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Byline: T. Sathyanarayana Rao, K. Shaji The proportion of older people in the world population is on the increase. For older people, mental health conditions are an important cause of morbidity and premature mortality. Among neuropsychiatric disorders, dementia and major depression are the two leading contributors, accounting respectively for one quarter and one sixth of all disability-adjusted life years (DALYs) in this group.[sup] [1] Special healthcare needs of the aged will have to be addressed by healthcare systems across the world. Functional dependency is common among older people and many would need assistance in the activities of daily living. Long-term care has become one of the major problems facing an aging society. The most striking effects of population aging are to be seen in the most rapidly developing regions such as China, India and Latin America. Due to the unprecedented pace of demographic aging, these societies will have comparatively little time to develop social and healthcare policies to deal with the healthcare needs of the elderly in their population. Most people with dementia live in developing countries, the prevalence rate being 60% in 2001 and predicted to increase to 71% by 2040. Rates of increase are not uniform-numbers are forecast to increase by 100% in developed countries between 2001 and 2040, but by more than 300% in India, China and the South Asian and Western Pacific regions.[sup] [2] With its devastating negative effects on careers and families, dementia will soon emerge as a major public health problem in most developing countries. The number of elderly people suffering from depression and other mental health problems will also increase. Current Scenario According to the 2001 census, India is home to more than 76 million people aged 60 years and over. This age group, currently only 7.4% of the population, is expected to grow dramatically in the next few decades. Analysis of the census data shows substantial variation in the rate of demographic aging across India: at present, 10.5% of Kerala's population is older than 60 years while in Dadra and Nagarhaveli, this proportion is only 4%. Regions with more favourable health indicators seem to be aging faster and the demand for specialist services will soon be evident in such places. The lack of priority accorded to the healthcare needs of the elderly seems to perpetuate the low level of public awareness about mental health problems of old age. Dementia and other mental disorders of older people, remain hidden problems rarely brought to the attention of healthcare professionals and policy makers. Cholinesterase inhibitors are now available at relatively low prices in India. This might lead to better identification and management of cases of dementia in clinical practice. Similarly, the availability of newer antidepressants with better side effect profiles will probably improve the identification and management of geriatric depression by physicians and general practitioners. Service development will become easier when health professionals and the public are more sensitive to the mental health needs of the elderly. There are hardly any specialized services for older people in the government-run public healthcare services in India compare to other speciality. General health services remain clinic-based and typically involve long waits in crowded clinics for brief consultations. The usual focus in these settings is on 'treatable' acute pathologies and not on long-term care. Old people find it difficult to get to these clinics as it involves travel and use of transport. Doctors continue to be a rare commodity in rural settings. Trained health workers play a pivotal role in providing outreach services in rural areas. However, they do not consider the care of older people their priority unlike maternal and childcare. They have no formal training in identifying and providing intervention for problems like dementia or depression in older people. …

Byline: T. Sathyanarayana Rao, Luigi. Zecca, K. Rao International Scenario The understanding of cellular neurodegeneration in brain disease is today's major challenge. The mapping of region-specific changes in the brain during neurodegeneration is a thrust area in neuroscience. Bipolar disorders are classical neuropsychiatric disorders where crosstalk between environmental factors and genetics plays an important role in the etiology of these disorders. Locus coeruleus (LC) is the main brain region containing norepinephrine neurons. The rostral projections from these neurons seem to be involved in the modulation of neuronal activity, metabolism and memory[sup] [1],[2] whereas the spinal cord projections are known to modulate spinal motoneuron function.[sup] [3],[4] Neuronal loss in LC occurs in Parkinson's disease (PD) and Alzheimer's disease and Down's syndrome[sup] [5],[6] in the midbrain regions. In Alzheimer's disease and Down's syndrome, it is not clear whether neuronal loss in LC is a primary event or a consequence of retrograde degeneration of cortically projecting cells due to the loss of cortical synapses. In PD, results have showed neuronal loss in substania nigra (SN) compared to LC.[sup] [5],[6],[7],[8] However, a recent study reported extensive impairment of LC neurons in PD.[sup] [9] SN and LC share anatomical and biochemical similarities, both being pigmented because of neuromelanin (NM) and both composed of catecholaminergic neurons. The relationship of factors like iron, ferritins and NM[sup] [10],[11],[12],[13],[14] to aging has been analyzed in previous studies. These factors may influence neuronal viability and undergo dramatic changes in PD. As aging is an important risk factor for PD, it would be relevant to establish the age-related changes in elements involved in oxidative stress like iron, copper and related molecules, all of which have been implicated as putative pathogenic factors. Due to their role in peroxidation, changes in iron, copper, their major storage proteins ferritin and ceruloplasmin (CP), together with the enzymes manganese-superoxide dismutase (SOD) and copper/zinc-SOD were determined in human SN and LC at various ages. Being a strong chelator of iron and other toxic metals,[sup] [14] NM has been shown to be a strong modulator of their cellular effects.[sup] [15],[16],[17] Luigi from the Italian group did a comparative analysis of metal-related neuronal vulnerability in two brainstem nuclei, the locus coeruleus (LC) and substantia nigra (SN), which are known targets of the etiological noxae in PD and related disorders. LC and SN pars compacta neurons both degenerate in PD and other Parkinsonisms although LC neurons are comparatively less affected with a variable degree of involvement. In this study, iron, copper and their major molecular forms like ferritins, ceruloplasmin, neuromelanin (NM), manganese-superoxide dismutase (SOD) and copper/zinc-SOD were measured in LC and SN of normal subjects at different ages. Iron content in LC was much lower than that in SN and the ratio of heavy chain ferritin / iron in LC was higher than in SN. The NM concentrations were similar in LC and SN although the iron content in NM of LC was much lower than in SN. In both regions, heavy and light chain ferritins were present only in glia and were not detectable in neurons. This data suggests that iron mobilization and toxicity are lower in LC neurons than in SN and are efficiently buffered by NM. The greater damage occuring in SN could be related to the higher content of iron. Ferritins accomplish the same function of buffering iron in glial cells. Ceruloplasmin levels were similar in LC and SN although copper content was higher in LC. However, the copper content in NM of LC was higher than that of SN, indicating a higher copper mobilization in LC neurons. Manganese-SOD and copper / zinc-SOD had similar age-related trends in LC and SN. These results may explain some of the underlying lower vulnerability of LC compared to SN in Parkinsonian syndromes. …

Byline: T. Sathyanarayana Rao, K. Jacob India's Supreme Court recently issued a ruling against human rights by reinstating a law that bans gay sex. [sup][1] The Court restored Section 377 of the Indian Penal Code, a 19 [sup]th century law, barring "carnal intercourse against the order of nature". The judgment has caused great dismay among liberal and progressive people and amongst activists and advocacy groups, which use judicial intervention to redress grievances against minorities of all shades in India. It has also been criticized from legal and human rights perspectives. [sup][2],[3],[4] The police use the law in question to threaten and blackmail gays, lesbians and transgender people. Violation of the law is punishable by a fine and imprisonment. Following the recent ruling, India's crimes bureau has stated that it will compile crime statistics under Section 377. The British colonial Government enacted Section 377 of the Indian Penal Code, based on Victorian morality, to criminalize non-procreative sex. The Naz Foundation, a non-Governmental Organization working in the field of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) and sexual health, challenged the constitutional validity of Section 377 because it violated the rights to privacy, to dignity and health, to equality and non-discrimination and to freedom of expression. It also argued that the law prevented public health efforts at reducing the risk of transmission of HIV/AIDS as the fear of prosecution prevented people from discussing their sexuality and life style. The Delhi High Court on 2 [sup]nd July 2009, in a landmark judgment, held Section 377 to be violative of Articles 21, 14 and 15 of the Constitution, as it criminalized consensual sexual acts of adults in private. [sup][5] Individuals and faith-based group appealed the High Court verdict. The Supreme Court of India, on 11 [sup]th December 2013, upheld Section 377 and overturned the judgment of the Delhi High Court that had decriminalized adult consensual same-sex conduct. [sup][1] National and International Human rights groups condemned the Supreme Court decision. The Naz Foundation and the Government of India have since filed a petition seeking review of the judgment. [sup][6],[7] They argue that there are a number of grave errors of law that need to be corrected. The judgment goes against the grain of the Supreme Court's own jurisprudence on advancement of fundamental rights and freedoms of all people, especially those who face marginalization in society. The Court's reliance on the principle of judicial restraint and Parliament's prerogative to change laws is misplaced, particularly when the law has been challenged for violation of fundamental rights of citizens. [sup][3] The judgment raises significant constitutional issues with far reaching public importance. There is a need to seek an interim stay on the operation of the judgment, as the judgment has caused immense prejudice to all adult persons who engage in consensual sex. This is particularly true for those from the Lesbian, Gay, Bisexual and Transgender (LGBT) community who had become open about their sexual identity since the High Court judgment and are now at risk of prosecution under criminal law. [sup][7] Historical records document the presence of homosexuality from time immemorial, even in our culture. The universality of same-sex expression coexists with variations in its meaning and practice across culture. Medicine and psychiatry, since the 1970's, abandoned pathologizing same-sex orientation, behavior and LGBT life-style choices. [sup][8] The new understanding was based on studies that documented a high prevalence of same-sex feelings and behavior in men and women, its prevalence across cultures and among almost all non-human primate species.[sup][9] Investigations using psychological tests could not differentiate heterosexual from homosexual orientation. …

Byline: T. Sathyanarayana Rao, K. Basavaraj, Keya. Das The human race is exposed to vagaries of life in terms of various hazards; or as the Greek would have it, "we are all but a heartbeat away from disaster." Major cause for psychopathology has been attributed to stress. A catalyst or precipitator of psychiatric illness and a stimulant to substantial mental agony. The term "stress" was coined by Hans Selye (1907-1982) who laid the concept of the adrenocortical system being the vital responder to stress. [sup][1] The more rudimentary term psychosomatic disease mirrors those illnesses whose evolutions are channeled by psychological (thoughts, emotions and behavior) issues; in contrast somatopsychic diseases echoes those where the biologic aspect of the disease affects the psyche. [sup][2] Psychocutaneous medicine impacts on the interaction between the mind, the brain and the skin. The brain and the skin originate from same germ layer i.e., the embryonic ectoderm and are under the influence of the same hormones and neurotransmitters. Psychiatric expertise focuses on the "internal indiscernible disease" conversely dermatological expertise focuses on "external discernible disease." Factors of a psychopathological nature tend to play an etiological role in the development of skin disorders, can exacerbate pre-existing skin disorder as well as patients suffering from dermatological disorders may bear the brunt of disfigurement. [sup][3] Psoriasis being a key disease in the cluster of psychocutaneous disorders, it has become a focus for exploration. Due to the intimate interplay between psychosocial factors and psoriasis, this disease confirms the said definitions. [sup][2] Psoriasis is a common, chronic, recurrent inflammatory disease of the skin, characterized by circumscribed, erythematous, dry, scaly plaques of varying sizes. [sup][2] The incidence of disease is 1-2% of the general population. [sup][4],[5] Stress acts as a catalyst for the onset as well as exacerbation of psoriasis. [sup][6],[7],[8] The neurogenic inflammation hypothesis of psoriasis put forth by Farber et al . states that neuropeptides like substance P (SP) and nerve growth factor (NGF) act as a crux in its pathogenesis. Unmyelinated terminals of sensory fibers in skin release SP and other NP's thereby resulting in generation of local neurogenic inflammation in those who are genetically primed. [sup][1] SP is synthesized in the dorsal root ganglion of nociceptor C fibers and transmitted peripherally in granules. Colocalization with other NP's including calcitonin gene related peptide and vasoactive intestinal peptide (VIP) in cutaneous sensory nerve endings are found via histochemical staining methods. [sup][9] Stressful life events are associated with higher levels of SP in the central and the peripheral nervous system of animal models. [sup][1] SP expressing neurons are in close and functional proximity of mast cells, which when activated release VIP. [sup][10] Autonomic pathways of the descending type via dorsal root ganglia in the spinal cord through SP containing neurons stimulate release of NP's, the neurons extend onto having connections to opioid interneurons in the dorsal horn. Increased release of adrenocorticotropic hormone, glucocorticoids and adrenalin during stress may be attributed to the stimulation of hypothalamic-pituitary-adrenal axis. Significantly increased expression of NGF in keratinocytes regulates skin innervations and up regulates NP's, this has found to be an early event in the pathogenesis of Psoriasis. NGF causes the proliferation of T lymphocytes and brings about mass cell degranulation resulting in production of a chemokine resulting in production of a chemokine RANTES,which is chemotactic for resting Cd4+ memory t cells and memory t cells. [sup][1] The severity of psoriasis is found to be ever fluctuating. Individuals are likely to cycle between differing levels of severity throughout their life time. …

