Erik Ganesh Iyer Søegaard

• Edwards, Maria G. P.; Furuholmen-Jenssen, Tobias; Søegaard, Erik Ganesh Iyer; Thapa, Suraj Bahadur & Andersen, Jens R. (2024). Exploring diet-induced ketosis with exogenous ketone supplementation as a potential intervention in post-traumatic stress disorder: a feasibility study. Frontiers in Nutrition. 11. doi: 10.3389/fnut.2024.1406366. Full text in Research Archive Show summary

  Background: Post-Traumatic Stress Disorder (PTSD) is a severe and pervasive mental disorder, and patients experience numerous distressing symptoms and impairments that significantly impact their lives. In addition to being a mental disorder, PTSD is strongly associated with a wide range of metabolic abnormalities that affect the entire body. Existing treatment options of psychotherapy and medications are often ineffective. Exploring other potential treatments is necessitated. The ketogenic diet has shown potential as a metabolic therapy in certain neurological and mental disorders and is a promising intervention in the treatment of PTSD. Aim: This study aimed to examine if a 4-week ketogenic diet intervention supplemented with exogenous ketones (KD-KS) was feasible in adult patients with PTSD, to what extent it was possible to recruit patients, attain and maintain ketosis (plasma concentration of β-hydroxybutyrate (BHB) ≥ 0.5 mmol/L), the occurrence of serious adverse reactions and adverse reactions to KD-KS, and acceptance of treatment. Our exploratory aims were changes in PTSD symptoms and health-related quality of life (QoL) from baseline to 4 weeks. Methods: Patients 18 ≤ 65 years old, diagnosed with PTSD, and receiving outpatient treatment for PTSD at Southern Oslo District Psychiatric Centre (DPC), Oslo University Hospital, Oslo, Norway, were included. The intervention consisted of a ketogenic diet supplemented with β-hydroxybutyrate salt to obtain ketosis. PTSD symptoms were measured with the PTSD Checklist for DSM-5 (PCL-5) and QoL was measured with the RAND 36-Item Health Survey 1.0. Results: During a 21-week inclusion period, three of four eligible patients (75% [95% CI: 30 to 95%]) were included. Two patients (67% [95% CI: 21 to 94%]) completed the 4-week intervention and one patient (33% [95% CI: 6 to 79%]) completed 2 weeks of intervention before discontinuing. Ketosis was achieved on day 1 in one patient, and on day 2 in two patients, and was maintained in 87% of the intervention. There were no serious adverse reactions. Adverse reactions were reported in a total of 70% of intervention days, the most frequent being headache followed by fatigue. The participant-perceived degree of adverse reactions was low to moderate. The treatment was accepted by patients on all intervention days. PCL-5 decreased by 20 points (70 to 50) in patient 1 and by 10 points (50 to 40) in patient 2, from baseline to 4 weeks, which is a reliable and clinically meaningful improvement. QoL improved in six of eight RAND-36 subscales in patient 1 and three of eight in patient 2. Patient 3 did not complete assessments after week 2. Conclusion: To the best of our knowledge, this feasibility study is the first study examining a ketogenic diet intervention in patients with PTSD. Three of four predefined feasibility criteria were achieved. Ketosis was attained fast and maintained, patients were compliant and there were clinically meaningful improvements in PTSD symptoms and QoL. Despite the small sample size, the knowledge obtained in this study is important for the planning of future studies with ketogenic diet interventions in this patient group. It is a first step for potential dietary and metabolic therapies in PTSD. Further feasibility and pilot studies with larger sample sizes are needed to determine feasibility and safety before planning future randomised controlled trials investigating an effect.

• Mainali, Anustha; Søegaard, Erik Ganesh Iyer; Hauff, Edvard & Thapa, Suraj Bahadur (2024). A comparative study of comorbidities, symptom profiles, and childhood trauma in PTSD and non-PTSD trauma patients at Oslo University Hospital. Nordic Journal of Psychiatry. ISSN 0803-9488. p. 1–8. doi: 10.1080/08039488.2024.2415306. Full text in Research Archive Show summary

