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Alcohol Abuse/Usein Suicide Attempters
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Key Facts AboutDepression
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Editorial
A Medical Bulletin from TIME Pharmaceuticals (P.) Ltd.
Sudarshan Lal ShresthaEditor in Chief
MOMENTS IN TIME
Mental disorders account for one of the largestand fastest growing categories of the burden ofdisease worldwide. Mental ill-health can havedevastating effects on individuals, families andcommunities, with one in every two peopleexperiencing a mental illness in their lifetime.There is a bitter truth which is proved by researchthat the serious mental illness can take between 7-24 years off a person�slife, which is similar to or worse than the impact of heavy smoking.The researchers found that the average life expectancy was 10-20years shorter than normal for people with schizophrenia, 9-20 yearsshorter for those with bipolar disorder, 7-11 years shorter for thosewith recurrent depression, and 9-24 years shorter for people with drugand alcohol abuse. It shows that it is more dangerous than life shortenedby heavy smoking.There are many different mental disorders, with different presentation.Depression and anxiety disorders are among the most common illnessesin the community and in primary care. After that, Dementia, a diseasemajorly affecting memory, is now leading as a cause of disability anddependency among the elderly. It is believed that a new case of dementiaoccurs somewhere in the world in every 3 seconds. With this, we canpredict that the cases of dementia are increasing day by day. There areover 100 forms of dementia. The most well known form of dementiais Alzheimer�s disease. Beside this, Psychosis is becoming one of themost life-impacting conditions in healthcare, and arguably mostsignificant in mental health in terms of poorest lifelong outcomes. Allthese diseases are increasing due to busy lifestyle and stress as well asunable to manage the work-life balance in their life.TIME Pharmaceuticals is now launching series of new molecules in thesector of depression and psychosis such as Setra (Sertraline 25, 50 and100mg), Alzicare (Donepezil 5 & 10mg) and Aripro (Aripiprazole 10and 15mg). Furthermore molecules are in the pipeline of R & D.Aripiprazole, a blockbuster molecule within a short period of launchingin the world with therapeutic effects on both positive and negativesymptoms of schizophrenia and related disorders with reduced sideeffects.In this issue, we are supported with the articles related to depressionand suicide which are the hot issues of current society. We feel honorto share the information from our valued doctors with our readers. Ithank fully acknowledge all medical fraternities for your continuoussupport for MEDITIME, and wish similar support with valuable feedbackand suggestion for improvement in it.
InsideEditorial 2
Health News Line 3
Alcohol Abuse/Use in Suicide Attempters: 4
Product Profile: Sertraline 7
Dementia 10
Product Profile: ALZICARE 11
Key Facts About Depression 12
Crossword Game 13
Winner Image 14
Response Form 14
Moments in Time 15
Propranolol 10/20/40mg TabletsHYPERNOLT o u c h i n g L i v e s , D e l i v e r i n g P r o m i s e sT o u c h i n g L i v e s , D e l i v e r i n g P r o m i s e s2
Clarithromycin 500mg TabletsCLARITH T o u c h i n g L i v e s , D e l i v e r i n g P r o m i s e sT o u c h i n g L i v e s , D e l i v e r i n g P r o m i s e s 15
Laxmi Pooja Celebration
Celebrating World Suicide Prevention Day
Participating at Mini Simon, Butwal
Diclofenac 1% w/w, Methyl Salicylate 10% w/w,Linseed Oil 3% w/w Gel
SALIF T o u c h i n g L i v e s , D e l i v e r i n g P r o m i s e sT o u c h i n g L i v e s , D e l i v e r i n g P r o m i s e s 3
SUICIDE:One Person Dies Every 40 SecondsThe number of countries with national suicide preventionstrategies has increased in the five years since thepublication of WHO�s first global report on suicide,said the World Health Organization in the lead-upto World Suicide Prevention Day on 10 September.But the total number of countries with strategies, atjust 38, is still far too few and governments need tocommit to establishing them.
Despite progress, "one person still dies every 40seconds from suicide,� said WHO Director-General,Dr Tedros Adhanom Ghebreyesus. �Every death is atragedy for family, friends and colleagues. Yet suicidesare preventable. We call on all countries to incorporateproven suicide prevention strategies into nationalhealth and education programmes in a sustainableway.�
Suicide rate highest in high-income countries; secondleading cause of death among young peopleThe global age-standardized suicide rate for 2016was 10.5 per 100 000. Rates varied widely, however,between countries, from 5 suicide deaths per 100000, to more than 30 per 100 000. While 79% ofthe world�s suicides occurred in low- and middle-income countries, high-income countries had the highestrate, at 11.5 per 100 000. Nearly three times asmany men as women die by suicide in high-incomecountries, in contrast to low- and middle-incomecountries, where the rate is more equal. Suicide wasthe second leading cause of death among youngpeople aged 15-29 years, after road injury. Amongteenagers aged 15-19 years, suicide was the secondleading cause of death among girls (after maternalconditions) and the third leading cause of death inboys (after road injury and interpersonal violence).
The most common methods of suicide are hanging,pesticide self-poisoning, and firearms. Key interventionsthat have shown success in reducing suicides arerestricting access to means; educating the media onresponsible reporting of suicide; implementingprogrammes among young people to build life skillsthat enable them to cope with life stresses; and earlyidentification, management and follow-up of peopleat risk of suicide.
