Letters to Editor
rating scale.[6] However, we are curious to know whether those involved in measurement of outcomes were blinded to the case or control status of the participants. This has obvious implications in terms of interviewer bias, which may have influenced the results otherwise. In summary, the study attempts to shed light on a hitherto unexplored area in India. The use of standardized rating scales and a control group lend a degree of credence to the findings. The wide confidence intervals for the effect sizes reported in the study could imply a small sample size. Future studies should be based in community settings with large samples in order to challenge the current dogma that increased psychological distress in out‑patients with functional gastrointestinal disorders are largely explained by health‑care seeking.[7]
REFERENCES 1.
Kabra N, Nadkarni A. Prevalence of depression and anxiety in irritable bowel syndrome: A clinic based study from India. Indian J Psychiatry 2013;55:77‑80. 2. Drossman DA, Corazziari E, Talley NJ. Rome II. The Functional Gastrointestinal Disorders. Diagnosis, Pathophysiology and Treatment: A Multinational Consensus. 2nd ed. McLean, VA: Degnon A; 1999. 3. Howell S, Talley NJ, Quine S, Poulton R. The irritable bowel syndrome has origins in the childhood socioeconomic environment. Am J Gastroenterol 2004;99:1572‑8. 4. Surdea‑Blaga T, Baban A, Dumitrascu DL. Psychosocial determinants of irritable bowel syndrome. World J Gastroenterol 2012 21;18:616‑26. 5. Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry 1960;23:56‑62. 6. Hamilton M. The assessment of anxiety states by rating. Br J Med Psychol 1959;32:50‑5. 7. Locke GR 3rd, Weaver AL, Melton LJ 3rd, Talley NJ. Psychosocial factors are linked to functional gastrointestinal disorders: A population based nested case‑control study. Am J Gastroenterol 2004;99:350‑7. Access this article online Quick Response Code Website:
R. Parthasarathy, Vikas Menon
Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India. E‑mail: [email protected]
www.indianjpsychiatry.org
DOI: 10.4103/0019-5545.146521
Asenapine‑induced double incontinence: A rare case report Sir, Asenapine is a serotonin dopamine antagonist used in the treatment of schizophrenia as well as an augmenting agent in obsessive compulsive disorder. Preliminary data indicate that the asenapine has less anticholinergic, cardiovascular side effects as well as minimal weight gain. There are some case reports of faecal incontinence and urinary incontinence with atypical antipsychotic medications.[1] However the literature is sparse about the double incontinence with a new drug like asenapine, thus, we are presenting a case report of a young female patient who developed double incontinence with administration of asenapine. An 18‑year‑old female patient with a known diagnosis of obsessive‑compulsive disorder with poor insight for last 2 years came for treatment in our psychiatry clinic. Patient was on treatment from a private practitioner, and she was prescribed 150 mg fluvoxamine, 75 mg of clomipramine and 1 mg of etiazolam per day. She reported no improvement with these medications, thus treatment regime was augmented with risperidone 1 mg/day and dose was increased after 4 weeks to 2 mg/day. Patient developed excessive sedation and severe extrapyramidal symptoms with risperidone and then risperidone was stopped. Later on, as augmentation therapy asenapine (5 mg) was added and within two days, she complained of bowel and bladder incontinence. The double 410
incontinence persisted despite the addition of anticholinergic medications (trihexyphenidyl 4 mg/day). The distressing problem of double incontinence was severe during day time. During the time period, 5 AM to 7 PM, patient had frequency of 1-2 times bladder and bowel incontinence but at night she complained of bladder incontinence only. Routine urine and stool screening examination were within normal limits. Detailed medical, neurological, surgical and urologist consultation ruled out any organic abnormality. There was no past history of double incontinence. Patient was diagnosed as drug‑induced double incontinence and asenapine was stopped. The distressing symptoms of double incontinence resolved within 24 h of stoppage of asenapine. Subsequently she was prescribed zotepine 25 mg. The patient tolerated this medication very well and her symptomatology showed significant improvement. The dose of zotepine was increased to 50 mg after 4 weeks. Patient reported no complaints of incontinence, and she improved with the treatment. Sometimes incontinence comes and goes with specific conditions or as a side effect of treatment for chronic or acute disorders with certain medications such as diuretics, sleeping pills, muscle relaxants, narcotics, antidepressants, antipsychotics and calcium channel blockers. A detailed medline review of the literature yielded no reports of asenapine‑induced double incontinence. However, there are reports of this adverse effect documented with Indian Journal of Psychiatry 56(4), Oct‑Dec 2014
Letters to Editor
olanzapine and clozapine.[2‑5] Reports of abnormalities of the adrenergic system in patients with idiopathic faecal incontinence provide insights into the pathophysiology of drug‑induced incontinence. It has been documented that patients with chronic mental disorders have high rates of urinary incontinence, but it is still not well understood whether the urinary incontinence is due to the severity of the mental illness or to the medication itself.[4] Exact cause of double incontinence is still not clear as it is too early to predict any new assumption. This problem of double incontinence raises some clinical issues, and this necessitates for more research in this area and suggests that clinician must remain cautious about development of new side effects with this molecule.
