Mental Health Care

For people with milder form of depression, the following measures may help lift their low spirits:

Share your feelings. Be it a positive achievement or a set back­share it with people whom you love. In no case should you mull over negative thoughts or difficulties all by yourself. Discuss it out with your spouse, family member or a trusted friend. They can offer you support, guidance and perspective.

Spend time with other people. A sound social support group is the best tonic for the mind. Humans need to be with others, to belong, and to win approval. Spending time with others can shore up your low spirits.

Think positive. The ancient Indian philosophies as well as modern thinking assert that all our thoughts become reality. If we think negative thoughts, we are led to helplessness and hopelessness and ultimately we become victims of depression. On the other hand, if we are positive and optimistic in our approach, we protect our minds and bodies from harm, and help ourselves to live a longer, healthier and happier life.

Give time to activities of your interest. Engage in activities that have interested you in the past, particularly activities that you have enjoyed. Spend time on music, reading, watching movies, theatre, art exhibitions, picnics, visiting museums, rowing, playing cards, chess, carom or anything that you like.

Take regular exercise. Regular moderate exercise, like 30-45 minutes of brisk walk, workout or sport may lend much to lift your mood. It relieves you of stress and strain, and leaves you fresh, alert and rejuvenated.

Get adequate rest. Rest and sleep are the biggest balm for the body and the mind. Overwork, too much stress and anxiety do not help anybody.

Set realistic goals. Don’t undertake too much at one time. If you have large tasks ahead, break them into smaller ones. Set goals you can accomplish.

Help others to help yourself.Look out for any opportunity to be of help to someone less fortunate. The benefits are immense. Your good deed for the day fulfils an inner human urge. Every religion and humanitarian philosophy teaches you that, and the goodness bounces back with more of the same. Researchers have found that it tones up the mind, the immune system, and physical health.

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The train of events begins when a person feels ’stressed’. Chemical messages are carried along the fibres of the netve cells to the hypothalamus, a major supervisory centre in the brain, which immediately sets off into action rapid-fire messengers to prepare the body for the fight-or-flee response.

The first signals reach the brain stem and spinal cord, arousing the sympathetic division of the autonomic nervous system. The sympathetic division holds a sway over the internal organs of the body. It galvanizes the core of the adrenal glands to release epinephrine (adrenaline) and norepinephrine (noradrenaline). These hormones prepare the body for action. Under their effect, the heart begins to beat more rapidly, blood pressure rises, muscle tension increases, and blood flow is diverted from the internal organs and skin to the brain and muscles. Breathing speeds up, the pupils dilate, and perspiration increases. This reaction is called the fight-or-flight response because it energizes the body to either confront or flee from a threat.

The hypothalamus also releases another hormonal messenger, the corticotrophin releasing factor, which quickly goes through to the pituitary gland, and directs it to secrete the adrenocorticotropic hormone (ACTH). ACTH travels down the circulation. Reaching the abdomen, it finds its way to the adrenal glands, which sit atop both kidneys. It stimulates the outer layer, or cortex, of the adrenal glands to release the stress hormone cortisol, which speeds up the body metabolism and increases the blood sugar to fuel the fight­or-flight response.

This primitive stress mechanism, which came to the aid of our ancestors, pushes our body machine into top gear ready for action. Yet, this heightened physiological and emotional arousal serves no good purpose in most modern day stressful sitUations. We can neither fight, nor flee from a threat. Unless we learn to flow with stress, it exhausts the body and mind, leaving us vulnerable to disease.

Signals of Stress

When the body is under too much stress it sends out clear distress signals. The effect is reflected through changes in mental, physical, and emotional behaviour and is visible in several forms.

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Until a few years ago, researchers believed that depression could be of two kinds: endogenous, caused by inexplicable sense of gloom; and exogenous, caused by reverses in life. That theory is no longer accepted. The current consensus is that only those people who suffer from certain biological and psychological vulnerabilities are prone to depression. Stressful life events can act as precipitating factors only. This theory explains why some people become depressed even when things are going well with them, and why others take even the most adverse circumstance in their stride and remain unaffected by it.

Biological factors

Functional imaging studies have shown that certain chemicals in the brain which act as transmitters in the brain circuit may play an important role in regulating human mood and emotions. The most significant of these are norepinephrine and serotonin.

