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Ask the Experts: What's Stressing Out Indian Kids?

January 20, 2018

Ask the Experts with Dr Amit Sen

 

Amrita Tripathi, Founder-Editor, The Health Collective
We’re in conversation today with senior psychiatrist Dr Amit Sen to take us through some of the most common stressors when it comes to child and adolescent mental health.

Dr Amit Sen, Founder, Children First
I think in India, one stressor that runs across all of childhood and adolescence is academics: education or the way education is viewed in our country. Schooling starts very early and a lot of our kids are not ready neuro-developmentally to engage with it in the way they are expected to by schools, by teachers, parents. A lot of these kids spend large amounts of their time trying to learn things, which perhaps they’re not ready for; at the expense of play time, building bonds, relationships, just being free and having fun. The pressure and expectations they keep rising as kids go from Nursery, KG to primary school.

The pressure starts very early, and even when a 3 year old is not able to do what they are expected to by a teacher, alarm bells start ringing. Parents start worrying, will start by disciplining or scolding the child. At the end of it, they might to really begin to worry about their future and take them to specialists and so on. It start very early. The system is to blame.

In our country, we start with academic learning way too early, and a large part of expectations is driven by rote learning. Hardly any flexibility and we see this right across primary school and as they get into secondary, middle and senior school, the expectations are higher.

Although the manifestations of that pressure is not seen so much in primary school — though sometimes they are, sometimes we see children for anxiety and behaviour disturbances only for academic pressure in primary school, but more often than not, they keep piling up. It’s like a dam bursting when they reach adolescence, and that’s when you begin to see depression and anxiety and a range of other issues, like substance misuse, so-called oppositional defiant disordered behaviours.

So it’s a relentless and eroding, oppressive system that we put our children through.

Also Watch: Ask the Experts: Dr Vikram Patel on Mental Health and Illness

RELATIONSHIP STRESS

Relationships no doubt are key and the cornerstone of emotional and social development of any child. Again, because of some of the other demands which are placed on children, sometimes we see the parent-child relationship begins to be affected very early, in primary school.

The time that parents might have had to just be with their kids or play with their kids or be without pressure and anxiety is simply diminishing. As they grow up, other kinds of relationships become important, peer relationships, relationships through social media of various kinds. And those become extremely complicated and warped at times.

Although social media is a great thing, you find that for young people it becomes a central thing in their lives. How many thumbs up they’ve got, how many likes they’ve got… What kind of person they are able to project, who is bullying whom in social media, who is getting ostracised and so on. A large part of their waking hours are being spent just engaging with that.

And those relationships are so complex. And adults, because we have so little knowledge about this whole dynamic of the social media are hardly able to guide them; adults come down very heavily, take away gadgets of young people or admonish them. We have to accept that young people know so much more, has such a mastery over it that we can't stop them from getting into it unless we come on the same side and try and understand it.

Also Watch: Ask the Experts: Dr Achal Bhagat on OCD 

For more do tweet us @healthcollectif or share your comments and feedback right here

Where to Find Help: Contacts and Helplines

 

Disclaimer: Material on The Health Collective cannot and does not claim to substitute for expert individual advice from a trained professional

 

 

Understanding ADHD/ ADD

January 17, 2018

By Devina Buckshee


What comes to mind when you think of Attention Deficit Hyperactive Disorder (ADHD) or Attention Deficit Disorder (ADD)?
“Unfortunately a child who has ADHD is always imagined/perceived as a child who has excess energy, fidgety and most probably bored and in my mind an under-utilised child,” says Janki Mehta, Co-founder Mind Mandala.

When we think of ADHD, we think of hyperactivity. We think of disruptive behaviour, and we are most often imaging a young boy fidgeting, shouting or causing a scene.

“His idle mind often is a devil’s workshop and yet again I’m only commenting on his energy and we are at fault, we have not found a way to use his energy productively. These children often when guided well emotionally can excel in something just finding a way beyond this regular schooling system will help,” Mehta tells The Health Collective.

Art by Kishore MohanHealth Collective


Our thinking pattern aligns with research that says ADHD is a hyperactive, impulsive condition.The hyperactivity associated with ADHD is more often seen in boys, with other symptoms like inattentiveness, distraction and disorganisation, reportedly often being missed, in girls.

“It would be harder to diagnose girls than boys. One of the reasons being cultural norms where girls are taught to behave themselves at all times whilst boys are allowed to act in an outward manner,” Havovi Hyderabadwalla, Co-founder Mind Mandala tells The Health Collective.

Undiagnosed in childhood, girls can grow into women with untreated or unmanaged ADHD, with potentially severe repercussions to their mental health and well-being. ADHD tends to manifest later in girls than in boys, according to this piece in Quartz, it manifests in puberty for girls. The tumultuous, confusing time of puberty is when girls anyway see a dip in their self-esteem.

Child and Adolescent Psychiatrist Dr Amit Sen tells The Health Collective that ADHD/ ADD is one of the most common disorders in childhood, though he acknowledges that there is still ongoing debate and controversy on whether it’s over-diagnosed in some countries.

“However, if you see the scientific literature and wide-scale studies by the WHO across the world including in centres in India, you will find that the prevalence of ADHD is as high as 5% at least, whereas in some Western countries, it’s thought to be 10%,” Dr Sen tells The Health Collective.


WHAT IS ADHD

ADHD is a neuro-developmental disorder and there are widely thought to be 3 main types:

  • Predominantly hyperactive

  • Predominantly inattentive (ADD)

  • Combined inattentive-hyperactive


Common signs would include being distracted, having poor concentration, interrupting, talking and fidgeting and difficulty staying focused.

“To a lay person, ADHD children tend to come across as 'difficult', 'badly behaved' or 'purposely' behaving in a particular manner. From a professional point of view, we understand that these children suffer from a neuro-chemical imbalance in the brain which leads them to behave the way they do. Most of these children suffer from a lot of emotional turmoil and have a hard time developing a secure sense of self. They require great amount of patience and nurturing from their family and different social support systems like peers and teachers to help them grow,” says Havovi Hyderabadwalla, co-founder Mind Mandala.