REFERENCES 1. Sagar R, Varghese ST, Balhara YP. Olanzapine‑induced double incontinence. Indian J Med Sci 2005;59:163‑4. 2. Speakman CT, Hoyle CH, Kamm MA, Henry MM, Nicholls RJ, Burnstock G. Adrenergic control of the internal anal sphincter is abnormal in patients with idiopathic faecal incontinence. Br J Surg 1990;77: 1342‑4. 3. Fuller MA, Borovicka MC, Jaskiw GE, Simon MR, Kwon K, Konicki PE. Clozapine‑induced urinary incontinence: Incidence and treatment with ephedrine. J Clin Psychiatry 1996;57:514‑8. 4. Warner JP, Harvey CA, Barnes TR. Clozapine and urinary incontinence. J Clin Psychiatry 1994;55:315‑6. 5. Mendhekar DN, Srivastav PK, Sarin SK, Jiloha RC. A case report of olanzapine‑induced fecal incontinence. J Clin Psychiatry 2003;64:339.
Access this article online Quick Response Code Website:
Gurvinder Pal Singh, Rajinder Kumar, Poonam Bharti
Department of Psychiatry, Gian Sagar Medical College and Hospital, Banur, Patiala, Punjab, India E‑mail: [email protected]
www.indianjpsychiatry.org
DOI: 10.4103/0019-5545.146523
The Rights of Persons with Disabilities Bill, 2014 and persons with mental illness Sir, The Rights of Persons with Disabilities Bill, 2014 has been introduced in the Rajya Sabha in February 2014 and is under enactment process.[1] In the Bill, ‘person with disability’ has been defined as “person with long‑term physical, mental, intellectual or sensory impairment, which hinders his full and effective participation in society equally with others”. Person with benchmark disability is the one having degree of disability more than 40%. The Bill defines the mental illness as “a substantial disorder of thinking, mood, perception, orientation or memory that grossly impairs judgment, behavior, capacity to recognize reality or ability to meet the ordinary demands of life, but does not include mental retardation which is a condition of arrested or incomplete development of mind of a person, specially characterized by sub‑normality of intelligence”.[2] The definition given under the Mental Health Care Bill, 2013 (MHCB) is same with the exception that ‘mental conditions associated with the abuse of alcohol and drugs’ are also included under mental illness in the MHCB.[3] Concerns were raised that the provisions regarding the legal capacity of persons with disability (PWD) as given in the previous drafts bill would create problem in mental health care and treatment and it was felt that psychiatric practice in our country would be greatly affected by these provisions.[4] It was provided in the previous drafts that all PWD would enjoy legal capacity on an equal basis in all aspects of life and have Indian Journal of Psychiatry 56(4), Oct‑Dec 2014
the right to equal recognition everywhere as persons before the law and any legislation, rules, customs etc., which has the effect of depriving any PWD of legal capacity would not be enforceable. Obviously these provisions were in conflict with those in the MHCB. However, it is satisfying to note that now the concerned section has been substantially revised and now it ensures the PWD to have right, equally with others, to own or inherit property, movable or immovable, control their financial affairs. Obviously, now the legal capacity under here is concerned with financial affairs only. PWD having high support needs have the right to access support system for the purpose, but a subsequent provision in the same section states that a PWD may alter, modify or dismantle any support arrangement and seek support of another. This provision may create confusion in mental health care. Therefore, it is advisable to have an explanation incorporated in this section that in case of mental health care and treatment, the provisions of MHCB would be applicable. Section 13 of the Bill authorizes a District Court to appoint “limited guardian” for a mentally ill person found incapable of taking care himself/herself, who shall take care and take all legally binding decision on his/her behalf in consultation with such person. In extra‑ordinary situations, the District Court may grant “plenary guardianship” to the mentally ill person and the guardian so appointed may take all legally binding decision on his/her behalf without any obligation to consult such person. 411
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.
rating scale.[6] However, we are curious to know whether those involved in measurement of outcomes were blinded to the case or control status of the participants. This has obvious implications in terms of interviewer bias, which may have influenced the results otherwise. In summary, the study attempts to shed light on a hitherto unexplored area in India. The use of standardized rating scales and a control group lend a degree of credence to the findings. The wide confidence intervals for the effect sizes reported in the study could imply a small sample size. Future studies should be based in community settings with large samples in order to challenge the current dogma that increased psychological distress in out‑patients with functional gastrointestinal disorders are largely explained by health‑care seeking.[7]
REFERENCES 1.