Pesticide regulation: an under-used but highlyeffective strategyThe intervention that has the most imminent potentialto bring down the number of suicides is restrictingaccess to pesticides that are used for self-poisoning.The high toxicity of many pesticides means that suchsuicide attempts often lead to death, particularly insituations where there is no antidote or where thereare no medical facilities nearby.
As indicated in the WHO publication the regulationsto prohibit the use of highly hazardous pesticides canlead to reductions in national suicide rates. The best-studied country is Sri Lanka, where a series of bansled to a 70% fall in suicides and an estimated 93,000lives saved between 1995 and 2015. In the Republicof Korea-where the herbicide paraquat accountedfor the majority of pesticide suicide deaths in the2000s-a ban on paraquat in 2011-2012 was followedby a halving of suicide deaths from pesticide poisoningbetween 2011 and 2013.
Dengue Cases and Deaths in NepalIncreasing at Alarming RateNepal has become victim to the deadly dengue epidemic, which hasaffected more than 4,000 people and is slowly taking their lives.
As of September 09, 2019, the number of dengue patients in thenation has increased by 52 percent. The country recorded a total of3,899 people affected with dengue until September 08, 2019.According to the Nepal Epidemiology and Disease Control Division,the given number of people was tested positive for dengue. Thenumber increased by 268 cases from September 03, 2019.
Following the rapid spread of the epidemic, lawmakers have begandrawing the attention from the government, who are yet to commentor take action on the alarming situation in Nepal. �We have to makea concerted effort to contain the infection as the government cannotdo much on its own. Every household and community should play aproactive role to limit the infection,� said a senior Health and PopulationMinistry official on condition of anonymity. The epidemic has begunclaiming lives of the affected, increasing the death toll at an alarmingrate.
Dengue Cases as of September 19, 2019
The dengue fever cases in Chitwan, Kathmandu and Bhaktapur isseeing a rapid upward climb, signaling the beginning of a dengueepidemic in Nepal. Chitwan has reported more than 2,000 cases ofdengue over the last two months. As many as 1,170 dengue caseshave been reported in Kathmandu until September 10, 2019.Bhaktapurhas recorded a total of 197 dengue cases within two weeks, as ofSeptember 18, 2019. Despite these alarming numbers, the NepalGovernment has not declared a state of emergency in Nepal. NepalDeputy Prime Minister of Health and Population Upendra Yadavstated that there was no need to declare �Health emergency� in thecountry, while addressing the House of Representatives on September18, 2019.
Yadav explained that dengue was a global concern as there was novaccine or medicine to treat or control the disease. �The most effectivemethod to contain the outbreak is to search and destroy larvae thatbreed dengue causing mosquitoes. Containing dengue outbreak hasbecome a major challenge even for the developed countries. Denguewas listed by the WHO as one of the most serious diseases,� Yadavsaid.
The disease has claimed six lives across Chitwan, Doti, Kathmandu,Sunsari and Sindhupalchowk as of September 09, 2019. 56 of the77 Nepali districts have been affected with Dengue. The districtswhich have recently started reporting of dengue include Dolakha,Manang, Myagdi, Pyuthan, Rolpa and Rukum. Province 3 has reportedthe highest number of dengue cases in the country, where 2,010people have been tested positive for the illness. Province 3 alonecontributes to 51 percent of the dengue cases in Nepal. GandakiProvince and Province 1 have recorded 896 and 831 dengue cases,respectively. Chitwan, Kaski and Makwanpur districts remain the most-affected with 1,036, 715 and 624 dengue cases, respectively.Kathmandu district has also recorded a steady increase in the numberof dengue patients, which has risen to 254 between September 03-09, 2019. The number of dengue patients in Lalitpur increased to 32during the same period, while in Bhaktapur the people infected bydengue increased to 33. Every year, the world reports about 360million cases of dengue annually. Human beings are infected with thedengue virus caused by the bite of the female Aedes aegypti mosquito.The change in Nepal�s rainfall pattern due to climate change is oneof the reasons for the rise of dengue cases in the country.
- nepalisansar.com
Sertraline 25/50/100mg TabletSETRAT o u c h i n g L i v e s , D e l i v e r i n g P r o m i s e sT o u c h i n g L i v e s , D e l i v e r i n g P r o m i s e s4
Dr. Dhana Ratna ShakyaDepartment of Psychiatry
BPKIHS, Nepal
AbstractBackground: Alcohol use is common in Nepalese society.Substance abuse/use is described as one of the 3 of thedeadliest combination for suicide. There is a scant datafrom Nepal about the relationship of alcohol with suicide.We aim to see alcohol abuse/use in cases of suicideattempt.
Methods: It is a hospital based descriptive studyconducted among the cases with suicide attempt. Allthe patients consulting the investigating psychiatrist ofa department of psychiatry of a teaching hospital ineastern Nepal within study period were enrolled afterinformed consent. With usual detailed work-up, suicidalstate was ascertained. Relevant informations wererecorded in the proforma. An intensive exploration wasmade in all suicide-attempt subjects into a range ofalcohol abuse/use. Alcohol use/disorder wasoperationally sorted out into various categories inrelation to suicide attempt.
Results: Out of 150 total cases of suicide attempt, 68%(102) were married and 58.7% (88) were female. Averageage was 28.8 ± 12.329 years. More of the cases werefrom village and semi-urban settings. Some cases hadused alcohol for the first time immediately prior to theattempt and some other had Alcohol dependencesyndrome (ADS). A clear and possible association wasseen in 56/150 (37%).
Conclusion: Alcohol abuse/use is common and appearsto precipitate and predispose the DSH attempt.
