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PERSONAL REMINISCENCES  
Year : 2018  |  Volume : 60  |  Issue : 6  |  Page : 177-182
Reminiscences and reflections on growth of psychiatry in India


Department of Psychiatry, National Academy of Medical Sciences, and Institute of Human Behaviour and Allied Sciences, New Delhi, India

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Date of Web Publication5-Feb-2018
 

   Abstract 


The paper is an autobiographical account of growth of Psychiatry in India, during the last six decades. It highlights on the development of treatment modalities in psychiatry especially on psychopharmacological drugs. The establishment of general hospital psychiatry and manpower development in the field of mental health are other areas which are discussed.

Keywords: General hospital psychiatry, growth of psychiatry in India, psychopharmacological drugs

How to cite this article:
Sharma S. Reminiscences and reflections on growth of psychiatry in India. Indian J Psychiatry 2018;60, Suppl S1:177-82

How to cite this URL:
Sharma S. Reminiscences and reflections on growth of psychiatry in India. Indian J Psychiatry [serial online] 2018 [cited 2021 Apr 19];60, Suppl S1:177-82. Available from: https://www.indianjpsychiatry.org/text.asp?2018/60/6/177/224658





   Introduction Top


The 70th Annual National Congress of Indian Psychiatric Society (IPS) will be meeting in February 2017, in Ranchi. It gives an opportunity to reflect on the progress and growth of psychiatry as a vibrant discipline during the last 57 years of my professional life. During these years, psychiatry underwent several spectacular changes. From 13 members in 1947, the membership of IPS has increased to over 6000 as per the latest membership directory of IPS, though the number of qualified psychiatrists in India will be more than 5500. We are training approximately 400 MD and DPM, and DNB students every year. Similarly, with the establishment of psychiatric units/department in over 400 medical colleges, there is rapid growth of PG training centers in India, with a shift from mental hospital training to the general hospital setting. The opening of psychiatric units/departments in almost all medical colleges of India has done more to advance psychiatry than any other diagnostic or therapeutic discovery. Significantly, these developments influenced psychiatry to shift its focus from mental hospital to general hospital and community setting. It all started with the discovery of new psychopharmacological agents such as chlorpromazine, antidepressants such as imipramine and meprobamate groups of drugs. In this paper, I would like to share my personal reflections briefly on the growth of psychiatry in India.

My interest in psychiatry antedated my formal training in psychiatry. The period of late 50's and early 60's were years of promise and excitement in the field of psychiatry. This was a period, when some bright young graduates in medicine opted for the field. During this period, psychiatry was slowly coming out of the high boundary walls of old mental hospitals. The postgraduate training of psychiatry on an organized level was mainly limited to few centers in Bengaluru, Ranchi, Mumbai, and later, in Calcutta. This was a period of rapid transition in the field of mental health, in training, service, and research in India. I belonged to the first batch of DPM in the Central Institute of Psychiatry at Ranchi. I got the first position in my class. Later, I passed my M.D Psychiatry in 1965. There were hardly 3 MDs in India. Dr. L. P. Verma was my teacher. He was the First MD in India in 1943. Dr. K. Bhaskaran did his MD in 1958. I was trained at Central Institute of Psychiatry at Ranchi, which, before India got independence was known as “European Mental Hospital,” and was managed by trained British Psychiatrists, to care for British and other European Patients and was later on managed directly by the Ministry of Health, Government of India since 1954, when it was renamed as Hospital for Mental Diseases.

During 50's and early 60's, insulin coma and electroconvulsive therapy (ECT) as treatment modalities were used commonly in mental hospitals but their popularity was slowly declining, and there was increasing use of few available phenothiazines and tranquilizers which were available in late 50's and early 60's. This changed the entire scene and practice of psychiatric care and service delivery system. It resulted in marked improvement in the clinical atmosphere of the hospitals and gave greater confidence to the psychiatrists. There was better control of patient's destructive behavior, with sharp increase in admission rates and decrease in duration of stay of the patients.

