Indian Journal of PsychiatryIndian Journal of Psychiatry
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   Table of Contents - Current issue
January-March 2017
Volume 59 | Issue 1
Page Nos. 1-131

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Dementia and the International Classification of Diseases-11 (Beta Version) p. 1
TS Sathyanarayana Rao, KS Jacob, KS Shaji, M. S. V. K Raju, Ajit V Bhide, G Prasad Rao, Gautam Saha, Mukesh Jagiwala
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Prevention of farmer suicides: Greater need for state role than for a mental health professional's role p. 3
TS Sathyanarayana Rao, Mahesh R Gowda, Kanchana Ramachandran, Chittaranjan Andrade
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Challenges in the scale-up of opioid substitution treatment in India Highly accessed article p. 6
Atul Ambekar, Pratima Murthy, Debasish Basu, G Prasad Rao, Ashwin Mohan
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Metamorphosis: A reason why many chronic schizophrenics get abandoned by their dear ones p. 10
James T Antony
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Sexual boundaries in the doctor–patient relationship: Guidelines for doctors p. 14
Sunita Simon Kurpad, Ajit Bhide
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The Rights of Persons with Disabilities Act, 2016: Does it address the needs of the persons with mental illness and their families p. 17
Choudhary Laxmi Narayan, Thomas John
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National mental health survey of India 2015–2016 p. 21
R Srinivasa Murthy
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How do psychiatrists in India construct their professional identity? A critical literature review p. 27
Clement Bayetti, Sushrut Jadhav, Smita N Deshpande
Psychiatric practice in India is marked by an increasing gulf between largely urban-based mental health professionals and a majority rural population. Based on the premise that any engagement is a mutually constructed humane process, an understanding of the culture of psychiatry including social process of local knowledge acquisition by trainee psychiatrists is critical. This paper reviews existing literature on training of psychiatrists in India, the cultural construction of their professional identities and autobiographical reflections. The results reveal a scarcity of research on how identities, knowledge, and values are constructed, contested, resisted, sustained, and operationalized through practice. This paper hypothesizes that psychiatric training and practice in India continues to operate chiefly in an instrumental fashion and bears a circular relationship between cultural, hierarchical training structures and patient–carer concerns. The absence of interpretative social science training generates a professional identity that predominantly focuses on the patient and his/her social world as the site of pathology. Infrequent and often superfluous critical cultural reflexivity gained through routine clinical practice further alienates professionals from patients, caregivers, and their own social landscapes. This results in a peculiar brand of theory and practice that is skewed toward a narrow understanding of what constitutes suffering. The authors argue that such omissions could be addressed through nuanced ethnographies on the professional development of psychiatrists during postgraduate training, including the political economies of their social institutions and local cultural landscapes. Further research will also help enhance culturally sensitive epistemology and shape locally responsive mental health training programs. This is critical for majority rural Indians who place their trust in State biomedical care.
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The journey of opioid substitution therapy in India: Achievements and challenges p. 39
Ravindra Rao
Opioids are one of the most problematic illegal substances globally. Opioid abuse is associated with complications in various spheres of the user's life, his/her family, and the society. Injecting drug use (IDU) is also linked to public health problems such as HIV infection and viral hepatitis. Medications form an important cornerstone in the treatment of opioid dependence. Treatment strategies such as “detoxification” alone or long-term treatment with opioid antagonist have limited acceptability and retention rates. Opioid substitution therapy (OST) has demonstrated better retention rates than other existing treatment strategies and helps improve the individual's functioning as well as his/her quality of life. The use of OST in India spans three decades, with initial use of low-dose buprenorphine followed by higher strength buprenorphine and buprenorphine-naloxone. Other medications such as slow-release oral morphine, and recently, methadone have also been introduced. Indian research also confirms the findings from Western literature on the effectiveness as well as acceptability of this treatment modality. OST received its biggest thrust when it became a part of the National AIDS Control Programme. In recent years, the number of OST centers in India has increased manifold. Practice guidelines, standard operating procedures, and capacity-building mechanisms have been put in place for effective OST implementation. Despite such widespread use, many challenges exist for OST implementation. The targets for ensuring adequate coverage of the population with this treatment are still far away. There is concern of OST being branded as a “harm reduction” intervention reserved only for injecting drug users. Despite three decades of advancements, certain sections of policymakers and practitioners still have reservations with this treatment modality. There is a need to overcome these barriers for OST to become easily accessible to those who need it.
