Kashmir is a picturesque valley wedged between India, Pakistan and
China. I trained and later worked as a psychiatrist at the only psychiatric
diseases hospital of the valley which is based in the capital city of Srinagar.
I remember the walk-in clinics, where at times we had up to 300 patients
waiting eagerly to have few minutes with a psychiatrist despite the huge stigma
associated with mental illness. The number of people seeking help for emotional
problems grew exponentially after the armed conflict started in 1989. One of
our studies reported the lifetime prevalence of exposure to the trauma of about
59%[1]. A
recent survey by Medicines Sans Frontiers (MSF) reported that about half of the
population is suffering from some kind of mental illness, with 50% women and
37% men suffering from a depressive illness[2]. During my research on PTSD patients,
depression was again the most common comorbidity in more than 80% of the study
sample[3].
One can argue that the diagnostic criteria as suggested in the ICD and
DSM may not fully hold true in the local cultural context for the diagnosis of
depression or even other disorders.
Asking the golden question, ‘How is your mood?’ usually gets a blank
response. People often talk in the
context of ‘heart’ when talking about their emotions and feelings, rather than
the mind. Typically, someone with depression would come saying, ‘My heart is
not good’, usually pointing to their chest.
I remember asking, ‘How is your heart?’ more often than ‘How is your
mood?’ Even the people from middle class and educated backgrounds would find it
hard to discuss mood. The same is true
about anxiety disorders with palpitations and other somatic symptoms often
being taken as a symptom of physical illness. http://www.rcpsych.ac.uk/pdf/VIPSIG_Depression_around_the_world.pdf
People usually do not come to the doctor with an idea that they will get
treatment for depression or even that they may be depressed. It is usually the
physical symptoms like tiredness, pain, palpitations, memory difficulties,
medically unexplained symptoms, and weakness in limbs and headaches that bring
them to the doctor. Conversion symptoms
are the most common presentations to the A&E department, typically a
teenage girl not able to talk, move a limb or being unresponsive. This has a
great cultural significance and is protective. If a woman reports feeling low
to her husband, she would hardly be taken seriously and probably get told off
for being lazy. However, when someone reports pain or physical symptoms, it is
often taken seriously and considered a valid reason to seek help from a
doctor.
Depression and other mental health problems form the biggest group of
illnesses and burden of disease in the local population. With such a variable
presentation of symptoms, patients often go to all kinds of specialists, quacks
and faith healers. This results in unnecessary costs, inadequate or wrong
treatment and, at times, iatrogenic harm.
There is a need for training doctors and other health professionals in
better identification and treatment of depression and other mental health
disorders. There has been some awareness
both among the doctors and the general public in seeking right help for mental
health problems. Finally, medication still
remains the sole therapeutic modality, keeping in view the lack of allied professionals
like psychiatric nurses, psychologists and therapists.
[1] Margoob, M. A.,
Firdosi, MM, Banal, R., et al. (2006). Community prevalence of trauma in south
Asia: Experience from Kashmir. JK-Practitioner, 13(Supplement 1), S14-S17.
[2] Medicine Sans Frontiers (Doctors without Borders) ‘’Kashmir Mental
Health Survey 2015’’ https://www.msfindia.in/sites/india/files/research_summary.pdf
[3] Firdosi MM,
Margoob MA. Socio-demographic profile and psychiatric comorbidity in patients
with a diagnosis of Post Traumatic Stress Disorder–A study from Kashmir Valley.
Acta Medica International. 2016;3(2):97-100
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