Till 1951, the physical methods of treatment in psychiatry in special hospitals included ECT and insulin coma treatment. Interestingly, even in the UK, which was very advanced in the field of psychiatry at that time, it was reported that within 3 months of onset of disease, effectiveness of treatment by insulin was considered as high as 75%.[1] In some hospitals in India, at Bengaluru and Ranchi, psychosurgery was practiced for which Dr. Egas Moniz was given Noble Prize in Medicine in 1951. Similarly, narcotherapy with the help of sodium pentothal was used to treat psychoneurosis and hysterical cases.[2] There was limited use of many indigenous drugs which were used by some psychiatrists. These drugs were like SILEDIN and Rauvolfia compounds. The use of carbon dioxide therapy in neurosis by some doctors was considered novel.[3] In 1958, chlorpromazine was introduced and later Prochlorperazine and Trifluoperazine were introduced and widely used in schizophrenics. Meprobamate was the only antianxiety drug used for neurosis/anxiety, and there were one or two antidepressants such as imipramine and MAO Inhibitors. Barbiturates, bromides, and injectable paraldehydes were still commonly used.

In 1959, chlordiazepoxide the first effective anti-anxiety drug was introduced, and in early 1960, amitriptyline was available in the market, by the end of 1970, there were about 50 psychotropic and antidepressants drugs available.

This soon enhanced the acceptability of pharmacotherapy for mental disorders and pharmacotherapy was scientifically accepted like in other physical diseases. This resulted in opening of psychiatric units in general hospital setting.


   General Hospital Psychiatry Top


My first major encounter with International Psychiatry was with WHO visiting Professors from University of Edinburgh and later in November 1965 with Prof. P. Bann, the then Chief of Mental Health, WHO and Dr. Tsung Yi Lin from WHO, Geneva who came to Ranchi for WHO. – DGHS Seminar; along with Dr. H. B. Miller, a WHO Visiting Professor from University of Edinburgh to participate in a WHO-sponsored symposium on the “Curriculum development of Undergraduate Teaching in Psychiatry,” where I was also a participant along with Dr. J. S. Neki, Dr. N. N. Wig, and K. Bhaskaran, Dr. L. P. Varma, Dr. K. C. Dube, Dr. C. C. Saha, and others.

In December 1965, I was selected to head the first independent Department of Psychiatry in Medical College, Baroda. Dr. R. L. Kapur was assistant professor, and Mrs. Kapur was the clinical psychologist. This medical college was identified by WHO, Government of India, and University of Edinburgh to develop as a most modern medical college in Southeast Asian Region. It was mainly because a great medical Statesman Dr. Jivraj Mehta was the Chief Minister of Gujarat. There was a regular exchange program of the faculty of Medical College Baroda and University of Edinburgh, which enabled me to setup a modern psychiatry department in a teaching general hospital. It also helped in establishing close collaboration with department of pharmacology and clinical pathology departments which were well equipped. In 1967, during the decade of the progress of Gujarat, the department of psychiatry and department of clinical pathology were highlighted in a Government Documentary. It may be relevant to mention that the first full-fledged independent department of psychiatry was established in 1963 in All India Institute of Medical Sciences (AIIMS) by Prof. D. Satyanand. He started MD psychiatry course in AIIMS, and other institutions in the country followed suit. Dr. D. Satyanand was my teacher in Ranchi before he moved to AIIMS. Till almost 1967–1968, the Department of Psychiatry in PGI Chandigarh, K. G. Medical College, Lucknow, was under the department of medicine. The history of development of general hospital psychiatry is interesting and has been written by the author and others in many publications.

My initial research work involved the use of TOLBUTAMIDE in place of INSULIN in schizophrenics, in Ranchi [4] when I was working with Professor L. P. Verma at Ranchi, insulin treatment was at that time popular and was considered as a powerful therapeutic method in India. I was also interested in biochemistry of depression. As a part of our ongoing research work program in Medical college, Baroda on biochemical aspects of depression, namely, on 17 hydroxycorticosteroids and estimation of all electrolytes in depression, which was at that time receiving attention from leading researchers in the field. This work was published in both international [5] and national journals. Another area of interest, during this period, was the presence of a pink spot in the urine of schizophrenics which was at that time considered a front area of research in psychiatry. In 1966, an ICMR research project on “Brain Polarization in Depression” was funded by ICMR. After few years, I was appointed to establish another new department in Goa Medical College in 1968. In our laboratory, we tried to resolve the confirmatory and contradictory reports, which had appeared in leading journals with respect to the identification and origin of the pink spot, in the urine of schizophrenics [6],[7],[8] and to see whether the substance dimethoxyphenylethylamine (DMPEA) was present in the cerebrospinal fluid (CSF). Due to the variation of amino acid composition in urine, we thought that CSF would be a better area to work with, in addition to urine and if DMPEA could be detected in the CSF, it would prove more significant.

