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9N zZ Š z{ ā ¬Šä:{IZÆ zgZyÔZk ŠÆVà2Œ XZ Çá3V1Í z{ āc*Š™gïZÆÈtÐ Æ XZy å;gázÛ»Vƒ zZ ŠK yZ YāZƒx¥ÂˆÅ2Ì ÅŠZ®ÅVCÍZ# ÔZzg å;gá7Ð h+×'Éσ7~4~]â´Å Zk ÂìLg7Zc¿6,`´ÐÏ°‡!*z{ ¤/Zā c*CÐZäÒç $Ë 7,] zg ¢Åä™4ZŠ~wõ7ZÐZÂìCƒ Z[yªÅ ]ZzgZk â´¤/ XZzgZ ìykZ»!Zy Xì Ø?HÙC„yYp¤/XZ ŠHH7 g{ !*zŠ g{ t» (Long Acting Injections )3Cæsî 3 Cæ sî Ì ä :{ IZ Æ XZk 1 ™ ègZ ÐZ ä nç p Ôå ;g™ kC XìÅe$×Å`´Ð (Long Acting Injections ) E +i E5éG4¢jXìCƒ~4~]gßÅ`´Ð(Long Acting Injections )3Š~Zsî G-4E& [ø7Š~M%Z~1960 Ž(LAI )qCæsî»±« (Ô Fluphenazine enthate ) ïHŸW GZ E Zw i+cì ZZzg ƒ[ø7Š~}‚Æ1970 (Fluphenazine decanoate ),Mre+i E5éG4¢jZƒ XŠHƒ[ø7Š~ð;ŠÅ 1980 (Haloperidol decanoate ),Mre

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Karachi Psychiatric Hospital Bulletin 95 Month March 2021 3

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Karachi Psychiatric Hospital Bulletin 96 Month March 2021 4

6,V²zZÆ`´ (Zzg Hb1Ac )RÅ]Å{â3D6~ypÔ]~ypìg.nÆãZôÅ] Xìï÷á (Lipid Profile ) E-Ê ((( Abnormal Involuntary Movement Scale DDDAIMS )))g£ »•wÅŸ¬Ð ä™ zq Ñ]c*zŠZ 1ðBGâŠg E-Ê E-Ê B‚Æ1ðBGâŠgƱ~uzŠ:Ñ‚ Zzg B‚Æ1ðBGâŠgƱ«ˆ{â6ÙCÁ Zi ÁXìCYÅ gl \Å X’e*Yc*ZÙCŠ c*C~`´ÆPaliperidone Palminate Æ{â1 (Zzg Haloperidol decanoate LAI ) H4 5Å Ô Z] W,ZtÒÔ†ŸZ~ Zg lÅ (Prolactin )èE»Gz6,~ypÔª,™«™ Zzg qZāì ŠH X¸7Z]u zZ Æ(Galactorrhea )Â_|ŠzŠ (Zzg Gynecomastia ) −(,»VZY

Karachi Psychiatric Hospital Bulletin 97 Month March 2021 5

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: Paliperidone Palmitate, Ariprazole Lauroxil.

(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.

Karachi Psychiatric Hospital Bulletin 98 Month March 2021 6

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. Karachi Psychiatric Hospital Bulletin 99 Month March 2021 7

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 equally compare a first-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

Karachi Psychiatric Hospital Bulletin 100 Month March 2021 8

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 facility for 3 hours post-injection.

Karachi Psychiatric Hospital Bulletin 101 Month March 2021 9

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

Karachi Psychiatric Hospital Bulletin 102 Month March 2021 10 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.

Karachi Psychiatric Hospital Bulletin 103 Month March 2021 11 šMFFF,ÅÅÅÛÛÛZZZDDD+CCCôôôZZZÅÅÅ(((ECT ))) ```´´´©©©âââ©âŠŠŠz g»YN e~Zzgg ÝZ8&+ kÔZ pZ (KÏ {Z~ h+`)

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Karachi Psychiatric Hospital Bulletin 104 Month March 2021 12

XìˆÅwEZ6,äe}(,~¥nÆä™Ýq]g'Åg»i§4g0+ZÆ šMF,J܉z ZzgZk Ïñ g~ £ÃšMF,“R, (z~Wg VR V) I~(ECT `) ´ â© Šz ~w¸NŠÅVÉ% Zzg ñYƒ:쇊OZ»ÒçāJZ# Ï}™ëZہykZnÆ Zg ƒ„pÐ ÑÅ XñYW:~4