  Purpose To explore the differences in mental health symptom profiles, trauma profiles, childhood trauma and comorbidities in patients with PTSD and those without PTSD. Materials and methods A cross-sectional study was carried out on 110 adult patients with trauma backgrounds attending a mental health outpatient clinic in Southern Oslo, Norway. In addition to self- report questionnaires, several standardized validated diagnostic tools were used to assess mental disorders. Multiple linear regression models were used to assess the association between trauma history, the mental health symptom profile of the patients, and PTSD diagnosis. Bivariate logistic regression was used to examine if childhood trauma/adversities were associated with PTSD. Results Patients diagnosed with PTSD had significantly higher rates of comorbid major depressive disorder, panic disorder, agoraphobia disorder, and social phobia compared to those without PTSD. We also found a positive association between PTSD diagnosis and all the different mental health symptoms domains of the Symptom Checklist-90-Revised instrument. When adjusted for age, gender, education, smoking habits, immigration, relationship, and employment status, these associations persisted with varying effects. We did not find any association between PTSD and childhood trauma/adversities, however, sexual abuse trended towards an association. Conclusion Adult trauma patients with PTSD may have more comorbid disorders and mental health symptoms. Childhood trauma may be less critical for the PTSD diagnosis in this group. In clinical practice, personalized treatment plans addressing both the symptom burden and its comorbidities may be beneficial.

• Koirala, Rishav; Aass, Hans Christian; Søegaard, Erik Ganesh Iyer; Dhakal, Hari Prasad; Ojha, Saroj Prasad & Hauff, Edvard [Show all 7 contributors for this article] (2023). Association of pro-inflammatory cytokines with trauma and post-traumatic stress disorder visiting a tertiary care hospital in Kathmandu. PLOS ONE. 18(2). doi: 10.1371/journal.pone.0281125. Full text in Research Archive Show summary

  Post-traumatic stress disorder (PTSD) is a mental disorder that can occur after trauma. Although inflammatory markers such as cytokines are found altered in trauma and PTSD, there is no consensus regarding which can be considered as biomarkers. Studies from South Asia region is also rare. We studied cytokines among trauma affected patients and matched healthy controls. Fifty patients (cases) with trauma, visiting the University hospital in Kathmandu and thirty-nine healthy controls were selected, and the levels of cytokines were determined using a Luminex IS 200. We compared the levels of the cytokines in thirty-four age and gender matched pairs of case and control among three groups: healthy volunteers, cases diagnosed as PTSD, and cases without PTSD. Among the 34 pair-matched cases and controls, IL-6 was significantly higher in both PTSD positive cases [2.43 (0.00–14.54) pg/ml; p = 0.004] and PTSD negative cases [3.00 (0.92–3.86) pg/ml; p = 0.005], than in controls [0.39 (0.00–11.38) pg/ml]. IL-1β was significantly higher in PTSD positive cases [0.17 (0.00–5.27) pg/ml; p = 0.011] than in controls 0.00 (0.00–0.12) pg/ml. Other cytokines did not show significant differences. IL-6 was higher in both the trauma affected groups and IL-1β was higher in the trauma affected group with PTSD when compared to healthy controls. This supports the immune system activation hypothesis after trauma.

• Kan, Zhanna; Søegaard, Erik Ganesh Iyer; Siqveland, Johan; Hussain, Ajmal; Hanssen-Bauer, Ketil & Jensen, Pia [Show all 12 contributors for this article] (2022). Coping, Social Support and Loneliness during the COVID-19 Pandemic and Their Effect on Depression and Anxiety: Patients’ Experiences in Community Mental Health Centers in Norway. Healthcare. 10(5). doi: 10.3390/healthcare10050875. Full text in Research Archive Show summary

  Background: Little is known about psychiatric patients’ experiences during the COVID-19 pandemic. The purpose of this study was to investigate associations of coping strategies, social support and loneliness with mental health symptoms among these patients. Methods: We recruited 164 patients from Community Mental Health Centers in June–July 2020. Participants responded to an online questionnaire on corona-related questions, Brief Coping Orientation to Problems Experience, Crisis Support Scale, a 3-item Loneliness Scale, and Hopkins Symptom Checklist-25. We used linear regression models to investigate associations between these and symptoms of depression and anxiety. Results: Almost 51% were aged 31–50 years and 77% were females. Forty-six (28%) participants reported worsened overall mental health due to the pandemic. The reported rates of clinical depression and anxiety were 84% and 76%, respectively. Maladaptive coping was independently associated with both depression and anxiety symptoms. Loneliness was independently associated with depression symptoms. Conclusions: Patients in Community Mental Health Centers in Norway reported high rates of depression and anxiety symptoms. Many of them reported worsening of their mental health due to the pandemic, even at a time when COVID-19 infections and restrictive measures were relatively low. Maladaptive coping strategies and loneliness may be possible explanations for more distress. Keywords: anxiety; depression; COVID-19; coping; Community Mental Health Centers; loneliness; social support

