Kulbhushan Jadhav in Pakistan

Why are people surprised by the way Kulbhusan Jadhav’s mother, Avanti, and wife, Chetan, were treated in Pakistan? Wasn’t it obvious that the whole charade of compassion and humanitarianism was only to score a small point in preparation for the next hearing at the International Court of Justice in The Hague? I’m surprised that India is surprised!

This was the verdict passed by the International Court of Justice on the 18th of May 2017: “Pakistan shall take all measures at its disposal to ensure that Mr. Jadhav is not executed pending the final decision in these proceedings.” I remember how well our Harish Salve did on that one!

Indians are apparently upset by:

  • the type of security check that the women had to go through
  • that they were made to change out of their nice clothes into something more suitable for use in Pakistan
  • they had to remove their mangalsutras and bindis
  • that Chetan’s shoes were stolen!
  • that they had to speak to Kulbhushan with a glass partition in between
  • that Kulbhushan’s mother was repeatedly interrupted with the instruction to speak to her son in English!
  • that they were harrassed by Pakistani journalists

All this was apparently done to intimidate the two women. I watched them on TV. What I saw was two strong women drinking in the sight of their beloved son and husband, not an iota of fear or intimidation on their countenances. These are Maharashtrians, descendants of people who stood up to both the Mughals and the British. They aren’t scared of anybody!

Regarding the above points:

  • Arsalan Bhatti, a Pakistani journalist, clarified on Indian television yesterday that he would have had to undergo exactly the same kind of security check if he had to enter the place. If this is true, fine.
  • Arsalan also said that the women changed their clothes of their own accord. Perhaps they did. Pakistani officials taking such a keen interest in what these ladies wore seems rather comical to me. Anyway, I’m sure Kulbhushan didn’t even notice what they wore, because he would have been overcome by a whole lot of mixed emotions in the circumstances.
  • I confess I’m mystified by the need to remove mangalsutra, bangles and bindi. Either it’s just garden-variety paranoia, or they are confused by women who aren’t completely invisible. Again, I doubt that either Kulbhushan or his mother or wife gave this much importance. This was too deeply emotional a meeting to worry about shringar.
  • Shoe-stealing is a common crime. Why do you think there are people posted outside our Taj Mahal to guard our shoes when we walk into the monument barefoot? This is probably a shared cultural issue, one of the things that make other countries hyphenate us as Indo-Pak.
  • The glass partition through which they had to see Kulbhushan was probably to discourage hand-holding, hugs and other forms of PDA. It could be a cultural thing in Pakistan. But seeing each other in the flesh, after seeing them only in their memories, must have made the glass unimportant and non-existant to them all.
  • Do Pakistani men speak to their mothers only in English? I guess it’s just an idiosyncrasy, or a colonial hangover. I have heard people in India address their moms as ‘Mother’ in English while speaking in their mother tongues. This is usually dismissed as a silly affectation.
  • The Pakistani press apparently harrassed the women. I suspect that the journalists were hoping to hear truth for a change. However, right after an emotionally charged meeting like that, the women were unlikely to have registered anything more than the noise level.

There’s one thing I want us to ask ourselves: Why don’t we believe Pakistanis when they say that they were being considerate and compassionate? Just because their ways don’t conform to our idea of what constitutes decent behaviour, it doesn’t mean that they are lying. Perhaps this is how compassion and consideration are expressed in Pakistani culture.

Different cultures have different standards. After the Brexit vote I remember being surprised by how quietly Cameron resigned and Teresa May took over. The English did not make a spectacle of themselves on the world stage and court disrespect and derision. This meeting between Kulbhushan and his wife and mother could have done with a little dignity. What a pity it had to be conducted in such a shoddy and cringeworthy manner by the Pakistani government, though, going by their protestations to the contrary, they are not even aware of having done so!



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: http://www.abc.net.au/news/2017-06-16/ditching-disposable-coffee-cups-war-on-waste/8625018


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?





echo chambers and shibboleths

My mother lost her brother in a religious street war when I was a school kid. I’ll never forget her reaction when she got the phone call from a cousin in her hometown. Nor my own shock and horror when I came to know that my uncle was stabbed over and over by a mob of people till he bled to death…

Such incidents still happen.

I wish we could simplify religion into a quiet private activity and not let it spill out into the streets as anger and outrage. And not onto the internet either.

Lies we believe about God’ by William Paul Young, and ‘Being Different’ by Rajiv Malhotra, are two books I happened to read back-to-back recently. Though they were both interesting, they were so different that I could practically feel and hear the clash of civilisations inside my head!

