IPS CPG Guideline

Volume 59, Supplement 1 January 2017
Indian Journal of Psychiatry • Volume 59 • Supplement 1 • January 2017 • Pages S***-S***
& IPS Clinical Practice Guidelines

Covered in
Science Citation for Psychiatrists in India
Reports (JCR)
(Revised Edition 2016)
Schizophrenia, Depression, Bipolar Disorder, Generalized Anxiety

Disorder & Panic Disorder, Obsessive Compulsive Disorder,
Sexual Dysfunctions, Sleep Disorders
Task Force on
Clinical Practice Guidelines
for Psychiatrists in India
National Workshop held at Jaipur 24 & 25 Oct. 2015
and on 6 & 7, Aug. 2016
Guest Editors:
Shiv Gautam
Ajit Avasthi
Sandeep Grover
Online at
www.indianjpsychiatry.org Published by: Indian Psychiatric Society
Indian Journal of
Psychiatry OFFICIAL PUBLICATION OF THE INDIAN PSYCHIATRIC SOCIETY
Print ISSN 0019-5545
E-ISSN 1998-3794
Honorary Editor SK Tandon, Bhopal Joesph Calabrese, U.S.A.

T. S. Sathyanarayana Rao R Thara, Chennai Jonathan M. Meyer, U.S.A.
Professor, Vikram Kumar Yeragani, Bangalore Juan E. Mezzich, U.S.A.
Department of Psychiatry, J. S. S. University Vinod Sinha, Ranchi Julio Arboleda Florez, Canada
JSS Medical College and Hospital, Vivek C. Kirpekar, Nagpur K. W. M. (Bill) Fulford, U.K.
M. G. Road, Mysore - 570004, India. Kadiamada Nanaiah Roy Chengappa, U.S.A.
Editorial Board Karl-Jürgen Bär, Germany
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Department of Psychiatry, #1111, First Floor, M. Kishor Rao Matcheri Keshavan, U.S.A.
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T. S. S. Rao (Chairman) Malay Ghosal (Co-Chairman) Rajiv Tandon, U.S.A.
Honorary Associate Editors Abhinav Tandon (Convenor) Ajit Bhide Rama Rao Gogineni, U.S.A.
Chittaranjan Andrade, Bengaluru Asim Kumar Mallick A. K. Kala Richard Balon, U.S.A.
9440422626 P. S. V. N. Sharma Arbinda Bramha Robert B. Pohl, U.S.A.
andradec@gmail.com S. K. Chaturvedi B. N. Gangadhar Robert Michael Carney, U.S.A.
S. M. Agarwal Charles Pinto Rohan Ganguli, U.S.A.
Sandeep Grover, Chandigarh S. Nambi Debasish Chatterjee Rudra Prakash, U.S.A.
09316138997 Shiv Gautham Shridhar Sharma S. R. Nimmagadda, U.K.
drsandeepg2002@yahoo.com Jayanth Chatterjee Smitha N. Deshpande Sanjay Dube, U.S.A.
Joseph P. Varghese Sudhir Kumar Sekhar Saxena, Geneva
Honorary Deputy Editors Kangan Pathak Vihang N. Vahia Sheila Hollins, U.K.
K. S. Shaji, Trissur Neelanjan paul Soumithra Ghosh Solomon Rataemane, South Africa
9495170655 Subhash Chander Bhatia, U.S.A.
drshajiks@gmail.com Indian Advisory Board
Subodh Dave, U.K.
A. B. Ghosh Narendra N. Wig Thomas Craig, U.K.
O. P. Singh, Kolkota Abraham Varghese Prasanna Raj
9434013231 Tony Elliott, U.K.
A. K. Agarwal P. Raghurami Reddy Vijoy K. Varma, U.S.A.
opsingh.nm@gmail.com A. K. Tandon R. Srinivasa Murthy Vikram Kumar Yeragani, U.S.A.
Honorary Assistant Editor Col. G. R. Golecha R. Sathianathan Vikram Patel, U.K.
G. G. Prabhu S. C. Malik
Abhinav Tandon, Allahabad
08400951567
K. A. Kumar S. C. Tiwari Distinguished Past Editors
K. Kuruvilla S. Kalyanasundaram N. N. De 1949 to 1951
abhinavtandon@ymail.com
International Advisory Board L. P. Verma 1951 to 1958
Speciality Field Editors A. N. Ramakrishnan, U.K. A. N. Bardhan 1958 to 1960
Co-ordinator: Swaminath G, Bangalore Abdul Malik, Pakistan Lt. Col. M. R. Vachha 1961 to 1967
Ajay Singh, Mumbai Afzal Javed, U.K. A. Venkoba Rao 1968 to 1976
Bhatia M. S., Delhi Alan Gelenberg, U.S.A. B. B. Sethi 1977 to 1984
Chittaranjan Andrade, Bangalore Allan Tasman, U.S.A. S. M. Channabasavanna 1985 to 1988
Debasish Basu, Chandigarh Anand Pandurangi, U.S.A. A. K. Agarwal 1989 to 1992
Devasish Ray, West Bengal Asha Mishra, U.S.A. K. Kuruvilla 1993 to 1996
Himanshu Sharma, Karamsad Bruce Singh, Australia J. K. Trivedi 1997 to 2002
Kamala Deka, Dibrugarh Dilip Jeste, U.S.A. Utpal Goswami 2003
Kangan Pathak, Assam Dinesh Bhugra, U.K. T. S. S. Rao 2004
Margoob Mustaq Ahmed, Srinagar Driss Moussaoui, Morocco Nimesh G. Desai 2005 to 2006
Om Prakash, New Delhi Eliot Sorel, U.S.A. T. S. S. Rao 2007
Nilesh Shah, Mumbai George Christodoulou, Greece G. Swaminath 2007
Prathap Tharyan, Vellore George E. Vaillant, U.S.A.
Rajshekhar Bipeta, Hyderabad Ghanshyam N. Pandey, U.S.A. Statistical Consultants
Sonia Parial, Raipur Glen Bryan Baker, Canada B. S. Mahananda, Mysore
Sujata Sethi, Rohtak Harischandra Gambheera, Sri Lanka B. S. Ramesh, Mysore
Sujit Sarkhel, Ranchi Helen Herrman, Australia Lancy Desouza, Mysore
Suresh Kumar, Chennai J. Sreenivasaraghavan, U.S.A. P. Nagabhushan, Mysore
Indian J Psychiatry 59 (Supplement 1), January 2017 i
Indian Journal of
Psychiatry
OFFICIAL PUBLICATION OF THE INDIAN PSYCHIATRIC SOCIETY
IPS Executive Council Members International affairs

President Chairperson: E. Mohandas
G. Prasad Rao, Hyderabad Co-chairperson: Rajesh Nagpal
prasad40@gmail.com Convener: Venu G Jhanwar
Vice President: President elect Constitution
MSVK Raju, Pune Chairperson: R.R. Ghosh Roy
msvkraju@gmail.com Co-chairperson: V.K. Sinha
General Secretary Convener: Shanti Bala K
Gautam Saha, Kolkata Mental Hospitals
drgsaha@yahoo.co.in Chairperson: Nirmal Bera
Hon. Treasurer Co-chairperson: Ram Ghulam Razdan
Mukesh P Jagiwala, Surat Convener: Nishant Goyal
mukeshjagiwala@yahoo.co.in Membership
Hon. Editor Chairperson: Prabir Paul
T. S. S. Rao Mysore Co-chairperson: U.K. Sinha
tssrao19@yahoo.com Convener: Ajish Mangot
Immediate Past President Parliamentary
Vidhyadhar Watve, Pune Chairperson: Sunil Mittal
vidyadharw@gmail.com Co-chairperson: Rajesh Sagar
Immediate Past Secretary Convener: Krishna Kadam
N N Raju PG Psychiatry Education
drnnraju@gmail.com Chairperson: Sudhir Bhave
Executive Council Members (Direct) Co-chairperson: Nitin Gupta
Kishore Gujar, gujarkishor46@yahoo.co.in, Convener: Abir Mukherjee
Mrugesh Vaishnav, drmrugesh@rediffmail.com, Finance
Om Prakash Singh, opsingh.nm@gmail.com, Chairperson: R Ponnudurai
Arabind Brahma, Co-chairperson: Arun Marwale
drarabindabrahma04@yahoo.com Convener: C.R. Mohapatra
Kshirod Kumar Mishra, IPS Publication
drkkmishra2003@yahoo.co.uk, Chairperson: Vinay Kumar
Om Prakash, drjhirwalop@yahoo.co.in, Co-chairperson: Sandip H Shah
Sunil Goyal, dr_sgoyal@yahoo.co.in Convener: Amlan Kusum Jana
Website
Zonal Representative Chairperson: Mainak Mukherjee
Central Zone Co-chairperson: Abhijeet Faye
Shashi Rai, shashi5284@rediffmail.com Convener: Samrat Kar
Jai Prakash Narayan, jpny62@yahoo.co.in Education Research & Training Foundation
East Zone Chairperson: Ajit Avasthi
Hiranya Goswami, goswamihiranya57@gmail.com Co-chairperson: T Jagadisha
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North Zone Social Security Scheme
B.S. Shekhawat, shekawatbharat1@gmail.com Chairperson: Sarvesh Chandra
Lalit Batra, dr_lalitbatra@yahoo.com Co-chairperson: Kaushik Gupte
South Zone Convener: V.G. Kulkarni
Abhay Matkar, drabhaymatkar@hotmail.com IPS Headquarters:
K. Uday Kumar, udayaspandana@gmail.com Chairperson: N K Bohra
West Zone Co-chairperson: Rajesh Rastogi
D M Dhavale, dmdhavale@gmail.com Convener: Brahmdeep Sindhu
Kaushik Gupte, guptekaushik@gmail.com
Speciality Sections
Assistant General Secretaries Military Psychiatry
Manaswi Gautam, Abdul Majid, Chairperson: R.C. Das
Neelanjana Paul, Vishal Indla Co-chairperson: Jyoti Prakash
Sub Committees Convener: Rajeev Saini
Awards Biological Psychiatry
Chairperson: I.R.S. Reddy Chairperson: A. Jagadish
Co-chairperson: Verghese Punnose Co-chairperson: Ganesan Venkatasubramanian
Convener: Venkata Ramana Cherukuri Convener: Vaibhav Dubey
CME Child and Adolescent Psychiatry
Chairperson: T.P. Sudhakar Chairperson: Debasish Konar
Co-chairperson: Sri Kumar Mukherjee Co-chairperson: Shanti Nambi
Convener: Aleem Siddique Convener: Anweshak Das
Ethics Community Psychiatry
Chairperson: Roy Abraham Kallilvayalil Chairperson: B.S. Chavan
Co-chairperson: Fiaz Ahmed Sattar Co-chairperson: V.D. Meel
Convener: Bhavesh Lakdawala Convener: Sanjay Gupta
Journal Geriatric Psychiatry
Chairperson: T S S Rao Chairperson: S.C. Tiwari
Co-chairperson: Malay Ghosal Co-chairperson: Alka Subramanyam
Convener: Abhinav Tandon Convener: Samir Kumar Praharaj
ii Indian J Psychiatry 59 (Supplement 1), January 2017
Indian Journal of
Forensic Psychiatry Clinic Software Development

Chairperson: C.L. Narayanan Chairperson: Umesh Nagapurkar
Co-chairperson: Basudev Das Co-chairperson: Sanjay Phadke
Convener: Sanjay Garg Convener: Vipul Singh
Rehabilitation Psychiatry Public Education & Stigma Reduction
Chairperson: C.R.S. Ramasubramanian Chairperson: Avdesh Sharma
Co-chairperson: V.K. Radhakrishnan Co-chairperson: Rajeev Gupta
Convener: V.D. Aravind Convener: P. Himakar
Private Psychiatry Media and Mental Health
Chairperson: Param Kulhara Chairperson: Jayanta Das
Co-chairperson: Pramod Kumar Co-chairperson: G.S.P. Raju
Convener: Amrit Pattojoshi Convener: Ranjan Bhattacharyya
Substance Use Disorders Young Psychiatrists’ Forum
Chairperson: Pratima Murthy Chairperson: Jay Shastri
Co-chairperson: Debasish Basu Co-chairperson: Debjani Bandyopadyay
Convener: Atul Ambekar Convener: Anitha Ravirala
Law and Ethics Workshop & Training
Chairperson: G. Gopalakrishnan Chair Person: P.K. Dalal
Co-chairperson: Tushar Jagawat Co-chairperson: Rashmin M. Cholera
Convener: Manu Arora Convener: K. Narasimha Reddy
Sexual Disorders SAARC Affairs
Chairperson: Uday Chaudhury Chairperson: U.C. Garg
Co-chairperson: Partha Pratim Roy Co-chairperson: Kuruvilla Thomas
Convener: Parth Vaishnab Convenor: Anil Prabhakaran
Women and Mental Health Pharmacological Management
Chairperson: Smita Deshpande Chairperson: Chittaranjan Andrade
Co-chairperson: M. Gowri Devi Co-chairperson: R.C. Maniar
Conveners: Srikala Bharath, Geeta Desai Convener: Sarmila Sarkar
General Hospital Psychiatry: Non Pharmacological Management
Chairperson: Lalit Batra Chairperson: Philip John
Co-chairperson: Radhika Reddy Co-chairperson: I.R. Rajkumar
Convener: Shahul Ameen Convener: Sagar Lavania
Suicide Prevention Yoga and Meditation
Chair Person: Subhangi Parker Chairperson: B.N. Gangadhar
Co-chairperson: Lakshmi Vijay Kumar Co-chairperson: P. Kishen
Convener: Sujit Sarkhel Convener: G.V. Ramana Rao
Parinatal Psychiatry Spirituality and Mental Health
Chairperson: Prabha Chandra Chairperson: S. Vijaya Kumar
Co-chairperson: Sonia Parial Co-chairperson: MVR Sharma
Convener: Anita Gautam Convener: Lt. Col. Harihar
Task Forces Boundary Guidelines
Practice Guidelines Chairperson: Ajit Bhide
Chairperson: Shiv Gautham Co-chairperson: Sunita S. Kurpad
Co-chairperson: Ajit Avasthi Convener: P. Srilakshmi
Convener: Sandeep Grover PWD Act & Certificate Guidelines
Mental Health Care Bill Chairperson: Asim Kumar Mallick
Chairperson: Rakesh Kumar Chadda Co-chairperson: Thomas John
Co-chairperson: B.M. Suwalka Convener: K. Ramakrishnan
Convener: Mahesh Gowda NGOs/Patients Career Group
Mental Health Policy Chairperson: G. Swaminath
Chairperson: Savita Malhotra Co-chairperson: Amarnath Mallik
Co-chairperson: Chandrasekhar Kammammettu Convener: R.Vikram
Convener: Deepanjali Medhi School Education/Counseling
Liaison of Mental Health Chairperson: Kesri Chavda
Chairperson: Dinesh Narayan Co-chairperson: Khyati Mehtalia
Co-chairperson: Hardeep Singh Convener: Arti V. Mehta
Convener: Kaustav Chakraborty Conference Guideline
UG Education Chairperson: Rajeev Jain
Chairperson: Mohan Chandran Co-chairperson: Abhay Matkar
Co-chairperson: P.B. Behere Convener: T. Sudhir
Convener: Mamta Sood Tribunal IPS
Administrative Psychiatry A.K. Agarwal (Chairperson)
Chair Person: Tophan Pati A.B. Ghosh, James Anthony, S. Nambi,
Co-chairperson: Nilesh Shah P. Palanniappan
Convener: A.K. Handigol
Disaster Management IPS Election Commission
Chairperson: Margoob Mustaq Ahmed Chairperson: Vivek Kirpekar
Co-chairperson: Arnab Banerjee Returning Officer: K. Sudharshan
Convener: Harish Delanthabettu Election officer: Roop Kumar Siddana
Indian J Psychiatry 59 (Supplement 1), January 2017 iii
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iv Indian J Psychiatry 59 (Supplement 1), January 2017

Indian Journal of
Volume 59, Supplement 1, January 2017
CONTENTS
Clinical Practice Guidelines S1
Changing times, moving ahead!: G Prasad Rao, President S2
Commitment for Clinical Excellence: MSVK Raju S3
Meeting the needs!: Gautam Saha S4
EDITORIAL
Clinical Practice Guidelines: Principles for Clinical Practice: T.S. Sathyanarayana Rao, Abhinav Tandon S5
IPS Task Force on Clinical Practice Guidelines Workshop held on Oct, 24, 25, 2015 S7
IPS Task Force on Clinical Practice Guidelines Workshop held on Aug, 6 & 7, 2016 S8
Preamble of the Clinical Practice Guidelines: Shiv Gautham, Ajit Avasthi, Sandeep Grover S9
ORIGINAL ARTICLE
Indian Psychiatric Society Survey on Clinical Practice Guidelines: Sandeep Grover, Ajit Avasthi S10
CLINICAL PRACTICE GUIDELINES

Clinical Practice Guidelines for Management of Schizophrenia: Sandeep Grover, Subho Chakrabarti,
Parmanand Kulhara, Ajit Avasthi S19
Clinical Practice Guidelines for the management of Depression: Shiv Gautam, Akhilesh Jain,
Manaswi Gautam, Vihang N. Vahia, Sandeep Grover S34
Clinical Practice Guidelines for Management of Bipolar Disorder: Nilesh Shah, Sandeep Grover,
G. Prasad Rao S51
Clinical Practice Guidelines for the Management of Generalised Anxiety Disorder (Gad) and
Panic Disorder (Pd): Shiv Gautam, Akhilesh Jain, Manaswi Gautam, Vihang N. Vahia, Anita Gautam S67
Clinical practice guidelines for Obsessive-Compulsive Disorder: Y.C. Janardhan Reddy,

A. Shyam Sundar, Janardhanan C. Narayanaswamy, Suresh Bada Math S74
Clinical Practice Guidelines for Management of Sexual Dysfunction: Ajit Avasthi, Sandeep Grover,
T S Sathyanarayana Rao S91
Clinical Practice Guidelines for Sleep Disorders: Ravi Gupta, Sourav Das, Kishore Gujar, K K Mishra,
Navendu Gaur, Abdul Majid S116
Indian J Psychiatry 59 (Supplement 1), January 2017 v

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vi Indian J Psychiatry 59 (Supplement 1), January 2017

TASK FORCE ON CLINICAL PRACTICE GUIDELINES
Clinical Practice Guidelines
We have great pleasure in placing in your hands the out suggested. The outcome is in your hands for ready use in
come of two workshops on Clinical Practice Guidelines day to day clinical practice for reference.
organised by Task force on Clinical Practice Guidelines
organised at Jaipur - First on Oct 24 & 25th 2015 on On behalf of the Task Force we extend heartfelt thanks to
Depression, Schizophrenia and BPAD under leadership of the executive council of two successive years for giving us
Dr. V G Watve as President and Dr. N.N. Raju as Hon. Gen. the opportunity to serve Indian Psychiatric Society.
Secretary of Indian Psychiatric Society and Second on Aug.
6th and 7th 2016 on OCD, GAD & Panic Disorder, Sexual We are grateful to Dr. T.S.S. Rao, editor IPS for Printing the
Dysfunctions and Sleep Disorders under leadership of Dr. G. CPG Guidelines as supplement at a short notice.
Prasad Rao as President and Dr. Gautam Saha as hon. General
Secretary of Indian Psychiatric Society. In each workshops Long Live IPS.
39 experts from different parts of the country participated
and contributed their wisdom (List of Participants experts Jai Hind
given earlier).
As in earlier Guidelines the draft papers were revised after Dr. Shiv Gautam Dr. Ajit Avasthi Dr. Sandeep Grover
obtaining the consensus of house on each guideline and Chairman Co- Chairman Convenor
the draft papers were revised in the light of ammendments
Access this article online This is an open access article distributed under the terms of the Creative
Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows
Quick Response Code
others to remix, tweak, and build upon the work non-commercially, as long as the
Website:
author is credited and the new creations are licensed under the identical terms.
www.indianjpsychiatry.org
For reprints contact: reprints@medknow.com
DOI:
How to cite this article: Clinical Practice Guidelines. Indian J
10.4103/0019-5545.196963
Psychiatry 2017;59:1.
© 2017 Indian Journal of Psychiatry | Published by Wolters Kluwer ‑ Medknow S1

MESSAGE FROM THE PRESIDENT
Changing times, moving ahead!
Dear Colleagues, and Sleep Disorders have also been formulated and these
Greetings from the President’s desk ! will also be presented in ANCIPS 2017.
The publication of Clinical Practice Guidelines for I congratulate Prof. Shiv Gautam, Prof. Ajit Avasthi and Dr.
Psychiatrists’ in India, by the Indian Psychiatric Society Sandeep Grover, for their dedication, hardwork, diligence
in 2004, were the first set of guidelines. These have and precision in making this possible. Additionally, I also
remained in use for over a decade by all members and thank the members of various expert groups for their inputs
were of use in the practice and had also been used by the in improving the guidelines. I thank all of them on behalf of
members in defending their clinical decisions in the court Indian Psychiatric Society.
of law.
I have no doubt that the revised Clinical Practice Guidelines
In last one decade there have been further advancements would be useful and informative not only to clinicians but
in understanding various aspects of psychiatric disorders. also to all mental health professionals.
Hence, it was thought that time has come to acknowledge
the advances in Psychiatry to be translated into the practice I thank all the members of my Executive Council for their
of Psychiatry in India. With this thinking, I must place on inputs and participation. During the coming years we
record that during Hyderabad ANCIPS on January 11th, are going to work on and bring further Clinical Practice
2015, the Executive Council, under the leadership of Dr. Guidelines for few more disorders. I am sure these
Vidhyadhar Watve decided to start the process of revision of guidelines would of immense help to all.
existing Clinical Practice Guidelines. As part of the revision,
first an online survey was conducted to understand how Dr. Gundugurti Prasad Rao
the earlier versions of the guidelines were used and what
are the expectations of the membership from the revised President, Indian Psychiatric Society
guidelines. Based on the findings of this survey, the lead
authors were advised to formulate guidelines, which
would be evidence based and at the same time more users This is an open access article distributed under the terms of the Creative
friendly. Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows
others to remix, tweak, and build upon the work non‑commercially, as long as the
Over the last 2 years, experts working in the various
areas of psychiatry, after a painstaking brainstorming,
had churned out the best way to practice. The Clinical
Access this article online
Practice Guidelines for schizophrenia, bipolar disorder
Quick Response Code
and depressive disorders, so summarized had been Website:
presented at Bhopal ANCIPS 2016. The Clinical Practice www.indianjpsychiatry.org
Guidelines for these disorders were also displayed in
the Indian Psychiatric Society website for the comments
from the membership during the month of September DOI:
2016‑ November 2016. Suggestions received were 10.4103/0019-5545.196964
considered and if required changes have been made in the
recommendations.
How to cite this article: Rao GP. Changing times, moving
The Clinical Practice Guidelines for Obsessive Compulsive
ahead!. Indian J Psychiatry 2017;59:2.
Disorder, Generalized Anxiety Disorder, Sexual Dysfunction
S2 © 2017 Indian Journal of Psychiatry | Published by Wolters Kluwer ‑ Medknow

Commitment for Clinical Excellence
It is the fundamental duty of any professional body of Dr (Brig) M S V K Raju

doctors to put in place a framework of uniform clinical
practice that is based not only on scientifically obtained Veteran Armed Forces Medical Services
evidence available from all parts of the world but also
on evidence obtained from research carried out in home Vice President (President Elect), Indian Psychiatric Society
country. Since 2005 the Indian Psychiatric Society has been
providing systematically developed patient care strategies This is an open access article distributed under the terms of the Creative
to its members for effective clinical decision making and Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows
delivery of care that is comparable to globally current
standards.
The present compilation of Clinical Practice Guidelines,

touching upon a broad gamut of conditions including Access this article online
Schizophrenia, Bipolar disorders, Depression, OCD, Quick Response Code
sleep disorders and sexual dysfunctions, will cater to a Website:
major chunk of clinical load that a psychiatrist generally www.indianjpsychiatry.org
encounters in practice. The guidelines will definitely spare
the harried psychiatrists from the time and effort spent in
DOI:
obtaining needed information from various sources.
10.4103/0019-5545.196965
The exertions of the team headed by Prof Shiv Gautam, Prof

Ajit Avasthi and Dr Sandeep Grover manifesting in the form
of clinical practice guidelines are ample testimony of their
How to cite this article: Raju M. Commitment for Clinical
tenacious commitment to excellence and therefore need to
Excellence. Indian J Psychiatry 2017;59:3.
be commended in full measure.

MESSAGE FROM HON. GENERAL SECRETARY
Meeting the needs!
It is indeed a matter of great pleasure to let you all know All the contributors earn our sincere gratitude for their
that Indian Psychiatric Society (IPS) is bringing out revised efforts on this publication.
“Clinical Practice Guidelines (CPGs)” for management of
various psychiatric disorders. I thank Prof. Shiv Gautam, Prof. Ajit Avasthi and
Dr. Sandeep Grover along with all the authors for
In earlier years, IPS has developed CPG for psychiatrists in completing such arduous task. This has been possible due
India and for management of various psychiatric disorders to outstanding support from President Dr. G. Prasad Rao,
and other issues important for practice of psychiatry in five Vice President Dr. M. S. V. K. Raju and other EC Members.
volumes from 2005 to 2009 under the expert guidance of
Prof. Shiv Gautam and Prof. Ajit Avasthi. Long live IPS !
This year, the CPGs Task Force of IPS led by Prof. Shiv Dr. Gautam Saha
Gautam as Chairperson, Prof. Ajit Avasthi as Co‑Chairperson
and Dr. Sandeep Grover as Convenor has developed the CPG Hon. General Secretary, Indian Psychiatric Society
to serve as an evidence‑based framework for practitioners’
in clinical decision‑making. I hope these guidelines become This is an open access article distributed under the terms of the Creative
among the most comprehensive, evidence‑based CPGs for Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows
these disorders. It summarizes treatment recommendations author is credited and the new creations are licensed under the identical terms.
and describes elements of psychiatric management in
the formulation and implementation of a treatment plan.
Besides the clinical issues, the guideline examines specific
socio‑cultural and feasibility issues which influence Access this article online
treatment plan, e.g., psychiatric factors, demographic and Quick Response Code
psychosocial variables, and co‑morbid general medical Website:
conditions. It provides a review and synthesis of available www.indianjpsychiatry.org
evidence regarding the efficacy of various treatments,
continuation treatment and maintenance treatment. DOI:
10.4103/0019-5545.196966
Indian Psychiatric Society is really happy to promote the
latest clinical developments in the field of disorders and I
believe that these CPGs will be of great use to all the mental
health professionals, especially to the clinicians, post
How to cite this article: Saha G. Meeting the needs!. Indian
graduate students and researchers. I wish that IPS will come
J Psychiatry 2017;59:4.
up with more CPGs on various psychiatric topics in future.
S4 © 2017 Indian Journal of Psychiatry | Published by Wolters Kluwer - Medknow

EDITORIAL
Clinical Practice Guidelines: Principles for Clinical Practice

T.S. Sathyanarayana Rao1, Abhinav Tandon2
1
Professor, Department of Psychiatry, JSS Medical College and Hospital, JSS University, Mysore, 2Asst Editor, Indian Journal
of Psychiatry, Consultant Neuropsychiatrist, Dr AK Tandon Neuropsychiatric Centre, Allahabad, India
“Principles are guidelines for human conduct that are print and electronic media where they come across lay
proven to have enduring, permanent value.”--- Stephen guidelines; doctors need to inform the patients regarding
Covey available treatment alternatives, their potential harms
and benefits, where clinical guidelines work as the best
A revision of the clinical practice guidelines (CPGs) by Indian available educative tool. CPGs highlight gaps in known
Psychiatric Society(IPS) was long overdue, considering literature where treatment recommendations are not
the intensity and momentum of current research in clear cut; hence it helps in identifying areas where future
Neurosciences. This daunting task was taken up and research should be focused. Guidelines often act as one of
completed by an expert group of academicians, after an the reference points in audits of clinicians and hospitals
initial online survey and later taking into consideration the for rating them with best care practices.5 It is easier for
opinion of the members of IPS, through open suggestion insurance companies to pay for standardized treatment
online. The online survey gave an insight into the usage of practices; public perception is likely to improve if a health
the existing guidelines and the expectations from members; care facility adheres to CPGs and publicizes the same. It is
prepublication copy of the revised guidelines were available likely that economic advantages of following CPGs is one
online for comments and suggestion from the members of the main reasons for their popularity.6
which were then streamlined and incorporated.
The phrase “evidence- based medicine” refers to the use
Field and Lohr in 1990 have described Clinical practice of treatment that has been tested rigorously to the point
guidelines (CPGs) as: “systematically developed statements of its becoming “state of the art.”7 EBM has received both
to assist practitioners and patient decisions about support and criticism from academicians and clinicians.
appropriate health care for specific circumstances”.1 The Evidence based medicine (EBM) contributes to improved
Institute of Medicine defines clinical practice guidelines quality of CPGs and hence better clinical care given to the
as “…statements that include recommendations, patients. Original research and systematic reviews provide
intended to optimize patient care, that are informed the best evidence and have the potential to provide the best
by a systematic review of evidence and an assessment health care at the lowest cost.8 EBMs are best considered
of the benefits and harms of alternative care options”.2 as educative tools, which should be used by the clinician
CPGs act as a valuable source of information for health for the appropriate group of patients and as check sheets
care providers in maintaining treatment standards which during the process of treatment.7 Evidence for a specific
are up-to-date, evidence based and in accordance with treatment, needs to be combined with experience of the
the latest advancements. Guidelines assist the clinicians clinician and patient’s preference for the best possible
in the decision making process, help them in taking outcome.
difficult decisions in complicated cases and allows them
to follow a particular treatment course (vs another Though it has been found in rigorous evaluations that
available one) for the best desired outcome. Guidelines clinical practice guidelines improve quality of health care,
help clinicians defend themselves in the Court of Law. whether they do so in daily practice is less clear.1This may
Guidelines describe clinical care based on best available be partially because patients, clinicians and managers
evidence, help maintain consistency in clinical practice, define quality differently and the current evidence
focus on appropriate usage of resources, help in quality about the effectiveness of a particular guideline may be
control, guide in developing pathways of healthcare which incomplete. The most important drawback of guidelines
are cost effective and give insight for future research.3 is that they may not represent the most appropriate
Patients suffering from the same problem are likely to treatment for the individual patient. The members of the
receive different care depending on the place, clinician or expert panel for guidelines development may be mislead
hospital. Guidelines can simplify this problem by making by the scientific evidence due to lack of well designed
it more likely that patients receive similar care regardless studies; another reason for flawed guidelines may be due
of the hospital or doctor treating them.4 Patients are to misinterpretation of scientific information.4 The expert
increasingly becoming aware of treatment options through panel may be biased in favour of a particular treatment
© 2017 Indian Journal of Psychiatry | Published by Wolters Kluwer - Medknow S5

Rao and Tandon: CPGs for Clinical Practice
due to flawed personal recollections when conflicting REFERENCES

data are available for different treatment options.9 Due
1. Field MJ, Lohr KN (Eds). Clinical Practice Guidelines: Directions for a New
to inadequate time and resources detailed scrutiny of all Program, Institute of Medicine, Washington, DC: NationalAcademy Press, 1990.
available evidence may not have been possible. Finally 2. Consensus report, Institute of Medicine. Clinical practice guidelines we
suboptimal treatments may be recommended to control can trust. March 23, 2011. http://www.iom.edu/Reports/2011/Clinical-
Practice-Guidelines-We-Can-Trust.aspx
the cost of treatment or balance the interests of doctors 3. OPEN CLINICAL: Knowledge Management for medical care: Clinical
and healthcare systems. CPGs may cross the boundary Practice Guidelines. Available at: http://www.openclinical.org/guidelines.html
4. Woolf SH, Grol R, Hutchinson A, Eccles M, Grimshaw J. Clinical
between benefit and harm when clinicians seek for secular guidelines: Potential benefits, limitations, and harms of clinical guidelines.
(but often self-benefitting) management procedures. BMJ. 1999 Feb 20; 318(7182): 527–530.
5. Agency for Health Care Policy and Research. Using clinical practice
Common recommendations often don’t take into account guidelines to evaluate quality of care. 1. Issues. Rockville, MD: US
the individual medical and psychiatric history of the patient Department of Health and Human Services, Public Health Services; 1995.
and care at the individual level may not be optimal.10 (AHCPR publication No 95-0045.)
6. Shapiro DW, Lasker RD, Bindman AB, Lee PR. Containing costs while
Flawed guidelines compromise quality of care and can improving quality of care: the role of profiling and practice guidelines. Annu
misguide the clinicians. Due to time limitations clinicians Rev Public Health. 1993;14:219–241.
7. Loewy EH.Ethics and Evidence-Based Medicine: Is There a Conflict?
often find usage of guidelines inconvenient. Algorithms MedGenMed. 2007; 9(3): 30.
in clinical guidelines which convert patient care into a 8. Lewis SJ, Orland BI. The importance and impact of evidence-based
medicine. J Manag Care Pharm. 2004 Sep;10(5 Suppl A):S3-5.
binary system of yes/no are likely to do grave injustice 9. Kane RL. Creating practice guidelines: the dangers of over-reliance on
to the practice of medicine involving complex decision expert judgment. J Law Med Ethics. 1995;23:62–64.
making. A theoretical concern is that of clinicians getting 10. Woolf SH. Shared decision-making: the case for letting patients decide
which choice is best. J Fam Pract. 1997;45:205–208.
sued for not following guidelines.11 Flawed guidelines 11. Hurwitz B, Eccles M. Legal, political and emotional considerations of
can also compromise future research and burden health clinical practice guidelines. BMJ (in press).
care delivery systems. Hence the editorial team believes

that pragmatic use of guidelines which are tailored for This is an open access article distributed under the terms of the Creative
the individual, family and the community encompassing others to remix, tweak, and build upon the work non-commercially, as long as the
nuances of reality and humane treatment are the best author is credited and the new creations are licensed under the identical terms.
options. We are confident these guidelines which are brain
child of the best possible expertise in the speciality will go Access this article online
a long way in meeting the expectations of the therapists, Quick Response Code
Website:
clients and the society.
The earlier guidelines were published by the CPG task force

but was made available at our IJP Website. The editorial DOI:
team is grateful for the responsibility bestowed on us to 10.4103/0019-5545.196967
publish to make it available as a supplement of IJP for the
easy documentation, dissemination and availability to all,
all the time. We are confident that it will serve the purpose
How to cite this article: Rao TS, Tandon A. Clinical Practice
of IPS and all the stake holders.
Guidelines: Principles for Clinical Practice. Indian J Psychiatry
2017;59:5-6.
Happy Reading! Long live IPS.
S6 Indian J Psychiatry 59 (Supplement 1), January 2017

IPS TASK FORCE
IPS Task Force on Clinical Practice Guidelines Workshop held on

Oct, 24, 25, 2015
Chairman : Dr. Shiv Gautam

Co- Chairman : Dr. Ajit Avasthi
Convenor : Dr. Sandeep Grover
Ex. Officio Members : Dr. V.G. Watve, President IPS
: Dr. N.N Raju, General Secretary IPS
CIPS GUIDELINE COMMITTEE ON DEPRESSION : Dr. Mrugesh Vaishnav (Ahmedabad), Dr. Vivek Kirpekar
(Nagpur), Dr. Vihang Vahia (Mumbai), Dr. D.K. Sharma
Dr. Shiv Gautam (Jaipur), Dr. N.N. Raju (Vishakhapatnam), (Kota), Dr. Mahendra Jain (Ajmer), Dr. Asim Kumar Mallick
Dr. S.C. Tiwari (Lucknow), Dr. Roop Sidhana (Shri Ganga (Kolkata), Dr. C.L. Narayaan (Patna)
Nagar), Dr. I.D. Gupta (Jaipur), Dr. Manaswi Gautam
(Jaipur), Dr. Anita Gautam (Jaipur), Dr. Akhilesh Jain (Jaipur),
Dr. Tushar Jagawat (Jaipur), Dr. T.S.S. Rao (Mysore),
This is an open access article distributed under the terms of the Creative
Dr. K.K Mishra (Vishakhapatnam), Dr. Gautam Saha (Kolkata),
Dr. Navendu Gaur (Ajmer) others to remix, tweak, and build upon the work non-commercially, as long as the
IPS GUIDELINE COMMITTEE ON For reprints contact: reprints@medknow.com
SCHIZOPHRENIA :
Dr. Ajit Avasthi (Chandigarh), Dr. Sandeep Grover
Quick Response Code
(Chandigarh), Dr. Subho Chakrabarti (Chandigarh), Dr. Lalit Website:
Batra (Jaipur), Dr. B.N. Gangadhar (Bangalore), Dr. P.K. Dalal www.indianjpsychiatry.org
(Lucknow), Dr. Kishore Gujar (Pune), Dr. O.P Singh (Kolkata),
Dr. Bharat Singh (Kota), Dr. Abhay Matkar (Bangalore),
Dr. Devendra Vijayvargiya (Kota), Dr. R.K. Solanki (Jaipur), DOI:
Dr. Adarsh Tripathi (Lucknow) 10.4103/0019-5545.196968
IPS GUIDELINE COMMITTEE ON BPAD :
Dr. Neelesh Shah (Mumbai), Dr. Anup Bharati (Mumbai), How to cite this article: IPS Task Force on Clinical Practice
Guidelines Workshop held on Oct, 24, 25, 2015. Indian J
Dr. Madhu Nijhawan (Jaipur), Dr. Vinay Kumar (Patna),
Dr. Vidhyadhar Watve (Pune), Dr. G. Prasad Rao (Hyderabad),

IPS TASK FORCE
IPS Task Force on Clinical Practice Guidelines Workshop held on

Aug, 6 & 7, 2016
Chairman : Dr. Shiv Gautam

Co- Chairman : Dr. Ajit Avasthi
Convenor : Dr. Sandeep Grover
Ex. Officio Members : Dr. G. Prasad Rao, President IPS
:Dr. Gautam Saha, General Secretary IPS
IPS GUIDELINE COMMITTEE ON OCD : IPS GUIDELINE COMMITTEE ON SLEEP
DISORDERS
Dr. Y.C.J. Reddy (Bangalore), Suresh Badamath
(Bangalore), Adarsh Tripathi (Lucknow), Om Prakash Ravi Gupta (Dehradun), Lalit Batra (Jaipur), Gautam Saha
Singh (Kolkata), Paramjeet Singh (Jaipur), Tushar Jagawat (Kolkata), R.K. Solanki (Jaipur), Amrit Pattojoshi (Orissa
(Jaipur), Aleem Siddiqui (Aligarh), K.K. Verma (Bikaner), Bhubaneswar), Kshirod Kumar Mishra (Nagpur) , Kishor Gujar
D.M. Mathur (Udaipur) (Pune), Navendu Gaur (Ajmer), Abdul Majid (Shrinagar)
IPS GUIDELINE COMMITTEE ON GAD & PANIC Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows
DISORDER : others to remix, tweak, and build upon the work non-commercially, as long as the
Shiv Gautam (Jaipur), Nilesh Shah (Mumbai), S.C. Tiwari For reprints contact: reprints@medknow.com
(Lucknow), Vihang N. Vahia (Mumbai), I.D. Gupta (Jaipur),

Pratap Sharan (New Delhi), Devendra Vijay Vergiya (Kota),
Quick Response Code
B.N. Gangadhar (Bangalore), Akhilesh Jain (Jaipur), Anita Website:
Gautam (Jaipur) www.indianjpsychiatry.org
IPS GUIDELINE COMMITTEE ON SEXUAL

DOI:
DYSFUNCTION :
10.4103/0019-5545.196969
Ajit Avasthi (Chandigarh), T.S.S. Rao (Mysore), Mrugesh

Vaishnav (Ahmedabad), Sanjay Jain (Jaipur), Sandeep
Grover (Chandigarh), G. Prasad Rao (Hyderabad), How to cite this article: IPS Task Force on Clinical Practice
Guidelines Workshop held on Aug, 6 & 7, 2016. Indian J
Neelanjana Paul (Kolkata), Mukesh P. Jagiwala (Surat),
Roop Sidana (Shri Ganganagar), M.S. Bhatia (New Delhi)
S8 © 2017 Indian Journal of Psychiatry | Published by Wolters Kluwer - Medknow

PREAMBLE OF THE CLINICAL PRACTICE
Preamble of the Clinical Practice Guidelines

Shiv Gautham, Ajit Avasthi, Sandeep Grover
From 2005 onwards, the Indian Psychiatric Society came up beliefs about the illness and their treatments are particularly
with treatment guidelines for various psychiatric disorders important, as are the availability of treatment-resources.
to meet the requirements of our patients in the context The general goals of treatment should be to decrease the
of prevailing existing resources. There have been several frequency, severity and impact of episodes (exacerbations)
developments in the management of these disorders and maximize functioning between the episodes. Specific
since then. In view of the same, it was decided to update goals will depend on the specific phases of illness.
the existing treatment guidelines for various psychiatric
disorders. These new set of guidelines attempt to update Table 1: Common ingredients of a management plan
the previous guidelines by emphasizing what is new in Comprehensive assessment of all factors that might impinge on treatment
the field. These guidelines should be read in conjunction Most patients will require comprehensive and continuous treatment for
with the earlier version of the clinical practice guidelines as long periods
developed and published by the Indian Psychiatric Society Evolving a treatment plan, which should be regularly updated according to
in the year 2005 & 2006. changing needs of patients and caregivers
Holistic biopsychosocial approach to treatment
Forming a therapeutic alliance with the patient
These guidelines are not particularly applicable to any Active collaboration with the family
specific treatment setting and may need minor modifications Ensuring adherence to treatment
to suit the needs of patients in a specific setting. The
recommendations are primarily meant for adult patients. This is an open access article distributed under the terms of the Creative
The needs of children or the elderly may be different. Finally, Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows
it is expected that recommendations made will have to be others to remix, tweak, and build upon the work non-commercially, as long as the
tailored to suit the needs of individual patients. Although
these guidelines focus on management of various disorders,
yet the clinicians need to remember that management must
focus on the whole patient and not just the disorder. The Access this article online
recommendations given as part of the revised guidelines Quick Response Code

Website:
are based on the available evidence base, expert consensus
and the feedback obtained from the membership.
Several factors influence the treatment of various DOI:

psychiatric disorders. Common ingredients of management 10.4103/0019-5545.196970
plan are shown in Table-1. Particular consideration needs
to be given to clinical parameters like cross-sectional and
longitudinal course of symptoms, type of predominant
symptoms, presence or absence of medical comorbidity, How to cite this article: Gautham S, Avasthi A, Grover
S. Preamble of the Clinical Practice Guidelines. Indian J
comorbid substance abuse/dependence, life stage of
patients and their special needs. Socio-cultural factors e.g.

ORIGINAL ARTICLE
Indian Psychiatric Society Survey on Clinical Practice Guidelines

Sandeep Grover, Ajit Avasthi
Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
ABSTRACT
Aim: This survey aimed to assess the utility of the earlier published clinical practice guidelines (CPGs) by IPS and to
understand the expectations of members of Indian Psychiatric Society from the proposed revised CPGs. In addition, the
survey also evaluated the current level of practice of psychiatry in terms of availability of different investigation facilities,
prescription patterns in terms of use of polypharmacy, and competence in carrying out certain nonpharmacological
treatments.
Methodology: An online survey was received by 3475 psychiatrist, of whom 608 (17.5%) participants completed the
survey.
Results: Almost all (93.8%) of the psychiatrists agreed that there should be separate CPGs for Indian setting. In terms
of problems with the previous version of the CPGs, this survey shows that the previous version of guidelines was used
in making clinical decisions by only one‑third (31.25%) of the participating psychiatrists. The major limitations of the
previous version of CPGs which were pointed out included the lack of consideration of socio‑cultural issues (33.2%),
lack of recommendations for many clinical situations that are encountered in clinical practice (43.15) and poor
dissemination (35.2%). In terms of expectations, the membership expects the society to come up with guidelines, which
are shorter in length (82.2%), has significant proportion of information in the form of tables and flow diagrams (58.7%),
besides the evidence base must also take expert opinions into account (84.7%), must be circulated before adopting (88.7%),
must be disseminated by displaying the same on the website (72%), and also by sending the same by E‑mails (62%).
Further, the membership expects the IPS to design online continuing medical education program on CPGs (54.3%). The
survey also suggests that it is feasible on the part of more than two‑third of the psychiatrists to monitor the metabolic
parameters in routine clinical practice and carryout various nonpharmacological treatments. Majority of the psychiatrist
opined that polypharmacy is not used in more than 25% of patients with schizophrenia and depression and hence the use
of polypharmacy should be recommended judiciously.
Conclusion: This survey shows that the membership of the IPS is interested in having own guidelines for the management
of various psychiatric disorders in Indian setting. Further, the survey provides insights into why the previous versions of
the guidelines were not very popular and what IPS should do improve the acceptability of guidelines in future.
Key words: Clinical practice guidelines, guidelines, India, Indian Psychiatric Society
INTRODUCTION
Address for correspondence: Dr Sandeep Grover,
Department of Psychiatry, Postgraduate Institute of Medical Indian Psychiatric Society (IPS), started publishing clinical
Education and Research, Chandigarh ‑ 160 012, India. practice guidelines (CPGs) for the management of various
E‑mail: drsandeepg2002@yahoo.com
Quick Response Code others to remix, tweak, and build upon the work non-commercially, as long as the
Website: author is credited and the new creations are licensed under the identical terms.
www.indianjpsychiatry.org For reprints contact: reprints@medknow.com
DOI:
How to cite this article: Grover S, Avasthi A. Indian
Psychiatric Society Survey on Clinical Practice Guidelines.
10.4103/0019-5545.196971
Indian J Psychiatry 2017;59:10-8.

Grover and Avasthi: Survey on clinical practice guidelines
psychiatric disorders in the year 2005 and between the collected by the authors, the survey was sent to 4394 E‑mail
year 2005 and 2009, published five volumes of treatment addresses. The survey was approved by the ethics committee
practice guidelines, covering most of the psychiatric of the research and training foundation of the IPS. The cover
disorders.[1‑5] A survey was conducted in the months of letter of the survey mentioned that the IPS has decided to
October–November 2008, to evaluate the usefulness, revise CPGs for the management of schizophrenia, bipolar
awareness, and implementation of IPS‑CPGs. The survey was disorder, and depression, and the Executive Committee
sent to 1100 psychiatrists, of whom 107 responded to the of IPS was seeking inputs from its membership prior to
survey. Among the responders, only half of the responders finalizing the CPGs. The participants were also informed
were aware about the four published volumes of the that a symposium on the CPGs will be held during the
guidelines at that time, and only 12.7% of the responders had ANCIPS‑2016. The participation in the survey was voluntary
read all the four volumes. About two‑thirds of the responders and the participants had the option of “opt‑out” from the
had referred to these guidelines in their clinical practice, survey. Completion of the survey implied informed consent.
either occasionally (46.1%), often (16.7%), or always (2%). The survey was sent twice a week for 6 consecutive weeks.
More than two‑thirds of the responders considered these Those who responded to the survey or “opted out” were
guidelines to be helpful in making day‑to‑day clinical decisions not sent the reminders. Those who completed the survey
in their practice, either occasionally (48%), often (19.6%), partially were also sent reminders in between to complete
or always (3.9%). In the open‑ended questions, many of the survey. The survey questionnaire included 41 questions
the responders discussed their dissatisfaction with these and required about 15–20 min to complete.
guidelines and gave suggestions as to how these guidelines
could be improved. Some of the areas of dissatisfaction The data were analyzed by SPSS (SPSS for Windows, Version
were the lack of uniformity, lack of consideration of local/ 14.0. Chicago, SPSS Inc.). Continuous variables were
cultural issues into account, not very useful, lengthy, not user analyzed in the form of mean, standard deviation, median,
friendly, poor quality of printing and typological errors. Some and range. Categorical variables were analyzed as frequency
of the suggestions which emerged from this survey included, and percentages.
rather than having guidelines on the basis of evidence base
only, guidelines may be drawn on the basis of consensus and RESULTS
may be field tested. Further, the IPS should try to focus on
drawing guidelines only on few disorders, rather than having Of the 4394 E‑mail addresses, the invitation to participate
guidelines for everything. In terms of circulation, participants “bouched‑back” for 712 E‑mail addresses and for 207 E‑mail
suggested that the guidelines should be sent to all the Indian addresses, people opted out to participate in the survey.
psychiatrists, and must be made available on the society’s Out of the eligible, 3475 participants, 608 (17.5%) of the
website or on the website of the journal.[6] participants completed the survey. The mean age of the
participants was 41 (standard deviation [SD] 11.78) years,
Besides criticism, many participants had expressed that with a range of 26–79 years and a median of 38 years.
overall it was good initiative of IPS and the society should As is evident from Table 1, about 80% of the participants
continue to formulate guidelines and must update the were ≤50 years with majority of the participants were in
same regularly. In 2015, IPS, again formed the Task force to the age range of 31–40 years. Four‑fifth of the participants
formulate/update the CPGs for various disorders. Keeping were males and about one‑fifth were females. More than
in view the findings of the previous survey, the Executive three‑fourth (77.5%) of the participants had done MD only
Committee of the IPS and Task force on CPGs in its first or had done MD along with an additional degree. The mean
meeting decided to carry out a survey, which should assess total experience in psychiatry, including the training period
the scenario in practice and must take the realities into was 14.22 (SD ‑ 10.89) years, with a median of 10 years and
consideration while formulating recommendations as part range of 1–53 years. Three‑fifth of the participants were in
of various treatment guidelines. Accordingly, the aims of this the government jobs (either fulltime government job only
survey were to assess the (1) utility of the earlier published or government job with private practice) and two‑fifth were
CPGs by IPS; (2) expectations from the new CPGs; (3) current in full‑time private practice only. In terms of place of work,
level of practice of psychiatry in terms of availability and one‑fourth were in full‑time private practice, one‑fifth were
use of different investigation facilities; and (4) prescription in the government medical colleges (without any private
patterns in terms of use of polypharmacy and competence practice). About one‑sixth were in central institutes [Table 1].
in carrying out certain nonpharmacological treatments. In terms of location, about three‑fourth of the psychiatrist
were practicing in the heart of the large city or in the
METHODOLOGY suburbs of a large city. One‑fifth were practicing in a town
and very few were practicing in villages. On an average, a
This survey was conducted by using Survey Monkey platform. psychiatrist was seeing 30 (SD 26.2) patients a day with a
Based on the E‑mail address database of various members of median of 25 patients a day and a range of 2–200. The mean
the society and E‑mail addresses of the trainee psychiatrist duration of time spent in consultation for a new patient was
Indian J Psychiatry 59 (Supplement 1), January 2017 S11

Table 1: Profile of participants (n=608) Views about guidelines

Variable Mean (SD)/frequency (%) A majority (81.6%) of the participants reported that
Age (years) 41 (11.78) (median: 38; they do follow some treatment guidelines for the
range 26-79) management of patients with severe mental disorders
Age categories (in years) such as schizophrenia, bipolar disorder, or depression.
<30 107 (17.6) Among those who were using guidelines, in terms of most
31-40 266 (43.6)
commonly followed guidelines for the management of
41-50 111 (18.3)
51-60 67 (11) patients with severe mental disorders, about two‑fifth (41%)
61-70 45 (7.4) were following Maudsley Prescribing Guidelines and about
>70 12 (2) one‑fourth (28.65%) were following American Psychiatric
Gender‑male/female 479 (78.8)/129 (21.2) Association guidelines. About one‑seventh (14.3%) were
Qualification (n=594)
following National Institute of Clinical Excellence (NICE)
MD only 353 (58.1)
MD along with one or more degrees 118 (19.4) guidelines and another one‑seventh (14.63%) were following
DPM 80 (13.2) IPS guidelines [Table 2]. Majority (82.24%) of those who
DPM + DNB 25 (4.1) were using various guidelines reported that they were able
DNB only 11 (1.8) to use the guidelines only partially.
MRCPsych/FRCPsych 4 (0.7)
DPM + MRCPsych/FRCPsych 3 (0.6)
Total experience in psychiatry (including 14.22 (10.89) (median: 10;
When enquired about having separate CPGs for Indian
the number of years of training in range 1-53) setting majority (93.8%) of the participants answered in
psychiatry) affirmation. When asked about earlier IPS guidelines,
Type of setting in which you are 83.3% of the participants were aware about the same and
working (n=572) about half (52.1%) had used the IPS guidelines. Those who
Full time government job with no 238 (41.6)
private practice
used the same had most often used the same to update
Full time private practice 224 (39.2) their knowledge (43.5%). About one‑third (31.25%) used
Government job with private practice 110 (19.2) the same for taking day to day clinical decisions and
Main place of work (n=590) one‑fourth (25.65%) used it for teaching and few (11%)
Central institute 95 (16.1) had used the same for defending themselves in the court
Full time private practice 151 (25.6)
Government Medical College 125 (21.2)
of law. When asked to report about the problems with
Government medical college with 62 (10.5) the earlier version of the guidelines, the most commonly
private practice reported problem was that these do not address many
Private Medical College 44 (7.5) clinical situations that are encountered (43.1%), followed
Private Medical College with private 62 (10.5) by problems in dissemination (35.2%), do not address the
practice
Mental hospitals 33 (5.6)
socio‑cultural issues encountered in practice (33.2%), and
Charitable hospital 18 (3.1) not evidence based (20.2%). Other details are shown in
Main place of work (n=595) Table 2.
In the heart of a large city 370 (62.4)
In the suburb of a large city 88 (14.8) Expectations from the revised clinical practice guidelines
Town 117 (19.2)
When asked about their expectations from the upcoming
Village 18 (3.0)
Number of patients seen by you in the 31.6 (26.20) (median: 25; CPGs, most of the participants expected that the guidelines
outpatient clinic on a typical day (type range 2-200) should be at best of <5 pages (45.8%) or 5–10 pages (36.4%)
in just the number) of Indian Journal of Psychiatry (IJP) [Table 3]. More than half
Average amount of time spent in 27.9 (16.3) (median: 25; of the participants expected the CPGs to be presented in
evaluating a new patient (in min‑enter range 6-120)
the form of tables and flow diagram format. Majority of the
just the number)
Average amount of time spent in 11.91 (6.94) (median: 10; participants expected that the guidelines must be based
evaluating a repeat visit patient (in 1-60) on evidence base along with expert opinion (84.7%), must
min‑enter just the number) be circulated before being adopted (88.7%) and having a
Are you part of the expert group for the 45 (7.4) symposium in ANCIPS would be beneficial (91.4%). When
formulation of clinical practice guideline
asked about how to improve the use of CPGs, majority
by the Indian Psychiatric Society?
The additional degrees included DM/DPM/DNB/MRCPsych/FRCPsych/
of the participants expected that the guidelines must
FRANZPsych. DPM – Diploma in Psychological Medicine; DNB – Diplomate be made available on the IPS website (72%) and this was
of National Board followed by the expectation of receiving the softcopy of
guidelines by E‑mail (62%) and presenting major parts of the
27.9 (SD ‑ 16.3; median 25) min and that for an old follow‑up guidelines in the form of flow charts and tables (58.7%) and
patient was 11.91 (SD ‑ 6.94; median 10) min. Only a small by conducting online continuing medical education (CME)
proportion (7.4%) of the participants had been part of the programs on the CPGs (54.3%) and least proportion of the
IPS CPG formulation groups in the past. participants (47.4%) considered sending parts of guidelines

Table 2: Views about guidelines (n=608) Table 3: Expectations from the guideline (n=608)

Variable Frequency (%) Variable Frequency (%)
Do you generally follow any treatment guidelines 496 (81.6) What should be the length of the CPGs for each disorder,
published by any psychiatric association for management which you think could be easily referred to in day to day
of your patients with severe mental disorders like clinical practice (n=579)
schizophrenia, bipolar disorder or depression? <5 pages of IJP 265 (45.8)
Most commonly followed treatment guidelines (n=485) 6-10 pages of IJP 211 (36.4)
National institute of clinical excellence 70 (14.3) 10-20 pages of IJP 74 (12.8)
American psychiatric association 139 (28.65) 20-30 pages of IJP 18 (3.1)
Maudsley prescribing guidelines 199 (41.03) 30-40 pages of IJP 11 (1.9)
Indian psychiatric society guidelines 71 (14.63) Should CPGs for each disorder be presented in the form 320 (52.6)
Canadian network for mood and anxiety treatments 6 (1.23) of flow diagrams/tables only?‑yes
If you follow any treatment guidelines, do you find it Recommendations of CPGs be drawn on the basis
useful in your clinical practice (n=490) of (n=589)
Able to follow the guidelines completely 84 (17.1) Both evidence base and expert opinion 499 (84.7)
Able to follow the guidelines partially 403 (82.24) Evidence base only 67 (11.4)
Not able to follow the guidelines 3 (0.6) Expert opinion only 7 (1.2)
Do you think that there is a need to have separate 556 (93.8) Other 16 (2.7)
clinical practice guidelines for Indian setting Is there a need for circulation of the CPGs to membership 539 (88.7)
Are you aware that Indian psychiatric society 506 (83.2) of IPS for inputs before adopting the guidelines?‑yes
had published the clinical practice guidelines for Will symposium on CPGs at ANCIPS be beneficial to the 556 (91.4)
management of various psychiatric disorders in the members of IPS?‑yes
past (i.e., between the year 2005 and 2010)? What should be done to increase the use of IPS CPGs in
Did you ever use the previously published clinical 317 (52.1) clinical practice
practice guidelines by the Indian psychiatric society? Making the guidelines available on the IPS website 438 (72)
If you ever used clinical practice guidelines published by Sending the copy of guidelines by email 377 (62)
Indian psychiatric society, did you find it useful for Sending parts of guidelines in the form of small 288 (47.4)
In taking day‑today clinical decisions 190 (31.25) educational capsules through email on regular basis
Updating your knowledge 221 (43.5) Presenting major parts of the guidelines in the form of 357 (58.7)
Defending yourself in court of law 67 (11) flow charts and tables
Teaching your students 156 (25.65) Online CME programs on the clinical practice 330 (54.3)
What do you think are the problems with the clinical guidelines
practice guidelines published by Indian psychiatric Is there a need to make the practice of psychiatry as per
society the IPS CPGs binding on the membership (n=590)
Too short 21 (3.45) Cannot say 124 (21)
Too long 82 (13.5) Definitely 33 (5.6)
Do not address the socio‑cultural issues encountered 202 (33.2) May be 146 (24.7)
in practice Not at all 287 (48.6)
Do not address many clinical situations that are 262 (43.1) CPGs – Clinical practice guidelines; CME – Continuing medical education;
encountered IPS – Indian Psychiatric Society
Not evidence based 123 (20.2)
Too much emphasis on pharmacotherapy 88 (14.5) Only two‑fifth (42.6%) had access to serum valproate levels
Poorly disseminated 214 (35.2)
and urine drug screen (40.6%). However, very few had access
to positron‑emission tomography and serum clozapine
in the form of small educational capsules through E‑mail on levels [Table 4]. For at least two‑third of the psychiatrists,
regular basis would be of benefit. About half (48.6%) of the it was possible to measure height, weight, blood pressure,
participants considered that the society should not make fasting blood glucose levels, and the lipid profile. More than
it mandatory for its membership to follow the CPGs and half (55.3%) also reported that it was feasible to measure
very few (5.6%) considered that it should definitely be made waist circumference of their patients.
mandatory.
Investigations carried out routinely prior to starting of
Feasibility of investigations various psychotropic medications
In terms of feasibility of carrying out investigations, for In terms of current practice, in general, more investigations
majority of the participants (>75%), it was feasible to were being done prior to starting of antipsychotics
order and get reports of hemogram, fasting blood glucose and mood stabilizers, when compared to the use of
levels, serum electrolytes, liver function test, renal function antidepressants. Investigations done prior to starting
test, lipid profile, thyroid function test, ultrasound of of antipsychotics by more than half of the psychiatrists
abdomen and pelvis, electroencephalogram, computerized included hemogram, fasting blood glucose levels, and
tomography of brain, X‑ray chest, and electrocardiogram. lipid profile. Further more than half of the psychiatrists
More than two‑third of the participants also had access to also monitored the same while using antipsychotics
serum lithium levels and magnetic resonance imaging. More [Tables 5 and 6]. Investigations done by about half or
than half had access to Vitamin B12 and Vitamin D levels. more psychiatrists, prior to starting of mood stabilizers

included hemogram, fasting blood glucose levels, liver investigations included hemogram, fasting blood glucose
function test, renal function test, and thyroid function test. level, and thyroid function test.
Of these, only liver function tests, renal function tests,
and thyroid function tests were being monitored while In terms of option given for other investigations, few reported
using mood stabilizers. In general, fewer psychiatrists evaluating serum drug levels (lithium and valproate) (5.9%)
carried out investigations prior to starting and while using and serum prolactin (3.8%), while monitoring patients on
various antidepressants. The most commonly carried out various psychotropic medications.
Table 4: Feasibility of investigations (n=608) Majority of the psychiatrists were carrying out renal
Variable Frequency (%) function test (84.9%), thyroid function test (78%), and serum
What all investigations are feasible at the clinical setting electrolytes prior to starting of lithium. However, very few
in which you practice (tick on whichever are feasible) psychiatrists reported evaluating 24 h urine osmolality and
Hemogram 554 (91.1) 24 h proteins prior to starting of lithium. Very few (5.6%)
Fasting blood glucose levels 555 (91.3) of psychiatrist reported not carrying out any investigations
Serum electrolytes 528 (86.8)
Liver function test 553 (91.0)
prior to starting of lithium.
Renal function test 535 (88.0)
Lipid profile 519 (85.4) Prescription practices
Thyroid function test 529 (87.0) When asked about polypharmacy, 26.8–32.37% of the
Serum lithium levels 435 (71.5)
participants reported using combination of antipsychotic
Serum valproate levels 259 (42.6)
Serum clozapine levels 90 (14.8) continuously for more than 2 weeks to manage acute phase of
Urine drug screen 247 (40.6) illness of patients with schizophrenia, depression, or bipolar
Ultrasound of abdomen and pelvis 458 (75.3) disorder [Table 7]. Combinations of antidepressants were
EEG 459 (75.5) used by 23% of participants in the management of acute phase
CT of brain 484 (79.5)
X‑ray chest 482 (79.3)
depression. Combinations of two classical mood stabilizers
MRI of brain 407 (66.9) (i.e., lithium, valproate, lamotrigine, carbamazepine, etc.,)
PET 111 (18.3) were used by 18.63% only for the management of mania.
Electrocardiogram 485 (97.8) However, combination of mood stabilizer (i.e., lithium,
Vitamin B12 levels 365 (60.0) valproate, lamotrigine, carbamazepine, etc.,) and an
Folic acid levels 289 (47.5)
Vitamin D levels 322 (53.0) antipsychotic medication were used for the management of
Which of the following is feasible to measure in all acute phase of mania by 58.3% of the participants.
patients before starting psychotropics (tick as many as
applicable) About one‑fourth (24.12%) of the participants, reported using
Height 436 (71.7)
the combination of antipsychotics in the stabilization/stable
Weight 541 (89.0)
Waist circumference 336 (55.3) phase of schizophrenia. In terms of management of bipolar
Hip circumference 239 (39.3) disorder in the maintenance phase, combination of a classical
Waist‑hip ratio 250 (41.1) mood stabilizer and antipsychotic medication was used in
Blood pressure 552 (90.8) about 40.5% of patients and this was followed by the use
Fasting blood glucose levels 477 (78.5)
Lipid profile 394 (64.8)
of a combination of two classical mood stabilizers (21.04%)
PET – Positron emission tomography; MRI – Magnetic resonance imaging;
or combination of two classical mood stabilizers and an
CT – Computed tomography; EEG – Electroencephalogram antipsychotic medication (14.71%).
Table 5: Investigations carried out routinely prior to starting of various psychotropic medications
Antipsychotics (%) Antidepressants (%) Mood stabilizers (%)
Hemogram 383 (63) 302 (49.7) 352 (57.9)
Fasting blood glucose levels 453 (74.5) 252 (41.4) 304 (50.0)
Serum electrolytes 155 (25.5) 191 (31.4) 224 (36.8)
Liver function test 304 (50.0) 213 (35.0) 374 (61.5)
Renal function test 256 (42.1) 197 (32.4) 364 (59.9)
Lipid profile 327 (53.8) 120 (19.7) 200 (32.9)
Thyroid function test 168 (27.6) 295 (48.5) 318 (52.3)
Urine drug screen 36 (5.9) 25 (4.1) 32 (5.3)
EEG 35 (5.8) 20 (3.3) 46 (5.3)
Electrocardiogram 276 (45.4) 186 (30.6) 211 (34.7)
Vitamin B12 levels 36 (5.9) 93 (15.3) 40 (6.6)
Folic acid levels 12 (2) 46 (7.6) 25 (4.1)
Vitamin D levels 25 (4.1) 66 (10.9) 23 (3.8)
EEG – Electroencephalogram

Table 6: Investigations carried out while monitoring patients on various psychotropic medications
Antipsychotics (%) Antidepressants (%) Mood stabilizers (%)
Hemogram 318 (52.3) 199 (32.7) 267 (43.9)
Fasting blood glucose levels 476 (78.3) 209 (34.4) 256 (42.1)
Serum electrolytes 133 (21.9) 181 (29.8) 199 (32.7)
Liver function test 290 (47.7) 176 (28.9) 369 (60.7)
Renal function test 191 (31.4) 146 (24.0) 329 (64.1)
Lipid profile 387 (63.7) 125 (20.6) 212 (34.9)
Thyroid function test 125 (20.6) 235 (38.7) 320 (62.6)
Urine drug screen 22 (3.6) 18 (3.0) 25 (4.1)
EEG 25 (4.1) 14 (2.3) 24 (3.9)
Electrocardiogram 216 (35.5) 137 (22.5) 146 (24.0)
Vitamin B12 levels 18 (3.0) 50 (8.2) 29 (4.8)
Folic acid levels 8 (1.3) 23 (3.8) 19 (3.1)
Vitamin D levels 14 (2.3) 33 (5.4) 11 (1.8)
EEG – Electroencephalogram
Table 7: Polypharmacy prescription practices (n=608)

Variable Mean (SD)/frequency (%)
• In what proportion of patients with schizophrenia do you use a combination of 28.23 (30.02) (median 20; range 0-100)
antipsychotic continuously for >2 weeks to manage acute phase of illness
• In what proportion of patients with depression do you use a combination of 26.8 (32.01) (median 10; range 0-100)
antipsychotics continuously for >2 weeks to manage acute phase of illness
• In what proportion of patients with bipolar disorder do you use a combination 32.37 (31.64) (median 20; range 0-100)
of antipsychotics continuously for >2 weeks to manage acute phase of illness
• In what proportion of patients with schizophrenia do you use combination of 24.12 (21.84) (median 20; range 0-100)
antipsychotics during the stabilization/stable phase of illness
• In what proportion of your patients with depression do you use a combination 22.88 (24.99) (median 15; range 0-100)
of antidepressants to manage acute phase of management
• In what proportion of your patients with mania do you use a combination of 18.63 (20.48) (median 10; range 0-100)
2 classical mood stabilizers during the acute phase (i.e., lithium, valproate,
lamotrigine, carbamazepine etc.)
• In what proportion of your patients with mania do you use a combination of 58.34 (32.23) (median 70; range 0-100)
one or more classical mood stabilizers (i.e., lithium, valproate, lamotrigine,
carbamazepine etc.) and an antipsychotic medication during the acute phase
• In what proportion of your patients with bipolar disorder do you use a 21.04 (17.93) (median 20; range 0-100)
combination of 2 or more classical mood stabilizers (i.e., lithium, valproate,
lamotrigine, carbamazepine etc.) for maintenance treatment
• In what proportion of your patients with bipolar disorder do you use a 40.54 (26.33) (median 40; range 0-100)
combination of one classical mood stabilizers (i.e., lithium, valproate,
lamotrigine, carbamazepine etc.) and an antipsychotic for maintenance
treatment
• In what proportion of your patients with bipolar disorder do you use 2 classical 14.71 (16.34) (median 10; range 0-100)
mood stabilizers (i.e., lithium, valproate, lamotrigine, carbamazepine etc.) and
one or more antipsychotic for maintenance treatment
SD – Standard deviation
Competence in nonpharmacological interventions and to understand the expectations of the membership with
Majority of the psychiatrist (>80%) considered their regard to the revised CPGs. In addition, the Task force of IPS
competence to carry out psychoeducation, cognitive on CPGs was also interested in understanding the feasibility
behavior therapy, behavior therapy, family intervention, of making certain recommendations such as carrying out
and relaxation exercises as “average” or “above average” investigations for the evaluation of metabolic syndrome
or “excellent.” However, for psychoeducation, only 64.4% and various nonpharmacological treatments.
considered their competence as “average” or “above
average”. In terms of carrying out cognitive remediation As there are no such surveys which have looked into these
therapy, only about half of the participants reported their aspects of practice of psychiatry, it would be difficult to
own competence as average or above average [Table 8]. compare the findings of the present survey with existing
literature. Hence, we would discuss the findings of this
DISCUSSION survey in the context of formulation of newer guidelines.
This survey intended to have basic information about the The present survey suggests that in Indian setting,
dissatisfaction and utility of previous version of CPGs of IPS majority of the psychiatrists follow one or other treatment

Table 8: Competence in nonpharmacological interventions (n=608)

How would you rate your competence in Above average (%) Average (%) Excellent (%) Poor (%)
delivering the following interventions (n)
Psychoeducation (536) 276 (51.5) 69 (12.9) 187 (34.9) 4 (0.75)
Cognitive behavior therapy (532) 140 (26.3) 256 (48.1) 42 (7.9) 94 (17.7)
Behavior therapy (531) 181 (34.1) 251 (47.3) 48 (9.0) 53 (10.0)
Cognitive remediation therapy (524) 89 (17) 216 (41.2) 12 (2.3) 207 (39.5)
Family intervention (535) 225 (42.0) 192 (35.9) 78 (14.6) 40 (7.5)
Relaxation exercises (532) 220 (41.3) 188 (35.3) 91 (17.1) 33 (6.2)
guidelines for the management of their patients with severe information being provided in the form of flow diagrams
mental disorders. This finding is very similar to the previous and tables and drawing the recommendations based
survey in which only 8.8% of psychiatrists had reported not on the evidence base and expert opinion. In addition,
following any specific treatment guidelines in managing the membership expects that the society should make
their patients.[6] In terms of preference, a large proportion these guidelines available to them electronically through
of psychiatrists was following treatment guidelines issued various resources. In addition, a significant proportion of
by other associations, i.e., Maudsley Prescribing Guidelines, the members expect that having online CME program on
American Psychiatric Association, and NICE and only a very guidelines could be of help IPS must take these views into
small proportion of psychiatrists based their day to day account while circulating the revised guidelines.
clinical decisions based on IPS guidelines. This finding can
be interpreted as possible lack of satisfaction with the IPS In terms of problems with the existing guidelines, a
guidelines. This lower reliance on IPS guidelines also can significant proportion of participants reported that
be due to the lack of awareness about these guidelines in the guidelines do not take into consideration various
about one‑sixth of the participants. socio‑cultural issues encountered in practice, do not
address many clinical situations that are encountered,
In terms of applicability, majority of the participants are not evidence based and there is too much emphasis
reported that they were able to use guidelines of different on pharmacotherapy. In addition, about one‑third of
associations only partially in their clinical practice. This the participants also pointed out the issue of poor
suggests that guidelines issued by various associations dissemination of these guidelines. This again suggest that
probably are not in tune with the real life situations revised version of guidelines must focus on these issues
faced by the psychiatrists and hence any new guidelines and must be disseminated properly.
must take these situations into account while making
recommendations. IPS Task force on formulation of treatment guidelines must
take these insights in terms of problems with earlier version
When asked about the need for separate CPGs for Indian of the guidelines and expectations of the membership in
setting, almost all (93.8%) of the participants expressed formulation of future CPGs. Some of the issues like making
the need to have separate treatment guidelines for Indian the recommendations on the basis of current evidence base
setting. This finding clearly reflects that there is a need for can easily be done by carrying out proper review of the
development of treatment guidelines by the IPS. Hence, it existing literature and drawing recommendations based on
can be said that decision of IPS to revise these guidelines is the same. The newer guidelines should provide adequate
in the right direction. In terms of using the previous version information about the nonpharmacological treatments, so
of guidelines only 52.1% of psychiatrists reported ever that these can be easily incorporated into clinical practice
using the IPS guidelines. Only one‑third of the psychiatrists, and emphasis on the use of only pharmacological measures
who used the IPS guidelines, reported that these were must be reduced. Problem of dissemination must be
useful in making day to day clinical decisions. In terms of addressed by publishing the guidelines as part of the IJP and
implementation of treatment guidelines, studies from other possibly making the guidelines available at the IJP website
parts of the world show that the barriers to implementation and sending the guidelines to the membership by E‑mail. IPS
to various treatment guidelines include organizational must look at developing online CME program for improving
resources, health care professional’s own characteristics, the acceptability of CPGs. This can be done probably by
and perception of guidelines and implementation having CME program which can evaluate the knowledge
strategies.[7] Accordingly, it is important for the IPS to keep of the participant about the content of IPS guidelines.
these facts in mind to reduce the barriers in implementation This program can also possibly help in evaluating specific
of treatment guidelines. dissatisfactions with the guidelines. In future, there is a
need to carry out a survey to understand the socio‑cultural
In terms of expectations, majority of the participants aspects and the clinical situations, which clinicians feel that
expressed the need to have shorter documents, with lot of the guidelines do not address.

