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2


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4


Understanding Long-Acting Injectable Antipsychotics

for Better Treatment Adherence

Michael W. Jann, PharmD, FCP

www.Psychiarictimes.com/view/assessing_malingered_voice_hearing

Clinical Pearls

- Long acting injectable antipsychotics (LAI) offer treating clinicians a viable

option for the long term management of symptoms.

- Patients often decline the offer of a (LAI ) psychotic at first, but this should

not discourage clinicians from continuing the discussion at follow up visits;

patient adherence should be assessed at every visit.

- (LAI) antipsychotics have been shown to be better than placebo and oral

antipsychotics in experimental and real world be studies.

- The efficiency data of LAI first generation and second generation

antipsychotics are similar, but their safety profiles differ.

- Two LAI second generation antipsychotics can be given at greater than

monthly intervals : Pal iper idone Palmitate, Ar iprazo le Lauroxi l .

(Not available in Pakistan).

CASE VIGNETTE

"John" is a 24-year-old male who 6 months ago received a diagnosis of

schizophrenia. After successful initial treatment with an oral antipsychotic, he

felt no further need to take his medications. Subsequently, over the next

several months, his family noticed that delusional symptoms began

reappearing and withdrawal behaviors from current activities increased.

5


At his next outpatient appointment, the prospect of a long-acting inject able

antipsychotic was introduced. Initially, John refused the injectable antipsychotic

saying that he can take oral medications. Over the next 2 weeks, his family

noticed that only part of his medication was taken and, when looking over the

number of tablets, it appeared that John was taking about half of his

medication. His clinician told him that if inconsistent adherence to treatment

continues, the symptoms likely will not get better and could get worse. If the

symptoms and his thinking get worse, he may need to be hospitalized

The option of a LAI was reintroduced. Although John was seemingly

reluctant, he was convinced by the treatment team and agreed to give the LAI

a try for the next few months. His family whole-heartedly supported the LAI

option knowing that this option would eliminate gaps in his pharmacotherapy.

Long-acting injectable (LAI) antipsychotics address both adherence and

nonadherence issues. Fluphenazine enthate, a first-generation antipsychotic,

became available as a LAI in the US in the 1960s; Fluphenazine Decanoate

LAI became available in the 1970s; and Haloperidol Decanoate LAI became

available in the 1980s.

- The first second-generation antipsychotic LAI, Risperidone Microsphere, was

FDA approved in 2003.

- Only three other LAI second-generation antipsychotics are currently available:

- Olanzapine Pamoate, Paliperidone palmitate, and Aripiprazole (available as

monohydrate and lauroxil formulations).

- Paliperidone palmitate has two formulations for monthly or three-month injection

intervals.

- Aripiprazole lauroxil also has formulations that allows for monthly, a 6-week, or

8-week administration intervals.

6


Second Generation long acting Long Acting Antipsychotics are not available in

Pakistan However in addition to Inj. Fluphenazine Depot two other Long Acting

injections are available i.e. a) Inj Flupenthixol Depot b) Inj. Clopenthixol Depot .

Summary of clinical studies

LAI second-generation antipsychotics are FDA approved for the acute

and/or maintenance treatment of schizophrenia. The LAI formulations have

several additional indications: monthly Paliperidone Palmitate is FDA approved

for schizoaffective disorder; Risperidone and Aripiprazole monohydrate are

FDA approved for bipolar disorder.Each of the studies with monthly LAI

antipsychotics showed efficacy. Patients had significantly fewer (P < .05)

relapse and hospitalization rates.

LAI first-generation versus second-generation

LAI Risperidone was not available to providers until 2003. Yet, the question

of comparing a first-generation antipsychotic with a second-generation

antipsychotic presented clinicians with an intriguing issue. For example, how to

design a study that can equal ly compare a f irst-generation to a

second-generation anti psychotic. A double-blind clinical study (funded by

Janssen, the manufacturer of Risperidone) evaluated oral Risperidone (mean

[± SD] dose 4.9 ± 1.9 mg) versus oral Haloperidol (mean dose 11.7 ± 5.0

mg).6 The study was undertaken to examine relapse prevention in outpatients

with schizophrenia or schizoaffective disorder (N = 397) with an extensive

criteria defined for relapse. The results indicated a higher relapse rate for

Haloperidol (risk ratio = 1.93, 95% CI = 1.33 - 2.80, P < .001) versus

7


Risperidone.

