the guttering candle of trust

What is the difference between a doctor-patient relationship and a service provider-consumer one in the practice of Medicine?

I started working at a time when the latter didn’t exist in my profession. That was in the eighties. Good patient care was the only thing that counted, and making a diagnosis on the basis of history and clinical examination alone was a matter of pride. Ordering a hundred irrelevant lab investigations would have been considered a waste of patients’ money then. The attitude of patients, doctors and nursing staff towards each other was one of mutual trust and respect. Defensive medicine was unheard of. This is all true, not distorted by nostalgia.

Cut to today, and the question I started this post with. I must emphasize that this is just how I feel. This may be irrelevant to other doctors, especially those in other specialties. Dealing with patients with psychiatric problems requires a different sort of engagement. A patient cannot bare his soul to a doctor he cannot trust.

When a patient meets me for a consultation for the first time it is with faith that I will understand and resolve his psychiatric problem. My conscience responds to the trust in his eyes, and I feel an eagerness to help. A rapport is easily established. He tells his story. I write it all down, clarifying and processing as he speaks, finish the examination, and formulate a diagnosis. I answer questions about his symptoms and treatment, and give a prescription if necessary. I give him a rough timeline regarding prognosis, no guarantees. He accepts that. By then he is visibly relaxed, more hopeful. Supportive psychotherapy, a part of psychiatric treatment, is carried out in an atmosphere of trust and mutual respect, the patient’s for me as a professional, and mine for him as a human being. I spend the last few minutes of the session outlining the schedule for that.

When a customer/consumer/client meets me for a consultation for the first time he looks at me doubtfully, or with a forced smile, or even with frank mistrust. Then he sits down gingerly, pulls out his cell phone and shows me what he has downloaded from the internet, and tells me his diagnosis. Or he might hand me a sheaf of heavily highlighted print-outs. He’s done his research. Fair enough. “Anything else?” I say. “Can I call you by first name?” he asks. I know that this question is just a way of letting me know that he’s been sent to America a couple of times on work by the firm he works for (and this hint is supposed to convey something more about his place in the world), because this sort of familiarity is not the norm here, and being Indian, he very well knows it. He’s obviously approaching the consultation like a meeting between two people with equal knowledge, warily, as if a deal is being struck between a buyer and seller in which there is a risk of his being cheated.

The warmth and concern that I feel towards a patient just don’t well up in me when I’m faced with a consumer. And the mistrust in his eyes doesn’t engage my conscience at all. There is no rapport, only a job to be done. So I take the history and do a mental state examination in a neutral, clinical manner. Diagnosis made, questions answered, prescription given, effects of medicines explained. Check, check, check, check. Duty as service provider faithfully completed. Unless a positive change occurs during the session – which can happen for various reasons – it can’t be a very satisfying experience for either of us. And supportive psychotherapy is not possible because that requires empathy, something that is not generated in a buyer-and-seller type of transaction.


When I was a postgraduate student one of the prescribed textbooks was the Oxford textbook of Psychiatry, a regular-sized medical text book. In the newer edition, New Oxford textbook of Psychiatry that runs into two huge volumes, there is a chapter titled The psychiatrist as manager that wasn’t in the old one.

Regarding Managed care* the authors say:

  • Managed care is the use of business managerial principles, strategies and techniques in health care.
  • Essentially, it is a reform of health care from its longstanding not-for-profit business principles into a for-profit model that would be driven by the insurance industry or governmental bodies ruled by the same principles.

This is the difference between then and now, patient and consumer, doctor and service provider, as I see it.

Regarding Quality management** the authors say: Excellence relies on a few fundamental concepts:

  • Results Orientation: Excellence is achieving results that delight all the organization’s stakeholders.
  • Customer Focus: Excellence is creating sustainable customer value.

Who are the organization’s stakeholders? Who are the customers? Hospital owners and patients respectively, I suppose. So patients bring sustainable customer value to give delightful results to the hospital owners? Unless I’m taking this jargon too literally, something doesn’t seem right with this paradigm in terms of caring for sick people.

Using the word customer (= a person who buys goods or services from a shop or business) in place of patient (= one who is suffering) seems to trivialize his suffering, although taken literally, the patient is buying a service. It’s as if compassion, empathy, the patient’s dignity, and ordinary niceties no longer have a place in this highly commercialized world of healthcare, where sick people are mere commodities to profit from.

Why has this happened? Is it plain greed? Is it part of the rampant corruption in our country? Or is it genuinely related to inflation? Is it because doctors run hospitals not in their capacity as medical people, but as businessmen? Or because people who own and run hospitals are not doctors at all? Could it be the numbing, desensitizing, faith-eroding effect of the large amounts of violence and injustice we all are exposed to in the form of news, television serials, computer games and movies? All of the above?

