| Abstract|| |
The Indian Diaspora, especially in North America, is a visible force in the field of psychiatric medicine. An estimated 5000 persons of Indian origin practice psychiatry in the USA and Canada, and an estimated 10% of these are in academic psychiatry. Wide ranging contributions, from molecular biology of psychiatric disorders to community and cultural psychiatry, are being made by this vibrant group of researchers. This article is a brief summary and work-in-progress report of the contributions by Indian - American psychiatric researchers. Although not exhaustive in coverage, it is meant to give the reader an overview of the contributions made by three waves of researchers over a span of 50 years.
Keywords: Indian - American, Indian Diaspora, Indian - American Psychiatric Research
|How to cite this article:|
Pandurangi AK. Indian - American contributions to psychiatric research. Indian J Psychiatry 2010;52, Suppl S3:47-55
| Introduction|| |
The Indian diaspora that has migrated to North America over the last 50 years, from 1960 until now, has established itself as a formidable intellectual force in Science, Engineering, Technology, Medicine, Education, Literature, and other fields.  Psychiatric Medicine has benefited from sustained and outstanding contributions of many academicians of Indian origin during this time. In this brief review, we present the contributions of this body of researchers, and make the first known attempt at tabulating Indo-American psychiatric researchers. In developing the data base for this article, several methods of data gathering were used, including searching through (1) Web pages and faculty rosters of major Departments of Psychiatry published on the web, (2) Google Scholar, (3) Forum  - a publication of the Indo-American Psychiatric Association, and (4) a brief survey of 25 known Indian psychiatric academicians, as well as the personal knowledge and observations of the author. We describe the researchers and their contributions in three chronological waves over the 50-year period.
First wave (1960-1975)
The first wave of immigrants who pursued academic psychiatry arrived in the 1960s, to settle in the largest cities of Canada and the USA. This was the period when biological psychiatry and psychopharmacology were developing. Psychoanalytic psychiatry was on the wane and University Departments were transforming. Deinstitutionalization was in progress, community and social psychiatry were on the ascent, and biopsychosocial models of psychiatric disorders were being formulated. Foremost among this first wave of researchers was the Montreal group, which worked out of Douglas Hospital and Allan Memorial Institute of the Department of Psychiatry at McGill University. Jambur Ananth who had trained at the All India Institute of Mental Health, in Bangalore, (now called the National Institute of Mental Health and Neurosciences or NIMHANS) began his research career here in 1968. His collaborators included eminent researchers such as Samarthji Lal and NP Vasavan Nair. After a 13-year productive research career, Ananth moved to the University of California, Los Angeles in 1981. Ananth was a prodigious researcher and published over 400-articles, several books, and many book chapters. There are several themes to Ananth's research, including, but not limited to, the biology and psychopharmacology of Schizophrenia and Depression. It would not be an exaggeration to say that until the year 2005, Ananth tested and helped develop virtually all psychopharmaceutical agents of the previous three decades. Noteworthy among his contributions are the role of nicotinic acid in psychoses, studies of the first and second generation antipsychotics, and antidepressants, and treatments for tardive dyskinesia. He edited the first text book on psychopharmacology authored predominantly by Indians.  Dr. N P Vasavan Nair and Dr. Samarthji Lal Ph. D, collaborators of Ananth, made significant independent contributions. Lal contributed heavily to our understanding of the role of monoamines in schizophrenia and depression, including the use of apomorphine in studying doapminergic function, and GABAergic regulation of dopaminergic neurons. He established a brain bank in Montreal. Vasavan Nair has conducted a career-long research into psychoneuroendocrinology, especially the relation between neurotransmitters, neuropeptides, and neurohormones, in the context of the biology of psychiatric disorders. He has published extensively on circadian biology and neurohormones, and more recently on the biology of aging. He established the Montreal Center for Studies on Aging.
