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(Long Acting Injectable Antipsychotics DîsZ~ŠgŠâÊ-BðGE1ZŠzc*]Æ3) 1
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ìX(ÆgŠâÊ-BðGE1ZŠzc*] Second Generation (ZzgŠzu~±) First Generation D«±) 4
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1
94Karachi Psychiatric Hospital Bulletin Month March 2021
àVÆŠzgZyÔZkÆZI{:䊬āz{ŠzZN9 2 ÐtÈÆZïg™Šc*āz{Í1V3áÇXZŒÐ7ág;åÔZzgZ#ÍCVÅ®ZŠÅ2ÌÅÂ¥xƒZāYyZKŠzZƒV»Ûzág;åXZyÆçÒäZÐCc*āZ¤/z{!*‡°Ïд`6,¿cZ7gLìÂZkÅ´â]~4~7ƒÏÉ'×h+yZ!»ZkyìXZzgZ¤/´â]ZzgZkŪyZ[ƒCìÂZÐZõ7w~ŠZ4™äÅ¢zg]7,$ËìX
(»tg{Šz!*g{7HŠHXZ¤/pYy„CÙH?Ø Long Acting Injections îsæC3)
Ck™g;åÔpçnäZÐgZè™1XZkÆZI{:äÌîsæC3
(д`Å×e$ÅìX Long Acting Injections)
(д`Åßg]~4~ƒCìXj¢45é EGEi+ Long Acting Injections îsZ~Š3)
~Z%M~Šø7[ 1960 (� LAI (Ô«±»îsæCq) Fluphenazine enthate Z&4-Ÿï GEGWH)
Æ‚}~Šø7[ƒZZzgìci+Zw 1970(Fluphenazine decanoate ƒZj¢45é EGEi+er,M)
ÅŠ;ð~Šø7[ƒŠHX 1980 (Haloperidol decanoate er,M)
(ÃZ%O%¡ Risperidone microsphere () LAI DŠzu~±»ªîsZÓŠq)
~àgHåX 2003 (ä FDA)
(Šø7[÷: LAI DZkz‰ÜÜs&ŠvŠzu~±ÆîsZOŠ3)
(Zzg Paliperidone palmitate (Ô³ci+Zy) Olanzapine pamoate DZz�Zà)
(Šø7[÷X)10*Îy~Zy~ÐÃðÌñ�Š7( Aripiprazole lauroxil Zk,"545é GFGFizw)
(Æ´z{ŠzŠzu}3 inj. Fluphenazine «±Æîsæ]ƬZbj¢45é EGEi+)
(Ì Inj. Flupentixol Depot (Zzgj"54-£½iðFGEG
w) Inj. Clopenthixol Depot ³"54-£½iðFGEG
w)
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(Å FDA (ÆZ’ðc*bàÆŠzgZy´`ÆnÌZ%O%¡) Schizophrenia ²z�Û«C)
2
95Karachi Psychiatric Hospital Bulletin Month March 2021
(ZzgpÙ Schizo Affective Disorder §sÐàg~qÝìXZyÃ]¿.çGEz�Û«C›c*8Lä)(ÆnÌàgHŠHìX Bipolar Affective Disorder Zzgc*8L)
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B¤/Zx(»£HX 5.0±11.7 ()pgZu Haloperidol B¤/Zx(Zzgìci+Zy) 1.9±4.9 pgZu
(397=N () Schizophrenia or Schizo affective disorder âÊ-BðGE1c*²zZ¢5»43ðE
GHGekWgeg)
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GHGekWgeg A C L A I M S 7ƒ@*Aƒ**e’X(zZá%ÉV~îsZÅ.š5éGŠZb"5Ó42.ç FGGFGi+zy Schizophrenia or Schizo affective)
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(ªziy(,−py~](,−÷XZknZéziyZzgpy~ Metabolic Syndrome ZW,Z])
3
96Karachi Psychiatric Hospital Bulletin Month March 2021
(Zzg´`ÆZz²V6, Hb1Ac â{Å]ÅR) 3D6 ]ÅôZãÆn.gìpy~]Ôpy~ X ÷áïì (Lipid Profile)
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(ÆzZu]Z7¸X Galactorrhea (ZzgŠzŠ|Â_) Gynecomastia YZV»(,−)
4
97Karachi Psychiatric Hospital Bulletin Month March 2021
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
98Karachi Psychiatric Hospital Bulletin Month March 2021
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
99Karachi Psychiatric Hospital Bulletin Month March 2021
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
100Karachi Psychiatric Hospital Bulletin Month March 2021
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
101Karachi Psychiatric Hospital Bulletin Month March 2021
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
102Karachi Psychiatric Hospital Bulletin Month March 2021
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
103Karachi Psychiatric Hospital Bulletin Month March 2021
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(ÅF,šMZkZzgŠzZðÆ´` RV (¹Æ÷XIV) Virtual Realty Zke~)
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104Karachi Psychiatric Hospital Bulletin Month March 2021
ÆZ0+g4§i»gÅ'g]qÝ™äÆn¥~(,}eä6,ZEwňìX(z~WgR,“F,šMãg~¯ñÏZzgZkz‰ÜJ-F,šM VR (~IV) ECT zŠâ©´`)
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(Æ´`Ь9»g~2**ÑìX ECT Šâ©´`)
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105Karachi Psychiatric Hospital Bulletin Month March 2021
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
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106Karachi Psychiatric Hospital Bulletin Month March 2021
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
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107Karachi Psychiatric Hospital Bulletin Month March 2021
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
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108Karachi Psychiatric Hospital Bulletin Month March 2021
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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109Karachi Psychiatric Hospital Bulletin Month March 2021
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110Karachi Psychiatric Hospital Bulletin Month March 2021
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18
111Karachi Psychiatric Hospital Bulletin Month March 2021
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
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112Karachi Psychiatric Hospital Bulletin Month March 2021
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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113Karachi Psychiatric Hospital Bulletin Month March 2021
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116Karachi Psychiatric Hospital Bulletin Month March 2021
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117Karachi Psychiatric Hospital Bulletin Month March 2021
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.