• Søegaard, Erik Ganesh Iyer; Kan, Zhanna; Aass, Hans Christian Dalsbotten; Koirala, Rishav; Hauff, Edvard & Thapa, Suraj (2022). Abnormal Cytokines in Trauma Patients Explained by Obesity, Musculoskeletal Disease, Smoking, and Lung Disease. Neuropsychobiology. ISSN 0302-282X. 81(6), p. 516–530. doi: 10.1159/000526806. Full text in Research Archive Show summary

  Introduction: Low-grade inflammation observed through abnormal plasma cytokine levels has been associated with post-traumatic stress disorder (PTSD). It is not clear whether PTSD independently causes the inflammation or if it is mainly through co-occurring somatic factors such as smoking and obesity. We wanted to explore the effects of biopsychosocial factors on cytokine levels in a clinical setting. Methods: The sample consisted of 51 patients with PTSD, 58 trauma patients without PTSD, and 40 matched controls. We selected cytokines and relevant risk factors for systemic inflammation through pairwise correlations. Then, we used linear regression to analyze the individual and combined effects of these on the (Log10) cytokines, particularly estimating the effect of PTSD adjusted for other factors. Results: Higher age, female gender, cigarette smoking, presence of lung and musculoskeletal disease, use of antipsychotic medication, and higher BMI were correlated with higher levels of interleukins IL-1RA, IL-2RA, and IL-6. In the adjusted regression analysis, higher BMI was associated with increased IL-1RA (B = 0.06, p < 0.01), IL-2RA (B = 0.01, p < 0.01), and IL-6 (B = 0.01, p = 0.03). Presence of musculoskeletal disease was associated with increased IL-1RA (B = 0.72, p < 0.01) and IL-6 (B = 0.16, p = 0.01), and decreased IL-2RA (B = −0.09, p < 0.01). Cigarette smoking (B = 0.16, p = 0.01) and presence of lung disease (B = 0.14, p = 0.02) were associated with increased IL-6. PTSD diagnosis was associated with decreased IL-2RA (B = −0.06, p = 0.04). Discussion/Conclusion: Altered cytokine levels in distressed trauma-affected individuals are probably mostly through co-occurring risk factors and not PTSD diagnosis. Increased BMI and musculoskeletal (pain) disease may be particularly strong risk factors and should be addressed.

• Søegaard, Erik Ganesh Iyer & Kan, Zhanna (2021). Koronasmitte i Oslos bydeler. Tidsskrift for Den norske legeforening (Tidsskriftet). ISSN 0029-2001. 141(6), p. 1–6. doi: 10.4045/tidsskr.20.1022. Full text in Research Archive
• Koirala, Rishav; Søegaard, Erik Ganesh Iyer; Kan, Zhanna; Ojha, Saroj Prasad; Hauff, Edvard & Thapa, Suraj (2021). Exploring complex PTSD in patients visiting a psychiatric outpatient clinic in Kathmandu, Nepal. Journal of Psychiatric Research. ISSN 0022-3956. 143, p. 23–29. doi: 10.1016/j.jpsychires.2021.08.030. Full text in Research Archive Show summary

  Decades of research on trauma patients have shown that a post-traumatic stress disorder (PTSD) diagnosis does not always cover the full spectrum of symptoms after severe trauma. Complex PTSD (CPTSD) was recently introduced in the International Classification of Diseases 11th Revision. There have been no published studies on CPTSD in the South Asian region to date. The objective of this study was to evaluate CPTSD in a sample of trauma patients in Nepal. We also examined quality of life (QOL) and mental health comorbidities and their association with CPTSD caseness. One hundred patients with a history of trauma who visited the outpatient psychiatry clinic at a hospital in Kathmandu from 2017 to 2018 were assessed. The Composite International Diagnostic Interview Version 2.1 was used to evaluate PTSD, major depressive disorder, and generalized anxiety disorder (GAD). Disturbance of self-organization symptoms from the Structured Interview for Disorders of Extreme Stress (SIDES) together with the PTSD diagnosis was used to confirm CPTSD caseness. The World Health Organization (WHO) QOL Scale Brief Version (WHOQOL-BREF) was used to assess QOL in four domains. Among the 83 patients who had PTSD, 42 also had CPTSD. CPTSD was significantly associated with major depressive disorder, GAD, female gender, and lower QOL in all four domains. CPTSD was prevalent among these patients. Having CPTSD was significantly associated with worse outcomes in terms of QOL and comorbid mental disorders, even with similar trauma. There is a need to explore CPTSD symptoms and to address trauma patients with CPTSD in this region.