ALSO READ: Ask The Experts: Child and Adolescent Mental Health

The India picture seems varied. We welcome your stories, comments and feedback -- share with us right here or tweet @healthcollectif.

Further reading: ADHD in India: A Complex Condition in The Swaddle



*COMING SOON: More from Dr Amit Sen on ADD/ ADHD in our ‘ASK THE EXPERTS’ VIDEOS*

 

Disclaimer: Material on The Health Collective cannot substitute for expert advice from a trained professional.

 
 

What is Love?

January 15, 2018



Relationships 101 with Dr Achal Bhagat 

One of the commonest questions I’m asked is: What is this thing called love?

I say to people and it’s not about falling in love it’s about working on a relationship; it’s about working in love you’re always standing and working in love. Love and relationships are about care, respect, responsibility and knowledge. If you fall in love it’s an impulsive decision… it’s more like infatuation than love. 

Love is about care, respect responsibility and knowledge: You need to know the person that you love... You need to know what they think, what they feel, the small things in life. Not in an intrusive kind of manner, but in a manner that you can care for them in a better way, that you can respect them as they wish to be respected… that you do not humiliate them act responsibly towards them, that you do not intrude upon them,  you do not take for their lives,  you do not neglect them, do not distrust them.  

ALSO READ: Breaking Up and Moving On: A Psychologist's Perspective

GENDER WAR: Unfortunately the commonest problem that happens in relationships in India is a gender war. It’s like we are 5,000 years back when the relationship gets into a problem.  My family thinks like this, your family things like this. Men are supposed to do this, Women are supposed to do this. We make assumptions about each other’s families, we make assumptions about  each other. We forget that these assumptions impact each other very negatively.

TREAT EACH OTHER WELL: So the first step is to get out of this gender war and start treating each other as human beings and start empathising with each other. Again empathy is not the proverbial ‘put yourself in somebody else’s shoes’. It is about trying to get to understand their feelings, their thoughts  and not waiting either for them to mind read or for you to mind read them...Mind reading doesn’t happen...Conversations do.

COMMUNICATE BETTER: Life is about having conversations with each other…about communicating with each other and we need to learn to communicate with each other if we need to solve our problems.
So in the relationship if your patterns are becoming unhelpful, if you are spending more than the usual time only solving problems, if you’re using words like always, never, should, must not, must…
If you are humiliating the other person or if you are feeling humiliated yourself and definitely if it’s bordering on to violence you must seek outside help.
Even the threat of violence is violence. Never be in a relationship and stay and bear the violence. Violence is about control. We need to move away from violence, we need to move towards communication, towards caring for each other. If you are distressed in a relationship do talk to your partner and seek out for help. 

 

ALSO SEE: Ask the Experts: What is OCD
 

Disclaimer: Material on The Health Collective cannot substitute for expert advice from a trained professional

We Need to Talk: Suicide and Suicide Prevention

January 13, 2018

By Amrita Tripathi

A recent article in the Times of India highlighted that in India, a student takes his/her own life every hour. Every hour. Every year, we talk about exam stress, often ignoring relationship stress, the magnitude of pressure on the young, and certainly overlooking the fact that – as senior psychiatrist and co-founder of Children First, Dr Amit Sen tells The Health Collective  suicide is the single largest killer of young Indians. 

We’ve seen considerable commentary and attention paid to the gruesome Blue Whale challenge in the media, but not as much attention, perhaps, paid to the scale of the issue when it comes to young people taking their own lives.

 
Art by Kishore Mohan
Dr Sen tells The Health Collective:

“The furore over the Blue Whale Challenge has suddenly brought into sharp focus the widespread and endemic nature of suicide in our country, a fact that we as clinicians, have been painfully aware of for years. A landmark article in the Lancet puts it as the number one cause of death in the youth (10 to 24) in India, ahead of Road Traffic Accidents
 and other illnesses.”

The bigger, underlying question is why, of course? What is going so terribly wrong? As many adults keep forgetting, adolescence is a hugely complicated minefield to navigate sometimes. Should we be paying more attention to underlying issues?

Also Read: The World is My Mirror: A First Person Account of Surviving

Dr Vikram Patel, renowned psychiatrist and co-founder of Sangath, points us to his article in in The Indian Express, where he articulates very eloquently:

That young people are developmentally primed to take risks and behave impulsively is well-recognised; it is the result of a unique combination of biological events (such as changes in the brain and puberty) and social expectations (such as those related to completing education and finding a partner) which occur during this period of life. 

His work, documented in The Lancet* looks at a nationally representative survey on Suicide Mortality in India, with this interpretation:

Interpretation: Suicide death rates in India are among the highest in the world. A large proportion of adult suicide deaths occur between the ages of 15 years and 29 years, especially in women. Public health interventions such as restrictions in access to pesticides might prevent many suicide deaths in India.

*(Suicide mortality in India: a nationally representative survey; Vikram Patel, Chinthanie Ramasundarahettige, Lakshmi Vijayakumar, J S Thakur, Vendhan Gajalakshmi, Gopalkrishna Gururaj, Wilson Suraweera, Prabhat Jha, for the Million Death Study Collaborators, 2012) 

While this study was done before suicide was de-criminalised in India, it also points out the high incidence of death by poisoning – indeed across South Asia, there has been a call for restricted access to pesticides. In an earlier interview, The Health Collective asked Professor U Vindhya of TISS, Hyderabad, about studies and findings published in the monograph Suicide in SAARC Countries**, which states:

A striking feature of the occurrence of suicide in developing countries is that the relationship between mental illness and suicide is not as pronounced as in the west where nearly 90% of suicides are said to be associated with some form of mental illness.

