Dx: Depression. Maybe not?

Thoughts never stop. You think at least 6000 thoughts during your waking hours. Constant processing of data from both your inner world and the outer world – even minute details that you might not consciously register – generates thoughts.

Unless you’re concentrating on something, thoughts switch 6-7 times over 1 minute, and each thought creates a corresponding fleeting micro-mood. If you’ve had an unproductive, lousy morning it could be because the average of these micro-moods has kept your mood below the baseline-neutral one that you usually bring to work.

Your thoughts stay focused if you’re in problem-solving mode, or totally immersed in something, or meditating, and your mood remains stable. Otherwise, they come and go like puffs of wind and you go through finely nuanced mood changes that give a particular colour to the ‘I’ of the moment, like flag colours of different countries that are shone on monuments like the Eiffel Tower to mark an occasion.

Or, moods are like visible shifting sands on the beach, thoughts like invisible gusts of wind that cause the waves that shift the sands.

Sadness is a mood. It is a biologically designed response, like pain. It tells you that something hurts inside you. You can’t always trace the feeling back to a particular thought because the link between the thought-clip and the mood-clip often disappears instantly.

You might self-diagnose depression because you see no obvious reason for you to be sad. Actually, feeling blue, being in a funk, being down in the dumps, being in the doldrums, feeling low – describe these passing bouts of sadness better. They happen to everyone.

Sadness is the tube of black paint nestled in the midst of greens, browns, blues, reds, yellows and whites in the box. Mixed with any other colour in a small amount, it adds depth. Too much of it smothers the other colour out of existence. Nevertheless, it belongs on your emotional palette and underlines the importance of someone or something in your life. It is also the basis of necessary emotions like empathy and compassion.

Sadness is physiological, i.e. feeling sad is a normal response to a sad situation, unlike depression, which is pathological. We shouldn’t brand a patient with a label that signifies a ‘disorder’ when he has cause to be sad. Every low mood is not depression. But since ‘depression’ is used interchangeably with ‘sadness’ in common parlance, it is compromised as a diagnostic term, though it’s still in use.

Depression, unlike sadness, doesn’t tell you something is wrong, but falsely makes you feel something is terribly wrong, because it takes away your insight. It’s like too much black paint. The visceral howl that escapes when a patient chokes out, “Why can’t I be like everyone else? Why can’t I just be happy? It’s so-o-o-o hard . . . ” comes from the depths of her being. Her misery is agonizing as she fights to understand how and when the dark abyss yawned open in her inner world.

This is depression, not sadness. It is closest to the grief of bereavement, a deep sorrow mixed with a sense of irrevocable loss. Here, it’s the loss of the Self that used to be a happy, normal girl before the bouts of black moods set in.

According to DSM-5 criteria, Major Depressive Disorder is diagnosed if sadness has been present for more than two weeks, there has been a loss of interest or pleasure in most activities, physical exhaustion, inability to think clearly, marked changes in appetite, weight and sleep pattern, feelings of worthlessness and guilt, recurrent thoughts of death and suicide. At least five of these, along with the sad mood, have to be present.

So, intense sadness lasting over two weeks and adversely affecting a patient’s ability to deal with day-to-day activities, eat, sleep, work and engage with the world as expected, qualifies for a diagnosis of Major Depressive Disorder and is to be treated accordingly.

In practice, the DSM has to be used along with clinical judgment and common sense, and the context in which depression has occurred must be taken into account to plan sensible treatment.

Sadness and depression are not synonyms. Sadness lies within the normal range of human emotions and doesn’t need medicines, except perhaps a dose of a mild sedative if there’s accompanying anxiety, insomnia or crying spells. Whereas, depression often benefits from antidepressants – they take the edge off melancholy, reduce anxiety, bring a little clarity to thought, and improve sleep. They are given for only a few months unless depression persists over time.

Depressed people need to return to normal and we have to use all available resources to help them along. Medicines may not be effective all the time, but we need to get what use we can out of them.

That’s not all. The probable trigger, the circumstances in which the episode originated, the course it took, coping strategies used, have to be examined for treatment to be complete, and to find ways to recognize and limit the effects of future episodes. Resilience is built into the human mental make-up, and most people process the experience and find ways to make sense of it, and therapy might help tap into that natural resilience.

The DSM-5 criteria for the diagnosis of Major Depressive Disorder are not set in stone. They get revised every few years based on current research in the domains of genetics, epigenetics, stress (hypothyroid-pituitary-adrenal stress response), neurological biomarkers, neuromodulators, individual variables, and psychic and social processes.

Here are a few representative references from research articles on depression, but please note, they are only by people working in the field of mental illness. People in other fields like Philosophy, Sociology, Evolutionary psychology, Psychological anthropology and Religion have their own take on why people get depressed. And I think every individual has his own theory too!

There are 227 possible ways to meet the symptom criteria for major depressive disorder.

Zimmerman, 2015

The current criteria for major depression have been criticized for the heterogeneity of the clinical syndrome they define. The genetics and neurobiology underlying the depressive disorder still remain largely unknown.

Østergaard, 2011

Diagnoses, like many psychological terms, are concepts that refer not to fixed behavioural or mental states but to complex apprehensions of the relationship of a variety of behavioural phenomena with the world.

Rosenman and Nasti, 2012

Neuroticism, morning cortisol, frontal asymmetry of cortical electrical activity, reward learning and biases of attention and memory have been proposed as endophenotypes for depression.

Goldstein and Klein, 2014

Neuroimaging studies have identified that anhedonia, a core feature of major depressive disorder, is associated with dysfunction in reward and cognitive control networks.

Liang Gong, 2018

Links between specific depressive symptoms and areas of the brain have been identified, for example, crying with fusiform gyrus, irritability and loss of interest with hippocampus, worthlessness with cingulate gyrus.

Hilland et al, 2020

Data-driven studies have identified biological subtypes of major depressive disorder based on clinical features, biological variables, disturbed neurotransmitter levels, medication response, inflammation, and weight gain.

Beijers, 2019

But here’s the thing. One group’s research often contributes only one little fact to the existing body of literature on a subject. It might not have an immediate application, or none at all, ever. It’s like how water has been discovered on the moon and on Mars – so what are we going to do about it? For the moment, nothing. Maybe future generations will.

Depression needs a tighter definition to be useful as a diagnostic term. It is the outer manifestation of many different processes. Two examples:

  • Many people respond with a low mood to reduced ambient light, a condition called Seasonal Affective Disorder caused by a process that leads to decreased serotonin levels in the brain. This sort of depression, then, comes from somewhere else, not directly from thoughts.
  • Then, there’s depression associated with low motivation, a lack of interest in chasing goals, apparently because of low dopamine levels. This is controlled by the limbic system in the brain, so emotions influence the endocrine system and the autonomic nervous system first, then the person uses thought to figure out why he does not particularly want what he is supposed to, and gets depressed.

As the current diagnostic criteria are based on symptoms and not the yet-unknown cause of depression we use the diagnosis of Major Depressive Disorder to address symptoms. This way, the patient can get his life back on track to an extent.

So ‘depression’ has been reduced to the status of ‘cough’ or ‘fever’. Without knowing the cause of a cough or a fever, the only treatment given is a dose of cough syrup or an antipyretic rather than an appropriate antibiotic.

For depression, it is a course of an antidepressant, which is like giving a course of a broad-spectrum antibiotic because there’s no lab available to run a culture and sensitivity test – not the best, but a fair chance that it will help. This is not the ideal way to treat a life-wrecking condition.