The ACLAIMS clinical trial compared 1-month Paliperidone Palmitate with

Haloperidol Decanoate in patients with schizophrenia or schizoaffective

disorder. The primary criteria for efficacy failure included psychiatric

hospitalization, need for crisis stabilization, increased frequency of outpatient

visits, ongoing or repeated need for adjunctive oral antipsychotic medications,

and several other reasons regarding transitioning from previous oral to inject

able antipsychotics. No statistically significant differences between 1-month

paliperidone palmitate and haloperidol decanoate in efficacy failure (HR =

0.98, 95% C.I. = 0.65 - 1.47) were found, which indicates that the

antipsychotics were equally effective in preventing relapse.

Taken together, the results of these comparative studies of first-generation

versus second-generation antipsychotics are reasonable.

Examining and comparing safety profiles

The overall outcomes from the LAI second-generation antipsychotics

studies found no new concerns regarding safety information. The only

exception where a LAI second-generation antipsychotic differs in the safety

profile from its oral counterpart is Olanzapine Pamoate. Approved by the FDA

in 2009, Olanzapine Pamoate has a warning regarding post-injection delirium

sedation syndrome, which occurs when the drug is inadvertently administered

into a blood vessel, which leads to rapid drug release. The resulting symptoms

are delirium, ataxia, confusion, or altered consciousness, thus the FDA

requires that patients remain at their treatment facil ity for 3 hours

post-injection.

8


When treating with LAI second-generation antipsychotic, long-term

monitoring is needed for metabolic syndrome, extrapyramidal effects

(especially tardive dyskinesia), and hyperprolactinemia. For metabolic

syndrome guidelines include monitoring of weight, fasting blood glucose,

Hb1Ac, and lipid profiles at various treatment intervals.

A baseline Abnormal Involuntary Movement Scale (AIMS) exam is

recommended before any antipsychotic medication is initiated; it should be

repeated at least every 6 months with first-generation antipsychotics and

annually with second-generation antipsychotics.

Communication strategies and considerations

Theoretically, any patient needing long-term maintenance antipsychotic

treatment is a candidate for LAI antipsychotics. LAI second-generation

antipsychotics are typically more expensive than oral antipsychotics.(And not

available in Pakistan).

The Case Vignette describes the initial challenges for treatment providers

and the need to collaborate with the patient in offering a LAI antipsychotic. LAI

second-generation antipsychotics are preferred over first-generation

antipsychotics because of fewer extra pyramidal adverse effects. (However

their other side effects are more serios). There are advantages for LAI

antipsychotics because the clinician has reliable information on how much

medication was given during treatment. Moreover, patient adherence with oral

antipsychotics can be overestimated and non adherence underestimated by

providers and caregivers.

The efficacy of LAI antipsychotics are at least as comparable to the oral

9


antipsychotics. Recent real-world designed large studies comparing LAI

antipsychotics to oral antipsychotics demonstrated superiority of the inject able

medications in preventing hospitalizations or relapse.

Summary

LAI antipsychotics have been available to providers for more than 40 years

yet they appear to be underutilized. LAI second-generation antipsychotics

have been well-studied in clinical situations and in regulatory trials their

adverse effects are well understood. LAI antipsychotics offer providers a viable

option to help with medication adherence and reduce any potential gaps in

treatment.

10


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11


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12


Safety and Fidelity in Electroconvulsive Therapy

(SAFE ECT)

A Novel Virtual Reality-Based Training Program in Electroconvulsive

Therapy (Phase 1)

Aakhus, Eivind PhD, MD?; Utheim, Egil Beng†; Vandli, Rune BSc; Sandaker, Johnny RN§; Juell,

Susan RN; Opsahl, Eivind RN, MPA

(ECT JOURNAL)

Authoritative guidelines and textbooks provide practitioners and trainees a

wealth of written information about all aspects of electroconvulsive therapy

(ECT) practice. However, currently, there are no recommendations for using

simulation training, virtual or augmented reality in the training of clinicians who

will learn to administer ECT. Electroconvulsive therapy technique varies

between and within countries. This is not necessarily a problem; research has

shown that many treatment techniques are effective, and there is no single

strategy that is superior to the other. However, treating a patient with ECT

requires, as most standardized medical procedures, skills to administer the

treatment. This includes an understanding of the necessary sequential steps to

provide the patient with a safe and effective treatment each time during an

index course or a maintenance series. For the clinician who administers ECT,

this requires an understanding of the device's technical facilities and

electrophysiological parameters, such as current, charge, pulse width, seizure

threshold and electrode placement, and their impact on the course of the

depression and adverse effects.

Although training in ECT is mandatory, it receives limited attention in most

13


textbooks. According to Sivasanker and Ninatu in The ECT Handbook, some

centers have used simulation for the training of psychiatrists, using a physical

mannequin, and this has been well received. The Royal College of

Psychiatrists have published the "Good practice guide to ECT" and provides a

detailed list of required knowledge and skills.