To get back to the point, people tend to give up on institutions that let them down too often. Adding to patients’ crisis of faith is public perception of hospitals as being more focused on profits than on healing, because incidents of patients being greatly overcharged for medical devices like coronary stents and knee implants, and consumables like syringes and needles are frequently being reported in the press today. Information about deleterious effects of prescription medicines, although often incomplete and misleading, is available on the net and people are more reluctant to take them. From what I hear from my own relatives and friends, people now have considerably lower expectations of doctors and hospitals, and some are openly cynical.

The trust between a doctor and patient — ­that was almost a given in the eighties — is now a guttering flame that I have to fan to life with almost every new case. While the blinkered juggernaut of allopathic healthcare barrels down its chosen route, patients are skipping out of its way by switching to alternative medicine for everything except the most acute medical problems. As a doctor I think they are throwing the baby out with the bathwater, but it’s going to be hard to convince them that many of us do abide by medical ethics. It is probably too late to win back their trust when it has reached a point where the government has had to step in with regulations to cap prices of drugs, medical devices, diagnostic services and treatment procedures, making newspaper headlines every day.

Of course, once we are totally replaced by Artificial Intelligence and robots, none of this will matter. Nobody can halt the inexorable advance of research in AI and people working in that field believe they are on to a good thing. Like driverless cars. Doctorless patients. Currently, computers can only analyze structured data, but it’s just a question of time before they are programmed to handle unstructured data generated by doctors’ observations and conclusions in individual cases. Sophia and her ilk can do the job. Doctors can be phased out. Going by the optimism and excitement in AI, I presume they will take care of sick people so perfectly that res ipsa loquitur will become redundant and the OED will call iatrogenesis an obsolete word.

Branches of study like Biomedical Engineering already exist in engineering colleges in India, and inter-professional programs are already part of medical curricula in many medical colleges in the US. So this change from the traditional practice of Medicine is bound to occur. This is the future, but thankfully not my future, so it has the feel of something viewed on a screen or imagined while reading a book. Anyway, I hope all this makes health care more accessible to the poor, that’s all.

* New Oxford textbook of Psychiatry, Vol 1, 2nd ed, page 45

** New Oxford textbook of Psychiatry, Vol 1, 2nd ed, page 43


our choices – and mental health

I feel like a Grinch writing this in the festive season, but the ‘Sale!!!’ signs are getting to me, because that’s all festivals seem to be reduced to. Buy, buy, buy.

I used to think advertising was about spreading information about a product, but now I know better. It’s about keeping us discontented and hankering for more. If we get tempted by advertisements and go broke there’s no one to blame – we did have a choice, right? So, if we aren’t alert, we actually have as much choice as a child with an open cookie jar within reach!


While on the subject of choice, look at this: everyone knows that wearing a helmet while riding a bike can protect their heads in case of an accident. But nobody in Bangalore wore helmets even when the statistics were heavily publicised. In September 2015 a law was passed to force motorcyclists to wear helmets. Though it stands to reason, people didn’t take that to mean that the pillion-rider should also wear one! So in January 2016 another law was passed to that effect. Not that it always works (pic above).

IMG_6706Now something has to be done about the helmet-less little children who ride in front of the rider (as in picture above), or squeezed in between the rider and pillion-rider! And people who carry their helmets in their hands (as in pic). 

Ideally, everything should be left to choice and common sense, but it doesn’t work. So, when push comes to shove, the government takes over and decides for us. So there’s no choice, no absolute freedom really, to break our head in a bike accident. The same thing happens with freedom of speech, freedom to live legally in a country with the right visa, and other freedoms we misuse.


World peace. Human rights. Poverty alleviation. A government that has been voted to power in a democracy. NGOs. Philanthropists. All these words suggest that there are nice people making fair choices for humanity as a whole. Altruistic folks who want to mitigate human suffering and make the world a peaceful and equitable place. But how much choice do they have when faced with ruthless lobbies that influence government policies? Especially when the lobbyists are more important to the economy. Peaceful, contented people are not good for the economy, people who keep money in circulation are.

Think what might happen if an activist fought for our garment industry workers’ human rights in India. Or someone owning prime land in Bangalore refused to sell it to a builder with connections. They would get warning calls from unknown people, and then some. And a journalist trying to expose a business-government nexus that hurts ordinary citizens is always a sitting duck. No, these well-meaning folks don’t have much of a choice. Lobbyists always get their way because the government knows which side of its bread is buttered.


Moving beyond the local, the US had a choice to not sell US$110 billion worth of weapons to Saudi Arabia. But then, I guess big companies like Lockheed Martin, Raytheon and Boeing would have lost out on profits, and their employees been out of jobs. To me, this seems like a good reason for selling, apart from having the Saudis fight their proxy war against Iran in Yemen. Also, perhaps the possibility of lucrative contracts to re-build the destroyed countries, something that usually follows use of weapons of mass destruction.

