy
helps in curbing craving.

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Approach to Substance Use Disorder/Problem

Substance use

Acute intoxication Harmful use Dependence

- Refer to nearest hospital, if

Counsel, refer to nearest any medical problems are
Counsel about stopping
secondary hospital (if any present.
substance use, keep under
medical problems are - If no medical problems,
regular follow up
present) follow the algorithm below.

Approach to take with patients with Dependence but with no immediate medical
problems

Willing to stop / decrease substance

use?

Yes No

- Motivate the person to seek help

- Educate patient and - Educate about the harmful effects of
family substance use
- Refer to mental health - Advice him/her to come back, when
professional he/she wants to quit
- Follow-up regularly - Follow up regularly
- involve family members in treatment
- Refer to mental health professional

REFERENCES
1. Miller WR, Rollnick S. Motivational interviewing: Helping people change. 3 rd ed. USA:
Guilford press; 2012
2. Murthy P, Nikketha B. Psychosocial interventions for persons with substance abuse: theory
and practice. National Institute of Mental Health and Neuro Sciences, Bangalore. Developed
under the WHO-GOI Collaborative Programme. 2006 - 2007.
3. Isaacs, A. N.1; Srinivasan, K.2; Neerakkal, I.2; Jayaram, G.3. Initiating a Community Mental
Health Programme in Rural Karnataka. Indian Journal of Community Medicine 31(2):p 86,
Apr–Jun 2006

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Chapter 6.2 Identification & Management of Alcohol Withdrawal

Alcohol withdrawal syndrome (AWS) is a set of symptoms that occur when a person who has
been drinking heavily suddenly stops or reduces their alcohol intake from their usual amount.
The symptoms of AWS range from minor ones, such as insomnia, anxiety symptoms and
tremors, to severe ones, such as seizures and delirium tremens.

AWS is diagnosed based on criteria established by the DSM-5, which include the cessation or
reduction of heavy alcohol use, the presence of at least two specific withdrawal symptoms
within hours to days of stopping or reducing alcohol use, and the symptoms causing significant
distress or impairment in social, occupational, or other areas of functioning.
The symptoms of AWS typically begin within 4-12 hours of stopping alcohol use and peak
during the second day, improving by the fourth or fifth day. However, some symptoms, such
as anxiety, insomnia, and autonomic dysfunction, may persist for up to 3-6 months.

Presenting Symptoms The usual time of

appearance after
stopping alcohol use

Withdrawal symptoms: 12 to 24 hours

Headache, anxiety, insomnia, tremulousness,
gastrointestinal disturbance, palpitations, alcoholic
hallucinosis: visual, auditory, or tactile hallucinations

Withdrawal seizures: Generalized tonic-clonic seizures 24 to 48 hours

Alcohol withdrawal delirium (delirium tremens): hallucinations 48 to 72 hours

(predominately visual), disorientation, tachycardia,
hypertension, low-grade fever, agitation, diaphoresis

Only less than 10% of people in withdrawal ever experience delirium or withdrawal
seizures.

When to suspect other causes of Seizures (Independent Seizure disorder)?

1. Seizures are focal or Complex partial seizures.

2. No definite history of recent abstinence from drinking.

3. Seizures occur more than 48 hours after the patient’s last drink.

4. The patient has a history of fever or trauma.

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Alcohol Withdrawal Delirium or Delirium Tremens:

It is a severe complication of AWS characterised by clouding of consciousness and
disorientation.

Alcohol withdrawal delirium, or delirium tremens, is characterized by clouding of

consciousness and disorientation. Untreated delirium tremens has a mortality rate of 1 to 5
percent.

Identification and Management of Alcohol Withdrawal Syndrome (AWS) for Primary

Care Doctors:
History: Critical historical data to be collected include:
1. Quantity of daily alcohol intake (30ml of 40% alcohol equals 1 unit of alcohol), duration
of alcohol use, time since last drink, episodes, and symptoms of previous alcohol withdrawals,
concurrent medical or psychiatric conditions, abuse of any other agents.
2. The physical examination should assess the withdrawal symptoms and also possible
complicating medical conditions, including arrhythmias, congestive heart failure, coronary
artery disease, gastrointestinal bleeding, infections, liver disease, nervous system impairment,
and pancreatitis.

3. It is essential to check a patient’s vitals, hydration status, any external injuries, and
hepatomegaly and perform a complete neurological examination.
4. Basic laboratory investigations must include a complete blood count, blood sugar levels,
liver function tests, and renal function tests.

Differential Diagnosis:

It is important to keep in mind the possibility of other medical conditions like CNS infections,
haemorrhage, head injury, electrolyte imbalance or withdrawal from other sedatives,
mimicking or co-existing with alcohol withdrawal syndrome, especially in cases where the
history of a pattern of use or last use is unclear.

Management:

The management of alcohol withdrawal syndrome involves both supportive care and
pharmacologic treatment.
Supportive care: This includes correcting dehydration and abnormalities in electrolyte levels,
providing multivitamins and thiamine (100 mg per day) to prevent Wernicke's
encephalopathy, and monitoring for any complications or co-occurring medical or psychiatric
conditions.

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If intravenous fluids are administered, thiamine (100 mg intravenously) should be given

before glucose is administered to prevent the precipitation of Wernicke’s encephalopathy.
Choice of treatment setting:

The choice of treatment setting depends on the severity of withdrawal symptoms. Mild to
moderate withdrawal symptoms can be managed on an outpatient basis, while severe
withdrawal symptoms require inpatient detoxification.

WHEN TO REFER:

If an individual has features such as:

• Any co-morbid serious medical issue E.g.- uncontrolled hypertension, diabetes,
etc
• Seizures (Fits)
• Episodes of unconsciousness
• Confusion
• Memory problems
• Fever, headache
• Vomiting of blood
• Using injectable drugs
• Abnormal behaviour / violence
The above symptoms are indicative that the person has serious medical problems, which
may even lead to death if left untreated.
Note: 90% of the cases can be managed at the PHC level. Only 10% have complications
which need referral.

Pharmacological treatment:
Benzodiazepines are the medication of choice for the treatment of alcohol withdrawal
syndrome (Detoxification). The choice of benzodiazepine depends on the pharmacokinetics
of the drug and the patient's individual needs.
Diazepam is a long-acting agent that provide a smoother withdrawal, while lorazepam and
oxazepam are intermediate-acting agents that are preferable in patients who have cirrhosis
/liver dysfunction or abnormal liver function tests.
Regimen:

A fixed-dose regimen involves administering doses of benzodiazepine at specific intervals,

Note: For every 30ml of hard liquor, half a bottle of beer (350ml), the benzodiazepine
equivalent to Diazepam 5mg.

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Below is the benzodiazepine equivalent to Diazepam 5mg for the commonly available drugs
at the PHC level:

Name Approx. dose equivalent to 5mg diazepam

Lorazepam 0.5 - 1mg
Oxazepam 10 mg

E.g.- 1. Tab Diazepam 10 mg 1-1-2 x 2 days

0-1-2 x 2 days

0-0-2 x 2 days
Then STOP
Follow-up:

After the initial detoxification, it is essential to follow up with treatment for alcohol
dependence, which may include both pharmacologic and non-pharmacologic interventions
such as anti-craving medications, deterrents, and behavioural therapies such as Motivational
Enhancement Therapy (MET) and Relapse Prevention Therapy (RPT).

REFERENCES

1. Bayard M, Mcintyre J, Hill K, Woodside J. Alcohol withdrawal syndrome. Am Fam Physician. 2004
Mar 15;69(6):1443-50

2. McKeon A, Frye MA, Delanty N. The alcohol withdrawal syndrome. J Neurol Neurosurg
Psychiatry. 2008 Aug. 2008 Aug 1;79(8):854-62

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Chapter 6.3 Medications to prevent relapse (Anti-craving agents)

Alcoholism is a relapsing and remitting chronic condition that imposes a significant social and
medical burden on society. Relapse in an alcoholic patient can occur for a variety of reasons,
including psychosocial issues, cravings, and more.
The FDA has approved four medications to treat alcoholism: Disulfiram, Naltrexone (oral and
long-acting injectable formulations), and Acamprosate.
Disulfiram:

Disulfiram was the first agent to be approved for preventing relapse in alcoholic patients in
1948. It works by inhibiting the enzyme aldehyde dehydrogenase and increasing the
concentration of acetaldehyde in the blood, leading to unpleasant symptoms when alcohol is
consumed.

• It is used as a deterrent and should be taken under supervision.