Kabra N, Nadkarni A. Prevalence of depression and anxiety in irritable bowel syndrome: A clinic based study from India. Indian J Psychiatry 2013;55:77‑80. 2. Drossman DA, Corazziari E, Talley NJ. Rome II. The Functional Gastrointestinal Disorders. Diagnosis, Pathophysiology and Treatment: A Multinational Consensus. 2nd ed. McLean, VA: Degnon A; 1999. 3. Howell S, Talley NJ, Quine S, Poulton R. The irritable bowel syndrome has origins in the childhood socioeconomic environment. Am J Gastroenterol 2004;99:1572‑8. 4. Surdea‑Blaga T, Baban A, Dumitrascu DL. Psychosocial determinants of irritable bowel syndrome. World J Gastroenterol 2012 21;18:616‑26. 5. Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry 1960;23:56‑62. 6. Hamilton M. The assessment of anxiety states by rating. Br J Med Psychol 1959;32:50‑5. 7. Locke GR 3rd, Weaver AL, Melton LJ 3rd, Talley NJ. Psychosocial factors are linked to functional gastrointestinal disorders: A population based nested case‑control study. Am J Gastroenterol 2004;99:350‑7. Access this article online Quick Response Code Website:
R. Parthasarathy, Vikas Menon
Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India. E‑mail: [email protected]
www.indianjpsychiatry.org
DOI: 10.4103/0019-5545.146521
Asenapine‑induced double incontinence: A rare case report Sir, Asenapine is a serotonin dopamine antagonist used in the treatment of schizophrenia as well as an augmenting agent in obsessive compulsive disorder. Preliminary data indicate that the asenapine has less anticholinergic, cardiovascular side effects as well as minimal weight gain. There are some case reports of faecal incontinence and urinary incontinence with atypical antipsychotic medications.[1] However the literature is sparse about the double incontinence with a new drug like asenapine, thus, we are presenting a case report of a young female patient who developed double incontinence with administration of asenapine. An 18‑year‑old female patient with a known diagnosis of obsessive‑compulsive disorder with poor insight for last 2 years came for treatment in our psychiatry clinic. Patient was on treatment from a private practitioner, and she was prescribed 150 mg fluvoxamine, 75 mg of clomipramine and 1 mg of etiazolam per day. She reported no improvement with these medications, thus treatment regime was augmented with risperidone 1 mg/day and dose was increased after 4 weeks to 2 mg/day. Patient developed excessive sedation and severe extrapyramidal symptoms with risperidone and then risperidone was stopped. Later on, as augmentation therapy asenapine (5 mg) was added and within two days, she complained of bowel and bladder incontinence. The double 410
incontinence persisted despite the addition of anticholinergic medications (trihexyphenidyl 4 mg/day). The distressing problem of double incontinence was severe during day time. During the time period, 5 AM to 7 PM, patient had frequency of 1-2 times bladder and bowel incontinence but at night she complained of bladder incontinence only. Routine urine and stool screening examination were within normal limits. Detailed medical, neurological, surgical and urologist consultation ruled out any organic abnormality. There was no past history of double incontinence. Patient was diagnosed as drug‑induced double incontinence and asenapine was stopped. The distressing symptoms of double incontinence resolved within 24 h of stoppage of asenapine. Subsequently she was prescribed zotepine 25 mg. The patient tolerated this medication very well and her symptomatology showed significant improvement. The dose of zotepine was increased to 50 mg after 4 weeks. Patient reported no complaints of incontinence, and she improved with the treatment. Sometimes incontinence comes and goes with specific conditions or as a side effect of treatment for chronic or acute disorders with certain medications such as diuretics, sleeping pills, muscle relaxants, narcotics, antidepressants, antipsychotics and calcium channel blockers. A detailed medline review of the literature yielded no reports of asenapine‑induced double incontinence. However, there are reports of this adverse effect documented with Indian Journal of Psychiatry 56(4), Oct‑Dec 2014
Letters to Editor
olanzapine and clozapine.[2‑5] Reports of abnormalities of the adrenergic system in patients with idiopathic faecal incontinence provide insights into the pathophysiology of drug‑induced incontinence. It has been documented that patients with chronic mental disorders have high rates of urinary incontinence, but it is still not well understood whether the urinary incontinence is due to the severity of the mental illness or to the medication itself.[4] Exact cause of double incontinence is still not clear as it is too early to predict any new assumption. This problem of double incontinence raises some clinical issues, and this necessitates for more research in this area and suggests that clinician must remain cautious about development of new side effects with this molecule.
