Stigma and Mental Health: What nobody wants to talk about

“...One half of mankind does not know how the other half lives...the experience most profoundly closed to most of us is that of madness.”

(From “guilty but insane”, the autobiography of an inmate of Broadmoor who signed himself ‘Warmark’.)

The word ‘madness’ is indeed closed to us (including psychiatrists) today as a politically incorrect term for any kind of mental illness. But as Warmark points out, when we discuss a bunch of multiple and largely unaddressed mental disorders, we need a clear umbrella term. Doesn’t Polonius in Hamlet also exclaim, ‘define true madness, what is it but to be nothing else but mad?’

India’s own languages and dialects often frankly recognise the variety of mental illnesses. They have their own words for them. In our childhood for example, one caught worried discussions in Kumaoni among Uttarakhand families: members, who suddenly turned all tearful and introverted were labeled as Gumsum, someone’s (mostly a widow or abandoned wife) successful or failed suicide attempt (Aatmhatya) made them persons to be watched (Nigah Rakhna).

Then there were the elderly who were sinking into dementia. They were referred to, half in jest, by saying “woh tau ab Paramhans ho gaye”. I also remember a frighteningly large number of relatives who had psychotic disorders (Ghore Paagal ), who had to be rushed periodically to asylums in Bareilly or Agra for a fearsome electric shock therapy. The latter alone were frankly referred within families as Paagal (Mad), who no one should be marrying their sons/ daughters to.

But by and large mental illness, though endemic, was mostly swept under the carpet from prying eyes and ears. It was deemed ‘shameful’. The attitude still exists. Families are still unable to face this elephant in our collective social Baithakkhana despite the fact that WHO had (as far back as 2012) referred to India as the ‘Suicide Capital of S.E. Asia’.

It has taken a pandemic like COVID to uncover how much mental stress and suicidal tendencies we as a society, have harboured within. Five years ago, the 2015 issue of Indian Journal of Psychiatry had pointed out that stress and suicide rates had risen alarmingly within a decade in India. It also underscored the nascent mental stress and mental disorders rampant that drove people to take the extreme step.

What is disturbing is that according to their study most suicides (65%) occurred among the young aged 15-24

years. A clear pointer that Indian adolescents in later stage, experience more stress which is often notched up as exam and/or job anxiety.

The infamous demonetisation (Notebandi) and the COVID Lockdowns (Talabandi), seem to have added fuel to the fire. Our National Crime Record Bureau (NCRB) figures bear this out. Among the total number of formally recorded suicides in India recently, the rate among the 15-29 age group is the highest, followed closely by 30-44 year olds.

It is worrisome that even young doctors and caregivers are increasingly stressed due to study, work and personal life related pressures. The year 2020 began badly for the community. In early January, COVID began to raise its fearsome head. By the time March came, the medical community realised that they were in the frontline as fire fighters but were literally not kitted out to cope with the viral load they faced

To compound their confusion, the public began unleashing their pent up fury against visiting bands of caregivers in the Bustees and colonies began to ostracise doctors’ families. Ironically, when the need for psychiatric counseling and treatment is so acute, in a country of 137 crores we realised we have only about 10,000 trained psychiatrists.

And then we began to hear of suicides among medical personnel, nurses and doctors. In January 2020 a nursing student in Kolhapur district hung herself. Then came the sudden Lockdown in March 2020 and the isolation and fear of job losses became more and more acute. This created a major wave of acute mental stress that swelled as it fed upon news about looming job losses, retrenchments, closure of major industrial hubs and the great migration of workers from cities to villages.

Since the Unlockdown, psychiatrists have been noticing a much big- ger spurt in mental disorders generally across states across caste/class boundaries. In Bhopal for example, in the 28-day period after the lifting of the Lockdown, there were 41 suicides while Mohali had 33 such cases.

At Delhi’s AIIMS, a 25-year old psychiatrist Dr Anurag Kumar this month jumped to his death from the 10th floor of the Residents’ hostel. It was revealed he had been undergoing treatment for stress and depression. Described by friends and colleagues as a promising and sensitive psychiatrist, Dr. Anurag Kumar has left behind a suicide blog which bears reading to understand the grim dimensions of clinical depression:

On the face of it, Anurag Kumar’s suicide defies reason and is paradoxical: a gifted and friendly psychiatrist and counsellor for people troubled by demons in their mind but who was himself a deeply troubled soul, haunt-ed by suicidal thoughts and constantly exploring various options for taking his own life.