Byline: T. Sathyanarayana Rao, Mehak. Nagpal, Chittaranjan. Andrade Much has been said, discussed, and reported in the media in the wake of the December 16, 2012, Delhi rape and murder incident, and a myriad other incidents of sexual crime in the country. It is therefore important for mental health professionals to re-examine psychosocial issues related to sexual coercion in the context of the current public debates on the subject. Sexual coercion is the act of being physically, psychologically, financially or otherwise forced or tricked into engaging in sexual activity; victims are most commonly women and children. Women run the risk of sexual abuse and violence across their whole life span. The risk of partner violence and rape, including dating violence and domestic violence; begins in late adolescence, peaks by middle age, and may even continue in the elderly. These acts are not a distinct phenomena and have a degree of overlap that can be viewed along a continuum of sexual violence as they have common causes and methods of prevention. [sup][1],[2] It is commonly believed that sexual coercion is perpetrated by the male sex against the female sex. However, this gender effect is less pronounced in child sexual abuse where women represent a large proportion of perpetrators and children of both sexes are subjected to sexual advances from adolescents and adults. Childhood sexual abuse includes three important elements: (1) Age and size difference between the child and perpetrator; (2) presence of sexual behaviors such as nudity, fondling, and penetration; and (3) gratification to the perpetrator. [sup][3],[4] Sequelae of coercive sexuality in children include subsequent development of sexual disorders, emotional instability, interpersonal withdrawal, and maladaptive coping in new situations. In young women, self-blame, guilt, shame, poor self-esteem, mistrust of others, and other repercussions get reflected in relationships and can be enduring. In any case of child sexual abuse, rape, domestic violence, or elder abuse; there is a common thread of betrayal, vulnerability, and ambivalence in the social norms that tolerate the abuse and the abuser. Role of Mental Health Practitioners and Physicians As is with all forms of sexual assault, the most serious health effects of rape are not physical but psychological. While some acts may traumatize the survivor immediately, other acts may additively manifest many years later, making it more difficult over time to resist overt acts of aggression. Long-term clinical problems include hypervigilance, anxiety and phobias, somatic complaints, dissociative disorders, depression, substance abuse, suicide attempts, and risk of revictimization. [sup][5] While most abuse associated with fatality occurs to young children, adolescent abuse can lead to risk taking behavior that, in turn, increases the risk of current and later morbidity and mortality. [sup][6] Clinicians must therefore recognize that recurrent injury at each stage of a woman's life cycle is predictable; and it requires safety planning in order to address the intratraumatic stress responses. [sup][2] There is also an urgent need to target the commonplace barriers to physician involvement, such as lack of training and awareness about community services, time constraints, and unresolved personal issues that would facilitate a nonjudgmental and supportive safe encounter with the victim. [sup][7] The role of a physician is not just to evaluate, document, and treat women who have been sexually assaulted. They also serve as an educator to guide the victim, her family, and those who become involved in her care. Here, it may be noted that it is important to address a common misperception in society that if women avoid certain behaviors they are not vulnerable to sexual assault. This belief and the subsequent tendency to blame; especially by the main supportive caregivers of the victim, needs to be addressed openly. …

Byline: T. Sathyanarayana Rao, L. Sam. Manickam, Roy. Kallivayalil "Only he who can see the invisible, can do the impossible" - Frank Gomes. The Beginning When we envisaged this project 2 years ago, we were clear as to what we intended to do. However, as we moved along we realized its complexities as aired by some of the eminent members of the psychiatry community. Though there were differences of opinion among the editorial team, we felt that we have to make a beginning. Over the years of practice of psychiatry in India, we realized that in order to provide effective care of the persons and families with mental disorders, we need to be innovative and inclusive of the diverse cultural setting which we hail from. Therefore, the real art of psychiatry depends on how well one integrates the diversity in one's practice. When we announced this initiative, several eyebrows were raised as to where we are heading to. Though we are not completely content with what we have achieved, but we could see the end of the tunnel after 2 years of incubation. We are hoping that there will be more psychiatrists who would dare to tread the path that we are laying, though it is not easy. The Impetus The models that we have are the steps taken by some of the pioneers in psychiatry who made solo ventures during their times and dared to move forward from the "scientific" tradition in which we are trained. Concepts that were considered alien to medicine and psychiatry were keenly searched and brought under the fabric of science. One of the treatises that was left unnoticed is ' The Yoga Sutras ' written by Girindrasekhar Bose. [sup][1] Efforts by Vahia, [sup][2] on bringing in Yogic concepts into the main stream has helped develop the branch of Yoga into a wider perspective and now a separate journal of Yoga is being published from India. Guru-Chela relationship that was proposed by Neki [sup][2] made researchers re-look at the doctor-patient and teacher-student relationship in the Asian cultural context. [sup][3] The concept of mind that is referred to in different Indian philosophical schools of thought intrigues many. [sup][4],[5],[6] The Current Effort From the time we launched this project two years ago, we have received numerous articles and many have shown interest to write. Out of the articles that we received, the editorial team has accepted almost half of the submitted articles for publication in this current volume. This decision was based on the pattern and flow of the content, relevance, completeness, and congruity with the basic Indian mental concepts as envisaged for this project. The very important determinant was its application to behavioral sciences, in general and psychiatric practice, in particular. Above all, space constraint had a significant role in the final outcome.. We would like to interact with those authors in future and provide mentorship to the young researchers as well. Some of the authors have considered Indian thoughts, without referring to the Indian treatise but have solely relied on authors from abroad that were available in Google search. However, there are several researchers in India, who have worked on different concepts but those may be in the libraries of different institutions in India or published in journals that are not yet accessible through the net search. Till Indian Journal of Psychiatry was available online and was indexed in PubMed, a lot of Indian research in psychiatry also went unnoticed by the International Community of Psychiatrists. Therefore, we urge those who are interested in the Indian mental concepts to unearth the unpublished doctoral and master level thesis as well as those articles that are published in several Indian journals, including the "Journal of Indian Psychology" and to scan through the comprehensive list of articles that are available in the ICSSR publication. [sup][7] Some Thoughts The current issue is being brought out as a first volume/supplementary and we look forward to your valuable suggestions, creative and critical comments, and feedback on this initiative, which would help us to develop a guideline for the new authors to explore the Indian mental concepts. …

Byline: T. Sathyanarayana Rao, Mahesh. Gowda, Kanchana. Ramachandran, Chittaranjan. Andrade There are substantial variations in the stated number of farmers committing suicide in India, each year, partly related to variations in the operationalization of the concept of farming as a profession. If these variations are ignored, and if data from the National Crime Records Bureau (NCRB) are accepted, it emerges that there have been 5650 farmer suicides in 1 year (2014), itself. Maharashtra is considered to be India's farmer suicide epicenter [sup][1] and has recorded 20,504 farmer suicides since 2001.[sup][2] Psychosocial Versus Socioeconomic Origins of Farmer Suicide Concerns about farmer suicide are not new, and studies on the subject have suggested different explanations for the act. One school of thought has suggested the primacy of an impaired mental health state, implying that the psychosocial needs of farmers have been neglected, and that caring community professionals need to address farmer distress.[sup][3] This school of thought additionally envisages a role for early psychiatric intervention as a primary preventive measure. In this connection, reports on the lack of psychiatrists offering to help have been of concern.[sup][4] However, there is evidence from studies in Karnataka, Kerala, Tamil Nadu, and other states in India that the role of socioeconomic stress in farmer suicide may be greater than the role of mental disorders.[sup][5],[6],[7],[8] Studies have not discovered conclusive evidence of psychiatric morbidity behind farmer suicides; rather these studies and other statistical data point toward severe socioeconomic adversity as the primary trigger. The NCRB 2014 data also support this conclusion as they indicate that almost 75% of the 5650 suicides that were recorded during 2014 were by small and marginal farmers holding up to two hectares of land; these sections of farmers are exposed to severe socioeconomic hardship. The same NCRB report attributed reasons such as bankruptcy, indebtedness, crop failure, and other farming-related issues to more than 60% of the suicide cases. It is therefore necessary to further investigate these adverse socioeconomic conditions and address the root cause of the suicide risk with the best pragmatic remedies. Socioeconomic Risk Factors in Farming Farming in India is a financially perilous profession with the annual farm income subject to many uncertainties. Farm work involves physical stress and can even be physically hazardous. There is psychological stress associated with coping with the regulatory framework and the dynamics of managing a farm business.[sup][9] The greatest risks, however, are economic in nature. More than 80% of Indian farmers have land holdings below two hectares. This fragmented and small land holding makes farming a risky economical proposition even under the best of conditions. In reality, the conditions are hardly anywhere near best. The smallness of the holding straightaway denies the farmers the benefits of mechanization, modern irrigation, and other investment-based technological improvements. As a result, productivity is suboptimal. The unpredictable, diminishing pattern of rainfall over India adversely impacts the farm output. Other climatic vagaries, such as hailstorms, can cause substantial crop damage. Migration from villages to towns and cities has decreased the availability of labor and increased its costs. The income earned from crops depends on the prevailing market situation, the greed of middlemen, the logistics of selling the produce, and other factors. Often, the government-administered minimum support price (MSP) may not even cover the cost of production. Consider, for example, the case of sugarcane production; the MSP is only INR 1000–1100 per unit against a production cost of INR 900–1000. On the surface, it appears that the farmer will make a (small) profit. …

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.

The development of the Diagnostic and Statistical Manual-5 (DSM-5) has been an exhaustive and elaborate exercise involving the review of DSM-IV categories, identifying new evidence and ideas, field testing, and revising issues in order that it is based on the best available evidence. This report of the Task Force of the Indian Psychiatric Society examines the current draft of the DSM-5 and discusses the implications from an Indian perspective. It highlights the issues related to the use of universal categories applied across diverse cultures. It reiterates the evidence for mental disorders commonly seen in India. It emphasizes the need for caution when clinical categories useful to specialists are employed in the contexts of primary care and in community settings. While the DSM-5 is essentially for the membership of the American Psychiatric Association, its impact will be felt far beyond the boundaries of psychiatry and that of the United States of America. However, its atheoretical approach, despite its pretensions, pushes a purely biomedical agenda to the exclusion of other approaches to mental health and illness. Nevertheless, the DSM-5 should serve a gate-keeping function, which intends to set minimum standards. It is work in progress and will continue to evolve with the generation of new evidence. For the DSM-5 to be relevant and useful across the cultures and countries, it needs to be broad-based and consider social and cultural contexts, issues, and phenomena. The convergence and compatibility with International Classification of Diseases-11 is a worthy goal. While the phenomenal effort of the DSM-5 revision is commendable, psychiatry should continue to strive for a more holistic understanding of mental health, illness, and disease.

Byline: T. Sathyanarayana Rao, Chittaranjan. Andrade In this issue of the journal, Avasthi et al . provides an overview of ethical issues in research. [sup][1] The ethics of medical research in India, including psychiatric research, have been much debated. [sup][2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13] With specific reference to psychiatric research in India, we wish to address two of the principles that Avasthi et al . lists in his overview because we believe that these are important yet neglected in this country (and surely in many other parts of the world, as well!). These two principles are non-exploitation of research subjects and release of the results of the research into the public domain. Exploitation of Research Subjects Avasthi et al . [sup][1] provides a broad description of what non-exploitation entails. With specific regard to medical or hospitalization costs and insurance claims when adverse events occur, we make the following observations: *Patients in India seldom have the financial resources to settle their medical or hospitalization expenses and wait for the insurance claims to be settled in order to obtain their reimbursements. Thus, if the study concludes without the patients requiring additional medical attention, no ethical issues arise. However, if special outpatient or inpatient expenses are incurred as a result of adverse events, and if patients have to settle these expenses through their personal resources, they have effectively been exploited. What is the solution? A novel approach is one that had been adopted by the National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, for many years. The NIMHANS Ethics Committee required clinical trial sponsors to provide an undertaking in the informed consent form that interim relief would be provided to patients and their families in the event of misadventure. The interim relief would cover all expenses related to investigation and treatment of the adverse event, and would include compensation in case of death. These benefits would help the family cope until the insurance claims were settled. *Patients in India do not have the ability to file claims with an international insurance company and defend these claims, if the claims are contested. Again, NIMHANS innovated by insisting that local insurance be obtained, so that claims could be filed in the city in which the study was conducted. *The lives of patients in India are valued at far lower levels than those of patients in Western countries. This is an unfortunate consequence of local insurance, and more attention needs to be paid to ensure that Indian subjects are treated at par with subjects recruited from other sites.There are other ways, as well, in which research subjects may be exploited in India. For example, in some private medical institutions, research subjects pay for investigations the results of which are included as major or minor variables in the dissertations of postgraduate students. Clearly, actual or potential exploitation of research subjects exist in many garbs. Non-Publication of Research There are hundreds of psychiatry postgraduate students who submit dissertations each year in part fulfillment of their course obligations. Scores of research papers are presented in state, zonal, and national conferences attended by psychiatrists. …