Members of all the societies expect their leaders to fulfill significant proportion of patients with schizophrenia and
their demands and aspirations. In the survey, a very large depressive disorders. However, a significant proportion of
proportion of the psychiatrists expressed that having a patients with bipolar disorder receive polypharmacy during
symposium in ANCIPS is going to help in formulation of the acute and maintenance phase treatment. Accordingly, it
guidelines. The Task force on the formulation of treatment can be said that guidelines should judiciously recommend
guidelines organized a symposium on the revised CPGs in the use of polypharmacy.
ANCIPS 2016. The attendance in this symposium was far
less than expected. This possibly reflects the apathy of the In terms of nonpharmacological treatment, more than
membership on this issue. Till the membership does not half of the psychiatrists reported average or above
take up their own responsibility sincerely, just blaming the average competence in carrying out nonpharmacological
leadership and people involved in the task of formulation treatments such as psychoeducation, cognitive behavior
would be unfair. Accordingly, the membership should take therapy, behavior therapies, family interventions, and
up their own responsibility more sincerely and provide their relaxation exercises. These findings suggest that future
inputs on this endeavor so that a collective effort can result guidelines must provide more information about the
in the formulation of CPGs which are practical and can be role of these interventions in management of various
used. psychiatric disorders. Further, the findings also suggest that
a significant proportion of psychiatrists are not very well
Over the last 1–2 decades, development of metabolic versed with cognitive remediation therapy. Accordingly, as
syndrome with the use of psychotropics has become capacity building measure, IPS must hold workshops and
an important issue. Various associations have issued symposiums on cognitive remediation therapy, so that
guidelines for monitoring of metabolic syndrome. This these can be practiced more often by its membership.
survey clearly shows that it is feasible for majority of the
psychiatrists to carry out most of the routine investigations This survey has certain limitations. The survey did not
in their clinical practice. Further, it was also feasible to evaluate the specific level of dissatisfaction among the
carryout anthropometric evaluation on part of majority of psychiatrists with regard to the existing guidelines. Further
psychiatrists. In terms of current practice too, it was evident the survey did not evaluate the specific expectations of the
that a significant proportion of psychiatrists were already psychiatrists from the newer guidelines. This survey did
carrying out baseline investigations and also were ordering not endeavor to assess the barriers to the implementation
for investigations while using psychotropics in long run. of treatment guidelines in clinical practice. Only about
Accordingly, the recommendations of guidelines in terms one‑sixth of the membership participated in this survey.
of carrying out baseline investigations and anthrometric Due to this, generalizability of this survey can be
evaluation must take these into account. Accordingly, questioned.
the guidelines may recommend monitoring of metabolic
parameters for patients recommended antipsychotic and CONCLUSION
mood stabilizers. If in future, these recommendations are
followed by the practicing psychiatrists in routine clinical The present survey shows that the majority of the psychiatrists
practice, this could possibly help in detecting metabolic are interested in having own CPGs and at present follow
abnormalities at early stages and prevention of development one or other treatment guidelines for the management of
of chronic physical illnesses such as diabetes mellitus and patients. In terms of problems with the previous version
hypertension. This all can probably also help in reduction of the CPGs, this survey shows that the previous version of
in premature cardiovascular mortality. The findings of this guidelines were used for making clinical decisions by a very
survey also shows that majority of the psychiatrists follow small proportion of psychiatrists only. The major limitations
the basic recommendations for prelithium investigations. of the previous versions which were pointed out included
Accordingly, future guidelines must make recommendations the lack of consideration of socio‑cultural issues, lack of
of this with ease. recommendations for many clinical situations that are
encountered in clinical practice and poor dissemination. In
There is a general perception that there is high rate of terms of expectations, the membership expects the society
polypharmacy in routine clinical practice. Some of the to come up with guidelines, which are shorter in length, has
psychiatrists argue about this issue and give this as an excuse more information in the form of tables and flow diagrams,
for not following treatment guidelines. Some claim that should take expert opinions into account, must be circulated
most patients require polypharmacy and it is not possible before adopting, must be disseminated by displaying the
to manage patients with monotherapy during the acute and same on the website, and also by sending the same by
maintenance phase. Keeping these views in mind, there is E‑mails. Further, the membership expects the organization
always a pressure of recommending polypharmacy as part to design online CME program on CPGs. The survey also
of CPGs. However, findings of the current survey clearly suggests that it is feasible to monitor the metabolic
shows that in general, polypharmacy is not practiced for parameters in routine clinical practice and carryout various

nonpharmacological treatments. In addition, the survey Disorder and Panic Disorder. Vol. 1. Jaipur: Indian Psychiatric Society;
2005.
suggests that polypharmacy is not used much; hence its use 2. In: Gautam S, Avasthi A, editors. Indian Psychiatric Society. Clinical
should be recommended judiciously. Practice Guidelines for Management of Substance Abuse Disorders,
Sexual Dysfunctions and Sleep Disorders. Vol. 2. Jaipur: Indian Psychiatric
Society; 2006.
Financial support and sponsorship 3. In: Gautam S, Avasthi A, editors. Indian Psychiatric Society. Geriatric
Psychiatry Clinical Practice Guidelines. Vol. 3. Jaipur: Indian Psychiatric
Nil. Society; 2007.
4. In: Gautam S, Avasthi A, editors. Indian Psychiatric Society. Child and
Conflicts of interest Adolescent Psychiatry Clinical Practice Guidelines for Psychiatrists in
India. Vol. 4. Jaipur: Indian Psychiatric Society; 2008.
There are no conflicts of interest. 5. In: Gautam S, Avasthi A, editors. Indian Psychiatric Society. Forensic and
Legal Issues. Vol. 5. Jaipur: Indian Psychiatric Society; 2009.
6. Grover S, Avasthi A. Views about clinical practice guidelines of the Indian
REFERENCES Psychiatric Society: A survey of psychiatrists in India. Indian J Psychiatry
2009;51:127‑33.
1. In: Gautam S, Avasthi A, editors. Indian Psychiatric Society. Clinical Practice 7. Forsner T, Hansson J, Brommels M, Wistedt AA, Forsell Y. Implementing
Guidelines for Psychiatrists in India on Schizophrenia, Depression, Bipolar clinical guidelines in psychiatry: A qualitative study of perceived facilitators
Affective Disorders, Obsessive Compulsive Disorder, Generalized Anxiety and barriers. BMC Psychiatry 2010;10:8.

Clinical Practice Guidelines for Management of Schizophrenia

Sandeep Grover, Subho Chakrabarti, Parmanand Kulhara, Ajit Avasthi
Department of Psychiatry, PGIMER, Chandigarh
previous guidelines. These guidelines are not particularly

Participants of expert group on CPG for Schizophrenia
applicable to any specific treatment setting and may need
minor modifications to suit the needs of patients in a
B.N. Gangadhar, P.K. Dalal, Lalit Batra, Kishore Gujar,
specific setting. The recommendations are primarily meant
O.P Singh, Bharat Singh, Abhay Matkar, Devendra
for adult patients. The needs of children or the elderly with
Vijayvargiya, R.K. Solanki, Adarsh Tripathi
schizophrenia may be different. Finally, it is expected that
recommendations made will have to be tailored to suit the
INTRODUCTION
needs of individual patients.
Schizophrenia is a serious mental disorder with prevalence
Assessment and evaluation (table-1)
rates of 2-3 per 1000 reported from India. The impact of
A comprehensive assessment of the patient and his/her
schizophrenia on patients, their families and the wider
caregivers needs to be carried out. The cornerstone of this
society are no different from what has been observed in
assessment is a detailed history and physical and mental state
the rest of the world. However, resource constraints, examinations. Efforts should be made to obtain information
poverty, lack of education and inadequate access to health from all sources, especially the family. Wherever possible,
care facilities for patients make the problem of providing diagnosis of schizophrenia be preferably made according
care particularly daunting in India. In 2005, the Indian to current diagnostic criteria, as such a diagnosis is more
Psychiatric Society came up with treatment guidelines for reliable. A reliable diagnosis facilitates communication
schizophrenia tailored to meet the requirements of our among clinicians, and allows for better applicability
patients in the context of prevailing existing resources. of evidence-based recommendations. Many clinical
There have been several developments in the management conditions that may mimic schizophrenia include mood
of schizophrenia since then. These new set of guidelines disorders, substance-induced psychoses and psychoses
attempt to update the previous guidelines by emphasizing secondary to physical illnesses. These should be ruled out
what is new in the field. These guidelines ought to be read as far as possible by history, examination and additional
in conjunction with the earlier version of the treatment investigations. In some instances a definitive diagnosis may
guidelines on schizophrenia as developed and published by need time. Further, because of the enormous psychosocial
the Indian Psychiatric Society in the year 2005. consequences a diagnosis of schizophrenia needs to be
made with great caution and sensitivity. In doubtful cases,
SCOPE OF THIS DOCUMENT a medication-free observation period can be considered.
However, consideration of medication free period need to
The major emphasis of the current guidelines is on areas in be balanced against the risks of delaying treatment or the
the management of schizophrenia, which have witnessed potential for harm to self and others in acutely ill patients.
significant developments since the publication of the It is important to remember that diagnosis is not a one-time
affair, but a continuous process. Accordingly, based on the
Address for correspondence: subsequent information from patients and caregivers, and
Dr. Ajit Avasthi, Department of Psychiatry,
Postgraduate Institute of Medical Education and Research,
on repeated clinical evaluations the diagnosis may need re-
Chandigarh ‑ 160 012, India. evaluation.
E-mail: drajitavasthi@yahoo.co.in
Access this article online Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows
DOI:
How to cite this article: Grover S, Chakrabarti S, Kulhara
P, Avasthi A. Clinical Practice Guidelines for Management of
10.4103/0019-5545.196972
Schizophrenia. Indian J Psychiatry 2017;59:19-33.

Grover, et al.: CPG for Schizophrenia
The assessment should cover all other areas such as Table 1: Components of assessment and evaluation
symptom dimensions, symptom-severity, comorbid Basic assessments
psychiatric and medical conditions, particularly comorbid • Comprehensive assessment of both patients and caregivers
substance abuse, the risk of harm to self or others, level of • Complete history with information from all possible sources
functioning and the socio-cultural milieu of the patient. A • Physical examination‑ record data such as blood pressure, weight and
wherever indicated body mass index and waist circumference
high index of suspicion along with thorough assessment can • Mental state examination
help in detecting most patients with comorbid substance • Establish diagnosis according to current diagnostic criteria
abuse/dependence. Wherever, facilities are available, urine • Differential diagnosis by ruling out secondary psychoses
or blood screens (with prior consent) can be used to confirm • Areas to be evaluated: symptom‑severity, symptom‑dimensions (reality
the presence of comorbid substance abuse/dependence. A distortion, disorganization, negative, depressive and cognitive
symptoms), comorbid physical, psychiatric and substance use
thorough physical examination need to be done to rule out conditions, risk of harm to self and others, level of functioning and
presence of any physical illness and also to rule out psychoses socio‑cultural milieu of the patient
secondary to physical illnesses. This may be supplemented • Basic investigations: haemogram, blood sugars and lipid levels, liver
by the judicious use of investigations. Wherever possible, functions, renal functions, electrocardiogram (focus on QTc)
• Assessments of caregivers: knowledge and understanding of the illness,
unstructured assessments need to be supplemented by
attitudes and beliefs regarding treatment, impact of the illness on them,
ratings on appropriate standardized rating scales. Other personal and social resources
options such as detailed cognitive testing can be done if • Ongoing assessments: response to treatment, side effects, treatment
required and feasible. The use of neuroimaging may be adherence, the impact of patient’s immediate environment, disability
indicated in those with first-episode psychosis, neurological assessments, other health‑care needs, ease of access and relationship
with the treatment team
signs, non-response to treatment and elderly patients.
Additional/Optional assessments
• Use of standardized rating scales to rate all aspects of the illness
Assessments of caregivers may focus on areas such as their • Psychological testing for cognitive functions
knowledge and understanding of the illness, their attitudes • Neuroimaging especially in those with first‑episode psychosis,
and beliefs regarding treatment, the impact of the illness on neurological signs, non‑response to treatment and elderly patients
them and their personal and social resources.
Table 2: Some indications for inpatient care during
It is important to remember that assessment is an ongoing acute episodes
process. As the treatment progresses other areas such as response
• Presence of suicidal behaviour which puts the life of the patient at risk
to treatment, side effects, treatment adherence, the impact of • Presence of severe agitation or violence which puts the life of others at risk
patient’s immediate environment, disability assessments, other • Refusal to eat which puts the life of patient at risk
health-care needs, ease of access and relationship with the • Severe malnutrition
treatment team may need to be assessed separately. • Patient unable to care for self to the extent that she/he requires constant
supervision or support
• Catatonia
Formulating a treatment plan (figure 1) • Presence of general medical or comorbid psychiatric conditions which
Formulation of treatment plan involves deciding about make management unsafe and ineffective in the outpatient setting
treatment setting, treatments to be used and areas to be
addressed. Patients, caregivers and staff involved in care
may be consulted while preparing the treatment plan. than the patient and/or family need to be informed about
Treatment plans be needs-based, practical, feasible and such a need and admission in nearest available inpatient
flexible. These should be continuously re-evaluated and facility may be facilitated.
modified as required.
Options for management for schizophrenia
Choice of treatment settings Treatment options for management of schizophrenia
The basic principle while choosing a treatment-setting can be broadly classified as antipsychotic medications,
is to provide care in the least restrictive setting, which electroconvulsive therapy (ECT), adjunctive medications
nevertheless meets the needs of patients and caregivers. The and psychosocial interventions (table-3).
commonest treatment settings would be either outpatient
clinics or inpatient wards. In some instances resources for Pharmacological treatment
long-term inpatient care, or community or residential care Choice of antipsychotic medication
may be available. The bulk of the patients would probably The essential choice is between using an antipsychotic
receive treatment in outpatient settings. Given their severe belonging to the class of typical antipsychotics (FGA- first-
shortage, inpatient beds are likely to be scarce. Common generation antipsychotic) or from the atypical group (SGA-
indications for inpatient care during acute episodes are second-generation antipsychotic). Since the publication of
shown in table-2. Whenever possible patient admitted to the previous guideline there is somewhat greater clarity on
the inpatient setting should have accompanying family this matter. The bulk of the evidence including large-scale
caregivers. In case inpatient care facilities are not available, real-world studies indicates that there is very little difference

Patient with Psychotic features
Consider differential diagnoses like

• Organic Mental Conditions
• Acute and transient psychotic disorder
• Persistent Delusional disorder
• Schizoaffective disorder
• Severe depression with psychotic symptoms
• Mania with psychotic symptoms
• Drug induced psychosis
Establish the diagnosis of schizophrenia
Assessment
• Severity of illness
• Risk of harm to self and others
• Comorbid substance use/dependence
• Level of functioning
• Detailed Physical examination
• Record- blood pressure, weight and wherever indicated body mass index and waist
circumference
• Mental Status Examination
• Investigations- haemogram, liver function test, renal function test, fasting blood glucose
level, electrocardiogram (focus on QTc)
• Treatment history- response to previous medication trials, compliance, side effects, etc.
• Patient’s and caregivers beliefs about the cause of illness and beliefs about the treatment
• Assessment for social support, stigma, coping
• Assessment of caregiver burden, coping and distress
• Decide about treatment setting- consider inpatient care in case of suicidality, severe agitation
and violence, malnutrition, catatonia, patient unable to care for self to the extent that she/he
requires constant supervision or support, comorbid general medical conditions making
management difficult at the outpatient setting
• Liaison with other specialists depending on the need of the patient
Pharmacological Management Electroconvulsive therapy Non-Pharmacological

• Choose an antipsychotic based on past • Catatonia, affective Management
treatment response, past history of side symptoms, rapid control • Psychoeducation
effects, cost, comorbidity, Patient/family of symptoms, suicidality, • Psychosocial
preference, preferred route of past response to ECT, intervention
administration, availability, current metabolic augmentation etc.
profile, past history of compliance,
treatment resistance
Figure-1: Initial evaluation and management plan for schizophrenia
Table 3: Options for management for schizophrenia in terms of efficacy, adherence and other subjective aspects
Antipsychotic medications between the FGA and the SGA group, or between individual
First‑generation antipsychotic medications (Oral/parenteral/depot or long antipsychotics belonging to either group. The only exception
acting‑ preparations) to this trend is clozapine, which appears to be more
Second‑generation antipsychotic medications (Oral/parenteral/depot or long efficacious than any other antipsychotic in patients with
acting‑ preparations)
Somatic treatments
treatment resistance. It follows from this that the choice of
Electroconvulsive therapy (ECT) the antipsychotic will depend on factors other than efficacy.
Adjunctive medications Some of these factors are included in table-4.
Anticholinergics, antidepressants, benzodiazepines, hypnotic‑sedatives,
anticonvulsants, lithium carbonate Dose
Psychosocial interventions
Family intervention, cognitive behavioural therapy, social skills training,
The recommended dose of various oral antipsychotics
cognitive remediation, individual therapy, group therapy, vocational available in India is shown in table-5. In general patients
rehabilitation, early‑intervention programmes, case management, with first-episode psychosis respond to lower doses. The use
community mental‑health teams, crisis resolution teams of high or very high doses (mega doses) of antipsychotics,
Other measures if required, may be used with caution in exceptional
Lifestyle and dietary modifications
circumstances. It is noted that Indian patients require lower

doses of antipsychotic drugs compared to patients from the Table 4: Factors that influence selection of
West. Although this is suggested by clinical experience and antipsychotics
pharmacokinetic studies of Asian patients, there is little • Past treatment response
evidence for, or against this supposition from clinical trials. • Cost of treatment, affordability
• Psychiatric comorbidity
Route of administration • Medical comorbidity
• Side effects
Acutely agitated patients often require parenteral • Patient or family preference
administration of antipsychotics to rapidly control the • Preferred route of administration
behavioural disturbance. Liquid or mouth-dissolving • Concomitant medications
formulations are often helpful in non-compliant patients. • Non‑adherence
Depot preparations are generally not used in acutely • Treatment resistance
agitated patients except zuclopenthixol acetate, which has
a half-life of about 20 hours. In general, it is recommended Table 5: Recommended therapeutic dose ranges for
that one drug is to be used by one route in order to minimise various antipsychotics
drug interactions and simplify clinical observations.
Usual daily dose Maximum
(in mg/day) daily dose
Depot preparations (table-6) are often helpful in ensuring First Generation Antipsychotics (FGAs)
medication-compliance and may be used in situations Chlorpromazine 300‑800 800
where compliance is a problem. Depot injectables may Haloperidol 5‑20 20
also be used if patients/relatives indicate a preference for Penfluridol 20‑60 mg/week 250 mg/week
this kind of treatment. Test doses are administered at the Perphenazine 12‑64 64
Pimozide 4‑10 10
start of treatment. When used, depot preparations need to
Thioridazine 300‑800 800
be prescribed within the standard recommended dosage Trifluoperazine 15‑30 30
and interval range to achieve optimum effectiveness in Zuclopenthixol 10‑50 50
preventing relapse. Second Generation Antipsychotics (SGAs)
Amisulpride 50‑800 1200
Aripiprazole 10‑30 30
Adequate antipsychotic trial
Asenapine 10‑20 20
The minimum recommended duration of treatment to Blonanserin 2‑8 24
consider it to be an effective trial for all antipsychotics is use Clozapine 150‑600 900
of medication in the highest tolerable dose for 6-8 weeks, Iloperidone 12‑24 24
with the exception of clozapine, where the minimum period Olanzapine 10‑30 30
Paliperidone 3‑12 12
of treatment is at least 3-6 months.
Quetiapine 300‑800 800
Risperidone 2‑8 16
Response Ziprasidone 80‑200 200
Antipsychotics are known to produce a significant remission Zotepine 75‑300 300
of positive symptoms. This could thus be a reasonable goal
of treatment during the acute phase. Antipsychotics are less
effective in management of negative symptoms, therefore a
Table 6: Antipsychotic depot preparations available in
mild to moderate reduction in negative symptoms is often
India
acceptable. Response indicators for other aspects of the
Name of antipsychotic Usual 2‑4 weekly dose in mg
illness (e.g. cognitive symptoms) are not clear. Patients on
Zuclopenthixol decanoate 200
antipsychotics need to be monitored regularly to ascertain
Paliperidone palmitate 234 initially followed by 117 monthly
the level of response and the emergence of side effects. Fluphenazine decanoate 12.5‑50
Haloperidol decanoate 50
Non-response (Figure-2) Risperidone depot 25‑50
In case a patient fails to respond to an antipsychotic (RisperidalConsta)
medication, poor compliance or non-compliance need Olanzapine pamoate 210‑405
to be evaluated prior to switching the medication to
another antipsychotic. If a patient is found to have poor with good compliance, a change in antipsychotic may be
compliance or non-compliance to medications, all efforts considered. Clozapine need to be considered after failure of
are to be made to understand the causes responsible for sequential trials of 2 antipsychotics (at least one of which is
lack of compliance and appropriate steps need to be a SGA). Clozapine may also be considered earlier in patients
taken to handle the problem. However, if a patient fails to who are violent, at risk for suicide, not responding to their
respond to an adequate trial of an antipsychotic medication current medication and those experiencing intolerable side
(i.e., adequate dose for at least 6-8 weeks duration) taken effects with two different classes of antipsychotics.

Patient given an adequate Adequate Response

antipsychotic trial (adequate dose for • Continue with the same
atleast 6 weeks duration) dose of antipsychotic
medication and keep on
monitoring the side effects
Non-response to treatment
Evaluation
• Re-evaluate the diagnosis
• Medication compliance
True Non-response Pseudo Non-response due to poor compliance

• Change the antipsychotic • Evaluate the causes, address the same and
medication ensure compliance
• In case of poor compliance due to intolerable
side effects –consider change of antipsychotic
(oral/depot)
Failure of 2 adequate trials of Adequate Response

antipsychotic, one of which is SGA • Continue with the same dose of
• Consider clozapine antipsychotic medication and keep
on monitoring the side effects
Inadequate Response to clozapine

• Consider combining clozapine with ECT
or another antipsychotic medication
• More intensive psychosocial intervention
Figure 2: Evaluation of patient with non-response to antipsychotic medications
Combination of antipsychotics is not recommended. It is better to start these drugs when

There is limited evidence for the efficacy of combination the patient actually develops extrapyramidal side effects.
of antipsychotics. In the initial phase, a clinician may Whenever anticholinergic agents are required, use may be
be compelled to use a combination of antipsychotics to limited to lowest possible doses and for shortest possible
manage agitation, but caution need to be exercised while time.
doing so. These should be used on SOS basis and for
shortest possible time. Combinations of antipsychotics for ELECTROCONVULSIVE THERAPY (ECT)
prolonged periods may be avoided, except in patients not
responding to clozapine. As in many other developing countries ECT is used quite
frequently in schizophrenia in India. The evidence for
ADJUNCTIVE MEDICATIONS efficacy of ECT in the acute phase of schizophrenia is
somewhat controversial. There is evidence for augmentation
Although antipsychotic agents are the mainstay of and acceleration of response. ECT is used in conjunction
treatment of schizophrenia, management may involve with antipsychotics in the acute phase, but the extent of the
use of adjunctive treatments like with antidepressants, benefit of adding ECT to antipsychotics is unclear and the
mood stabilizers or benzodiazepines. However, these can positive effects seem to last only for the first few weeks of
be used with proper rationale and for shortest possible treatment. However, there may be some merit in adding ECT
duration. At every assessment a proper evaluation need to the treatment regimen in patients who respond poorly to
to be done for the continuation of the same. Lithium and antipsychotics. The more unequivocal indications for ECT
other mood stabilizers can be prescribed in agitated, in combination with antipsychotics are included in table-7.
overactive patients or those with affective symptoms ECT is not useful in chronic schizophrenia and there is not
responding poorly to their current drug. Benzodiazepines enough evidence to recommend its use in the longer term
can be useful in managing agitation and sleep disturbance. except in exceptional circumstances. Finally, whenever ECT
Antidepressants may be of use in post-psychotic depression is used adequate information and support for patients and
and may be avoided when the patient has florid psychotic caregivers, informed consent, proper administration and
symptoms. In general prophylactic use of anticholinergics careful monitoring of response and side effects be done.

PSYCHOEDUCATION FOR PATIENTS AND OR mental-health teams and of crisis resolution teams have been
FAMILY (TABLE-8) proven to be useful in the management of schizophrenia.
The usefulness and delivery of psychosocial treatments has
Psychoeducation may be considered both for the patient and probably not attracted the research attention it deserves in the
family members. The aim is to educate the patient and family Indian context. Nevertheless, there is ample Indian evidence
about the illness. Simple and brief explanations about the and experience with family treatments, rehabilitation and
nature of the patient’s illness, treatments, likely side effects, other modalities such as community programmes, yoga and
likely length of treatment etc. can be offered. Relatives also cognitive remediation. Based on these data, psychosocial
need to be given time to confront the painful fact of the illness, interventions, from the simple to the complex, can be
and what it entails for the patient and the family as a whole. recommended for patients with schizophrenia and their
It is important that professionals are careful and considerate, families. An approach which prioritizes the needs of patients
but clear and thorough in their use of clinical language and and their families could be followed.
in the explanations they provide. No blame is to be attached
to the family. Treatment adherence will be another main FAMILY INTERVENTIONS
objective at this stage. Prior to every session, feedback of the
previous sessions may be taken and psychoeducation is to be There has been a long tradition in India of involving
tailored to the needs of the patient and the caregivers. families in the care of their members with mental illness.
There are several studies documenting the delivery of
PSYCHOSOCIAL INTERVENTIONS family interventions. Several formats of predominantly
psychoeducational treatments such as informal or
Psychosocial interventions are acknowledged to be an unstructured programmes, structured treatments, group-
integral part of management of schizophrenia. Different based interventions, and integrated psychosocial treatments
psychosocial interventions including family treatments, have been tried. From the number of controlled trials it
cognitive behavioural therapy, social skills training, cognitive appears that a wide range of interventions and treatment-
remediation, individual supportive therapy, group therapy, delivery, from the simple to the complex, may be useful
vocational rehabilitation, case management, use of community in the Indian context. The basic emphasis need to be on
continued contact and medication adherence while offering
Table 7: Possible indications of use of ECT in patients of emotional and practical support. A needs-based approach,
schizophrenia in which interventions are tailored to the background
• Catatonic symptoms
and needs of the families, is more likely to enhance their
• Affective symptoms acceptability and positively influence the readiness of
• Need for rapid control of symptoms families to participate in such interventions.
• Presence of suicidal behaviour which puts the life of the patient at risk
• Presence of severe agitation or violence which puts the life of others at risk ADVISE FOR LIFE STYLE AND DIETARY
• Refusal to eat which puts the life of patient at risk
• History of good response in the past
MODIFICATIONS
• Patients not responding to adequate trial of an antipsychotic medication
• Augmentation of partial response to antipsychotic medication All the patients are to be advised for a change in the life
• Clozapine resistant schizophrenia style and diet to reduce the risk of metabolic side effects
• Not able to tolerate antipsychotic medications and cardiovascular morbidity and mortality. These include
physical exercises, dietary modifications and abstinence
Table 8: Basic components of Psychoeducation from smoking etc.
• Assessing the knowledge of the patient and caregivers about aetiology,
treatment and prognosis REHABILITATION
• Introducing the diagnosis of schizophrenia into discussion
• Discussing about various symptom dimensions Similar to family treatments, rehabilitation programmes
• Providing information about aetiology need to be be culturally moulded and adapted to the
• Providing information about treatment in terms of available options, their
efficacy/effectiveness, side effects, duration of use
needs of patients and their families. However, unlike family
• Discussing about importance of medication and treatment compliance interventions, resources for more elaborate rehabilitation
• Providing information about possible course and long term outcome strategies may not be available in every centre. Nevertheless,
• Discussing about problems of substance abuse, marriage and other issues relatively simple and inexpensive strategies can form a part
• Discussing about Communication patterns, problem solving, disability of the overall psychosocial intervention package.
benefits
• Discussing about relapse and how to identify the early signs of relapse
• Dealing with day today stress INDIVIDUAL SUPPORTIVE THERAPY
• Improving insight into illness
• Handling expressed emotions and improving communication A supportive empathic relationship between patients and
• Enhancing adaptive coping to deal with persistent/residual symptoms
professionals, in which good listening promotes a lasting

therapeutic alliance is an essential part of good practice. Table 9: Recommendations about psychosocial
Additional elements could include support and advice, interventions
encouraging continued engagement, treatment-adherence • Assessment of psychosocial factors involving the patient and the family is
and healthy lifestyles. Efforts to minimize stress may also an integral part of psychosocial interventions.
be beneficial. Individual support along with medication is • There is a wide range of interventions that have proved useful in Indian
the most commonly practiced treatment in schizophrenia. settings
• Choice of the intervention will be shaped by the needs of patients and
Patients and families consistently rank individual support as their families as well as the resources available.
among the most highly valued services offered to patients • Basic components of any intervention include: promoting a therapeutic
with schizophrenia. alliance with the patient and the family, encouraging ongoing
engagement, information about various aspects of the illness, focusing on
OTHER PSYCHOSOCIAL INTERVENTIONS treatment‑adherence and healthy lifestyles, and offering emotional and
practical support.
Other interventions that hold promise are home-based

care, support groups for caregivers, community-based Table 10: Factors associated with poor medication
interventions, cognitive training or remediation, and yoga. compliance
More research on the efficacy of these strategies and their Demographic risk factors
wider implementation is needed. • Younger age, male gender, unemployment, lower socioeconomic status
Patient related factors
Basic components of any psychosocial intervention are • Knowledge about illness and treatment, perceived need for
treatment (insight), motivation, beliefs about treatment risks and benefits,
depicted in table-9. For more specific recommendations past experiences/“transference”, past history of adherence, self‑stigma
other sources may be consulted. Social risk factors
• Living independently, poor social support, poor financial support
TREATMENT ADHERENCE Clinical risk factors
• Poorer premorbid functioning, earlier age of onset, prior history of
non‑adherence
Adherence is defined as “the extent to which the Symptom‑related risk factors
patients’ behaviour, in terms of regular clinic visit, taking • Lack of insight, paranoia, grandiose delusions, conceptual
medications, following diets, executing lifestyle changes, disorganization, impaired cognition, substance abuse, comorbidities,
coincide with the clinical prescription”. Non-adherence depression, refractoriness, spontaneous remissions
in this context thus denotes failure to enter a treatment Treatment‑related risk factors
• Medication side effects, poor treatment alliance, complex dosing,
programme, premature termination of treatment, or negative experience of medication, route of administration, length of
incomplete implementation of instructions, including treatment, cost of treatment, number of medications
those that pertain to medication administration. Evidence Service‑related risk factors
suggests that about half of the patients with schizophrenia • High cost of medication, poor accessibility of treatment services
do not comply with the treatment recommendations, Family/caregivers‑related risk factors
• Lack of supervision, negative attitudes towards treatment, lack of
about one-third miss their appointments with the knowledge about medicines, nature of relationship with patient,
clinicians and 20-60% of patients drop out from treatment. perceived need for treatment, beliefs about benefits and risks with
Common factors associated with poor medication non- continued treatment, involvement in treatment, stigma, financial
compliance are shown in table-10. Factors consistently constraints, support from other sources
linked to non-adherence include poor insight, negative Clinician/provider related factors
• Therapeutic alliance, frequency and nature of contact with clinicians,
attitude or subjective response to medication, comorbid expected duration of treatment, duration of past treatment, accessibility
substance abuse, and poor therapeutic alliance. Clinicians to clinicians and services, reimbursement, psychoeducation and
need to make efforts to reduce the rates of medication psychosocial treatment, complexity of administration
compliance and treatment non-adherence. It is important
for the clinicians to understand that besides the
or treatment compliance, all efforts need to be made
contextual or situation factors, patient related factors
to understand the reasons behind the same. Proper
and illness related factors, certain clinician related
factors are responsible for poor medication compliance evaluation of non-adherence need to cover assessment
and higher dropout rates. Some of the common clinician of familial, social, biological and pharmacological
related factors which may be relevant in Indian context perspectives. Patients/caregivers concerns need to be
include poor communication between the clinician and addressed by proper psychoeducation and modification of
the patient/caregiver, poor therapeutic alliance and nonpharmacological treatment. Medication compliance can be
collaborative decision-making. Hence, clinicians need to improved by using depot preparations and use of mouth
focus on better communication and improve therapeutic dissolving formulations under supervision. Evidence
alliance with patient and the family to improve overall also suggests beneficial effects of cognitive-behavioural
outcome. Whenever clinicians encounter poor medication approaches and motivational interviewing.

PHASES OF ILLNESS/TREATMENT MANAGEMENT IN THE ACUTE PHASE OF

TREATMENT
Management of schizophrenia can be broadly divided into
three phases, i.e., acute phase, continuation treatment or Most patients in this stage are likely to exhibit florid
stabilization phase, maintenance or stable phase. Some psychotic symptoms such as delusions or hallucinations,
patients may present very early in a prodromal phase and disorganized thinking and behavioural disturbances. Their
appropriate strategies for detection and management for functioning may be severely impaired and they can be at
this phase might be required. risk of harming themselves or others. Additionally both the
patient and the family might have considerable difficulty in
Prodromal stage coming to terms with the onset of acute symptoms. The
It is now well known that onset of frank psychosis is often various aspects of management in the acute phase are
preceded by psychological and behavioral abnormalities included in table-11.
involving cognition, emotion, perception, communication,
motivation and sleep. These symptoms may precede the MANAGEMENT IN THE CONTINUATION
psychosis by weeks to years. Various diagnostic systems TREATMENT PHASE
categorise the symptoms as: basic symptoms, attenuated
positive symptoms, brief limited intermittent psychotic This phase begins once the acute symptoms reduce in
symptoms, features of schizotypal personality disorder, severity or remit and conventionally lasts for about 6-12
genetic risk paired with functional deterioration, as well months. Different components of this phase are shown in
as general symptoms that are not specific to psychosis. table-12. Consolidation of remission, continued reduction
Evidence also suggests that many patients with prodrome, in symptoms and prevention of early relapses are the usual
especially the high risk group have higher chance of treatment objectives during this phase. Reduction of stress
conversion to frank schizophrenia. Conversion rates have on the patient and the family by continuing engagement
been reported to range from 25-40%. Further, prodrome
itself may have negative impact on the social, emotional Table 11: Management in the acute phase
and cognitive development. Therefore, now more and Comprehensive assessment (psychiatric/medical/psychosocial)
more emphasis is laid on early detection and intervention. Deciding on goals of treatment
Factors which have been shown to predict conversion to Patients
Eliminate/reduce symptoms of schizophrenia and improve the level of
psychosis include presence of genetic risk with recent
functioning
deterioration in functioning, higher degree of unusual Promote safety, reduce risk of harm, reduce stress
thought content, suspiciousness/paranoia, presence of Caregivers
social impairment, longer duration of symptoms, high Minimise caregiver distress
levels of depression, reduced attention and history of Offer help to enable them to cope with the illness in their relative
Both
substance abuse. In terms of management of prodrome
Develop a therapeutic alliance and provide opportunities for patients and
it is suggested that treatment ought to be based on the caregivers to actively engage in treatment
needs of the patient. There is some evidence to suggest Offer basic information and support tailored to needs of patients and
that use of antipsychotics in prodromal phase can delay the caregivers
conversion to psychosis and antidepressants may be useful Choice of treatment setting
Antipsychotic treatment
in symptomatic improvement in a sub-group of patients.
Choice of drug
However, at present evidence for use of antipsychotics in Dose
prodromal phase is not convincing to recommend its use in Route of administration
all patients. There is also preliminary evidence to suggest Duration of treatment
the beneficial effect of certain agents like omega-3 fatty Determining response or non‑response
Combining antipsychotics
acids. In contrast, evidence suggest that psychological
Use of adjunctive medications when indicated
interventions like cognitive behaviour therapy, cognitive Use of ECT when indicated
therapy, psychosocial stress management, etc can improve Psychosocial interventions‑ relatively basic and mainly for the purpose
functioning and symptomatology during the prodromal of fulfilling the goals of treatment listed above
phase, although the active components of these treatments Planning for further treatment
are not well known. Accordingly, whenever a patient
presents with symptoms suggestive of prodromal phase of Table 12: Management in the continuation treatment
schizophrenia, initial management is done in the form of phase
psychosocial intervention. Use of pharmacotherapy need to Determining goals
be weighed against the side effects of antipsychotics and Further assessment
sensitization of dopamine receptors in brain, which can Antipsychotic treatment
possibly lead to supersensitivity psychosis or rapid-onset Psychosocial interventions
Monitoring for response, side effects and treatment adherence
psychosis following stoppage of antipsychotic medication.

and support and enhancing their adaptation to life after Re-evaluating/modifying the treatment plan: As time elapses
discharge from the hospital, are other important goals of the nature of the illness, problems faced by the relatives,
management. Management includes continuing medication needs of the patient and the family and previously determined
treatment, monitoring of response and side effects and targets are all expected to change. Regular contact, awareness
furthering psychosocial interventions. Medications need and monitoring are needed to detect these changes. Ongoing
to continue preferably at the same dose for the next 6-12 assessment is thus essential. It allows those modifications to be
months. The continued goals of psychosocial treatment are made in the treatment plan, which are required to accommodate
to maintain treatment engagement and adherence, offer any new problems or demands that may have arisen.
support for patients and their families and help prepare
the patient for life in the community. More elaborate Assessments and monitoring: Monitoring is required for
psychosocial interventions may be tried at this stage. assessing response and for side effects that may emerge. Further
Finally, regular monitoring of response, side effects and assessments may be required during this period especially
treatment-adherence needs to continue. if psychosocial treatments are being planned. Information
should be obtained from the patients, family members, and
MANAGEMENT IN THE MAINTENANCE OR other available sources. Frequency of contact will depend
STABLE PHASE on several factors such as clinical state, the distance of the
hospital from the patient’s home, social support available for
During this phase of illness, symptoms are stable and the patient, the type of treatment being administered etc.
usually less severe than in the acute stage. Negative
symptoms may predominate and deficits in social and Antipsychotic treatment
occupational functioning become more apparent. Dose: The dose of the antipsychotic needs to be
Maintaining or improving level of functioning, prevention individualized. A balance has to be struck between the
of recurrences and promoting psychological/personal need to reduce side effects and the need to prevent relapse.
recovery are the major aims of treatment during this Stable patients who do not have positive symptoms may
phase of management. Different components of this phase be candidates for reduction in doses. Doses need to be
are shown in table-13. reduced gradually at the rate of about 20% every 6 months
till a minimum effective dose is reached.
During this phase, follow-ups can be scheduled once every
2-3 months and more frequently in times of crises, or if Reduction of dose/ withdrawal of antipsychotic medication
desired by the family. During this phase of management, may be be undertaken gradually whilst regularly monitoring
regular feedback need to be obtained from the family. signs and symptoms for evidence of potential relapse.
Any new issues that arise are discussed and some of the Following withdrawal from antipsychotic medication,
previous issues may need reemphasis. Management in monitoring for signs and symptoms of potential relapse, need
the stable phase involves carrying forward the gains to continue, for at least 2 years after the last acute episode.
achieved. The management plan should be relooked for Any re-emergence of symptoms is to be immediately treated.
any need for change. It also involves determining the
goals, continuing further assessment, continuing with Duration of treatment: Duration of treatment depends on
antipsychotic medications and monitoring of side effects a number of factors and will need to be individualized. The
and furthering the psychosocial interventions. In addition suggested guidelines are as follows:
the management need to focus on rehabilitation, enhancing • First-episode patients ought to receive 1-2 years of
personal recovery. maintenance treatment
• Patients with several episodes or exacerbations are to
Goals of treatment: The goals of treatment during this receive maintenance treatment for 5 years or longer
phase are to maintain or improve functioning, improve after the last episode
quality of life and facilitate personal recovery. Psychotic • Patients with history of aggression or suicide attempts
exacerbations need to be effectively treated. Adverse effects should receive treatment for longer period or lifelong.
are to be noted and managed.
The usual indications for use of long term or lifelong
antipsychotic medications are shown in table-14.
Table 13: Management in the maintenence phase
• Determining goals Psychosocial interventions
• Re‑evaluating/modifying the treatment plan
• Assessments and monitoring
The psychosocial interventions started in the previous
• Antipsychotic treatment treatment phases is to be continued and the gains obtained
• Psychosocial interventions till now should be evaluated. Further, the clinicians should
• Monitoring for response, side effects and treatment adherence evaluate as to whether any change is required in terms of
• Early intervention for relapses
goals and strategies used.

Table 14: Indications for life long/long term use of also seen with SGAs. The acute EPS include acute dystonia,
antipsychotic medications pseudo-parkinsonism and akathisia. Acute EPS is usually
History of multiple relapses while on treatment seen during the first few days or weeks of starting treatment,
History of relapses when the medications are tapered off is dose dependent and subsides with stoppage of offending
History of 2 episodes in last 5 years agent. Chronic EPS is usually seen after prolonged use
History of suicidal attempts (months to years) of antipsychotics and these include
Presence of residual psychotic symptoms
Family history of psychosis with poor outcome
tardive dyskinesia, tardive dystonia and tardive akathisia. It
Comorbid substance dependence is important to note that chronic EPS is not dependent on
the dose of antipsychotics and persists even after stopping
the offending agent. It is important to be aware of the risk
Rehabilitation factors for development of these side effects (table-17).
Facilities for vocational rehabilitation are scarce. However,
if the patient is already working efforts can be made to help In case a patient is experiencing Parkinsonism during the
out in any problems at the work place, which could be due initial phase of treatment, the first step of management
to the effects of the illness. If the patient is unemployed, involves lowering the dose of the antipsychotic medication.
their suitability for work needs to be assessed. If he is If reduction in dose is associated with unacceptable efficacy
ready for work, he is to be encouraged to seek appropriate than change of antipsychotic medication may be considered.
jobs. However, if the patient requires rehabilitation then When change of antipsychotic medication is considered, a
culture-specific characteristics for that rehabilitation medication with lower EPS potential need to be opted. In
programme need to be adopted in order to be successful. patients who respond to an antipsychotic and continue to
experience Parkinsonism, a short course of anticholinergic
Early intervention for relapses medications may be considered.
The management plan needs to be organised to respond as
quickly as possible to any relapses in the patient’s condition. Acute dystonia is also seen during the initial phase
Patients and relatives need to be educated to recognise early of treatment, i.e., after receiving first few doses of
symptoms of a relapse. They need to be told about the need antipsychotics. Acute dystonias respond dramatically
for early intervention in impending cases of relapse. They need to administration of parenteral anticholinergic or
to have easy access to treatment facilities such as emergency antihistaminergic medications. Recurrence of acute
services or inpatient settings, which will cater to the needs dystonias can also be prevented by using a short course of
of a patient on the verge of a relapse. Contact need to be anticholinergic medications.
increased during this phase. Crisis intervention measures
such as brief admissions or frequent home visits need to be First step in management of acute akathisia involves
adopted, whenever feasible. All these are important steps in reduction in dose or changing the antipsychotic to a
efficient detection and treatment of relapses. medication with lower EPS potential. Some patients
may require the use of medications like beta-blockers
SPECIAL SITUATIONS and benzodiazepines like clonazepam or lorazepam for
management of akathisia.
Clinicians often encounter certain clinical situations which
either require special attention or can influence treatment Neuroleptic Malignant Syndrome (NMS): It is an acute
decisions. Management of these situations is summarised psychiatric emergency, which has been reported to occur more
in table-15. often with FGAs. However, data in the form of case reports
and case series also suggest association of almost all SGAs with
SIDE EFFECTS AND THIER MANAGEMENT development of NMS. Various factors which increase the risk
of NMS are shown in table-18. Management involves stopping
Antipsychotics are associated with many side effects, which the antipsychotic medication, supportive measures and use of
require intervention. Some of the common side effects that bromocriptine, amantadine or dantrolene. Use of lorazepam
can be very distressing to the patients include extrapyramidal may also be helpful and those patients with NMS, who donot
side effects, cardiovascular side effects, sexual dysfunction respond to these treatments, may benefit with ECT.
and metabolic side effects. The cardiovascular side effects
can be life threatening too. The common management Sedation: Many antipsychotics are known to cause sedation
strategies for these side effects are shown in table-16. by virtue of their antihista-minergic, antiadrenergic, and
anti-dopaminergic action. The risk of sedation is high with
Extrapyramidal side effects: Extrapyramidal side effects chlorpromazine, clozapine and quetiapine. Initial strategy
(EPS) are often noted in patients receiving FGAs, especially should be to wait and watch and if this is not beneficial, if
high potency antipsychotic medications. However, EPS is possible dose reduction must be considered.

Table 15: Issues related to special situations

Special situation Strategies
First‑episode • Longer duration of untreated psychosis is powerful predictors of subsequent poor outcome
psychosis and early • Attempts need to be made to reduce the duration of untreated psychosis, to promote remission through effective
intervention pharmacological and psychosocial interventions, to maximize functioning, and to prevent relapse and other adverse
outcomes
• Early detection, comprehensive assessment, emphasis on continued engagement, and flexible treatment enable early
intervention services to meet these goals
• It is still not clear for how long patients with first‑episode psychosis are to continue maintenance antipsychotic medication
• A 1‑2 year period is usually recommended, though many patients may require longer periods, and some may require shorter
periods of treatment
Suicidality in • Suicide is more common during the initial period after discharge from the hospital
schizophrenia • Risk factors which have been specifically associated with suicide among patients with schizophrenia include younger age,
high socio‑economic status, high premorbid scholastic achievement and high intelligence quotient, high aspirations and
expectations, early age of onset, younger age at first hospitalization, a chronic and deteriorating course with multiple relapses
and higher level of insight into the illness
• Some of the treatment related issues which have been shown to be associated with suicide include inadequate treatment, poor
medication adherence, poor response to treatment and akathisia
• As it is not possible to predict suicidal behaviour, clinicians need to pay greater attention to presence of suicidal ideations,
which are predictors of suicidal attempt and suicide at every phase of treatment
• High risk management need to be followed during the initial phase of admission and every effort need to be made to retain
the patient in the inpatient set‑up
• Adequate treatment of psychotic symptoms with antipsychotic medication and of depression when present with appropriate
therapy can prevent suicide
• Clozapine has been shown to reduce the risk for suicidal behaviours. Accordingly, it may be preferred for patients who have
multiple suicide attempts or persistently report suicidal ideations.
• Psychoeducation of patient and family need to focus on discussing about warning signs of suicide. Patients
experiencing severe distress due to a feeling of loss, stigma etc., need to be provided psychological support and
monitored closely.
Violence and • All patients are to be evaluated for violence and dangerousness during every assessment, especially during the acute phase of
Aggression in illness
Schizophrenia • Whenever a patient is found to have serious threat for violence or exhibits violence, inpatient management is to be
considered
• Injectable antipsychotics like haloperidol or lorazepam can be used for management of violence and aggression
Comorbid Substance • Presence of substance use disorder is often associated with overall poor outcome of illness
use Disorders • Clinicians also need to pay attention to these disorders and the additional aims of the treatment are abstinence from the
substances or at least harm reduction
• Pharmacological agents shown to be effective for management of detoxification and pharmaco‑prophylaxis for different
substance use disorders may be considered if required
• Psychosocial interventions like relapse prevention counselling, cognitive behavioural interventions and motivation
enhancement treatment may be included in the treatment plan
• Patients are to be continuously monitored for relapse of substance use disorder
Depression • A rational approach to treating depression in schizophrenia first needs to consider and rule out organic conditions, negative
symptoms, antipsychotic associated side effects (dysphoria, akinesia and akathisia), schizoaffective depression, stress‑related
reactions, and an impending psychotic episode
• Controlled trials with SGAs have shown that they are superior to FGAs in their antidepressant efficacy.
• Clozapine may be particularly effective in patients at high risk for suicide
• Antidepressants are generally ineffective during the acute phase. They may even worsen the psychosis, and are best
avoided
• On the other hand, results of controlled trials have demonstrated the efficacy of adjunctive antidepressant therapy in
post‑psychotic depression
• Clinical experience suggests that ECT may be helpful
Catatonia • Whenever a patient with schizophrenia presents with catatonia, all possible differential diagnosis for catatonia is to be
considered. Appropriate investigations may be carried out and the underlying causes are to be managed
• Initial management may involve use of benzodiazepines, especially lorazepam, which leads to symptomatic relief in
significant proportion of cases
• In case the catatonia does not respond to benzodiazepines or relapse after stopping benzodiazepines, ECT is to be
considered
Negative symptoms • First step in management of predominant negative symptoms is to rule out secondary negative symptoms. However, if
negative symptoms persist, they are presumed to be primary negative symptoms of the deficit state
• No treatments have proven efficacy for management of primary negative symptoms, although some benefit has been reported
with clozapine and amisulpride
• Psychosocial interventions in the form of social skill training, token economy may be attempted
Contd...

Table 15: Contd...
Obsessive • Obsessive compulsive disorder/Obsessive compulsive symptoms are common in patients with schizophrenia and these may
compulsive be part of the prodrome of schizophrenia, may be part of clinical manifestation of schizophrenia along with other symptoms,
symptoms in may be treatment emergent or may precede the onset of schizophrenia
schizophrenia • Treatment emergent obsessive compulsive symptoms are commonly reported with SGAs like clozapine, olanzapine and
risperidone
• There is little evidence in the form of randomized controlled trials for management of obsessive compulsive symptoms in
schizophrenia
• In general it is suggested that if the obsessive compulsive symptoms appear to be part and parcel of schizophrenia, initially
patients may be treated with antipsychotics only and the obsessive compulsive symptoms need to be monitored
• If the obsessive compulsive symptoms are considered to be treatment emergent then reduction in dose of antipsychotic,
change of antipsychotic or use of antiobsessional agents are to be considered
• Among the antiobsessional agents, there is some data for the efficacy of clomipramine and fluvoxamine
• Cognitive behaviour therapy in the form of exposure and response prevention has also been tried with beneficial effects
Comorbid Physical • Patients with schizophrenia have high rate of physical illnesses
illnesses • All patients need to receive thorough assessment for possible physical illnesses and depending on the feasibility may be
investigated as per the requirement
• Those with comorbid physical illnesses need to be continuously monitored during all the phases of treatment
• Comorbid physical illnesses and concomitant medications need to be taken into account while selecting the treatment setting
and antipsychotic medication per se
Treatment‑resistance • The first step in the management of treatment‑resistance is to establish that the disorder has failed to respond to adequate
schizophrenia (TRS) trials of antipsychotics in terms of dosage, duration and adherence
• Other causes of non‑response need to be considered such as, non‑compliance, adverse effects, comorbid conditions such as
substance misuse, before actually diagnosing treatment refractoriness
• Clozapine has been reported to be beneficial among patients with TRS
• The role of ECT in TRS has not been examined, although studies suggest that it could be useful
• Chosocial interventions such as cognitive therapy, family treatment, assertive outreach or crisis intervention are also
beneficial.
Clozapine – • There is some evidence to suggest that combining ECT with clozapine improves the outcome of patients who donot respond
resistance to clozapine alone
• Evidence for usefulness of combining clozapine with other antipsychotics, antidepressants, mood stabilizers is limited and
not convincing
Difficult to treat • Factors which make the patient difficult to treat include: inadequate response to antipsychotic, problems of adverse drug
schizophrenia effects, poor medication compliance, comorbidities, treatment failure and relapse on adequate drug dosages
• Issues related to medication compliance and adverse effects need to be addressed
• Antipsychotic need to be selected keeping the medical and psychiatric comorbidities in mind
• Patients with treatment resistance may be treated with clozapine.
• Patients having relapse of symptoms despite adequate dosages of 2 or more antipsychotics may also be treated with clozapine.
• Psychosocial factors influencing medication compliance need to be evaluated and addressed
Pregnancy • Many patients with schizophrenia have unplanned pregnancies and because of illness related variables, compared to those
without schizophrenia, women with schizophrenia more commonly have pregnancy outcomes in the form of low birth
weight, preterm birth, still birth and perinatal deaths
• Patients and caregivers need to be counselled about pregnancy and the risks and unplanned pregnancies may be avoided
• Most of the psychotropics belong to category ‘C’ or ‘D’, except for clozapine
• In general it is said that high potency antipsychotics have lower risk of foetal malformations
• Any decision to start antipsychotics, continue or discontinue antipsychotics need to take into account current level of
symptomatology, longitudinal course of symptoms, risk of relapse with stoppage of medication, effect of a particular
antipsychotic on foetal malformation and obstetrical complications
• All decisions about medications are to be taken after proper consultation with the patient, spouse and caregivers. A close
liaison with the obstetricians is helpful in monitoring patients during the pregnancy
Anticholinergic and antiadrenergic side effects: These Cardiovascular side effects: Among the cardiac side effects, the
side effects manifest as dry mouth, blurred vision, commonly encountered side effects include QTc prolongation,
constipation, urinary retention, thermoregulatory effects, orthostatic hypotension and tachycardia. QTc interval of
impaired learning and memory and slowed cognition. Some more than 500 milliseconds is associated with elevated risk
patient may develop confusion, delirium, somnolence and of ventricular arrhythmias, known as “torsades de pointes”,
hallucinations due to severe anticholinergic side effects. which may lead to ventricular fibrillation and sudden cardiac
Anticholinergic side effects are more commonly seen with death. Among the older antipsychotics, thioridazine, pimozide
clozapine and chlorpromazine. It is reported that the and high dose of intravenous haloperidol are reported to be
anticholinergic side effects are usually dose-dependent associated with increased risk of QTc prolongation. Among
and reduce with reduction in the dose of antipsychotic or the SGAs, ziprasidone is reported to have higher risk of
concomitantly used anticholinergic agent. QTc prolongation; however, this has not been shown to be

Table 16: Management of Side Effects of Antipsychotics

Side effect First Step Other options
Antipsychotic induced Parkinsonism Reduce the dose Change the antipsychotic to an antipsychotic with lower EPS
potential
Acute dystonia Parenteral ‑ anticholinergic or antihistaminergic Short term use of anticholinergics to prevent recurrence
medications
Acute Akathisia Reduce the dose Change the antipsychotic to an antipsychotic with lower EPS
potential
Use‑ beta‑blockers, benzodiazepines
Tardive dyskinesia Stop the offending agent Clozapine in case there is worsening of psychosis
Vitamin‑E, benzodiazepines, anticholinergics
Tardive dystonia Stop the offending agent Clozapine in case there is worsening of psychosis
Neuroleptic malignant syndrome Stop the offending agent In treatment refractory NMS consider ECT
Supportive measures
Bromocriptine, amantadine, dantrolene
Lorazepam
QTc prolongation Reduce the dose Stop the offending agent
Change the antipsychotic to an antipsychotic with lower
potential for QTc prolongation
Orthostatic hypotension Reduce the dose Stop the offending agent
Change to an antipsychotic with lower antiadrenergic or no
antiadrenergic activity
Use of stockings, increasing the salt intake, fludrocortisone
Tachycardia due to anticholinergic Wait and watch for sometime in those without Peripherally acting beta‑blockers
action cardiac disease
Hyperprolactinemia and Sexual Reduce the dose Change to an antipsychotic with lower potential to cause
dysfunction hyper‑prolactinemia
Consider use of bromocriptine or amantidine if there is
hyperprolactinemia
Sexual dysfunction not associated with
hyperprolactinemia‑ Yohimbine, Cyproheptadine,
Imipramine (for retrograde ejaculation), Phospho‑diaesterase
inhibitors (for erectile dysfunction), antidepressants like
paroxetine, dapoxetine (for premature ejaculation)
Sedation Wait and watch – most patients develop tolerance In case of persistent sedation
Reduce the dose
Change to night time dose, if using the medication in divided
doses
Change to a less sedating agent
Anticholinergic and antiadrenergic Stop concommitant anticholinergic agent if used Change to an antipsychotic with lower anticholinergic properties
side effects Reduce the dose Constipation‑ high fibre diet, increase water intake, laxatives
In case of severe side effect like delirium
stoppage of offending agent may be required
associated with sudden cardiac deaths. In case, there is QTc anticholinergic activity, as seen with clozapine may be
prolongation, change of antipsychotic is to be considered. managed with low dose peripherally acting beta-blockers.
Hypotension associated with various antipsychotics is attributed Hyperprolactinemia and Sexual dysfunction: All antipsychotics
to antiadrenergic activity. It is commonly seen with clozapine, are shown to be associated with sexual dysfunction, although
risperidone, quetiapine. Among the FGAs, hypotension is often the rates vary with different antipsychotics. In general, rates
seen with chlorpromazine. Hypotension can be prevented of sexual dysfunction are reported to be higher with FGAs and
by starting with lower doses and slow upward titration of risperidone. One of the common causes for sexual dysfunction
medication. When a patient develops hypotension with a with FGAs and risperidone is increase in prolactin levels,
particular antipsychotic medication, the first step in management which leads to disruption of hypothalamo-pituitary-gonadal
is to reduce the dose of the offending agent. If this does not axis. Females have been reported to be more sensitive to
help than switching to another agent with lower antiadrenergic hyperprolactinemia related sexual dysfunction. First step in
activity is to be considered. Additional management strategies management of hyperprolactinemia and sexual dysfunction
include use of stockings, increasing the salt intake and use of is reduction in the dose of antipsychotic medication. If this
fludrocortisone, which is a fluid retaining corticosteroid. option is not acceptable, change in antipsychotic is to be
considered. If change of antipsychotic is not possible, than
Tachycardia may be associated with hypotension or it may management with bromocriptine or amantidine may be
result due to anticholinergic activity. Tachycardia due to considered to lower the prolactin levels.

Table 17: Risk factors for acute and tardive Monitoring for metabolic side effects: It is now well known
extrapyramidal side effects with antipsychotics that compared to subjects in the general population,
Acute Dystonia patients with schizophrenia have high rates of metabolic
Use of high potency FGAs syndrome. Higher prevalence of metabolic syndrome
Young age suggests that clinicians need to monitor the patients for
Male gender emergence of metabolic side effects and manage the same
High doses
Intramuscular administration of antipsychotic medications
to reduce the cardiovascular morbidity and mortality.
Acute Akathisia Antipsychotics have also been shown to increase the risk
Use of high potency FGAs of development of diabetes mellitus. Further evidence
Tardive dyskinesia suggests that there is some discriminatory effect of various
Older age
antipsychotic medications on metabolic profile. Clozapine
Female gender combined with postmenopausal status
Use of FGAs and olanzapine have been reported to be associated
Use of high doses of antipsychotic medications with highest risk for development of weight gain, lipid
Antipsychotic‑induced parkinsonism abnormalities and elevation in blood glucose levels (See
Concurrent general medical conditions like diabetes table-18).
Affective disorder (particularly major depressive disorder)
Tardive dystonia
Use of high potency FGAs Considering the metabolic side effects associated with
Neuroleptic Malignant syndrome antipsychotics, various guidelines have been proposed and
Young age there are certain variations in the proposed monitoring
Male gender frequency. In general it is suggested that patients need to
Use of high potency antipsychotic
be monitored for metabolic disturbances at baseline, at
Rapid increase in the dose of antipsychotic
Use of intramuscular preparation 4-6 weeks and 12 weeks after starting antipsychotic and
Acute agitation then after every 3 months or at least annually (table-19).
Preexisting neurological disability However, those who have personal and family history of
Comorbid physical illness obesity, diabetes mellitus, dyslipidemia, hypertension
Dehydration
and/or cardiovascular disease are to be monitored 3
monthly.
Table 18: Risk of Metabolic side effects associated with
various antipsychotic medications6 However, in Indian setting, due to poor follow-up rates and
Antipsychotic medications Risk of lipid and/or Risk of available resources, it may not be feasible to monitor all the
glucose metabolism weight gain parameters regularly. Efforts need to be made to monitor
abnormalities the weight and fasting blood glucose levels at every
FGAs treatment facility. Patients managed at training centres and
Chlorpromazine High (limited data) Substantial resourceful settings may consider complete monitoring of
Fluphenazine Low (limited data) Neutral/low metabolic parameters.
Haloperidol, Perphenazine Low Neutral/low
Thioridazine High (limited data) Intermediate
SGAs If a patient develops metabolic abnormalities, switching
Clozapine, Olanzapine High Substantial of antipsychotic may be considered. In general if a patient
Quetiapine Moderate Intermediate gains more than 7% of the baseline weight or develops
Risperidone, Iloperidone, Mild Intermediate hyperglycemia, hyperlipidemia, hypertension or any other
Paliperidone, Sertindole
Lurasidone Low (limited data) Intermediate
significant cardiovascular or metabolic side effect, then
Zotepine Not reported Intermediate a change in antipsychotic is to be considered. However,
Asenapine Low (limited data) Low while considering switching, clinicians need to take into
Amisulpride Mild Neutral/low consideration the entire course of the illness, comorbid
Ziprasidone, Aripiprazole Low Neutral/low
physical illnesses, side effect profile of medication which
Table 19: Monitoring for metabolic disturbance while receiving various antipsychotic medications
Baseline 6 weeks after starting 12 weeks after starting Atleast annually
antipsychotics antipsychotics thereafter
Medical History X
Weight/waist circumference/BMI X X X X
Blood Pressure X X X X
Fasting glucose levels X X X X
Fasting lipids X X X X
Lifestyle modification advise X X X X

caused metabolic side effects and the potential side effects 21. Kulhara P, Chakrabarti S. Clinical Practice guidelines for management of
schizophrenia. In: Clinical Practice Guidelines for Psychiatrists in India
with proposed medication to be used after switching. If on Schizophrenia, depression, bipolar affective disorders, obsessive
switching of antipsychotic is not possible then medications compulsive disorder, Generalized anxiety disorder and panic disorder.
Eds: Gautam S, Avasthi A. Indian Psychiatric Society, 2005.
like metformin or topiramate may be considered, along 22. Kulhara P. Management of Schizophrenia: An Update. Indian J Psychiatry
with more intensive dietary and life style modifications. A 1998;40: 120-134.
close liaison need to be maintained with endocrinologist 23. Larsen ER, Damkier P, Pedersen LH, Fenger-Gron J,
Mikkelsen RL, Nielsen RE, Linde VJ, Knudsen HED, Skaarup L,
and cardiologist to provide best quality care to patients. Videbech P. Use of psychotropic drugs during pregnancy and breast-feeding.
ActaPsychiatrScand 2015: 132 (Suppl. 445): 1–28
24. Lehman AF, Kreyenbuhl J, Buchanan RW, Dickerson FB, Dixon LB,
SUGGESTED READING Goldberg R, Green-Paden LD, Tenhula WN, Boerescu D, Tek C,
Sandson N, Steinwachs DM. The Schizophrenia Patient Outcomes
1. American Psychiatric Association. Practice guideline for the treatment of Research Team (PORT): updated treatment recommendations 2003.
patients with schizophrenia, second edition. Am J Psychiatry 2004; 161 Schizophr Bull 2004;30(2):193–217.
(supplement):1-56. 25. Lehman AF, Lieberman JA, Dixon LB, McGlashan TH, Miller AL, Perkins DO,
2. Avasthi A, Agarwal M, Grover S, Khan MKR. Research on antipsychotics Kreyenbuhl J; American Psychiatric Association; Steering Committee on
in India. Indian J Psychiatry, 2010; 52 (Suppl): S317-340. Practice Guidelines. Practice guideline for the treatment of patients with
3. Chakrabarti S. Impact of Schizophrenia on caregivers: The Indian schizophrenia, second edition. Am J Psychiatry 2004;161(2 Suppl):1-56.
Perspective. In: Schizophrenia: The Indian Scene. Eds (2nd edition): 26. Leucht S, Corves C, Arbter D, Engel RR, Li C, Davis JM. Second-generation
P Kulhara, A Avasthi, S Grover. Published by PsyPROM, PGIMER, versus first-generation antipsychotic drugs for schizophrenia: A
Chandigarh, Chandika Press, Barwala, Haryana, 2010, pp 215-262. meta-analysis. Lancet. 2009;373:31-41.
4. Chakrabarti S. What’s in a name? Compliance, adherence and 27. Lieberman JA, Stroup TS, McEvoy JP, Swartz MS, Rosenheck RA,
concordance in chronic psychiatric disorders. World J Psychiatry 2014; 4: Perkins DO, Keefe RS, Davis SM, Davis CE, Lebowitz BD, Severe J,
30-36. Hsiao JK. Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE)
5. CRAG/SCOTMEG Working Group on Mental Illness. Services for people Investigators Effectiveness of antipsychotic drugs in patients with chronic
affected by schizophrenia. A good practice statement. The Scottish Office. schizophrenia. N Engl J Med. 2005 22;353:1209-23.
National Health Service in Scotland, 1995. 28. Lieberman JA, Stroup TS. The NIMH-CATIE Schizophrenia Study: what
6. De Hert M, Detraux J, Winkel R, Yu W, Correll CU. Metabolic and did we learn? Am J Psychiatry. 2011;168:770-5.
cardiovascular adverse effectsassociated with antipsychotic drugs. Nat. 29. Malhotra N, Grover S, Chakrabarti S, Kulhara P. Metabolic Syndrome
Rev. Endocrinol. 2012; 8: 114–126. in Schizophrenia: A review.Indian J Psychological Medicine 2013; 35:
7. Expert Consensus Guidelines, LLC. Expert Consensus Guideline Series. 227-240.
Treatment of Schizophrenia. Memphis, Physicians Postgraduate Press 30. McEvoy JP, Lieberman JA, Perkins DO, Hamer RM, Gu H, Lazarus A,
Inc, 1999. Sweitzer D, Olexy C, Weiden P, Strakowski SD. Efficacy and tolerability
8. Gasquet I, Haro JM, Tcherny-Lessenot S, Chartier F, Lépine JP.
of olanzapine, quetiapine, and risperidone in the treatment of early
Remission in the outpatient care of schizophrenia: 3-year results from the
psychosis: a randomized, double-blind 52-week comparison. Am J
Schizophrenia Outpatients Health Outcomes (SOHO) study in France. Eur
Psychiatry 2007;164:1050-60.
Psychiatry. 2008;23:491-6.
31. McEvoy JP, Lieberman JA, Stroup TS, Davis SM, Meltzer HY,
9. Grover S, Avasthi A. Antipsychotic prescription pattern: a preliminary
Rosenheck RA, Swartz MS, Perkins DO, Keefe RS, Davis CE, Severe J,
survey of Psychiatrists in India. Indian J Psychiatry, 2010; 52: 257-259.
Hsiao JK. Effectiveness of clozapine versus olanzapine, quetiapine, and
10. Grover S, Avasthi A. Mood Stabilizers in pregnancy. Indian J Psychiatry
risperidone in patients with chronic schizophrenia who did not respond to
2015; 57 (Suppl 2): 308-23.
prior atypical antipsychotic treatment. Am J Psychiatry 2006;163:600–10.
11. Grover S, Avasthi A. Views about clinical practice guidelines of the Indian
32. McEvoy JP, Scheifler PL, Frances A. The Expert Consensus Guideline
Psychiatric Society: A survey of psychiatrists in India. Indian J Psychiatry
Series: Treatment of Schizophrenia 1999. J Clin Psychiatry 1999;60
2009; 51: 127-33.
(Suppl 11).
12. Grover S, Dutt A, Avasthi A. Indian Research: focus on Clozapine. Indian
33. Miller AL, Chiles JA, Chiles JK, Crismon ML, Rush AJ, Shon SP. The Texas
J Psychiatry, 2010; 52:168-173.
Medication Algorithm Project (TMAP) schizophrenia algorithms. J Clin
13. Grover S, Hazari N, Kate N. Combined use of clozapine and ECT: A
review. ActaNeuropsychiatrica 2015; 27: 131-142. Psychiatry. 1999;60:649-57.
14. Haro JM, Edgell ET, Frewer P, Alonso J, Jones PB on behalf of the 34. Nakajima S, Takeuchi H, Fervaha G, Plitman E, Chung JK, Caravaggio F,
SOHO Study Group. The European Schizophrenia Outpatient Health Iwata Y, Mihashi Y, Gerretsen P, Remington G, Mulsant B, Graff-Guerrero A.
Outcomes Study: baseline findings across country and treatment. Comparative efficacy between clozapine and other atypical antipsychotics
ActaPsychiatrScand 2003;107(suppl. 416):1–9. on depressive symptoms in patients with schizophrenia: analysis of the
15. Haro JM, Edgell ET, Novick D, Alonso J, Kennedy L, Jones PB, Ratcliffe CATIE phase 2E data. Schizophr Res. 2015;161:429-33.
M, Breier A. Effectiveness of antipsychotic treatment for schizophrenia: 35. National Institute for Health and Care Excellence. Psychosis and
6-month results of the Pan-European Schizophrenia Outpatient Health schizophrenia in adults: prevention and management Clinical guideline
Outcomes (SOHO) study. ActaPsychiatrScand 2005: 111: 220–231. (CG 178), 2014.
16. Haro JM, Novick D, Suarez D & Roca M: Antipsychotic treatment 36. Novick D, Haro JM, Suarez D, Vieta E &Naber D: Recovery in the
discontinuation in previously untreated patients with schizophrenia: outpatient setting: 36-month results from the Schizophrenia Outpatients
36-month results from the SOHO study. J Psychiatr Res. 2009 ;43:265-73. Health Outcomes (SOHO) study. Schizophr Res. 2009; 108:223-30.
17. Hazari N, Kate N, Grover S. Clozapine and Tardive movement Disorders: 37. Perkins DO, Gu H, Weiden PJ, McEvoy JP, HamerRM , Lieberman JA.
A review. Asian J Psychiatry 2013;6: 439-451. Comparison of Atypicals in First Episode study group Predictors of treatment
18. Jones PB, Barnes TR, Davies L, Dunn G, Lloyd H, Hayhurst KP, Murray RM, discontinuation and medication nonadherence in patients recovering
Markwick A & Lewis SW. Randomised controlled trial of effect on quality from a first episode of schizophrenia, schizophreniform disorder, or
of life of second- vs first generation antipsychotic drugs in schizophrenia: schizoaffective disorder: a randomized, double-blind, flexible dose,
Cost Utility of the Latest Antipsychotic drugs in Schizophrenia Study multicenter study. J Clin Psychiatry. 2008; 69:106-13.
(CUtLASS 1). Arch Gen Psychiatry 2006;63:1079-87. 38. Stroup TS, Lieberman JA, McEvoy JP, Swartz MS, Davis SM,
19. Kahn RS, Fleischhacker WW, Boter H, Davidson M, Vergouwe Y, Capuano GA, Rosenheck RA, Keefe RS, Miller AL, Belz I, Hsiao JK.
Keet IP, Gheorghe MD, Rybakowski JK, Galderisi S, Libiger J, Hummer M, Effectiveness of olanzapine, quetiapine, and risperidone in patients with
Dollfus S, López-Ibor JJ, Hranov LG, Gaebel W, Peuskens J, Lindefors N, chronic schizophrenia after discontinuing perphenazine: a CATIE study.
Riecher-Rössler A &Grobbee DE; EUFEST study group. Effectiveness of Am J Psychiatry 2007;164(3):415–27.
antipsychotic drugs in first-episode schizophrenia and schizophreniform 39. Stroup TS, Lieberman JA, McEvoy JP, Swartz MS, Davis SM, Rosenheck
disorder: an open randomised clinical trial. Lancet. 2008;371 RA, Perkins DO, Keefe RS, Davis CE, Severe J, Hsiao JK. Effectiveness
(9618):1085-97. of olanzapine, quetiapine, risperidone, and ziprasidone in patients with
20. Kulhara P, Chakrabarti S, Avasthi A, Sharma A, Sharma S. chronic schizophrenia following discontinuation of a previous atypical
Psychoeducational intervention for caregivers of Indian patients with antipsychotic. Am J Psychiatry 2006;163(4):611–22.
schizophrenia: a randomised-controlled trial. ActaPsychiatr Scand. 40. Suarez D, Haro JM. Overview of the findings from the European SOHO
2009;119(6):472-83. study. Expert Rev Neurother. 2008; 8:873-80.