In sixties, phenothiazine and both tricyclic and monoamine oxidase inhibitors were common psychopharmacological agents available in India for the treatment of acute and chronic schizophrenia and depression. However, extrapyramidal side effects and other side effects such as lactation [9] and tardive dyskinesia were commonly encountered with these drugs. During the search, for newer neuroleptic agents, GO 3315, a new butyrophenone was synthesized at Ciba-Geigy Research Centre, Mumbai. This center was doing outstanding research in the field of clinical pharmacology. This molecule GO 3315 was found to possess an interesting neuroleptic profile in different animal test systems, and it had minimal extrapyramidal effects at pharmacological doses. The toxicity was low in experimental animals. Human tolerability was also found to be acceptable and effective in Phase I and Phase II clinical trials. However, due to reasons not known to the investigators, after Phase I and Phase II clinical studies, in spite of its good therapeutic efficacy and tolerability in schizophrenics, the drug was not introduced in the market by Ciba as CIBA HQ in Basel thought otherwise.

Another interesting molecule developed by Janssen Laboratories was pimozide. Dr. Paul AJ Janssen, who was the director of research at Paul AJ Janssen Lab at Beease in Belgium, who to his credit had over one hundred patents, and who was discoverer of Haloperidol in 1958, and later pimozide and many other drugs. We tried pimozide, before it was marketed even in Europe. The drug showed great promise in selected schizophrenics, who were delusional but not grossly psychotics. This drug was therapeutically very incisive in early schizophrenics and had low EPS side effects. The reasons why this drug could not become popular in North America was because it had shown carcinogenic changes in animal experiments. By early seventies, most of the neuroleptics and antidepressants which were introduced in Western countries were available in India. In India, before marketing any drug, it is made mandatory by Drug Controller Authorities that there should be clinical trials for both its efficacy and safety. The department of psychiatry at Goa was conducting some interesting double-blind studies on newer antipsychotics and antidepressants, etc., such as nomifensine (1980)[10] and dothiepin (1977).[11] In 60's and 70's many clinical studies from India were published from Mumbai, Goa, Bengaluru, and Lucknow centers.

In 1972, I had the first major exchange of ideas and collaboration with many world leaders in the field of psychopharmacology when I was visiting some leading research centers in Europe and North America. My visit to Europe and North America was more like a pilgrimage to me. I was keen to visit the important centers and meet leading men who were forerunners in the field of psychopharmacology and in biochemical studies and with many of them, I was earlier in correspondence. During this visit, not only did I personally visit their laboratories but also made the acquaintance of a number of leading leaders in the field. I would specifically like to mention about my visit to Dr. Delay and Dr. P. L. Deniker's department in Paris in 1972, discoverers of chlorpromazine, I met him few times after that and my last meeting with him was during the WPA Conference in Athens in 1989 where he spoke on History and New Developments in Neuroleptic Treatments. In 1972, I also met Prof. P. Kielholz and Prof. Dr. Werner P. Koella in Ciba-Geigy Research Centre in Basel, with Ciba, when I was doing collaborative clinical trials on a new drug GO 3315A in India. In Copenhagen, Prof. Ole Rafelson was doing interesting work on electrolytes in depression, and he had shown some interest in my work on depression and electrolytes, in which we were interested. My friendship with Prof. Rafelson continued till his sudden tragic death. Dr. George Sakalis, in department of biochemistry along with Prof. Michel Shepherd and Prof. Jim Birley, Prof. J. K. Wing at Maudsley Hospital and Prof. Linford Rees in Psychopharmacology in London provided a good opportunity of learning from UK experience. Dr. Denis Leigh who was then Secretary General of W. P. A. was of immense help to introduce me to the then world leaders in W. P. A. and other countries. Dr. Leigh was a friend of India; he was posted in India during the Second World War.

