Health

Anil Yadav, 47, Lucknow
Writer and journalist

Depression comes without warning. And before you know what's happening, you are already in its grip. I went through a cycle of severe depression after a failed relationship. I understood it was over but I didn't know how to work through the loss, move past the anger and take back my life. And I got sucked into a classic case of what's called anhedonia in psychiatry, the inability to experience joy. I had no appetite to speak of, lost weight dramatically, my memory was like a sieve, my self-esteem reached a nadir, my immunity was compromised and I started falling sick too often. I had also started drinking heavily. Friends and family members took me to several doctors but nothing worked. That's when I discovered Vipassana meditation. It was just about the most amazing experience of my life. It taught me to watch everything around, including myself, as an observer. I came away feeling I had found a new kind of happiness, deeper than the kind I'd always pursued. My depression gave me the best time to change my life for the better, inside out.

Sandhya Menon, 35, Bengaluru
Founder of Knotanki, an online enterprise selling handmade crochet products

Depression cost me one marriage and my job. It also meant three years of sleeping an hour a night, with two children, aged 1 and 4, losing the ability to drive, not knowing right from wrong, losing my memory, having zero impulse control, being belligerent to everything and having chaos in every sphere of life. There have been days when I couldn't get out of bed to eat (once four days at a stretch) or shower (once in five days). When I'm in one of those phases, I prefer being around strangers on Twitter, sending one message every four minutes. It's a huge relief and escape from a bad day. Part of my treatment is creating a routine so that my brain gets comfortable with the idea. That's when I took to crochet: it's repetitive, it's colorful and therapeutic.

No one is immune

"Money, youth, success, talent, nothing safeguards against depression's grip," says Dr Ashit Sheth, consultant psychiatrist with Bombay Hospital & Medical Research Centre, Mumbai. Every day in his chamber in Marine Drive, 15-20 people of varying age and background seek treatment. On a given day, the range is astonishing: a wealthy young man caught in family conflict, distressed and unable to function in his business ("I try to be nice to everyone. Nobody understands me"); an elderly man who tried to jump from the 11th floor, and saved by his son in the nick of time; a bright student of 10th standard, brought in for her mind-wracking fear of exams; a young MNC executive, who worked relentlessly hard, without a break, for three years, listless and fatigued now, unable to enjoy anything in life; a young divorcee, with a child, who finds it hard to drag herself out of bed and sustain any job beyond six months; a young law student, who has come back from her university in Canada, unable to bear the alienation and solitude of a new environment. "People from affluent sections of society have very low threshold," Dr Sheth says. "They haven't suffered too much and can't cope when faced with the realities of life."

Depression, like its victims, is not one entity but a spectrum. Consider this: about 10-20 per cent Indians are found to have clinical depression. Let's include the wide range of other mental disorders that enhance the risk of depression-bipolar disorder, dementia to schizophrenia-and afflicts 2-3 per cent Indians. Add to it untreated emotional distress in the community at large: up to 10 per cent. Then there are the "medically ill"-with heart disease, cancer, diabetes or arthritis-up to 50 per cent of whom go through profound grief and depression (heart disease and diabetes raise depression risk three-fold). There is also "chronic low-grade depression" or dysthymia, that according to the Diagnostic and Statistical Manual of Mental Disorders, stands for "depressed mood" that lasts through the day for at least two years. It's one of the most commonly encountered psychiatric ailments in day-to-day practice, affecting one in 20 people. Sometimes, dysthymic disorder exists along with major depression in three per cent of the population as "double depression".

I give up

There is more to the story. Every four minutes, someone commits suicide. If that's a young life, below 30, then it is the second most common way to die in India today, four times more typical than it was a decade earlier. "Out of a hundred who take their own lives, 90 would have had a mental disorder at the time of death and 75 little reason other than depression," says Dr Samir Parikh, director, Mental Health and Behavioral Sciences at Fortis Healthcare, Delhi. The burgeoning numbers point to the coming scourge. And tragic stories of people who succumb to their inner demons haunt every city.

Mumbai, the Maximum City, has one eye always cocked on the next big thing. And South Mumbai is the jewel in its crown: the richest parliamentary constituency of the country, with the highest concentration of millionaires. Exactly a year ago, 800 people gathered for a funeral in one of its tony localities, causing a major traffic gridlock. They had come to celebrate the memory of Dipti, 32. A vibrant and charismatic woman, in the grip of a mind-numbing depression she had believed she was all alone. They had loved her for her quick smile and bright eyes. And she had thought she was fat and ugly, eternally starving herself on cucumber and olive oil. They had valued her exuberance. And she had plumbed the depths of despair in her alone-time. They had never understood why someone could be miserable despite having it all. She had called it quits to escape the torment of her flawed brain-the neuro-chemical storm of malfunctioning chemicals-that subsumed her in waves of inexplicable sadness, without warning or alert.

