The Health Collective 

Mental health

Fetish: Selena Gomez on a Disturbing Mental Health Issue

July 28, 2017

By Nikita Mishra

Queen Sel might have sparked more than a few conversations with her new music video FetishHer latest single is a complete 180-degree turn from the cutesy vibe she carries and seems to have baffled fans with layers of intense, dark imagery mainly around her mouth. The ‘Bad Liar’ star has been teasing the video release on her Instagram the last couple of weeks and had Selanators anticipating a steamy number about unrequited love. What they got in return is a LOT more.

The video begins with the 25-year old pop star looking mesmerising in the morning sunlight, walking in an abandoned street to a quaint house, picking peaches, writhing on the kitchen floor, sitting at a candle-lit table as it starts to pour inside the house.

And eating lipstick.


And soap. 

And glass.  And then she presses her tongue with an eyelash curler.  Whatttt the….right? Let's take a moment.

Unsettling and Intentionally So

Though Selena is yet to talk about her version of the metaphors sprinkled in the video, it clearly edges on mental derailment, addiction, powerlessness… and the unhealthy fetish of love and strange, inedible things.

The condition of eating soap, for example, is medically called pica, which often affects people along with depression and obsessive compulsive disorder (OCD). People feel compelled to consume things like faeces, pins, nails, knives, blades, mud, hair, and other inanimate, sometimes dangerous objects.

“Pica definitely needs to be addressed because of the dangers associated with it. Growing up, a lot of kids suffer from pica to some extent but they generally outgrow it," Dr Anjali Karia, Consultant Psychiatrist in Mumbai tells The Health Collective. "We don’t know exactly why this happens but it is linked to nutritional deficiencies of zinc and iron. The worrying part is when it strikes adults and they are totally helpless even though they realise it can be toxic. Many times it is co-morbid with other psychiatric disorders like depression, anxiety, developmental disabilities or OCD,” she adds.

With this single, the reigning queen of Instagram cultivates a platform where people can talk about their addictions or obsessions. The overall mental breakdown in this dark, fluttering track, the undertones of self harm are real mental health issues gripping our often fragile, overwhelmed, over-stressed population.

Anxiety and depression are clinical disorders that grip one out of four adolescents or adults in the world, according to the World Health Organisation. It cuts across countries and demographics. Here in India, self-harm is the top reason for adolescent and youth deaths in the 15 to 24 age group. It takes 60,000* lives each year (according to a study conducted by the Institute for Health Metrics and Evaluation, based on 2013 data). It leaves an even bigger number disabled.  

Talking About Health Issues Is Not New to Selena
In 2015, Selena opened up about the brief career hiatus she took to check herself into rehab. While entertainment glossies went into overdrive mode speculating about her possible drug addiction and substance abuse; behind closed doors, the global sensation was struggling with lupus and undergoing chemotherapy.

“I wanted so badly to say, ‘You guys have no idea. I’m in chemotherapy. You’re assh****. I locked myself away until I was confident and comfortable again. It’s so disappointing that I’ve become a tabloid story. The hate motivated me.  – Selena Gomez to Billboard Magazine

Also Read: Ask the Experts: Is Therapy for Everyone?

Lupus is an autoimmune disorder where the immune system attacks healthy cells, making the diagnosis and treatment very difficult. There is no cure. The disease is unpredictable and will never go away. One of the side-effects of lupus is anxiety and depression, both linked with compulsive eating behaviours like pica.

Selena has been vocal about mental health issues in the past as well. In 2016, she cut short her Revival tour to check into rehab for 90 days for depression and panic attacks. She visits her therapists five times a week and has been a public advocate of the Dialectical Behaviour Therapy (DBT), a skills-based approach which focuses on mindfulness to quash anxiety and depression.

Go watch the video again. It’s deeply disturbing, but mental illnesses are not fun and games...and it deserves props for getting the conversation started. If only more celebrities could be so forthright and break down the facade of perfection, perhaps the 50 million sufferers of depression, in India itself, would feel less alone. 


Nikita Mishra on The Health Collective

About the Author:

Nikita Mishra is a health journalist with over nine years of experience in broadcast (CNN-IBN) & digital ( She is also a lover of cakes, shoes and dreams...and the chaser of an over-smart kid. She welcomes feedback and comments.



The Law and You: Mental Health and Employee Rights

July 27, 2017

By Vandita Morarka

Let's take a look at understanding what employment and employee rights exist in India, with reference to those with mental illnesses. The Mental Healthcare Act, 2017 looks at healthcare and support provisions for those who have mental illnesses, you can read a piece explaining this law in detail here.

The Rights of Persons with Disabilities Act, 2016 (hereinafter PwD Act) is another key law at play here. It looks at the rights of those with any kind of disability, physical or mental, it defines “person with disability” as meaning a person with long-term physical, mental, intellectual or sensory impairment which, in interaction with barriers, hinders her/his full and effective participation in society equally with others.

Also Read: The Law and You: Mental Health in India

Both Acts define ‘mental behaviour’ as ‘mental illness’ -- that means a substantial disorder of thinking, mood, perception, orientation or memory that grossly impairs judgment, behaviour, capacity to recognise reality or ability to meet the ordinary demands of life, but does not include retardation which is a condition of arrested or incomplete development of mind of a person, specially characterised by subnormality of intelligence.

The interpretation of such a definition could technically include aspects of depression, anxiety, high levels of stress and so on as well.

Unfortunately in practice, due to the varying nature and spectrum of such illnesses, all employment policies do not account for such rights for those with mental health illnesses that are not deemed ‘substantial’ enough. These Acts don’t provide clear guidelines for rights of those afflicted with any kind of mental health illness in relation to their workplace. The PwD also doesn’t understand that the workplace support needs of those with mental health illnesses would differ from those with physical health issues and hence policies would need changing to account for both separately. At the same time, we can build on certain rights that can be inferred from these laws. It is mainly the PwD Act that creates a basis for employee rights in cases of mental illnesses that can be termed as a disability:

  • The PwD Act is meant as an Act to give effect to the United Nations Convention on the Rights of Persons with Disabilities. The Convention clearly identifies non-discrimination and equality of opportunity as a key principle for empowerment of persons with disabilities of any kind.