We are constantly looking for ways to define and diagnose depression, but we aren’t anywhere close to giving an irrefutable statement of what it is. Medicines and therapy are the best we’ve got at present, imperfect though they both are. Tracing the history of depression from Melancholia to Depressive Disorder through the centuries shows that it has been a fraught journey, and still is.

and this is my robe, slightly singed

Narcissus, gazing at his image in the pool, wept.
A friend passing by saw him and asked, “Narcissus, why do you weep?”
“Because my face has changed”, Narcissus said.
“Do you cry because you grow older?”
“No. I see that I am no longer innocent. I have been gazing at myself long and long, and so doing have worn out my innocence”.

I don’t know where this passage is originally from. It was quoted in a novel I read in my twenties soon after graduating from NIMHANS as a psychiatrist.

Here, Narcissus mourns his loss of innocence from gazing too long at himself. I could relate to this feeling. As a post-graduate student of Psychiatry I often felt disconcerted by gazing too long into other people’s minds, then gazing into my own to fathom the meaning of what was going on in those other minds. Lectures, seminars and case conferences were also about much the same thing, as they had to be.

Studying the human psyche too closely can recalibrate the filters of one’s mind. I realised this when I stepped out of University into the regular world, because looking for layers of meaning had become second nature.

Like Narcissus, I keenly felt the loss of innocence.

*****

A couple of months ago I bought a book of poems by the Polish poet Wisława Szymborska from a tiny bookstore in New York, the sort where poetry books sit cheek by jowl with books on philosophy, history, geology and other things, crammed together without strict categorisation, exactly the way I like bookstore shelves to be. It leaves room for serendipitous finds like this one! I had never heard of Szymborska but the first few pages got me hooked.

I am halfway through the book now, reading one every two-three days, savouring each poem slowly. This is one I read last week.

Soliloquy for Cassandra

Here I am, Cassandra.
And this is my city under ashes.
And these are my prophet’s staff and ribbons.
And this is my head full of doubts.

It’s true, I am triumphant.
My prophetic words burn like fire in the sky.
Only unacknowledged prophets
are privy to such prospects.
Only those who got off on the wrong foot,
whose predictions turned to fact so quickly—
it’s as if they’d never lived.

I remember it so clearly—
how people, seeing me, would break off in midword. Laughter died.
Lovers’ hands unclasped.
Children ran to their mothers.
I didn’t even know their short-lived names.
And that song about a little green leaf—
no one ever finished it near me.

I loved them.
But I loved them haughtily.
From heights beyond life.
From the future. Where it’s always empty
and nothing is easier than seeing death.
I’m sorry that my voice was hard.
Look down on yourselves from the stars, I cried,
look down on yourselves from the stars.
They heard me and lowered their eyes.

They lived within life.
Pierced by that great wind.
Condemned.
Trapped from birth in departing bodies.
But in them they bore a moist hope,
a flame fuelled by its own flickering.
They really knew what a moment means,
oh any moment, any one at all
before—

It turns out I was right.
But nothing has come of it.
And this is my robe, slightly singed.
And this is my prophet’s junk.
And this is my twisted face.
A face that didn’t know it could be beautiful.

Having never formally studied poetry I don’t know how to critique a poem. If it speaks to me, that’s it, I read it over and over again and enjoy it for a long time.

One of the reasons I read poems is because the glimpses I catch from not being able to fully understand them make them tantalising, like an unsolved mystery, or an entrancing world spied through a lace curtain. I love the fuzziness of impressionist paintings for the same reason.

I hadn’t heard this story before, the story of Cassandra who was given the gift of prophecy but was fated to never be believed. Her triumph was only in knowing the future, because the predictions turned to fact so quickly. How frustrating that must’ve been!

Cassandra raving
Met Museum collection, impression from an 1852 reissue of the 1795 original

*****

It’s how I feel about mental illnesses like schizophrenia that can only be managed, not cured. So triumph is only in diagnosis, while the poor prognosis of the illness, sadly, turns to fact quickly. That goes for a host of physical diseases as well, not only psychoses.

Patients diagnosed schizophrenic often relapse because of missed doses despite the time and effort I put into explaining possible outcomes to the caregiver, with diagrams, with special emphasis on the need for regular meds. But there, that’s how it goes. I know how hard it is to care for someone 24/7, so I simply slip into damage-control mode, like the GPS in my car that merely suggests a different route when I miss a turn.

It turns out I was right.
But nothing has come of it.

Yet –

They lived within life.
Pierced by that great wind.
Condemned.
Trapped from birth in departing bodies.
But in them they bore a moist hope,
a flame fuelled by its own flickering.
They really knew what a moment means,
oh any moment, any one at all
before—

They lived within life. I admire their moist hope (which I take to mean either ‘alive’ or ‘tear-soaked’) that tomorrow will be better, their son’s new medicine will work better, they will soon see him going out to work like other youngsters, getting married, being ordinary. A flame fuelled by its own flickering. This, to me, is hope, not denial.

When they smilingly report an incremental improvement it seems they really knew what a moment means, any one at all before . . . Maybe not. Maybe I read the hope in their eyes that way, or they reflect the hope I convey, because I never give up until there are no options left and the disease inexorably settles into chronicity.

After all, schizophrenia is caused by a gene connected with the immune system, one that was meant to control the handling of invading organisms and cell debris, but has unfortunately been repurposed – wrongly – for pruning synapses of brain cells. The logical treatment for schizophrenia is still in the future, reducing current treatment to controlling symptoms and normalising the patient’s life to the extent possible.

Individual lines in the poem leap out at me like coded messages, exhorting me to look back at the years I spent working with patients, to ask myself if my voice was hard, and my caring ever seemed haughty because I had to school my expression most of the time.

Did I inadvertently make patients lower their eyes, make them feel judged by the impatience that crept into my voice when they fiddled with their doses? When I urged them to see the big picture, to look down on yourselves from the stars, did it come across as patronising?

And this is my head full of doubts.

This poem gave words to some of the feelings that swirled within me for the longest time, especially helplessness in the face of illnesses that could only be managed and not cured.

That’s the thing about Art and Poetry; they gently tap and feel and nudge around what lies dormant in your heart and, in so doing, shake loose a repressed feeling that has been sitting there like a stone in a shoe. They make you feel lighter – at least for a few moments – that you are not alone in your turmoil, that somebody, somewhere on earth, possibly living in a different time, has felt what you feel.

And this is my robe, slightly singed.
And this is my prophet’s junk.

My robe – my old lab coat – now lies folded in a corner of my wardrobe, unlikely to be used again since I stopped working some time ago. Books, notes, photocopies of journal articles, and more than twenty years worth of patients’ case files – my prophet’s junk – lie in a cupboard in my study, to be eventually shredded and sent for pulping.

The last two lines of this poem are harsh and bitter. I don’t know what to make of them. They bring up a completely different set of images in my mind.

And this is my twisted face.
A face that didn’t know it could be beautiful.

Cassandra’s inability to use her gift was due to Apollo’s curse, and the backstory has parallels in today’s world – of broken promises, misunderstandings, anger and retaliation. A significant number of women – and a smaller number of men – in bad relationships consider their life a curse and seek help for depression, anxiety, anger, insomnia, suicidal thoughts, breakdowns and other mental health problems.

Could any of us have come up with a solution for Cassandra’s predicament? I don’t think so, just as we can’t for some illnesses that can’t be cured, no matter how much we know about them.