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118Karachi Psychiatric Hospital Bulletin Month March 2021
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.
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119Karachi Psychiatric Hospital Bulletin Month March 2021
"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
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120Karachi Psychiatric Hospital Bulletin Month March 2021
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
121Karachi Psychiatric Hospital Bulletin Month March 2021
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
122Karachi Psychiatric Hospital Bulletin Month March 2021
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
(�™zñÎxÆZz6,~{ Ribo Nucleo Pro gZ1E®ÓÒ3ðG6,z”™) Telomere ÷X÷÷6,ƒD÷ZzgZkÅ™«™D÷(z‰ÜÆ‚Bc*ÚzÐgLƒYD÷XVwÆîg6,Ô¿
(”VƧi¿Ô'×Z`~p~aZ™CìÔŒVJ-āù¦D/ÐÌ TL ÅMð) Telomere
(Z374545ë EGEGH!*Çâg™ T L zZhìX@*ëÔt!*]zZãîg6,¥x7ìXƒYìā)(ÅÁMðÐ݃(Ô>ä TL (ƒ)ªicÅ1”V~) Epigenetic biomarker)
;({Ô 29 âƒVZzgâiZG{”VŠâV»_·HXâN)XÅZz‰/Ô 155 Zkãîg6,ÜÆW¸iЄ‚(~ÔZyÆZL‚Å>Ï)‰zZ−+Åf6Fg~Ô:t(ÔIZiaZöÆ 38 ‚;CÔ 52
(»± TL â{ƈŠ@ˆXâiZG{”VÆ) 18 ÔZzg 12 ÔÔ 4 ÚƒÔc*8LÔZzgc*8LÅŠgzÈ~ÅR â{6,ŠgzÈ~ÅX 18 â{~ìÆfg)HŠHÔZzgâƒVäèpZgÆ)bÐ0|u 18 Zzg 12Ô4
‚(ƈicÆZ’Zð 19 IZiaZöÚƒÔZzgaZöƈaZƒäzZáf6Š!*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™CìāâVƂŤÔ',ÎVÔÚƒZzgZzÑŠ~ZW,Z]ù%A$ƒMh
÷ÔZzgZ’Zð‚~6,.yÁŠ!*]ÐÝZzgçnÃZyÏVîsæCZW,Z]Ãf‚~ge’X
30
123Karachi Psychiatric Hospital Bulletin Month March 2021
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
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124Karachi Psychiatric Hospital Bulletin Month March 2021
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.
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125Karachi Psychiatric Hospital Bulletin Month March 2021
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126Karachi Psychiatric Hospital Bulletin Month March 2021
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34
127Karachi Psychiatric Hospital Bulletin Month March 2021
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128Karachi Psychiatric Hospital Bulletin Month March 2021
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
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129Karachi Psychiatric Hospital Bulletin Month March 2021
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
130Karachi Psychiatric Hospital Bulletin Month March 2021
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
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131Karachi Psychiatric Hospital Bulletin Month March 2021
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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132Karachi Psychiatric Hospital Bulletin Month March 2021
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133Karachi Psychiatric Hospital Bulletin Month March 2021
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134Karachi Psychiatric Hospital Bulletin Month March 2021
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135Karachi Psychiatric Hospital Bulletin Month March 2021
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43
136Karachi Psychiatric Hospital Bulletin Month March 2021
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44
137Karachi Psychiatric Hospital Bulletin Month March 2021
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138Karachi Psychiatric Hospital Bulletin Month March 2021
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139Karachi Psychiatric Hospital Bulletin Month March 2021
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140Karachi Psychiatric Hospital Bulletin Month March 2021
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141Karachi Psychiatric Hospital Bulletin Month March 2021
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142Karachi Psychiatric Hospital Bulletin Month March 2021
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143Karachi Psychiatric Hospital Bulletin Month March 2021
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
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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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