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.

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/

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

 

 

bilgy deal

 

My husband is a captain on Very Large Crude Carriers (VLCCs) and I’ve spent years on tankers that transport crude oil, like the one in this picture. I have a rudimentary idea of the oil trade, very basic, because it’s as complicated as any other business when you’re not on the inside.

The first time I realised that there was more to it than simply loading and discharging cargo was when I heard the big conspiracy theory about what America did with the crude oil we transported from the Arabian Gulf countries.

In the nineties our ships frequently visited US ports in the Gulf of Mexico to discharge crude oil from Arab countries. At every port – LOOP, New Orleans, Beaumont, Galveston, Corpus Christi, Brownsville – we heard this one story from someone or other. Agents, pilots, ship chandlers, all were convinced that the US was secretly storing massive amounts of crude oil bought from Arab countries in enormous underground salt caverns under all of New Orleans and Baton Rouge! One day, the story went, the oil fields in the Arabian Gulf would be depleted and then America would sell the oil back to the world at a solid profit! Of course, we all bought the story – who can resist a good conspiracy theory on such a large scale?

Well, now it looks like nothing so sinister was ever afoot! The US was prudently putting aside a modest stock of crude oil to tide over emergencies of the sort it had faced during the Yom Kippur war in 1973. Even now there’s only about 700 million barrels of Strategic Petroleum Reserve (SPR), enough to last only a month or two, is what I gather from the net.

I believe many countries now have their own SPRs. India has enough to last only twelve days – how pitifully inadequate that sounds! Apparently the government is planning to increase it to last twenty-two days by setting up reserves in Odisha and here in Karnataka.

Meanwhile, India has agreed to buy American shale oil to help reduce our trade deficit with the US. I think it has also agreed to not buy from Iran. And soon it may not be able to buy from Venezuela either. Which means:

• We will not get the sort of discount that Iran gives us because, as Wilbur Ross, the commerce minister, explained, the vendors of US shale oil are private suppliers, not the US government . . .
• Shale oil is more expensive to extract by horizontal drilling (fracking, or hydraulic fracturing) between and through rocks, unlike the simpler, cheaper, vertical drilling employed in crude oil fields. It also takes millions of gallons of water. These costs will undoubtedly be passed on to the buyer, that’s us . . .
• At present, LOOP (Louisiana Offshore Oil Port) is the only port where VLCCs can be loaded because it’s a SBM (Single Buoy Mooring) and, therefore, there’s no draft restriction. That means shale oil from other parts of the US will have to be brought to LOOP and loaded by reverse lightering from smaller tankers until existing ports are expanded to accommodate VLCCs. At least, that’s how I imagine loading operations will pan out. I’m guessing the lighterage charges will be invisibly included in our bill . . .
• The composition of Arabian Gulf crude is different from US shale oil. So Indian refineries have had to be modified to process shale oil. More costs for the Indian oil industry . . .

Losses at every stage! And if what I’ve read is true, that the supply of shale oil tapers sharply about one year from starting fracking, I don’t know how we can expect an uninterrupted supply.

I am aware these are the government’s problems and not mine to solve. But as an Earth citizen I can’t help feeling sorry that we’re importing oil from distant places like Brazil, Venezuela and the US, when it would have made more environmental sense to buy it from the neighbourhood. What a colossal waste of bunkers! I’m sure we indirectly pay for that as well! Unfortunately, India produces only 20% of its crude requirement because there are geographical hurdles to extracting more – or maybe this is only an excuse for government inefficiency.

As an Earth citizen, I also think fracking for shale oil, releasing all that methane into the air, using up gallons of water, then pouring back chemical-laden water into the soil, cannot be good for the earth, especially for the people who live in regions where fracking is done.

“It’s the economy, stupid!” I know. I’m not young and idealistic, nor am I naïve. But I’ve been a doctor, a psychiatrist, for too long to view human progress and mental health through the lens of Economics alone. I can’t convince myself that a high GDP is all that matters, and certainly not if it depletes Earth’s resources at this rate. Earth Overshoot Day came three days earlier – on July 29th last week – than it did last year, and five months earlier than in the seventies!