Although ECT training includes theoretical education, to understand

indications, risks, benefits, and opportunities in the device's facilities to adjust

and modify treatment strategies, the treatment modality also requires an

understanding of the logical order of steps to provide the treatment. This is

where virtual reality (VR)-based training may be helpful.

Virtual reality training has been used extensively in medicine to obtain

improved procedural skills within surgery and general medicine and recent

studies show that VR-based training can teach health care workers the BLS

(Basic Life Support) algorithm faster.11 Although VR has been used in

treatment of certain psychiatric disorders, experiences in using VR in mental

health training is limited. Studies in ECT are, to our knowledge, lacking.

Using VR to improve skills within a certain discipline is regarded as

" s i m u l a t i o n - b a s e d m a s t e r y l e a r n i n g " ( S M B L ) , a c c o r d i n g t o

Griswold-Theodorson et al. The goal of SMBL is to "ensure that all learners

accomplish all educational objectives or reach competency standards beyond

proficiency levels with little or no variation in outcome." Although evidence is

limited, findings indicate that SMBL in surgery procedures can improve patient

care processes and outcomes.

Checklist-based VR training in ECT will standardize training and provide a

possibility for the trainee's endless repetitions until procedure is internalized

14


and, thus, may enhance the trainee's confidence in the technique and improve

patient care during ECT.

CHECKLIST IN MEDICINE AND PSYCHIATRY

The use of checklists was introduced in aviation 1935 after a fatal air crash

and has since then been considered as permanent and mandatory tool to

reduce accidents caused by human errors. After decades, the use of checklists

has expanded beyond aviation and is now mandatory tools used by many

other industries including medicine and mental health. In 1999, the Institute of

Medicine proposed the use of checklists to both avoid reliance on memory by

standardizing and simplifying key processes, as well as maintain vigilance.

Surgical checklists have been demonstrated to reduce adverse events and

improve patient care. The "WHO surgical safety checklist" was published in

2007. Subsequently, Woodcock et al.17 modified this checklist addressing

practice in the ECT suite. The number of patients was too small to draw any

conclusions regarding significant reduction in patient morbidity. However, the

authors experienced that the use of checklist revealed potential somatic risk

situations, such as misprescriptions, the discovery of deep vein thrombosis,

and abdominal aortic aneurysms, and ensured that the correct ECT dose was

given to the correct patient.

CULTURAL SETTING

In our hospital, we train and certify approximately 10 to 15 clinicians in ECT

annually. A relatively large group of clinicians participate in the regular ECT

services at 2 sites in the hospital trust. Ten years ago, in a retrospective quality

15


assessment comparing two different initial dosing principles within the hospital

trust (not published), we discovered that from 69 age-based ECT courses, we

had to exclude a substantial number of initial treatment sessions because of

uncertainty regarding the dosing technique. Based on this experience, an

expert group consisting of consultants in psychiatry and psychiatric and

anesthetist nurses developed a quality improvement program for ECT practice,

consisting of a certification program, an e-learning course, and a web-based

clinical pathway for ECT.

AIM

The aim of this project was to develop an ECT checklist-based training

program based on VR technology. This first phase includes a model for a

stepwise training, preparing the candidate for the required sequences that

precede the actual treatment.

Author Information

The Journal of ECT: September 2020 - Volume 36 - Issue 3 - p 158-160

doi: 10.1097/YCT.0000000000000653

16


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18


Normalise That Time of the Month

The agony faced by women when menstruating ….Ushna Shah

You have got to give it to Ushna Shah. The actor sure knows how to bring

up social taboos on the public platform. Earlier this week, she had admitted to

enjoying being "thick" when a troll had called her fat. And now, she is openly

talking about women's menstrual health.

Shah recently took to Instagram and shared her thoughts on being

body-shamed. When a user advised her to keep her "gaining weight" in check,

the Balaa star had penned, "I am no longer 21. I am a grown woman who

enjoys food and has a naturally curvy body type. I am most comfortable in this

weight because this is who I am and am very much in control of how I want to

look. Society and sample sizes don't define my standard of beauty; I set my

own and I like being fit and thick!"

Now, she is hoping to normalise the topic of menstruation. In a picture

posted from presumably the sets of an upcoming project, Shah can be seen

sitting with a heating pad on her abdomen. "Dear men," she began.

"Normalise being normal about women's Time of The Month, please. You

cannot begin to imagine how difficult this time is for us. The difficulty varies

from woman to woman but for many of us, it is a week (or more) of pure hell."