Choices involving thousands of innocent lives are made based on material gains of some sort, and don’t seem to have any moral underpinnings. That’s how it seems to me, an ordinary Earth citizen, a mere observer of events. Words like ‘big business’ ‘big government’ and ‘big pharma’ make me uneasy because the choices they make can have seismic effects.


So, is there a place for teaching children to be good girls and boys in today’s world? Believe me, I faced this dilemma all through my children’s school years. By trying to raise children to be good – as ‘good’ is generally understood – are we setting them up to be misfits or wimps and fail in today’s world? Pure 24-karat gold is too soft to be fashioned into jewellery. Lesser metals like silver, zinc or nickel have to be added to make it 22-karat, for it to be crafted into durable jewellery. I think I just hoped my kids would pick up the silver, zinc and nickel on their own in adapting to the world.

Or have we pragmatically scrapped the whole business of goodness and switched to simply teaching them consumerism? Looking around Bangalore’s shopping malls, massive hoardings and the monstrous garbage heaps all over the city, I suspect this is what is happening.


What bothers me is that Earth Overshoot Day was on 2nd August this year, and has been coming earlier every year. That means, on 2nd August our resource consumption for this year exceeded Earth’s capacity to regenerate them! Ideally, this date should be at the end of December. It was 20th October in 2005, 21st Nov in 1995 and the third week of December in the mid-eighties.

When I look at all those cotton clothes in store windows, I wonder how much water and labour it takes to grow and pick cotton in India. It takes about 35 cotton-bolls to make a tee shirt (a boll weighs 2-6 grams, a tee shirt about 150 grams), I’m told. Why is there such a glut of clothes in the world? What happens to unsold clothes, those left over after discount sales? Actually, I find everything is in excess – like electronics, packaged foods, shoes, LED lighting in malls, cosmetics… I know people are happy to have a wide choice, and these industries generate jobs for millions of people – so is it all right for our generation to overuse Earth’s resources? And is the guiding principle of shopping greed, and not need, because it is tacitly – no, quite overtly – encouraged by our way of life?

I’m not much of an activist. All I do is follow the reduce-reuse-recycle mantra, compost part of the kitchen waste, and stick to need-based shopping, an adaptation of the Hippocratic oath, ‘first, do no harm’. And I send a bag of vegetable and fruit peelings from my kitchen to my maid’s neighbour’s cow every day; at least one cow in Bangalore gets to eat a little bit of something nutitious, rather than discarded plastic bags. One only needs to google images of ‘cows eating plastic’ to know how rampant it is.

I am aware that there are people actually doing things that make a difference in small and big ways all over the world. Vigga Swensen (Denmark) and Justin Bonsey (Australia) are two people whose initiatives I came across recently. Vigga’s is a little tricky as some people may balk at the very notion of dressing their babies in used clothes. Justin’s initiative could be adopted in cities anywhere:


The WHO defines mental health as ‘a state of well-being in which an individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community.’

The WHO also acknowledges that ‘poor mental health is associated with rapid social change, stressful work conditions, gender discrimination, social exclusion, unhealthy lifestyle, risks of violence, physical ill-health and human rights violations.’ We, the ordinary citizens of India, are plagued by every one of these.

Can universal mental health ever become a reality considering the individual choices we make in our daily lives, and the choices that people in government make, whether it is Kim Jong Un, Xi, Maduro, Trump, Netanyahu, Nigel Farage, or the politicians who have led India for the past seventy years? Moreover, will the economy survive the impact of contented people who will not buy expensive branded clothes to feel more confident, join pricey gyms for the ‘perfect’ body, eat at fancy restaurants to upload photos on facebook, buy the latest cell phones for bragging rights, and so on?





when seeing a psychiatrist might help

(When I browse the net, or listen to people, I find that many think Psychiatry is about Freudian theories, ‘chemical imbalance’ and dangerous medicines that turn patients into zombies. This post is for anyone who might want to know how psychiatrists deal with mental illness.)


People sometimes tell me they don’t believe in mental illness.

I think that’s a reasonable belief to hold if one has never had a brush with it, never known anyone with a mental illness, nor heard of people like John Nash.

As a psychiatrist, I view mental illness like any other medical problem. But this is only the starting point of the treatment algorithm.

An orthopaedic surgeon fixes a broken humerus, depending on

  • the position and type of fracture,
  • the degree of displacement of the fragments, and
  • the intrinsic stability of the fracture.

To treat a patient with a disruptive break in the normal tenor of his life I look at the same parameters as the orthopaedic surgeon, viz.

  • position and type of break, i.e. whether it is psychotic, depressive, anxiety-related, relationship-related, etc.,
  • degree of displacement, i.e. how much it has thrown his life is out of whack, and
  • intrinsic stability of his psyche, i.e. what are his strengths and what support he needs.

And these are the things I may do:

  1. prescribe medication, or admit him for in-patient treatment,
  2. help him keep his life together, like the plates, screws and cast that keep the broken ends of a bone in contact, until he’s able to cope (supportive psychotherapy) ,
  3. help him learn how to protect what is broken and re-set, the way an orthopedic surgeon might suggest a safe sleeping position with a fractured collar bone (cognitive therapy).

