Indian psychiatry: Research and international perspectives

East–West divides. ABSTRACT Indian psychiatry has many contributions to the world psychiatry to its credit. These include active participation in the international scientific organizations, research, and also creation of the manpower resources in many other countries. India has been an active partner in the research initiatives of the World Health Organization and the World Psychiatric Association. Research by the Indian psychiatrists played an important role in recognition of the entity of acute and transient psychotic disorders, some culture bound syndromes like Dhat syndrome and understanding the role of families in care of schizophrenia and course and outcome of schizophrenia.

Modern psychiatry in India developed as an extension of British psychiatry, as most of the psychiatrists who started modern psychiatry in India were trained in the United Kingdom. The training of psychiatry in various medical schools and the mental health institutes also had strong influences of British and American psychiatry. However, most of the current generation of psychiatrists have been primarily trained in India, although some might have received further training abroad. The Indian Council of Medical Research (ICMR) as well as the WHO have made an important contributions funding many quality research projects in the country. India has made tremendous contributions to world psychiatry. The contributions are in various areas including creating manpower resources around the world, especially in the English speaking countries, in research, therapeutics, international psychiatric associations, and the WHO. The contributions of the country can be traced back to some ancient Indian medical texts, which at that time had given elaborate classification of psychiatric disorders, as well as teachings of religious texts, which have relevance in psychotherapy.
This chapter discusses the contributions of Indian psychiatrists to world psychiatry starting from the ancient period and also briefly on how World Psychiatry has influenced Indian Psychiatry. It is not possible to summarize all the contributions in a single article. The authors have attempted to highlight some important areas. It is possible that some important contributions may have been missed inadvertently.
Indian Psychiatry has had a considerable influence on World Psychiatry, especially by promoting a broad conceptualization of health, which is enshrined in the World Health Organization's (WHO's) constitution. India has also contributed to the development of the cultural bases of psychiatry through the work of many eminent researchers, such as Venkoba Rao, Kapur, Wig, Varma, Shekhar Saxena, Dinesh Bhugra and others. Contributions of many clinical scientists of Indian origin are also noteworthy in the development of biological psychiatry. Indian psychiatrists have also contributed immensely to the research, academics, and organizational activities of the World Psychiatric Association (WPA) and the World Association for Social Psychiatry (WASP). World Psychiatry has in turn influenced Indian Psychiatry by providing a global framework within which Indian psychiatrists and institutions are making specific contributions, and also by facilitating the development of collaborative links within and across the North-South and East-West divides.

CONTRIBUTIONS OF ANCIENT INDIA
Mental health being an important component of health was recognized even by the ancient physicians of India including Charaka and Sushruta, more than two thousand years ago. Ayurveda, is the ancient Indian text on medicine. The concept of mind and a description of psychosis, 'unmad', have been given in the Vedas sometime between 5000 and 10000 BC. [1] A discourse by Lord Krishna to the historical warrior 'Arjuna' in the battle field of Mahabharata, available in text form, in the Gita, is an excellent treatise on psychotherapy. Gita is available in a translated version, in English. Many Indian psychiatrists like Vidya Sagar and A Venkoba Rao have emphasized on the use of teachings from the Gita in psychotherapy. [2] Professor Vidya Sagar often used anecdotes from the Gita in his group sessions with patients and their families. Buddha's teachings to his disciples also have tremendous psychotherapeutic potential. [3] Ayurveda has given an elaborate classification of mental diseases as neuroses or chittodwaga (anxiety disorders), unmada (psychoses), apasmara (convulsive disorders, epilepsy) and attattvabhinivesa (obsessive disorders); while mada (intoxication), murcha (syncope), and sanyasa (coma) are considered to be psychosomatic diseases. Unmada or psychosis, is described by Charaka as 'the perversion of the mind, intellect, conscience, behavior, and conduct.' According to Charaka, there are five types of unmada: vata, pitta, kapha, samnipatika (combined vitiation of all the three doshas) and exogenous. Samnipatika is considered incurable. Exogenous insanity is different from the insanity caused by vitiated doshas, and is believed to be caused by karma and the '…effects of sinful activities in past life' Ayurveda also gives a personality classification based on interaction between 'doshas' and 'Gunas'. [4] The origin of the yogic method of relaxation can also be traced to the ancient India. Recently, Suchitra et al., [5] have given a tridimensional model of psychosis (unmada) based on Ayurveda.

CONTRIBUTIONS OF THE INDIAN PSYCHIATRISTS IN THE LAST 50 YEARS
In the last 50 years, Indian psychiatrists have conducted research in many areas including schizophrenia and related psychotic disorders, mood disorders, anxiety disorders, substance use disorders, epidemiology, community psychiatry, child and adolescent psychiatry, disaster-related mental health problems, and many other areas. Psychiatric units in the general hospitals are one of the main providers of health care in India. They provide scope for close integration of psychiatry with other specialties, and have also helped in reducing the stigma associated with mental disorders.