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Twelve-month prevalence and treatment gap for common mental disorders: Findings from a large-scale epidemiological survey in India p. 46
Rajesh Sagar, Raman Deep Pattanayak, R Chandrasekaran, Pranit K Chaudhury, Balbir S Deswal, RK Lenin Singh, Savita Malhotra, S Haque Nizamie, Bharat N Panchal, TP Sudhakar, JK Trivedi, Mathew Varghese, Jagdish Prasad, Somnath Chatterji
Background: Common mental disorders, such as mood, anxiety, and substance use disorders, are significant contributors to disability globally, including India. Available research is, however, limited by methodological issues and heterogeneities. Aim: The present paper focuses on the 12-month prevalence and 12-month treatment for anxiety, mood, and substance use disorders in India. Materials and Methods: As part of the World Health Organization World Mental Health (WMH) Survey Initiative, in India, the study was conducted at eleven sites. However, the current study focuses on the household sample of 24,371 adults (≥18 years) of eight districts of different states, covering rural and urban areas. Respondents were interviewed face-to-face using the WMH Composite International Diagnostic Interview after translation and country-specific adaptations. Diagnoses were generated as per the International Classification of Diseases, 10th edition, Diagnostic Criteria for Research. Results: Nearly 49.3% of the sample included males. The 12-month prevalence of common mental disorders was 5.52% - anxiety disorders (3.41%), mood disorders (1.44%), and substance use disorders (1.18%). Females had a relatively higher prevalence of anxiety and mood disorders, and lower prevalence of substance use disorders than males. The 12-month treatment for people with common mental disorders was 5.09% (range 1.66%–11.55% for individual disorders). The survey revealed a huge treatment gap of 95%, with only 5 out of 100 individuals with common mental disorders receiving any treatment over the past year. Conclusion: The survey provides valuable data to understand the mental health needs and treatment gaps in the Indian population. Despite the 12-month prevalence study being restricted to selected mental disorders, these estimates are likely to be conservative due to under-reporting or inadequate detection due to cultural factors.
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Prevalence and correlates of obsessive-compulsive disorder and subthreshold obsessive-compulsive disorder among college students in Kerala, India p. 56
TS Jaisoorya, YC Janardhan Reddy, B Sivasankaran Nair, Anjana Rani, Priya G Menon, M Revamma, CR Jeevan, KS Radhakrishnan, Vineetha Jose, K Thennarasu
Context: There are scarce data on the prevalence of adult obsessive-compulsive disorder (OCD) in India. Aims: The aim was to study the point prevalence of OCD and subthreshold OCD and its psychosocial correlates among college students in the district of Ernakulam, Kerala, India. Settings and Design: A cross-sectional survey of 5784 students of the age range of 18–25 years from 58 colleges was conducted. Materials and Methods: Students were self-administered the OCD subsection of the Clinical Interview Schedule-Revised, the Composite International Diagnostic Interview for obsessive-compulsive symptoms (OCSs), and other relevant instruments to identify OCD, subthreshold OCD, and related clinical measures. Statistical Analysis: The point prevalence of OCD and subthreshold OCD was determined. Categorical variables were compared using Chi-square/Fisher's exact tests as necessary. Differences between means were compared using the ANOVA. Results: The point prevalence of OCD was 3.3% (males = 3.5%; females = 3.2%). 8.5% students (males = 9.9%; females = 7.7%) fulfilled criteria of subthreshold OCD. Taboo thoughts (67.1%) and mental rituals (57.4%) were the most common symptoms in OCD subjects. Compared to those without obsessive-compulsive symptoms (OCSs), those with OCD and subthreshold OCD were more likely to have lifetime tobacco and alcohol use, psychological distress, suicidality, sexual abuse, and higher attention-deficit/hyperactivity disorder symptom scores. Subjects with subthreshold OCD were comparable to those with OCD except that OCD subjects had higher psychological distress scores and academic failures. Conclusions: OCD and subthreshold OCD are not uncommon in the community, both being associated with significant comorbidity. Hence, it is imperative that both are identified and treated in the community because of associated morbidity.