*****

negative effects of therapy

More people are in therapy now than a generation ago. Some benefit from it, some don’t. Not everybody is comfortable opening up to a stranger, something I totally understand, because I would find it hard to bare my soul to someone in the transactional way in which therapy occurs in practice. That is why I empathize readily and try to put patients at their ease. It is also why I feel for those who are mortified at the thought of opening up, and weep hot tears of shame after they do.

It was in 2009 or so that I began to notice that therapy had limitations. Sometimes therapy didn’t help a patient at all. Sometimes it created a new set of problems for the patient, usually interpersonal, which made me question what I was doing wrong.

At that time I could not find much useful research on why therapy might be ineffective or harmful. I went over the notes of my sessions and summarized their outcomes as honestly and objectively as I could, trying to figure out how therapy worked, or didn’t work, for different patients.

A combination of psychiatric medicines and psychotherapy using an eclectic approach benefitted at least 80% of patients. Some patients said their medicines were very effective and they didn’t need to know what was wrong with them, and that it was enough that I knew what was wrong with them!

But when patients did benefit from therapy, I was never convinced that it wasn’t only because I had seen many more summers than a lot of my patients had, plus I had looked closely at the inner lives of hundreds of people over the years. Then, was it more of experience and less of method that mattered? It’s hard to tell, because for a professional in any field, domain knowledge becomes second nature, something taken for granted.

Many types of therapy exist, with rigorous rules laid down for their practice. But I still see therapy as quite subjective because, no matter what a method is in theory, it finally passes through the medium of the therapist’s psyche and is influenced/modified by the person she is and the antecedents that made her who she is. It is not as simple as cooking from a recipe, though, in that too, the nature of ingredients can differ due to local factors and the final product can turn out different than what is expected.

***

As a psychiatrist I am expected to be neutral when a patient tells his story. But I have to separate the chaff from the grain in his jumbled outpourings, for which I have to judge what is chaff and what is grain. A certain amount of subjectivity creeps in right away. And every prompt and um-hum might seem a micro-judgment to him, regardless of my neutral tone and expression.

The deepest currents of meaning and knowledge take place within the individual through one’s senses, perceptions, beliefs and judgments . . .

This requires a disciplined commitment to remain with a question intensely and continuously until it is illuminated or answered . . .

– Clark Moustakas

Psychotherapy as a treatment modality is necessarily, inherently, a heuristic process for a psychiatrist attempting to tune into a patient’s frequency. She first has to put herself in his shoes to see where he is coming from.

I am well aware that I can fall prey to cognitive biases in this heuristic process: availability bias, confirmation bias, egocentric bias, framing, representativeness – and all sorts of unconscious ones besides. And, sometimes, I do. Just as judges do, despite having strict laws to base their judgments on, because judges are also human, and deal with the unpredictable doings of other humans. An investigative interview conducted by police to gather information can also falter if a suspect is hard to read, or ready to confess to anything he’s accused of, out of sheer anxiety.

There are  hundreds of variables in the complex therapeutic relationship between psychiatrist and patient that influence what is said and what meaning is taken. The patient is not a passive recipient of psychotherapy; he is a thinking person who is weighing what and how much he can tell his doctor.

Intuition, thin-slicing, tacit knowing and non-verbal communication are as important as what is being said. Sometimes I pick up on a tell and pursue it with surprising results, but cannot explain how that happened, not even to myself. If I were contributing data to an evidence-based study I would feel restricted because staying with a script would mean not following up important leads that I catch in the spaces between utterances, the non-verbal parts.

I have often been guilty of positivity bias and shown more optimism than a patient’s situation merited. I have had to check my inner Pollyanna several times when empathy and wishful thinking briefly eclipsed facts.

So, basically, I have to watch out for my own biases all the time.

***

I recently revisited the problem of negative effects of therapy after a 20-year-old girl told me that she had confronted the adults in her joint family about the sexual abuse she had been subjected to by a family member as a little girl. She had not wanted to, but an older cousin who had been similarly abused by the same person had convinced her she should. She felt exposed, angry and confused, because the adults ‘trivialized’ it – played it down – exactly the way she knew they would.

In the earliest years of my clinical practice I might have naïvely suggested exactly what the cousin had, with the expectation that her mother at least would support her. And I might have counted the unhappiness and anger she felt when that didn’t happen as some sort of ‘negative effects of therapy’.

Now, this young girl wanted to transcend that experience, build a successful career, so that the memory – and the perpetrator – became insignificant in her life. She didn’t want to talk about it. In fact, she said, “I will not be a victim and give him so much importance”. To deal with it in her own way was her prerogative; sometimes therapy means leaving well alone. True, time might never heal a wound completely, but neither might therapy.

***

There’s more literature published on the negative effects of psychotherapy now than what was available to me in 2009.

These are some of the negative effects of therapy listed by various researchers. Most psychiatrists encounter them and find ways to reduce their impact.

  • Worsening of symptoms: Symptoms can worsen temporarily in the first 2-3 sessions because old scabs may be peeled off, leaving old wounds exposed.
  • Treatment failure: The worst cases I have seen are those where someone unfamiliar with mental illness has failed to diagnose a psychotic break and has tried to reduce the patient’s agitation with ‘counselling’.
  • Emergence of new symptoms: Patients who present early in the course of a mental illness can develop new symptoms unrelated to therapy, e.g. obsessions being addressed in therapy could turn out to be prodromal symptoms of schizophrenia. Acting out, common during therapy, might be reported as an alarming new symptom, or worsening caused by therapy.
  • Heightened concern regarding existing symptoms: The line of questioning leading to a diagnosis can be unsettling for a patient. Explaining the biological or psychological basis of symptoms helps, also outlining what can be done, treatment-wise.
  • Suicidality: a patient treated for depression sometimes snaps out of inertia and finds the energy to plan and execute a suicide. So all involved – doctor, patient and the people the patient lives with – must be alert to signs. In some cases, depression might be the only visible part of a deeper disturbance, and the provisional diagnosis might not point to the possibility of self-harm.
  • Occupational problems: People sometimes function best on high alert, juggling multiple balls and deftly keeping them all up in the air, albeit at a steep cost to their mental health. If a patient is distracted from this hyperfocused state too fast with the intention of reducing anxiety, he might lose focus and drop all the balls, and this can cause serious problems at work. Therapy takes time.
  • Stigmatization: This can happen when a patient shares the fact of his treatment with people he believes are his wellwishers, but they use it to control him instead. He might be disillusioned  and need support to hold on to the gains he has made.
  • Changes in the social network: Self-awareness and insight are products of therapy. A patient might distance himself from toxic people and develop healthier social ties. This could have negative effects on his support system, yet be positive for his growth.
  • Strains in relationships: If a patient gains new perspectives and seeks a more equitable relationship, a close family member whose self esteem is tied up with his sick role might react angrily and put a strain on the relationship.
  • Therapy dependence: A clarification at the beginning that therapy will only be for a short time – the way a plaster cast is retained only until broken bones are healed – can pre-empt dependence.
  • Undermining of self‐efficacy: Some people fall in their own estimation if they see themselves as needing to be propped up by another person. A psychiatrist must watch for this and prevent damage to a patient’s self-image.

Recent studies have concluded that adverse effects occur in 5-20% of patients, and 50% of patients show no clinically significant change with therapy. Most of the published research is based on patients being treated by therapy alone. Since psychiatric treatment is a combination of phamaco- and psychotherapy, our patients ought to be doing better than what these numbers show . . .

***

Psychotherapy is not like fundamental Physics. It’s a human interaction, with all its imperfections. If anything, mental illness is closer to String Theory in its simplest form! Most psychiatric symptoms are an exaggeration of normal thoughts and feelings, like the vibrations of strings that make them look like particles. They can be toned down with medicines and psychotherapy.