Later, I visited Canada and USA. My first meeting with Prof. H. E. Lehman, a leader in Psychopharmacology in Canada in 1972 was very rewarding who used chlorpromazine first time in Canada in 1954. I also met Dr. T. Ban in Douglas Hospital in 1972, where some of my friends from India were also working. I would like to mention the name of Dr. N. P. V. Nair who is still there and doing excellent work in psychopharmacology while Dr. J. Ananth, a bright psychiatrist later moved to UCLA at Los Angeles in USA. Dr. Ananth was very active in IPS meeting till his untimely death. I also met Prof. D. C. Cameron, the former President of WPA, Prof. Cleghorn (Senior) and Dr. Sawer Foner in Canada. My association with Douglas Hospital actively continued till 2003 in my capacity as a member of the International Advisory Committee of WHO Collaborative Research centre in Montreal. I have given many lectures during my visits. During the same trip in 1972, I was invited to give a lecture by Dr. Nathan S. Kline, the inventor of one of the antidepressant in his Rockland Research Centre (now Nathan S. Kline Research Centre)[12] and by Prof. Joel Elkes in John Hopkins Psychiatric Centre, who earlier had used chlorpromazine first in 1954 in UK, he was working in Baltimore in the Henry Phipps Psychiatric Clinic during my visit to USA, I met Dr. Ross J. Baldessarini at the Psychiatric Research Laboratory at Massachusetts General Hospital in Boston. It was an honor to be invited by Prof. L. J. West in UCLA, Los Angles. In 2003, I was again invited as a visiting professor in the University of California in 2002. Similarly, my visit to the University of Upsalla in Sweden with Prof. Witterberg was a very stimulating experience who was doing outstanding work in the area of pineal gland. Prof. Witterberg later moved to Karolinska Institute in Stockholm. In 1972, during the silver jubilee celebration of Indian Independence, a documentary was prepared by Government of India, in which the department of psychiatry was included.

I had the opportunity to meet Dr. Frank M Berger in 1972 in New Jersey, USA, the inventor of Meprobamate in 1955, the first antianxiety drug tranquilizer and the precursor of all drugs of this kind, (if was marketed in India as Miltown and Equanil). He was the Director of Research – Carter Wallace Laboratories and he was kind enough to invite me to his department and was my personal host.

This extensive visit of mine to many of these leading centers, stimulated my interest in the field but now the research was getting more and more complex and highly technology based. By this time, I had established a good postgraduate department of psychiatry at Medical College, Goa. In 1974, I was elected as the General Secretary of the Indian Psychiatry Society in Trivandrum and continued for a period of 4 years till 1978. Goa Medical College became active in national scene. The period of 1974–1978 in Indian Psychiatry was quite remarkable in many ways. This was a period when the various IPS Zones were formalized and consolidated. During this period, the various awards like Bhagwat and Marfatia Awards and Dr. D. L. N. Murthy Rao Orations were started. In 1978, for the first time, a W. P. A. regional Symposium was held in AIIMS in New Delhi during the annual conference. It was during this conference that for the first time the Hon'ble Prime Minister of India Sh. Moorarji Desai, inaugurated the meeting. It may be interesting to mention that right from 1947, when IPS was established, two resolutions which were invariably discussed were (1) first, that the Lunacy Act of 1912, has become outdated and it needs to be replaced by a modern Mental Health Act, and (2) second, teaching of psychiatry at undergraduate level is inadequate and psychiatry teaching should find more place in the MBBS curriculum. During the IPS Conference in 1978 in Delhi, while welcoming the Prime Minister, I had politely mentioned that Indian Lunacy Act has become outdated and Government should bring out a new legislation. This had a very positive effect. When I returned to Goa after the conference, there was a telegram from the Health Ministry to send the draft bill to the Ministry at the earliest. The bill was introduced in the Parliament and later referred to the Select Committee. Finally, the Mental Health Act was passed by the Parliament in 1987. Earlier in 1977, in India, the Conferences were inaugurated by the Vice President of India the Governor of West Bengal and the Chief Minister were also the Chief guests. The Membership of the IPS also grew from 250 in 1974 to 500 in 1978. This growth though may look small but was a great achievement at that point.

