For many years now Sarvesh (name changed) has been living in a kind of emotional seesaw that makes him swing like a pendulum between deep depression and manic excitement. He is afflicted with Bipolar Affective Disorder (BPAD) and life has not been easy for him or his family members. The latter have however accepted his condition and are supportive.

Stated in simple terms, BPAD is a psychiatric disorder that makes it very difficult for people to control their mood swings. Medication is an essential part of the treatment.

How did it begin for Sarvesh? 13 years ago, as an alcoholic, Sarvesh, joined the de-addiction centre at NIMHANS, in Bengaluru, at the behest of his sister. Shortly thereafter, he was diagnosed with BPAD. Nobody knows which came first in his case – bipolar disorder or alcoholism.

“I am not supposed to take any break from medication. It is like diabetes where you have to keep taking medication to keep the blood sugar levels under control. It is similar. Of course, the dosage is lower (now) as the moods are steadier,” he says.

Bipolar disorder hasn’t affected Sarvesh’s intellect. He is now doing his PhD in Law from Symbiosis as a full-time external research scholar. “Mental health is a state of mind – that is what I would like to say. It is all in the mind,” he says.

Sarvesh knows how important monitoring and medication is and meets his doctor once a month without fail.  

Dr S Kalyanasundram, Consultant Psychiatrist and Honorary CEO, Richmond Fellowship Society. Pic: Deepa Vaishnavi

Speaking about the common mental ailments affecting people nowadays, Dr S Kalyanasundram, a Bengaluru based Consultant Psychiatrist and Honorary CEO, Richmond Fellowship Society, who has decades of postdoctoral experience says, “Whether it is Bengaluru or anywhere else in the world, the picture is very similar. Estimates vary, but it would be fair to say that about 20% of the population suffer from common mental disorders like anxiety, depression, bipolar, etc.”

We asked Dr Kalyanasundram a few more questions to understand mental health issues that affect people commonly and how to deal with these. Here are some excerpts from the interview:

Who can recognise the first signs of mental illness in a person?

The ones who recognize the symptoms first are the patients themselves, for they are the ones who first experience the ailment. It is not a disease that is exhibited by fever, cough, cold…it is something experiential. Something that you go through in the emotional / psychological sphere. Whether he or she recognizes it as a problem is another matter.

The other person who sees what is going on is an immediate family member or friend or somebody in the immediate circle. These are the people who notice this. The tragedy is that most of them do not think it is a disease – something that needs attention, and treatment. People dismiss it as if it is of no consequence.

And if anything, what is usually available is wrong advice. “Oh, you can ignore it”, “You can pull your socks up”, “You can handle it.”, “Do you think I have no problems in my life? “If I can do it, so can you” …

This kind of free advice is often offered and it makes the person undergoing a problem feel worse because he or she believes that “Maybe I am not doing enough to overcome it.”

When they go through this, they do not know what to do. They do not know whom to take help from. They do not know where to go.

(Mind you) experiencing is not identifying! The patient experiences something is wrong but she may not identify it as an illness. Because of the behavioural pattern, the family members may notice the change, but they are (mostly) clueless. They do not know who to go to or where to go either. In such cases, the illness continues and becomes a little more chronic.

Sometimes families even visit faith healers or seek alternative medication or alternative therapies. If at all they recognize the need to see a doctor, they end up perhaps with a general physician or a general practitioner. Unfortunately, in our country the training that is offered to undergraduate students or even practitioners regarding recognition and management of common mental disorders is mostly inadequate. We spend so much time in UG courses teaching them about various physical ailments, very little time is spent on mental health issues. Some of them recognize and offer help, but many do not!

So how are these patients treated then?

Sometimes, by sheer luck, a good referral happens. And that is when they see a specialist – a psychiatrist.

Most of these illnesses can be managed by simple medication. Unless they are in the very early stage or in a mild form, psychological methods of management also come into play – both for anxiety and for depression. Even in moderate to severe depression, medication alone is not the answer. These illnesses are biologically determined, it is a brain disease as we understand it today, and medication is the mainstay of management. In addition, counselling, psychotherapy, cognitive behavioural therapy – many types of therapies, can be offered depending upon the condition and the need.

For example, we know there are some triggers – triggers that seem trivial to many may indeed be very significant for someone suffering from one of these disorders. So, if you do not know how to identify, recognize and handle the triggers and you treat the illness alone and the triggers are not addressed – the triggers will keep surfacing and result in relapses. If you (those suffering from one of these disorders) have not learnt enough coping skills, another breakdown is just around the corner!

