Objective: Addiction comorbidity is an important clinical challenge in mood disorders, but the best way of pharmacologically treating people with mood disorders and addictions remains unclear. The aim of this study was to assess the efficacy of pharmacological treatments for mood and addiction symptoms in people with mood disorders and addiction comorbidity. Methods: A systematic search of placebo-controlled randomized controlled trials investigating the effects of pharmacological treatments in people with bipolar disorder (BD) or major depressive disorder (MDD), and comorbid addictions was performed. Treatment-related effects on mood and addiction measures were assessed in a meta-analysis, which also estimated risks of participant dropout and adverse effects. Results: A total of 32 studies met systematic review inclusion criteria. Pharmacological therapy was more effective than placebo for improving manic symptoms (standardized mean difference [SMD] = −0.15; 95% confidence interval [95% CI], −0.29 to −0.02; P = 0.03) but not BD depressive symptoms (SMD = −0.09; 95% CI, −0.22 to 0.03; P = 0.15). Quetiapine significantly improved manic symptoms (SMD = −0.23; 95% CI, −0.39 to −0.06; P = 0.008) but not BD depressive symptoms (SMD = −0.07; 95% CI, −0.23 to 0.10; P = 0.42). Pharmacological therapy was more effective than placebo for improving depressive symptoms in MDD (SMD = −0.16; 95% CI, −0.30 to −0.03; P = 0.02). Imipramine improved MDD depressive symptoms (SMD = −0.58; 95% CI, −1.03 to −0.13; P = 0.01) but Selective serotonin reuptake Inhibitors (SSRI)-based treatments had no effect (SMD = −0.06; 95% CI, −0.30 to 0.17; P = 0.60). Pharmacological treatment improved the odds of alcohol abstinence in MDD but had no effects on opiate abstinence. Conclusions: Pharmacological treatments were significantly better than placebo in improving manic symptoms, MDD depressive symptoms, and alcohol abstinence but were not better for bipolar depression symptoms. Importantly, quetiapine was not more effective than placebo in improving bipolar depression symptoms nor were SSRI’s for the treatment of MDD depression. Our findings highlight the need for further high-quality clinical trials of treatments for mood disorders and comorbid addictions.

Exposure to alcohol misuse is considered an adverse childhood experience impacting on neurodevelopmental and behavioural outcomes in adolescents including substance use, mental illness, problem behaviours, suicidality, and teenage pregnancy. Most research on this issue has focussed on higher income countries, whereas patterns of alcohol use and related factors may be different in low- and middle-income countries (LMICs). This systematic review therefore seeks to collate all published studies from 1990–2020 on the topic set in LMICs. 43 studies were included, totalling 70,609 participants from 18 LMICs. Outcomes assessed included: substance use; depression/anxiety; suicidal ideation; problem behaviour; emotional dysfunction; teenage pregnancy; and self-harm. Despite heterogeneity in the studies identified, this review documented some association between exposure to household alcohol misuse and adverse adolescent outcomes in LMICs, including mental health problems, problem behaviours, and suicidality. The mechanisms leading to these outcomes are likely varied, and further research in different socio-economic and cultural contexts, particularly in the form of longitudinal studies, is called for.

Childhood exposure to alcohol misuse by household adults has been related to childhood developmental delay, cognitive impacts, mental illness, and problem behaviours. Most evidence comes from high income countries. This systematic review only included studies from low- and middle-income countries (LMICs). Five databases were searched from 1990–2020. Twenty-eight studies of children 0–12 years were included, with 42,599 participants from 11 LMICs. The most common outcome was behavioural problems/disorders (19 studies). Despite varying study designs, this review found that alcohol misuse by household members in LMICs is associated with adverse child neurodevelopmental outcomes, although casual inferences cannot be drawn in the absence of well conducted prospective studies. Statistically significant correlations were described between parental alcohol misuse and child emotional and behavioural difficulties, cognitive delay, and risky behaviours. In future, prospective cohort studies are recommended, with adjustment for confounders.

Toba Tek Singh," which describes the exchange of mental asylum inmates between India and Pakistan in the wake of partition, was perhaps Saadat Hasan Manto's most wellknown short story. Manto's work was coloured by his experience of mental illness, including alcohol addiction and possible depressive disorder. This essay attempts to use "Toba Tek Singh" as a lens through which to shine an integrative light on the role of mental illness in Manto's work and life, by discussing his personal experiences, themes of mental illness in the story, and the implications of his writing in the historical context of post-partition South Asia.

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