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Study of sexual functioning and disorder in women before and after tubal sterilization (tubectomy) p. 63
Shweta Patil Kunkeri, TS Sathyanarayana Rao, Chittaranjan Andrade
Introduction: Sexual relationship is a basis for mental health and continuity of the healthy generation. There are very few studies on the female sexual functioning, especially in India. Sterilization being the most common contraceptive method, sexual functioning in women undergoing this surgical intervention has not been adequately explored. Available studies have found conflicting results; some have reported that sterilization has positive effects on sexual functioning since anxiety of getting pregnant is abolished. However, few Indian studies have reported a decline in sexual functioning following the sterilization procedure as women lack interest and perceive sexual function only for the purpose of procreation. The cultural differences and lack of sex education among Indian women are thought to be the reason for such a difference. Materials and Methods: A total of sixty married women above 18 years, who were consulting Family Planning Association, Mysore, for the purpose of undergoing tubal sterilization, and who gave a written consent were interviewed twice; before the sterilization procedure and 6 months post-sterilization. These women were assessed for sexual functioning using female sexual function index and sexual functioning index. Results: The prevalence of sexual dysfunction in the study population was 36.7% before the tubal sterilization. This rate increased to 71.7% after the procedure which was statistically significant. The common disorders were orgasm, arousal, and desire. Pain disorder was least common. This dysfunction exists across all the ages, education level, occupation, and residence. Conclusion: The study shows that whatever may be the attribution, tubal sterilization impairs the sexual functioning among women. A proper education and counseling need to be incorporated to prevent the problems.
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Treatment compliance and noncompliance in psychoses p. 69
K Nagaraja Rao, Jitty George, CY Sudarshan, Shamshad Begum
Background: Compliance or noncompliance with treatment significantly influences course and outcome of psychiatric disorders. While noncompliance has been extensively researched, compliance has received less attention. The current study was conducted to elicit reasons for compliance and noncompliance in patients having psychoses attending psychiatric clinics. Materials and Methods: A total of 196 compliant and 150 noncompliant patients were interviewed using self-designed tools to elicit sociodemographic data, details of illness, and treatment. Factors contributing to compliance and noncompliance were grouped under illness-related, clinician-related, medication-related, family-related, and economic-related domains and compared. Results: Compliance was significantly more in females and middle- and high-socioeconomic status patients. They had less substance use, high physical comorbidity, high attendance in the outpatient department, and better remission. Clinician-related, family-related, and medication-related domains were contributing more to compliance whereas illness-related and economic-related domains seemed to have more bearing on noncompliance. Conclusions: Compliance and noncompliance are determined multidimensionally. Domains related to clinician, family, and medications have to be reinforced to enhance compliance. Illness-related and economic domains have to be resolved to reduce noncompliance.