Keywords: Alcohol use; Deliberate self harm; Alcoholuse disorder; Nepal; Suicide
Abbreviations: ADS: Alcohol Dependence Syndrome;ARD: Alcohol Related Disorder; AUA: Acute use ofalcohol; AUD: Alcohol Use Disorders; BPKIHS: BP KoiralaInstitute of Health Sciences; DSH: Deliberate Self Harm;DSM: Diagnostic and Statistical Manual of MentalDisorders; HUA: Harmful Use of Alcohol; ICD 10: TheInternational Classifications of Diseases 10th Edition;IERB: Institute Ethical Review Board; SPSS: StatisticalPackage for Social Studies
IntroductionSuicide is a complex phenomenon with multi-factorialcausation[1-4]. Complex interplay of various psychological,social, cultural and biological factors is implicated behindsuicide and its attempt[2-5] though many of times; someparticular precipitating event/factor stands out inparticular set-up and region indicating need for theidentification and some specific strategies[3]. Amongsuicide attempters, the combination of depression,hopelessness and substance/alcohol abuse/use has beenreported as the deadliest one as risk[5]. Alcohol abuse/useis common and suicide/attempt has been observedmore among alcohol users in Nepalese context too[6,7].Data on magnitude of alcohol abuse/use in
suicide/attempt will help guide devising needfulstrategies[3]. There is, however a dearth of informationabout alcohol use and related disorders among suicideattempters in Nepalese setting. This study was conductedin the department of psychiatry, B.P. Koirala Instituteof health sciences, Nepal in 2011 to sort out the alcoholuse/related disorders among suicide attempters.
MethodsIt is a hospital based-cross sectional descriptive studylooking into alcohol abuse/use among suicideattempters. All patients consulting the investigatingpsychiatrists-team of B. P. Koirala Institute of HealthSciences, Dharan, Nepal, within study period (12 months,2010 October/ 2011 September) were enrolled afterinformed consent. With usual detailed work-up, suicidalstate was ascertained. Relevant informations wererecorded in a predesigned proforma. An intensiveexploration was made in all the subjects into a range ofalcohol use and alcohol use disorders (ICD-10)[8]. Alcoholabuse/use was categorized in relation to suicide attemptinto:
a. Single and first time use just prior to the attempt.b. Occasional but not during attempt.c. Occasional and also during attempt.d. Harmful use and also during attempt.e. Harmful use but not during the attempt.f. Regular use/Alcohol dependence syndrome (ADS)
but not during attempt.
e.g: ADS and use during attempt. The information andviews collected from the subjects and their care takers(when the subject was not in position to respond)(through semi-qualitative approach) regarding the roleof alcohol use and disorder in the suicide attempt weresorted out. The information was kept confidential. Ethicalclearance was obtained from the Institute Ethical ReviewBoard of BPKIHS. Data were entered into a computerand analyzed using �Statistical Package for Social Studies�(SPSS) - software 17.
Resultsa. Out of the total of 150 cases enrolled in this study;
88 were female, with M : F ratio of 0.71: 1.b. Average age was 28.8 ± 12.329 years, with age range
of 14-81. Patients of age groups (20-29) and (< 20)years constituted the largest proportion 40.7% and22.7%. Majority 102, 68.0% were married; with 43,28.7% % single, 3, 2.0% widow and 1, 0.7% eachdivorcee and engaged. Great majority 82% wereeducated to various levels (Table 1).
Table 1: Age, Marital status and Education of suicideattempt casesAge group (yrs.) No. (%)< 20 34 (22.7)20 - 29 61 (40.7)30 - 39 26 (17.3)40 - 49 18 (12.0)³05 11 (7.3)Marital statusSingle 43 (28.7)Married 102 (68.0)Separate/ divorce 1 (0.7)Widow 3 (2.0)Engaged 1 (0.7)Education LevelIlliterate 27 (18.0)Literate - 3 16 (10.7)4 - 7 29 (19.3)8 - SLC 52 (34.7)PCL and above 26 (17.3)
c. Caste/ethnicities classified as per the system of�Government of Nepal, 2007 for Free Health services,District Health Service Report 2064� revealed: UpperHill caste (e.g. Brahmin, Chhetri, Thakuri, etc.),disadvantaged Hill Janajati (e.g. Magar, Rai, Tamang,Limbu, Sherpa, etc) and relatively advantaged Janajati(e.g. Newar, Gurung, Thakali) as the commonestcaste/ethnicities. Hindu cases (127, 84.7%)predominated here; with 11, 7.3% Kirat; 6, 4.0%Buddhist; 4, 2.7% Muslim and 2, 1.3% Christian. Halfof the total 75, 50.0% were from villages; 24, 16.0%from cities and 51, 34.0% semi-urban (Table 2).
Table 2: Caste/Ethnicity, Religion, Family type andResidential settings.
