New Delhi: India may not be the depression capital of the world, but a paucity of trained psychiatrists and the social stigma dramatically increases the odds for Indians with mild symptoms to develop major depression—a severe, debilitating form of the syndrome.
Last week, an international team of mental health researchers, including those from India’s Directorate General of Health Services, published results of interviews with 89,000 people across 18 countries. Their numbers suggest that people who reported being depressed (or tested positive for two-three symptoms associated with the standard definition of depression) were highest in developed countries such as France and the US. However, those who showed five symptoms or more and tested positive for extended periods of major depression were proportionally highest in India.
India’s health ministry has rejected this, saying that the data from the country was sourced almost entirely from Puducherry and the number of people questioned was half the average sample size in other countries. However, several psychiatrists suggest India faces a very real threat from major depression syndrome.
“The main reason for such disparity is that minor depression isn’t adequately addressed in India and, therefore, the chances of progressing into full-blown major depression are much higher in the country,” said Rajesh Sagar, a psychiatrist at the All India Institute of Medical Sciences.
India has 3.5 psychiatrists per million people. But, according to health activists, given that these doctors are predominantly in the cities and that mental health treatment facilities in primary health care centres are poor, the number of mentally ill in villages is high.
“Though the situation isn’t as bad as 15 years ago, there are still a worryingly high number of mentally ill patients in villages. This is due to inadequate facilities,” said Nathan Selvaraja, who’s worked with several non-governmental organizations (NGOs) concerned with rural mental health issues.
Depression affects nearly 121 million people worldwide and is the second leading contributor to a shorter lifespan and poor health for individuals 15-44 years of age, according to the World Health Organization, which sponsored the study. Various estimates put the number of Indians who suffer from depression at around 10 million.
In general, women were twice as likely to experience depression and the strongest link to depression was separation or divorce.
In an interview to Bloomberg, Ronald Kessler, a professor of healthcare policy at Harvard Medical School and one of the study’s authors, said the higher percentage of depression reported by people in wealthier countries may reflect differences in societal expectations for a good life.
“There are a lot of people in the US who say they aren’t satisfied with their lives. US expectations know no bounds and people in other countries are just happy to have a meal on the table,” he said.
The study differentiated between clinical depression and mild depression; many of the respondents from France and the US were victims of the latter, Kessler said.
Clinical depression encompasses a range of symptoms such as a general lack of enjoyment in once pleasurable activities, a sudden loss or gain of weight, and a consistent lack of motivation.
What constitutes depression is itself open to interpretation across cultures.
“Depression is more than just feeling uncontrollably sad,” said Sagar. “In India, people usually rely on social networks such as family to get over sadness. With urbanization, nuclear families, etc., these networks are less readily available and several might genuinely not know that they are depressed.”
But several psychologists and psychiatrists say the greatest impediment to mental health treatment in India is the stigma associated with visiting a psychiatrist.
“It stems from a philosophical quandary called the mind-body problem,” said I.R.S. Reddy, a former director of the Vijayawada Institute of Mental Health and Neurosciences, Andhra Pradesh.
In an article published in the Indian Journal of Psychiatry, Reddy said because the mind was seen as separate from the body, it is considered as untreatable and irredeemable.
He said the situation in urban India was improving with better awareness but things haven’t changed much in most of rural India.
One Delhi-based psychiatrist uses magnets rather than the powerful drugs usually employed in treating depression.
Repetitive transcranial magnetic stimulation (rTMS), a recent therapy approved by the US Food and Drug Administrator, uses a powerful magnet to focus a field on specific regions of the brain. The idea is to stimulate or relax neurons that may have been damaged by physical or emotional stress and restore the brain to a normal state of equilibrium.
“It’s quite an expensive treatment,” according to Sanjay Chugh. “Each session costs Rs 5,000 and, on an average, it takes about 30-40 sessions.” He said, however, that he has treated hundreds of people and has patients using the therapy on an almost daily basis, an indication of the sizeable number of Indians who now visit psychiatrists and are willing to pay for new treatments.
While legislation exists to address the concerns of mental health in the country, some major changes are planned to improve healthcare delivery services, said Nimesh Desai, director, Institute of Human Behaviour and Allied Sciences, a Delhi-government body.
“Currently, family consent is required for mental health treatment at government healthcare facilities. We are trying to change legislation (to) allow government to intervene if there are reports of improper medical care by neighbours, NGOs, etc.”
The move comes on the back of recent instances of severely depressed people having confined themselves to their homes and at least one death due to starvation.
Desai added that with longer lifespans, India will go the way of Western countries with more cases of mild depression. “Given our population growth projections, if healthcare facilities aren’t sufficiently ramped up, there would be a double whammy of mild and major depression cases. That could seriously impact our workforce.”
The depression story
•Depression affects one in 10 Indians, and is five times more likely than schizophrenia and bipolar disorder
•Figures from the health ministry suggest that women are twice as likely to suffer from depression that men
•The average age of onset of depression in Indians is 32 years, as opposed to 26 in high-income countries
•While there are, on average, 3.5 psychiatrists per million of India’s population there’s less than one per million in rural areas
•Depression is about 1% of the total burden of disease and 2.8% of the Years lived with disability