WHY YOUR GENERAL PHYSICIAN HESITATES TO TELL YOU ITS A MENTAL HEALTH ISSUE?

 

For the last 16 years, I worked with a senior Doctor who is an accomplished Physician. He is a great advocate of mental health and often refers patients to me. But sometimes- even his expertise and authority does not convince the patient that, in fact, the symptoms he/ she suffers, arise from anxiety and depression rather than dysfunction of other organs like the stomach or heart.

Though people commonly think in terms of 'real' and 'psychological' or 'body' and 'brain'; reality is much different. For disease, there is no such thing as separateness. This is particularly true for disorders of the brain such as depression. Symptoms of anxiety and depression are likely to present as chest pain, palpitations, hypertension, aches and pains, indigestion, acidity, diarhoea, dizziness, skin rashes...and so on. This is because the brain is connected to every organ and cell of the body through the neuroendocrine system. Bodily symptoms of depression are not accompanied by any set patterns of disease in that body part. On the contrary they are accompanied by depression and anxiety. When actively suffering, patient is unable to understand this and gets obsessed with establishing the 'cause' and controlling the test report numbers of whatever symptom they think are important. As physicians perceive a certain resistance to hearing the truth, they tell the patient its 'stress- related' which is actually a euphemism for depression-anxiety. If patient shows any interest to explore and deal with this suggestion, they always encourage the patient to meet a mental health professional. In my experience and my discussions with my senior colleague, we noted that most of the patients are not interested in listening to the real diagnosis. Then rather than argue with the patient and make him/ her more miserable or defensive, the only recourse is to prescribe a mild sleeping dose which helps partially and hope for the best.

A number of times, I have gone to meet the patient to examine and been rudely turned away from the ward- "are we mental? Does dr think our illness is fake?". Hence the general and family physician learns that uttering the word 'Psychiatrist' causes a severe reaction that includes anger, aggression and lots of unpleasantness. Considering the high frequency of such events, the doctor learns to be tactful and agree with the patient rather than explain facts.A good number of my colleagues call me and express their total disinterest and helplessness when they continue to encounter patients with multiple bodily complaints. Being the doctor they have to be patient and considerate- but they dont feel satisfied with their work as they know this needs expertise of a mental health professional. For them it is a 'damned if you do, damned if you dont' situation.

Some doctors are unable to detect mental health problems the first time. But eventually, they do figure out. A small fraction of doctors who are motivated by financial incentives will encourage the patient to pursue the search and cure for bodily symptoms- despite knowing that its depression and anxiety. Patients are more than willing to get multiple and expensive tests and treatments. Usually persons with a hefty medical insurance or working in public sector companies (where they get leave and medical costs reimbursements) follow this pathway. But even these doctors, eventually find it difficult to sustain the indulgence of health anxiety. For us mental health professionals, such patients turn out to be very difficult cases too. After years of believing something, suddenly patients are abandoned into mental health care. It is something they dont agree with and do not want. But now there is no money to do further tests and no doctor (non psychiatrist) willing to give them time or sympathy. Its very difficult.

Instead I look forward to a scenario where patients are more accepting and open. So that their doctors can openly tell them whats wrong. Psychiatrists are full medical doctors. If they even suspect that there is a disease other than mental illness, they will refer you back to the appropriate doctor. So there is no worry of something getting missed by going to a Psychiatrist. But depression and anxiety are disorders that can impair your life and worsen other diseases due to the mind-body interactions. So best to check it out. And get it treated in the best possible way from a mental health professional. And return to normal and happy life as soon as possible.

BETWEEN A ROCK AND A HARD PLACE

"Lack of Professionals, Social Stigma: India Has Miles to Go in Establishing Mental Health Infrastructure" https://www9%2Fwww.news18.com%2Fnews%2Flifestyle%2Flack-of-professionals-social-stigma-india-has-miles-to-go-in-establishing-mental-health-infrastructure-4283723.html

The average Indian still thinks of MOdern Evidence based medicine as "Allopathy"- a harsh, mysterious, drastic, dangerous form of treatment with massive side effects and given by callous commercial doctors. They still prefer quacks, charlatans and traditional approaches which have no concept of mental health, let alone an approach to its treatment. This enhances stigma. A complete cure 'from the root' of it, without absolutely any side effects and in total harmony with your religious/ magical/ superstitious beliefs is the promise they fall for. This is the present nature of stigma. It is not about deriding the condition of mental illness, it is come to derision and suspicion of any sane conversation that is scientifically informed. 