Caste/ Ethnic Groups No. (%)Upper Hill 40 (26.7)Upper Terai 15 (10.0)Relatively Advantaged Janajati 16 (10.7)Religiously Minorities/ Muslim 5 (3.3)Disadvantaged Non-Dalit Terai 21 (14.0)Disadvantaged Hill Janajati 39 (26.0)Disadvantaged Terai Janajati 1 (0.7)Hill Dalit 11 (7.3)Terai Dalit 2 (1.3)ReligionHindu 127 (84.7)Buddhist 6 (4.0)Muslim 4 (2.7)Christian 2 (1.3)Kirat 11 (7.3)Family TypeNuclear 74 (49.3)Joint 54 (36.0)Broken/ Separated/ Alone/ Other 22 (14.7)Residential SettingUrban 24 (16.0)Semi-Urban 51 (34.0)Rural 75 (50.0)
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d. Majority of these subjects (115, 76.7%) had psychiatricdisorder. The most common psychiatric diagnosiswas depression (unipolar mainly and some bipolar)(Table 3).
e. Consumption of poison was the most common mode(118, 75%) of suicide attempt*. Among the 118subjects attempting suicide by consuming poison,the commonest poison used was Organophosphorouscompounds. Two subjects had consumed 2 poisons(Table 4).
f. Many cases 71/150 had high intent and 58/150 hadhigh lethality of effect of the attempt (Table 5).
g. More than half of subjects (82/150, 54.7%) reportedto use psychoactive substance, mainly alcohol (Table6).
h. One third of the subjects 50/150, 33.3% reported toconsume alcohol immediately prior to the suicideattempt (Table 7).
i. In 56, 37.3% cases, some relationship (definite andpossible) was reported between alcohol abuse/useand suicide attempt.
Table 3: Psychiatric diagnoses*.ICD Code Psychiatric Diagnosis No. (%)
Suicide, Impulsive 35 (23.3)Present 115 (76.7)Physical Disease 8 (5.33)
F10-19 Psychoactive Substance Use 48 (32.00)F20-29 Schizophrenia, Schizotypal & Delusional 10 (6.67)F30-39 Mood (Affective) 59 (39.33)F30- 34, Manic Episode, Bipolar Affective 1 (0.67)38, 39
Depressive Episode, Bipolar Affective 4 (2.67)Depressive (Including Dysthymia- 1) 54 (36.00)Stress Related/Adjustment 17 (11.33)
Others Organic/Mental Retardation/Personality 16 (10.67)
*Multiple response category - One respondent mayhave one or more responses.
Table 4: Mode of Suicide attempt and Type of Poisonsused*.
Mode of No. (%) Mode of No. (%)Attempt PoisoningPoisoning 118 (74.55) Organophosphorous 92 (77.9)Hanging 23 (15.33) Zinc Phosphide 15 (12.7)Strangulation 5 (3.33) Drug Overdose 6 (5.1)Cut/Injury 6 (4.00) Chemical 4 (3.4)Other/Mixed 9 (6.00) Other/Mixed 3 (2.5)
Table 6: Substance use among out patients with Suicideattempt*.
Substance Use No. (%)None/Never 68 (45.3)Occasional/Social Alcohol 20 (13.3)Harmful Use of Alcohol 27 (18.0)Alcohol Dependence 20 (13.3)Alcohol + Other Substance 8 (5.3)Other Substance 8 (5.3)Inadequate 7 (4.7)
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f. Regular use/Alcohol dependence syndrome (ADS)but not during attempt.
e.g. ADS and use during attempt. We explored in thesubjects (by semi-qualitative approach; i.e. theirinformation and view) into the possibility of the role ofthe alcohol use and related factors in suicide attempt.Analysing (statistical and definite) the relationship andmechanisms of alcohol and suicide is beyond the scopeof this study; however, this could be the area of furtherstudy in this setting as well.
Other perspective is acute alcohol use (AUA) just priorto the attempt and chronic long standing use resultinginto alcohol use disorder (AUD) among the cases ofsuicide attempt. Both of these have been reportedhigher among suicide and suicide attempts[3]. We have50/150 (33.3%) of the suicide attempt subjects usingalcohol before the attempt which is comparable toavailable literature[3,18,19]. Nearly one third of thesubjects (32%) fulfilled the criteria for one or otheralcohol use disorder (ICD-10: Acute Intoxication, Harmfuluse, Alcohol dependence syndrome, other induceddisorders)[8] again keeping this study in line with availabledata from other parts[3,20]. Exploration was madethrough semi-qualitative approach into the relationship/association of alcohol in suicide attempt. Someassociation was seen in 56/150 (37%) of the deliberateself harm (DSH) attempters. Five cases had used alcoholfor the first time prior to the attempt and some otherhad Harmful use (18%), and Alcohol dependencesyndrome (ADS) (13.3%) comparable to large scale studyfrom Canada[9]. We have over all 50% of suicide attemptcases who have alcohol use/abuse, replicating the similarfinding in other areas[1,9]. It makes a strong ground forthe alcohol prevention programs here as well which willpositively impact the public mental health and helpreduce suicide risk in/directly[2].
Both suicide/attempt and substance are stigma ladenissues and their information is hidden[9]. We made anattempt to collect information about suicide and alcoholabuse/use in suicide attempt cases. Hence, the collectedinformation is liable to forgetting, modification andhiding. In some cases, information was notavailable/inadequate in this study to ascertain someimportant issues, i.e. intent/ lethality of suicide attempt,substance/alcohol use/disorders in these suicide cases.Many of these cases might add to the figure ofsubstance/alcohol abuse/ use in these cases during thesuicide and as a whole. Second issue is that our studyis hospital based and is among psychiatry patientsseeking consultation for suicide attempts. This bias maylimit its generalization to other setting. However, webelieve that for a suicide like phenomenon (relativelyepidemiologically rare, complex and stigmatized issue),it is a method[3] and it does not make difference for thestudy objective of looking into alcohol ab/ use amongsuicide attempters. Definite statistical correlationalanalysis and other in-depth cause effect analysis isbeyond the scope of this study which could be theobjective of further study though challenging in thistype of subject[2]. We intended only to directly see theoccurrence of alcohol abuse/use in suicide attemptcases. We did not mean in this work to intensivelyexplore in-depth to other possible bio-psycho-socialand cultural factors somehow associated with suicideattempt in acute alcohol use (AUA), e.g. circumstances/
Table 7: Alcohol use during Suicide attempt.