She went on, "I am talking PMS (Premenstrual Syndrome) or even PMDD

(Premenstrual Dysphoric Disorder) for a week prior to the actual cycle,

including mood swings, depression, indigestion, nausea, hunger, acne and

insomnia, to name a few."

The starlet attempted to explain the agony faced by women when they are

19


on their period. "And then, the day comes when it begins. It is uncomfortable,

messy, painful (the cramps; oh God, the cramps!), the swelling (note my

hands), bloating, water retention, many of the previous symptoms," she

continued. "The truth is, all women go through this and it is nothing to be

ashamed of. If we take away the embarrassment and stop being awkward

about it, you can help us deal with it and make our days easier."

The Cheekh actor remarked on how the crew of a show took care of her

when she got her period on set. "This picture is from right now. I walked on to

a set filled with men, by a production house run entirely by men. Not a single

woman on set aside from me. But thankfully, I could open up to my team and

these men went out of their way to make sure I'd be as comfortable as

possible." Shah penned. "From a hot water bottle (and continuous refills) to

soup to rest between takes, I am in good hands today. Please make it so that

the women in your home and workplace are also in good hands!"

Shah concluded, "Even some kind words make a huge difference. Ask

how we are, give us a day off if you have the authority, stock the loo with

tissues and trash baskets (please), if we are having an emotional moment. Be

understanding (but don't blame PMS if we react to something bad you did, lol."

Let's take a moment to commend Shah for batting for women around the

world.

Comment by Dr Mubin - The quran and Hadees have supported this fact and

due to this and other female body features have assigned a role to women

which is physically easy but following the western concepts most women

leaders claim that they are 'equal' to men and can do all that men do.

20


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24


Influential Israeli Spy Who Posed as an Arab

Isaac Shoshan (1924 - 2020)

By Ronen Bergman

TEL AVIV - Isaac Shoshan, a Syrian-born Israeli undercover operative who

posed as an Arab early in his career, participating in bombings and an

assassination attempt, before making major contributions to the country's

espionage methods, died on Dec. 28 in Tel Aviv. He was 96.

His daughter Eti confirmed the death, in Ichilov Hospital. He had suffered a

stroke, she said.

In a tribute on Twitter, former Prime Minister Ehud Barak, who once served

in an Israeli intelligence unit that Mr. Shoshan helped conceive, said Mr.

Shoshan had "risked his l ife again and again" on behalf of Israel.

"Generations of warriors learned their trade at his feet," he added, "me too."

Mr. Shoshan was born Zaki Shasho in Aleppo, Syria, in 1924 to an

Arabic-speaking Jewish family. He studied at a French-language school,

learned Hebrew at Orthodox Jewish schools and as a youth belonged to the

Zionist Hebrew Scouts. At 18, motivated by his Zionism, he traveled to what

was then British-ruled Palestine and within two years was recruited by the

Palmach, the Jewish underground fighting force.

During his training, he was posted to a secret unit known as the Arab

Platoon. Made up of Jews who could pass as Arabs, it was charged with

gathering intelligence and carrying out sabotage and targeted killings.

25


The unit was set up in expectation of "a civil war in Palestine between the

Jews and the Arabs," said Yoav Gelber, a professor and historian of the

period.

The unit's members, most of them immigrants from Arab lands, were

trained in intelligence gathering and undercover communications - Morse

code, for example - as well as in commando tactics and using explosives.

They also underwent intensive study of Islam and Arab customs so that they

could live as Arabs without arousing suspicions.

Mr. Shoshan began taking part in intelligence-gathering operations after the

United Nations voted in 1947 to partition Palestine into separate Jewish and

Arab states, setting off clashes that would turn into war.

But in February 1948 he was called on to put another aspect of his training

to use: to help assassinate a Palestinian leader, Sheikh Nimr al-Khatib, who

was said to be on his way to Palestine from Lebanon with weapons.

Gunmen were to fire on the sheikh's car, and Mr. Shoshan, as a seeming

Arab bystander, was instructed to "run back and appear to be helping, but

actually to make sure the sheikh was dead, and if not, to finish the job off with

my handgun," he said in an interview in 2002.

The sheikh was indeed shot in his car - the assassins "sprayed it with fire

from submachine guns," Mr. Shoshan said - but survived after British soldiers

prevented Mr. Shoshan from reaching it. Badly wounded, the sheikh left

Palestine and stopped playing an active role in the war.

Shortly afterward, Mr. Shoshan and another member of the Arab Platoon

were dispatched to a garage in Haifa, Israel, where intelligence indicated that

a car bomb was being assembled.

26


"The owners never suspected us at all," Mr. Shoshan said. "Of course they

didn't want to let our car in, but agreed to allow us in for a moment to use the

bathroom."

