Srinagar: At 11am, in a corridor of Shri Maharaja Hari Singh (SMHS) Hospital in Srinagar, eight men and women are waiting to see the psychiatrist.
Arshad Hussain hurries into his office, holding a sheaf of medical records. He calls the first name and sits at his desk in the bare room. One by one, the patients enter and sit down on a stool at his side of the desk. The doctor works with practised efficiency, touching shoulders, faces and knees, pausing every few minutes to answer his phone. He writes out prescriptions as he calls the next name. There’s little privacy to be had; patients overlap in the room, jostling to be next in line. Each has about 3 minutes of his time.
“These are just follow-up appointments,” explains Hussain. “We are lucky it’s a hartal today; people can’t get here because of the strikes. Usually there will be about 200 people out there in the corridor.”
Stress in the valley
Hussain’s schedule was not always this hectic. He’s been working at SMHS and the nearby Government Psychiatric Diseases Hospital since the early nineties.
Since 1989, the number of patients at the psychiatric hospital has increased from 1,800 a year to at least 100,000 a year now, he says. At SMHS, the number has grown to around 50,000.
Reliable national figures on depression are not available. But while it’s clear that depression is increasing worldwide (the World Health Organization predicts that depression will be the second most common illness globally by 2020), the rapidity of the rise in Kashmir has been alarming.
Most patients Hussain has seen in the past hour suffer from serious depression or a related ailment.
A man with a black beard and delicate glasses takes his place on the stool. He leans close to the doctor, describing his symptoms in whispers. His wife stands behind him in a burqa and niqab. Hussain asks them a few questions, pausing with a grimace to silence his phone, and writes out another prescription.
“That man was suffering from premature ejaculation,” says Hussain afterwards. “I have started him on treatment but in this case they really need couple’s therapy.”
Many patients are confused, prone to showing physical symptoms for their depression or stress, describing strange aches and pains, insomnia, or a general inability to concentrate. Premature ejaculation, for example, is commonly treated with antidepressants and can be a side effect of depression or anxiety.
Though depression has many triggers, it’s clear that there’s a connection between the rapid deterioration of mental health in the valley and the turmoil that militancy and ongoing military operations have brought to its residents since the late 1980s.
“Depression is a global disorder,” says Hussain, “But this place has been a high-stress environment for 20 years, and people who are prone to depression here will get it.”
In a 2006 paper in medical journal JK Practitioner, Mushtaq Margoob, a psychiatrist practising in Kashmir, published a study he had made of 1,200 individuals from four districts of the valley. Margoob found the nature of the Kashmiri conflict—sustained, unpredictable violence over a long period—has a particularly bad effect on mental health in the region. Similar issues have been reported in war zones such as Rwanda, Bosnia and Northern Ireland.
“The exposure to traumatic events rises manifold when the fight takes the form of guerilla warfare, which extends for a long time,” said the study. Margoob found a “phenomenal increase in psychiatric morbidity, including stress-related disorders”, since the early 1990s, with 58.69% of respondents reporting some traumatic experience.
The problem doctors in Srinagar face now is not only how to cope with so many patients, but how to evolve long-term treatments that don’t rely solely on the prescription of antidepressants and tranquillizers. But alternative treatments, such as counselling or cognitive behavioural therapy, require time and manpower, and there is a tangible lack of both.
The resources of the government hospitals are improving, says Hussain. “When I joined in 2000, there were two psychiatrists in our department and not more than six in the whole of Kashmir,” he says. “There are 18-20 working (across the state) now, but manpower is the most critical factor in psychiatry.”
In November, the Central government identified the Psychiatric Diseases Hospital as a future centre of excellence under the National Institute of Mental Health, which will improve finance and recruitment in the long term. But for now, the pressure isn’t letting up.
Journalist and author Justine Hardy runs the Kashmir Lifeline and Health Centre in Srinagar, which offers free counselling, reiki and other therapies. The minimum appointment time is 40 minutes, but this means that the clinic can only see about 15 patients in a day.
“The government hospital is inundated,” Hardy says. “The thing that is most apparent is the lack of time each doctor has. Counselling or the concept of therapy just does not exist here. The government solution has often been blanket medication of sedatives and anti-psychotics, but what do you do with a whole society that is suffering from some form of PTSD (post-traumatic stress disorder)? ”
In the last five years, the demand for antidepressants has created a “mental health industry” in Kashmir, and a number of “store front” practitioners have set up shop to provide them, according to Arif Khan, a doctor who works with Hardy.
“You see their boards everywhere,” Khan says. “They aren’t psychiatrists. They are medical students or grads (graduates) who make arrangements with pharmacists.”
Hasty or inexpert diagnosis can be dangerous. Says Khan: “I’ve seen patients who have had stomach ulceration or diabetes, but because they were on so much medication for psychiatric disorders, they hadn’t realized it.”
Hussain acknowledges this problem. “In a vacuum, people have to come in,” he says. “You get quackery everywhere, but there’s a big market for health here. It still sells.”
At SMHS, Mohammad Ismael Reshi, a 27-year-old shopkeeper, is getting a repeat prescription of his antidepressants. Reshi has suffered from depression for 12 years. In that time he’s tried many treatments, from visiting holy men to counselling, but he says that only medication really helps. “I don’t want to take it,” he says, “but counselling doesn’t help and when I’m on medication, I can do my work up to a point.”
Reshi’s skin is pale, he has trouble sleeping, can’t hold down a job and hates loud noises. “It’s not a physical thing, it’s my soul that is ill,” he says. “If two men are fighting, I won’t get involved. If someone slams the door, I feel anxious. I’m always late for things and everyone tells me that I am a lazy man.”
His hands move nervously as he speaks, clasping and unclasping, feeling for things to prod or pat. “When we were young, we used to go out in the evenings for a walk, a movie, and it used to help us be normal,” Reshi says. “Now it’s like we are hens that have to go into the coop at night. Nothing is normal here.”
It’s common for people to seek help locally before going to government hospitals, says Reshi. “I think 80% of people suffer from this problem but they don’t know what it is,” he says. “So they go to some outside clinic, who will take money from them and give them the wrong drugs.”
He gestures at the line of patients waiting to see Hussain.
“Some people take ages to realize,” he says. “Eventually they all wind up here.”
Next: Levels of addiction to prescription drugs have surged in Kashmir, as has the suicide rate, prompting the police and other health clinics to set up suicide helplines.