Deep brain stimulation (DBS) has been proposed to improve symptoms of obsessive–compulsive disorder (OCD) but is not yet an established therapy.

To identify relevant guidelines and assess their recommendations for the use of DBS in OCD.

Medline, Embase, American Psychiatric Association PsycInfo and Scopus were searched, as were websites of relevant societies and guideline development organisations. The review was based on the PRISMA recommendations, and the search strategy was verified by a medical librarian. The protocol was developed and registered with PROSPERO (CRD42022353715). The guidelines were assessed for quality using the AGREE II instrument.

Nine guidelines were identified. Three guidelines scored >80% on AGREE II. ‘Scope and Purpose’ and ‘Editorial Independence’ were the highest scoring domains, but ‘Applicability’ scores were low. Eight guidelines recommended that DBS is used after all other treatment options have failed to alleviate OCD symptoms. One guideline did not recommend DBS beyond a research setting. Only one guideline performed a cost-effectiveness analysis; the other eight did not provide details on safe or effective DBS protocols.

Despite a very limited evidence base, eight of the nine identified guidelines supported the use of DBS for OCD as a last line of therapy; however, multiple aspects of DBS provision were not addressed.

Low and middle-income countries (LMICs) hold the majority of disease burden attributed to major depressive disorder (MDD). Despite this, there remains a substantial gap for access to evidence-based treatments for MDD in LMICs like Pakistan. Measurement-based care (MBC) incorporates systematic administration of validated outcome measures to guide treatment decision making and is considered a low-cost approach to optimise better clinical outcomes for individuals with MDD but there is a paucity of evidence on the efficacy of MBC in LMICs.

This protocol highlights a randomized trial which will include Pakistani outpatients with moderate to severe major depression.

Participants will be randomised to either MBC (guided by schedule), or standard treatment (guided by clinicians’ judgement), and will be prescribed with paroxetine (10–60mg/day) or mirtazapine (7.5–45mg/day) for 24 weeks. Outcomes will be evaluated by raters blind to study protocol and treatment.

National Bioethics Committee (NBC) of Pakistan has given full ethics approval. The trial is being conducted and reported as per recommendation of the CONSORT statement for RCTs.

With increasing evidence from high-income settings supporting the effectiveness of MBC for MDD, it is now necessary to explore its feasibility, utility. and efficacy in low-resource settings. The results of the proposed trial could inform the development of a low-cost and scalable approach to efficiently optimise outcomes for individuals with MDD in Pakistan.

None Declared

Bipolar disorder (BD) is a source of marked disability, morbidity, and premature death. There is a paucity of research on personalized psychosocial interventions for BD, especially in lowresource settings. A previously published pilot randomized controlled trial (RCT) of a Culturally adapted PsychoEducation (CaPE) intervention for BD in Pakistan reported higher patient satisfaction, enhanced medication adherence, knowledge and attitudes towards BD, and improvement in mood symptom scores and health-related quality of life measures compared to treatment-as-usual (TAU).

This protocol describes a larger multicentre RCT to confirm the clinical and cost-effectiveness of CaPE in Pakistan.

A multicentre individual, parallel arm, RCT of CaPE in 300Pakistani adults with BD. Participants over the age of 18, with adiagnosis of bipolar I and II and who are currently euthymic, will berecruited from seven sites including Karachi, Lahore, Multan, Rawalpindi,Peshawar, Hyderabad and Quetta. Time to recurrence will be the primaryoutcome assessed using Longitudinal Interval Follow-up Evaluation(LIFE). Secondary measures will include mood symptomatology, qualityof life and functioning, adherence to psychotropic medications, andknowledge and attitudes towards BD.

Full ethics approval has been received from National Bioethics Committee (NBC) of Pakistan and Centre for Addiction and Mental Health (CAMH), Toronto, Canada. The study has completed sixty-five screening across the seven centres, of which forty-eight participants have been randomised.

A successful trial will lead to rapid implementation of CaPE in clinical practice, not only in Pakistan, but also in other low-resource settings including those in high-income countries, to improve clinical outcomes, social and occupational functioning, and quality of life in South Asian and other minority patients with BD.