In Chicago, Illinois, USA, another group of Indian researchers had formed in the late 1960s. Dr. Nedathur Narasimhachari, an organic chemist and faculty in the Department of Psychiatry at the University of Illinois and Illinois State Psychiatric Institute, worked closely with psychiatrists Harold Himwich and later John Davis. Their studies on the role of serotonin and its toxic variants in psychosis, and the presence of phenylethylamine in the human brain, are an important part of the history of biological psychiatry. Another stalwart psychiatric researcher from this institution, also not a psychiatrist is Ghanshyam Pandey. He is a professor of pharmacology in psychiatry at the University of Illinois Chicago and the Psychiatry Institute under the umbrella of the Illinois State Psychiatric Institute. Dr Pandey is a versatile researcher in many aspects of neurotransmitter function and is best known for his ground breaking research on the role of serotonin receptors in suicide. This institute has served as the formative and sustaining ground for many second-wave Indian psychiatrists and scientists, including psychiatrists Prakash Desai (Cultural and Social Psychiatry - see a little later in the text), Nagamani Pavaluri (Pediatric mood disorder), and Rajiv Sharma (neurochemistry of psychosis, gene regulation in neurons) who are all currently on its staff. Another pioneer from the 'first wave' with a lasting contribution to neuropsychiatric disorders is Dr. Harbans Lal, who promoted the concept of neuroprotection well before it became a fashionable term. Lal, a pharmacologist, held various teaching and research positions at the University of Kansas, University of Chicago, and University of Rhode Island, and eventually settled as Chair of Pharmacology and Neurosciences at the Medical College of the University of North Texas Health Science Center. Dr Sachin Pradhan, also a pharmacologist has contributed to our understanding of the effects of psychomimetic drugs such as PCP and inhalants. He has had a long tenure at Howard University in Washington DC, and edited a text book of pharmacology. Separately, he also published a book on the contribution of Indians in USA.  Dr. Salman Akhtar, psychiatrist, psychoanalyst and a postgraduate alumnus of PGIMER, Chandigarh, Department of Psychiatry, began his US career in 1972, and is one of the earlier members of this first wave of researchers and occupies a unique position among Indo-American scholars, as the undisputed leader in psychoanalytic psychiatry (see a little later in the text).
Second Wave (1975-1990)
The second wave of researchers consist of those that began their research careers in USA or Canada between approximately 1985 and throughout the 1990s. By now, some of these academicians have nearly 30 years of contributions to their credit and occupy endowed chairs and leadership positions in academic psychiatry. Although no exact count exists, it is estimated that there are at least 50 such researchers forming a solid core of psychiatric academicians of Indian origin. Geographically, they have spread their wings across the span of USA and Canada, and are at leading academic centers of the two countries. This group has accumulated an impressive record of contributions from the bench to the remote corners of the community, and has deservedly acquired a reputation for intelligence, originality, diligence, collegiality, collaboration, and leadership, nationally and internationally. There are too many individuals in this cadre to mention all, and it is beyond the scope of this article to review their work individually. See [Table 1] for a selective listing of these individuals and their main areas (s) of work.
Dr. Rohan and Dr. Mary Ganguli, Dr. Dilip Jeste, Dr. Matcheri Keshavan, Dr. Shitij Kapur, Dr. Ranga R Krishnan, Dr. Madhukar Trivedi and Dr. Lakshmi Yatham epitomize the cream of this crop. Jeste developed his research career at the National Institute of Health (USA) before moving to the University California at San Diego. The first phase of his research focused on the biology and treatment of schizophrenia, and subsequently on the identification and treatment of tardive dyskinesia (TD). TD had become a major challenge in the treatment of schizophrenia and it was important to know through systematic studies, its prevalence, cause, and potential treatment. Dr. Jeste rose up to this challenge and provided researchers and practitioners reliable data on the prevalence of TD over the short and long term. In the second phase of his research career, which started at UCSD, Dr. Jeste shifted his attention to geriatric psychiatry, and quickly assumed the mantle of an undisputed research leader in this field. Especially noteworthy is his work on psychoses in the elderly. Jeste also took on various leadership roles including being President of the Association of Geriatric Psychiatry and an editor of its flagship journal. Dr. Ranga Rama Krishnan of the Duke University is a prolific biological researcher of international fame. His group at Duke has conducted numerous investigations on the biology of depression, and championed the concept of vascular depression in the elderly, based on their original findings of excessive hyperintensity lesions demonstrated by magnetic resonance imaging. They are also considered leaders in the development of technology for psychiatric brain imaging. Ranga Krishnan became the first chair of Indian origin in a major private university such