What strikes one about this blog is that this may not be a paradox but a rare insight into what happens when a highly intelligent mind meets a Savage God: a traumatic pull for depression. This is what Susan Sontag calls, “melancholy minus its charms.” The pain of severe depression you encounter in Dr Anurag Kumar’s blog has so far been quite unimaginable for most of us, who have not suffered acute depression, which can become so unbearable that it results in suicide.

The prevention of mental illnesses that are surfacing in alarming numbers all over the world and also in India after the “Unlockdowns” will continue to be stalled, until there is a general social awareness about the nature of this pain and the urgent need for proper medication and constant counseling and monitoring of the patient.

Many blessed ones do survive Depression through the healing process of time combined with loving family care, regular medical intervention and hospitalisation when needed.

But let’s not forget there still remain a tragic legion including celebrities like actors Guru Dutt, Kushal Punjabi, Kunal Singh or Sushant Singh Rajput to Dr Anurag Kumar, who are compelled by their inner

It is clearly time to destigmatise mental illness like homosexuality and let there be a more frank discussion on coping mechanisms for both victims and their near and dear ones. Like cancer patients, there must be no stigma attached to the victims of such terminal depression. We must realise clinical depression is a major silent killer like hyper tension. Also, that it afflicts millions directly and many millions more who take care of the victims as relatives or friends. Like COVID, it does not discriminate and strikes a Kaamwali Bai and a million- aire’s wife or a movie star alike.

Today through advances in bio- chemistry and genetics, modern psychiatry has immeasurably improved our understanding of mental abnormalities. So, let’s not pity Dr Anurag Kumar or see his blog simply as delusional. It contains astonishing insights from a trained psychiatrist, into disturbed minds including his own.

It is time we began a process of healing by acknowledging the extent and depth of the malady in India and the need for easily available and affordable professional help, counseling and treatment.

Doctor, heal thyself

Doctors and nurses for the first time are working away from their families. it has placed them under pressures they were never exposed to

Dr. Jitendra Nagpal

There is no doubt that the entire lot of caregivers, that includes doctors, psychiatrists, nurses and others in hospitals, are under tremendous stress. Just this morning (July 15), I had as many as three phone calls from members of this fraternity urgently seeking professional counselling and help in coping with severe personal and professional stress: the twin demons this pandemic has released. One of them was a young 30-year old doctor who has finished his Post-Graduation just two years ago.

Few people seem to realise that when they come face to face with a doc tor in his protective gear, within all those wraps there is also a sensitive and fragile human being, who is also beginning to suffer from a severe drain of his mental and physical energy. Our frontline workers in hospitals are also separated from their own families. Working among severely ill for 24x7, makes it imperative that they reconcile themselves to not seeing their families for weeks.

The medical fraternity all over the country are on call through the day to cope with emergencies which are pouring in as cases rise steadily. Among them there have been so far at least 116 COVID deaths. And an estimated number of those already infected is five times that. So, you can imagine the mental state of one whose job under such circumstances is not limited to treating the patients, but also counselling their bewildered families, parents, young wives, pregnant women and teenaged attendants.

As we try to keep up their hopes and morale, we are also duty bound to com- municate to them in clear medical terms, the possibility that some of the severely ill patients may not survive. Losing any patient affects not just the families but also the doctors.

So, I am seeing a lot of hidden stress building up within our medical fraternity. Within the fraternity the number of stressed doctors is larger among surgeons, anaesthetists and neuro physicians. But today as all hands are pressed into service, almost all doctors, nurses and other caregivers are approaching clinical psychiatrists in increasing numbers for professional advice: how to maintain their own inner equilibrium and coping mechanism in daily lives, so the stress does not impact their own mental wellbeing and affect their work.

Some of us clinical psychiatrists have created a group that is available 24x7 to our fraternity for any kind of help or guidance. Times are tough but as professionals we must soldier on. Mother Teresa had once said, “One must give till it hurts.” It is only now that I am beginning to understand what these words truly mean.