A person who seeks help has to therefore do it in secret- for an army of 'well wishers' is waiting among relatives, friends and so-called loved ones to dissuade. From taking poison. From getting 'F*****d' up by the Psychiatrist. From drugging your child. telling you instead to use hemp oil.

Welcome to the new age stigma of 'Mental health is important' but 'beware of proper treatment'.

The other alternative; 'THerapy' is very expensive and not freely available due to shortage of trained therapists.

SO an average Indian person is now caught between a rock and a very hard place.

Of one- sided ethics

 https://timesofindia.indiatimes.com/city/mumbai/mumbai-pharma-co-allowed-cost-of-france-workshop-for-docs-as-tax-deduction/articleshow/86739550.cms

"Mumbai Pharma Co allowed cost of France workshop for docs as tax deduction"

further ITAT tribunal has commented that the ethical guideline issued by Medical Council of India forbidding financial arrangements with pharma companies applies SOLELY to doctors and not to Pharma companies.

Now the ball is in the regulatory body's court- should they pull up the doctor's for accepting this junket? Or stay silent so the epidemic swells....Also is there no such thing as 'abetment of malpractice' ? and no reasonable mandate for its prevention.

As one wise person said "In today's healthcare índustry' pharma, corporates and tech are the big fish. Doctors and patients are bit players. So it will be that doctors and patients interests will be compromised to uphold the so-called larger interest of industry and progress" Hence what is completely unethical for doctors and detrimental to patients is absolutely allowed and encouraged for Pharma companies- as in above example.

suicide reporting

"Mumbai woman feeds sleeping pills to kids, kills herself | Mumbai news - Hindustan Times" https://www.hindustantimes.com/cities/mumbai-news/mumbai-woman-feeds-sleeping-pills-to-kids-kills-self-101631024874519-amp.html

https://www.tv9marathi.com/crime/mumbai-crime/mumbai-16-year-old-girl-committed-suicide-because-clash-with-brother-over-playing-a-mobile-game-534189.html

After reading the above two articles, I am wondering if journalists or newspaper editors are aware of reporting guidelines? Or they purposely choose to ignore them?

Ideally and according to guidelines, suicides should be reported in a matter-of-fact tone without mentioning details of the process. Sensationalizing, interpreting the cause and detailed explanation of process give ideas to vulnerable persons and result in more successful attempts.

I would say journalists need education; or failing that regulation and punishment for such transgressions.

THE PHARMACY PROBLEM

For a Psychiatrist, its also a good thing if Pharmacists dispensing medications are qualified and work with integrity. I will tell you why.

Firstly I write generic or molecular names of medications instead of brand names. Medical Council has made this practice mandatory- but that’s not actually the only reason I follow the practice. I also observed that my patients come from different areas and the distribution of medication brand-wise is not something I want to remember. Plus, I also don’t want to be seen as promoting one brand over another- because frankly I have not experienced any differences other than price & packaging. However, at the other end if the pharmacist is unqualified or dumb- they plainly tell patients such medication does not exist in India. Its happened for very common drugs like clonazepam or lorazepam too. Pharmacists have an excel sheet with all medications and this usually has only brand names; they have ‘grown out’ of the habit of referring to the CIMS. I also don’t know if they have any mandatory continued education to keep up with new molecules and laws. 

Next are malicious pharmacists who make fun, taunt or plainly misguide the patient upon noticing that they are on psychotropic medications. This may be through subtle behaviors like looking wide- eyed, winking or through making brazen comments like áre you mad to take these medications. Psychiatrist only want to get you addicted to these’. Nothing can be done other than calling them up and confronting- if the matter comes to my notice. Mostly patient (who is already having an inferiority complex and feeling miserable) goes home, thinks about it and stops medication. There is no proof for such behavior and all that I can do is to find out which fellow that is and advice my patients not to go there again. Unfortunately quite a number of pharmacists seem to enjoy this perverse sport.

Another pharmacist is a thorough businessman. Initially they cooperate with the patient and the process is very smooth. Suddenly they start insisting patient order more medicines and other stuff from their shops- then only they will get medication. Some of these shops are ‘medication and general stores’. It’s a vexing problem for the patient- I don’t know what to suggest. Because usually such shops are the only ones stocking psychotropics in that area.