But of course, this is not all there is to it.

The International Classification of Diseases, or ICD-10, defines a mental disorder as ‘a clinically recognisable set of symptoms or behaviours associated in most cases with distress and with interference with personal functions.’

The American Psychiatric Association makes it simpler, saying ‘mental illnesses are health conditions involving changes in thinking, emotion or behaviour (or a combination of these). Mental illnesses are associated with distress and/or problems functioning in social, work or family activities.’

These bland definitions don’t reflect how devastating mental illness is.

  • It is not just thinking, emotion and behaviour, but the patient’s integrity as a human being that is at stake: he cannot control his mind, the very essence of who he is.
  • And it is not merely problems functioning in social, work or family activities, he can’t even understand what’s going on within him. It is distress with a capital D.

People are confused about whom to go to for anything that bothers their minds. This lack of clarity is because the roles of psychiatrists, psychologists and others who help the mentally troubled have been blurred in recent years. Obviously, they all don’t do the same thing, but offer help in different ways.

As a psychiatrist my way is to treat mental illnesses with medication and psychotherapy. Though the earliest psychiatric medicines were serendipitously discovered, specific medicines have been introduced through research since the 1950s. They work. I have seen them work.

Used judiciously, medicines are very effective. To appreciate their value one only has to remember what happened to the mentally ill before the 1950s. Patients don’t come back every month to pay me a social visit; they come back for review and prescriptions because they can see the difference, after the hell they and their families have been through before taking medicines.

I discuss both therapeutic effects and short- and long-term side effects with my patients, and they are willing to take their chances. There is a great deal we don’t know about the workings of the mind, but I explain in simple terms what might be happening in their brains. If nothing else, this allays the guilt that they somehow caused their own mental illness. Some of them are relieved that medicines exist because they’ve come with the expectation of ‘electric shock treatment’, thanks to movies!

The much-maligned term ‘chemical imbalance’ is just shorthand for reassuring patients that maybe a small brain process is affected – or ‘balance’ if you will – and they don’t have lesions like tumours in their heads, as some think. I use this term only when patients request CT scans of their heads to see what is wrong with their brains, or ECGs to figure out why they get palpitations during panic attacks. I need to convey that they can’t see it, any more than diabetics can see the defect in their pancreas on a scan.


So, what are mental ilnesses?

The DSM-5 (Diagnostic and Statistical Manual, 5th edition) and the ICD are the two classificatory systems in use. I will highlight mental illnesses most commonly seen in practice and, just for convenience, follow the order in which they appear in the DSM-5.

I hope this helps.

The DSM-5 starts with the category of Neurodevelopmental Disorders.

When brain and nervous system development are disturbed during foetal life children can manifest any of these problems:

  • intellectual disabilities
  • inattentiveness and hyperactivity
  • problems recognising letters and numbers as in specific learning disorders
  • odd behaviour as in autism spectrum disorders
  • problems in physical coordination

There are special centres that care for children with these disorders. Keeping them on our radar is important because ongoing research has definitively shown that they have a biological basis, which means they may be preventable some day.

Of these, children with Attention Deficit Hyperactivity Disorder do well with medication. A detailed history from parents, a clear description from the class teacher, and my observation of the child over the 30-40 mins I spend with him and his parents are carefully weighed before reaching this diagnosis. No child should be given a medication unless it is fully justified.

Most children with mild ADHD settle down without medications by the time they are eight or nine years old. So I prescribe medication only if the ADHD is moderate-severe, which is a clinical judgment. Almost every child I have prescribed medications for has shown a marked and sustained improvement with medication. There are known side effects that I minimise by using lowest possible doses and allowing drug holidays. The diagnostic validity of ADHD is constantly being questioned, and many people call them ‘indigo kids’ and have them home-schooled. I understand that sentiment too.

The DSM-5 then moves on to Schizophrenia spectrum and other psychotic disorders.

These illnesses affect about 1% of the human population and are characterised by delusions, hallucinations and disorganised speech and behaviour. However, before making a diagnosis, it is important to rule out brain pathology like a tumour, infection, or the use of street drugs that present with similar symptoms.

An example: Some time ago, a middle-aged man was brought to me with complaints of sudden change in behaviour, uncharacteristic violence and incoherent speech. History and physical examination led me to a provisional diagnosis of meningitis, possibly tuberculous. I immediately had him seen by a physician, who concurred. The diagnosis was confirmed by lab and radiology, and treatment started.

Once schizophrenia is diagnosed, antipsychotic medicines are given and the patient returns to nearly normal in a few days. Medicines need to be continued and they improve quality of life in the long term. Of course, there are side effects, but they get better with time.