as Duke, and has gone on to International leadership in medical education by leading the development of the Duke Graduate Medical School in Singapore under the aegis of the Duke University and the National University of Singapore. Both Dr. Jeste and Dr. Krishnan were inducted into the Institute of Medicine, an honor bestowed on very select academicians. This speaks for the high stature they hold in the medical academia. Matcheri Keshavan is an alumni of NIMHANS, Bangalore. Dr. Keshavan received advanced research training in Vienna and worked at the Maudsley in London. In USA, his career began at Wayne State University, although the majority of his work occurred during his tenure at the Western Psychiatric Institute and Clinic (WPIC) of the University of Pittsburgh. Of late, he was appointed as an endowed professor and one of the Vice Chairs at the Harvard University. Keshavan's contribution to the understanding of the first episode of psychoses, especially the integrity (or lack thereof) in the neuronal energy mechanisms, demonstrated by magnetic resonance spectroscopy is an excellent example of his incisive insights into the biology of psychosis. Another area of much clinical and biological research by Keshavan and his group has been in the neurodevelopmental origins of schizophrenia. The WPIC in Pittsburgh serves as the psychiatry department of the University of Pittsburgh. With prominent Indian academicians such as Rohan Ganguli, Mary Ganguli, and Keshavan generously offering their expertise and mentoring early career psychiatrists, it has been a nidus for many budding psychiatric researchers of Indian origin. Although often mentioned together, Rohan and Mary Ganguli have made very different and specialized contributions in their fields of expertise, respectively. Rohan Ganguli has conducted extensive studies in the immunology of schizophrenia, and in more recent years has concentrated his efforts on the metabolic burden in this disease, especially that associated with atypical antipsychotics. Mary Ganguli is a geriatric psychiatrist, best known for her work in the epidemiology and assessment of dementia, including a cross-national study between the Monongahela valley in Pennsylvania, USA, and Ballabgarh, Haryana, India. The nidus effect is also visible in many prominent universities where a researcher of Indian origin has excelled, attracting younger researchers to the department. Duke University is one such where Ranga Krishnan's presence and leadership has led to a nexus of both senior and mid-level Indian psychiatrists, such as, Prakash Masand (psychosomatic medicine, psychopharmacology), Meera Narsimhan (Psychiatry and Primary Care, Telepsychiatry - now moved to the University of South Carolina as Research Vice-Chair), Ashvin Patkar (Addiction Psychiatry), Murali Doraiswamy (Brain Imaging, Biology of Mood Disorders), and others have gone to establish niche areas of research and onto academic leadership roles in their own right. Two other examples are (1) University of Texas, South Western Medical Center (UTSW), where MadhuKar Trivedi leads an internationally acclaimed mood disorders institute. Trivedi's leadership role in the largest, publicly supported algorithmic treatment research program of depression, is well-recognized. This study (STAR-D) provides an excellent roadmap for treating depression for clinicians and researchers, alike. UTSW has 10 psychiatrists of Indian origin on its full-time faculty roster, with wide ranging academic specializations; (2) University of California at San Diego (UCSD) where Dilip Jeste has served as the magnet, with recent early-career psychiatric researchers Ipsit Vahia and Gowri Savla Nayak. These selective examples serve as powerful evidence of how brilliant individuals with research excellence transform programs and departments to the benefit of many. Institutions in India and elsewhere aspiring for their own excellence would be well advised to emulate this.
In reviewing the first wave of researchers,the work of Indo-Canadian investigators at McGill was mentioned. Within the second wave, the work of what might be termed the bipolar group is especially note worthy. Vivek Kusumakar at Dalhousie University, until he moved to Johnson and Johnson Company in the USA - he had an untimely death in 2009, and Lakshmi Yatham at University of British Columbia, Vancouver, both alumni of NIMHANS have lead major research in the treatment of bipolar disorders. They co-chaired the Canadian Network for Mood & Anxiety Treatments (CANMAT) and developed the bipolar treatment guidelines in Canada; Yatham is president of the International Society for Bipolar Disorders. The University of Western Ontario, University of British Columbia - Vancouver, University of Toronto and its affiliates have served as fertile grounds for the pursuit of academic careers by Indo-Canadian Psychiatrists (See [Table 1] for listing of individuals at these centres).
[Table 1] lists 100 psychiatry researchers of Indian origin in USA and Canada. By no means is this tabulation a comprehensive list and during the research for this article, this author was amazed at the number of early to mid-career psychiatrists of Indian origin who are contributing to various subspecialties of psychiatry through their research. Nor is there any rigorous methodology in the selection. It is simply the assessment of one individual, with all its biases and short comings, albeit with the benefit of 35 years of observation.