We all need money, yes, but I don’t see the point of accumulating riches in ways that harm an already helpless section of humanity. The simplest illustration I can think of is powerful mining conglomerates taking over land that has belonged to tribal people for millennia, and summarily evicting its inhabitants. In the case of oil politics too, poorer Indians will feel the pinch when they shell out a few more rupees for bus tickets or petrol for their two-wheelers, because they will have to scrimp on some other necessity, like food, for that.

 

 

 

 

the guttering candle of trust

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

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

Cut to today, and the question I started this post with.

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

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

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

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

Regarding Managed care* the authors say:

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

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

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

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

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

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

(received as a forward)

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

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

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

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

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

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

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

blogging on wordpress x 5 years

I thought I would write about parents and children, and people would read what I wrote, and I would thus contribute in a small measure to making India a better place for children. I would write about  common mental illnesses, so lay people could recognise the symptoms and seek treatment early.

Naïve? Sure, yes.

A young patient started this blog for me five years ago, in March 2012. It was meant primarily for writing about child-raising and mental health. But I was scared to write. I busied myself putting up photographs and other less-threatening things on it. It was nearly one year later that I dared to take the plunge. A very simple topic: Being parents. Something I had experience with. After that it got easier.

I had written a series of articles on mental illness for a local newspaper a couple of years before. Someone suggested I list their links on this blog. So I did. Someone else suggested I write a short gist for each article as well. I did that too.

As many people are afraid to take psychiatric medicines, I wrote a series of short blog posts about psychiatric medicines and sometimes referred patients to them.

Over time, I started liking my blog. It became a place I could visit, a place where I could express myself. Here, I was obliged to clarify things in my mind before I wrote, unlike a diary where I might allow sloppy thinking, half-baked ideas and excessive emotion.

I try to be precise as it is very easy to be misunderstood, which takes away from the spontaneity and raw quality of writing that bloggers appreciate. Sharing unexamined thoughts is just not me. Frankly, everyone – from ordinary people like me to important people like the president of the United States – shouldn’t be putting unprocessed thoughts on public display. People might act on them, like Adam Purinton of Kansas who shouted “Go back to your country” as he shot two men.

Though I think I’m aware of things happening around the world, I’m hesitant to comment on them here, especially after I came to know that ‘fake news’ exists and is not just something Trump rants about. A lot of stuff floats around like space junk in my head, but can’t be neutralised because of missing bits of information. Random example: Colombia – Juan Manuel Santos – Nobel peace prize – FARC – José  Luis Mendieta – forgiveness/punishment … After some time I just let it go.

I didn’t write for nearly two years as I didn’t feel the need to. In November 2016 I wrote ‘Change’ because I needed to sort out my thoughts about this phase of my life. Writing helped.

Of late, I’ve been in a nostalgic mood. Things are too quiet around the house with the kids having flown the nest. That’s why I’ve been writing almost exclusively about the time I lived on different ships over a six-year period. Those days now seem like a wonderful lifetime lived centuries ago. I’ve been sharing the links to these posts with everyone: cousins, my high school whatsapp group, and friends made over the years in different places.

The upshot of all this is that I’ve connected again with some nice people I had lost touch with, because they’ve called up or messaged to tell me how much they enjoyed the posts. Then, there’s my 13-year-old niece who said, “Aunty, I didn’t know all this had happened to you!” It was a revelation to her that I had been living for a long time doing other things, before she met me thirteen years ago!

This month I complete five years of blogging, irregular though it has been. I really need to thank wordpress for giving me this space. Blogging has given me a lot of relief, and pleasure too. There are so many bloggers whose posts I’ve enjoyed reading too.

