The theme of the World Health Day 2017 is “Depression: Let's Talk”, which is being celebrated on the 7th of April 2017. According to the World Health Organization (WHO) estimates, the number of people living with depression has increased by more than 18% between 2005 and 2015. More than 80% of this disease burden is among people living in low- and middle-income countries. Globally, it is estimated that more than 300 million people suffered from depression in 2015. Nearly half of these people live in South East Asia, China and India to be specific. As per WHO estimate, around 56,675,969 people suffer from depression in India, which is 4.5% of the total population. The same report suggests that depression is responsible for 10,050,411 years lived with the disability which is around 7.1% of the global burden of disease. Depression is ranked as the single largest contributor to global disability. Depression is also the major contributor to suicide deaths which is close to 800,000 annually. However, when it comes to the allocation of resources and funds to tackle this global epidemic and disability, depression or mental health, in general, is usually not a priority for the policy makers.
Kashmir is not foreign to the concept of psychological problems and many reports have been published in the last year alone about the high prevalence of depression and other mental health problems in the local population. 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 around 59% with most people having suffered directly or indirectly from some traumatic incident. A recent survey by the 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. During my research on PTSD patients, depression was again the most common diagnosis in more than 80% of the patients. Another study published by Action Aid India showed a high prevalence of depressive illness, anxiety disorders and other mental health problems.
The burden of disease more so in the female population is huge although we do not have actual numbers. The number of patients coming to the hospital is just the tip of the iceberg and many more do not seek help or aren’t aware that they can be helped. The awareness about depression and other mental disorders has improved overtime; however, there is still a lot of stigma associated with visiting a psychiatrist. I know of cases where families would not allow members to seek help for emotional problems fearing they would be judged by the society which at times, is true. Some families still prefer for their children to be in prison than in a psychiatric hospital and some go as far as paying to get their loved ones locked up.
Depression can present in various forms and I believe that the Western criteria set by the WHO or the American Psychiatric Association (APA) to diagnose depressive illness, are not always applicable to our population. The core symptoms of depression are low mood and lack of interest in pleasurable and day to day activities. When we talk about mood, and expressing it in words, apart from some highly educated people, most are not aware of what it means. Hence asking someone, ‘how is your mood?’ does not apply. Most of us think in terms of ‘Heart' and something not right with it. ‘Meh Haz dil pareshan (My heart is sad)', ‘meh haz weanijih rawan (my heart is missing beats/palpitations)', are the classical statements one hears when talking to someone with depressive symptoms in our cultural context. It is one of the reasons why people suffering from depression end up visiting cardiologists and at times undergo expensive and unnecessary investigations, when in reality nothing is wrong with their heart or its proper functioning.
The common symptoms for someone suffering from depressing in our cultural context are tiredness, difficulties with memory, stomach problems, aches and pains, headaches, back pain, weakness in arms and legs, inability to move an arm or leg, episodes of loss of consciousness, weight changes, irritability, tearfulness, and suicidal thoughts. 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 casualty department, typically a teenage girl not able to talk or move her arms or legs 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 be 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. It is important then to be mindful, when going to the doctor repeatedly and not getting better, even after undergoing multiple treatments – one should strongly consider depression or an anxiety disorder as a possibility of on-going poor health.
Hence if you are suffering from symptoms as mentioned above or someone in your family is, please do consider depression and seek help. Depression is a treatable condition at a much lower cost than one would spend visiting various specialists and undergoing costly investigations. Sometimes your psychiatrists or doctor may request tests like thyroid function and blood sugar which can be associated with depression. People who suffer from long term physical health conditions like diabetes or heart disease are at an increased risk of developing depression than rest of the population. Treatment of depression is necessary in such patients as it can affect the physical health condition adversely and worsen the outcome. In people suffering from diabetes, treatment of depression helps with better blood sugar control.
One cannot blame the general public for not knowing where to seek help as it is not always easy to make sense of the symptoms. It becomes the duty of every doctor to identify depression, treat it if they can and refer if they feel it is beyond their capability or area of expertise. Unfortunately, at times people are put through unnecessary investigations and even invasive tests, deliberately or unknowingly when the problem lies somewhere else. Some female patients typically suffering from vague pain symptoms are advised to have surgeries like removal of the uterus which not only deprives the woman of an essential organ but in long run, makes her depression and pain symptoms worse. It is an open secret that there is an epidemic of such unnecessary surgeries and even young girls who have even not conceived are deprived of their womb. This can only be stopped when people are aware about their symptoms. It is therefore imperative that patients seek a second opinion and rule out depression before going under the knife.
Lately, there has been a surge in the number of people, including doctors writing about depression, its causes, suicide and other mental health issues. This may seem a harmless enough exercise to most people, but when doctors who are themselves uninformed write about such issues in a manner that causes more harm than good, the results can be devastating. Many articles have been published which instead of informing, misinform the general public and increase the stigma already attached to depression and suicide. Sadly, some have even gone as far as to suggest that depression and suicidality are due to a lack of willpower and go on to sermonise with threats of hell and wrath of God. People who suffer from depression and suicidal thoughts are already under tremendous pressure from the illness and need treatment, not threats. They need support and empathy. To call people suffering from depression and suicidal thoughts as weak-willed or cowards or idiots is not only derogatory but deeply shameful and inhumane. Such articles and misinformation can trigger or even push someone over the edge by worsening their feelings of guilt and putting them through shame. Let's reiterate again that depression and other mental health problems are clinical conditions, mostly treatable and at times curable. Like diabetes and high blood pressure, people suffering from depression need medicine and other help on an ongoing basis. Hence it is better to seek the right help at the right time to reduce the disease burden and improve the quality of life. Doctors have a huge role to play in reducing the stigma, identifying those suffering from depression and providing the right treatment. The media houses also have a huge responsibility to check that what is printed is not misleading and ask expert opinion before publishing in public domain.
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