If suicide is one way of estimating depression's spread, consumption of medicine is another. One of the biggest markets for pharmaceuticals is the antidepressant market, globally as well as in India, thanks to the explosion it has witnessed since the 1990s when Prozac came into the global market. The US accounts for three-quarters of the world's $16-billion antidepressant market. In India, antidepressant use has been rising steadily over the past decade: from a market size of Rs.136 crore in 2001, it is now worth Rs.855 crore, and growing at 12 per cent a year, according to AIOCD AWACS, a pharmaceutical market research organization.

Disease of loneliness

In a shadowy corner of the internet, anonymous young men and women are coming together since 2013 to share with each other their saddest secrets-heartbreak to crises at work-on India's first emotional networking site, SharingDard.com. The idea of launching the site came to four IIT students once they found that the phrase "I am lonely" is searched 46,000 times a day on an average in India.

Little lives of little people don't always make a splash. In January 2015, the headlines did get one's attention: "Deepika Padukone Speaks About Personal Battle With Depression". Bollywood's top actress talked about waking up one morning in 2014 "feeling different", the "strange emptiness" that stalked her, forcing her to seek psychiatric treatment: "The most common reaction is, 'How can you be depressed? You have everything going for you.' But it's not about what you have or don't have."

"It's about urban loneliness," says social psychologist Ashis Nandy. "The more cluttered our lives are with work, information, entertainment, technology and other trappings of worldly success, the less we have room for authentic intimacy, sharing of life's challenges with those who really care." Until recently, the extended family and neighbours used to act as emotional buffers, he explains. Today, our cities are more crowded, yet more people live alone in our cities. Divorce rate is rising. There are more single person households. More people have fewer children. Work or education take us further away from our families and communities. "We constantly navigate between the need to be on our own and with others," he says. Over time, relationships thin out. Driven by the 'cult of busyness' we work more, sleep less, and allow technology to become the prime architect of our intimacies, writes Sherry Turkle, MIT professor of social studies of science and technology, in her 2011 book, Alone Together: Why We Expect More From Technology And Less From Each Other. But loneliness can also act on our stress hormones, immune system, our heart, change our behavior. Loneliness is also a known factor for suicide.

Fragile youth

In room number 4090, on the fourth floor of AIIMS Teaching Block, a 22-year-old is flipping through her diary. Dr Manju Mehta, professor of psychiatry, looks on. That diary is an essential part of her treatment: Cognitive Behavior Therapy (CBT), a psychological therapy where doctors try to change the grip of rigid thinking, especially automatic negative thoughts, on depressive patients. The young woman came to Dr Mehta, listless and heartbroken, after a failed romantic relationship. There was more: intense pressure from her patients to get married. "Through CBT, we have to reduce her anxiety, strengthen her sense of worthlessness and build confidence," says Dr Mehta. "The question of drugs comes later. She may or may not need it." For now, the young woman has to maintain a diary, jot down the situations she faces every day and solutions for those. "For instance, how she has to explain to her mother that she is not ready for marriage. That she has to learn." Dr Mehta also recommends "lifestyle management", as inadequate sleep and lack of physical activity can change one's metabolic system and push one towards depression.

The vulnerability of the youth to depression and suicide makes Dr Samir Parikh worry. Since 2000, when he started practice, he has been working closely with schoolchildren. With the support of his hospital, he has been continuously surveying them, especially in schools around Delhi, to find a measure of the problem. Based on the surveys conducted in the past few years, he has found significant levels of depressive symptoms amongst the youth: from low mood to self-harm to suicide ideation. "In a survey among adolescents aged 13-19 in 2012, 45 per cent teenagers with symptoms of depression reported using alcohol or drugs to deal with their feelings," he says. When quizzed, 75 per cent teens had complained about rampant bullying in schools as a major stressor. "Research shows link between bullying and depression on teen mood and self-esteem," he adds.

Science of sad

Surprisingly, scientists know startlingly little about why depression occurs. "It's not just one brain area. Depression affects multiple areas of the brain. And that makes it hard to pin it down," explains neurobiologist Sumantra Chattarji, who runs the Centre for Brain Development and Repair at the National Centre for Biological Sciences (NCBS) in Bengaluru. Brain-imaging studies show depressed people display abnormally low activity in the prefrontal cortex, at the front of the brain, involved in judgement, planning and decision-making. The right half of prefrontal cortex, involved in establishing negative feelings, shows the greatest signs of weakness in depressed people. "The emotional hubs of the brain, especially hippocampus in mid-brain, actually shrink in volume," he points out. "It regulates emotions, moods, and memory." The three neurotransmitters that are important in mood regulation-dopamine, norepinephrine, and especially serotonin-show unusually high activity in depressed patients. "In depression, the 'talking' that takes place between molecules, neurons, nerve networks in different areas of the normal brain goes out of balance," he says.

