Neuropsychiatry service provision in India and South Asia

Neuropsychiatry as a medical specialty is significantly underrepresented in India, with neurology and psychiatry giving each other a wide berth in many of the country’s regions. This chapter reviews the state of neuropsychiatric services in India and South Asia, before moving on to explore what constitutes a Comprehensive Neuropsychiatry Programme (CNP). This encompasses education and research into neuropsychiatric outcomes, advocacy at a governmental level, and community-engendered activities, all with a view to attaining optimal levels of participation in activities of daily living (ADLs), health-related quality of life (HRQoL), and various social and educational milestones. The model employed by a multidisciplinary team for use in developing nations is then described, along with a case study to demonstrate best practice.

Delirium

Delirium is a common, complex neuropsychiatric syndrome that occurs in approximately one in five hospitalized patients. It is associated with a range of adverse healthcare outcomes that are independently predicted by the severity and duration of delirium. Typically 50% or more of cases of delirium are missed, misdiagnosed, or diagnosed late in everyday practice. However, routine systematic cognitive testing aligned to formal screening for delirium in high-risk cases can improve detection in everyday practice. The relationship between delirium and dementia is complex; dementia is a potent risk factor for delirium and 50% of delirium occurs in the context of a pre-existing dementia, but evidence also indicates that the occurrence of delirium can accelerate the course of dementia and that many cases of delirium are followed by long-term cognitive impairment. Delirium is highly preventable, with a third of cases avoidable by addressing a variety of patient, illness, and treatment factors. Treatment of incident delirium requires careful consideration of underlying causes, aggravating environmental factors, and prudent use of pharmacological strategies, with antipsychotic agents the preferred pharmacological intervention. Careful attention to post-delirium care can minimize functional loss, address any psychological sequelae, and reduce the risk of further episodes.

Neuropsychiatry of aggression

Conditions affecting the central nervous system, such as trauma or degenerative illness, often lead to neurobehavioural disorders. One of the most difficult of these to treat is aggression. Outwardly directed aggression can be divided into two types—reactive and proactive—the first of which is less structured and generally presents with visible anger, while the latter is structured and premeditated. While there exists no specific diagnostic criteria for either type of aggression, the closest that exist are intermittent explosive disorder (IED) for the former and conduct disorder (CD), which has been known to evolve into personality disorders (PDs), for the latter. This chapter explores the relation between aggression and other neuropsychiatric conditions, beginning with its neurobiological underpinnings. It then describes assessment methods, such as the Behaviour itself, Medical/ organic issues, Person showing the behaviour, Psychiatric/psychological issues, and Social/ occupational/ personal issues (BMPPS) model, before discussing treatments, both pharmacological and non-pharmacological. For the former, the effectiveness of various medications is discussed, from antipsychotics to mood stabilizers.

Neuropsychiatry of neurometabolic, neuroendocrine, and mitochondrial disorders

This chapter examines the role of neurometabolic, neuroendocrine, and mitochondrial disorders in causing neuropsychiatric syndromes. It examines how disorders of cellular metabolic processes, particularly those that affect the brain, can result in major psychiatric syndromes and the over-representation of some neurometabolic disorders in psychiatric illness. It also discusses a range of endocrine disorders, particularly disorders of increased or reduced endocrine function and endocrine tumours, in producing psychiatric syndromes. The chapter also reviews the role of mitochondrial disorders in disrupting central nervous system processes and metabolism, and how some mitochondrial disorders result in psychiatric illness.

Neuropsychiatry of consciousness

Consciousness requires wakefulness and awareness. Many neuropsychiatric syndromes involve the disturbance of these functions. This chapter provides an overview of the various clinical presentations involving quantitative or qualitative disturbances of consciousness in order to explore the associated pathologies and underlying neurophysiological mechanisms. It lays out a number of clinical syndromes associated with impaired consciousness, such as persistent vegetative state (PVS) or unresponsive wakefulness syndrome (UWS), where the patient’s bodily functions can continue independently and show activity in higher motor areas when prompted under functional magnetic resonance imaging, yet are unable to communicate or follow commands. Focus is then given to altered mental states where conditions, such as neuroleptic malignant syndrome (NMS), may cause patients to experience depersonalization, fugue states, and hallucinations. After exploring the neuroanatomy and neurophysiology of such disorders, with a description of the function and significance of the ascending reticular activating system (ARAS), a number of clinical scenarios are presented.