Therefore, there should be adequate management with medications called antidepressants for depression, and therapy to either support your recovery or identify triggers or teach you coping mechanisms. The ideal approach would be to go to a qualified trained psychiatrist, get a clinical diagnosis, and get the right treatment to recover from the problem.

Are there any tests to diagnose mental health issues?

Most of the psychiatric illnesses are diagnosed only by talking, understanding the problem and evaluating the symptoms of the patient. Various questions are asked to make a diagnosis. Questions could be related to sleep, appetite, mood, sex drive, trigger issues, what is it that makes one unhappy, etc. There are questionnaires that can be used also, though in most cases, they are not necessary. These tests are not like a blood test or doing a scan.

What does treatment involve?

Antidepressant medication, often coupled with therapy and counselling. Wherever necessary, significant family members must also be involved in the therapy. We also assess to see which of the family members provide strength and support to the patient and which ones may contribute and add to the stress. Most importantly, we use this opportunity to educate the family about the illness and the methods to prevent relapses.  

What have you observed about families accepting such patients?

Well, there are families, and there are families. Each one is different in its knowledge and acceptance. There are some who are willing to come, listen and discuss and clarify their doubts. They listen carefully to the information we provide. They are willing to accept and get benefitted.

Some of them are in denial. “It is not possible!”, “Nobody in my family has depression.” And some of them come with a kind of underlying guilt — “maybe the doctor is calling me to point a finger at me; that I am responsible for this person’s illness” — and they become very defensive.

We are not here to sit in judgement. We are here to find out what the problem is and how it can be remedied. So, if you provide sufficient time and break down the defences, almost all families are willing to sit and listen. After all, we must work jointly. You (the patient) and we (the doctors) and the family must work jointly. There is only one goal – your (patient’s) recovery. That is the only goal.

There are many fears around the use of antidepressants; can these be stopped at any point of time?

Yes, it can be stopped in most instances, provided the person has recovered sufficiently well. However, it can only be done after detailed discussion with the treating psychiatrist. Many factors will need to be considered before deciding this.

We used to believe that antidepressants could be given for one year and then gradually withdrawn, but those concepts have become outdated. We now know that depression can be long lasting; it can persist for a long time. And we know by experience that if we discontinue depression treatment, relapse can happen.

Every time a relapse happens it is more difficult to get the person back on track. So, the longer we maintain them on a very small maintenance dose, the better and it’s good for their mental health.

What about the impact on physical health?

Depression makes you vulnerable to other physical diseases too, because your immune system is susceptible.

Research has shown that a part of the brain called hippocampus literally shrinks during depression. The hippocampus is an area of the brain responsible for memory and emotion and it physically shrinks in size in people with recurrent and poorly treated depression. These findings highlighted the importance of treating depression early, particularly in teenagers and young adults.

It is better to be safe than sorry. For example, can we stop treatment for low thyroid activity? We always keep you on a maintenance dose. Does it do any harm taking for a long time? No. Is it addictive? No.

People ask me, ‘When I discontinue medication, I get depression back again. So is it not addictive?’ I say, ‘If you take treatment for diabetes and stop medication, you get your diabetes back. Is diabetes medication addictive then? It is not.’

So you would not recommend people stopping depression medication?

Without the doctor’s advice, never!

Are people suffering from depression or anxiety prone to harming themselves?

At times, yes. One of the risk factors of depression is suicidal ideas, suicidal thoughts, suicidal planning and suicidal attempts. Unfortunately, some of them even succeed.

If you don’t treat depression, depression can get worse. They can get so hopeless, helpless, that they find there is no way out. They sometimes think, ‘If I am not there, it is a relief for me and for everyone else.’ It can go to that depth. That is more reason why depression should not be taken lightly and should be treated fully and effectively.  

Is there a difference between counselling and therapy? There are a lot of organizations in our cities today that offer counselling and / or therapy…

Counselling and Psychotherapy are often considered to be interchangeable therapies that overlap in many ways. The key difference between these two courses of therapeutic communication treatment lies in the recommended time required to see benefits.

Counselling usually refers to a brief treatment that centres around behaviour patterns. Psychotherapy focuses on working with clients for a longer-term and draws from insight into emotional problems and difficulties.

Therapy is very specific. For a person to be a therapist, she needs to be qualified as a therapist, (and must have) undergone training / supervision from a qualified senior therapist. There are people who do M Sc (Counselling) course, for example. It is a theoretical course. They don’t have sufficient clinical exposure; if at all, very minimal exposure to counselling techniques.

(Treatment through) Counselling is a serious matter. You can’t be a doctor if you have not trained for five and a half years. Similarly, for a person to be a therapist, he / she must be trained under a senior qualified therapist, under supervision, for lengths of time – to be taking cases, then working, then going to the supervisor, being monitored over a period. This happens only in well recognised teaching centres.