The only really terrible, irreversible side effect of some antipsychotics is Tardive Dyskinesia – jerky movements – that can develop in patients who have been taking antipsychotics for a long time. Reports regarding its prevalence vary widely and there are no approved treatment methods, except to switch to a drug that is less likely to cause TD. This is a highly unsatisfactory state of affairs that has no solution at present. Of the hundreds of patients I have prescribed antipsychotics for over the years I have seen only two cases of TD. I cannot predict who will develop TD any more than someone can predict who will develop leukaemia, nor can I withhold antipsychotics within the medical framework of treatment.

The third part of treatment is counselling family members. This includes explaining the illness, answering their questions, and giving them guidelines for keeping him stable. Often family members are under tremendous stress and need support too.

The next category in the DSM-5 is Bipolar and related disorders.

Bipolar Disorder is common, affecting about 2.5% of the population worldwide. Wild, uncontrollable variations in mood, or mood swings, are a distinctive feature of Bipolar Disorder.

Medicines control mood swings quite well. They are far from perfect, but patients are grateful they work as well as they do. They are glad they don’t have to get up in the morning dreading what mood they may get sucked into that day. They don’t live in fear of breaking down and howling for no discernible reason, or going into a ‘high’ and doing something regrettable. Medicines do give them the stability to live and work as they wish. But none of them will take to the internet to write an ode to Lamotrigine or Lithium, which is probably why one only comes across diatribes against psychiatric medicines on the net.

Mood disorders sometimes present with high-risk behaviours like attempting to jump off the top of a multi-storied building with the happy conviction that one can fly, or suicidal attempts due to deep depression. These are treated as emergencies. The patient is out of touch with reality and has to be protected. A brief history is obtained from the attendant and the patient is sedated. A detailed history and relevant investigations to rule out epilepsy, endocrine disorders, brain tumours or substance abuse must follow.

When the patient is stable he needs counselling to understand his illness. His family has to be taught to recognise behaviours that presage a relapse. The family often needs emotional support too. All of these are the responsibility of the treating psychiatrist.

The next category is Depressive Disorders.

I view depression more as a symptom than a diagnosis. Just as ‘fever’ and ‘headache’ cannot be diagnoses, depression points to an underlying medical or psychological problem.

When a depressive episode has lasted longer than two weeks it is called Major Depressive Disorder. In some cases there are obvious triggers. In others the low mood seems to just come out of the blue. In some, long-suppressed anxiety may have led to depression. Depressive episodes can usually be dealt with by medicines/counselling, though some patients require long-term psychotherapy. A lot of what is labelled ‘depression’ by people are just the normal vicissitudes of life, and temporary. Everyone needs a patient ear and a shoulder to lean on at some time in their lives, and with the dissolution of the joint family system, outside help may be needed.

That brings me to something I have been confronted with several times over the years. Patients, especially smart and sensitive young people, telling me they are depressed because life is pointless: study, earn, marry, have kids, buy house, buy car, go on exotic holidays, then what? Of course, the depression is real and does benefit from psychotherapy, but it is not a mental illness. Perhaps there should be consultant philosophers to answer these existential questions!

Still, it is important to be alert to symptoms and signs of physical illness. Why, even vitamin deficiencies or anaemia could present as depression!

Here is an example: A 56-year-old man with no past history of depression presented with repeated expressions of suicidal intent. His wife was in tears while he answered my questions tonelessly. From the history and examination I reached a provisional diagnosis of hypothyroidism and sent for necessary lab tests. The diagnosis was confirmed. I referred him to an endocrinologist and reassured him and his wife that it was a common problem – like diabetes – and he just needed a medicine for his thyroid problem.

Another case: A few years ago I saw a 60-year-old woman who was facing a bad life situation and had symptoms of depression. There was no past history of depression. A week later she had marked memory loss that couldn’t be explained as dementia or pseudodementia. I referred her to a neurologist and the diagnosis was Creutzfeldt-Jakob disease, a rare degenerative brain disease whose prevalence is one in a million per year. She passed away in six months, life expectancy after diagnosis being less than a year.

Psychiatry is a branch of medicine. It is imperative to rule out possible organic causes before diagnosing mental illness. Having said all that, I must emphasise that there are a significant number of patients who fit the diagnosis of ‘dysthymia’ and remain depressed for years. They do well with a long-term maintenance (small) dose of an antidepressant, but relapse on stopping the medication. Therapy helps. Some patients say they benefit greatly from yoga and meditation.

The next category in the DSM-5 is Anxiety Disorders.

Under this rubric are many conditions whose hallmark is crippling anxiety. Therefore, treatment depends on the specific diagnosis. They usually need a short course of medication to control anxiety, followed by therapy.

Obsessive-Compulsive and related Disorders is the next category of mental illness listed. This includes trichotillomania (hair-pulling), excoriation (skin-picking) and body image distortions.

As the prevalence of OCD is 2-3% of the population anywhere in the world, it is rather common and presents with a variety of symptoms. However, as symptoms come in phases, patients initially dismiss them as habits that will go away in a few months. So they often come for a consultation many years after onset.