REFERENCES 1. Sagar R, Varghese ST, Balhara YP. Olanzapine‑induced double incontinence. Indian J Med Sci 2005;59:163‑4. 2. Speakman CT, Hoyle CH, Kamm MA, Henry MM, Nicholls RJ, Burnstock G. Adrenergic control of the internal anal sphincter is abnormal in patients with idiopathic faecal incontinence. Br J Surg 1990;77: 1342‑4. 3. Fuller MA, Borovicka MC, Jaskiw GE, Simon MR, Kwon K, Konicki PE. Clozapine‑induced urinary incontinence: Incidence and treatment with ephedrine. J Clin Psychiatry 1996;57:514‑8. 4. Warner JP, Harvey CA, Barnes TR. Clozapine and urinary incontinence. J Clin Psychiatry 1994;55:315‑6. 5. Mendhekar DN, Srivastav PK, Sarin SK, Jiloha RC. A case report of olanzapine‑induced fecal incontinence. J Clin Psychiatry 2003;64:339.
Access this article online Quick Response Code Website:
Gurvinder Pal Singh, Rajinder Kumar, Poonam Bharti
Department of Psychiatry, Gian Sagar Medical College and Hospital, Banur, Patiala, Punjab, India E‑mail: [email protected]
www.indianjpsychiatry.org
DOI: 10.4103/0019-5545.146523
The Rights of Persons with Disabilities Bill, 2014 and persons with mental illness Sir, The Rights of Persons with Disabilities Bill, 2014 has been introduced in the Rajya Sabha in February 2014 and is under enactment process.[1] In the Bill, ‘person with disability’ has been defined as “person with long‑term physical, mental, intellectual or sensory impairment, which hinders his full and effective participation in society equally with others”. Person with benchmark disability is the one having degree of disability more than 40%. The Bill defines the mental illness as “a substantial disorder of thinking, mood, perception, orientation or memory that grossly impairs judgment, behavior, capacity to recognize reality or ability to meet the ordinary demands of life, but does not include mental retardation which is a condition of arrested or incomplete development of mind of a person, specially characterized by sub‑normality of intelligence”.[2] The definition given under the Mental Health Care Bill, 2013 (MHCB) is same with the exception that ‘mental conditions associated with the abuse of alcohol and drugs’ are also included under mental illness in the MHCB.[3] Concerns were raised that the provisions regarding the legal capacity of persons with disability (PWD) as given in the previous drafts bill would create problem in mental health care and treatment and it was felt that psychiatric practice in our country would be greatly affected by these provisions.[4] It was provided in the previous drafts that all PWD would enjoy legal capacity on an equal basis in all aspects of life and have Indian Journal of Psychiatry 56(4), Oct‑Dec 2014
the right to equal recognition everywhere as persons before the law and any legislation, rules, customs etc., which has the effect of depriving any PWD of legal capacity would not be enforceable. Obviously these provisions were in conflict with those in the MHCB. However, it is satisfying to note that now the concerned section has been substantially revised and now it ensures the PWD to have right, equally with others, to own or inherit property, movable or immovable, control their financial affairs. Obviously, now the legal capacity under here is concerned with financial affairs only. PWD having high support needs have the right to access support system for the purpose, but a subsequent provision in the same section states that a PWD may alter, modify or dismantle any support arrangement and seek support of another. This provision may create confusion in mental health care. Therefore, it is advisable to have an explanation incorporated in this section that in case of mental health care and treatment, the provisions of MHCB would be applicable. Section 13 of the Bill authorizes a District Court to appoint “limited guardian” for a mentally ill person found incapable of taking care himself/herself, who shall take care and take all legally binding decision on his/her behalf in consultation with such person. In extra‑ordinary situations, the District Court may grant “plenary guardianship” to the mentally ill person and the guardian so appointed may take all legally binding decision on his/her behalf without any obligation to consult such person. 411
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.