In addition to those discussed earlier, from among the second wave of researchers, the contributions of the following individuals have also enriched our knowledge of psychiatric disorders and their treatment. In alphabetical order, Roy Chengappa (psychopharmacology of serious mental illnesses), D. Devanand (electroconvulsive therapy, memory disorders in the elderly), Sanjay Dube (psychopharmacology), Choudhary Jampala (phenomenology and biology of schizophrenia), Geeta Jayaram (safety and quality improvement), Shitij Kapur (biology of schizophrenia, brain imaging, and receptorology, now at King's College and Institute of Psychiatry, London, UK), Arifulla Khan (psychopharmacology of depression, placebo effect), Vivek Kusumakar (mood and anxiety disorder treatment, child psychiatry), Ashok Malla (early psychosis), Anil Malhotra (genetics, pharmacogenomics), Rahul Manchanda (early psychoses, brain injury rehabilitation), Sukdeb Mukherjee (ECT, bipolar disorders), Viswajit Nimgaonkar (psychiatric genetics), Phillip Ninan (anxiety disorders, schizophrenia, Anand Pandurangi (structural and biological abnormalities in schizophrenia, psychopharmacology), Uma Rao (pediatric mood disorders and addictions), Rajiv Tandon (nosology of psychoses, psychopharmacology of psychosis), Gunwant Thaker (biology of schizophrenia), Lakshmi Yatham (bipolar disorder treatment), and Vikram Yeragani (anxiety disorders, heart rate variability).
Lest the reader get the impression that Indo-American psychiatric academicians have focused their careers only on biological psychiatry, it should be emphasized that many noteworthy contributions have been made in the psychological aspects as well [Table 2]. CV Ramana was an early psychoanalyst of Indian origin in the USA, and wrote an important article on the history of psychoanalysis in India. Dr. Salman Akhtar was among the first wave of researchers and was a leading psychoanalytic contributor from the USA. In fact, it would be no exaggeration to describe him as a world leader in this field. His studies on personality disorder, cultural aspects of the immigrant experience, and psychodynamics have earned him a marquee place in American psychodynamic psychiatry. Akhtar is a prodigious writer and multi-talented. He has published over 45 books on various aspects of psychodynamics. This brief article would not do any justice in documenting his productivity, and this author is not qualified to assess the significance of his extensive writings. [Table 3] is dedicated to a listing of his books. Mantosh Dewan and colleagues have published, on brief psychotherapies, and the difficult to treat patient. Dewan's study on the benefits of combined psychotherapy and medication management by the psychiatrist garnered national attention even as the profession of psychiatry (again) struggles with its identity. Prakash Desai at UIC has been a major contributor in the area of bioethics, especially from the perspective of its history in India.
There are three other important modalities of scholarly contributions made by psychiatrists of Indian origin in the USA and Canada. The first modality is through book writing or editing. Although sometimes a book is a culmination and summary of many years of an individual researcher's work, it may also be a compilation of the research of many authors in one place, and at other times it is a more user-friendly, narrative of one's experiences and observation of a subject in depth. [Table 2] and [Table 3] lists the books authored or edited by Indian-American psychiatrists, as another index of their scholarly contribution. The second modality is primarily a service but, has added significantly to our knowledge of the cultural dimension of adaptation, mental health, and psychiatric disorders. The third modality is educational in nature. The second modality in this instance pertains to narrating, understanding, and assisting with the Indian immigrant experience and its attendant challenges, unique mental health issues, and cultural adaptation. Jambur Ananth and his son Karthik Ananth co-authored a book on the immigrant experience from the psychological perspective. A group of psychiatrists in New York City have also called attention to the cultural dimension in the treatment of the Indian-American patient. Although not a comprehensive list, this group includes Manoj Shah, Satish Verma, Ramanathan Viswanathan, Nalini Juthani, Ashvin Pandya, Seeth Vivek, and others. They have championed the cause of the first and second generation Indian immigrant, especially those with limited resources, to obtain specialized treatment tailored to their cultural needs. Indeed it is the foresight of several members of this group that culminated in the formation of the Indo-American Psychiatric Association (IAPA) in 1979. Their studies have been presented at National conferences and symposia and printed in professional publications.