Medicines work extremely well in more than 90% of patients. They are happy to get their lives back on track, with no unwarranted worries about checking locks, replacing objects just so, repeatedly washing hands, counting stuff, time-consuming rituals, useless rumination, etc. But when realisation dawns, there is much regret about grades lost, opportunities missed and suffering endured over the years, especially as the average age of onset is about the time kids are in high school or college. Awareness about OCD has risen enough for the acronym to have entered common parlance. It will hopefully translate into early treatment of sufferers.

Well, there are several more categories listed in the DSM-5, but they are not common in clinical practice and can be dealt with better by clinical psychologists, sexologists, or by a team of people from different disciplines in Psychiatry departments of hospitals, for example Eating Disorders, Substance-Related Disorders, Sexual Dysfunctions and Relational Problems.

Regarding Sleep-Wake Disorders, insomnia connected with anxiety and depression usually gets better with treatment of the underlying problems, but primary insomnia is harder to treat. Patients are first advised to maintain ‘sleep hygiene’ for a few days and see if it makes a difference. If there’s no change, a trial of a hypnotic is given for a maximum of one month, which sometimes seems to reset the sleep rhythm. However, this could be a placebo effect. If this happy outcome does not take place I refer them to a clinical psychologist for cognitive therapy. A sleep study in a sleep lab may help find the cause, but that can wait.

Sleep-wake disorders have a biological basis in circadian rhythms, an area of active research. In fact, this year’s Nobel prize for Medicine went to people working on circadian rhythms.

The last category I want to draw attention to is Personality Disorders.

These are people whose way of being doesn’t fit in with what is considered normal. Their problems usually arise when they have to interact with people, because of being any of these: aloof, mistrustful, awkward, remorseless, deceitful, intense, unstable identity, attention-seeking, grandiose, inhibited, submissive, clingy, rigid, perfectionistic.

Most of them function as well as ‘normal’ people a lot of the time. Like anyone else, they come for a consultation when they have a problem and are upset – angry, sad, anxious, confused, sleepless, unable to concentrate. The personality traits that have caused them grief become apparent to me during the next two or three review visits. However, they are satisfied when their presenting symptom is taken care of and are not interested in going deeper.

Some of them are prone to brief psychotic episodes lasting a couple of days at a time, when they lose touch with reality and become angry, violent, destructive or suicidal. This is how they wind up being brought to the hospital in an emergency.

When an unusual crime is committed, ‘mental illness’ is often the first conclusion, e.g. Stephen Paddock in Las Vegas recently. Even if Paddock had inherited a genetic predisposition to Antisocial Personality Disorder from his father’s side it need not have manifested at all. He functioned well enough for 64 years. Looking at his life from other angles, contributory factors could be:

  • sociological – family background and milieu
  • psychological – childhood, parenting, risk-taking behaviour
  • medical – use/abuse of a psychotropic drug
  • ?religious – apparent lack of a moral compass
  • ?philosophical – lack of direction

A prescription for Valium dated 10 June 2017 was found in his hotel room. Had he been diagnosed dangerously mentally ill, he wouldn’t have been prescribed only Valium. Since no motive has been established, what if Valium use/abuse triggered aggressive behaviour?

Whereas Devin Kelley, who sprayed bullets into a congregation in a church in Texas  a couple of days ago, was certainly mentally ill, going by his history as reported in the media.

Is the human race getting more despicable, or are people simply adapting to the rot they are steeped in? Integrating education, psychology, sociology, religion, ethics, environmental science, economics and political science (and whatever else) into a ‘theory of everything’ to raise children well – maybe this should be the job of people working in public mental health. ‘Can a bent plant be straightened after it grows into a tree?’ is a Kannada saying that sums it up well. Apparently it can, but needs the botanical equivalent of therapy.

Psychiatrists are frequently accused of medicalising mental illness. Yes, I certainly believe there is biology underlying every single thing that happens to a human being. Why not, when the body is made out of oxygen, hydrogen, carbon, nitrogen and other elements? For example, it was suspected from the 1800s that schizophrenia has a biological basis, but facilities for research were inadequate; now there’s a huge body of research that proves schizophrenia is a neurodevelopmental disorder. The exact neurobiology of mental illnesses is something we must continue to look for, not give up on.

Decades passed between Dalton’s introduction of his Atomic Theory and the discovery of leptons. Complicated computer codes are ultimately just arrangements of 1s and 0s, and Artificial intelligence using just 1s and 0s is now set to replace human minds. (I can’t help thinking Elon Musk, Stephen Hawking and Bill Gates may be right in cautioning AI enthusiasts, though.) Everything has a starting point, things don’t suddenly appear out of thin air, and researchers in every field try to get to the bottom of things.

