Vasant, a 15 year-old boy, tried to kill himself by drinking a pesticide. Luckily for him, he was brought to hospital on time. After spending two weeks in the hospital, including a week in the ICU on a ventilator, he was discharged -- alive and well. The question was: why did he do it? His parents admitted that Vasant had threatened suicide several times before, but they did not take him seriously. Vasant was in fact suffering from undiagnosed depression and anxiety. He is now healthy and well, after seeing a psychiatrist.
Many others are not so lucky. In Kerala, over 8,000 people commit suicide every year – and the majority are young people like Vasant. Though the state has the highest doctor-patient ratio in the country and active 24/7 suicide helplines, the number of suicide cases has remained high. The main reason is undiagnosed depression and anxiety, compounded by social isolation in an increasingly nuclear, urbanized and materialistic culture.
This story raises important questions.
1. Why was Vasant’s illness not diagnosed earlier?
2. Why did his parents take suicide threats lightly?
There is not only a failure to recognise the symptoms of mental illness, but there is reluctance to seek the help of a psychiatrist. This article explores the reasons for this deficiency, and offers feasible solutions.
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Psychiatric illness - a disorder of the brain as much as the mind
Psychiatric illness refers to a large group of disorders including anxiety, depression, bipolar disorder, personality disorders, attention deficit disorder, schizophrenia, alcoholism and so on. Contrary to popular belief, most of these patients are socially productive, and may seem perfectly normal to their colleagues or family. Increasingly, these illnesses are considered to be of neurological origin, and the boundary between psychiatric illness and diseases of other systems, like the digestive system – is fading.
Some psychiatric illnesses can have associated symptoms like physical pain (also called psychosomatic disease), memory loss, palpitations, indigestion or breathing trouble, and may undergo extensive investigations that reveal no finding. Mental illnesses like depression can also follow bodily ailments like heart attack or cancer; diligent treatment ensures better outcomes.
Unfortunately, society stigmatises all psychiatric illness as equivalent of the loud, dramatic and hysterical illnesses portrayed in popular movies such as Kilukkam or Manichitrathaazhu. Just as only a small portion of illnesses seen by a medical doctor are cancerous, only a small portion of the illnesses seen by a psychiatrist have the ‘classical’ psychotic features that society ’expects’ of a psychiatric patient.
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In other words, not all psychiatric illnesses have dramatic manifestations.
Why are people reluctant to seek the help of a psychiatrist?
1. The stigma attached to mental illness remains the main reason. Traditionally, psychiatric illnesses have been the subject of much ridicule. Patients are looked down upon by others, like it is their fault, or as though they had been convicted of a serious crime. Unfortunately, this stigma not only prevents patients from getting the right treatment at the right time, but leads several patients and families down the dark corridors of quackery.
2. Ignorance of the spectrum of psychiatric illness -- many people are not aware of their own anxiety, depression or personality disorders. Many symptoms get glossed over with superficial explanations by the so-called pundits of society as ‘she is of arrogant nature’ or ‘she is a possessive person’ or ‘he is moody’. Such patients lose the opportunity to get diagnosed and treated early.
3. Threat of suicide is still considered part of normal behaviour by a large number of people. Many take it as a joke; some even try to justify it by saying: “She has only threatened suicide a few times, but never actually committed it. She’s just sensitive.”
Instead of consulting a psychiatrist, such serious symptoms often get referred to a senior relative who freely dispenses unqualified ‘life-advice’. Such advice can range from:”Get him married, and he will be alright” to “Give her a child; she will forget all this”. This is equivalent to treating severe insulin-dependent diabetes by starving the patient, and still expecting a good outcome.
4. Many people lament that psychiatric illnesses are incurable, but fail to realise that even common ailments like spondylitis and hypertension are also not exactly ‘curable’. Not everyone with mental illness requires long-term medication.
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5. Patients may feel abandoned or rejected by their treating doctor when a referral to the psychiatrist is made. Some patients misunderstand the suggestion of psychosomatic illness as ‘imaginary illness’ or ‘it’s all in the head’. This is wrong. Not only is the pain real, it will also respond to appropriate psychotropic medication.
6. Patients believe that psychotropic medications might make them too sleepy and incapable of work. While some medications do cause drowsiness in the first few days, most people are able to function adequately at home or work, once the dose has been titrated with the help of the doctor.
7. Many people have difficulty understanding the concept of psychiatric illness. In contrast with heart disease that can be explained to the patient using an angiogram report or diabetes that can be demonstrated on blood test report, there is no ‘diagnostic test’ or scan for psychiatric illness.
Psychiatric illnesses are associated with minute chemical alterations in our brain. Much of the communication between our nerve cells happens through molecules called neurotransmitters, some of which are excitatory and others, inhibitory. Examples include serotonin, glutamate and norepinephrine. An imbalance in the normal ratio of these substances can cause several behavioural and emotional symptoms of psychiatric illnesses.
8. People still have the ‘one disease, one medicine’ concept, made worse by doing internet-based searches on prescribed medications. For example, if the doctor prescribed sodium valproate for a mood disorder, the patient may do a Google search and conclude that this medication is used for epilepsy. Suspecting that the doctor wrote the wrong medication, this person might even stop the tablet without notifying the doctor. This leads to non-compliance.