Clinical Practice Guidelines for the management of Depression

Shiv Gautam, Akhilesh Jain1, Manaswi Gautam2, Vihang N. Vahia3, Sandeep Grover4
Director Professor, Director, Gautam Hospital & Research Center, Consultant Psychiatrist Gautam Hospital and Research
Center, 1Specialist Psychiatry ESI Hospital, 2Gautam Hospital and Research Center and Gautam Institute of Behavioural
Sciences and Alternative Medicine, Jaipur, 3Consultant Psychiatrist, Gaur Medical Health Clinic, Ajmer, 4Additional
Professor, Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
ASSESSMENT AND EVALUATION (table-1)

Participants of expert group on CPG for Depression
Management of depression involves comprehensive
Gautam Saha, I.D Gupta, Navendu Gaur, Tushar Jagawat,
Anita Gautam, T. S Sathyanarayana Rao assessment and proper establishment of diagnosis. The
assessment must be based on detailed history, physical
examination and mental state examinations.History must be
INTRODUCTION
obtained from all sources, especially the family. The diagnosis
must be recorded as per the current diagnostic criteria.
Depression is a common disorder, which often leads to
poor quality of life and impaired role functioning. It is
Depression often presents with a combination of
known to be a major contributor to the global burden
symptoms of depressed mood, loss of interest or pleasure,
of diseases and according to World Health Organization
decreased energy and fatigue, reduced concentration
(WHO), depression is the fourth leading cause of disability
and attention, reduced self-esteem and self-confidence,
worldwide and it is projected that by 2020, it will be
ideas of guilt and unworthiness, bleak and pessimistic
the second most common leading cause of disability. views of the future, ideas or acts of self-harm or suicide,
Depression is also associated with high rates of suicidal disturbed sleep and diminished appetite. Depending on
behaviour and mortality. When depression occurs in the the severity of depression some of these symptoms may
context of medical morbidity, it is associated with increased be more marked and develop characteristic features that
health care cost, longer duration of hospitalization, poor are widely regarded as having special clinical significance.
cooperation in treatment, poor treatment compliance and These symptoms are known as somatic symptoms of
high rates of morbidity. Depression is also known to be depression and include symptoms of loss of interest or
associated with difficulties in role transitions (e.g., low pleasure in activities that are normally enjoyable, lack of
education, high teen child-bearing, marital disruption, emotional reactivity to normally pleasurable surroundings
unstable employment) and poor role functioning (e.g., and events, waking up in the morning 2 hours or more
low marital quality, low work performance, low earnings). before the usual time, depression worse in the morning,
It is also reported to be a risk factor for the onset and objective evidence of definite psychomotor retardation
persistence of a wide range of secondary disorders. or agitation (remarked on or reported by other people),
Available data also suggests that between one-third marked loss of appetite, weight loss (often defined as 5%
and one-half of patients also experience recurrence of or more of body weight in the past month) and marked
depressive episodes. loss of libido. It is important to note that for the diagnosis
of depressive disorder these symptoms need to be present
Address for correspondence: for at least 2 weeks and need to be associated with
Dr. Sandeep Grover, Additional Professor, Department of
Psychiatry, PGIMER, Chandigarh, India. psychosocial dysfunction.
E-mail: drsandeepg2002@yahoo.com
DOI:
How to cite this article: Gautam S, Jain A, Gautam M,
Vahia VN, Grover S. Clinical Practice Guidelines for the
10.4103/0019-5545.196973
management of Depression. Indian J Psychiatry 2017;59:34-50.

Gautam, et al.: CPGs for depression
Table 1: Components of assessment and evaluation Some of the patients with depression may present with
Basic assessments predominant complaints of aches, pains and fatigue and
• Complete history with information from all possible sources they may not report sadness of mood on their own. A careful
• Physical examination‑ look for thyroid swelling, evidence for evaluation of these patients often reveals the underlying
malnutrition or any specific nutritional deficiency features of depression. However, it is important to note that
• Record blood pressure, weight and wherever indicated body mass index
and waist circumference many patients with depression will also have associated anxiety
• Mental state examination symptoms. With increasing severity of depression patients may
• Establish diagnosis according to current diagnostic criteria report psychotic symptoms and may also present with catatonic
• Differential diagnosis by ruling out secondary depression features. Thorough assessment also ought to focus on evaluation
• Rule out bipolar disorder, premenstrual dysphoric disorder
for comorbid substance abuse/dependence. Careful history of
• Assess the severity, specifier, subtype of depression
• Areas to be evaluated: symptom‑severity, substance intake need to be taken to evaluate the relationship
symptom‑dimensions (psychotic symptoms, catatonic symptoms, of depression with substance intoxication, withdrawal and
melancholic symptoms, reverse vegetative symptoms and cognitive abstinence. Whenever required appropriate tests like, urine or
symptoms), comorbid physical, psychiatric and substance use blood screens (with prior consent) may be used to confirm the
conditions, risk of harm to self and others, level of functioning and
socio‑cultural milieu of the patient
existence of comorbid substance abuse/dependence.
• Basic investigations: haemogram, blood sugars and lipid levels, liver
functions, renal functions, thyroid function test (if indicated) Many physical illnesses are known to have high rates of
• Assessments of caregivers: knowledge and understanding of the illness, depression. In some situations the physical illnesses have
attitudes and beliefs regarding treatment, impact of the illness on them, causative role in development of depression, whereas in other
personal and social resources
• Ongoing assessments: response to treatment, side effects, treatment
situations the relationship/co-occurrence is due to common
adherence, the impact of patient’s immediate environment, disability etiology. Some of the physical illnesses commonly associated
assessments, other health‑care needs, ease of access and relationship with depression are listed in Table-2. When depression
with the treatment team occurs in relation to physical illness attempt may be made
Additional/Optional assessments
to clearly delineate the symptoms of depression and physical
• Use of standardized rating scales to rate all aspects of the illness illness. Further, while making the diagnosis, it maybe clearly
• Neuroimaging especially in those with first‑episode of depression seen
in late or very late age; those have neurological signs, those having
mentioned as to which diagnostic approach [i.e., inclusive
treatment resistant depression approach (symptoms are counted whether or not they might be
attributable to physical illness), substitute approach (nonsomatic
symptoms are substituted with somatic symptoms), exclusive
Table 2: Some of the physical illnesses commonly approach (somatic symptoms are deleted from the diagnostic
associated with depression criteria) or best estimate approach] was followed. Further,
• Epilepsy • Disease while reviewing the treatment history of medical illnesses,
• Post stroke • Depression in Malignancy medication induced depression must be kept in mind, as
• Parkinson’s Disease • Hypothyroidism
• Multiple Sclerosis • Hyperthyroidism
many medications are known to cause depression (Table-3).
• Degenerative Brain Disease • Hyperparathyroidism
• Alzheimer’s Disease • Cushing’s Syndrome It is always important to take the longitudinal life course
• Coronary Artery • Addison’s disease perspective into account to evaluate for previous episodes
• Diabetes mellitus
and presence of symptoms of depression amounting to
Table 3: Medications known to cause depression

Cardiovascular drugs Azathioprine Ampicillin Penicillin G Benzodiazepines Efavirenz
ACE inhibitors Bleomycin Chloramphenicol procaine Chloral hydrate Enfuvirtide
Calcium channel Cisplatin Methylphenidate (Ritalin) Streptomycin Ethanol Saquinavir
blockers Cyclophosphamide Chloroquine Sulfonamides Other drugs Zidovudine
Clonidine Doxorubicin Clofazimine Tetracycline Choline Anticonvulsants
Digitalis Vinblastine Cycloserine Trimethoprim Cimetidine Ethosuximide
Guanethidine Vincristine Cyclosporine Hormones Disulfiram Phenobarbital
Hydralazine Antiparkinsonian Dapsone Adrenocorticotropin Lecithin Phenytoin
Methyldopa drugs Ethambutol Anabolic steroids Methysergide Primidone
Procainamide Amantadine Ethionamide Glucocorticoids Phenylephrine Tiagabine
Propranolol Bromocriptine Foscarnet Oral contraceptives Physostigmine Vigabatrin
Reserpine Levodopa Ganciclovir Antipsychotic drugs Ranitidine Anti‑inflammatory
Thiazide diuretics Stimulants Griseofulvin Fluphenazine Statins agents
Guanabenz Amphetamines Isoniazid Haloperidol Tamoxifen NSAIDS
Zolamide diuretics withdrawal) Metoclopramide Sedatives and Antiretroviral drugs
Chemotherapeutics Caffeine Metronidazole antianxiety Atazanavir
6‑Azauridine Cocaine (withdrawal) Nalidixic acid drugs
Asparaginase Anti‑infective agents Nitrofurantoin Barbiturates

dysthymia. Evaluation of history also takes into consideration induced switch. Presence of psychotic features, marked
the relationship of onset of depression with change in psychomotor retardation, reverse neurovegetative
season (seasonal affective disorder), peripartum period and symptoms (excessive sleep and appetite), irritability of
phase of menstrual cycle. Further, the longitudinal course mood, anger, family history of bipolar disorder and early
approach may also take into account response to previous age of onset need to alert the clinicians to evaluate for the
treatment and whether the patient achieved full remission, possibility of bipolar disorder, before concluding that they
partial remission and did not respond to treatment. are dealing with unipolar depression.
An important aspect of diagnosis of depression is to rule Area to be covered in assessment include symptom
out bipolar disorder. Many patients with bipolar disorder dimensions, symptom-severity, comorbid psychiatric and
present to the clinicians during the depressive phase of medical conditions, particularly comorbid substance abuse,
illness and spontaneously do not report about previous the risk of harm to self or others, level of functioning and
hypomanic or manic episodes. Careful history from the the socio-cultural milieu of the patient.
patient and other sources (family members) often provide
important clues for the bipolar disorder. It is often useful to In case patient has received treatment in the past, it is
use standardized scales like mood disorder questionnaire to important to evaluate the information in the form of type of
rule out bipolarity. Treating a patient of bipolar depression antidepressant used, dose of medication used, compliance
as unipolar disorder can increase the risk of antidepressant with medication, reasons for poor compliance, reasons for
Patient with Depressive features

• Organic Depression, medication induced depression,
substance induced depression, premenstrual dysphoric
disorder
• Rule out bipolar disorder
Establish the diagnosis of Depression
Assessment
• Severity of illness
• Risk of harm to self and others- current suicidal ideations, suicidal attempts;
past history of non-suicidal self-harm behaviour, past history of suicidal attempts,
severity of attempt
• Personality factors
• Level of functioning- work dysfunction
• Detailed Physical examination- thyroid swelling, evidence for nutritional deficiency,
and physical illness which could contribute to depression
circumference
• Investigations- haemogram, liver function test, renal function test, fasting blood glucose level,
thyroid function test (if required), Urine pregnancy test (if required)
• Decide about treatment setting- consider inpatient care in case of suicidality, malnutrition,
catatonia, comorbid general medical conditions making management difficult at the
outpatient setting
Pharmacological Management Electroconvulsive therapy Non-Pharmacological

• Choose an antidepressant based on past • Catatonia, suicidality, Management
treatment response, past history of side severe depression, past • Psychoeducation
effects, cost, comorbidity, patient/family response to ECT, • Psychotherapeutic
preference, availability augmentation etc. intervention
Figure 1: Initial evaluation and management plan for Depression

discontinuation of medication, response to treatment, side at the outpatient setting. However, some patients have
effects experienced etc. If the medications were changed, severe depression which may be further associated with
then the reason for change is also to be evaluated. psychotic symptoms, catatonic symptoms, poor physical
health status, suicidal or homicidal behaviour etc. In such
Wherever possible, unstructured assessments need to be cases, careful evaluation is to be done to decide about the
supplemented by ratings on appropriate standardized treatment setting and whenever necessary inpatient care
rating scales. Depending on the need, investigations may be offered. In general, the rule of thumb is that the
need to be carried out. The use of neuroimaging may be patients may be treated in the setting that is most safe and
indicated in those with first-episode of depression seen in effective. Severely ill patients who lack adequate social
late or very late age; those have neurological signs, those support outside of a hospital setting may be considered
having treatment resistant depression. for admission to a hospital whenever feasible. The optimal
treatment setting and the patient’s ability to benefit
Besides, patients, information about the illness need to be from a different level of care may be re-evaluated on an
obtained from the caregivers too and their knowledge and
ongoing basis throughout the course of treatment. Some
understanding of the illness, their attitudes and beliefs
of the common indications for inpatient care are shown
regarding treatment, the impact of the illness on them and
in Table-4.
their personal and social resources need to be evaluated.
FORMULATING A TREATMENT PLAN (FIGURE-1) Table 4: Some indications for inpatient care during
acute episodes
Formulation of treatment plan involves deciding about • Presence of suicidal behaviour which puts the life of the patient at risk
treatment setting, medications and psychological treatments • Severe malnutrition
to be used. Patients and caregivers may be actively consulted • Catatonia
while preparing the treatment plan. A practical, feasible and • Presence of general medical or comorbid psychiatric conditions that make
flexible treatment plan can be formulated to address the needs outpatient treatment unsafe or ineffective
of the patients and caregivers. Further the treatment plan can
be continuously re-evaluated and modified as required. All inpatients should have accompanying family caregivers.
In case inpatient care facilities are not available, than the
EVALUATE THE SAFETY OF PATIENT AND patient and/or family need to be informed about such a
OTHERS need and admission in nearest available inpatient facility
can be facilitated.
A careful assessment of the patient’s risk for suicide should
be done. During history inquiry for the presence of suicidal THERAPEUTIC ALLIANCE
ideation and other associated factors like presence of
psychotic symptoms, severe anxiety, panic attacks and Irrespective of the treatment modalities selected for
alcohol or substance abuse which increases the risk of suicide patients, it is important for the psychiatrist to establish a
need to be evaluated. It has been found that severity of
therapeutic alliance with the patient. A strong treatment
depressive symptomatology is a strong predictor of suicidal
alliance between patient and psychiatrist is crucial for poorly
ideation over time in elderly patients. Evaluation also includes
motivated, pessimistic depressed patient who are sensitive
history of past suicide attempts including the nature of those
to side effect of medications. A positive therapeutic alliance
attempts. Patients also need to be asked about suicide in their
family history. During the mental status examinations besides always generates hope for good outcome.
enquiring about the suicidal ideations, it is also important to
enquire about the degree to which the patient intends to act ENHANCED TREATMENT COMPLIANCE
on the suicidal ideation and the extent to which the patient has
made plans or begun to prepare for suicide. The availability The successful treatment of major depressive disorder
of means for suicide be inquired about and a judgment may requires adequate compliance to treatment plan. Patients
be made concerning the lethality of those means. Patients with depressive disorder may be poorly motivated and
who are found to possess suicidal or homicidal ideation, unduly pessimistic over their chances of recovery with
intention or plans require close monitoring. Measures such as treatment. In addition, the side effect or requirements of
hospitalization may be considered for those at significant risk. treatment may lead to non-adherence. Patients are to be
encouraged to articulate any concern regarding adherence
CHOICE OF TREATMENT SETTINGS and clinicians need to emphasize the importance of
adherence for successful treatment. Simple measures
Majority of the cases of depression seen in the clinical which can help in improving the compliance are given in
setting are of mild to moderate severity and can be managed table-5.

ADDRESS EARLY SIGNS OF RELAPSE be educated about the risk of relapse. They can be educated
to identify early signs and symptoms of new episodes. Patients
Many patients with depression experience relapse. can also be asked to seek adequate treatment as early in the
Accordingly, patients as well as their families if appropriate may course of a new episode as possible to decrease the likelihood
of a full-blown relapse or complication.
Table 5: Measures which can improve medication
compliance TREATMENT OPTIONS FOR MANAGEMENT
• When and how often to take medicines FOR DEPRESSION
• Preferably give once a day dosing
• Prescribe minimum number of tablets Treatment options for management of depression can be
• Always ask the patient about kind of formulation (e.g. tablet, capsule etc)
broadly be divided into antidepressants, electroconvulsive
which they would prefer to take
• Check the whole prescription to avoid duplication of medication therapy (ECT) and psychosocial interventions. Other less
• Explain the patient that the beneficial effect will be seen only after commonly used treatment or treatments used in patients
2‑4 weeks of intake of medications with treatment resistant depression include repetitive
• Explain the patient the need to take medication even after feeling better
transcranial magnetic stimulation (rTMS), light therapy,
• Explanation of side effects, If patients asks about the side effects‑ explain
the patient about the same transcranial direct stimulation, vagal nerve stimulation,
• Explain the patient as to what to do‑ if they encounter side effects deep brain stimulation and sleep deprivation treatment.
• Encourage the patient to report side effects In many cases benzodiazepines are used as adjunctive
• The need to consult with psychiatrist before discontinuing medications
treatment, especially during the initial phase of treatment.
Table 6: Antidepressants Armamentarium

Antidepressant Usual dose range (mg/day) Common side effects
Selective serotonin reuptake inhibitors (SSRI)
Fluoxetine 20‑80 Sexual dysfunction, GI distress, weight loss/gain,
Paroxetine 20‑60 anxiety, insomnia
Fluvoxamine 50‑300
Sertraline 50‑200
Citalopram 20‑40
Escitalopram 10‑20
Tricyclic tertiary amines (TCAs)
Amitriptyline 50‑200 Sexual dysfunction, anticholinergic effects, drowsiness,
Doxepin 75‑300 orthostasis, conduction abnormalities, mild GI distress,
Imipramine 75‑300 weight gain
Clomipramine 75‑300
Tricyclic Secondary Amines
Desipramine 100‑300
Nortriptyline 25‑150
Protriptyline 15‑20
Tetracyclic
Maprotiline 50‑75
Unicyclic
Bupropion 150‑450 Mild GI distress, high risk of seizure after 450 mg/day
Norepinephrine Serotonin reuptake
Inhibitors (NSRI)
Venlafaxine 75‑300 Mild anticholinergics effects, drowsiness, conduction
Duloxetine 20‑60 abnormalities, GI distress
Milnacipran 50‑200
Desvenlafaxine
Norepinephrine Serotonin Reuptake
Enhance (NSRE)
Tianeptine 25‑50 Nausea, constipation, abdominal pain, headache,
dizziness and changes in dreaming
Noradrenaline and Specific Serotonin
Antidepressants (NaSSA)
Mirtazapine 15‑45 Mild anticholinergic effects, drowsiness, orthostasis,
conduction abnormalities, GI distress, weight gain
Atypical antidepressants/Serotonin
Modulators
Trazadone 150‑300 Mild anticholinergic effects, drowsiness, orthostasis,
Nefazodone 100‑300 conduction abnormalities, GI distress, weight gain,
severe hepatotoxicity
Contd...
Table 6: Contd...
Antidepressant Usual dose range (mg/day) Common side effects
Reversible Selective Mono Amine Oxidase
Inhibitors (RIMA)
Moclobemide
Mono Amine Oxidase Inhibitors (MAOI)
Phenelzine 45‑90 Orthostatic hypotension, drowsiness,
Isocarboxazid 30‑60 insomnia, headaches
Tranylcypromine 20‑60
Serotonin partial agonist reuptake
inhibitor (SPARI)
Vilazodone 20‑40 Diarrhea, nausea or vomiting, and insomnia
Table 7: Factors that determine the selection of response to pharmacotherapy as well as the emergence of
Antidepressant Drug side effects and safety. Factors to consider when determining
Patient specific the frequency of monitoring include severity of illness,
• Patients preference patient’s co-operation with treatment, the availability of
• Previous history of response/tolerability to medication in the patient or social support and the presence of comorbid general medical
family member
problems. Visits may be kept frequent enough to monitor
• Past side effects with medication
• Other medication being taken – drug interactions and address suicidality and to promote treatment adherence.
• Patient’s age – with increasing age the pharmacokinetic and Improvement with pharmacotherapy can be observed after
pharmacodynamic changes become more important 4-6 weeks of treatment. If at least a moderate improvement is
• Comorbid medical illness (e.g., glaucoma, cardiac conditions) not observed in this time period, reappraisal and adjustment
• Comorbid psychiatric disorder/symptoms
• Gender issues – sexual dysfunction
of the pharmacotherapy should be considered.
• Intellectual and psychological capacities
Drug specific Psychotherapeutic interventions
• Side effects A specific, effective psychotherapy may be considered
• Cost
as an initial treatment modality for patients with mild to
• Dosing strategy
• Type of formulation ‑ Tablet, Cap, Syrup moderate depressive disorder. Clinical features that may
• Safety in overdose (Relative Toxicity) ‑ fatal overdose is significantly suggest the use of a specific psychotherapy include the
• Lower with SSRIs than with tricyclic antidepressants presence of significant psychosocial stressors, intrapsychic
conflict and interpersonal difficulties. Patient’s preference
Additionally in some cases, lithium and thyroid supplements for psychotherapeutic approaches is an important
may be used as an augmenting agent when patient is not factor that may be considered in the decision to use
responding to antidepressants. psychotherapy as the initial treatment modality. Pregnancy,
lactation, orthe wish to become pregnant may also be an
Antidepressants indication for psychotherapy as an initial treatment. Various
Large numbers of antidepressants (Table-6) are available for psychotherapeutic interventions which may be considered
management of depression and in general all the antidepressants based on feasibility, expertise available and affordability are
have been shown to have nearly equal efficacy in the management shown in Table-8.
of depression. Antidepressant medication may be used as
initial treatment modality for patients with mild, moderate, Cognitive behavioral therapy (CBT) and interpersonal
or severe depressive episode. The selection of antidepressant therapy are the psychotherapeutic approaches that have the
medications may be based on patient specific and drug specific best documented efficacy in the literature for management
factors, as given in Table-7. In general, because of the side of depression. When psychodynamic psychotherapy is used
effect and safety profile, selective serotonin reuptake inhibitors as specific treatment, in addition to symptom relief it is
(SSRIs) are considered to be the first line antidepressants. Other frequently with broader long term goals.
preferred options include tricyclic antidepressants, mirtazapine,
bupropion, and venlafaxine. Usually the medication must be The psychiatrist should take into account multiple
started in the lower doses and the doses must be titrated, factors when determining the frequency of sessions for
depending on the response and the side effects experienced. individual patients, including the specific type and goals
of psychotherapy, the frequency necessary to create and
Dose and duration of antidepressants maintain a therapeutic relationship, the frequency of visits
Patients who have started taking an antidepressant required to ensure treatment adherence, and the frequency
medication should be carefully monitored to assess the necessary to monitor and address suicidality. The frequency

of outpatient visits during the acute phase generally varies ACUTE PHASE TREATMENT
from once a week in routine cases to as often as several
times a week. Regardless of the type of psychotherapy The goal of acute phase treatment is to achieve remission,
selected, the patient’s response to treatment should be as presence of residual symptoms increase the risk of
carefully monitored. For a given patient, time spent and chronic depression, poor quality of life and also impairs
frequency of visit may be decided by the psychiatrist. recovery from physical illness. Treatment generally results
in improvement in quality of life and better functional
Psychoeducation to the patient and, when appropriate, to capacity. The various components of acute phase treatment
the family are shown in Table-10 and the treatment algorithm is shown
Education concerning depression and its treatments can in figure-2 and 3.
be provided to all patients. When appropriate, education
can also be provided to involved family members. Specific In acute phase psychiatrist may choose between
educational elements may be helpful in some circumstances, several initial treatment modalities, including
e.g. that depression is a real illness and that effective pharmacotherapy, psychotherapy, the combination of
treatments are both necessary and available may be crucial medication and psychotherapy, or ECT. Selection of an
for patients who attribute their illness to a moral defect initial treatment modality is usually influenced by both
or witch craft. Education regarding available treatment clinical (e.g. severity of symptoms) and other factors
options will help patients make informed decisions, (e.g. patient preference).
anticipate side effects and adhere to treatments. Another
important aspect of providing education is informing the Antidepressant medication may be used as initial treatment
patient and especially family about the lag period of onset modality for patients with mild, moderate, or severe major
of action of antidepressants. Important components of depressive disorder. Clinical features that may suggest that
psychoeducation are given in Table-9. medication are the preferred treatment modality includes
history of prior positive response to antidepressant
Combination of pharmacotherapy and Psychotherapy medication, severity of symptoms, significant sleep and
There is class of patients who may require the combination appetite disturbance, agitation, or anticipation of the need
of pharmacotherapy and psychotherapy. In general, the for maintenance therapy. Patients with severe depression
same issues that influence the choice of medication or with psychotic features will require use of combination of
psychotherapy when used alone should be considered antidepressant and antipsychotic medication and/or ECT.
when choosing treatments for patients receiving combined
therapy. The initial selection of an antidepressant medication is
largely be based on the anticipated side effects, the safety
PHASES OF ILLNESS/TREATMENT or tolerability of these side effects for individual patients,
patient preference and comorbid physical illnesses.
Management of depression can be broadly divided into three
phases, i.e., acute phase, continuation phase and maintenance Dose and duration of antidepressants: Once an
phase. Maintenance phase of treatment is usually considered antidepressant medication has been selected, it can be
when patient has recurrent depressive disorder. started initially at lower doses and careful monitoring to
Table 8: Psychotherapeutic interventions for Depression

Type of therapy
Cognitive Behaviour Therapy (CBT) • Identifying problems, Identifying cognitive distortions/errors, generating alternative thoughts,
problem solving, mastery and pleasure rating, activity scheduling, anxiety management
strategies‑ relaxation exercises
Interpersonal Therapy (IPT) • Focuses on losses, role disputes and transitions, social isolation, deficits in social skills, and other
interpersonal factor that may impact on the development of depression
Supportive psychotherapy • Allowing the patient to ventilate, providing emotional support, guidance, increasing the patient’s
self‑esteem, accepting feelings at face value, enhancing hope, enhancing adaptive coping
Behavioral Therapy (BT) • Activity scheduling, social skills training and problem solving
Marital Therapy (MT) • Marital therapy conceptualizes depression as an interpersonal context such that both members of
the marital dyad are included in therapy. Treatment includes behavioral exchange, communication
training, problem solving, and resolution of conflict around issues such as financial, sex, affection,
parenting, and intimacy
Family Therapy • When interpersonal problems in the context of pathological family dynamics are responsible for
depression, than family therapy may be considered. It would involve all the family members and
include similar principles as for marital therapy
Brief Psychodynamic Psychotherapy (BPD) • The premise of brief psychodynamic psychotherapy is that depressive symptoms remit as patient
learns new methods to cope with inner conflicts. Several different approaches have been described

Mild to moderate Depression
Evaluate for the type and severity of depression

Evaluate for past history of depression
Evaluate for past history of treatment and response
Evaluate for family history of depression
Evaluate for physical and psychiatric comorbidity
Evaluate for concomitant drugs which patient is receiving
Evaluate for the presence of psychosocial stressors
Patient’s preference
No past history of depression
Mild to moderate depression Patient’s preference
Presence of psychosocial stressors Past and family history of
Past history of good response good response
Receiving other medications and high Low risk of drug interactions
risk of drug interactions Moderate depression
Psychotherapy Pharmacotherapy Remission

Remission
No response Partial response No response
Optimize the treatment Change antidepressant

Change to • Increase the frequency of psychotherapy or
antidepressant • Increase the dose of antidepressants to Switch to psychotherapy
maximum tolerable dose
Change/Combination
• If receiving psychotherapy – add antidepressants
• If receiving antidepressants – add psychotherapy or change the antidepressant
Augmentation/Combination
• If receiving antidepressants – add second antidepressants/
augmenting agent taking into consideration the issue of tolerability
and side effects
Figure -2: Treatment algorithm of mild to moderate Depression
Table 9: Basic components of Psychoeducation be done to assess the response to pharmacotherapy as

• Assessing the knowledge of the patient and caregivers about aetiology, well as the emergence of side effects, clinical conditions,
treatment and prognosis and safety. Factors to consider when determining the
• Explain about the diagnosis and symptoms of depression frequency of monitoring include severity of illness, patient’s
• Explain that depression is a medical disorder which is treatable cooperation and presence with treatment, and availability
• Explain about the lag period of onset of action
• Provide information about aetiology
of social support andpresence of comorbid general medical
• Provide information about treatment in terms of available options, their problems. Visits may be frequent enough to monitor and
efficacy/effectiveness, side effects, duration of use address suicidality and to promote treatment adherence.
• Discuss about importance of medication and treatment compliance Improvement with pharmacotherapy can be observed after
• Provide information about possible course and long term outcome 4-6 weeks of treatment. If at least a moderate improvement
• Discuss about problems of substance abuse, interpersonal conflict, stress etc
• Discuss about how to deal with day today stress
is not observed in this time period, reappraisal and
• Discuss about communication patterns, problem solving etc adjustment of the pharmacotherapy maybe considered.
• Discuss about relapse and how to identify the early signs of relapse In the initial phase, depending on the symptom severity and
• Encourage healthy life styles
type of symptoms, such as presence of insomnia or anxiety,
Severe Depression
Evaluate for past history of depression

Evaluate for past history of treatment and response
Evaluate for family history of depression
Evaluate for physical comorbidity
Evaluate for concomitant drugs which patient is receiving
Evaluate for the presence of psychosocial stressors
Evaluate the cognitive functions
Evaluate for suicidality, oral intake
Patient’s preference
Past history of good response Patient’s preference
Receiving other medications Past and family history of good response
and high risk of drug interactions Low risk of drug interactions
Suicidal
Poor oral intake
Catatonic symptoms
Pharmacotherapy
ECT+ Pharmacotherapy
(ECT for treatment of acute disturbance and
antidepressants for the continuation phase)
Partial response
No response
Optimize the treatment

• Increase the dose of antidepressants to
maximum tolerable dose
No further response
Switch to an antidepressant from same or different

pharmacological class or dual acting agent
Add ECT
Add second antidepressants/ augmenting agent
taking into consideration the issue of tolerability
and side effects
Figure 3: Treatment algorithm of Severe Depression
Table 10: Management in the acute phase patient shows 25-50% improvement during the initial 4
• Comprehensive assessment (psychiatric/medical/psychosocial) weeks of antidepressant trial, the dose must be optimized
• Deciding on goals of treatment to the maximum tolerable dose. If there is less than 50%
Achieving remission improvement with 6-8 weeks of maximum tolerable dose
Ensure safety of patient and others and the medication compliance is good, a change in
• Choice of treatment setting
• Choosing a treatment modality: antidepressant medication, psychotherapy, antidepressant may be considered.
combined treatment with antidepressant and psychotherapy
• Use of adjunctive medications when indicated If after 4-8 weeks of treatment, if a moderate improvement is
• Use of ECT when indicated not observed, then a thorough review and reappraisal of the
• Psychoeducation
diagnosis, complicating conditions and issues, and treatment
plan may be conducted. Reappraisal of the treatment
benzodiazepines or other hypnotics may be used for short regimen may also include evaluation of patient adherence and
duration. pharmacokinetic/pharmacodynamic factors. Following this
review, the treatment plan can be revised by implementing one
Failure to response: If at least some improvement (>25%) of several therapeutic options, including maximizing the initial
is not observed following 4 week of pharmacotherapy, a medication treatment, switching to another antidepressant
reappraisal of the treatment regimen be conducted and medication, augmenting antidepressant medications with
a change in antidepressant may be considered. When other agents/psychotherapy/ECT. Maximizing the initial

Continuation Phase treatment
Treated with Treated with Treated with combination Treated with combination
antidepressants psychotherapy of psychotherapy and of antidepressants and
during the acute during the acute antidepressants during the ECT/antipsychotics during
phase phase acute phase the acute phase
Continue antidepressants Continue psychotherapy at Continue with Continue with

at the same dose for 6- the same or decreased antidepressants at the antidepressants and
9month after achieving frequency for 6-9 months same dose and antipsychotic at the same
remission after achieving remission psychotherapy at the dose and for 6-9 months
same or decreased after achieving
frequency for 6-9 remission
months after achieving
remission
Monitor for relapse of symptoms
No past H/O depression Past H/O depression
Discontinue treatment depression treatment Maintenance Treatment
Figure 4: Treatment algorithm for continuation phase treatment of depression
Maintenance Phase treatment

(H/O of ≥ 3 episodes)
• Treated with antidepressants during the acute • Treated with • Treated with
and continuation phase psychotherapy during antidepressants and
• Treated with combination of antidepressants the acute and psychotherapy during
and ECT/ antipsychotics during the acute continuation phase the acute and
and continuation phase continuation phase
• Continue with same treatment preferably for life long

• Monitor symptoms and treatment tolerability
Figure 5: Treatment algorithm for maintenance phase of depression
treatment regimen is perhaps the most conservative strategy. SSRI to another SSRI) or to one from a different pharmacologic
While using the higher therapeutic doses, patients are to be class (e.g., from an SSRI to a tricyclic antidepressant). Some
closely monitored for an increase in the severity of side effects expert suggests that while switching, a drug with a different
or emergence of newer side effects. or broader mechanism of action may be chosen.
Switching to a different antidepressant medication is a Augmentation of antidepressant medications may be helpful,

common strategy for treatment-refractory patients, especially particularly for patients who have had a partial response
those who have not shown at least partial response to the to initial antidepressant monotherapy. Options include
initial medication regimen. There is no consensus about adding a second antidepressant medication from a different
switching and patients can be switched to an antidepressant pharmacologic class, or adding another adjunctive medication
medication from the same pharmacologic class (e.g., from an such as lithium, psychostimulants, modafinil, thyroid hormone,

an anticonvulsant etc. Adding, changing, or increasing the of symptoms. The treatment algorithm to be followed is
intensity of psychotherapy may be considered for patients shown in figure-4. Patients who have been treated with
who do not respond to medication treatment. Following any antidepressants in the acute phase need to be maintained on
change in treatment, close monitoring need to be done. If at same dose of these agents for 16-24 weeks to prevent relapse
least a moderate level of improvement in depressive symptoms (total period of 6-9 month from initiation of treatment). There
is not seen after an additional 4–8 weeks of treatment, another are evidences to support the use of specific psychotherapy
thorough review need to be done. This reappraisal may include in continuation phase to prevent relapse. The use of other
verifying the patient’s diagnosis and adherence; identifying and somatic modalities (e.g. ECT) may be useful in patients where
addressing clinical factors that may be preventing improvement, pharmacology and/or psychotherapy have failed to maintain
such as the presence of comorbid general medical conditions stability in continuation phase. The frequency of visit during
or psychiatric conditions (e.g., alcohol or substance abuse); the continuation phase may be determined by patient’s clinical
and identifying and addressing psychosocial issues that may condition as well as the specific treatment being provided. If
be impeding recovery. If no new information is uncovered to maintenance phase treatment is not indicated for patients who
explain the patient’s lack of adequate response, depending on remain stable following the continuation phase, patients may
the severity of depression, ECT maybe considered. be considered for discontinuation of treatment. If treatment
is discontinued, careful monitoring be done for relapse, and
Choice of a specific psychotherapy: Out of the various treatment to be promptly reinstituted if relapse occurs.
psychotherapeutic interventions used for management
of depression, there is robust level of evidence for use of TREATMENT IN MAINTENENCE PHASE
CBT. The major determinants of type of psychotherapy
are patient preference and the availability of clinicians The goal of maintenance phase treatment is to prevent recurrence
with appropriate training and expertise in specific of depressive episodes. On an average, 50-85% of patients with
psychotherapeutic approaches. Other clinical factors which a single episode of major depression have at least one more
will influence the type of psychotherapy include the severity episodes. Therefore, maintenance phase treatment may be
of the depression. Psychotherapy is usually recommended considered to prevent recurrence. The duration of treatment
for patients with depression who are experiencing stressful may be decided keeping in view the previous treatment history
life events, interpersonal conflicts, family conflicts, poor and number of depressive episodes the person has had in the
social support and comorbid personality issues. past. Mostly the treatment that was effective for acute and
continuation phase need to be used in the maintenance phase
The optimal frequency of psychotherapy may be based on (Figure-5). Same doses of antidepressants, to which the patient
specific type and goals of the psychotherapy, the frequency had responded in previous phase is considered. The frequency
necessary to create and maintain a therapeutic relationship, of visit for CBT and IPTcan be reduced during the maintenance
the frequency of visits required to ensure treatment phase (once a month). There is no consensus regarding the
adherence, and the frequency necessary to monitor and duration and when to give and when not to give maintenance
address suicidality. Other factors which would also determine treatment. There is agreement to large extent that patients
the frequency of psychotherapy visits include the severity who have history of three or more relapses or recurrences need
of illness, the patient’s cooperation with treatment, the to be given long-term treatment.
availability of social supports, cost, geographic accessibility,
and presence of comorbid general medical problems. DISCONTINUATION OF TREATMENT
Besides the use of specific psychotherapy, all patients and their The decision to discontinue maintenance treatment may
caregivers may receive psychoeducation about the illness. be based on the same factors considered in the decision to
initiate maintenance treatment, including the probability
Role of Yoga and Meditation in management of of recurrence, the frequency and severity of past episodes,
depression: Studies related to role of traditional therapies the persistence of depressive symptoms after recovery, the
like meditation, Yoga and other techniques have been presence of comorbid disorders, and patient preferences.
mostly published in documents of various organizations When the decision is made to discontinue or terminate
propagating that particular technique. Well-designed psychotherapy in the maintenance phase, the manner in
scientific studies to authenticate these claims need to which this is done may be individualized to the patient’s
be conducted; however, efficacy of these techniques as needs. When the decision is made to discontinue maintenance
supportive/adjuctive therapy is widely accepted. pharmacotherapy, it is best to taper the medication over
the course of at least several weeks to few months. Such
TREATMENT IN CONTINUATION PHASE tapering may allow for the detection of emerging symptoms
or recurrences when patients are still partially treated and
The goal of continuation phase is to maintain the gains therefore can be easily returned to full therapeutic intensity.
achieved in the acute phase of treatment and prevent relapse In addition, such tapering can help minimize the risks of

Table 11: Management of depression Special situations

Suicidal risk • Risk of suicide is high in patients with depression.
• Suicide risk to be assessed initially and over the course of treatment.
• If the patient has suicidal ideation, intention, and/or a plan, close surveillance is necessary.
• Whenever possible, information about presence of suicidal ideation in patient be shared with family members and
they need to be instructed for various safety measures to be taken.
• The risk of suicide in some patients recovering from depression increases transiently as they develop the energy
and capacity to act on self‑destructive plans made earlier in the course of their illness. However, it is not possible
to predict with certainly whether a given patient will kill himself or herself.
• A careful selection of antidepressants and ECT is an important decision to be taken by psychiatrist after
considering all related factors.
• Wherever feasible, the prescribed drugs need not be in the possession or reach of patient having suicidal intention.
Psychotic features • Depression with psychotic features carries a higher risk of suicide than does major depression uncomplicated by
psychosis
• It also constitutes a risk factor for recurrent depression.
• Depression with psychotic features responds better to treatment with a combination of antidepressants and
antipsychotics than to treatment with either component alone.
• ECT is also highly effective in depression with psychotic features.
Atypical features • Atypical depressive feature include severe anxiety, vegetative symptoms of reversed biological functions (i.e.,
increased rather than decreased sleep, appetite, and weight), marked mood reactivity, sensitivity to emotional
rejection, phobic symptoms, and a sense of severe fatigue that creates a sensation of “leaden paralysis” or extreme
heaviness of the arms or legs.
• Tricyclic antidepressants yield response rates of only 35%‑50%. Response rates with MAO inhibitors are in
the range of 55%‑75% in patients with atypical depression. If it is determined that the patient does not wish to,
cannot, or is unlikely to adhere to the dietary and drug precautions associated with MAO inhibitor treatment, the
use of an alternative antidepressant is indicated.
• The results of several studies suggest that SSRIs, MAOIs, and possibly bupropion maybe more effective
treatment for atypical depression.
Alcohol and/or substance • Because of the frequent comorbidity of depression and alcohol or other substance abuse, efforts need to be made
abuse or dependence to obtain a detailed history of the patient’s substance use.
• If the patient is found to have a substance use disorder, a program to ensure abstinence may be regarded as a
principle priority in the treatment.
• It is also advisable, if other factors permit, to detoxify such a patient before initiating antidepressant therapy.
• Benzodiazepines and other sedative hypnotics carry the potential for abuse or dependence and these may be used
cautiously except as part of a detoxification regimen.
• Hepatic dysfunction and hepatic enzyme induction frequently complicate pharmacotherapy of patients with
alcoholism and other substance abuse; these conditions require careful monitoring of blood levels.
Depression with features of • Clomipramine and the SSRIs have been demonstrated to be efficacious in the management of
obsessive‑compulsive disorder obsessive‑compulsive symptoms in addition to their antidepressants efficacy.
Depression with panic and/or • Panic disorder complicates major depression in 15%‑30% of the cases.
other anxiety disorders • TCAs and SSRIs may initially worsen, rather than alleviating anxiety and panic symptoms; these medications
may therefore be introduced at a low dose and slowly increased when used to treat such patients.
• High potency benzodiazepine like alprazolam and clonazepam may sometimes be used with benefit either in
combination with antidepressants or as the sole pharmacological agent for anxiety, with or without panic, coupled
with milder forms of depression.
Depression with cognitive • Signs and symptoms of cognitive inefficiency routinely accompany major depression.
dysfunction (pseudo • Some patients have both depression and dementia, while others have depression that causes cognitive
dementia) impairment (i.e., pseudo‑dementia).
• Several clinical features help in differentiating pseudo‑dementia from true dementia. Pseudo‑demented patients
generally exert relatively less effort but report more incapacity than patients with true dementia. In more
advanced stage, patients with dementia typically fail to recognize their cognitive failure.
• It is important that patients with major depression with cognitive disturbance are not misdiagnosed and thereby
denied the antidepressant medication or ECT.
• Depression related cognitive dysfunction is a reversible condition that resolves with treatment of the underlying
depression.
Dementia • Individuals suffering from dementia need to be prescribed antidepressants which have least potential of
anticholinergic effect, e.g., bupropion, fluoxetine, sertraline, and, of the tricyclic agents, desipramine or
nortriptyline. Alternatively, some patients do well when given stimulants in small doses.
• Among SSRIs, paroxetine may be avoided.
• ECT is also effective in depression superimposed on dementia, and it may be used if medications are
contraindicated, not tolerated, or if immediate resolution of the major depressive disorder episode is medically
indicated (such as when it interferes with the patient’s acceptance of food).
Post Psychotic Depression • Adding an antidepressant agent to the patient’s antipsychotic regimen can help in managing post‑psychotic
depression effectively.
Contd...
Table 11: Contd...
Depression during pregnancy • Women in childbearing age may be counseled about the risk of becoming pregnant while taking psychotropic
or following Childbirth medications.
• Whenever possible, a pregnancy is to be planned in consultation with psychiatrist so that medication may be
discontinued before conception if feasible.
• The clinicians need to carefully weigh the risks and benefits of prescribing psychotropic agents to the pregnant
patient, taking into consideration the possibilities of physical (especially during the first trimester) and behavioral
teratogenesis.
• In patients whose safety and well‑being require antidepressants medications, antidepressants may be justifiably
used, after the first trimester, if possible.
• ECT may be used as an alternative treatment; the current literature supports the safety for mother and fetus, as
well as the effectiveness of ECT during pregnancy.
• Postpartum depression is to be treated according to the same principles delineated for other depressive condition.
• However, issue of breast feeding and appropriate precautions need to be explained to patient and caregivers.
Seasonal depression • Some individuals suffer annual episode of depression whose onset is in the fall or early winter, usually at the
same time each year.
• The depressive episodes frequently have atypical features such as hypersomnia and overeating.
• The entire range of treatments for depression may also be used to treat seasonal affective disorder, either in
combination with or as an alternative to light therapy.
Depression in elderly • Antidepressants are effective in treatment of depression in old age.
• The high rates of adverse effects associated with TCAs suggest that these agents must not be used as the first line
agents.
• The lower rate of adverse events in the newer antidepressants (SSRIs) makes them more acceptable. However,
nortriptyline has a role in severe depression in the elderly.
• ECT has demonstrated efficacy in treatment of old age depression with the benefit of rapid response in the
severely ill with and without psychotic symptoms.
Depression in Children • There are evidences that SSRIs are effective in child and adolescent depression and these are generally the first
choice of drug.
• The commonly used SSRIs include fluoxetine. Other newer antidepressants have not been adequately evaluated
in childhood and use of all these classes of drugs may be used with careful monitoring.
• Psychotherapeutic interventions like CBT and IPT have also been shown to be efficacious in children and
adolescents.
Post‑ Stroke Depression • Post Stroke Depression is a common problem seen in at least 30‑40% of survivors of intra‑cerebral hemorrhage.
• Antidepressant drugs may be beneficial in managing depressive symptoms and allow faster Post Stroke
rehabilitation.
• Treatment is complicated by medical co‑morbidity and by the potential for interaction with other co‑prescribed
drugs.
• Fluoxetine and nortriptyline are probably the most standard and seen to be effective.
Cardiac disease: • The presence of specific cardiac conditions complicates or contraindicates certain forms of antidepressant
medication therapy, notably use of TCAs.
• Cardiac history is to be carefully explored before the initiation of medication treatment. Although TCAs have
been used effectively to treat depression in patients with some forms of ischemic heart disease, particular care
need to be taken in using TCAs in patients with a history of ventricular arrhythmia, subclinical sinus node
dysfunction, conduction defects (including asymptomatic conduction defects), prolonged QT intervals, or a recent
history of myocardial infarction.
• SSRIs, bupropion, and ECT appear to be safer for patients with preexisting cardiac disease, although the latter
may require consultation with a specialist and treatment modification before use. However, there are also reports
which suggest that SSRIs can also lead to arrhythmia.
• MAOIs do not adversely affect cardiac conduction, rhythm, or contraction but may induce orthostatic
hypotension and also run the risk of interacting adversely with other medications that may be taken by such
patients. There is anecdotal evidence that trazodone may induce ventricular arrhythmias, but this agent may be
avoided in elderly because of orthostatic blood pressure decrements.
• Consultation with the patient’s cardiologist before and during antidepressant medication treatment may be advisable
and is especially advisable during any treatment for a patient who has recently had a myocardial infarction.
Hypertension • Antihypertensive agents and TCAs may interact to either intensify or counteract the effect of the antihypertensive therapy.
• The action of antihypertensive agents that block alpha receptors (e.g., prazosin) may be intensified by
antidepressant medications that block these same receptors, notably the TCAs and trazodone. TCAs may
antagonize the therapeutic actions of guanethidine, clonidine, or α‑methyldopa.
• Antihypertensive, like diuretics which mainly act on kidney, may precipitate SIADH, when given along with
SSRIs.
• Concurrent antihypertensive treatment, especially with diuretics, increases the likelihood that TCAs, trazodone,
or MAOIs will induce symptomatic orthostatic hypotension.
• β Blockers, especially propranolol, may be a cause of depressive disorder in some patients.
• Dose‑dependent elevations in blood pressure with venlafaxine are usually mild, although more severe elevations
have been observed, making this agent less preferable in patients with hypertension.
Contd...
Table 11: Contd...
Diabetes mellitus • SSRIs may reduce serum glucose by up to 30% and cause appetite suppression, resulting in weight loss.
• Fluoxetine may be avoided, owing to its increased potential for hypoglycaemia, particularly in patients with
non‑insulin dependent diabetes. If fluoxetine is prescribed, the patient should be advised of the need to monitor
serum glucose levels regularly.
• T CAs are more likely to impair diabetic control as they increase serum glucose levels by up to 150%,
increase appetite (particularly carbohydrate craving) and reduce the metabolic rate. They are generally
considered safe unless the diabetes is very poorly controlled or is associated with significant cardiac or
renal disease.
• Antidepressants such as amitriptyline, imipramine, duloxetine and citalopram are also used to treat painful diabetic
neuropathy.
Asthma • Antidepressant medications except MAOI may be used for patients with asthma without fear of interaction. Other
antidepressant like SSRIs, TCAs, etc., may be used for patient with asthma without any apprehension about drug
interaction.
Glaucoma • Antidepressants that cause or exacerbate acute close angle glaucoma include medications with anticholinergics,
serotonergic or adrenergic properties.
• TCAs have the greatest anticholinergic properties,
• SSRIs and SNRIs by virtue of their action on serotonin receptor can also cause mydriasis and thereby can produce
papillary block.
• Antidepressants lacking anticholinergic and serotonergic activity (bupropion) may be preferred.
• Benzodiazepines (Diazepam) have mild anticholinergics properties.
Obstructive uropathy • Prostatism and other forms of bladder outlet obstruction are relative contraindications to the use of antidepressant
medication compounds with antimuscarinic effects.
• Benzodiazepines, trazodone, and MAOIs may also retard bladder emptying.
• The antidepressant medications with the least propensity to do this are SSRIs, bupropion, and desipramine.
Parkinson’s disease • Bupropion, exerts a beneficial effect on the symptoms of Parkinson’s disease in some patients but may also induce
psychotic symptoms, perhaps because of its agonistic action in the dopaminergic system.
• MAOIs (other than selegiline, also known as L‑deprenyl, a selective type B MAOI is recommended in the treatment
of Parkinson’s disease) may adversely interact with L‑dopa products.
• Selegiline loses its specificity for MAO‑B in doses greater than 10 mg/day and may induce serotonin syndrome
when given in higher doses in conjunction with serotonin‑enhancing antidepressant medications.
• There is no evidence favoring any particular antidepressant medication from the standpoint of therapeutic efficacy
in patients with Parkinson’s disease complicated by depressive disorder.
• The theoretical benefits of the antimuscarinic effects of some of the TCAs in the treatment of patients with depressive
disorder with Parkinson’s disease are offset by the memory impairment that may result.
• ECT exerts a transient beneficial effect on the symptoms of idiopathic Parkinson’s disease in many patients.
• Amoxapine, an antidepressant medication with dopamine‑receptor blocking properties, may be avoided for patients
who have Parkinson’s disease.
• Lithium may in some instances induce or exacerbate parkinsonian symptoms.
Malignancy • In treatment of depression in subjects with malignancy, SSRI are considered to be the first line drugs. The advantage
of SSRI is that they can act as effective adjunct analgesic drugs, especially in neuropathic pain. Disadvantages
of SSRI are drug‑drug interaction with drugs that are metabolized by CYP450/3A4 (e.g. cyclophosphamide,
doxorubicin). Fluoxetine, may be used with caution especially is patients with hepatic insufficiency, since it has
a long half‑life.
• TCAs are also good adjunct analgesics. But the disadvantages with TCAs are anticholinergic side effects and
orthostatic hypotension. They can also worsen their side effects of drugs like opioids (e.g. constipation and dry
mouth) which are often needed for pain control.
• Psychostimulants, with their rapid onset of action have some advantages for depressed cancer patients in the sense
of promoting a sense of well‑being, decreasing fatigue, stimulating appetite, potentiating the analgesic effect of
opioids and decreasing opioid induced sedation.
• The goal of psychological treatment in depressed patients with cancer is to reduce emotional distress, improve
morale, coping ability, self‑esteem and sense of control.
Drug induced depression • If medication induced depression is suspected, the suspected drug should be discontinued if possible and replaced
with another agent less likely to induce depression.
• When this is not possible or when discontinuation does not result in remission of the depressive symptoms,
pharmacotherapy for the depression may be considered.
Contd...

Table 11: Contd...
Liver disease • Liver impairment affects basic elements of medication pharmacokinetics, from absorption to metabolism,
distribution to elimination, changing drug levels, duration of action, and efficacy.
• Most antidepressants are highly protein‑bound‑ except, venlafaxine, and methylphenidate.
• In liver failure, a reduction in albumin and alpha1‑acid‑glycoprotein production, along with altered protein‑binding,
leads to higher levels of free pharmacologically‑active drug. This is offset by a compensatory increase in the rate of
hepatic metabolism, and this is especially important for drugs with low intrinsic clearance.
• Most antidepressants are highly lipid‑soluble and require hepatic metabolism (biotransformation into more polar
compounds) to allow them to be cleared from the body in urine or bile.
• Antidepressants can also be divided into two major categories of clearance, determined by their enzyme affinity.
Flow‑limited drugs have high hepatic extraction, and their hepatic clearance is dependent on the rate of delivery of
the drug to the liver. TCAs undergo significant first pass metabolism of greater than 50% after oral administration.
• Drugs with low hepatic‑enzyme affinity (e.g., paroxetine) are metabolized more slowly, as enzyme saturation is the
rate limiting step. The severity of impairment rather than the underlying aetiology is the most important factor to
consider in prescribing for this group. Renal function may also be affected.
• As the risk of drug toxicity increases with disease severity, lower starting and total doses of medication are
recommended (starting dose ‑about one forth that of adults).
Renal disease • In this group of patients, TCAs are probably safer than SSRIs.
• The degree of renal impairment rather than the cause is most important.
• Renal impairment may be present without a raised creatinine level. TCAs metabolites are excreted by the kidneys,
hence accumulation may occur. Of the SSRIs, sertraline is not recommended by its manufacturers in renal failure.
• Fluoxetine, citalopram and paroxetine may be started at very low dose in patients with a glomerular filtration rate
of at least>10 ml/min.
• Lithium may only be prescribed if absolutely necessary, at low doses, on alternate days, with frequent checking of
serum levels.
Perioperative period • TCAs may preferably be stopped prior to surgery. SSRIs and MAOI can interact with pethidine, pentazocine, and
dextromethorphan, at the pharmacodynamics levels and lead to serotonin syndrome, therefore such drugs may be
avoided during the perioperative period. However, SSRIs may not be discontinued in order to prevent anesthetic
interactions, except when the SSRI is used in combination with aspirin or an Non-steroidal anti-inflammatory
drugs and when the SSRI is used in patients over 80 years of age. In these patients, the balance of risks of
withdrawal and bleeding is to be discussed with patients. Because abrupt discontinuation can cause serious
withdrawal symptoms, the drugs may be gradually discontinued over few days to 2 weeks before surgery.
• Lithium can contribute to hemodynamic instabilities, interfere with sodium and potassium metabolism, and the
renal excretion of lithium can be reduced in presence of renal complications. The physical risk of intoxication,
with its detrimental and fatal risks for the central nervous system, is unacceptable. Therefore, lithium
discontinuation is recommended. Lithium can be stopped at once because no withdrawal symptoms occur.
• When, postoperatively, the patient is hemodynamically stable, is able and allowed to drink, and is not on new,
potentially interfering drugs, the medication may be restarted gradually.
antidepressant medication discontinuation syndromes. signs of depression, and a plan for seeking treatment in
Discontinuation syndromes have been found to be more the event of recurrence of symptoms may be formulated.
frequent after discontinuation of medications with shorter Patients may be monitored for next few months to identify
half-lives, and patients maintained on short-acting agents relapse. If a patient suffers a relapse upon discontinuation
may be given even longer, more gradual tapering. Paroxetine, of medication, treatments need to be promptly reinitiated.
venlafaxine, TCAs, and MAOIs tend to have higher rates of In general, the previous treatment regimen to which the
discontinuation symptoms while bupropion-SR, citalopram, patient responded in the acute and continuation phase are
fluoxetine, mirtazapine, and sertraline have lower rates. The to be considered.
symptoms of antidepressants discontinuation include
flu-like symptoms, insomnia, nausea, imbalance, sensory MANAGEMENT OF TREATMENT RESISTANCE
disturbances (e.g., electrical sensations) and hyperarousal DEPRESSION
(agitation). If the discontinuation syndrome is mild,
reassurance may be sufficient. If mild to moderate, short- Initial treatment with antidepressant medication fails to
term symptomatic treatment (analgesics, antiemetics, or achieve a satisfactory response in approximately 20%-30%
anxiolytics) may be beneficial. If it is severe, antidepressant of patients with depressive disorder. In some cases the
are to be reinstated and tapered off more slowly. apparent lack of treatment response is actually a result
of faulty diagnosis, inadequate treatment, or failure to
After the discontinuation of active treatment, patients appreciate and remedy coexisting general medical and
should be reminded of the potential for a depressive psychiatric disorders or other complicating psychosocial
relapse. Patient may be again informed about the early factors. Adequate treatment for at least 4-6 weeks is

necessary before concluding that a patient is not responsive who has not responded to medication is carrying out
to a particular medication. First step in care of a patient a thorough review and reappraisal of the psychosocial
and biological information base, aimed at revarifying the
Depression diagnosis and identifying any neglected and possibly
No Response to treatment
contributing factors, including the general medical
problems, alcohol or substance abuse or dependence,
other psychiatric disorders, and general psychosocial issues
impeding recovery. Algorithm for arriving at the diagnosis
Reassess diagnosis Correct the diagnosis and of treatment resistant depression is given in figure-6.
treat accordingly
Some clinicians require two successive trials of medications

of different categories for adequate duration before
Has the patient received considering treatment resistant depression (TRD).
adequate doses for
sufficient duration? Management of TRD involves addition of an adjunctive
agent, combining two antidepressants, addition of ECT
or other somatic treatments like rTMS.Algorithm for
management of TRD is given in figure-7.
Is adherence to medication
proper?
Are Side effects interfering Addition of an adjunct to an antidepressant: Lithium
with treatment? is the drug primarily used as an adjunct; other agents
in use are thyroid hormone and stimulants. Opinion
Look for emerging organic differs as to the relative benefits of lithium and thyroid
causes, rule out any other Treatment Resistant supplementation. It is reported that lithium is useful in over
comorbidities/stressors Depression
50% of antidepressant nonresponders and is usually well
Figure 6: Algorithm for arriving at the diagnosis of Treatment tolerated. The interval before full response to adjunctive
Resistant Depression lithium is said to be in the range of several daysto 3 weeks.
Treatment Resistant
Depression
Partial or no response
Augmentation with Combination Other e.g. Lamotrigine,

ECT/
Lithium/Thyroid / Antidepressants fluvoxamine,
rTMS
Buspirone (TCA + SSRI) or Mirtazapine+ Bupropion,
(Bupropion + SSRI) Olanzapine etc. (Provide
Rationale)
Continuation Phase
Maintenance Phase
Figure 7: Algorithm for management of Treatment Resistant Depression

If effective and well tolerated, lithium may be continued stimulation duration and intensity, can produce the most
for the duration of treatment of the acute episode. Thyroid benefits. Moreover, there is no consensus of the exact brain
hormone supplementation, even in euthyroid patients, localization for individual coil placement.
may also increase the effectiveness of antidepressant
treatment. The dose proposed for this purpose is 25 μg/ MANAGEMENT OF SPECIAL CONDITIONS
day of triidothyronine increased to 50 μg/day in a week.
Clinicians often encounter certain clinical situations which either
Simultaneous use of multiple antidepressants: Depression is require special attention or can influence treatment decisions.
a chronic disabling condition in case patient does not respond Management of these situations is summarized in table-11.
to single drug regimen; clinicians may use combination/
polytherapy with close monitoring of side effects and drug REFERENCES
interaction profile. Combinations of antidepressant carry
1. American Psychiatry Association. Practice Guideline for the Treatment of
a risk of adverse interaction and sometimes require dose Patients With Major Depressive Disorder, Third Edition, 2010; pp -152.
adjustments. Use of a SSRI in combination with TCA has 2. Avasthi A, Grover S, Agarwal M. Research on antidepressants in India.
Indian J Psychiatry, 2010; 52 (Suppl): S341-354.
been reported to induce a particularly rapid antidepressant 3. Avasthi A, Grover S, Bharadwaj R. Clinical Practice guidelines for
response. However, fluoxetine added to TCAs causes an treatment of depression in old age. (Eds): Shiv Gautam & Ajit Avasthi.
increased blood level and delayed elimination of the TCA, Published by Indian Psychiatric Society, 2007; Volume III, 51-150.
4. Ellis P; Royal Australian and New Zealand College of Psychiatrists Clinical
predisposing the patient to TCA drug toxicity unless the dose Practice Guidelines Team for Depression. Australian and New Zealand
of the TCA is reduced. Another strategy involves combined clinical practice guidelines for the treatment of depression. Aust N Z J
Psychiatry. 2004 Jun;38(6):389-407.
use of a tricyclic antidepressant and a MAO inhibitor, a 5. Gautam S, Batra L. Clinical Practice guidelines for management of
combination that is sometimes effective in alleviating severe depression. (Eds): Shiv Gautam & Ajit Avasthi. Published by Indian
Psychiatric Society, 2005; Volume I, 83-119.
medication-resistant depression, but the risk of serotonin 6. Grover S, Dutt A, Avasthi A. Research on Depression in India. Indian J
syndrome necessitates careful monitoring. Psychiatry, 2010; 52 (Suppl): S178-S188.
7. Kennedy SH, Lam RW, McIntyre RS, Tourjman SV, Bhat V, Blier P,
Hasnain M, Jollant F, Levitt AJ, MacQueen GM, McInerney SJ, McIntosh
Electroconvulsive therapy: Response to ECT is generally D, Milev RV, Müller DJ, Parikh SV, Pearson NL, Ravindran AV, Uher R;
good and the response rates are like any form of CANMAT Depression Work Group. Canadian Network for Mood and Anxiety
Treatments (CANMAT) 2016 Clinical Guidelines for the Management
antidepressant treatment and it may be considered in of Adults with Major Depressive Disorder: Section 3. Pharmacological
virtually all cases of moderate or severe major depression Treatments. Can J Psychiatry. 2016 Aug 2. pii: 0706743716659417. [Epub
ahead of print] PubMed PMID: 27486148.
who do not respond to pharmacologic intervention. 8. Kessler RC, Bromet EJ. The epidemiology of depression across cultures.
Approximately 50% of medication resistant patients exhibit Annu Rev Public Health. 2013;34:119-38.
9. Lam RW, Kennedy SH, Grigoriadis S, McIntyre RS, Milev R, Ramasubbu R,
a satisfactory response to ECT. Lithium may be discontinued Parikh SV, Patten SB, Ravindran AV; Canadian Network for Mood and
before initiation of ECT, as it has been reported to prolong Anxiety Treatments (CANMAT). Canadian Network for Mood and Anxiety
postictal delirium and delay recovery from neuromuscular Treatments (CANMAT) clinical guidelines for the management of major
depressive disorder in adults. III. Pharmacotherapy. J Affect Disord. 2009
blockade. Oct;117 Suppl 1:S26-43.
10. National Institute of Health and Care Excellence. Depression in adults:
Recognition and Management. Clinical guideline (cg 90), 2009, pp 5-64.
Repetitive Transcranial Magnetic Stimulation (rTMS) 11. Parikh SV, Segal ZV, Grigoriadis S, Ravindran AV, Kennedy SH, Lam RW,
Patten SB; Canadian Network for Mood and Anxiety Treatments (CANMAT).
Canadian Network for Mood and Anxiety Treatments (CANMAT) clinical
Repetitive transcranial magnetic stimulation (rTMS; a type of guidelines for the management of major depressive disorder in adults. II.
TMS that occurs in a rhythmic and repetitive form) has been Psychotherapy alone or in combination with antidepressant medication. J
put forward as a new technique to treat this debilitating Affect Disord. 2009 Oct;117 Suppl 1:S15-25.
12. Royal Australian And New Zealand College Of Psychiatrists Clinical
illness. Current evidence suggests that rTMS applied to the Practice Guidelines Team For Depression. Australian and New Zealand
left dorsolateral prefrontal cortex (DLPFC) is a promising clinical practice guidelines for the treatment of depression. Australian and
New Zealand Journal of Psychiatry Vol. 38, Issue 6, 2004.
treatment strategy for depression, but not all patients show 13. Sarkar S, Grover S. A systematic review and meta-analysis of trials of
a positive outcome. Current clinical outcome studies report antidepressants in India for treatment of depression. Indian J Psychiatry
2014; 56: 29-38.
rather modest superiority compared with placebo (sham). 14. Singh T, Rajput M. Misdiagnosis of Bipolar Disorder. Psychiatry
To date, it remains unclear which TMS parameters, such as (Edgmont).2006; 3: 57–63.

Clinical Practice Guidelines for Management of Bipolar Disorder

Nilesh Shah, Sandeep Grover1, G. Prasad Rao2
Department of Psychiatry, L. T. M. Medical College and General Hospital, Sion, Mumbai, 1Department of Psychiatry,
Post Graduate Institute of Medical Education and Research, Chandigarh, 2Schizophrenia and Psychopharmacology Division,
Asha Hospital., Banjara Hills, Hyderabad, India
shown to have subthreshold BPAD with a range of 0.1 to 2.4%

Participants of expert group on CPG for Bipolar Affective
with a mean of 1.4 (SD-0.8). There is no nationwide study to
Disorder
evaluate the prevalence rates of BPAD in India. In a country
like India, patients have limited resources, poor knowledge
Vidhyadhar Watve, Mrugesh Vaishnav, Vivek Kirpekar,
about the disorder and treatment; have inadequate access
D.K. Sharma, Mahendra Jain, Asim Kumar Mallick,
to the health care facilities, which makes treatment of
C.L. Narayan, Anup Bharti, Madhu Nijhawan.
BPAD a challenge. Indian Psychiatric Society (IPS) made first
attempt to formulate Clinical Practice Guidelines (CPGs) for
INTRODUCTION
management of BPAD in 2005. Since then, over the last one
decade there have been several developments, especially in
Bipolar disorder (BPAD) is a serious mental disorder
the form of emergence of new evidence for some of the
characterized by episodes of depression, hypomania/mania
pharmacological agents. Accordingly, these new guidelines
and mixed episodes, with interepisodic recovery. However,
attempt to update the previous guidelines published by
many patients with BPAD continue to exhibit residual
IPS. These guidelines should be read along with the earlier
symptoms in the interepisodic period. The illness usually
version of the CPGs, published by IPS in 2005.
starts in adolescence or early adulthood and has significant
negative impact on the life of the sufferer and their caregivers.
ASSESSMENT AND EVALUATION [TABLE-1]
Patients with BPAD encounter educational difficulties, job
related problems, interpersonal difficulties, psychosocial
Assessment of patients is an ongoing process and
dysfunction, disability, marital problems, multiple suicidal
comprehensive assessment of a patient involves the
attempts, completed suicide and medication side effects.
assessment of patients themselves and their caregivers.
Additionally patients with BPAD have high rates of physical
The role of taking a proper history from the patient and
and psychiatric comorbidity. The prevalence rates of BPAD
all the available resources cannot be over-emphasized. In
vary from country to country. A large multinational study
addition to the history taking, proper attention must be
suggests that lifetime prevalence of BPAD-I ranges from
paid to the mental status examination. Diagnosis of BPAD
0-1% with a mean of 0.6 (SD-0.4). The prevalence rate of
is to be made on the basis of current diagnostic criteria,
BPAD-II ranges from 0 to 1.1% with a mean of 0.4 (SD-0.3).
because a diagnosis based on diagnostic criteria can be
Additionally a significant proportion of patients have been
considered more reliable, facilitates communication among
various clinicians and paves the way for management on the
basis of evidence based recommendations. It is important
Address for correspondence:
Dr. Nilesh Shah, Department of Psychiatry, L. T. M. Medical to remember that especially during the initial part of the
College and General Hospital, Sion, Mumbai - 400 022, illness, the symptoms may be confusing and at times it
Maharastra, India. may be difficult to distinguish symptoms of mania from
E-mail: drnilshah@hotmail.com,
other psychiatric syndromes like schizophrenia, acute
Dr. Sandeep Grover, Additional Professor, Department of
Psychiatry, PGIMER, Chandigarh, India.
E-mail: drsandeepg2002@yahoo.com
DOI:
How to cite this article: Shah N, Grover S, Rao GP. Clinical
Practice Guidelines for Management of Bipolar Disorder.
10.4103/0019-5545.196974
Indian J Psychiatry 2017;59:51-66.