• Søegaard, Erik Ganesh Iyer; Kan, Zhanna; Koirala, Rishav; Hauff, Edvard & Thapa, Suraj Bahadur (2021). Gender differences in a wide range of trauma symptoms after victimization and accidental traumas: a cross-sectional study in a clinical setting. European Journal of Psychotraumatology. 12(1), p. 1–13. doi: 10.1080/20008198.2021.1975952. Full text in Research Archive Show summary

  Background There are large gender differences in PTSD prevalence. Gender differences in a wide range of trauma symptoms including disturbances in self-organization have not been extensively researched. Objective To explore gender differences in a wide range of trauma symptoms by comparing victimization trauma (VT) with accidental trauma (AT). Method A cross-sectional study of 110 traumatized patients attending a mental health outpatient clinic in Oslo, Norway (38.2% men, Mage = 40.4, 40% ethnic Norwegians). The trauma was categorized as VT or AT based on the Life Events Checklist. The Structured Clinical Interview for DSM-IV-PTSD-module and Structured Interview for Disorders of Extreme Stress Not-Otherwise-Specified (DESNOS) assessed a wide range of trauma symptoms. First, we examined gender differences within the trauma categories, then MANCOVA for an adjusted two-by-two between-groups analysis. Results Among VT patients, men reported more symptoms of alteration of negative self-perception (p = .02, ES = 0.50) and alteration in systems of meaning (p < .01, ES = 1.04). Within the AT group, women reported more symptoms of affect and impulses (p = .01, ES = 0.94). The VT-AT difference was significantly higher in men in intrusion (p < .01, η2 = 0.04), affect and impulses (p < .01, η2 = 0.12), negative self-perception (p < .01, η2 = 0.11), difficulty in relations (p = .01, η2 = 0.10) and alterations in systems of meaning (p = .01, η2 = 0.14). Conclusion: Comparing the VT-AT differences between the genders, men with VT had relatively more symptoms of intrusion, self-organization, identity, ideology/meaning, cognition, and relations difficulties. Effect sizes were moderate to large. Men may be relatively more vulnerable to VT than AT, while women may be more equally affected by VT and AT. Acknowledging possible gender differences in a wider range of trauma symptoms depending on trauma category may have clinical benefits

• Koirala, Rishav; Søegaard, Erik Ganesh Iyer; Ojha, Saroj Prasad; Hauff, Edvard & Thapa, Suraj B. (2020). Trauma related psychiatric disorders and their correlates in a clinical sample: A cross-sectional study in trauma affected patients visiting a psychiatric clinic in Nepal. PLOS ONE. 15(6), p. e0234203–e0234203. doi: 10.1371/journal.pone.0234203. Full text in Research Archive Show summary

  Background Nepal, like many other low-income countries, has a great burden of mental health issues but few resources to meet them. In addition, Nepal has endured several traumatic events in recent decades but the impact on mental health has not been studied in clinical settings. This study explores trauma-related psychiatric disorders and their correlates. Methods 100 patients with a history of trauma who visited the outpatient psychiatry clinic at a University hospital in Kathmandu were assessed. The Composite International Diagnostic Interview 2.1 (CIDI) was used to evaluate lifetime and current depressive disorder, generalized anxiety disorder (GAD) and lifetime post-traumatic stress disorder (PTSD). Current PTSD was evaluated using PSTD Checklist—Civilian Version (PCL-C). Results The median number of lifetime traumatic events was two. Natural disaster was the most common trauma type (84%) compared to other types of trauma. Rape was reported as the most traumatizing. Current PTSD was found in 15%, depression in 33% and GAD in 38% of the patients. The lifetime rates were PTSD 83%, depression 45% and GAD 40%. There was high comorbidity between the disorders. The 31 to 45 years age group, above high school education level and trauma types other than earthquake were independently associated with current PTSD. Marital status and upper socioeconomic status (SES) compared to upper-middle SES were independently associated with lifetime PTSD. Both lifetime and current depression rates were independently associated with the upper SES compared to upper-middle SES. Place of living, education above high school and lower-middle SES were significantly associated with lifetime and current GAD. Conclusion PTSD, depression and GAD were prevalent in a trauma exposed patient population visiting a psychiatric clinic in Nepal. High rates of comorbidities and several risk factors were identified. Our findings highlight the need for addressing trauma related disorders in clinical settings in developing countries.