Byline: T. Sathyanarayana Rao, Roy. Kallilvayalil, Chittaranjan. Andrade This issue of the Indian Journal of Psychiatry brings to readers a vigorous debate on the covert or surreptitious medication of difficult patients with major mental illness. Several authors offer their thoughts on the subject; one of these is a parent who has practiced covert medication in a personal context, and another is a client who has received covert medication in the past. Arguments for and against the subject are proposed, some emotional and others cold in logic. Although to medicate a patient without his knowledge and against his likely wishes appears intuitively improper, we wish to play the devil's advocate and discuss why there may be merits in covert medication as an approach by a troubled family to re-establish homeostasis in the household. In our discussion, rather than reproducing the arguments already well expressed in this issue of the journal [sup][1],[2],[3],[4],[5],[6],[7] , and elsewhere [sup][8],[9],[10],[11],[12],[13],[14] , we introduce or emphasize lines of thought that have received little or no attention in the debate. The views that we express are our own; readers may therefore note that our article does not represent an official position of this journal or of the society of which this journal is an organ. There are six relatively independent matters that we address on the subject of covert medication of a difficult, uncooperative, and sometimes violent patient with major mental illness. Each of these is considered in turn. A Matter of Risk: The Unknown Patient Covert medication of a patient who has not been formally assessed by a psychiatrist is unwise, unsafe, and illegal. There is no assurance that the history provided is genuine or, if genuine, accurate. Most practitioners would agree with these assertions. Nevertheless, most practitioners also know of unusual cases in which patients were covertly medicated by their families as the only practical way in which the patients could be brought into treatment for the first consultation. The emphasis here is on the word "practical" for, although legal avenues exist to treat the uncooperative, mentally ill patient, these avenues are almost always too impractical or too traumatic for most families. The clinician, therefore, faces a difficult situation: Does the potential benefit of covert medication by the family outweigh the risk that the diagnosis and treatment is wrong? A matter of practice: do patients really make an informed choice? India has only a few thousand psychiatrists who cater to the mental health needs of over 1.2 billion citizens. As a result, psychiatrists are overburdened with case loads and have little time to provide patients with education about diagnosis and the effects of prescribed medications. Thus, patients do not really make an informed choice about their treatment, and autonomy is indirectly violated almost as a rule. The only difference between this situation and covert medication is that in the latter, the patient is ignorant not only about his diagnosis and treatment but also about the fact that he is receiving treatment. The administration of depot antipsychotics is another example of how autonomy is indirectly violated because it amounts to daily dosing with no capacity to withdraw consent in between. These are admittedly strange arguments to support covert medication, but the obvious point is that ethicists should consider the ecological background in which covert medication occurs before they rule on the subject. That is, if "Take this and don't argue because I think it's best for you" is widely practiced and even accepted as right because it is done with good intention (paternalism), is covert medication with good intention really all that different or bad? To a family in distress, these distinctions and their implications for autonomy are meaningless. The applicability of autonomy as an argument is examined in later sections of this editorial and a guest editorial in this issue. …

Byline: T. Sathyanarayana Rao, Chittaranjan. Andrade The previous issue of the Indian Journal of Psychiatry carried an editorial [sup][1] which observed that India does not have adequate psychiatric manpower, that there are few psychiatric centers in the country that are strongly oriented toward academics and research, and that, in consequence, many psychiatric centers with an interest in research may not have the necessary skills to demonstrate or create excellence in research. The editorial [sup][1] further observed that sustained exposure to good quality research in high ranking journals, combined with the development of the ability to critically evaluate a study and its place in the field, are together necessary to drive the desired improvements. The editorial [sup][1] referred to an initiative that was in the pipeline at the time of writing. This initiative sought to develop an e-platform for discussing and imparting training in research-related issues in the field of mental health and the allied neurosciences, linking postgraduate and academic psychiatry departments across the country. We are delighted to announce that, during the second week of March, 2015, the E-Journal Club (eJCIndia) initiative was successfully launched by the Task Force of the Indian Psychiatric Society on Psychopharmacology, along with the Task Force of the Indian Psychiatric Society on Workshops and Training, and with the support of the Department of Psychopharmacology at the National Institute of Mental Health and Neurosciences, Bengaluru. As of the first week of April, 2015, the e-group already has nearly 200 members, comprising postgraduate students, postgraduate teachers, and psychiatrists who are interested in academia even though their practice is not part of an academic environment. The eJCIndia group has completed several activities. The first activity presented an extract from the results of a meta-analysis [sup][2] and invited the membership to comment on whether they would alter their clinical practice based on a highlighted statistically significant finding. After discussion, an answer was provided that explained concepts in meta-analysis, aspects related to schizophrenia rating using the Positive and Negative Syndrome Scale (PANSS), and the clinical significance (as distinct from statistical significance) of a difference in PANSS ratings. Another activity sought to stimulate critical thought by examining paradoxes in the pillars of homeopathy, a school of treatment that enjoys popularity in India and elsewhere. Homeopathy considers that the administration of a diluted dose of a substance that produces a symptom will treat that symptom when that symptom occurs as part of an illness; the greater the dilution, the greater the efficacy of the treatment. It was discussed that the water that we drink has, in the past, come in contact with thousands of chemicals. This water, to use a concept in homeopathy, will therefore contain "memories" of those chemicals. Hence, water should be therapeutic for every disease! Alternately, how do we know that the memories in the water that we drink won't cancel out the memories of the homeopathic medicines? Then, what about the solvent that was used for the dilution of the homeopathic treatment; that would also have previously come in contact with plenty of substances with therapeutic or adverse effect potential, resulting with the potential to interact with the homeopathic substance(s). …

We report a 40-year-old male who self-administered sildenafil for 10 years, in progressively increasing doses from 100 mg per occasion in the 1(st) year to 1300 mg per occasion in the 9(th)-10(th) years of (ab)use. The frequency of abuse was 2-3/week. The only adverse effect of concern that was reported was transient (up to about 12 h), self-limited blurring of vision in the last 2 years, especially in the last 2 months at the highest dose. The patient was otherwise normal. This report is unique because it describes what may be the highest dose of sildenafil reported in literature, abused across a protracted period of time. We discuss issues related to dose and safety of and tolerance to the drug.

Neuropsychiatric disorders represent the second largest cause of morbidity worldwide. These disorders have complex etiology and patho-physiology. The major lacunae in the biology of the psychiatric disorders include genomics, biomarkers and drug discovery, for the early detection of the disease, and have great application in the clinical management of disease. Indian psychiatrists and scientists played a significant role in filling the gaps. The present annotation provides in depth information related to research contributions on the molecular biology research in neuropsychiatric disorders in India. There is a great need for further research in this direction as to understand the genetic association of the neuropsychiatric disorders; molecular biology has a tremendous role to play. The alterations in gene expression are implicated in the pathogenesis of several neuropsychiatric disorders, including drug addiction and depression. The development of transgenic neuropsychiatric animal models is of great thrust areas. No studies from India in this direction. Biomarkers in neuropsychiatric disorders are of great help to the clinicians for the early diagnosis of the disorders. The studies related to gene-environment interactions, DNA instability, oxidative stress are less studied in neuropsychiatric disorders and making efforts in this direction will lead to pioneers in these areas of research in India. In conclusion, we provided an insight for future research direction in molecular understanding of neuropsychiatry disorders.

Byline: T. Sathyanarayana Rao, Rajiv. Radhakrishnan, Chittaranjan. Andrade What are standard operating procedures (SOPs)? These are a specific set of practices that are required to be initiated and followed when specific circumstances arise. For example, emergency room physicians have SOPs for patients who are brought in an unconscious state; nurses in an operating theater have SOPs for the forceps and swabs that they hand over to the operating surgeons; and laboratory technicians have SOPs for handling, testing, and subsequently discarding body fluids obtained from patients. The origins of the term SOP are obscure. The Encyclopedia Britannica indicates that the abbreviation came into use around the mid-1900s [sup][1] and was already in use during World War II. Today, SOPs exist in contexts ranging from military operations to business routines, and from manufacturing processes to medical activities. In military circles, the term standard operating procedure or standing operating procedure is used to describe a procedure or set of procedures for the performance of a given action or for a reaction to a given event. There is a popular misconception that SOPs are standardized across the universe of practice. However, the very nature of an SOP is that it is not universally applied, such as across a large military element (e.g. a corps or division), but rather describes the unique operating procedure of a smaller unit (e.g. a battalion or company) within that larger element. That the operating procedure in question is said to be standing indicates that it is in effect until further notice, and that it may later be amended or dissolved. In the context of clinical trials, the International Conference on Harmonisation (ICH), born in 1990 out of an effort to harmonize regulatory requirements for medicinal products, defines SOPs as detailed, written instructions to achieve uniformity of the performance of a specific function. This is also in keeping with the goal of Good Clinical Practice. [sup][2] In present day medicine, clinicians are familiar with SOPs in restricted contexts, such as those described at the beginning of this article. Clinicians are also aware of the use of SOPs in the context of clinical trials, either with regard to the functioning of ethics committees or with regard to screening, consenting, assessing, and treating patients across the course of the clinical trial. An idea whose time has now come is the introduction of SOPs into routine clinical practice; that is, not for special patients (e.g. those who are unconscious) or for special circumstances (e.g. clinical trials), but for every patient in everyday clinical care. To understand why such SOPs are necessary, let us first pose a question to the reader: How often in routine practice do we ask female patients of reproductive age about the date of their last menstrual period, or about contraceptive precautions that they may have adopted? Do we record these details? Chances are that such information is not regularly obtained; yet, it should be obvious that this information should be sought and recorded at every consultation (whether initial or follow-up) with every female patient in whom pregnancy is even a remote possibility. If SOPs are set in place, it is unlikely that such information would be neglected. Digressing briefly, how are SOPs different from practice guidelines? The terms SOPs, guidelines and pathways are defined by different medical bodies. [sup][3],[4],[5],[6],[7],[8] Furthermore, whereas clinical practice guidelines are systematically developed statements that assist decisions about appropriate health care for specific circumstances, [sup][9],[10] SOPs are more specific than guidelines and are defined in greater detail. They provide a comprehensive set of rigid criteria outlining the management steps for a single clinical condition or aspects of organization. [sup][11] Guidelines are rigorously developed using evidence-based medicine criteria and consist of two distinct components: the evidence summary and the detailed instructions for the application of that evidence to patient care. …

Deoxyribonucleic acid (DNA) conformation and stability play an important role in brain function. Earlier studies reported alterations in DNA integrity in the brain regions of neurological disorders like Parkinson's and Alzheimer's diseases. However, there are only limited studies on DNA stability in an aging brain and the factors responsible for genomic instability are still not clear. In this study, we assess the levels of Copper (Cu), Iron (Fe) and Zinc (Zn) in three age groups (Group I: below 40 years), Group II: between 41-60 years) and Group III: above 61 years) in hippocampus and frontal cortex regions of normal brains. The number of samples in each group was eight. Genomic DNA was isolated and DNA integrity was studied by nick translation studies and presented as single and double strand breaks. The number of single strand breaks correspondingly increased with aging compared to double strand breaks. The strand breaks were more in frontal cortex compared to hippocampus. We observed that the levels of Cu and Fe are significantly elevated while Zn is significantly depleted as one progresses from Group I to Group III, indicating changes with aging in frontal cortex and hippocampus. But the elevation of metals was more in frontal cortical region compared to hippocampal region. There was a clear correlation between Cu and Fe levels versus strand breaks in aging brain regions. This indicates that genomic instability is progressive with aging and this will alter the gene expressions. To our knowledge, this is a new comprehensive database to date, looking at the levels of redox metals and corresponding strand breaks in DNA in two brain regions of the aging brain. The biological significance of these findings with relevance to mental health will be discussed.

Alzheimer's disease (AD) is a complex neurological disorder resulting from both genetic and environmental factors with the latter being particularly important for the sporadic form of the disease. As such, diets rich in saturated fatty acids and alcohol, and deficient in antioxidants and vitamins appear to promote the onset of the disease, while diets rich in unsaturated fatty acids, vitamins, antioxidants, and wine likely suppress its onset. In addition, evidence suggests that diets rich in polyphenols and some spices suppress the onset of AD by scavenging free radicals and preventing oxidative damage. Metal ions are known to catalyze the production of free radicals and induce mental retardation or dementia, and several studies have also identified metals such as Pb, Fe, Al, Cu, and Zn in AD pathogenesis. While specific metal chelators have been tested for therapy, they have not been very successful, probably due to their late administration, i.e., after brain damage has been triggered. Since several dietary polyphenols are known to chelate metals, their routine use may also be protective against the onset of AD. In this review, we summarize beneficial dietary techniques in the fight against AD.