That was long enough to activate a timed fuse on an explosive device and

flee. Minutes later a huge blast shook the entire area, demolishing the garage

and several adjoining buildings, killing at least five people and injuring many

more.

In 1948, after British forces withdrew from Palestine and Israel declared

independence, Arab Platoon agents were dispatched to neighboring Arab

countries with the dual goal of gathering information and thwarting perceived

threats.

"Although we were sent to gather intelligence, we also saw ourselves as

soldiers, and we looked for opportunities to act," Mr. Shoshan said.

Sent to Beirut, he and his colleagues bought a kiosk and an Oldsmobile,

which they used as a taxi to provide cover for their activities.

On one occasion, the unit was ordered to plant a bomb in a luxury yacht

belonging to a rich Lebanese. (They were told that Adolf Hitler had used it

during World War II.) Intelligence suggested that the vessel would be

converted into a gunship for use against the Jews. The ensuing explosion did

not sink the yacht but damaged it enough to ensure that it could not be used

for military operations.

The team's most significant operation - a mission to assassinate Prime

Minister Riad al-Solh of Lebanon - was supposed to take place in December

1948. Mr. Shoshan and the others devised a plan to kill the prime minister as

they trailed his movements. But the operation was called off at the last

27


moment by senior Israeli leaders, to Mr. Shoshan's great disappointment, by

his account.

In his two years in Beirut, Mr. Shoshan encountered relatives of those killed

in the Haifa garage bombing. They spoke with him freely, thinking he was a

Palestinian.

"Before that I never thought about the people who were killed there,"

Mr. Shoshan recalled in the book "Men of Secrets, Men of Mystery" (1990),

which he wrote with Rafi Sutton, a fellow former intelligence colleague.

"And there, in Beirut, an old Arab sat facing me and weeping for his two sons

who were killed in the blast that I had taken part in carrying out."

That encounter was one of the events that caused a shift in Mr. Shoshan's

thinking, his son Yaakov said later. "Dad always knew that if we only use

force," he said, "it would only lead to more wars, and he always supported the

'two states for two peoples' solution."

The capture and execution of some Arab Platoon members eventually led

Israel to abandon the use of Jewish spies assimilating with Arabs. Mr.

Shoshan turned to recruiting and managing Arab agents, a role that called on

him to turn them into turncoats.

"He turned out to be blessed with a talent for this job too," Mr. Sutton, the

co-author, said in an interview. "Agents are a problematic lot, and you have to

know when they are lying to you or telling the truth, and how not to allow them

to extort you and take control of the relationship between you, without

damaging their readiness to work with you."

Mr. Shoshan on his 80th birthday in 2004. After he retired he was

occasionally called back into espionage service. Credit...via Shoshan family

28


Mr. Shoshan later urged a resumption of the assimilation program, which

led to the formation of Sayeret Matkal, a military special operations espionage

unit. The unit was established to carry out intelligence gathering in the heart of

enemy countries, in part by using fighters trained to use an Arab cover. Among

its members were a young Benjamin Netanyahu, now the prime minister, and

his predecessor Mr. Barak, who commanded it.

Mr. Shoshan was given the responsibility of training the members who

posed as Arabs.

He played a part in building the cover story for Eli Cohen, the Israeli spy

who penetrated the top circles of the Syrian regime in the 1960s but who was

ultimately exposed and executed.

Ms. Shoshan retired in 1982 but was mobilized from time to time by the

Israeli intelligence agency Mossad to train agents and sometimes participate in

operations himself.

Going undercover, he would take the part of an Arab old man who might

pretend to be in need of help - to enter a building to make an urgent phone

call, for example, or to make casual contact with a target of recruitment. An

older man, his handlers believed, was less likely to arouse suspicion.

29


ppppZZZZ''''ÆÆÆÆ‚‚‚‚ÆÆÆÆ1111ŠŠŠŠ{{{{zzzzZZZZuuuu]]]]ZZZZyyyyÆÆÆÆ””””VVVV6666,,,,ÌÌÌÌZZZZWWWW,,,,ZZZZ0000++++ZZZZiiiiƒƒƒƒDDDD÷÷÷÷XXXXEsteves KC et al:2019m6 Z*Z;C

http://www.jwatch.org/na49363?query=etoc jwsych&jwd=00010193688&jspc=p

: ÜÜÜÜāāāā…Z[J-9§bÐ¥x7ìāâƒVÅ‚;‚~¾§bZyÅZzÑŠÅ¡ÃOW,™C

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(”VÆ§i¿Ô'×Z`~p~aZ™CìÔŒVJ-āù¦D/ÐÌ TL ÅMð) Telomere

