Letters to Editor
7. 8.
9.
inpatient population with hysteria in India. J Am Acad Child Adolesc Psychiatry 1993;32:822‑5. Mendhekar DN, Gupta D, Girotra V. Sertraline‑induced hypomania: A genuine side‑effect. Acta Psychiatr Scand 2003;108:70‑4. Oedegaard KJ, Neckelmann D, Benazzi F, Syrstad VE, Akiskal HS, Fasmer OB. Dissociative experiences differentiate bipolar‑II from unipolar depressed patients: The mediating role of cyclothymia and the Type A behaviour speed and impatience subscale. J Affect Disord 2008;108:207‑16. Jans T, Schneck‑Seif S, Weigand T, Schneider W, Ellgring H, Wewetzer C, et al. Long‑term outcome and prognosis of dissociative disorder with onset in childhood or adolescence. Child Adolesc Psychiatry Ment Health 2008;2:19.
Access this article online Quick Response Code Website: www.indianjpsychiatry.org
DOI: 10.4103/0019-5545.148548
Accounting for confounding Sir, Went through an article entitled “impact of psychiatry training on attitude of medical students toward mental illness and psychiatry” published in Indian Journal of Psychiatry.[1] The authors deserve credit for touching on the important issue of “role of training” in medical sciences. However, I have a concern. The authors stated aims are: (1) To compare the attitude of medical students and interns in a medical college toward mental illness and psychiatry and (2) to assess the impact of psychiatric training on attitude toward the mentally ill person and mental illness. The authors have done full justice to the first aim of this study in presenting comparable data about the attitude of medical students and interns. However, the second aim of this study, that is, impact assessment has been handled inadequately. The fact that the difference between attitudes of interns and undergraduate medical students (not yet fully exposed to clinical subjects) can provide an idea on impact of training, does not seem logical. The comparison groups are diverse enough to be included for comparison. The fact that interns have undergone clinical training in other disciplines (other than psychiatry) during their under graduation as well as internship period may influence their attitude to psychiatry and mental illness as well and thus act as a confounder in this study. This has not been accounted for in the study. In statistics, a confounder is an extraneous variable that correlates (directly or inversely) with both the dependent variable and the independent variable. A perceived relationship between an independent
variable and a dependent variable that has been misestimated due to the failure to account for a confounding factor, gives rise to a spurious relationship. The methodology to estimate the impact of psychiatry training should have been modified and study could have been conducted on interns only before and after they had received their training in psychiatry.
Sunil Kumar Raina
Department of Community Medicine, Dr. RPGMC, Tanda, Kangra, Himachal Pradesh, India E‑mail: [email protected] REFERENCE 1.
Gulati P, Das S, Chavan BS. Impact of psychiatry training on attitude of medical students toward mental illness and psychiatry. Indian J Psychiatry 2014;56:271‑7.