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Karachi Psychiatric Hospital Bulletin 105 Month March 2021 13

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

Karachi Psychiatric Hospital Bulletin 106 Month March 2021 14 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

"simulation-based mastery learning" (SMBL), accordi ng to

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

Karachi Psychiatric Hospital Bulletin 107 Month March 2021 15 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

Karachi Psychiatric Hospital Bulletin 108 Month March 2021 16 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

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Karachi Psychiatric Hospital Bulletin 111 Month March 2021 19

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

Karachi Psychiatric Hospital Bulletin 112 Month March 2021 20 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.

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Karachi Psychiatric Hospital Bulletin 117 Month March 2021 25

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 life 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.

Karachi Psychiatric Hospital Bulletin 118 Month March 2021 26

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.

Karachi Psychiatric Hospital Bulletin 119 Month March 2021 27

"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

Karachi Psychiatric Hospital Bulletin 120 Month March 2021 28 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

Karachi Psychiatric Hospital Bulletin 121 Month March 2021 29

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.

Karachi Psychiatric Hospital Bulletin 122 Month March 2021 30 XXX÷÷÷DDDƒƒƒiiiZZZiZ000+ZZZWWW,ZZZÌÌÌ666,VVV”””ÆÆÆyyyZZZy ]]]Z]uuuZZZzzzZ {{{z{ŠŠŠ1ÆÆÆ‚ÆÆÆ'''ZZZppp Esteves KC et al :2019 m6C;Z*Z http://www.jwatch.org/na49363?query=etoc jwsych&jwd=00010193688&jspc=p :āāāÜÜÜ C™W,OÃ¡ÅŠÑ Zz Å bZy §¾~‚;‚ÅVƒâāì7x¥Ðb§9J Z[ … { ~6,Zz ÆxÎñz™Ž(Ribo Nucleo Pro )™”z6,ðG3ÒÓ®E1gZ Telomere ÷÷ X÷ ¿Ô6,gîÆwVX÷DYƒ LgÐzÚc*B‚Æ܉ (z ÷D™«™Å ZzgZk ÷Dƒ6, ÌÐ/D¦ùāJVŒÔìC™Za~p~ Z`×'Ô¿i§ÆV”(TL )ðMÅ Telomere E ™gâ Ç!*ëH5G45G4E7 3 (Z T L ) ā ì Yƒ Xì 7x¥6,gî ãzZ ]!*t Ôë@*Xì h zZ ä>(Ô ƒÝÐðMÁÅ(TL )~V”1Åciª)ƒ(Epigenetic biomarker ) {Ô (;29 Ô/ ‰ Zz Å X)NâXH_»VâŠV”{G iZ â VZzg ƒâ155 „Ði¸WÆÜ6,gîãkZ ÆöZa Zi I t(Ô : g~Ô F6fÅ+− zZ ‰)Ï>Å‚LZÆ ÔZy ~(‚38 ÔC;‚52 ±» (TL )ÆV”{G iZ âXˆ@ŠˆÆ{â18 ÔZzg 12 ÔÔ 4 RÅ~ÈzgŠÅ8L c*ÔZzg 8L c*ÔƒÚ XÅ~ÈzgŠ6,{â18 u|0Ðb)Æ Zg pèäVƒâ ÔZzg ŠHH) fg Æì~{â18 Zzg 12 Ô4 ðZ’ZÆciˆÆ(‚19 ÅVƒâ)ƒ!*Š6fá zZ äƒZaˆÆöZa ÔZzg ƒÚ öZa Zi I Æ{â18 Ð{â4äã.6,Åc Ôi āth+×'X¸h zZ Ð(TL )÷÷LgÆ Zg pè]u zZ t ðÍ76, gz Z[yÆV” LgÆ{â18 ā@*Å’A ]!*B‚Æ÷÷{Šc*iÐ{Šc*yi xgŠ XnYÅ (((Dr. Joel Yagar ))) ¤¤¤///ccc***bbbŽŽŽ ËËËZZZeeeZ DDDe {{{D{û ïtpÔìŠzö~ÈzgŠÅ zV ^,Y Zy ñƒD™g®Z6,¿i§ Zzg C; zgZy ŠÆcip¤/Z MhƒA$%ù Z] W,Z~ ŠÑ ZzgZz ƒÚÔˆVÎ',ԤłÆVâāìC™ÙCªtg!*«~Vâ¨KZ ~‚fà Z] W,Z Cæ sîVÏ Zy Ãnç Zzg ÝÐ ]!*ŠÁy.6,~‚ðZ’ ÔZzgZ ÷ X’e´g

Karachi Psychiatric Hospital Bulletin 123 Month March 2021 31

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

Karachi Psychiatric Hospital Bulletin 124 Month March 2021 32 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.