Substance use During Suicide Attempt No. (%)Not Present 91 (60.7)Never Used 68 (45.3)Occasional but not During Act 13 (8.7)Harmful Use but not During Act 9 (6.0)Present 50 (33.3)First time Use at the Time of Act 5 (3.3)Occasional and Use During Act 7 (4.7)Harmful & use During Act (Excluding First Time Use) 18 (12.0)Regular and Use During Act 8 (5.3)Increased Regular Use During Act 12 (8.0)Inadequate Information 9 (6.0)
DiscussionSuicide and its attempts is a serious problem with greatimpact for individual, family, society and nation[9,10]. Itsrate is reported to increase in recent years[2], more soin the developing countries[10]. Nepal is also witnessinghigh and rising suicide rates, in various settings[11,12]
though we have a limited nationwide community baseddata[13]. Suicide is the result of a complex process ofinteraction of protective and risk factors, i.e. interplayof bio-psycho-socio-cultural factors[1- 5]. Hence, theprevention efforts are challenging and also required tobe multi-factorial and multi-dimensional[2,9]. As withother health problems, suicide prevention endeavoursinclude primary, secondary and tertiary prevention inthe form of universal, selective, targeted and indicatedinterventions[2,9]. Related factors may predispose orprecipitate the suicide phenomena and may alsocontribute to cause repeated attempts[2,9]. Importantperspective is to analyze and address modifiable factorsin a particular setting and locality[3,14]. Identification ofmodifiable factors and managing them consist of animportant aspect of suicide prevention[3]. We have somestudies looking into associated clinical correlatesincluding depression and other psychiatric morbidities[15]
and common stressors[16] in suicide attempt subjects.We aim in this study to see the alcohol use and disordersamong suicide attempt cases coming in psychiatricdepartment of a teaching hospital in eastern Nepal.Since alcohol use and disorders are remarkably high inthis part[7,17], we view that this effort would make ameaningful step towards comprehensive understandingand suicide prevention here.
Occurrence of any factor in a health problem can be ofcoincidental, co-occurrence or causal (cause and effect)relationship. Alcohol use and its related disorders insuicide also may be one of these possibilities; complexand still far from conclusive[2,3,9,14]. In this study, weaim to see the occurrence of a spectrum of alcohol useand alcohol use disorders among the psychiatric patientsseeking consultation for suicide attempts. Alcoholabuse/use was operationally categorized in this studyin relation to suicide attempt into:
a. Single and first time use immediately prior to theattempt.
b. Occasional but not during attempt.c. Occasional and also during attempt.d. Harmful use and also during attempt (excluding first
time use just prior to the attempt in this study whichis conceptually a Harmful use).
e. Harmful use but not during the attempt.
Levofloxacin 250/500/750mg TabletsL-FROX T o u c h i n g L i v e s , D e l i v e r i n g P r o m i s e sT o u c h i n g L i v e s , D e l i v e r i n g P r o m i s e s 7
FDA approved Indications of SETRAw Major Depressive Disorderw Panic Disorderw Pre-menstrual Dysphoric Disorderw Post Traumatic Stress Disorderw Social Anxiety Disorderw Obsessive Compulsive Disorder
Pharmacodynamics of SETRASelectively inhibit the reuptake of serotonin at thepresynaptic membrane. This results in an increasedsynaptic concentration of serotonin in the CNS, whichleads to numerous functional changes associated withenhanced serotonergic neurotransmission. It issuggested that these modifications are responsible forthe antidepressant action observed during long termadministration of antidepressants.
Pharmacokinetics of SETRAw Absorption : Mean peak plasma concentrations
occurred between 4.5 to 8.4 hours. The steady-stateconcentrations are reached after 1 week followingonce-daily administration. May be taken with orwithout food.
w Protein Binding : Highly bound to serum protein (98%)
w Metabolism : Extensively metabolized in the liver.Sertraline metabolism involves N-demethylation,N-hydroxylation, oxidative deamination, andglucuronidation of sertraline carbamic acid.N-desmethylsertraline to be substantially less activethan sertraline.
w Route of Elimination : Sertraline is extensivelymetabolized and excretion of unchanged drug in urineis a minor route of elimination.
w Half Life: The elimination half-life of sertraline isapproximately 25-26 hours.
Pregnancy Category : CContraindicationsw In patients taking monoamine oxidase inhibitors
(MAOIs) is contraindicatedw In patients with a hypersensitivity to sertraline or any
of the inactive ingredients
Generic Name : SertralineStrength : 25/50/100 mg TabletAnti-Therapeutic Category : Anti-Depressant
Product InformationClass of Anti-Depressant :Selective Serotonin Reuptake InhibitorDose : ODPackaging : 10 x 10 Tablets PVC Blisters
motivation to drink, distress/mental state, impulsivity,etc. and in alcohol use disorder (AUD) subjects, e.g.depressive disorder, AUD symptoms severity, low socialsupport, stressful life events, medical illness orcomplaints, and unemployment or other indications ofeconomic adversity etc. which are not less important[3].
