Cognitive psychiatry in India

Cognitive deficits have been shown to exist in various psychiatric disorders. Though most Indian studies pertaining to cognition have been replication studies, well designed original studies have also been conducted. This article traces the evolution of cognitive psychiatry in India. Cognitive research has huge potential in India and can help us unravel mysteries of the human mind, identify etiopathogenesis and facilitate treatment of psychiatric disorders.

through Google scholar and PUBMED search using the words India, cognition, cognitive, memory, attention, concentration, executive, neuropsychological, learning, amnesia etc in various combinations. Back references of articles were done and this yielded a few more articles. The topic of dementia has been left out as most of Indian studies have involved epidemiological aspects only. The studies have been presented in tabular form for the sake of convenience and ease in reading. "

Evolution of cognitive psychiatry in India
The first study relating to cognition in Indian Journal of Psychiatry was published in the year 1966 by Murthy et al. [2] on the effect of ECT on intelligence and memory in schizophrenic patients. This was followed up by studies on cognition in cannabis users and other populations.
Indian studies have generally been carried out in small number of subjects and tried to replicate research findings from the West; they have studied cognitive deficits in patients with common psychiatric disorders without involving less common entities. Of late, studies have included parents, siblings [3] and offsprings [4] of patients and revealed that they too suffer from cognitive deficits, which is in line with western research. There is a paucity of studies involving the pediatric population. [5] Although most Indian studies have been cross sectional studies, long term follow-up [6] studies have also been done by researchers. Recent studies have shown correlation between cognitive deficits and work functioning, rehabilitation. [7,8] The type of cognitive tests administered has evolved from simple tests like MMSE to more sophisticated computer based tests. However, more sophisticated tests are available only in select centers in the country. Earlier studies used western tests like Wechsler memory scale, Luria Nebraska neuropsychological battery etc. Over the past few decades, Indian tests like PGI battery of brain dysfunction [9] and NIMHANS neuropsychological battery [10] to assess cognition have been developed and have been widely used in later studies. Indian norms of western tests have also been derived recently. [11,12] Recently, Trivedi et al. (personal communication) translated MATRICS-CCB in Hindi. This is likely to provide a standardized way of assessing cognition in Indian patients and pave the way for  [24] 25 Charas smokers 25 Bhang drinkers 25 controls Bender Visual-Motor Gestalt Test, Maudsley Personality Inventory short form, and digit span tests from the WAIS Compared with controls, cannabis users were found to react more slowly, to be poorer in concentration and time estimation, and greater perceptuo-motor disturbance. The charas smokers were the poorest performers and also showed poor memory, lowered psychomotor activity, and poor size estimation. Sabhesan et al. 1990 [37] 11 alcohol dependent (DSM-III) head injured patients continuing to consume alcohol 11 alcohol dependent head injured patients abstaining from alcohol 11 non-alcoholic head injured patients PGI memory scale Head injured persistent alcohol abusers were the poorest in performance and abstinence was followed by a welcome change Narang et al. 1991 [38] 30 DSM III alcoholic patients P.G.I. battery of brain dysfunction Significant relationship between cognitive impairment and duration of alcohol use Mendhiratta et al., 2006 [6] Follow up study of Mendhiratta et al., 1978 [24] [4] 25 high risk offspring of treatment seeking patients with alcohol dependence; 25 low risk offsprings of volunteers Visual evoked response potential Strong association between lower P300 amplitudes over frontal brain areas and an excess of externalizing behavior in high risk offsprings clinical trials of molecules targeting cognition.
Early research work studied effect of ECT [2,13,14] and Lithium [15] on cognition. Recently, there have been human studies on the effect of herbal formulations [16,17] and piribedil [18] in patients of mild cognitive impairment. Notable work has been done on the effect of various drugs in ECS related amnestic deficits [19][20][21][22][23] in rats, which has helped to further our knowledge. However, there has been no significant work on the effect of commonly used psychotropic medications on cognition in psychiatric patients. Schizophrenic patients perform better than braindamaged but had poor performance than in comparison to normal controls Ananthanarayanan et al. 1993 [33] 24 remitted schizophrenics, 25 currently ill neurotic depressives (ICD-9) Computer based tests for visual information processing: Simple reaction time, choice reaction time, forced choice span of apprehension test Remitted schizophrenics performed poorly on all these measures as compared to neurotic depressives Mandal et al. 1999 [41] 12 schizophrenics (DSM-III R) each with predominantly positive and negative phenomenology; 12 healthy controls 'Recognition of Emotion' sub-test of the Penn Facial Discrimination Task Schizophrenic patients with negative symptoms exhibited a generalized emotion-recognition deficit. Schizophrenic patients with positive symptoms showed a deficit in recognition of 'sad' emotion   [42] 60 schizophrenic patients (ICD-9) Luria Nebraska neuropsychological battery  [3] 172 schizophrenic and schizoaffective patients (DSM-IV) and their parents (n =196) ; 120 controls Trail making test Cases as well as their parents showed more cognitive impairment than controls on the TMT     [59] 18 month follow up of 61 head injury patients PGI memory scale Patients with acceleration injuries showed a poor performance in comparison to those with contact injuries. Memory was found to be related to indices of severity of injury, particularly post traumatic amnesia (PTA). Sabhesan et al. 1990 [37] 11 alcohol dependent (DSM-III) head injured patients continuing to consume alcohol, 11 alcohol dependent head injured patients abstaining from alcohol and 11 non-alcoholic head injured patients PGI memory scale Head injured persistent alcohol abusers were the poorest in performance and abstinence was followed by a welcome change The sibling group performed poorly on cognitive domains studied as compared to controls. Siblings from multiplex families performed poorly in some domains of executive function.  [64] 30 women exposed to methylisocynate (MIC) in Bhopal gas disaster 30 control women PGI battery of brain dysfunction MIC exposed women had significant neurocognitive dysfunction in some specific areas as compared to control Srinivasan et al. 2005 [65] 130 patients aged $60 years of age admitted for medical or surgical treatment   [2] 15 Schizophrenic patients on ECT Alexander scale of intelligence, Wechsler memory scale No significant impairment of Intellectual efficacy and memory function due to ECT Improvement in the intelligence scores and a quick recovery after ECT course, of memory functions to their pre-ECT level, appear to be pre-conditions for a good prognosis on ECT in schizophrenics Shah et al. 1974 [13] 10 depressed patients on unilateral dominant and unilateral non-dominant ECT each Wechsler memory scale No significant difference in mean scores of memory scales in both unilateral dominant and non-dominant ECT Kunigiri et al. 2007 [14] 15 right handed patients with major depressive patient with melancholic features Orientation battery test, Trail making test-form A, Wechsler memory scale, Benton visual retention test Disorientation more pronounced after 5 th ECT Significant memory impairment following ECT In the Memorin group, on most tests significant improvement in performances were observed after treatment; improvement in many of the memory tasks was, however, confined to males Nagaraja et al. 2001 [18] 19 patients of mild cognitive impairment on piribedil and 8 patients of mild cognitive impairment on placebo; 90 days study