Byline: T. Sathyanarayana Rao, B. Praveena, K. Jagannatha Rao For every eight seconds, a Baby Boomer turns 60 in the world. By 2015, nearly 15% of our population will be over 65 years of age. This is increasing and expected to increase geriatric population burden in health and financial sector in every country. We have limited geriatric healthcare and care giving facilities and this is the essential need due to changing social and financial spheres in our lives. Research on aging and aging processes leads the way to a greater understanding of all age-related diseases.[sup] [1],[2],[3],[4],[5],[6] It has the potential to improve public health to a far greater extent than science that examines only one disease at a time. Research on aging also provides the hope and the promise for everyone to live healthier, longer lives, less susceptible to disease and disability. Aging research is likely to be the least expensive path to preventing and curing many diseases of aging. Studying aging requires two complementary approaches: studying the components of disease that are related to aging and studying the underlying mechanisms of aging and how they regulate the processes in our bodies.[sup] [7],[8] In USA, for 28 years, the American Federation for Aging Research (AFAR) has been at the forefront of this revolutionary approach to the science of healthier aging. AFAR has played a major role in providing and advancing knowledge of aging and mechanisms of age-related diseases by providing grants to more than 2,600 talented scientists. There is an urgent need in India too to have advanced research in aging related to Indian situation. We don't have any cross sectional study either on healthy aging or age related neurological disorders and their burden in India. Government of India need to play a significant role in funding geriatric research. Americans are living longer than ever, according to the latest life expectancy statistics. But American men still aren't living as long as American women. The average life expectancy for men in the US is now roughly 75 years. For women, it's more than 80. Exactly why men are shorter-lived than women isn't entirely clear. Even in infancy, boys run a higher risk of dying than girls, and researchers aren't sure why. Research, however, does suggest that a leading reason for the "longevity gap" between men and women is that men don't take care of themselves as well as women do. Surveys have found, for example, that women are much more likely to have a regular healthcare provider, and to see him or her within the course of the year, than men are. Men are also more likely to engage in "risky" behavior - like smoking and drinking heavily then women. The greatest health asset for geriatric population is spending time and doing things with other people, of all ages, which can help keep them mentally, physically and emotionally fit. It can also give brain a boost and lift the mood. They need to volunteer, or join community or other groups and get involved in activities they enjoy. But in the current situation is not so satisfactory for our aged. In India, there is an urgent need to develop models to keep geriatric populations active through out life. We need to provide a comprehensive plan on post retirement healthy and active living.[sup] [9],[10],[11] Unhealthy aging is a risk factor for geriatric mental disorders. The failure in normal healthy aging leads to mental disorders in aged population. Bipolar disorder (BD) is a major geriatric mental health problem and affects about 1% of the population and causes severe neuropsychological impairments and is implicated in functional impairment. What is meant by normal aging and healthy aging and what are the triggering risk factors for geriatric mental health problems are the major puzzling issues. We need to understand biology of aging properly. Biological changes during aging include neuropeptide (involved in memory and emotion), calcium balance, hormones like oxytocin, neural networks, metal homeostasis, and genetic instability and related gene expression changes. …

Byline: T. Sathyanarayana Rao, K. Jagannatha Rao, M. Asha Exploring avenues for stimulating and harnessing the tremendous self-healing potential of the human genome, is one of the hot spot areas in current research. A prime candidate for illness is a person whose life is devoid of love or of any level of human warmth. Add to this, unresolved or deeply consuming emotional, psychological or spiritual stress along with a disempowering belief system-you have a perfect recipe for creating disease. When a person feels that he or she has no choice in the matters of his or her own life, their emotional response can lead to the development of a disease. The violation of a person's choice, often, is teeming with hostility, fear, anger and rage. 'The Lost Soul Syndrome', when a person is in 'Existential Vacuum', where suffering is accompanied by the absence or loss of meaning in one's life, could be a significant contributor to illness. This is primarily because, a life sans meaning, more often than not, leads to despair, depression and worthlessness. This implies that the physical body is strongly affected when one's state of mind and emotions are full of suffering, stemming from feelings of emptiness.[sup] [1] Life is a learning experience. By redirecting our focus, we bring about a new course of events into focus while releasing an existing course of events that may not serve us any longer. Nowhere this is more significant than where our genes are concerned. Of late, geneticists have begun to address the DNA (NOT the Brain) as our Bio-computer. It can be hypothesized that, in order to set the "bioenergy system" right, it is vital to access the source of electromagnetic malfunction in our genetic code. To facilitate this, it is essential to employ special sounds and intention.[sup] [2] According to Dr. Valerie Hunt, the author of "Infinite mind: Science of the Human vibrations of consciousness", the mind actually exists at the dimension of electromagnetic fields, rather than residing in the brain. Natalie Dobrova believes that, an individual's system comprising organs, has its own electromagnetic rhythm. Disruption in this cellular symphony signifies disease.[sup] [3] DNA is regarded as the master blue print for our biology. Vedas state that "In the beginning was Brahman with whom was the WORD". A parallel for this can be found in The New Testament where John states "In the beginning was the WORD." A reference in Genesis 1:3 reads "And God said , Let there be light: And there was light." All these point to the potential of light (electromagnetic waves) and sound (electromagnetic waves) on DNA and their EXPRESSION.[sup] [2] Horowitz, the author of "DNA: Pirates of the sacred spiral", states that the research carried out by neurophysiologists has clearly shown the following: "One-third of the sensory-cortex area of the brain is fully devoted to the oral cavity, tongue, lips and speech." This implies that bioacoustic waves (oral frequency emissions- spoken or sung) have tremendous impact over life and vibrating genes which in turn influence total wellness of individuals and probably affect evolution of the species too.[sup] [2] Dr. Jeremy Norby, a French anthropologist, conducted detailed studies on Healing techniques of Shamans in the Amazon forests, has also authored the book "The Cosmic serpent: DNA and the Origins of Knowledge". He compared DNA or genetic code to books, which can be read, written or REWRITTEN (Reprogrammed). Now comes the important piece of the puzzle - the significance of 'Junk DNA' - parts of the DNA called "Introns" which are regarded as noncoding genetic sequences, in contrast to "Exons" that have identifiable coding functions in protein building through transcription. It is also interesting to note the presence of "Jumping DNA" or "transposons" in the supposedly useless 97% of junk DNA.[sup] [2] It is proposed that these mysterious junk DNA have some important function since mother Nature never does anything dumb. …

A Pilot study was Carried out to study the association of consanguinity marriage with depression. It was observed that the consanguinity of marriage was associated with depression. The odds ratio was 5.66 (CI: 2.42-13.54). The age and sex had an association with depression. The age and sex adjusted odds ratio of consanguinity marriage was 7.66 (CI: 3.93-19.45) indicating that it is independently associated with depression.

Byline: T. Sathyanarayana Rao, M. Asha, B. Ramesh, K. Jagannatha Rao Introduction Few people are aware of the connection between nutrition and depression while they easily understand the connection between nutritional deficiencies and physical illness. Depression is more typically thought of as strictly biochemical-based or emotionally-rooted. On the contrary, nutrition can play a key role in the onset as well as severity and duration of depression. Many of the easily noticeable food patterns that precede depression are the same as those that occur during depression. These may include poor appetite, skipping meals, and a dominant desire for sweet foods.[sup] [1] Nutritional neuroscience is an emerging discipline shedding light on the fact that nutritional factors are intertwined with human cognition, behavior, and emotions. The most common mental disorders that are currently prevalent in numerous countries are depression, bipolar disorder, schizophrenia, and obsessive-compulsive disorder (OCD).[sup] [2] The dietary intake pattern of the general population in many Asian and American countries reflects that they are often deficient in many nutrients, especially essential vitamins, minerals, and omega-3 fatty acids.[sup] [3] A notable feature of the diets of patients suffering from mental disorders is the severity of deficiency in these nutrients.[sup] [3] Studies have indicated that daily supplements of vital nutrients are often effective in reducing patients' symptoms.[sup] [4] Supplements containing amino acids have also been found to reduce symptoms, as they are converted to neurotransmitters which in turn alleviate depression and other mental health problems.[sup] [4] On the basis of accumulating scientific evidence, an effective therapeutic intervention is emerging, namely nutritional supplement/treatment. These may be appropriate for controlling and to some extent, preventing depression, bipolar disorder, schizophrenia, eating disorders and anxiety disorders, attention deficit disorder/attention deficit hyperactivity disorder (ADD/ADHD), autism, and addiction.[sup] [4] Most prescription drugs, including the common antidepressants lead to side effects.[sup] [4] This usually causes the patients to skip taking their medications. Such noncompliance is a common occurrence encountered by psychiatrists. An important point to remember here is that, such noncompliant patients who have mental disorders are at a higher risk for committing suicide or being institutionalized. In some cases, chronic use or higher doses may lead to drug toxicity, which may become life threatening to the patient.[sup] [4] An alternate and effective way for psychiatrists to overcome this noncompliance is to familiarize themselves about alternative or complementary nutritional therapies. Although further research needs to be carried out to determine the best recommended doses of most nutritional supplements in the cases of certain nutrients, psychiatrists can recommend doses of dietary supplements based on previous and current efficacious studies and then adjust the doses based on the results obtained by closely observing the changes in the patient.[sup] [4] When we take a close look at the diet of depressed people, an interesting observation is that their nutrition is far from adequate. They make poor food choices and selecting foods that might actually contribute to depression. Recent evidence suggests a link between low levels of serotonin and suicide.[sup] [5] It is implicated that lower levels of this neurotransmitter can, in part, lead to an overall insensitivity to future consequences, triggering risky, impulsive and aggressive behaviors which may culminate in suicide, the ultimate act of inwardly directed impulsive aggression. Depression is a disorder associated with major symptoms such as increased sadness and anxiety, loss of appetite, depressed mood, and a loss of interest in pleasurable activities. …

Bipolar disorders are complex neuropsychiatric in nature and are clinically classified as Type I, Type II, and Type V. The etiological factors include environmental-genetic inter-relations. Trace metals play a significant role in neurological disorders. There is very limited information on the role of macro and trace elements in bipolar disorders.Trace elements namely Na, K, S, Ca, Mg, P, Cu, Fe, Zn, Mn and Al were analyzed in serum samples of 3 bipolar types: bipolar I, bipolar II and bipolar V with a control group using inductively coupled plasma-atomic emission spectrometry (ICP-AES). The patients were assessed as per the standard diagnostic criteria and classified into the bipolar type I, II hypomanic, II depressives and V.In bipolar I (mania), Na, K, P, Cu, Al and Mn were increased significantly (p0.001). In bipolar II hypomania, Na, S, Al and Mn were increased significantly (p0.02), while in bipolar II depression, Na, K, Cu and Al were increased (p0.001). In bipolar V, Na, Mg, P, Cu, and Al were increased significantly (p0.002), though S (p0.00001), Fe (p0.002) and Zn (p0.004) were decreased in all 3 bipolar groups.There is a disturbance in the charge distribution and element-element interdependency in bipolar serum when compared to controls. These results suggest that there is a definite imbalance in macro and trace element homeostasis as evidenced by element inter-relationships in serum samples of bipolar groups when compared to controls.