Some of the postulates in both books have been angrily denounced by readers as straw man arguments. How much critical thinking can one apply to something as subjective and faith-based as religion? My view is that most religions – the body of accepted truths, myths, miracles, tenets and stories about important personages in the history of every religion – exist because of collective validation.

The only way everyone in a large group can have exactly the same beliefs is by meeting regularly to validate each other. The meeting place thus becomes an echo chamber where certain beliefs are reinforced, while alternative or competing concepts are not allowed to be discussed. If not for these echo chamber meetings, people would end up with different beliefs over the years based on their own thinking and experiences. Instead, they are pruned to turn out like identical bushes in a formal garden, rather than trees growing freely in a forest. Even though trees are of different types and heights, a forest is a coherent whole, more natural and authentic than a formal garden.

Maybe there would be a better chance of peace if everyone arrived at their own individual belief systems regarding god and religion, and kept them private. I think experiential learning is far superior to received wisdom that is swallowed whole without being sifted and vetted and sent through the filters of one’s own mind. Hopefully, the young people of today will do better.

For centuries, religious leaders have been making rules and putting a stamp of divine authority on them. I do see that these rules help a lot of people walk the straight and narrow path. Religions help stabilise societies and bring out the empathic and altruistic side of people, and that’s a good thing for the human race. Without them the world might have been more of a dog-eat-dog place than it is. That much I concede.

But I think beliefs should be fluid enough to change with experience. For example, an innocent child who has been taught that her family’s god is the only real god will eventually notice that her friends’ gods are equally real to them. How will she deal with that? She has to change her idea of god. Will she be allowed? Why was she even taught something so divisive in the first place?  It seems to me that group gods are shibboleths that unite some people, who together exclude other people by declaring them either wrong or inferior.

Considering how much talk there is of human rights in today’s world, choosing how one wants to imagine god should be a basic human right! Yes, elders have to teach things to children, but I’m not sure this sort of indoctrination is teaching. Elders could perhaps use their wisdom better by introducing their family god to their children, then telling them that others may see god differently, and assuring them that this is perfectly okay.


As Rajiv Malhotra says in ‘Being Different’, the only way billions of people can live peacefully on earth is by mutual respect towards each others’ religions, not by mere tolerance. Tolerance is the ‘ability or willingness to tolerate the existence of opinions or behaviour that one dislikes or disagrees with’ (Oxford English dictionary). That is, you put up with them and conceal your annoyance behind a wall of tolerance.

In a pluralistic society nobody can say when that wall of tolerance will be breached. All it needs is one careless remark by someone, or sometimes, nothing at all. Perhaps the simmering negative energy of tolerance reaches critical mass and erupts. We then have those sickeningly familiar scenes of violence and bloodshed, cops and ambulances, placards and flowers and wakes, on primetime news. In 24 hours the whole incident will be replaced by some other breaking news, and only those who lost loved ones will remember the incident for ever.











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.







Isabel and the aghoris

Outsiders may view them with the same horror as a vegetarian reacting to the terrified shriek of an animal being slaughtered for meat or a ritual sacrifice. Or a suckling pig roasted whole and served with an apple stuck in its rictus. Or meat shops festooned with skinned carcasses. Different things disgust or horrify different people.

But the aghoris in India freely follow the strange customs of their tribe that most people might find revolting. And people who live around the areas they inhabit – Indians who don’t share these customs – apparently let them be. They believe the aghoris are merely following their karmic paths.

Is this indifference? It could be, but it probably isn’t. It’s more likely acceptance. Or deep-rooted fatalism. It is the belief that aghoris are born into or adopt this life for a purpose that can’t be rationally explained, but can be spiritually understood in terms of karma and rebirth.

The aghoris haven’t been corralled with the goal of integrating them into the dominant culture, if there is one. They retain their identity. Joining the mainstream is an individual choice and happens organically. Maybe this is true freedom?

So far, the government hasn’t tried to homogenise India and has largely stuck with ‘unity in diversity,’ the phrase used by Jawaharlal Nehru to describe us. Social engineering may only deracinate them, so they are left worse off, unless specific measures to rehabilitate them are put in place beforehand. This is difficult because there are too many groups clamouring for government support. Unfortunately this gives opportunists room to prey on their ignorance and defencelessness.