MMSE
Patients with mild cognitive impairment had improvement in global cognitive function when treated with the dopamine receptor agonist piribedil Raghav et al. 2006 [17] 18 patients of age associated memory impairment on standardized Bacopa monniera extract (SBME) and 17 patients on placebo; 12 weeks study Tests of Wechsler memory scale SBME produced significant improvement on mental control, logical memory and paired associate learning Jaykaran et al. 2009 [67] 31 patients with depression on fluoxetine; 1 month study PGI memory scale, six letter cancellation test

Patients show significant improvement on cognitive functions
Research relating cognition to other biological research (like neuroimaging) to map neuroanatomical correlates has just begun. [14] There has been no significant work in areas of social cognition, which has received much attention in the international forum.
The results of most Indian studies have been in accordance with western work with a few notable exceptions like negative correlation between cognition and work performance in Indian schizophrenic patients which was hypothesized to be due to social factors. [8] There has been a steady increase in the number of articles pertaining to cognition in Indian Journal of Psychiatry over the past decade. It is encouraging to note that work by Indian researchers has also been published in reputed international journals. [6,19,[24][25][26] There have been editorials on the subject in Indian Journal of Psychiatry. [27] Marfatia award [4] and DLN Murthy Rao orations [1,20] have been delivered in ANCIPS for Indian research pertaining to cognition.