Most Pharmacists mind their own business and only do what they are supposed to be doing. They will just make sure your papers are in order, you have the money and get on with it. They are not concerned who you are, who your doctor is. They will go as far as booking an order and home-delivering your medication if its not immediately available. If something is not ok, they refuse to give you medication and leave you to coordinate with your doctor and whoever else required. They go by the rules and believe in just doing their job- which is to give medication in a way allowed by the Government. They are not for or against anyone- they know their job and do it well and go home. I am happy to note most pharmacists are like this. They do their part and I can concentrate on mine.

Some Pharmacists are a league apart. One pharmacist will not only give medication but also make sure patient has understood how to take the medicine. Another maintains meticulous records of how many tablets have been dispensed and once he informed me of patient’s abnormal approach in this regard and I was able to inform family and take timely action as patient was becoming symptomatic. Many pharmacist will phone me and try to understand directly if they feel any doubts from my prescription. On occasion, I have received a firm chastisement where my handwriting not clear or spelling is wrong. I like them and respect them.

Like all groups, ‘it takes all types to make the world’.

 

Deepika....well...

'Dr does Deepika also take these medications ' 'yes I suppose so' ' does she also have depression? ' 'umm I think yes' ' does she have side effects'.....at this point I had to confess that I didn't know because that was not covered in the interview I read.

Deepika Padukone is a brave young person to have spoken about mental health and illness as a personal experience. 

Among non mental health professionals it's  a myth that we routinely gossip about patients. But I never heard anything about Deepika other than what she herself had published. A matter of credit to her drs and therapists...whoever they are.

 Fact is: like many people she went through a mental health challenge and she took the proper path to resolve it. Minute particulars are not so important as the message: common challenge meets reasonable response results in desirable outcome.

Happy days

Why do students love NIMHANS so much? The people particularly the faculty teachers have a lot to do with it.

On the first day, my husband and I met Dr MKI our head of the Department and I was asked to meet Dr Pratima Murthy for further joining formalities. For some reason she was not available that day and husband and I spent the whole afternoon estimating what Pratima Murthy would be like.

I was short of wringing my hands upon having a woman teacher as my point of first contact. My experience was that medical teachers are frustrated hags or insecure around younger girls. Some were so housewifey that you would constantly expect them to just reach out and switch off the gas stove. Others only made their way by fluttering eyelids and cooking for the unit. All of them made sure to preserve patriarchy and make it harder for younger women colleagues saying ' even we went through it all. '

On Monday night after meeting Madam I was on the phone Pronto....Dr Pratima Murthy was nothing like that.

She was absolutely the teacher of my dreams...after a long time I met such a teacher.

Family, fashion, studies, relationships, hobbies, looks ...Mam was on top of everything. I am so delighted and not a bit surprised by her becoming the Director of NIMHANS. She is a person who has inspired many like me. 

It brings back memories of the happy days. 

THE SPECIAL NEEDS CHILD

 

The transition from person to parent is among the most beautiful milestones. For some folks it is surrounded by pregnancy and birth complications and the outcome is a child with special needs. The special needs of this child are in the realms of medical, therapeutic, emotional, educational and vocational. Special needs children have diagnoses of ‘high risk births’, neurological disorders, cerebral palsy, autism, sensory disorders, muscle and bone disorders, mental retardation and metabolic conditions. The first few years are spent only getting the diagnosis, prognosis and treatments streamlined. While every kind of professional expert is now available in India, the process is never easy. First- no matter what the condition parents spend years looking for a cure. The professional who is honest enough to declare the condition incurable (but treatable) is promptly dropped and parents usually hunt far and wide for anybody who is non- committal about the prognosis (let’s see what happens, we can try, start this and see) or straightway promises the moon (of course, I will cure him/ her, nothing is wrong with him/ her).