**(Galab, S., Vindhya, U. and Revathi, E. Suicide in SAARC countries: Multidisciplinary perspectives and evidences. Centre for economic and social studies, Hyderabad, 2010)

She told The Health Collective,

“While suicide is of course a personal, individual act, there is a long-standing debate on what is the responsibility of societal factors that drive individuals to choose this option. The magnitude of the problem in developing countries and in India in particular is a pointer to systemic factors. This finding places the onus on structural inequalities and the distress and frustrations that such inequities unleash on people. A case in point is the large scale suicides of farmers.”

Also Read: Understanding Suicide in India: Do We Need a New Approach to Prevention

Even if we wrap our heads around the scale of the problem, are we any closer to understanding what's causing this "epidemic"? 

Dr Sen tells us:

“More than two thirds of young people completing suicide suffer from a mental illness, most commonly Depression. Substance misuse, trauma and abuse, domestic violence, suicide in family, bereavement and breakdown in relationships can contribute to it. In India, academic expectations, failure in exams and emotionally loaded responses from parents & schools are major precipitants of suicide, as borne out by the numerous cases that are reported soon after exam results come out each year.”

There are multiple factors, and they are clearly varied and complex  one can't presume to speak on behalf of anyone who chooses to take this ultimate, drastic step. But surely we need to understand, or make an effort to understand just what is going wrong. We can’t afford to ignore some of these societal and structural inequities and pressures. Our conversations on Mental Health and Mental Illness cannot only be restricted to a few sensationalised cases, or even skew only towards to urban over rural, or hang on to taglines rather than digging deeper.

Also See: WHERE TO GET HELP: CONTACTS AND HELPLINES

For our colleagues in the Media, please note that with every article and story reported on suicide, there are some best practices including by the WHO and Samaritans. You can read the guidelines right here; and keeping in mind the "copycat" or Werther effect, you could do an incredible amount of good and avoid doing immeasurable harm, by avoiding the "sensationalised" sort of reporting we've gotten used to, there's nothing to be gained by reporting on the method of suicide, for example. Let's all aim for responsible reporting.

Also Read: The Media Portrayal and Understanding of Suicide

And finally, for parents and educators, what are signs to look out for?

“The signs of suicide are varied and complex,” Dr Sen tells us, but breaks down some common signs to look out for.

“There can be signs of depression, hopelessness and despair, embarrassing experiences with feelings of humiliation and shame, notes and messages expressing the same, previous attempts at self harm and becoming socially cut off. Many a times, such expressions are interpreted as attention seeking behaviours, and therefore neglected, with tragic consequences.”

Most importantly, perhaps:

“Young people should be encouraged to approach anyone who listens, understands and is willing help.”

We are building out and sharing a list of contacts and helplines on our page here, do reach out for help, if you or someone you know share signs of concern, discuss ending it all, or feel overwhelmed. As Dr Patel tells us in another interview,

“There is nothing brave about struggling alone, and if you have got mental health experiences that are very distressing, speak to someone. It could be a friend, it could be a family member, a counsellor, it could be a mental health professional. But don’t just lock it up inside yourself.”

Please don't ignore any signs of distress or play it down, and if you're struggling, please do remember you are not alone. 

ALSO WATCH: Hidden Illness: Dr Vikram Patel in Conversation with The Health Collective

 

Disclaimer: Material on The Health Collective cannot substitute for expert advice from a trained professional.

If you would like to share your thoughts or stories, do reach out to us by email or tweet @healthcollectif. You're #NotAlone
If you have helplines or contact you'd like to submit to the database, please do email us

Hidden Illness: The Dr Vikram Patel Interview

January 9, 2018

As part of our series, Ask the Experts, The Health Collective is delighted to share PART TWO of this interview with renowned psychiatrist Dr Vikram Patel, the Co-Founder, Sangath.

Also Watch: Part One of the Interview

 

 

Amrita: Dr Patel, just to pick up a little bit from what we’re talking about in terms of the lack of trained resources, the work you’re doing with your organisations is showing that it’s imperative to have community participation and intervention, can you take us through what you were saying about Indian attitudes to psychotherapy and how you’re seeing trained resources there.

Dr Patel: Sure, you know earlier I had mentioned the National Mental Health Survey of India reported that only about 10% of Indians with a mental disorder in the last 12 months had sought or received help. 

But actually if I ask the question, what proportion of Indians had received psychological therapies, which are amongst the most effective of all medical interventions for any health condition, psychological and social interventions for mental, substance use disorders, the figure would be 100% have not received, with the small exception of very affluent, urban folks who are able to pay for private psychotherapy, the vast overwhelming majority of Indians do not have access to these therapies. 

That is because many people assume Indians don’t like talking therapies, they prefer pills. I’ve heard doctors say when a patient comes to my clinic, they want a pill, they want an injection. Well, our experience has been exactly the opposite, our work has largely focused on challenging the myth that Indians don’t like talking therapies. We now have shown time and again that very high proportions of those who are offered psychotherapies engage with them and complete the treatment. We also challenge the myth that psychological therapies require extremely expensive, highly trained, people to deliver it. 

Our work has shown that you can use lay people in the community, we can train them, and with adequate training and supervision, they can effectively deliver scientifically sound psychological intervention with very large clinical economic and social benefits to those who are affected by a range of conditions, ranging from autism to drinking problems, depression, psychosis etc.

Can you give us a few examples even anecdotally of the work you’ve been doing? 

Sure, one of the more recent programs of work that I’m really excited about is our demonstration that in about a 6-8 session psychotherapy delivered over 2-3 months based on the psychological theory of behaviour activation -- that is to say, to get someone to actually engage with rewarding and pleasurable activities -- is a very effective treatment for severe depression when delivered by lay people in routine primary health care settings.

I’m also excited that this particular treatment that we call The Health Activity program is now being tried out in Nepal, Uganda, Zambia. It’s also being tested in other parts of India, and so could be genuinely be an innovation that’s developed in India and has value and application in many other parts of the world. Very pleased about that. We’ve done similar work on drinking problems, producing 2-4 session treatment for harmful drinking called the Counselling for Alcohol Problems, and a particular area of work that I’m currently engaged in? Is to develop digital training intervention and supervision interventions to scale up these psychological therapies. 