• Starting dose - 250 mg in the morning, once a day.
• Start only after one week of complete stoppage of alcohol.
• Consent- Take written consent from the patient before starting.
• Disulfiram card – A special identification card which states that patient is on
disulfiram and the serious side effects possible when alcohol is consumed.
• Common side - drowsiness, headache, fatigue, allergic dermatitis, and gastrointestinal
upset.
• Duration of treatment – one year
• Contraindications - Cardiovascular disorder, Psychosis, pregnancy. Instruct to avoid
the use of Alcohol and alcohol-containing products (aftershave, alcohol-containing
cough syrup, certain homoeopathic and ayurvedic medications, etc.) as it can cause a
reaction (Disulfiram Ethanol reaction).

Symptoms Management
- Sweating, flushing - Supportive management with IV fluids
- Hyperventilation, Dyspnoea - Airway management
- Nausea, Vomiting, Abdominal pain - Sedation if required
- Chest pain, palpitations, hypotension, - Fomepizole can be used in severe
tachycardia cases
- Agitation
- Seizures, Coma

Naltrexone:
Naltrexone works by blocking the effects of opioids on the brain and reducing cravings for
alcohol. It is available in oral and long-acting injectable formulations. The oral form can be
taken once daily.

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Indications for Naltrexone

• Wish to reduce heavy drinking or Pursue abstinence
• Do not have significant hepatic insufficiency

• Not taking or consuming opioids

Dosage- 50 mg/day once daily in the morning with food
It can be started at 25mg/day once daily in morning and increased to 50mg/day after a week.

It can be used in combination with counselling and should be avoided in patients with current
opioid dependence. It can be for as long as patient wants to maintain abstinence.

Naltrexone may cause adverse reactions such as nausea, vomiting, headache, fatigue,
insomnia, nervousness, irritability, and injection site reactions. It is essential to monitor the
liver function test (LFT) before starting the medication and then at one month and annually.
It is partially contraindicated for patients with liver functions that are 3-4 times normal and is
contraindicated in patients with liver failure or acute hepatitis.
Suitable Patients for Naltrexone:

Naltrexone may be suitable for patients with high levels of craving, a positive family history
of alcoholism, who want to reduce heavier drinking behaviour without the goal of abstinence,
or on days when drinking is anticipated. It can be used in combination with psychotherapy
and support, and patients should be closely monitored for potential side effects and potential
interactions with other medications.

Acamprosate:
Acamprosate works by modulating the balance of neurotransmitters in the brain and reducing
cravings for alcohol. It is taken three times a day and should be used in combination with
psychotherapy. It should be avoided in patients with kidney impairment.
Dosage- Patients > 60 kg should receive 333 mg 2-2-2
Patients <60 kg should receive 333 mg 1-1-2

No titration is required while starting and stopping; it can be started early in abstinence.
Acamprosate may cause adverse reactions such as headaches, diarrhoea, nausea, vomiting,
abdominal pain, and pruritus. It is important to note that patients with mild to moderate renal
impairment may require a dose reduction. In contrast, patients with severe renal impairment
(creatinine clearance of ≤30 mL/min) should avoid the medication. It should also be avoided
in patients with hypercalcemia (total >10.3, ionized >5.4 mg/dl). Patients should be monitored
for depressive symptoms and suicidal ideation.

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Appropriate Patients for Acamprosate:

Acamprosate may be appropriate for patients who, at treatment onset, are motivated for
complete abstinence and who have started the treatment after a period of sobriety. It may also
be beneficial for patients with harmful emotional state cravings and protracted alcohol
withdrawal symptoms such as sleep difficulties. Patients on Opioid Agonist Therapy (OAT)
for pain management and patients with multiple medical issues and taking many other
medications may also benefit from acamprosate treatment. It should be used in combination
with counselling and support, and patients should be closely monitored for potential side
effects and potential interactions with other medications.
Other agents that have been found to help prevent relapse include Topiramate, Baclofen, and
SSRIs. It is important to note that these medications should be used in combination with
psychotherapy and support for best results
It is important to note that, even with proper treatment, relapses are common in patients with
alcohol use disorder, and multiple treatment attempts may be needed. Medications can be an
effective tool in preventing relapse, but they should be used in combination with other support,
such as counseling and support groups.

REFERENCES
1. Kranzler, H. R., & Soyka, M. (2018). Diagnosis and pharmacotherapy of alcohol use disorder: a
review. Jama, 320(8), 815-824.

2. Mahler, S. V., Smith, R. J., Moorman, D. E., Sartor, G. C., & Aston-Jones, G. (2012). Multiple roles
for orexin/hypocretin in addiction. Progress in brain research, 198, 79-121.

3. Jung, Y. C., & Namkoong, K. (2006). Pharmacotherapy for alcohol dependence: anti-craving
medications for relapse prevention. Yonsei Medical Journal, 47(2), 167-178.

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 Primary Care Psychiatry: A Clinician’s Companion

Chapter 6.4: Tobacco use and management

Introduction:

Tobacco dependence poses serious health risks to individuals and society. Smoking, the
leading cause of preventable deaths globally, results in over 7 million fatalities annually. This
chapter outlines the prevalence, features, and treatment strategies for nicotine dependence.

Prevalence and Significance:

With an estimated 28.6% of Indian adults using tobacco in some form, the prevalence of
tobacco use remains high. Nicotine dependence is characterized by a compulsion to use
tobacco, difficulty in control, withdrawal symptoms, tolerance, neglect of activities, and
continued use despite consequences.

Nicotine Withdrawal and Treatment:

Nicotine withdrawal symptoms, occurring within the first week of quitting, encompass both
affective and physical aspects. These include irritability, anxiety, depressed mood, insomnia,
fatigue, and constipation. Treatment involves a comprehensive approach.

Pharmacological Treatment:

Varenicline:

- Acts as a partial agonist on nicotinic receptors, reducing pleasurable effects.

- Adverse effects: nausea, insomnia, nightmares, mood changes.
- Dosage: Gradual increase to 1mg twice daily.
- Duration: 3-6 months.

Bupropion:

- Enhances CNS neurotransmitter release.

- Initiate a week before quitting at 150mg daily.
- The dose should be increased to 150mg twice daily after three days.

Nicotine Replacement Therapy (NRT):

- NRTs alleviate withdrawal symptoms by providing controlled nicotine doses.

- Forms: gum, patch, lozenge, inhaler, nasal spray.
- Dosages and durations vary depending on smoking habits.
- Side effects: insomnia, rash, nightmares, allergies.

Gum, Lozenges, Inhalers, Sublingual Tablets:

- Taken every 1-2 hours while awake.

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- Proper gum usage: chew slowly, "park" between cheek and gums.
- Dosages: 2mg for 25 cigs or less, 4mg for >25 cigs.
- Maximum: 24 gums/day.
- Side effects: mouth soreness, dyspepsia.
- Duration: 12 weeks, with gradual dosage reduction.

Method of Chew and Park:

First, they should chew the gum very slowly until they notice a minty taste or tingling feeling,
then “park” the gum between the cheek and gums for 1 to 2 minutes to allow nicotine to pass
through the gum tissue and be absorbed. Patients should gradually resume chewing until a
tingling or minty taste returns after two minutes or after the tingling stops, and then "park" the
gum in a different location on the gums. Instruct patients to use the "chew and park" technique
once more until there is no longer any taste or tingle (around 30 minutes).

Side effects of this method include headaches, a painful, dry mouth, dyspepsia, nausea, and
jaw pain.
How nicotine gums help:

• Effective in controlling withdrawal symptoms.

• Tobacco use concurrently doesn't lead to any significant issues.
• It can begin without completely quitting cigarette consumption.

• Nicotine dosage is user-controllable.

Pharmacotherapy Precautions, Adverse Dosage Duration of

contraindications effects treatment
Varenicline Significant Nausea, 0.5mg/day for 3-6 months
Kidney Disease Insomnia, 3 days then
Nightmares,
Depressed 0.5mg
mood, and twice/day for 4
psychiatric days then
symptoms
1mg twice/day

Nicotine Patch Local skin 21mg/day 12 weeks

irritation, 14mg/day Tapering to a
Insomnia 7mg/day lower dose can
be done after 2-
Depends on 6 weeks and
the number of then at 4-8
weeks

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cigarettes used
per day
Nicotine Gum Mouth 25 cigs= 2mg 12 weeks
Soreness, every 1-2 Week 1-6:1
Dyspepsia hourly piece every 1-2
h
> 25 cigs = Week 7-9: 1
4mg every 1-2 piece every 2-4
hourly h
(Maximum: 24 Week 10-12: 1
gums/day) piece every 4-8
h

Non-Pharmacological Interventions:
Five Ds technique for managing Craving:

Delay: Wait until urge passes.

Distract: Shift focus to a different activity.
Drink water: Reduces craving and withdrawal effects.

Deep breathing: Relaxation technique.

Discuss: Talk to supportive individuals or groups.

5As Approach for Motivating to address Tobacco use:

Assess: Identify tobacco use and motivation to quit.