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;({Ô 29 âƒVZzgâiZG{”VŠâV»_·HXâN)XÅZz‰/Ô 155 Zkãîg6,ÜÆW¸iÐ„‚(~ÔZyÆZL‚Å>Ï)‰zZ−+Åf6Fg~Ô:t(ÔIZiaZöÆ 38 ‚;CÔ 52

(»± TL â{ÆˆŠ@ˆXâiZG{”VÆ) 18 ÔZzg 12 ÔÔ 4 ÚƒÔc*8LÔZzgc*8LÅŠgzÈ~ÅR â{6,ŠgzÈ~ÅX 18 â{~ìÆfg)HŠHÔZzgâƒVäèpZgÆ)bÐ0|u 18 Zzg 12Ô4

‚(ÆˆicÆZ’Zð 19 IZiaZöÚƒÔZzgaZöÆˆaZƒäzZáf6Š!*ƒ)âƒVÅâ{Æ 18 â{Ð 4 (ÐzZh¸X'×h+tāÔicÅ6,.ãä TL tzZu]èpZgÆgL÷÷)

â{ÆgL”VÆyZ[gz�6,7Íð 18 Šgxyic*Š{Ðic*Š{÷÷Æ‚B!*]’AÅ@*āÅYnX

((((Dr. Joel Yagar ûûûû{{{{DDDDeeeeZZZZËËËË��bbbbcccc****¤¤¤¤////))))Z¤/picÆŠzgZy;CZzg§i¿6,Z®g™DƒñZyY,zVÅŠgzÈ~özŠìÔptï

ZKâV~«!*gtªCÙ™CìāâVÆ‚Å¤Ô',ÎVÔÚƒZzgZzÑŠ~ZW,Z]ù%A$ƒMh

÷ÔZzgZ’Zð‚~6,.yÁŠ!*]ÐÝZzgçnÃZyÏVîsæCZW,Z]Ãf‚~ge’X

30


A mother's Experience of Early Adversity Has a

Transgenerational Impact

Esteves KC et al. Am J psychiatric 2019 Sep 6

http://www.jwatch.org/na49363?query=etoc_jwsych&jwd=000101093688&jspc=p

Meternal early childhood adversity can affect her offspring's telomere length

and problematic behaviors.

We will still do not understand how adverse childhood experience in

women alter the subsequent health and well-being of their offspring. Telomere

(ribonuclleoprotein complexes that cap and protect chromosomes) shorten

over time or from stress; for example, short telomere length (TL) has been

associated with children's behavior, mood disturbances, and even overall

longevity. However, the directionality of these relationships is unknown.

Posting that TL could be an epigenetic biomarker (i.e., maternal distress would

be associated with shorter telomere in children), researchers prospectively

studied 155 mother-infant dyads, starting in pregnancy.

Mothers (mean age, 29; black, 52%; white, 38%) answered questionnaires

about 10 possible life stresses during their own childhood (e.g., parental

mental illness, divorce), rated prenatal stress and depression, and rated

depression levels at 4, 12, and 18 months postpartum. Infant's TL was tested

via buccal swabs at 4, 12 and 18 months, and mothers rated infant's

problematic behavior's et 18 months.

After adjustments for demographics, prenatal stress, and postnatal

depression (19% of mothers) , greater maternal early adverse events were

associated with shorter infant TL. Further, maternal adversity interacted with

greater telomere attrition between 4 and 18 months to predict problematic

31


externalizing behavior of toddlers at 18 months.

Comment- DR JOEL YAGER

Although limited by reliance on maternal ratings for psychological and

behavioral assessments, this study is the first to demonstrate in humans how

mother's childhood adversity might, years later, be epigenetically reflected in

offspring biomarkers associated with stress and aging and how these effects

might, in turn, be associated with problematic behavior in early childhood.

Studies delineating the biological and psychological developmental of

Transgenerational traumas might suggest additional opportunities for clinicians

to ameliorate these traumas' deleterious long-term effects.

32


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35


How Covid-19 Threatens Native Languages of

Red Indians in America

By Jodi Archambault - The New York Times

Ms. Archambault is a Hunkpapa and Oglala Lakota and former special assistant to the president for

Native American affairs under President Barack Obama.

CANNONBALL, N.D. - Over four centuries, (9) out of (10) Native

Americans (Red Indians) perished from war or disease. Now our people are

dying from Covid-19 at extraordinarily high rates across the country. North and

South Dakota, home to the Lakota reservations, lead the United States for

coronavirus rates per capita. We are losing more than friends and family

members; we are losing the language spoken by our elders, the lifeblood of

our people and the very essence of who we are.