The norepinephrine link. There is now considerable experimental evidence that a deficiency of norepinephrine in certain brain circuits leads to depression, while its overabundance generates mania. A whole, intricate mechanism has been discovered explaining how it works. The circuits that feel either paucity or abundance of norepinephrine originate in the brain stem, primarily in a region called the pigmented locus coetuleus. These circuits extend to many areas of the brain, including the limbic system, which play a significant part in regulating emotions.

Serotonin connections. Serotonin has taken the centre stage in research on the causative factors of depression, ever since the newer antidepressants that change serotonin levels have met with good therapeutic success. The view is that a deficiency of serotonin at the serotonin-using synaptic junctions in the brain circuit can upset the mood and emotions by promoting, or permitting, a fall in norepinephrine levels. The anatomical basis to this finding has also been outlined.

There may also be other mechanisms at work. Serotonin depletion might affect many brain regions that participate in depressive symptoms-including the amygdala (an area involved in emotions), the hypothalamus (involved in appetite, libido and sleep) and cortical areas that participate in cognition and other higher processes.

The most clinching evidence to the serotonin theory comes from these medications, called the selective serotonin reuptake inhibitors SSRIs), that have revolutionized the treatment. They are highly effective and produce milder side effects than older medications.

Hormonal abnormalities. Depressed people have an imbalance of hormones, possibly fuelled by a chronic activation of the hypothalamic-pituitary-adrenal axis-the system that manages the body’s response to stress. They generally have higher than normal levels of corticotropin-releasing factor, ACTH, and cortisol, and this may affect the mood. In addition, depression has also been linked to both a deficient or overactive thyroid gland.

Role of other organic disorders. A variety of organic conditions have a link with depression. Deficiencies of vitamin B6, vitamin B12, and folic acid; degenerative neurological disorders, such as Alzheimer’s disease and Huntington’s chorea; strokes in the frontal part of the brain, and certain viral infections are some of them.

Medication as the culprit. A variety of medications, which include those given for pain relief, some antibiotics and anti-fungals, blood pressure lowering medicines, steroids, oral contraceptives, anti-ulcer drugs, and several others may also cause depression in some cases.

Genetic Factors

Both depression and bipolar disorder are known to run in families. The evidence for heredity is much stronger for bipolar illness than for unipolar depressive illness. If a parent has bipolar disorder, there is a 27 per cent chance that his or her child will have a mood disorder. The risk goes up to 50 to 75 per cent if both parents suffer from the illness.

The role of genetic factors in the genesis of depression also finds corroboration in twin-studies. Genetically identical twins, raised in the same environment, are likely to suffer from depression three times more than the non-identical twins who only have about half of the genes in common. Adoption studies also support this theory. These studies show that children of depressed parents are vulnerable to depression even when raised by adoptive parents. On the other hand, children of healthy parents fostered by. depressed adoptive parents need not suffer depression.

Psychological Factors

Stressful life events and depression. Stressful life experiences may play a significant role in the genesis of depression. According to reliable data, the loss of a parent before age 11 is the most significant event associated with the development of depression in later years. The loss of a spouse or some other loved one is also a common environmental stressor that may trigger depression. Other stressful experiences include divorce, pregnancy, the loss of a job, and even childbirth. Many women experience a postpartum depression, after delivering a baby. The transition from one stage in life to the next, such as adolescence, adulthood, middle age and old age, also puts individuals at an increased risk of depression. Women in particular are at risk in middle life, when the children leave home to make their separate existences. Likewise, retirement is another such time, especially for people who derive satisfaction, status, or esteem from their jobs. Serious physical illnesses or disabilities can also be a real burden for some and lead to depression.

Personality factors. All humans, of whatever personality pattern, can and do get depressed, but people with depressive personality traits appear to be more vulnerable. Depressive personality traits include gloominess, pessimism, introversion, self-criticism, excessive scepticism and criticism of others, deep feelings of inadequacy, and excessive brooding and worrying. In addition, people who regularly behave in dependent, hostile, and impulsive ways also appear to run a greater risk of this illness.

Psychoanalytic links. Sigmund Freud believed that depression was a psychological response to loss-either real loss, such as the death of a parent or spouse, or symbolic loss, such as the failure in achieving an important goal. Freud believed that a person’s unconscious anger over such loss leads to a weakening of the ego and the loss of energy.

Theory of ‘learned helplessness’. When animals were exposed during experimental work to repeated electric shocks from which they could not escape, they soon developed an attitude of helpless resignation and made no attempt to escape from future shocks. Basing on these experiments, psychologists have proposed that human beings, when exposed to uncontrollable and inescapable events for long, also develop a similar attitude of ‘learned helplessness’-that, one cannot control the outcome of events. This leads to apathy, pessimism and loss of motivation-the characteristic symptoms of depression.