Advise: Offer clear advice to quit.

Agree: Collaboratively set a quit date.
Assist: Provide support, medications, and resources.

Arrange: Schedule follow-up and ongoing support.

REFERENCES

1. Spatial, temporal, and demographic patterns in prevalence of smoking tobacco use and attributable
disease burden in 204 countries and territories, 1990–2019: a systematic analysis from the Global
Burden of Disease Study 2019

2. U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years
of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human

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Services, Centers for Disease Control and Prevention, National Center for Chronic Disease
Prevention and Health Promotion, Office on Smoking and Health, 2014

3. Van Schayck OCP, Williams S, Barchilon V, Baxter N, Jawad M, Katsaounou PA, Kirenga BJ,
Panaitescu C, Tsiligianni IG, Zwar N, Ostrem A. Treating tobacco dependence: guidance for primary
care on life-saving interventions. Position statement of the IPCRG. NPJ Prim Care Respir Med. 2017
Jun 9;27(1):38.

4. Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update Panel, Liaisons, and
Staff. A clinical practice guideline for treating tobacco use and dependence: 2008 update. A U.S.
Public Health Service report. Am J Prev Med. 2008;35(2):158-176.

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Primary Care Psychiatry: A Clinician’s Companion

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 Primary Care Psychiatry: A Clinician’s Companion

Chapter 7.1 Schizophrenia and Psychotic Disorders

Schizophrenia is a severe mental disorder that affects a person's thinking, perception, self-
experience, cognition, volition, affect, and behaviour.
It is considered an illness that causes severe functional impairment and significantly limits
one's major life activities. The term schizophrenia is derived from two Greek terms meaning
"to split" and "mind," literally meaning "a split of mind."
The prevalence of schizophrenia in India is around 0.8% in the general population and affects
males and females equally. The prevalence in the primary health care settings is also around
0.8 %.
Symptoms of schizophrenia are first recognizable in late adolescence or early twenties.

Individuals with schizophrenia are two to three times more likely to die earlier than the general
population, with suicide being the leading cause of death.
The natural course of schizophrenia is variable, and some patients experience exacerbation
and remission of symptoms periodically throughout their lives.

Symptom domains Example of symptoms

Positive symptoms Delusions, Hallucinations,

Extreme aggression/agitation,
Disorganised speech

Negative symptoms Flattened affect, Avolition

(reduced motivation),
asociality (social isolation),
Anhedonia (lack of pleasure),
Alogia (poverty of speech)
Mutism; posturing; rigidity

Psychomotor Mutism, Posturing, Rigidity,

Symptoms Mannerisms

Cognitive Symptoms Poor memory and

comprehension, poor attention
and concentration,
disorganised thinking

Different symptom domains have different courses and outcomes. Positive symptoms respond
well to antipsychotics, while negative symptoms may worsen with antipsychotics.

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According to the Clinical Schedule for Primary Care Psychiatry (CSP), psychosis can be
subtyped as :
1. Acute onset: Acute Transient Psychotic Disorder
2. Episodic Course: Bipolar Affective Disorder
3. Continuous Course: Schizophrenia

Clinical Features of schizophrenia

For ease of understanding and relevance of use in primary care practices, we have described
the most common symptoms of psychosis in detail in this chapter. These include delusions,
hallucinations, and aggression. Other symptoms include disorganized thoughts, the delusion
of control, and catatonia. Before diagnosing schizophrenia, it is essential to rule out any
organic cause using the CSP questionnaire.
Hallucinations:
False sensory perceptions (visual, auditory, tactile, olfactory, gustatory) that occur without
external stimuli. Usually experienced as originating from the outside world and not from
within the person’s mind as imagination.
Delusions:

Delusions are false, firm beliefs that are held with extraordinary convictions even when
evidence to the contrary is given. These beliefs are usually not shared by others in society.
Based on the content of the delusions, there can be different types of delusions.

Delusion of reference A delusional belief that people are referring to the patient in their
action

Delusion of A delusional belief that people are plotting against the patient
persecution

Disorganized behaviours:

These refer to actions that are erratic, unpredictable, and lack a clear purpose or structure. It
can manifest as difficulties in organizing daily activities, maintaining personal hygiene, or
adhering to social norms.

E.g.: A person experiencing disorganized behaviour due to psychosis may exhibit difficulties
in completing simple tasks. For instance, they might attempt to brush their teeth with a
hairbrush or wear mismatched shoes without realizing the error. Their actions may appear
confusing and unrelated to the task at hand, reflecting the disorganization of thought processes
associated with psychosis.

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Catatonia
This is a condition which is characterised by a range of movement abnormalities such as stupor
(prolonged immobility and unresponsiveness), agitation, posturing (assuming unusual or rigid
body positions), mutism (limited or absence of speech) and , staring for long periods without
blinking.

Assessment of a patient with probable psychotic disorder:

Whenever a patient is brought to the PHC with behavioural symptoms, the doctor should
screen the patient as per the Clinical Schedule for Primary care clinicians (CSP) screening
questions.
General screening questions as per CSP
● How was your sleep for the last few weeks?
● How has your appetite been for the last few weeks?
● How is your interest in doing your daily work?

If any of the general questions are answered as “disturbed,” it is likely that the patient is
suffering from some psychiatric illness. In such cases, the remaining eighteen questions
should be asked. The penultimate four questions should be asked in all cases suspected to have
psychotic illnesses (i.e., question number 17 - 20).

Screening questions for psychotic disorders as per CSP

● In the past few weeks, have they talked or smiled to themselves/Hallucinations?
● Have they had poor self-care/wandering in the past few weeks?
● In the past few weeks, have they had suspiciousness/talking big/delusions?
● In the past few weeks, have they been talking excessively/ sleeping less/hyperactive?
If the attendant of the patient responds positively to any of the above questions, further details
of the illness, e.g., onset, duration, and progress of the illness, should be enquired. Usually,
the onset is gradual in schizophrenia.

When to refer to a Psychiatrist?

• If the patient is actively suicidal

• If the patient is very aggressive
• When the diagnosis is not clear
• When the diagnosis is clear, but there is confusion over the treatment plan
• If the patient has shown no improvement after taking medicine for a month
• If the patient has developed severe side effects with medication
• If the patient is not taking medicine regularly and needs a depot injection
• If the family members or patient want a second opinion
• If there is any organic cause suspected

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REFERENCES
1. Gururaj G, Varghese M, Benegal V, Rao GN, Pathak K, Singh LK, et al (2016). National Mental
Health Survey of India, 2015-16: Summary. Bengaluru, National Institute of Mental Health and
Neuro Sciences, NIMHANS.

2. Manjunatha N, Kumar CN, Math SB, & Thirthalli J. (2020) Clinical Schedules for Primary Care
Psychiatry (CSP), version 2.3 (COVID-19). Bengaluru, National Institute of Mental Health and
Neuro Sciences, NIMHANS.

3. Suchandra HH, Reddi VK, Aandi Subramaniyam B, & Muliyala KP (2021). Revisiting lorazepam
challenge test: Clinical response with dose variations and utility for catatonia in a psychiatric
emergency setting. Australian & New Zealand Journal of Psychiatry, 55(10), 993-1004.

4. Harrison P, Cowen P, Burns T, & Fazel M (2017). Shorter Oxford textbook of psychiatry. Oxford
university press.

5. Isaacs, A. N.1; Srinivasan, K.2; Neerakkal, I.2; Jayaram, G.3. Initiating a Community Mental Health
Programme in Rural Karnatak. Indian Journal of Community Medicine 31(2):p 86, Apr–Jun 2006.

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Chapter 7.2 Antipsychotics - Olanzapine and Risperidone

Antipsychotics are a group of drugs used to treat schizophrenia and other psychotic disorders.
Schizophrenia is one of the most severe psychiatric illnesses with high morbidity
The dopamine hypothesis of schizophrenia is a commonly accepted explanatory model. It
states that hyperactivity of the mesolimbic dopamine pathway causes the positive symptoms
of schizophrenia, such as delusions and hallucinations. This is supported by the fact that D2
receptor blockers, which reduce dopamine activity, effectively reduce these symptoms.

Antipsychotics are broadly classified into two groups: typical and atypical antipsychotics.
Atypical antipsychotics or second-generation antipsychotics have a different mechanism of
action than typical antipsychotics. They act as dopamine receptor D2 and serotonin receptor
5-HT2A antagonists. This action in the mesolimbic pathway causes fewer extrapyramidal
symptoms. Additionally, atypical antipsychotics have been found to have a lower risk of
developing tardive dyskinesia. They also have better efficacy in treating negative symptoms,
cognitive impairment, and affective symptoms of schizophrenia. Some atypical antipsychotics
have also been used to treat other psychiatric disorders, such as bipolar disorder, major
depressive disorder, and even as adjunctive therapy in treatment-resistant depression.