Last year I lost my uncle Jesse (Jay) Taken Alive and his wife, Cheryl, to

the virus. My uncle, a former chairman of the Standing Rock Sioux Tribe, was

a leading proponent of efforts to revitalize the Lakota and Dakota language.

Lakota and Dakota are dialects of the same language; if you speak one, it is

easy to understand the other, though some words and accents are different.

After he retired from politics, he taught our language to public-school children.

The task is urgent. In 2020, there were only 230 native Dakota and Lakota

speakers on the Standing Rock Reservation. Two hundred and thirty speakers

- down from 350 in 2006, according to the tribe's surveys. There are only a

couple of thousand speakers, in total, in the United States and Canada.

As Covid-19 takes a fearsome toll on our people, it also threatens the

progress we have made to save our languages. The average age of our

speakers - our treasured elders who have the greatest knowledge and depth

36


of the language is 70. They are also those who are at most risk of dying from

Covid-19.

Before the pandemic, we had been making progress. Cultural warriors

young and old had created immersion schools, including on the Standing

Rock, Pine Ridge, and Rosebud Reservations. The Lakota language program

at Sitting Bull College in Fort Yates, N.D. - Lakol'iyapi Wahopi/Wihakini

Owayawa - pairs young children with adult speakers.

Now we are mourning the loss of instructors who helped revitalize the

language at Sitting Bull College - Paulette High Elk, Delores Taken Alive and

Richard Ramsey, all of whom died of the virus last year. We celebrate when

others recover: Thomas Red Bird, Earl Bullhead.

That we still have Lakota speakers at all is a miracle. Earlier generations

were removed from their land and families, to boarding schools that beat

children for speaking their native tongue, and more recently, to classrooms

that nearly erased their Lakota culture.

We cherish Lakota speakers, because the language they speak

embodies a beautiful worldview - alive and harmonious - based on a

harmonious relationship to one another and to Mother Earth. Lakota speakers

live by the values hard-wired into that language.

The reach of our languages has been felt far beyond North and South

Dakota. Global sustainability movements have adopted Lakota concepts like

"Water is life" (Mni Wichoni), the understanding that life does not exist without

water; "We are all related" (Mitakuye Oyasin), the interconnectedness of all

energy in the universe, including humans; and planning for the future

(Thokatakiya awoyukcan etan oyuhapi), the idea that we must care for future

37


generations in all our actions.

The cultural richness our languages contribute to the world is no less vital

to life on this planet than biodiversity. Nor is it any less valuable than the

cultural contributions of the rich or descendants of people from Europe.

On Standing Rock, Lakota elders who are fluent in our language will be

prioritized for the vaccine. I exhaled a breath of relief when Grace Draskovic

and Ruby Shoestring, fluent elders and teachers at the immersion nest who

have remained free of the virus, received their first dose of the vaccine. Other

tribal nations should do the same.

We are running out of time. We are losing the links that bind thousands of

generations to the present day. We are losing our chance to inherit their

understanding of what it means to be human.

This is why it is critical that we have a coordinated federal Covid-19

response. The governments of North and South Dakota have failed us.

President Biden now has an opportunity to help. That means providing the

highest quality health care and preventive measures on reservations, and a

top-down reform of the Indian Health Service, a long-neglected treaty right.

Finally, the next federal budget must fully fund tribal language restoration

programs; we are asking for $750 million a year - a pittance compared with the

resources expended over the centuries to destroy our languages and cultures.

Rather than dwelling on our suffering, consider the extraordinary resilience of

my people. Covid-19 has only strengthened our resolve to honor and protect

our elders, the languages they speak, and the wisdom they carry. I believe that

if Americans knew what we're facing, they would help us. If history has taught

us anything, it is that generations to come will need that wisdom more than we

38


can imagine.

My uncle Jay used to perform a ceremony to welcome the thunders back

in the spring. He is gone, but we will welcome back the thunders. If not this

spring then the next.

(Jodi Archambault is a Hunkpapa and Oglala Lakota woman and former

special assistant to the president for Native American affairs under President

Barack Obama.)

(1) Dr. Mubin's Note: The same happens to our children when they get

admitted to missionary or so called English Medium Schools that they are

penalized for speaking Urdu or other mother language of Pakistan.