Cognitive theory. Some people habitually tend to focus only on the negative aspects of any given situation; they interpret facts in negative ways and blame themselves for all misfortunes. This is a negative, self-defeating attitude which often takes roots in early childhood. It makes situations seem much worse than they really are and increases the risk of depression, especially in stressful situations.

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Never trust in the popular theory which claims that a person with a strong will can shake off or will away his or her depression. If it were that simple, the incidence of depression would be much lower. If you suspect that you have a depressive illness or feel that a family member or friend is similarly affected, seek help. See a mental health physician. Without proper treatment the illness usually runs a long course.

Effective treatment is possible with the help of antidepressant medications, psychotherapy, or a combination of both. Unless the illness is severe and carries the risk of self-injury, suicide, or violence to others, or the support system of the person is weak, the treatment can be done at home. Few people require hospitalization.

Medication

Antidepressant medications. Medications that can lift up the mood are the mainstay of the treatment. About 70 to 80 per cent of people with acute depression respond to them, but it generally takes at least two to three weeks before these medications become effective. They primarily work by restoring serotonin, norepinephrine, and other neurotransmitters in the brain to normal levels.

Antidepressant medications are not addictive, but they may produce unwanted side effects, which differ with each medication. They must be taken on a regular basis for several months and sometimes longer to avoid relapse. People who discontinue treatment midway or immediately after their symptoms improve usually run into depression again.

The commonly used anti­depressant medicines fall into four major classes: tricyclics, tetracyclics, monoamine oxidase inhibitors(MAG inhibitors), and selective serotonin reuptake inhibitors (SSRIs).

Tricyclics, named for their three-ring chemical structure, include imipramine, nortriptyline, doxepin, amitriptyline, trimipramine, dothiepin and clomipramine. Side effects of tricyclics may include drowsiness, palpitation, dizziness upon standing, blurred vision, constipation, dry mouth, and confusion.

Tetracyclics have a four-ring chemical structure, and include mianserin and mirtazapine. Their possible adverse effects may range from weakness, flu-like symptoms, back pain, increased appetite, weight gain, constipation and dry mouth. There may also be abnormal dreams, abnormal thinking, tremors and confusion.

MAO inhibitors which include moclobemide have largely been discarded in favour of the safer alternatives. They can lead to many of the same side effects as tricyclics, and also carry the risk of a serious interaction with tyramine, a substance found in wine, beer, some cheeses, ripe bananas and many fermented foods. This can lead to a dangerous rise in blood pressure. People who take MAG inhibitors must therefore follow a diet that excludes tyramine.

SSRIs include fluoxetine, sertraline, paroxetine, and venflaxine. These drugs generally produce fewer and milder side effects than the other types of antidepressants, although they may cause anxiety, insomnia, drowsiness, headaches and sexual dysfunction. Antidepressant medication takes time to show any benefit. Although some signs of change may be evident in as little as two weeks, full benefit may require six weeks or more. This lengthy process may be a little discouraging to the patient. It is important that the family members provide the support and encouragement during this time. The treatment should be taken for at least six months, but it may have to be continued for a longer time. Antidepressants must never be stopped abruptly; the dose has to be gradually reduced before it is discontinued.

Lithium. Lithium carbonate, a natural mineral salt, has been used in the treatment of bipolar disorder since 1949. The treatment is started after admitting the person if the person is unwell. It may also be prescribed during periods of relatively normal mood to delay or even prevent subsequent mood swings. Side effects of lithium include nausea, stomach upset, vertigo and frequent urination. Regular estimation of plasma lithium is necessary to check adverse effects such as impairment of thyroid function.

Other medications. Even though lithium still remains the standard medication for bipolar disorder, a variety of other medications including carbamazepine, valproic acid, and verapamil have also been found useful.

Psychotherapy

Psychotherapy can be an effective treatment for a mild to moderate depression. There are many kinds of psychotherapy. While some forms of psychotherapy try to help people resolve their internal, unconscious conflicts, other forms teach people skills to correct their abnormal behaviour. Studies have shown that psychotherapy scores over anti­depressants in at least two ways-it is free of physiological side effects, and leaves a lasting benefit with a lower relapse rate than if the treatment is solely dependant upon antidepressant medication. However, psychotherapy usually takes longer to produce benefits and studies have found that a combination of psychotherapy with medication works best.