Genetics of neuropsychiatric disease

To better understand the intricacies of genetic influences on neuropsychiatric disease, it is important first to have a grounding in the models of human inheritance and current diagnostic techniques. This chapter covers the fundamentals of genetic disorders, giving insights into chromosomal, single-gene, and mitochondrial disorders. Moreover, it explores the changing applications of genomic technologies, such as whole exome and whole genome sequencing, through the lens of their implications for neuropsychiatry. Clinical examples are provided to give an idea of the genetic underpinnings of Alzheimer’s disease, Parkinson’s disease, and other familiar disorders.

The history and scope of neuropsychiatry

This chapter discusses the clinical necessity from which the intersection of neurology and psychiatry arose, exploring different eras and their associated intellectual milestones in order to understand the historical framework of contemporary neuropsychiatry. Identifying Hippocrates’ original acknowledgement of the relation of the human brain to epilepsy as a start point, the historical development of the field is traced. This encompasses Thomas Willis and his nascent descriptions of the limbic system, the philosophical and alchemical strides of the Enlightenment, and the motivations behind the Romantic era attempts to understand the brain. It then follows the growth of the field through the turn of the twentieth century, in spite of the prominence of psychoanalysis and the idea of the brainless mind, and finally the understanding of the ‘integrated action’ of the body and nervous system, which led to the integration of psychiatry and neurology, allowing for the first neuropsychiatric examinations of epilepsy.

Neuropsychiatry services in Central, Southern, and Eastern Europe

In order to promote international homogeneity of neuropsychiatric services and standards of practice, one must consider local historical perspectives. This chapter focuses on the variety of historical perspectives on neuropsychiatry between countries in Central, Southern, and Eastern Europe, focusing first on Central Europe, from its initial understanding with Hippocrates, through the inter- to post-war disciplinary fracture of neurology and psychiatry, to the eventual influence of the Anglo-American tradition in the latter half of the twentieth century that saw the fracture mended. Further connections between different cultural perspectives on neuropsychiatry are explored, such as the German tradition’s influence on neuropsychiatry in Franco’s Spain, and the impact of Pinel and Charcot’s nineteenth-century advances in the French school on Europe as a whole. Given the advance of globalization, an international paradigm is now needed for neuropsychiatry, which could help define the discipline and incorporate new integrative perspectives such as neurophenomenology and neuropsychoanalysis.

Neuropsychiatry services in Japan

This chapter deals with the neuropsychiatric service provision, training, career opportunities, particular issues in aged society, and scientific activities for understanding the situation of neuropsychiatry in Japan. The proportion of people aged 65 years and older in Japan reached the world’s highest at 21.0% in 2006. The elderly population has since increased persistently and is estimated at 27.1% of the total population. In addition to this, the ratios of people aged 75 years and over and those aged 85 years and over are estimated at 13.2% and 4.1%, respectively. The ‘oldest old ’ group has contributed to the increasing prevalence of dementia. According to the governmental survey, the estimated number of elderly persons with dementia was 2.80 million in 2010 and 3.45 million in 2015. It is predicted to increase to 4.1 million by 2020 and 4.7 million by 2035. The number of patients with major neuropsychiatric disorders, especially Alzheimer’s disease, vascular dementia, and Parkinson’s disease, has been increasing for the last two decades, and the needs for neuropsychiatric services are also rapidly increasing. Neuropsychiatric services consist mainly of provision of clinical diagnosis, based on clinical examination, and medical treatment for neuropsychiatric symptoms, i.e. psychiatric symptoms of neurological disorders. Neuropsychiatric services should be provided by neuropsychiatry specialists. There are approximately 13,000 psychiatrists and 8000 neurologists working in psychiatric hospitals, general hospitals, medical schools, and private clinics. However, the number of neuropsychiatry specialists is quite limited. Therefore, there is urgency for the Japanese Neuropsychiatric Association (JNA) to set up an appropriate training system for clinicians in order to remediate the shortage of neuropsychiatrists.

Neuropsychiatric services in Australia and New Zealand

In New Zealand and Australia, until recently, neuropsychiatric patients with disorders like Parkinson’s disease, epilepsy, or Huntington’s disease were generally treated in state institutions, and there has been an axiomatic shift to short-stay inpatient units and community management, often with insufficient resources. This chapter explores the provision of adult neuropsychiatric services in the Australasian public health sectors and the current inadequacies in its planning frameworks. Divided by region, the facets of the main neuropsychiatric bodies in each are explored such as the Neuropsychiatric Institute (NPI) in New South Wales and the Royal Melbourne Hospital (RMH) Neuropsychiatry Unit. While there are a number of centres in Australasia that satisfy the ‘hub’ requirement of the ‘hub and spoke’ model recommended for the implementation of neuropsychiatric services, the ‘spokes’ are inconsistently developed, leading to patchy provision across the countries.