Karachi Psychiatric Hospital Bulletin 125 Month March 2021 33

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Karachi Psychiatric Hospital Bulletin 126 Month March 2021 34 g.' XÅŠæ~ä™{0+iÃy!*i äVrÔZ ¸ñƒ]ÐzzÅk],wzZ ‚ÔÐ~XÔö Geg l Zzgg CZ H XåG5;XÐE& eÔZgw ',i+g éå ª÷ DoÙpë Â÷ Dƒ [c*¡}uzŠ ŠZہZ vŠā Z# zgÔ ŠÐæ Zzg }iÅ Zy ÃVYðZ’ XZ ì{7qZ÷ŠŽñá zZ %1y!*iN*Ñà g0+Z}gøāt Ìwj ÔZ ~„wqÌ (ÔZzgZ 1)¶CYÅùgâ6,%1y!* g~i ŠâKZÃV”V˜Ô~VßjZ8 ge 1 y!*iŽ z{ èYÔ÷D™ Zx Z»Vß zZ %1N*Ñà ëXåc*ŠSÃ×ÆN*Ñà d$ÛŒd$ÛŒäV2ñ E5é E4G5kG$Z ëÆ *Š ªVâ g~ ø }Zzg uzŠqZŽìsŠZá»°Wë {Zzg 0+Xi tÃ@¬]gzpq z{Z ÷s1 X÷D™¬Ï0+i ._Æ Zg ŠZ à zZ y!*i Zk á zZ %1N*Ñà Xì6,ŠãCÅ°W äVr’ÅxPZ@¬Xì„gYÅkCÌZÅVâ!* g~i ø~ ´˜zg ŠÐN*Ãe!† Zzg àÑ ë'' Xì7ŠŽzð »Ã Ï0+i%Æã0*ā'tÔìc*CZà gZ] ¦ÆN*Ñà ‰(ãäF)'' ìÏ0+iã0*'' E ~:W E5é 4´xZ Ó~]Ñ»ÉVâ¨K (ÔZ Mitakuye Oyasin ) '' ÷h zZ Ð}uzŠqZƒ ~wq xZ ÓLZ…āìwì»]!*Zk ÌZ÷ìg™~È/nÆw XZzg ÷ñƒ }a X ǃ´gÌwì»VY{ÒW Zzg qªzŠÅŠZہZá zZ pgmÐ\g6,}g( z{Zk ÷îŠ gkŠDpŽ~*Š3!* g~i ø X÷7ËÁЕ ZÑDpÅ Zy Zk ä~XñY~ŠßF,Åëz7ÔZ ÷npgã gzZ ~y!* g~i øŽ+Z+qÆN*Ñà Ô6, gZu 8œZ Š WiZ Ðk],zZ Ž{E+‚ZÆsV˜Xu Zzgz +Z+qã ÔgzZ “7Ø! aZzggz j egZ ö¤/Z# 1÷‚»y\Z܉z j½& W` ëX÷ì gg ¦/Ð܉z ÂëX’e*™* „(ZÌÃVñ¸©D~uzŠXB gZu p«ÅèEGzà ÔZzgZy ìg XìÈH»äƒy¨KZā÷ìgÅñ»äƒ_ zZg ЙŠZy ëX÷ìgÅ* gzZ ÝÐVY ZgzV ÙD !† Zzg àÑ ~x» XZk ’e*ƒ/»«™Ð19 Xi+zùà oz 1%qkZ 0*}gøāìëZtāìzz¸ X÷ˆƒx»*‘ÓÅN*Ãe ¡+F,ZZ0Ð]˜āìtÈ» XZk ìñqZ»ä™Šæ kZ[ 0*Æyà!*gœ Ð{@çÐá²sîqZŽÔ]q&Z~ zkuƒ+&+ ÔZzgZ *™* ëZہ]âZŠZõ™ wZzg ¸NŠÅ Vƒ*™* ëZہi6,gîåÃVñZ¤/z6,ÆàbÅy!*i©D~P¹Ã {z Ò ÔW~yXW ÷ìg™ãZŠ¤/zŠ