I heard about the documentary on the aghoris on CNN from someone living in the US. A man of Indian origin working in the US, Srinivas Kuchibhotla, had been fatally shot in Kansas just a few days before the program was aired. The Hindu community in the US was afraid that all Hindus would be seen through the lens of this documentary and violence against them would increase. At the time I shared their fears. It occurred to me a little later that they were only concerned about how it made them look, about how this perception could endanger their lives. To be fair, I would’ve had the same concerns if I lived there.

Even so, I wish someone had spoken up for the aghoris: “Let them be. Why ridicule them? They have not harmed anyone. They have never forced their beliefs on anyone. They haven’t threatened anyone who has criticised or mocked their religion. Targeting people who won’t pick up arms and retaliate – what a cowardly thing to do.”


Isabel, a girl born and raised here in Bangalore, spent a few hours with aghoris while travelling in Varanasi with friends. She refers to them respectfully as aghori babas.

She and her friends sat with them peacefully smoking chillum. They talked about Life. One baba said, “What do you take from this life? Nothing. We learn to live with nothing.”

This is Isabel’s take on aghori babas:

They leave everything and go through life not wanting anything. They connect with God this way. I feel they do a job like what undertakers and gravediggers do for society. They respect the dead and don’t recoil from them.  

It’s a myth that they all eat human flesh. Very, very few of them do. They just apply the ash from burnt bodies on themselves like how tribes put on war paint.

Many of them are there by choice, they come leaving families behind to live this way. All are not born there. I met people who talked about homes and families elsewhere … I don’t remember seeing women … 

They are nomadic. They move around quite a lot. I met them in Manali and in Calcutta too. They are a community. The younger people are expected to take care of the old.

Every spring many of them go to Kailash on a pilgrimage for Shiva’s blessings.

To my questions she replied:

Local people give them their space, they don’t interfere.

They’re confident – other people’s opinions of their religion don’t make them insecure.

Her acceptance, her lack of censure of any sort, moved me. She shrugged it off as just being Indian. Her Christian values of compassion and love had blended with values she had imbibed from other religions. From Hindus, acceptance of all life situations as arising from past karma; from Muslims, the idea of brotherhood, which she extended to encompass all human beings; from Buddhists, inner quietude and the ability to live in harmony with others.

They never asked us for money. They accepted food and provisions. They made tea and shared it with everyone. 

The older ones don’t like being treated like tourist attractions. They refuse to be photographed. They say you’re capturing a part of their soul. But the younger ones don’t mind because they’re used to cell phones…

Of course, Isabel didn’t get herself photographed with the aghoris. She wouldn’t impose on them. She would consider it an affront to their dignity.

May her tribe increase.

Note: This is a sequel to the post ‘Believer, CNN: Aslan and the aghoris’ :




the kohinoor diamond

The Supreme Court has disposed of a petition to bring the kohinoor diamond back to India. The Court isn’t going to interfere with the diplomatic process that this would involve.

The kohinoor was discovered in Andhra Pradesh in India in the 13th century. Or maybe it was Krishna’s legendary shyamantakamani. There’s plenty written about its sad history. In 1849, 13-year-old Maharaja Duleep Singh was coerced by Dalhousie into sailing to England to give it to Queen Victoria as a ‘gift.’ All of thirteen, did the poor kid have a choice? The stone is now in the Tower of London.

Personally, I’m not sure we must try to bring it back to India. These are my reasons:

  • There are elaborate arrangements in the Tower of London for guarding it. Can we keep it equally safe here? How many crores in taxpayers’ money will that cost?
  • Excited crowds will come to view it and there will be airport level security, or worse. It won’t be fun visiting it. After standing in queues in lots of tourist places, I know.
  • There could be tragic stampedes when hordes of people are funnelled into the necessarily small display area in front of a glass case.
  • It could be a target for terror attacks.
  • It is flawed. It has yellow flecks deep inside that prevent it from shining by refracting light. It is lacklustre. Only flawless diamonds have value as far as I know. It may be just a glorified lump of carbon.
  • It is cursed.
  • It is not beautiful despite attempts over centuries to chisel it into shape, remove its flaws and place it in flattering display cases.
  • It has been through the hands of the likes of Alauddin Khilji, Malik Kafur, Aurangazeb and Dalhousie and gathered a great deal of negative energy. That’s what a crystal healer told me. Queen Victoria apparently confessed to her daughter that she disliked wearing it.

When he visited India in July 2010, David Cameron, the British Prime Minister, said about returning the diamond, “If you say yes to one you suddenly find the British Museum would be empty.” Very true! They can’t afford to return things to their rightful owners, so they won’t. ‘Finders, keepers’ is a favourite English saying, though it has its origins in ancient Roman law. The ethical – and perhaps legal – problem is in defining when something is considered ‘found.’ Just like what exactly constitutes a ‘gift!’