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Rape: Is it a lifestyle or behavioral problem? p. 77
Zeel N Kamdar, Jayendrakumar K Kosambiya, Bansari L Chawada, Mamtarani Verma, Abhinav Kadia
Introduction: In India, girl is raped every 20 min. The majority of reports reveals youth is vulnerable group for rape victimization. A set of prejudicial, stereotyped, or false beliefs about rape, rape victims, and rapist exist in the community. Aims/Objectives: To study the attitude and myths toward rape among college going students of Surat City. Materials and Methods: College students of various streams were participated in the study based on attitude toward rape scale (21 items) and updated Illinois Rape Myth Acceptance Scale (22 items). A total of 332 participants from three different colleges of the city took part in the survey. Data analysis was done with the SPSS version 19. Results: Among the responders, 61.75% were female. Mean age of participants was 20.22 ± 1.27 years. Almost two-third (73%) of female participants and 42% of the male participants disagreed with the myth that “When a woman says 'no' she really means 'yes'.” Around 30% of the participants were uncertain about the myth that “A woman cannot be raped by someone she previously knew or had sex with.” While almost 35% of participants believed that “Most rapes are carried out by strangers.” Strong sexual desire of guys, drunkenness, and girl's clothes were reported to be factors that provoke rape by 50%, 40%, and 33% of respondents, respectively, around 95% of female and 92% of male participants think that 7-year imprisonment for rape is not enough. Conclusions: Rape myths are found to be highly prevalent among youth and higher among males.
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Long noncoding RNAs: New evidence for overlapped pathogenesis between major depressive disorder and generalized anxiety disorder p. 83
Xuelian Cui, Wei Niu, Lingming Kong, Mingjun He, Kunhong Jiang, Shengdong Chen, Aifang Zhong, Wanshuai Li, Jim Lu, Liyi Zhang
Background: About half of patients with major depressive disorder (MDD) have clinically meaningful levels of anxiety. Greater severity of depressive illness and functional impairment has been reported in patients with high levels of anxiety accompanying depression. The pathogenesis for the comorbidity was still unsure. Aim: This study aimed to determine whether there would be molecular link for overlapped pathogenesis between MDD and anxiety disorder. Materials and Methods: Using long noncoding RNA (lncRNA) microarray profiling and reverse transcription polymerase chain reaction, six downregulated lncRNAs and three upregulated lncRNAs had been identified to be the potential biomarkers for MDD and generalized anxiety disorder (GAD), respectively. Then, the lncRNAs were cross-checked in forty MDD patients, forty GAD patients, and forty normal controls. Results: Compared with normal controls, six downregulated MDD lncRNAs also had a significantly lower expression in GAD (P < 0.01), and there was no significant difference between GAD and MDD (P > 0.05). In addition, three upregulated GAD lncRNAs had no different expression in MDD (P > 0.05), but there was remarkable difference between MDD and GAD (P < 0.01). Conclusions: These results indicated that lncRNAs in peripheral blood mononuclear cells could be potential molecular link between MDD and GAD, which added new evidence to the overlapped pathogenesis and suggested that anxious depression could be a valid diagnostic subtype of MDD.
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Wisconsin Card Sorting Test performance impairment in schizophrenia: An Indian study report p. 88
Shailja Singh, Tapas Kumar Aich, Raju Bhattarai
Aim: The present study attempted to find out the relationship between positive and negative clinical symptoms and Wisconsin Card Sorting Test (WCST) performance in a group of schizophrenia patients. Methodology: Fifty schizophrenia patients were assessed using the Positive and Negative Syndrome Scale (PANSS) by a trained psychiatrist (TKA) and two groups, each of 25 positive symptom and 25 negative symptom schizophrenia patients were formed. On these fifty patients with schizophrenia and 15 normal control groups, WCST measures were applied by a clinical psychologist (SS) who remained blind to the PANSS score. Results: Schizophrenia diagnosis significantly affects WCST performances. One-way analysis of variance (ANOVA) revealed schizophrenia patients showed a significant impairment on all WCST indices compared with normal subjects except versus total number of correct responses. Post hoc comparison (Tukey HSD Test) between means revealed that negative schizophrenia patients showed significantly worse performance on most WCST performance parameters: percent errors, perseverative responses, percent perseverative responses, perseverative errors, percent perseverative errors, and conceptual level responses. Conclusions: Both positive and negative symptom schizophrenia patients have some distinct WCST measures deficits.