Karachi Psychiatric Hospital Bulletin 127 Month March 2021 35 aynÆä™»ÃV:p VZzg â!* g~i øVœŽ ÷ìg8â° eZ 750 ~w‚qZëXÐ X7̼~«£Æb‚z âà ‰K VÔ Íg),}gøä19 eX ÃX,™g¨6,Eà©)ÅV ßÍ }÷ÔñOÆä™g¨6,;‚ XìŒe$¾Ãx³}gøÆ«™ ZiZzg ³ZÆ Zy= fg Æ~ÔZŠÅ VÔZzgZy â!*ià zZ äYà1Å Zy õg@*¤/XZ Ð,™Šæ g~ ø z{  ÷ìg™o‚»Õ¾ëāñYƒ ØÃVÃ% xZ ¬¤/Zāì¢= R}÷Xì~y!* g~i øŽÏƒ] zg ¢Å~ÔZŠ ZkÃVYà zZ äWāìtÂÔìc*2¼…ä h+æWlp: zZ ÃVŽ¤/ëpÔŠH` Xz{ ¸D™d$½qZnÆwLZÆ®`¤/~gÌñZ E4X .9 Æâ!*Zz gZu !*gœ yZzg Â{N*Ȇ ZzgZz F5é ½5 ïHE5Ò F e~Zg Ž X) w‚ŒZÂ7~gÌñ Zk¤/XZ Ð} X( ÷àS zy ç.‚nÆgñZ O%ZŠZ5,O%Z â

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Karachi Psychiatric Hospital Bulletin 128 Month March 2021 36

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

Karachi Psychiatric Hospital Bulletin 129 Month March 2021 37 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

Karachi Psychiatric Hospital Bulletin 130 Month March 2021 38 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

Karachi Psychiatric Hospital Bulletin 131 Month March 2021 39 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.

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Karachi Psychiatric Hospital Bulletin 133 Month March 2021 41

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Karachi Psychiatric Hospital Bulletin 134 Month March 2021 42

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Karachi Psychiatric Hospital Bulletin 135 Month March 2021 43

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Karachi Psychiatric Hospital Bulletin 137 Month March 2021 45

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Xóó ,™[NZ»5 gZ Ï ZZ ®ÔìCƒ•', Karachi Psychiatric Hospital Bulletin 138 Month March 2021 46

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ÆŠZہZá zZ ä™g!*gz »» ]øÂÐs§ÅÖ#Ó~wq‹gß g~ ‚ XZk ÷CYƒùŸ3Y Karachi Psychiatric Hospital Bulletin 139 Month March 2021 47

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Karachi Psychiatric Hospital Bulletin 140 Month March 2021 48 !y!*iò¸ g~ øzŠ Zg ì zg~ ¢zŠ £Zg Î ]g-!‚gŠZP‚

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Karachi Psychiatric Hospital Bulletin 141 Month March 2021 49

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Karachi Psychiatric Hospital Bulletin 142 Month March 2021 50

Ð~8Š{h+ŠÌ…ðŒÌZÅy!*iKZÃm,ôZ~pÖ uZ IzŠäŠ xWiZ æZ1Z*Ññb§T ŠŽñy!*i+4qZÌk0*}gøX7fÍëāǃ*CÃ*Š Zzg ǃ*™* fλzŠ yZg !*iò¸ g~ \KZ }g!*ÆTX÷s˜ gk ~Vâ»pÖZ,èÆTìyTÅVEÎ0*ë6,}iñ gz ZkŽì Xì¹äàz£Z²÷á ~

ñWÒpÐÂÙCÂ}™]!*z{ " "ñ zWŠ Zg &á1„zà1+Z

Karachi Psychiatric Hospital Bulletin 143 Month March 2021

KARACHI PSYCHIATRIC HOSPITAL KARACHI ADDICTION HOSPITAL

Established in 1970

Modern Treatment With Loving Care

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: Mubin House, Block B, North Nazimabad, Karachi

E-mail: [email protected] Skype I.D: [email protected] Visit our website:

0 MESSAGE FOR PSYCHIATRISTS

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:

Semi Private Room Rs 700/= 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.