What about the argument that depression can also be genetic? "We know that for major depression, environmental factors, say negative life events and inability to cope with that stress, are hugely important," says Chattarji. But there's also some contribution from genetic factors, it is believed. In clinical practice, doctors often come across patients where there is a distinct line of depression, suicide or bipolar disorder running through one side of the family or other. "So a genetic component does seem likely, although we haven't really been able to come up with a list of genes that are closely linked to depression," he says.

As a result, the 'silver bullet' approach to design depression drugs has failed. Beyond Valium in the 1970s and Prozac in the 1990s, the science of blockbuster drugs has been largely stagnant. But with scientific advances such as genetic testing, sequencing and editing, the complex biology underlying depression is being rapidly understood. It's not just technology. New theories are also coming up. Scientists are probing if depression is a symptom and not a disease: what if it's the result of inflammation caused by the body's immune system? Inflammation is known to zoom during depressive episodes. A new buzz has started as evidence stacks up. To some, the inflammation is caused by parasitic, bacterial or viral infection (Biology of Mood & Anxiety Disorder, November 2014) while others point to diets (rich in trans fats and sugar), obesity and stress (especially loneliness) as possible causes that can set off inflammation and switch the brain on sick mode. According to industry digest NeuroPerspective, new medicines for severe depression could reach the market within the next few years.

Happiness project

It was not any 'incident' that plunged her into depression. Nor did anyone in her family suffer from it. She was in Class XI when she realised that something was wrong with her. "Awfully wrong. I could not sleep, started avoiding people and even stopped taking care of myself. A perpetual gloom hung over me," recalls 29-year-old Aakriti Kashyap, a software engineer with an MNC in Chandigarh.

Although she used to complain constantly about her condition even as a child, her parents never took her seriously. "Like everybody else in this country, my businessman father and homemaker mother played doctor and blamed me for it," she says. "Sadly, they still think all one needs is will-power to overcome depression."

Kashyap first went to a psychiatrist at Chandigarh's Postgraduate Institute of Medical Education and Research (PGIMER) as a first-year engineering student in 2005. Things had worsened by then. Sleep evaded her; she would cry without reason. "I just could not understand what my professors said in class, although I was always a good student." Kashyap still recalls what the doctor had told her the very first day: "It's a disease. It may not be cured but it is highly treatable." Words she was waiting to hear for years.

A decade later, she is still on medication, has a "normal work and play balance", and still consults the same doctor. "He has given me a second life. I have to take medication all my life and always be ready for some days that would not be very bright, despite taking the pills." Her only regret is that she wasn't diagnosed sooner: "It would have saved me so much torture."

No. Depression cannot be cured. But it can be treated well and managed well. That is the message from doctors. But there's more hope than meets the eye: every doctor reports a new mindset among people they see, a cultural paradigm shift, that's making people come out with their problems. There is also great advance in medical technology. "New drugs, with fewer side effects, are now available. They are very effective if prescribed and monitored right," says Dr Sagar. "Earlier we used to get unmanageable patients, brought in years after their diseases had taken root," says Dr Sheth. "Now the number of hospital in-patients has come down, as has the number and frequency of electric shock treatment." CBT, although time-consuming, works wonders for depressive patients. Armed with psychological testing, profiling, psychotherapy, hypnosis to relaxation training and group therapies, relief for patients is real and tangible.

Does India care?

India does not have enough doctors: there's a shortfall of 8,500 psychiatrists, 6,750 psychologists, 22,600 psychiatric social workers and 2,100 psychiatric nurses. The nation has not even bothered to find out how many people actually suffer from mental illness in more than six decades of Independence. It's only with the WHO labelling the country as the "most depressed nation", with a 36 per cent depression rate, that alarm bells have started to sound. Calling the report mistaken, India has now started its first survey across the country.

The country did not have an officially approved mental health policy-even on paper-as recently as October 2014, when the first such policy was launched: to provide access, reduce stigma and suicides. The Mental Health Care Bill, which aims to protect the rights of patients, continues to get scuttled in Parliament. The government allocates less than a tenth of a per cent of its health budget-one of the lowest globally as a percentage of GDP-on mental health. What will it be now, with the 20 per cent cut to the health budget announced in December 2014?

It's not just India. Psychiatric disorders are rising across the world. The more cities grow, higher will be their share of the disease pie. Cities are lonely zones. They breed psychiatric maladies. With the next wave of urbanization slated to take place in India by 2050, loneliness and its collateral damage, depression, may just become the catch-all word for all urban angst in that distant future.

Source: India Today