Also Watch: Part One of the Dr Vikram Patel Interview

Imagine for example, that a few years from now, anyone who wanted to learn these therapies, all they had to do is to go online, access our training program, complete it, complete the online supervision, and then be equipped with the skills to deliver this intervention in their community.

And you’re seeing this success cases, when they go out, and interventions?

Well that would be a success story, yes. At the moment, the success is that we’ve designed this intervention and shown it works in a clinical trial, and are now engaged in scaling it up.

That’s incredible. I want to ask you a little bit about … I mean our attempt is to be a safe space for conversations, and completely take your point that you are talking to people of incredible amount of privilege when you are talking to largely urban audiences, you’ve brought in the need to involve the community. We do see -- and I want to ask you about the work that It’s Ok to Talk is doing -- because we do see with younger people more of an openness to discuss some of the issues, and how they can make a change. Can you take us through any insights?

I’m glad you brought up It’s Ok to Talk - that’s a website, actually, and the name tells you what it’s all about… it’s about encouraging young people in particular to disclose their own experience of mental health and mental health problems, and the idea is that through disclosure, much the same way with celebrity disclosure, but ordinary young people, that we will challenge some of the stigma and the shame around mental health and mental health problems.

It’s part of a larger initiative of engaging young people -- we’re also using other methods like theatre, film, other kinds of media interactions, and this in itself is part of a bigger program, where we are developing a psychological program for students in secondary schools in Delhi and Goa...that includes a very strong component of self care as well as an app-based delivery of psychological therapy for young people with anxiety or mood or behavioural problems.  

To come back to the need to talk about things and help erase the stigma in that way, you’ve shared your story, part of your story, on the site, talking about your mother being one of the 40 million Indians who suffered depression. It was so interesting -- and thank you for sharing that, I think it was a very powerful account -- coming back to the fact that most people don’t get treatment, you say, there’s no X ray or blood test to determine depression, can you take us through a little bit of of your personal story and how it resonates with other people?

Yeah, you know it’s one of the reasons I believe that one of the most important reasons that mental health problems are often missed, is because they are hidden. And what is hidden will obviously be harder to find. There is no blood test, there is no objective, pathological sign that you have a mental health problem, and certainly not one that is of commercially any value, and so there is no commercial incentive either to doctors or to auxiliary service like a pathology lab to actually screen people for mental health problems.

What you need to do is to ask people questions, you need to ask them a set of different questions that explore a set of mental health issues, and then assemble all that in order to arrive at an understanding about their mental health. This is too time-consuming, it’s too vague, there’s no money in it. And therefore to be honest, I”m being blunt, a lot of medical practice is driven solely by commercial value. If there is money in it, there will be more of that done. That’s why you have so many blood tests and X-rays. But this has no value in it, at the moment at least, therefore mental health problems go undetected.

 

Dr Vikram Patel on The Health Collective
The Health Collective

 

And if there’s anything to end on -- was there anything cathartic for you in sharing that story? Has anyone come up to you after you shared that -- it’s been 20 years of course and more that you’ve been talking about mental illness. Is there anything you feel that sharing your own story personally that connects with others?

 I think sharing your own story always connects you with others. If I was giving a talk to students or a scientific audience, I would typically give a dry, science-based lecture, because that’s what I’m there for. But if I’m talking to a general audience, a community, to invoke my own personal story connects me to people. It connects my story with theirs. And of course because I can also bring in the expertise as a psychiatrist, as a researcher, that also adds value.

Certainly with my mother’s story, perhaps the most telling lesson for me was that I myself missed my mother’s depression for many years. It was when her diabetic doctor pointed out, hey Vikram, you’re a psychiatrist, can’t you see that your mother’s diabetes is out of control because she’s depressed. It was only then that I paused and did a clinical interview with her and discovered my goodness, my mum was very severely depressed.

So again, going back to the point, it’s so well-hidden from view, that even someone like myself who is fully trained as a mental health professional, couldn’t see it in my own mother.


Dr Patel, to ask you, if there were two or three things you wished everyone in India to know about mental illness what would that be?

First of all, mental health is not just the absence of mental illness.

Secondly, that each and every one of us has a very unique life story that determines our mental health. That life story is a product of our genetic inheritance and of the social environments that we’ve experienced, particularly in the early years of our life, from very early childhood to young adulthood. The implication of this is that for all of us in society who are concerned with mental health, our primary emphasis for prevention and promotion must be the early years to ensure that environments for young children, whether at home or schools or in communities, are nurturing, because this is the most powerful prevention that we can actually ensure the healthy development of the brain, and thus mental health in adulthood.

And finally, that the best guardian of your own mental health is yourself. Be equipped with knowledge and skill on how to protect and promote your own mental health, but equally remember that there is nothing brave about struggling alone, and if you have got mental health experiences that are very distressing, speak to someone. It could be a friend, it could be a family member, a counsellor, it could be a mental health professional. But don’t just lock it up inside yourself.

Amrita: Thank you so much.

Shared your comments and feedback right here or tweet us @healthcollectif

Love, Understanding, and a Boyfriend with Bipolar Disorder

January 7, 2018

By NN* 

I fell in love when I was 19. A seemingly innocuous statement that could have underlined the life of any person in the last year of their teens. But when I write love, I mean it was really love. The kind that matures over years of being together, tethered by a shared life and the love that binds you, yet gives you ample freedom to tread your own journey. Only, it took us all of three months to get there.

It was a rapid process of falling for an extremely bright, relatively shy and handsome boy in my college, who was pleasantly and utterly different from all the crushes in my admittedly brief series of romantic pursuits. Despite abiding differences in our intellectual and emotional backgrounds, different experiences of growing up – with him certainly in a more evolved space than I – he encouraged our relationship to be on equal terms. Nineteen is hardly an age for a nuanced understanding about how important that is to any relationship.
 

https://www.rawpixel.com/image/91677#
Image Courtesy: Raw Pixel
 

No wonder, then, that my time with this academically remarkable, sporty, immensely kind and ridiculously artistic person, was an exceptional one. I have to say, I never placed him on a mental pedestal, though initially I did try, he managed to unravel this odd complex reverence and tuned our relationship such that it was always balanced and fraught with mutual admiration. And it stayed that way for the next 13 years.