C.E.O Contact # 0336-7760760 111-760-760 Email: [email protected]

Our Professional Staff for Patient Care 6. Sanoober Ayub Mayo  Doctors: M.S.C (Psychology) 7. Madiha Obaid 1. Dr. Syed Mubin Akhtar M.S.C (Psychology) MBBS. (Diplomate American Board of 8. Danish Rasheed Psychiatry & Neurology) M.S. (Psychology) 2. Dr. Muhammad Shafi Mansuri 9. Naveeda Naz MBBS, F.C.P.S (Psychiatry) M.S.C (Psychology) 3. Dr. Akhtar Fareed Siddiqui 10. Hira Rehman MBBS, F.C.P.S (Psychiatry) M.S.C (Psychology) 4. Dr. Major (Rtd) Masood Ashfaq 11. Anis ur Rehman MBBS, MCPS (Psychiatry) M.A (Psychology) 5. Dr. Javed Sheikh 12. Farah Syed MBBS, DPM (Psychiatry) M.S(Psychology) 6. Dr. Syed Abdurrehman 11. Sadaqat Hussain MBBS M.A (Psychology) 7. Dr. Salahuddin Siddiqui MBBS (Psychiatrist) 8. Dr. Sadiq Mohiuddin  Social Therapists MBBS 1. Kausar Mubin Akhtar 9. Dr. Zeenatullah M.A (Social Work) Director Administration MBBS, IMM (Psychiatry) 2. Roohi Afroz 10. Dr. A.K. Panjawani M.A (Social Work) MBBS 3. Talat Hyder 11. Dr. Habib Baig M.A (Social Work) MBBS 12. Dr. Ashfaque 4. Mohammad Ibrahim MBBS M.A (Social Work) 13. Dr. Murtaza 5. Syeda Mehjabeen Akhtar MBBS B.S (USA) 14. Dr. Salim Ahmed 6. Muhammad Ibrahim Essa MBBS M.A (Social Work)/ General Manger 15. Dr. Sanaullah MBBS 16. Dr. Javeria MBBS 17. Dr. Sumiya Jibran MBBS  Research Advisor Prof. Dr. Mohammad Iqbal Afridi MRC Psych, FRC Psych  Psychologists: Head of the Department Of psychiatry, JPMC, Karachi 1. Syed Haider Ali (Director)  Medical Specialist: MA (Psychology) Dr. Afzal Qasim. F.C.P.S 2. Shoaib Ahmed Associate Prof. D.U.H.S MA (Psychology), DCP (KU)  Anesthetist 3. Syed Khurshied Javaid Dr. Shafiq-ur-Rehman Director Anesthetist Department M.A (Psychology), CASAC (USA) Karachi Psychiatric Hospital. 4. Farzana Shafi  Dr. Vikram M.S.C(Psychology), PMD (KU) Anesthetist, 5. Rano Irfan Benazir Shaheed Hospital M.S (Psychology) Trauma Centre, Karachi xxx bbb WWW 05 Ï% 110 &Zp܉zƬ 21 Œ*0A7W HEE G 35 $fåG54G5¢bé£-G4$ 42 `´z ccc 111 ' 79 *0*Nñ 123 1Æ‚Æ Zp 141 Ô90 zŠ Zg 90 ¸ 126 Vâ*!iò£ wwwŠŠŠ { Zx Z 104 (ECT )`´ â© Šz 126 k%Z E-Ê 18 wŠ 94 (Schizophrenia )1ðGB â 114 kÎY¢ZuZ yyy fff [[[ 31 $-;f 05 } zg ŠC; 18 /f,( kkk 35 ^a â© ŠÃV” ~ 39 ypg]— 75 ^z»g~÷‚ 133 Ô 18 L8*c 49 `´ â© Š¹,' 85 (Hypnosis )èâ lll 57 n%C;XŠqˆ 82 L8*c~V” 18 Vâ*cÑ 123 V” 31 Z[Ñ \ ooo \\ 18 V*.,6 94 á zZ 䙿c]æsî s ``` 133 `¯ 01 éZpÒ u 45 A¼ 77 éZpÒ 44 Zx /¤z,6,RÛ YE 91 Y1857 ~Š WiZ ëL58E 60 (Covid-19 )*z™ 137 ï¬P