This study is however expected to open avenues for thein-depth and large study on the relationship of substanceand suicide and might indicate various future studyareas, e.g. effect of acute (AUA) and chronic use (AUD),many other associated factors. Overarching the objectiveof this study would be to devise the strategies as targetedand indicated measures for these high risk and survivorsof suicide attempts in this setting, e.g. sensible/ reduceddrinking, comprehensive treatment including that foralcohol problem[3], exploring and monitoring the suiciderisk at intervals in follow ups and consultations[2]. Forthis, it is important to give information and training tothe related stakeholders, e.g. general practitioners andother health professionals, parents, teachers, clean ex-users of substance coming in contact with at-riskindividuals[2].
ConclusionAmong the subjects seeking psychiatric consultation forsuicide attempt; female were more, majority were lessthan 30 years and more were married. Three fourthshad psychiatric disorder, the most common beingdepression. Poisoning was the most common mode ofsuicide attempt and the commonest poison used was
organophosphorous compound. Half of these subjectsreported to use psychoactive substance, mainly alcohol.One third of the cases had consumed alcoholimmediately prior to suicide attempt. Some (clear andpossible) relationship was seen between alcoholabuse/use and the suicide attempt in 37% of the cases.This indicates the need to explore and treat substance/alcohol use disorder simultaneously in these suicideattempt cases and to screen and manage suicide risk inalcohol ab/use cases.
DeclarationEthics approval and consent to participate- Approvalfrom Institute Ethical Review Board (IERB) of BPKIHS(Ref. No.- Aca 216/068/069) and Consent to participatetaken from the subjects.
AcknowledgementProf. Rupa Singh, Department of Paediatrics andNeonatology, BPKIHS.
Authors� ContributionsOverall responsibility born by the author (solo).
For the references, please mail us [email protected]
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CONTROLFLOW OF URINE
Alfuzocin HCl 10 mg Extended Release Tablets
What is DEMENTIA ?
It is a syndrome (and not a disease)in which there is deterioration inmemory, thinking, behaviour and theability to perform everyday activities.It is group of brain disorders thatmake it hard to remember, thinkclearly, make decisions or even controlyour emotions. Worldwide, around50 million people have dementia, andthere are nearly 10 million new casesevery year. Although dementia mainlyaffects older people, or likelyhod ofdementia increase with age BUT it isnot a normal part of ageing.
The number of patients withAlzheimer's disease in Nepal wasestimated to be 78,000 in 2015 andestimated to double every 20 years.
Dementia Types : There are severaltypes of dementia, including:1. Alzheimer �s Disease: I t is
characterized by plaques betweenthe dying cells in the brain andtangles within the cell, both aredue to protein abnormalities.
2. Dementia with Lewy bodies: It isa neurodegenerative conditionlinked to abnormal structure in thebrain.
3. Mixed Dementia: It refers todiagnosis of two or three types ofdementia occurring together. Eg:Alzheimer�s Disease & VascularDementia at the same time.
4. Parkinson�s Disease: Also markedby presence of Lewy bodies.Although Parkinson�s is oftencons idered a d isorder ofmovement, it can lead to dementiasymptoms.
5. Huntington�s Disease: It ischaracterized by specific types ofuncontrolled movements but alsoincludes dementia.
6. Vascular Dementia: It is the secondmost common type of dementia(after Alzheimer's disease). 30% ofStroke Survivors will developVascular Dementia. Stroke doublesthe risk of Dementia. Preclinicaland clinical evidence indicates thata cholinergic deficit, similar to thatseen in Alzheimer disease isassociated with Vascular Dementia.
Alzheimer�s Disease
Alzheimer�s is named after Dr. Alois Alzheimer. Alzheimer's disease is themost common cause of dementia - a continuous decline in thinking,behavioral and social skills that disrupts a person's ability to functionindependently. The early signs of the disease may be forgetting recentevents or conversations. As the disease progresses, a person withAlzheimer's disease will develop severe memory impairment and losethe ability to carry out everyday tasks.
The Hallmarks of the Disease are the accumulation of NeurofibrillaryTangles and Amyloid plaques causing neuron cells to die. Breaking theseconnections causes neurons to be lost. Deficit or loss of cholinergicneurons/ cholinergic transmissions an potentially influence all aspectsof Cognition, Behaviour and Processing informations.
Ach has an important role in cognitive processes, & is pointed as animportant factor in many forms of dementia, including AD. Deficits in thecholinergic transmission can potentially influence all aspects of cognitionand behavior, including cortical and hippocampal processing information.Cholinergic neuronal loss, especially in the basal forebrain, leads to AD.
Donepezil 5/10 mg TabletsALZICARET o u c h i n g L i v e s , D e l i v e r i n g P r o m i s e sT o u c h i n g L i v e s , D e l i v e r i n g P r o m i s e s10
Aripiprazole 10/15mg TabletsARIPRO T o u c h i n g L i v e s , D e l i v e r i n g P r o m i s e sT o u c h i n g L i v e s , D e l i v e r i n g P r o m i s e s 11
ALZICARE : FDA APPROVED INDICATIONS INw In mild, moderate and severe stages of AD, vascular
dementia and dementia associated with Parkinson'sdisease
w Cholinesterase Inhibitor helps with the BehavioralElements of Parkinsonism Disease
Pharmacodynamics
Donepezil is a centerally active, reversible inhibitor ofAcetylcholinesterase.
Acetylcholinesterase is an enzyme that degradesacetylcholine after it is released from the presynapse.