Interpersonal therapy. Interpersonal therapy is a short-term psychotherapy, normally consisting of 12 to 16 weekly sessions. It has been developed to treat people with unipolar depressive illness on an out patient basis. The therapist helps a person resolve problems in relationships with others that may have caused the depression. The subsequent improvement in social relationships and support helps alleviate the depression.

Cognitive-behavioural therapy. The cognitive theory assumes that depression stems from negative, often irrational thinking about oneself and one’s future. In this type of therapy, a person learns to understand and eventually eliminate those habits of negative thinking. The goal of cognitive therapy is to alleviate depression and prevent its recurrence by developing more positive and flexible ways of thinking.

Psychoanalytically oriented therapy. The psychoanalytic therapy aims at effecting a change in the personaliry structure or character, and not just at alleviating the symptoms. This therapy focuses upon an improvement in the person’s interpersonal trust, intimacy with others, development of coping mechanisms, the capaciry to grieve, and the abiliry to experience a wide range of emotions.

Behaviour therapy. Several behaviour therapies have been developed for the depression treatment. The goal is to bring about a change in behaviour so that the patient does not relapse due to a faulry behaviour pattern.

Electro-convulsive therapy

Electro-convulsive therapy is effective in both major depression and bipolar disorder. It is found to be particularly useful in people who suffer from severe depression and are suicidal, and also in those who fail to respond to antidepressant medication and psychotherapy. In this type of therapy, a low-voltage electric current is passed through the brain for a few milliseconds to produce a controlled seizure. Usually six to ten treatments are needed, spread over a few weeks.

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Even though there is no definite cure for schizophrenia, the use of antipsychotic medicines can dramatically improve the quality of life. They can check or eliminate the disturbing symptoms, and allow the person to lead a relatively trouble-free life. With their help, a large majority of people with schizophrenia can return to active social life. They usually, however, need to take medicine for a long time if not for the rest of their lives. This is necessary to prevent a relapse.

There are many antipsychotic medicines which are effective. These include clozapine, risperidone, olanzapine, haloperidol, thioridazine, chlorpromazine, fluphenazine, and trifluoperazine.

Many people with schizophrenia stop taking medicines because they do not understand that they are ill. Some may also have a delusion that the family and the physician are conspiring against them. In that circumstance, the family has to take some difficult decisions. Either the person has to be placed in institutional care, or the family has to take the responsibility of administering the medication. Some antipsychotic medicines are also packaged in liquid form. After due consultation with the physician, they may be given mixed with foods and beverages. This is a difficult ethical issue, although the benefit it holds out for a loved one should make the decision easier.

Some families become careless about the treatment as soon as the person shows improvement. This can undo the good effect of medication and the symptoms can worsen.

However, medication can sometimes lead to unpleasant side effects. Minor side effects include dry mouth, constipation, dizziness, blurred vision and drowsiness. These can often be overcome with some little changes in lifestyle, or by substituting one medicine for another. Difficulty arises when the side effects are more serious and debilitating. These may include muscle spasms or cramps, tremors, and tardive dyskinesia, a condition marked by uncontrollable movements of the lips, mouth and tongue. Newer medications, such as risperidone, clozapine and olanzapine, produce fewer of these side effects, but the search for a better trouble-free medication is still not over.

Some people continue to experience difficulties despite taking medication and may suffer from overriding suicidal thoughts. These people require other types of treatments, including electro-convulsive therapy, to get better. They may have to be committed to institutional care, so that the risk of suicide can be nullified.

Suitable attention should be paid to individual and group psychotherapy, family counseling and vocational rehabilitation in order to maximize the benefits of the treatment and to restore the person to useful public life. Training in social and behavioural skills can help them conduct and manage themselves better.

The Role of the Family

The family of the patient has a major role in the management and the eventual outcome of the illness. Each family member must take part in active counselling. This enables them to develop a proper understanding of the illness and treatment, and they can learn to monitor the progress and create a low-stress environment for the patient.

The family must realize that it is pointless to discuss and debate the logicality of thoughts and actions with the patient. Any attempt at this is likely to complicate matters, simply because the patient lacks insight and cannot be expected to be logical. The situation may become further complicated because of the delusions and hallucinations that occupy the mind of the patient.

The first and foremost duty of the family is to ensure that the patient gets the best possible treatment. If the situation carries risk of self-harm, suitable preventive measures must be initiated. Those people with schizophrenia who express suicidal thoughts require immediate medical attention.