Byline: T. Sathyanarayana Rao, G. Rao, M. S. V. K.. Raju, Gautam. Saha, Mukesh. Jagiwala, K. Jacob The recent past has been turbulent for Lesbian Gay Bisexual and Transgender (LGBT) people and Gay Rights in India. The Delhi High Court's landmark judgment in July 2009, which read down Section 377 of the Indian Penal Code, was a major victory. It held that Section 377 to be violative of Articles 21, 14, and 15 of the constitution, as it criminalized consensual sexual acts of adults in private.[sup][1] The judgment struck down a 19[sup]th century law, which the police used to threaten and blackmail LGBT people. Violation of the law is punishable by a fine and imprisonment. Subsequently, India's Supreme Court issued a ruling against human rights by reinstating the law that bans gay sex in 2013.[sup][2] The response from mental health and legal establishment to this manifest bigotry was weak.[sup][3] The hesitancy of the establishment to clearly support LGBT rights exposes their subscription to prevailing societal prejudices. Fortunately, the Supreme Court referred a batch of curative petitions against Section 377, to a five-judge Constitution Bench for an in-depth hearing.[sup][4] The Science Modern medicine and psychiatry, since the 1970s, have abandoned pathologizing same-sex orientation and behavior.[sup][5] The World Health Organization accepts same-sex orientation as a normal variant of human sexuality.[sup][6] The United Nations Human Rights Council values LGBT rights.[sup][7] Psychiatry's new understanding is based on studies that document a high prevalence of same-sex feelings and behavior in men and women, its prevalence across cultures and among almost all nonhuman primate species.[sup][8],[9] Investigations using psychological tests could not differentiate heterosexual from homosexual orientation. Research also demonstrated that people with homosexual orientation did not have any objective psychological dysfunction or impairments in judgment, stability, and vocational capabilities. The consistency of same-sex attractions, the failure of attempts to change, the lack of success with treatments and the harm caused by these efforts support the stability of homosexual orientation.[sup][3],[8],[9] Science continues to debate the relative contributions of nature and nurture, biological and psychosocial factors, to sexuality.[sup][3],[8],[9] However, classical theories of psychological development employ untestable conjectures and argue without proof that the origins of adult sexual orientation lie in childhood experience and development. Similarly, genetic and biological theories are reductionistic and do not explain complex aspects of human behavior, including natural inclination and choice. The universality of same-sex orientation and behavior and variations in its meaning and practice across cultures undermine single and simplistic explanations. Human sexuality is complex; the distinction between desire, behavior, and identity acknowledges the multidimensional nature of sexuality.[sup][3],[8],[9] The fact that these dimensions may not always be congruent in individuals suggests the complexity of the issues. Bisexuality and the discordance between biological sex and gender role and identity add to the complexity. The Cultural Context Anti-LGBT attitudes once considered the norm, have changed over time in many social and institutional settings in the west. However, heterosexism is also common; it idealizes heterosexuality and considers it the standard while denigrating and stigmatizing all nonheterosexual forms of behavior, identity, relationships, and communities. Religious and social orthodoxy and patriarchy complicate the issues in many conservative and tradition-bound societies. This is particularly true in India, making it difficult for LGBT people to be accepted as equals in society.[sup][3],[8],[9] The hesitancy of the Indian medical and legal establishments to fully support LGBT rights exposes their subscription to prevailing societal prejudices. …

Byline: T. Sathyanarayana Rao, Chittaranjan. Andrade This is an era in which we are increasingly concerned about the quality of the air that we breathe and the food that we eat. Alcohol, a beverage that has pleased our species for millennia, is one of the "foods" the consumption of which, in the words of the immortal bard, should give us pause. In this editorial, we express our concerns on the subject through a presentation and discussion of the results of two large epidemiological studies [sup][1],[2] published nearly two decades apart. A voluminous body of literature shows that men and women who consume alcohol regularly have higher death rates from accidental injury, violence, suicide, poisoning, cirrhosis of the liver, cancer, and, possibly, hemorrhagic stroke. Much literature also supports the view that men and women who regularly drink have lower death rates from coronary heart disease and thrombotic stroke. What is the net impact of these favorable and unfavorable alcohol-mediated effects on persons with regular alcohol intake? Because the incidence of different alcohol-related events varies between men and women, across age groups, and across other sociodemographic and clinical categories, it is evident that any study of the balance of risk will need to take subpopulations into account. The subject was addressed in a large epidemiological study, described by Thun et al . [sup][1] in 1997. The sample in this study [sup][1] comprised nearly half a million Americans, aged 30 years or more, who provided complete information about smoking and drinking habits. There were totally 238,206 men and 251,420 women aged 30-104 years (mean, 56 years). About 98% of these men and women could be followed for up to 9 years, during which period 12% died. Death certificates were obtained for all but 2% of those who died. In this study, alcohol consumption was assessed at baseline and at endpoint using questionnaires, and was categorized as none, less than daily but at least thrice a week, 1 drink per day, 2-3 drinks per day, and 4 or more drinks per day. For operational purposes, one drink was considered as 12 g of absolute alcohol; in common parlance, this amounts to about one small peg (30 ml) of 75[degrees] proof liquor. On the surface, it appears that this classification is somewhat unsatisfactory on several counts; more useful quantitative indices, for example, might have been average daily consumption of absolute alcohol, lifetime consumption of absolute alcohol, and quantity of absolute alcohol consumed per drinking occasion. However, such indices can be reliably calculated only from data obtained through direct interview; furthermore, such quantitative indices may not be helpful when the relationship between alcohol consumption and mortality variables is nonlinear (as actually transpired for several variables in the study). Therefore, considering the epidemiologic nature of the investigation, the investigators [sup][1] did the best that was possible under the circumstances. After excluding from analysis former drinkers and those with baseline cancer or cirrhosis, it was discovered that the results, in general, supported existing literature: *In men, consumption of alcohol was associated with significantly increased risk of mortality due to the following: Cirrhosis, alcoholism, or both; injuries and external causes; alcohol-related cancers (mouth, esophagus, pharynx, larynx, liver); colorectal cancer; all other cancers *In women, consumption of alcohol was associated with significantly increased risk of mortality due to the following: Cirrhosis, alcoholism, or both; alcohol-related cancers; breast cancer. Risks of death due to colorectal cancer, all other cancers, injuries, and external causes were not significantly elevated *In both sexes, consumption of alcohol was found to significantly decrease the risk of mortality due to the following: Coronary heart disease when there was no disease preexisting; coronary heart disease when such disease did preexist; stroke; other circulatory disease; all cardiovascular disease; all other causes. …

Byline: T. Sathyanarayana Rao, Chittaranjan. Andrade The current classification of drugs was introduced by the World Health Organization in 1976.[sup][1],[2] This classification is known as the ATC system, where A refers to the anatomical site of action (e.g., the central nervous system [CNS]), T refers to the therapeutic indication (e.g., the treatment of depression), and C refers to the chemical class of the drug (e.g., selective serotonin reuptake inhibitor [SSRI]). In the ATC classificatory system, the anatomical site of action could be the CNS (e.g., carbamazepine), the respiratory system (e.g., salbutamol), the cardiovascular system (e.g., digoxin), the gastrointestinal system (e.g., omeprazole), and so on. A problem here is that, for example, antimicrobials and antineoplastic drugs do not act on a specific anatomical system; however, they do act at a specific anatomical target, such as bacterial or neoplastic cells. Vitamins are other examples of drugs that are hard to classify with regard to an anatomical target. For Level 1 CNS drugs, Level 2 includes analgesics, anesthetics, antiepileptics, anxiolytics, antidepressants, antipsychotics, antidementia drugs, mood stabilizers, hypnotics, and others. A problem here is that drugs are classified according to the original indication for which they were studied and approved. However, many drugs have many indications. For example, SSRIs have demonstrated efficacy in depression, generalized anxiety disorder, panic disorder, social anxiety disorder, posttraumatic stress disorder, obsessive-compulsive disorder (OCD), premenstrual dysphoric disorder, migraine (prophylaxis), and other conditions. Nevertheless, SSRIs are still classified as antidepressants. Similarly, antipsychotics such as aripiprazole are effective in schizophrenia, in mania, as antidepressant augmentation treatment in major depressive disorder, as SSRI augmentation treatment in OCD, and in the treatment of delirium. Quetiapine and lurasidone are specifically effective as monotherapy for bipolar depression, and quetiapine is effective as monotherapy for generalized anxiety disorder. Some of these are not approved indications but are indications for off-label use. In like manner, antiepileptics such as valproate are effective in epilepsy, bipolar disorder, pain syndromes, migraine prophylaxis, aggression, anxiety, tardive movement disorders, and other labeled or off-label indications. For Level 1 CNS drugs and Level 2 antidepressants, Level 3 includes monoamine oxidase inhibitors (MAOIs), tricyclic antidepressants (TCAs), SSRIs, serotonin-norepinephrine reuptake inhibitors (SNRIs), noradrenaline reuptake inhibitors, noradrenergic and selective serotonergic antidepressants, and other drugs. Here, the method of classification is a little unsystematic, for example, whereas MAOI, SSRI, and SNRI are mechanisms, TCA describes a structure. Terms such as “newer” antidepressants tell us nothing about the drugs. Classifying Antipsychotic Drugs The problem is greater with the antipsychotic drugs. In the early decades, it was convenient to classify these drugs, based on structure, as phenothiazines, butyrophenones, diphenylbutylpiperidines, and other drugs. With subsequent drug development, many agents were synthesized that had no other member in their group. However, around the same time, a change in adverse effect profile spawned the atypical/typical distinction and usage, and afterward, the older/newer and first/second/third generation antipsychotic terminologies. A problem here is that some of the older antipsychotics did not produce much extrapyramidal adverse effects (EPS), if at all, and were, therefore, atypical in action; thioridazine is an example. In contrast, risperidone, ziprasidone, aripiprazole, blonanserin, and many other newer antipsychotics do produce considerable dose-dependent EPS and akathisia. …

Byline: M. Kishor, Mohan. Isaac, M. Ashok, Lakshmi. Pandit, T. Sathyanarayana Rao Psychiatric disorders are considered one of the leading causes of morbidity and mortality worldwide.[sup][1] They are closely associated with other medical conditions such as diabetes and hypertension, adversely affecting their outcome.[sup][2],[3] India has more than 1/6[sup]th of the global population, and is a rapidly developing country with enormous changes in all spheres of life. Mental health issues are gaining a great deal of importance, in keeping with other health issues, and are likely to play a key role in the diverse indicators of development. Suicide rates in India are reportedly one of the highest in the world and have already attracted political and socio-cultural trajectories in both causation and solutions for the problem, underplaying mental health causes for the same, as well as understating the inadequacy of mental health services in India.[sup][4] Concerns regarding the mental health scenario in India are directly related to a lack of awareness among the public and a lack of the minimal mandatory training in psychiatry for medical undergraduates, which has consistently produced thousands of doctors who are incompetent to diagnose and manage common conditions such as depression and suicide.[sup][5] Training undergraduates in the field of psychiatry can be considered as one of the most important pathways to improve mental health services in India. That undergraduate training in psychiatry is inadequate has been the contention from the first report of the subcommittee on undergraduate teaching in psychiatry, Indian Psychiatry Society (1965).[sup][6] The emphasis has been on inadequate hours of training in psychiatry as well as a lack of the required trained staff. Painfully, despite the numerous evidences about benefits of undergraduate psychiatry training [sup][7],[8],[9] nothing seems to have changed in this half of the century (1965–2015) as the Medical Council of India is reluctant to make psychiatry a mandatory subject for the MBBS examination,[sup][10] impairing the mental health component of basic health services in India. This great lacuna in Indian medical education is likely to have an adverse effect on mental health services for the next few decades. In addition is the issue that India has a large deficit of psychiatrists with just 0.3 for 100,000 populations, as mentioned in world mental health atlas 2014.[sup][11] To address this challenge, we may have to look for solutions that enable us to attract medical students to the subject of psychiatry, and build psychiatric knowledge and skill in them through diverse ways. The onus for achieving this lies on each faculty and the department as a team, the policies of the Institution and University to which they belong, as well as professional bodies like the Indian Psychiatric Society, each of whom will have a major role to play. The efforts of Indian Psychiatry Society have been well-summarized by Dr. Roy Abraham Kallivayalil in his presidential address at ANCIPS 2012, Kochi. The Medical Council of India had made it mandatory for all medical colleges to have a department of psychiatry as a part of teaching hospitals, providing mental health services in a general hospital setting. Needless to say, most nonteaching hospitals in India, public or private, do not have psychiatric services on a regular basis. Hence, medical colleges are crucial centers for providing Mental Health Services. Currently, there are 412 medical colleges in India with 52,325 MBBS seats.[sup][12] The onus of training these medical graduates in psychiatry for whom the subject is not mandatory, as in, not assessed in the current examination system, lies with the faculty in psychiatry, they have to use their knowledge and passion in delivering psychiatric training for these students. Departments that have recognized postgraduate seats must also put in the same degree of effort in teaching the undergraduates. …

Byline: T. Sathyanarayana Rao, Chittaranjan. Andrade Many previous editorials in this journal have addressed ethical issues in publication and research.[sup][1],[2],[3],[4] In this editorial, we examine an issue that has troubled the journal editors in recent years; the subject was also raised in eJournal Club India, a collaborative initiative from the Indian Psychiatric Society and the Department of Psychopharmacology at the National Institute of Mental Health and Neurosciences, Bengaluru.[sup][5] The issue relates to part publication of data from a completed research study. Consider the situation where a team of investigators conducts and completes a study. The investigators, for manifold reasons, wish to publish as many papers as possible from the data that were collected. It occurs to them that they could analyze the data from about half of the sample and publish the results in one journal, and then analyze the data from the entire sample and publish the results in another journal. Is this ethical? The short answer is no, it is absolutely unethical to publish an analysis of data from only a part of the sample after a study is complete. When Part Publication Is Unethical Why is part publication unethical? One reason is that the purpose of communicating medical research findings is to advance the cause of science and to benefit patients. Publishing an analysis of data from only part of the sample could generate inconclusive or even misleading results because the analysis would be underpowered, or the subsample could be nonrepresentative. This could deceive a reader who does not see the second paper (or who sees the second paper much later) that presents the analysis of the entire dataset. Additional deceptions are that it would seem that two studies have been conducted, and perhaps that two studies support the conclusions of the authors when, in reality, there is only one study. Finally, meta-analyses would count the two publications as separate studies, thereby duplicating patient data and inflating the contribution of that study to the meta-analysis. When Part Publication May Be Permissible There could indeed be situations when publishing part of the data is acceptable. These situations can arise when the study is ongoing, and there is a specific reason why a preliminary analysis, followed by the publication of the preliminary results, is deemed necessary. An example is to present pilot data that carry an important message or to present the results of the preliminary analysis of data from an adaptive study design where the results of the preliminary analysis will influence the methods or design of the rest of the study. Such a preliminary analysis is usually preplanned, stated in the study protocol, and approved by the Ethics Committee or the Institutional Review Board. There is nothing unethical in conducting a study and presenting part of the results in one paper and the rest of the results in another paper as long as each paper is based on the full sample and each paper contains sufficient information for a standalone publication. For example, in a study of antipsychotic efficacy in schizophrenia, it could be reasonable to present psychopathology ratings, global ratings, assessments of quality of life, and assessments of adverse effects in one paper, and magnetic resonance imaging findings correlated with neuropsychological test battery results in another paper. …