My technophobia is starting to feel like ingratitude. I guess it’s time I re-examined my attitude towards technology. Ah, I can almost hear my children’s sighs of relief!

about this blog: 2016

View from Uttaribetta near Bangalore

One often sees this scene in movies: someone standing on top of a mountain shouting out his ecstasy, rage or a Big Question. It’s obvious he just needs to get it out of his system. For me, this blog has been that mountain. I yelled out in my head a lot of things that I wrote here. Sometimes I found I had typed it all in caps lock and had to re-type it.

I could write the same things in a diary but that would be just between me and myself. I need to express niggling thoughts as if I’m sharing them with other human beings. Transferring them from my head onto a blog, or setting them free in cyberspace, gives a sense of resolution as they are now out of my system.

When I look at what I wrote under ‘About this blog’ in 2012 I find that much of it is not true of today.

About parenting: The kids have grown up and flown the nest. Right now, I only hope they have come to Earth with decent natal charts to see them through this lifetime.

About teaching children to respect others’ religious beliefs: In the present milieu I would find it hard to advocate blanket acceptance of everybody’s religious beliefs as worthy of respect. The problems caused by differing religious beliefs among people are in the news every day. I would probably not talk about comparative religion at all, but just say that people ultimately get their just desserts.

About mental health: The brain is an organ, the mind a process. I broadly accept that everything that can go wrong with the mind has a biological basis, because nerve cells that mediate mental processes communicate via chemicals. Nevertheless, I am now reluctant to use the term ‘mental illness’ too freely.

About history: My interest is only in subaltern history, the story of the common people, rather than that of kingdoms, conquests and colonisations.

About nature: The only thing that hasn’t changed is my pleasure in taking photographs and sharing the nice ones here. It’s still only about capturing a moment on my phone, “nothing hi-tech, just point and shoot” as I’ve said before.

So, what will I be writing about? Whatever wells up and needs to be expressed. With one rule: try not to complain about things too much.

A little about taking medicines for depression and anxiety

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

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

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

• Antidepressants are not addictive and are usually given as a course for a few months.

• Side effects usually appear at the beginning of treatment, last just a couple of weeks or so, and get lesser day by day. In case they don’t go away, there are other options.

• Side effects cause some discomfort, but don’t affect work – and life in general – enough to discontinue their use. You don’t have to throw the baby out with the bathwater.

• Therapeutic effects are seen in less than a fortnight with some antidepressants, although some can take up to 1½ months to make a difference.

• The choice of medicine depends on what side effects you are trying to avoid.

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

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

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

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

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

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

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

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

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

Using psychiatric medicines

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

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

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

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

• How long do I have to take the medicine? I want to stop.

• Is there a treatment that doesn’t give me side effects?

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

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

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

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

Side effects of psychiatric medicines

I am often surprised by blogposts where someone declares that he will never see a psychiatrist. I wonder what else can be done for illnesses that are a result of neural circuits that don’t work, because connections between some nerve cells are lost and need to be reestablished. This is how medicines work. And they DO work.

Psychiatry is about biology.

Psychiatry is mainly about behaviour disturbances caused by biology. Psychological factors are relevant only where, for example, too many stressful experiences can impact ‘risk genes’ and cause mental illness. Or being stressed for a long time can prevent brain cells from growing. Things like that.

The brain is an organ. The ‘mind’ is a process. This process happens because cells in the brain connect environmental cues, thoughts and feelings, and generate actions. Mental illnesses are a result of this process being interrupted at different points.

Going by what I’ve come across on the net, most people seem upset by side effects of psychiatric medicines. If the rule ‘start low and go slow’ is followed there should be practically no side effects. At least, no more than what you get when you take an antihistaminic for a cold.

Medicines are not magic potions. They are not going to make your longstanding problems disappear overnight. They need to reach a certain level in the body before they show the effects you want to see. This can take a few days. If you start with a high dose, or raise the dose too fast, there will certainly be side effects.

Starting low introduces the medicine to your body and lets you know what sort of side effects you can expect. For example, if you are likely to react with stomach acidity, you’ll get a mild attack with a small dose, and something can be done about it.