  • The PwD Act further defines “discrimination” in relation to disability to mean any distinction, exclusion, restriction on the basis of disability which is the purpose or effect of impairing or nullifying the recognition, enjoyment or exercise on an equal basis with others of all human rights and fundamental freedoms in the political, economic, social, cultural, civil or any other field and includes all forms of discrimination and denial of reasonable accommodation.
    This effectively ensures that in all matters of employment or workplace policies, persons with mental health illnesses cannot be discriminated against. Their treatment has to be at par to what would legally be required of someone towards a person with physical disabilities.

  • The PwD Act states that the Government shall take measures to protect persons with disabilities from being subjected to torture, cruel, inhuman or degrading treatment.
    he interpretation of such treatment can also be workplace policy or practice that doesn’t allow for unfair treatment of anyone with a mental illness or any behaviour, at a workplace, that demeans a person with mental illness.

  • The PwD Act clearly states that a government workplace can’t discriminate against any person with disability in any matter relating to employment; the government though can notify of any specific employment roles that are not subject to this provision. This essentially implies that if you have a mental illness and have the qualifications to do a job, unless clearly specified why you can’t do the job by way of a notification, the government cannot discriminate against you while making a hiring choice.

  • All employers, government and private, are supposed to clearly state their equal opportunity policy. The policy details measures they would be taking to comply with provisions under the law, to ensure the rights of those with disabilities are upheld. It means that all employers need to ensure that they have a policy in place that gives equal opportunity to someone with any disability, be it physical or mental. It would also mean that in keeping with such policies they build support structures and programs to give actual effect to the policy.

Offences committed by persons or companies are punishable under the PwD Act. In the case of a company, all person(s) in charge of the conduct of the business of the company will be responsible.

The main problem that arises here in India, like several other countries, UK for example, is that such law seems to account for mental health related issues and rights only when the issue can be classified as a disability that is substantial and long term.

What the law and company policies need to account for, is the need to recognise mental health as a spectrum, the same way physical health is viewed. The law in itself seems to discriminate against mental health by not understanding it the way physical health/ illness is understood.

It is important to practise equality and non-discrimination in terms of all aspects of mental health and not just those that would be defined as a disability by the law. The same way company policy would account for sick leave for an employee when they have viral fever, it needs to account for sick leave for stress. It is imperative for companies to break down the complete extreme of acknowledging mental illness only as ‘substantial’ disorders and also look at it at par to physical illnesses, where physical health is not looked at as two extremes but as a continuing spectrum.

This would mean that you can as easily take a day off because you feel mentally unwell and in the need of mental health care as you would if you felt physically unwell, without it having to be an illness that is necessarily of a higher intensity and prolonged.

There is also an urgent need to bring the need for systemic awareness creation relating to mental health into a policy format for employers to follow, to reduce the stigma and social ostracisation that those with mental health issues are affected with. As has been done with the law relating to sexual harassment at workplaces, the government can easily mandate compulsory awareness creation and support systems for redressal in terms of mental health illnesses.

There is an urgent need for companies to evolve a workplace mental health policy and supportive practices. The WHO provides a module that can be used a starting point for those employers wanting to build in such practices to make their workplaces more inclusive and humane.

Note: Both laws referred here are fairly recent and hence do not have adequate supportive case law. None of this content is meant to act as legal advice under any circumstances.


About the Author

Vandita Morarka is an independent policy consultant, legal researcher and gender rights facilitator. She is currently the Policy, Legal and UN Liaison Officer at Safecity (Red Dot Foundation). She is working on a series for The Health Collective looking at The Law and You: an attempt to understand the law that governs mental health in India and its resultant rights and duties.

Views expressed are personal. Material on The Health Collective cannot substitute for professional mental health advice from a trained professional. For more on help available, do click here



Ask the Experts: A Case for Emotionality

July 25, 2017

By Varkha Chulani

In the recent past I have seen too many clients getting into trouble due to self-control! Yes, sounds a bit odd, because mankind’s main problem seems quite contrarian. Decadence and intemperance being the bane for many, with self-indulgence and instant gratification playing a significant role in the decay of health. Not to mention the avoidance in tolerating and bearing legitimate suffering that life offers. So, in a way self-control IS the need of the hour, isn’t it? Well, not in the area of beneficial emotionality!

Mansi came and saw me with complaints of anxiety and panic. A young twenty-seven-year old she was experiencing difficulty breathing, with palpitations that sounded like her heart was going to burst, a restlessness she wasn’t able to control, and a feeling of doom whenever she was with herself alone.

Also Read: Breaking Up and Moving On: A Psychologist's Perspective

As the session progressed it came to light that Mansi had recently been led down the garden path in a relationship. As is the case most often, she brushed aside the anguish this had caused, went about her daily life as if nothing had happened. She was trying to remain upbeat and cheerful, suppressing emotions and not allowing herself to feel “bad”, as she put it. This was Mansi’s way of moving on... She wanted to get on with it, to recover, and not “wallow” as most people would say!

Just be positive! Look at the silver lining! Everything will be well! Life is beautiful! Keep your chin up! In this trying to stay in a sunshine-and-roses-stay-positive culture we are beginning to abhor ‘negative’.

You are too ‘negative’”, “Tsk, tsk, do you always see the glass half-empty?” are some messages that one often hears when one displays or talks about unhappiness.

We are afraid of negativity. To us, expressions of sadness, regret, annoyance, concern, disappointment and dissatisfaction are just too adverse. But heck, stop a moment and think! Do you really believe that Mansi ought not to have stayed with her feelings, acknowledging the hurt, the loss, and the pain she went through having suffered a break up?

Psychologist Varkha Chulani makes the case for emotionality, on The Health Collective.

The case for emotionality argues that thankfully human beings are not objects. We can emote. And due to our higher order (?!) cognitive functioning, a step beyond the animal kingdom. The range of emotional capacities that humans can enjoy exists! The operative word being can!