Schizophrenia and related disorders
India was a member country in the WHO's multicentric International Pilot Study of Schizophrenia (IPSS; World Health Organization, 1979) and the Determinants of the Outcome of Severe Mental Disorders (DOSMED) study. [6] Both provided convincing evidence for a better outcome in India (along with other less industrialized countries) than in the West. This finding of a good outcome of treatment also emerged in the Chandigarh studies. [7,8] The discovery of a good prognosis of schizophrenia, in Indian patients with schizophrenia, was further confirmed by the ICMR's multisite study of the Factors Affecting the Course and Outcome of Schizophrenia (SOFACOS), which had an extended follow-up to 10 years. [9,10] Indian psychiatrists have also done extensive work on acute psychoses. Short-term follow-up also showed the delineation of acute psychosis as distinct from schizophrenia and affective disorders, [11] and was responsible for the acceptance of the concept of acute and transient psychotic disorders.
Another important difference in which India differs from the West is that more than 90% of the patients of schizophrenia stay with their families. Families face substantial burden due the care-giving role. Indian psychiatrists have worked on the area of expressed emotions, family burden, family interventions, and development of support groups. One study has shown lesser expressed emotions in the Indian families. [12] The recognition of the importance of families has led to the creation of facilities for families to stay with patients in some centers, such as the National Institute of Mental Health and Neurosciences in Bangalore, and the Christian Medical College in Vellore. This facilitates the extensive participation of families in therapeutic programs. [13] Coping by families has also received some attention, with particular reference to religious coping methods. [14,15] There have also been studies exploring the needs of patients of schizophrenia. [16] Qualitative research in the area of caregiving is also being undertaken. [17,18] Psychiatrists in India have also been working on contemporary issues in schizophrenia. There have been many important contributions by the Indian Psychiatrists in areas such as the metabolic syndrome in schizophrenia. One recent study reported the low prevalence of the metabolic syndrome and obesity in untreated patients of schizophrenia. [19] Others have worked on the role of the second generation antipsychotics in causing the metabolic syndrome. [20] There has also been work exploring the genetics of schizophrenia as well as the biological abnormalities. Venkatsubramanian et al., [21] have recently been able to identify deficits in the corpus callosum in antipsychotic naïve patients of schizophrenia.

Culture bound syndromes
One seminal article by Professor NN Wig has introduced the concept of the Dhat syndrome more than 50 years ago, [22] which can be considered as a form of somatization. It is a culture-bound syndrome, characterized by a belief of passing semen in urine, which leads to loss of sexual vigor and is accompanied by a number of vague somatic symptoms as well as secondary anxiety and depressive symptoms. [23] The patients present with a characteristic profile of illness behavior with hypochondriasis and denial. [24] The syndrome has been mainly reported from South East Asia, although some authors have contested its occurrence only in this population and its being a culture-bound syndrome. [25] Excessive vaginal discharge is another common complaint reported by women from the Indian subcontinent and has attracted the interest of the Indian psychiatrists. The complaint is often accompanied by vague somatic symptoms, which indicates the underlying psychological stress. In the local parlance, the complaint is referred to as leucorrhea, 'safed pani', 'shwet prader' and many other local names are used. [26,27] In one community survey, nearly 15% of the women complained of excessive vaginal discharge. [28] Koro has also been reported both as isolated cases as well as an epidemic from India. [29,30]

Mood disorders
Mood disorders have attracted the interest of the Indian psychiatrists since the beginning. The initial study was on the symptomatology of depression, especially the finding of less prevalence of guilt in Indian patients as compared to the west. [31][32][33] Indian patients suffering from depression have also been reported to show higher scores on items such as poor appetite, hypochondriasis, diurnal variation, and psychomotor retardation; and lower scores on anxiety and middle insomnia. [33] Some workers have carried out studies on the role of melatonin in depression. [34] Social issues such as disability associated with depression, untreated depression, and attitudes toward depression still remain an area of interest to the Indian psychiatrists. Poverty and poor physical health have been recognized as important risk factors in old age depression, whereas, good social support is protective. [35] Chakraborty et al., [36] identified erroneous beliefs about antidepressants in patients with depression, which can interfere with compliance, thus highlighting the need of psycho-education.
A number of Indian psychiatrists have worked in the area of neurocognition, burden and care-giving, and quality of life in bipolar disorder. A number of Indian researchers have tried to identify sources of burden and care-giving models in bipolar disorder. [15,37,38] Trivedi et al., [39] have identified impairments in executive functioning in the euthymic state, in patients with bipolar disorder. The same group of authors also found poor executive function of vigilance in the normal siblings of patients with bipolar disorder. [40] Impairment in executive functioning and soft signs have also been detected in euthymic states, in bipolar patients, in some Indian studies. [41,42] Chand et al., [43] could not find any differences in the quality of life of patients with bipolar disorder, while in a euthymic state, as compared to the normal controls.
In recent years, research has also been carried out to study the brain functioning in bipolar disorder. Bhardwaj et al, [44] by using a (99 m) Tc-ECD SPECT, found reduced perfusion in the left frontal area, and left anterior cingulated and parietal cortices in patients with mania, and lowered rCBF in the anterior temporal regions bilaterally, as also in the left parietal area, in patients with bipolar depression.