A diamond has to be perfect, flawless, brilliant and hypnotising to be called a jewel. Lacking all these attributes and merely being one of the world’s largest lacklustre diamonds is not enough to be a gem. Five countries want it, so there’s a demand of sorts, so nobody is going to say “the emperor has no clothes!”

Maybe we should have one of those exciting referendums that are held countrywide for every confounded issue nowadays: Indians! Do you want the kohinoor back? Yes or No?

mean sojourn time* of threescore years and ten

When I was four I used to pester my great-grandmother to tell me how her mother looked.

“Did she look like you?”

“No, no.”

“Like Bapama?” That is, her daughter, my father’s mother.


“Did she look like me?”

“No, you look like your ma.”

My great-grandmother was probably fed up with this obsessive questioning. She would cannily switch to a subject that always got my attention: the flooding of the Netravati river when she was a young girl and lived on its banks. When red water forced its way noisily into her house and carried away everything in it, even the big tin of chakli she had spent the whole of the previous afternoon frying. The lid had come off and the crisp, crunchy chakli had floated out and become soggy. The slo-mo image of red water dragging the tin out of reach of her outstretched hands made me sigh with sadness. Much later, I wondered why we never talked about how she escaped, or what happened to her family.

Through my early school years I realised that if I tried to imagine my ancestors, the same face would appear in my imagination no matter how many great-great-greats I added. It would always be my great-grandmother’s face.

I once asked my younger sister if she could do it. Her eyes widened as she tried to, then she shook her head. We both looked at our youngest sister expectantly. She screamed, “Don’t, you’re scaring me!” We were taken aback. “You’re making me think of lots and lots and lots of old, bent people everywhere, with bald heads and no teeth and sad faces, walking with sticks!” Phew! She definitely had loads of imagination.

Even now I can’t go very far back in time. In my mind’s eye I always see what other people have already created in movies and documentaries. Known Earth history dates back to 590 million years, the period called the Cambrian age that lasted more than 50 million years. And that is only the known history of the Earth. Prior to that there was an age called the Pre-cambrian age that makes up seven-eighths of Earth’s history, about which very little is known! I can’t imagine any of this. To me, visualising anything beyond 5,000 years is a stretch.

It is the same with space. The Milky way can be seen as a clear strip across the sky. I don’t have to struggle to imagine it. I have seen Andromeda, our nearest galactic neighbour, both with the naked eye and through a telescope. Apparently, there are many more galaxies in the universe. If I try to imagine them I see a scattering of stardust fading away into the distance. In my mind’s eye it is astonishingly close to the edge of the Milky way, because I simply can’t go that far, distance-wise, in my imagination.

When I think of an atom I can understand quarks combining to form hadrons, i.e. the protons and neutrons, of the nucleus. Then a vague picture of the Hadron collider flits across my mind for a split second and then it hits me that I can’t imagine beyond quarks. Of course, it’s a highly specialised subject and I don’t expect to understand it, but the main feeling I’m left with is that human beings are actually in a straightjacket with very little wiggle room, in a way. This life, this reality, is a narrow band on the spectrum of all there is.

The importance that we human beings give ourselves individually and our countries collectively is so disproportionate to everything in the universe: galaxies to quarks to historic time. Add to that, all the species of animals, plants and other living/extinct organisms, the broad category to which we belong. We’re upstarts and we have an infant’s belief that the world revolves around us. In the face of all that is known isn’t that ludicrous? We are not masters of our fate in terms of birth and death, the two most significant events of our lives. We are mere accidents, like everything else on earth. Just a coming together of molecules in a certain form in the primordial soup, a form that has stumbled upon a code to perpetuate itself.

There are people like Hans Rosling who have said this is the best time to be alive. Going by statistics, it is true. We know terrible things are happening in different parts of the world. But people are happy with their lot in other parts of the world, that we don’t hear about. Regardless of events that are heavily publicised on television and awful stories that fill newspapers, I think there’s something to be said for taking a Pollyanna view of things considering how brief our sojourn on earth is.

Psalm 90, verse 10:

The days of our years are threescore years and ten;
and if by reason of strength they be fourscore years,
yet is their strength labor and sorrow;
for it is soon cut off, and we fly away.

*The mean sojourn time for an object in a system is a mathematical term for the amount of time an object is expected to spend in a system before leaving the system for good.