Wrestling the Demon Called Depression
Iris C F Gomes
We live in a world where mental illness carries a stigma that by itself fuels additional stress, further impeding the resolution or mitigation of mental turmoil. In Goa especially, the issue of depression as a mental disorder is often ignored as a serious problem. The superstitious, overly religious people label it as possession and the more rational tend to demand that the sufferer snap out of it, judging it a weakness of character.
Major depressive disorder is a huge concern in India and Goa because it is often the root cause of addictive behaviours and suicide. ‘Unless we have a healthy mind, we are not going to be achievers…. People have high IQs – but if they have low EQs, if their emotional quotient is low, if their thinking capacity is not up to the mark, they do not succeed to the level that they actually can,’ says Dr Peter Castelino, psychiatrist and co-founder of COOJ (Cause of Our Joy), a non-profit organisation that provides rehabilitative measures to persons with mental disorders. Speaking at the Mapusa Municipal Council programme on World Health Day to raise awareness about depression, Dr Castelino explained the symptoms we can adjudge as associated with depression, and called for the dire need for empathy in dealing with people with major depressive disorder and building a better mental health status for Goa.
Around 350 million people all over the world suffer from depression, and it is the leading cause of disability globally, beating blindness, loco-motor disability and hearing impairment. By 2030, depression will be the principal contributor to the global disease burden. Every year about 8 lakh people die throughout the world due to suicide. Based on this information, it is estimated that in India there are 130,000 suicide related deaths annually.
Statistics further show that 3 of every 100 urban Indians suffer from depression. WHO states that 10.9 per lakh people attempt suicide in India. Suicide is the second leading cause of death in the age group of 18-29; rightly confirming the scholastic and professional duress that young people have to endure. However little is being done to provide sanctuary to this age group. ‘In fact, there is only one psychiatrist for every four lakh Indians. There are more Indian psychiatrists in the West than there are in India,’ says Dr Castelino. In 2015 there were almost 57 million (4.5 percent of the population) people in India suffering from depression.
Often depression manifests itself through symptoms such as headaches, loss of appetite, sleep disturbances, weakness and so on. People do not normally approach psychiatrists because, as Dr Castelino says, ‘Indians are not used to talking about their emotional problems as health problems.’ Since the physical manifestation is evident, patients tend to visit a doctor who would treat those problems, which is usually at a primary healthcare centre. While the symptoms are treated, the depression that is behind the symptoms is left undiagnosed. 10-40 percent of people who visit primary healthcare centres are actually suffering from depression and/or anxiety.
5-10 percent of young adults in Goa are affected by depression and stress related problems and 15-25 percent of people visit primary healthcare centres. 12.8 percent or one out of every eight young people between the ages of 1 and 16 years has some form of mental health issue. There are three million children around the world living with depression every year (source: Newsweek).
According to WHO (2001), within the age group of 15-44, 16.4 percent of people live with depression as a disability. The fact that unipolar depression, alcohol abuse, schizophrenia and bipolar disorder make the list of the top ten disabilities should be incentive enough to urge the government to make policies and provisions to make sure that people with these disabilities obtain the help they need. In India, major depression is listed as a leading cause of disability, above other causes such as HIV, diabetes, lower back pain and iron deficiency.
The National Crime Record Bureau (NCRB) says there was an average rate of 11.2 per lakh population (in 2012) committing suicide in India. Despite being a high literacy state, Goa has a greater rate of suicide (15.8 per lakh population) than the national average. Dr Castelino says, ‘For every one person who has died from suicide, there are 20 more who have attempted and survived suicide, and a hundred more who are thinking about it.’
The high rate of suicide among young people should prompt programmes at school level to educate, create awareness, and remove the stigma that prevents young people from seeking assistance for their mental health issues. China once had a higher rate of suicide than India, but has now seen a decline thanks to spreading awareness at the grassroots and conducting programmes to allow people with mental health problems to avail of treatment.
The DSM-V (Diagnostic and Statistical Manual of Mental Disorders) has specific criteria for diagnosing major depression. One has to have a depressed mood, or loss of interest or pleasure, which extends over a period of at least two weeks. Other symptoms include: weight gain or loss, insomnia or hypersomnia, loss of energy, feelings of worthlessness and guilt, loss of concentration and decisiveness, thoughts of death and suicide, and psychomotor agitation. ‘All suicides are not only because of depression. This is very important to note because people think that everyone who attempts suicide is depressed. In our country, a large number of suicides are due to interpersonal relationship problems. It could be domestic violence, the break-up of a relationship, grief due to the death of a loved one… It could be intimate partner abuse, which is a big problem that no one speaks about,’ says Dr Castelino. Suicide due to mental health problems is more common in the West than in India. Impulsive suicides due to interpersonal relationship issues are more prevalent, especially among younger people in India. Suicide prevention programmes need to look at reducing access to methods of suicide to curb impulsive suicides.