Shah, et al.: CPGs for bipolar disorders
Table 1: Components of assessment and evaluation stressors and biological rhythms in onset of illness,
Basic assessments precipitation of relapse and continuation of symptoms need
• Comprehensive assessment of both patients and caregivers to be understood thoroughly.
• Complete history with information from all possible sources in terms of
type of first episode in lifetime, predominant polarity of illness, duration A thorough assessment includes assessment of comorbid
and severity of episodes, inter‑episodic recovery, presence or absence of
suicidal behaviour, violence and agitation, seasonal variation in onset of
psychiatric and medical conditions. It is important to
symptoms, presence of rapid cycling and ultra‑rapid cycling features remember that many a times; comorbidity is not very evident
• History taking focusing on precipitating factors‑ psychosocial stressors, during the acute episode of illness. The comorbid conditions
disturbances in biological rhythms become more evident when the patient has come out of the
• Physical examination‑ record data such as blood pressure, weight and acute episode of the illness. Evaluation of comorbid substance
wherever indicated body mass index and waist circumference
• Mental state examination
abuse needs to consider the type and frequency of substance
• Establish diagnosis according to current diagnostic criteria abuse. If the patient does not provide adequate information
• Differential diagnosis by ruling out secondary affective disorder about the substance use pattern, but there is high index of
• Proper assessment of the current polarity of the illness suspicion, urine or blood screens (with prior consent) can be
• Evaluate the risk for suicidal behaviour‑ suicidal ideations, intent, plans; used to confirm the existence of comorbid substance use/
access to means for suicide, possible lethality in case patient uses the
means, psychotic symptoms in the form of commanding hallucinations,
dependence, wherever such facilities are available. Functional
severe anxiety, comorbid substance use, past history of suicidal impairment in various domains of life including impact of the
attempts and non‑suicidal self‑harming, family history of self‑harm and illness on the family functioning and psychosocial impact of
completed suicide the illness on the caregivers is not to be neglected. A thorough
• Areas to be evaluated during the current episode: symptom‑severity, physical examination need to be done to rule out presence of
symptom‑dimensions, comorbid physical and psychiatric including
substance use conditions, risk of harm to self and others, level of
any physical illness and also to rule out episodes secondary
functioning and socio‑cultural milieu of the patient to physical illnesses. This may be supplemented by the
• Past treatment history: type of medications used, response to treatment, judicious use of investigations. Depending on the feasibility,
duration of use of treatment, side effects experienced and reasons for unstructured clinical assessments need to be supplemented
discontinuation by documentation of severity and extent of symptoms on
• Basic investigations: haemogram, blood sugar and lipid levels, liver
functions, renal functions, electrocardiogram
appropriate standardized rating scales. Patients with bipolar
• Assessments of caregivers: knowledge about illness, knowledge about disorders also have cognitive deficits. Accordingly, depending
treatment, their attitudes and beliefs regarding treatment, the impact of on the need, detailed cognitive testing may be undertaken.
the illness on them and their personal and social resources in the form of The use of neuroimaging may be indicated in those with
burden, distress, stigma, personal and marital life atypical features, neurological signs, non-response to
• Ongoing assessments: response to treatment, side effects, treatment
adherence, issues of marriage and pregnancy, disability, other health‑care
treatment and having first episode of illness at a later age
needs, ease of access to treatment team, therapeutic alliance, etc. and elderly. Caregiver’s assessment may involve evaluation of
Additional/Optional assessments their knowledge about illness, knowledge about treatment,
• Use of standardized rating scales to rate various aspects of the illness their attitudes and beliefs regarding treatment, the impact of
• Psychological testing for cognitive functions the illness on them and their personal and social resources
• Neuroimaging especially in those with atypical features, neurological
signs, non‑response to treatment, later age of onset and elderly patients
in the form of burden, distress, stigma, personal and marital
life etc.
and transient psychosis and other psychiatric disorders. In case patient has received treatment in the past, then it is
A possibility of substance induced disorder or disorder important to record the type of medications used, response
secondary to organic causes is to be considered, when to treatment, duration of use of treatment, side effects
the symptoms are atypical or there is evidence of the use experienced and reasons for discontinuation.
of substance or underlying organic causes. Occasionally
establishing the definite diagnosis of BPAD may require Importance of ongoing assessment cannot be
time. underestimated. With progress in treatment, new issues like
response to treatment, side effects, treatment adherence,
The assessment may cover history of number of previous marriage, pregnancy, disability, other health-care needs,
episodes, type of first episode in lifetime, predominant ease of access to treatment team and therapeutic alliance
polarity of illness, duration and severity of episodes, may need to be assessed from time to time.
inter-episodic recovery, presence or absence of suicidal
behaviour, violence and agitation, seasonal variation in FORMULATING A TREATMENT PLAN [FIGURE 1]
onset of symptoms, presence of rapid cycling and features of
ultra-rapid cycling. Assessment of current episode may also Formulation of treatment plan will involve decision making
focus on the issues of severity of symptoms, suicidality and about the treatment setting, treatments to be used and areas
agitation. Understanding the role of various psychosocial to be addressed. Treatment plan need to be formulated in

Patient with Affective Symptoms

• Organic Mental Conditions
• Substance induced disorder
• Acute and transient psychotic disorder
• Other psychotic disorders
Establish the diagnosis of BPAD
Assessment
• Severity of Current episode
• Risk of harm to self and others
• Level of functioning
• Detailed Physical examination
circumference
• Investigations- haemogram, liver function test, renal function test, fasting blood glucose
level, electrocardiogram
• Decide about treatment setting- consider inpatient care in case of suicidality, severe agitation
and violence, malnutrition, catatonia, patient unable to care for self to the extent that she/he
requires constant supervision or support, comorbid general medical conditions making
management difficult at the outpatient setting
Electroconvulsive therapy Non-Pharmacological

Pharmacological Management
• Catatonia, rapid control Management
• Choose an agent based on the current
of symptoms, suicidality, • Psychoeducation
polarity, presence or absence of psychotic
past response to ECT, • Psychosocial
symptoms in the current episode, past
augmentation etc. intervention
treatment response, past history of side
effects, cost, comorbidity, patient/family
preference, preferred route of
administration, availability of medications,
current metabolic profile, past history of
compliance, treatment resistance
Figure 1: Initial evaluation and management plan for schizophrenia
consultation with patients, caregivers and other members OPTIONS FOR MANAGEMENT OF BIPOLAR
involved in the treatment team. Treatment plans may be DISORDER
guided by the needs and be practical, feasible and flexible.
Further, the treatment plan is be re-evaluated from time to Treatment options for management of BPAD can be broadly
time and be modified as per the needs. classified as mood stabilizers, antidepressants, antipsychotic
medications, electroconvulsive therapy (ECT), adjunctive
CHOICE OF TREATMENT SETTINGS medications and psychosocial interventions [Table-2]. Use of
various treatment options is guided by the phase of illness
In general, most of the patients with BPAD are managed (mania/hypomania/depression/mixed) in which patient
on the outpatient setting. However, some patients may presents to the clinician and past treatment history.
require inpatient care. Whenever possible patient admitted
to the inpatient setting should have accompanying family PHARMACOLOGICAL MANAGEMENT OF
caregivers. In case inpatient care is required and such BIPOLAR DISORDER
facilities are not available, than the patient and/or family
need to be informed about the need for inpatient care and The mainstay of management of BPAD is mood stabilizers.
patient may be referred to the nearest available inpatient The available mood stabilizers include lithium, valproate,
facility and admission may be facilitated. lamotrigine, carbamazepine/oxcarbazepine and topiramate.

Lithium meq/litre and for prophylaxis range from 0.6 to 0.8 meq/
Lithium is the oldest mood stabilizer used in the management litre; however, few studies suggest that serum levels as low
of BPAD. It has been found to be efficacious in management as 0.4 to 0.8 meq/litre may be sufficient for prophylaxis,
of acute episode of either polarity and has been found to albeit are associated with higher risk of relapse. Once the
be efficacious in prevention or relapse of episodes of either dose is stabilized, patient may be shifted to once a day
polarity. Additionally, it has been shown to have a role in dose to reduce the side effects and improve the medication
prevention of suicide in patients with BPAD. compliance. Serum lithium levels may be monitored every
3-4 months. Renal function tests need to be monitored
Prior to starting lithium, history need to be reviewed for once in every 2-3 months during the initial 6 months of
the presence of physical illnesses like renal dysfunction, therapy and thyroid function tests need to be monitored
thyroid dysfunction and cardiac conduction abnormalities. once or twice during the first 6 months of treatment.
Additionally information needs to be reviewed for Later, renal and thyroid function tests may be monitored
presence of dermatological diseases. In case of women, once in 6 months to 1 year in clinically stable patients
last menstrual period is to be ascertained and if required and more frequently if so indicated (see table-3). Lithium
urine pregnancy test need to be done. Further, prior to is usually preferred in patients who have classical mania,
starting lithium, patients need to be educated about the bipolar depression, predominant polarity of illness is that
various side effects of lithium, use of salt-restricted diet and of depression, episodic course of illness, manic-depressive-
avoidance of medications (diuretics, angiotensin-converting euthymic course, non-rapid cycling course of illness, lack
enzyme inhibitors, non-steroidal anti-inflammatory drugs, of mixed episode, older age of onset for BPAD, presence
cyclooxygenase-2 inhibitors, etc.) which can increase of family history of BPAD and presence of family history of
serum lithium levels. Patients also need to be informed to lithium response.
avoid dehydration. Whenever lithium is started, it need to
be started in low doses, preferably in divided doses and Divalproex/valproate
the dose need to be titrated upwards with monitoring
Divalproex and its formulations (sodium valproate
of serum lithium levels. As steady state levels of lithium
and valproic acid) have been found to be useful in the
are achieved after about 5 days of starting lithium or dose
management of BPAD. It has been found to be efficacious
increment, the levels are be done after 5 days of start of
treatment or change in the dose. However, the levels may
be checked earlier if patient manifests features of toxicity. Table 3: Investigations prior to starting of lithium and
The serum levels of lithium, which are usually required for while monitoring lithium therapy
management of acute episode, are in the range of 0.6 to 1.0 Pre‑lithium evaluation
• Serum Urea, Creatinine
• Serum electrolytes
Table 2: Options for management for Bipolar disorder • Thyroid function test
Mood Stabilisers • May evaluate serum osmolality
• Lithium • May evaluate 24 hour urine volume, proteins, creatinine, osmolality
• Divalproex/valproate • May calculate the eGFR
• Carbamazepine/Oxcarbazepine • Haemogram
• Lamotrigine • Urine Pregnancy test (in case of women)
• Topiramate • Electrocardiogram
• Gabapentin • Fasting blood sugar
Antidepressants • Lipid Profile
• Tricyclics, Selective serotonin reuptake inhibitors, Serotonin and • Anthropometry‑ height, weight, waist circumference
nor‑epinephrine reuptake inhibitors, bupropion, mirtazapine, etc. Monitoring of lithium therapy
Antipsychotic medications • During the initial phase of illness, serum lithium levels must be done
• First‑generation antipsychotic medications (Oral/parenteral/depot or after 5 days of a stable dose.
long acting‑ preparations) • Sample for serum lithium levels must be taken 12‑14 hours after the last
• Second‑generation antipsychotic medications (Oral/parenteral/depot or dose of lithium
long acting‑ preparations) • If the medication is being given as BD or TID dose, the morning dose
Somatic treatments need to be withheld prior to collection of blood sample for serum
• Electroconvulsive therapy (ECT), transcranial magnetic lithium level
stimulation (rTMS), transcranial direct current stimulation (tDCS) Monitoring of side effects: at every visit enquire about polyuria/
Adjunctive medications polydipsia, gastrointestinal side effects; Check for tremor, dysarthria,
• Anticholinergics, antidepressants, benzodiazepines, hypnotic‑sedatives, ataxia
anticonvulsants, lithium carbonate Monitoring of serum lithium levels: Once the dose of lithium has been
Psychosocial interventions stabilized the serum levels must be done once in every 3‑4 months; more
• Social rhythm therapy, cognitive behavioural therapy, family frequent monitoring may be done in elderly and those receiving with
intervention, cognitive remediation, individual therapy, group therapy, concurrent medications like diuretics, and in those with renal impairment
social skills training, vocational rehabilitation Investigations to be repeated 6‑12 monthly as indicated: 24 hour urine
Other measures volume, urinary proteins, serum urea and creatinine, Thyroid function
• Lifestyle and dietary modifications tests, eGFR, S. Calcium

in management of acute mania and mixed episodes. The Table 4: Investigations prior to starting of valproate and
evidence for its efficacy in acute depression is not as robust while monitoring valproate therapy
as that for lithium. It is also efficacious in prevention of Pre‑valproate evaluation
mania and depression, when used during the maintenance • Haemogram
phase. As with lithium, prior to starting valproate, clinicians • Liver Function Test
need to review the medical history for presence of any • Urine Pregnancy test (in case of women)
• Fasting blood sugar
hepatic, haematological and bleeding problems. Prior • Lipid Profile
to starting of valproate, patient is to be educated about • Anthropometry
the side effects, especially about signs and symptoms of Monitoring of valproate therapy
hepatic and haematological dysfunction. They need to be Routine monitoring of haemogram and liver function test is not
instructed to report to the clinicians at the earliest if these recommended. May be done every 6‑12 monthly in patients receiving
long term valproate therapy
signs and symptoms emerge. Prior to starting valproate, it The therapeutic range for serum valproic acid level is 50‑100 µg/mL
is important to investigate the patient for liver function test Serum valproate levels during initial titration are to be done after 5 days
and haemogram. In young women, last menstrual periods of a stable dose.
need to be ascertained and if required urine pregnancy test When to collect the sample: sample may be collected after 12 hours in
case patient is receiving immediate release formulation, however, if the
need to be done to rule out pregnancy. As valproate is
patient is taking extended release formulation, blood sample need to be
associated with weight gain and metabolic abnormalities, it collected 21‑24 hours after the last dose to estimate the serum valproate
may be a good practice to evaluate the lipid profile, fasting levels
blood glucose levels and anthropometry (Table-4).
Usually valproate is started in low doses, i.e., 250 mg BD or Table 5: Investigations prior to starting of valproate and
250 mg TID and titrated upwards with monitoring of side while monitoring valproate therapy
effects and serum levels. However, some of the studies Pre‑Carbamezapine evaluation
have also evaluated rapid titration of valproate dose with • Haemogram
• Liver Function Test
initial dose of 20-30 mg/day and have shown that it is well • Urine Pregnancy test (in case of women)
tolerated. Maximum daily dose which is recommended is • Renal Function test
60 mg/day but most patients do not require such high doses. • Serum electrolytes (in case of elderly)
The usual therapeutic serum levels which are considered to • Fasting blood sugar
• Lipid Profile
be efficacious vary from 50 to 100µg/ml. Once the dose
• Anthropometry
of valproate is stabilized, the dosing schedule need to be Monitoring of carbamazepine therapy
changed to OD or BD dosing to reduce the side effects and • Monitoring of haemogram including platelet counts and liver function
improve compliance. In case OD dosing is given, extended test need to be done every 2 weekly during the initial 2 months of
release formulation may be used. However, it is important treatment
• After first 2 months: if no abnormalities are noted during the first
to remember that the bioavailability of extended release
2 months, than the Haemogram and liver function tests may be done
formulations is about 15% less than the immediate release every three monthly.
preparations and the dose is to be increased accordingly. • The therapeutic range for serum carbamazepine level is 4‑12 µg/ml
Serum valproate levels are to be done after 5 days of starting • Serum carbamazepine levels during initial titration are to be done after
or increase in the dose of valproate. The sample need to 5 days of a stable dose.
When to collect the sample: sample may be collected after 12 hours of
be collected after 12 hours in case patient is receiving
the last dose
immediate release formulation, however, if the patient is
receiving extended release formulation, the sample may be
collected after 21 to 24 hours (table-5). There is evidence relapse of depression. However, the most dreaded side
to suggest that patients with BPAD-II, dysphoric or mixed effect of lamotrigine includes skin rash, including Stevens
mania, rapid cycling affective disorder, stable episode - Johnson syndrome and toxic epidermal necrolysis.
frequency, later age of onset of illness, shorter duration of The skin lesions can occur any time during the therapy,
illness, long and severe course of illness respond well to but are more often reported during the initial phase of
valproate. Other indicators for good response to valproate treatment and when used along with valproate. Evidence
include presence of comorbid alcohol use disorder, mental suggests that the risk of skin rash can be reduced by
retardation, anxiety and panic attacks, post-traumatic stress slow upward titration of the dose. Accordingly, while
disorders, marked sleep disturbances, explosive dyscontrol considering lamotrigine, patients need to be informed
and aggression and comorbid migraine. about the possibility of rash and told to contact the
treating psychiatrist in case rash is seen. When the rash
Lamotrigine is more widespread, diffuse and associated with systemic
The role of lamotrigine in management of BPAD has been symptoms like fever or sore throat, lamotrigine may be
well studied now and it has been shown to be efficacious stopped. When initiated, lamotrigine may be started at
in management of bipolar depression and prevention of the dose of 25 mg/day for initial 2 weeks, then it may be

given at the dose of 50 mg/day during the 3rd and 4th week. valproate have been shown to be efficacious in prevention
After that 50 mg/day can be increased per week depending of relapse of both depression and mania. Antipsychotics
on the therapeutic response. like long acting risperidone, ziprasidone have been shown
to be beneficial in prevention of mania as monotherapy or
Carbamazepine as adjunctive medications to lithium or valproate.
Carbamazepine has been shown to be efficacious in the
management of acute bipolar mania and prevention of Combination therapy
relapse. Prior to starting carbamazepine, clinician needs There is evidence to suggest that when lithium or valproate
to focus on the history of blood dyscrasias and hepatic is combined with antipsychotics in the management of acute
dysfunction. When carbamazepine is considered, patients mania, the efficacy is higher and the onset of action is faster
need to be informed about the signs and symptoms of than that reported for single agent. Accordingly, depending
hepatic dysfunction, haematological dysfunction and skin on the severity of mania, combinations may be used.
reactions and told to report to the psychiatrist if these
symptoms emerge. Baseline investigation prior to starting Electroconvulsive Therapy (ECT)
of carbamazepine may include complete haemogram, liver There is evidence for use of ECT in the management of acute
function tests and renal function test (Table-5). When used mania, mixed episode and bipolar depression. Indications
in elderly serum electrolytes may also be done, in view of the for use of ECT are shown in Table-6.
risk of hyponatremia. Usual starting dose of carbamazepine
is 200 mg/day given in divided doses and titrated upward Benzodiazepines
slowly. Once the dose of 800-1000 mg/day is reached the Studies have evaluated the efficacy of adds-on
increment of dose may be slower and the usual maintenance benzodiazepines like clonazepam and lorazepam to lithium
dose is about 1000 mg/day, but it can vary from patient to and current level of evidence suggests that the antimanic
patient and may be 200 to 1600 mg/day. The carbamazepine properties of these agents are difficult to distinguish from
therapeutic drug levels have not been established in patients the sedative properties of these agents. Accordingly, these
with BPAD and the serum levels of 4-12 µg/ml, which is agents are considered to be adjunctive agents, which may
recommended for seizure disorders is commonly used. As be useful in management of acute episode. Further, there is
with lithium and valproate the serum levels need to be done evidence to suggest the beneficial role of lorazepam in the
after 5 days of initiation of treatment or increment of dose. management of agitation and catatonia.
Other anticonvulsants Other agents

There is lack of data in the form of double blind randomized Many other medications like calcium channel blockers,
controlled trials for Oxcarbazepine, but small open label zonisamide, levetiracetam, acamprosate, omega-3 fatty
studies suggests that it may be of some benefit as monotherapy acids, allopurinol etc, have been evaluated in small sample
or add-on therapy in patients with refractory mania. The data size trials as monotherapy or add on agents. However,
from open label studies suggest the usefulness of add-on available the evidence is not sufficient to recommend these
therapy with topiramate in patients with bipolar depression. medications as first line agents in management of bipolar
Studies which have evaluated the role of gabapentin in mania and depression.
management of mania have yielded negative results.
Antidepressants
Antipsychotics Conventionally antidepressants have been used in the
Over the last decade or so, many large multicentric double management of bipolar depression. However, over the last 2
blind placebo controlled and active comparator randomised decades or so, use of antidepressants in patients with bipolar
controlled studies have evaluated the role of various atypical
antipsychotics like olanzapine, quetiapine, aripiprazole, Table 6: Possible indications of use of ECT in patients of
risperidone, paliperidone, amisulpiride, asenapine, schizophrenia
ziprasidone and haloperidol etc. in the management of
• Bipolar depression not responding to adequate pharmacotherapy
bipolar depression, bipolar mania and for maintenance • Bipolar mania not responding to adequate pharmacotherapy
phase treatment. Data from these studies suggest that • Catatonic symptoms
antipsychotics like olanzapine, quetiapine, aripiprazole, • Need for rapid control of symptoms
risperidone, paliperidone and ziprasidone are effective in • Presence of suicidal behaviour which puts the life of the patient at risk
• Presence of severe agitation or violence which puts the life of others at risk
the management of acute mania. There is evidence for use
of quetiapine monotherapy, and olanzapine and fluoxetine • History of good response in the past
combination in the management of bipolar depression. • Augmentation of partial response to pharmacotherapy
There is evidence for lurasidone in the management of acute • Not able to tolerate pharmacotherapy
episode of bipolar depression. Olanzapine and quetiapine • Treatment resistant illness
• Episodes of severe depression or mania during pregnancy
monotherapy or as adjunctive medications to lithium or

depression has emerged as a controversial topic in view of Table 7: Basic components of Psychoeducation
the risk of antidepressant-induced manic/hypomanic switch. • Assessing the knowledge of the patient and caregivers about aetiology,
Evidence from metanalysis suggests that use of antidepressants treatment and prognosis
along with mood stabilizers is superior to use of combination • Introduction of diagnosis
of a mood stabilizer and a placebo and is not associated with • Discussing the symptoms of depression, mania, hypomania and mixed
episodes
increased risk of manic switch. Most of the studies which • Providing information about aetiology
have not found adds-on antidepressants to be beneficial • Dealing with day today stress
have involved paroxetine, hence, if one want to avoid use of • Providing information about the importance of stress management and
an antidepressant, paroxetine is to be avoided. Among the regular habits
various antidepressants, bupropion has been reported to be • Providing information about available treatment options, their efficacy/
effectiveness, side effects, duration of use
associated with lowest risk of antidepressant induced switch. • Discussing about importance of medication and treatment compliance
However, it is important to remember that antidepressants • Providing information about possible course and long term outcome
should not be used as monotherapy, and in those with rapid • Discussing about problems of substance abuse, marriage and other issues
cycling affective disorder and mixed episodes. • How to detect early signs of relapse
• Discussing about Communication patterns, problem solving, disability
benefits
Adequate trial • Discussing about relapse and how to identify the early signs of new
The minimum recommended duration of treatment to episodes
consider it to be an effective trial for an acute manic episode • Improving insight into illness
is about 3-4 weeks. In case of bipolar depression, a 6 weeks • Handling expressed emotions and improving communication
trial is considered as an adequate trial.
• Advise for lifestyle and dietary modifications
NON-PHARMACOLOGICAL MANAGEMENT OF
BIPOLAR DISORDER Interpersonal and social rhythm therapy (IPSRT)
This therapy is based on the theory that circadian rhythms in
Psychosocial management as an adjunct to pharmacotherapy patients with BPAD are vulnerable to external factors and any
has been shown to be of significant benefit during disruption of circadian rhythms can precipitate an episode.
the management of acute phase of bipolar depression Accordingly, it emphasizes on regularizing the social rhythms
and maintenance phase of illness. Among the various or routine of the patient and improving the interpersonal
psychosocial interventions, data supports the use of relationships of the patients so that they can derive more
psychoeducation (individual and group), interpersonal and satisfaction in their social roles. The basic aim is to teach the
social rhythm therapy (IPSRT), cognitive behaviour therapy patient as to how they can prevent the development of a new
and family focused intervention. These psychosocial episode (Table-8). Patients are informed that new episodes
interventions have been shown to be associated with can be precipitated by poor medication adherence, stressful
reduced risk of relapses, better functioning and better life events and disruption of social rhythms. Patients are
treatment adherence. The basic components of all these provided with skills as to how they can address interpersonal
programs involve informing the patients about their illness, problems and issues in the social roles. They are also advised
identifying the early signs of relapse, handling stress, to maintain a regular daily routine and pay attention to the
maintaining social rhythms, addressing the interpersonal day to day stresses which can influence their daily routine
issues and expressed emotions, problem solving and and how they can minimize the impact of these day to day
enhancing medication and treatment adherence. stressors on their daily routine.
Psychoeducation for patients and or family (Table 7) Cognitive Behaviour therapy

Psychoeducation may be considered both for the patient Cognitive behaviour therapy (CBT) has been shown to be
and family members (Table 7). The aim is to be to efficacious in the management of bipolar depression and
educate the patient and family about the illness. They during the maintenance phase of treatment. The basic
may be provided simple explanations about the nature goals of CBT is to educate the patient about the illness,
of the illness, treatment options, possible side effects of teaching them cognitive behavioural skills for coping with
medications and likely length of treatment etc. Caregivers their illness and psychosocial stressors and problems
may also be provided with an opportunity to vent out their arising out of the same, enhance medication and treatment
feelings and distress. Psychoeducation may also address compliance, monitor the symptoms to prevent relapse.
the important issue of treatment adherence and identifying
early signs of new episode. It is important to remember that Family focused interventions
psychoeducation is not a onetime event and prior to every Family forms an integral part of treatment in Indian setting.
session, feedback of the previous sessions may be taken They are involved in treatment decision making, supervision
and psychoeducation need to be tailored to the needs of of treatment and monitoring of treatment. However, family
the patient and the caregivers. members can also contribute to relapse due to constant

criticism, poor supervision or over-involvement. High Table 8: Basic components of Interpersonal and social
expressed emotion leads to increased risk of relapse and rhythm therapy (IPSRT)
poor outcomes. Studies have shown that family focused Goals
interventions can reduce the chances of relapse, improve • Stabilize daily routines and sleep/wake cycles
medication adherence and reduce the frequency of • Understand the bi‑directional relationship between moods and
depressive episodes. Family focused interventions help interpersonal events
• Minimize or remove the interpersonal problems related to grief, role
the relatives and patients to integrate the experiences transitions, role disputes, interpersonal deficits
associated with mood episodes, acknowledging the Administered in 4 steps
vulnerability of having future episodes, accepting the Step‑1
need to continue with medications, educating the family • Give rationale for IPSRT
• History taking with special focus on understanding the relationship of
about the difference in patients personality and BPAD,
episodes with interpersonal problems and social routine
recognising and coping with stress and establishing a • Assess the patient’s current and past interpersonal relationships
functional relationship (Table-9). • Educating the patient about bipolar disorder
• Identify interpersonal problem areas to focus, for example grief, role
Advise for life style and dietary modifications transition, role dispute
• Agree on a topic to discuss
As it is well known that patients with BPAD are at increased
• Initiating the Social Rhythm Metric (i.e., quantify daily rhythms of life)
risk for cardiovascular mortality and develop metabolic Step‑2
side effects due to use of psychotropic medications, all • Help the patient to establish a regular daily routine and resolve
the patients need to be advised about life style and dietary interpersonal problems
measures to reduce the risk of metabolic side effects and • Analyse the communication patterns, identify the problematic
communication patterns, suggesting alternative communication
cardiovascular morbidity and mortality. These include methods, role play
physical exercises, dietary modifications and abstinence • Maintaining social rhythms
from smoking, alcohol and other substances etc. Step‑3
• In the continuation or maintenance phase encourage the patient to use
Rehabilitation the skills learned in the previous phases of IPSRT
Step‑4
Rehabilitation programmes may be culturally moulded and • Termination
adapted to the needs of patients and their families.
Treatment adherence Table 9: Basic components of Family focused

Mediation and treatment adherence is very important for interventions
management of patients with BPAD. Available evidence • Assessment of family
suggests that 20-60% of the patients with BPAD become • Psychoeducation about symptoms, early recognition, etiology, treatment,
adherence
non-compliant with medication and drop out of treatment.
• Communication skills training ‑ behavioral rehearsal of effective speaking
Hence, all efforts need to be made to enhance the medication and listening strategies
compliance and treatment adherence. Measures which can • Accepting that patient is vulnerable for having future episodes
help in improving the compliance are given in table-10. • Able to differentiate between patient’s personality and bipolar disorder
• Recognising and coping with stress
• Problem‑solving skills training
MANAGEMENT OF DIFFERENT PHASES OF
• Establishing and maintaining a functional relationship
BIPOLAR DISORDER
Management of BPAD will depend on the phase of illness Table 10: Measures which can improve medication
in which patient presents to the clinician, i.e., bipolar compliance
depression, bipolar hypomania/mania, first episode • Explain when and how often to take medicines
hypomania/mania, mixed episode or clinical remission. In • Preferably give once a day dosing
addition to the phase of illness, factors which may help • Prescribe minimum number of tablets and medications
• Always ask the patient about kind of formulation (e.g. tablet, capsule etc)
in deciding about the pharmacological agent include past which they would prefer to take
history (number of episodes, type of episodes), comorbidity • Check the whole prescription to avoid duplication of medication
(comorbid psychiatric/physical disorders, substance • Explain the patient/family that the beneficial effect will be seen only after
dependence disorder), past treatment history (response, days to weeks of intake of medications.
side effects) and clinical course (rapid cycling), associated • Explain the patient the need to take medication even after feeling better
• Explanation of side effects- If patients ask about the side effects, explain
symptoms (presence of psychotic symptoms) etc. In general the patient about the same.
based on the level of evidence, various pharmacological • Explain the patient as to what to do‑ if they encounter side effects
treatments are categorised as first line agents, second • Encourage the patient to report side effects
line agents and third line agents. Selection of an agent • The need to consult with psychiatrist before discontinuing medications on
their own
on the basis of current polarity and past history can be of

benefit, as in most cases, same agent is continued in the Table 11: Management in the acute phase
maintenance phase. •Comprehensive assessment (psychiatric (including alcohol and
substance)/medical/psychosocial)
The basic principles of management in the acute phase • Discontinue antidepressants if indicated (patient exhibiting hypomanic/
are shown in Table-11. Clinicians may focus on carrying manic/mixed symptoms)
• Deciding on goals of treatment
out a comprehensive assessment (psychiatric/medical/ • Patients
psychosocial), decide about the treatment goals, ensure - Eliminate/reduce symptoms of phase of illness in which patient presents
safety of the patient and others, decide about the treatment with and improve the level of functioning
setting, decide about the choice of medication in liaison - Promote safety, reduce risk of harm, and reduce stress
with the patient and the family by taking into account • Caregivers
- Minimise caregiver distress
the clinical and treatment related factors and institute - Offer help to enable them to cope with the illness in their relative
psychosocial interventions at the earliest so as to provide • Both
comprehensive management. If patient is using alcohol or - Develop a therapeutic alliance and provide opportunities for patients and
other illicit substance, all efforts are to be made to stop - Caregivers to actively engage in treatment
the same. Similarly, if a patient is on antidepressants and - Offer basic information and support tailored to needs of patients and
caregivers
presents with hypomanic/manic or mixed symptoms, these • Choice of treatment setting
need to be stopped immediately. Some of the indicators of • Choice of medication
inpatient care are shown in Table-12. - Type and severity of current episode
- Type of past episode (s)
All treatment decisions need to be made in consultation - Predominant polarity
- Past treatment history‑ response, side effects, compliance
with the patient and or family members and need to be • Use of adjunctive medications when indicated
documented. Whenever mood stabilizers are used, the • Use of ECT when indicated
required investigations need to be done prior to starting • Psychosocial interventions
of mood stabilizers, patient’s serum levels of medications • Planning for further treatment‑ Pharmacoprophylaxis
are to be monitored and other investigations need to be
repeated from time to time as indicated for various mood
Table 12: Some indications for inpatient care during
stabilizers.
acute episodes
Mania/mixed
The evidence for efficacy of various agents in management of • Presence of severe agitation or violence which puts the life of others at
different phases of illness (mania, depression, maintenance risk
phase) vary and it is important to be aware of the same. • Presence of general medical or comorbid psychiatric conditions that
Table-13, provides an update on the available level of make outpatient treatment unsafe or ineffective
evidence for different phases of illness. • Patient not responding to a combination of first line agents
• Treatment‑refractory mania/mixed episode
Depression
MANAGEMENT OF HYPOMANIA/MANIA/ • Presence of suicidal behaviour which puts the life of the patient at risk
MIXED EPISODE • Presence of severe agitation or violence which puts the life of others at
risk
The goal of management in mania/mixed episode is to • Refusal to eat which puts the life of patient at risk
• Severe malnutrition
control the aggression, agitation and disruptiveness of • Patient unable to care for self to the extent that she/he requires constant
patients at the earliest. Depending of the severity of supervision or support
symptoms, inpatient care may be considered. If patient is • Catatonia
on antidepressants then this is to be stopped immediately. • Presence of general medical or comorbid psychiatric conditions that
make outpatient treatment unsafe or ineffective
• Patient not responding to a combination of medications
In terms of pharmacological management, first line agent
for management of mania may involve use of lithium or
valproate, olanzapine, haloperidol, quetiapine, aripiprazole, Among these agents, lithium is thought to have slower onset
risperidone, paliperidone or ziprasidone as monotherapy. of action. Accordingly, it can be said that if the mania is
Typical antipsychotics like haloperidol, trifluoperazine and less severe, monotherapy be considered. However, if mania
chlorpromazine have also been used in the Indian scenario. is severe and associated with significant disruption than
These are very useful in the management of irritability,
combination therapy need to be considered. Use of adjunctive
aggression, impulsivity and psychotic features. However,
these are associated with high incidence of extrapyramidal benzodiazepines for short duration may be required.
reactions. However, there is some evidence to suggest that Patients who refuse medications and are unmanageable may
combining lithium or valproate with an antipsychotic may be be given depot antipsychotics like risperidone, paliperidone,
more effective than any of these agents when used alone. olanzapine or a depot of typical antipsychotic medication.

Table 13: Comparison of several monotherapy and combination Pharmacotherapies for bipolar disorders
Bipolar Mania Bipolar Depression Mixed episodes Prevention of Prevention of
relapse of depression relapse of mania
Monotherapy
Lithium (Li) √ √ √ √ √
Valproate (V) √ @ √ √ √
Lamotrigine (L) X √ NA √ X
Carbamazepine (C) @ ? X @ @
Oxcarbazepine (O) ? NA NA NA NA
Topiramate (T) X X NA X X
Gabapentin X NA NA X X
Olanzapine (OLZ) √ ? ? √ √
Quetiapine (Q) √ √ NA √ √
Asenapine (ASP) √ NA NA NA ?
Aripiprazole (ARP) √ X ? X √
Risperidone (R) √ NA √ NA @
Paliperidone √ NA ? NA @
Haloperidol @ NA NA NA
Ziprasidone √ X ? NA @
Chlorpromazine ? NA NA NA NA
Clozapine ? NA NA NA NA
Cariprazine NA ? NA NA NA
Lurasidone NA @ NA NA NA
Combination
Li + V √ √ √ √ √
Li + OLZ √ NA NA ? √
Li + R √ NA NA NA √
Li + L NA @ NA NA NA
Li + C NA ? NA NA NA
Li + SSRI NA √ NA NA NA
Li + Venlafaxine NA ? NA NA NA
(Li/V) + ARP ? X NA NA NA
(Li/V) + ASP ? NA NA NA NA
(Li/V) + (Q/ARP/Z) NA NA NA NA √
V + OLZ NA NA ? NA NA
V + SSRI NA √ NA NA NA
OLZ + SSRI NA √ NA √ NA
OLZ + C X NA NA NA NA
R+C X NA NA NA NA
L+Q NA ? NA NA NA
√ – Established efficacy; @ – Efficacy not Established clearly; X – Established that not useful; ? – Evidence limited to open label studies; NA – Evidence not available
If a patient comes with a ‘breakthrough’ hypomanic/manic of patient and family and family focused intervention be
episode, then the first step in the management involves started at the earliest. Psychosocial interventions like CBT
optimization of the ongoing agent. The optimisation can be or IPSRT, focused specifically on the patient, should be
done by monitoring the serum levels of agents like lithium considered when patient is cooperative.
and valproate. If required, additional antipsychotics and
benzodiazepines may be used, depending upon severity of MANAGEMENT OF BIPOLAR DEPRESSION
the episode.
The main goal of management is to achieve euthymia,
If the first-line agent used in optimal dose fails (lack of normal level of functioning and to avoid switching to
significant clinical benefit after 2 weeks of use), another hypomanic/manic episode. Among the various mood
first line agent need to be added to the ongoing treatment. stabilizers, there is ample evidence to suggest that lithium
Alternative strategies may include changing lithium to and lamotrigine may be used as the first line medications in
valproate or vice versa, changing to carbamazepine, adding the management of bipolar depression.
antipsychotic medication if not used earlier, changing
the antipsychotic if used earlier. ECT may be considered If the patient presents with a breakthrough episode, the
if patient is very disruptive, not responding to a trial of initial strategy is to check the medication compliance and
combination of medications, has history of good response ensure adequate compliance. If compliance is not an issue,
to ECT in the past, pregnancy and those experiencing mixed initial strategy is to optimise the mood stabilizer which the
episode. Psychosocial interventions like psychoeducation patient is already getting.

If the patient is not on any mood stabilizer, than lithium or Table 14: Risk factors for Rapid Cycling Affective
lamotrigine may be considered. Among the antipsychotics, Disorder
data suggests that quetiapine monotherapy may also be Risk factors for RCAD
beneficial. There is evidence for use of olanzapine and • Hypothyroidism
fluoxetine combination too. If the patient does not respond • Long term aggressive use of antidepressants
• Comorbid substance use
to monotherapy with mood stabiliser or antipsychotics,
• Minor tranquilizer/stimulant or caffeine abuse
combination of these agents with antidepressants may • Cyclothymic and hyperthymic temperament
be considered. Use of antidepressants without the use of • Female gender
concurrent mood stabilizer or an atypical antipsychotic is • Menopause
to be avoided. Benzodiazepines may be used as per the • Temporal lobe dysrhythmias
• Several episodes/stressors as an effect of kindling
need. Psychosocial intervention in the form of CBT may also
• Onset of illness as depression
be considered when the depression is of mild to moderate • Frequent and more depressive episodes
severity. ECT may be considered, if depression is severe, • ? COMT/BDNF gene abnormality
in presence of suicidality, risk of harm to others, catatonic • ? Biological rhythm disturbances like wakefulness, light exposure
symptoms, psychotic symptoms, patient is pregnant, when
use of various psychotropics is limited due to concurrent side effects. Long acting risperidone has been shown to
medical illnesses. There is preliminary evidence to suggest be beneficial in prevention of recurrence. Lamotrigine has
the beneficial effect of transcranial magnetic stimulation been shown to be efficacious in prevention of depressive
and direct cranial stimulation. episodes, but not for prevention of manic episodes.
Olanzapine, aripiprazole, ziprasidone and asenapine has
RAPID CYCLING AFFECTIVE DISORDER been shown to be of benefit in prevention of recurrence
of manic episodes, but not for depressive episodes.
Rapid cycling affective disorder (RCAD) is Carbamazepine has also been shown to be effective in
characterised by having 4 or more episodes prevention of recurrence; however, it is less preferred
(depression/mania/hypomania/mixed) in a single year. compared to lithium and valproate because of its side effect
These episodes should be separated from each other by profile and drug interactions. Studies have also evaluated
partial or full remission for at least 2 months or a switch the efficacy of lithium and valproate in combination with
to an episode of opposite polarity. Many risk factors various antipsychotics. Besides use of pharmacotherapy,
(Table-14) have been identified for development of there is evidence to suggest the beneficial role of adjunctive
RCAD. Accordingly, the first step in the management of psychosocial intervention in the management of BPAD.
RCAD is to evaluate the patients for underlying medical Maintenance ECT may also be considered in patients who
conditions which may be contributing to the RCAD. Among have responded to ECT during their acute episodes.
medications, use of antidepressants has been shown to
increase cycling. The general principle of management during the
maintenance phase of treatment is to continue the
In terms of psychotropics, there is evidence to suggest that medication started during the acute phase of illness.
lithium or valproate may be used as the first line agents. Accordingly, while selecting the agent during the acute
Other mood stabilizers which can be considered include episode, clinicians may take into consideration the patient’s
lamotrigine. If patient does not respond to monotherapy, preference, clinical factors which may influence the long
then combination of mood stabilizers or a combination term outcome, recurrence of episodes and side effects.
of mood stabilizer and antipsychotic medication may be If the patients have more manic episodes then one may
considered. prefer lithium, valproate or carbamazepine while for more
depressive episodes one may consider Lithium, lamotrigine
MAINTENANCE TREATMENT FOR BIPOLAR or quetiapine. In severe cases, combination of lithium and
DISORDER valproate may be considered.
The primary goal of maintenance treatment is to prevent the It is important to note that patients with mood disorders are
recurrence of episode of either polarity, reduce/eliminate more vulnerable to extrapyramidal side effects like tardive
the residual symptoms and improve the overall functioning dyskinesia with long term use of antipsychotics, especially
of the patient. In terms of pharmaco-therapeutic agents, best typical antipsychotics. Patients who have been treated with
evidence for maintenance treatment is available for lithium a combination of lithium and antipsychotic or valproate and
and valproate. In recent years evidence has also emerged for antipsychotic medication, the need for continued use of
use of olanzapine and quetiapine in prevention of recurrence antipsychotic need to be reassessed on the basis of longitudinal
of both depressive and manic episodes. However, these may course. Similarly, stoppage of antidepressants needs to be
be avoided because of associated higher risk of metabolic considered once bipolar depression remits. Combination

Bipolar Hypomania/Mania/Mixed Episode
Currently on treatment (Breakthrough Currently not on treatment

episode/switch in presence of First line therapy:
antidepressants) • Monotherapy: Lithium, valproate, antipsychotics
• Stop antidepressant- if patient • Combination: Lithium+ antipsychotic/
is getting the same valproate+antipsychotic
• Optimize the dose of the mood • Use Benzodiazepines as per the need
stabilizer which the patient is on • Use of depot antipsychotic may be considered
• If the symptoms do not respond if patient is not willing to take oral medications
to optimisation of the dose or are • ECT: may be considered with monotherapy or
severe, consider adding an combination therapy as per the indication
antipsychotic medication
• Benzodiazepines may be used
depending upon the need
Failure of adequate trial of
first line treatment
Second line therapy:

Monotherapy: Change lithium to lamotrigine or vice
versa
Combination:
• Add antipsychotic if not used
Failure of adequate trial of • Change from Lithium+ antipsychotic to
first line treatment valproate+antipsychotic medication
• Change from Valproate+antipsychotic to
lithium+antipsychotic medication
• Continue lithium/valproate and change the
antipsychotic medication
• Consider changing lithium/valproate to carbamazepine
• Use Benzodiazepines as per the need
• Use ECT if not considered earlier
• Consider clozapine if mania is treatment refractory
• Consider other agents
Figure 2: Management of Hypomania/ Mania/Mixed Episode
therapy during the maintenance phase is to be considered guidelines for schizophrenia. The recommendations made for
only for those who have not responded to the optimal dose of monitoring of metabolic side effects associated with various
monotherapy during the maintenance phase of illness. atypical antipsychotics may also be followed in patients with
BPAD, if long term antipsychotic medications are considered.
SPECIAL SITUATIONS
Use of lithium is associated with multiple side effects. These
Clinicians often encounter certain clinical situations which side effects can be classified on the basis of occurrence (i.e.,
either require special attention or can influence treatment
those occurring during the early or late phase of treatment)
decisions. Management of these situations is summarised
and frequency (Common, uncommon, rare and very rare)
in table-15.
(Table-16). Most of these side effects can be managed with
SIDE EFFECTS AND THEIR MANAGEMENT reduction in dose of medication or shifting to a sustained
release preparation as the first line strategy.
Various classes of psychotropic medications used for the
management of BPAD are associated with many side effects, The common management strategies for the side effects
which require intervention. The side effects associated associated with lithium, valproate and carbamazepine are
with antipsychotics are discussed in the clinical practice shown in Table-17.

Bipolar Depression
Already on treatment Not on treatment
Valproate, Lithium First line therapy:

Olanzapine, Lamotrigine • Monotherapy/combination: Lithium, lamotrigine,
Risperidone, Antipsychotics quetiapine, olanzapine-fluoxetine combination,
other valproate+lithium, valproate+ antidepressant
atypicals • Combination: mood stabiliser/antipsychotics+
antidepressant
• Psychosocial intervention: if depression is
mild to moderate
• ECT: may be considered with monotherapy or
combination therapy as per the indication
Optimise the Optimise the
dose dose
• Add antidepressant – bupropion, SSRI

• Add or change to lithium, lamotrigine or quetiapine
• Consider changing from one agent (lithium/lamotrigine/quetiapine) to other
• Consider Valproate along with lithium or antidepressant
• Consider combinations
• Consider psychosocial intervention if the depression is mild to moderate
• Consider ECT as per the indication
• Consider rTMS, tDCS
Figure 3: Management of Bipolar Depression
Table 15: Issues related to special situations

Special Strategies
situation
Suicidality • Risk of suicide is high in patients with BPAD.
• Suicidal behaviour is seen during the depressive episode, mixed episode and also in manic episode. Suicide have also been reported
during the euthymic phase
• Clinicians need to carefully evaluate the patients for suicidal ideations, plans, suicidal attempts at every follow‑up.
• High risk management be instituted and inpatient management may be considered if the patient is at high risk.
• Psychoeducation of patient and family need to focus on discussing about warning signs of suicide. Patients experiencing severe distress
due to a feeling of loss, stigma etc., are to be provided psychological support and monitored closely.
• Use of lithium has been shown to lower the risk of suicide.
• ECT is an important therapeutic option in patients at high risk of suicide during an acute episode.
Catatonia • Catatonic features may be seen in both depressive and manic phase of illness.
• Whenever a patient with BPAD presents with catatonia, all possible differential diagnosis for catatonia need to be considered.
• Investigate to rule out organic cause (s).
• Initial management may involve use of benzodiazepines, especially lorazepam, which leads to symptomatic relief in significant proportion of cases.
• In case the catatonia does not respond to benzodiazepines or relapse after stopping benzodiazepines, ECT is to be considered.
Psychotic • Psychotic symptoms are seen in a significant proportion of patients with BPAD.
features • When present, use of antipsychotics is warranted.
Violence and • All patients, especially those in mania need to be evaluated for violence and dangerousness during every assessment, especially during
Aggression the acute phase of illness.
• Whenever a patient is found to have serious threat for violence or exhibits violence, inpatient management may be considered.
• Injectable antipsychotics like haloperidol or lorazepam can be used for management of violence and aggression.
Comorbid • Substance use can precipitate an episode, increase the frequency of episode, may be associated with RCAD, higher risk for suicide, poor
Alcohol and response to treatment, longer time to achieve remission, can influence the choice of medication, lead to higher vulnerability for side effects.
Substance • Both BPAD and substance use disorders need to be treated concurrently.
use Disorders • Efforts need to be made to keep the patient abstinent from alcohol and other substance(s), both during the acute episodes and during the
maintenance phase of illness.
Comorbid • Patients of BPAD have high rate of comorbid anxiety disorders, ADHD etc.
Psychiatric • Comorbid disorders, may not be evident during the acute episodes. Accordingly, patients need to be evaluated during the maintenance
disorders phase for any kind of comorbid psychiatric disorders.
• Management of comorbid disorders need to be done along with concurrent management of BPAD.
Comorbid • Patients with bipolar disorder have high rate of physical comorbidities.
Physical • All patients need to receive thorough assessment for possible physical illnesses and depending on the feasibility may be investigated as
illnesses per the requirement.
• Those with comorbid physical illnesses are to be continuously monitored during all the phases of treatment.
• Comorbid physical illnesses and concomitant medications also need to be taken into account while selecting the treatment setting and
antipsychotic medication per se.
Contd...
Table 15: Contd...
Special Strategies
situation
Perioperative • When used during the perioperative period, lithium can contribute to hemodynamic instabilities, interfere with sodium and potassium
period metabolism, and the renal excretion of lithium can be reduced in presence of renal complications. Therefore it is recommended that
lithium need to be discontinued prior to surgery.
• Postoperatively, when the patient is hemodynamically stable, is able and allowed to drink, and is not on potentially interfering drugs, the
medication may be restarted gradually.
Pregnancy • Mood stabilizers, including lithium are considered to be teratogenic and associated with higher rate of congenital malformations.
• Pregnancy is to be planned.
• Whenever feasible, exposure to lithium, valproate, carbamazepine, lamotrigine need to be avoided during pregnancy. Hence, attempt
need to be made to discontinue these medications.
• If patient is not able to tolerate the discontinuation of medication, than the pros and cons of continuation of the medications during the
first trimester need to be discussed and documented.
• If required, lithium may be used during second and third trimester of pregnancy; Use the minimal optimal dose.
• If required, antipsychotics, especially high potency typical antipsychotics may be considered.
• Use folic acid during pregnancy.
• If patient is receiving mood stabilizer during the pregnancy – monitor alpha feto‑protein levels at 20 weeks.
Post‑partum • There is high risk of relapse during the post‑partum period.
& Breast • The new‑born be evaluated thoroughly, if the mother was on psychotropics during pregnancy for malformations, drug overdose and withdrawal.
feeding • Lithium need to be used with caution during the postpartum.
• When valproate is used during the post‑partum, liver function tests and haemogram of the neonate need to be monitored adequately.
Elderly • Have high rates of comorbid medical illnesses and substance use disorders.
• More sensitive to side effects of medications, at risk for fall and fracture of hip.
• May develop cognitive deficits with use of lithium or benzodiazepines.
• Start low and go slow.
Children & • Have high rates of comorbidity in the form of Attention‑hyperkinetic disorder (ADHD), conduct disorder, substance use disorders.
Adolescents • At times it may be difficult to distinguish between symptoms of mania and ADHD.
• Take longer time to stabilize.
• Data on use of lithium before 12 years of age is not available and use of lithium prior to this age is not recommended.
• Start at lower doses and titrate slowly.
MANAGEMENT OF TOXICITY Table 16: Side effects of lithium

Early onset side effects Common side effects
Among the lithium, valproate and carbamazepine, valproate Weight gain Short term dose related
has a wide therapeutic window. Lithium and carbamazepine Tremor Nausea, diarrhea, epigastric pain
toxicity may be fatal and are medical emergencies. The Anorexia, Nausea, Diarrhea Tremor
Aggravation of cutaneous Thirst, polyuria
therapeutic range for serum lithium levels varies from conditions Metallic taste
0.4 to 1.2 meq/litre. Toxic effects of lithium are usually Mild thirst Long term side effects
seen when the serum levels of lithium rise above 1.5meq/ Polyuria Weight gain
litre. When the levels exceed 2meq/litre, life threatening Late onset side effects Hypothyroidism in women
Nephrogenic diabetes insipidus Reduction in eGFR
side effects may emerge. Various signs and symptoms Hypothyroidism Tubular dysfunction
of toxicity with lithium, valproate and carbamazepine Thyroiditis Uncommon side effects
are shown in Table-18.Management of lithium toxicity Hyperthyroidism Fluid retention (oedema)
is an acute emergency and involves stoppage of lithium, Cognitive dulling Hypothyroidism
Rare side effects
maintaining the airways, maintaining an intravenous line
Acne
and use of haemodialysis if serum lithium levels are more Psoriasis
than 2.5 mEq/Litre. However, in patients with end stage Hair loss
renal disease, haemodialysis may be considered in levels Fatigue
below 2.5mEq/litre as well. Arrhythmia
Cognitive deficit
Seizures
Management of valproate toxicity also involve use of Sexual side effects
haemodialysis. However, there are no clear guidelines for Very Rare side effects
the same. Management of carbamazepine intoxication ↑WBC count
↑serum Ca++, Mg++
involves gastric lavage, hemoperfusion and use of supportive ↑ parathyroid hormone
measures. ↑blood sugar
Benign intracranial hypertension
Financial support and sponsorship Parkinsonism disease’s like
symptoms
Nil.

Table 17: Management of side effects of mood stabilizers

Side effects Management
Lithium
Dose‑related side effects: polyuria, polydipsia, weight gain, Reduce the dose and/or shift to once a daily dose of medications, if the side effects
cognitive problems (e.g., dulling, impaired memory, poor still persist than use other medications:
concentration, confusion, mental slowness), tremor, sedation Tremors: beta‑blockers
or lethargy, impaired coordination, gastrointestinal distress Polyuria, polydipsia, edema: diuretics
(e.g., nausea, vomiting, dyspepsia, diarrhoea), hair loss, benign Acne: Topical antibiotics, retinoic acid
leukocytosis, acne, and edema Gastrointestinal side effects: give lithium after meals, change to lithium citrate
Electrocardiogram (ECG) Changes Cardiac Side effects: Reduce the dose, if the abnormalities persist, may have to stop
lithium in consultation with the cardiologist depending on the severity of the cardiac
conduction abnormalities
Renal Side effects: Impaired concentrating capacity, interstitial Renal side effects: Diuretics for impaired concentrating capacity‑ thiazides, amiloride
fibrosis, tubular atrophy
Hypothyroidism Hypothyroidism: Not an indication for stopping lithium, add levothyroxine
Dermatological: Reduce the dose, appropriate dermatological treatment, if does not
respond then may consider stopping lithium
Psoriasis Inositol supplementation, TNF α inhibitors (Etanercept), Conventional treatment of
Psoriasis (Topical corticosteroids, Keratolytics, Vitamin D analogues, Oral retinoids,
Psoralen, Ultraviolet A (PUVA) therapy , Methotrexate)
May have to consider stopping lithium in treatment resistant cases of psoriasis
Valproate
Dose‑related side effects: Gastrointestinal distress (nausea, Resolve with reduction in dose, if persist, then
vomiting, diarrhoea etc), tremor, sedation, benign hepatic GI disturbances: change of preparation from Valproic acid to Divalproex,
transaminase elevations Proton‑pump blockers, Histaminic blockers
Tremors: beta‑blockers
Hepatotoxicity Discontinuation of valproate
Leukopenia, Thrombocytopenia Discontinuation of valproate
Hair loss, increased appetite, weight gain Dietary restriction for increased appetite and weight gain
Polycystic ovarian disease May have to discontinue valproate if other options are available, metformin
Hepatic failure, haemorrhagic pancreatitis, and Discontinuation of valproate
agranulocytosis
Carbamazepine
Ophthalmological: diplopia, blurred vision Reduce the dose
Gastrointestinal: nausea Reduce the dose
Neurological: ataxia Reduce the dose
Dermatological: skin rashes Reduce/Stop Carbamazepine
Haematological: leukopenia, thrombocytopenia Mild leukopenia may resolve on its own, in case of severe leukopenia, stop the
medication
Electrolyte imbalance: Hyponatremia May require discontinuation of carbamazepine
Endocrine: hypothyroidism May require addition of levothyroxine
Serious side effects: agranulocytosis, aplastic anemia, Stop Carbamazepine, manage the medical condition
thrombocytopenia, hepatic failure,
Stevens‑Johnson syndrome, pancreatitis
Table 18: Signs and symptoms of Toxicity of lithium, Table 18: Contd...

valproate and Carbamazepine Carbamazepine
Lithium levels 1.5‑2‑5 meq/litre Dizziness, Ataxia, Sedation, Nystagmus, Ophthalmoplegia, Cerebellar
Neurological: Fine tremors, Apathy, Fatigue, Muscle weakness, and extrapyramidal signs, Impaired consciousness, Seizures, Respiratory
Hyperreflexia, Incontinence, Gait disturbances depression, Stupor, Coma, Tachycardia, Arrhythmia, Cardiac conduction
Gastrointestinal: nausea, vomiting, diarrhoea disturbances, Hypotension
Cardiovascular changes: Bradycardia, T‑wave changes, sinoatrial block, AV
block
Lithium levels >2.5 meq/litre Conflicts of interest
Neurological: course tremors, slurring of speech, dysarthria, ataxia, There are no conflicts of interest.
hypertonia, spasticity, rigidity, myoclonus, seizures, stupor, coma,
permanent neurological deficits
REFERENCES
Gastrointestinal: nausea, vomiting, diarrhoea
Cardiovascular changes: bradycardia, T‑wave changes, sinoatrial block,
1. Merikangas KR, Jin R, He JP et al. Prevalence and correlates of bipolar
AV block, hypotension
spectrum disorder in the world mental health survey initiative. Arch Gen
Renal: Renal failure Psychiatry 2011; 68: 241–251.
Valproate 2. Sidor MM, Macqueen GM. Antidepressants for the acute treatment
Somnolence, Heart block, Coma of bipolar depression: a systematic review and meta-analysis. J Clin
Psychiatry 2011; 72: 156–167.
Contd.. 3. Grunze H, Vieta E, Goodwin GM, Bowden C, Licht RW, Möller HJ,

& Kasper S. The World Federation of Societies of Biological Psychiatry 23. De Berardis D, Marini S, Carano A, Padovan Lang A, Cavuto M, Piersanti M,
(WFSBP) guidelines for the biological treatment of bipolar disorders: Di Giannantonio M. Efficacy and safety of long acting injectable atypical
update 2012 on the long-term treatment of bipolar disorder. The World antipsychotics: a review. Current clinical pharmacology, 2013; 8(3),
Journal of Biological Psychiatry 2013; 14(3), 154-219. 256-264.
4. Yatham LN, Kennedy SH, Parikh SV, Schaffer A, Beaulieu S, Alda M, 24. Chou YH, Chu PC, Wu SW, Lee JC, Lee YH, Sun IW, Yen YC. A Systemic
Berk M. Canadian Network for Mood and Anxiety Treatments (CANMAT) Review and Experts’ Consensus for Long-acting Injectable Antipsychotics
and International Society for Bipolar Disorders (ISBD) collaborative in Bipolar Disorder. Clinical Psychopharmacology and Neuroscience,
update of CANMAT guidelines for the management of patients with bipolar 2015; 13(2), 121.
disorder: update 2013. Bipolar disorders; 2013;15(1), 1-44. 25. Joffe RT, MacQueen GM, Marriott M, Robb J, Begin H, Young LT. Induction
5. National Institute for Health and Care Excellence. Bipolar disorder: The of mania and cycle acceleration in bipolar disorder: effect of different
assessment and management of bipolar disorders in adults, children and classes of antidepressant. ActaPsychiatricaScandinavica, 2002;105(6),
young people in primary and secondary care. Draft for consultation, April 427-430.
2014. http://www.nice.org.uk/ 26. Thase ME, Sachs GS.. Bipolar depression: pharmacotherapy and related
6. American Psychiatric Association. Guideline Watch: Practice guideline for therapeutic strategies. Biological psychiatry, 2000; 48(6), 558-572.
the treatment of patients with bipolar disorder, 2ndedn. Washington DC: 27. Gijsman HJ, Geddes JR, Rendell JM, Nolen WA, Goodwin GM.
American Psychiatric Association; 2005. Antidepressants for bipolar depression: a systematic review of randomized,
7. Goodwin GM. Evidence –based guidelines for treating bipolar disorder: controlled trials. American Journal of Psychiatry 2014; 161: 1537-47.
revised second edition- recommendations from the British Association for 28. Henry C, Sorbara F, Lacoste J, Gindre C, Leboyer M.Antidepressant-induced
Psychopharmacology. J Psychopharmacol 2009; 23:346-388. mania in bipolar patients: identification of risk factors. Journal of Clinical
8. Cipriani Andrea, et al. “Comparative efficacy and acceptability of antimanic Psychiatry, 2001; 62(4), 249-255.
drugs in acute mania: a multiple-treatments meta-analysis.” The Lancet 29. TohenM, Vieta E, Calabrese J, Ketter TA, Sachs G, Bowden C,Breier
378.9799 (2011): 1306-1315. A. Efficacy of olanzapine and olanzapine-fluoxetine combination in the
9. Fountoulakis KN, Kontis D, Gonda X, Yatham LN. A systematic review of treatment of bipolar I depression. Archives of general psychiatry, 2003;
the evidence on the treatment of rapid cycling bipolar disorder. Bipolar 60(11), 1079-1088.
disorders; 2013; 15(2), 115-137. 30. McElroy SL. Prescribing antidepressants for bipolar depression: what
10. Rao PG. An overview of Indian research in bipolar mood disorder. Indian does the evidence say?.The Journal of clinical psychiatry, 2014; 75(9),
Journal of Psychiatry. 2010;52(Suppl1):S173-S177. e24-e24.
11. Avasthi A, Grover S, Aggarwal M. Research on mood stabilizers in India. 31. Silverstone T. Moclobemide vs. imipramine in bipolar depression: a
Indian J Psychiatry 2010;52, Suppl S3:355-61 multicentre double‐blindclinical trial. ActapsychiatricaScandinavica,
12. Grover S, Avasthi A, Sinha V, Lakdawala B, Bathla M, Sethi S, 2001; 104(2), 104-109.
Mathur D M, Kathuria P, Shah S, Baalasubramanian D S, Agarwal V, Deka 32. Nivoli AM, Colom F, Murru A, Pacchiarotti I, Castro-Loli P,
K. Indian Psychiatric Society multicentric study: Prescription patterns of González-Pinto A,Vieta E. New treatment guidelines for acute bipolar
psychotropics in India. Indian J Psychiatry 2014;56:253-64 depression: a systematic review. Journal of affective disorders, 2011;
13. Grover S, Avasthi A. Mood stabilizers in pregnancy and lactation. Indian J 129(1), 14-26.
Psychiatry 2015;57, Suppl S2:308-23 33. Vázquez GH, Tondo L, Undurraga J, Baldessarini RJ. Overview of
14. Tighe SK, Mahon PB, Potash JB. Predictors of Lithium Response in Bipolar antidepressant treatment of bipolar depression. International Journal of
Disorder. Therapeutic Advances in Chronic Disease. 2011; 2(3):209-226. Neuropsychopharmacology, 2013; 16(7), 1673-1685.
15. Cipriani A, Hawton K, Stockton S, & Geddes JR. Lithium in the prevention of 34. Schöttle D, Huber CG, Bock T, Meyer TD. Psychotherapy for bipolar
suicide in mood disorders: updated systematic review and meta-analysis. disorder: a review of the most recent studies. Current opinion in psychiatry,
BMJ. 2013; 346:f3646. 2011; 24(6), 549-555.
16. Malhi GS, Tanious M. Optimal frequency of lithium administration in the 35. Scott JAN, Paykel E, Morriss R, Bentall R, Kinderman P, Johnson T,
treatment of bipolar disorder: clinical and dosing considerations. CNS Hayhurst H. Cognitive–behavioural therapy for severe and recurrent
Drugs 2011; 25(4): 289-98. bipolar disorders. The British Journal of Psychiatry, 2006; 188(4),
17. Ng F, Hallam K, Lucas N, Berk M. The role of lamotrigine in the management 313-320.
of bipolar disorder. Neuropsychiatric disease and treatment, 2007; 3(4), 463. 36. Miklowitz DJ. A review of evidence-based psychosocial interventions for
18. Bowden, C. L., Asnis, G. M., Ginsberg, L. D., Bentley, B., Leadbetter, R., bipolar disorder. Journal of Clinical Psychiatry, 2006; 67, 28.
& White, R. Safety and tolerability of lamotrigine for bipolar disorder. Drug 37. Chanpattana W. Combined ECT and clozapine in treatment-resistant
safety, 2004; 27(3), 173-184. mania. J ECT 2000; 16:204-207.
19. Tränkner A, Sander C, Schönknecht P. (2013). A critical review of the 38. Devanand DP, Polanco P, Cruz R, Shah S, Paykina N, Singh K, and Majors
recent literature and selected therapy guidelines since 2006 on the use L: The efficacy of ECT in mixed affective states. J ECT 2000; 16:32-37.
of lamotrigine in bipolar disorder. Neuropsychiatric disease and treatment, 39. Mukherjee S, Sackeim HA, Schnur DB. Electroconvulsive therapy of acute
2013; 9, 101. manic episodes: a review of 50 years’ experience. Am J Psychiatry 1994;
20. Tohen M, Zhang F, Taylor CC, Burns P, Zarate C, Sanger T, Tollefson, G. A 151:169-176.
meta-analysis of the use of typical antipsychotic agents in bipolar disorder. 40. Ismail Shihabuddeen TM, Gopinath PS. Group meetings of caretakers
Journal of affective disorders, 2001; 65(1), 85-93. of patients with schizophrenia and bipolar mood disorders. Indian J
21. Gao K, Gajwani P, Elhaj O, Calabrese JR. Typical and atypical Psychiatry 2005;47:153-6.
antipsychotics in bipolar depression. The Journal of clinical psychiatry, 41. Durgam S, Starace A, Li D, Migliore R, Ruth A, Németh G, Laszlovszky I.
2005; 66(11), 1376-1385. The efficacy and tolerability of cariprazine in acute mania associated with
22. Gigante AD, Lafer B, Yatham LN. Long-acting injectable antipsychotics for bipolar I disorder: a phase II trial. Bipolar Disord. 2015;17:63-75.
the maintenance treatment of bipolar disorder. CNS drugs, 2012; 26(5), 42. Muneer A. The Treatment of Adult Bipolar Disorder with Aripiprazole: A
403-420. Systematic Review. Cureus. 2016 Apr; 8(4): e562.

Clinical Practice Guidelines for the Management of Generalised Anxiety

Disorder (GAD) and Panic Disorder (PD)
Shiv Gautam, Akhilesh Jain, Manaswi Gautam, Vihang N. Vahia, Anita Gautam
Participants of expert group on CPG for Generalised Panic Disorder- Episodes of intense fear or discomfort
Anxiety Disorder (GAD) and Panic Disorder accompanied by severe autonomic activity, palpitations,
sweating, dyspnoea, chocking sensation or other somatic
S.C Tiwari, Nilesh Shah, I.D. Gupta, B.N. Gangadhar, symptoms like chest pain, trembling, nausea, discomfort
Devendra Vijay Vergiya, Pratap Sharan or fluttering sensation in abdomen and impending fear of
death. Patient perceives it as a serious medical condition
and invariably reaches to a medical emergency setup where
INTRODUCTION
after thorough physical evaluation he is declared normal.
Short description of anxiety disorders
Phobias- Many patients with GAD suffer from irrational,
Generalized Anxiety Disorder (GAD)
unrealistic fears and acute autonomic reactions to certain
Definition: One of the anxiety disorders, where the primary
specific situations or extreme fear to certan inanimate objects.
symptoms of anxiety are present at most days for at least
They include agarophobia (fear of open spaces) fear of crowds,
several weeks at a time, and usually for several months. The
being out side home alone or traveling in a bus train or car.
symptoms should usually involve elements of:
Some may have fear in closed spaces (claustrophobia) fear of
(a) Apprehension (worries about future misfortunes,
heights (acrophobia) fear of opposite sex (hetero-phobia) fear
feeling “ on edge”, etc)
of sight of blood (erythrophobia) or fear of facing certain social
(b) Motor tension (restlessness, inability to relax, trembling)
situations (social anxiety disorder) the common feature among
(c) Autonomic over activity (light-headedness, sweating,
all phobias being intense fear, increased autonomic activity and
tachycardia, tachypnea, dry mouth etc)
avoidance behavior (avoiding the fearful object or situation).
The transient appearance of depressive symptoms, does
Obsessive compulsive disorder- (OCD) has been seperately
not rule out the diagnosis of GAD as main diagnosis. The
dealt with in details in these guidelines however the
sufferer must not meet the full criteria for depressive
patients suffering from OCD have recurrent repetitive
episode, phobic disorder, panic disorder or OCD.
unwanted intrinsic thoughts (obsessions) or actions
(compulsions) or both which lead to extreme distress, loss
Patients with generalised anxiety disorder have high anxiety
of time and impairment of functioning of the individual. The
and are worried about intrapsychic conflicts or external
obsessious include douts, ideas of contamination, sexual
environmental events. They have multiple somatic symptoms
thoughts or religious preoccupations or negative thoughts
of anxiety, restlessness, difficulty in concentration, irritability,
towards gods/goddess, the compulsions include activities
fatigue, muscular tensions and difficulty in sleeping
like counting, checking, repeating, washing hoarding
particularly early insomnia. They have vague apprehension
and touching objects, some have to and fro movements
about future events and fear of unknown. Common features
of body parts. Patient is aware of the irrationality of
observed in anxiety disorders include:
thoughts/actions but cannot control them, which produces
Address for correspondence: intense anxiety and autonomic arousal with feelings of
Dr. Shiv Gautam, Director Professor, Gautam Institute of helplessness and guilt.
Behavioral Sciences and Alternative Medicine, Jaipur.
E-mail: dr_shivgautam@yahoo.com This is an open access article distributed under the terms of the Creative
Access this article online others to remix, tweak, and build upon the work non-commercially, as long as the
Quick Response Code author is credited and the new creations are licensed under the identical terms.
Website: For reprints contact: reprints@medknow.com
How to cite this article: Gautam S, Jain A, Gautam M,

DOI:
Vahia VN, Gautam A. Clinical Practice Guidelines for the
Management of Generalised Anxiety Disorder (GAD) and
10.4103/0019-5545.196975
Panic Disorder (PD). Indian J Psychiatry 2017;59:67-73.

Gautam, et al.: CPG for GAD & Panic Disorder
Post-traumatic stress disorder (PTSD) - Usually it occurs after COMMON INGREDIENTS OF MANAGEMENT

a terrifying event that involving physical or psychological PLAN (FLOW CHART-1 AND 2)
traumatic event. It may also occure because of witnessing
or experiencing a serious harm to other significant persons The aim of management is to provide relief in psychological
in life. Patients have terrifying recollections of the event, or and somatic symptoms and minimize the impairment. This
nightmares. Some patients have an experience of living the can be addressed in following ways.
event in an illusionary or imaginary situation with hallucinations,
or flashback episodes. The patients suffer from intense 1. Pharmacotherapy
psychological or physical distress. Many patients develop loss The drug treatment of GAD is some times required as long
of interest, estrangement from others, sleep disturbances, as 6-12 month treatment, some evidence indicate that
irritability, diffi culty concentrating, hypervigilance, and treatment should be long term.
exaggerated startle response. This phenomenon may persist
for one month or more before it is diagnosed. 2. Psychotherapy
i. Cognitive behaviour therapy
Natural history and course ii. Behavioural techniques
The age of onset is difficult to specify, as most of the patients iii. Supportive Psychotherapy
have been anxious for long but report late. Nearly 1/3rd of iv. Insight oriented Psychotherapy
the patients who have GAD seek psychiatric treatment.
Many go to GPs, physicians, cardiologist, chest specialist Goals
for the somatic component of the disorder. Because of the • Psycho-education Direct explanation of the symptoms
high incidence of co-morbid mental disorders, the course and disorder to the patient and the family.
and prognosis is difficult to predict.The occurrence of • Monitoring of anxiety
several negative life events greatly increases the likelihood • Cognitive restructuring: Corrects the hypothesized
that the disorder will develop. In all, a chronic condition cognitive distortions and helps to identify and counter
may be life long. fear of bodily sensations.
Patient Presenting with Anxiety
GAD
Diagnosis by ICD 10 Criteria
Psychopharmacology Psychosocial Intervention Psychopharmacology

combined with Psychotherapy
Benzodiazepines
Clonazepam Cognitive – behaviour therapy Long-term outcome is better when

Chlordiazepoxida Relaxation therapy they are used in combination.
Diazepam Yoga & Meditation
Alprazolam Supportive Psychotherapy
Iniate from minimum adequate Insight therapy
Dose/ prescribed for a limited Family therapy
Period (6-8 weeks) Psycho education
Use with caution for dependence
SSRIs Paroxetine; Sertraline; Fluoxetine Appendix– Flowchart - 1
Venlafaxine GAD
SNRI
Mirtazapine
NaSSA
Other Buspirone
TCA Tricyclic & Tetra cyclic
Beta Blockers Propranolol

Flowchart 1: Management of Generalized Anxiety Disorder

PANIC DISORDER
Diagnosed by ICD 10
Acute Attack Long Term Care
Psychopharmacological Psychotherapy Psychopharmacological Psychotherapy

Treatment Treatment
i. SSRI- i. CBT i. BZDs CBT

Fluoxetine ii. Psychodynamic ii. SSRIs Psychodynamic
Paroxitine Psychotherapy iii. TCAs Psychotherapy
Sertraline iii. Group therapy iv. Venlafaxine Group therapy
Fluvoxamine v. NaSSA
Citalopram vi. Beta Blockers
ii. BZDS (Propanlol)
Alprazolam Ravi Kiran Mathur
Clonazepam
Diazepam
iii. SNRI
Venlafaxine
iv. NaSSA
v. Beta Blockers : Propanlol

Useful when combined
With BZDs
vi. TCAs
Imipramine
Clomipramine
Flowchart 2: Management of Panic Disorder
Efficacy It includes history of present illness, current symptoms;

Cognitive Behavioural Therapy has proven efficy other past psychiatric history, general medical history and history
psychotherapies do help in ameliorating symptoms of of substance use, personal history (eg. psychological
anxiety. It addresses cognitive distortions and somatic development, life events and response to those events),
symptoms. More effective with chronically anxious social, occupational and family history; review of the
patients, may need 8-10 sessions. It has been shown that patient’s medications; physical and mental status
yogic techniques produced greater motivation to practice examination and adequate diagnostic tool and criteria.
than progressive relaxation Meditation was found to be as Diagnose GAD according to ICD-10 (W.H.0,1992).
effective as pharmacotherapy in controlling symptoms of
anxiety. The overall efficacy claims are backed by very few Anxiety should not be due to the other Axis I disorder
Indian studies, but are useful. It requires considerable time (eg. mood disorder, psychotic disorder, social phobia, OCD,
and discipline from the patients. somatization disorder, hypochondriasis, PTSD) or a general
medical condition (eg. hyperthyroidism) or substance use
Adverse effects disorder (intoxication or withdrawal), (see appendix-1 for
These are relatively benign. Some patients may develop flow chart).
dependence on the therapist and that needs cautious
vigil. 2. Evaluating particular symptoms
Patients experience excessive anxiety but many of them
3. Combined pharmacological and psychotherapeutic experience panic attacks, which may worsen the clinical
intervention picture. The prolonged illness may cause depressive symptoms
Long-term outcome is better when they are used in with emergence of suicidality and substance abuse.
combination.
3. Evaluating severity of functional impairment
ASSESSMENT AND EVALUATION Many may continue to function in their social and
occupational lives with some impairment, others may
1. Performing a diagnostic evaluation become severely incapacitated and give up their jobs and
Psychiatric evaluation and physical examination is social duties. The impairment in different areas can be
necessary. assessed self-administered visual analog scale.