Calling therapy an art would make the treated patient a product. Calling it a science would mean that a patient’s recovery is backed by strong measurable evidence and the results can be replicated in another patient by repeating the process. How is that possible, when each patient, his circumstances, as well as a therapist’s own inner life are all in flux all the time? The approach has to fit the need of the moment and a lot depends on the rapport between doctor and patient.

It is difficult to observe the effects of psychotherapy on patients – the way one might study the effect of heat on copper sulphate crystals – because the therapist factor greatly affects the process, as does the patient’s capacity for introspection and abstraction. For that matter, even pharmaceuticals do not have the same effect on every patient and, therefore, a list of  possible idiosyncratic side effects comes with every medicine.

Therapy is only possible because the experience of being human is common to all of us. We have all been there, or been somewhere like it.

‘It came upon her now, as it always had done: a happy flood of feeling, a wild unrest. This moment counts. This moment, and no other. That old man with a crutch, that woman crying, the boy with a spinning top, those lovers smiling: they were part of something known and shared and remembered, an oft-recurring richly coloured pattern. The child who fell in the gutter was herself and so was the the girl who waved from an upper window, “This was what I was once, I’ve been them all” – that aching heart, that burst of sudden laughter, those angry tears, that bubble of desire.’

– From Mary Anne, by Daphne du Maurier

So, the ability to synthesise the disparate facts of an anxious or depressed patient’s life into a cogent whole that he confidently recognises as a better and manageable version of himself is perhaps neither an art nor science. It is a perspective, or a skill, like the ability to do mental math like a whizz, or the ability to visualise a prospective movie frame by frame while reading a novel.

A psychiatrist ultimately uses her personhood as an instrument to empathise with the patient; she syncs her mind with the patient’s, then disengages herself to analyse the information objectively. It takes time, effort and a lot of introspection to get closer to the unachievable target, perfection, on the lines of ‘aim at a star and you’ll shoot high’. Even so, some unexpected developments – side effects – can occur in the process of therapy and must be dealt with as par for the course, the way we do with medications.

insurance exclusions

I was surprised when the Supreme Court recently questioned why insurance companies didn’t cover the cost of psychiatric treatment under medical insurance. Didn’t they? I didn’t know that. After the Mental Healthcare Act was enacted in 2017 the IRDAI (Insurance Regulatory and Development Authority of India) had issued a directive to all insurance companies to do so. But it obviously didn’t happen.

Okay. ‘Mental illness’ is a slippery slope for sure, like euthanasia, living will, Do Not Resuscitate orders, pro-life arguments and punishment of juveniles for heinous crimes. People have different notions of mental illness to begin with.

The Mental Healthcare Act, 2017 defines mental illness as follows:

A substantial disorder of thinking, mood, perception, orientation or memory that grossly impairs judgment, behaviour, capacity to recognise reality or ability to meet the ordinary demands of life, mental conditions associated with the abuse of alcohol and drugs.”

All of these are observations that a psychiatrist makes in the course of a patient’s Mental State Examination. His inferences can be construed as subjective and biased by anyone who chooses to do so. For example, if I think a patient is severely depressed and admit him because I think there is a risk of suicide, will the insurance company reimburse him if the suicide doesn’t happen? Will I be suspected of profiteering in some way from the patient’s hospital admission?

Insurance contracts are structured between providers and insurers both of whom benefit from a patient being hospitalised and sent through lab and radiological investigations, procedures or surgery. So ­– between doctors, hospital owners, insurance people and patients – does anyone trust anyone else anymore?

Regarding mental illness, insurance companies list exclusions in their brochures and policy documents, like depression, alcohol-related illnesses, ‘nervous breakdown’ and anxiety, all of which we recognise as symptoms of mental illness needing treatment.

Some are also smug about the fact that since most mental illnesses need only outpatient treatment very few patients can take advantage of the IRDAI directive to cover psychiatric treatment. True. Which means, any directive will look good on paper but won’t benefit patients.

There seems to be no consensus among concerned parties on what constitutes mental illness in spite of the legal definition. Our criteria are often unacceptable to non-psychiatrists, and the way insurance policy documents are worded suggests that insurance agencies think we are out to con them!

If we tell them that Panic Disorder is a mental illness and not a character flaw, that it is not something that afflicts a weak person who can’t face life, they are sure to think it’s a scam.

They are equally likely to think Major Depressive Disorder is sadness caused by ‘overthinking’ about things that don’t concern you, when your job is to work, eat, deal with your social media, watch something on your phone and go to sleep.

What about OCD? They most likely believe that a stubborn person who believes she knows best about cleanliness and perfection doesn’t deserve insurance if she ends up in hospital due to her cleaning mania. She’s clearly got her comeuppance.

People with AIDS, alcohol-induced health problems and reconstructive surgery are not covered by insurance. Looks like insurance people think these people brought it upon themselves and must be punished!

What about grief that eventually turns out to be a patient’s first Major Depressive Episode, precipitated by bereavement and needing hospitalisation?

And anorexia, bulimia and other eating disorders? I haven’t found any insurance company that covers Eating Disorders – they probably view rejecting food as entitled behaviour!

Autoimmune disorders are exclusions too! So are behavioural, neurodevelopmental and neurodegenerative disorders! How come? If anyone needs help, these people need it most because their illnesses are not curable and need lifelong treatment. The word insurance literally means assurance and comes from the French seur, meaning safe, which comes from the Latin securus meaning ‘free from care, secure’. The idea of insurance implies kindness and support – how ironic!

Don’t people who run insurance companies learn these things as part of their training? I’m sure they do, or else how would they be so good at finding loopholes!

There are only two conditions lay people seem to understand as mental illness: one, schizophrenia, only if the patient has florid hallucinations and delusions and is violent; two, the manic phase of Bipolar Disorder where even a casual observer can see that the patient’s behaviour is off-kilter.

No insurance agent seems to know that for every mental illness we see as strange behaviour, there’s something happening in the brain to cause it, just as the illnesses that his company does cover have an underlying malfunction in some organ. The disorder is not in the mind but in the brain, a large organ, just like the heart, liver, kidneys and lungs! As I’ve said before, Psychiatry is Neurology at a cellular/biochemical level.

I can’t imagine being a consultant to IRDAI and giving them advice on providing insurance cover for mental illness. It would be incredibly hard to convince people in the insurance business that a mental illness is as real as fractured bones or a ruptured appendix.

Half the world can’t imagine something they can’t see. They need something tangible like a BP reading or a blood test or a CT scan report, just as the other half of the world wouldn’t know how to hustle and make serious money instead of sticking with a safe job and a fixed salary. It’s just the way different people are wired.

No matter how much we try to increase awareness, the concept of mental illness is hard to convey because there are too many grey areas. For example, is someone with Antisocial Personality Disorder mentally ill? Or is he a morally bankrupt criminal who ought to be in jail? If admitted for surgery following an attack by a rival gang, and APD is diagnosed through his history, and psychiatric treatment is attempted, should the insurance company cover his psychiatric treatment as well? Who decides this?

The Indian Psychiatric Society has much to clarify about mental illness if we are to make things easier for our patients. To whom, I don’t know. The government? The IRDAI? Insurance companies? Why will the latter be interested when they don’t stand to gain?

I guess it’s down to lawyers, insurance people and the government – mainly the government – to come up with guidelines, preferably with input from the Indian Psychiatric Society. The sheer number of suicides in our country should make recognition and treatment of mental disorders a priority without creating so many stumbling blocks in the form of insurance exclusions.

hoping for miracles

Work has always been about food and safety since the beginning of human time. It still is for most people. But some of us have moved away from that basic premise and work to fulfill either our higher needs or unmet psychological needs. We tend to treat food and a safe home like collateral benefits.