But in a culture which defines emotionality as a weakness, sensitivity as vulnerability and sentimentality as susceptibility, we are trying very hard to curb if not squelch emotions altogether. Or at least the so-called ‘negative’ ones. And with so many self-styled counselors, coaches and ‘experts’ who have never learnt the distinction between what construes as healthy and unhealthy emotions, categorising everything simply as ‘positive’ or ‘negative’, is leading to a population that is leaning towards the unhumane. Because to be human is to emote. Humaneness is tenderness. And tenderness is not frailty!

Also Read: Ask the Experts: Is Therapy for Everyone?

But to believe the above one has to shorn off yet another message many lay-people and even the ‘experts’ believe. That if one feels ‘negatively’ then one is not “strong’. Does ‘strength’ mean being ‘emotionless’?

So lets not do us a disservice anymore and be fearful of emotionality. Mansi would be better off being true to herself and authentically allowing herself to feel sad, disappointed, grief, at the loss of love. Allowing her to experience and feel sorrow ironically would veto anxiety and panic! Yes, you read right. Had she given herself the go-ahead to experience the expected reactions to loss, and had not exhibited restraint, the suppression wouldn’t have burgeoned into a debilitating anxiety.

I believe life is a tragedy to those who hold back, a pleasantry to those who feel!


About the Author: 

Varkha Chulani is a clinical psychologist and psychotherapist at Lilavati Hospital in Mumbai. She is an associate fellow and supervisor at The Albert Ellis Institute, New York City. She writes a regular column for The Health Collective -- you can find her piece on the need to build pockets of stillness into our lives here.

Views expressed are Personal. Material on The Health Collective cannot substitute for professional mental health advice from a trained professional. 


Ask the Experts: How to Cope with Break-ups, Divorce (Hindi)

July 21, 2017

Psychologist Varkha Chulani writes on The Health Collective

ब्रेकअप और आगे की राह: एक मनोवैज्ञानिक का नजरिया

ऐसा कहा जाता है कि मृत्यु के बाद दूसरा सबसे बड़ा तनाव का कारण अलग होना या तलाक होता है। मगर ऐसा ही हो ये जरूरी नहीं है यदि हम ब्रेकअप को अलग नजरिए से देख सकते हैं- जैसे इसे अगर हम सामाजिक तरीके से, समझदारी से, वास्तविकता के साथ और यहां तक कि दार्शनिक रूप से देखें तो। क्योंकि रिश्ता समाप्त होने को लेकर हमारा दृष्टिकोण यह निर्णय लेने में काफी मदद करेगा कि हम इस पर कैसे प्रतिक्रिया करते हैं और इससे कैसे निपटते हैं। रिश्ते के टूटने पर हमें टूटने की आवश्यकता नहीं है क्योंकि हम उसके निहितार्थ को चुन सकते हैं जिसे हम अलगाव की वजह बता सकते हैं।

सबसे पहले, प्यार और प्यार में बने रहने के अपने तथ्यों पर गौर करें तो आप देखेंगे कि प्यार के खत्म होने के दुख को कम दर्द के साथ सह सकते हैं। किसी भी अन्य भावना की तरह प्यार जन्म, विकास और मृत्यु के अधीन है। लेकिन यदि आप उन रुमानी लोगों में से हो जो यही मानते हैं कि सच्चा प्यार कभी खत्म नहीं होता और चूंकि 'हमारा खत्म हो गया, तो यह कभी भी सत्य नहीं था' आप अपने आप को बहुत कटु और असंतुष्ट पाएंगे। हो सकता है कि आप अपने से वायदा भी करें कि "मैं फिर कभी प्यार नहीं करूंगा!"

अलगाव पर हमारे अतिप्रतिक्रियावादी हो जाने की एक वजह यह भी है कि हमने किसी भी तरह प्यार की अवधारणा को विकसित किया है और इसके साथ प्यार में हैं। हम इसको पवित्र बना देते हैं और शीर्ष स्थान पर रख देते हैं और इसकी पूजा करते हैं। और देखिए, तब क्या होता है? जब 'प्रेम' खत्म होता है या खत्म होने लगता है तो हम इसे इस रूप में स्वीकार नहीं कर पाते हैं और इसके खात्मे के तरह-तरह के अपुष्ट अर्थ गढ़ने लगते हैं।

प्यार से रोमांस को हटाकर (एक विडंबना) और इसे वैसे ही देखना जैसा यह है- यानी बेहद सामान्य, इसके लिए और ऐसा बने रहने के लिए जरूरत होती है बेहद कोशिशों की, और इसमें शिखर और गर्त दोनों ही सामने आएंगे- और हमारी प्रतिक्रिया मुनासिब हो सकती है 'जब मौत भी हमें जुदा नहीं करती है'। बेशक यह दुर्भाग्यपूर्ण और दुखद है जब कोई जोड़ा आगे जोड़ा नहीं रह जाता है और यह अफसोसनाक और निराशाजनक है कि ऐसे रिश्ते जिनका भविष्य उज्जवल लगता था अब वह खत्म होने की कगार पर हैं। परंतु तब फिर लोग अलग होकर रहने लग जाते हैं और क्या वे प्रेमी लोग नहीं कहे जाते हैं। चीजें बदलती हैं और अगर कई बार दोहराई बात को कहा जाए तो परिवर्तन ही स्थायी भाव है। ऐसे में भावना की अराधाना क्यों न हो।

आगे का रास्ता

यह सोचते हुए कि मेरा दोष है या फिर उसका दोष है अगर आप ब्रेकअप को व्यक्तिगत तौर पर लेते हैं तो आश्वस्त हो जाइये कि आप अवसाद की स्थिति में चले जाएंगे और/या शत्रुतापूर्ण हो जाएंगे और समस्या वहीं की वहीं रह जाएगी उसका समाधान नहीं हो सकेगा।

समस्या-सुलझाने के दृष्टिकोण को अपनाइये और जुदाई के कारणों का मूल्यांकन करिये। ऐसा करने में आपकी बुद्धिमानी होगी। ब्रेकअप का मतलब आपके या अपने साथी के बारे में कुछ नहीं है। इसका मतलब यह है कि आप दोनों की अपेक्षाओं में एक असमानता थी। और अजीब तरह से, हम बहुत बुरी चीज़ों को अच्छी चीजें में बदल सकते हैं।

इसके अलावा, अलगाव से आपको चौंकाने वाली एक अच्छी बात भी आ सकती है। मिसाल के तौर पर आगे ​के रिश्तों के बारे में क्या नहीं करना है।

कैसे अपने अगले साथी की पसंद में अधिक चयनात्मक होना है। साथ ही यह समझने और स्वीकार करने का भी मौका मिलता है कि प्यार परस्पर और बराबरी से चलने वाली चीज है जिसमें अगर एक तरफ संतुलन बिगड़ा तो ब्रेकअप की नौबत तक आ जाती है। रोमांस के साथ-प्यार बहुत खूबसूरत चीज हो सकती है और तलाक कोई ऐसी तबाही वाला घटनाक्रम नहीं है!