Background: Realizing a dearth of data on this topic, especially in the Indian context, an epidemiological study was conducted in a south Indian rural population to identify the sexual activity patterns and sexual problems among the population above 60 years of age. Objectives: (1) Assessment of sexual activity patterns among individuals above 60 years. (2) Assessment of the prevalence of sexual disorders among individuals above 60 years. Materials and Methods: The study sample consisted of 259 participants, which included both males and females above 60 years of age. Subjects who were sexually active and fulfilled the study criteria were administered Arizona Sexual Experience Scale as a screening tool, for the presence of sexual problems. Those who were found to have sexual problems were interviewed further using appropriate questionnaires. Results: Only 27.4% of the individuals above 60 years were sexually active, and it progressively dropped as age advanced and none were sexually active after 75 years of age. Among the sexually active males, erectile dysfunction (ED) was prevalent in 43.5%, premature ejaculation in 10.9%, hypoactive sexual desire disorder (HSSD) in 0.77% and anorgasmia in 0.38% of the subjects. Among females, arousal disorder was prevalent in 28%, HSSD in 16%, anorgasmia in 20% and dyspareunia in 8% of the subjects. Conclusion: The study gives us an insight into the sexual problems of the elderly and brings home the point that sexual problems are very much common among both men and women in the older population. Among elderly males, ED is the most common sexual disorder whereas in elderly females, arousal disorder is the most prevalent female sexual dysfunction, implicating biology plays an important role in men, whereas psychology plays an important role in women sexual functioning.

Byline: Shajahan. Ismail, Ashika. Shajahan, T. Sathyanarayana Rao, Kevan. Wylie Sex education is defined as a broad program that aims to build a strong foundation for lifelong sexual health by acquiring information and attitudes, beliefs and values about one's identity, relationships, and intimacy. Sexual health is considered to be a state of physical, emotional, mental, and social well-being in relation to sexuality and not merely the absence of disease or infirmity as defined by the WHO.[sup][1] Psychological and sociocultural influences in the delivery of this education can increase the likelihood of effectiveness. Primarily, during adolescence (10–19 years) its provision is a crucial preventative tool, as it is the opportune time when young people experience developmental changes in their physiology and behavior as they enter adulthood.[sup][2] The complex emotional state in which youth find themselves in, stigma surrounding matters of a sexual nature in the Indian society and widespread gender inequality faced makes it increasingly challenging for adolescents to attain the knowledge they need. Through what is termed “family life education” (FLE), we can hope to teach the roles and responsibilities of males and females toward each other in all relationships in familial and social contexts, thus endowing the knowledge necessary to maintain sexual health as they navigate through the vulnerabilities of life.[sup][2] However, the existence of strong stigma and controversy handicaps any existing adolescent health programs, with them being incomprehensive and failing to fully address the main health issues adolescents are vulnerable to. These include several negative sexual and reproductive health outcomes,[sup][3] such as early and closely spaced pregnancy, unsafe abortions, sexually transmitted infection (STI), HIV/AIDS, and sexual violence, the rates of which are already increasing at a disturbing rate. Need for Sexual Education for Indian Adolescents The importance of delivery of sex education in a timely fashion to this significant demographic is emphasized by current statistics that show that almost one in every fifth person on the globe is an adolescent.[sup][4] They comprise 18% (1.2 billion) of world's population in 2009, with 88% living in developing countries. India has the largest adolescent population (243 million with more than 50% of the adolescent population living in urban areas). These figures indicate the importance of specifically addressing the healthcare needs of this considerable demographic, particularly for the developing countries such as India.[sup][5] Recent literature suggests that at this time they are highly likely to experiment and engage in the types of risky behaviors that have the potential to influence the quality of health and probability of survival in both short- and long-term over their lifetime. Therefore, meeting the needs of such a vulnerable group and overcoming existing shortcomings in the delivery of tailored primary preventative measures would significantly improve the survival and general health conditions, nutritional status, and sexual and reproductive health of the future Indian adult population.[sup][6] This encompasses issues such as early pregnancy, unsafe abortions, STIs including HIV, and sexual abuse and violence. The Current Scenario in Clinical Settings The sexual and reproductive health needs of adolescents [sup][7],[8],[9],[10] in India are currently overlooked or are not understood by the Indian healthcare system. This could be owing to the lack of knowledge of scientific evidence along with the gross unpreparedness of the public health system. Healthcare professionals often lack the knowledge themselves that impacts upon imparting information to the adolescent population who seek it. Often comprehensive sexual histories are not taken, and sexual health is not openly discussed due to cultural and traditional norms in society. …

Background: Sexuality is an important aspect of the personality of an individual and influences psychological, physical and social well-being of both men and women. It is a paradox, that in the country where 'kamasutra' (by Vatsyayana) took birth, there is a lack of research publications and sexuality related literature; hence the current study was conducted, to estimate the prevalence and association of sexual disorders with various socio-demographic variables, in the selected rural population. Materials and Methods: Subjects who were sexually active and fulfilled the study criteria were administered Arizona Sexual Experience Scale as screening tool for the presence of sexual problems. Those who were found to be having sexual problems were interviewed further using appropriate questionnaires. Results: 21.15% of the male subjects were diagnosed to have one (or more) sexual disorder. Prevalence of erectile dysfunction was found to be 15.77%, male hypoactive sexual desire disorder (HSDD) 2.56%; premature ejaculation was found to be prevalent in 8.76% of the male subjects. Around 14% of the female subjects were diagnosed to have female sexual disorders. Prevalence of female arousal dysfunction was found to be 6.65%, female HSDD 8.87%, female anorgasmia 5.67%, female dyspareunia 2.34% and female sexual aversion disorder was found to be prevalent in 0.37% of the female subjects. Conclusion: This study concluded that one in five males and one in seven females were suffering from one (or more) sexual disorder. Improving the training of undergraduate medical and nursing students in sexuality related issues, increasing trained individuals in sexual medicine by starting new courses, providing sex education to the general population using media and merging sexual health care with primary care, are likely to play a significant role in addressing the increasing sexual health morbidity.

Byline: T. Sathyanarayana Rao, Chittaranjan. Andrade Flibanserin (BIMT 17; Addyi; Sprout Pharmaceuticals, North Carolina, USA) is an agonist at postsynaptic (but not presynaptic) serotonin (5HT) 5HT1a receptors and an antagonist at 5HT2 receptors; the binding appears preferential for prefrontal cortex (PFC) pyramidal neurons that regulate monoamine release. Thus, flibanserin dosing results in increased release of dopamine (DA) and norepinephrine (NE) in the PFC. Flibanserin is also associated with decreased release of 5HT in the PFC, nucleus accumbens, and hypothalamus, but not hippocampus. Whereas DA and NE putatively increase sexual desire and arousal and 5HT inhibits sexual desire and arousal, this pharmacodynamic profile may explain the suggested benefits of the drug in women with hypoactive sexual desire disorder (HSDD). Weak and probably nonsignificant actions of flibanserin include antagonism at 5HT2b, 5HT2c, and D4 receptor sites.[sup][1],[2] Flibanserin was originally developed as an antidepressant [sup][3] with a potentially rapid onset of action;[sup][4] it was effective in some but not all animal models of depression.[sup][5] Phase 2 randomized controlled trials (RCTs) failed to find it effective against depression; however, interestingly, the drug outperformed placebo on responses to the question“how strong is your sex drive."[sup][3] On September 22, 2015, only 76 hits emerged in a PubMed search with the key word flibanserin, and only 9 hits emerged with the clinical trial search filter applied. The failed antidepressant data are unavailable in PubMed and presumably remain unpublished, but the sexual function findings have been released. Kennedy [sup][6] examined data from 4 RCTs of flibanserin (100–200 mg/day) in men ( n = 369) and women ( n = 523) with major depressive disorder. All RCTs had an active comparison treatment arm, and two RCTs were additionally placebo-controlled. Patients in the RCTs had been assessed using the Arizona Sexual Experiences Scale and the Hamilton Depression Rating Scale (HAM-D) genital symptoms item. In general, it appeared that flibanserin was associated with low or placebo-level risk of treatment-emergent sexual dysfunction. In one RCT, reported improvement in sexual functioning in women with baseline sexual dysfunction was 70% versus 30% for flibanserin versus placebo groups. In another RCT, flibanserin was associated with significantly greater improvement on the genital symptoms HAM-D item at weeks 4, 6, and 8. In the other RCTs, outcomes related to sexual functioning were inconsistent.[sup][6] Thus, there seemed to be a weak signal suggesting that flibanserin carries benefits for sexual functioning in women with depression. Four important RCTs and two long-term studies have now been published on the use of flibanserin for HSDD. HSDD is characterized by low sexual desire as a result of which the individual experiences distress or interpersonal difficulty. The condition is not diagnosed if the low desire is due to medications, substances of abuse, a co-existing medical or psychiatric condition, or relationship problems. HSDD is considered to be acquired when it arises in an individual who had normal sexual desire earlier; it is considered generalized when it is not specific to a type of sexual activity, a situation, or a partner.[sup][7] The four RCTs, with a somewhat sexist slant, were named after flowers: DAISY,[sup][8] VIOLET,[sup][9] BEGONIA,[sup][10] and SNOWDROP.[sup][11] All RCTs were 24 weeks studies, conducted in women with premenopausal HSDD. The mean age of the women was about 36 years, and the mean duration of HSDD was about 5 years. All women in these studies were generally healthy, and so the findings of safety and efficacy cannot be generalized to women with medical and neuropsychiatric conditions, especially those receiving psychotropic drugs. The major outcomes were assessed in the last 4 weeks of treatment relative to baseline. …

Byline: Prakash. Behere, T. Sathyanarayana Rao, Akshata. Mulmule Life, as they say, is a gift from god and can be given only by him. Hence, taking away life and that too one's own, has always been forbidden. Suicide has, since times immemorial, been a topic of constant controversy and unending debate. Religion, monarchy, and colonialism all condemned and prohibited suicide. Suicide is defined as death caused by self-directed injurious behavior with any intent to die as a result of the behavior. Suicide attempt, on the other hand, is a nonfatal self-directed potentially injurious behavior with any intent to die as a result of the behavior. A suicide attempt may or may not result in injury. [sup][1] The people who committed or attempted suicide have always been the subjects of wrath of the religion bound societies in the past. Following this religious trail, lawmakers in the past, served punishments to both the bodies of the victims and the survivors of a suicide attempt. Sometimes even the surviving family members were punished for their act. But liberalization and education with the help of progress in understanding the underlying causes of suicide, has led to a change in this stance worldwide. Gravity of Problem There has been an alarming increase in suicide rates in recent years. There were 127,151 cases of suicide noted in the National Crime Records Bureau in 2009 which have increased to 134,799 in 2013. Suicide rate that is, the incidence of suicide per one lakh population, has increased from 10.9 in 2009 to 11.4 in 2010. Family problems and illness were the two major reasons for suicides, together accounting for 46% of all suicides. Drug abuse/addiction (3.3%), love affairs (3.2%), bankruptcy or sudden change in economic status (2.0%), poverty (1.9%), and dowry dispute (1.6%) were the other causes of suicides. [sup][2] Religion and Suicide Almost all the religions condemn and prohibit suicide with each having an elaborate description of the punishments incurred by the offenders in their respective hells. Hinduism believes in the individual turning into a ghost and wandering between the mortals and the heavenly till the time of their actual death as per fate, whereas Islam mentions the fate of the person who commits suicide, remains to repeat the same act by which he committed suicide till eternity in the fire of hell. Some religions, like the Jews, have discrimination against those who commit suicide in the form of separate burial away from the normal deaths and limited mourning rights to the kings. The Indian Law on Suicide and its Past The Indian penal code drafted in 1860 on the recommendations of first law commission of India established in 1834 under the Charter Act of 1833 under the chairmanship of Thomas Babington Macaulay came into force in British-ruled India in 1862. [sup][3],[4] It has substantially survived for over 150 years without major amendments in several jurisdictions. But there has been a need to rethink and amend several of its sections as per the prevailing societal beliefs from time to time. The recent amendment of the section 377 is one such example. As per the Indian penal code, 1860, chapter XVI of offences affecting the human body and of offences affecting life, section 309 deals with Attempt to commit suicide. It states that "whoever attempts to commit suicide and does any act toward the commission of such offence, shall be punished with simple imprisonment for a term which may extend to 1-year." [sup][5] This law has remained untouched and not amended for the past 155 years since it came into force, thus warranting a relook and repeal as per today's scientific understanding of the subject and societal attitude. Evolving Consensus Over the Years - World View Destigmatization of the act of suicide started with the pioneering work of Durkheim. His theory that external pressures or societal stressors, can contribute to suicidal behavior, increased awareness about suicide and helped to begin destigmatization. …