S.NO. TYPICAL ANTIPSYCHOTICS ATYPICAL ANTIPSYCHOTICS

1 Haloperidol Olanzapine 10mg

2 Fluphenazine (Depot Injection) 25mg Risperidone 4mg

fortnightly

OLANZAPINE

Dose:

It is prescribed from a starting dose of 5mg/day and can be increased by 5 mg/d every 5 days
up to 20mg/day, based on tolerability and response.
Timing Of Medication:

It can be given as once daily dose at night.

Side Effects:
Weight gain, increased appetite, diabetes, and dyslipidemia. It also causes sedation, orthostatic
hypotension, and constipation. Less frequently, it can cause akathisia and tremors.

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RISPERIDONE
Dose:

Risperidone is prescribed from a starting dose of 2 mg/day, increased by 2 mg every 3 days

up to a maximum dose of 8 mg/day.
Formulations:

Risperidone is available as an oral tablet formulation of strength 0.5mg, 1mg, 2mg, 3mg, and
4mg, oral liquid or syrup formulation (1 mg/ml).

Timing Of Medication:
It is given once daily at night.
Side Effects:

The extrapyramidal side effects of risperidone are usually dose related. Risperidone can also
cause other side effects, such as weight gain and serum prolactin elevation.

HALOPERIDOL
Dose:

Haloperidol is prescribed from a starting dose of 0.5 mg/day, increased by

2 mg every 3 days up to a maximum dose of 10 mg/day.

Formulations:
Haloperidol is available as an oral tablet formulation of strengths 0.5 mg, 1 mg, 1.5 mg, 2 mg,
2.5 mg, and 5 mg.

An injection form of Haloperidol 5mg/1ml is available, which can be used for sedation of
agitated patients. It should be used along with Lorazepam 2 mg or 4 mg IV.

Timing Of Medication:
It is given once daily at night
Side Effects:
The side effects of haloperidol include drowsiness, nausea, vomiting, constipation, tremors,
etc.

LONG-ACTING FLUPHENAZINE
Usually long-acting fluphenazine is given when the patient doesn’t take medications regularly
and is prescribed by a psychiatrist.

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At the primary health care level, it is vital to know the side effects and dosage of long acting
fluphenazine for follow-up.
An injection form of fluphenazine 25mg/1ml is available and is usually given twice a month,
15 days apart.
Side effects
The side effects include drowsiness, nausea, vomiting, constipation, tremors, etc.

Side Effects Of Antipsychotic Medications

These are the extrapyramidal side effects, metabolic side effects, ECG changes in the form of
QTc prolongation, and hyperprolactinemia.
Extrapyramidal Symptoms:

• Parkinsonism is characterized by stiffness, slowness of movements, tremors, drooling of

saliva, slurring of speech, short-stepping gait, reduced blink rate, and diminished facial
expressions. It typically occurs 5-7 days after starting the medication and can be managed
by reducing the dose of the antipsychotic and/or adding anticholinergic medicines such as
trihexyphenidyl.
• Acute dystonia is characterized by sudden twisting of the neck, tongue protrusion, abnormal
posturing of limbs, trunk, and blepharospasm starting within a few hours to days of starting
the antipsychotic medication. As a treatment, Inj Promethazine 25-50mg only IM can be
given.
• Akathisia is characterized by a subjective feeling of restlessness, objective signs of
restlessness, or both. It is associated with anxiety, inability to remain still, and pacing or
rocking movements. It can be treated with beta-blockers such as propranolol and
benzodiazepines and managed by reducing the dose of the antipsychotic or changing the
antipsychotic.
• It's important to note that tardive dyskinesia is a potentially irreversible condition, and it is
essential to monitor patients receiving antipsychotics for signs of tardive dyskinesia and to
discontinue treatment if the symptoms appear. The risk of developing tardive dyskinesia is
highest in older adults and those who have been taking antipsychotics for a prolonged period
of time.
• NMS is a life-threatening adverse event that can occur at any time after starting
antipsychotic medication. The symptoms include muscular rigidity, dystonia,
agitation, hyperthermia, excessive sweating, tachycardia, and elevated blood pressure.
Patients with NMS should be referred to higher centres for management.

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CONSIDER REFERRAL TO A HIGHER CENTRE

● Neuroleptic malignant syndrome (NMS)

● Hypersensitivity to antipsychotics

● Treatment resistance

Good Clinical Practice Guidelines

● Check weight, blood sugar levels, and family history of DM before starting
antipsychotics.
● Start at a lower dose and increase based on tolerability
● Prescribe a single antipsychotic. Polypharmacy should be avoided.
● Switch to another antipsychotic if there is no improvement after an adequate dose
(minimum dose mentioned in CSP) and duration of treatment( the duration mentioned
in CSP)
● Monitor for side effects during every follow-up consultation
● When stopping the medication, slowly reduce the dose over weeks to months.(25% of
dose every 3 months)

REFERENCES

1. Gururaj G, Varghese M, Benegal V, Rao GN, Pathak K, Singh LK, et al (2016). National Mental
Health Survey of India, 2015-16: Summary. Bengaluru, National Institute of Mental Health and
Neuro Sciences, NIMHANS.
2. Stahl SM. (2020). Prescriber’s guide: Stahl’s essential psychopharmacology. Cambridge
University Press.
3. Manjunatha, N, Kumar, C, Math SB, Thirthalli J. (2020) Clinical Schedules for Primary Care
Psychiatry (CSP), version 2.3 (COVID-19). Bengaluru, National Institute of Mental Health and
Neuro Sciences, NIMHANS.

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Chapter 7.3: Bipolar Disorder and Management at Primary Health Centre

Introduction:

Bipolar Affective Disorder is a type of severe mental illness. It is grouped under “Mood
disorder.” It is also known by various names, such as, ‘bipolar disorder”, “bipolar affective
disorder (BPAD)”, and “manic-depressive illness”. It is characterized by episodes of
depression, hypomania/mania, and mixed episodes; between the episodes, the recovery is
usually good.

According to the National Mental Health Survey (NMHS), 0.3%-0.5% of the population, i.e.,
Around 4-5 million individuals, have a bipolar illness, and the treatment gap is 70%, which
implies that roughly 30-35 lakh people do not receive any treatment for the illness.

It usually starts in the adolescent/early adult age group and impacts the patient and caregivers
if timely and adequate intervention is not provided. Also, patients with BPAD face various
problems, including the risk of suicide.

Clinical Presentation:
Mania:
Diagnosed when a patient exhibits the following for a continuous period of 7 days of more -
- Elevated or irritable mood
- Increased psychomotor activity – patient has increased movements and does all actions
at faster pace
- Decreased need for sleep – patient feels energetic even after sleeping for only a few
hours
- Pressured speech – patient speaks continuously and cannot be interrupted
- Racing thoughts
- Grandiose beliefs
- Impulsivity, and high-risk behaviours
- Severe cases may require hospitalization

Depression:
Diagnosed when a patient exhibits the following for a continuous period of 14 days of more -
- Low energy levels
- Low/Sad mood
- Decreased activity and interest in previously pleasurable activities
- Difficulty concentrating
- Disrupted sleep and appetite
- Low self-esteem
- Feelings of guilt, worthlessness ,hopelessness, or helplessness
- Thoughts of suicide or other suicidal behaviours

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Antidepressant-Induced Switch:
Some individuals may experience manic or hypomanic episodes triggered by antidepressant
medications.

Figure - Course of Bipolar disorder

Heritability and Comorbidity:

Heritability: Bipolar disorder has a genetic component. If one parent is affected, the risk is
8-16%, increasing to 32-35% if both parents are affected. The risk further rises to 20-40% for
non-identical twin siblings and as high as 60-80% for identical twin siblings.
Comorbidity: Bipolar disorder frequently coexists with other conditions. Substance use
disorders, anxiety disorders, OCD, ADHD, and personality disorders are common
comorbidities.
Initial Assessment:

• Age of Onset and Polarity: Determine when the disorder began and whether depressive
or manic episodes predominate can aid diagnosis and treatment planning.
• Episode Severity: Assess the severity of episodes, identifying risk factors like suicidal or
aggressive behaviours.
• Treatment Response and Side Effects: Evaluate past treatment experiences, including
responses and potential side effects.

Baseline Investigations To Be Done:

• Detailed General Physical Examination – Height, weight, BMI, Waist circumference
• Complete hemogram
• Liver function test
• Renal function test
• Thyroid function test
• ECG

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Management and Treatment:

Pharmacological Treatment
Mood stabilizers: Mood stabilizers are the mainstay of treatment for BPAD.

