REPAIR A RUNNING CAR

I have often wondered if there is any time that a running car gets repaired? I have seen cars being serviced in record time during races, but they do stop for it to be done. But in mental health, we are expected to treat the patients while they are in action continuously.

A lot has been written about the loss of concept of 'convalescence'. But in psychiatry its worse- patients don't want to stop even when actively and severely ill. Particularly if the patient is a child or adolescent- the parents rarely allow any concessions in their packed schedule or attempt of various exams. Even celebrity sportsmen take a break when injured- but our patients- never do.

I often feel like I am continuously running to catch up with a running car and simultaneously trying to change its tires. When I do any intervention and expect result- instead patient has gone and stressed themselves out further- forget being over the initial problem- now there is a new problem to handle.

If only people would take it a bit easy and allow the body to heal- that would ensure they recover with minimum medication, minimum side effects and it will be a proper recovery. They should go back to work and life slowly and as advised.

When we talk about Juvenile crime.

https://www.hindustantimes.com/cities/mumbai-news/minority-report-why-juvenile-crime-is-on-the-rise-101664128656202.html 

Social and rule- based behavior is a legitimate part of mental health. For ages there has been the question 'Mad or Bad?'. In my work I am frequently required to deal with behaviors that reflect thoughtlessness, callousness, predatory or depravity. A good number of my patients are children and adolescents. When I read the above article- I thought it was a good piece of reporting; in terms of the observations made and impressions collected from experts. But it also carried a bias- it seems that children from certain backgrounds are upto to something and that progresses to Juvenile crime. A few of my thoughts and observations follow.

I observe that children from less disadvantaged backgrounds also show such behaviors. But they get timely help or worse- their folks make sure the matter never reaches the authorities. Parents of these children put up a fight against the world to safeguard their child's right to misbehave- later they start moving homes or schools in the belief that other kids are spoiling them or being unsupportive. The true commonality between these children and those from poorer backgrounds is deprivation- deprivation of close and balanced adult supervision, deprivation of role models, deprivation of emotional structure, deprivation of limit setting and deprivation of treatment for medical issues like hyperkinetic disorders and learning disorders.

Children of all backgrounds need sufficient time and space to explore, take risks, learn social behaviors and expend their energies (both mental and physical). There could not be a single person in the world who did not think of a painful prank, shirk some work, gain some pleasure by pulling down peers or simply be upto something to 'see what happens'. Boredom and unfettered imagination are the key features of a normal child who is capable of thinking and learning. Surroundings catering to such needs must be provided in the community. Which means unstructured space and time- but under the eye of a caring adult who steps in, though just enough for course correction. We adults have failed to provide this to children. For various reasons our children are left free to learn from their mistakes- how to progress and master them not to correct them. And we get into the picture only to indulge and misguide or punish and stonewall. A child with hyperkinetic disorder and learning issues suffers from greater boredom and inability to engage in curricular learning. But parents refuse to treat children based on their false pride and misinformation.

Juvenile offending can be reduced only if children's need for emotional support and exploration is regarded as legitimate and we make space for their needs in society. A large well- patrolled park with free access to kids, a good after school program, adolescent vocational training and robust medical treatment of developmental problems- all these are needed simultaneously. The community should think if they want landscaped garden with expensive shrubs that is 'free of troublesome' children or a large park where youngsters of all ages can grow into useful members of community.

WHAT IF I MISS A DOSE?

 

Medications for mental health are usually 'long acting'. This means that every dose of medication is able to work for several hours, usually exceeding one full day. Yet there are some things that one needs to understand before answering the common question – "What will happen if I miss one dose of the medicine".

If you observed yourself taking medication, you would have noticed that the response is not immediate. In fact, there is usually an adjustment period with some discomfort before the medication begins to work as intended. The adjustment effects are because of the body's response to the 'new' drug and somewhat unfamiliar changes in the body's chemistry. But the intended effects are delayed because firstly the medication has to achieve 'steady state levels' in the body. This means a certain level of medication has to be maintained in the body at all times. This happens after you have taken the medication for 5to7 days. After that the medication begins its work and the symptoms reduce slowly.

So if you miss a dose- the reverse effect occurs. As the steady state is already achieved, your disease symptoms remain under control. If you have any side effects of medication- you will not experience them that day and so feel better than usual. Thus the usual experience on missing a single dose is to actually feel better overall. However, some medications have an additional action to calm you down and this is a sort of 'short term' effect. For these particular medications, you will begin to feel a withdrawal effect 6 to 10 hours after the missing the dose. The withdrawal can vary from mild uneasiness to miserable degree of dizziness and nausea. The withdrawal symptoms also depend on the persons metabolism, state of mind that day and other diseases and medications. The longer term problem with occasionally missing a dose, is that the steady state level becomes reduced overall- so the medication becomes ineffective and symptoms of the disease come back in a 'relapse'.

Thus the best thing to do is to make sure you do not miss a single dose anytime. As a doctor, I find it difficult to respond to the question because you are not SUPPOSED to miss any doses. So its a scenario that I would rather prevent totally than prepare you for.

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.