There is a science to clinical or major depression that allows us a tangible explanation for its occurrence. In the brain, impulses move from neuron to neuron with the aid of neurotransmitters. Serotonin is a neurotransmitter that plays a significant role in clinical depression. When the levels of the ‘happy’ neurotransmitter serotonin are lowered, depression begins to manifest. The situation can be compared to a vehicle running out of fuel. One may push for a while but after some time tiredness sets in and you can push no more. ‘The initial part is called mild depression, when we can still push. Then it becomes morbid depression when pushing becomes a little more difficult, and when you are totally fatigued, it is severe depression. That’s where you feel worthless, you feel you can’t do anything in life…that’s when the thoughts of what’s the point of living come in and the thoughts of suicide come in,’ says Dr Castelino. PET scans show that there is a clear difference in the blood flow and oxygenation in the brain of a depressed person in comparison to the brain of a normal person. Medication increases the levels of serotonin and helps in alleviating the symptoms of depression.
Consequences of depression are interpersonal problems such as marital conflicts; academic and professional difficulties with the inability to concentrate and focus; risky behaviour like alcohol and drug abuse, unprotected sex, rash driving, etc (more common in younger people with depression); comorbidity, that is other health conditions occurring along with the depression; and obesity, which brings about other health issues.
20 percent of people with depression have psychotic symptoms. Around 10-15 percent of women develop postpartum depression and this can lead to tragedies such as the mother taking the life of the child and committing suicide. Substance abuse is seen in 33 percent of depression sufferers as they try to use drugs and alcohol to cope with the disorder. Depression can intensify chronic pain.
A study by the Society for Human Resource Management (SHRM) on finance and banking, travel and hospitality, and the IT industry showed the effect of depression on the economy. They found that there was a loss of Rs 105 crores in the finance and banking sector due to depression. In the IT industry it was almost Rs 50 crores and in the travel and hospitality sector it was about Rs 10.5 crores.
Clinical depression is treatable at three levels: psychosocial interventions, psychotropic medication and rehabilitation (in severe cases). In mild cases, psychosocial interventions suffice. This would include the patient having somebody to listen to them so that they can unravel their emotions. The next step in psychosocial interventions is counselling, where clinical methods come in. Counselling and introspection leading to lifestyle changes is necessary, for example, learning to focus on different parts of our lives and not be money driven. One’s base philosophy is important for this first level to be efficacious as resilience, principles, and belief systems can play a positive role in dealing with depression.
If the first level of treatment is not enough, then medication is given. Since medication can take 4-6 weeks to be effective, in serious cases (suicidal tendencies) electroconvulsive therapy (ECT) is advised. ECT is conducted under anaesthesia and helps bring the levels of neurochemicals to normal.
Rehabilitation comes in when the depression is chronic and has associated complications that need to be dealt with as well.
Despite all the statistics showing the impact of depression on individuals, their quality of life, and the economy of the country, less than 2 percent of the health budget is allocated to mental health. In Goa, at the present time, the District Mental Health Programme is functional only in South Goa and there are only three or four people involved in this programme. The good news is that the flawed Mental Health Act of 1987 has been replaced by the Mental Healthcare Bill 2016 passed by the Lok Sabha in 2017. The bill has decriminalised suicide, allowing people who have such tendencies to be open about it and seek help. Every person has the right to mental healthcare and affordable treatment of good quality. The government is supposed to provide a range of services: halfway homes, sheltered accommodation, outpatient and inpatient services, supported accommodation, hospital and community based rehabilitation, free medicines and specialised services for child and adolescent mental health problems, and geriatric care centres. The government has to ensure that budgetary provisions are made towards these services. Now mental health problems will be covered under medical health insurance.
There is hope yet for people grappling with the demon of depression through the government playing a major role in encouraging people to avail of treatment and disseminating information about mental health problems. Prominent personalities like Deepika Padukone are speaking candidly about their battles with depression and other mental health issues and motivating individuals to seek assistance, and NGOs like COOJ carry out various activities and programmes to alter the mental health scenario.