None Declared

Deep brain stimulation (DBS), an invasive neurosurgical treatment where electrical stimuli are delivered in target brain areas, is an intervention that has traditionally been used for neurological movement disorders, but that has recently been considered for the management of psychiatric conditions, one of these being obsessive compulsive disorder (OCD). This review aimed to identify and assess clinical practice guidelines on the use of DBS for OCD, and, secondly, whether or not recommendations are tailored to individual patient characteristics, such as age, gender and comorbidities.

A systematic search of MEDLINE, EMBASE, APA Psych Info and Scopus was conducted, along with guideline development organisation websites, using all relevant synonyms of: “Guideline and DBS and OCD”. Studies were assessed by two independent reviewers, and discrepancies managed by a third reviewer. The protocol was registered with PROSPERO, following the PRISMA checklist. Included guidelines were appraised using the AGREE-II instrument.

Nine guidelines were identified in total. Eight recommended DBS as a last-line option in the management of OCD, whilst the National Institute for Health and Care Excellence (NICE) recommended DBS should be used for research purposes only in OCD. Variability in the recommendations was also noted; indeed, only NICE undertook a cost-effectiveness analysis, and only the Congress of Neurological Surgeons (CNS) recommended target areas for electrode placement (i.e. subthalamic nucleus and nucleus accumbens). No guidelines clarified DBS settings, nor peri-operative optimisation measures. Patients’ preferences, age groups differences, ethnicity or comorbidities were not considered by any guideline. The guidelines’ quality ranged from moderate to high (50–92%), as per AGREE-II, with domains ‘scope and purpose’ and ‘editorial independence’ scoring the highest and ‘applicability’ and ‘stakeholder involvement’ the lowest across all guidelines.

Whilst eight guidelines supported the use of DBS for OCD as last-line therapy, a lack of cost-analysis, specific DBS settings, peri-operative procedures, and patients’ circumstances were analysed. Given the lack of randomised controlled trials in this field, more rigorous research is needed prior to wider DBS implementation.

Depression is a global public health problem with highest rates in women in low income countries including Pakistan. Paediatricians may be a resource to help with maternal depression. Little is known in low income countries about the prevalence of depression and its social correlates in mothers of children attending paediatric clinics.

Using cross-sectional design consecutive women attending the paediatric clinic were screened using the Edinburgh Postnatal Depression Scale (n=185). Women scoring 12 or more (n=70) and a random sample of low scorers (n=16) were interviewed using the Clinical Interview Schedule Revised (CIS-R) to confirm the diagnosis of depression, the Oslo scale was used to measure social stress and EQ-5D for health related quality of life.

The prevalence of maternal depression was 51%. The mean age of the sample was 26 years. Depressed mothers were more likely to be living in a joint family household, they were less educated and they and their husbands were less likely to be employed. The depressed mothers had more financial difficulties and they were more likely to sleep hungry during the last month due to financial problems. The depressed mothers had less social support and poorer quality of life compared to non depressed mothers.

Maternal depression in this health care setting is high and it is associated with social stress and poor social support. Paediatric appointments may be an opportunity for care and care delivery for maternal depression.

To assess psychiatric comorbidity in patients of alcohol dependence.

All the patients of alcohol dependence attending alcohol and drug de-addiction OPD and adult psychiatry OPD on specific days were screened. Those fulfilling the selection criteria were included in the study. A detailed evaluation was done for socio-demographic variables and history of drug using semi-structured proforma especially prepared for the study. Diagnosis of alcohol dependence was made according to DSM-IV-TR criteria. The patients were seen for co-morbid psychiatric illness by applying Structured Clinical Interview for DSM-IV-TR I & II (SCID I & II).

Out of 37 patients 24 (64.8%) were found to have comorbid psychiatric illness. Axis I and Axis II comorbidity was found in 64.8% and 5.4% of the samples, respectively. Patients of cluster A & B personality were equally distributed in the sample. Patients with more than one comorbidity accounted for 37.8% of the sample.

Psychiatric comorbidity in alcohol dependence is very high, other substance in particular. Number of comorbid diagnoses in a person may as high as three.

There are major health care implications of quality of life (QOL) in longstanding disorders such as Bipolar affective disorder (BD) for the patients and their caregivers.

The aim of the present study is to compare quality of life among bipolar disorder patients, their caregivers and to assess whether the level of depression correlates with the scores of quality of life in Bipolar Disorder patients.