Access this article online Quick Response Code Website: www.indianjpsychiatry.org
DOI: 10.4103/0019-5545.148549
Pregabalin dependence with pregabalin induced intentional self‑harm behavior: A case report Sir, Pregabalin is a novel gamma amino butyric acid (GABA) analogue which is used for neuropathic pain and partial onset seizures.[1,2] Drug enforcement agency has categorized pregabalin as a schedule V drug under the terms 110
of controlled substances act. In 2008, US Food and Drug Administration announced a class warning regarding increased risk of suicidality in patients on pregabalin with epilepsy and psychiatric disorders.[3] This case report describes a case of pregabalin dependence with pregabalin induced intentional self-harm behavior. Indian Journal of Psychiatry 57(1), Jan-Mar 2015
Letters to Editor
A 30‑year‑old married male was brought by his mother with a history of pregabalin dependence since 4 years. Patient was started on 75 mg of pregabalin for neuropathic pain in temporomandibular joint. As he experienced euphoria and increased energy levels after pregabalin consumption, his consumption increased to 20 capsules (equivalent to 1500 mg) at irregular intervals per day over the period of 1 year and since last 2 years his consumption increased to 40 capsules (equivalent to 3000 mg) per day due to tolerance to pregabalin. He would experience withdrawal symptoms such as palpitations, restlessness, and dysphoria on missing the doses. After continuous use of 3 years of pregabalin, patient attempted suicide by consuming organophosphorus compound on two occasions. There was no antecedent life event stressor. He had no past or family history of psychiatric illness or drug seeking behavior. On admission, mental status examination revealed that he was conscious, oriented with dysphoric mood, anxious affect, ideas of worthlessness and passive suicidal ideations. He was in the action stage of motivation that means he chose a strategy for change to remain abstinent from pregabalin and pursued it. His diagnosis according to International Classification of Disease‑10 criteria is mental and behavioral disorders due to use of pregabalin, independence, currently in uncomplicated withdrawal with intentional self‑poisoning (F19.20, 19.30, X68). On admission, his HAM A score was 19/56 HAM D score was 30/64, Beck suicide intent scale was 7/40. He was started on equivalent dose of pregabalin and gradually 75 mg of pregabalin was tapered on every alternate day. He was given antidepressants and motivational enhancement therapy and was successfully detoxified over a period of 2 months. Although, pregabalin has been labeled a schedule V drug (lowest abuse potential), our patient in the absence of any family or prior history of drug seeking behavior developed pregabalin dependence. It has stated that the GABAergic
effects due to pregabalin may cause positive reinforcement leading to abuse potential in some patients.[1,4] Tandon et al. in 2013 reported a case of pregabalin induced self‑inflicted multiple injuries over forearm after continuous use of pregabalin.[5] The probable mechanism explained for the self‑harm behavior is reduction of serotonin by pregabalin. Thus, our case highlights the abuse potential of pregabalin and risk of self‑harm behavior with its continuous use. It has the implication for the pregabalin use in pain disorders Hence, we recommend all clinicians to remain vigilant and mindful of the potential for abuse or dependence of pregabalin, while prescribing it for the patients, irrespective of their drug seeking behavior.
S. Ashwini, Dharmadhikari R. Amit, Netto S. Ivan, Pawar V. Alka
Department of Psychiatry, B. J. G. Medical College, Maharashtra Institute of Mental Health and Sassoon General Hospitals, Pune, Maharashtra, India E‑mail: [email protected] REFERENCES 1.
Gahr M, Franke B, Freudenmann RW, Kölle MA, Schönfeldt‑Lecuona C. Concerns about pregabalin: Further experience with its potential of causing addictive behaviors. J Addict Med 2013;7:147‑9. 2. Schifano F. Misuse and abuse of pregabalin and gabapentin: Cause for concern? CNS Drugs 2014;28:491‑6. 3. Patorno E, Bohn RL, Wahl PM, Avorn J, Patrick AR, Liu J, et al. Anticonvulsant medications and the risk of suicide, attempted suicide, or violent death. JAMA 2010;303:1401‑9. 4. Yargic I, Ozdemiroglu FA. Pregabalin abuse: A case report. Bull Clin Psychopharmacol Bull 2011;21:64‑6. 5. Tandon VR, Mahajan V, Gillani ZH, Mahajan A. Pregabalin‑induced self‑harm behavior. Indian J Pharmacol 2013;45:638‑9.
Access this article online Quick Response Code Website: www.indianjpsychiatry.org
DOI: 10.4103/0019-5545.148550
From benzodiazepine to pregabalin dependence: Different agents, similar problems Sir, The literature provides only few plausible case reports of pregabalin (PRG) abuse/dependence.[1‑4] Hence, further data are necessary to identify risk factors for the development Indian Journal of Psychiatry 57(1), Jan-Mar 2015
of PRG‑associated addictive behaviors. Here, we present a further case of a patient with PRG dependence. The 33‑year‑old female patient was diagnosed with borderline personality disorder approximately 10 years 111
Copyright of Indian Journal of Psychiatry is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
7. 8.