The third modality has focused on the other dimension of academic psychiatry, namely, psychiatric education and has attracted some of the brightest minds among Indian-American psychiatrists. Mantosh Dewan was one of the earliest to chair a University Department of Psychiatry at the State University of New York in Syracuse (now re-named Medical University of Syracuse), followed by Ranga Krishnan at Duke University. Since then, and especially in the last decade, many Indian-American academicians have been appointed to this coveted leadership position including Nutan-Atre-Vaidya, Anand Kumar, and Murali Rao, in Chicago. Many psychiatry residency directorships are (have been) occupied by Indo-Americans, including Chetan Haldipur, Bhaskar Dave, Nyapati Rao, Nalini Juthani, and others. Among the recipients of the Nancy Roeske Certificate for Teaching Excellence awarded by the American Psychiatric Association (APA), is a long list of psychiatrists of Indian origin. Nyapati Rao has especially played a strong role in the development of the residency curriculum, and the newer methods of examination for the American Boards. Geeta Jayaram distinguished herself by becoming the first (and so far only) Indo-American psychiatrist to have been the Scientific Program Director of the Annual APA meetings for four years, and Dilip Jeste and Prakash Desai are the only Indo-American psychiatrists to have won the national elections to important positions within organized psychiatry. These accomplishments although not traditional research are mentioned, as the reader will no doubt appreciate the impact of such accomplishments on the training opportunities, including research training, and on the academic recruitment, career development, and productivity of younger Indian psychiatrists migrating to America.
Significant scholarly contributions have also been made in specialties such as child and adolescent psychiatry by Shashi Elongovan (foster care), Vivek Kusumar (mood disorders, psychopharmacology), Uma Rao (pediatric mood disorders, addictions), Aradhana Sood (psychopharmacology, ADHD, campus violence), and others. Women's mental health has benefited from the dedication and research of several Indian psychiatrists including Shaila Misri at the University of Vancouver in Canada, Shamsa Sonawalla in Harvard, and Lilian Gonsalves at the Cleveland Clinic. Ashok Srinivasaraghavan (University of Illinois, Springfield) has been a leader in Law and Psychiatry. Asha Mishra (Virginia Commonwealth University, Richmond, Virginia - VCU) in Community Psychiatry, Ramakrishna Shenoy (VCU) and Jaisimha Rao (Ontario, Canada) in Developmental Disorders, and Chetan Haldipur (Upstate Medical University, NY) to the history of psychiatry, especially as it pertains to ancient India, to name only a few, have made unique contributions.
Third Wave (1991-Now)
In the twenty-first century, a new and much larger group of academicians of Indian origin is emerging to carry on the good work of their predecessors. Of the 5000+ psychiatrists of Indian origin in North America, it is estimated by this author that over 500 are now in academic psychiatry. A small sampling of names is included in [Table 1]. Not only is this group pursuing the traditional areas of scholarship and teaching, they are also blazing the trail in newer areas such as tele-psychiatry, web psychiatry, genomics, community service models, global psychiatry, computational psychiatry, neural networks, disaster psychiatry, and so on.
There can be no question that Indian American psychiatrists have woven strong threads in the fabric of American Psychiatry and that this experience has been a mutually advantageous relationship. Indian-American psychiatrists form a strong and integral part of American psychiatry, and it is hard to imagine the latter without the former. The growth of the IAPA and recognition of its formidable strengths is one indicator of this core role and strength.
Challenges and Opportunities
The challenges confronting psychiatrists in India wishing to migrate and pursue a research career are uphill requirements of the American licensure system, limited availability of mentors, lack of strong networking within the Indo-American academic community, extremely competitive nature of federal funding, and the occasional glass ceiling that one confronts in career advancement. From the perspective of contributions in India by the Indian-American psychiatric research community, we should add that the absence of clear and user-friendly mechanisms in India for academic collaborations, joint appointments, restrictions on overseas travel for Indian collaborators, restrictions on research with DNA and biological tissues, and limited research infrastructure in most Indian institutions, have all worked to limit such contributions. The potential is indeed unlimited, and the benefit to advancement of knowledge and the care of our patients is tremendous, if only we can effectively address these challenges, and harness the full potential of the proven current generation and the extremely talented next generation in both countries. The Indo-US and Global Health Care Summits and the recent Indo-Global Psychiatry Initiative are good examples of current efforts to do so. On balance though, the accomplishments have far outweighed the challenges. We may comfortably and confidently declare this natural experiment of immigration to the USA / Canada a colossal success for the psychiatrist, psychiatry, and most importantly our patients.
| References|| |
|1.||Pradhan SN. India in the United States: Contributions of India and Indians in the United States of America. Virginia: SP Press International, Inc; 1996. |
|2.||Indo-American Psychiatric Association 25th Anniversary Souvenir - Profiles in Excellence, IAPA, NY. Available from: http//www.myiapa.org/souvenir.pdf [last accessed on 2004]. |
|3.||Textbook of Psychopharmacology: Editor Jambur A, New Delhi, India: Jaypee Brothers Medical Publishers (P) Ltd; 1999. |
Anand K Pandurangi
Virginia Commonwealth University, P.O. Box 980710, Richmond, Virginia - 23298
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3]