Introduction: India accounts for the highest estimated number of suicides in the World. In 2012, more than 258,000 of the 804,000 suicide deaths worldwide occurred in India. Early identification and effective management of suicidal ideation and behavior are paramount to saving lives. However, mental health resources are often scarce and limited. Throughout India, there is a severe shortage in mental health professions trained, which results in a treatment gap of about 90%. A comprehensive needs assessment was undertaken to identify the nature of the deficits in suicide prevention training for physicians in three Indian cities: Mumbai, Ahmedabad, and Mysore. Materials and Methods: The study was carried out in several concurrent phases and used a mixed-method approach of converging quantitative and qualitative methodologies. Data were collected using survey questionnaires, focus groups, consultations, and environmental scans. A total of 46 physicians completed the questionnaire. Focus groups were conducted in Mumbai and Ahmedabad with 40 physicians. Consultations were carried out with psychiatrists and psychiatric residents from hospitals and clinics in Mumbai, Ahmedabad, and Mysore. Results: Training gaps in suicide prevention exist across the health care professions. Existing training lacks in both quality and quantity and result in critical deficits in core competencies needed to detect and treat patients presenting with suicidal ideation and behavior. Only 43% of the surveyed physicians felt they were competent to treat suicidal patients. The majority of surveyed physicians believed they would greatly benefit from additional training to enhance their suicide risk assessment and intervention skills. Conclusions: There is a dire need for medical schools to incorporate suicide prevention training as a core component in their medical curricula and for continuing medical education training programs for physicians to enhance competencies in early detection and management of suicidal behavior.

Byline: T. Sathyanarayana Rao "Start by doing what is necessary Then do what is possible. And suddenly, you are doing the impossible." So goes a saying and has been our motto. Stepping into New Year, let me wish you all 'A Very Happy New Year' along with my team. It is also the time worth looking into what has been achieved and what you can look forward to in the coming year. Schedule All the issues of 2008, special supplement of January on Dementia and the January - March 2009 issue are already in our website and hard copies are being distributed to members at ANCIPS. The posting of copies will commence after ANCIPS 2009 conference. Possibly this is happening for the first time in the history of our journal. But this is a necessity rather than anything special because the above scheduling is essential if we are serious about getting the journal indexed. However, the general body has to look into this issue next year in view of elections due then. As the new editor needs time to settle, if changes do come about, a provision has to be made to the publication of the Jan-march issue by the previous editor himself, preferably before ANCIPS. I seek the permission of the esteemed EC and the members. Archiving the Journal I am very happy to present a DVD containing: *All the published issues of IJP since 1958-2008. A powerful search engine has been embedded to data mine based on titles, authors, abstracts and keywords. Many people have supplied the issues of the past journals but some names deserve a special mention. I am grateful to Dr. O. Somasundaram, who supplied majority of the issues, Dr. Chittaranjan Andrade from Bangalore and Dr. Smita N. Deshpande from New Delhi for supplying the journals from their private collections. *All the published issues of Indian Journal of Neurology & Psychiatry for the years 1949- 1953 edited by Dr. N.N. De and Dr. A.K. Deb respectively. It had stopped publication between 1954-1957 and it came out with the current name of Indian Journal of Psychiatry in 1958. I am grateful to Dr. Haque Nizamie, Director & Dr. D. Ram, Professor, Central Institute of Psychiatry, Ranchi for all the interest and effort in getting these copies scanned and transmitted to us for processing. The Commemorative Volume featuring 50 golden years was published in January 2008 and for those still missing the issue and interested in it, it is available as a supplement at our website. *As a service to the society, we have also included the clinical practice guidelines edited and published by Dr. Shiv Gautham & Dr. Ajit Avasthi for the Indian Psychiatric Society. It contains: *First Publication of 2004 covering 6 major disorders - Schizophrenia, Depression, Bipolar disorders, Obsessive compulsive disorders, Generalized anxiety disorder and panic disorder *Second Edition covering - substance abuse disorders, sexual dysfunctions & sleep disorders (2005) *Third Edition covering - Geriatric Psychiatry (2006) *Fourth Edition covering - Child Psychiatry (2007) I am grateful to Dr. Shiv Gautham & Dr. Ajit Avasthi for all the help and effort in getting the CPGs. *We have also included free the photo-directory containing the updated membership codes, names, addresses and photos of all the members in PDF format. I must thank our treasurer Dr. Asim Kumar Mallick from Kolkata and his team for all the effort and help. The preparation of the DVD was a mammoth task and I will be failing in my duty if I do not thank the whole team that put up their heart and soul in the task. I must thank in addition to Dr. O. Somasundaram, from Chennai, the PGI group led by Dr. P. Kulhara, Dr. Ajit Avasthi and Dr. Sandeep grover for the input which changed our archiving ways dealing with digitalization. Dr. Swaminath G. & Dr. Ajit Bhide have spent many hours and days to beat the deadline. …

Byline: T. Sathyanarayana Rao "Change is the law of life. Those, who look only to the past or present, are certain to miss the future". John F. Kennedy These thoughts are but loud thinking of a sort. Personally, my being in the field of psychiatry for the last 28 years I have seen the journal grow in leaps and bounds. I bow with reverence to the past editors who have strived to keep the journal in the forefront and as the true indicators of sweeping changes happening in our Indian society in general and the psychiatry, in particular. Quarter century may be a short period in the millennium but too important a time to be missed out. Last few years, in fact the journal has changed quite a bit for good - It can definitely rate among the best publications the world over - talk of the get up, available intellectual input and stimulating content. Hailing from the silicon valley of India, yet I felt we can make use of best available changes around us, particularly the information technology and its varied avatars. That is the stimulus for all the changes I am contemplating for the journal which I am narrating in this editorial. *Keeping in mind the developments internationally our journal will hence forth use online manuscript submission and electronic peer review system. (www.journalonweb.com). It is going to reproduce the function of an editorial office on the web, providing individualized password protected area of each authority (Author, Reviewer, Editor and Staff), Double-blind peer review, automated email notifications and reminders and MEDLINE links for editors and referees. The system requires web-browser and internet connection only and there no need of any special software or computer resources. With this change, there will be accessibility from any PC. No set business hours - Articles can be received and processed at any hour of the day, faster clerical work, reduced submission - decision time and authors can check and track the submitted articles. With this I am also contemplating best use of referees both near and far and their time, avoiding paper work and global authorships and referencing [Figure 1]. *Web site is being designed and should be available to all by early May, 2007. The full text of the articles will be available from www.indianjpsychiatry.org. We are aware that Researchers, as authors, require access to the largest possible audience to disseminate their findings; researchers, as readers, need the broadest possible access to the relevant literature. To the avoid the time lag the articles can be "published" - posted on the Web - as soon as it is accepted and prepared for publication. It is likely to provide faster dissemination of scientific information by expediting peer review, editorial and production work and distribution. …

Byline: T. Sathyanarayana Rao, Chittaranjan. Andrade The attention of authors and readers is drawn to two small but important changes that the Indian Journal of Psychiatry is implementing with immediate effect. The first change is that case reports will continue to be accepted for consideration by the Journal but, if accepted for publication, will appear only as letters to the editor; exceptions will be made only for reports that have high citation-worthiness. The second is that authors will be required to provide a complete declaration about their contributions to their submitted manuscript; this declaration will appear in the printed article. What do these changes mean and why are they necessary? With regard to the publication of case reports, the Indian Journal of Psychiatry is seeking its first impact factor rating, and this is expected in the next 1-2 years. The impact factor is calculated by dividing the number of citations to articles published in the journal (numerator] by the number of articles published in the journal (denominator) during a specified period of time, such as the past 2 years. The impact factor is a putative measure of the quality of the journal. [sup][1],[2] Case reports are rarely cited and hence seldom contribute to the numerator. However, case reports are counted among the articles published by the journal and therefore swell the denominator. Thus, case reports pull down the impact factor of the journal. [sup][3] Authors aspire to be published in journals with high impact factors; therefore, journals with low impact factors do not attract good manuscripts and consequently do not command much respect. Journals with low impact factors are also less likely to be read or purchased by libraries. [sup][1] Case reports that are published as letters to the editor do not compromise the impact factor because, whereas citations to these reports may be included in the numerator for impact factor calculation, they are not counted in the denominator. This is a win-win situation for authors and the journal editors and owners. It must also be recognized that case reports convey messages that, usually, cannot be generalized to populations of patients. By very virtue of their unusual nature, they do not usually advance knowledge in the field by much, nor do they usually carry much relevance to ordinary clinical practice. Case reports, therefore, do not justify being accorded the same space as regular studies, especially when, because of space restrictions, the publication of a case report would delay the publication of an important study to a later issue of the journal. For these reasons, all high-ranking medical journals either do not publish case reports at all or publish these only as letters to the editor. Some journals, in fact, publish case reports only in their online edition and not in the print edition. Given that the Indian Journal of Psychiatry is the longest-existing and the most prominent journal in the field of psychiatry in this country, and given that efforts are being made to secure a good impact factor, the Journal will no longer publish case reports as full papers. Rather, case reports will only be published as letters. …

Byline: N. Manjunatha, Murali. Thyloth, T. Sathyanarayana Rao The field of psychiatry is still growing; [sup][1] however, the phenomenal growth occurred in many areas in the field of Indian psychiatry in last decade. One of them is the increase in postgraduate seats (Diploma in Psychological Medicine (DPM)/Doctor of Medicine (MD)/Diplomate of National Board (DNB) of psychiatry to address the shortage of psychiatrists in our country. In curious latest development two medical institutes in our country started two super-specialties psychiatry courses (after branching out from department of psychiatry) in the academic year of 2011-2012 such as Doctor of Medicine (DM) (Geriatric Mental Health) at 'King George Medical University', Lucknow (http://www.kgmu.org/dept_geriatric.php) and DM (Child and Adolescent Psychiatry) at 'National Institute of Mental Health and Neurosciences' (NIMHANS), Bangalore (http://www.nimhans.kar.nic.in/cap/default.htm) for candidates of MD/DNB psychiatry. Other awaiting super-specialty psychiatry course is DM (Addiction Medicine) at 'National Drug Dependence Treatment Centre' of 'All India Institute of Medical Sciences', New Delhi and 'Centre for Addiction Medicine', NIMHANS, Bangalore. Debate *In an outlook it is a welcome step, however, authors consider this rise of super-specialties in still growing field of Indian psychiatry is a debatable issue. When our country is already facing 77% average national deficit of psychiatrists, [sup][2] will not this step lead further shortage of general psychiatrists in India? India is currently producing 357 MD (Psychiatry) and 129 Diploma in Psychological Medicine (DPM) per year in various medical college/institutes of our country. [sup][3] Along with these reasons and the migration of qualified psychiatrists to developed countries, will this step be a pragmatic one for MD psychiatry candidates to enter DM in these super-specialties? *Then, what is the need of having super-specialty psychiatric courses? Is there a demand for clinical service, if so, having separate clinic/unit in the psychiatry department (one of the requirement of Medical Council of India (MCI) to start MD psychiatry course) shall be sufficient. Is there a demand in research point of view, if so, developing a separate 3 years course is not justified? If the development for teaching purpose due to lack of expertise, having separate clinic/unit within department of psychiatry would suffice. Considering all above points, Indian academic psychiatry is not ready for premature branching out as 3 years DM course. It may be pragmatic to wait till required number of psychiatrists of India is available for clinical service. *Another important aspect of this development is the employability after their training. Authors tend to believe as not so lucrative for these super-specialties as there are already inadequate practicing general psychiatrists and inadequate teaching psychiatric faculties in medical colleges. *In view of public mental health, when India is struggling to provide primary care psychiatry and facing difficulty in the implementation of 'National Mental Health Program', can we afford to have these super-specialties in psychiatry which further reduces the human resources? Progress in Indian Medical Education with Respect to Super-Specialties Authors feel that the developing new courses with new name are becoming fashionable in the field of Indian education. Medical education of our country is not the exception for this and is already developed new courses in last few decades such as DNB, DM, Magister Chirurgiae (MCh), etc., Irony in this development is having same name (i. …