FORMULATING TREATMENTS AND CHOICE OF treatment should be started with half the recommended
TREATMENT SETTINGS dose or less in order to minimize initial adverse drug events.
The antidepressant dose should be increased to the highest
The aim of management is to provide relief in psychological recommended therapeutic level if the initial treatment with
and somatic symptoms and minimize the impairment. This a low or medium dose fails.
can be addressed in following way.
For patients who do not improve with standard treatments,
1. Establishing and maintaining atherapeutic alliance a number of alternative options should be tried including
The treatment of GAD may be long lasting hence the augmentation with small dose of antipsychotics or adding
alliance is crucial. Understanding the life events, the extent another anxiolytic agent or addition of non-pharmacological
and severity of symptoms requires confiding and lasting therapy like cognitive behavioral therapy (CBT) or Yoga,
therapeutic relationship. Meditation and increased physical activity as described
below.
Attention to the patient’s worries and fears are essential for
long term gains 4. Non-pharmacological treatment
Non pharmacological treatment found useful in treatment
2. Monitoringthe patient’s psychiatric status of anxiety disorders include supportive therapy, Exposure
The symptomatic improvement in psychological and therapy (e.g. gradual exposure in vivo, “flooding”) and response
autonomic symptoms leads to greater confidence in the prevention. Psychoeducational advice, and suggesions to not
treating doctor. The anxiety goes slowly with treatment to avoid feared situations are helpful in management.
and bursts of severe symptoms during the treatment need
constant monitoring. Cognitive Behavioural Therapy: Adequate strength of
evidence is available for Individual CBT, Group CBT and Self-
3. Pharmacotherapy directed CBT. Choosing between medications and CBT is
The drug treatment of GAD is some times is seen as determined by a number of factors, particularly the patient’s
a 6-12 month treatment, some evidence indicate that preference, treatment options at hand, adverse drug
treatment should be long term. effects, onset of efficacy, comorbidity (e.g. with depression),
financial considerations, time availability, accessibility of
a). Goals psychiatric and psychological treatment resources, and
Reduce psychological and autonomic symptoms and other experience of the clinician.
co morbid conditions. Improve occupational and social
functioning. Steps of CBT shall include:
1. Psychoeducation
b). Efficacy 2. Self-monitoring
Little Indian data to address the issue; mainly western data 3. Systemic exposure to panic inducing cues
available. 4. Countering anxious beliefs
5. Exposure to fear cues
c). Adverse effects 6. Modify [mal-adaptive behaviors
Different for different class of drugs. 7. Relapse prevention
8. Dealing with transference issues
Selective serotonin reuptake inhibitors (SSRIs), serotonin- 9. Resolving interpersonal and other emotional issues.
norepinephrine reuptake inhibitors (SNRIs), and pregabalin
are recommended as first line drugs due to their favorable Initial expectations and anticipation favoring CBT
risk-benefit ratio, with some differentiation regarding • Accept that the worrying is out of control
the various anxiety disorders. The common category of • Perhaps, worrying offers some protective value.
pharmacological agents used in management of generialised • CBT will facilitate future adversities, despite the worrying.
anxiety disorders include SSRIs,SNRIs, Pregabalin, TCAs,
Benzodiazepines, Antihistamines, Atypical antipsychotics, During the course of the treatment, revised
and Antioxidants. Role of vitamin A, C and E has been understanding:
evaluated and recommended in adequate doses for patients • The reasons for worrying and fears cannot be controlled
suffering from GAD. • Subjectively learn to control response to the fears and
worries
Dosing • Learn to obviate the behaviour of worrying
Majority of patients respond to the low dose of • Worrying does not have a protective value
antidepressants (with the exception of OCD). In the elderly, • Actually, worrying reinforces negative thinking

Excesive worrying increases likely hood or more 6. Addressing early signs of relapse
anxieties in the future The education that the illness is a chronic relapsing
CBT does not alter the method of managing source of illness is essential and emergence of anxiety with or
the worries without treatment should be promptly treated. Sudden
CBT helps to be better equipped to handle the future discontinuation may lead to emergence of withdrawal
stress. symptoms thus early recognition by the patient and the
family helps in prompt treatment.
Indian modules of psychotherapy
Several therapists have talked about Search of Indian MANAGEMENT AS PER THE DIFFERENT STAGES
module of psychotherapy and it is a felt need to have such a OF THE ILLNESS
module, which is socially and culturally relevant.
The treatment recommendations for the different anxiety
Ancient Indian thought has provided very rich knowledge disorders are summarized in Table I. Some antianxiety drugs
regarding mind and its functioning. From the Vedic period are effective in all anxiety disorders, whereas some drugs
issues relating to mind, consciousness, understanding of have only been studied in specific anxiety disorders and thus
human life, its existence and the concept of Atman have should be reserved for use in these particular disorders.
been widely studied and several explanations to improve
the quality of human life are available in Vedic and Post Panic disorder and agoraphobia. In acute panic attacks, mouth
Vedic literature. The Bhagvad Gita contains in condensed desolving short-acting benzodiazepines and reassurance
form all the philosophical and psycholoical wisdom of the to the patient may be sufficient. SSRIs SNRIs are first-line
Upanishads. Bhagwad Gita describes all aspects of yoga, treatments for longterm management. Patients should be
psychology and is unique among the psychlogical and treated for atleast six to eight months or longer to prevent
philosophical teachings for a student of psychotherapy,
relapses.
various aspects of psychotherapeutic techniques are
described in it.
A combination of CBT and anxiolytic medication has been
shown to have the best treatment outcomes.
In this excellent module of Psychotherapy through
18 chapters way of self knowledge, the Yoga of action
In GAD and Social anxiety disorder (SAD): Choice of Drugs for
(karma) knowledge of renunciation and action, the path of
Management are SSRIs, SNRIs and pregabalin. Buspirone and
meditation, knowledge of the absolute and eternal, yogic
hydroxyzine are second line treatment. Benzodiazepines
vision, yoga of devotion, profound knowledge of three
should only be used for long-term treatment when other
Gunas and the wisdom of renunciation and liberation
have been described at length, which leads to personality drugs or CBT have not shown results.
transformation of Arjuna. In the modern psychotherapy,
cognitive restructuring is the goal of psychotherapy, which Specific phobia: Specific phobia should be treated with
has been accomplished a great deal through Bhagwad Gita. behaviour therapy including systematic desensatisation.
SSRIs or short acting benzodiazepines should be tried in
Prekshadhayan cases not responding to behaviour therapy.
A Jain Meditational technique propounded by Acharya
Mahapragya, which includes relaxation, meditation, OCD: Choice of treatments is the SSRIs and the TCA
yoga, asanas and pranayam, a comprehensive capsule of clomipramine. Cognitive behaviour therapy (CBT) and
behavioural management has been tried in management of exposure and response prevention are other proven
GAD. On mental level, it proves to be an applied method techniques of management.
to train the mind to concentrate. It offers a way to treat
serious anxiety disorders with or without drugs. Large trials PTSD: Choice of treatments includes the SSRIs and
of this technique are still awaited. At present, few scientific venlafaxine. Therapeutic conversation, psychoeducation
studies are available. and regrief therapy are non-pharmacological treatment
techniques advocated.
5. Providing Education To The Patient And Family
This seemingly unimportant aspect is most relevant to TREATMENT UNDER SPECIAL CONDITIONS
Indian settings where awareness of psychiatric illness and its (FLOW CHART-3)
realization and need for treatment with compliance is little.
Many feel dejected, angry, isolated and may have suicidal Pregnancy.The use of SSRIs and TCAs in pregnancy does not
ideas. Family and the patient need to be told that this is like have increased risk for malformations. It is recommended to
any other illness that needs treatment and success depends avoid paroxetine alprazolam use among pregnant women
on compliance. or women planning to become pregnant.

Anxiety Disorder
Child and Adolescent Geriatric Suicidal Patient Substance use

Population Population disorder
Scant Literature in West Lower initial dose Adequate dose Treatment of substance
and India Lower target dose Inform patient’s family use disorder essential
SSRIs Gradual escalation
BZDs
Flowchart 3: Management of Anxiety Disorders in Special Population
Breast-feeding. SSRIs and TCAs are excreted into breast milk, possibilities of recurrence, response to triggers and his/
they do not cause any harm to the new born because the her ability to cope with the situation should be discussed
concentration in breast milk is very small however infants of at length. Patient’s personal view should be included in
mothers on benzodiazepines, should be observed for signs decesion making of stopping the treatment. Patient should
of sedation, lethargy, poor suckling, and weight loss, and if be encouraged to adapt alternative methods of anxiety
high doses have to be used and long-term administration is reduction like yoga, pranayam, relaxation techniques
required, breast feeding should probably be discontinued. including progressive muscular relaxation (PMR)/Shavasan
etc. which can be mastered by him before weaning off the
Treating children and adolescents. Choice of treatment smallest dose of antianxiety medication. Mindfulness-Based
should be SSRIs concerns about increased risk of suicidal Cognitive Behavior Therapy (MBCBT) for reducing cognitive
ideation and behavior have ben reported therefore careful and somatic anxiety and modifying dysfunctional cognitions
monitoring is advisable, presence of comorbid depression in patients with anxiety disorders has been tried where in
should be looked fore. different versions of mindfulness meditation, cognitive
restructuring, and strategies to handle worry, such as,
Treating the elderly. Elderly have increased sensitivity for worry postponement, worry exposure, and problem solving
anticholinergic properties, an increased risk for orthostatic have been employed. However, these studies are on small
hypotension, and ECG changes during treatment with TCAs, number of patients and need carefull review for further
and possible paradoxical reactions to benzodiazepines, application.
which include depression, with or without suicidal
tendencies, phobias, aggressiveness, or violent behavior. MANAGEMENT OF SIDE EFFECTS OF
Thus, treatment with TCAs or benzodiazepines is less MEDICATION
favorable, while SSRIs appear to be safe.
Diffrent side effects will emerge with different category of
Treatment of patients with severe Physical disease. Patients antianxiety medication. They should be carefully observed
with cardiovascular, cerebrovascular and endocrine disease, and addressed to. Side effects of medication can be drug
irritable bowel syndrome, malignency, stroke, chronic related or dose related. If it is drug, related, alternative class
obstructive pulmonary disease (COPD) hyperthyroidism of drug should be tried for adequate length of time. If it is
may have associated anxiety reactions with their somatic dose related then the dose of the drug has to be reduced.
disease state. Such anxiety disorders may compound the
management and the prognosis of these primary conditions. Things to remember for GAD:
Advocated pharmacological agents in such conditions 1. Anticholinergic and cardiovascular side effects to be
include SSRIs and Venlafaxine. kept in mind when using tricyclic and Tetra cyclic for
side effects. Precaution in suicidal patients.
WHEN TO STOP TREATMENT 2. Long-term treatment may be required.
3. Psychopharmacological therapy combined with
Decesion to stop treatment will depend on clinical psychotherapy works better.
response of the patients. Usualy the treatment is stopped
in a tapering manner after atleast 6 months stability of SUGGESTED READING
clinical improvement and asymptomatic status of the 1. Guidelines for the pharmacological treatment of anxiety disorders,
patient. Before stopping the treatment, the nature of illness obsessive – compulsive disorder and posttraumatic stress disorder in

primary care review article international Journal of Psychiatry in Clinical management of generalized anxiety disorder. J. Clin. Psychopharmacology,
Practice, 2012; 16: 77–84. 10, 101S.
2. Generalised anxiety disorder in adults – diagnosis and management www. 9. Caulpepper.L. (2003) Evidence for using Atypical Antipsychotic in mood
bpac.org.nz keyword: anxiety. and anxiety disorders. Primary Care Companion, Journal of Clinical
3. Spirituality and mental health edited by Dr. Avdhesh Sharma, Published by Psychiatry,5, Supl(3) page 27-32.
Indian J Psychiatry. 2008 Oct-Dec; 50(4): 233–237. 10. Chandrashekhar,C.R. and Reddy,M.V.(1998). Prevalence of mental and
4. Indian Culture and Psychiatry, Shiv Gautam, Nikhil Jain, Published behavioural disorders in India: A meta-analysis,UP, 40(2):149-157.
by Indian Journal of Psychiatry year 2010 Volume 52 Issue 7 11. Levitt.J.T., Hoffman,E.C., Grisham, J.R., Barlow.D.H. (2001) Empirically
(P. 309-3013). supported treatments for panic disorder. Psychiatr. Ann.,31,(8): 478.
5. Prekshadhyan, Manaswi Gautam, published in spirituality and mental 12. Ontario guidelines for Management of Anxiety disorder.Primary
health by Indian psychiatric society task force editor Avdesh Sharma care(2000). 1st Edn. Pollock.M.H., Mathews.J., Scotter (1998) Gabapentin
(2008-2009): 163-176. as it for Anxiety disorder.American Journal of Psychiatry, 155,992.
6. Mental Health in Ancient india and its relevence to modern psychiatry. 13. Sahasi.G., Chawala.H.M., Dhar.N.K., Katiyar.M. (1991) Comparative
Shiv Gautam Presidential Address, Indian Journal of Psychiatry (1999) study of progressive relaxation and yogic techniques of relaxation in
41 (1) 5-18 and “spirituality and mental health, task force (2008-2009): management of anxiety Neurosis, UP 33 (1);27-32.
25-52. 14. World Health Organization (1992) The ICD-10 Classification of Mental and
7. ORIGINAL ARTICLE: Role of antioxidants in generalised anxiety disorder Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines.
and depression Medhavi Gautam, Mukta Agrawal, Manaswi Gautam, World Health Organization, Geneva.
Praveen Sharma, Anita Sharma Gautam, Shiv Gautam Indian Journal of 15. Vahia.V.N., Shetty.H.K., Motiwala, S., Thakkar.G., Fernandes.L,
Psychiatry, Year 2012, Volume 54, Issue 3 [p. 244-247]. Sharma, C.J. (1993) Effect of Meditation in Generalised Anxiety
8. Rickels, K., Schweizer.E. (1990) The clinical course and long term Disorder,35 (2);87-92.

Clinical practice guidelines for Obsessive-Compulsive Disorder

Y.C. Janardhan Reddy, A. Shyam Sundar, Janardhanan C. Narayanaswamy, Suresh Bada Math
Department of Psychiatry, OCD Clinic, National Institute of Mental Health & Neurosciences (NIMHANS), Bangalore,
Karnataka, India
Participants of expert group on CPG for Obsessive intrusive thoughts, images or urges that are mostly ego-
Compulsive Disorder dystonic and cause severe distress or anxiety. Compulsions
Adarsh Tripathi, Om Prakash Singh, Paramjeet Singh, (or rituals) are repetitive behaviours or mental acts that
Tushar Jagawat, M, Aleem Siddiqui, K.K. Verma, are performed in response to an obsession to reduce
D.M. Mathur anxiety/distress or prevent a dreaded consequence.
Obsessions and compulsions are time consuming,
distressing and are often resisted unsuccessfully. Clinical
INTRODUCTION manifestations of OCD are remarkably similar across
cultures and geographic locations. Common obsessions and
Obsessive-compulsive disorder (OCD) is a common compulsions and symptom dimensions identified through
psychiatric illness with lifetime prevalence of 1-3% [1]. It is the factor-analytical studies are shown in Table 1.
fourth-most common psychiatric illness and a leading cause
of disability. OCD is associated with significant impairment Diagnosis
in functioning, quality of life and disability. If untreated, OCD Many people experience intrusive thoughts and exhibit
is a chronic illness with a waxing and waning of symptoms. repetitive behaviours. A diagnosis of OCD is made only if
A recent meta-analysis of long-term naturalistic prospective symptoms are time consuming (e.g., more than an hour
studies demonstrated that nearly a half of patients experience per day), distressing or cause significant interference in
remission with much higher rates of remission in Indian functioning. This is reflected in DSM-5 diagnosis of OCD
patients compared to those in the west [2]. Early diagnosis and in the upcoming ICD-11 [3]. The ICD-11 criteria for OCD
and appropriate treatment may improve outcomes. Despite are likely to be very similar to the DSM-5 criteria [3, 4]. The
OCD being a common mental illness, most seek treatment ICD-11 may include an insight specifier along the same lines
after several years of suffering. Those who suffer from as DSM-5. There are sweeping changes to the description
OCD tend to be secretive about their symptoms and suffer of OCD in the proposed ICD-11. Duration criteria and
from shame and embarrassment. Less than a third of OCD subtyping of OCD may be removed in the revision for lack
sufferers receive appropriate pharmacotherapy and even less of evidence and clinical relevance. In ICD-10, a diagnosis of
receive evidence-based psychotherapy. OCD was discouraged in the presence of schizophrenia, tic
disorder or depression. This criterion too may be removed
Symptoms paving the way to make a diagnosis of OCD even in the
The hallmarks of OCD are presence of obsessions and presence of these comorbid disorders.
compulsions. Obsessions are repetitive, unwanted,
Another major change to the diagnosis of OCD is creation
of OCD and related disorders in DSM-5 (and in the ICD-
Address for correspondence:
Y. C. Janardhan Reddy, 11) and exit from the group of anxiety disorders. Many
Professor of Psychiatry, NIMHANS, Bangalore 560029, disorders are included in this group: body dysmorphic
Karnataka, India.
E-mail: ycjreddy@gmail.com This is an open access article distributed under the terms of the Creative
Access this article online others to remix, tweak, and build upon the work non-commercially, as long as the
Quick Response Code
Website: For reprints contact: reprints@medknow.com
How to cite this article: Janardhan Reddy YC, Sundar AS,

DOI:
Narayanaswamy JC, Math SB. Clinical practice guidelines
for Obsessive-Compulsive Disorder. Indian J Psychiatry
10.4103/0019-5545.196976
2017;59:74-90.

Reddy, et al.: CPGs for OCD
Table 1: Common symptoms of OCD other conditions find a place in this group that include
Obsessions tic disorders, hypochondriasis and olfactory reference
Contamination related obsessions syndrome. All these disorders are grouped together based
• Concern/disgust with bodily secretions and waste such as stools and urine on shared clinical features (e.g., repetitive behaviours),
• Fear of dirt or germs/infections, concern with sticky substances comorbidity patterns, familiality, neuropsychological
• Fear of getting ill because of contaminants (e.g., AIDS) deficits, treatment response and importantly shared brain
Sexual obsessions
circuitry abnormalities. Hoarding disorder which may not
• Unwanted, forbidden sexual thoughts, images or urges about strangers,
family friends, etc share many features with OCD is grouped along with OCD
• Sexual thoughts of molesting children, thoughts of sexual identity (am because of historical association with OCD and obsessive-
I a gay?) compulsive personality disorder.
Harm/aggression related obsessions
• Fear might harm self or others (fear of jumping off the building, fear
Comorbidity
of harming babies, stabbing a friend, running over pedestrians while
driving etc) OCD is often comorbid with other psychiatric disorders. It
• Violent/horrific images (murders, mutilated bodies, accidents) is important to assess all patients with OCD for associated
• Fear of uttering obscenities psychiatric comorbidity since they may have an effect on
Religious/blasphemy treatment outcome if left untreated. Depression and anxiety
• Sacrilege and blasphemy (blasphemous thoughts, fear of uttering insults
disorders are present in over a half of patients seeking
to God)
• Excessive concern about right/wrong, morality treatment for OCD. Common comorbid disorders are
Pathological doubts about daily activities (doubts of having not locked listed in Table 2. Those with early onset OCD, in particular
doors, turned off gas knobs) those with onset in childhood have high rates of attention
Need for symmetry and exactness deficit hyperactivity disorder (ADHD), oppositional defiant
• Concern about things being not properly aligned, symmetrical, perfect
disorder (ODD) and tic disorders.
or exact
• With magical thinking (child may have an accident if things are not
properly arranged in kitchen) Bipolar disorder, in particular type 2, is reported to
Miscellaneous be not uncommon in OCD [5]. Similarly, OCD is not
• Need to know/remember (number plates, advertisements etc.) uncommon in those with primary diagnosis of bipolar
• Intrusive non‑violent images, thoughts
disorder [6, 7]. OCD when comorbid with bipolar disorder
• Superstitious fears (passing a cat, cemetery)
• Lucky/unlucky numbers, colors tends to run an episodic course [8] with worsening of
Compulsions
symptoms in depressive phases and improvement in
hypomania/ mania phases. It is important to recognise OCD-
Washing/Cleaning (excessive or ritualized hand washing, showering,
bathing, brushing/excessive cleaning of household items, floors, kitchen bipolar comorbidity because of treatment implications. The
vessels etc) in response to contamination obsessions specific serotonin-reuptake inhibitors (SSRIs) traditionally
Checking used to treat OCD may induce switch to mania or rapid
• In response to pathological doubts (appliances, locks, stove, doors) cycling course.
• To prevent harm to self or others (check to make sure that you have not
caused accident, examining for injuries etc.)
Repeating Obsessive-compulsive symptoms and OCD are not
• Re‑reading or rewriting because you didn’t understand or write properly uncommon in schizophrenia. Nearly a third of schizophrenia
• Repeating routine activities (going in and out of doorway, sit and stand patients report OC symptoms or OCD. Presence of OCD
up repeatedly, repeating till you feel just right) may have a negative effect on the long-term course of
Counting (money, floor tiles)
schizophrenia. Therefore treatment of OCD with SSRIs
Ordering and arranging (often till you feel just right)
Miscellaneous and cognitive-behavior therapy (CBT)/behavior therapy (BT)
• Mental rituals (praying, replacing bad thought with good thought) may have to be considered although there is not much of
• Superstitious behaviours systematic evidence supporting their efficacy in treatment
• Need to tell/ask/confess of OCD in schizophrenia.
Symptom dimensions[41]
• Contamination fears and cleaning/washing
• Forbidden thoughts (aggression, sexual, religious, and somatic COMMON INGREDIENTS OF MANAGEMENT
obsessions and checking compulsions) PLAN
• Symmetry (symmetry obsessions and repeating, ordering, and counting
compulsions) Common ingredients of managing OCD include the
• Hoarding (hoarding obsessions and compulsions)
following:
disorder (BDD), trichotillomania (TTM), skin picking 1. Detailed assessment of symptoms and comorbid patterns
disorder, hoarding disorder, substance/medication- including suicidal behaviours either by unstructured
Induced obsessive-compulsive and related disorder clinical interview alone or supplementation with
and obsessive-compulsive and related disorder due to structured assessments.
another medical condition. In the upcoming ICD-11, few 2. Decision on setting for treatment (outpatient vs. inpatient

Table 2: Comorbid disorders in OCD ASSESSMENT AND EVALUATION

Mood disorders
• Major depression In routine clinical practice, use of structured /
• Dysthymia semistructured interviews and rating scales may not be
• Bipolar disorder necessary. They are optional. However, they may be used
Anxiety disorders
when the clinician needs supplementary information. A list
• Panic disorder
• Generalized anxiety disorder of useful instruments in the assessment of OCD is provided
• Social Phobia in Table 3.
OCD related disorders
• Body dysmorphic disorder The Yale-Brown Obsessive-Compulsive Scale (YBOCS) is the
• Hypochondriasis
most widely used severity rating scale for OCD in both adults [9]
• Trichotillomania
• Skin picking disorder and children [10] and is considered a gold standard instrument
• Tic disorders to measure severity of OCD. It is a 10-item observer-rating scale,
Attention deficit hyperactivity disorder also available as self-rated instrument. It measures the overall
Oppositional defiant disorder severity of obsessive-compulsive symptoms for the preceding
Personality disorders
week. The YBOCS is a global measure of symptoms and does
• Obsessive‑compulsive personality disorder
• Anxious‑avoidant personality disorder not provide severity of individual symptom dimensions. A
• Borderline personality disorder total score of ≥ 16 is considered to be indicative of clinically
• Schizotypal personality significant OCD. The YBOCS severity scale also has an
Differential diagnoses to consider associated symptom check list of 15 categories of obsessions
• Depression (depressive ruminations are usually ego‑syntonic, reflective
and compulsions including miscellaneous symptoms. The
of depressive cognitions such as self‑criticism, failure, regret, guilt,
pessimism without any compulsions) checklist elicits both current (1 month) and past symptoms.
• Generalized anxiety disorder (anxious ruminations are about real‑life
concerns and not associated with compulsions) On the YBOCS item-11 insight scale, the insight is graded
• Body dysmorphic disorder (concerns limited to physical appearance) as follows: 0 = excellent (fully rational thinking), 1= good
• Trichotillomania (limited to hair pulling)
insight (readily acknowledges absurdity or excessiveness
• Skin picking disorder (confined to excessive skin picking)
• Hoarding disorder (difficulty in discarding or parting with possessions, but has some lingering doubts), 2 = fair insight (reluctantly
accumulation of possessions; not secondary to obsessions) admits absurdity, but waivers; has some unrealistic fear but
• Eating disorders (confined to weight and food) no fixed conviction), 3 = poor insight (overvalued ideas;
• Tics (often preceded by premonitory sensations and not aimed at maintains they are not unreasonable or excessive, but
neutralizing obsessions)
acknowledges validity of contrary evidence), and 4 = lack
• Psychotic disorders (Even poor insight/delusional OCD is associated
with typical obsessional content and compulsions whereas delusions of insight (delusional). A higher score on the Y–BOCS item-
have persecutory, grandiose themes with other symptoms such as 11 indicates poorer insight.
hallucinations or formal thought disorder)
• Obsessive‑compulsive personality disorder (enduring and pervasive FORMULATING A TREATMENT PLAN
pattern of excessive preoccupation with perfectionism, orderliness
and rigid control; rigidity, stubbornness, scrupulosity and over
conscientiousness. Typically ego‑syntonic. No obsessions and Formulating a treatment begins with correct diagnosis of OCD
compulsions) as per the DSM or ICD classificatory systems. When feasible
a structured clinical interview is recommended to obtain a
comprehensive account of patient’s problems. Once a diagnosis
care depending upon the severity, treatment resistance is established, a detailed assessment of symptom profile is
etc.) mandatory. Family members often accommodate patient’s rituals
3. Detailed psychoeducation of the patient and family and contribute to poor outcome. In most severely ill patients, an
member (s) about OCD, its course and treatment elaborate family assessment may be needed. Once assessment is
options including duration of treatment. complete, short-term and long-term goals of treatment have to be
4. Choice of treatment: drugs vs. CBT vs. combination established. Enhancing treatment adherence is a vital aspect of
5. In the Indian context, SSRIs are first-line treatments formulating a treatment plan. It is important to educate patients
preferred over CBT because of feasibility, affordability about lag in the onset of action of drugs and that improvement
and limited number of trained therapists. CBT may be may occur over several months of continuous treatment. Brief
considered if SSRIs alone are not beneficial. education about basic principles of psychotherapy should
6. Discussion on side-effects of drugs; in women risks vs. be explained if psychotherapy is being planned. Essentials of
benefits of drugs during pregnancy and in the post- formulating a treatment plan are summarized in Table 4. All
partum period patients and their immediate family members should be provided
7. Follow-up plan after initiating treatment psychoeducation about OCD (Table 5).

Table 3: Commonly used instruments to assess Table 4: Essentials of formulating a treatment plan
OCD (optional) Establishing a diagnosis if OCD
Diagnostics interview schedules Diagnosis of comorbid disorders (optional structured clinical interview)
• The Mini International Neuropsychiatric Interview (MINI)[42] Detailed evaluation for a range of OCD symptoms (clinical interview/
• Structured Clinical Interview for DSM‑5 (SCID‑5)[43] YBOCS or similar check list)
Severity rating scales Detailed symptom evaluation
• Yale‑Brown Obsessive‑Compulsive Scale (YBOCS): symptom checklist • Identify principal symptoms that are the target of treatment (especially
and severity rating scale (adult and child versions)[9,10] useful to identify principal symptoms if CBT is planned)
• Dimensional YBOCS (DYBOCS)[44] • Identify proxy compulsions, avoidance and safety behaviours
Scales to assess insight in OCD • Determine level of insight
• Yale‑Brown Obsessive‑Compulsive Scale (YBOCS), Item 11[9] • Assess family accommodation of patient’s rituals
• Brown‑Assessment of Beliefs Scale (BABS)[45] Short‑term goals
• Overvalued Ideas scale (OVIS)[46] • To achieve clinical response and if possible remission
Obsessive‑beliefs questionnaire (OBQ) to measure beliefs underlying • Remission of depression, if comorbid
obsessions [47] • Help deal with suicidal thoughts, behaviour if any
The Family Accommodation Scale (FAS) assesses the degree to which • To determine tolerability to medicines
family members of those with OCD accommodate patient’s compulsions/ • Identify and manage side‑effects
rituals[48] Long‑term goals
• Achieve recovery
• Restore psychosocial functioning and enhance quality of life
CHOICE OF TREATMENT SETTINGS • Long‑term treatment to prevent relapses
Enhancing treatment adherence
• Psychoeducation to the patient and family members
In the Indian scenario, treatment is either on an outpatient or an
• Provide education materials to patient and family members
inpatient basis. Outpatient treatment is usually sufficient for most • Deal with unrealistic expectations of quick recovery; educate
OCD patients who are mild to moderately ill and for those who patients and family about lag in the onset of action of drugs and that
are likely to be adherent to treatment. Patients may be followed- improvement may occur over several months
up at periodic intervals, initially once in a month or two and • Sensitise patient about potential side‑effects and help to deal with them
• Use medicines that are effective, easily available and affordable
subsequently at longer intervals depending upon the response to
• Treat comrbid disorders and personality disorders if any; if left
treatment and tolerability and side-effects. Hospital treatment may untreated may contribute to poor treatment adherence
be considered for those who are at high suicide risk, dangerous Enhancing adherence to psychotherapy (CBT)
to self or others, and intolerant to side-effects. Many severely • Detailed education about principles behind exposure and response
ill and treatment-resistant patients may require prolonged (2-3 prevention
• Reassure that exposure and response prevention will be graded and
months) hospitalization for intensive treatment with CBT and for
tasks will be determined based on collaborative approach
rationalization of pharmacotherapy. Inpatient care may also be • Emphasize the role of motivation, home‑work compliance and need to
required for severe depression, mania or psychosis that may be tolerate some anxiety
comorbid with OCD. Admission in rehabilitation services may be • Reduce unrealistic expectations of quick recovery
necessary for some patients who may not have benefited from
standard treatments including inpatient care.
comorbidities, previous treatment trials, affordability, accessibility,
PHARMACOLOGICAL TREATMENT hypersensitivity, side-effect profile, patients’ values etc.
The clinical practice guideline is framed based on a RELEVANT CLINICAL ISSUES

review of relevant scientific literature. As a first step, we
framed relevant questions which arise in the minds of the 1. First-line pharmacological treatment for OCD
practitioner while treating a patient suffering from OCD. Meta-analyses of RCTs show that selective-serotonin
A literature search was conducted in PubMed to answer reuptake inhibitors (SSRIs) are significantly more effective
these questions. We also reviewed the existing guidelines than placebo in the treatment of OCD [16]. SSRIs are
on treatment of OCD [11-14]. After a thorough literature associated with many adverse effects but are usually well
review, the treatment strategies were rated based on the tolerated. The only other medication which has shown to be
Strength of Recommendation Taxonomy (SORT) [15]. consistently effective in OCD is the serotoninergic tricyclic
antidepressant clomipramine. Clomipramine has been found
Consistent evidence from multiple randomized controlled to be significantly more effective than placebo in multiple
trials (RCT) constitutes the highest level of evidence for a RCTs and meta-analysis of RCTs [16]. Network meta-analysis
recommendation. However, the external validity of RCTs has comparing the efficacy of clomipramine vs. SSRIs failed to find
been questioned due to the rigid protocols in undertaking the any efficacy advantage over SSRIs [16]. Most head-to-head
studies. A practitioner may make a clinical decision based on comparison trials have not found any significant difference
the available evidence considering other relevant factors that between the efficacy of clomipramine and SSRIs [17].
influence the decision making process. A non-exhaustive list Further, meta-analyses and individual RCTs have found that
of these factors might include psychiatric and other medical the tolerability of clomipramine is worse than that of SSRIs

Table 5: Components of psychoeducation Table 6: Medications recommended as monotherapy in

• Obsessions and compulsions are symptoms of OCD and that they are OCD
similar in most people who suffer from OCD; OCD is a brain disorder Drug Suggested dosage Strength of recommendation*
• Obsessions are not a reflection of one’s character or unresolved mental
Escitalopram 20‑30 mg A
conflicts
Fluoxetine 60‑80 mg A
• Explain the link between the components-Obsessions, compulsions and
Fluvoxamine 200‑300 mg A
distress
Paroxetine 40‑60 mg A
• Clarify myths and misconceptions about the illness
Sertraline 150‑200 mg A
• Explain the biological and psychological basis of OCD : OCD is a
Citalopram 40‑60 mg A
problem of aberrant functioning of certain brain circuits involved in
Clomipramine 150‑225 mg A
disregarding unwanted thoughts, dysfunction of certain neurotransmitter
Venlafaxine 225‑300 mg B
systems such as serotonin and glutamate, faulty interpretation
and excessive importance given to certain intrusions resulting in *Based on modified Strength of Recommendation Taxonomy (SORT)[15]
A – Consistent, good‑quality patient‑oriented evidence i.e., Meta‑analysis of
manifestation of obsessions Randomized controlled trials (RCT) with consistent findings or high quality
• Discuss the course and outcome of OCD-regarding the waxing and individual RCT
waning course with optimism that outcome is good in a majority of the B – Inconsistent or limited‑quality patient‑oriented evidence i.e., systematic
people if adequately treated review/meta‑analysis of lower quality clinical trials or studies with inconsistent
• Provide information regarding the available treatment strategies : findings/lower quality clinical trial/cohort study/case‑control study
C – Consensus based clinical guidelines extrapolations from bench research,
pharmacotherapy and cognitive behavior therapy
disease‑oriented evidence, usual practice, opinion, case‑series
• Sensitize with the idea that treatment is a continued process and often
long‑term
• Educate that medications take time to work, sometimes as long as few Table 7: Predictors of response to SSRIs
months before appreciable improvement is seen
Clinical predictors of poor response
• Psychological treatment too needs sustained efforts and sometimes
Early age of onset
booster sessions
Longer duration of illness
• Prevention of relapse addressed within the general context of OCD as a
Poor insight
chronic disorder
Presence of hoarding, sexual/religious obsessions, cleaning/washing,
• Educate the family regarding the need to reduce expressed emotions
repeating/counting compulsions
such as criticality, accommodative behaviors and proxy compulsions;
Comorbidities in the form of tics and depressive disorder
thus being supportive in the treatment process
Comorbid schizotypal, borderline and anxious avoidant personality
disorders
Neuroimaging predictors
[13, 17]. The anticholinergic, cardiac and neurological side
Lower baseline orbitofrontal cortex (OFC) and anterior cingulate
effects of clomipramine may be problematic in this regard. cortex (ACC) metabolism and greater pretreatment caudate metabolism
predicted better response (PET studies)
CONSIDERING THE CONSISTENT EFFICACY Reduction in thalamic volume and increase in OFC volume is associated
AND BETTER TOLERABILITY, GUIDELINES with SSRI response (structural MRI)
Increased dorso-lateral prefrontal cortex (DLPFC) activation with
RECOMMEND SSRIs AS FIRST LINE
Stroop task and decreased activation of frontal regions with symptom
TREATMENT FOR OCD (TABLE 6). provocation task predicted good response
Genetic predictors
Choice of SSRI Specific polymorphisms in the promoter region of serotonin transporter (5
Meta-analyses comparing the different SSRIs [16] and direct HTTLPR) associated with treatment response
CYP2D6 polymorphisms associated with SSRI response
head-to-head comparisons [17,18] have not shown superiority
Ref:[49]
of any one SSRI over the other. SSRIs differ to some extent
in their propensity to cause certain adverse effects and drug
interactions. However, there is no unequivocal evidence to higher dose of SSRI than that used in depression (Table 5). A
suggest that these differences may be clinically meaningful. meta-analysis of fixed-dose comparison studies have found a
Recently, concerns have been raised regarding cardiac greater efficacy with higher doses of SSRI (60-80 mg fluoxetine
adverse effects with high dose of citalopram, which is equivalent) compared to medium (40-50 mg fluoxetine
commonly used in OCD. Hence, high-dose citalopram may be equivalent) and low doses (20-30 mg fluoxetine equivalent)
used with caution in those with risk for arrhythmias. [19]. However, all three dose ranges were significantly more
effective than placebo. The increased efficacy comes at the
THE PRACTITIONER IS RECOMMENDED TO cost of poor tolerability as evidenced by increased dropouts
CHOOSE AN SSRI FOR AN INDIVIDUAL PATIENT due to adverse effects [19]. A review of individual fixed-dose
BASED ON FACTORS SUCH AS PREVIOUS comparison studies found that the dose-response relationship
RESPONSE, COMORBIDITY, TOLERABILITY, is more evident for escitalopram, fluoxetine and paroxetine,
ACCEPTABILITY, ADVERSE EFFECTS, COST AND while it is less clear-cut for citalopram and sertraline [17].
DRUG INTERACTIONS. Clomipramine has not been tested in such fixed dose
comparison studies. However, most studies have employed a
Dose of SSRI flexible dosing at 150-250 mg [17]. It should be remembered
It is generally recommended that OCD be treated with a that there is likely to be inter-individual differences in

SSRI© CBT/BT
First line +SSRI**
CBT/BT #
treatments*
response
Response after No
15-20 sessions SSRI: If recovered or minimal
symptoms continue for 1-2
Yes years & then gradual taper
over several months.
Inadequate Indefinite treatment:
Continue till remission response Persistent symptoms,
with periodic booster previous history of relapses,
sessions for severe illness
4-6 months CBT: booster sessions for
4-6 months
Partial response No response
Options
Options • 2nd SSRI / CBT( if not
• CBT/BT (if not offered) Inadequate offered)
• Aripiprazole/risperidone response • Clomipramine / CBT (if
• Memantine not offered)
• Lamotrigine • Other untried SSRIs
• 5HT-3 antagonists • Venlafaxine
Inadequate
response
Other experimental treatments

• Ultra-high dose SSRI
• Augmentation with
clomipramine
• Ketamine
• rTMS€ /tDCS$
• Riluzole/N-acetyl cysteine
Ablative neurosurgery/ Deep

brain stimulation
Figure 1: Treatment algorithm for treating a patient with OCD. *First line treatment chosen based on feasibility and severity
of illness, #CBT/BT- Cognitive behavior therapy/Behavior therapy, @SSRI – Selective serotonin reuptake inhibitor, %rTMS-
repetitive transcranial magnetic stimulation, $ - tDCS- transcranial direct current stimulation. ** Preferred for severe OCD
pharmacokinetic profile of drugs due to intrinsic variations in majority of improvement occurs early on in the course
drug metabolism and drug interactions. of treatment [20]. However, improvements seen early
in the course of treatment may not be always clinically
GUIDELINES RECOMMEND TREATMENT OF meaningful. In many patients, clinically meaningful
OCD WITH HIGHER DOSE OF SSRIs. HOWEVER, improvements may be seen only after weeks or months
IF AN INDIVIDUAL PATIENT IS NOT ABLE TO of treatment. It is recommended that an adequate trial of
TOLERATE HIGHER DOSE, LOW TO MEDIUM a SSRI (or clomipramine) should be at least for 12 weeks
DOSE TREATMENT CAN BE CONSIDERED. to account for the lag in the onset of action. The APA
guidelines recommend upward titration to the maximum
Duration of trial and dose titration FDA-approved doses by 4-6 weeks and continuation in that
A recent meta-analysis of 17 RCTs found that SSRIs dose for another 6-8 weeks or so to determine efficacy
separate from placebo as early as 2 weeks and that [11]. Certain clinical and biological predictors of treatment

Non-response to 2 adequate trials with SSRIs Given the absence of evidence from placebo-controlled
trials, venlafaxine is not the first-line treatment for OCD.
Hence, the guidelines consider venlafaxine as a second-line
Add CBT/ BT Clomipramine if CBT / BT are not feasible monotherapy agent in the treatment of OCD.
No response
No response Mirtazapine has been studied as a monotherapy in two
Clomipramine BT / CBT
small open-label trials with inconsistent findings. Therefore,
mirtazapine cannot be recommended as monotherapy in
No response
No response treatment of OCD.
Switch to third SSRI Switch to third SSRI
3. Treatment strategy for non-responders to first-line
No response treatment
Definitions of treatment outcome [21] are given in
Add Risperidone or Table 8. Estimates suggest that around 40-70% patients
Aripiprazole to SSRI
show an adequate response to a trial of SSRI with a
No response
remission rate of 10-40% [16]. Clinicians often face the
subsequent challenge of partial and non-response to SSRIs.
Add 5-HT 3 antagonists / memantine / lamotrigine to SSRI
Continuing improvement has been noticed with prolonged
No response trial of SSRIs as discussed above. Hence, the initial trial
may be continued further if there is evidence of ongoing
Try untried SSRI or venlafaxine
improvement. A general treatment algorithm for OCD and
No response for non-responders to SSRIs is shown in Figures1 and 2
Inpatient intensive treatment with CBT / BT + SSRI for severe OCD
respectively.
Try outpatient CBT / BT for second time in mild-moderate OCD
a. Switching to another medication

No response
Switching to another first-line medication has been found
Ultra-high dose SSRIs, addition of clomipramine, rTMS , to be effective; experts provide a rough estimate of 40-
Mirtazapine, N-acetyle cysteine, Ketamine
50% response rate for the second SSRI and decreasing
No response response rates with further trials. Switching to a second
SSRI is suggested for non-responders to a first SSRI. In
DBS, ablative surgery for severe, chronic, treatment refractory OCD
partial responders, changing medication may entail
Figure 2: Strategies for non-responders to SSRIs. SSRI- loss of the response to the earlier medication. Hence,
Selective serotonin reuptake inhibitors, CBT/BT-Cognitive switching is recommended in partial responders only if
behavior therapy/behavior therapy, rTMS- repetitive there are severe persisting symptoms or upon failure of
transcranial magnetic stimulation other augmenting strategies such as CBT and atypical
antipsychotics.
response to SSRIs have been identified but they are not
robust predictors (Table 7). b. Switching / Augmenting with CBT/BT
It is uncertain whether initiating a combination of BT/CBT
GUIDELINES RECOMMEND CONTINUING simultaneously with SSRI is advantageous compared to
MAXIMALLY TOLERATED EFFECTIVE DOSE OF either treatment alone. However, CBT/BT has been proven
A SSRI FOR AT LEAST 12 WEEKS FOR JUDGING to be effective as an augmenter in partial/non-responders
ITS EFFICACY. GUIDELINES ALSO RECOMMEND to SSRIs [18, 22, 23]. Where feasible, CBT/BT is a potential
DOSE ESCALATION TO EFFECTIVE DOSE first-line augmenting option for partial/non-responders to
RANGES WITHIN 4-6 WEEKS AND CONTINUATION SSRI treatment.
IN THE SAME DOSE FOR ANOTHER 6-8 WEEKS.
c. Augmenting with another medication (Table 9)
2. Other medications that can be tried as monotherapy in The following medications have been commonly tried as
OCD augmenters to SSRIs. Atypical antipsychotics, risperidone
Venlafaxine, a serotonin-norepinephrine reuptake inhibitor and aripiprazole have the best evidence.
with preferential serotonergic action, has been studied
in comparison to paroxetine in a double blinded study i Antipsychotics
and clomipramine in a single blinded study. The studies Antipsychotics are the most widely studied augmenting
found no difference in the efficacy between venlafaxine agents of SSRIs [23]. The literature on antipsychotic
and the comparator agents in acute control of OCD. augmentation is fraught with methodological limitations

Table 8: Definitions of treatment outcome in OCD

Consensus definitions and operationalization of treatment response, partial response, remission, recovery, and relapse for Obsessive‑Compulsive
Disorder (OCD)
Conceptual Definition Operationalization
TREATMENT RESPONSE A clinically meaningful reduction in symptoms (time, A ≥35% reduction in (C) Y‑BOCS scores plus CGI‑I rating of
PARTIAL RESPONSE distress, and interference associated with obsessions, 1 (‘very much improved’) or 2 (‘much improved’), lasting for
compulsions, and avoidance) relative to baseline at least one week
severity in an individual who meets diagnostic criteria A ≥25% but <35% reduction in (C) Y‑BOCS scores plus CGI‑I
for OCD rating of at least 3 (‘minimally improved’), lasting for at least
one week
REMISSION The patient no longer meets syndromal criteria for the If a structured diagnostic interview is feasible, the person no
disorder and has no more than minimal symptoms. longer meets diagnostic criteria for OCD for at least one week
Residual obsessions, compulsions, and avoidance If a structured diagnostic interview is not feasible, a score of
may be present but are not time consuming and do not ≤12 on the (C) Y‑BOCS plus CGI‑S rating of 1 (‘normal, not
interfere with the person’s everyday life at all ill’) or 2 (‘borderline mentally ill’), lasting for at least
one week
RECOVERY The patient no longer meets syndromal criteria for If a structured diagnostic interview is feasible, the person no
the disorder and has had no more than minimal longer meets diagnostic criteria for OCD for at least one year
symptoms. Residual obsessions, compulsions, and If a structured diagnostic interview is not feasible, a score of
avoidance may be present and slightly fluctuate in ≤12 on the (C) Y‑BOCS plus CGI‑S rating of 1 (‘normal, not
severity over time but, overall, they are not time at all ill’) or 2 (‘borderline mentally ill’), lasting for at least
consuming and do not interfere with the person’s one year
everyday life and therefore require no further
treatment. The clinician may begin to consider
discontinuation of treatment or, if the treatment
continues, the aim is to prevent relapse
RELAPSE After response or remission or recovery was achieved, For responders who did not necessarily remit/recover: The
the patient experiences a return of symptoms. person no longer meets the definition of ≥35% reduction
For patients who were in remission or recovered, on (C) Y‑BOCS scores (relative to pre‑treatment) plus CGI‑I
obsessions, compulsions, and avoidance are again rating of 6 (‘much worse’) or higher for at least one month
sufficiently time consuming, distressing, and For remitters/recovered: OCD criteria are met again,
impairing for the individual to meet diagnostic criteria according to a structured interview (if feasible). Alternatively,
for OCD the person no longer meets the definition of remission/
recovery (i.e., the person again scores 13 or above on the (C)
Y‑BOCS) plus CGI‑I rating of 6 (‘much worse’) or higher
for at least one month or needs to be withdrawn prematurely
from the trial before one month has elapsed due to a severe
worsening of OCD symptoms. Discontinuation of the trial due
to reasons other than a worsening in OCD symptoms (e.g.,
suicide risk) is not considered a relapse
Abbreviations: CGI‑I – Clinical Global Impression Improvement; CGI‑S – Clinical Global Impression Severity; (C) Y‑BOCS – (Children’s) Yale‑Brown Obsessive
Compulsive Scale; OCD – Obsessive-Compulsive Disorder. Ref: [21]. This table is reprinted with permission from the lead author of the Delphi survey. The table is
not part of the publication
including small sample sizes, varying doses and duration of adequately. Meta-analyses do not throw any light on
treatment with both antipsychotics and concomitant SSRIs, adequate dose and duration of antipsychotic treatment
varying degree of treatment resistance etc. Two recent [24]. Antipsychotics should be used in low doses (e.g., 1-3 mg
meta-analyses of 14 RCTs on antipsychotic augmentation of risperidone, 5-10 mg aripiprazole) for a period of at least
found that antipsychotic as a group was significantly more 8 weeks for an adequate trial. Use of antipsychotics in the
effective than placebo in decreasing YBOCS scores [24, 25]. long-run should be considered after weighing the benefits
About a third of patients responded to antipsychotic and risks of long-term use.
augmentation. Aripiprazole and risperidone are consistently
found to be effective as augmenting agents. The evidence BASED ON THE AVAILABLE EVIDENCE,
for haloperidol should be interpreted with caution as it ARIPIPRAZOLE AND RISPERIDONE MAY
was based on a single study. A fairly large RCT comparing BE CONSIDERED THE FIRST CHOICE FOR
CBT, risperidone and pill placebo augmentation of SSRI PHARMACOLOGICAL AUGMENTATION
found that risperidone did not separate from placebo in
augmenting efficacy [26]. This study has raised questions ii. Glutamatergic agents
on the efficacy of risperidone as an augmenter. Quetiapine There is a strong theoretical rationale supporting the use
and olanzapine have not been consistently found to be of glutamatergic drugs in OCD. The following glutamatergic
effective, while other antipsychotics have not been studied agents have been studied in OCD [23]:

Table 9: Pharmacological augmenting agents in OCD iv. Other augmenting agents

Drug Suggested dosage $ Strength of recommendation* Buspirone, lithium and clonazepam have not been found
Aripiprazole 5‑10 mg A effective and hence are not recommended as augmenting
Risperidone 1‑3 mg A agents. The safety and efficacy of psychostimulants and
Haloperidol 2.5‑10 mg B opioid drugs have to be systematically studied before they
Memantine 10‑20 mg B are recommended for routine clinical use. Intravenous
Lamotrigine 100mg B
ketamine has been found to have acute anti-obsessive
Ondansetron 2‑4 mg twice a day B
Granisetron 1 mg twice a day B effects in a “proof-of-concept” study, which needs
$ ‑ Rough estimate based on available evidence replication and long term evaluation before the strategy can
*Based on modified Strength of Recommendation Taxonomy (SORT)[15] be recommended for routine clinical use.
A – Consistent, good‑quality patient‑oriented evidence i.e., Meta‑analysis of
Randomized controlled trials (RCT) with consistent findings or high quality
individual RCT B – Inconsistent or limited‑quality patient‑oriented evidence d. Other experimental strategies
i.e., systematic review/meta‑analysis of lower quality clinical trials or studies While there appears to be some short-term benefits for
with inconsistent findings/lower quality clinical trial/cohort study/case‑control
study C – Consensus based clinical guidelines extrapolations from bench intravenous clomipramine in treatment resistant patients,
research, disease‑oriented evidence, usual practice, opinion, case‑series the long term benefits are uncertain. This formulation is
not available in India and is not recommended at present
a. Memantine: found effective in 2 double blinded and for clinical use. There are a few uncontrolled trials
one single blinded RCT. demonstrating the utility of higher than recommended
b. Lamotrigine: found effective in 2 double blinded RCTs doses of SSRIs (up to 400 mg of sertraline, 40-50 mg of
c. Topiramate: effective in 2 small double-blind RCTs, but escitalopram) in resistant patients. This strategy should be
poorly tolerated considered experimental and may be used only in resistant
d. Riluzole: inconsistent results in two RCTs patients after exhausting other regular safer options.
e. N-acetylcysteine: conflicting results from three RCTs,
has to be studied further. ROLE OF OTHER NON-SOMATIC TREATMENTS
BASED ON THE EVIDENCE AND ITS RELATIVELY Around 20% of patients do not respond to available
BETTER TOLERABILITY, MEMANTINE IS pharmacological and psychological treatments.
PREFERRED OVER LAMOTRIGINE AS THE Neuromodulatory and neurosurgical treatments targeting
FIRST CHOICE GLUTAMATERGIC AUGMENTING the cortico-striato- thalamo-cortical (CSTC) circuits have
AGENT. been tried in resistant patients.
iii. Serotonergic agents NON-INVASIVE BRAIN STIMULATION

5HT-3 antagonists including ondansetron and granisetron TECHNIQUES
are reported to be effective and well tolerated in small RCTs
[27]. However, due to the methodological limitations of the 1. Electroconvulsive therapy(ECT)
individual studies, 5HT-3 antagonists are recommended as ECT has not been systematically evaluated for the treatment
second line augmenting agents along with glutamatergic of OCD. Available evidence, in the form of case reports and
agents. case series, do not provide evidence for the efficacy of ECT
[28]. Hence, ECT is not recommended as a treatment for
Preliminary evidence suggests that clomipramine can OCD and may be considered for the treatment of comorbid
be an effective augmenting agent. Clomipramine and conditions like severe mood and psychotic disorders, if
SSRI combination should be used cautiously, especially indicated.
with fluoxetine and fluvoxamine, as they may increase
clomipramine related adverse effects (including serious 2. Repetitive transcranial magnetic stimulation (rTMS)
events like seizures, cardiac effects, serotonin syndrome) rTMS entails the possibility of non-invasive and focal
due to pharmacokinetic interactions. Clomipramine stimulation of superficial cortical regions, thereby
augmentation of SSRI may be tried but adequate precautions increasing or decreasing their excitability based on the
need to be taken keeping in mind the potential adverse frequency of stimulation. The regions implicated in OCD
effects of the combination. are usually not accessible with available technology of
rTMS. Hence rTMS has been tried in superficial cortical
Mirtazapine augmentation has been found to hasten the regions which have connections with other deeper
response with no significant long term benefits [23] and structures implicated in OCD. Controlled trials of low
hence may be considered as an augmenting agent in partial frequency or high frequency rTMS over either dorsolateral
responders and non-responders. prefrontal cortex (DLPFC) have yielded conflicting results

but low frequency rTMS over supplementary motor area 60% of patients improve over 6-24 months following surgery.
(SMA) and orbitofrontal cortex (OFC) appear promising There is some suggestion that capsulotomy may be more
[29]. However, the evidence has not been very consistent. effective procedure in OCD [30] and that its efficacy may be
Overall, the findings have to be replicated in larger similar to that of deep brain stimulation (DBS)[31]. Surgery
samples with long term follow-up. There is no convincing may be associated with short-term and persistent adverse
evidence that beneficial effects persist for longer than effects including personality changes, seizures and cognitive
the trial period. The guideline recommends rTMS as an adverse effects although rates are not high.
intervention for further research and not for routine
clinical use. 2. Deep brain stimulation
Deep brain stimulation (DBS) is a potentially reversible
3. Transcranial direct current stimulation (tDCS) procedure involving high frequency stimulation of
tDCS is another focal and superficial cortical modulatory implanted electrodes in the brain. Although the mechanism
intervention, which either increases or decreases the of action is poorly understood, it is hypothesized to modify
excitability of the underlying cortex depending on the dysfunctional circuits. DBS for OCD has been evaluated
polarity of the stimulating electrode. There are only a few in sham controlled studies targeting nucleus accumbens,
case reports and an open-label trial on tDCS in OCD. It ventral capsule/ventral striatum, anterior limb of internal
has to be evaluated more systematically before it can be capsule, ventral caudate and subthlamic nucleus. A recent
recommended for clinical use in OCD. meta-analysis found a responder rate of 60% with a mean
YBOCS reduction of around 45% [32]. DBS is an invasive
NEUROSURGICAL PROCEDURES procedure and is associated with short term and long term
adverse effects. Further, the battery needs to be replaced
1. Ablative neurosurgery periodically which may be quite expensive. DBS can be
Ablative neurosurgical procedures involve producing lesions recommended in carefully selected refractory OCD patients
in specific regions of the CSTC circuit, which is hypothesized (Table 10) after discussion regarding the pros and cons of
to be dysfunctional in OCD. Reliable lesions can be produced the procedure.
with the help of “invasive” stereotactic surgery or “non-
invasively” with the help of image guided gamma radiation. The neurosurgical procedures are not curative in nature
Anterior cingulotomy and a refined version of capsulotomy and the procedures are only one aspect of a comprehensive
known as ‘gamma ventral capsulotomy’ are practiced treatment program which should continue following
in treatment refractory OCD in a few centers. Due to the
surgery.
irreversible nature, these procedures are generally employed
in treatment refractory patients (Table 10). Evidence primarily
Surgical procedures may be considered only in selective
in the form of uncontrolled studies suggests that around 40-
patients after careful evaluation of patients for treatment
refractoriness, severity of illness and comorbidities.
Table 10: Selection criteria for surgery Patients should be explained about the realistic possibility
1. Severe (YBOCS >28) and chronic unremitting OCD of benefits and risks. They should be evaluated by an
2. The disorder is causing substantial distress and impairment in independent team consisting of a psychiatrist, a neurologist
functioning (GAF ≤45) and a neurosurgeon for suitability for surgery. The treatment
3. The following treatment options tried systematically without appreciable
should be conducted under close collaboration of a team
effect on the symptoms
• Adequate trial with at least 2 of the SSRI antidepressants for at least 3 of psychiatrist, neurosurgeon, radiotherapist, imaging
months each specialist and psychologist with close monitoring of adverse
• Treatment with clomipramine at optimum dosage for at least 3 months effects. Suggested criteria for suitability to undergo surgery
unless poorly tolerated are shown in Table 10.
• Augmentation with at least 2 agents, one of them being an atypical
antipsychotic: atypical antipsychotic (ripseridone, aripiprazole),
clomipramine, memantine, ondansetron/granisetron PSYCHOLOGICAL TREATMENTS FOR OCD
• At least one adequate trial of cognitive behavior therapy (at least 20 (TABLE 11)
sessions of exposure and response prevention) or demonstrated inability
to tolerate the anxiety due to therapy
A. Cognitive Behavioral Therapy (CBT) / Exposure
• Previous treatment trials have not been abandoned prematurely due to and Response Prevention (ERP)
solely mild side effects Consistently, CBT/ERP has been shown to be efficacious in
4. Patient gives informed consent the treatment of OCD [33]. All treatment guidelines have
5. Willing to participate in the pre‑operative evaluation and post‑operative
suggested the use of CBT as a first-line treatment option.
periodic follow‑up
Relative contraindications: CBT for OCD includes ERP.
1. Comorbid intellectual disability, psychosis, bipolar disorder and severe
personality disorders CBT/ERP is a first-line treatment option for OCD. ERP is
2. Clinically significant and unstable neurologic illnesses the most important component of CBT along with belief

Table 11: Psychotherapy in OCD effective compared to supportive therapy / relaxation

Psychotherapy Strength of methods [36, 37].
recommendation
Cognitive behaviour therapy (including exposure A Where resources are available, 15-20 hours of therapist
and response prevention) assisted CBT / BT may be considered. The evidence for ICBT
Behaviour therapy (exposure and response A and computerized CBT is very preliminary and it may be
prevention) recommended in certain circumstances where regular face-
Mindfulness based cognitive behaviour therapy C
Acceptance and commitment therapy C
to-face CBT is not feasible.
Stress management and relaxation training C
Thought stopping C B. Other Psychological therapies
Dynamic psychotherapy C 1. Acceptance and Commitment Therapy
*Based on modified Strength of Recommendation Taxonomy (SORT)[15] This therapy aims to improve psychological flexibility
through the practice of acceptance and mindfulness in
modification. When facilities are available, CBT/ERP addition to commitment and behavior modification exercises.
monotherapy may be recommended in mild to moderately Preliminary evidence suggests its benefits but it needs to be
ill patients. In severely ill patients a combination of CBT and tested and compared with CBT in larger samples.
SSRI is recommended.
2. Stress management and relaxation training
CBT as an augmentation strategy These have been conventionally used in many studies
It is uncertain whether initiating a combination of CBT/ERP as control arm in studies CBT. Stress management and
and SSRI is advantageous compared to either treatment relaxation training may have non-specific effects but there is
alone. However, CBT/BT is found to be effective in no evidence suggesting their efficacy in treatment of OCD.
augmenting SSRIs in partial/non-responders to SSRIs [34].
A recent study found CBT to be superior to risperidone and 3. Mindfulness based cognitive therapy
placebo in augmenting SSRIs in OCD [35]. Patients in the CBT Mindfulness based therapy is thought to be useful in
group had significantly greater reductions in OCD symptom OCD. Preliminary data suggests its utility in treating OCD.
severity compared with participants taking risperidone or Protocols for RCT are published but there is no published
placebo. Risperidone was not superior to placebo on any evidence in the literature in clinical population.
outcome measures.
4. Family inclusive treatments
When facilities for CBT are available, CBT / BT is Family-inclusive treatment (FIT) approaches aim to include
recommended as the first line augmenting strategy in the family members in the treatment so as to improve
partial/non-responders to SSRI treatment. the family functioning, facilitate behavioral therapy etc.
Studies targeting family accommodation of obsessive-
Mode of CBT/ERP delivery and adaptations compulsive symptoms report greater improvements in
Although various models are available for CBT in OCD, patient functioning. Family members may be encouraged to
the major components are psychoeducation, development participate in CBT since family accommodation of symptoms
of symptom hierarchy, cognitive restructuring and ERP is associated with poorer treatment outcomes.
(Table 12). The method of conducting ERP has been found
to be important with ‘therapist–assisted’ ERP producing 5. Others
a greater change in symptom severity. Therapist-guided The other forms of psychological therapies with isolated
exposure is better than self-guided exposure. The numbers studies include adjunct motivational interviewing to ERP
of CBT sessions have varied between 12 and 20 sessions and Eye Movement Desensitization and Reprocessing
across various studies. It has ranged from intensive daily 2 (EMDR). There is one study examining the role of brief
hour sessions for 5 days a week for 3 weeks to less intensive dynamic therapy in OCD with negative result. In addition,
twice weekly sessions in other studies. the potential benefits of adding D-cycloserine prior to ERP
sessions has been examined in few studies.
Even though group CBT has been compared with individual
CBT, the results have been mixed. While a couple of MANAGEMENT AS PER THE DIFFERENT PHASES
studies have reported comparable efficacy for group and OF ILLNESS
individual forms of CBT, some other studies demonstrated
the superiority of individual mode of CBT compared to Acute phase
the group CBT. Another adaptation of CBT which has This includes decision on choice of treatment modality
been examined in the recent years is the internet based (SSRI vs. CBT), implementation of treatment, monitoring for
CBT (ICBT) and computerized CBT. They are found to be the response and side-effects, and planning for sequential

Table 12: Components of CBT for OCD

Step Components
Assessment • Assess nature and severity of OCD symptoms (YBOCS symptom checklist and severity rating)
• Examine insight in to the OCD symptoms
• Assessment of safety behaviors and avoidance strategies employed by the patient
• Look for current comorbid conditions such as depression that may interfere with CBT
• Assess the motivation levels and personality attributes of the patient
• Family’s involvement (accommodating the symptoms, proxy compulsions, expressed emotions) needs to be
explored
Psychoeducation • Educate regarding the nature of obsessions and compulsions
• Explain the cycle of propagation of obsessions through performing compulsions and by avoiding the stimuli
• Discuss in detail the rationale behind CBT (concepts of habituation, fear extinction and the role of
dysfunctional beliefs)
• Educate the family members about principles in CBT
Formulate the therapy • Formulation needs to be personalized
• Identify the specific cognitive distortions (maladaptive thinking patterns) such as exaggerated threat
perception, inflated responsibility, perfectionism, need to control thoughts etc.
• Develop a collaborative understanding of the formulation with the patient (e.g., the goal is to eliminate fear of
• HIV infection and not reduce/prevent the chances of contracting HIV)
Handling the thoughts • Explain the “neutral spectatorship” principle towards obsessions (don’t interpret them, observe )
• Demonstrate how offering active resistance to obsessions is counterproductive and increases their salience
Challenging the dysfunctional • Foster the practice of gathering evidence for the thoughts (how likely would it happen/what is the worst
beliefs consequence/less threatening alternative explanations etc.)
• Socratic questioning initiated
• Examining the faulty appraisals with examples
• Preparing for behavioral experiments (exposure and response prevention)
Behavioral Experiments-Exposure • ERP forms the core of CBT. Exposure to anxiety provoking situations in a graded manner with negotiations
and Response prevention and contracts at every step
• Rationale of ERP with examples-explain the habituation and extinction principle with the aim of anxiety
reduction as well as disconfirmation of the fears
• Make a list of anxiety provoking situations/triggers in a hierarchical manner using subjective units of
distress (0 to 10 subjective rating by the patient)
• Expose the patient starting from the lowest anxiety provoking situation and gradually escalate the level. Each
session lasting for 1‑1 ½ hours , till the patient experiences reduction in distress/anxiety
• Homework assignments, consistent performance of ERP tasks insisted upon
Relapse prevention • Explain that treatment is a continuous process
• Periodic booster sessions to review the situation and to troubleshoot emerging issues
• Anticipation of future concerns such as change in the form of symptoms, relapse under stress, emergence of
subtle avoidance behaviors etc
• Encourage regular work and other normal behaviors
treatment trials if initial treatments failed to produce MANAGEMENT OF COMORBID CONDITIONS

satisfactory improvement.
Depression and Anxiety disorders
Maintenance treatment (How long the treatment should Most common co-occurring illness is major depression. The
be continued?) Pharmacological treatment strategy does not change much,
There is evidence for ongoing improvement with continued however in severe depression CBT/ERP for OCD needs to
use of SSRIs and clomipramine in long term continuation kept on hold until the patient recovers from depression.
studies for a period of up to 1 year[18]. Guidelines Severe depression with prominent suicidal ideas needs
recommend continuation of SSRIs / clomipramine for at to be evaluated thoroughly and ECT may be considered if
least 1-2 years after achieving remission. Clinical experience indicated. Comorbid dysthymia is common and may require
dictates that discontinuation of medication beyond that individual therapy.
period may be associated with increased chance of relapse.
Hence discontinuation of medications should be carefully Comorbid anxiety disorder needs to be treated aggressively
considered based on individual patient factors including since untreated anxiety disorder may contribute to poor
severity and duration of illness, past history of relapse on treatment outcome. Comorbid anxiety disorders may
discontinuation, residual symptoms, comorbidities etc. require CBT in addition to SSRIs.
Most patients may require continued pharmacotherapy to
prevent relapses. Medications are generally recommended Tic disorders
to be continued at the same dose that resulted in Tic disorders show best response to antipsychotics
improvement, unless the dosage is not tolerated. (haloperidol, pimozide, risperidone and aripirazole).