We compared bipolar disorder (N = 40), their caregivers (N = 40) and no psychiatric illnesses (N = 150) on health related quality of life (HRQOL) which was assessed using the 26-item World Health Organization QOL instrument (WHOQOL-BREF Hindi version). All patients were diagnosed using the Structured Clinical Interview for DSM IV. Within the group with bipolar disorder, we examined the relationship between HRQOL using WHOQOL BREF Hindi version and depression assessed using the 17-item Hamilton Depression Rating Scale (HDRS).

Patients in bipolar disorder group had lower QOL on all the four domains compared to healthy controls, caregivers. The four domains of the WHOQOL scale correlated negatively with the HDRS.

Our findings suggest that bipolar depression and residual symptoms of depression are negatively correlated with QOL in BD patients.

Schizophrenia is a mental disorder characterized by social problems and disorders of thought, behaviour and cognitive functions. These impaired cognitive functions may be associated with alterations in resting state functional connectivity in schizophrenia. Therefore, the present study has been carried out to determine the resting state functional brain connectivity changes associated with schizophrenia in all the resting state networks (RSNs) using independent component analysis approach (ICA) and dual-regression based approach.

The objective of this study was to investigate the aberrant resting-state functional connectivity patterns in schizophrenia patients as compared to healthy controls.

35 schizophrenia patients and 31 healthy controls were recruited for the study and scanned by using resting state functional magnetic resonance (rsfMRI). Pre-processing and post-processing of the resting state functional data were performed using the FMRI Expert Analysis Tool (FEAT), which is a part of FSL (FMRIB's Software Library, www.fmrib. ox.ac.uk/fsl).

Our results showed significantly decreased functional connectivity in the regions of left fronto-parietal network, lateral visual network, medial visual network, motor network and default mode network (DMN) in schizophrenia patients as compared with healthy controls.

The overall findings suggest that the alterations in these resting state network connectivity may, in part, contribute to the impairments in cognitive functions associated with schizophrenia. These findings also suggest that aberrant resting state network connectivity contributes to regional functional pathology in schizophrenia and bears significance for core symptoms.

Movement disorders associated with exposure to antipsychotic drugs are common and stigmatising but underdiagnosed.

To develop and evaluate a new clinical procedure, the ScanMove instrument, for the screening of antipsychotic-associated movement disorders for use by mental health nurses.

Item selection and content validity assessment for the ScanMove instrument were conducted by a panel of neurologists, psychiatrists and a mental health nurse, who operationalised a 31-item screening procedure. Interrater reliability was measured on ratings for 30 patients with psychosis from ten mental health nurses evaluating video recordings of the procedure. Criterion and concurrent validity were tested comparing the ScanMove instrument-based rating of 13 mental health nurses for 635 community patients from mental health services with diagnostic judgement of a movement disorder neurologist based on the ScanMove instrument and a reference procedure comprising a selection of commonly used rating scales.

Interreliability analysis showed no systematic difference between raters in their prediction of any antipsychotic-associated movement disorders category. On criterion validity testing, the ScanMove instrument showed good sensitivity for parkinsonism (90%) and hyperkinesia (89%), but not for akathisia (38%), whereas specificity was low for parkinsonism and hyperkinesia, and moderate for akathisia.

The ScanMove instrument demonstrated good feasibility and interrater reliability, and acceptable sensitivity as a mental health nurse-administered screening tool for parkinsonism and hyperkinesia.

None.

To quantitatively test the hypothesis that older patients have increased thyroarytenoid muscle atrophy by comparing thyroarytenoid muscle volumes across different age groups.

A retrospective chart review was conducted. The study included 111 patients with no history of laryngeal pathology. Two investigators reviewed magnetic resonance imaging studies of these patients and manually traced the thyroarytenoid muscles on multiple slices bilaterally. Thyroarytenoid muscle volumes were then computed using imaging analysis software. Patients were stratified into three age groups (18–50 years, 51–64 years, and 65 years or older) for comparison.

Intra- and inter-rater reliabilities were excellent for all measurements (intraclass correlation co-efficient > 0.90). There was no statistically significant difference in the mean volumes of left and right thyroarytenoid muscles in all age and gender groups.

Given the lack of statistically significant difference in thyroarytenoid muscle volume between age groups on magnetic resonance imaging, the prevailing assumption that age-related thyroarytenoid muscle atrophy contributes to presbyphonia should be re-examined.