Being in the company of someone extremely bright, didn’t once make me feel weary. In fact, I often joked that he would excel at everything – being a consultant, a journalist, the Prime Minister, a janitor – just anything. And that I would celebrate and welcome any of that.

ALSO READ: How To Travel Light, an Interview with Shreevatsa Nevatia

What came with these intensely bright years were a few over the top incidents. We were in college, though, and outrageous behaviour was often seen as a badge of honour. Breaking furniture in the hostel for fun, drunken nights, near-savage ragging, missing classes, lack of punctuality or order in your life, only made one more popular.

Largely, I remember his time in college as him being outstanding at everything he did. I was particularly intrigued by his artistic abilities – sketching with charcoal - and the confident nonchalance to tear it all up in a moment. Everything about him added up to make me fall deeper in love and sure that our relationship would endure anything.

Despite that, despite a deep understanding of each other and a hearteningly real relationship, we couldn’t fathom – individually or together – the cause of what was brewing in his mind. It was a mix of anxiety and deep-rooted depression manifesting in simple things like not being able to wake up in time, not showing up for things and feeling desperately alone, despite my being around.

ALSO READ: What It's Like to Live with Bipolar Disorder

Together and with the help of his mother, we attributed it to remnants of a broken home and the emotional upheaval that was surfacing years later -- his parents had parted in a non-amicable manner when he was about 11 or 12.

Professional help soon followed and over the next couple of years, the words manic depression, mood charting, OCD, bipolar and lithium became part of my lexicon. Words that had never knowingly impacted my world before were going to define my life.

I’ll skip a few ‘passionately in love’ years of a long distance relationship to a time when I was fully integrated with his family, got an opportunity to stay with him for 3-4 months and was absolutely attuned to this mental health condition.

In all the years that followed we discussed the deeply dark side of his mind and the guilt, anxiety and mood swings that came with it and how we could deal with it together. By then, Stephen Fry, Kay Redfield, Carrie Fisher, Jerry Pinto and many others who had touched on the topic were part of our reading, watching and listening.

We were always switched on to the topic, with healthy discussions and enquiries into it. His mother had a massive role to play in this openness and creating this space. Bipolar can be large and boulder-like, and can weigh on the person with the condition and the family around to unimaginable depths of helplessness.
 

The Health Collective
The Health Collective
 

Fortunately, I can only remember a handful of times, when our world spiralled temporarily out of control. Even when he had to drop out of higher studies midway, only to reboot and join the best educational institutes in the world later on. Even when he wouldn’t move for three whole days from his room or not be able to be present to me at all times.

The timely medical attention, support from family and more than anything else, his own desire to keep his chin above the water, helped us wade through anything that came with being bipolar.

Years of a long distance relationship and an unfortunate unraveling of our deep and mutually respectful relationship, altered from the context of being romantically inclined, to a renewed friendship that we will cherish forever. We broke up after 13 years, but that had absolutely nothing to do with his condition. Despite many suggesting that it was tough work being with someone who is diagnosed with a bipolar condition, for me it was always a prominent pillar that had held our relationship strong even in troubled times.

ALSO READ: Breaking Up and Moving On: A Psychologist's Perspective

In turn, I was and always will be thankful for being richer for an experience of being an ally for so long. I could never be more grateful to him and his family to let me into his fragile and dark world and make myself productive in the process. I recall this with utmost humility, as he often told/tells me that I was of great help and support. More than being a supportive girlfriend, being an ally opened my world and mind to several things. I feel like my heart grew stronger with this exposure. Not only was it an expansion of my feelings, but also the brain. This was a period to soak in the information around mental health and how it was impacting so many people around us. I began to clearly see the taboos and how it was so difficult for people to navigate through society.

The other critical navigation that was happening at that time was that of my own emotions around it. I can’t reach for the exact feelings now, but the blur had a fairly clear accent to it. I was so sure that this did not make me weak, uncomfortable, embarrassed or unsure. In fact, I found strength and confidence in myself, while dealing with it on a daily basis. At some level, it made me even surer of the relationship, not in an overcompensating messiah sort of a way, but in my inadvertent confidence to stick around despite it. It taught me how to build up my partner, even in times that were not socially ideal or be able to stand up for him, and us, in turn.

Love had a new meaning. It didn’t lie in discovering new music, books, people or places together. It was heartening to feel that the love was not based on any romanticism but with the reality of being in the company of a severe mental health condition that could potentially stir our life on a regular basis. It didn’t make me pre-empt any cracks. It only made me feel stronger in my ability to handle situations that would be tangentially related. It could be a loss of job, financial stress, ailing parents or just simple fatigue of life.

Photo by sydney Rae on Unsplash
Photo by sydney Rae on Unsplash


Over the years, I inadvertently find myself lending a voice to mental health in a variety of situations. This is not only limited to being able to understand or lend an ear to someone who is medically diagnosed, but to be deeply and fully sensitive to whoever might be going through a vulnerable time. It has ended up in many people trusting me with their thoughts, without feeling judged. And that has certainly helped in urging them to get professional help. For those who have been diagnosed with a medical term, my giving them a positive example to go by has always helped in them feeling more confident to handle their own condition.

Over the years, I have seen my now ex-boyfriend relentless about his future, determined to do well in life and not let bipolar dominate everything. We marvel at his lighthearted way of dealing with it, not so much on difficult days, but always being able to turn things around when they look bleak. He is currently studying in the world’s most revered institution for public administration, with an unstoppable need to wring out the best that life has to offer.

Of course, he has an extremely supportive family to help him function and a set of friends that offer comfort and rootedness. Our friendship restored, we find ourselves in an excellent place of having renewed our bond, which has given me fresh eyes to understand the notion of love and togetherness.