9. Many people do not know the difference between a psychologist and a psychiatrist. While both psychologists and psychiatrists can provide expert counselling and psychotherapy sessions, only the psychiatrist has the license to prescribe medications.
Why are doctors reluctant to send the patient to a psychiatrist?
1. Because of the stigma involved, some doctors are afraid to offend the patient by suggesting a psychiatric evaluation. They fear that the patient might not take their advice, and therefore prefer not to raise the topic.
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2. Even though psychiatric illnesses account for over 20 percent of patients in a general outpatient clinic, proportionate importance is not given to psychiatry in the MBBS curriculum. Often, doctors graduate after attending just a few lectures and clinics in psychiatry -- hardly enough to equip them with the knowledge or skill to tackle the large volume.
3. At least a minority of doctors are sceptical about the scope of psychiatry; this attitude comes largely from ignorance. Although they will acknowledge that diseases of one part of the body can affect another organ – for example, diabetes can cause retinopathy or eye disease -- they often fail to realise that the body and the mind are one entity, and many physical illnesses of the body can have their origins in the mind.
4. Instead of taking a proactive approach and referring the patient early, they may avail of the psychiatrist’s help only as a ‘last resort’ by which time the patient would have suffered several years of poor quality of life already without a proper diagnosis.
5. Doctors practising in fields other than psychiatry might not have updated their knowledge since completing MBBS 30 years ago, when understanding of pathophysiology was limited, and effective treatment options were few.
What is new in psychiatry?
Psychiatry has come a long way since the attractive and popular Freudian theories of the 18th century, which attempted to explain adult mental illness as a consequence of childhood sexual experiences, with emphasis on analysis of dreams.
The recent Nobel Prize-winning work of Paul Greengard and Arvid Carlsson on neurotransmitters that facilitated greater understanding of psychotropic drugs, and the experiments of Eric Kandel which demonstrated neuronal structural changes occurring with learning and memory -- are path-breaking examples of scientific progress. More recently, genes controlling calcium channel activity have been linked with several psychiatric illnesses. Better medications with more targeted action and fewer side-effects have now become available. The contributions of experts like Stephen Stahl to psychopharmacology have led to a more tailored approach to prescribing, based on the individual neurotransmitter involved.
Newer and exciting developments in psychiatry include the role of neuroplasticity: structural remodelling that occurs in the brain as a result of medication and other intervention. For example, certain areas of the brain like hippocampus and prefrontal cortex undergo volume loss (shrinkage) in depression. Early diagnosis and treatment of depression helps in preservation of brain structure and volume, as evidenced by MRI scanning. The loss of brain volume was worst among those who had prolonged periods of untreated depression. Biological psychiatry is an evolving field, which is increasingly defining a biological and structural basis for mental illness.
What can be done to improve the situation?
1. The stigma surrounding psychiatric illness has to be erased. More recently, celebrities like Deepika Padukone spoke out against this stigma, openly admitting that she had suffered mental illness. Such endorsements are powerful tools to break social stigma.
2. When someone threatens suicide, it should not be taken lightly as an attention-seeking prank. Most people who commit suicide have a past record of having made such threats. Such behaviours can be part of mood disorders like depression, or a manifestation of borderline personality disorder -- a mental illness that can escape notice by almost all except those living with the patient. People with suicidal tendency should not be left unattended, and regular appointments should be kept with the psychiatrist. Every psychiatrist will recall stories of patients who killed themselves while alone at home.
3. Privacy of health information is a priority – and not just in the case of mental illness. The tendency to discuss medical matters openly with nosy neighbours, distant relatives and colleagues must be curbed. Those who are not the primary decision-makers in the patient’s case are better kept out of this, as their slandering and judgmental approach will only cause long-term harm to those who are already suffering.
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4. The following is a partial list of symptoms that could suggest underlying psychiatric disorder, and should prompt an evaluation:
a. Persistent inability to sleep
b. Chronic pain not explained by routine investigations
c. Persistently low mood and lack of interest in routine activities
d. Sexual dysfunction
e. Relentless suspicion of spouse’s fidelity
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f. Threats of self-harm or of violence
g. Recurring difficulty with relationships and possessive behavior
h. Intermittent excessive talkativeness and mood fluctuation
i. Social withdrawal, talking to oneself
5. Doctors should become proactive in working as a team with the psychiatrist and psychologist in helping the patient get better. When routine investigations fail to find an organic cause of the patient’s symptoms, it is better to say: “Your tests have fortunately ruled out serious illnesses like cancer. Let’s now work together with some colleagues of mine to find out why you are continuing to feel this way, and to help you get better” rather than dismissively declare “There’s nothing wrong with you”.
Even a single day spent without enjoying life and feeling alive is a day wasted -- it is lost forever. Mental illnesses take a huge toll on the quality of life of the sufferer as well as their family. With effective treatments now available, it is no longer justifiable to ignore the spectrum of psychiatric disease.
(The author is a senior consultant gastroenterologist and deputy medical director, Sunrise group of hospitals)