-- Brought to you in partnership with our friends at NewsroomPost

Ask the Experts: Mental Health 101

July 19, 2017

Amrita Tripathi interviews psychologist Arpita Anand for The Health Collective

1. What is some generic advice you would give readers about mental health -- what do you wish for people (to know) across the board?

The first thing would be acceptance: A lot of people with emotional difficulties end up suffering because they are in denial. For example, a person with depression may continue to believe that they are feeling tired and having sleep difficulties because of physical health problems and refuse to accept that these may be symptoms of depression. As a result, they may delay getting the right help and carry the risk of their condition worsening. 

Another would be to get some help if required: I often tell my patients that just the way they would consult a physician if they were having physical health problems, they ought to get help from a mental health professional. 

Lastly, we should all talk about mental health openly: Openness will lead to de-stigmatisation. 

2. Does it help to think of mental health as a continuum -- apart from specific conditions and diagnoses... And increasingly I've been hearing from people who fear they were mis-diagnosed or that they are much more than their condition or label -- what should friends and family keep in mind?

I agree about considering mental health conditions along a continuum.  For instance depression may be mild, moderate or severe.
OR someone may not meet diagnostic criteria for depression but still may show some symptoms.

It is important to recognise what the person is feeling and to treat it accordingly. Friends and family should essentially focus on the support the individual requires and offer that in a consistent and supportive way.

Also Read: Ask the Experts: Relationships, Happiness, Living the Life you Want

3. Mental Health in the Workplace is a huge over-arching theme (this year for World Mental Health Day). From your practice over the past few decades, can you shortlist some common issues that come up, that are work-related?

Work pressure, interpersonal dynamics at the workplace can contribute to high stress, competitiveness, mismatch between skills and job profile to name a few.

Views expressed are Personal. Material on The Health Collective cannot substitute for professional mental health advice from a trained professional. 


Long Read: Anxiety Disorders in India

July 17, 2017

By Arti Malik

Most of us have experienced feelings of apprehension or physical unease, for example (and often) when we are faced with a difficult situation. We live in an environment that is dynamic and challenging in multiple ways and this can often lead to stress. While we tend to possess effective coping mechanisms to deal with everyday stress, sometimes these mechanisms can become over-activated, maladaptive, and can lead to anxiety.

Anxiety vs Anxiety Disorders

Anxiety is a subjective feeling of being in a state of unease, apprehension, worry, fear or discomfort  often accompanied by physical symptoms such as heart palpitations, trembling, sweating, headache, etc. These are perfectly normal ways in which a person responds to a real or potential danger. However, if these feelings and physical symptoms occur for a prolonged period of time, or often in an extreme or disproportionate fashion that makes a person feel helpless and debilitated, then the person may be suffering from an Anxiety Disorder.

Anxiety disorders are grouped as a range of mental disorders characterised by feelings of anxiety and fear. They include generalised anxiety disorder, social anxiety disorder, specific phobia, separation anxiety disorder, panic disorder, etc.

Anxiety disorders are among one of the most prevalent mental, emotional and behavioural problems in the world, estimated to affect 3.6% of the global population as of 2015, or about 264 million people, according to WHO figures.

They are and should be an important focus of research and an issue for public health as they seriously affect the quality of life of a person suffering from any of them and they pose a heavy cost burden in managing the disorders in patients.

Also Read: Ask the Experts: Understanding Anxiety Disorders

Thirty-five year old Isha* suffers from social phobia, one of the most common anxiety disorders. She tells The Health Collective about her university days and early work life.  “I came across as shy or even arrogant sometimes, to most of my college-mates and colleagues. I had few friends and I was constantly overwhelmed by the thought of attending social events, parties and even extra curricular activities involving a group of people, and chose to mostly excuse myself from them. On one hand I felt extremely lonely and on the other totally terrified by social situations.”

Even today, socialising can be an ordeal, but she is equipped with more knowledge about her condition. “It is only after I began therapy in my late twenties that I realised I suffered from social phobia. It is easier now than before, but even now my automatic reaction to an invitation to socialise is a vehement no.”

Prevalence in India

Epidemiological studies and research, specifically on anxiety disorders has been inadequate in India. According to an article by Trivedi and Gupta (Indian J Psychiatry, 2010), on the overview of Indian research on anxiety disorders, there is discrepancy on prevalence rates of anxiety disorders due to many reasons including under-reporting, poor screening instruments, exclusion of certain anxiety disorders from the surveys, small sample size, etc.

The first ever nationwide survey on mental health covering 28 states in 2015- 2016 gives us a better idea about the prevalence of anxiety disorders in India. The National Mental Health Survey conducted by the National Institute of Mental Health and Neuro Sciences (NIMHANS) in 2015 -2016, indicates that the total prevalence of anxiety disorders in India amount to 3.1 percent of the population.

According to this, the prevalence of anxiety disorders such as phobic disorders, agoraphobia, generalised anxiety disorder, obsessive compulsive disorder is higher in females than in males. Adolescents are also disproportionately affected with anxiety disorders as in many cases, symptoms of an anxiety disorder manifest themselves in early adolescence and may continue to persist throughout adulthood and old age. The survey also indicates that mental disorders including anxiety disorders affect the productive age group between 30 and 49 the most and peaks during this time.