If I had a few things to say to my younger self, or to anyone who’s going through something similar -- a girlfriend, life partner, friend, sibling, it would be:

  • Educate yourself on the subject
  • Seek counselling to offer relevant support to your partner and yourself
  • Never ever be afraid to be in a relationship with someone suffering from a mental health condition

 

**N chooses not to disclose her identity. She shared this story with The Health Collective, in an effort to raise awareness and help defeat the stigma, and did discuss doing so with her ex-boyfriend

Do tweet us @healthcollectif with your comments. Let's keep the conversations going.

 

Mental Health and Illness in India

January 6, 2018

As part of our series, Ask the Experts, The Health Collective is delighted to share this interview with renowned psychiatrist Dr Vikram Patel, the Co-Founder, Sangath.

 

 

Amrita: How important is it to normalise conversations around mental health and mental illness, especially in India, where people have to deal with stigma on an everyday basis?

 

Dr Patel: Mental health is something we all as human beings should aspire to. I want to distinguish between mental health and mental illness. We often use the word mental health, when most of us are talking about mental illness. Mental health is actually a positive, valued aspiration. If we accept that is what mental health is, then it affects us all.

 

Amrita: Do you find that we’re moving the needle somewhat here in India, in the last few years? Do you find that it’s more comfortable now for people to talk about mental illness? If you have a celebrity who talks about depression, for example, that does shift the conversation to a more positive space, though we are talking more about neurosis not psychosis.

 
Dr Patel: There’s been a dramatic transformation and openness with which people are talking about mental health and also the sensitivity with which the subject is being discussed.

I can remember 20 years ago, for example, if I went into a ministry or to a media conference and say I want to work in the area of mental illness, they would often laugh at me and say this is not an issue that is of public interest...It’s something that is embarrassing, shameful, scary to discuss. And today, here you are interviewing me about my work, mental illness and mental health, and that in itself is a sign of the broader change of how society around us. This is something I’m very pleased about and we should celebrate.

The point you made about celebrities is an important one. I personally think it’s an important aspect of the openness with which mental health is being discussed. However, there is one caveat.

Often people think that mental health is for the rich, the affluent, the westernised, and therefore the assumption is that poor people, who represent the majority of our country, really have more important things, more basic needs to be met, and that mental health is somehow a luxury item for poor people.
Actually the truth is that mental illness is much more common among those who are poor, disadvantaged, discriminated (against), marginalised, and I just want to hope that celebrity disclosures don’t perpetuate the myth that mental illness is a problem of the rich and affluent.

 

Amrita: When we look at the numbers, when they say 1 in 4 people will have a mental health episode in their lives, does that number hold for India, as the big picture?

 

Dr Patel: Mental health and mental illness are not the same thing. Mental illness is a bio-medical entity, where we diagnose people with disorders, as defined by the WHO, say, so in this way you divide the world into people with a mental health disorder or without. It’s a binary approach. If I take that approach, the National Mental Health Survey of the Government of India is probably the best data that we have on the prevalence. That survey showed that 1 in 10 adult Indians at any given point in time will have a mental disorder. This also includes substance use disorders like alcoholism.

That doesn’t necessarily mean that the other 90% are enjoying good mental health. We may have no mental disorder and yet have poor mental health.

 

 
 

A very good example would be suicides. Quite a large number of people who end their lives might not meet diagnostic criteria of having a mental disorder, but they could not have been in good mental health if they chose to end their lives. This is quite a complex set of what seem to be contrasting views of mental health and mental disorder, which is a kind of a diagnostic entity which then triggers a range of clinical interventions.

 

Amrita: Would it be safe to say that the numbers might be under-diagnosed? So maybe to club both questions into one, we know that in India, when it comes to trained mental health professionals, that there’s a huge shortage of resources. I wanted to tie that in with the work that you’ve been doing. The last number I heard was 5000 trained psychiatrists in the country.
And what would you say about the paucity of resources?

 

Dr Patel: The National Mental Health Survey of India gives us very accurate figures on the proportion of individuals with a mental disorder who have sought help or have received help in the last 12 months. It’s a staggering proportion. Only 5 to 10% have received or sought help.

 

Put another way, over 90% of Indians who are currently affected by a mental disorder have neither received nor sought help in the last 12 months.

 

There are many reasons for this. One obvious reason is the inadequate supply of skilled human resources, particularly within the formal health sector to address mental health problems. Equally one must acknowledge, there is a demand side issue, that is to say when people have experiences which we consider are signs of a mental disorder, they don’t consider they have a mental disorder themselves.

Very often, in fact the most common way, in our culture and our society that people understand the experience of mental disorder is through social explanations. For example, I’m feeling the way I am because something terrible has happened in my life. Some people may invoke supernatural or spiritual or religious explanations. For example, my luck is down because I may have committed misdeeds or sinned. And therefore even though the experiences are very distressing, you don’t think of going to a doctor because you don’t conceive of it as a health problem, leave alone a mental health problem.

 

Amrita: How do you see that conversation changing, if at all?

 
Dr Patel: This is to me a very important challenge. I can draw on some of the work we did in rural Maharashtra, a program where we sought to change the narrative about mental illness in rural communities where there was a high proportion of individuals attempting suicides, in fact the epicentre of farmer suicides in India, which is Vidarbha.

 

Over a couple of years, we engaged with communities, with panchayats, village health workers, asha workers, anganwadi workers, key people within the village community and began a dialogue with them to understand how they understand mental health experiences and incorporated those values, ideas, beliefs, metaphors within our own communication strategy. I’ll tell you, the results were quite staggering.

When we started this program, only about 5% of people who met diagnostic criteria for depression had actually sought help. At the end of 18 months, when we repeated a survey to look at the impact of the program, this proportion had shot up 6 times to nearly 30%.

Now of course it’s not yet 100%, but still going from 5 - 30% in 18 months, purely through engaging communities, is a reflection of what strategies we need to use.

 

Also See: Understanding Therapy

 

Amrita: You’ve spoken also about the need to deliver healthcare by whatever resources are available. Will you take us through some more of that model and some of the work you’re doing in Goa with Sangath?