Indian tests to assess cognition
The validated Indian tests available in the field are 1. NIMHANS neuropsychological battery: [10] Composed of tests taken from other standardized battery of tests, such as the Luria-Nebraska Neuropsychological battery. 2. PGI battery of memory dysfunction: [9] Includes 10 subtests including forward and backward digit spans, one minute delayed recall of a word list, immediate recall of sentences, retention of similar word pairs, retention of dissimilar pairs, visual retention, visual recognition, recent memory, remote memory and mental balance test. 3. Hindi cognitive test battery of "The Indo-US cross national dementia epidemiology study": [28,29] Is based on the English language cognitive screening panel used by the MOVIES project. The MOVIES battery includes a brief global cognitive scale (general mental status), the mini-mental status examination (MMSE) and a set of other tests tapping several other cognitive domains.
NIMHANS neuropsychological battery has recently been validated for children. [30] Hindi MMSE [28] was developed as part of the Indo-US cross-national dementia epidemiology study but has been shown to be different from MMSE. [31] Normative data for Wisconsin card sorting test (WCST) for the Indian population was reported recently. [11] The study found highly significant differences between the means on almost all WCST scores among the western and Indian sample, except for the number of correct responses.
The scores of Trail making tests in Indian population have been shown to vary from published results from other cultural groups. [12] Indigenous methods [32][33][34] have been developed by authors to assess cognition.

Cognition and substance abuse
The studies on cognition and substance abuse are reviewed in table 2.

COGNITION AND SCHIZOPHRENIA
The studies on cognition and schizophrenia are reviewed in table 3.

COGNITION AND BIPOLAR DISORDER
The studies on cognition and bipolar disorder are reviewed in tables 4 and 5. Khanna et al. (1991) [48] described findings on Luria Nebraska neuropsychological battery in a 12-yearold boy with mania following encephalitis. The patient showed perseveration on rapid sequential hand movement, graphaesthesia items, extemporaneous speech and spontaneous writing. Attention problems and a tendency to answer impulsively and randomly was seen on spatial orientation items (Clock reading and Raven's items), in counting numbers or days of week backwards and in memorizing a series of seven words. Interference procedures diminished his ability to remember. He had gross problems in arithmetic. Abstract reasoning was poor. Sequential thinking and planning skills were poor. After three months treatment with haloperidol, the patient showed some impairment in memory and intelligence though none of the clinical and summary scales were above the critical level.

COGNITION AND DEPRESSION
The studies on cognition and depression are reviewed in table 6.

COGNITION AND OCD
The studies on cognition and OCD are reviewed in table 7.

Cognition in brain injured patients
The studies on cognition in brain injured patients are reviewed in  (LNI) on a group of brain damaged patients. Nizamie (1983) used LNI on a group of brain damaged patients. A number of studies since have been carried out (Nizamie et al., 1988;Panda, 1988;Sasi, 1989;Srivastava, 1989; James, 1990; Khanna et al., 1991;James et al., 1991) using the original version of Luria Nebraska Neuropsychological Battery. [40] There has been case reports that cognitive rehabilation improves cognition and functional ability in patients with reversible and progressive brain injury. [60]

Cognition in other patients
The studies on cognition in other patients, cognition and ECT, psychotherapeutic studies on cognition and cognitive experiments on animals are reviewed in tables 9, 10, 11 and 12 respectively.
In separate studies, Andrade et al. found that the herbal formulations, Mentat and Memorin effectively attenuated anterograde and retrograde amnestic effects of electroconvulsive shocks (ECS). An aqueous extract of Shankpushpi (Evolvulus alsinoides) conveyed no cognitive benefits to rats which received ECS. In similar experiments, Brahmi (Bacopa monniera) and mandookaparni (Centella asiatica) alone or in combination did not facilitate pe-ECS learning but attenuated ECS-induced anterograde and retrograde amnesia. [21] In separate experiments, Andrade showed that Verapamil, Felodipine, sodium nitroprusside [22] , phenylephrine, [19] mifepristone, indomethacin [69] and celecoxib attenuated ECT induced retrograde amnesia. [20] The theoretical explanations and possible implications have been discussed by Andrade in his DLN Murthy Rao oration. [20] CONCLUSION A commendable effort has been put in by Indian workers in the field of cognitive sciences despite dearth of psychiatric centers, research facilities and resources in India. Andrade cited lack of funds as the reason due to which translational research to examine safety and efficacy of herbal formulations in humans who are treated with ECT for psychiatric disorders could not be done. [20] Given the many constraints that exist in our setup, sheer diligence and innovativeness at times has led to publication of studies with very sound methodology.