Although antipsychotics may be more effective, adrenegic α2 discussion with patient and spouse regarding options,
agonists (clonidine and guanafacine) may be tried first to treat and active liaison with obstetricians, ultrasonologists and
tics in view of adverse effects associated with antipsychotics. pediatricians.
Habit-reversal therapy (HRT) is a potential first-line treatment
option instead of or in combination with pharmacotherapy. Following is the summary of SSRIs in pregnancy and lactation:
OCD patients with tic disorders may require a combination 1. If the patient is symptom-free for a long period, an
of an SSRI and an antipsychotic. There is evidence that OCD attempt may be made to withdraw the SSRI gradually.
comorbid with tic disorders may not respond satisfactorily However, a risk of relapse following discontinuation
to SSRI alone. should be discussed.
2. Benefits vs. risks of continuing SSRIs during pregnancy
Bipolar Disorder should be discussed keeping in mind the fact that OCD
Comorbid bipolar disorder calls for a different treatment can relapse following discontinuation.
strategy because SSRIs are well known to cause/exacerbate 3. SSRIs as a group do not appear to be major teratogens.
hypomania or mania. Mood stabilization should be the 4. SSRIs, paroxetine in particular have been associated with
primary goal in treating OCD-bipolar patients [38]. In increased risk for cardiac malformations (septal defects)
many patients with comorbid bipolar disorder, OCD often (1.5-2%), as compared to the general population (1%)
manifests / increases in severity in depressive episodes but but the evidence is inconsistent. Paroxetine may be
improves in mania / hypomania episodes. In such patients, avoided; it is less safe than the other SSRIs.
treatment with mood stabilizer alone may be considered. 5. Some studies have reported an association between SSRI
If OCD persists outside of the mood episodes, CBT may be use in first trimester and anencephaly, craniosynostosis,
preferred over SSRIs. However, if patient requires an SSRI, and omphalocele. However, it must be emphasized that
it has to be prescribed under the cover of mood stabilizers the risks are rare and absolute risks are small.
or an atypical antipsychotic. 6. When taken in late pregnancy, SSRIs may increase the
risk of persistent pulmonary hypertension by more
Psychosis than twofold in the newborn (absolute risk, 3 infants
OC symptoms and OCD are not uncommon in those with per 1000 exposed vs. 1.2 infants per 1000 unexposed).
schizophrenia; up to 25% of the schizophrenia patients 7. SSRIs have also been associated with decreased
report clinically significant OCD symptoms. SSRIs may be gestational age, low birth weight and spontaneous
used in treating OCD comorbid with schizophrenia, but there abortion
is limited published evidence. Some atypical antispychotics 8. Following birth, serotonergic toxicity and antidepressant
such as clozapine, risperidone and olanzapine may induce discontinuation symptoms may manifest, therefore it is
or even worsen OCD symptoms. In case of drug-induced OC important to liaise with pediatricians.
symptoms, if feasible, one may consider reducing dose or 9. Sertraline, fluvoxamine and paroxetine are present in
changing to another antipsychotic. very low concentrations in plasma of breast-fed infants
(<3% of maternal dose). It is surmised that they are
Personality disorders relatively safe during breast feeding. With fluoxetine
20% of the participants suffer from at least one comorbid and citalopram, infants can receive up to 15% of the
personality disorder (PD). The most common are obsessive- maternal dose.
compulsive, narcissistic and anxious avoidant personality
disorders. Presence of PD can complicate the course and OCD in child and adolescent population
outcome. OCD patients with different comorbid PDs differ SSRIs and clomipramine are efficacious in treating OCD and
in their therapeutic response to treatment. Borderline, are superior to placebo with modest effect size [40]. CBT
obsessive-compulsive and schizotypal personality disorders has superior efficacy compared to SSRIs in children [40]. A
can contribute to poor outcome. There are no systematic combination of CBT and SSRI seems to have no additional
studies comparing the effects of treatment in OCD coexisting advantage over CBT alone indicating that SRI treatment
with PD. Generally it is agreed upon that a combination of adds little to concomitant CBT. However, combined
medications, CBT-ERP and individual therapy are advocated. treatment is better than SSRI alone. In partial responders to
SSRIs, adding CBT is superior and efficacious as compared
OCD during pregnancy and lactation to continuing a SSRI. In view of superior efficacy of CBT,
Medication should be guided primarily by its safety data, many guidelines advocate CBT as the first line treatment
severity of the illness, and benefit vs. risk to the developing in children. In children, where facilities are available, CBT
fetus. For newly diagnosed OCD during pregnancy and in may be preferred over SSRIs as the first-line treatment. In
the post-partum period, CBT/ERP is the preferred option children with severe OCD, a combination of CBT and SSRI
[39]. Pre-pregnancy counseling for all women should is recommended over SSRI alone. SRIs are the alternative
include planning pregnancy, folate supplementation, first-line treatment for OCD in children in situations where

Table 13: Side‑effects of SSRIs

Somnolence Comment Management
Drowsiness, All SSRIs can cause somnolence Drowsiness: Prescribe bulk of dose at bedtime
insomnia Insomnia more common with fluoxetine Insomnia: Fluoxetine may be prescribed in the morning.
Benzodiazepines, Trazadone or zolpidem may be used for
insomnia
Hypotension Not a usual side‑effect
Conduction SSRIs have no effect on QTc and are not associated with SSRIs are generally safe in patients with cardiovascular
disturbances arrhythmias and conduction disturbances diseases including the post myocardial infarction period
Exception: Citalopram (? escitalopram) is associated with dose Sertraline appears to be the safest. Citalopram and escitalopram
related increase in QTc and Tosades de pointes in overdose should be used with caution in those at risk for arrhythmia
Anticholinergic Not prominent with SSRIs except with paroxetine Most get over the side‑effects. If they are troublesome, reduce
the dose or change the SSRI
Gastrointestinal Nausea, vomiting, diarrhea, dyspepsia and anorexia are common. Common GI side‑effects usually settle down with continued
Nausea more common with Fluvoxamine. Paroxetine can cause use. If they persist, reduce dose or change the SSRI. Proton
constipation pump inhibitors may be useful
SSRIs may increase the risk of gastrointestinal bleeding Use SSRIs with caution when co‑administered with aspirin,
NSAIDs or oral anticoagulants
Neurological Headache (and worsening of migraine), tremors and rarely Fine tremors, akathisia may respond to propranolol.
akathisia, extrapyramidal symptoms, seizures and dyskinesias Extrapyramidal symptoms respond to trihexiphenidyl.
Headache responds to acetaminophen prn
Activation/ Usually seen with fluoxetine Increase the dose gradually; benzodiazepines may help
agitation
Switch to mania/ Risk of switch to mania/hypomania is known in those with bipolar Always use under the cover of mood stabilizers or atypical
hypomania disorder antipsychotics
Sexual All SSRIs are associated with sexual dysfunction; prevalence may Identify if other causes such as depression and medical causes
dysfunction be as high as 60% are contributing to sexual dysfunction
All phases of sexual response are affected including decreased If possible, reduce dose or employ drug holidays but this
libido, erectile dysfunction, decreased vaginal lubrication, delayed approach has the risk of relapse
orgasm, and ejaculatory delay. Erectile dysfunction and ejaculatory Change to other SSRI may be considered
delay are worse with paroxetine compared to other SSRIs Siddenafil or tadalafil, cyproheptadine, and bupropion may
improve sexual dysfunction
Hyponatremia SSRIs are associated with hyponatremia because of syndrome of Hyponatremia is common in elderly. Monitoring is essential.
inappropriate secretion of antidiuretic hormone (SIADH). Risk Referral to specialists if serum level is <125 mmol/L
factors include old age, female gender, co‑administration of drugs
known to cause hyponatremia (diuretics, NSAIDs, ACE inhibitors
etc), reduced glomerular filtration rate, and medical comorbidity
Serotonin Nausea, vomiting, diarrhea, tremor, sweating, disorientation, Stop the offending drugs immediately. Symptomatic
syndrome restlessness, agitation, headache, increased heart rate, changes in management: benzodiazepines to treat agitation and/
blood pressure & temperature, twitching, tremors, myoclonic jerks, or seizures, intravenous fluids to maintain hydration,
hyperreflexia, high fever, seizures, arrthymias, agitation, confusion, anti‑emetic and anti‑pyretic medications. In severe cases,
delirium and even coma cyproheptadine (8‑12mg/day) is given orally
Can occur with very high doses of SSRIs or a combination of
SSRIs in high doses
Weight gain Known with all SSRIs although there may be initial weight loss. If weight gain is significant, an attempt may be made to shift to
Paroxetine is associated with weight gain more than other SSRIs another SSRI
Lifestyle modification may be discussed
Drugs such as topiramate may be tried
Suicidal SSRIs are associated with increased suicidal ideation and attempts Children on SSRIs should be monitored closely for emergence
behavior in children of suicidal thoughts
Discontinuation Abrupt discontinuation may cause discontinuation syndrome, Withdraw gradually. Taper SSRI by no more than 25% per
syndrome particularly with short‑acting drugs (dizziness, nausea, vomiting, week
diarrhea, headache, fever, sweating, chills, insomnia, paresthesias,
electric‑shock‑like sensations, anxiety, agitation, irritability,
disorientation). Reported mostly with paroxetine. Typically occur
within a week of discontinuation
Drug Fluoxetine, paroxetine and fluvoxamine inhibit cytochrome P‑450. Caution should be exercised in combining ceratin SSRIs
interactions Inhibit the metabolism and elevate levels of drugs metabolizedd by with drugs that are essentially metabolized by cytochrome
this system P‑450 system. SSRIs can elevate clomipramine level resulting
in more side effects, particularly seizures and serotonin
syndrome; this combination should be used judiciously and
patients have to be monitored closely
CBT is either not available or the child cannot comply with SSRIs in medically ill
CBT. SSRIs are generally safe in patients with cardiovascular

Table 14: Summary of treatment recommendations need to be considered, particularly in elderly who are likely
• Establish a diagnosis of OCD. Assess for comorbid conditions such as to be on many medications for other medical conditions.
depression and anxiety disorders and certain personality disorders. It is Citalopram / escitalopram and sertraline do not substantially
important to treat comorbid conditions since untreated comorbidity may inhibit P450 enzymes and therefore are associated with less
contribute to poor outcome drug interactions. All SSRIs are renally excreted. Depression
• Where feasible, employ instruments such as the YBOCS to assess
symptoms and their severity
is common in those with chronic kidney disease (CKD)
• Psychoeducation of the patient and family about OCD, its course and and end stage renal disease (ESRD). If indicated SSRIs are
treatment options is essential the preferred antidepressants. SSRIs such as paroxetine,
• SSRIs and CBT are the first‑line evidence based treatment options for citalopram and escitalopram may have to be administered
OCD. In the Indian context, SSRIs are often the preferred first‑line
in lower doses in CKD and ESRD in the background of
treatment options
• All SSRIs are equally effective but they differ in their side‑effect profile. compromised renal functions. Since many patients with
Choice of an SSRI for an individual patient is based on factors such as CKD and ESRD also suffer from cardiovascular disorders,
previous response, tolerability, acceptability, adverse effects, cost and citalopram (and perhaps escitalopram) may be used with
drug interactions caution since high doses of citalopram is associated with
• Most patients require higher than the usual antidepressant dose of an SSRI
QTc prolongation and torsades de pointes.
• There is no convincing evidence that clomipramine is superior to SSRIs.
Since clomipramine has many side‑effects, it is not recommended as the
first‑line treatment option. It may be considered if patient fails to respond Side Effects of SSRIs
to 2 or more SSRIs The dosage of anti-obsessive drugs is usually higher than
• An adequate trial of an SSRI (or clomipramine) should be for at the usual anti-depressant dose; hence it is important for
least 12 weeks in optimum doses. Premature discontinuation is not
recommended since most patients show improvement gradually over
the clinician to discuss regarding the common side-effects.
several weeks This issue is important because patients need to be on
• SSRI has to be continued at least for 1‑2 years after remission However, medications for a long duration. Sometimes an adjustment
most patients may require indefinite continued treatment with a SSRI to in dose or a switch in the time of the day the dose is taken is
prevent relapses particularly those with severe and chronic illness, past all that is needed. Rarely, stopping a particular medication
history of relapse on discontinuation and clinically significant residual
symptoms. SSRIs are generally recommended to be continued at the same
and switching to another medication may be required. Side-
dose that resulted in improvement, unless the dose is not tolerated effects of SSRIs and possible remedies are given in Table 13.
• CBT alone may be recommended in mild to moderately ill patients if
facilities for CBT exist. However, most severely ill patients benefit from a Summary
combination of an SSRI and CBT Recommendations are summarized in Table 14. The SSRIs
• In partial responders and non‑responders to SSRIs, addition of CBT
is recommended as the first option. If CBT is not feasible, an atypical and CBT are the first-line treatment options for OCD. CBT
antipsychotic in low dose (risperidone and aripiprazole) may be added as alone may be tried in mild to moderately ill patients if
an augmenting agent facilities for CBT are available. In severe OCD, a combination
• Inpatient treatment is recommended for severely ill, treatment of SSRI and CBT is recommended. In the Indian context,
resistant patients and for comorbid conditions such as severe
SSRIs are the preferred first-line treatment for OCD because
depression
• ECT has no proven value in the treatment of OCD. There is inconsistent of limited resources for delivering CBT. SSRIs are effective,
evidence regarding the efficacy of rTMS; hence it is not recommended for well tolerated and safe. For partial responders and non-
routine use responders to SRIs, CBT is an effective augmenting agent
• DBS and ablative surgery may be considered in chronic, severely ill followed by atypical antipsychotics. Although an attempt
treatment refractory OCD patients
may be made to taper and stop SSRI after 1-2 years of
sustained remission, most patients may require indefinite
problems. Citalopram (? Escitalopram) is associated with continued treatment with a SSRI. DBS and ablative
arrhythmias but the risk is low and may not be clinically surgery may be considered in chronic, severe OCD if other
significant, but may be used with caution or avoided in established treatment options have failed to produce any
those at risk for arrhythmias. SSRIs are widely used to clinically significant improvement.
treat depression in diabetes. They may improve diabetic
parameters: improvement in HbA1c levels, reduced insulin REFERENCES
requirement, enhanced insulin sensitivity and improved
glycemic control. SSRIs are not hepatotoxic, but they 1. Ruscio AM, Stein DJ, Chiu WT, Kessler RC (2010): The epidemiology
of obsessive-compulsive disorder in the National Comorbidity Survey
need to be used in lower doses and with caution in the Replication. Molecular Psychiatry. 15:53-63.
presence of significant hepatic impairment since all SSRIs 2. Sharma E, Thennarasu K, Reddy YC (2014): Long-term outcome of
are biotransformed in liver. All SSRIs are metabolized by obsessive-compulsive disorder in adults: a meta-analysis. The Journal of
Clinical Psychiatry. 75:1019-1027.
the Cytochrome P450 system and fluoxetine, fluvoxamine, 3. Simpson HB, Reddy YC (2014): Obsessive-compulsive disorder for ICD-
and paroxetine also significantly inhibit P450 enzymes. 11: proposed changes to the diagnostic guidelines and specifiers. Revista
Brasileira de Psiquiatria. 36 Suppl 1:3-13.
Therefore, these agents may potentially interfere with wide 4. Stein DJ, Kogan CS, Atmaca M, Fineberg NA, Fontenelle LF, Grant JE,
variety of other medications. Interactions with other drugs et al. (2016): The classification of Obsessive-Compulsive and Related

Disorders in the ICD-11. Journal of Affective Disorders. 190:663-674. Augmentation of Serotonin Reuptake Inhibitors in Treatment-Resistant
5. Amerio A, Odone A, Liapis CC, Ghaemi SN (2014): Diagnostic validity Obsessive-Compulsive Disorder: An Update Meta-Analysis of Double-
of comorbid bipolar disorder and obsessive-compulsive disorder: a Blind, Randomized, Placebo-Controlled Trials. The international journal
systematic review. Acta Psychiatrica Scandinavica. 129:343-358. of neuropsychopharmacology / official scientific journal of the Collegium
6. Zutshi A, Reddy YC, Thennarasu K, Chandrashekhar CR (2006): Internationale Neuropsychopharmacologicum. 18.
Comorbidity of anxiety disorders in patients with remitted bipolar disorder. 25. Veale D, Miles S, Smallcombe N, Ghezai H, Goldacre B, Hodsoll J
European Archives of Psychiatry and Clinical Neuroscience. 256:428-436. (2014): Atypical antipsychotic augmentation in SSRI treatment refractory
7. Shashidhara M, Sushma BR, Viswanath B, Math SB, Janardhan Reddy YC obsessive-compulsive disorder: a systematic review and meta-analysis.
(2015): Comorbid obsessive compulsive disorder in patients with bipolar-I BMC Psychiatry. 14:317.
disorder. Journal of Affective Disorders. 174:367-371. 26. Simpson HB, Foa EB, Liebowitz MR, Huppert JD, Cahill S, Maher MJ,
8. Mahasuar R, Janardhan Reddy YC, Math SB (2011): Obsessive- et al. (2013): Cognitive-behavioral therapy vs risperidone for augmenting
compulsive disorder with and without bipolar disorder. Psychiatry and serotonin reuptake inhibitors in obsessive-compulsive disorder: a
Clinical Neurosciences. 65:423-433. randomized clinical trial. JAMA Psychiatry. 70:1190-1199.
9. Goodman WK, Price LH, Rasmussen SA, Mazure C, Fleischmann RL, 27. Serata D, Kotzalidis GD, Rapinesi C, Janiri D, Di Pietro S, Callovini G,
Hill CL, et al. (1989): The Yale-Brown Obsessive Compulsive Scale. et al. (2015): Are 5-HT3 antagonists effective in obsessive-compulsive
I. Development, use, and reliability. Archives of General Psychiatry. disorder? A systematic review of literature. Human Psychopharmacology.
46:1006-1011. 30:70-84.
10. Scahill L, Riddle MA, McSwiggin-Hardin M, Ort SI, King RA, Goodman WK, 28. Fontenelle LF, Coutinho ESF, Lins-Martins NM, Fitzgerald PB,
et al. (1997): Children’s Yale-Brown Obsessive Compulsive Scale: reliability Fujiwara H, Yücel M (2015): Electroconvulsive therapy for obsessive-
and validity. Journal of the American Academy of Child and Adolescent compulsive disorder: a systematic review. The Journal of Clinical
Psychiatry. 36:844-852. Psychiatry. 76:949-957.
11. Koran LM, Hanna GL, Hollander E, Nestadt G, Simpson HB, American 29. Trevizol AP, Shiozawa P, Cook IA, Sato IA, Kaku CB, Guimaraes FB,
Psychiatric A (2007): Practice guideline for the treatment of patients with et al. (2016): Transcranial Magnetic Stimulation for Obsessive-Compulsive
obsessive-compulsive disorder. The American Journal of Psychiatry. Disorder: An Updated Systematic Review and Meta-analysis. The Journal
164:5-53. of ECT.
12. Baldwin DS, Anderson IM, Nutt DJ, Allgulander C, Bandelow B, 30. Leiphart JW, Valone FH (2010): Stereotactic lesions for the treatment of
den Boer JA, et al. (2014): Evidence-based pharmacological treatment psychiatric disorders. Journal of Neurosurgery. 113:1204-1211.
of anxiety disorders, post-traumatic stress disorder and obsessive- 31. Pepper J, Hariz M, Zrinzo L (2015): Deep brain stimulation versus anterior
compulsive disorder: a revision of the 2005 guidelines from the British capsulotomy for obsessive-compulsive disorder: a review of the literature.
Association for Psychopharmacology. Journal of Psychopharmacology. Journal of Neurosurgery. 122:1028-1037.
28:403-439. 32. Alonso P, Cuadras D, Gabriels L, Denys D, Goodman W, Greenberg BD,
13. National Collaborating Centre for Mental Health(UK). (2006): Obsessive- et al. (2015): Deep Brain Stimulation for Obsessive-Compulsive Disorder:
Compulsive Disorder: Core Interventions in the Treatment of Obsessive- A Meta-Analysis of Treatment Outcome and Predictors of Response. PloS
Compulsive Disorder and Body Dysmorphic Disorder, National Institute for One. 10:e0133591.
Health and Clinical Excellence: Guidance. British Psychological Society, 33. Skapinakis P, Caldwell D, Hollingworth W, Bryden P, Fineberg N,
Leicester (UK). Salkovskis P, et al. (2016): A systematic review of the clinical effectiveness
14. Bandelow B, Zohar J, Hollander E, Kasper S, Moller HJ, Wfsbp Task and cost-effectiveness of pharmacological and psychological interventions
Force on Treatment Guidelines for Anxiety O-C, et al. (2008): World for the management of obsessive-compulsive disorder in children/
Federation of Societies of Biological Psychiatry (WFSBP) guidelines for adolescents and adults. Health Technology Assessment (Winchester,
the pharmacological treatment of anxiety, obsessive-compulsive and post- England). 20:1-392.
traumatic stress disorders - first revision. The world journal of biological 34. Simpson HB, Foa EB, Liebowitz MR, Ledley DR, Huppert JD, Cahill S,
psychiatry : the official journal of the World Federation of Societies of et al. (2008): A randomized, controlled trial of cognitive-behavioral therapy
Biological Psychiatry. 9:248-312. for augmenting pharmacotherapy in obsessive-compulsive disorder. The
15. Ebell MH, Siwek J, Weiss BD, Woolf SH, Susman J, Ewigman B, et al. American Journal of Psychiatry. 165:621-630.
(2004): Strength of recommendation taxonomy (SORT): a patient-centered 35. Simpson HB, Foa EB, Liebowitz MR, Huppert JD, Cahill S, Maher MJ,
approach to grading evidence in the medical literature. The Journal of the et al. (2013): Cognitive-behavioral therapy vs risperidone for augmenting
American Board of Family Practice / American Board of Family Practice. serotonin reuptake inhibitors in obsessive-compulsive disorder: a
17:59-67. randomized clinical trial. JAMA Psychiatry. 70:1190-1199.
16. Skapinakis P, Caldwell DM, Hollingworth W, Bryden P, Fineberg NA, 36. Andersson E, Enander J, Andren P, Hedman E, Ljotsson B, Hursti T, et
Salkovskis P, et al. (2016): Pharmacological and psychotherapeutic al. (2012): Internet-based cognitive behaviour therapy for obsessive-
interventions for management of obsessive-compulsive disorder in adults: compulsive disorder: a randomized controlled trial. Psychological
a systematic review and network meta-analysis. The Lancet Psychiatry. Medicine. 42:2193-2203.
3:730-739. 37. Tumur I, Kaltenthaler E, Ferriter M, Beverley C, Parry G (2007):
17. Fineberg NA, Reghunandanan S, Brown A, Pampaloni I (2013): Computerised cognitive behaviour therapy for obsessive-compulsive
Pharmacotherapy of obsessive-compulsive disorder: evidence-based disorder: a systematic review. Psychotherapy and Psychosomatics.
treatment and beyond. The Australian and New Zealand Journal of 76:196-202.
Psychiatry. 47:121-141. 38. Amerio A, Odone A, Marchesi C, Ghaemi SN (2014): Treatment of comorbid
18. Arumugham SS, Reddy YC (2014): Commonly asked questions in bipolar disorder and obsessive-compulsive disorder: a systematic review.
the treatment of obsessive-compulsive disorder. Expert Review of Journal of Affective Disorders. 166:258-263.
Neurotherapeutics. 14:151-163. 39. Marchesi C, Ossola P, Amerio A, Daniel BD, Tonna M, De Panfilis C
19. Bloch MH, McGuire J, Landeros-Weisenberger A, Leckman JF, Pittenger (2016): Clinical management of perinatal anxiety disorders: A systematic
C (2010): Meta-analysis of the dose-response relationship of SSRI in review. J Affect Disord. 190:543-550.
obsessive-compulsive disorder. Molecular Psychiatry. 15:850-855. 40. Ivarsson T, Skarphedinsson G, Kornor H, Axelsdottir B, Biedilae S,
20. Issaria Y, Jakubovski E, Bartley CA, Pittenger C, Bloch MH (2016): Heyman I, et al. (2015): The place of and evidence for serotonin reuptake
Early onset of response with selective serotonin reuptake inhibitors in inhibitors (SRIs) for obsessive compulsive disorder (OCD) in children and
obsessive-compulsive disorder: a meta-analysis. The Journal of Clinical adolescents: Views based on a systematic review and meta-analysis.
Psychiatry. 77:e605-611. Psychiatry Research. 227:93-103.
21. Mataix-Cols D, Fernandez de la Cruz L, Nordsletten AE, Lenhard F, 41. Bloch MH, Landeros-Weisenberger A, Rosario MC, Pittenger C,
Isomura K, Simpson HB (2016): Towards an international expert consensus Leckman JF (2008): Meta-analysis of the symptom structure of obsessive-
for defining treatment response, remission, recovery and relapse in compulsive disorder. The American Journal of Psychiatry. 165:1532-1542.
obsessive-compulsive disorder. World psychiatry : official Journal of the 42. Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J,
World Psychiatric Association. 15:80-81. Weiller E, et al. (1998): The Mini-International Neuropsychiatric Interview
22. Albert U, Aguglia A, Bogetto F, Cieri L, Daniele M, Maina G, et al. (2012): (M.I.N.I.): the development and validation of a structured diagnostic
Effectiveness of cognitive-behavioral therapy addition to pharmacotherapy psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry. 59 Suppl
in resistant obsessive-compulsive disorder: a multicenter study. 20:22-33;quiz 34-57.
Psychotherapy and Psychosomatics. 81:383-385. 43. First MB, Williams JBW, Karg RS, Spitzer RL (2015): Structured
23. Arumugham SS, Reddy JY (2013): Augmentation strategies in obsessive- Clinical Interview for DSM-5 Disorders, Clinician Version (SCID-5-CV).
compulsive disorder. Expert Review of Neurotherapeutics. 13:187-202; Arlington, VA, American Psychiatric Association.
quiz 203. 44. Rosario-Campos MC, Miguel EC, Quatrano S, Chacon P, Ferrao Y,
24. Dold M, Aigner M, Lanzenberger R, Kasper S (2015): Antipsychotic Findley D, et al. (2006): The Dimensional Yale-Brown Obsessive-

Compulsive Scale (DY-BOCS): an instrument for assessing obsessive- validation of the obsessive belief questionnaire and interpretation of
compulsive symptom dimensions. Molecular Psychiatry. 11:495-504. intrusions inventory--Part 2: Factor analyses and testing of a brief version.
45. Eisen JL, Phillips KA, Baer L, Beer DA, Atala KD, Rasmussen SA (1998): Behaviour Research and Therapy. 43:1527-1542.
The Brown Assessment of Beliefs Scale: reliability and validity. The 48. Calvocoressi L, Lewis B, Harris M, Trufan SJ, Goodman WK,
American Journal of Psychiatry. 155:102-108.
McDougle CJ, et al. (1995): Family accommodation in obsessive-
46. Neziroglu F, McKay D, Yaryura-Tobias JA, Stevens KP, Todaro J (1999):
The Overvalued Ideas Scale: development, reliability and validity in compulsive disorder. The American Journal of Psychiatry. 152:441-443.
obsessive-compulsive disorder. Behaviour Research and Therapy. 49. Hazari N, Narayanaswamy JC, Arumugham SS (2016): Predictors of
37:881-902. response to serotonin reuptake inhibitors in obsessive-compulsive
47. Obsessive Compulsive Cognitions Working G (2005): Psychometric disorder. Expert Review of Neurotherapeutics. 16:1175-1191.

Clinical Practice Guidelines for Management of Sexual Dysfunction

Ajit Avasthi, Sandeep Grover, T S Sathyanarayana Rao1
Department of Psychiatry, PGIMER, Chandigarh, 1Department of Psychiatry, JSS Medical College Hospital, JSS University,
Mysore
Although sexual problems are highly prevalent, these

Participants of the Expert group on CPG for
management of sexual dysfunction are frequently under-recognized and under-diagnosed in
Murgesh Vaishnav, G Prasad Rao, Neelanjana Paul, clinical practice. It is also noted that clinicians also have
Mukesh P Jagiwala, Roop Sidana, M S Bhatia lack of understanding about the approach for identification
and evaluation of sexual problem. It is often recommended
that the treating psychiatrists and collaborating specialists
INTRODUCTION
need to possess broad knowledge and appropriate attitude
towards human sexuality.
Sexual functioning is a complex bio-psycho-social process,
coordinated by the neurological, vascular and endocrine
The essential concepts underlying the management of sexual
systems. In addition to the biological factors, the psychosocial
factors like societal and religious beliefs, health status, problems are adoption of a patient-centered framework
personal experience, ethnicity and socio-demographic for evaluation and treatment. Principles of evidence-based
conditions, and psychological status of the person/couple medicine may be followed in both men and women in
play an important role in adequate sexual functioning of a diagnostic and treatment planning and adoption of common
person. In addition, sexual activity incorporates interpersonal management approaches for sexual dysfunction. The
relationships, each partner bringing unique attitudes, needs purpose of these guidelines is to present a framework for the
and responses into the coupling. A breakdown in any of evaluation, treatment, and follow-up of the patient/couple,
these areas may lead to sexual dysfunction. who presents with sexual dysfunction. We hope that these
guidelines would help in facilitating proper management of
Prevalence of sexual dysfunction in general population is patients presenting with various types of sexual dysfunction.
very high. It is suggested that about 43% of women and 31% These guidelines are to be read along with the earlier version
of men have one or other kind of sexual dysfunction. Among of Indian Psychiatric Society Guidelines.
men, premature ejaculation is the most common male
sexual dysfunction. There is lack of consensus with regards CLASSIFICATION OF SEXUAL DISORDERS
to the most common sexual dysfunction in women with
some studies reporting hypoactive sexual desire disorder Compared to DSM-IVTR, DSM-5 has fewer categories
to be the most common entity, followed by orgasmic for describing sexual dysfunction and has provided
and arousal disorders; whereas other studies suggest gender-specific sexual dysfunctions (Table-1). Other
that difficulty achieving orgasm and vaginal dryness to be major change in DSM-5 includes the duration criteria.
the most common type of sexual dysfunction in women. According to DSM-5 the minimum duration for making
Problems of sexual dysfunction may be lifelong or acquired, the diagnosis of sexual dysfunction is 6 months (except
general or situational. substance-/medication-induced sexual dysfunction) for
almost all the disorders and also specifies the frequency
Address for correspondence: of dysfunction to be 75-100%. DSM-5 has also done away
Dr. Ajit Avasthi, Department of Psychiatry, Postgraduate
Institute of Medical Education and Research,
with the categories of sexual aversion disorder and sexual
Chandigarh ‑ 160 012, India. dysfunction due to a general medical condition. The category
E-mail: drajitavasthi@yahoo.co.in
DOI:
How to cite this article: Avasthi A, Grover S, Sathyanarayana
Rao TS. Clinical Practice Guidelines for Management of Sexual
10.4103/0019-5545.196977
Dysfunction. Indian J Psychiatry 2017;59:91-115.

Avasthi, et al.: Sexual dysfunction
Table 1: Comparison of diagnostic categories of ICD‑10 & DSM‑5 of sexual disorders

Disorders according to ICD‑10 DSM‑5
sexual cycle
Sexual desire disorders Lack or loss of sexual desire Male hypoactive sexual desire disorder
Sexual aversion Female sexual interest/arousal disorder
Excessive sexual drive
Sexual arousal Failure of genital response Male
disorders Erectile disorder
Orgasm disorders Orgasmic dysfunction Male
Lack of sexual enjoyment Premature (early) ejaculation
Premature ejaculation Delayed ejaculation
Female
Orgasmic disorder
Sexual pain disorders Nonorganic dyspareunia Female
Nonorganic Vaginismus Genito‑pelvic pain/penetration disorder
Substance/Medication induced sexual dysfunction
Other sexual disorders
Paraphilias Paraphilic disorders
Gender identity disorders Gender Dysphoria
Gender Dysphoria in children
Gender Dysphoria in adolescent and adults
Other specified Gender Dysphoria
Unspecified Gender dysphoria
Other sexual dysfunction, not caused by
organic disorder or disease
Unspecified sexual dysfunction, not
caused by organic disorder or disease
of substance induced sexual dysfunction is now labelled as Table 2: Subtypes of sexual dysfunctions according to
Substance/Medication induced sexual dysfunction. The Not DSM‑5
Otherwise Specified (NOS) category has also been removed. Subtypes
The substance or medication-induced sexual dysfunction has Onset Lifelong: present since the Acquired: develops after a period
been retained as such. Various types of sexual dysfunctions onset of sexual functioning of normal functioning
are categorized on the basis of onset and context (Table-2). Context Generalized : not limited to Situational: limited to certain types
certain types of stimulation, of stimulation, situation or partner
situation or partner
ICD-10 describes sexual disorders under the headings
of: Sexual dysfunction, not caused by organic disorder
or diseases (F52) under the broad heading of Behavioral sideward curvature of penis and watery semen. Thus, there
syndromes associated with physiological disturbances are exaggerated apprehensions in males centered on sexual
and physical disorders, Gender Identity disorders (F64), performance on “First wedding night (Suhaag raat)”. Some
Disorder of sexual preferences (F65), Psychological and of the studies have also shown that many females who have
behavioral disorders associated with sexual development leucorrhoea, for which no infective or pathological cause
and orientation (F66), under the broad heading of Disorders could be found have psychasthenic syndrome or female Dhat
of adult personality and behavior. syndrome, similar to Dhat syndrome in males.
Other sexual disorders/dysfunctions in Indian context Sexuality is understood as a broader concept which goes
Although both the nosological systems have classified sexual beyond sexual dysfunctions. These guidelines are applicable for
disorders, but they don’t include certain sexual disorders management of sexual dysfunctions and some of the disorders,
commonly seen by Indian clinicians. Indian researchers have like Dhat syndrome which are seen in the Indian context and
consistently alluded to the existence of certain unique socio- are associated with high rates of comorbid sexual dysfunctions.
culturally determined sexual clinical conditions such as, Dhat
syndrome and Apprehension about potency. Dhat syndrome has ASSESSMENT OF PATIENTS WITH SEXUAL
been coded in ICD-10 under other neurotic disorders (F48.8), DYSFUNCTIONS
but the diagnosis of apprehension about potency doesn’t find
mention. The clinical entity of apprehension about potency Evaluation of any patient with sexual dysfunction requires
is related to the commonly held belief in most of the Indian thorough understanding about the type of sexual
sub-cultures that masturbation and night emissions before dysfunction, factors associated with or contributing to
marriage result in loss of potency in marital conjugal relations. sexual dysfunction and factors maintaining the sexual
Masturbation is considered to be responsible for shrinkage or dysfunction. Accordingly, proper evaluation includes

detailed history taking (sexual, medical and psychosocial), An important aspect of sexual history taking in females is
focused physical examination, laboratory tests (routine to remember that women play different roles at different
and specific) and consultation with appropriate specialists. times in their life. Many women have several roles-the
Careful attention always be paid to the presence of professional or worker, housewife, mother, daughter,
significance comorbidities or underlying etiologies (e.g., friend, and lover. It is often seen that the over the years
cardiovascular disease, diabetes, depression). as the demands of other roles increase, lover role fades
away. Paying attention to these issues can be very useful,
Important aspects of evaluation of patients with sexual and this information can be collected by using a process
dysfunctions called the “timetable of life.” Both partners can be asked
Discussing sex-related issues can be embarrassing both for to fill in a timetable representing a typical week from their
the clinician and the patient. Patients often carry the feeling initial interaction to the time of presentation. Various
of failure or that they are abnormal. Clinicians should aspects which can be covered during the assessment of a
anticipate the embarrassment of patient and acknowledge week during a typical time frame may include, family time
that it could be difficult talking about such issues. For (that is, with children and partners), work time (both at
example, the clinician may say, “Most people find it difficult work and work in the house), extended family time (with
parents and relations), social time, personal time, and
to talk about these things and may feel a bit embarrassed. I’d
relationship time (time spent together as a couple). The
just like to reassure you that everything you say is confidential
relationship time must also include information about the
and that I’d like to help you if I can. The first step is to find out
sexual activity. A timetable almost always brings forward
exactly what’s going on so that we can figure out how to make
various elements missing in the relationship and personal
things right again. Please feel free to be open with me and to ask
time. Repeating the “timetable” for different times in life
questions whenever you have any doubt.” Some of the other
and comparing it during courtship, when sexual desire
important issues for evaluation are given in Table-3. was probably good, with the timetable for a time when
sexual desire was low is useful and can show how priorities
The basic principles of sexual history taking are given in change and how this influences desire for sexual activity.
table-4. The patient needs to be asked to describe their Looking at what happens in a sexual situation often gives
problem in terms of time and manner of onset, its course much information about the defenses used when a patient
over the period, its current status, and associated medical engages in sexual activity. Clinician may also note what
or psychological problems. While taking history, attention turns a patient on and off, how engorged he/she becomes
must be given to features which can help in distinguishing in the sexual experience, and whether loss of desire occurs
predominantly psychogenic from predominantly organic every time or it is situational. Other important aspects
sexual dysfunctions (Table-5). But, it is important to note which can enhance the understanding about the problem
that, in many cases, organic and psychogenic factors may include sexual fantasy, masturbation, genital functioning,
coexist, particularly in individuals or couples with long- and contraception.
standing or chronic sexual dysfunction. In such cases,
clinicians need to assess the independent and interactive Psychosocial history: Psychological factors associated with
role of both organic and psychogenic factors. sexual dysfunction can be divided into three categories:
Table 3: Important aspects in evaluation of sexual dysfunctions

• Conduct the evaluation in a comfortable surroundings and ensure privacy
• Be empathic, non‑judgmental, and understanding
• Preferably use the language in which patient is comfortable
• Use neutral terms (as opposed to vulgar terms) and proper medical terms as long as these are in common usage (e.g., use `penis’ and `vagina’, but perhaps
`lips’ rather than `labia’)
• Use anatomical drawings to understand patients knowledge and explain sexual issues to the patient
• Reassure the patient that sexual dysfunction or adjustment problems are common and treatable. For example, “It is common for some people to .”
• Explain things in simple, clear and specific terms. Some patients may not be able to understand the language which is commonly used by clinicians and
may feel embarrassed to admit this. Hence, whenever new terms are used, provide alternatives or explanations. Check with the patients that they understand
the terms used.
• Start with general, non‑threatening questions first (e.g., “Do you have a regular partner?”) then ask more specific and potentially embarrassing
questions (e.g., “Do you also experience this problem when you masturbate, that is, when you touch or stimulate yourself?”).
• Assumptions must be avioded (e.g., sexual orientation, number of partners, sexual practices)
• If a couple has presented together, gather the information for a sexual history from each individual separately (i.e., not in each other’s presence).
• Conduct the evaluation in presence of a female attendant/relative while examining patients of opposite gender.
• Make sure that the `problem’ does not just reflect a lack of knowledge or unrealistic expectations on the part of the presenting individual or their partner.
• Understand the cultural and religious factors which influence sexual issues
• Although sexual dysfunction may occur in isolation, but in many cases there may be co‑existing problems contributing to the dysfunction (e.g., relationship
difficulties, psychiatric or physical illness) ‑ prioritize the treatment goals in such situations
• Assess psychological sophistication and motivation of the patient/couple

Table 4: History taking for sexual disorders

Components Basic ingredients
Basic goals of history taking • To understand the type of dysfunction and its cause
• To differentiate between potential organic and psychogenic causes in the etiology of a patient’s sexual problem
• To evaluate the potential role of underlying or comorbid medical conditions
• To assess the use of concomitant medications
Basic questions in assessment LIBIDO/INTEREST
of sexual functioning for a • Do you look forward to sex?
male • Do you enjoy sexual activity?
• Do you fantasize about sex?
• Do you have sexual dreams?
• How easily are you sexually aroused (turned on)?
• How strong is your sex drive?
AROUSAL/PERFORMANCE
• When was the last time you had a satisfactory erection?
• How did you your problem start ‑ gradual or sudden?
• When did you have last normal erection?
• Do you experience morning or night time erections?
• Are you able to initiate an erection with sexual stimulation?
• Are you able to maintain an erection with sexual stimulation?
• Does your erectile dysfunction is related a specific partner or situation?
• Do you lose erection before penetration, or before climax?
• Do you have to concentrate to maintain an erection?
• Is there a significant bend in your penis?
• Do you experience pain while having erection?
• Do you have difficulty in certain sexual positions?
• Do you feel subjectively excited when you attempt intercourse?
• Does your vagina become sufficiently moist? (for females)
EJACULATION/ORGASM/SATISFACTION (males)
• Do you ejaculate when you have sex?
• Do you ejaculate when you masturbate?
• Do you ejaculate before you want to?
• How often you ejaculate before you want to?
• How often do you ejaculate before your partner wants you to?
• How does your partner react if you ejaculate before your partner wants you to?
• Do you take too long to ejaculate?
• Do you feel like nothing comes out?
• Do you experience pain with ejaculation?
• Do you see blood in your ejaculate?
• Do you have difficulty in reaching to orgasm?
• Is your orgasm satisfying?
• What percentages of sexual attempts are satisfactory to your partner?
ORGASM/SATISFACTION (females)
• Are orgasms absent and/or very delayed and/or markedly reduced in intensity?
• Is there adequate and acceptable stimulation with partner and/or with masturbation?
• Is the degree of trust and safety, you feel you need, present?
• Is there fear of letting go of control?
• What do you fear may happen that could be negative?
DYSPAREUNIA/VAGINISMUS (females)
• Where does it hurt?
• How would you describe the pain?
• When does the pain occur (with penile contact, once the penis is partially in, with full entry, after some
thrusting, after deep thrusting, with the partner’s ejaculation, after withdrawal, with subsequent micturation?)
• Does your body become tense when your partner is attempting, or you are attempting to insert his penis?
• What are your thoughts and feelings at this time?
• How long does the pain last?
• Does touching cause pain?
• Does it hurt when you wear tight clothes?
• Do other forms of penetration hurt (tampons, fingers)?
• Do you recognize the feeling of pelvic floor muscle tension during sexual contact?
• Do you recognize the feeling of pelvic floor muscle tension in other (non‑sexual) situations?
• Do you feel subjectively excited when you attempt intercourse?
• Does your vagina become sufficiently moist?
• Do you recognize the feeling of drying‑up?
Past Treatment history Past treatment history for the presenting sexual problem‑local practitioners, Ayurvedic, Homeopathic, over the
counter medications, etc.

predisposing factors, precipitating factors, and maintaining Table 5: Differentiating features between psychogenic
factors (See table-6), which can co-exist with each other. and organic sexual dysfunction
The areas to be explored in psychosocial history are enlisted Characteristics Predominantly Organic Predominantly
in table-7. It is to be remembered that the existence of Psychogenic
an organic disease does not rule out the possibility of a Age Older Younger
coexisting psychogenic factor. Conversely, the presence Onset Gradual (except trauma or surgery) Acute
of psychogenic conditions, such as anxiety, anger, guilt, or Circumstances Global Situational
Symptom Course Consistent or progressive Intermittent
marital discord, need not be considered as evidence for a
Desire Normal to start with Decreased
sole primary causation. Organic risks Present Absent, variable
Partner problem Usually Secondary Usually at the onset
The current psychological state need to be assessed with Anxiety and fear Usually Secondary Usually Primary
special focus on symptoms of anxiety or depression, low
self-esteem and coping skills, previous and current partner
Table 6: Psychological factors associated with sexual
relationships, history of sexual trauma/abuse, occupational
dysfunctions
and social stresses, socioeconomic status, and educational
Factors
level. Sexual dysfunction may affect the patient’s self-esteem
and coping ability, as well as his or her social relationships Predisposing • Restrictive upbringing
factors • Disturbed family relationships
and occupational performance. These aspects need to be • Traumatic early sexual experience
assessed in each case. Clinicians need not assume that • Inadequate sexual information
every patient is involved in a monogamous, heterosexual • Insecurity in the psychosexual role
relationship. • Distraction
Precipitating • Unreasonable expectations
factors • Random failure
Considering the fact that sexual problems arise in the • Discord in the relationship
interpersonal context, the clinician need to carefully assess • Dysfunction in the partner
past and present partner relationships. Another important • Infidelity
aspect of psychosexual history is inquiring specifically about • Reaction to organic disease
the quality of the relationship between the couple with respect • Pregnancy/Childbirth
• Poor emotional intimacy
to nonsexual factors, i.e., how to they get along on most issues, • Expectation of negative outcome
communication patterns, gender equality/inequality, level • Depression or anxiety
of commitment, dealing with stress, etc. While interviewing Maintaining • Performance anxiety
the couple together it is important to note the dynamics factors • Guilt
between the partners. Relationship problems may be due to • Poor communication
• Loss of attraction between partners
intrinsic differences between the two, and expectations about • Impaired self‑image
sexual fulfillment may also vary. Many a times, lack of proper • Restricted foreplay
communication between the couple, which may be due to • Poor emotional intimacy
embarrassment, may be mistaken as lack of caring. • Depression or anxiety
• Expectation of negative outcome
• Fear of intimacy
Another important aspect of psychosocial evaluation is the • Sexual myths and misconceptions
identification of patient/couple needs, expectations from • Poor communication
each other, priorities and treatment preferences. These may
be significantly influenced by cultural, social, ethnic and
religious perspectives. Patient education about the problem evaluated. While evaluating women careful medical history
is also important in enhancing therapeutic relationship, is to be obtained about any health problem that might
communication between patient and physician and ensuring affect sexual anatomy, the vascular system, the neurological
patient compliance. Partner involvement is important. On the system, and the endocrine system. Indirect causes i.e.,
first visit, it is not always possible to involve the partner but factors that cause chronic pain, fatigue, and malaise may
efforts need to be made to involve the patient’s partner early also contribute to dyspareunia.
in the treatment process at the earliest. If the psychosocial
assessment reveals the presence of significant psychological Substance use History: Excessive use of alcohol or use of
distress or conflict between the couple, further evaluation other recreational drugs may cause sexual dysfunction,
and management may be carried out either prior to, or along either by a direct effect on the penile neurovascular system
with treatment of sexual dysfunction. or by causing increased secretion of prolactin, reduction in
production of testosterone, or both.
Medical history: Historical events related to the presence of
chronic disease, use of pharmacological agents, endocrine Treatment/Medication History: Clinicians should also enquire
disorders, prior surgeries and trauma is to be carefully about the medication intake, including prescription drugs,

Table 7: Psychosocial assessment of sexual dysfunctions of any masses or plaque formation, angulation, unprovoked
Variables Areas covered persistent erection, or tight unretractable foreskin.
Background • Marital history, Children, Educational level, Social
variables class, Occupation, Religious beliefs, family system Similarly in females genital examination is often highly
and relationships informative, especially in cases of dyspareunia, vaginismus,
Life style factors • Alcohol, Smoking, Opioids with a history of pelvic trauma and with any disease
Psychiatric history • Depression, Anxiety disorder
Sexual History
potentially affecting genital health. If there are indications
• Childhood and adolescent sexual learning and
activities from history, the opportunity for pap smear/sexually
• Masturbation history, nocturnal emissions, Dhat, transmitted disease investigation is to be taken.
Interpersonal sexual activity
• Breadth and flexibility of sexual script with all Recommended Laboratory Testing
partners
• “Time table of different phases of life”
Recommended laboratory tests for men and women with
Current sexual • Current masturbatory and interpersonal sexual sexual problems typically include blood glucose levels,
functioning activities cholesterol, lipids, hormonal profile and X-ray spine for spina
• Nature of the problem, onset, course, frequency bifida. Additional laboratory tests (e.g., thyroid function)
• Spontaneous sexual experiences (morning erections) may be performed at the discretion of the clinician, based
Relationship with • Harmony, Communication, Partner’s health
partner on the medical history and clinician’s judgment. When an
Life stresses • Recent life stress, Current life stress, Losses infective etiology for dyspareunia remains a possibility-
Expectations • Need, Expectations, Priorities, Treatment vaginal, cervical and vulval discharge microscopy/cultures
from treatment preferences need to be performed.
over the counter medications and culturally sanctioned Assessment of Knowledge and Attitude towards sex
aphrodisiacs. Medications commonly associated with sexual Few patients may not actually have sexual dysfunction,
dysfunction include diuretics (thiazides, spironolactone), but may perceive the same, because of poor knowledge
sympatholytics agents (Central agents like methyldopa , and negativistic attitude towards sex. Further, in some
clonidine and peripheral agents like reserpine), alpha blockers, patients the sexual problems may be attributed to the
beta blockers (particularly nonselective agents), angiotensin- beliefs and cultural practices. Some of the scales like
converting enzyme inhibitors, calcium channel blockers, Sexual Knowledge and Attitude Questionnaire and Dhat
antipsychotics, antidepressants, benzodiazepines, buspirone, syndrome Questionnaire, which have been validated in the
lithium, disulfiram, digoxin, histamine H2-receptor blockers, Indian context, may be used for structured assessment and
ketoconazole, niacin, phenobarbital, phenytoin, allopurinol, documentation. These scales can also help in determining
gemfibrozil, clofiberate, phenobarbital, phenytoin, danazol, the area to be focused in sex education and psychoeducation.
GnRH agonists, oral contraceptives etc.
Specialist Consultation and Referral
Physical Examination Patients with history of medical problems be referred to
Every effort be made to ensure the privacy, confidentiality appropriate specialty to evaluate the severity and state of
and personal comfort of the patient while conducting the disease control (See table-8). Sometimes there may not be
physical examination. Careful physical examination not only a need for referral, but if patient requests for the same, it is
corroborates the medical history but at times also reveals to be done. Further diagnostic evaluation also needs to be
unsuspected physical findings (e.g., decreased peripheral conducted in case of lifelong or primary sexual dysfunction,
pulses, vaginal atrophy, atrophic testes, penile plaque). in the presence of specific anatomic or endocrine factors
and failure of initial therapy. Patients with hyposexual
In addition, to the general and systemic evaluations, detailed desire and absent or retarded emission or anorgasmia may
assessment of gonadal function, vascular competence, need to be evaluated for the presence of diseases involving
neurological integrity, and genital organ normalcy is to the nervous system. Patients with prolonged or painful
be performed on every patient. Patients suspected of erection need to be evaluated for the possibility of primary
hypogonadism need to be assessed for evidence of muscle penile disease, hematological disorder, or other systemic
development, size and structure of the penis, normal urethral diseases associated with penile complication.
opening, hypospadias, size and consistency of the testes
and the prostate. Alcohol swabs can be used to test penile By the end of assessment the clinician should be able to
temperature sensation. Bulbo-cavernosus reflex can be answer the following questions for themselves to plan
elicited by squeezing the glans penis and assessing the evoked management:
contractions of external anal sphincter or bulbo-cavernosus 1. Does patient/couple actually have sexual dysfunction?
muscles. This reflex response is clinically detectable in 70% of 2. Whether the dysfunction is primarily psychogenic or
normal males. The penis also needs to be examined for evidence primarily organic?

3. If the dysfunction has organic etiology, then is there a emotive therapy, Master Johnson’s behavioural therapy or
psychological overlay too? its modifications, systematic desensitization, ban on sexual
4. If there are more than one dysfunction, then which is intercourse and skill training in communication of sexual
the primary? preferences etc have been used. Unfortunately there are no
5. Does patient has any comorbid psychiatric disorder? well designed studies which have evaluated the effectiveness
6. If subject has a psychiatric disorder, then is the sexual of these psychotherapies. Most of the studies done have
dysfunction secondary to it? used convenience sampling, don’t describe their sample
7. If subject has a psychiatric disorder, then how severe it adequately, have not used standard definitions for various
is? disorders and are silent about the therapist variables. Hence
8. Is there a marital discord between the couple, which the results cannot be generalized. Among all the techniques,
needs to be addressed? which have been used, cognitive behavioural measures of
9. What is the motivation of the patient/couple to seek Master Johnson or its modifications are the most popular
treatment? and have been found to be most useful.
10. What is the level of psychological sophistication?
Selection of treatment: The final selection of treatment is to
MANAGEMENT OF SEXUAL DYSFUNCTION be according to patient/couple’s choice. The therapist needs
to inform the patient/couple about the available modalities
Principles of management and help them to make a reasoned choice. Agreed treatment
Management of sexual dysfunction involves patient centered goals need to be established at the start of treatment.
approach and clinicians are expected to consciously adopt Figure-1 and 2 shows the general outline for management
the patient’s perspective and respect the ideas, feelings, of cases of sexual dysfunction presenting with or without
expectations and values of their patients. Some of the basic psychiatric comorbidity. Initial evaluation involves detailed
principles of patient centered approach are given in Table-9. psychosexual history and getting the basic investigations.
Besides taking a proper history ,screening questionnaires
Formulation: After complete assessment, the first step in can be used to assess the sexual knowledge and attitude.
the management is to provide the patient/couple a brief The initial evaluation will help in ascertaining the type(s) of
and simple account of the nature of their problems and sexual dysfunction. The next step involves establishing the
possible contributory factors. The aims of the formulation probable etiological basis of the dysfunction, i.e., whether
are threefold. First, it helps the couple to understand their the dysfunction is organic in origin, psychological in origin
difficulties. This can be a source of encouragement, especially or has components of both. If the dysfunction is organic in
if the therapist also explains how common such problems are. origin the patient is to be referred to the concerned specialists
Second, the therapist point out the likely contributory factors, and need to be investigated and treated accordingly. It is
particularly the maintaining factors which will be the focus often seen that some patients may have sexual dysfunction
of therapy, and thus establish a rationale for the treatment of organic origin, but would also have psychological factors
approach. Finally, providing a formulation also helps to check contributing to its maintenance. Such patients are the most
that the information obtained during the assessment has difficult to treat and require very good liaison between
been correctly interpreted. So the couples need to be always the psychiatrist and the physicians. In patients who have
asked to give a feedback of the formulation. psychogenic sexual dysfunction, the next step involves
evaluation for sexual knowledge, relationship issues,
Balancing the partners: It is important for the therapist to presence of comorbid psychiatric disorder, motivation and
understand the contribution of individual partner to the psychological sophistication of the patient for treatment.
problem and need to strike a balance between individual
partners. The therapist must emphasize the need of Assessing the sexual knowledge and relationship issues
collaboration between the partners for the success of the are important aspect of treatment of sexual dysfunction as
therapy. The therapist needs to emphasize positive aspects many a time the patient/couple may not have any sexual
of the couple’s relationship. dysfunction per se but the reported complaints may be
arising due to faulty beliefs or relationship issues. If any of
Treatment options: Treatments for various sexual these two factors are found to be contributing to the sexual
dysfunctions can be broadly classified into general dysfunction, these need to be focused and once they have
and specific measures. The general measures include been adequately addressed, the sexual dysfunction is to be
sex education and relaxation exercises. The specific reassessed and if present needs to be treated adequately.
measures can be either pharmacological measures, non-
pharmacological measures or a combination of both. If comorbid psychiatric disorder is present, the next step
involves ascertaining – is it primary or secondary (primary-
Among the non-pharmacological measures, many types of psychiatric disorder causing sexual dysfunction; secondary –
psychotherapies like psychodynamic, interpersonal, rational psychiatric disorder is secondary to sexual dysfunction). The

Table 8: Medical history, physical examination and investigations for sexual dysfunctions
Components Basic ingredients
Medical History • Cancer (bladder, prostate, uterus, cervix, rectum or other)
• Chronic fatigue or weakness
• Diabetes mellitus
• Heart disease (heart attack, chest pain with exercise or sex)
• Hormone problems (testosterone, thyroid, steroids)
• Hyperlipidemia (elevated cholesterol or triglycerides)
• Hypertension
• Joint pains (severe or chronic problems moving or changing positions)
• Kidney disease
• Neurological problems (Parkinson’s Disease, multiple sclerosis, spinal injury)
• Prostate problems
• Radiation therapy to bladder, prostate, uterus or rectum
• Sexually transmitted diseases
• Sleep apnea (severe snoring, daytime sleepiness)
• Trauma or injury to: penis, pelvis, perineum, testes, uterus or rectum
• Unexplained weight loss
• Urinary problems (urgency, frequency, hesitancy, weak stream, infection)
• Vascular disease (stroke, mini‑stroke, blockage of arteries, aneurysms)
Treatment history • Current medications for physical illnesses
Psychiatric history • Diagnosis, severity of current symptoms, treatment
Physical examination • Complete physical examination
• General physical examination to look for evidence of cardiovascular, neurological diseases
• Complete genital exam
• Secondary sexual characteristics (e.g., gynecomastia)
• Body hair, fat distribution
• Blood pressure, heart rate, peripheral pulses, edema
• Vibratory sensation
• Lower extremity strength and coordination
Investigations • Heamogram
• Renal function test, Liver function test
• Fasting blood sugar
• Hormonal studies‑ FSH, LH, Prolactin, testosterone
• X‑ray spine for spina bifida
• Lipid Profile
• Penile Doppler
Special investigations • Nocturnal penile tumescence and rigidity testing
• Penile tumescence monitoring (Nocturnal penile tumescence (NPT) monitoring evaluates the presence or absence of the
involuntary unconscious erections, which normally occur during the REM stages of sleep, during 1-3 nights. Normal
nocturnal tumescence has been defined as a total night erection time greater than 90 min and an increase in penis
circumference in excess of 2 cm. A change in circumference of 16 mm or 80% of a full erection is thought to reflect a
sufficient degree of penile rigidity for vaginal intromission)
• Estimation of structural abnormalities of penis (penile biopsy, penile imaging, electrical activity of corpus cavernosum
• Penile angiography, radionuclear scintigraphy and measurement of cavernous oxygen tension
• Neurological investigations [biothesiometry (assesses vibration perception threshold), dorsal nerve conduction velocity,
bulbocavernosus reflex (sacral reflex arc) latency, Pudendal nerve somatosensory (genitocerebral)‑evoked potential and
Perineal electromyography.
Assessment of Knowledge • Sexual Knowledge and Attitude Questionnaire
and Attitude towards sex • Dhat syndrome Questionnaire‑ available in 10 Indian languages which can be completed by the patients themselves
Relationship issues • General relationship between the couple, marital discord etc
Indications for • Patient request
referral to urologist/ • Primary ED (poorly sustained erections, lifelong)
Gynecologist/ • Anatomic penile deformities ‑ Peyronie’s Disease, hypospadias, chordee, Phimosis, Short penis, buried penis
Endocrinologist • Pelvic/perineal trauma
• Endocrinopathy
• Complex vascular problems
• Complex neurologic problems
• Vaginismus/Dyspareunia
patient who have primary comorbid psychiatric dysfunction treatment of sexual dysfunctions. While treating these
or those who have prominent psychiatric symptoms (may disorders adequate care needs to be taken in selecting
be secondary in origin), the psychiatric disorders is to the pharmacological agent, so that the dysfunction is not
be treated first and adequately before focusing on the worsened. In some cases the side effects of the drugs can in

Patient presenting with sexual dysfunction
• Detailed psychosexual history

• Use questionnaires to assess the sexual knowledge & attitude
• Get the basic investigations done
Ascertain that the sexual dysfunction is not due to poor

sexual knowledge or poor relationship between the couple
Treat marital discord Ascertain that the sexual dysfunction is Sex Education
prior to treatment of not due to poor sexual knowledge or & reassess for
sexual dysfunction poor relationship between the couple the diagnosis
• Ascertain the type of sexual dysfunction

• Try to ascertain whether it is due to organic or psychological causes
Etiology- psychological in nature

Assess for comorbid psychiatric disorders
Etiology organic in Comorbid psychiatric Comorbid psychiatric

nature disorders present disorders absent
Refer to concerned specialist Follow figure-3 Assess motivation and

(Endocrinologist, Urologist, psychological sophistication
and Gynecologist)
Motivation low/ inadequate

psychological sophistication Motivation high/ adequate
psychological sophistication
Start with Pharmacotherapy; Manage with combination of non-

motivate the patient for nonpharmacological &
pharmacological management pharmacological measures
Figure 1: Treatment Algorithm for Evaluation & Management of a case of Sexual dysfunction
Table 9: Principles of treatment is to be treated first. An important aspect of treatment

• Inform the patient about all the available choices and guide them make a involves understanding the motivation and psychological
choice sophistication. If the motivation for treatment is low or
• Provide information to the patient in an unbiased manner about different if patient has poor psychological sophistication, then the
treatment options, their pros and cons primary mode of treatment is pharmacotherapy. Patients
• Select the treatment as per the patient’s choice
• Provide adequate information about the treatment selected, including
who are highly motivated and/or have good psychological
advice on what to do and whom to contact in case of side effects, sophistication are to be treated with combination of non-
problems and complications pharmacological and pharmacological therapies.
• Do not deny treatment in case patient does not have a partner or is not
able to bring the partner General Non-pharmacological measures: Education about
• Document the mutually agreed treatment goals
sexuality
The first step in the treatment of any sexual dysfunction
fact help in decreasing/ameliorating the sexual dysfunction, is sex education/psychoeducation. The sex education needs
for example, for a case of depression with premature to aim at normalization of the individual’s experiences
ejaculation selective serotonin reuptake inhibitors like and reduce anxiety about sex by providing accurate
paroxetine may be beneficial. If the psychiatric disorder is information. The various components of sex education are
secondary and not prominent then the sexual dysfunction shown in Table-10. Although all the areas are to be covered,

Patients presenting with sexual dysfunction & comorbid

psychiatric disorder
• Assess whether comorbidity is primary (psychiatric disorder causing sexual

dysfunction) or secondary (Psychiatric disorder is secondary to sexual
dysfunction)
• Assess the Severity of the comorbid disorder
Secondary
Primary or Secondary But
Prominent But Not prominent
Prominent
Treat sexual
dysfunction first
Intensive therapy based on

comorbid diagnosis
Assess motivation and

psychological sophistication
Select Pharmacotherapy taking into

consideration- severity of the disorder & type
of sexual dysfunction e.g. for a case of
Depression with PME give SSRIs or TCA;
Depression with ED give Trazodone
Motivation low/ inadequate Motivation high/ adequate

psychological sophistication psychological sophistication
Start with Pharmacotherapy;

Manage with non-
motivate the patient for non-
pharmacological measure ±
pharmacological management
Pharmacotherapy
Figure 2: Assessment and Management Algorithm for a case of sexual dysfunction with psychiatric comorbidity
special emphasis needs to be given to those areas, which General Non-pharmacological measures: Relaxation
are directly related to the patient’s problem. Where ever exercises
possible figures and diagrams are to be used for reference Relaxation therapy should be taught to patient using
and illustrations. In some cases the reading material can Jacobson’s Progressive Muscular Relaxation Technique or
also be provided to the couple/patient. Sex education and Benson Henry Relaxation Technique. This can be combined
teaching relaxation is to be carried out over about four with the biofeedback machine so as to facilitate objective
sessions. evidence and mastering of anxiety by the patient.
Understand and clarify sexual myths: For some individuals, Specific Non-pharmacological management of Sexual
inappropriate sexual beliefs or myths can cause problems Dysfunction
within a relationship. Individuals acquire expectations The specific non-pharmacological measures will vary according
about what sex should be like and how they or their partner to the type of sexual dysfunction. However, one of the
should behave. One of the components of sex-education is important components, of the specific measures includes home
to help the individual and his or her partner alter any sexual work assignment for the couple. It is important to remember
beliefs that interfere with the individual’s enjoyment of sex. that many of these measures are carried out simultaneously.
Some of these apply equally to both men and women, while
others will be more relevant to one gender than the other. Homework assignment for the couple: The homework
Some of the common myths are given in Table-11. assignment provides a structured approach, which allows

Table 10: Aims and Components of education about sexuality

Aims of Sex Education
• Normalize the individual’s experiences (i.e., help the individual realize that there are many others who have the same needs, problems, and experiences)
• Reduce anxiety about sex by providing accurate information about arousal and normal sexual response, clarify sexual myths and dispel unrealistic
expectations
Components of Sex Education
• Discuss about anatomy of the sex organs
• Discuss about menstrual cycle, pregnancy, puberty, masturbation, formation of semen, nightfalls, types of sex, stages of sexual intercourse, normal male
and female sexual response cycle
• Educate the patient/couple about the wide variation in the extent and frequency of feelings of sexual desire from one individual to the next
• Educate patient/couple about the importance of the timing of sex. The time of day that suits one partner may not suit the other. Help the couple plan their
time so that they have regular blocks of time alone in which they can relax, enjoy each other’s company, and engage in sexual play if desired
• Educate the couple as to how to communicate with each other to express the desire for sex
• Educate partners about how to refuse sex diplomatically
• Educate patient/couple that sex will sometimes be refused and that the refusal is not necessarily an insult or a personal rebuff
• If culturally appropriate, encourage partners to accept the use of masturbation or manual stimulation if sexual advances are refused
• Remind couples that masturbation does not represent a lack of love or desire for one’s partner
• Assist shy or reluctant partners with learning to initiate sex more frequently
• Educate patient/couple about the fact that sexual desire levels fluctuate over the life span
• Encourage patient/couple to communicate their needs for desire and sexual arousal
• Encourage patient/couple to show each other what sort of stimulation is required for orgasm to occur (e.g., manual or oral stimulation)
• Educate males that some females may be able to have multiple orgasms (especially if a vibrator is used) and hence may sometimes find it pleasurable if
genital stimulation is continued after the initial orgasm
• Encourage patient/couple to talk about what kinds of caresses they do and do not like immediately before, during, or after orgasm (e.g., genital
stimulation after orgasm may be unpleasant)
Table 11: Common Myths about Sex this stage is to help the partners develop a sense of trust
• The man should be the sexual leader and closeness, to become more aware of what each one likes
• Masturbation is wrong and to encourage communication. Details of the procedural
• A woman should not initiate sex aspect of non-genital sensate focus session are given in
• Men should not express their emotions
Table-13. It is to be explained to the couple that they need
• A woman should always have sex when her partner makes sexual
approaches to “refrain from sexual intercourse and touching of each
• All physical contact must lead to sex other’s genitalia and the women’s breast” to ensure that they
• Good sex leads to a wild orgasm are not continually confronted by those aspects of sexuality
• A man feels like having sex at any time
that is most likely to cause anxiety, and to enable them to
• Sex equals intercourse
• Sex happens automatically concentrate on rebuilding their physical relationship by first
• A `respectable’ woman should not enjoy sex too much and should learning to enjoy general physical contact. Initial reactions
certainly never masturbate to these sessions vary according to the nature of the couple’s
• All other couples have sex several times a week; have orgasm every time problem. Some couple’s may find this enjoyable and others
they have sex & orgasm simultaneously
• There must be something wrong with the relationship if sex is not good
may react negatively. In some cases it will be appropriate for
• Cultural beliefs about formation of Semen and genital secretions the therapist to just acknowledge the problem and reassure
• Role of ‘Physical strength’ or ‘Muscle power’ in sexual performance and encourage the couple. In some cases therapist have to
• Size of the penis explain that this is understandable and expected, but that in
• Circumcision and sexual performance
• Bending of Penis
order to overcome a sexual problem like theirs it is necessary
• Vasectomy/tubectomy decreases sexual potency to approach it in a systemic fashion and with due course of
• Drugs enhance sexual potency in normal persons time they will begin to get pleasure out of their sessions and
• Porn increases sexual drive these would come as spontaneous behaviour.
the couple to rebuild their sexual relationship gradually. The Some couples will have more serious difficulties in the form
stages of this programme are labeled using the terminology of negative responses to homework assignments, persistent
introduced by Master and Johnson (1970) is: non-genital breaking of the ban on sexual intercourse, or cessation of
sensate focus, genital sensate focus and vaginal containment. homework assignments. In such cases the focus of therapy
There are some basic principles of giving and carrying out might have to be changed temporarily and sessions may
the homework assignments as shown in table-12. be required to help the partners express their feelings and
anxieties. In occasional cases no progress can be made in
Non-genital sensate focus: This assignment is particularly developing understanding of why couple is encountering
helpful for a couple to establish physical intimacy in difficulties. In such cases it is worth seeing the partners
a comfortable and relaxed fashion, and allows open separately to find out whether important information is
communication about feelings and desires. The basis aim of being withheld by one of them.
Genital sensate focus: The couples, who go through the Vaginal Containment: This stage is an intermediate one
non-genital sensate focus sessions successfully, need to in the introduction of sexual intercourse to the therapy
be told to move to the genital sensate focus sessions. programme. It is relatively minor stage for couples whose
The aim and procedural aspect of genital sensate focus difficulties have by now largely resolved. For others it is
are given in Table-14. As with the non-genital sensate extremely important, especially when vaginal penetration
focus, some couples immediately find these sessions is the key step (e.g. ED, PME, and vaginismus). The couple
is instructed that when they both are feeling relaxed and
pleasurable while others would react adversely. This
sexually aroused the women can introduce her partner’s
stage is particularly likely to generate anxiety, especially
penis into her vagina and the partner to then lie still,
about sexual arousal or intimacy, so it is very important
concentrating on any pleasant genital sensations. The best
that the therapist specifically encourages partners to position to attempt vaginal containment is female superior
focus on pleasurable sensations. Some of the techniques position or a side to side position. The couple be asked to
for dealing with specific dysfunctions also need to be maintain containment as long as they wish, and then they
introduced at this stage. can return to genital and non-genital pleasuring. The couple
can repeat the containment up to three times in any one
Table 12: Principles of giving and carrying out the session. Once this stage is well established the couple to
homework assignments introduce movement during containment, with preferably
Components and goals of Homework Assignments: women starting the movements first. With this the general
• Aid in identification of specific factors (cognitions, attitudes), which programme of sex therapy is completed and now the
may be maintaining the sexual dysfunction
treatment need to include superimposition of treatment for
• The homework assignments also provides the couple the specific
techniques to deal with particular problems specific sexual dysfunctions.
Important Procedural Aspects of Homework Assignments
• The instruction need to be detailed and precise It is important to remember that during the whole therapy
• The therapist need to always check that the couple have fully registered feedback be taken after every session and any doubts/
and understood the instructions before the treatment session ends
• When giving instructions the therapist needs to ask the couple how
misconceptions be clarified.
they feel about the instructions and do they anticipate any difficulty. If
problems are anticipated, the therapist need to endeavor to resolve their Home work assignments for single male
fears before they attempt the assignment Management of sexual dysfunctions in single males also
• A couple need not be asked to move to next stage of the programme involves same principles. The subject be provided with sex
until they have mastered the current assignments
• A couple should never be left with the option of moving from one stage
education and thought relaxation exercises. The principles
to the next between treatment sessions depending on how they progress, of home work assignments for single male with erectile
because uncertainty can be detrimental dysfunction and premature ejaculation are given in Table-15
• The couple need to be informed that the therapist will be asking for the and Table-16. At the end the patient be counseled and
detail feedback on the progress at the next treatment session
reassured that he can now indulge in heterosexual experience
Table 13: Non‑Genital Sensate Focus

Aims of non‑genital sensate focus
• To help the partners develop a sense of trust and closeness, to become more aware of what each one likes and to encourage communication
Frequency of homework sessions per week
• Do not impose a too rigid schedule, but make it clear to the couple that they should at least practice 3 sessions of homework per week
Procedural Aspect of non‑genital sensate focus
• One partner inviting the other partner for a home‑work session by giving explicit invitation
• Other partner should accept the invitation if he or she is feeling either positive or neutral about it. If the feeling is negative, it is important that the partner
conveys the same with explanation about such feeling
• Invitation by the partner who did not initiate at the first instance
Caressing session: don’ts
• Refrain from sexual intercourse
• Refrain from touching of each other’s genitalias and the women’s breast
Caressing session: do’s
• Can occur wherever the couple wishes, as long as they feel comfortable (but need to avoid becoming bored), warm and there is no risk of them being
disturbed
• Need to do in a way that gives pleasure to both of them
• During the early sessions this exercise need to be like a massage
• Need to begin with one partner exploring and caressing the other partner’s body all over, except for ‘no‑go’ areas
• The partners need to swap round when they wish to, so that the passive partner now takes over caressing
• During the caressing the passive partner need to focus on the sensations elicited by the caressing and need to provide feedback on what he/she likes and
dislikes and how things could be improved
• If any of the partner becomes sexually aroused during this stage, they need to enjoy this but need not go beyond the agreed limits of caressing
• There is no restriction to self‑masturbation if any partner wishes to, for relieving the sexual tension, but not to be done in presence of the partner

without difficulty. However, he be cautioned that it should be genital sensate focus. If the therapist suggests that during
done after few days, not in a hurry, and to be carried out in the initial phase the man tries not to have an erection this
familiar surroundings without guilt or fear and anxiety. can have the opposite effect. Men with erectile dysfunction
often have difficulty attending to erotic stimuli, especially
ERECTILE DYSFUNCTION when an erection develops, tending instead to think about
the quality of their erection or whether they will be able to
An important aspect of assessment of erectile dysfunction maintain it. The therapist need to specifically encourage the
is to distinguish between psychogenic and organic erectile man to focus his attention on the pleasurable sensations he
dysfunction (See table-17). Non-pharmacological measures experiences during the partner’s genital caressing (the use
are to be used in patients with psychogenic or mixed of a lotion can often heighten these sensations), areas of his
erectile dysfunction along with pharmacological agents. partner’s body that he finds arousing, and the pleasure of
witnessing his partner’s sexual arousal.
Specific Non Pharmacological treatment for erectile
dysfunction Pharmacological treatment for erectile dysfunction
Men with psychogenic erectile dysfunction will usually Besides the psychological measures, other therapeutic
start experiencing erections during either non-genital or options for erectile dysfunction includes medications,
constriction ring, vacuum constriction devices, intra-
Table 14: Genital Sensate Focus
cavernosal injections, intra-uretheral medication devices,
Aims of genital sensate focus
penile prosthesis and reconstructive surgery (Table-18).
• To make the couples caressing more sexual and arousing and also to
encourage them to continue discussing their feelings and desires
Procedural Aspect of genital sensate focus Oral erectogenic agents
• Continue with pattern of alternate inviting and taking turns at caressing, Oral therapy with vasoactive agents has emerged as the
but to extend this to include both partner’s genitalia and women’s breast first line treatment and has transformed the management
• Emphasize the need for this stage to be added to the previous one, and
not to replace it
of erectile dysfunction.
• Taking turns of being active and passive need to continue
Caressing session: do’s Phospho-diaesterase inhibitors (PDE-5 inhibitors), i.e.,
• Caressing need to be initially gentle and exploratory, without sexual sildenafil, tadalafil, vardenafil have proven efficacy and
arousal being the objective; if any of the partners becomes sexually
safety in men with erectile dysfunction and are considered
aroused during this stage, they need to enjoy this
• Guiding the partners hand can again be a useful means of helping the as first line pharmacotherapy for management of erectile
partner learn what is enjoyable dysfunction. The profile of these drugs is shown in
• Lotions can also be used if the couple wishes table-19. Among the available PDE-5 inhibitors, sildenafil
• If either partner wish to experience orgasm they may feel free to do so, and vardenafil have short half-life, whereas tadalafil have
but this is not to be the goal of the session
relatively longer half-life. Available data also suggests the
safety of some of these PDE-5 inhibitors in patients with
Table 15: Home work assignments for Single Male with erectile dysfunction associated with diabetes mellitus,
Erectile Dysfunction spinal cord injury, chronic renal failure, Parkinson’s disease,
Home work Assignment antidepressant use and following radical prostatectomy. It
• Read erotic material, or see erotic material in books/movies and to note
the sense of sexual pleasure out of the same and to focus on it
is important to remember that action of PDE-5 inhibitors
• In subsequent sessions patient is asked to be alone and imagine about is dependent on androgens. Hence, in patients with
the content of erotic material hypogonadism management with PDE-5 inhibitors may not
• In subsequent sessions, patient also need to be asked to visualize, as far be effective and use of androgens may be an effective choice.
as possible, of being involved in the same erotic/sexual activity
Adverse effects of PDE-5 inhibitors are generally mild and
• If patient perceives erection, he shouldn’t get anxious or excited about
the same and need to continue to concentrate on the erotic stimuli and dropout rates due to side effects are similar to placebo.
related pleasure PDE-5 inhibitors are metabolized by the cytochrome P450
• In later sessions patient is advised to combine reading of and seeing 3A4 and as a result may affect metabolism of protease
erotic material with his fantasy and to focus on himself in foreplay and inhibitors and antifungal medications. In general PDE-5
later, intercourse
• In subsequent sessions, reading, seeing and fantasizing is to be
inhibitors have been shown to be safe and have not been
combined with fondling of penis and additional masturbatory hand associated with increased risk of myocardial infarction.
movements on the penis by using non‑dominant hand However, it is important to remember that use of PDE-5
• Terminate masturbation before the desire for ejaculation inhibitors is contraindicated in those receiving nitrate. Use
• At the end of the therapy the patient is instructed to fantasize about
of PDE-5 inhibitors along with antihypertensive medication
himself indulging in sexual intercourse with the process of ejaculation
and orgasm like ACE inhibitors, angiotensin-receptor blockers, calcium
Don’ts to be followed during the initial sessions channel blockers and diuretics can result in small additive
• Not to look for the erection decreases in blood pressure. Use of PDE-5 inhibitors along
• Not to note the extent of erection, if any
with alpha blockers can result in orthostatic hypotension.