I am one of those who strongly believes a good counsellor / therapist must have strong

clinical grounding. Because, if you do not have clinical training, and you are just, say an M Sc (Counselling), you have no exposure to diagnosing and distinguishing between anxiety, depression, schizophrenia or OCD and other common mental ailments. You are perhaps familiar with the names, but you have not seen the patients or handled those patients in a clinical situation and have not been taught to make those diagnoses.

So, how can counsellors help?

If you make a diagnosis of clinical depression in a patient, the first thing you should do is refer the person to a psychiatrist. If you don’t do that, if you think you can do therapy, it will have no impact.

It is a very touchy area. We, as professionals, are very concerned about those who have had only theoretical knowledge, and have not had any qualified supervised training in therapy, to be called therapists.  

‘You should not cry.’, ‘you should not do this, you should not do that’… – this is what is called lay counselling with no proper training. That, your neighbour can tell you, or your aunt will tell you. It makes no difference.

People would rather go to a counsellor because it seems far less threatening to them than seeing a psychiatrist. They don’t know any better and they get into these kinds of situations; and they don’t get better and then they get stuck. When you have cancer, you go to a cancer specialist and not a general doctor. If you have a heart condition you will see a cardiologist. you will not go and see a GP. Just as there are specialists for each area, so in Mental Health too.

In addition, certain yogasana and meditation practices also help people suffering from depression and anxiety. However, once again, it must be borne in mind that it should be practiced only under supervision from a qualified Yoga Therapist. Also one must make sure the medication is not discontinued and always keep in mind that yoga practices are not substitutes for medication.

Can people with mental illness harm others too?

This is the kind of myth that goes around a lot. Most people with mental illness do NOT harm others on their own; unless you go and tease them or provoke them or they are defending themselves.  

On the contrary, people with mental illness, very rarely attack someone on their own. (In the isolated cases where they do so,) They probably suffer from other severe psychiatric illness — like severe paranoia.

You will hear about campus shootings, for example. This person thinks, ‘There is a conspiracy against me by the Faculty in the department… they have sent a message about me… they are all going to come and attack me when I step out of the building. Before they attack, I want to hit them.’ This is an example of severe paranoid disease / paranoid schizophrenia.

Something like this does not happen overnight. It evolves over a period. We ignore it. We allow it to ferment. Then it assumes extreme proportion. It can.There have been cases that have been ignored which have resulted in such episodes.

Do children too get depression?

I don’t deal with depression in children. But I know childhood depression is a reality. They

express themselves in different ways. It can come in the form of a refusal to go to school, conduct disorder, or in any form of disturbed behaviour. Only a specialist who is specialised in child psychological problems will be able to identify, treat and manage. There are doctors in Bangalore, for example, who treat children with such problems.

Where can we get a database of psychiatrists and therapists?

Indian Psychiatric Society, All India and State Medical Associations (all branches)…

So, we have the mental health patients, the caregivers, the medical faculty (psychiatric doctors, psychotherapists and psychiatric nurses), and the others who do not have any mental health ailments but are decision makers. Any message for each of these categories?

All those involved in caring must work in tandem. At the end of the day, we want the person to recover, and get back to his/her school, college or work situation. Those in decision-making positions should be willing to accept them, (just) as they would for any other illness.

They must provide the kind of support the person needs because, any time the person gets back to working (or to his normal life), he does not want to be treated as an odd person. If industry does not understand this, or if the co-workers are not willing to keep an open mind, they are destroying the youth of the organization. Most industries do not pay sufficient attention to this. It’s indeed sad!

To me, the health of an organization does not depend on how healthy you are physically. A healthy organization is all about how willing it is to take care of those who have health issues, including mental health.

Some (IT) companies have counsellors…

Some of them are qualified people. I am not questioning that. But, the critical thing is that they should be able to identify clinical issues that require medication also. One cannot bypass that.

Regarding companies that have annual health check-ups…

Thank you very much for bringing it up. Have you ever seen an annual health check-up that includes mental health check-up? This is something I feel very strongly about. You go from neck to toe. Yes, your eyes, nose, mouth… But the most critical part of your body is your brain! Do you pay any attention at all?

A simple questionnaire for anxiety, stress, depression – if that is administered, if that (a mental health issue) is picked up, it can be identified and treated early. Your productivity improves too.

One of the largest reasons for absenteeism in organisations is depression / anxiety. The annual health check-up (in its current form) is inadequate. We tend to ignore mental health issues.