9.
inpatient population with hysteria in India. J Am Acad Child Adolesc Psychiatry 1993;32:822‑5. Mendhekar DN, Gupta D, Girotra V. Sertraline‑induced hypomania: A genuine side‑effect. Acta Psychiatr Scand 2003;108:70‑4. Oedegaard KJ, Neckelmann D, Benazzi F, Syrstad VE, Akiskal HS, Fasmer OB. Dissociative experiences differentiate bipolar‑II from unipolar depressed patients: The mediating role of cyclothymia and the Type A behaviour speed and impatience subscale. J Affect Disord 2008;108:207‑16. Jans T, Schneck‑Seif S, Weigand T, Schneider W, Ellgring H, Wewetzer C, et al. Long‑term outcome and prognosis of dissociative disorder with onset in childhood or adolescence. Child Adolesc Psychiatry Ment Health 2008;2:19.
Access this article online Quick Response Code Website: www.indianjpsychiatry.org
DOI: 10.4103/0019-5545.148548
Accounting for confounding Sir, Went through an article entitled “impact of psychiatry training on attitude of medical students toward mental illness and psychiatry” published in Indian Journal of Psychiatry.[1] The authors deserve credit for touching on the important issue of “role of training” in medical sciences. However, I have a concern. The authors stated aims are: (1) To compare the attitude of medical students and interns in a medical college toward mental illness and psychiatry and (2) to assess the impact of psychiatric training on attitude toward the mentally ill person and mental illness. The authors have done full justice to the first aim of this study in presenting comparable data about the attitude of medical students and interns. However, the second aim of this study, that is, impact assessment has been handled inadequately. The fact that the difference between attitudes of interns and undergraduate medical students (not yet fully exposed to clinical subjects) can provide an idea on impact of training, does not seem logical. The comparison groups are diverse enough to be included for comparison. The fact that interns have undergone clinical training in other disciplines (other than psychiatry) during their under graduation as well as internship period may influence their attitude to psychiatry and mental illness as well and thus act as a confounder in this study. This has not been accounted for in the study. In statistics, a confounder is an extraneous variable that correlates (directly or inversely) with both the dependent variable and the independent variable. A perceived relationship between an independent
variable and a dependent variable that has been misestimated due to the failure to account for a confounding factor, gives rise to a spurious relationship. The methodology to estimate the impact of psychiatry training should have been modified and study could have been conducted on interns only before and after they had received their training in psychiatry.
Sunil Kumar Raina
Department of Community Medicine, Dr. RPGMC, Tanda, Kangra, Himachal Pradesh, India E‑mail: [email protected] REFERENCE 1.
Gulati P, Das S, Chavan BS. Impact of psychiatry training on attitude of medical students toward mental illness and psychiatry. Indian J Psychiatry 2014;56:271‑7.