Donepezil binds reversibly to acetylcholinesterase andinhibits the hydrolysis of acetylcholine, thus increasingthe availability of acetylcholine at the synapses,enhancing cholinergic transmission
Pharmacokinetic
w Donepezil is well absorbed with a relative oralbioavailability of 100% and reaches peak plasmaconcentrations in 3 to 4 hours.
w Food does not affect the absorption.w Protein Binding : 96%w Donepezil is both excreted in the urine intact and
extensively metabolized to four major metabolites,two of which are known to be active.
Compilations of VARIOUS RESEARCH ARTICLES1. According to Dement Neuropsychol 2011, confirmed
that Donepezil is well tolerated & improves CognitiveSymptoms & Functional Abilities in Vascular CognitiveImpairment (VCI) patients.
2. According to The Lancet, 2006, many clinical studieshave shown that use of Donepezil at an early stageresults in delayed progression of the disease, andincreased longevity, implying a disease-modifyingeffect rather than the simple suppression of symptomsthat might be expected from AcetylcholinesteraseInhibition.
3. According to American Journal of Alzheimer's Disease& other Dementias, 2009, Donepezil has strong datathroughout the Alzheimer's disease spectrum and,therefore, represents a First-Line Monotherapy thatcan provide benefits to patients in all stages ofAlzheimer's disease.
4. According to Clinical Interventions in Aging, 2008.Efficacy & Safety of Donepezil, Galantamine,Rivastigmine for the treatment of Alzheimer's Disease.Donepezil is significantly better than Galantaminewith regard to behavior & global assessment of change& showed a better efficacious with least side effects.
Brand Name : ALZICARE
Generic : Donepezil
Strength : 5 & 10 mg Tablets
Product InformationTherapeutic Category : Anti-Alzheimer's Disease
Class of Drug : AcetylCholinesterase Inhibitor
Dosage : OD Before Sleep
Cefpodoxime Proxetil 200mg FC Tablets, 100mg DT & DSCEFIMET o u c h i n g L i v e s , D e l i v e r i n g P r o m i s e sT o u c h i n g L i v e s , D e l i v e r i n g P r o m i s e s12
What is Depression ?Depression is a common illness worldwide, with more than 300 millionpeople affected. Depression is different from usual mood fluctuations andshort-lived emotional responses to challenges in everyday life. Especiallywhen long-lasting and with moderate or severe intensity, depression maybecome a serious health condition. It can cause the affected person tosuffer greatly and function poorly at work, at school and in the family. Atits worst, depression can lead to suicide.Close to 800 000 people die due to suicide every year. Suicide is the secondleading cause of death in 15-29-year-olds.Although there are known, effective treatments for depression, fewer thanhalf of those affected in the world (in many countries, fewer than 10%)receive such treatments. Barriers to effective care include a lack of resources,lack of trained health-care providers, and social stigma associated withmental disorders. Another barrier to effective care is inaccurate assessment.In countries of all income levels, people who are depressed are often notcorrectly diagnosed, and others who do not have the disorder are too oftenmisdiagnosed and prescribed antidepressants.The burden of depression and other mental health conditions is on the riseglobally. A World Health Assembly resolution passed in May 2013 has calledfor a comprehensive, coordinated response to mental disorders at countrylevel.
Symptoms of DepressionDepending on the number and severity of symptoms, a depressive episodecan be categorized as mild, moderate, or severe.A key distinction is also made between depression in people who have ordo not have a history of manic episodes. Both types of depression can bechronic (i.e. over an extended period of time) with relapses, especially ifthey go untreated.
Types of DepressionRecurrent depressive disorder: This disorder involves repeated depressiveepisodes. During these episodes, the person experiences depressed mood,loss of interest and enjoyment, and reduced energy leading to diminishedactivity for at least two weeks. Many people with depression also sufferfrom anxiety symptoms, disturbed sleep and appetite and may have feelingsof guilt or low self-worth, poor concentration and even medically unexplainedsymptoms.
Depending on the number andseverity of symptoms, a depressiveepisode can be categorized as mild,moderate, or severe. An individualwith a mild depressive episode willhave some difficulty in continuingwith ordinary work and socialactivities, but will probably not ceaseto function completely. During asevere depressive episode, it is veryunlikely that the sufferer will be ableto continue with social, work, ordomestic activities, except to a verylimited extent.Bipolar affective disorder: This typeof depression typically consists ofboth manic and depressive episodesseparated by periods of normalmood. Manic episodes involveelevated or irritable mood, over-activity, pressure of speech, inflatedself-esteem and a decreased needfor sleep.
Contributing factors & preventionDepression results from a complexinteraction of social, psychologicaland biological factors. People whohave gone through adverse lifee v e n t s ( u n e m p l o y m e n t ,bereavement, psychological trauma)are more likely to developdepression.Depression can, in turn, lead to morestress and dysfunction and worsenthe affected person�s life situationand depression itself.There are interrelationshipsbetween depression and physicalhealth. For example, cardiovasculardisease can lead to depression andvice versa.Prevention programmes have beenshown to reduce depression.Effective community approaches toprevent depression include school-based programmes to enhance apattern of positive thinking inchildren and adolescents.Interventions for parents of childrenwith behavioural problems mayreduce parental depressivesymptoms and improve outcomesfor their chi ldren. Exerciseprogrammes for the elderly can alsobe effect ive in depress ionprevention.