To conclude, I believe that psychiatry is a medical discipline and psychiatrists can only

  • recognise and institute management of medical problems that present with mental symptoms,
  • intervene in crises like psychotic breakdowns, manic episodes and suicidal attempts, where patients are in physical danger,
  • treat mental illnesses that interfere so much with a patient’s biological, social and occupational functioning that he cannot have anything approximating a normal life without the help of medicines, and
  • provide counselling and supportive psychotherapy of an eclectic kind that includes elements of cognitive therapy, interpersonal therapy and gestalt therapy.







the bhavana case – or should it be called the sunil case?

On the night of February 17th a young actor from Kerala, Bhavana, was raped by six men. She was in her car, being driven from Kochi to Thrissur. It was a planned attack by her driver, Martin, and her former driver, Sunil, whose services she had terminated as she had come to know that he was a suspect in a murder case.

Why did Martin agree to Sunil’s plan instead of warning his employer? What is the equation between these two men apart from the fact that Sunil got Martin his job?

People trust their drivers. To the best of my knowledge, such horrendous incidents are not commonplace, though in clinical practice I have seen a significant number of women who have been abused by drivers and servants as children. Now, mothers often go along when drivers drop off and pick up their kids from school. This practice has been prevalent for many years now.

There was no way Bhavana could have suspected Martin, not even when he got out of the car to investigate the staged accident. How can we run background checks on our employees before hiring them, because nearly everyone can produce a fake good reference? And how reliable are our instincts, especially when dealing with experienced conmen?

Is this case about Bhavana or about Sunil? Bhavana was the unfortunate victim. She didn’t do anything wrong. Is Sunil a case of antisocial personality disorder – otherwise known as psychopathy?

  • police say he’s a rowdy sheeter
  • is a suspect in another murder case
  • has planned and executed this incident
  • no remorse, no empathy

Sunil’s sister has said to the media that “he doesn’t share good relations with the family since he turned 17.” Further information is not available, but it seems unlikely that they had only minor disagreements.

Psychopaths make up about 1% of the general population and as much as 25 % of male offenders in correctional settings. Dr. Robert Hare, the psychologist who came up with the 20-item test called the Hare Psychopathy checklist, says psychopaths may be a result of an evolutionary survival mechanism. This article appeared in ‘The Independent’ in 2012.

Is he right? Are people’s aspirations, ambitions and need to survive in an increasingly expensive and competitive world generating adaptive mechanisms that belong in the *psychopathy checklist? Maybe not the full-blown psychopath personality, but just traits getting exaggerated?

Dr. Liane Leedom, a psychiatrist, and Linda Hartoonian Almas, an educator with criminal justice experience, who has worked as a police officer, have explained psychopathy from a behavioural sciences perspective. They say it is not an adaptation but an aberration. This is how they explain it.

There are four social behaviour systems involved in adaptation:

  • attachment system
  • caregiving system
  • dominance system
  • sexual systems.

Psychopathy is associated with excessive sexual responses, lack of caregiving, and aberrant dominance responses. ‘Caregiving’ behaviour, however, may be used to gain power and dominance, so the recipient of the ‘care’ may be fooled until the psychopath’s objective is achieved.

Here’s the link to their article:

In 2006, during a genetic imaging study in which he was a control subject, Dr. James Fallon, professor of psychiatry at UC Irvine, discovered that his brain was similar to the brains of psychopaths!

In 2013 he gave a TED talk on exploring the mind of a killer. He mentioned the interaction of risk genes, brain damage and the environment, that result in psychopathic behaviour.

This is his conclusion regarding why he became a successful neuroscientist and family man instead of a psychopath.

“But why, in the light of the fact I have all of the biological markers for psychopathy, including a turned off limbic system, the high risk genetic alleles, and the attendant behaviours, including well over half of those listed in the psychopathy tests and low emotional empathy, did I turn out to be a successful professor and family man? One most likely reason is that although I have the genetic makeup of a “born” psychopath, some of those very same “risk” genes in someone showered with love (versus abuse or abandonment), from childbirth through the critical first few years of life, appear to offset the psychopathy-inducing effects of the other “risk” genes.”

As I’ve said in an earlier blog post, being born with the risk genes for psychopathy doesn’t mean the condition has to manifest.

To think that one man’s warped mind came up with a callous, inhuman and remorseless plan that needlessly devastated an innocent young woman. There are strong rumours that Sunil was paid to do this, but the fact remains that he had no qualms about going ahead with it.

*Psychopathy Checklist:

Arrogant and Deceitful Interpersonal Style

Glibness/Superficial charm

Grandiose sense of self-worth

Pathological lying


Deficient Affective Experience

Lack of remorse or guilt

Shallow affect

Callous/Lack of empathy

Failure to accept responsibility

Lack of realistic long-term goals

Impulsive and Irresponsible Behavioural Style

Need for stimulation/Proneness to boredom

Parasitic lifestyle



A little about taking medicines for depression and anxiety

‘Depression’ and ‘anxiety’ are two problems for which people often seek help. Help from family physicians, counsellors, psychologists, therapists, psychiatrists, reiki experts, yoga teachers, NLP practitioners, astrologers and a host of other possibly helpful people.