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Serum NUCB2/nesfatin-1 levels in different stages of alcohol dependence: Is there a relationship with craving? p. 94
Gokhan Umut, Cuneyt Evren, Alparslan Cansiz, Mustafa Akkus, Nesrin Karamustafalioglu
Introduction: In the literature, the relationship between appetite regulating peptides and alcohol craving is on the debate. Aim: This study aims to investigate serum level of NUCB2/nesfatin-1, which is discovered as appetite-related neuropeptide, in patients with alcohol dependence who were in craving and abstaining phase and to compare with healthy controls. Settings and Design: Research, Treatment, and Training Center for Alcohol and Substance Dependence, (AMATEM) Bakirkoy Training and Research Hospital for Psychiatry Neurology and Neurosurgery, Istanbul, case–control and prospective study design were used. Statistical Analysis: Chi-square, Mann–Whitney U, paired samples, independent samples t- and Pearson correlation tests were used for analysis. Materials and Methods: Forty-three patients with alcohol dependence who have been admitted for detoxification and thirty healthy controls were included in the study. The blood samples were drawn after the 1st day of admission and postdetoxification treatment in inpatients who reached to abstinence period and from 30 healthy controls. The Penn Alcohol Craving Scale and the Obsessive Compulsive Drinking Scale were applied to detect craving scores. Results: Initial serum NUCB2/nesfatin-1 levels in patients were significantly lower than in the healthy control group (P < 0.001). The NUCB2/nesfatin-1 level of initial phase was significantly lower than abstinence phase (P = 0.027). No correlation was found between craving scores and NUCB2/nesfatin-1 level (P > 0.05). Conclusion: This study is the first that showed significant differences of serum NUCB2/nesfatin-1 level according to different stages of alcohol dependence. Plasma NUCB2/nesfatin-1 levels were lower in highest craving phase and tended to normalize after abstinence. Since we could not find a correlation between craving and NUCB2/nesfatin-1 levels, the increase of NUCB2/nesfatin-1 in abstinence phase might have been resulted from other reasons apart from craving.
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What they think of us: A study of teaching medical specialists' attitude towards psychiatry in India p. 100
Suravi Patra, Binod Kumar Patro
Context: Attitudes of teaching medical specialists are important in shaping medical students' attitudes toward psychiatry. Data on attitudes of teaching medical specialists of India toward psychiatry are limited. Aims: The aim was to study the attitude of teaching medical specialists of an academic medical center in East India toward psychiatry. Settings and Design: This was a cross-sectional descriptive study. Materials and Methods: We administered attitude toward psychiatry-30 (ATP 30) scale to teaching medical specialists of the All India Institute of Medical Sciences, Bhubaneswar, based on convenience sampling. Of 104 specialists contacted, 88 returned the completed questionnaire. Statistical Analysis: We carried out descriptive statistical analysis and expressed results in mean and standard deviation. We analyzed the association of demographic characteristics, specialization, and duration of professional experience with total ATP scores using Chi-square test. We used subgroup analysis to compare mean ATP scores in different demographic and professional groups. We used independent t-test and ANOVA for between group comparisons. Results: The response rate was 84.62% with a mean ATP score of 88.60. Female gender and having a family member with mental illness was significantly associated with favorable ATP. Notable findings were that 97% of participants were favorable toward patients with psychiatric illness, 90% felt psychiatric interventions as effective whereas 87% found psychiatry unappealing and 52% said that they would not have liked to be a psychiatrist. Conclusions: While favorable attitudes toward patients with psychiatric illness and psychiatric interventions may mean better patient care; unfavorable attitudes toward psychiatry as a career choice may adversely affect postgraduate recruitment rates.