Many families may fail in their duty if they blame themselves and feel guilty for the illness, or simply put the blame on others for it. For this kind of illness, nobody really is at fault. The family should therefore never waste time, effort and resources discussing such trivialities. Rather, they should work cohesively and ensure that the treatment of the patient is not hampered.

The effort must also be geared towards maintaining the patient’s passion for life. The patient must be encouraged to take up the chores of daily living, and when appropriate, suitable responsibilities may be given such that he may find confidence and faith in self and feel that he still has a useful role to play. A home filled with hostility, criticisms, and emotional over-involvement can result in a relapse and affect the outcome adversely.

The family must never disparage the benefits of medication. Many people think that it can be substituted by yoga, meditation, diet, and (or) naturopathy. This belief is misguided. The long-term prospects for people with schizophrenia depend on a family that understands the illness and takes cogent decisions about its management. The illness can be conquered provided the family acts rationally and offers love and care and trust and encouragement to the patient and is ready to raise its own threshold of tolerance.

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The events that cause stress are called stressors. Stressors vary in severity and duration. For example, the responsibility of caring for a child born with birth defects may be a source of continuous major stress, whereas getting late to office may lead to mild, short­term stress. Some events, such as the death of a loved one, are stressful for everyone. Yet in other situations, people may respond differently to the same event-what is a stressor for one person may not be a worry for another. For example, a student who is unprepared for a test and knows he will get a bad grade, will be under stress, whereas his classmate who studies in advance may go out confident by of a good grade. An event or situation becomes a stressor for a person when they appraise it as threatening, and lack the coping resources.

Stressors are broadly classified into three categories: major social events, which include natural and man-made catastrophes, major events in an individual’s life, and everyday annoyances or hassles of life that all of us must live with.

Major social events

Life may suddenly come under the shadow of a serious, life­ threatening calamity or disaster. Earthquakes, fires, floods, tornadoes, hurricanes, wars, terrorist attacks, and big-scale accidents can push people to the limits of endurance. For example, there are reports that survivors of the Bhuj (Gujarat) earthquake continue to suffer nightmares and other several emotional problems years after the event. Similarly, many of the survivors of India-Pakistan trauma partition continued to show serious emotional disturbances long after they were settled.

Major life events

Any new event, even positive events such as the birth of a child, a child leaving home for a better future, your own major personal achievement brings you some stress. The list of negative stressful events may be endless-a death in the family, divorce, imprisonment, losing one’s job, a major personal illness. All these occupy the high seats of stress.

Researchers have found that experiencing a large number of major life changes in a short period of time can affect the health more adversely. Two American researchers in particular, psychiatrist Dr. Thomas Holmes and psychologist Dr. Richard Rahe, have explored the linkages, drawing on extensive clinical research. They have come up with a social readjustment rating scale and, also, a predictive risk score.

Stress of daily life

The role of small everyday annoyances in contributing to psychological stress is best illustrated by the poet Charles Bukowski­

…It’s not the large things that
send a man to the
madhouse…no, it’s the
continuing series of
small tragedies
that sends a man to the madhouse…
not the death of his love
but a shoelace that snaps
with no time left…

A number of studies uphold the significance of the ’snapped shoelace’ factor. Researchers have discovered that the relentless pressures in our daily lives pertaining to our jobs, personal relationships, and everyday living circumstances do lead to considerable stress. We live through anxieties every day. The day may begin with no water in the taps, tripped power lines, and a dead phone. Leaving the ‘comfort’ of your home well on time, you inch your way through extra long miles of slow and noisy traffic, laden with frayed nerves and road rage to reach your office. Late for work, you open your office door and find the boss pacing up and down inside the room. You stand humbled. He looks at you with a glint in his eye and gives you a dressing down. You peep at the paperweight on the desk and long to hit a bull’s eye but, instead, look down and mumble an apology. All through the day, you do not get a moment to vent your frustration. Your stomach churns, muscles stay knotted, and blood pressure rises. The day over, you return home crawling through the same cruel traffic with the idea that you would relax with your family. But you reach home to a heap of demands. The family announces it has voted to raise its budgeted monthly spending, the children wish to fly out for a holiday, and your spouse wants a diamond ring for the anniversary. You bury your head in despair.