Its important that parents accept the diagnosis and get to work on helping their child as soon as possible. Parents should do a thorough search and find a professional who is known to be an expert in the field. Find two- no problem. Preferably they must be from institutions of repute. Pay attention to the process of assessment- it should be thorough, unhurried and by a team of experts in particular domains. This may take some resources of time and money- but believe me- its completely worth. Once the expert/s have given you their opinion, tell them to give a clear plan for the coming years and suggest professionals nearer to your area to implement these plans. Collect all reports, prescriptions and file them properly. Upon coming back home- coordinate with a pediatrician who has time and inclination to be a ‘çase manager’ to support you and monitor outcomes. And put your head down and get to work. Connect with other parents with similar difficulties and be alert to new trends in management- take time to discuss with your pediatrician about it. Every few years you can approach the institutional expert for a review.

Bringing up a child with special needs is definitely challenging. But a lot of the challenges are similar to bringing up someone without these needs- like it’s a 24/7 job with no holidays. It has good days and bad. You have to worry about the health, safety, happiness and long term stability of your child. The major difference is that the world is not adapted to provide the special needs- so you are going to spend lot of time doing research, being an advocate of your child, spending money, worrying if you are doing right. There are all kinds of facilities- but parents you are literally left HOLDING THE BABY and the BUCK STOPS AT YOU. Your effort makes all the difference.

So while you are at it- also remember that you need to remain alive, healthy and in a mindset to be able to complete your responsibilities ably. Pay attention to your health, maintain fitness and learn stress management.

 

 

EMOTIONAL MOMENTS IN COVID

 My regular work usually involves consulting patients who are admitted for treatment of medical or surgical problems and then need some mental health care advice. I dont get too involved with such patients as technically they are the responsibility of the treating Specialist and I am supposed to just fine- tune their treatment with my inputs. COVID-19 was completely different.

Patients were often alone. The treatment of COVID19 was being given by a team of doctors who would hand over charge of patient as duty ended- same was with the nursing and caretaking staff. Thus patients had to deal with a high degree of impersonal healthcare. At such a time, our mental health care team filled the gap for consistency and communication to minimise the feeling of loneliness and helplessness among patients. Each mental health professional was looking after designated patients and wards and in keeping with the Government guidelines, all patients were followed up twice weekly at least. Sometimes we were the people in front of whom they let off steam- complaining about hospital, government or family members. All that ventilation was allowed and diffused to ensure patient comfort and recovery. I decided to set aside my normal reserve and allow patients to be emotionally close to me.

So AB had dementia and so many other issues, but she had no difficulty recognising me in my PPE. SB and I shared the interest in classical music and spoke about the stalwarts and different 'taals'- he actually promised to take my practice as I was not getting much time to do so at home. SS was a proud granny and it was often difficult to get her to stop her long stories- difficult because they were so lovely to listen to; but I had work to do! SN wanted to go home but she needed to be in the ICU and relatives were keen to get her treated as best as possible. So it was me- telling her all sorts of stories and consoling her like a toddler. After 2 weeks, she sees me and throws her arms open for a hug. I had to hug her- she recovered so beautifully and told me to keep her 'as long as it takes'. Mr and Mrs D arrived together for admission and later lost touch because of being in different wards. Mr D was really missing and worried about the MRs. When I found  out that she was doing well and conveyed it to him, he held my hand close to his chest and eyes full of tears just chanted 'Thank you' like a 100times.

AD was not very sick but she fought against every small intervention. She spat out the oxygen mask- brother spent an entire day just standing by her and consoling her and holding the oxygen mask in place so she would not desaturate- but Madam didnt want to have anything to do with the mask- so she went down and needed invasive treatment. One   FS was so posh; he held family to ransom- would cooperate with treatment only if family gave in to his demands of special food, certain way of talking to him and all. Needless to say, this temper tantrum caused the affected treatment compliance and he had to avail of intensive care. It seemed to me- there are more ways of self harm than suicide- and all not by mentally ill people. So called 'normal' people have more mental health problems and they are resistent to interventions. These made me lose sleep.

The best moment was when we were in the consultants room watching the cctv monitors. On one screen was a middle aged lady and her two teenaged daughters. On another a young lady with a basket approaching the entrance. And suddenly both screens lit up with joy and dance from these 4 females. The entrance is placed in a way that one can see right upto the entrance of wards- that's the place relatives call patients so they can actually see them from afar. The young lady placed her basket and moved back. Then one youngster picked it up- then again a series of dance moves from both sides- this time with kisses flying to and fro. This was the most beautiful moment of relatives being thrilled with seeing each other and breaking into a dance and air kissing.