Byline: P. Behere, T. Sathyanarayana Rao, Akshata. Mulmule Introduction Manu Smruti described about women values in ancient time - " Yatr naaryastu pujayante ramante tatr devtaa ," that is Gods abound where women are honored, this was the ancestral enchanting in the land of Bharatvarsha (India) where gory heinous crimes against women and specially children are on rise these days. [sup][1] It is said that sexual abuse is the most common and threatening behavior calculated to induce fear in all women, it means men have chosen to maintain control over women. Rape is the fastest growing crime in the country. [sup][2] Rape occurs in India every twenty minutes. [sup][3] Ministry of Women and Child Development concluded that 53.22% of children reported having faced sexual abuse of which 21.90% faced severe form. [sup][4] Sexual abuse in children refers to sexual behavior between a child and an adult or between two children when one of them is significantly older or uses coercion. More than 70% of abusers are immediate family members and close acquaintance. [sup][5] There is hence a need to focus the enquiry on children. The perpetrator and the victim may be same sex or opposite sex. The sexual behaviors include touching breast, buttocks and genitals, whether the victim is dressed or undressed; exhibitionism; fellatio; cunnilingus and penetration of the vagina or anus with sexual organs or object. Sexual abuse may involve behavior over an extended time or a single incident. In addition to the form, inappropriate sexual touching, sexual abuse also refers to sexual exploitation of children for instance, conduct or activities related to pornography depicting minors promoting or trafficking in prostitution of minors. [sup][6] It is not just a phenomenon by itself but also has very serious and long lasting impact as psychological disturbances. Thus, ranges from anxiety to sexual dysfunction or post-traumatic stress disorder that follow sexual abuse. Research so far has concentrated on sexual crimes against women in the reproductive age. There is increasing incidences of sexual abuse in children today. This area is very sensitive. We should be receptive for early identifications and prevention of such incidences in girls in the community. How Big is the Problem? Child abuse in one or another form has existed in almost all societies throughout the history however, recognition of child abuse as a social problem is of recent origin. The research on child sexual abuse (CSA) in India has not received much attention this due to low reporting of victims . Nearly, 53% of children faced some amount of sexual abuse; among them 52.94% were boys and 47.06% girls. The significant finding was that contrary to the general perception, the overall percentage of boys was much higher than that of girls. Across the country, every second child is being subjected to one or other forms of sexual abuse and every fifth child is facing severe forms of sexual abuse. [sup][4] A total of 33,098 cases of sexual crime against children were reported in country in 2011 as compared to 26,694 in 2010 it means increase by 24%. Number of cases under procuration of minor girls increased from 679 (2010) to 862 in 2011, i.e., increase by 27%. A total of 7,112 cases of child rape were reported in country during 2011 as compared to 5,484 in 2010, increase by 29.7%. Sexual abuse is highest in Madhya Pradesh (1,262) followed by Uttar Pradesh (1,088) and Maharashtra (818). [sup][7] In 2011, more than 24 thousand cases were reported - about 70 a day. New figures released by the Delhi Police reveals that a woman is raped every 18 h or molested every 14 h. [sup][8] There are 80,000 pending rape cases in India and nearly 1,000 rape cases are pending in Delhi courts. [sup][9] Off late, we have seen some cases of CSA in Wardha district which is again a very traumatic event. The cases are yet to start in court. …

Byline: T. Sathyanarayana Rao, Chittaranjan. Andrade In this issue of the Journal, Berger [sup][1] presents his personal viewpoint on matters related to screening for future disease in the population, use of psychological tests for clinical purposes, and the limitations of psychotherapy as a clinical intervention. All the issues raised are important, and in this editorial we consider additional theoretical and practical matters that arise from the points that he makes. Screening for Future Disease Berger [sup][1] describes the results in New York of screening for Krabbe disease, an inborn error of metabolism. Only 24 babies tested positive out of about a million tested. Of these, 4 developed clinical features of the disease. Two of the 4 children died (one, of treatment complications) and the other 2 showed poor outcomes despite treatment. Parents of the children who tested positive were emotionally traumatized by the test results. So, was the screening cost-effective and did it serve the purpose? It appears not. Screening for disease in the population should serve a purpose. [sup][2] For example, the use of mammograms or cervical smears can identify breast or cervical cancer sufficiently early for intervention to increase life expectancy. Or, a negative test for Huntington's disease in a family member of an affected patient can offer immense relief whereas a positive test, while generating stress, would at least allow the individual the opportunity to plan for his future. Leave alone the risk of future disease, screening for early disease in medical contexts is itself not without controversy. Take women's health, for example. Benefits as well as harms have been described in relation to breast cancer screening; [sup][3] this is because no screening instrument is perfect, and false negatives and false positives (especially the latter, because they are more common) result in unnecessary interventions that are emotionally and physically damaging. A crude estimate obtained from available data suggests that, for every case of breast cancer mortality prevented, approximately, three women would have been unnecessarily identified and treated. [sup][3] Whereas, the outcome would be good for the one life saved, it would be traumatic for the remaining 3 women. With regard to men's health, prostate specific antigen screening has resulted in similar difficulties: There is no consensus that screening has improved survival, and there is no consensus on even whether or not screening should be performed. [sup][4] Unfortunately, there are no screening tests in psychiatry that reliably predict future disease. Indeed, the presence of the APOE epsilon 4 allele increases the risk of Alzheimer's disease, [sup][5] but the sensitivity, specificity, positive predictive value, and negative predictive value of this biological marker are too poor for screening for this allele to be of practical value. [sup][6] The same holds true for genes such as neuregulin, [sup][7] presenilin, [sup][8] dysbindin, [sup][9] DISC1, [sup][10] COMT, [sup][11] and others that have been found to be associated with schizophrenia. The situation is no different for other psychiatric conditions. At the moment, therefore, there does not seem to be hope for effective screening for future disease in psychiatry. The use of Psychological Testing for Diagnosis Berger describes the emergence of depression with suicidal ideation in an 8-year-old son of a woman with a history of major depression; neither family dynamics nor school issues could explain the child's depression. On the one hand, the positive family history notwithstanding, it is uncommon for clinical depression to emerge in one so young; so, a case might be made for psychological testing and probing for hidden sources of stress. On the other hand, given the apparent severity of the phenomenology in the child and the atheoretical nature of the current diagnostic systems (which dictate diagnosis based on phenomenology alone), surely immediate intervention was indicated, even if only of a psychological nature. …

Byline: T. Sathyanarayana Rao, Rajesh. Gopalakrishnan, Anju. Kuruvilla, K. Jacob Sexual health can be defined as 'a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. [sup][1] Many complex issues including sexual behavior and attitudes, societal and cultural factors, biological risk and genetic predisposition, mental and physical illness influence sexual health. The limited data from India are from nonsystematic surveys and opinion polls, which explore a limited and superficial range of issues. [sup][2],[3],[4],[5],[6],[7],[8],[9] Social, cultural, economic, psychological, and genetic factors, which affect desire, attitude, behavior and practice are rarely investigated. The silence of the Indian culture on issues related to sexuality compound many issues including help seeking related to neurotic and anxiety disorders (e.g., Dhat syndrome), the HIV epidemic, reproductive tract infections, sexual violence, contraception, abortion services and female genital mutilation. Despite the "Kama sutra", Indian society is extremely conservative about sex and is ambivalent about sex education in high schools. The barriers to sexual well-being include issues related to individual empowerment and choice, access to educational and clinical services, social stigma, discrimination and sexual violence. Even professional medical education does not transfer skill and confidence related to sexual health and sexual medicine. [sup][10],[11],[12],[13] The resultant vacuum is often exploited by "healers" who also propagate sexual misconceptions and misinformation. The cultural ambivalence and manifest conservatism result in a lack of political will to improve sex education in schools and formulate and implement policies related to sexual health. Existing Policies, Plans and Practice The National AIDS Control Program, with its focus on educating the general population about responsible sexual behavior, safer sex and condom use has had a significant impact. The reduction in the rate of HIV transmission in the country suggests success. [sup][14] The extensive treatment provision for HIV and AIDS is also an achievement. On the other hand, the National Family Welfare and the Reproductive and Child Health Care programs have focused on antenatal care, hospital deliveries, immunization and contraception with an emphasis on postpartum sterilization. Sex education in schools has met with resistance and has had a restricted impact across the country. Although India has some policies on paper, the approach is fragmentary. In addition, the principal thrust based on health, makes it one-dimensional and much less effective. Addressing Social Determinants Countries, which have accepted the need for a national policy, approach the task from a broad base employing multisectoral perspectives. The World Health Organization (WHO) has developed a framework, identified opportunities and challenges and recognized the need for contextualization and adaptation to cultural contexts in order to help promote appropriate, affordable, and accessible sexual health programs of high quality. [sup][15],[16] The WHO has argued for a broader context to sexual health going beyond fertility and reproduction and including sexual dysfunction, disability, sexual violence and sexuality. It has grounded the framework within international human rights and affirmed a rights-based approach to sexual health. The framework has argued for social determinants and includes: (i) law, policies and human rights, (ii) education, (iii) society and culture, (iv) economics, and (v) health systems. [sup][15],[16],[17] Legal mechanisms are crucial in introducing health intervention, protecting human rights and guaranteeing promotion, protection and provision of sexual health information and services. Laws can also help prevent discrimination related to sexuality and lifestyle. …

Byline: T. Sathyanarayana Rao, K. Jacob The shift in the understanding of homosexuality from sin, crime and pathology to a normal variant of human sexuality occurred in the late 20 [sup]th century. [sup][1],[2] The American Psychiatric Association, in 1973, and the World Health Organisation, in 1992, officially accepted its normal variant status. Many countries have since decriminalised homosexual behavior and some have recognised same-sex civil unions and marriage. The new understanding was based on studies that documented a high prevalence of same-sex feelings and behavior in men and women, its prevalence across cultures and among almost all non-human primate species. [sup][2] Investigations using psychological tests could not differentiate heterosexual from homosexual orientation. Research also demonstrated that people with homosexual orientation did not have any objective psychological dysfunction or impairments in judgement, stability and vocational capabilities. Psychiatric, psychoanalytic, medical and mental health professionals now consider homosexuality as a normal variation of human sexuality. Human sexuality is complex. [sup][2] The acceptance of the distinction between desire, behavior and identity acknowledges the multidimensional nature of sexuality. The fact that these dimensions may not always be congruent in individuals suggests complexity of the issues. Bisexuality, both sequential and concurrent, and discordance between biological sex and gender role and identity add to the issues. Medicine and psychiatry employ terms like homosexuality, heterosexuality, bisexuality and trans-sexuality to encompass all related issues, while current social usage argues for lesbian, gay, bisexual and transgender (LGBT), which focuses on identities. The prevalence of homosexuality is difficult to estimate for many reasons, including the associated stigma and social repression, the unrepresentative samples surveyed and the failure to distinguish desire, behavior and identity. The figures vary between age groups, regions and cultures. Medicine and science continue to debate the relative contributions of nature and nurture, biological and psychosocial factors, to sexuality. [sup][2] Essentialist constructs argue for biology and dismiss personal and social meanings of sexual desire and relationships. On the other hand, constructivists support the role of culture and history. While essentialism and constructionism, on the surface appear contradictory, they may mediate orientation and identity, respectively. Anthropologists have documented significant variations in the organisation and meaning of same-sex practices across cultures and changes within particular societies over time. The universality of same-sex expression coexists with variations in its meaning and practice across culture. Cross-cultural studies highlight the limits of any single explanation of homosexuality within a particular society. Classical theories of psychological development hypothesize the origins of adult sexual orientation in childhood experience. [sup][2] However, recent research argues that psychological and interpersonal events throughout the life cycle explain sexual orientation. It is unlikely that a unique set of characteristics or a single pathway will explain all adult homosexuality. The argument that homosexuality is a stable phenomenon is based on the consistency of same-sex attractions, the failure of attempts to change and the lack of success with treatments to alter orientation. [sup][2] There is a growing realisation that homosexuality is not a single phenomenon and that there may be multiple phenomena within the construct of homosexuality. Anti-homosexual attitudes, once considered the norm, have changed over time in many social and institutional settings in the west. However, heterosexism, which idealises heterosexuality, considers it the norm, denigrates and stigmatises all non-heterosexual forms of behavior, identity, relationships and communities, is also common. …