Also Read: Ask the Experts: Child and Adolescent Mental Health

A study conducted by, a professional counselling company found that every 1 in 2 employees in corporate jobs in India suffers from anxiety and depression.

Symptoms, Causes and Management

Physical sensations include headache, nausea, vomiting, sweating, trembling, stomach pain, tingling, weakness, body ache, feeling shortness of breath, hot flashes or chills, etc.

Emotional sensations include nervousness, fear, irritability, worry, insecurity, isolation from others, self consciousness, desire to escape, etc. The effect of these symptoms leads to the impairment of cognitive processes such as thinking, decision-making ability, perception of the environment, learning ability, memory and concentration.  

Persons suffering from an anxiety disorder, therefore, may find it difficult to carry out certain tasks or respond to certain situations in an appropriate manner.

Research shows that a variety of biological, psychological and social factors can contribute to anxiety disorders. Biological factors may include genes that may predispose certain people to anxiety disorders. Psychological factors may include behavioural factors where a person may develop a maladaptive learned response to specific past experiences and and applies it to future similar situations. Social factors that can lead to anxiety disorders include life experiences such as death in a family, divorce, financial troubles, major illnesses, long term exposure to abuse, violence, etc.

To effectively diagnose and treat anxiety disorders, it is important to understand the underlying causes of the disorder.

Psychiatrist Dr. Jai Meher from the Institute of Human Behaviour and Allied Sciences (IHBAS) tells the Health Collective, “In my clinical practice, I have seen that often patients suffering from an anxiety disorder have maladaptive coping mechanisms formed in their childhood due to lack of appropriate parental guidance or neglect or other social, psychological or biological factors, which are difficult to shake off in adulthood. Therefore in treating and managing anxiety, the importance in therapy should be given to learning new coping mechanisms and that can take time and patience."

Diagnosis and Management of Anxiety Disorders

Diagnosis and management of anxiety disorders in India can be challenging for a number of reasons.

  • Mental disorders in general still carry a lot of stigma attached to them in India and thus can lead to neglect and marginalisation

  • Particularly because of their subjective nature, anxiety disorders can further lead to more neglect. A person suffering from an anxiety disorder may not be able to comprehend their feelings and in turn may not be able to communicate to others what they are experiencing.

  • Lack of awareness regarding anxiety disorders can also hinder one’s ability to seek help

  • Research and epidemiological studies on mental disorders have neglected anxiety disorders in India for a long time, which affects the diagnosis, treatment and management of anxiety disorders.

  • The abysmal mental health care system in India and its high costs invariably come in the way of persons seeking help, especially if they belong to rural, low-income, marginalised and vulnerable groups.

Management/ Treatment

Once diagnosed, anxiety disorders can be treated in a number of ways:

  • Anti-anxiety medication may be prescribed to relieve physical and emotional symptoms.
  • Cognitive behavioural therapy and/or other psychotherapies address underlying issues, coping mechanisms and responses of a person, which may help in managing anxiety and its symptoms.

  • Learning relaxation and stress management techniques and exercises such as mindfulness and yoga can be beneficial in the long term management of anxiety.

Challenges: What India Needs

Despite availability of medication, therapy and other techniques that can significantly reduce the discomfort and debilitation associated with anxiety disorders and help people lead more productive and healthier lives, most persons suffering from anxiety disorders are not able to seek appropriate treatment and care.

One of the first steps towards addressing anxiety disorders in India would be to create awareness among people of all ages and among all populations. Improving access and affordability to mental health care would encourage more people to seek help. Moreover, focused research on the social and cultural aspects in specific contexts of the population in India would help in determining the causes and perhaps designing interventions to adequately address the problem of anxiety disorders in India.

*Name changed on request
** This post was updated to correct the information on global prevalence of anxiety disorders as per WHO estimates 


About the Author
Arti Malik is trained as a lawyer and has a Master's degree in Education and Health Promotion from the University of London. She has worked in law, public health and education for the past 12 years. She currently works with The Community Library Project.

Views Expressed are Personal. Material on The Health Collective cannot substitute for professional mental health advice from a trained professional. 


Reporter's Diary: Mental Health Challenges for Gender and Sexual Minorities

July 14, 2017

By Devanik Saha

In an earlier column on The Health Collective, I had written about the severity of the mental health crisis in India. Even though not enough attention is paid to the issue (both in India and abroad), conversations around mental health are gaining traction. In March 2017, India passed the Mental Healthcare Bill which decriminalised suicide and safeguarded the rights of mentally-ill persons in India.

Also Read: The Law and You: Mental Health in India

Even though mental health discussions are being normalised, it is critical that these discussions and deliberations include gender and sexual minorities, who are more vulnerable to suffer from mental illnesses than the rest of the population. It is preferable to use the terms “gender and sexual minorities” rather than the commonly used term LGBT (Lesbian, Gay, Bisexual, Transgender) because LGBT conflates gender and sexual identities, but this article will focus use both terms interchangeably due to limited research.

Lack of Sufficient Data on Mental Health and Gender, Sexual Minorities

Gender and sexual minorities are in themselves issues which have been traditionally underserved, therefore, there is a lack of data on mental health issues related to them. But a few studies from advanced economies point us to the high likelihood of minorities being more vulnerable to mental health illnesses.

A 2016 study in the US suggests that gay and bisexual high schoolers are four times more likely to have attempted suicide in the past year than their straight classmates, according to the first nationally representative study of queer youth in the country. Another study conducted in the United Kingdom across 7000+ adults in 2007 revealed that self-reported identification as non-heterosexual was associated with unhappiness, neurotic disorders, suicidal thoughts and harms and other mental disorders and illnesses.

Sweden is considered one of the most gender-equal countries globally, but a 2017 study revealed that gay and lesbian individuals were more likely to receive treatment for anxiety disorders and bisexuals were more likely to receive treatment for mood disorders and substance abuse when compared with heterosexuals. The study added that the impact of stressful issues such as exposure to victimisation or threat of assaults and lack of social support partly explain these disparities.

Though there is no large-scale nationally representative study in India, the above mentioned studies and anecdotal evidence and reports suggest that gender and sexual minorities in India are likely to be more vulnerable to mental health illnesses as well.