• Divalproex/ Valproate
• Carbamazepine/ Oxcarbazepine

Lithium, a common mood stabilizer, is not discussed here as it is not recommended for
prescription in primary care settings. This is due to its potential interactions with many
common drugs and the necessity for vigilant monitoring due to the risk of toxicity and side
effects. Kindly refer to a psychiatrist if a patient is on Lithium.
Antipsychotics medications: mainly used during acute episodes.

• Risperidone
• Olanzapine

Valproate:

Indications: Acute Mania, Prophylactic treatment of BPAD

Dose: 20-30 mg/kg body weight BD dose

Valproate can be started at 15mg/kg body weight BD dose and gradually up titrated by
250mg/d every week to a target dose of 20-30 mg/kg body weight

Precautions: Consider the teratogenic effects in women of childbearing age. Common side
effects include gastric irritation, weight gain, and tremors.

Valproate Toxicity: Symptoms include altered mental status, CNS depression, coarse tremors,
and multi-system involvementteev2 Stop the drug immediately, monitor vitals, and send CBC,
LFT, RFT, serum electrolytes, and ammonia levels. Refer to a higher centre if needed.

Carbamazepine / Oxcarbazepine:

Indications: Acute Mania (2nd line), Maintenance phase (2nd line)

Dose: Start with 100 mg to 200 mg, gradually increasing (200mg every week) to 400 mg BD.
Be cautious with Clozapine co-administration due to the risk of blood dyscrasia.

Side Effects: Common side effects include drowsiness, headache, nausea, and dry mouth. Be
vigilant for erythematous rashes, hyponatremia, and altered liver function tests.

Carbamazepine Toxicity: Symptoms include diplopia, ataxia, confusion, agitation, vomiting,

and abdominal pain. Stop the drug immediately, monitor vitals, and serum levels, and refer if
necessary.

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Antipsychotic Drugs:

Antipsychotics are mainly used in acute phases for symptom control. Once stabilized on mood
stabilizers, consider withdrawal. Risperidone and Olanzapine are suitable for acute mania or
hypomania episodes, often alongside Benzodiazepines.

Duration of Treatment:
The duration varies based on the number of episodes and family history. Lifelong medication
may be necessary for recurrent episodes.
However, below is a guideline that will help you in managing patients with bipolar
disorders:

• If the patient presents with first-episode mania, the treatment consists of two parts:
o Acute treatment, which would last for around 3 months and
o Maintenance phase, which would last for about 6 months.
• Hence for the first episode, the total duration of treatment would be 9 months.
• If there are 2-3 episodes, then the duration of treatment would be 5 years.
• And for more than 4 episodes, the treatment would be lifelong.

Aggression Management:

In acute episodes with aggression, oral or intramuscular medications like Lorazepam,

Promethazine, and Haloperidol may be used.

Agitation and acute episodes of bipolar disorder can be challenging to manage in primary care
settings. Below are guidelines for managing these situations effectively.

Adults:
Lorazepam (1 to 2 mg) or Promethazine (25 to 50 mg) can be administered orally or
intramuscularly. If benzodiazepines are inappropriate, consider using Promethazine.

Alternatively, Haloperidol (2 to 5 mg) with Promethazine (25 to 50 mg) can be considered.

Consider In-Patient care or refer to a higher centre if the patient has the following
features:

• Recent Suicidal attempt

• Severe agitation or violence

• Severe episodes

• Risk of harm to others

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• Not able to take care of themselves

• Catatonic features present

• Co-morbid medical illness where Out patient monitoring is difficult

Psychoeducation:

• Assess patients' and caregivers' understanding of aetiology, treatment, and prognosis.

• Discuss the symptoms of depression, mania, hypomania, and mixed episodes.
• Provide information about available treatment options, their durations, efficacy, and
potential side effects.
• Emphasize the importance of compliance and supervised medication.
• Explain the possible course of the disorder and its long-term outcomes.
• Discuss maintaining a regular sleep-wake cycle and practicing good sleep hygiene.
• Address potential issues related to substance use.

REFERENCES
1.Gururaj, G & Varghese, Mathew & Benegal, Vivek & Rao, Girish & Pathak, Komal & Singh,
Lokesh & Mehta, Ritambhara & D, Ram & Shibukumar, Tm & Kokane, Arun & RK, Lenin &
Chavan, Bhagyshri & P, Sharma & C, Ramasubramanian & Dalal, Pronob & Saha, Pranesh & SP,
Deuri & Giri, Anjan & AB, Kavishvar & India, NMHS. (2017). National Mental Health Survey of
India, 2015-16 Prevalence, Pattern and Outcomes.

2.Shah N, Grover S, Rao GP. Clinical Practice Guidelines for Management of Bipolar Disorder.
Indian J Psychiatry. 2017 Jan;59(Suppl 1): S51-S66. Doi: 10.4103/0019-5545.196974. PMID:
28216785; PMCID: PMC5310104.

3. Rapid Tranquillisation https://www.bcpft.nhs.uk/documents/policies/r/1084-rapid-

tranquilisation/file

Click on the topic or scan QR code below to learn more about the management of Bipolar
Disorder:

Bipolar Disorder

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Chapter 8.1: Emotional and Behavioural Disorders of the Elderly

ROLE OF A PRIMARY CARE DOCTOR:

There is a growing need to integrate geriatric mental health into the existing primary care
system, as it may reduce the treatment gap significantly through early diagnosis and
interventions, thereby reducing morbidity and mortality. Common mental health conditions
seen in the elderly are depression, dementia, delirium, anxiety, insomnia, psychotic illness,
and substance use.

HOW TO APPROACH AN ELDERLY PERSON:

I. INTERVIEW WITH PATIENT AND FAMILY:
Begin by asking the name and place of the patient

-What are their chief complaints?

-Follow by asking three basic questions:
a) How is your sleep?
b) How is your appetite?
c) Are you able to do your daily routine work (eating, bathing, brushing)?
If the answer is “no” or “disturbed” for any of the above, proceed as below:

1. Delirium:

PATIENT FAMILY/DOCTORS
Orientation to time, place, and person: 1. When did the confusion start?
1. What is the approximate time now (is 2. Sleep-wake cycle reversal (does he
it morning/afternoon/evening) sleep during the day and wake at
2. Where are you currently? night)
3. Who has come with you now? 3. Is there any abnormally confused
behaviour

Management:

• Detailed investigations to be done: Blood tests- Kidney functions, Complete blood

count, electrolytes, sugars
• Refer to a higher centre for evaluating the cause
• Brief pharmacological management: ONLY IF AGITATED/DISRUPTIVE-
T. Risperidone 0.5mg 0-0-1 to 1-0-1 or T. Haloperidol 0.5-1mg 0-0-1

2. Depression:

PATIENT FAMILY
Follow CSP screener

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Management:

• Relevant blood investigations to be carried out: CBC, RFT, sugars, electrolytes

• Start T. Escitalopram 5mg for 2 weeks, then increase to 10mg 0-0-1
OR T. Fluoxetine 10mg for 2 weeks, then 20mg 1-0-0
If sleep disturbance: T. Clonazepam 0.25mg 0-0-1
• If there is a high suicidal risk or decline in personal care- refer to a higher centre

3. Anxiety:
• Introduction- one of the most common symptoms in the elderly, especially fear of falls,
health anxiety, worries related to death
a) Health anxiety:
✓ Health anxiety disorders (e.g., hypochondriasis) are prevalent, and have a late age onset.
✓ Typically arises following stress, serious illness, significant loss, or following exposure to
disease-related stimuli.
b) Fear of falling:
✓ Consists of moderate to severe fear with avoidance of multiple situations and activities
(approximately 3 %).

✓ The fear of falling is also impairing, limiting mobility, and contributing to functional
decline and institutionalization.

• Medical conditions to keep in mind for anxiety in the elderly- Stroke, Parkinson’s disease,
Angina, Arrhythmia, Asthma, Irritable Bowel Syndrome, metabolic abnormalities, and
vitamin deficiency states.
Management:

Pharmacological-
✓ SSRI- fluoxetine, escitalopram
Non-pharmacological-
o Lifestyle modifications: Sleep, diet, exercise, socialization, Structured daily activities
Patients should be referred if:

o Comorbid severe depression (and, at times, suicidality) is present.

o Anxiety disorder is severe and treatment-resistant. e.g., OCD.
o Concurrent serious medical illnesses and treatment need evaluation and management.

4. PSYCHOSIS:

PATIENT FAMILY
Follow CSP screener

• Management:
o To do investigations

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o Start. T Risperidone 0.5 to 2mg 0-0-1 in 2-4 weeks, depending on symptoms OR T.

Olanzapine 2.5mg to 5mg 0-0-1 in 2 weeks.
o If the risk of harm to self or others is, unmanageable- refer to a higher centre.
5. INSOMNIA:
Sleep disturbances are common in the elderly. Any change in routine, medical, or psychological
problems may worsen sleep.