There are no comparative trials to suggest superiority of A subject who does not respond to 6-8 doses of a PDE-5
one PDE-5 inhibitor over the other. However, preliminary inhibitor with sexual stimulation at maximum dose is
data from some of the cross-over trials suggest that some considered as non-responder to a PDE-5 inhibitor. However,
patients may respond better to one PDE-5 inhibitor than it is to be remembered that most often patients fail to
to another. Accordingly, it can be said that a patient who respond due to incorrect use of PDE-5 inhibitors and these
include failure to use adequate sexual stimulation, adequate
does not respond to one agent, may be shifted to another
dose and failure to wait for the adequate duration for the
PDE-5 inhibitor. Some preliminary data also suggest that a action of the medication to start. It is to be remembered
proportion of patients who fail to respond to intermittent that even though all the 3 PDE-5 inhibitors have onset of
dosing, may respond to daily dosing. action within 30 minutes of oral ingestion, in most patients a
lag of 60 minutes is required for sildenafil and verdenafil and
The selection of medication is to be done on the basis 2 hours for tadalafil. Based on the half-life of the medication,
of frequency of intercourse. Although very robust data is the normal window of efficacy of sildenafil and verdenafil is
not available, but daily use of tadalafil is associated with 6-8 hours after ingestion, whereas the window of efficacy
improved endothelial function with a sustained effect after for tadalafil is about 36 hours. Patient prescribed PDE-5
its discontinuation, whereas such effects are not seen with inhibitors are to be adequately psychoeducated with respect
to dose of medication, timing of medication, relationship
use of on-demand tadalafil.
of dosing with fatty meal, need for sexual stimulation and
window during which desired effect will be perceived.
Table 16: Home work assignments for Single Male with
Premature Ejaculation Other oral erectogenic agents
Don’ts to be followed during the initial sessions Trazodone: One of the earliest drugs used in erectile
• Abstain from heterosexual intercourse and not to experiment during
these sessions
dysfunction was trazodone. Trazodone and its active
Home work Assignment/Procedural aspects metabolite have antagonistic effect on 5HT2C receptors and
• Read erotic material, or see erotic material in books/movies, to visualize may also have adrenoceptor antagonistic action. Available
it and note the sense of derived sexual pleasure with subsequent erection data suggest that trazodone is more efficacious than
of penis placebo in mixed and psychogenic erectile dysfunction.
• Imagine himself in the same situation
• In subsequent sessions, combine reading/seeing with gentle touching
of the penis or the testicles/groin region to enhance pleasure, but he Yohimbine: It is a α2-adrenergic blocker. Before introduction
shouldn’t stroke the penis or indulge in masturbation of sildenafil, yohimbine was the most widely used oral
• Once, the previous step is mastered, patient is asked to combine the medication for management of erectile dysfunction. Available
imagery with fondling of penis so as to build up sexual pleasure and can evidence suggests that it is more efficacious than placebo.
even indulge in masturbation
• While masturbation, when patient has the feeling of imminent
ejaculation, he is to be instructed to immediately stop masturbation and Apomorphine: Apomorphine is a dopamine agonist (D1 & D2
practice squeeze technique receptors) and its sublingual form (Apo-SL) is a new central
• At the end of the therapy the patient is instructed to fantasize about initiator of erection and has been found to be effective in
himself indulging in sexual intercourse with the process of ejaculation
various types of erectile dysfunction.. Recent studies show
Table 17: Differentiating features between psychogenic and organic erectile dysfunction

Parameters Psychogenic Organic
Onset of disorder Situational with defined onset (onset Insidious
associated with specific emotional event)
Precipitating event Psychogenic condition Debilitating disease, vascular insufficiency or CNS
abnormality, penile trauma or interfering drugs
Erectile function before intromission May be present Usually absent except in patients with pelvic steal phenomenon
Erectile function after intromission Variable with different partners Usually absent
Erectile response to other sexual stimuli Usually present Usually absent
Nocturnal or morning erections Initially present and full, lost in longstanding Absent or reduced in frequency and intensity
dysfunction
Course of disorder Episodic or transient loss of erection Persistent and progressive erectile
Dysfunction
Associated ejaculatory disorder Premature ejaculation and intermittent loss of Retrograde or absent ejaculation
ejaculation
Nocturnal penile tumescence > 90‑180 min/night <60 min/night
Total time 0.2 cm 2 cm
Circumferential change >0.70 <0.60
Penile‑brachial index (PBI) <35 sec >40 sec
Bulbocavernosus reflex latency

Table 18: Treatment options for erectile dysfunction levels, exacerbation of untreated sleep apnea, benign prostatic
Oral Agents hyperplasia, and an increased risk of adenocarcinoma of the
• Sildenafil prostate. Accordingly, periodic examination of prostate,
• Tadalafil estimation of prostate-specific antigen (PSA) and heamogram
• Vardenafil are recommended in all patients receiving supplemental
• Trazodone
• Yohimbine
androgens. Obtaining a testosterone level during therapy is
• Apomorphine necessary for optimizing the dosage.
• Phentolamine
• L‑arginine Vasoactive Intracavernosal Injections (ICI)
• Androgens (Testosterone) Since early1980s, till advent of sildenafil, intracavernous
Vasoactive Intracavernosal Injections (ICI)
• Phenotolamine mesylate
injections were the mainstays of the treatment of erectile
• Papavarine dysfunction. The agents which have been used for
• Vasoactive intestinal peptide (VIP) intracavernous injections include phentolamine mesylate,
• Forskolin papavarine, vasoactive intestinal peptide (VIP), forskolin
• Alprostadil and alprostadil.
Intraurethral therapy
• Alprostadil
Transdermal therapy Phentolamine mesylate, an a - adrenoceptor antagonist
• Testosterone acts via increasing cAMP and decreasing intracellular Ca2+
• Nitroglycerine and also possibly via nitric oxide synthase (NOS) activation.
• Minoxidol Clinical efficacy and safety of intracavernosal mesylate has
Vacuum constriction devices (VCD)
Penile Prosthesis
been well documented.
Reconstructive surgeries
Papavarine is a non-selective inhibitor of phosphodiesterase
(PDE) and acts by increasing cAMP thus decreasing
that sublingual apomorphine has a safe cardiovascular intracellular smooth muscle. It is used in papavarine (20-
profile and thus making it a new treatment option for 80 mg) induced penile erection (PIPE) test to distinguish
patients with concomitant disease including cardiovascular between psychogenic and organic ED. However, it has
disease and diabetes mellitus. limited efficacy so it is used with other agents such as
phentolamine and with phentolamine and prostaglandin E1.
Phentolamine: Oral phentolamine mesylate, is a competitive
inhibitor of α- adrenergic receptor. It also has the advantage VIP and Forskolin which increase cAMP, have been found
of lack of interaction with nitrates and hence has been to be efficacious in moderate to severe erectile dysfunction
suggested as an alternative to treatment of erectile resistant to monotherapy and polypharmacotherapy. No
dysfunction in patients with cardiac illness. pain at site of injection has been reported with VIP, which
is an advantage to patients.
L-arginine: L-arginine is the precursor of Nitric Oxide (NO)
and has been shown to improve erections in 40% of patients. Alprostadil, a synthetic prostaglandin E1 is an adenylate
cyclase activator and is now the drug of choice of intra-
Androgens cavernosal pharmacotherapy. Intracavernous alprostadil in
Androgens are useful for erectile dysfunction in men with the dose of 5-40 μg is most efficacious as monotherapy. It
severe hypogonadism and may be useful as adjunctive therapy leads to erection in 5-15 minutes and the duration of ejection
when other treatments are unsuccessful by themselves. Libido depends on the dose of the medication used. It is reported
and an overall sense of well-being are likely to improve when have an efficacy of more than 70% and has also been found to
serum testosterone levels are restored to the reference range. be effective in patients with erectile dysfunction associated
Some evidence suggests that combination of testosterone and with diabetes mellitus and cardiovascular disease. Patient
PDE-5 inhibitors yields better results. Usually testosterone and partners also report high satisfaction rates. However,
is used parenterally, either once a week or once in 2 in long run use of intra-cavernosal alprostadil is associated
weeks. Other methods of administration like skin patches, with high dropout rates (41-68%), with most dropouts’
testosterone gel is also available, but this is to be used daily occuring during initial 3 months of therapy.
and is costly. Testosterone implants are also available, which
can last for 3-6 months. However, it is to be remembered that When used it is to be initially be given in the clinicians
use of exogenous androgens suppresses natural androgen office at the lowest dose and gradually the dose need to be
production. Elevated serum androgen has the potential to titrated to an adequate erectile response while monitoring
stimulate growth of prostate gland and increase the risk of for syncope. Intracavernosal alprostadil is considered to be
cancer. Use of exogenous testosterone is also known to be more effective and better tolerated over the intraurethral
associated with erythrocytosis, elevated serum transaminase form. Due to this Intracavernosal alprostadil is preferred

Table 19: Comparison of various PDE‑5 inhibitors

Sildenafil Vardenafil Tadalafil
Time to maximum plasma 30-120 (median 60) 30-120 (median 60) 30–360 (median 120)
concentration (T max) in minutes
Half‑life in hours 2.6 to 3.7 3.9 17.5
Plasma protein binding 96% 94% 94%
Bioavailability 41% 15% Not known
Onset of action in minutes 15‑60 25 16‑45
Duration of action1 4 4 36
Absorption Fatty meals cause a mean delay in Cmax of Fatty meals cause a Not affected by food
60 minutes reduction in CMAX
Available doses in mg 25, 50, 100 2.5, 5, 10,20 2.5, 5, 10,20
Recommended starting does in 50 10 10
mg/day
Maximum Dose in mg/day 100 20 20
Dose adjustments required • Patients >65 years old • Patients >65 years old • Patients >65 years old
• Hepatic impairment • Hepatic impairment • Hepatic impairment
• Renal impairment • Renal impairment • Renal impairment
• Concomitant use of potent cytochrome P450 3A4 •C oncomitant use of • Concomitant use of
inhibitors, such as ketoconazole, itraconazole, potent cytochrome potent cytochrome
erythromycin, clarithromycin, HIV protease P450 3A4 inhibitors, P450 3A4 inhibitors,
inhibitors (ritonavir and saquinavir) such as ketoconazole, such as ketoconazole,
• Concomitant use of rifampicin, phenobarbital, itraconazole, erythromycin, itraconazole, erythromycin,
phenytoin and carbamazepine, may induce CYP3A4 clarithromycin, HIV clarithromycin, HIV protease
and enhance the breakdown Concomitant use of protease inhibitors (ritonavir inhibitors (ritonavir and
cimetidine and saquinavir) saquinavir)
• Concomitant use of • Concomitant use of rifampicin,
rifampicin, phenobarbital, phenobarbital, phenytoin and
phenytoin and carbamazepine, may induce
carbamazepine, may induce CYP3A4 and enhance the
CYP3A4 and enhance the breakdown
breakdown
Contraindication Patients receiving organic nitrates either regularly or • Patients receiving organic • Any patient using organic
intermittently nitrates either regularly or nitrates either regularly or
Hypersensitivity to any component of the tablet intermittently intermittently
• Hypersensitivity to any • Hyper‑sensitivity to any
component of the tablet component of the tablet
Side effects Headache Headache Headache
Flushing Flushing Dyspepsia
Dyspepsia Rhinitis Back pain
Nasal congestion Dyspepsia Myalgia
Alteration in colour vision Sinusitis Nasal congestion
Recommended time between 1 hour 1 hour 1 to 12 hours
medication intake and intercourse
over intraurethral alprostadil. Common side effects of (8-16 mg) + Prostaglandin E1 (10-20 μg)] to sildenafil,
intra-cavernosal alprostadil are penile pain, edema and regardless of the etiology.
hematoma, palpable nodules or plaques, and priapism.
Patients are to be clearly informed about the chances of A meta-analysis of 25,000 patients showed that the
occurrence of priapism and what do in such situation. The advantage of mixing above agents is that lower doses of
patient is to be counseled that if the erections persists for drugs are required thus leading onto synergistic effects with
more than 4 hours, they need to seek emergency medical lesser side effect. Prominent side effects are pain, priapism,
help. Management of priapism in such situations involves corporal fibrosis and scar tissue formation. Also, being an
aspiration of blood from corpus cavernosum under local invasive procedure, many patients find it inconvenient to
anaesthesia. If this fails than intra-cavernosal phenylephrine inject repeatedly. Procedural complicacy, bleeding and
injection is to be given with proper monitoring for severe injury to urethra caused higher attrition rates at 1 year
hypertension, tachycardia and any arrhythmia. follow-up of patients being treated with intracavernous
vasoactive drugs.
Due to its synergistic action, it is often used with
phentolamine and papavarine. Some studies have Intraurethral therapy
demonstrated that patients of erectile dysfunction preferred Medicated urethral system for erection (MUSE), which
combination [Phentolamine (0.25-1.5 mg) + Papavarine contains 500-1000 mg of alprostadil, has shown success

rates varying from 43-69% in efficacy studies. It has curvature, sickle cell anaemia or blood dyscrasias and those
advantages that it can be self-administered and has little on anticoagulants.
systemic and local side effects.
Penile Prosthesis
Topical therapy (Transdermal delivery) Since their introduction about 3 decades ago, penile
This option minimizes both systemic exposure and tissue implants are still a widely chosen treatment option, mostly
traumatization and involves administration of vasoactive after failure of all forms of therapy for erectile dysfunction.
substances across skin of the penis. This has added benefit There are various forms of penile prosthesis, i.e., semi-rigid
from the patient’s perspective in being a less invasive rod prosthesis consists of two rod like cylinders that are
option. Pilot studies using Soft Enhanced Percutaneous implanted into corpora cavernosum, mechanical rods (Dura
Absorption (SEPA) technology, give ground for optimism. II), malleable rods and inflatable penile prosthesis (Unitary,
Preliminary evidence suggests that prostaglandin-E1+ two-piece, and three-piece devices). Usually 3 piece
SEPA are effective in 80-90% of patients. Nevertheless, this inflatable penile prosthesis is preferred as it leads to more
option requires more intensive research before approval by natural erections. Postoperative complications of penile
regulatory authorities. implants include infection and mechanical malfunction.
Peri-prosthetic infection requires immediate antibiotic
Testosterone therapy for ED is indicated only in confirmed therapy and removal of prosthesis.
cases of endocrinopathies and is to be reserved for
patients with documented hypogonadism. Transdermal Reconstructive surgery
administration has been developed recently. Gel containing Surgery for venous leakage involves penile venous ligation
2.5-5.0 mg of testosterone-applied daily to the abdomen, or embolization. Venous ligation restores spontaneous
back, thighs or upper arms have shown to produce normal erections in only 50% of patients. Arterial revascularization
plasma testosterone levels. Patients using testosterone is an experimental procedure used for treatment of
skin patches have reported improvements in libido, sexual vasculogenic ED. Upto 65% of patients report return of erectile
function, energy and mood. Adverse skin reaction (9% of cases) function following arterial revascularization, but careful
can be treated with topical hydrocortisone or antihistamine patient selection is necessary. Generally, good results are
cream. Serum prostate specific antigen (PSA) levels is to be obtained only in young men with pure arteriogenic erectile
measured before testosterone therapy is started. dysfunction. A number of complications associated with
arterial revascularization including arterial haemorrhage,
Nitroglycerine, a nitric oxide donor and minoxidil ointments glans-penis hyperemia, anastomotic occlusion, diminished
have met with only minimal success. Although still under penile sensation and fibrosis.
investigation, but these agents could acts as another tool in
the armamentarium for treating erectile dysfunction. Steps in the Management of Erectile Dysfunction
First step is to confirm the diagnosis of erectile dysfunction
Vacuum constriction devices (VCD) as per the prevailing nosological system. The consensus is
Vacuum devices work by exerting a negative pressure on that inability to attain and maintain an erection sufficient
the penis, which results in an increase in corporeal blood to permit satisfactory sexual performance, lasting for more
flow and erection. A constriction ring placed around the than 6 months, is considered to be an indicator of presence
base of the penis prolongs the erection by decreasing of erectile dysfunction. The general principles of evaluation
corporeal drainage. The erection obtained with a vacuum of erectile dysfunction are shown in Table-20. The most
device is different from that obtained normally as there important issue in management is evaluation for the organic
is no relaxation of the trabecular smooth muscle. Instead factors, look for comorbid psychiatric conditions, comorbid
blood is trapped in the intra and extracorporeal regions sexual dysfunction and marital disharmony. However, it is
of the penis. The time taken to achieve an erection varies, to be remembered that although the cause may be organic,
but is generally around 2-2.5 mins. The band need not be psychological causes can worsen the ED, so treating with
left in the place for more than 20 mins. Majority of the behavioural measures in such cases is also an important
vacuum devices currently marketed use either a battery or step in the management. Once the evaluation is complete
a hand pump to generate vacuum. Overall success rate with the patient/couple is to be explained about the potential
VCD has been reported to be around 90%, with more than beneficial and adverse effects of available treatment and
80% of patients continuing with the device. Another study guide them to make an informed choice. The selection of
quoted that 53% patients reported satisfaction with only treatment strategy for erectile dysfunction is outlined in
23% continuing with the device. Drawbacks of VCDs include figure-3. If patient has Dhat syndrome along with erectile
pain, petechiae, obstruction of ejaculation, penile pivoting, dysfunction, it is to be addressed first. Psychiatric disorders
numbness and slight bluish colouration due to cyanosis. and marital harmony is to be addressed prior to treatment
Almost all patients of ED can use VCDs. The vacuum devices of erectile dysfunction and a similar protocol need to be
are contraindicated in patients with severe Peyronie’s followed.

Initial treatment involves providing sex education, In terms of pharmacological treatments (see Table-21),
clarifying the myths, teaching relaxation exercises, PDE-5 inhibitors are considered to be the first line therapy
and sensate focus training. After assessing coexistent in treatment of erectile dysfunction. The PDE-5 inhibitors
problems, while providing formulation and sex education, available in India include sildenafil, vardenafil and tadalafil.
education about factors that create a normal sexual Apomorphine sublingual has the advantage of quick onset
response and erectile dysfunction can help patients
and their partners cope with sexual difficulties. It is
Table 20: General principles of evaluation of erectile
also important to change/remove/reduce the associated
dysfunction
modifiable or reversible factors, including lifestyle or
• Establish diagnosis based on the history, physical examination and
drug-related factors. Changes in lifestyle like smoking
investigations as per requirement
cessation, control of diabetes/ cholesterol, weight loss and • Establish the cause of erectile dysfunction (psychogenic, organic, mixed)
reduction in stress are of prime importance. The success based on the history, physical examination and investigations as per
of psychosexual therapy is guided by the motivation of requirement
the patient, as this require him to work with the therapist • Use validated questionnaires like International Index of Erectile
Function (IIEF) for grading the severity so as to monitor the response to
to understand what prevents him from experiencing
specific treatment
normal sexual arousal. • Evaluate for presence of comorbid psychiatric disorders and establish the
relationship with erectile dysfunction (i.e., what is primary psychiatric
Follow-up plan is to be tailor made for the individual and disorder or erectile dysfunction)
there is no single follow-up regime. However, regular • Evaluate the severity of underlying organic cause and treat the primary
illness first
follow-up at 4 weeks for 6 months is usually recommended.
Treat Dhat Identification of Erectile Dysfunction Liaison with

syndrome & • Sexual, Medical, Psychosocial history specialist for
Marital Discord • Assessment of relationship with partner organicity
prior to (both sexual & non-sexual)
management of • Physical Examination
ED • Evaluate for Psychiatric comorbidity
• Evaluate for other sexual dysfunctions
Psychiatric comorbidity
present/ severe
Functional
erectile
dysfunction
Treat appropriately
and then focus on ED
First line therapy

• Sex Education, Relaxation, Sex therapy, Life style modification
• Oral erectogenic agents (PDE5 inhibitors)
• Evaluate for the reasons for lack of response- improper use of PDE-5
inhibitors, poor compliance with medication, missed physical comorbidities,
missed hypogonadism
Retrial with PDE-5 inhibitors

• Proper education about how to use PDE-5 inhibitors Erectile
• Change from intermittent use to daily use Dysfunction
• Combine with testosterone in case of presence of hypogonadism resolved
Second Line therapy:

• Change Oral Erectogenic Agent Reevaluate for
• Intracavernosal self injection Organic cause
• Intraurethral alprostadil
• Combine PDE-5 inhibitors with
second line agents
Figure-3: Treatment algorithm for management of patients with ED

of action. It is well tolerated and there is no interactive The stop-start technique developed by Masters and Johnson
action with other medications, food and alcohol. This can is highly effective for the treatment of premature ejaculation
be prescribed by physicians to patients with psychogenic with success rates of as high as 90%. The technique aims
and a mild organic impotence. It is also used when PDE-5 to increase the frequency of sexual contact and sensory
inhibitors are contraindicated. VCDs are better accepted by threshold of the penis. It is best carried out in the context
older patients especially who have a stable partner. Penile of sensate focus exercises because some males ejaculate
pain, numbness and delayed ejaculation are some of the so early that direct stimulation of the penis of any kind
side effects that treating psychiatrist need to be aware of. can trigger ejaculation straight away. Starting with non-
Psychosexual therapy is also the first line treatment and it genital caresses allows the male more time to identify the
is used in patients with significant psychological problems, sensations that occur immediately prior to ejaculation. The
though psychological component may be present in all stop-start technique consists of the man lying on his back and
cases of erectile dysfunction. It is used either alone or in focusing his attention fully on the sensation provided by
combination with other first line therapies. The motivation the partner’s stimulation of his penis. When he feels himself
of the patient is of utmost importance for any psychosexual becoming highly aroused he is to indicate this to her in pre-
therapy. The major advantages are that it is non-invasive, arranged manner at which point she need to stop caressing
involves the partner, and leads to sustainable improvement and allow his arousal to subside. After a short delay this
in sexual function and satisfaction. However, it takes time, procedure is repeated twice more, following which the
is associated with high dropout rates and is associated with woman stimulates her partner to ejaculation. At first the
variable results. man may find himself ejaculating too early, but usually
gradually develops control. Later a lotion can be applied to
If the first line therapies fail or are contraindicated than the the man’s penis during this procedure, which will increase
second line treatment includes use of intracavernosal and his arousal and make genital stimulation more like vaginal
intraurethral injections. Patient’s comfort and education is containment.
very important while using intracavernosal and intraurethral
injections. Use of an automatic special pen that avoids The squeeze technique is an elaboration of the stop-start
the needle view can avoid fear of penile puncture. It is technique, and probably only needs to be used if the latter
helpful in most cases of erectile dysfunction; however, it proves ineffective. The couple proceeds as with the stop-
is contraindicated in patients with hypersensitivity to drug start procedure. When the man indicates he is becoming
employed and priapism. Erection appears within 5-15 mins. highly aroused his partner should apply a firm squeeze
The psychiatrist is to be aware of the side effects like to his penis for about 15-20 seconds. During applying the
priapism, penile pain and fibrosis. In cases where the penile pressure, the forefinger and middle finger are placed over
erection lasts more than 4 mins aspiration of blood by a the base of the glans and shaft of the penis, on the upper
19 gauge needle has been suggested. If it still does not surface of the penis, with the thumb placed at the base of
resolve then 200mg of Phenylepherine intracavernosal the undersurface of the glans. This inhibits the ejaculatory
injections every 5 mins is recommended. Intraurethral PGE1 reflex. As with the stop-start technique this is repeated
as semisolid pellets is a less invasive procedure but success three times in a session and on the fourth occasion the man
rates are lower. In case both first and second line therapies may ejaculate.
fail, use of inflatable penile prosthesis can be considered.
Both procedures appear to help a man develop more control
over ejaculation, perhaps because he gradually acquires the
Premature Ejaculation (PME)
cognitive techniques associated with ejaculatory control,
Specific Non Pharmacological for specific sexual dysfunctions
or perhaps because he gradually becomes accustomed
It is considered that behavioural management is to be
to experiencing sexual arousal without getting anxious
the first line of therapy where ever possible. The specific
(Hawton, 1989). Stop-Start technique and Squeeze technique
behavioural techniques for PME involves stop- start or
have been documented to have anywhere between 60-95%
squeeze techniques, which are usually introduced during
success rates.
genital sensate focus.
Pharmacological management of Premature Ejaculation
Table 21: Management of Erectile dysfunction (PME)
First line therapy: Phospho‑diesterase‑5‑inhibitors, apomorphine, vacuum Pharmacological treatment of premature ejaculation includes
constriction devices and psychosexual therapy
use of topical anesthetic agent, tricyclic antidepressants and
Second ‑ line therapy ‑ intracavernosal and intraurethral injections:
prostaglandin E1, phentolamine, vasoactive intestinal peptide and selective serotonin reuptake inhibitors (SSRIs) (Table-22).
papavarine. There is preliminary data for use of sildenafil and some of
Third line therapy: penile prosthesis. The inflatable type is cosmetically the Chinese herbs. However, it is important to note that
better but prosthesis infection is most problematic complication.
none of these agents have been approved.

Over the last few years, dapoxetine, another non-selective Table 22: Treatment options for premature ejaculation
SSRI, has been marketed specifically for management of PME. Antidepressants Recommended dose
Dapoxetine has been found to be efficacious in both lifelong Non selective 25‑50 mg/day or 25 mg 4‑24 hours prior to intercourse
and acquired PME. Dapoxetine is associated with side effects Serotonin
like nausea, diarrhoea, headache and dizziness. Combining reuptake inhibitor
dapoxetine with PDE-5 inhibitors is associated with increased ‑ Clomipramine
SSRI ‑ Fluoxetine 5‑20 mg/d ay
risk of syncope. It is generally recommended that patient’s
SSRI ‑ Paroxetine 10‑40 mg/day or 20 mg, 3‑4 hours prior to intercourse
blood pressure is to be evaluated prior to starting of dapoxetine. SSRI ‑ Sertraline 25 to 200 mg or 50 mg 4‑8 hrs prior to intercourse
SSRI ‑Dapoxetine 30 mg and 60 mg, on demand use, 1‑2 hours before
Among the SSRIs, paroxetine has been found to be useful. intercourse
However, data also exist for the beneficial effect of sertraline. Tramadol 62 mg of tramadol oral dispersible tablets, and 89 mg
of tramadol oral dispersible tablets, used on demand
Studies which have compared various SSRIs suggest that
Topical therapies Dose
paroxetine is superior to fluoxetine, clomipramine and Lidocaine/ Lidocaine 2.5‑5%, 20‑30 mins. prior to intercourse
sertraline. Data also suggest that sertraline is better than prilocaine cream
fluoxetine; however, the efficacy of clomipramine is not
significantly different from fluoxetine and sertraline.
Table 23: General principles of evaluation of premature
Chinese herbs like S-S cream, which are used as topical agents, ejaculation
have claimed good efficacy and favorable side effect profile. • Establish diagnosis based on the history given by patient and the partner
• Proper physical examination of genitalia and secondary sexual characters
is necessary
PDE-5 inhibitors have also been evaluated for management • Evaluate the general relationship issues and marital discord between the
of PME. Some of the available data suggests that using couple
combination of SSRIs and PDE-5 inhibitors leads to better • Look for comorbid sexual dysfunction, psychiatric morbidity and physical
outcome than use of SSRIs alone. illnesses
• Evaluate relationship with comorbid psychiatric disorders (i.e., what is
primary ‑ psychiatric disorder or premature ejaculation)
SSRIs can be used on continuous basis or on situation basis, • Evaluate the severity of underlying organic cause and treat the primary
i.e. pre-intercourse. It is unclear as which of the two is illness first
more effective. There is no clear consensus as to whether
SSRIs will effect an eventual cure of PME allowing for
present) contributing/causing the dysfunction and following
discontinuation of the medication, or whether SSRIs will be
the sensate focus training. It is considered that behavioural
required for life. The general consensus is that PME usually
returns upon discontinuation of therapy. management is the first line of therapy wherever possible.
But some authors suggest that men with lifelong premature
Steps in management of Premature Ejaculation (PME) ejaculation need to be managed with a combination of
Firstly, the diagnosis of premature ejaculation be made as pharmacotherapy and behavioural management, while
per the prevalent nosological system. The working diagnosis those with acquired or situational PME can be treated with
of PME is made if ejaculation occurs sooner than desired pharmacotherapy and/or behavioral therapy according
either before or soon after penetration causing distress to to patient/partner preference. The specific behavioural
either or both partner for more than 3 months. The general techniques for PME involves stop- start or squeeze techniques,
principles of management are shown in Table-23. which are usually introduced during genital sensate focus. The
pharmacotherapy involves use of Dapoxetine, SSRIs, TCAs,
The general guideline for selection of mode of treatment Buspirone and topical agents. If either of the therapeutic
is given in figure-4. The first step for treatment involves measure fails then a combination of both may be tried.
evaluation for presence of comorbid sexual dysfunctions, Combination of SSRIs and PDE-5 inhibitors has also been
comorbid psychiatric disorders and marital discord. If reported to lead to better outcome than use of SSRIs alone.
patient has erectile dysfunction or Dhat syndrome along
with PME, these is to be addressed first. If patient has a Selection of specific treatment modality is to be made based on
psychiatric disorder it needs to be carefully evaluated – is it physician judgment and patient’s informed choice. The primary
primary or secondary to sexual dysfunction, and how severe outcome measure is to be the patient’s and partner satisfaction.
it is. If the psychiatric comorbidity is primary and/or severe,
it is to be addressed first. Sometimes the PME is secondary Risk and benefits of all treatment options are to be discussed
to the poor interpersonal relationship between the couple, with patient prior to any intervention.
so it needs to be addressed prior to treatment of PME.
Dhat syndrome
Initial treatment involves providing sex education, clarifying The first step in the management of Dhat syndrome
the myths, relaxation and correction of situational factors (if involves evaluation for comorbid sexual dysfunctions,

psychiatric disorders and presence of possible urinary Whenever patient has comorbid Dhat syndrome along with
tract infection (UTI) and sexually transmitted diseases PME or ED, Dhat syndrome is to be treated first. If the
(STD). Where ever there is a suspicion, local examination, psychiatric comorbidity is primary and/or severe, it need to
appropriate investigations for infective pathology and be addressed first (See figure-5).
phosphaturia need to be done and adequate treatment
is to be provided. Even after appropriate treatment, if The most important aspect of treatment of Dhat syndrome is
the symptoms persist then the subject is to be provided providing adequate sex knowledge and clarifying sexual myths.
adequate sexual knowledge. Sex education mainly focuses on anatomy and physiology
of sexual organs and their functioning with reference to
Diagnosis is based
masturbation, semen formation, nocturnal emissions and
on sexual history their functioning with genitourinary system independent of
gastro-intestinal tract etc. If there is the presence of associated
Evaluate for other sexual anxiety or depressive symptoms that impede the process of
dysfunctions
• ED Treat ED, Dhat therapy, anxiolytics or/and antidepressants can be added for
• Dhat syndrome syndrome first
the least possible time and in the least possible doses.
Impaired sexual interest in men or women:

• Look for the presence of couple Treat marital
Treat psychiatric
morbidity if disharmony, depression, disharmony before Besides the general measures, no particular procedures are
prominent and anxiety, situational factors behavioural
management
used in the treatment of this problem. The main emphasis
severe
is on setting the right circumstances for sexual activity,
reducing anxiety, establishing satisfactory fore play, focusing
Discuss treatment options with patient and partner
attention on erotic stimuli and cognitions and resolving
Discuss the efficacy of each treatment options the general issues of relationship between the couple. It is
generally agreed that desire disorders have a substantially
PHARMACOLOGICAL poorer response to psychotherapy (<50%) than other forms
Topical anesthetic
Oral medications
NON-PHARMACOLOGICAL
Reassurance, Sexual education
of sexual dysfunction (≥ 70%). In addition, therapy tends
Antidepressants –Dapoxetine, SSRIs, TCA Relaxation to be more difficult and the conventional sex therapy
Buspirone, combination of SSRIs+PDE-5 Sensate focus
inhibitors Stop and start technique techniques (e.g., sensate focus) are generally inadequate.
Oral medications +Topical anaesthetic Squeeze technique
Hence, a more flexible and person centric approach to
treatment is required. Many authors have tried approaches
like cognitive-behavioral therapy, systems approach, script
Combination of Pharmacological & Non-Pharmacological treatment
modification, clinical hypnosis, guided fantasy exercises,
Figure 4: Guidelines for Premature ejaculation and sexual assertiveness training. Cognitive-behavioral
Dhat Syndrome
Treat with
appropriate
Pharmacotherapy,
Evaluate for comorbid sexual somatic treatment
Investigate & dysfunction and psychotherapy
Treat appropriately Evaluate for comorbid
in liaison with Psychiatric disorders
specialist Evaluate for possible UTI and
STD
Treat Dhat syndrome before ED / PME

Assess for sex knowledge & clarify the misconceptions
and myths
Provide knowledge about semen formation & nocturnal
emissions
Relaxation technique
Treat other sexual dysfunctions if present
Figure 5: Treatment Algorithm of Dhat syndrome

therapy emphasizes the role of thoughts and beliefs in Female sexual Dysfunction
perpetuating the maladaptive behavior and is useful Formulation of a treatment plan
when beliefs held by the patient or couple about norms Firstly female sexual disorders need to be diagnosed as per
or responses is contributing to the sexual problem. The the current definitions. Initial treatment planning requires a
“systems” approach, targets dynamics between the couple thorough assessment of the patient, with the goals of support,
and allows assessing the extent to which sexual dysfunction normalization, permission giving, sex education, stress
is used by the couple to maintain a “sexual equilibrium” reduction, symptom alleviation, improve communication skills
within the relationship (i.e., the way sexual dysfunction is (sexual & others) and attitude change. The thorough assessment
used to regulate intimacy or to allow the share of blame includes a comprehensive medical and psychological history of
between partners for the failure of the relationship). the patient and her partner. Like in male sexual dysfunction,
psychiatrist treating female sexual dysfunction is to be aware
Steps in the management of impaired sexual interest in of the etiology including genitourinary, endocrinological,
men or women: vascular and neurological systems. The general principles of
The most important issue in management is evaluation for assessment of female patients with sexual dysfunction are
the organic factors, evaluation for presence of comorbid given in Table-24. A multidisciplinary approach is of paramount
psychiatric conditions, comorbid sexual dysfunction importance in female sexual dysfunction.
and marital disharmony. But it is to be remembered that
although the cause may be organic, psychological causes Vaginismus
can decrease the sexual interest, these also need to be It is important to remember that many women who present
focused adequately. Many couples have marital disharmony with vaginismus have negative attitude towards sex and
associated with decrease sexual interest and treating the quite a few are victim of sexual assault. Some may also
same would be the only thing which is required. have the belief that premarital sex is wrong or sinful. This
belief may be so ingrained that, even when intercourse is
Besides the general measures, no particular procedures sanctioned by marriage, it may be difficult to relax physically
are used in the treatment of this problem. The main or mentally during sexual intercourse. Some times the cause
emphasis is on setting the right circumstances for sexual of vaginismus may be a fear that is instilled by friends or
activity, reducing anxiety, establishing satisfactory fore family by suggesting that the first experience of intercourse
play, focusing attention on erotic stimuli and cognitions is likely to be painful or bloody. Another important cause of
and resolving the general issues of relationship between vaginismus is fear of pregnancy.
the couple. More flexible and individualistic approach to
treatment is required. The general outline of management The sex education needs to focus on clarifying normal
is shown in figure-6. sexuality and reducing negative attitude for sex. Besides
Hypoactive sexual desire
Investigate & Treat Treat with

appropriately in appropriate
liaison with specialist Pharmacotherapy,
Evaluate for comorbid somatic treatment and
Psychiatric disorders psychotherapy
Evaluate for Marital problems
Look for organic causes
Treat general
marital issues prior
to sex therapy
Psychological management
• General behavioural management- relaxation, sex
education, clarification of myths, sensate focus
• Individual therapy
Pharmacological
• Apormorphine (Sublingual) , Bupropion
• Hormonal Treatment - estrogen, testosterone
• Sildenafil
Treat other sexual dysfunctions if present
Figure 6: Treatment Algorithm of Hypoactive sexual desire

Table 24: General principles of evaluation of female 4. Vaginal containment. When vaginal containment is
sexual dysfunction attempted the pelvic muscle exercises and the lotion
• Assessment of predisposing, precipitating and maintaining factors are used to assist in relaxing the vaginal muscles and
• Evaluation of sexual relationship with partner making penetration easier. This is often a difficult
• Comprehensive medical and psychosexual history stage and the therapist therefore needs to encourage
• Assessment for sexual abuse, recurrent depression, substance abuse, the woman to gain confidence from all the progress
self‑harm and promiscuity
• Focused pelvic examination for pelvic trauma and PAP smear need to be
made so far. Persisting concerns about possible pain
done in all cases of sexual dysfunction. may need to be explored, including how the woman
might ensure that she retains control during this stage.
5. Movements during containment: Once containment
the use of general relaxation exercises, the relaxation is well established the couple is asked to introduce
procedure also needs to focus on teaching the women to movement during containment, with preferably women
relax muscles around the inner thigh and pelvic area. starting the movements first. With this the general
programme of sex therapy is completed and now
The specific management involves the following stages: the treatment needs to include superimposition of
1. Helping the woman develop more positive attitudes treatment for specific sexual dysfunctions.
towards her genitals. After fully describing the female
sexual anatomy, the therapist need to encourage Steps in the management of vaginismus: Treatment is to
the woman to examine herself with a hand mirror be individualized for each woman and/or partner, whenever
on several occasions. Extremely negative attitudes possible with their input. Psychological issues as well as
(especially concerning the appearance of the genitals, interpersonal issues need to be addressed first. The sex
or the desirability of examining them) may become education needs to focus on clarifying normal sexuality
apparent during this stage, possibly leading to failure and reducing negative attitude for sex. Besides the use of
to carry out the homework. Some women find it easier general relaxation exercises, the relaxation procedure needs
to examine themselves in the presence of the partners; to focus on teaching the women to relax muscles around
others may only get started if the therapist helps them the inner thigh and pelvic area. The specific behavioural
do this first in the clinic. If this is necessary a medically management is to be followed.
qualified female therapist is to be involved.
2. Pelvic muscle exercises. These are intended to help the Dyspareunia
woman gain some control over the muscles surrounding Besides the general measures and sensate focus, treatment
the entrance to the vagina. If she is unsure whether or of dyspareunia involves sex education. The sex education
not she can contract her vaginal muscles she may be need to focus on the importance of adequate arousal and
asked to try to stop the flow of urine when she next the couple may also be helped by specific suggestions for
goes to the toilet. The woman can later check that she modifying their usual intercourse positions. Couple may be
is using the correct muscles by placing her finger at the helped by avoiding positions that lead to deep penetration
entrance to her vagina where she need to be able to feel (such as vaginal entry from the rear) and by adopting
the muscle contractions. Subsequently she is advised to positions in which the woman is in control of the depth
practice firmly contracting these muscles for an agreed of penetration (woman on top) or in which penetration is
number of times (e.g. 10) several times a day. not too deep (side by side or `spoons’ position). Another
3. Vaginal penetration. Once the woman has become important aspect of treatment of dyspareunia due to
comfortable with her external genital anatomy she is psychological causes is helping the woman become aroused
advised to explore the inside of her vagina with her by teaching the sensate focus programme.
fingers. This is partly to encourage familiarity and partly
to initiate vaginal penetration. Negative attitudes may In woman with repeated pain experience on intercourse,
also become apparent at this stage (e.g. concerning the it is likely that they will tense up on future occasions in
texture of the vagina, its cleanliness, fear of causing anticipation of further pain. Such tension may actually
damage, and whether it is ‘right’ to do this sort of increase pain as the muscles may be more resistant to
thing). The rationale for any of these objections is penetration. Due to this, relaxation exercises prior to or
to be explored. At a later stage the woman might try during intercourse may be helpful. Progressive muscle
using two fingers and moving them around. Once she is relaxation prior to sexual activity may allow the women
comfortable inserting a finger herself, her partner need to reduce the body tension, while more specific relaxation
to begin to do this under her guidance during their exercises just prior to intercourse may help to relax the
homework sessions. A lotion (e.g. K-Y or baby lotion) muscles around the pelvic region and may enhance arousal.
can make this easier. Graded vaginal dilators can be As a woman acquires a number of coping techniques for
used. However, clinical experience has shown that the minimising the likelihood of pain, positive self-talk may be
use of fingers is just as effective. helpful. Such self-talk can involve the woman reminding

herself that she is in control of the situation and she will be is generalized or partner specific needs to be explored.
the one to determine when penetration is to occur and how Although empirically validated non-pharmacological
deep penetration will be. treatments are not available yet, individual/couples
therapy and medical/ psychological treatment have been
Steps in the management of Dyspareunia: As with most tried in desire disorders in females. In recent times, a
of the other sexual dysfunctions, the first step is to rule pharmacological agent, flibanserin has been approved for
out other causes/factors that can cause pain. Also the the management of hypoactive sexual desire disorder in
assessment needs to rule out vaginismus and dryness of premenopausal women. The recommended dose0 is 100
vagina. Treatment of dyspareunia includes sex education mg per day at bed time. Data from metanalysis shows
and teaching sensate focus (Figure-7). In particular, it that compared to placebo, flibanserin is associated with
may be helpful for the couple to avoid deep penetration higher satisfying sexual events per month. Its use is
positions (such as vaginal entry from the rear) and to assume associated with side effects like dizziness, somnolence,
positions in which the woman is in control of the depth of nausea, and fatigue. If a patient does not show
penetration (woman on top) or in which penetration is not improvement, the drug needs to be discontinued after
too deep (side by side or `spoons’ position). 8 weeks.
Arousal disorder Aversion disorders

It is very important to rule out comorbid desire disorders Sexual abuse or rape, trauma, relationship problem, marital
before treating arousal disorders. If there is comorbid desire problem can lead to sexual aversion disorder. Therefore,
disorder then it needs to be treated first before arousal all clinicians treating sexual aversion disorders need to
disorders are treated. There is no empirically validated be aware of these causes. In Aversion disorders also no
treatment available for arousal disorders due to the fact that empirically validated treatment is available however the
this is a less researched area. Approach usually depends on clinicians usually employ couple / individual therapy.
the etiology of the arousal disorders. Sensate focusing, CBT,
systematic desensitization, individual and couples therapy, Termination of treatment
directed masturbation and communication skills have been The termination of the treatment must be planned carefully.
tried in arousal disorders with moderate results. The various strategies and component of termination are:
Desire disorders Prepare for termination from the start of treatment: The
Assessment regarding whether primary or secondary patient/couple should be told about the likely duration of
needs to be settled. Also, whether the desire disorder therapy at the beginning of the treatment. Setting the time
Dyspareunia
• Note: Dyspareunia should only be diagnosed if there is no
other sexual dysfunction such as vaginal dryness or
vaginismus that is causing the pain.
Investigate & • Evaluate for comorbid

treat sexual dysfunction
appropriately in • Evaluate for comorbid
liaison with Psychiatric disorders
Treat with
specialist • Evaluate for possible
appropriate
local pathology - UTI,
Pharmacotherapy,
STD, episiotomy scar,
somatic
endometriosis, ovarian
treatment and
cyst etc.
psychotherapy
Sex education
Provide information about suitable intercourse
positions
Progressive muscle relaxation prior to sexual activity
Positive self-talk
Sensate focus
Figure 7: Treatment Algorithm of Dyspareunia

frame will encourage the patient/couple to work on the Interventions to treat premature ejaculation: a systematic review short
report. Health Technol Assess. 2015;19:1-180.
homework assignments. 13. Grover S, Avasthi A, Aneja J, Gauri Shankar, Ravi Mohan M, Nehra R,
Padhy S. Comprehensive Questionnaire for assessment of Dhat syndrome:
development and use in patient population. J Sexual Medicine 2014; 11:
Towards the end of treatment extend the intervals between 2485-95.
sessions: The intervals between the last two to three sessions 14. Grover S, Avasthi A, Gupta S, Dan A, Neogi R, Behere PB, Lakdawala B,
Tripathi A, Chakraborty K, Sinha V, Bhatia MS, Pattojoshi A, Rao TS,
need to be extended to two to three weeks. Rozatkar A. Comorbidity in patients with dhat syndrome: a nationwide
multicentric study. J Sex Med. 2015;12:1398-401.
Prepare for relapse: The therapist need to prepare the couple 15. Grover S, Avasthi A, Gupta S, Dan A, Neogi R, Behere PB, Lakdawala B,
Tripathi A, Chakraborty K, Sinha V, Bhatia MS, Pattojoshi A, Rao TS,
for relapse. About three-fourth of men will experience Rozatkar A. Phenomenology and beliefs of patients with Dhat syndrome:
recurrence of their problem following treatment. Hence, A Nationwide multicentric study. Int J Soc Psychiatry 2016;62: 57-66.
16. Grover S, Avasthi A, Gupta S, Hazari N, Malhotra N. Do female patients
treatment also needs to assist men to cope well with with nonpathological vaginal discharge need the same evaluation as for
relapse. Most recurrences occur in a temporal pattern (i.e., Dhat syndrome in males?. Indian J Psychiatry 2016;58:61-9.
will occur more at certain times than at others) and usually 17. Grover S, Kate N, Avasthi A, Rajpal N, Umamaheswari V. Do females
too suffer from Dhat syndrome: a case series and revisit of the concept?
improve naturally or with self-initiated restart of treatment Indian J Psychiatry 2014; 56: 388-392.
techniques. The understanding that relapses are normal 18. Hatzichristou D, Rosen RC, Broderick G, Clayton A, Cuzin B, Derogatis L,
Litwin M, Meuleman E, O’Leary M, Quirk F, Sadovsky R, Seftel A. Clinical
expected helps to reduce the anxiety and sense of failure evaluation and management strategy for sexual dysfunction in men and
that may otherwise prolong erectile difficulties. women. Journal of Sexual Medicine, 2004;1:49-57.
19. Hatzichristou DG, Hatzimouratidis K, Bekas M,Apostolidis A, Tzortzis V,
Yannakoyorgos K. The diagnostic steps in the evaluation of patients with
Follow-up assessments: Follow-up assignments help the erectile dysfunction. J Urol,2002; 168:615–20.
therapist to evaluate the short-term effectiveness of 20. Hatzimouratidis K, Eardley I, Giuliano F, Hatzichristou D, Moncada I,
Salonia A, Vardi Y, Wespes E. Guidelines on Male Sexual Dysfunction:
treatment. Erectile dysfunction and premature ejaculation. European Association of
Urology Web site. http://uroweb.org/guideline/male-sexual-dysfunction/.
Updated 2015.
SUGGESTED READING 21. Hawton K. Sex therapy: A Practical guide. New York, Oxford University
Press, 1985.
1. Abdel Hamid IA, El Naggar EA, ElGilany AH. Assessment of as needed 22. Hawton K. Sexual dysfunctions. In: Cognitive Behaviour Therapy for
use of pharmacotherapy and pause-squeeze technique in premature Psychiatric Problems A Practical Guide ( Eds: K Hawton, P M Salkovskis,
ejaculation. International Journal of Impotence Research, 2001; 13: 41-45. J Kirk, D M Clerk). Oxford University Press, New York, 1989.
2. Abdel Hamid IA. Phosphodiesterase 5 inhibitors in rapid ejaculation: 23. Hoy SM, Scott LJ. Dapoxetine: in premature ejaculation. Drugs
potential use and possible mechanisms of action. Drugs, 2004; 64: 13-26. 2010;70:1433-43.
3. Alberta Medical Association. The Guidelines for the Investigation and 24. Hutchinson K, Cruickshank K, Wylie K. A benefit-risk assessment
Management of Erectile Dysfunction, 2005. of dapoxetine in the treatment of premature ejaculation. Drug Saf.
4. American Psychiatric Association. Diagnostic and statistical manual 2012;35(5):359-72.
of mental disorders: DSM-5. Washington, D.C: American Psychiatric 25. Jaspers L, Feys F, Bramer WM, Franco OH, Leusink P, Laan ET. Efficacy
Association, 2013. and Safety of Flibanserin for the Treatment of Hypoactive Sexual Desire
5. Anastasiadis AG, Salomon L, Ghafar MA,Burchardt M, Shabsigh R. Disorder in Women: A Systematic Review and Meta-analysis. JAMA Intern
Female sexual dysfunction: State of the art. Curr Urol Rep, 2002; 3: Med. 2016;176:453-62.
484–91. 26. Markou S, Perimenis P, Gyftopoulos K, Athanasopoulos A,
6. Asimakopoulos AD, Miano R, Finazzi Agrò E, Vespasiani G, Spera E. Does Barbalias G. Vardenafil (Levitra) for erectile dysfunction: a systematic
current scientific and clinical evidence support the use of phosphodiesterase review and meta-analysis of clinical trial reports. International Journal of
type 5 inhibitors for the treatment of premature ejaculation? A systematic Impotence Research, 2004; 16: 470-8.
review and meta-analysis. J Sex Med. 2012;9:2404-16. 27. Masters WH & Johnson V. Human Sexual Inadequecy. Churchill, London,
7. Avasthi A, Gupta N. Manual for standardized Management of Single males 1970.
with sexual Disorders. Marital and Psychosexual Clinic, Department of 28. Masters WH & Johnson V. Human Sexual Response. Little, Brown & Co,
Psychiatry, PGIMER, Chandigarh, 2002. Boston, 1966.
8. Avasthi A, Rao TSS, Grover S, Biswas PS, Kumar S. Indian Psychiatric 29. McMahon CG. Dapoxetine for premature ejaculation. Expert Opin
Society: Clinical Practice Guidelines for management of sexual Pharmacother. 2010;11:1741-52.
dysfunctions. (Eds): Shiv Gautam & Ajit Avasthi. Published by Indian 30. Men C, Yu L, Yuan H, Cui Y. Efficacy and safety of phosphodiesterase
Psychiatric Society, 2006; Volume II, 144 -231. type 5 inhibitors on primary premature ejaculation in men receiving
9. Avasthi AK, Varma VK, Nehra R, Das K. Construction and standardization selective serotonin reuptake inhibitors therapy: a systematic review and
of a sex knowledge and attitude questionnaire (SKAQ) in simple Hindi, for meta-analysis. Andrologia. 2016 Jan 21. doi: 10.1111/and.12540. [Epub
North Indian population. Indian Journal of Psychiatry, 1992; 34:24-27 ahead of print]
10. Bai Y, Pu C, Han P, Li J, Yuan H, Tang Y, Wang X, Wei Q. Selective 31. Rosen C. Prevalence and risk factors of sexual dysfunction in men and
Serotonin Reuptake Inhibitors Plus Phosphodiesterase-5 Inhibitors for women. Curr Psychiatry Rep. 2000;2:189-95.
Premature Ejaculation: A Systematic Review and Meta-analysis. Urology. 32. Smith-Harrison LI, Patel A, Smith RP. The devil is in the details: An
2015;86:758-64. analysis of the subtleties between phosphodiesterase inhibitors for
11. Choi HK, Jung GW, Moon KH, Xin ZC, Choi YD, Lee WH, Rha KH, Choi erectile dysfunction. Transl Androl Urol. 2016;5:181-6.
YJ, Kim DK. Clinical study of S-S cream in patients with lifelong premature 33. World Health Organization. ICD-10 classification of mental and behavioural
ejaculation. Urology, 2000;55: 257-261. disorders: Diagnostic criteria for Research. World health organization,
12. Cooper K, Martyn-St James M, Kaltenthaler E, Dickinson K, Cantrell A. Geneva, 1993.

Clinical Practice Guidelines for Sleep Disorders

Ravi Gupta, Sourav Das1, Kishore Gujar2, K K Mishra3, Navendu Gaur4, Abdul Majid5
Dept. of Psychiatry and Sleep Medicine, Himalayan Institute of Medical Sciences, Doiwala, Dehradun, 1Consultant
Psychiatrist and Sleep Specialist, Medica Superspeciality Hospital, Kolkata; Somnos Sleep Clinic, Kolkata. 2Dy. Medical
Superintendent, YCM Hospital, PCMC, Pimpri, 3HOD, Dept. of Psychiatry, JNMC, Wardha, 4Director, Gaur Mental-Health
Clinic, Ajmer-305001, 5Department of Psychiatry, SKIMS Medical College, Srinagar
Participants of expert group on CPG for Sleep Disorders is a common complaint with a number of Psychiatric
Ravi Gupta, Kishore Gujar, K K Mishra, Navendu Gaur, disorders e.g., depression, anxiety, and withdrawal from the
Abdul Majid, Gautam Saha, Amrit Pattojoshi, RK Solanki substances that depress cerebral functioning. In addition,
we now have evidence that link the depression, bipolar
disorder and schizophrenia with the disordered circadian
INTRODUCTION rhythms and many of these patients show delayed sleep
wake phase cycle.Similarly, antidepressants are known
Sleep disorders are common, still we have limited data to induce a number of sleep disorders including NREM
regarding the prevalence and management of sleep parasomnias (sleep talking, sleep walking) as well as REM
disorders from India. Although the systematic research parasomnias (REM sleep behavior disorder) and restless
is limited from our country, still case reports from Indian legs syndrome.Antipsychotics may cause weight gain and
thus they may lead to obstructive sleep apnea in a number
population suggest that we see all kinds of sleep disorders.
of patients.Similarly, opioid users suffer from central sleep
apnea and during withdrawal many of them develop RLS.
Prevalence of various sleep disorders is shown in Table 1.
Both these conditions may worsen the quality of the sleep.
Among all, we have population data for two disorders from
Secondly, daytime manifestations of a number of sleep
Indian adult population- one is Obstructive Sleep Apnea
disorders e.g., insomnia, hypersomnia, restless legs
(OSA) and second is Restless Legs Syndrome (RLS). Sleep syndrome, sleep apnea mimic that of Psychiatric disorders
problems have been investigated among Indian children e.g., depression, fibromyalgia, chronic fatigue syndrome
more frequently through variety of approaches, most and somatoform disorders.
common through the questionnaire based screening in
school-based cohorts. Considering the recent evidences and changes in the
management of sleep disorders,, Indian Psychiatric Society
Knowledge of sleep disorders is essential for psychiatrists has decided to update the existing guidelines. However,
for two reasons.First, some of the sleep disorders are few points must be kept in mind while you consider these
common in Psychiatric patients. They may be related directly guidelines for your practice:
to the pathophysiology of psychiatric illness, or may be the 1. These are consensus statements
consequence of the treatment modalities offered. Insomnia 2. Original research in this area from India is limited. Most
of the literature reviewed has been generated from the
Address for correspondence: studies involving Caucasian and European population.
Dr. Ravi Gupta,
Department of Psychiatry and Sleep Medicine, Himalayan
They are culturally, phenotypically and genetically
Institute of Medical Sciences, Doiwala, Dehradun. different from Indian population. All three factors-
E-mail: sleepdoc.ravi@gmail.com
DOI:
How to cite this article: Gupta R, Das S, Gujar K, Mishra
KK, Gaur N, Majid A. Clinical Practice Guidelines for Sleep
10.4103/0019-5545.196978
Disorders. Indian J Psychiatry 2017;59:116-38.

Gupta, et al.: CPGs for sleep disorders
culture, phenotype and genotype influence the sleep Table 1: Prevalence of various sleep disorders in general
patterns, pathophysiology of sleep disorders and their population
management- both pharmacological as well as non- Disorder Prevalence
pharmacological. Insomnia 10‑15%
Hypersomnia Not known
With this background, we will discuss the guidelines Obstructive Sleep Apnea# 14%
regarding management of individual sleep disorders. Restless legs syndrome# 2%
Delayed Sleep wake phase disorder 10%
Advanced Sleep Wake phase disorder 1%
INSOMNIA Shift worker disorder 2%
# Data from Indian population
ICD-10 defines insomnia as a condition where there is a
problem in initiating the sleep, staying asleep or waking up Table 2: Sleep Disorders that may mimic insomnia
early in the morning at least for 3 nights/week for at least Sleep related breathing disorders
1 month. It should be associated with significant distress • Obstructive sleep apnea
and persistent preoccupation with the deficiency of sleep. • Central sleep apnea
Central disorders of hypersomnolence
Narcolepsy
DSM-5 defines insomnia as a condition where a problem has Sleep related movement disorders
been reported in initiating , maintaining the sleep or there • Restless Legs Syndrome
is an early morning awakening. This problem should occur • Nocturnal Myoclonus (sleep starts)
despite adequate opportunities to fall asleep and must • Sleep Related leg cramps
• Sleep related bruxism
occur at least 3 nights a week. It should be associated with
• Sleep related rhythmic movement disorder
significant distress in the personal, social or occupational Parasomnias
life. If it persists for at least 1 month but less than 3 months, • Sleep‑walking
it is considered as episodic; if it persists for at least 3 months, • Sleep terrors
it is considered as persistent insomnia. • Nightmare disorder
Circadian Rhythm Sleep Disorders
• Advanced Sleep Wake Phase disorder
Our understanding regarding insomnia has changed over • Delayed Sleep Wake phase disorder
the years. Earlier we used to differentiate between primary • Shift worker disorder
and secondary insomnia, however, the recent research • Irregular Sleep wake rhythm disorder
Others:
has challenged this belief. Current literature suggests
• Sleep related asystole
that insomnia cannot be considered merely as a symptom • Sleep related epilepsy
of psychiatric disorders. It is rather co-morbid with the • Sleep related laryngospasm
psychiatric and other medical conditions, and if not treated
early, through the process of kindling it becomes chronic Through a careful history and clinical examination, these
which has multiple health and economic implications. conditions can be ruled out (Table 2).
For this reason, in the third edition of International While taking the history of a patient with insomnia, special
Classification of Sleep Disorder (ICSD-3), which appeared in focus should be provided to the initiation of symptoms,
2014, insomnia has been divided into two categories: short its course and progression. Information from the
term insomnia disorder and chronic insomnia disorder. In bed-partner/ room-partner who had seen the patient while
addition, subtyping of the primary insomnia into adjustment, asleep should be sought and incorporated.(Table 3).
psychophysiological, paradoxical and idiopathic that
prevailed till ICSD-2 has been omitted. This has happened He should be asked for the daytime symptoms of insomnia,
for multiple reasons.First, all the insomnia sufferers have in as in their absence, insomnia can’t be diagnosed. Frequency
common one issue i.e., hyperarousal and second, change in of symptoms must be asked along with the duration and
the sleep related behavior and compensatory mechanisms frequency of symptoms per week. It must be ensured
were found similar across different insomnia subtypes. that the patient has adequate opportunities to fall asleep.
Hence, all the modalities that are used for the treatment of Excessive daytime sleepiness must be ruled out. Clues
insomnia are directed towards reducing the hyperarousal. regarding the predisposing, precipitating and perpetuating
factors of insomnia should be assessed in detail.
Assessment and evaluation
Management of the insomnia case starts with the history It is essential to ask for the sleep pattern while the patient was
taking and general physical examination. It is of paramount asymptomatic and compare it with the sleep schedule during
importance as a number of sleep disorders may mimic symptomatic period. Sleep related behavior and rituals must
insomnia. Hence, having knowledge regarding these mimics be asked before and after the symptoms onset as they may
will help the clinician to reach to an accurate diagnosis. provide a good idea about the possible interventions.
Table 3: Information regarding a typical night Table 4: Other medical disorders that may induce sleep
Information regarding Description disturbance
Sleep Schedule • Time to bed Cardiovascular
• Time to fall asleep • Arrthythmias
• Wake time • Congestive heart failure
• Time taken to get up from bed • Myocardial infarction
• Quality of nocturnal sleep • Varicose veins
• Daytime Napping Pulmonary
• Timing • Chronic obstructive pulmonary disease
• Duration • Interstitial lung disorder
• Quality of sleep during naps • Scoliosis
• Number of naps GIT
• Regularity of this schedule • Peptic ulcer disease
Nocturnal Awakenings, if any • Number of awakenings • GERD
• Reasons for awakenings • Chronic constipation
• Time taken to fall asleep again CNS
Pre‑bedtime behavior • What does he do since evening • Intracranial space occupying lesions
• Mental state before going to bed • Dementia
Compensatory strategies • Behavior and thoughts during • Seizures
nocturnal awakenings • Stroke
Addictive substances • Nature of substance consumed • Parkinson’s disease
• Usual timing Neuromuscular disorder
• Usual effect: Stimulant/ Genitourinary
Somnolent • Chronic kidney disease
• Frequency of consumption • Benign Prostatic hypertrophy
• Withdrawal/Intoxication Musculoskeletal:
interfering with sleep • Rhumatoid arthritis
Drugs • If person is taking any drug, • Connective tissue diseases
then effect of drug on sleep
Environment of the bedroom • Look for possible factors that
Severity of insomnia may be assessed using a brief
can interfere with sleep
Time spent in bed in awake state questionnaire- Insomnia severity index, available in English
in a whole day as well as Hindi.
This should be followed by a thorough general physical

Many of the patients with insomnia start worrying while examination and if any system appears dysfunctional, that
they are not able to fall asleep in the bed. Dysfunctional should be examined in detail.
thoughts before the bedtime or while in bed lead to
hyperarousal and they may be assessed using Dysfunctional Sleep diary provides a good opportunity to assess the sleep-
Beliefs and Attitudes about Sleep, which is available in pattern and helps in differentiating insomnia from circadian
English as well as Hindi Language. rhythm sleep disorders. (Figure 2).
Many of the medical conditions may induce symptoms that At times, objective data is necessary to reach to a diagnosis
may mimic insomnia. Hence, the disorders provided in and in those cases actigraphy may be performed. In cases of
Table 4 must be ruled out. chronic insomnia that is not responding to treatment, video-
synchronized 24-channel polysomnography is desirable.
Algorithm for the diagnosis of insomnia is depicted in Fig 1.
Formulating a treatment plan
Effect of the insomnia on the daytime functioning must Treatment of insomnia is individualized and tailor-made.
be assessed. Special care should be taken to differentiate For the short term insomnia, pharmacotherapy is indicated,
between fatigue and sleepiness. Mood during the day must while for the chronic insomnia, cognitive behavior therapy
be assessed. Depression and other psychiatric disorders for insomnia (CBT-I) is preferred.
that may mimic daytime symptoms of insomnia may be
differentiated by asking “how do you feel during the day Various hypnotic agents are described below. Importance
which is followed by a good night sleep?”. If the patient of behavioral intervention should not be underestimated
reports a remarkable improvement, diagnosis of psychiatric and it is better that they should be started even in cases
disorder shall be deferred till the insomnia resolves. with short term insomnia. For example, a person might
be having genetic predisposition to insomnia and a recent
If the patient is undergoing any treatment for other medical stress might have precipitated the insomnia, which could
disorders (pharmacological as well as non-pharmacological), be perpetuated by the dysfunctional beliefs about sleep or
its’ effect on the sleep should be examined. maladalptive strategies to control it. Common maladaptive

Paent presenng with complaints suggesve of insomnia
No
Adequate opportunies for sleep No Insomnia
Yes
No
Dayme Symptoms of Insomnia No Insomnia
Yes
Difficulty Iniang Sleep Early morning awakening

Difficulty maintaining Sleep
> 30 min for > 3 Nights/wk > 30 min for > 3 Nights/wk
> 30 min for > 3 Nights/wk
No Total Sleep Time normal

Symptoms of RLS Total Sleep Time Total Sleep
Abnormal acvity at night Snoring present if le to sleep
normal if le to sleep me
Yes Yes decreased
Yes
Yes Screen for NO
OSA
RLS Delayed Sleep Wake Phase Disorder
Seizures
Advanced sleep
Parasomnia wake phase
disorder
High Risk
Nocturnal EEG
REMBD Level 1
NREM
Polysomnography
Normal
NREM
No
Parasomnia
OSA or
Normal
RBD
Confirmed
Terminal Insomnia
Inial Insomnia Middle Insomnia
Duraon
<3 >3
months months
Short term Chronic

Insomnia Insomnia
Figure 1: Algorithm for the diagnosis of Insomnia
strategies that we see include, but not limited to- spending Goals of the therapy
excessive time in bed, start smoking or start drinking 1. Improve the sleep onset latency, total sleep time and
caffeine while awake, spending time on screen while awake reduce awakenings, thus improving sleep efficiency
or spending majority of the time during the day in bed. 2. Improving quality of sleep
3. Ameliorate or significantly reduce the daytime
Wherever indicated, opinion from a relevant specialist symptoms of insomnia
may be sought. If there is evidence of sleep disorders 4. Sustain the effect of treatment and reduce the chances
that mimic insomnia, management should be directed to of the relapse
those disorders, rather than the insomnia. In some cases,
insomnia is co-morbid with these sleep disorders, and in Choice of treatment settings
these cases, both should be treated. Treatment of insomnia is usually offered on an outpatient

Figure 2: Sleep diary depicting long sleep onset latency with normal total sleep time when the patient is following natural pattern
of sleep. However, the patient gets the sleep late in the night and wakes up late in the morning. This data suggests delayed
sleep wake phase disorder
basis. Hospitalization may rather worsen the condition by agents may have residual daytime effects and may produce
enhancing hyperarousal. However, in some patients it may the somnolence during the day (Table 6).
improve sleep by removing environmental factors and may
provide a clue to the underlying pathophysiology. Melatonin and its agonists include the melatonin itself
and the molecules that act on MT1 and MT2 receptors.
Pharmacological treatment Melationin is available as 3 mg tablet formulation.
Pharmacological treatment for the insomnia is limited to short- This may be used to induce sleep, however, data do not
term insomnia and they are not routinely recommended for support its efficacy as a hypnotic agent. It is rather used
the management of chronic insomnia. A wide variety of drugs as a chronobiotic. Melatonin receptor agonists- ramelteon
is available that may induce sleep e.g., benzodiazepines, (8-24 mg/day) and agomelatine (25-50 mg/day) are available
Benzodiazepine receptor agonists, sedating antidepressants, in India. Remelteon is a short-acting-drug with half-life of
second generation antipsychotics, antihistaminics, melatonin around 3-4 hours. It shows an improvement in the time to fall
and its agonists and orexin receptor antagonists. Table 5 shows asleep with minimal adverse effects.Agomelatine is another
the factors that influence the choice of a particular drug. molecule that in addition to having an agonist action on
melatonin receptors, also has antagonist action on 5-HT2C
Benzodiazepinesand benzodiazepine receptor agonists receptors. It has been found effective in improving both
(BzRA) are usually divided into short, intermediate and sleep and mood in clinical trials, and because of it’s short
long acting and one of them may be chosen based upon half life (1-2 h) is free from daytime somnolence.
the case. In general, short acting are preferred when the
patient is having difficulty in sleep initiation, intermediate Orexin-receptors antagonists have recently been discovered
acting when the patient has difficulty in maintaining the for the management of insomnia. Controlled trial data is
sleep and long acting when the patients complain of early available for one of the molecule i.e., Survorexant. It has
morning awakening. However, intermediate and long acting been found to improve total sleep time with variable findings

on the nocturnal arousals and time spent awake after sleep is available for treatement with Z drugs for as long as 6
onset. Usual prescribing dose varies between 10-40 mg/day. months without any major adverse effects. Considering the
Common adverse effects include nausea abnormal dreams. limited availability of trained CBT-I therapist, consensus
was reached that in certain circunstances where CBT-I
Sedating antidepressants e.g., tricyclics, trazodone and is not possible for any reason, pharmacothepray may be
mirtazapine may be used if there is comorbid psychiatric institutedfor long term.
disorder that warrants their use. In addition, they may also
be preferred when adverse effects of the benzodiazepines Non-Pharmaclogical therapies
and BzRAs are not tolerable. However, there are insufficient Cognitive behaviour therapy for Insomnia (CBT-I) is
evidences for their efficacy in insomnia. the mainstay of therapy for chronic insomnia. It is a
multicomponent therapy that includes education regarding
Antihistaminicdrugs are available as over-the-counter drugs, sleep physiology, sleep hygiene, addressing dysfunctional
and they are commonly used for self medication.However, beliefs, stimulus control therapy, sleep restriction and
data regarding their efficacy in insomnia is limited. However, relaxation training.Each of these components may be used
a tricyclic drug Doxeipin has been approved for the treatment as a primary focus in a given patient which makes this
of insomnia in low doses (10 mg). At this dose, it primarily therapy highly individualized. In general, goal of the therapy
acts on the H1receptors and work as an antihistaminic. is to reduce the hyperarousal, hence, educating the patient,
cognitive restructuring (to address dysfunctional belief) and
Antipsychotics are used off-label for the treatment of relaxation are necessary in almost all patients. CBT-I has been
insomnia, particularly chlorpromazine, clozapine, olanzapine found effective for long term management of insomnia in
and qutiapine. However, we do not have data regarding their the randomized controlled trials comparing it with hypnotic
efficacy as hypnotic agents. In addition, while prescribing agents. It has been repeatedly shown that though, it takes
them, it is essential to consider potential adverse effects some time to show its effects, once they appear, they are
e.g., metabolic syndrome and extrapyramidal symptoms. longer lasting as compared to pharmacotherapy and also
reduce the chances of relapse.One of the major advantages of
Long term pharmacotherapy the CBT-I is the fact that it has also been found useful in cases
Although the pharmacotherapy is not routinely of insomnia co-occurring in context of medical disorders.
recommended for the long term treatment in view of
availablibility of non-pharmacological therapies, still, data Since the CBT-I is time consuming and requires the expertise,
it has been tried to be delivered through internet, computer
Table 5: How to choose a drug from the available and in groups.Though the computerized CBT-I has been
molecules? found superior to the placebo and pharmacotherapy, still it’s
Age of the patient and risks associated with sedation efficacy has been found low when compared to the face to
Comorbid psychiatric and other medical disorders face CBT-I. Administration of CBT-I in a group has also been
Pharmacokinetic properties of the molecule in question
Drug interactions with other medication that the patient is taking
tried, with the results similar to the computerized CBT-I.
Adverse effects of the drug in question: short term as well as long term
Availability of the molecule Results of sleep education and sleep hygiene alone have
Cost of the drug been found to have limited value unless they are associated
Allergy to the molecule in question
with some other component of the CBT-I.
Table 6: Benzodiazepines and Benzodiazepine Receptor Agonists

Molecule Half Life (hr) Dose (mg/d) Formulations Common Adverse effects
Benzodiazepines
Oxazepam 3‑20 10‑30 mg Tablet Memory lapses, daytime sleepiness,
ataxia, fall, automatism, slurred speech
Trialzolam 1.5‑5.5 0.5‑1 mg Tablet
Lorazepam 10‑20 1‑4 mg Tablet/Injection
Alprazolam 6‑20 0.25‑1 mg Tablet/Sustained released
Diazepam 20‑50 5‑20 mg Tablet/Injection
Clonazepam 18‑40 0.5‑2 mg Tablet/Mouth dissolving
Nitrazepam 30‑40 5‑10 mg Tablet
Benzodiazepine
Receptor Agonists
Zaleplon 1 5‑10 Tablet Memory lapses, hallucinations,
Eszopiclone 5 1‑2 Tablet paradoxical excitement
Zolpidem 2‑4 5‑10 Tablet/Extended release/Sublingual low
dose/Sublingual high dose/Oral spray

Exercise, especially the aerobic exercise along with the Special population
sleep hygeine has been found to be beneficial for the Pharmacotherapy should be cautiously advised to the
sleep and daytime activity. It has been found to reduce the elderly because of the drug interactions and adverse
time taken to fall asleep and improve the sleep efficiency effect profile. This should also be cautiously used in
in randomized control trials.Thus, patients should not be children and patients with other medical disorders for
advised not to engage into any exercise before bed-time, as the same reasons. CBT-I is not possible in patients with
conventionally thought. Rather they should be allowed to neurocognitive deficits and non-compliant patients,
analyse their sleep reactivity towards the exercise and if is hence they should not be started it without assessing
found to interfere with sleep, then they should be advised their motivation.
not to get engaged into it before bedtime.
Pregnancy: Duing first trimester it is best to avoid all
One of the focus of the therapy is to reduce the total time medications. In disabling cases, sedating antihistaminitcsmay
spent in bed in an effort to fall asleep by sleep restriction. be used for the shortest possible period.
Evidence is less robust regarding the utility of the sleep
restriction therapy.However, a recent review suggested Lactation: Amount of psychotropicdrugs that is excreted in
that sleep restriction therapy is one of the most effective milk varies from molecule to molecule. Reader is advised
components of the CBT-I.This must not be used in cases to consult the pharmacology book for details regarding
of bipolar disorders and epilepsy as it may worsen the individual molecule.
comorbid medical condition.
HYPEROSMNIA
In Indian context, since patients have been found focussing
on the daytime worries, rather than on the sleep, problem Alertness is an integral necessity for learning, performance
solving technique may be added.Recently, mindfulness and safety. Excessive daytime sleepiness impairs productivity
based relaxation therapy has been found to improve the and exponentially increases the risk of accidents, particularly
sleep.Mindfulness based stress relaxation (MBSR) has in occupations like transportation, military, healthcare,
been found equally efficacious to the face to face CBT-I, factory workers etc. excessive sleepiness is reported by
pharmacotherapy and better than sleep hygiene alone.This 10-25% of the general population in different parts of the
has been found more efficacious when it has been included world. However, as of now there are no prevalence studies
as a component of CBT-I. from India on hypersomnia/ excessive sleepiness.
Management as per the different phases of illness International Classification of Sleep Disorder, 3rd edition
On of the major issues with the patients with chronic (ICSD 3) defines daytime sleepiness as: “the inability to
insomnia is that they desperately want to sleep soon after stay awake and alert during the major waking episodes of
the initiation of treatment. However, CBT-I takes longer time the day, resulting in periods of irrepressible need for sleep
to improve the situation because it is delivered in sessions. or unintended lapses into drowsiness or sleep”. Sleepiness
And each session has a focus which is guided by prevailing varies in severity and is more common during sedentary,
sleep problems since last session. During CBT-I patient is boring, and monotonous situations that require little
expected to maintain a sleep diary and change his cognition active participation. Some patients are aware of increasing
and behavior. Many of the patients are not able to do that. In sleepiness before falling asleep, whereas others can fall asleep
those cases, the treatment is started with pharmacotherapy with little or no prodromal symptoms (“sleep attacks”).
along with the CBT-I. Gradually, the pharmacotherpay is
tapered and patient remains only on the CBT-I. Thus, patient The most common cause of excessive daytime sleepiness
benefits from the immediate response of hypnotics that (EDS) in modern day world is the combination of suboptimal
reduces the burden and hyperarousal in addition to long duration of sleep, poor sleep hygiene, and changing
term benefits of CBT-I. Though many sleep specialists are work schedules. In addition, various sleep disorders like
practicing it, still it has not been thoroughly investigated. obstructive sleep apnea, circadian rhythm sleep disorders
and periodic limb movement disorder may be associated
When to stop treatment with excessive daytime sleepiness.
Though we do not have any literature on this issue, still,
for the short term insomnia, patient should be requested Primary causes of hypersomnolence have been classified
to give drug holidays intermittently and to restart the under the heading of “Central disorders of hypersomnolence”
treatment when the symptoms appear again. CBT-I may in ICSD 3. The various central causes of hypersomnolence
be discontinued once the sleep of the patient is stabilized according to different classification systems is given in
for at least 4 weeks, though this number has been chosen the table 7 below and Algorithm to approach a case of
arbitrarily. hypersomnia is given in Fig 3.