At one extreme, Elon Musk says, “Why do you want to live? What is the point? What do you love about the future? If the future does not include being out there among the stars and being a multi-planet species, I find that incredibly depressing.”

I don’t deny that the launch of his manned rocket is a huge feat. It’s just unsettling to have news of his rockets and driverless cars juxtaposed with images of hunger and homelessness of millions caused by corona, then Amphan, Nisarga, Christobal and earthquakes and forest fires.

But then, everything else can’t stop just like that, right? So other things happening – like the launch of Falcon 9 with two brave people inside – alongside the march of the corona virus, worldwide protests against racial discrimination, and extreme weather events is just how life works.

Far removed from Elon Musk’s reality there is a lot of anxiety in the world of ordinary people right now. Anxiety, unfortunately, is not something that happens in a small corner of the mind. It involves the whole person. It can eventually cause high blood pressure, a heart attack or a stroke if it becomes chronic.

I think everybody knows most of this, but I’ll do a quick recap:

  • It starts with the eyes and ears observing and transmitting data to the back of the brain.
  • In a flash the information reaches the forebrain, which interprets it and sends it to the midbrain, the emotional part we have in common with lower animals, and we feel fear.
  • This sets off a cascade of stress-related hormones that course through the blood stream and whip the heart, lungs, guts and kidneys into action, preparing us for fight, flight or freeze.
  • So the heart beats furiously, blood pressure goes up, lungs pant out heaving breaths, sweat glands pour out sweat, the stomach churns, and there might be an urge to run to the bathroom, as all systems are in overdrive.
  • Within the brain itself, the hippocampus opens the folder of memories related to the current fear and reminds us how terrible it was the last time around.
  • And the amygdala computes the emotional value of the information and decides how awful we should feel.

Different neurotransmitters are released in the brain at each stage of information transfer. There are more brain chemicals swirling around in an anxious brain than the number of mind-altering ingredients in a glass of LIIT!

Anti-anxiety medicines stop this hectic activity and reduce restlessness, depression and confusion. I prescribe them if anxiety is severe, and only for a short time, because they cause dependence in the long term. So they are not a solution.

The mind of a super-anxious person is like a blast furnace. Somebody has to collect the slag, turn it into skid-resistant asphalt aggregate and use it to pave the rutted road of his life, and that’s what I do. I use the period of relative calm when a patient is on meds to sort out things through therapy – to some extent. So this is only a partial solution and that too, only for some patients.

I realize that one might learn all the mental gymnastics therapy can teach, but when there’s hunger and fear and creditors knocking on the door, autosuggestions to be positive might seem delusional. There is a limit to cognitive restructuring and trying to neutralize negative thoughts in the face of reality. And reality is so harsh for millions that therapy doesn’t even enter the picture; it would be like Marie Antoinette allegedly said, “let them eat cake”.

There isn’t always a simple solution, hence the number of corona-related suicides in the news. We need more than psychiatrists and mental health workers to reduce the suicide rate because people don’t kill themselves for the simple 2+2=4 reasons that relatives and friends usually give the police. Despair – a complete loss of hope of getting support – pushes people over the edge when a trigger like corona comes along and wrecks their fragile financial systems.

I hear from those who received regular rations from the Public Distribution System in the last four months that they were okay because they didn’t have to go hungry during the lockdown. That, and physical shelter, is what we didn’t give the migrant labourers who wound up walking across the country for thousands of miles to reach home.

As I said in my last post, we can’t control everything in life. The idea of God is a natural outcome of people having to deal with a difficult present and an unseen future, like now. Hoping for miracles is not that different from a therapist telling you to be positive in a hopeless situation.

I sometimes think that what people are going through is more like grief at the death of someone dearly loved than any other emotion. The new normal is an unalterable reality and we are never going to get back the life we knew and liked. There’s a profound sense of loss.

Those who depended on the gig economy in some way, including the migrant laborers who trekked across the country in thousands, are devastated. Even those who stayed afloat financially feel grief for the loss of a familiar way of life, mixed with relief and gratitude as in ‘there, but for the grace of God, go I.’

People who had slowly crawled out of poverty are mourning for the lives they had painstakingly constructed, rupee by rupee.

  • I talked with Kiran, a 23-year-old who works for a small event-management company putting up decorations at venues. No events, no gigs, no income.
  • Ashwini, a young assistant at a dentist’s office, has been on half-pay since her employer sees only occasional emergency cases due to corona risk.
  • Sunil, the barber near the market, shut shop just before lockdown and rushed back to his hometown. The owner of the general store next to the barbershop says he isn’t coming back now fearing institutional quarantine.

I don’t know how these people will rebuild their lives when this sad chapter is over. Maybe they are more resilient and stronger in spirit than I think. Mothers forget the intense labour pains of their first delivery and go on to have more children – my friend Mario’s mother had fourteen!

Viktor Frankl, the famous neurologist and psychiatrist, did a lot of meaningful work after surviving the Holocaust. He lived to be 92. Maybe the ability to forget pain – despite having every single memory stored somewhere in the brain – is a gift. It’s probably what keeps us going, because none of us go through life unscathed.

changing constructs

There’s much talk among psychiatrists about dealing with people affected by the corona pandemic. What can a psychiatrist say that people haven’t already got from the deluge of information and inspirational quotes that their friends have shared on social media? Be optimistic, don’t panic, eat a balanced diet, exercise, sleep well, maintain a routine, don’t give up hope, do yoga and meditate, learn something new – this will pass!

People say that we are all in this together. But we are not.

  • Those who can work from home and draw the same salaries as before are not affected much. Nothing has been taken away from them except the frills, the inessentials.
  • Those whose occupations need them to go out, like shopkeepers and domestic workers, who have dependent family members and survive on a steady income, find it hard to make ends meet.
  • Those whose business involves perishables are likely to feel doomed, like fruit and vegetable farmers
  • Those who have factories that can’t allow in workers because of social distancing norms can’t hope to recover soon.
  • Those who have been laid off as their employer is downsizing will find it hard to get another job. Maybe they could use the time to upskill?
  • Those who have lost jobs but have fairly substantial savings could husband their resources and wait out the pandemic.
  • Those whose work entails a lot of travel really don’t have a choice till travel safety details are worked out.

And so forth. There are so many realities needing different solutions.

I might understand and comfort patients, but can I offer them real help? Patients are fearful, anxious and vulnerable, especially now with all the uncertainty. As a medical professional I can’t even assure them that a vaccine will soon be available because that’s not certain at all. Sometimes a patient’s reality is so stark that my words sound like a bunch of hollow platitudes to my own ears. I can prescribe medicines but they’re only palliative and won’t solve the patients’ problems.

Right now, sitting safe at home, not much affected by the pandemic, I feel something akin to survivor guilt when I see images of the worldwide suffering this virus has caused. I have no solutions and it doesn’t look like anyone else in the world does either. If I had to counsel someone hit by this disaster my key word would be acceptancethat we don’t have as much control as we wish. This is something most disadvantaged people are aware of all the time. It’s us middle class Indians that are brought up to believe we can do anything and we should let nothing stand in our way. So we stubbornly try to slash through, rather than slowly make our way around, obstacles. Maybe we need to modify some of our personal constructs.