Discrimination Faced by Minorities is Associated with Mental Health

In India, the gender and sexual minorities face huge stigma and find it difficult to be accepted by society, which proscribes their desire to speak openly about their gender and sexual identities publicly and this is a critical problem.

Dr Qazi Rahman, a lecturer and researcher at the Institute of Pscyhiatry at Kings College London spoke to The Health Collective in depth about this issue.

He said, “LGBTs have a social identity that is not visible unlike say ethnic identity. Concealing this identity may be detrimental to mental health because it causes anxiety and hyper-vigilance about being found out, detached from one’s true social identity impairs self-esteem, and having to make repetitive decisions about whether to disclose one’s identity depletes cognitive resources.”

In the case of transgenders - a gender minority - there has been some limited progress which includes legal recognition, jobs given by government agencies, participation in electoral politics, etc. But there is still a long way to go. In May 2017, the newly-launched Kochi Metro employed 23 transgenders, which was the first time a government-owned company in India provided employment in large numbers to the minorities. However, within a month, many of them left the job as several home owners refused to rent their homes to them in Kochi - an example of discrimination meted out to them despite legal recognition.


The Health Collective spoke to Leyla*, a transgender and an activist, about her view on the issue.

She said, “When you're constantly made to feel guilty about being different, you start checking yourself a lot. You begin to lose your confidence and every time start asking if it's your fault. Anxiety is very common among queer folks. After I came out to my parents, I've been struggling with a lot of anxiety. I sought help but I stopped seeking it because it made me feel even more guilty because I didn't tell my parents about seeking help.”

The situation is much worse for sexual minorities. In December 2013, the Supreme Court (SC) upheld Section 377 and criminalised homosexuality in India. This decision was vehemently protested by activist groups and researchers as they argued that apart from curbing freedom of sexuality, this would lead to further discrimination and marginalisation of sexual minorities. In Chennai, as many as 16 people belonging to sexual minority groups committed suicide in 18 months after this verdict, as reported by the New Indian Express in October 2015.  

Vikram Patel, a  renowned mental health expert and Professor at Harvard Medical School, told the Health Collective, “Any form of discrimination, Section 377 in India’s case, will lead to a greater burden of stress and anxiety for those who are targeted, and this represents a violation of an individual’s fundamental right to mental health and freedom of expression.”

Tirana Gay (P)ride 2016: Photo By Albinfo (Own work)
[CC BY-SA 4.0 (], via Wikimedia Commons

Future Challenges: What Should be done

The passing of the Mental Healthcare Bill was a critical step as it addresses rights, but it is clearly not enough. As highlighted earlier, discrimination is a key factor associated with poor mental health and illnesses.

Though the Article 15 (1) of the Indian Constitution prohibits discrimination on account of religion, race, caste, sex, place of birth, it has primarily  been interpreted as discrimination based on a single ground and not intersectional discrimination. For example, it addresses the discrimination against a man or a women on account of being a man or a woman, but doesn’t address discrimination faced by a Dalit lesbian woman, which is a multiply marginalised identity.

In March 2017, Dr Shashi Tharoor, Member of Parliament from Thiruvananthapuram, introduced the Anti-Discrimination and Equality Bill 2016 in the Lok Sabha, which addresses every form of discrimination faced by people in India, including gender and sexual minorities. The Bill is yet to be passed by both houses of the Parliament.

Dr Rahman says “In the case of sexual orientation, it appears that people make judgements about whether someone is gay or not from their levels of gender typical appearance, gestures, behavior and voice. So it is possible that LGBT people who are more gender non-conforming are a greater risk of being stigmatised and socially excluded than LGBT people (who) are more gender-conforming. This means that people can be targets of stigma and discrimination not only when they identify themselves openly but also when they are perceived to be a minority”.

Dr Rahman’s views are echoed by this video below, in which transgenders employed with Kochi Metro urge the public to not look at them as different individuals, rather a normal human being.

The passage of Dr Tharoor’s bill is critical to address discrimination against gender and sexual minorities.

Collection of Evidence:
Another critical step going forward would be to collect evidence, according to Dr Rahman.
He said, “We need to develop evidence-based interventions that address the unique mental health issues affecting LGBTs. This is because mental health disparities are never entirely eliminated if you just deal with social policies. Thus, we might work towards developing psychological interventions which reduce the use of cognitive rumination subsequent to a discrimination- related experience or use psychological therapies to augment emotion regulation skills in LGBT people.”

Efforts are ongoing. Dr Neeral Sheth, a psychiatrist based in the US, is leading this study on LGBT and mental health in India.

(*Name changed on request; Leyla told The Health Collective that she doesn’t want to disclose her name because it will bring unnecessary limelight and increase her anxiety.)


About the Author

Devanik Saha is an MA Gender & Development student at the Institute of Development Studies, University of Sussex and a freelance journalist. He tweets @devanikindia. ​

Views Expressed are Personal. Material on The Health Collective cannot substitute for professional mental health advice from a trained professional. 

The Law and You: Mental Health in India

July 10, 2017

Mental health can be simply understood to mean a state of mental well-being. The World Health Organisation looks at understanding mental health and its definition quite comprehensively here. Mental health in India has long been a misunderstood issue; there is a lack of awareness on issues of mental health, corresponding treatment and frameworks that govern mental health. As a result, the way issues of mental health are dealt with are more under the aegis of superstitions and taboos, rather than scientific medial processes.

Vandita Morarka kicks off a special series for The Health Collective in an attempt to understand the law that governs mental health in India and its resultant rights and duties.

Recognising the Agency of Persons with Mental Illness

The Mental Healthcare Act, 2017 is a recent law that positions its approach towards mental health and mental healthcare from a rights-based perspective. Its aim is to provide mental healthcare in a manner that is in line with protecting, promoting and fulfilling the rights of persons with mental illness, throughout the care process.