Causes: physical (pain, frequent urination, breathing difficulty), psychiatric, environmental

causes (light, sound, uncomfortable bedding), medications

Interventions:
Nonpharmacological techniques- Sleep problems are pretty common; before considering
medications, explain sleep hygiene techniques, as illustrated in previous chapters

Pharmacological treatment:
Agents such as lorazepam, clonazepam, or diazepam may be used with caution.
T. Lorazepam 1mg 0-0-1 OR. T clonazepam 0.25 to 0.5mg 0-0-1.
Discourage continuation after one month.

6. Dementia:
Ask for the duration of symptoms and dysfunction because of the problems.

PATIENT FAMILY
1. Do you feel you have forgotten 1. Does he/she appear distracted?
things recently? 2. Is there slow decline in their higher mental
2. Do you misplace things in the functions especially memory?
house? 3. Does he/she forget ways/get lost in the
3. Are you able to do your previous house?
activities well- cooking, shopping, 4. Are there any changes noticed in their
household chores, dressing, and speech- naming difficulty, asking questions
using the phone (if applicable) ? repeatedly?
5. Is he/she able to do ADL themselves?
6. Any behavioural disturbance- insomnia,
irritability, aggression, etc.

ADL: Activities of Daily Living, e.g., sleeping, eating, bathing, toileting

Management:

• Relevant blood investigations to be carried out: CBC, RFT, sugars, and electrolytes to
rule out other causes.
• Refer to a higher centre for a detailed evaluation of dementia

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II. INTERVENTIONS AND TIPS FOR THE CAREGIVERS:

✓ Empathetic listening towards the caregivers' account of their feelings and what they
are concerned about disturbed behaviours.
✓ Reassure the families that these behaviour problems are common during old age.
✓ Ensuring dignity and privacy (especially during activities such as dressing and
bathing).
✓ Establishing a daily routine.
✓ Safety: Keeping a chair to sit while bathing, a mat to prevent slipping, etc
✓ Speak slowly and clearly; if the person has not understood, try to say things using
simpler words and shorter sentences. Minimise background noise.
✓ Use of identification bracelet/necklace in case of a history of wandering
behaviour and getting lost.
✓ Locking doors in the night- in case of wandering.
✓ Use clothes that can be easily removed.
✓ Limiting water intake in the evening and night.
✓ Use of bed-pan if needed.
✓ Try and identify the triggers for anger and avoid it. Identify activities that
soothe them: e.g., music/ walking.
✓ Use memory aids such as labelling doors to the bathroom or a writing board in
the room on which today’s day and date are written every day.

REFERENCES
1. Issac TG, Ramesh A, Reddy SS, Sivakumar PT, Kumar CN, Math SB. Maintenance and
Welfare of Parents and Senior Citizens Act 2007: a critical appraisal. Indian Journal of
Psychological Medicine. 2021 Sep;43(5_suppl):S107-12.
2. International Institute for Population Sciences (IIPS), National Programme for Health Care
of Elderly (NPHCE), MoHFW, Harvard T. H. Chan School of Public Health (HSPH), and
the University of Southern California (USC) 2020. Longitudinal Ageing Study in India
(LASI) Wave 1, 2017-18, India Report, International Institute for Population Sciences, Mu

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Chapter 8.2: Neuro-Developmental Disorders, Behavioural & Emotional Disorders Of

Childhood

The central nervous system of a child develops in five domains, namely fine motor, gross
motor, language, social, and cognitive domains called developmental milestones. These
domains correspond to a certain group of neuronal connections and areas of the brain. Damage
to all or a few of these connections and brain areas during their development from birth leads
to Neurodevelopmental disorders. These disorders, which can be identified by parents,
teachers, and doctors, are generally overseen, leading to a missed diagnosis.
Behavioural disorders are disturbances or changes in the behaviour of a child causing
significant distress in themselves, at home, or in other social circumstances, including school.
It includes any of the following: inability to concentrate, being easily distracted, not being
able to control urges, not obeying parents, teachers, or other elders, being involved in fights,
lying, stealing, or other such notorious behaviours. It could be a result of various factors
interplaying with each other, including parenting styles, the conflict between parents or family
members, etc.
Emotional disorders are disorders in which children experience excessive and prolonged
sadness and fear while facing stressful situations in their lives. This shall impact their
performance at school and behaviour at home, which shall reduce or increase based on their
in-born abilities and available family support.

As children are still learning about emotions and mastering them, they tend to have difficulty
in expressing internal emotional states/feelings verbally; symptoms usually manifest as
behavioural/physical symptoms. Hence, the majority of the parents do not recognize the needs
of their children and respond to them in a harsh and punitive manner which leads to children,
in turn, reacting with more unmanageable acts and emotions, making it a vicious cycle.
Moreover, all these disorders can coexist and can be potential risk factors for each other. Also,
NDD can have medical comorbidities like seizures, cerebral palsy, congenital heart disease,
genetic syndromes, and metabolic and endocrine abnormalities, which can interfere with the
natural growth trajectory of the child.

SUB-TYPES
Types of Neurodevelopmental disorders:

1. Specific Learning Disorder (SLD)

2. Intellectual Developmental Disorder(IDD)
3. Autism Spectrum Disorder (ASD)

4. Specific disorders of language development

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Figure: Steps to assess & manage neurodevelopmental disorders

Types of Behavioural Disorders:

1. Attention Deficit Hyperactivity Disorder (ADHD)

• Inattention:
o Difficulty in paying attention while talking or doing a task
o Difficulty in concentrating on studies
o Often misplacing or forgetting items
o Easily distracted
• Hyperactivity:
o Talking excessively, interrupting while others are talking
o Not able to sit in a place (Always ‘on the go’)
o Feeling fidgety when controlled
• Impulsivity
o Not able to wait for his/her turn in games
o Doing things without thinking about the consequences
• Poor planning and organization of routine and academic responsibilities
• All these symptoms are present at home and school
2. Oppositional Defiant Disorder (ODD)

• Irritable and angry mood or becoming easily annoyed

• Argumentative (talking back) on parents, deliberately annoys them
• Wanting to hurt somebody without good reason (vindictive)
• But NO lying, stealing, or being involved in bullying or fights
• NO causing cruelty to other children or animals seen

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3. Conduct Disorder (CD)

• Involving in fights and bullying with peers

• Not following rules
• Lying, stealing, causing damage to properties
• Causing cruelty to animals or other children
• Disobedient and throwing temper-tantrums

Types of Emotional Disorders:

1. Depression: crying, irritability, dull appearance, less interaction and spending time alone,
poor study performance, disturbed appetite and sleep, suicidal thoughts

2. Anxiety: anxious about daily activities (studies, the health of oneself & parents, etc.), not
wanting to sleep alone or go to school, avoiding anxiety-provoking situations
3. Conversion Disorder – unresponsive episodes, abnormal movements, hyperventilation
episodes

RISK FACTORS

Risk factors for Neuro-Developmental Disorders:

• History of premature birth

• Low birth weight
• Birth asphyxia
• Postnatal infection
• History of seizures or neonatal ICU admission

Risk Factors for Behavioural & Emotional Disorders :

• Biological: History of Depressive disorder/anxiety disorder in one or both parents

• Child (individual) characteristics: inferiority complex, stubborn thinking, sensitivity to
criticism
• Parenting and family factors: Harsh, over-controlling, or over-protective parenting, critical
nature of communication, physical disciplining, excessive social and academic demands,
and expectations
• Social factors: peer rejection, neglect by teachers, bullying experiences
• Stressors/Negative life events: death of loved ones, parental divorce, fights or job loss,
adverse events in school like poor academic performance

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LIFETIME CONSEQUENCES
Lifetime impact if not identified and treated:

Area Impact

Educational achievement Lower attainment; higher rates of school

dropout

Occupational adjustment Higher unemployment; frequent job changes

Marital adjustment Higher rates of separation, divorce

Social adjustment Less contact with relatives, friends

Physical health Higher rates of hospitalization, mortality in non-

communicable diseases

Mental health Higher rates of psychiatric disorders in

adulthood

Conflict with the law (Behavioural Arrests, rates of driving while intoxicated
disorders)

Substance use Smoking tobacco, cannabis, consuming alcohol

Inter-generational More children with similar problems

GUIDELINES FOR BRIEF MANAGEMENT

A. Addressing the distress of Parents:

Do's for Addressing Parents' Distress Don'ts for Addressing Parents' Distress

Provide a Safe Space - Avoid Blame

Create a safe environment for parents by using Important to address any guilt or self-blame
counselling skills described before which parents might have about the child’s
condition

Prioritize Parental Mental Health – Discourage Expression –

Provide parents with resources to local support

groups. Regularly check mental health of

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parents and help them to seek help in case of any Let the parents express their concerns freely
issues. in the consultation by creating a non-
judgement atmosphere