Common mental disorders
There has been an extensive study on various common mental disorders including anxiety disorders, somatoform disorders, and depression in primary care. A number of researchers in India have studied psychiatric diagnoses in somatizing patients. Depressive, anxiety, and somatoform disorders are the common diagnoses, but a substantial number of patients are placed under unspecified categories of these disorders. [45,46] Chaturvedi and Bhandari [47] have studied illness behavior patterns in somatizing patients. Younger patients were found to have disease phobia and preoccupation with the disease. Srinivasan and Suresh [48] used a method of screening for nonspecific symptoms, to identify psychiatric morbidity in primary care. Symptoms such as weakness of body or mind, headache, fatigability, and burning sensations are commonly reported by Indian patients. [46,49] In another study on somatization and depression, Raguram et al., [50] concluded that the tendency to perceive and report distress in psychological or somatic terms is influenced by various social and cultural factors, including the degree of stigma associated with particular symptoms. Patel et al, [51] have studied the somatic and psychological models of common mental disorders. Duddu et al, [52] have hypothesized alexithymia in the background of somatization and depression in Indian patients.

Person-centered medicine
Indian Psychiatry has been more recently collaborating and advancing the concept of person-centered psychiatry. We have been associated with the Institutional Program for Person-Centered Psychiatry of the World Psychiatric Association initiated by Juan E Mezzich (President of World Psychiatric Association 2005 -2008). The concept, 'Toward person-centered medicine: from disease to patient to person,' has been discussed by Mezzich et al. [53] Roy Abraham Kallivayalil and Trivedi have been roped in as the steering committee members of this Program and are participating in person-centered diagnostic developments. Preparing educational curricula for person-centered clinical care, its integration with General Health Care, training Primary Care Physicians in person-centered medicine, and integration with the National Mental Health Program are agendas for the future.

Indian psychiatry and world psychiatric association
India is a member of the WPA and has been closely involved with its activities. Advancing the regional development of world psychiatry through the studies of many Indian colleagues is notable. Trivedi was the Zonal representative in 2005 -2008 and Mohandas in the current period. They have been involved with coordinating WPA activities in the South Asia Region. Roy Abraham Kallivayalil is the co-chairman of the WPA Preventive Psychiatry Section, and a book on 'Suicide Prevention -a handbook for community gate-keepers' was published in 2009, [54] by the National Alliance for Mental Health, India, as an important activity of the Section.

India and social psychiatry
Promoting the development of social psychiatry through the contributions of many scholars and through the Indian Association of Social Psychiatry (IASP) has been remarkable. Varma, Sridhar Sharma, Rakesh K Chadda, Roy Abraham Kallivayalil, and others have led the Social Psychiatry movement in India. IASP has been the participant in the recent WPA Survey on 'Reducing the treatment gap for mental disorders.' [55] India and the mental health legislation India has made significant strides in providing humane treatment for the mentally ill. The Mental Health Act (1987) annulled many archaic provisions of the Indian Lunacy Act (1912). However, further improvements in the mental health legislation have become necessary and imperative and these have been discussed in a recent article by Kallivayalil and Trivedi. [56] Indian psychiatrists in other parts of the world India has contributed to the world psychiatry in another way by being a supplier of an extensive workforce of psychiatrists and other mental health professionals to the developed world. A recent report [57] estimates that 4687 psychiatrists of Indian origin are currently registered in countries like UK, USA, Australia, New Zealand, and other countries. The number is much more than the Indian psychiatrists working in India. They have also made a significant impact in these countries, in areas of service as well as research. Many of them have reached important academic positions in the Universities and have also made important contributions to the international agencies like the WHO. The assumption of office of Shekhar Saxena as the Director, Department of Mental Health and Substance Abuse at WHO, Geneva, is worth special mention. One of the psychiatrists of Indian origin -Dinesh Bhugra -was recently elected President of the Royal College of Psychiatrists in the United Kingdom.

CONCLUSION
Indian Psychiatry is on the path of rapid development. Vast improvements in mental health delivery have been made during the last few decades, but the paucity of resources, lack of adequate mental health personnel, and the general apathy toward mental health are obstacles that need to be overcome. Despite many severe constraints, India has made the most significant contribution to the world, among South Asian countries. The liaison with world psychiatry has also progressed further by affording links to global medical organizations such as the World Psychiatric Association, World Association for Social Psychiatry, World Medical Association, World Federation for Mental Health, and others, which represent new opportunities and horizons for development and fulfillment.