  • The law recognises the capacity in ALL persons, including those who have mental illness, to make decisions regarding their own mental healthcare and the treatment they would want to undertake
  • Such capacity is recognised, if a person understands all relevant information related to the treatment, comprehends the consequences of her/his decision and communicate this information
  • This communication may also be by way of sign language or through visual aids 
  • The law expressly states that if another person views any such decision as wrong, it does not mean that one cannot make such a decision

This is the key pivot around which the law builds upon, as it recognises the agency of persons to make decisions regarding their personal mental healthcare by themselves.

The law gives every adult the right to make an Advance Directive, in writing, which has to specify the manner in which they wish to be treated (or not be treated) for a mental illness, along with provisions to appoint a Nominated Representative.

An advance directive can be made by a person irrespective of their past history of mental illness or treatment, as long as it is not in violation of any other law. This directive can only come into force once the person ceases to have the capacity to make such a decision and stops being in force once the person regains such capacity. The person making such a directive can revoke, amend or cancel it at any point.

Also Read: Ask the Experts: Ten Things to Know About Domestic Violence

If a mental health professional or a relative does not wish to carry out treatment of the person in accordance with the advance directive, she/he will have to make an application to the concerned Board for a review and any changes. In the case of minors, the legal guardian has the right to make such an advance directive. By providing such a measure, the Act makes it easier for a person to formalise and have control over the treatment process. While the clause allowing for treatment against such directives by way of application can be misused, it is being viewed as necessary, as cases evolve.

What other rights does the Act provide to persons with mental illness to further their personal agency?

The Act recognises the right of persons with mental illness to live a life of dignity, that is one without discrimination and reaffirms their equality in all aspects of treatment to persons with physical illness. It further provides protection from cruel, inhumane and degrading treatment, at mental healthcare establishments.

  • This Law gives those with mental illness the right to community living and governmental support for cases where the person does not have familial support, to live outside of a mental healthcare establishment, when they can medically do so
  • It provides the person with the mental illness and her/his nominated representative with the right to information regarding the law, nature of illness and treatment, in a comprehensive manner and the right to access medical records
  • All mental healthcare professionals are to maintain confidentiality regarding their clients
  • No information or photographs relating to a person with mental illness can be released to the media, without the consent of the person
  • A person with a mental illness retains the right to decide on personal contacts and communication, in keeping with the guidelines of the mental health establishment, unless otherwise specified. This would include emails, personal visits, phone calls etc., and allows the person to refuse or agree to contact any person
  • The Act also provides for good quality, accessible and affordable mental healthcare facilities by the Government and for free services for those that are homeless or Below Poverty Line (BPL), even if they do not possess a BPL card
  • Persons with mental illness are given the right to free legal aid as well as the right to raise complaints regarding deficiencies in services they are receiving
  • In a final act of recognising the agency of persons with mental illness regarding their own lives and understanding the causes behind suicide attempts, the Act decriminalises attempts to commit suicide

Pragya Lodha, a counsellor based in Mumbai, tells The Health Collective, “The Mental Healthcare Act is a patient-centric law, a definite progressive step towards India’s better mental health.”

It changes the conversation and brings it back to the person with the mental illness, giving her/him the right to choose and to make decisions. However, the Act does raise concerns amongst mental healthcare professionals regarding how effective such a patient -centred approach would be realistically.


About the Author

Vandita Morarka is an independent policy consultant, legal researcher and gender rights facilitator. She is currently the Policy, Legal and UN Liaison Officer at Safecity (Red Dot Foundation). She is working on a series for The Health Collective looking at The Law and You: an attempt to understand the law that governs mental health in India and its resultant rights and duties.

Views expressed are personal. Material on The Health Collective cannot substitute for professional mental health advice from a trained professional. For more on help available, do click here


Depression, BPD and Far From a Stereotype

July 5, 2017

The first time I got to label the feelings I had had in me since childhood, I was 22 years old. I was told I was suffering from Depression and Borderline Personallity Disorder.

I was told it would be a struggle that I would overcome only if I genuinely wanted to help myself. It has been a decade long journey since.

I have seen good days. I have seen better days. I have seen days I shouldn’t have. But like they say, bad decisions make for good stories and I am a good storyteller. I am where I am because I decided to take the plunge and not shy away from the fact that I was living with a condition. A medicalcondition.

What helped me personally was the fact that I had a physical distance from my family. There was no constant pressure or scrutiny on my recovery. I could take my own time. Also, my friends at that point in time respected my personal space, had their boundaries. The fact that I had so much to process about myself was at times overwhelming. People I have befriended or dated since have taken the time and put in that effort to educate themselves about my condition.

The most important thing that one can do is inculcate the three Es:

  • Educate
  • Empathise
  • Enable

Educate yourselves about what mental illness(es) your loved ones are suffering from. You may not understand what exactly they are going through but you can empathise with them. You can enable and encourage them to seek help and talk about it. Give them that personal space to assimilate the information in hand. Be there. A lot of times we don’t say it, but we need you. Just be that strong calming presence. It is a lot of pressure for you but it will be met genuine heartfelt acknowledgement and affection.

There are days when I feel like a butterfly high on Cocaine and Adderall together. There are days when a sloth would seem like the fastest animal in comparison to me. There will be days when I will be a constant source of sunshine & rainbows. There will be days when I will have a personal gloomy cloud above my head. I have learnt to live with it and aim to channelise my energies into achieving more sunshine and rainbows. I refuse to give up. I refuse to give in. I refuse to be the stereotype. 

About the Author:
Mehak Sabat is a 31-year-old movie marketing professional who comes from Bhubaneshwar, Odisha. She is currently working in Mumbai. 

Views expressed are personal. Material on The Health Collective cannot substitute for therapy or expert advice from trained professionals.


Relationships, Happiness, Living the Life You Want

July 1, 2017

Amrita Tripathi interviews psychotherapist, radio host and the author of
HAPPY RELATIONSHIPS: At Home, Work and Play (Fingerprint Rs 250), Lucy Beresford. 


1) You host a Sex and Relationships show on radio... Can you tell us some of the common themes/ questions that come up?