Our grandparents had a clear idea of their limitations and accepted that some things just befell them and they had to cope. They had to find strength within themselves and their community. They accepted that natural disasters and epidemics were not under their control. The idea that gods watched over them was also helpful in accepting the vagaries of life, including suffering, and I think this is a source of strength for a lot of people even today.

People used to save for a rainy day. There was always a nest egg to cushion the impact of a crisis. I think the current reliance on credit rather than savings has taken that away. Not only do people have no savings, they now have loans to repay as well, and no income. Should we re-think our approach to earning, spending and saving money when things settle down somewhat?

We seem to have lost direction as a species. We are living in the Anthropocene epoch that started in 1950, the epoch of human-induced global change. Imagine – an epoch named after the destruction we have caused! For delineating a new epoch, geological impact must be global, and has to be big enough to appear in the geological record of the earth. Like plastic pollution and nuclear testing are both part of our Anthropocene epoch. Maybe this applies to the global impact of the creation of the corona virus in a lab – if proven – as well.

born under an unlucky star

Parents feel immense grief and helplessness when too many things go wrong, one after another, in the life of their adult child. So they get him to come back home, to take care of him until things are better. They say he was born under an unlucky star.

What is Luck? This is what researchers who have been studying Luck have to say:

  • Luck is subjective, and a positive attitude can make you luckier.
  • Alert people who watch for opportunities can create good luck by grasping a chance quickly.
  • Lucky people tend to use serendipitous encounters cleverly, though they might say, “I got lucky”.
  • Lucky people vary their routines and thus increase the likelihood of serendipitous events.
  • Successful gamblers hone their betting patterns to get luck on their side. I don’t know how that might work, but that’s what they say.

Is there no such thing as pure luck that is controlled by Destiny alone? I do believe there is. Some people seem more prone to having things go dreadfully wrong with everything they try. I think the fear and negative attitude are a result, rather than the source, of bad luck.

I’ve heard people described as ‘someone whose touch can turn gold into mud’, the opposite of ‘someone with a Midas touch’. Some of them have gone from mistake to astonishing mistake, so you might wonder for a moment if they did create their own bad luck. But if you listen carefully to their story you can quite see that they couldn’t have done things differently in the circumstances of the time. Only in hindsight does it look like they could have.

As psychiatrists, we don’t usually make room for luck in interpreting patients’ problems, especially as people in India express it in astrological terms like, “Our astrologer told us he is going through saade-saatha shani”, and we know nothing about Astrology. We are trained to look at events in a patient’s life pro forma:

Problem

How did it start and progress

What was the immediate cause

Why does it persist

What has been done about it so far

Has such a thing happened before

Family history

Personal history

How is his current mental state

Though we empathise, our primary job is to objectively work out how best to alleviate his distress using solutions that Science offers.

Answering our questions can’t be easy for the patient. He can’t always justify the steps he took as he tried to scramble to his feet after each slide. He can’t explain why all his efforts have failed. He looks and sounds utterly defeated. That’s when the accompanying family member protectively steps in to say that he has had a lot of bad luck, and gives a number of instances.

His family is not going to abandon him when he is down and out. This impression could be something that inched into my mind subliminally over the years. Or, it is unconscious cherry picking I did out of a need to believe in human goodness, because I’m one of those people who read the newspaper every morning.

These cases give me hope that people still care, though things I read make me feel that we are done with all that, and now it is only about making the world high-tech, obviating the need for human beings and their troublesome emotions. Of course, I’m also aware that for every person who gets support from a loving family there are many who aren’t welcome back in the fold, but well . . .

With the corona virus unleashing a sort of guerilla war on us, a lot of young adults who are graduating from college this year are apprehensive. For many, confirmed job offers have been rescinded. Those who graduated last year and are in their first job are no longer certain what will happen to them. Young people who started new enterprises in recent years, and have not yet broken even, are worried. Those studying abroad are in limbo, online classes being a poor substitute for the vibrancy of real college life.

It’s bad luck that the corona pandemic intersected with their lives at this point in time. Many of them will suffer from anxiety and depression, and incipient psychotic illnesses will flare up in those at risk. It’s quite likely that many of these graduates will be jobless and need family support for an unpredictable length of time. This is pure bad luck and it’s not because of a negative attitude, a lack of alertness, or wasted chances.

They will eventually find a way around it. Some say “And this, too, shall pass away” was first carved by wise sages on a finger ring for an unknown Eastern monarch centuries ago. Some say the Eastern monarch was King Solomon. Some say Rumi originally wrote these words, and some say Rumi got them from Attar . . . Whatever their source, these wise words are our common inheritance, they belong to everyone, and are especially comforting for youngsters who might be feeling very unlucky in these locked down times.

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hikikomori

There are many lost kids out there. They are either dragging their feet in college for years after they are supposed to have finished, or have graduated but are disinclined to apply for jobs. Some of them take up jobs that are far below their ability and qualification. They use the paltry pay as pocket money and continue to stay in their parents’ home, neither asking for nor contributing anything.

What bothers parents most is the stonewalling, the refusal to engage in a conversation about it. The worst cases are where the kid stays holed up in his room with a laptop, does not come out even for meals, and raids the fridge at night.

There is no word in English – nor is there one in the DSM-5 ­– for this. However, the Japanese have a word for it: hikikomori, which roughly translates to acute social withdrawal. Hikikomori are adolescents or adults who have withdrawn totally from society, not leaving their room for weeks or months on end.

This phenomenon has been studied most in Japan because the country’s demography, culture and current job situation have apparently turned many youngsters ­– and adults – into hikikomori.

Who are these reclusive youngsters who quit mainstream life? This is a generalisation based on kids I have seen in clinical practice. A hikikomori in India is most likely to:

  • belong to a middle- or upper-middle-class family
  • be described as ‘sensitive’ and more inclined towards the arts, though he might hold a degree in science, business or law
  • have been sent to the ‘best’ educational institutions, hence expected to ‘succeed’ spectacularly by everyone, including extended family, a daunting situation that he is not up to facing
  • have done extremely well in school but poorly in college
  • have a recent history of failure, either academic or in a romantic relationship
  • not want to attend family events because he’ll have to explain why he is doing nothing
  • muse about whether all the slogging through school and college was worth it because life is pointless
  • tell you he’s reading philosophy and it makes more sense than the boring lectures in college
  • say that he sleeps during the day and sits up all night because it is peaceful

All these young people unhappily searching for meaning and direction, looking for peace, trying to hide from nosey relatives to protect their parents’ honour . . . It’s sad. Why is this happening to our kids?

One reason could be that they never got a chance to find out what they wanted from life because parents had set the course for them. To give parents their due, most see education as a means to a career and a steady income, not necessarily an exciting job. After all, they are funding it. The tussle over choice is now a common Hindi movie trope, and Indian parents are hopefully re-thinking Education.

Anyway, right now we have to do something about these apathetic kids. Without motivation there’s no impetus to go anywhere, get a job, do anything. So they stay in their rooms, numb, lost in their own world.

The apathy you see in hikikomori is not different from the apathy of a patient with a lesion in the prefrontal cortex, because that is the part of the brain that buzzes with ideas and energy to explore new possibilities.

One part of the prefrontal cortex gets you energised to make a plan; another sets the tasks for carrying out the plan; another executes it; another part monitors the execution; another part moderates your emotions. The foremost rounded part of the brain, the frontal pole, coordinates all of this, plus input from some other parts of the brain. So there can’t be any progress without energisation, the starting point for action. This is apathy, and it manifests as withdrawal. That is what neuroscience tells us.