Access this article online Quick Response Code Website: www.indianjpsychiatry.org
DOI: 10.4103/0019-5545.148549
Pregabalin dependence with pregabalin induced intentional self‑harm behavior: A case report Sir, Pregabalin is a novel gamma amino butyric acid (GABA) analogue which is used for neuropathic pain and partial onset seizures.[1,2] Drug enforcement agency has categorized pregabalin as a schedule V drug under the terms 110
of controlled substances act. In 2008, US Food and Drug Administration announced a class warning regarding increased risk of suicidality in patients on pregabalin with epilepsy and psychiatric disorders.[3] This case report describes a case of pregabalin dependence with pregabalin induced intentional self-harm behavior. Indian Journal of Psychiatry 57(1), Jan-Mar 2015
Letters to Editor
A 30‑year‑old married male was brought by his mother with a history of pregabalin dependence since 4 years. Patient was started on 75 mg of pregabalin for neuropathic pain in temporomandibular joint. As he experienced euphoria and increased energy levels after pregabalin consumption, his consumption increased to 20 capsules (equivalent to 1500 mg) at irregular intervals per day over the period of 1 year and since last 2 years his consumption increased to 40 capsules (equivalent to 3000 mg) per day due to tolerance to pregabalin. He would experience withdrawal symptoms such as palpitations, restlessness, and dysphoria on missing the doses. After continuous use of 3 years of pregabalin, patient attempted suicide by consuming organophosphorus compound on two occasions. There was no antecedent life event stressor. He had no past or family history of psychiatric illness or drug seeking behavior. On admission, mental status examination revealed that he was conscious, oriented with dysphoric mood, anxious affect, ideas of worthlessness and passive suicidal ideations. He was in the action stage of motivation that means he chose a strategy for change to remain abstinent from pregabalin and pursued it. His diagnosis according to International Classification of Disease‑10 criteria is mental and behavioral disorders due to use of pregabalin, independence, currently in uncomplicated withdrawal with intentional self‑poisoning (F19.20, 19.30, X68). On admission, his HAM A score was 19/56 HAM D score was 30/64, Beck suicide intent scale was 7/40. He was started on equivalent dose of pregabalin and gradually 75 mg of pregabalin was tapered on every alternate day. He was given antidepressants and motivational enhancement therapy and was successfully detoxified over a period of 2 months. Although, pregabalin has been labeled a schedule V drug (lowest abuse potential), our patient in the absence of any family or prior history of drug seeking behavior developed pregabalin dependence. It has stated that the GABAergic
effects due to pregabalin may cause positive reinforcement leading to abuse potential in some patients.[1,4] Tandon et al. in 2013 reported a case of pregabalin induced self‑inflicted multiple injuries over forearm after continuous use of pregabalin.[5] The probable mechanism explained for the self‑harm behavior is reduction of serotonin by pregabalin. Thus, our case highlights the abuse potential of pregabalin and risk of self‑harm behavior with its continuous use. It has the implication for the pregabalin use in pain disorders Hence, we recommend all clinicians to remain vigilant and mindful of the potential for abuse or dependence of pregabalin, while prescribing it for the patients, irrespective of their drug seeking behavior.
S. Ashwini, Dharmadhikari R. Amit, Netto S. Ivan, Pawar V. Alka
Department of Psychiatry, B. J. G. Medical College, Maharashtra Institute of Mental Health and Sassoon General Hospitals, Pune, Maharashtra, India E‑mail: [email protected] REFERENCES 1.
Gahr M, Franke B, Freudenmann RW, Kölle MA, Schönfeldt‑Lecuona C. Concerns about pregabalin: Further experience with its potential of causing addictive behaviors. J Addict Med 2013;7:147‑9. 2. Schifano F. Misuse and abuse of pregabalin and gabapentin: Cause for concern? CNS Drugs 2014;28:491‑6. 3. Patorno E, Bohn RL, Wahl PM, Avorn J, Patrick AR, Liu J, et al. Anticonvulsant medications and the risk of suicide, attempted suicide, or violent death. JAMA 2010;303:1401‑9. 4. Yargic I, Ozdemiroglu FA. Pregabalin abuse: A case report. Bull Clin Psychopharmacol Bull 2011;21:64‑6. 5. Tandon VR, Mahajan V, Gillani ZH, Mahajan A. Pregabalin‑induced self‑harm behavior. Indian J Pharmacol 2013;45:638‑9.
Access this article online Quick Response Code Website: www.indianjpsychiatry.org
DOI: 10.4103/0019-5545.148550
From benzodiazepine to pregabalin dependence: Different agents, similar problems Sir, The literature provides only few plausible case reports of pregabalin (PRG) abuse/dependence.[1‑4] Hence, further data are necessary to identify risk factors for the development Indian Journal of Psychiatry 57(1), Jan-Mar 2015
of PRG‑associated addictive behaviors. Here, we present a further case of a patient with PRG dependence. The 33‑year‑old female patient was diagnosed with borderline personality disorder approximately 10 years 111
Copyright of Indian Journal of Psychiatry is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