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Concurrent validity of Indian disability evaluation and assessment scale with sociooccupational functioning scale in patients with schizophrenia p. 106
Swapnajeet Sahoo, Sandeep Grover, Devakshi Dua, Subho Chakrabarti, Ajit Avasthi
Background: The Government of India (GOI) has recommended the use of Indian Disability Evaluation and Assessment Scale (IDEAS) for the assessment and certification of disability in patients with mental illness. Although data are available in terms of internal consistency and construct validity of IDEAS, concurrent validity of IDEAS has rarely been evaluated. Aim: The aim was to study the concurrent validity of IDEAS with Global Assessment of Functioning (GAF) and Social and Occupational Functioning Scale (SOFS) in patients with schizophrenia. Materials and Methods: One hundred and seventy-eight consenting patients with schizophrenia in remission were assessed for disability, functioning, and psychopathology using the IDEAS, SOFS, GAF, and Positive and Negative symptom scale (PANSS) respectively. Results: Mean total PANSS score was 51.3 (standard deviation SD −11.19). Disability (>40%) was present in 84.8% of the sample. All the component scores of IDEAS (self-care, interpersonal activities, communication, and work), total IDEAS score, and Global IDEAS score correlated significantly (P < 0.001) with the three domains of SOFS (adaptive life skills, social appropriateness and communication, and interpersonal relationships) along with the total SOFS score. GAF total score had significant negative correlation (P < 0.001) with all the components of IDEAS, total IDEAS score and global IDEAS score. Higher residual psychopathology was also associated with overall higher disability as assessed by total IDEAS score and Global IDEAS score. Conclusions: This study shows that the GOI-modified IDEAS had good concurrent validity with global and sociooccupational functioning as assessed by GAF and SOFS respectively.
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Prevention, early intervention, and harm reduction of substance use in adolescents p. 111
RC Jiloha
This paper presents a systematic review on the effectiveness of prevention, early intervention, and harm reduction including treatment of substance abuse among adolescents for tobacco, alcohol and illicit drugs. Taxation, public consumption bans, restriction on advertisements, and minimum legal age for consumption, are effective measures to reduce the use of tobacco and alcohol. School-based prevention and skill-training interventions are effective tools to reduce substance use among adolescents. Social norms and intervention to reduce substance use in adolescents do not have strong evidence of effectiveness. Road-side testing and reduction of injection related harm are effective. However, further research is needed to support it. Moreover, the available research evidence comes from the Western countries with questionable applicability in Indian setting. Research is needed to increase the evidence base on interventions that aim to reduce the high burden of substance use in adolescents in India.
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Siva - The mad lord: A Puranic perspective p. 119
Ottilingam Somasundaram, Tejus Murthy
The eccentricities of Lord Shiva, especially His attire, behavior - particularly the midnight dance at the cremation grounds surrounded by various strange beings, fondness to remain naked, and love for strange pets such as snakes and fawn, have attracted the loving and devout attention from His various adiyargal (devotees). This has resulted in the outpouring of their love for their Lord in the form of Thevaram and Thiruvachakam of Sambandar, Appar, Sundarar, Karaikal Ammaiyar, and Manickavachakar. Along with these writings, the background Puranic myths are mentioned. It is suggested that these ideas could be utilized to destigmatize mental illness among the sufferers and their carers.
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Interpersonal relationships: Building blocks of a society p. 123
Lakshmi Sravanti
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”IDEAS” and the IPS p. 124
KA Kumar
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Unmodified electroconvulsive therapy: Concerns about reporting in a retrospective study p. 125
Chittaranjan Andrade, Samir Kumar Praharaj, Nachiketa Desai, Devavrat Harshe, Sagar Karia
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Leaf it or not: A case of khat dependence from India p. 126
Sriniwas Gupta, Era S Dutta, M. S. V. K Raju, Abhishek Kumar
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Methodological challenges in understanding sexuality in Indian women p. 127
Michelle S Barthakur, Mahendra P Sharma, Santosh K Chaturvedi, Suraj K Manjunath
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Depression in mothers of the mentally retarded patients: Need to look deeper! p. 129
Sagar Chandra Bera
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Delusion of pregnancy in a 70-year-old male p. 130
Bhagyashree H Gaikwad, Amit R Dharmadhikari, Alka A Subramanyam, Jahnavi S Kedare, Ravindra M Kamath
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Hypnosis p. 131
Ajit V Bhide
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