The details may vary, but the sabre-toothed tiger that purrs when it smells stress is definitely on the prowl. You are forced to a tightrope walk what with the pulls and pressures of market economy, the virtues of simple life lost in its glamour, the plethora of moral contradictions and warped values, the turmoil in human relationships, the lack of consideration for each other, the people you thought of as friends ready to upstage you (as a bureaucrat once remarked, ‘people hold on to their chair with one hand and put their best hand forward to shake you out’), the serpentine queues all around you and noisy places breaching your inner calm-there are any number of irritants to drive you nuts. Life in the fast lane of 21st century isn’t easy! The straws on the camel’s back are one too many. Only, this time it is your own back not a camel’s. Community surveys have assessed that more the exposure to these daily agitations the higher is the risk of our falling a victim to the stress-related illnesses.

Yet, these stressful forces must stay. A sociologist friend cites the theory of eternal decay and laughs them off, but unless you are vigilant and prepared to change, the price of these stressors is too heavy to pay. The idea is to build better defences against them rather than using the outdated fight-or-flee natural response.

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Stress is a major contributor, either directly or indirectly, to a number of physical and psychological health problems. Stress-even in a short burst-can lead to disturbing physiological disorders, involving specific body organs, ranging from minor ailments like tension headaches, stiff shoulders, a bad neck, migraine, backache, and chronic pain. It can also lead to palpitations, muscle twitches, diarrhoea, constipation, worsening of pimples, eczema, rash and other skin conditions, disturbed sleep, and a host of psychological and behavioural symptoms.

However, it is the chronic stress which produces serious problems. Selye proposed a three-stage model of the stress response, which he termed the general adaptation syndrome. The three stages in this model are alarm, resistance, and exhaustion. The alarm stage is a generalized state of arousal during the body’s initial response to stress. In the resistance stage, the body adapts to the stress and continues to resist it with a high level of physiological arousal. When the stress persists for a long time, and the body is chronically overactive, resistance fails and the body moves to the exhaustion stage. In this stage, the body is vulnerable to disease.

Studies have linked chronic stress to a number of major physical illnesses: including chronic fatigue, high blood pressure, atherosclerosis, and coronary heart disease, ulcers and irritable bowel disease, skin. conditions, and some forms of cancers. It can also trigger attacks of asthma, and worsen other illnesses.

The body’s resistance fails, since the immune system is also hit. The T-lymphocyte white blood cells-the natural policemen of the body-that catch and kill the body-raiding bacteria and viruses, and the macrophages that gobble them up, go into a phase of relative inactivity increasing the body’s susceptibility to infection.

The effect is most apparent on the mental health. People who experience a high level of stress for a long time-and who cope poorly with this stress-may become irritable, socially withdrawn, and emotionally unstable. They may also have difficulty concentrating and solving problems and may take to alcoholism and drug abuse. Some people under intense and prolonged stress may be ill with extreme anxiety, and suffer from eating disorders, insomnia, or depression. They may suffer from generalized anxiety disorder, phobias, panic disorder, and obsessive-compulsive disorder-all anxiety related disorders which may be propelled by stress. Continual stress also increases the risk of accidental deaths and suicides.

Sometimes, severe acute stress such as following a cataclysmic event can also lead to an anxiety disorder called ‘post-traumatic stress disorder’ in people who survive the catastrophe. They often appear emotionally numb, and reexperience the traumatic event again and again in dreams and in disturbing memories or flashbacks during the day. Many people who saw their loved ones die in Bhuj, or lived on following the terrorist attack of 9/11 on the twin towers in New York continue to be haunted by this disorder.

Unless managed appropriately, stress is a deadly killer. The secret of managing stress lies in developing simple coping mechanisms, learning to flow with it, and conquering it with mental techniques­strategies.

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Depression can appear at anytime in anybody. The illness may begin slowly and it may deepen gradually over months or years, or may spark off all of a sudden over a few days or weeks.

Often at first the sufferer is so taken up with negative thoughts, and the feelings of sadness, hopelessness and helplessness are so overwhelming that the family feels the person has had a nervous breakdown. He or she may cry for hours together, think that life is not worth living, and may not feel pleasure in meeting with people, or engaging in work and activities that used to bring him or her happiness at one time. Thoughts of death and suicide may dominate over him or her and he or she may constantly demand company and support.

A depressed person’s body language also tells the story. A stooped posture, lack of spontaneous movements, and a downcast, averted gaze is the classic description.

The symptoms of depression may vary with age. In younger children, a depressive disorder may present with vague physical complaints, such as stomachaches and headaches, as well as changes in eating habits, irritability, social withdrawal, and isolation. Such children show a lack of enthusiasm. They do not feel happy about taking part in any activity or in attending school.