• Søegaard, Erik Ganesh Iyer; Kan, Zhanna; Koirala, Rishav; Hauff, Edvard & Thapa, Suraj Bahadur (2020). Variations in psychiatric morbidity between traumatized Norwegian, refugees and other immigrant patients in Oslo. Nordic Journal of Psychiatry. ISSN 0803-9488. 74(6), p. 390–399. doi: 10.1080/08039488.2020.1714724. Full text in Research Archive Show summary

  Background: There is a lack of clinical studies that focus on different psychiatric disorders after trauma and the relationship with migration status. Purpose: To examine differences in psychiatric morbidity in traumatized patients referred to psychiatric treatment in Southern Oslo. Materials and methods: Hundred and ten patients with trauma background attending an outpatient clinic in Southern Oslo were studied. Forty-four of the participants (40%) were ethnic Norwegians, 25 (22.7%) had refugee background and 41 (37.3%) were first- or second-generation immigrants without refugee background. Thorough diagnostic assessment was done by experienced psychiatrists through several structured clinical interviews and self-report questionnaires. Results: Ninety-eight patients (89%) were diagnosed with at least one Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR) disorder. There was a clear difference in the presentation of certain psychiatric disorders between the groups. Ethnic Norwegian patients were more likely to have anxiety disorders: agoraphobia, social phobia and panic disorder than non-refugee immigrant patients. They also had higher rates of alcohol abuse/dependence. Somatoform pain disorder was more common in both the refugee and other-immigrant groups than among the ethnic Norwegian patients. The refugee patients had significantly more major depressive disorder, post-traumatic stress disorder (PTSD) and both co-occurring. Conclusion: Trauma is frequently associated with depression, anxiety disorders, somatoform pain disorder and PTSD in a clinical population. The clinical presentation and comorbidity of these disorders seem to vary significantly between traumatized patients with Norwegian, refugee and non-refugee immigrant backgrounds. After a major trauma, refugees may be at greater risk for both PTSD and depression than other immigrants and the native population.

• Koirala, Rishav; Søegaard, Erik Ganesh Iyer & Thapa, Suraj Bahadur (2017). Updates on pharmacological treatment of post-traumatic stress disorder. Journal of Nepal Medical Association. ISSN 0028-2715. 56(206), p. 274–280. doi: 10.31729/jnma.3108. Full text in Research Archive Show summary

  Post-Traumatic Stress Disorder affects a significant proportion of those who have been exposed to exceptionally threatening or catastrophic events or situations such as earthquakes, rape and civil war. The condition can often become chronic and disabling. Medical intervention can therefore be of paramount importance. There are no national guidelines for trauma disorders in Nepal and there is a lack of adequate knowledge regarding drug treatment of PTSD among doctors and other service providers. Though psychotherapy is internationally regarded as the first line treatment for PTSD, it is often not feasible in Nepal due to lack of resources and skilled health workers in this field. The use of right psycho-pharmacotherapy is therefore important to reduce the burden of disease. A wide range of pharmacotherapy has been tested in the treatment of PTSD. This article is based on a selected sample of relevant articles from PubMed, PsycINFO, national guidelines from other countries and our own clinical experience. We have tried to give a concise and practical review regarding the use of drugs, their side effects and available evidence in the treatment of PTSD. The main findings point to use of Selective Serotonin Reuptake Inhibitors as the first line pharmacotherapy, and they can have effect on the full range of symptoms in PTSD. SNRIs show similar efficacy. Adjuvant drugs like Alpha-blockers and atypical antipsychotics have shown strong evidence in treating partially remitted cases and resolving ancillary symptoms.

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