Helplessness
Weight Changes
Guilt
Abandoning hobbies
Difficulty sleeping
Thoughts of death
Energy loss
Isolation
Anger
Anorexia or over-eating
Dr. K.B ShresthaENT- Butwal
Dr. Sabina BhattaraiDerma-Kathmandu
Dr. Rajdev P. KushwahaOrthopedics-Birgunj
30th Issue Winner List
Dr. Navin Kumar KarnOrthopedics- Biratnagar
Dr. Sushma ShresthaPeads-Kanti Children Hospital
Phr. Toya Nath PaudelAnnapurna Rural Municipality
Dr. Sandeep Chandra ShresthaBirtacity Hospital
Dr. Santosh GautamIM, Kist Hospital
Trine,Square,Sinex,OrosisD,Urodine,Rabepra
Word Scramble
Iron Hydroxide Polymaltose Complex 100mg &Folic Acid 1mg Tablets
POLYMAX T o u c h i n g L i v e s , D e l i v e r i n g P r o m i s e sT o u c h i n g L i v e s , D e l i v e r i n g P r o m i s e s 13
Diagnosis and treatmentThere are effective treatments formoderate and severe depression.Health-care providers may offerpsychological treatments (such asbehavioural activation, cognitivebehavioural therapy [CBT], andinterpersonal psychotherapy [IPT])or antidepressant medication (suchas selective serotonin reuptakeinhibitors [SSRIs] and tricyclicantidepressants [TCAs]). Health-careproviders should keep in mind the
possible adverse effects associatedwith antidepressant medication, theability to deliver either intervention(in terms of expertise, and/ortreatment avai labi l i ty) , andindividual preferences. Differentpsychological treatment formats forconsideration include individuala n d /o r g ro u p fa c e - to - fa c epsychological treatments deliveredby professionals and supervised laytherapists.
Psychosocial treatments are alsoeffective for mild depression.Antidepressants can be an effectiveform of treatment for moderate-severe depression but are not thefirst line of treatment for cases ofmild depression. They should not beused for treating depression inchildren and are not the first line oftreatment in adolescents, amongwhom they should be used withextra caution.(This Article is abstracted from World
Health Organization, 2018 )
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Linagliptin 5mg TabletsLINTABT o u c h i n g L i v e s , D e l i v e r i n g P r o m i s e sT o u c h i n g L i v e s , D e l i v e r i n g P r o m i s e s14
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Dr. Binay AdhikariDM Cardiologist
Dr. Utsav SharmaDermatologist, DI Skin Hospital
Luliconazole 1 % w/w cream
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Editorial
A Medical Bulletin from TIME Pharmaceuticals (P.) Ltd.
Sudarshan Lal ShresthaEditor in Chief
MOMENTS IN TIME
Mental disorders account for one of the largestand fastest growing categories of the burden ofdisease worldwide. Mental ill-health can havedevastating effects on individuals, families andcommunities, with one in every two peopleexperiencing a mental illness in their lifetime.There is a bitter truth which is proved by researchthat the serious mental illness can take between 7-24 years off a person�slife, which is similar to or worse than the impact of heavy smoking.The researchers found that the average life expectancy was 10-20years shorter than normal for people with schizophrenia, 9-20 yearsshorter for those with bipolar disorder, 7-11 years shorter for thosewith recurrent depression, and 9-24 years shorter for people with drugand alcohol abuse. It shows that it is more dangerous than life shortenedby heavy smoking.There are many different mental disorders, with different presentation.Depression and anxiety disorders are among the most common illnessesin the community and in primary care. After that, Dementia, a diseasemajorly affecting memory, is now leading as a cause of disability anddependency among the elderly. It is believed that a new case of dementiaoccurs somewhere in the world in every 3 seconds. With this, we canpredict that the cases of dementia are increasing day by day. There areover 100 forms of dementia. The most well known form of dementiais Alzheimer�s disease. Beside this, Psychosis is becoming one of themost life-impacting conditions in healthcare, and arguably mostsignificant in mental health in terms of poorest lifelong outcomes. Allthese diseases are increasing due to busy lifestyle and stress as well asunable to manage the work-life balance in their life.TIME Pharmaceuticals is now launching series of new molecules in thesector of depression and psychosis such as Setra (Sertraline 25, 50 and100mg), Alzicare (Donepezil 5 & 10mg) and Aripro (Aripiprazole 10and 15mg). Furthermore molecules are in the pipeline of R & D.Aripiprazole, a blockbuster molecule within a short period of launchingin the world with therapeutic effects on both positive and negativesymptoms of schizophrenia and related disorders with reduced sideeffects.In this issue, we are supported with the articles related to depressionand suicide which are the hot issues of current society. We feel honorto share the information from our valued doctors with our readers. Ithank fully acknowledge all medical fraternities for your continuoussupport for MEDITIME, and wish similar support with valuable feedbackand suggestion for improvement in it.
InsideEditorial 2
Health News Line 3
Alcohol Abuse/Use in Suicide Attempters: 4
Product Profile: Sertraline 7
Dementia 10
Product Profile: ALZICARE 11
Key Facts About Depression 12
Crossword Game 13
Winner Image 14
Response Form 14
Moments in Time 15
Propranolol 10/20/40mg TabletsHYPERNOLT o u c h i n g L i v e s , D e l i v e r i n g P r o m i s e sT o u c h i n g L i v e s , D e l i v e r i n g P r o m i s e s2
Clarithromycin 500mg TabletsCLARITH T o u c h i n g L i v e s , D e l i v e r i n g P r o m i s e sT o u c h i n g L i v e s , D e l i v e r i n g P r o m i s e s 15
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Alcohol Abuse/Usein Suicide Attempters
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Key Facts AboutDepression
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