In adolescents, common symptoms include sad mood, sleep disturbances, and lack of energy. They may also experience sudden mood swings. Adults may suffer similar symptoms, including changes in appetite, sleep, and energy level, sadness, loss of self-esteem, and the lack of volition. Many people suffer from physical problems. This is also the case with elderly people. They may unconsciously believe that physical complaints are more likely to win attention and treatment, but often the attending physicians fail to diagnose the emotional problem. Often, the signs of depression are thought of as eccentricity and dismissed summarily as a part of ageing, and the family members may fail to recognize the symptoms.

The classic symptoms of depression include:

Poor self-esteem. People with depression often suffer from a persistent feeling of worthlessness, helplessness, guilt, and self-blame. They may interpret a minor failing on their part as a sign of incompetence, or interpret minor criticism as condemnation. Even a competent and decent person may feel deficient, useless, stupid, or guilty of having deceived others.

Negative thoughts. Added to the negative perception of self, depressed people also tend to take a persistent negative view of the world. This may turn them into a social recluse. They may draw away from all activity and typically become slow and monosyllabic in their response.

Lasting sadness. A feeling of overwhelming sadness may swallow up the person’s routine. He may weep silently and suffer from black despair. Nothing seems to please him and he does not enjoy the activities that used to give him profound pleasure.

Inability to take decisions. Depressed people often suffer from irritability and mood swings. They have difficulty in thinking clearly, suffer from slowness of thought, lack concentration, and find it difficult to take any decisions.

Persistent lack of energy. Depression also leads to a drop in one’s energy level. Depressed people generally experience great fatigue, lack of energy, and a feeling of being worn out or overburdened.

Bodily symptoms. A number of depressed people complain of bodily symptoms such as headaches, stomachache, weakness, and fatigue. Generally, these people end up going through a number of clinical tests without any useful result and continue to suffer because the physician cannot figure out their root problem.

Loss of appetite or overeating. Depression usually alters a person’s appetite. While some depressed people take to overeating, more often they just stop to eat or eat barely to survive. This leads to a loss of weight. Depressed people may also suffer from indigestion, constipation, or diarrhoea.

Changes in sleep habits. People with depression may oversleep. But, more commonly, they have difficulty in falling asleep and also staying asleep. A depressed person thus might go to sleep at midnight, sleep restlessly, and then wake up after two or three hours of sleep feeling tired and gloomy. This recurrent early morning awakening at 3AM or 4AM is a typical sign of depression.

Loss of interest in sex. The negative emotions also play havoc wjth the love life of the depressed people. They may lose all interest in sex and this may also affect their marriage.

Suicidal thoughts and risk. A major depression can lead to such extreme emotional distress that people may contemplate or attempt suicide. Some 15 per cent of the seriously depressed people do commit suicide, and many more attempt it.

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Schizophrenia is a devastating mental illness. It imprisons the human consciousness in cobwebs of absurdity. The person loses contact with reality, and the thinking apparatus goes haywire. With thought processes going awry, the mind becomes a prisoner of private fantasies. Emotional expressiveness gets blunted, behaviour becomes odd, actions turn bizarre, the person becomes limited in his or her ability to interact with other people and often withdraws from the outside world.

Of all the mental illnesses, schizophrenia is probably the most difficult to understand for everyone involved. The first signs of illness typically emerge in adolescence or young adulthood. Most people suffer the illness throughout their lives, thereby losing opportunities for careers and relationships. Due to a lack of public understanding about the illness, people with schizophrenia often feel isolated and stigmatized, and are reluctant or unable to talk about their illness. This secretiveness comes as a major shock to families and friends. They feel acutely distressed and confused to see the effects of the illness on their relative, who they remember as being active and lively person before being taken ill. The economic burden and social stigma associated with supporting such a person can also complicate the situation, and family members may try to deny the existence of the illness. Earlier on, this illness was sometimes described as ‘cancer of the mind’ or even ‘living death’ because the person was totally lost to the ‘normal’ world. With modern treatment and management this is no longer true of the majority.

Modern antipsychotic medications can limit its symptoms quite effectively. More than 60 per cent people with schizophrenia can return to normal and lead active fruitful lives. There are a number of people, including some rich and famous and some who have given much to the world, who have flown over the cuckoo’s nest. The famous mathematician, John K Nash, who gave the framework of the Game Theory and received the Nobel prize in 1994, is just one of the many such success stories. In societies where the family network and support is robust, the outcome is even better as the sufferer is not able to totally withdraw into his or her inner fantasy world­the real world never loses its hold on the person.