 

Dr Patel: Earlier you brought up the very small number of mental health professionals in India. Actually that small number is further exacerbated by the distribution; the majority of that limited number actually live and work in urban metro areas, or in the private sector, essentially excluding the majority of the rural poor from accessing those services. So in some parts of India, there might only be one psychiatrist for several million people. Now, it’s very obvious that with that small number, we do need to think of alternate resources to deliver mental health interventions.
It isn’t just about the number. I would propose that many mental health interventions do not need a mental health professional. Given the scale of mental health problems in our society and indeed, globally, and because mental health is something that must concern all of us, even if we don’t have a mental disorder, we must empower every individual in our community to understand the skills through which one can promote and protect our mental health.
So: the most important human resource to me, is each and every citizen.

 

Up next: Part Two of our Interview
 

 

And do share your comments and feedback here or @healthcollectif

Epic Fail: Transport Woes and Your Stress Levels

January 2, 2018

By Devanik Saha 

We tend to talk about mental health at the work place, because as individuals we spend more than 1/3rd of our adult lives there, which makes it an obvious place of intervention. However, what about before you even start your work day? What about the difficulties in reaching your place of work? What does an urban Indian have to go through? Is travelling in public transport more often a harrowing experience than a comforting one? For those who can afford it, does having a car help?

Also Read: Reporter’s Diary: Workplaces and Mental Health

The Health Collective spoke to citizens across our metros to gauge their views on how travelling to their workplaces affects their mental health, an issue not really acknowledged or discussed, even as we all struggle to come to terms with ever-rising pollution in our mega cities.

  • Transport Woes: Overcrowding, Gridlocked Traffic
“I have an issue with the public transport in Delhi...The government increased the fare and metro parking charges. But despite all this, the frequency of the Delhi Metro remains the same. I have been travelling using the Delhi Metro for the last nine months and believe me, it is a task!” Ratnendra Ashok Pandey, a manager with a multi-national company in Gurugram tells The Health Collective. “The case is same with DTC buses. You cannot rely on them. They are always overcrowded, plus there is no fixed timing.” 

Maximum City doesn't seem to have it easier, despite trains being the lifeline of the city. “Travelling in a local train is a big no no for me. People always push each other and jostle for space, which really affects your mental psyche. This is the reason why I bought a car, Nikhil Kejriwal, founder of the Mumbai-based tech start-up Troope tells The Health Collective. 

(There are physical risks as well, though they are beyond the remit of this piece. An estimated nine people die every day on Mumbai local train tracks, as I had reported back in 2015 for IndiaSpend, analysing data from the Government Railway Police in Maharashtra.) 

When it comes to crowds and jostling, it turns out the attendant strain and fatigue is not just physical, but also mental.

“While a cheap and reliable mode of communication, public transport can cause not only physical but mental strain as one has to adjust with lack of space and an exhausting commute,” says Anjali Singla, a psychologist from Manas Foundation. 

“For instance, I find it challenging to commute during the peak hours as the rush is high and the thought of being pushed and shoved in a metro doesn’t sound appealing at all. It can cause one to feel an increased sense of tiredness. After a point, the monotony of the routine adds to this sense of exhaustion, which is more psychological than physical,” Singla tells The Health Collective.

But it's not like driving is a panacea. Far from it, given the grid-locked traffic that is increasingly the norm in our big cities. “In Mumbai, I always encounter bumper to bumper traffic, so by the time I reach office, I am mentally exhausted. After reaching office, I spend 30 minutes to one hour relaxing in the AC, before I get to work,” Kejriwal adds. 

  • Safety also an issue

“Though I go to office via the office cab service which picks me up and drops me, if I have to go out and meet friends, then the mode of transport is a worry. When I was in college, I was mugged once and I stopped going out for almost two weeks. That did create a sense of paranoia for a long time,” says Kainat Sarfaraz, a journalist with a leading newspaper in Delhi.

Sarfaraz prefers public transport, primarily the Delhi Metro, to app-based taxis, commenting on the number of cases of crimes against women that have come to light. "That is a problem in some cases," she tells The Health Collective, So I do check beforehand. Sometimes I take DTC, sometimes a rickshaw or something. But I always enquire before leaving.”


Rajiv Chowk image, Wikimedia Commons
By Chandradhar yadav (Own work) [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)], via Wikimedia Commons


Also See: Voices: What's stressing out Delhi's Girls? 

Kripa Ramachandran, a working professional from Chennai prioritises safety over convenience. “Safety is of course a priority while travelling, but having lived in major cities, I would say Chennai fares much better than Delhi when it comes to public transport. Within public transport, I prefer to travel in less crowded modes, even though it means a longer wait,” she tells The Health Collective. “A long time ago, I was groped in a crowded bus, hence I am sceptical of travelling in crowded buses and trains,” she shares. 

Delhi-based journalist Urmi Bhattacharya prefers cabs to public transport. “One, it saves time, and two, one is assured of a seat unlike the Metro where you have to jostle for space, she tells The Health Collective. "But if I am travelling to a super shady place at night for an event or party, I might ask someone to pick me up in their car.” 

As many as 315 cases of “insult to modesty of women” (under section 509 of the Indian Penal Code) in public transport were reported in 2015, an increase of 160% over the preceding year, according to government data, as reported by media portal FactChecker.

"We don’t realise how much stress it causes.  Making plans is so stressful, because cabs are not safe and there is no proper or safe public transport,” says Sarfaraz.

  • Benefits of Good Public Transport

Apart from convenience and safety, accessibility to good public transport could contribute to a reduced risk of depression, especially for women and the elderly, by increasing opportunities to move around and have an active social life, according to this 2015 study conducted in Italy. And a 2014 study in the UK reportedly found that taking public transport instead of driving to work makes people happy.