Psychology says there is a deficit of Theory of Mind, i.e. difficulty understanding others’ intentions, and how their own behaviour impacts others. This is the same kind of deficit one sees in people with autism spectrum disorders and schizophrenia! So, the tendency to withdraw rather than confront might be a stable trait, that is, hardwired in the personality. Anyone trying to help a hikikomori re-integrate into the mainstream would have to consider this limitation.

There is no established way of dealing with hikikomori as yet. We probably have to connect with them, find out what energises them, light a spark and hope the other steps in the prefrontal cortex follow. We have to be supportive until they are ready to test the waters. This is not easy and it takes time. It might not even succeed. Meanwhile, we need to reset our priorities vis-à-vis raising children before we start giving these unhappy people labels or creating a new category in the DSM-6.

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because the human brain is plastic

This is a heuristic take on therapy.

Listening to a patient is not very different from listening to a friend in trouble. As the patient tells her story, you feel her emotions and note her expressions, choice of words and factual consistency, apart from watching for telltale signs of physical illness. You empathise.

Meanwhile, the patient gauges whether you are able to understand her situation and emotions. It’s a two-way process, a lot of it non-verbal, during which mutual trust is established.

Psychotherapy sounds like something the patient passively receives. It isn’t. It’s a dialogue. The patient is a therapist’s ally because she knows herself much better than anyone else does. As professors often reminded us in college, “the patient tells you much more than she thinks she’s telling you, so listen.”

People see a therapist regularly for years for certain conditions, but I’ll leave that aside for the moment. I think therapy, by and large, ought to be brief and goal-directed. The idea is to help a patient learn to catch fish, not sell her some every week. For that I need to do some data mining within her history, personality and current situation and find her raison d’etre.

What keeps her going in life, what motivates her?

Does her motivation come from outside or from within? The type of motivation – external or internal – that drives people depends on their genes. I know that sounds discouragingly immutable, and that bothers me too. But if you look at families you know, or even at your own parents, siblings, aunts, uncles and cousins, you can see how that might work.

To give a simple example, you work either for a reward, or solely because you enjoy it. If your motivation is only internal and you love your work but are underpaid because you didn’t think of negotiating your salary when you accepted the job, you might feel shortchanged and get depressed and anxious. Therapy might help you discover that you need to develop external motivation as well.

But here’s the thing. By nature, you believe a job well done is its own reward. Asking for a raise is something you force yourself to do, something you’re not entirely comfortable doing. You might wish you weren’t wired that way.

Many of the sad stories of people who messed up their lives, and the happy ones of people who fought incredible odds to get somewhere in life, are algorithms that gave them a choice at every point. What motivated them to choose as they did?

A father tells me that he controlled certain personality traits with much effort long before his son was born, but the teenager now exhibits the same distressing traits and risky behaviour. What does it mean, considering only nature is in play here, not nurture, at least to the extent that the father consciously controls his behaviour? Traits – good and bad – are inherited and make you to do things? If this boy should grow up to be a ‘psychopath’, a court won’t let him off because genetic traits motivated him to steal, mug or kill. So therapy might prevent the predictable outcome.

Does learning ‘better coping skills’ and ‘developing mature defence mechanisms’ through therapy merely mean that you learn to exercise self-control and behave more appropriately, tucking away your maladaptive tendencies somewhere in a dark recess of your mind? Or does it change you at a deeper level? Or do people just grow up and grow out of certain attitudes regardless of therapy?

Then, there are people who are satisfied with who they are and what they have. Aren’t they motivated to be famous or acquire more stuff? Perhaps they have simpler ambitions and are easily satisfied. Maybe they are naturally risk-averse. Or wise. Maybe they don’t care about being judged. Or they may be detached souls who consider life a brief stop on a much longer journey of the soul. Either way, that’s how they are wired.

So, is it all down to the genes that control motivation? Where does volition come in then?

There is a tiny structure called the nucleus accumbens in the base of the forebrain. It’s called the ‘reward centre’. The nucleus accumbens is part of a loop that aggregates a lot of information that the brain receives. It is concerned with processing motivation, reward, choice, aversion, fear, impulse and pleasure ­–­ pretty much everything that makes you do, or want to do, anything at all. Your genes might decide what your brain considers a ‘reward’.

Does this mean that therapy changes something in this loop? As the brain is plastic, new neural connections occur every time you learn something. And these new connections possibly change the way you think . . .

Perhaps the new connections re-wire parts of the prefrontal cortex – the part of the brain that thinks and makes decisions – to respond in a more measured way to signals from the reward centre clamouring for gratification. So there is a biological basis for therapy as a treatment modality in Psychiatry.

As the nucleus accumbens also plays a role in reinforcement learning, the new way of thinking possibly becomes second nature. If this is so, the boy in the case mentioned earlier might be able to stop himself from mugging the man walking alone on a dark street if he has received the right type of therapy! Rehabilitation of juvenile offenders is a huge issue for which therapy focusing on each child’s unique reward system might be useful.

There’s so much published about how therapy works and how each part of the brain works. But I don’t think we know how they come together.

In my first year at medical college, I found Embryology fascinating. While it was easy to see how each organ and system was developing, I never understood how they started working. I still don’t.

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A page from my Anatomy record – FY MBBS (eons ago!)

For example, the sino-atrial node, the self-sustaining pacemaker in the wall of the right atrium of the heart, starts beating when the embryo is less than a month old. It starts producing action potentials (electrical activity) that start the heart beating, and this continues till the end of life! I can’t imagine how it does that, though I understand how voltage-gated ion channels in the cell membrane generate action potentials using energy from adenosine triphosphate.

And this is a single structure with a single function. Maybe the answers lie neither in biology nor in psychology, and we ought to look for them elsewhere. What I found regarding the sino-atrial node was completely beyond my comprehension. This is a study by mathematicians!

https://www.frontiersin.org/articles/10.3389/fphy.2013.00020/full

So I won’t pretend that I can completely figure out something as complex as what happens in your brain when you talk things over with another person! The point is that the human brain is plastic, and that gives us scope to change ourselves. We can free ourselves from the constraints of negative emotions like anxiety and depression – all of which are controlled by the brain – and let our spirits soar.

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a sisyphean task

I keep coming across this statistic in the media: India has only 0.75 psychiatrists per 100,000 people. This is apparently the reason for countrywide neglect of mental health.

How can that be? We are talking about mental health here, not mental illness. Psychiatrists are medical doctors who treat individual patients suffering from mental illness, while other agencies are responsible for the mental health of populations. Substandard education, nutrition, housing and healthcare systems, unemployment, corruption, inadequate infrastructure and safety, disillusionment due to chronic mismanagement by successive governments, coupled with unattainable aspirations ­­– these are responsible for compromised mental health.

Let me put it another way. Physicians treat cancer, infectious diseases, metabolic diseases like diabetes, etc., but as an interdependent society, we are responsible for causing many of these diseases. Some examples:

  • Farmers using pesticides contribute to mutations in foetuses and cancer in adults.
  • The people who manufacture and sell sodas, fried foods and sugar-rich confections contribute to obesity and metabolic disorders, as also uninformed cooks who prepare food for others.
  • Unhygienic food handlers cause epidemics like typhoid.
  • Manufacturers of various goods, e.g. fabrics, cause sickness by dumping effluents into drinking water sources.
  • Almost all of us use automobiles irresponsibly, and also mindlessly buy and discard tonnes of clothes that are eventually burnt, contributing to air pollution.

Doctors can only do damage control, one patient at a time, and are not responsible for public health. A psychiatrist taking a patient’s history methodically rules out medical conditions as he goes along, before moving on to the Mental State Examination, so that organic causes are not missed.