Very depressed people don’t much care what happens to their lives, and very anxious people can barely listen to anyone, even if they try. It’s difficult to reach them. Medicines can bring down depression or anxiety enough to help the patient think a little more clearly, and listen to what people concerned about his wellbeing are telling him.

Many antidepressants reduce both anxiety and depression. Extremely anxious people may need an additional dose of an anti-anxiety medicine for a week or two.

  • Antidepressants are not addictive and are usually given as a course for a few months.
  • Side effects usually appear at the beginning of treatment, last just a couple of weeks or so, and get lesser day by day. In case they don’t go away, there are other options.
  • Side effects cause some discomfort, but don’t affect work – and life in general – enough to discontinue their use. You don’t have to throw the baby out with the bathwater.
  • Therapeutic effects are seen in less than a fortnight with some antidepressants, although some can take up to 1½ months to make a difference.
  • The choice of medicine depends on what side effects you are trying to avoid.

These medicines are like an umbrella. Under their calming influence a patient can sort out his life. He can do this either on his own – by coming up with better ways of coping, or by talking things over with his psychiatrist, a psychologist or a therapist. And really, if the depressive episode or anxiety attack was brought on by a situation, talking things through with a friend may be enough!

He can explore meditation, yoga or any other lifestyle changes that he finds useful, and make them a part of his life from then on. If he can figure out what triggers anxiety or depression in him, that’s useful too.

More medicines to combat side effects of psychiatric medicines – isn’t that unfair?

This seems like the ultimate injustice, if I go by people’s blogposts.

Actually, there are very few situations where this needs to be done. It usually happens with antipsychotics, the strong medicines used to treat severe conditions like schizophrenia.

We can’t inject medicines directly into thousands of those tiny synapses (the little spaces where two nerve cells in the brain meet and communicate through chemicals) that are defective in schizophrenia. Orally administered medicines go all over the body and affect other systems.

Even then, it is possible to switch to a medicine that does not cause the particular side effect that the patient finds distressing. For example, one antipsychotic causes restlessness and a need to keep moving. Changing to another equally effective antipsychotic gets rid of this side effect. Since every patient does not get every side effect listed in the books, we can be optimistic about finding a fit, a medicine to match the patient’s needs.

Agreed, we are sometimes in a situation where we have to prescribe more medicines to control side effects of medicines used for treatment. Research is underway to find better molecules that will be as free of side effects as possible. Until then we have to titrate doses of medicines to minimize side effects, without compromising on effectiveness.

I can say with certainty that the medicines being prescribed today are far superior to those that were available 25 years ago, mainly in terms of side effects. And a preview of those in the pipeline tells me better medicines are on their way.

Using psychiatric medicines

Even as I wrote the first paragraph of my last post I realized there was room for disagreement.

Firstly, not everybody believes that mental illnesses like schizophrenia have a scientific basis. Not everybody believes in allopathic medicines either. For people who haven’t had much to do with science, believing in psychiatry may be a stretch. So, when I wrote the blogpost about side effects of medicines used in psychiatry, I was only addressing the concerns of people using them.

Some patients believe that medicines are only for physical illness. They look completely unconvinced when you tell them their odd symptoms (hearing threatening voices, fear that someone’s tapping their phone, etc.) can be controlled by these little pills, tablets that aren’t even the substantial size of a Crocin or the awe-inspiring size of Brufen 400!

There seem to be all sorts of remedies available – herbal, ayurvedic and homeopathic. I find that a lot of patients and, more often, caregivers of people with severe mental illnesses like schizophrenia, reach out for help on sites that offer alternatives to allopathic medicines. Their main concerns:

  • How long do I have to take the medicine? I want to stop.
  • Is there a treatment that doesn’t give me side effects?

These medicines need to be seen as making up for a tiny but important part of the brain not working. It’s not very different from getting diabetes because one tiny but important part of the pancreas is not working. Isn’t treatment for diabetes lifelong?

Virtually everything that goes into your body has ‘side effects’. Like the coffee you drink as a beverage, and the food you eat for nourishment. Spinach has the good ‘side effect’ of giving you fibre along with nutrients, while fried chicken has the ‘side effect’ of raising your cholesterol.

Nobody has a perfect life. Everybody has some cross to bear, and sometimes it is a heavy one. Having to swallow a couple of pills every night before going to bed is yours. Thanks to those pills you can live a fairly normal life with a few ‘side effects’ that are better – much better – than what the illness was doing to you.

I also need to add that there are many, many patients who have their medicines regularly, come for a review every three months, and have practically no side effects because they are on optimum doses of their medicines. Occasionally I find one of them responding to a post discussing alternative medicines, earnestly telling people how they have benefitted from allopathic medicines. I do feel glad when this happens.