| Abstract|| |
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.
Keywords: Attention, bipolar disorder, brain injury, cognition, compulsive disorder, depression, executive function, memory, mini-mental status examination, obsessive compulsive disorder, Electroconvulsive therapy (ECT), psychotherapeutics, schizophrenia, substance abuse
|How to cite this article:|
Dalal P K, Sivakumar T. Cognitive psychiatry in India. Indian J Psychiatry 2010;52, Suppl S3:128-35
| Introduction|| |
What is cognition?
Cognition is what enables humans to function in everyday life: Personal, social, and occupational. The ability to attend to things in a selective and focused way, to concentrate over a period of time, to learn new information and skills, to plan, determine strategies for actions and execute them, to comprehend language and use verbal skills for communication and self-expression, and to retain information and manipulate it to solve complex problems are examples of mental processes that are referred to as cognitive functions.
Cognitive deficits may result in the inability to:
Cognition and psychiatric disorders
- Pay attention
- Process information quickly
- Remember and recall information
- Respond to information quickly
- Think critically, plan, organize and solve problems
- Initiate speech
Cognitive abilities have been shown to be impaired in patients with psychiatric disorders [Table 1]. 
Cognitive deficits contribute to poor functional outcome and therefore have been suggested as treatment targets in schizophrenia and possibly in other psychiatric disorders as well. They have also been shown to be possible endophenotypes.
| Methodology|| |
For this review, a web-based review of current and past issues of Indian journal of psychiatry was carried out with keywords cognition, cognitive, memory, attention, concentration, executive, neuropsychological, learning, amnesia etc. Publications in other journals were accessed 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. 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  and offsprings  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.  Although most Indian studies have been cross sectional studies, long term follow-up  studies have also been done by researchers. Recent studies have shown correlation between cognitive deficits and work functioning, rehabilitation. ,
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  and NIMHANS neuropsychological battery  to assess cognition have been developed and have been widely used in later studies. Indian norms of western tests have also been derived recently. , 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 clinical trials of molecules targeting cognition.
Early research work studied effect of ECT ,, and Lithium  on cognition. Recently, there have been human studies on the effect of herbal formulations , and piribedil  in patients of mild cognitive impairment. Notable work has been done on the effect of various drugs in ECS related amnestic deficits ,,,, 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.
Research relating cognition to other biological research (like neuroimaging) to map neuroanatomical correlates has just begun.  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. 
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. ,,,, There have been editorials on the subject in Indian Journal of Psychiatry.  Marfatia award  and DLN Murthy Rao orations , 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
NIMHANS neuropsychological battery has recently been validated for children. 
- NIMHANS neuropsychological battery:  Composed of tests taken from other standardized battery of tests, such as the Luria-Nebraska Neuropsychological battery.
- PGI battery of memory dysfunction:  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.
- Hindi cognitive test battery of "The Indo-US cross national dementia epidemiology study": , 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.
Hindi MMSE  was developed as part of the Indo-US cross-national dementia epidemiology study but has been shown to be different from MMSE. 
Normative data for Wisconsin card sorting test (WCST) for the Indian population was reported recently.  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. 
Indigenous methods ,, 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 [Table 4] and [Table 5]. Khanna et al. (1991)  described findings on Luria Nebraska neuropsychological battery in a 12-year-old 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.
|Table 5: Studies comparing cognition in schizophrenia and bipolar disorder|
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| 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 [Table 8]. Sharma et al. (1981) first reported the clinical usefulness of Luria Neuropsychological Investigation (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.  There has been case reports that cognitive rehabilation improves cognition and functional ability in patients with reversible and progressive brain injury.
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 [Table 9], [Table 10], [Table 11] and [Table 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. 
In separate experiments, Andrade showed that Verapamil, Felodipine, sodium nitroprusside  , phenylephrine,  mifepristone, indomethacin  and celecoxib attenuated ECT induced retrograde amnesia.  The theoretical explanations and possible implications have been discussed by Andrade in his DLN Murthy Rao oration. 
| 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. 
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.
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. We require an earnest endeavor on the part of mental health professionals and greater support from Government agencies, International organizations, pharmaceutical companies and private foundations for further progress in this exciting field.
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Department of Psychiatry, All India Institute of Medical Sciences, New Delhi
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12]