Offer Practical Solutions – Disregard Self-Care -

Help them to learn problem solving coping It is important to ensure that the parents have
strategies as described in the chapter on LIPI healthy self-care practices like regular
exercise, sufficient sleep and balanced
nutrition

Encourage Open Discussions. – Ignore Practicality –

Help parents to have open communication It is important to help parents set realistic
between each other, without engaging in fights expectations for their child and have practical
or blaming each other solutions for the problems they are facing

B. Educating the Parents on Neurodevelopmental Disorders (working through stigma)

Educating Parents on Neurodevelopmental Disorders (NDD) and Overcoming

Stigma
About NDD and Management
- NDD stems from brain damage before, during, or after birth; no cure via
medicine/surgery.
- Train children for daily self-care and independence, despite longer learning times.
- Consult specialists for medical/psychiatric aspects like seizures or ADHD.
- Balance discipline, set limits, avoid overprotection/permissiveness.
- Identify and encourage child's strengths and interests
Working Through Stigma
- Clear misconceptions about NDD.
- Stress NDD isn't child/parents' fault.
- Foster open discussions for reduced stigma and better understanding.
- Share success stories to inspire hope.
- Advocate inclusivity at home and in the community.
- Connect parents with support

C. Educating the Parents on Behavioural & Emotional Disorders (working through stigma)

• As children grow, they can feel stressed from school, friends, and family. How parents
act matters—being supportive helps a lot.

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• Talk openly with children about feelings, and be patient.

• Understand that children grow differently.
• Symptoms are real but they may have psychological roots
• Help children face challenges step by step.
• Explain to children it's okay to feel good about themselves, not just when they do well
in school.
• If a child talks about hurting themselves or feeling really down, teach them to ask for
help.
• If things stay tough, a Psychiatrist can help.
• Remind children to have routines, get enough sleep, relax, and have fun hobbies.

REFERRAL
How to refer children' ‘at risk’ for neuro-developmental disorders?

• Assess for the delay in developmental milestones

• DO NOT advise, ‘Let’s wait and watch.’
• Do Brief Management with Parents
• Refer the child to a Psychiatrist for further intervention
• If confident, can refer to Speech and/or Occupational therapist directly
• If necessary, refer the child to Paediatrician in case of comorbid physical ailments
• Arrange a follow-up if interested.

How to refer children ‘at risk’ for Behavioural & Emotional Disorders?

• Identify symptoms and assess for risk factors

• DO NOT advise, ‘Let’s wait and watch.’
• Do Brief Management with Parents
• Refer the child to a Psychiatrist or a Clinical Psychologist for further intervention.
• If necessary, refer the child to Paediatrician in case of comorbid physical ailments.
• Arrange a follow-up if interested.

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Identification of
the disorder

Understanding the
Risk factors

Addressing the
distress of Parents

Educating the
Parents regarding
the Disorder

Refer
Appropriately

Flowchart 1: Overview of the Approach to Children with Psychiatric Disorders

REFERENCES
1. Kiragasur RM, Kommu JV, CN Kumar, Shetty VB, Parthasarathy R, Math SB. Child and
Adolescent Mental Health: A Manual for Medical officers. National Institute of Mental Health
and Neuro Sciences. Bengaluru: NIMHANS Publication no. 176; 2020 (ISBN: 978-81-945815-8-
1).

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Applicability Of Mental Health Care Act (2017) in the Primary Health Care

MHCA, 2017 was passed by the Parliament of India on April 7, 2017. It has been in force
since 29 May 2018; hence this chapter is written keeping in mind the challenges and
opportunities encountered by a PHC doctor in the application of MHCA, 2017 at the
grassroots level.

No individual can be treated against his or her wish unless there is an emergency or a life-
threatening situation. The right to refuse medical treatment is a fundamental right. Article 21,
Right to Life and Liberty, lays down that no person shall be deprived of his life or personal
liberty. The restrictions may be imposed on the fundamental rights only in pursuance of law,
and limitations must not be arbitrary, unfair, or unreasonable. Deprivation of Article 21 (Right
to life and personal liberty) can only be practised under the ‘procedure established by law.
This procedural law is the Mental Healthcare Act 2017 which has laid down the procedures
for the registration of Mental Health Professionals (MHP), registration of Mental Health
Establishments (MHE), admission and discharge, and Rights of Persons with Mental Illness.
The preamble of the Mental Healthcare Act 2017 says, “It is an act to provide mental
healthcare and services for persons with mental illness and to promote and fulfil the rights of
such persons during delivery of mental healthcare and services.

Application Of MHCA in Primary Health Care

1. Emergency Treatment For The Mentally Ill (SECTION 94)
Any Medical Officer can treat a person with Mental Illness (PMI) in any place, including the
community. Emergency treatment is initiated where it is immediately necessary to prevent—
(a) Death or irreversible harm to the health of the person; or
(b) The person inflicting serious harm to himself or others; or

(c) The person causing serious damage to property belonging to himself or to others where
such behaviour is believed to flow directly from the person’s mental illness.
Emergency treatment is limited to 72 hours or till the time the patient reaches the Mental
Health Establishment, whichever is earlier. This time of 72 hours also includes time for
transportation of the person with mental illness to the nearest Mental Health Establishment. If
a Medical Officer needs to admit the patient, PHC should be registered as a Mental Health
Establishment. If PHC is unregistered as a Mental Health Establishment, a referral for
admission needs to be made to the nearest MHE after providing emergency care. However,
MHCA does not bar treatment in PHC, the community, and camps.

In an emergency, the patient can be sedated with an I.M./I.V. Injection of haloperidol (5-10
mg) or an I.M./I.V. injection of lorazepam(2-4 mg)

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2. Role of PHC Doctor During Admission

A. Voluntary Admission
As per section 86 of the MHCA,2017, a PHC doctor alone can authorize voluntary admission
of a person with mental illness (PMI) but only in a PHC registered as a mental establishment.
B. Involuntary Admission
As per sections 89 and 90 of the MHCA,2017, in case of involuntary admission, a PHC doctor
alone cannot authorize the admission of a PMI.
3. Follow-Up Care

Patients can be seen by a doctor at PHC or referred to a Mental Health Establishment for
follow-up care. Home visits can be done to provide follow-up care. Under section 18,
subsection 10, PHC needs to maintain a stock of Essential drugs to be made available to all
persons with mental illness free of cost (Appendix II).

4. Rights Of Persons With Mental Illness (Section 18- 28)

● Section 18: Right to Access Mental Healthcare
Ensure mental health services are affordable, high-quality, abundant, and accessible to
all, without discrimination based on various factors such as gender, sex, sexual
orientation, religion, culture, caste, social or political beliefs, class, disability or any
other basis. Delivery should be acceptable to individuals with mental illness, their
families, and caregivers.

● Section 19: Right to Community Living

A PMI (Person with Mental Illness) cannot be restricted to an MHE (Mental Health
Evaluation) just because he is homeless, abandoned by family, or due to a lack of
community-based facilities. The government shall provide for less restrictive
community-based establishments like halfway homes, group homes, etc. The
government would provide support and legal aid for facilitating the right to the family
home and living in the family home.

● Section 21: Right to Equality and Non-Discrimination

Emergency and ambulance services must be provided at par with those provided to
patients with physical illnesses. Insurers need to provide insurance for mental illness
on the same basis as is available for physical illness.

● Section 22: Right to Information

PMI and the relative (Nominated Representative) have the right to information about
the mental illness, proposed treatment, and the side effects in the language they
understand.

● Section 23: Right to Confidentiality

A PMI has the right to confidentiality in respect of mental illness and treatment.
Exceptions can be made when information is needed by a relative for making treatment

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decisions, when there is a threat to the life of the patient or others, or when information
needs to be shared with other MHPs or health professionals for treatment purposes.
Only such information as is necessary should be released.

● Section 24: Restriction on The Release of Information in Respect Of Mental

Illness
No photograph or any other information, including that stored in digital format, shall
be released to media without the consent of the patient.

● Section 25: Right to Access Medical Records

All doctors working at PHC need to maintain minimum basic records even if the
patient is seen in an emergency or on an OPD basis. The patient has the right to access
basic medical records.

● Section 27: Right to Legal Aid

A person with mental illness shall be entitled to receive free legal services to exercise
any of his rights under this Act.