The most common themes tend to be (from men) erectile dysfunction and (from women) how to cope after discovering an affair, but to be honest I get calls about every sexual or relationship subject under the sun. Nothing is taboo on the show, and because we can keep people anonymous callers know they can talk about their most intimate worries – often for the first time, which can be a really healing experience. I also get tons of calls from people in their twenties being messed around by Apps in the world of dating. People of all sexual orientations are finding it hard to commit when they sense the other person is keeping their options open to a degree that simply wasn’t possible 5-10 years ago.

1a) What are, say, 4/5 things you wish everyone knew?

My mission is to help everyone see that they can have the life they have always dreamed of so long as they believe in their heart it will happen.
It’s important to remember that:

  • Communication is crucial in relationships, so take time to speak fully and respectfully
  • Painful times will pass and your time for joy will come again
  • Trust is hard won and yet can be quickly lost; think twice before you act in a manner which will break trust
  • Size doesn’t matter! Sexually, it doesn’t matter so much what you look like, but what your personality is like

2) You've been to India, where there is still some hesitation in speaking about issues -- like sex, certainly -- but also when it comes to mental health. Conversations have started happening, and there's an improvement, we hear, but there are also several challenges. How important is it to be comfortable to speak about mental health issues/ experiences?

In the past 10 years I’ve had three clinical sabbaticals in New Delhi working at the Delhi Psychiatry Centre. There have been huge developments in terms of people in India feeling more comfortable talking about their emotions – I think celebrities have helped, in talking about their mental health issues or relationship problems – but a related issue is that government funding has been reduced so it’s harder for people to get professional help.

3) We are trying to create a safe space for people to share their stories. Any comments on this? Or on the need for this... 

I think it’s absolutely vital to be able to speak out about mental health issues and experiences. Talking enables you to feel heard, get help or feel supported. Deepika Padukone has blazed a trail speaking about her experiences. And I’m shooting a documentary at the moment in India, about how important it is for people to focus less on what we all look like, the colour of our skin, thickness of hair etc, and to see that what unites us is greater than what divides us.

4) As a psychotherapist, what would be your advice to people --  again, slightly generically but a key take-away from your experience? That could be helpful?

Wearing my psychotherapy hat, I’d love people to respect themselves more. Reach for the life you want to have and also have the courage to walk away from people who hurt you.

Also Read: The Importance of Being Kind to Yourself

5) What is The Kindness Club? And what led you to set it up? What have some of the reactions been to it?

I set up The Kindness Club to encourage more random acts of kindness around the world. In my view, we are all made up of columns of kindness within, and there is always room for more acts of kindness throughout the world. One of the initiatives I set up was helping prisoners in a prison do kind things in their outside community, which was really well received. And another initiative which is ongoing, is where people send me women’s and children’s books that I then pass on to shelters looking after women and kids affected by domestic violence. People love sending me a copy of their favourite book, with perhaps a note attached about why the book means so much for them. It’s a simple and easy way for people to feel they are making a difference – which they are!
6) We have a post here on the importance of being kind to yourself as well. Would you have any comments on this?

I love Ratna’s post on being kind to yourself, it’s got some great advice, especially about not isolating yourself in case you spiral downwards. I think being kind to yourself and practising self-compassion is an absolutely vital life-skill to learn, as it will help you in so many situations. Rather than relying on other people or external forces to maintain that emotional stability It’s about taking responsibility for yourself, your wellbeing and ultimately your contentment in life.

Views expressed are Personal. Material on The Health Collective cannot substitute for professional mental health advice from a trained professional. 


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What It's Like to Live With Anxiety and Depression

Do check out this incredible comic (created by Nick Seluk of The Awkward Yeti). I first saw it on Upworthy and was blown away by it -- like so many others have been. It is reproduced here with the kind permission of The Awkward Yeti.



This incredible comic was created by Nick Seluk, creator of The Awkward Yeti, based on a story told by Sarah Flanigan, and published on 

It is reproduced here with kind permission from The Awkward Yeti


Adolescents, Relationships and Stress

In India, year after year, we are almost inured to stories of students driven to extreme stress by board exams. At times, in the absence of learning coping mechanisms or other ways of releasing these incredibly high levels of stress, a significant number of them choose, tragically to cut short their young lives.


The National Crime Records Bureau report looking at Suicides in India (2004-2014) analyses the 'Percentage Distribution of Suicide Victims by Profession during 2014' to find that 6.1% of suicide victims in 2014 were students. (Another shocking statistic: 15.3% of suicide victims were found to be housewives; find an analysis of the data and concerns about under-reporting here on IndiaSpend)

There doesn't seem to be enough attention paid to causes of suicide -- often a web of causes, not just one simple cause.

Nonetheless, many counsellors I had spoken to over the years, including some manning exam helplines for Indian students, mentioned that frequently callers dial in to talk about relationship issues and relationship pressures. It's not just the stress of exams/ Board exam results and the massive pressure we've been socially conditioned to accept as normal, that is.


Noted child and adolescent psychiatrist Dr Amit Sen had told me years ago, about how kids are in relationships at ever younger ages -- think tweens or pre-tweens -- and aren't always able to navigate the complications of this; often relationships of course are due to peer pressure.

 Dr Amit Sen's own words on the context in India: 

"For the longest time we have found correlations between exam stress and rising depression in adolescents. There is no doubt in my mind that study and exam pressure takes a heavy toll on the minds and well being of teenagers in India. It robs them of other experiences that are vital for adolescent development. Paradoxically, as they begin to slip under the pressure, the system exerts even more pressure.

More recently, we have become increasingly aware of the close relationship between romantic relationship and depression. And indeed, as the article suggests, it is not only to do with break ups but also ongoing/"serious" relationships that often become too complicated for the mid-teens to handle. The cause and effect relationship is,however, not always clear. Its also true that depressed teenagers make themselves more vulnerable and tend to get into messy relationships more easily. A lot depends on the readiness/maturity of the person and clarity about what the relationship means and where the boundaries lie. In India, and perhaps in all places, teenagers often get widely conflicting messages about romantic relationships. This is where life skills and sex education (that is sustained and ongoing) might be preventive/protective of the many ills that plague our children today."

-- This was in response to this article in The Huffington Postwhich, among other things, raised some key points from a startling survey of more than 8,000 American adolescents on issues of depression and romantic relationships.




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