39


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50


KARACHI PSYCHIATRIC HOSPITAL

KARACHI ADDICTION HOSPITAL

Main Branch

Nazimabad # 3, Karachi

Phone # 111-760-760

0336-7760760

Other Branches

Male Ward: G/18, Block-B, North Nazimabad, Karachi

Quaidabad (Landhi): Alsyed Center (Opp. Swedish Institute)

Karachi Addiction Hospital:

Visit our website: <www.kph.org.pk>

Established in 1970

Modern Treatment With Loving Care

��

Mubin House, Block B, North Nazimabad, Karachi

E-mail: [email protected]

Skype I.D: [email protected]

0

Karachi Psychiatric Hospital was established in 1970 in Karachi. It is not

only a hospital but an institute which promotes awareness about mental disorders in

patients as well as in the general public. Nowadays it has several branches in

Nazimabad ,North Nazimabad, and in Quaidabad. In addition to this there is a

separate hospital for addiction by the name of Karachi Addiction Hospital.

We offer our facilities to all Psychiatrists for the indoor treatment of

their patients under their own care.

Indoor services include:

24 hours well trained staff, available round the clock, including Sundays &

Holidays.

Well trained Psychiatrists, Psychologists, Social Workers, Recreation &

Islamic Therapists who will carry out your instructions for the treatment of

your patient.

An Anesthetist and a Consultant Physician are also available.

The patient admitted by you will be considered yours forever. If your patient

by chance comes directly to the hospital, you will be informed to get your

treatment instructions, and consultation fee will be paid to you.

The hospital will pay consultation fee DAILY to the psychiatrist as follows:

Rs 700/= Semi Private Room

Private Room

Rs 600/= General Ward

Rs 500/= Charitable Ward (Ibn-e-Sina)

The hospital publishes a monthly journal in its website by the name ‘The Karachi

Psychiatric Hospital Bulletin” with latest Psychiatric researches. We also conduct

monthly meetings of our hospital psychiatrists in which all the psychiatrists in the city

are welcome to participate.

Assuring you of our best services.

MESSAGE FOR PSYCHIATRISTS

C.E.O Contact # 0336-7760760

111-760-760

Email: [email protected]

Our Professional Staff forPatient Care

Doctors:1. Dr. Syed Mubin Akhtar

MBBS. (Diplomate American Board ofPsychiatry & Neurology)

2. Dr. Muhammad Shafi MansuriMBBS, F.C.P.S (Psychiatry)

3. Dr. Akhtar Fareed SiddiquiMBBS, F.C.P.S (Psychiatry)

4. Dr. Major (Rtd) Masood AshfaqMBBS, MCPS (Psychiatry)

5. Dr. Javed SheikhMBBS, DPM (Psychiatry)

6. Dr. Syed AbdurrehmanMBBS

7. Dr. Salahuddin SiddiquiMBBS (Psychiatrist)

8. Dr. Sadiq MohiuddinMBBS

9. Dr. ZeenatullahMBBS, IMM (Psychiatry)

10. Dr. A.K. PanjawaniMBBS

11. Dr. Habib BaigMBBS

12. Dr. AshfaqueMBBS

13. Dr. MurtazaMBBS

14. Dr. Salim AhmedMBBS

15. Dr. SanaullahMBBS

16. Dr. JaveriaMBBS

17. Dr. Sumiya JibranMBBS

Psychologists:1. Syed Haider Ali (Director)

MA (Psychology)2. Shoaib Ahmed

MA (Psychology), DCP (KU)3. Syed Khurshied Javaid

M.A (Psychology), CASAC (USA)4. Farzana Shafi

M.S.C(Psychology), PMD (KU)5. Rano Irfan

M.S (Psychology)

6. Sanoober Ayub MayoM.S.C (Psychology)

7. Madiha ObaidM.S.C (Psychology)

8. Danish RasheedM.S. (Psychology)

9. Naveeda NazM.S.C (Psychology)

10. Hira RehmanM.S.C (Psychology)

11. Anis ur RehmanM.A (Psychology)

12. Farah SyedM.S(Psychology)

11. Sadaqat HussainM.A (Psychology)

Social Therapists1. Kausar Mubin Akhtar

M.A (Social Work) Director Administration2. Roohi Afroz

M.A (Social Work)3. Talat Hyder

M.A (Social Work)4. Mohammad Ibrahim

M.A (Social Work)5. Syeda Mehjabeen Akhtar

B.S (USA)6. Muhammad Ibrahim Essa

M.A (Social Work)/ General Manger

Research AdvisorProf. Dr. Mohammad Iqbal AfridiMRC Psych, FRC PsychHead of the Department Of psychiatry, JPMC, Karachi

Medical Specialist:Dr. Afzal Qasim. F.C.P.SAssociate Prof. D.U.H.S

AnesthetistDr. Shafiq-ur-RehmanDirector Anesthetist DepartmentKarachi Psychiatric Hospital.

Dr. VikramAnesthetist,Benazir Shaheed HospitalTrauma Centre, Karachi

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