5. Wandering Mentally Ill (Section 100)

A wandering Mentally Ill person shall be taken under the protection of the officer-in-charge
of the area police station and be brought to the public health establishment for assessment
within 24 hours. Such a person cannot be detained in lock-up or prison under any
circumstances. The medical officer at PHC will be responsible for arranging the assessment
of the person. Further treatment - Emergency or, if admission is needed, may be provided by
the PHC doctor as per the provisions of the act as discussed above.
It is the duty of the police officer in charge to trace the family members and inform them about
the whereabouts of the PMI. For a homeless PMI, once treatment is completed, it is the duty
of the officer-in-charge to take the person to a government establishment for homeless
persons.
7. SUICIDE (SECTION 115)

A person with an attempt to suicide will be presumed to be suffering from severe mental stress.
The appropriate Government shall have a duty to provide care, treatment, and rehabilitation
to a person who has severe stress and who attempted suicide to reduce the risk of recurrence
of the attempt to commit suicide.

REFERENCES

1. Mental Health Act,1987- https://egazette.nic.in/WriteReadData/2017/175248.pdf

2. Oxford Handbook of Psychiatry 4th Edition

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3. Math SB, Murthy P, Chandrashekar CR. Mental health act (1987): Need for a paradigm shift
from custodial to community care. The Indian Journal of medical research. 2011
Mar;133(3):246.
4. Math SB, Chaturvedi SK. Euthanasia: right to life vs. right to die. The Indian Journal of
medical research. 2012 Dec;136(6):89

Click on the topic or scan QR code below to learn more about MHCA 2017:

MHCA 2017

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Collaborative Care – Tele MANAS

The term 'Primary Care' means the provision of essential healthcare made universally
accessible to individuals and acceptable to them. It involves the community’s full participation
and should be affordable at every stage of development. Mental health conditions are often
underdiagnosed in primary care despite their higher prevalence (30-40%). Among the mental
health conditions, Common Mental Disorders (CMDs) are found to be comorbid with many
medical disorders (Hypertension, Diabetes Mellitus, etc.), and their prompt recognition and
treatment are imperative for the overall well-being of the patient.
The innovations in the training of primary health officers continue to evolve, with current
examples being the use of telepsychiatry services to train doctors in real-time in their clinics.
This model of digital training of primary care doctors is being successfully organized in
various states like Karnataka, Chhattisgarh, Bihar, Uttarakhand, Punjab, etc.,
The COVID-19 pandemic resulted in an increase in mental health issues in the country.
However, it also resulted in the acceptability of tele-mental health services. To deal with the
increasing mental health problems and provide quality mental health services, the government
of India conceptualized providing digital mental health services through Tele MANAS.

National Tele Mental Health Programme of India; Tele Mental Health Assistance and
Networking Across States (Tele MANAS):
Tele MANAS is a digital arm of the NMHP. It was announced as an extension to the service
delivery framework of the existing NMHP in the Union Budget in February 2022. It aims to
provide universal access to equitable, accessible, affordable, and quality mental healthcare
through 24/7 tele-mental health counselling services as a digital component of the National
Mental Health Programme (and its operational arm, DMHP) across all Indian States and UTs
with assured linkages.

Objectives of Tele MANAS:

1. To exponentially scale up the reach of mental health services to anybody who reaches
out across India, any time, by setting up a 24x7 tele-mental health facility in each of
the States and UTs of the country.
2. To implement a fully-fledged mental health service network that, in addition to
counselling, provides integrated medical and psychosocial interventions, including
video consultations with mental health specialists, e-prescriptions, follow-up services,
and linkages to in-person services.
3. To extend services to vulnerable groups of the population and difficult-to-reach
populations.

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Workforce and components:

Workforce/human resources under Tele MANAS is divided into two tiers based on the level
of the services provided (counselling, psychiatric consultation, along with pharmacotherapy/
psychotherapy) and the expertise. Tier-1 will comprise the State Tele MANAS cells, which
include trained counsellors and mental health specialists. Tier 2 will comprise specialists at
DMHP/Medical College resources for physical consultation and/or e-Sanjeevani for audio-
visual consultation.

Tele-Mental health services include providing advice, counseling, connecting with a mental
health professional for telepsychiatry services, and enabling people to seek help when it is not
possible for them to come physically to a hospital or a help centre.

Beneficiaries of Tele MANAS:

Any individual with mental health issues can reach out to Tele MANAS services for help.
Primary healthcare providers such as MBBS primary care doctors (PCD), AYUSH healthcare
providers, nurses, and grass root healthcare providers/community health providers, i.e.,
Accredited Social Health Activists (ASHAs) may al reach out to Tele MANAS, wherein
collaborative care shall be provided to the individual.

Relevance to Primary Care Doctors:

Convenience: Receiving care in a primary care setting may be more convenient for some
individuals, as it may be easier to access than a specialized psychiatric clinic.

Continuity of care: By receiving care from a primary care psychiatrist, individuals can
establish a long-term treatment relationship and receive care that is coordinated with their
other medical care.

Early intervention: By identifying and treating mental health conditions early on, primary
care psychiatrists can help prevent more serious mental health issues from developing.

Integration with physical health care: Primary care psychiatry allows for the integration
of mental and physical health care, as the primary care psychiatrist can work closely with
the individual's primary care physician to ensure that all of their health needs are met.

Cost: Receiving care in a primary care setting may be less expensive than receiving care in
a specialized psychiatric clinic.

If, at any time, the PCD feels like they might need support in managing a person with a
probable mental health condition, they can seek Tele MANAS services and do collaborative
consultations with a mental health professional.

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REFERENCES
1. Jayasankar, P., Manjunatha, N., Rao, G. N., Gururaj, G., Varghese, M., Benegal, V., &
Group, N. I. N. C. (2022). Epidemiology of common mental disorders: Results from
“National Mental Health Survey” of India, 2016. Indian Journal of Psychiatry, 64(1), 13.
2. Parthasarathy, R., Channaveerachari, N. K., Manjunatha, N., Sadh, K., Kalaivanan, R. C.,
Gowda, G. S., ... & Thirthalli, J. (2021). Mental health care in Karnataka: Moving beyond
the Bellary model of District Mental Health Program—Indian Journal of Psychiatry, 63(3),
212.
3. Math S B, Manjunatha N, Kumar C N, Basavarajappa C, Gangadhar B N. Telepsychiatry
operational guidelines - 2020. Bengaluru: NIMHANS; 2020.
4. Tele MANAS: India’s First 24X7 Tele Mental Health Helpline Brings New Hope for
Millions Tarannum Ahmed , Neha Dumka , Atul Kotwal Operational guidelines NIMHANS
Online: https://telemanas.mohfw.gov.in/

Click on the topic or scan QR code below to learn more about Tele-MANAS:

Tele-MANAS

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APPENDIX I
CLINICAL SCHEDULES FOR PRIMARY CARE
PSYCHIATRY (CSP v2.4)
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APPENDIX II
ESSENTIAL DRUG LIST
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APPENDIX III
SAD PERSONS SCALE
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SAD PERSONS SCALE

The ‘sad persons scale’ is an attempt to assist non-psychiatrists in assessing suicide risk. It
may help as a guide regarding the need for referral or admission.

• S Sex Male
• A Age <19 Or >45
• D Depression
• P Previous Attempt
• E Ethanol
• R Rational Thinking Loss
• S Social Supports Lacking
• O Organised Plan
• N No Partner
• S Sickness

Score one point for each factor. The total score ranges from 0 (very little risk) to 10 (very high
risk).
Guidelines for Action with the scale:

Total points Proposed clinical action

0-2 Send home with appropriate follow-up
3-4 Close follow-up; Consider hospitalisation
5-6 Strongly consider hospitalisation depending on confidence in follow-up
arrangement
7-10 Admit to hospital

NB. This is a guide only and should not be used to replace clinical judgement.
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APPENDIX IV
TELEMANAS POSTER
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APPENDIX V
ADDITIONAL RESOURCES
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For more information, scan the QR code to explore additional manuals published by NIMHANS
Digital Academy, addressing various topics relevant to primary care doctors, including Suicide
Prevention, Child and Adolescent Health, and more.
 Primary Care Psychiatry: A Clinician’s Companion

FEEDBACK

“As an Assistant Professor, Department of Community Medicine and

Family Medicine, AIIMS Kalyani, I work at the Community Mental Health
and Deaddiction Centre in Urban Primary Health Care Centre. This manual
will enable us to cater to the mental health needs of those in need and
reduce the treatment gap in the community.” - Dr Ashish Pundhir (Batch
35), Diploma in Community Mental Health for Doctors

“This manual is a treasure for life as it will serve as a resource we can keep
going back to easily, as and when required, to revise and consolidate our
concepts in basic mental healthcare.”- Dr Deepali Goel (Batch 38),
Diploma in Community Mental Health For Doctors

“The manual is written in a crisp and precise manner. Topics of relevance,

such as depression, anxiety, and insomnia, that are commonly encountered
in primary care practice are covered in depth. This will be an invaluable
resource for all primary care doctors.” - Dr. Rini Raveendran (Batch 31),
Diploma in Community Mental Health For Doctors
Primary Care Psychiatry: A Clinician’s Companion