In 1976, I was selected by the WHO, as Senior WHO Fellow in Epidemiology and International Mental Health to visit WHO, Geneva, London, Denmark, Prague, and Moscow. During this visit, I was also invited to the Second meeting of WHO Investigators in Biological Psychiatry at Institute of Psychochemistry at Copenhagen in 1976. The leading investigators who were participating were Prof. Ole Rafelson, Prof. Hippius, from Munich, Prof. Allec Coppen from London, P. Kielholz from Basel, Dr. M. Vartnian from Moscow, Dr. Van Praag from the Netherlands, and Dr. W. E. Bunny from NIMH in USA. At that time, the main focus of the WHO study was to study “the effect of Psychotropic Drugs” in different population in different countries. Later, Dr. B. B. Sethi was associated with this group.

The meeting provided a good opportunity for interacting with the leading investigators in the field. The small group meetings are normally more productive than large meetings. The experience gained during this interaction helped me to modernize the laboratories in Goa. During this visit, about 2 weeks were spent in Aarhus in the Department of Psychiatry with Prof. E. Stromgren, a leading epidemiologist and Prof. M. Schou, who had done extensive work on the use of Lithium. In 1981, I was awarded Dr. B. C. Roy National Award for development of Psychiatry in India, where I had established a new Institute of Psychiatry and Human Behaviour in Panaji.

In early Eighties, when I was Director at Central Institute of Psychiatry, I was part of a collaborative research work on new molecules developed by Central Drug Research Institute (CDRI) Lucknow, Centbutindone, an antipsychotic drug and a new antidepressant “Centpropazine,” in Phase I and Phase II clinical trials. Later, my focus shifted to Ethical and Human Rights issues related to Psychiatric patients [13],[14] when I served first as a member and later as Chairperson of WPA Committee on “Abuse of Psychiatry.” My insight and knowledge in the field of Psychopharmacology were of great help in resolving many ticklish issues. This also gave me good opportunity of working with Prof. Pierre Pichot (President) and Prof. Peter Berner (Secretary General who were then leading World Psychiatric Association as President and Secretary General respectively and also with Prof. Stefanis, who later became President of the W. P. A., from Greece, Dr. Lars Jacobson from Sweden, Prof. Leo Ettinger from Norway, Prof. M. Y. Gosselin from Canada, Prof. Harold Visotsy from USA, and Prof. Lars Jacobson from Sweden when I was the chairperson of the WPA Committee on the Abuse of Psychiatry'.

In 1984, I was elected as President Elect of the IPS, and in 1985, gave my Presidential talk on “Poverty, Health and Quality of Life” linking Mental Health with economics and poverty. I believe principles of Mental Health can play important role in poverty reduction and social upliftment of people. In 1985, as a President of IPS I had organized the Second WPA Symposium in Jaipur.

By 80's and 90's, it was becoming more clear that many of the controlled studies do not always answer various variations that are actually seen in clinical practice in different cultures. I became more interested in rational use of drugs and also to address the problem of selecting a right neuroleptic or antidepressive drug for a right patient from a large number of such drugs available in the country. It is now becoming an important issue to select a suitable drug. In India, like other developing countries we were equally concerned about the rising cost of drugs. This is a problem, being faced by patients from low-income countries, whereas considering various other pharmacological considerations; their social relevance and cultural background cannot be ignored. From long clinical experience, one is also convinced that the course of disease like Schizophrenia is not uniform and also patients change remarkably in their clinical status and in different cultures in the same countries. These questions are relevant and significant for every clinician, and need to be addressed while considering other emerging social issues such as cost-effectiveness and the role of social environment in the present age of globalization, especially when mental health continues to be a neglected entity in most of the developing countries. Easy availability of effective and safe drugs to the mentally ill, at an affordable cost is a very important issue in most of the countries. I share the belief of many, that with continuing research in the field of psychopharmacology and neuroscience and human genome, it is only a matter of time that we will have more effective and specific drugs, using genetic engineering but the rising cost will deprive the benefit of science to many poor patients who cannot afford the same in the present day ideology of market economics. We have to address this significant ethical, social and economic issue.

After spending 5 years as a Director, Central Institute of Psychiatry from 1981 to 1986, I was transferred to Safdarjung Hospital as its Medical Superintendent. I was the first nonsurgeon to head this largest General Hospital in Delhi. This was good for the image of Psychiatry. From 1988 to 1993, I worked first as Dy. Director General and later as Additional Director General of Health Services. Besides other noncommunicable diseases, I was looking after Mental Health and Medical Education. It was during this period a separate fund was allotted to the National Mental Health Programme. In between 1990 and 1991 I was temporarily posted as a Director of P. G. I. Chandigarh.