Let me briefly clarify what is mental illness:

  • The innermost circle represents physical illnesses that present with psychiatric symptoms, like certain types of epilepsy, meningitis, encephalitis, brain tumours, vitamin deficiencies, memory disorders, intellectual deterioration, confusion, changes in personality, complications of diabetes, hypertension and other conditions, thyroid dysfunction, collagen vascular diseases.
  • The second circle represents illnesses that befall people, like schizophrenia, bipolar disorder, severe OCD. The causes are inherent, usually involving communication between different parts of the brain. A lot of Psychiatry is Neurology at a cellular level in the brain.
  • The third circle represents mental states like anxiety and depression due to a physical illness like the ones mentioned in the innermost circle, or life stresses, or an inability to cope. If the cause is psychological, symptoms are triggered by external factors, maintained by activation of particular brain circuits, and need short- or long-term psychiatric treatment.
  • The fourth circle represents behaviours of people who are dysfunctional for reasons that are a combination of nature and nurture. Some of their problems are psychiatric, but most are social or interpersonal.
  • The outermost circle is the one that keeps expanding. It is like the drawer into which you toss odds and ends that you mean to sort out some day. These problems are somehow seen as the responsibility of Psychiatry because the overt symptoms relate to the mind even though they arise from continuing, seemingly ineradicable, social ills.

Take alcohol addiction for example. A psychiatrist obviously evaluates a patient from a medical doctor’s standpoint. For instance, if someone is dependent on alcohol to sleep, I will investigate the cause of insomnia first and not label it alcohol abuse/dependence. Likewise, internet addiction might be the first obvious symptom of OCD. A young patient I recently saw for what his parents called phone addiction turned out to be a case of schizophrenia with comorbid OCD.

Alcohol addiction is considered a chronic, relapsing brain disease, and 50% of vulnerability is apparently due to genes. That still leaves 50% without a genetic cause. This study* by my colleague, Dr Vivek Benegal from NIMHANS, Bangalore, conducted for the government of India in collaboration with the WHO, details drinking patterns, harmful effects and management of alcohol abuse across India.

An excerpt:

Compared to 5 years back, there is an increasing availability and greater accessibility to alcohol (“It is much easier to get alcohol than milk!”), greater social acceptance of alcohol use and rampant and visible surrogate advertising (“No advertisement is needed for the sale of alcohol”). Increased prices have not lowered demand (“Now people are consuming more expensive drinks”).

Alcohol use is not considered a liability in relation to work efficiency. Festive drinking – customs (drinking during festivals such as Diwali or Ugadi) and traditions (use of alcohol at times of death, marriage celebrations and birth of children) – is more common than previously reported in India.

Narratives about heavy drinking of free alcohol distributed during elections at local, municipal and national levels were common.

Alcohol is easily available because you can’t ban it any more than you can ban sugar or butter saying they are harmful if abused. People are supposed to use them sparingly. Society as a whole is resigned to taking care of addicts because of addicts’ apparent lack of self-control. We go along with this when patients are brought in for treatment by anxious relatives, even though we know that this usually amounts to management of an episode rather than a permanent change in the patient’s outlook. It’s a Sisyphean task.

In my experience the most common reasons for this approach have been

  • awareness that alcohol abuse is a genetic disease in about 50% of abusers; also, that alcoholism is a depression spectrum disorder
  • depression and attempts/threats of self-harm by the patient
  • damage to organs caused by excessive drinking
  • empathy for parents/spouse desperate to get their kids/spouse off alcohol and get back to a normal life of responsibility
  • sympathy for the patient after hearing his story
  • knowing that people are unfortunately influenced by advertisers to see alcohol as an aspirational product, the way it was with cigarettes when the Marlboro man was the epitome of cool

Therefore, we focus on assessing suicide risk, managing physical effects like liver damage and vitamin deficiencies, treating depression, and attempting to support and counsel both patient and family. We can’t control the external stressors, the triggers. The multiple hospital admissions of patients who come for rehab have rightly been described as a revolving door pattern.

And there’s this too, from the same study:

Drinking continues to be mostly a solitary, under-socialised affair, mostly after work and outside home, and 50% of income is spent on alcohol.

The greater role of alcohol in domestic violence was recognised universally as also creating public nuisance:

“After drinking he purposely fights for small issues and behaves violently with family and others”; “After drinks, who is wife and who is children! They are beaten squarely”.

Ambivalent attitudes were also observed:

“My husband is a good person when not drunk but after drinking he will simply fight with me without any reason, scream at children and no more peace in the house”.

“(Husband) often beats children when he is drunk, otherwise he is such a good father”.

I have heard many such stories over the years from a significant number of female patients who present with symptoms of depression. Being married to an abusive alcoholic who is either unemployed or does underpaid freelance work makes them feel helpless. The cause of his problem ­– on the face of it – is unemployment, financial distress and lack of an education that could have led to a job. The root cause, however, could be genetics, his personality, priorities of his family of origin, or current circumstances. It’s hard to say whether it’s a mental illness, or lack of mental health. The poor wives accept it as kismet or karma.

As a doctor what is my role when an index patient is not sick? I wouldn’t prescribe an antidepressant for the wife as it makes no sense to pump chemicals into someone whose problem is somebody else! She needs support from some agency that doesn’t exist, and she needs her husband to be rehabilitated by a system that is either inadequate or doesn’t exist. I continue to be available and hope it helps.

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If every departure from what is regarded as normal behaviour is given a clinical diagnosis the meaning of ‘mental illness’ will be diluted even more than it already is. While I accept that we are often the first point of contact for anyone in mental distress, I don’t think every patient who consults us has psychiatric problems.

The first fallacy about mental health is that it’s an absence of mental illness. But people can be free of mental illness, yet not have mental health.

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

When there aren’t enough decent schools, colleges or jobs for people to realise their potential, when there are daily stresses like dense traffic, polluted air, flooded roads, unsafe sidewalks, a pervasive culture of bribery and rudeness, when you can’t work productively because, say, the internet keeps going off . . . you can’t have mental health. Of course, you can look at the positives, count your blessings and all the rest of the things that whatsapp forwards fervently propagate, but are they the real deal?

The long-term solution for meeting the mental health needs of a population does not actually lie in creating armies of psychologists, counsellors, life coaches, help lines, gatekeepers and what have you. I think the rot in society has spread far and deep, and the established systems that used to make people feel secure have been torn away, leaving them vulnerable.

Mental health is a public health concern, the health of entire communities. There’s a crying need for an overhaul of our national priorities. There’s only so much that individual psychiatrists can do because public mental health depends on government policies and a culture that makes it possible for people to have satisfying lives.

Removing roadblocks like the widespread corruption in our country ought to be the first step to achieving national mental health, not increasing the number of psychiatrists! This is the province of Applied Sociology or some other discipline, not Psychiatry.

As things stand, however, we need all hands on deck. Just as some of us need an accountant to help with our taxes, others need help in sorting themselves and their relationships out. People can’t always dig themselves out of holes they have fallen into, so someone has to hand them the tools. So we psychiatrists will continue to see anyone in mental distress. And concerned, empathic, people are welcome to help. Counsellors in India come from all backgrounds and, often, no particular qualification is needed as shown by these women in Tamil Nadu.

https://timesofindia.indiatimes.com/blogs/Globalpositioning/an-army-trains-to-tackle-mental-health-issues-in-rural-tamil-nadu/

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*http://nimhans.ac.in/cam/sites/default/files/Publications/WHO_ALCOHOL%20IMPACT_REPORT-FINAL21082012.pdf