Strangely though, the name schizophrenia is a misnomer. Its origin goes back to a Greek word which means ’split mind’. However, contrary to the popular belief, a person with schizophrenia does not have split or multiple personalities. Radler, the illness is a disorder of the thinking apparatus. A person with schizophrenia has difficulty in telling the difference between real and unreal experiences, logical and illogical thoughts, and appropriate and inappropriate behaviour. It is as if the electrical circuitry of the brain has gone haywire and wrong or random cross connections result in odd fragmented thinking. These characteristics were first noted by Eugene Bleuler, a Swiss psychiatrist, who wrote a classic paper on the subject, giving the illness its modern name.

Schizophrenia is not a disease of the new age. It merits description in several of the ancient texts, some as old as 1400 BC. The founder of modern psychiatry, German psychiatrist Emil Kraepelin, who devised the first scientific system to identifY and classifY mental disorders, gave it the name of dementia praecox in 1899. Schizophrenia causes an enormous cost to society, both in terms of treatment and lost productivity. Those who suffer from the illness occupy the largest number of beds in psychiatric wards. During an acute phase of the illness they may require hospitalization because of the danger they pose to themselves. Some 40 per cent people with schizophrenia try to commit suicide and 15 per cent end their lives this way. With nobody to take care of them, many people with schizophrenia wander around, homeless. The need in their case is the treatment of the illness, rather than letting them slip away.

One in a Hundred

Schizophrenia affects between one and two per cent of people during their lifetime. The illness is found all across the world. Race and culture do not affect the numbers, and men and women are at equal risk. Whereas most men face the onset of the illness between 16 and 25 years of age, women frequently develop the symptoms between the ages of 25 and 30. There are other differences as well between the two sexes. The illness generally takes a less severe course in women than in men-they need fewer hospitalizations than men, and function better socially in the community.

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Like it or not, stress-the modern day sabre-toothed tiger­is on the loose. Ready to snarl and gnaw at you and make mincemeat of you, if you let it. You must not fight it, nor flee from the scene, but keep it on a leash without letting it get perilously dose. This may not be easy. Its progeny romps everywhere, be it the streets of your city, your office, or home, in so many shapes and forms that you may sometimes even fail to recognize their real face till they are at your neck.

Stress pundits believe that Homo sapiens were never under so much pressure before. At the dawn of human history, man did have the demands of protection from natural elements-rain, sun, darkness at night, extremes of temperature, storms, and hurricanes, he had to hunt for food and shelter, was himself hunted, but the dangers were recognizable, not lurking in the dark.

The modern jungle is far more menacing and treacherous. Panic over a deadline, fiercely competitive workplace, an insecure boss, people not keeping time and sending the entire day’s schedule into a topspin, over crowded housing facilities, long queues, jam-packed roads, honks and hackles, a reckless driver on one’s tail are the new beasts over which you have no control. They can make your muscles tense, set your heart and lungs racing, put the teeth on edge, wash you up with your sweat, and you cannot even pick a rock and hurl at them. The physiological elements that prepared our ancestors for the fight-or-flee response serve no useful purpose in these settings. The burst of adrenaline is inappropriate to today’s social stresses. It is in fact dangerous and takes a heavy toll on your physical and psychological well-being.

What is Stress?

Before we take a reality test on different elements of modern day stress, let us try and understand what stress actually means. Broadly, it is an unpleasant state of emotional and physiological arousal that we experience in situations that we perceive as dangerous or threatening to our well-being; yet, if you ask people what stress means to them each may come up with a different answer. Some people describe stress as events that cause them to feel tension, pressure, or negative emotions such as anxiety and anger. Others view stress as the response to adverse situation. However, most psychologists regard stress as a process involving a person’s interpretation and response to a threatening situation.

To be honest, none of the descriptions are wide off the mark. Yet the simplest definition is the one enunciated by the founding father of stress research, Dr. Hans Selye. Born in Austria, Selye was a medical student at the University of Prague when he got interested in what he described as a pre-disease ’stress syndrome’ and devoted more than 50 years of his life to work out and identify its secrets. According to Dr. Selye, stress is simply ‘the rate of wear and tear in the body’.

The wear and tear occurs when the flight-or-fight response gets too pervasive, becomes chronic, and allows no let-ups. It is associated with an extraordinary set of physiochemical changes, with ramifications in the brain, the nervous system, and in almost all the major organs of the body.

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