"Researchers reported that car commuters were 13 per cent more likely to feel they were under constant strain or unable to concentrate."  The Independent

Also Read: The Importance of Being Kind to Yourself

These conversations reveal that travelling to workplaces is a harrowing and mentally exhausting experience for many Indians. Therefore, it may not be a coincidence that in 2017, India ranked 122 on a list of the world’s most happiest countries, below its neighbours Pakistan, Sri Lanka, Bangladesh and Nepal.

Social life can take a hit as a result. “The trauma or the fear of driving through such intense levels of traffic and cars makes me cancel my plans,” says Kejriwal.

The quality of life between India and other countries is stark, says Kaavya Singh, a recent graduate of the University of Sussex, UK. “Being a student in Brighton, UK, I have no qualms in saying that the lifestyle in Delhi was much worse than here. As an undergraduate student of Delhi University, travelling in the city always meant being paranoid about safety and trying to choose the right mode of transport. By the time you reach your desired destination, you are mentally exhausted, she says. Whereas in the UK and other European countries, owing to efficient public transport systems, one can travel in a much more relaxed manner.”

For Further Reading: book ‘Why Loiter’ explores how women navigate public spaces very differently from men. While men usually walk in a straight line, choosing the shorter or more stimulating route, women walk with almost an altered map of the city in their heads, given the perceptions of threat, whether it's staring, stalking, heckling or harassment.  


Tell us what you think. Share your thoughts with the hashtag #Voices and tweet @healthcollectif or leave your comments right here.
 
 
Coming Soon on The Health Collective: Remote Working and Mental Health

Talking Mental Health in the New Year

January 1, 2018

 

The World is My Mirror

December 28, 2017

By Unnati Sethi

It's such a cliche but it's true -- I've always been my daddy's girl and I've known it all my life. For my dad, I’m perfect. If you ask him he'd tell you I was brilliant, beautiful and charming, destined for greatness. And yet, when I look back, I realise, I was also a deeply unhappy person. As a child, I rarely made any friends. I preferred the company of my books to that of my peers. In my early teens, anger was a constant companion. Somewhere in my pre-teens, a friend showed me how to wrap my rubber hair ties on my wrist so tight that they'd dig into the flesh and leave wounds or bruises. These wounds I'd cover by pulling down the sleeves of my school cardigan as we’d compete to see who could hurt herself more.

Eventually I grew out of it into being a fairly normal, morose kid who made decent grades but had a perverse love for writing really bad, sad poetry. Like most teenagers, I thought I was deeply misunderstood. I was a rebel without a cause although, honestly, I brooded more than rebelled.

The brooding and self destruction eased up when I got to college and I found friends who gave me the space to explore myself and taught me how to be light-hearted. Yet, somewhere deep, the anger and unhappiness lingered, usually rearing its head only when I was at home with my family. I struggled to understand myself. Why did I lose all self-control when I was with family? Why did I become so toxic around them? I never figured it out and I always hated myself for it. I felt like I was failing at everything and the loneliness broke me.

My first suicide attempt was at 22. My next one was four years later at 26. The years in between were spent punishing myself for being a failure by committing to a destructive, abusive relationship followed by the alcohol-infused haze of the subsequent break up. My second suicide attempt was a wake-up call. In the spring of 2007, my wrist bandaged and once again hidden by the long sleeves of my cardigan, I knew something had to change. So I sought help and went into therapy.

I have always been deeply afraid of developing a dependency on anti-depressants so I refused to take them and, against the advice of my therapist, I insisted on figuring out how to deal with my depression without medication. This may not be advisable for everyone but it was crucial for me. Therapy helped me a little bit.

Also Find: Contacts and Helplines

As I struggled to define what happiness meant for me, I learned that “fake it till you make it” really does work. I learned that if you smile through it, even if you're gritting your teeth and forcing the smile, eventually it will feel real and it will lighten the load.

Fake it, Make it by Kishore Mohan for Health CollectiveArt by Kishore MohanHealth Collective


What helped me fake it was when my friend and roommate at the time taught me how to ‘change the narrative’. Before, I'd sit at a window during the rains, look at the rivulets of water on the glass and imagine that the Gods were weeping. Once I forced myself to think of an alternate narrative, the same raindrops became little children playing a game of tag racing each other to an imaginary finish line. And I found myself smiling. I know it feels trite and pithy to tell someone to “just smile through it” but in my experience, it was the simplest thing I could do to get myself through my darkest phases.

That was a decade ago.

In the last ten years I have learned to recognise the triggers that “bring on the funk” and I've developed other active mechanisms for tackling those moments. Therapy helped me acknowledge my fears of being inadequate. I learned to think deeply about what I want and why. It helped me accept who I am. I learned how to be happy with myself. Over the years I made smiling a habit and now I find it easier to bounce back.

Also Read: Spread the Word on Dangers of Blue Whale

And I've discovered something incredible that I'd never thought would happen. I learned that the world isn't my oyster, closed and toxic, there to secrete acid at me until I become a pearl. I've found that the world is actually just a mirror, vast and shiny, throwing my feelings right back at me.
When I'm unhappy, I find that the world treats me callously. I am slighted easily. I have a much harder time navigating the system, be it a simple banking transaction or ordering a meal at a restaurant. On the other hand, I've found that when I make the effort to smile, the world smiles back at me a lot more as well. When I'm not unhappy, when I'm smiling (inwardly or outwardly) people respond more positively and smile back. They try and accommodate my requests, they go out of their way to help me and they genuinely care. The world suddenly becomes a much easier place to live in when you spread a little bit of pleasantness around.

Honestly, it's not always easy. And yes, it's such a cliche. And yet, something as simple as a smile, even a deliberate one, really does boomerang right back to you. I still have days when I'm sad and on those days I push myself to be cheerful, to go out and deliberately find something to laugh at. All I can say is -- Happiness is hard work sometimes but it's absolutely worth it.


Read Further: Your Stories on The Health Collective

 

View older posts »

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 taptastic.com 

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.


YOUNG SUICIDES

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.
 

RELATIONSHIP PRESSURE AND ADOLESCENTS

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.


FROM THE ARCHIVES:
 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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