It’s Sadder In Denial

According to the WHO, close to 50 million Indians suffer from depression, and the alarming part is that 80 percent of them don’t receive any treatment whatsoever. Despite the grim statistics, Indians persist in ignoring the ominous presence of mental illnesses. They would rather pop pills for diabetes and heart disease, than confront the imbalance of their brains. Most won’t accept that depression is a disease, and attribute their emotional distress to inherent “character flaws” instead. In a recent survey of attitudes to mental health, three-fourth of a group of 3,000 participating adults said that depression was a “sign of weakness,” and that the best cures were “personal willpower and strength.” The survey was released last week by the Department of Mental Health and Behavioural Sciences at a Fortis Healthcare event, on the World Health Day.

There has been a 50 per cent surge of depressive disorders between 1990 and 2013 in ­India, say experts, blaming the rising levels of stress to modern lifestyles and breakdown of family structures. Though the media tends to focus on depression in the context of suicide, rarely is this seen as a medical disorder caused by the interplay of biochemical, genetic and social factors. Symptoms of depression include fatigue, distress and dysfunction. There’s cause for alarm if you wake up feeling low six out of seven mornings a week, especially if your dejected mood affects your ability to work and socialise normally. “Transitory feelings of sadness are normal, but when these persist beyond a fortnight and affect a person’s life adversely, clinical depression may be the culprit,” says Dr Samir Parikh, dir­ector, Department of Mental Health & Behavioural Sciences, Fortis Healthcare.  Once regarded a disease of the rich and famous, depression has invaded the lives of the average person—one in 20 Indians suffers from depression, says the ­National Mental Health Survey, 2015-16, accounting for one-sixth of the 300 million depressed individuals in the world. Today, depression has become world’s second biggest cause of disability.

Depression is insidious, and has debilitating consequences. Left untreated, it diminishes the brain’s coping mechanism. Roughly 10 per cent of the normal population risks developing depression, though risk shoots up to 30 per cent in those with diseases such as diabetes, hypertension and heart disease, highlighting the need for policies to improve the management of depression within general medicine. “Every general practitioner needs to be aware of depression as a co-existing condition with other diseases, and take a call on treatment and referral when required,” says Dr Parikh.

The interplay of protective factors such as diet, sleep, resilience, coping mechanism, exercise, social network are more effective in warding off the disease in some. Though depression can’t really be prevented, experts say that early interventions can teach people to tackle difficult emotions effectively, sometimes preventing them from escalating into full blown depression. “Basic psychological interventions at the community level can help develop awareness and equip people to recognise early signs and symptoms,” says Dr Rajesh Sagar, Professor of Psychiatry, AIIMS.

Numerous treatments are available for depression. “Every patient with depression has unique brain biochemistry, and finding the right combination of drugs, psychotherapy and other influencing factors, may take some juggling,” says Dr Manushree Gupta, psychiatrist, Safdarjung Hospital.  In the ‘80s, the selective serotonin reuptake inhibitor (SSRI), like Prozac, heralded a new era of safer drugs. Since then, various SSRIs and serotonin-nor epinephrine reuptake inhibitors (SNRIs) have been developed as new antidepressants. Hope is pinned in two newer treatments: Brintellix, an FDA-approved-antidepress­ant, found effective in treating sev­ere dep­r­e­ssive disorder; and Ketamine, a medication currently used for anaesthetic and pain relief.  Unlike Prozac and other SSRIs, Ketamine is effective within hours, making it a promising treatment for suicidal depression. But only time and several large-scale studies will be able to confirm its safety for long-term use.

Natural alternatives such as the St John’s-wort plant have gained popularity too, and the latest in this category is a food supplement called Serelax, which contains GABA, L-theanine, Passionflower, Kava kava, Valerian, Jujube, Skullcap, and Roman Chamomile to help relax the nervous system. Another recent treatment is the Neurostar TMS Therapy—a non-invasive, out-patient procedure that involves targeting magnetic pulses at the under­­active areas of the brains of depressed individuals, to help stimulate these. In India, this treatment is available as rTMS or repetitive Transcranial Magnetic Stimulation at several psychiatric facilities in hospitals.

Much has been made of the Mental Health Care Bill 2017, which decriminalises suicide and adopts a more humane view to mental illnesses. The National Health Policy 2017 also makes a show of prioritising mental health services within the gamut of non-communicable diseases. But the gaps between intention and reality are telling: there is no specific fund allocation or a collective, collaborative approach to the problem that inc­ludes all sectors and stakeholders.

Speaking out is the first step to breaking the stigma surrounding depression. Seeking help from a mental health professional is a vital component of recovery. But what to do when there aren’t enough doctors to help you? Tackling depression full-force calls for a strong network of mental health professionals. Government figures highlight the dismal number of mental healthcare professionals in India—3,800 psychiatrists, 898 clinical psychologists, 850 psychiatric social workers, and 1,500 psychiatric nurses nationwide. There are three psychiatrists per million people in India, while in other Commonwealth countries; the ratio is 5.6 psychiatrists for the same, says the WHO. What hope do the millions of depressed Indians have?

Partial answers lie in the onl­ine space. Public-health organisations are amenable to the platform too; WHO’s Mental Health Action Plan 2013–2020, recommended “the promotion of self-care, for instance, through the use of electronic and mobile health technologies.”

And then there’s wearable technology to combat depression. One such device is the Fischer Wallace Stimulator, app­roved by the FDA to treat depression. This is a headband which claims to stimulate the production of dopamine and serotonin when placed on the temples. Based on a doctor’s advice, individuals can go about their daily lives wearing this band which provides neurostimulation therapy. Another device said to reduce stress levels by up to 50 per cent is the Spire, which can be clipped onto a belt, and is connected to a mobile application.  Spire detects breathing patterns, emotions and other physiological responses, and sends notifications to your device, with tips on how to alleviate stress. The new technology frontier brings with it some uncertainty, since there’s barely any industry regulation, or data on the effectiveness of apps. But electronic int­erventions are not new to psychology.  Online therapeutic programmes, such as internet-based cognitive behavioural therapy (CBT), have been successfully used for the past decade. Younger people prefer the newer, mobile version—‘Dep­ression CBT’—an application which provides educational resources and advice to help users monitor moods and understand behaviour patterns. Smartphone apps like these suit lifestyles and address the issue of stigma and secrecy.  Anot­her popular choice is ‘7 Cups’, a website and mobile application that offers free online therapy and counselling to those experiencing anxiety and depression. Interactions are kept anonymous and help is provided through trained act­ive listeners or therapists. This kind of technology may indeed be the first step to seeking help. The ubiquity of smartphones makes such apps a viable digital lifeline—particularly in rural and low-inc­ome regions, making speaking out a real possibility for every Indian.