Table 7: Comparative terminologies of causes of hypersomnolence between ICD‑10 and ICSD‑3

ICSD 3 ICD 10 ICD 10 code:
Narcolepsy Type 1 Narcolepsy With Cataplexy G47.411
Narcolepsy Type 2 Narcolepsy Without Cataplexy G47.419
Idiopathic Hypersomnia Idiopathic Hypersomnia With Long Sleep Time G47.11
Idiopathic Hypersomnia Without Long Sleep Time G47.12
Kleine‑Levin Syndrome Recurrent Hypersomnia G47.13
Hypersomnia Due to a Medical Disorder Hypersomnia Due to Medical Condition G47.14
Hypersomnia Due to a Medication or Substance F11‑F19
Hypersomnia Associated with a Psychiatric Disorder Hypersomnia due to other mental disorder F51.13
Insufficient Sleep Syndrome Insufficient sleep syndrome F51.12
Primary Hypersomnia F51.11
Other hypersomnia not due to a substance or F51.19
known physiological condition
Symptoms of Excessive insufficient sleep, inadequate Psychoeducation/ Sleep

Daytime Sleepiness sleep hygiene, job or familial Hygiene/ Behavior Therapy/
Yes
stressors and work schedules CBTi
from history
Recurrent hypersomnia, e.g. No

Klein Levin syndrome (usually
associated with behavioral Episodic/ recurrent
change, hyperphagia, Suggestive history for hypersomnia:
irritability) Yes No
Irresistable urge for sleep in daytime (or
in middle of activities)/ sleep attacks/
cataplexy/ hypnagogic or hypnapompic
Yes
Rating scales: hallucinations/ sleep paralysis/ REM
Polysomnography Within Epworth Sleepiness Scale behavioral disorders/ prolonged sleep
Normal limits Sleep diary Yes time/ confusional arousals
Full night attended Level I

Polysomnography preferably Objective evidence of OSA/ Treat accordingly
with video recording CSA/ PLMD/ Parasomnias
Yes
Followed by Multiple Sleep
Latency Test next day With cataplexy or CSF
MSLT findings: Hypocretin 1 conc. either <=
MSLT: SL<=8 min, >= 2 SOREMPs Yes 110pg/mL or <1/3 of mean
reference values
MSLT findings:
MSLT: SL<=8 min, < 2 SOREMPs
Yes No
Narcolepsy Narcolepsy
Total 24 hr sleep time >=660 Type 1 Type 2
Idiopathic
mins by 24 hour PSG/ wrist Hypersomnia
actigraphy +sleep log Yes
Underlying medical
Yes Underlying medical condition Hypersomnia due to condition diagnosed by MRI/
judged to be directly causing a medical disorder SPECT/ Immunology etc.
the excessive sleepiness Yes
Yes
No
Attributable to sedative Hypersomnia due to a
Primary Narcolepsy
medications, alcohol or drugs medication or
Narcolepsy secondary to
of abuse Yes substance
(Type 1 or 2) medical
condition
(Type 1 or 2)
Attributable to underlying Hypersomnia
psychiatric conditions like associated with a
moods disorders, somatic Yes psychiatric disorder
symptom disorder etc.
Figure 3: Algorithm for the diagnosis of Hypersomnia

Hypersomnias of central origin associated with anti-Ma-2 or anti-aquaporin-4 antibodies,

Narcolepsy type 1: caused by a deficiency of hypothalamic multiple sclerosis, myotonic dystrophy, Prader-Willi syndrome,
hypocretin (orexin) signaling. Excessive daytime sleepiness Parkinson disease, and head trauma.
and signs of REM-sleep dissociation are the characteristic
features of narcolepsy, however, the most specific feature Idiopathic hypersomnia: is characterized by excessive
is cataplexy (defined as more than one episode of generally daytime sleepiness that occurs in the absence of cataplexy,
brief (< 2 minutes), usually bilaterally symmetrical sudden is accompanied by no more than one SOREMP on MSLT and
loss of muscle tone with retained consciousness). There preceding polysomnogram combined, and is not adequately
are repeated daily episodes of an irrepressible need to explained by another disorder. Sleep drunkenness,
sleep or lapses into sleep (sleep attacks). Most patients consisting of prolonged difficulty waking up with repeated
awaken refreshed after a sleep episode but begin to feel returns to sleep, irritability, automatic behavior, and
sleepy again after variable times. Many narcolepsy patients confusion may be present. Subjects typically do not easily
have lapses in vigilance, sometimes in combination awaken to alarm clocks and frequently use special devices
with automatic behavior, such as writing gibberish or or procedures to wake up. Naps are generally long, often
interrupting a conversation with a completely different more than 60 minutes, and described as unrefreshing by
topic. Apart from cataplexy and sleep attacks, 33% to 80% 46% to 78% of patients. Associated symptoms which suggest
of narcolepsy patients have hypnagogic hallucinations and/ a dysfunction of the autonomic nervous system may be
or sleep paralysis. Hypnagogic hallucinations are defined present. These symptoms include headache, orthostatic
as vivid dreamlike experiences occurring at the transition disturbance, perception of temperature dysregulation, and
from wake to sleep. Typically, hypnagogic hallucinations peripheral vascular complaints (Raynaud-type phenomena
have a multimodal or “holistic” character, often combining with cold hands and feet).
visual, auditory, and tactile phenomena. Hypnopompic
hallucinations are similar but occur at sleep to wake Recurrent Hypersomnia: Kleine-Levin syndrome is
transitions. Sleep paralysis describes the disturbing characterized by recurrent episodes of excessive
temporary inability to move voluntary muscles at sleep- sleepiness,however, associated cognitiveand behavioral
wake transitions. Despite being awake and conscious of disturbances are not uncommon. A typical episode
the sleeping environment, it is impossible for subjects to lasts a median 10 days (range, 2.5–80 days), with rare
move their limbs or even open their eyes. The experience episodes lasting several weeks to months. Usual reported
may last for several minutes and can be very distressing. triggering factors for the first episodes are infection or
Other symptoms may include ptosis, blurred vision, and alcohol intake, with further episodes recurring every
diplopia, presumably as a result of sleepiness. Obesity is 1–12 months (median three months) for years. During
another common symptom of narcolepsy. episodes, patients may spend as long as 16 to 20 hours
per day in sleep, and they usually wake-up only for the
Narcolepsy type 1 due to a medical condition: This condition natural calls (incontinence is not observed). They remain
is primarily associated with central nervous system (CNS) arousable, but are irritable if prevented from sleeping.
disorders, including autoimmune or paraneoplastic When they are awake during episodes, most patients
disorders associated with anti-Ma2 or antiaquaporin4 appear exhausted, indifferent, confused with psychomotor
antibodies, and tumors or other lesions of the hypothalamus retardation. Anterograde amnesia is typical and most of the
or severe head trauma. patients report derealization. A larger chunk of patients eat
ravenously (66%, although one third eat less), nearly half of
Narcolepsy type 2: is characterized by excessive daytime them turn hypersexual (53%, principally men), may show
sleepiness and abnormal manifestations of REM sleep on childish behavior and nearly half appear depressed (53%,
polysomnography/MSLT [mean sleep latency less than or predominantly women). They often become anxious when
equal to eight minutes and two or more sleep onset REM left alone and after seeing strangers, and nearly third of them
periods (SOREMPs) on an MSLT (or one SOREMP on an MSLT experience hallucinations and delusions (30%). Importantly,
and one on the preceding nocturnal polysomnogram)]. patients are completely asymptomatic in between episodes.
Cataplexy is absent, although some atypical sensations of
weakness triggered by unusual emotions such as stress Hypersomnia Due to a Medical Disorder:Patients with
and anger may be reported. Refreshing daytime naps are this disorder have excessive nocturnal sleep, daytime
characteristic. Sleep paralysis, hypnagogic hallucinations, sleepiness, or excessive napping that is attributable to
or automatic behavior, memory lapses, automatic behavior, a coexisting medical or neurological disorder. Daytime
ptosis, blurred vision, and diplopia may be present. sleepiness may be of variable severity and may resemble
that of narcolepsy (i.e., refreshing naps) or idiopathic
Narcolepsy type 2 due to a medical condition: Neurologic disorders hypersomnia (i.e., long periods of unrefreshing sleep).
associated with narcolepsy type 2 include tumors or sarcoidosis Other symptoms of narcolepsy e.g., sleep paralysis,
of the hypothalamus, autoimmune or paraneoplastic disorders hypnagogic hallucinations and automatic behavior may

be present. Hypersomnia due to a medical disorder is only Management

diagnosed if the medical condition is judged to be directly A. Pharmacotherapy: Pharmacotherapeutic options for the
causing the excessive sleepiness. Hypersomnolence has management of hypersomnia are depicted in Table 8.
been described in association with a number of conditions
e.g., metabolic encephalopathy, head trauma, stroke, B. Behavioral Treatment:
brain tumors, encephalitis, systemic inflammation (e.g.,
chronic infections, rheumatologic disorders, cancer), • Education about type of hypersomnia, course, prognosis
genetic disorders, and neurodegenerative diseases. and management principles
• Regular frequent nap times of 10-20 mins at 2-4 hour
Hypersomnia due to a medication or substance:Patients intervals during the day
with this disorder have excessive nocturnal sleep, daytime • Emphasize need for a regular nocturnal sleep schedule
sleepiness, or excessive napping that is attributable to • Try to obtain 9 hours of nocturnal sleep
sedating medications, alcohol, or drugs of abuse. This
diagnosis also includes hypersomnolence associated CIRCADIAN RHYTHM SLEEP DISORDERS
with withdrawal from amphetamines and other stimulant
drugs. The circadian rhythm sleep disorders comprise of following
disorders having major feature is a misalignment between
Subtypes the patient’s sleep pattern and the sleep pattern that is
Hypersomnia due to sedating medications: desired or regarded as the societal norm ie. share a common
Hypersomnia due to substance abuse: underlying chronophysiologic basis.
Hypersomnia due to stimulant withdrawal: 1. Time Zone Change (Jet Lag) Syndrome
2. Shift Work Sleep Disorder
Hypersomnia associated with a psychiatric disorder: 3. Irregular Sleep-Wake Pattern
Patient may report increased duration of nocturnal sleep 4. Delayed Sleep-Phase Syndrome
associated with daytime sleepiness or excessive napping. 5. Advanced Sleep-Phase Syndrome
In addition, they often complain of poor quality and 6. Non-24-Hour Sleep-Wake Disorder
nonrestorative sleep. Patients are often intensely focused 7. Circadian Rhythm Sleep Disorder Not Otherwise
on their hypersomnolence, and psychiatric symptoms Specified
may become apparent only after prolonged interviews or
psychometric testing. Associated psychiatric conditions Diagnostic subtypes can be specified with the diagnosis of
include mood disorders, conversion or undifferentiated intrinsic type (due to neurologic disease) or extrinsic type
somatoform disorder, and less frequently other mental (due to environmental or social circumstances) Severity
disorders such as schizoaffective disorder, adjustment Criteria: Mild: Moderate: Severe:
disorder, or personality disorders.
Duration Criteria: Acute: Subacute: Chronic:
Subtypes:
Hypersomnia associated with mood disorder Major problem among all CRSDs is the inability to fall asleep or
Hypersomnia associated with a conversion disorder or somatic staying awake when desired or expected. Since sleep episodes
symptom disorder occurring at inappropriate times, the corresponding wake periods
also seen at undesired times. Therefore, the patient complains
Insufficient sleep syndrome:Many people curtail a small of insomnia or sleepiness but importantly both of them are
portion from their normal sleep duration for prolonged occurring at inappropriate times. For most of the CRSDs, once
periods owing to societal or professional demands. Since sleep is initiated, the major sleep episode is of normal duration
sleep deprivation has cumulative effect, they remain in a with normal architecture. However, if any other sleep disorder
state of chronic partial sleep deprivation that is insufficient to appears to influence the sleep timing, diagnosis of CRSD should
maintain normal levels of alertness and wakefulness. Physical be deferred.For example patients with inadequate sleep hygiene
examination reveals no medical explanation for the patient’s may show some degree of shift in sleep and wake timing. Hence,
sleepiness. A detailed history of the sleep pattern reveals that CRSD should be diagnosed only when the symptoms can be
patient is not spending adequate time in sleep and that he ascribed to the major shift in timing of sleep.
has curtailed his sleep in past few days/months. Sleep time
that is markedly extended on weekend nights or during 1. Time Zone Change (Jet Lag) Syndrome: Synonyms and
holidays compared to weekday nights is also suggestive Key Words: Jet lag, transmeridian flight desynchronosis, air
of this disorder. Individuals with this condition may show travel, transmeridiandyschronism.
cognitive and behavioral symptoms e.g., irritability, attention
deficits, distractibility, reduced drive, anergia, dysphoria, Essential Features: Time zone change (jet lag) syndrome
fatigue, impatience, incoordination, and tiredness. consists of varying degrees of difficulties in initiating or

Table 8: Pharmacotherapy for Hypersomnia

Used for: Drug Mechanism of action Dose range (mg/day) Pediatric use
Hypersomnia Amphetamine stimulants 5‑60 mg Not recommended in pts<3 years
in Narcolepsy, Methyphenidate stimulants 20‑40 mg in adults; Not recommended in pts<6 years.
Idiopathic 5‑20 mg in children Parameters of growth are should be
hypersomnia, etc. regularly monitored in children
Modafinil non‑amphetamine 100‑400 mg SECNE
wakefulness‑promoting
medication
Armodafinil (R)‑ enantiomer of modafinil with 50‑250 mg SECNE
a longer half‑life.
Sodium oxybate rapidly acting sedative/hypnotic/ 4.5‑9 g per night SECNE
(also used for Cataplexy, anesthetic medication.
sleep paralysis, hypnagogic
hallucinations)
Selegiline MAO‑B inhibitor that is 5‑10 mg SECNE
metabolized to amphetamine and
methylamphetamine
Atomoxetine selective noradrenaline reuptake 10‑25 mg generally well tolerated in children and
inhibitor (NARI) adolescents
Reboxetine selective noradrenaline reuptake 10 mg SECNE
inhibitor (NARI)
Ritanserin 5‑HT2 antagonist 5‑10 mg SECNE
Cataplexy Fluoxetine Selective serotonin reuptake 10‑40 mg Safety and effectiveness assessed in
inhibitor (SSRI) children aged 8‑18 yrs with major
depressive disorder and 7‑18 yrs with
OCD
Venlafaxine# serotonin‑norepinephrine reuptake 75‑375 mg SECNE
inhibitor (SNRI)
Protriptyline Tricyclic antidepressant (TCA) 10 mg SECNE
Viloxazine selective norepinephrine reuptake 50‑200 mg SECNE
inhibitor (NRI)
Imipramine Tricyclic antidepressant (TCA) 25‑200 mg SECNE
Clomipramine Tricyclic antidepressant (TCA) 25‑200 mg Can be used in children aged 10 years
and above
Desipramine Tricyclic antidepressant (TCA) 25‑200 mg Not approved for use in children
Recurrent Lithium* Mood Stabiliser 300‑900mg Special caution advised
hypersomnia (Klein
Levin Syndrome)
SECNE – Safety and effectiveness in children not established; NE – Not established *Carbamazepine and valproate can also be used for KLS, some benefit noted
in behavioral symptoms, but no consistent benefit observed in hypersomnia #Duloxetine and desvenlafaxine can also be used to treat cataplexy, though there is
lack of formal research data at present.
maintaining sleep, excessive sleepiness, decrements in time and wake time both are delayed in relation to the
subjective daytime alertness and performance, and somatic environmental timing, however, total sleep time remains
symptoms (largely related to gastrointestinal function) adequate (Fig 1). These patients can’t fall asleep till late in the
following rapid travel across multiple time zones. night and wake up late in the morning having optimal duration
of sleep. If they go to bed early in the evening, they have a long
2. Shift Work Sleep Disorder: Symptoms of insomnia or sleep onset latency and if they are made to wake up early in
excessive sleepiness are seen in association of work shifts. morning, they have reduced awareness and feel sleep.
These patients are often having work shifts that defy the
natural sleep-wake cycle and thus they feel sleepy or unable 5. Advanced Sleep-Phase Syndrome: This is opposite of the
to fall asleep at inappropriate time, e.g., while on work or delayed sleep phase disorder. These patients starts feeling
after reaching home, respectively. sleepy early in the evening, spent optimal time in sleep but
wake up early. If they are made to stay awake till late in
3. Irregular Sleep-Wake Pattern: These patients have night, they show reduced vigilance.
inconsistent timings of sleep and wakefuleness, although
the total duration of sleep remains normal in 24 hours. 6. Non-24-Hour Sleep-Wake Syndrome
When their circadian rhythm is examined through sleep
diary or actigraphy, it appears constantly changing. When seen through sleep diary and Actigraphy, these
patients have optimal duration of sleep, although the timing
4. Delayed Sleep-Phase Syndrome: In this condition, sleep of sleep appears delayed by 1-2 hours each day.

In January of 2014, the FDA approved the melatonin agonist level, Parkinsonism disorder, end stage renal disease is
HetliozTM (tasimelteon) for the treatment of N24SWD among important.
the blind. This is the first FDA-approved drug for any CRSWD.
Management
Diagnosis of CRSD The selection of therapy depends upon a number of
Polysomnography and Morningness-Eveningness factors, including disease severity, patient age, co
Questionnaire is not routinely indicated for any of the morbidities (e.g., pain, depression, anxiety and history of
CRSDs. Actigraphy is recommended for the delayed sleep impulse control behaviours), drug side effects and patient
wake phase disorder and advanced sleep wake phase preferences.
disorder but may also be used to diagnose other CRSDs.
Sleep diary must be maintained to diagnose all CRSDs. 1. Non – pharmacological
Actigraphy is a good tool to measure the progress.
Proper maintenance of sleep hygiene, exercise, restriction
Management of coffee beverages, pneumatic compression stocking help
Planned naps are recommended for Shift worker disorder. in the symptom reduction
Timed bright light therapy is useful for shift worker disorder
and delayed sleep wake phase disorder. Jet lag disorder can Behavioral strategies — Use of the following interventions
be managed by timed melatonin administration. Hypnotics is supported primarily on the basis of clinical experience in
may be used to induce sleep in Shift worker disorder, some cases, and small randomized trials
however, stimulants are usually not recommended for the • Avoidance of aggravating factors, including
management of CRSDs. consideration of withdrawal of possibly predisposing
medications
RESTLESS LEG SYNDROME • Moderate regular exercise
• Reduced caffeine intake
Restless legs syndrome/Willis-Ekbom disease (RLS/ • For symptomatic relief – walking, bicycling, soaking the
WED) is characterized by an urge to move legs that affected limbs, and leg massage, including pneumatic
is often accompanied by dysesthesias in the muscles. compression
The urge improves with the movement of the legs or • Short daily hemodialysis for patients with end-stage
application of a counterirritant. Symptoms are seen only renal disease.
in the evening and rest worsens the symptoms.A number
of conditions like nocturnal leg cramps, habitual leg Avoidance of aggravating factors — Sleep deprivation is
movement, varicose, arthralgia, positional leg discomfort known to aggravate symptoms of restless legs syndrome/
and leg edema must be excluded before making the Willis-Ekbom disease (RLS/WED) in many patients, and
diagnosis of RLS. This condition interferes with the sleep general principles of sleep hygiene should be reviewed.
significantly. In some patients, significant sleep fatigue
or poor concentration is reported in absence of RLS, Psychotropic drugs e.g., antidepressants, antipsychotics
but with polysomnographic evidence of periodic limb and other dopamine-blocking antiemetics such
movements during sleep (PLMS), in all such cases the as metoclopramide, and sedating antihistamines (including
term periodic limb movement disorder (PLMD) is used. those found in nonprescription medications) may lead to
It is an autosomal dominant, sensorimotor disorder in emergence of RLS/WED or worsening of prior symptoms.
which patient complains of a peculiar creepy or crawling Most antidepressant classes have been associated withRLS/
sensation in the extremities Prevalence varies between WED, including tricyclics, selective serotonin reuptake
2-11% across different studies depending upon the inhibitors, and serotonin-norepinephrine reuptake inhibitors.
geographical locations and populations included.
Discontinuation of antidepressantsmay not be possible
Assessment & evaluation in case of RLS among all patients. In all such cases, symptoms of
The diagnosis of restless leg syndrome is primarily secondary RLS/WED should be treated in the same
based on the symptoms reported by the patient or the way as primary RLS/WED. Bupropion is an alternative
observer. Nocturnal polysomnography may help in the antidepressant that may be less likely to induce or
diagnosis by having PLMs in the recording. Serum iron worsenRLS/WED.
level estimation may be helpful as iron is a co-factor
for tyrosine hydroxylase which is essential for synthesis Iron replacement
of dopamine.The Cambridge Hopkins RLS diagnostic Serum ferritin concentration lower than 45 to
questionnaire(CHRLSQ )and its Hindi version can be 50 mcg/L (ng/mL) has been associated with an increased
used during surveys and epidemiological studies. severity of restless legs syndrome. If the serum ferritin
Looking for risk factors viz - elderly population, low iron level is lower than 75 ng/ml, iron replacement is

suggested. However, care must be taken not to induce • Pramipexole 0.125 mg once daily. The dose may be
iron overlaod. increased by 0.125 mg every two to three days until
relief is obtained. In a clinical trial, all three doses
Both oral iron therapy as well as intravenous iron have been of pramipexole (0.25, 0.50, and 0.75 mg daily) were
found effective in treatment of RLS. equally effective, and some patients responded to the
initial dose of 0.125 mg daily. However, side effects
2. Pharmacological were more common with the 0.50 mg and 0.75 mg
daily doses. Therefore, it is expected that 0.25 mg daily
The major classes of drugs used include dopaminergic has the best therapeutic margin. Most patients require
agents, alpha-2-delta calcium channel ligands, opioids, and 0.5 mg or less, but doses up to 1 mg may be needed.
benzodiazepines • Ropinirole 0.25 mg once daily. The dose may be
increased by 0.25 mg every two to three days until
Chronic persistent symptoms relief is obtained. Most patients require at least 2 mg,
Chronic persistent restless legs syndrome is defined as RLS and doses up to 4 mg may be needed. The maximum
that is frequent and troublesome enough to require daily recommended dose is 3 mg in patients with end-stage
treatment, with symptoms usually occurring at least twice renal disease on hemodialysis.
a week on average and resulting in moderate or severe
distress. Rotigotine — Rotigotine is a non-ergot dopamine
agonist that is formulated as a 24-hour transdermal patch
Choice of therapy — Patients who do not respond to non .Transdermal rotigotine is a once-daily patch that is
pharmacologic therapy and correction of iron deficiency, typically started at 1 mg/24 hours and titrated upwards to a
pharmacologic treatment with a dopamine agonist or an maximum dose of 3 mg/24 hours. Application site reaction
alpha-2-delta calcium channel ligand is recommended. is the most common adverse effect of rotigotine, reported
• For patients with very severe RLS/WED, co morbid by 40 to 50 percent of patients.
depression, or obesity / metabolic syndrome, a dopamine
agonist is preferred over other drugs as initial therapy. Alpha-2-delta calcium channel ligands — Gabapentin
• For patients with comorbid pain, anxiety, or insomnia enacarbil, gabapentin, and pregabalin are alternative
or a history of impulse control disorder or addiction choices for patients with chronic persistent RLS.
associated with use of a dopamine agonist an alpha-2-
delta calcium channel ligand. Is preffered Gabapentin enacarbil — Several randomized, placebo-
• Most other patients, initial trial an alpha-2-delta calcium controlled studies have demonstrated that gabapentin
channel ligand because of the of augmentation with enacarbil is effective in reducing RLS/WEDsymptom severity.
dopamine agonists, but other potential side effects of The recommended dose of gabapentin enacarbil for
the various drugs should also be considered. In general, RLS/WED is 600 mg, taken in the early evening
older patients are more prone to side effects of alpha-
2-delta ligands. If the first drug chosen is ineffective Gabapentin —Limited data suggest gabapentin may be
or poorly tolerated, then a drug of the other class effective in RLS/WED.
should be tried , including levodopa, benzodiazepines,
and opioids, but generally these are reserved for Pregabalin — Pregabalin in the doses of 75-300 mg/day
intermittent use or in patients with more refractory found effective in treatment of RLS.
symptoms.
Duration of therapy
Dopamine agonists — A number of dopamine agonsits are RLS/WED is often a lifelong disease, but the optimal and
available in market e.g., cabergoline, lisuride, pergolide, safe duration of pharmacologic therapy has not been well
pramipexole, ropinirole,rotigotine, and sumanirole. All established. Most of the supporting data are based on
except sumanirolehave been found superior to placebo. In relatively short (≤12-week) randomized trials, with fewer
two trials, cabergoline and pramipexole were superior to long-term extension studies supporting efficacy for 6
levodopa for improvement in disease severity as measured to 12 months of therapy with either a dopamine agonist
by the International Restless Legs Syndrome Study Group or gabapentin enacarbil.
(IRLS) rating scale.
Special populations
Pramipexole and Ropinirole — Action of pramipexole and Pregnancy and lactation — Management of restless
ropinirole usually starts 90 to 120 minutes after intake. legs syndrome during pregnancy should be individualized
Therefore, these medications should be started two hours based on symptom severity, comorbidities such as
before RLS/WED symptoms start. The recommended doses depression or anxiety, and patient preferences. Many
are as follows: patients can be managed successfully with education,

reassurance, iron supplementation if indicated, and self-defence. The reported prevalence rates are 0.38%-0.5% in
nonpharmacologic strategies. Pharmacologic therapies such general population and, probably higher (≥6%) in 70-90 year
as clonazepam or carbidopa-levodopa may be considered olds. Even more interesting is the equally higher prevalence
for severe symptoms. of RBD in psychiatric population (5.8%). The early-onset
(<50y) variety (EORBD) has more atypical clinical presentation
End-stage renal disease — The management of RLS/WED in showing female preponderance, less violent behaviour, may
patients with end-stage renal disease is similar to that in occur early during the night, and may get out of bed more
patients with normal renal function. However, medication frequently. There is preponderance of idiopathic cases and
doses may need to be adjusted, especially if the patient is more association is seen with narcolepsy, depression, anti-
not yet receiving dialysis, as dopamine agonists and alpha- depressants and parasomnia overlap disorder (POD).
2-delta ligands are all excreted by the kidneys. Careful
attention to iron status is especially important in this group.. Indian demographics regarding this illness are largely
unknown and the published evidence is limited to half a
REM-SLEEP BEHAVIOUR DISORDER dozen case reports, retrospective chart reviews, prospective
questionnaire-based study and a case control study. All
Most parasomnias are benign unwelcome phenomenon discuss RBD as part of PD except one (table 9).
observed in and around sleep that seldom present alarmingly.
It is a common observation that more often than not, they are The aetiology of RBD is still speculative. RBD may be either
a cause of least concern both to patient and clinician. One such primary idiopathic type (iRBD) or secondary (table 10) to
sleep-related phenomenon is REM-sleep behaviour disorder other disorders. It is unclear whether the idiopathic variety
(RBD) that was first systematically defined 30 years back. It is an independent entity or it is merely a precursor
is a kind of parasomnia characterized by dream enactment ‘cryptogenic’ prodromal syndrome anti-dating degenerative
behaviour (DEB) that emerges during rapid eye movement brain disorders predominantly of α-synucleinopathy type
sleep and may lead to injury or disturbance of sleep. Behaviours ((Parkinson’s disease (PD), dementia of Lewybody(DLB),
include excessive abnormal and/or purposeful motor activities Multiple system atrophy (MSA)). RBD patients are at higher
such as vocalization and simple limb twitching to flailing risk of having cognitive, motor and autonomic impairments
and punching of arms, sitting up, and kicking. Occasionally, at baseline. It may be that spontaneous iRBD precede a
patients climb out of bed, something akin to sleep walking. parkinsonian neurodegenerative illness by several decades
More complex and violent behaviours may occur rarely or and thus have a prognostic and therapeutic relevance. The
many a times during the same night, most action occurring risk of iRBD converting to parkinsonian disorder varies
in bed. Not keeping with their waking personality, the between 40-80% over 5-15 years. There is now a growing
vocalizations may be loud and full of abuse and obscenities. body of evidence that suggests that depression may also be
The routine REM-sleep atonia is typically absent. It manifests a preclinical marker of PD in iRBD cases and anti-depressants
as sustained muscle activity or transient phasic muscle simply unmask the underlying pathology. Following are the
twitches in either the chin or limb electromyography (EMG) on environmental and behavioural risk factors associated with
polysomnography (PSG). Most cases arise after the age of 50. RBD (in common with PD):
Its usual presentation in a speciality clinic is like a 65-year old, 1. traumatic brain injury,
male whose partner expresses concern about some unusual 2. farming,
sleep behaviour or who had injured himself or assaulted his 3. pesticide exposure, and
partner during sleep while having vivid, action-filled dreams of 4. low education.
Table 9: Evidence base on RBD‑ Indian studies

Authors Year Title Type of study Journal
Vibha D et al. 2011 RBD in Parkinson’s disease: a clinical case control study from India Case control Clinical Neurology
&Neurosurgerry
Gupta R et al. 2013 REM sleep behavior disorder in Parkinson’s disease: A case from India Case report Journal of Neurosciences
confirmed with polysomnographic data in Rural Practice
Mahale R et al. 2014 Rapid eye movement sleep behaviour disorder in young ‑ and older ‑ onset Cross‑sectional Sleep Medicine
Parkinson disease ‑ a questionnaire‑based study
Yadav R et al. 2015 Is palmomental reflex an important clinical marker of REM sleep behaviour Cross‑sectional Movement Disorders
disorder in patients with Parkinson’s disease?
Gupta S et al. 2015 Idiopathic REM Sleep Behavior Disorder: A Report on Two Cases with Case report Indian journal of
Contrasting Features Psychological Medicine
Siddiqui M M et al. 2015 Detection of rapid eye movement behaviour disorder using short time frequency Experimental Biomedical Research
analysis of PSD approach applied on EEG signal (ROC‑LOC)
Prashanth R et al. 2014 Parkinson’s disease detection using olfactory loss and REM sleep disorder Experimental Engineering in Medicine
features and Biology Society

Table 10: Secondary causes of RBD physician is unaware of RBD or the case may be misdiagnosed
Multiple System Atrophy Brain tumours a more common ailment such as epilepsy or sleep-walking.
Dementia of Lewy Body Multiple sclerosis Thus, an elaborate history with direct questions to
Parkinson’s disease (PD) Guillain‑Barre syndrome confirm the presence or absence of the symptoms of some
Mild Cognitive Impairment Stroke
Spinocerebellar Ataxia 3 Narcolepsy
parasomnia is a must [Figure 4].
Guadeloupean parkinsonism Obstructive sleep apnoea (Pseudo‑RBD)
Alzheimer’s disease Medications (anti‑depressants, beta‑blockers) In RBD, a careful interviewing of bed-/room-partner will help
Progressive supranuclear Substance withdrawal (alcohol, barbiturate) in eliciting of a history of brief recurrent DEB that occur
palsy
chiefly in the latter half of the night with patient confined
Huntington’s disease Limbic Encephalitis
Frontotemporal dementia to bed distinguishing it from non-REM sleep parasomnias
that predominantly occur during first half without any dream
mentation. Two major classificatory systems define the
Studies on animal model suggest involvement of brainstem criteria for RBD diagnosis- International classification of sleep
REM-sleep regulating nuclei, namely dorsal pontinesublateral disorders- third edition (ICSD-3) criteria and DSM-5 (Table
dorsal nucleus and/or magnocellular reticular formation. 11 & 12). The DSM-5 now classifies RBD as an independent
The role of several genetic links is under study at present. disorder. ICD-10 is yet to come up with its own criteria of RBD
though ICD-10 CM does include RBD (G47.52) as a billable
The risk of sleep-related injury (SRI) is markedly increased in code for the purpose of reimbursement claims in America.
RBD cases and their bed partners (33%-95%). DEB vary from
harmless actions like knitting, singing, etc., to injurious ones There are several disorders that can present in a fashion similar
and common injuries include bruises, abrasions, lacerations, to RBDs that one needs to rule out. It should be also kept in
fractures and dislocations, attempt at strangulation of partner mind that these conditions may co-exist with RBD (Table 13).
and occasionally, subdural hematomas. Lifetime incidence of On such example is POD, a younger-onset variant of RBD.
head injury is around 20%. Risk factors for SRI are:
• Idiopathic RBD A baseline neurological examination (NE) that involves
• Severe limb movements during DEB specific evaluation of cognition and screening for
• Dream recall extrapyramidal symptoms should be done once a diagnosis
• Falling out of bed during DEB of RBD is established (Table 14). RBD precedes parkinsonian
neurodegenerative disorders and is fairly prevalent (50-90%) in
It is to be noted that as against the common wisdom, α-synuclein disorders, while in rest of the neurodegenerative
DEB frequency has not been found to be associated disorders RBD follows (except spinocerebellar ataxia 3) other
with the frequency and severity of SRI. Cases of PD- neurological deficits and is uncommon.
RBD are less likely to injure themselves compared to
idiopathic RBD and injuries and falls are more common Following investigations will aid to the diagnosis of RBD:
in PD-RBD than PD alone. RBD is a progressive disorder
and spontaneous remissions are witnessed very seldom. Specific
There can be a gradual reduction of RBD symptoms over • PSG with time-synchronized video (vPSG) is the single
the years in approximately 30% of the patients and they most important investigation.
may remit spontaneously in 14-30% of RBD-PD patients • Electro-oculogram (EOG) monitoring
per year. These data are probably reflective of progressive • EMG with multiple channels for chin, bilateral extensor
neurodegeneration. DEB is absent in up to 30% of reported digitorum, and tibialis anterior muscles.
cases of RBD. • Electrocardiogram (ECG)
• Nasal air flow
Assessment and evaluation • Arterial blood oxygen saturation.
Despite the presence of RBD in a higher number of patients
with PD, less than 1% complain about it at the time of The revised scoring of PSG features of RBD has been detailed
presentation. The reasons can be in AASM Manual for the Scoring of Sleep and Associated
• RBD being considered not severe enough or infrequent Events: Rules, Terminology and Technical Specifications,
to consult a physician Version 2.2. RBD is the only parasomnia that requires vPSG
• Symptoms being perceived not worthy of discussion for confirmation of diagnosis.
• Unaware of their presence
• Waiting for them to resolve with time Others
• Feel shy to discuss. To aid in diagnosis or monitor:
• Routine lab investigations
Even if the above hiccups get surmounted, the required • Neuroimaging – currently used as research tools to
support may still elude the patient either because the identify pre-clinical disease markers

• Transcranialsonography (TCS)- substantianigra (SN) Scales/Questionnaires/Inventories

echogenicity, a disease marker Since access to vPSG is limited, clinical interview and
• Positron-emission tomography (PET)- to assess questionnaires may come in handy in early screening of RBD
severity and extent of neurodegeneration cases and related morbidities. Number of tools are available
• Single photon emission computed tomography for this purpose and to choose the right tool will depend on
(SPECT)- to study the SN dopaminergic neuronal whether it is required for rapid screening of RBD in general
status population, or in specific specialized population such as
• Post-mortem brain autopsy psychiatric cases and patients suspected of neurodegenerative
illness, or to monitor progress of illness or effects of some
Table 11: ICSD‑3 criteria intervention, and who is the source of information. It is to be
Criteria A‑D must be met noted that despite their ease of availability and applicability,
Repeated episodes of sleep related vocalization and/or complex motor screening tools are not a replacement for vPSG. RBD scales
behaviours* help us point out probable RBD cases and thus to plan out
These behaviours are documented by PSG to occur during REM sleep
RBD specific assessment and targeted intervention services
or, based on clinical history of dream enactment, are presumed to occur
during REM sleep without causing a resource crunch.
PSG recording demonstrates REM sleep without atonia (RWA)**
The disturbance is not explained more clearly by another sleep disorder, For RBD screening
mental disorder, medication, or substance use
1. RBD Questionnaire-Hong Kong (RBDQ-HK)
On occasion, there may be patients with a typical clinical history of RBD
with DEB, who also exhibit typical RBD behaviours during vPSG, but do 2. RBD screening questionnaire (RBDSQ),
not demonstrate sufficient RWA, based on the current evidence‑based data, 3. Mayo sleep questionnaire (MSQ),
to satisfy the PSG criteria for diagnosing RBD. In such patients, RBD may 4. RBD1 questionnaire,
be provisionally diagnosed, based on clinical judgement. The same rule
applies when vPSG is not readily available.
5. Innsbruk RBD inventory,
*Dream enactment is not exclusive to RBD **In ‘Subclinical’ RBD, criteria C is
present in absence of dream enactment For RBD severity
1. RBD severity index (in Japanese),
Table 12: DSM‑5 criteria of RBD (327.42) 2. Minnesota parasomnia injury scale,
Recurrent episodes of arousal during sleep associated with vocalization
and/or complex motor behaviours For sleep
These behaviours arise during rapid eye movement (REM) sleep and 1. Epsworth sleepiness scale,
therefor usually occur more than 90 minutes after sleep onset, are more 2. Pittsburgh sleep quality index
frequent during the later portions of the sleep period, and uncommonly
occur during daytime naps.
Upon awakening from these episodes, the individual is completely awake, For baseline cognitive screening
alert, and not confused or disoriented. 1. Modified mini-mental state examination
Either of the following: 2. Montreal cognitive assessment
RWA on PSG
A history suggestive of RBD and an established synucleinopathy
diagnosis (e.g., parkinson’s disease, multisystem atrophy) For parkinsonian features
The behaviours that cause clinically significant distress or impairment in 1. Unified Parkinson disease rating scale
social, occupational, or other important areas of functioning (which may
include injury to self or bed partner)
The disturbance is not attributable to the physiological effects of a Formulation of a treatment plan & Choice of treatment
substance (e.g., a drug of abuse, a medication) or another medical setting [Figure 4]
condition Any treatment plan concerning RBD will involve reduction of
Coexisting mental and medical disorders do not explain the episodes
DEB and prevention of injury, irrespective of frequency and
Table 13: Differential diagnosis of RBD

Disorders of arousal Others
Primary Secondary
Sleep terror Periodic limb movement disorder Physiologic hallucinations of sleep
Sleep walking Nocturnal seizures (e.g., frontal lobe epilepsy) Dissociative/conversion disorder
Sleep talking Gastroesophageal reflux disease Malingering
Confusional arousals Obstructive sleep apnoea Domestic violence
Post‑traumatic stress disorder
Vertigo
Absence seizures
Epilepsy in mentally retarded
Other seizure disorders (e.g., juvenile myoclonic
epilepsy, benign epilepsy of childhood)
Hereditary quivering chin syndrome

Table 14: Neurological history and examination‑salient severity of DEB. The choice of treatment setting will be largely
features determined by the presenting complaints. Hospitalization
Triad of impending Explore for Early bradykinesia Subtle signs on NE: may be required for assessment of RBD, treatment of SRI
neurodegeneration: • Difficulty in turning over • Affect and/or current medical condition. SRIs in RBD can be life-
• RBD with chronic in bed • Voice volume
threatening and may have medico-legal consequences.
unexplained • Slowing of eating or dressing • Speed of articulation
• Hyposmia • Above difficulties • Blink rate
• Constipation unilateral (u/l)/bilateral • Motor tone While formulating a treatment plan of RBD following should
• If, Impaired colour (u/l significant of • Cogwheel rigidity be included:
identification, rapid parkinson’s disease) • Gait testing: stride
conversion to PD • Change of hand‑writing length, arm swing,
• Non-pharmacological measures
•*psychiatric disorders • Lowering of speech volume number of steps to • Safety measures
(depression) may also • Whether ever felt feet stuck turn, freezing • Removal or minimization of aggravating factors
be a predating factor to the floor • Postural instability
• Counselling of patient and care-givers
No
Adequate opportunity for sleep Rules out insomnia
No
Difficulty in maintaining sleep Evaluate for other sleep disorders
No
Evaluate for OSA &/or other sleep
Abnormal behavioural activity during night sleep
disorders
Clinical features of a parasomnia
No
Assess for NREM parasomnias/ other
Suggestive of RBD
causes of insomnia
vPSG fulfilling diagnostic criteria
Assess for type of RBD
No
Assess & manage causes of secondary
iRBD RBD
Environmental & life style modifications
No
Try different drug &/or non-
Response
pharmacological measures
Yes
Continue indefinitely Response
No
Regular follow-up and monitoring for

appearance of any neurodegenerative disorder Review diagnosis
Figure 4: Diagnosis and management of REM-sleep behaviour disorder

Table 15: Drugs used in treatment of RBD

Molecule t1/2 (hr) Dose (mg/d) Formulations Adverse effects
Benzodiazepines
Alprazolam 12‑15 1‑3 Tablet/extended Sedation, fatigue, dizziness, ataxia, confusion,
release/solution forgetfulness (B)
Clonazepam 30‑40 0.5‑2 Tablet (B) + blood dyscrasias, grand-mal seizures
Temazepam 8‑15 7.5‑30 Capsules (B) + hallucinations, mania, hypotension, hypersalivation
Triazolam 1.5‑5.5 0.125‑0.5 Tablet (B) + Anterograde amnesia, mania, dry mouth, hypersalivation
Non‑benzodiazepine
receptor agonist
Zopiclone 3.5‑6.5 7.5 Tablet Sedation, dizziness, ataxia, dose‑dependent amnesia,
hyperexcitability
Melatonin and
melatonin‑receptor
agonists
Melatonin 0.33‑0.83 (dose 3‑12 Tablet, capsule, Vivid dreams, nightmares, drowsiness, abdominal cramps,
& route cream, lozenges, headache, irritability, ↑depression, ↑risk of seizures in
dependent) intranasal spray children with severe neurological problems. RARE‑ ↓libido,
gynaecomastia, psychosis
Agomelatine 1‑2 25‑50 Tablet Nausea, dizziness, somnolence, hyperhidrosis. RARE‑ mania,
hepatitis
Ramelteon 2‑5 8 Tablet Sedation, dizziness, fatigue, headache
Anti‑depressants
Desipramine 24 50‑300 Tablet Blurred vision, constipation, urinary retention, increased
appetite, dry mouth, weight gain, sedation, sexual dysfunction.
RARE‑↑intraocular pressure, paralytic ileus, ↑QTc
Paroxetine 24 10‑40 Tablet‑IR & CR Sexual dysfunction, diarrhoea, constipation, insomnia,
sweating, tremors. RARE‑ hyponatremia, suicidality, mania,
bleeding
Pramipexole 8‑12 0.5‑1.5 Tablet Dizziness, Sleep attacks, somnolence, insomnia, nausea,
constipation, asthenia, peripheral oedema, impulse control
disorders, gambling, sexual urges, hallucinations & psychosis,
RARE‑ dyskinesias, rhabdomyolysis, peritoneal/pleural/
pulmonary fibrosis
Dopaminergic
L‑dopa 0.83‑1.5 250‑1250 Tablet, Agitation, delusions, hallucinations, confusion, tremors,
extended‑release, fainting; depression, blurring of vision, blepharospasm.
capsule RARE‑ hypertension, priapism, seizures, gastrointestinal
bleeding
Herbal
Yoku‑kan‑san/Yi‑Gan 1.72‑12.3 2.5‑7.5 Freeze‑dried granules Hypokalaemia (in old), drowsiness, tiredness, gastrointestinal
San (component upset. RARE‑ interstitial pneumonitis, dermatitis,
dependent) hepatotoxicity
Acetyl cholinesterase
inhibitors
Donepezil 70 5‑10 Tablet Nausea, diarrhoea, vomiting, ↓appetite, weight loss,
insomnia, abnormal dreams, muscle cramps. RARE‑ seizures,
syncope (B)
Rivastigmine 1‑2 6‑12 Capsule, liquid, (B) + headache, asthenia, sweating
transdermal
GABA agonist
Sodium Oxybate 0.5‑1 2500‑9000 Oral solution Swelling over face or extremities, weight gain, paraesthesias.
Anxiety, rash, perspiration, palpitation, tightness in chest,
seizures, coma.
Anti‑epileptic
Carbamazepine 12‑17 (repeated 400‑1200 Tablet, capsule, Sedation, dizziness, confusion, unsteadiness, headache,
doses) suspension nausea, vomiting, diarrhoea, rash. RARE‑ aplastic anaemia,
Anti‑psychotic
Clozapine 5‑16 N.A. Tablet ↑risk for diabetes/dyslipidaemias, ↑salivation, sweating,
sedation, constipation, weight gain. RARE‑ tardive dyskinesia,
agranulocytosis, seizures (dose‑dependent), neuroleptic
malignant syndrome, deep vein thrombosis and pulmonary
embolism, ↑risk of death and cerebrovascular events in elderly
patients with dementia‑related psychosis

• Others Pharmacological treatment

• Pharmacotherapy The only REM-sleep parasomnia where pharmacotherapy is
clearly indicated is RBD. Many pharmacological agents have
Non-pharmacological meassures been tried for this purpose, but there is marked variation
The primary goal of RBD treatment is SRI prevention. in their efficacy and there is lack of standardization of the
Among the non-pharmacologic measures, modification of dose of medication and the duration of its continuation
sleep environment should be initiated as the first step. (Table 15). Among all the medications utilized till date,
the most robust support is for clonazepam and melatonin.
A. Environmental modification may include: A medication that improves sleep quality with minimum
Patient safety. e.g., day time effects and results in improvement of objective
lowering of bed measures of RBD such as RWA on PSG should be chosen.
putting a mattress on the floor alongside bed
sleeping on the floor mattress itself Clonazepam
shift bed/ bedroom to the lowest floor of the house Recommended as first-line medication. The evidence
barricading with pillows around the bed base is almost exclusively in terms of retrospective
using a bed with padded rails case reports and case series in over 300 patients. Initial
minimize furniture around the bed response to low dose clonazepam (0.5-2mg) is seen in
maximize the distance from ungrilled windows upto 90% of patients but later tolerance and treatment
soft-pad the sharp edges of furniture around the house failures are reported. Because of its long half-life, it may
remove fire-arms or knives from within reach become a cause of concern if causing impaired alertness,
(preferably lock away) morning sedation and gait impairment in parkinsonian
safety locking of windows and doors disorders and elderly patients and can worsen concomitant
physical restraint. e.g., sleeping bags, padded belts, obstructive sleep apnoea (OSA). It vanquishes DEB but do
padded waterbeds not re-establish REM sleep atonia. It helps markedly in
Partner safety reduction of SRI, one study reporting a reduction from
Bed partner should sleep separate from the patient 80.8% pre-treatment events to 5.6% post-treatment levels.
till the problem symptoms of RBD are brought Patients on clonazepam should be regularly monitored
under control with treatment. for development of newer symptoms of dementia or gait
It is a matter of investigation whether environmental disorders. Clonazepam is metabolized by cytochrome p450
manipulation is enough in itself for the management of RBD enzyme system (cyp2C19 & cyp3A4). Thus, the possibility
or it has only an adjunct role to pharmacotherapy. of drug-drug interactions should be kept in mind especially
in elderly population where polypharmacy is a rule rather
B. Patient or caregiver should be asked to maintain a sleep diary than exception.
C. Avoid sleep deprivation- maintain adequate total sleep
time with a fixed waking time. Melatonin
D. Avoid alcohol and/or other recreational drugs. The pineal gland secretion, melatonin when used
E. Treat co-morbid sleep disorders, if any. exogenously is said to be effective in RBD in few case reports,
F. Reassure and counsel patient and family about need case series and a small randomized controlled trial of eight
of treatment, regular follow-ups, and the possibility of patients. Recent studies find melatonin as efficacious as
onset of a neurodegenerative disorder. clonazepam in RBD with a better adverse effect profile
G. Review ongoing medication charts. Remove or reduce and re-establishment of REM atonia especially in those
the dose of aggravating agent wherever possible. with dementia or sleep apnoea. Efficacy is not known in
Antidepressants can trigger RBD or expose RBD in up cases where RBD co-exists with both PD/dementia and
to 6% cases of depression. Tapering off might result depression that requires treatment with anti-depressants.
in symptom reduction but not complete remission Most patients respond to 3mg dose with minimal or no side
in such cases. Bupropion is the only anti-depressant effects. The mechanism of action of melatonin in RBD is not
not reported to be associated with RBD till date. known, though calmodulin antagonism is suggested as a
Thus, it might be considered for use in those where potential mechanism and the effects probably go beyond
pharmacotherapy is indicated for depression. simple hypnosis.
Along with these measures, pharmacological treatment Others

should be instituted. As no large randomized double-blind In cases where clonazepam and melatonin are not
or head-to-head controlled trials are available till date indicated or are refractory to these medications, other
to assess efficacy of medications, the current treatment medications may be tried. But so far, the evidence in
guidelines are largely expert consensus, based on evidence their favour is inadequate or at times, contradictory.
of large case series or small clinical trials. e.g., there are just two case reports of successful RBD

treatment with sodium oxybate. Acetylcholinesterase It should be noted that most patients who ultimately
inhibitors may be instituted in patients with dementia or developed neurodegenerative illness were on clonazepam
synuleinopathies. indicating clonazepam’s ineffectiveness as a preventive
agent. It is recommended that an annual neurological
Among all the tried medications, the only preparation that examination should be done for the earliest detection and
is claimed to have some neuroprotective effects in in-vitro management of PD.
and in-vivo animal studies is Yi-Gan San/Yoku-kan san. It
is a Chinese/ Japanese traditional kampo preparation that Special populations
consists of seven different herbs- Japanese Angelica root The basic tenets of diagnosis, assessment and management
(3g), Atractylodeslancea rhizome (4g), Bupleurum root (2g), of medicine are equally applicable to the special populations
Poriasclerotium (4g), Glycyrrhiza root (1.5g), Cnidium rhizome of RBD. The following few things should be kept in mind
(3g), and Uncaria hook (3g). Its neuropharmacodynamic while dealing with them:
actions include serotonergic, glutamatergic, cholinergic,
dopaminergic, adrenergic, GABAergic along with Children
anti-inflammatory, anti-stress, neuroplasticity, and Assessment of children will require a careful approach
neuroprotective effects. It is through these mechanisms depending on their ability to communicate which can be
it is supposed to exert its effects in its primary indication limited given their age or co-morbidity. Idiopathic RBD in
for behavioural and psychological symptoms of dementia this population is rare and is usually seen in context with
including alzheimer’s disease, dementia of Lewy body, and narcolepsy, epilepsy, brain tumours, or, medication effects.
PD. There is one case report of successful management of
three RBD patients with Yi-Gan San. Elderly
After the onset of idiopathic RBD almost half of the patients will
Other Pharmacological Treatment Modalities develop a parkinsonian disorder within a decade, and nearly
It is very ironic that currently there are no cognitive or 80-90% will develop some neurodegenerative disorder in their
cognitive-behaviour therapies available for REM-sleep lifetimes. Therefore, middle-aged or elderly people presenting
“behaviour” disorder probably highlighting the with RBD symptoms should be counselled and monitored
‘non-functional’ organic nature of the disorder. Two about these future possibilities. An opportunity to enrol them
therapies- one behaviour and one somatic- does require a in any ongoing research clinical drug trials for developing and
mention though. testing disease-modifying drugs can also be explored.
Bed Alarm Relying on the brain’s ability to process complex Women

auditory stimuli during REM sleep similar to wake state and RBD is infrequently reported in females. This may be
low arousal threshold for external stimulus Howell et al. at because firstly, they might be having less injurious and
university of Minnesota developed a pressurized bed alarm less dramatic behaviours during dream enactment; and
customized with a pacifying pre-recorded message in a secondly, they may outlive their partner (gender difference
familiar person’s reassuring voice to calm down the patient at in life expectancy) thus having less likelihood of coming
the onset of dream enactment behaviour. This prevents bed- to the notice of family members and receive the required
exiting and averts potential injuries. It can be used in patients medical attention. All medications require caution for use
who are refractory to pharmacotherapy or do not tolerate it. during pregnancy and lactation and should be taken only
under expert guidance.
Deep brain stimulation of subthalamic nucleus is
ineffective in RBD though it does improve the subjective The paramount importance of recognizing RBD as a
sleep quality. treatable parasomnia lies in the fact that it can prevent
serious life-threatening injuries. Psychiatrists should
Management as per different phases of illness & when to actively screen for the presence of RBD as patients usually
stop do not come forward to report these symptoms for a
RBD is a progressive neurological disorder. Though variety of reasons. The population of India grew at 17.7%
clonazepam is highly effective and works in almost 70-90% between 2001-11. During the same period there was a
of the cases, relapse rates are high on discontinuation so quantum jump in the population of those above 60 years- a
pharmacologic treatment should be continued indefinitely. staggering 35.5%. With an all-time high elderly population
Regular monitoring to assess risk for neurodegenerative of 8.6%, it is high time we brace-up for the identification of
disorders should be taken up keeping in mind the strong RBD and appreciate its importance as a pre-clinical marker
relationship of RBD as a prodrome of such illnesses. of neurodegenerative illnesses. The success of any future
neuroprotective and preventive interventions will, thus,
At present, there are no treatment strategies available to rely on early and reliable identification of illness in its
prevent or delay the development of PD in iRBD cases. nascent stage.

Table 16: Symptoms of Obstructive sleep apnoea (OSA) cerebrovascular disorders, diabetes mellitus, pulmonary
Somatic symptoms Cognitive and Behavioural symptoms hypertension, arrhythmias, systemic hypertension,
Daytime sleepiness Decreased concentration memory disturbances, cognitive dysfunction and sexual
Fatigue Memory loss problems.
Irritability Decreased libido
Snoring Learning difficulties In addition, psychiatric disorders and OSA are also
Gasping/choking at night Impaired cognitive functioning
Morning headaches Personality changes
frequently comorbid, especially depression.Mood
Non-refreshing sleep Depression disturbance may represent a consequence of sleep apnoea.
Nocturia Anxiety Psychiatric disorders associated with weight gain may
also contribute to and promote the development of sleep
apneas. Medications with depressent effect on CNS can
Table 17: Medical history to be taken in patients
worsen or exacerbate the symptoms of OSA.Patients with
with OSA
sleep apnea often have fregmatned sleep and thus they may
Depression
Sedatives
have daytime symptoms of poor quality sleep e.g., fatigue,
Parkinsonism lethary, poor appetite, poor concentration, memory lapses,
Narcolepsy headache, distressed mood that may be mistaken for
Restless leg syndrome/periodic limb movement disorder depression. Fregmented sleep often presents as multiple
Hypothyroidism
somatic symptoms during the daytime suggesting the
β‑blockers
Idiopathic hypersomnolence diagnosis of somatoform disorder.
Excess alcohol
Previous head injury The symptoms are the direct consequences of OSA and
DystrophicaMyotonica occur due to the repetitive collapse of upper air ways.
Stimulants (caffeine, theophyllines, amphetamines)
Thin and lean individuals with significant apnoea are likely
OBSTRUCTIVE SLEEP APNOEA (OSA) to show upper airway abnormalities. These include, e.g.,
hypertrophic tonsils and adenoids, a low-set palate or
Sleep apnoea is charcaterized by recurrent pauses (at least palatal webbing, a large uvula, a large tongue or a small
5/hour) in breath, each lasting at least 10 seconds and is mandible.
important for the Psychiatric practice as it can mimic or
exacerbate symptoms of psychiatric disorders such as Risk factors, Screening, Examination and Diagnosis of OSA
depression, anxiety and panic disorder. The prevalence of OSA is higher in patients who have a
combination of the following risk factors: obesity, neck
Three types of apnoeas have been described in literature. larger than 17 inches for men or 16 inches for women,
In obstructive sleep apnoea (OSA), cessation of breathing male gender, middle age, large tonsils, or recessed chin.
occurs despite persistent respiratory efforts. In central Besides anatomical factors, physiological factors that
apnoea, there is no respiratory effort. Mixed apnoea has influence the tone of the upper airway muslces play
initial part similar to central apnea but in the later part, equally important role in generation of OSA. It is prudent
effort to breath is seen with absence of airflow throughout to screen all patents who are at risk since untreated OSA
the period. Excessive daytime sleepiness, one of the major is an independent risk factor for mortality. In addition,
symptoms of OSA is seen in one-third of the patients and information regrading conditions as described in Table 17
many report mid-nocturnal awakenings due to chocking must be gathered.
which may be mistaken for panic. On the other hand, central
sleep apnea has subtle clinical manifestations and often Physical Examination
these patients present with chronic non-restorative sleep. Examination is very important to exclude other causes for
the patient’s symptoms mentioned below:
Obstructive sleep apnoea (OSA) is a common disorder
with an estimated prevalence in the general population of Following points should be kept in mind during physical
2–5% (Table 16). Apnoea during sleep leads to decrease in examination
blood oxygen level which leads to disturbance in sleep and
frequent arousals. Sleep apnoea severity is assessed with • Weight and height should be documented.
apnoea-hypopnoea index (AHI), which is the number of
apnoeas and hypopnoeas per hour of sleep. • Mandibular and tongue abnormality.
• Assessment of Nasopharyngeal abnormality.
Obesity is a major risk factor for OSA. Untreated OSA leads
to significant clinical problems including cardiovascular and • Measurement of Blood Pressure.

• Perform routine respiratory, cardiovascular and I. Mandibular Advancement Splints (MAS). This works
neurological examination to detect any coexisting disease. by moving the mandible forward along with the
tongue and increasing the caliber of upper airway.
Diagnosis
Certain questionnaires e.g., STOP-Bang, Berlin Questionnaire Surgical Options
have been developed to screen the OSA. However, the gold The treatment of choice for moderate to severe OSAS is
standard for the diagnosis of OSA is polysomnography. continuous positive airway pressure (CPAP) devices , but
Ideally, in-lab attended video-synchronized full patient adherence to these devices has been a limiting factor.
polysomnography (level 1) is indicated for the diagnosis of In ‘selected cases’, surgical treatment on the upper airway
OSA, however, among high risk cases, limited channel level (UA) or on the facial skeleton may be beneficial in alleviating
3 polysomnography may also be used. This is also known as this disease or improving the use of CPAP. Following surgical
Home Sleep testing. procedures can be beneficial to patients with OSA.
Treatment Any of the single staged procedure has not been found
Depending upon the severity the various treatment options effective in management of OSA in large controlled trials.
is most appropriate for the management of OSA. Patient should be educated regarding possible recurrence
of OSA after 1-2 years of surgery, especially when it is done
Treatment options can be broadly divided into: on the soft tissues.
1. Patient education
2. Behavioural interventions Treatment for comorbidities
3. Non-surgical options Hypothyroidism, depression, etc, are more prevalent
4. Surgical options. .Obstructive sleep apnea (OSA) and hypothyroidism are
5. Treatment for comorbidities. relatively common disorders that have similar clinical
features and are thought to be causally linked. The
Patient Education mechanisms proposed to explain how hypothyroidism
Patients and their attendants should be educated about the might cause OSA include mucoprotein deposition in the
pathophysiology, risk factors, clinical consequences and the upper airway, decreased neural output to the upper airway
treatment of OSA. musculature, obesity, and abnormalities in ventilatory
control.
Education should include behavioural modification like
weight loss, sleep position, alcohol avoidance, risk factor Treatment of hypothyroidism in the presence of sleep apnea
modification, and medication effects. is potentially hazardous and may lead to cardiovascular
complications. Management by a combination of Nasal
Behavioural Interventions continuous positive airways pressure(CPAP) and low-dose
Lifestyle changes can be very effective in mitigating the thyroxine is helpful in this situation.
symptoms of sleep apnoea. However, large control trials are
not available in this regard. OSA patients may have comorbid depression or any other
1. Weight loss is most important in all those who are psychiatric illness. In such cases bothe the disorders must
overweight. Weight reduction improves symptoms in be adequately and optimally treated.
OSA
2. Exercise Obstructive sleep apnea (OSA) leads to frequent arousals,
3. Avoidance/Reduction of smoking and alcohol is which are characterized by fragmented sleep. Persistent
beneficial. sleep loss can lead to depressive symptoms. Patients may
4. Sedatives or sleeping tablets should be avoided. be treated for depression, but if the underlying symptoms
5. Snorers should be discouraged from sleeping on their are caused by OSA and the apnoea is not treated, depressive
backs. symptoms can remain. We may be treating someone with
antidepressants when what we really should be doing is
Non-Surgical Options
treating their sleep disorder, which could in turn restore
1. Positive Air Pressure (CPAP). This is the “gold standard”
their normal mood.
treatment for OSA. Optimal pressure of the PAP should
be titrated as per the standard guidelines so as to
SUGGESTED READINGS
ameliorate all kinds of sleep related breathing events-
apnea/hypopnea, RERA and snoring. Automatic PAP has 1. Sharma S, Trivedi JK. Guidelines for the treatment of Sleep disorders.
limited application in these cases. Available at www.indianjpsychiatry.org/cpg/cpg2006/cpg-mgmt_16.pdf.
Last accessed 10 Oct 2016
2. Oral Appliances: These are effective only in mild to 2. Sharma SK, Kumpawat S, Banga A, Goel A. Prevalence and risk factors
moderate severe cases of OSA. of obstructive sleep apnea syndrome in a population of Delhi, India. Chest

2006;130:149–56. 2016;17:118.
3. Rangarajan S, Rangarajan S, D’Souza GA. Restless legs syndrome in an 15. Allen RP, Burchell BJ, MacDonald B, Hening WA, Earley CJ. Validation
Indian urban population. Sleep Med 2007;9:88–93. of the self-completed Cambridge-Hopkins questionnaire (CH-RLSq) for
4. American Academy of Sleep Medicine. International Classification of Sleep ascertainment of restless legs syndrome (RLS) in a population survey.
Disorders. 3rd ed. Darian, IL: American Academy of Sleep Medicine; 2014. Sleep Med 2009;10:1097-100.
5. Gupta R, Zalai D, Spence DW, BaHammam AS, Ramasubramanian
16. Gupta R, Allan RP, Pundeer A, Das S, Dhyani M, Geol D. Hindi translation
C, Monti JM, et al. When insomnia is not just insomnia: the deeper
correlates of disturbed sleep with reference to DSM-5. Asian J Psychiatr and validation of Cambridge-Hopkins diagnostic questionnaire for RLS
2014;12:23–30. (CHRLSq).Annals of Indian Academy Of Neurology . 2015 Jul ; 18(3): 303
6. Gupta R. Presleep thoughts and dysfunctional beliefs in subjects of 17. Scholz H, Trenkwalder C, Kohnen R, et al. Dopamine agonists for restless
insomnia with or without depression: Implications for cognitive behavior legs syndrome. Cochrane Database Syst Rev 2011; :CD006009.
therapy for insomnia in Indian context. Indian J Psychiatry 2016;58:77–82. 18. Wilt TJ, MacDonald R, Ouellette J, et al. Pharmacologic therapy for
7. Dhyani M, Rajput R, Gupta R. Hindi translation and validation of primary restless legs syndrome: a systematic review and meta-analysis.
dysfunctional beliefs and attitudes about sleep (DBAS - 16). Ind Psychiatry JAMA Intern Med 2013; 173:496.
J 2013;22:80–5. 19. American Psychiatric Association. Diagnostic and Statistical Manual of
8. Morin CM, Vallières A, Ivers H. Dysfunctional beliefs and attitudes Mental Disorders. 5th ed. Arlington (VA): American Psychiatric Association;
about sleep (DBAS): validation of a brief version (DBAS-16). Sleep
2013.
2007;30:1547–54.
9. Morin CM, Belleville G, Bélanger L, Ivers H. The Insomnia Severity Index: 20. Aurora RN, Zak RS, Maganti RK, Auerbach SH, Casey KR,
psychometric indicators to detect insomnia cases and evaluate treatment Chowdhuri S, et al. Standards of Practice Committee, American Academy
response. Sleep 2011;34:601–8. of Sleep Medicine. Best practice guide for the treatment of REM sleep
10. Lahan V, Gupta R. Translation and validation of the insomnia severity behavior disorder (RBD). J Clin Sleep Med 2010;6:85-95.
index in hindi language. Indian J Psychol Med 2011;33:172–6. 21. Berry RB, Brooks R, Gamaldo CE, Harding SM, Lloyd RM, Marcus CL,
11. Thompson W, Quay TAW, Rojas-Fernandez C, Farrell B, Bjerre LM, et al. The AASM Manual for the Scoring of Sleep and Associated Events:
Pringsheim T, et al. Atypical antipsychotics for insomnia: a systematic Rules, Terminology and Technical Specifications, Version 2.2. Darien (IL):
review. Sleep Med 2016;22:13–7. American Academy of Sleep Medicine; 2015.
12. Laudon M, Frydman-Marom A. Therapeutic effects of melatonin receptor 22. Johns MW. A new method for measuring daytime sleepiness: the Epworth
agonists on sleep and comorbid disorders. Int J Mol Sci 2014;15:15924–50.
sleepiness scale. Sleep. 1991;14(6):540–545.
13. Mitchell MD, Gehrman P, Perlis M, Umscheid CA. Comparative
effectiveness of cognitive behavioral therapy for insomnia: a systematic 23. Chung F, Yegneswaran B, Liao P, et al. STOP questionnaire: a tool to screen
review. BMC Fam Pract 2012;13:40. patients for obstructive sleep apnea. Anesthesiology. 2008;108:812.
14. Morin CM, Edinger JD, Krystal AD, Buysse DJ, Beaulieu-Bonneau S, Ivers H. 24. Oğuztürk Ö, Ekici M, Çimen D, Ekici A, Senturk E. Attention
Sequential psychological and pharmacological therapies for comorbid and deficit/hyperactivity disorder in adults with sleep apnea. J ClinPsychol Med
primary insomnia: study protocol for a randomized controlled trial. Trials Settings. 2013;20(2):234–239.

Editor Dr. T. S. Sathyanarayana Rao. Printed and published by Wolters Kluwers (India) Pvt. Ltd. on behalf of Indian Psychiatric Society, Mysore and
printed at Nikeda Art Prints Pvt. Ltd., Bhandup (W), Mumbai, and published at B5-12, Kanara Business Centre, Ghatkopar, Mumbai, India.

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Volume 59, Supplement 1 January 2017

Indian Journal of Psychiatry • Volume 59 • Supplement 1 • January 2017 • Pages S***-S***

& IPS Clinical Practice Guidelines

Schizophrenia, Depression, Bipolar Disorder, Generalized Anxiety

Honorary Editor SK Tandon, Bhopal Joesph Calabrese, U.S.A.

IPS Executive Council Members International affairs

Forensic Psychiatry Clinic Software Development

Subscription Information Permissions

iv Indian J Psychiatry 59 (Supplement 1), January 2017

Clinical Practice Guidelines S1

Changing times, moving ahead!: G Prasad Rao, President S2

Commitment for Clinical Excellence: MSVK Raju S3

Meeting the needs!: Gautam Saha S4

CLINICAL PRACTICE GUIDELINES

Clinical practice guidelines for Obsessive-Compulsive Disorder: Y.C. Janardhan Reddy,

Indian J Psychiatry 59 (Supplement 1), January 2017 v

vi Indian J Psychiatry 59 (Supplement 1), January 2017

Clinical Practice Guidelines

© 2017 Indian Journal of Psychiatry | Published by Wolters Kluwer ‑ Medknow S1

Changing times, moving ahead!

S2 © 2017 Indian Journal of Psychiatry | Published by Wolters Kluwer ‑ Medknow

Commitment for Clinical Excellence

It is the fundamental duty of any professional body of Dr (Brig) M S V K Raju

The present compilation of Clinical Practice Guidelines,

The exertions of the team headed by Prof Shiv Gautam, Prof

© 2017 Indian Journal of Psychiatry | Published by Wolters Kluwer ‑ Medknow S3

Meeting the needs!

S4 © 2017 Indian Journal of Psychiatry | Published by Wolters Kluwer - Medknow

Clinical Practice Guidelines: Principles for Clinical Practice

© 2017 Indian Journal of Psychiatry | Published by Wolters Kluwer - Medknow S5

due to flawed personal recollections when conflicting REFERENCES

care delivery systems. Hence the editorial team believes

The earlier guidelines were published by the CPG task force

S6 Indian J Psychiatry 59 (Supplement 1), January 2017

IPS Task Force on Clinical Practice Guidelines Workshop held on

Chairman : Dr. Shiv Gautam

Dr. Adarsh Tripathi (Lucknow) 10.4103/0019-5545.196968

IPS GUIDELINE COMMITTEE ON BPAD :

© 2017 Indian Journal of Psychiatry | Published by Wolters Kluwer - Medknow S7

IPS Task Force on Clinical Practice Guidelines Workshop held on

Chairman : Dr. Shiv Gautam

(Lucknow), Vihang N. Vahia (Mumbai), I.D. Gupta (Jaipur),

IPS GUIDELINE COMMITTEE ON SEXUAL

Ajit Avasthi (Chandigarh), T.S.S. Rao (Mysore), Mrugesh

S8 © 2017 Indian Journal of Psychiatry | Published by Wolters Kluwer - Medknow

Preamble of the Clinical Practice Guidelines

recommendations given as part of the revised guidelines Quick Response Code

Several factors influence the treatment of various DOI:

© 2017 Indian Journal of Psychiatry | Published by Wolters Kluwer ‑ Medknow S9

Indian Psychiatric Society Survey on Clinical Practice Guidelines

S10 © 2017 Indian Journal of Psychiatry | Published by Wolters Kluwer ‑ Medknow

Indian J Psychiatry 59 (Supplement 1), January 2017 S11

Table 1: Profile of participants (n=608) Views about guidelines

S12 Indian J Psychiatry 59 (Supplement 1), January 2017

Table 2: Views about guidelines (n=608) Table 3: Expectations from the guideline (n=608)

Indian J Psychiatry 59 (Supplement 1), January 2017 S13

S14 Indian J Psychiatry 59 (Supplement 1), January 2017

Table 7: Polypharmacy prescription practices (n=608)

Indian J Psychiatry 59 (Supplement 1), January 2017 S15

Indian Journal of Psychiatry • Volume 59 • Supplement 1 • January 2017 • Pages S-S

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