After my retirement in 1993, I was requested by the Government to establish a new Institute of Human Behaviour and Allied Sciences (IHBAS) as an autonomous body in my capacity as its Founder Director. It was a challenging assignment but very satisfying.

Later, I was requested to setup a new Institute of Psychiatry at Tejpur. A draft project was prepared, various departments were created and a final plan for the building was approved.

After my retirement, I was appointed as a Lifetime Emeritus Professor of Psychiatry in IHBAS and in 1997 as an Emeritus Professor of Psychiatry of National Academy of Medical Sciences.

In 1996, I was also elected as President-Elect of the World Association of Psychiatry and President of the WASP from 2001 to 2004. During 2005–2011, I was also elected as member of the Board of World Federation of Mental Health and later it's Vice President – Development. All these activities kept me busy academically and professionally.

I believe the last few decades of the last century will be remembered by the availability of new and wide spectrum of drugs, open market policy in the health sector, greater concern about ethical issues and human rights, including concern on stigma of mental illness and the rising cost of drugs. Finally, I have been personally privileged to participate and witness many momentary decisions regarding various programs and policies in India both in the profession and government in partnership with many great names, friends, and colleagues in the advancement of psychiatry in India and also at global level.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Sargant W, Slater E. Introduction to physical methods in treatment in psychiatry. Edinburgh; Livingstone: 1944.  Back to cited text no. 1
    
2.
Vahia NS – 'Narcotherapy in pychoneurosis. Indian J Neurol Psychiatry 1952;152:120-8.  Back to cited text no. 2
    
3.
Jetley SK. The use of carbon dioxide therapy in neurosis. Indian J Psychiatry 1959;1: 61-3.  Back to cited text no. 3
  [Full text]  
4.
Sharma SD. The use of tolubtamide for hypoglycaemic subcome treatment. Indian J Psychiatry 1965; 8:131-7.   Back to cited text no. 4
    
5.
Sharma SD, Shah PB, Acharya PT. Urinary 17-hydroxycorticosteroids levels and urine electrolytes in depression. Dis Nerv Syst 1970;31:343-7.  Back to cited text no. 5
[PUBMED]    
6.
Sharma S, Sinari VP. Pink spot in the urine and CSF of Schizophrenics. Dis Nerv Syst 1971:32:831-4.  Back to cited text no. 6
    
7.
Perry TL, Hausen S, Macintyre L Failure to detect 3,4-dimethoxyphenylethylamine in the urine of schizophrenics. Nature 1964;202: 519-20.  Back to cited text no. 7
    
8.
Takaseda M, Kakimoto Y, Sano I, Kaneko Z. 3,4-dimethoxyphenylethylamine and other amines in the urine of schizophrenic patients. Nature 1963;199:203-4.   Back to cited text no. 8
    
9.
Sharma S, Gajwani AK, Sukerkar NV. Trifluperidol induced lactation. Canadian Psychiat Assoc J 1974;19:99-102.  Back to cited text no. 9
    
10.
Sharma SD. A Double Blind Clinical Evaluation of nomifensine a new dopaminergic antidepressant; Current Therapeutic Research 1980;27:157-63.  Back to cited text no. 10
    
11.
Sharma SD, Nandkumar VK. A comparison of a divided and a single dose of regime of dothiepin and its therapeutic effectiveness. Indian J Psychiatry 1977;19: 92-100.  Back to cited text no. 11
  [Full text]  
12.
Kline NS. Report of the Rockland Research Institute: Twenty years of Progress (1954-1974) 1974.  Back to cited text no. 12
    
13.
Sharma S. Human rights in psychiatric care: An asian perspective. Acta Psychiat Scand Suppl 2000;399: 97-101.  Back to cited text no. 13
[PUBMED]    
14.
Sharma S. Human rights of mental patients in India: a global perspective. Current opinion in Psychiatry 2003;16:547-51.  Back to cited text no. 14
    

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Correspondence Address:
Dr. Shridhar Sharma
Institute of Human Behaviour and Allied Sciences, D-127, Preet Vihar, New Delhi - 110 092
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/psychiatry.IndianJPsychiatry_430_17

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