Words are the physicians of the mind diseased.
— Aeschylus, Prometheus Bound
I still remember the very first patient with depression that I saw as a trainee psychiatrist in the USA. It was my first year of training and in our large public hospital in Houston, Texas, she was brought in late at night after having taken an overdose on some household medicines.
“Joanna” (not her real name) was a thirty something housewife with two children who had suffered from depression since teenage. After that first meeting in the emergency room, she came to see me weekly for over two years in our outpatient clinic and taught me some valuable lessons about taking care of people with this debilitating illness. Although I sometimes despaired of ever being able to help her, in the end, our relationship did help her a great deal, perhaps even keeping her from actually committing suicide.
Today, almost twenty five years and thousands of patients later, she is the one I remember most vividly. One reason for that is the ubiquity of the illness that first brought her into contact with me. Depression, or as we call it in technical parlance, “Major Depressive Disorder” is the commonest of all the emotional illnesses.
The World Health Organisation has estimated that up to 20 per cent of people in the world at any one time are afflicted with this illness, and it is currently the fourth leading cause of disability in the world. By 2020, it is projected to surpass cancer, diabetes and many other common medical illnesses to reach second place, just behind heart disease.
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Think about that for a second. In less than three years, depression will be the cause of more suffering and more early deaths than cancer, diabetes, tuberculosis, road traffic accidents, HIV and many other illnesses put together.
And that’s not the worst part. Worse than all is the fact that in most people’s minds, depression does not even count as an illness but rather as a ‘character flaw’, a ‘moral weakness’ or just ‘fraud’.
While accurate studies in Pakistan are lacking (about depression and most other common illnesses), in contrast to Western countries where the prevalence of depression at any one time is estimated to be around 10-15 per cent of the population, the few studies that have been done in Pakistan estimate the prevalence of depression to be in the range of 33 per cent to 60 per cent of the population. That translates to literally tens of millions of people at any one time suffering from this illness.
In addition to the personal suffering that the illness inflicts on these people, there is a huge social cost associated with the condition as well. People with depression cannot function in their day-to-day roles. Employees cannot work effectively, students cannot study, housewives cannot manage their households, and so on. The monetary cost of the illness to society has never been calculated in Pakistan but in the USA it runs into tens of billions of dollars each year.
So, what actually is ‘depression’? Perhaps it might be simpler to start with what it is not: depression is not a ‘character weakness’ and people with depression are most decidedly not ‘faking it’. It is not the result of ‘sin’ or lack of religiosity. Half of the patients that I see are devout, observant Muslims who pray five times a day and observe all the rituals prescribed by faith. It is not the result of the ‘evil eye’, malignant spirits, or ‘saaya’, black magic, etc.
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It is a medical illness caused (we think. The exact brain cause has yet to be determined) by an imbalance of the chemicals in the brain essential for normal thinking and feeling (the brain runs on a mix of chemical and electrical signals). In some cases, the cause of depression can be pretty obvious: a medical illness which can also alter brain chemistry to cause depression, such as hormonal problems, diabetes, heart disease, etc. In other cases, abuse of certain drugs or medicines can also cause it (alcohol, ‘charas’, sleeping pills, etc).
Overwhelming stress (illness or death in the family, divorce, loss of a job etc) is a common cause. Genetics also plays a role. If one or both of your parents were depressed, your risk goes up substantially. In many cases though, no obvious and immediate ‘cause’ can be found despite our best efforts.
Either way, the features of depression are similar. Overwhelming, unremitting sadness and despair, sleep and appetite problems, fatigue, memory problems, lack of interest and pleasure in daily activities, and, in severe cases, sometimes thoughts of suicide or altered perceptions (hearing voices (‘hallucinations’) or other symptoms). All of these are compounded by a lack of understanding and sympathy from family and friends as well as, sadly, the medical community.
Clinical depression has been recognised and treated as the severe medical illness that it is, in the West for decades. Unfortunately, despite daily newspaper headlines about suicides and such, the whole field of mental illness remains under-discussed in Pakistan. Part of this relates to the stigma that has been associated with mental illness since ancient times when these illnesses were attributed to supernatural forces, an idea that still persists in Pakistan and other under-developed countries today.
In addition, the shocking ignorance about common health conditions in Pakistan also extends to mental illness, and is a reflection of the low level of general awareness about health related issues.
This ignorance begins from the medical profession.
While in the West, psychiatry and mental illness are taught as essential subjects along with surgery, medicine and the like, in Pakistani medical schools (including the one where I teach), it is treated almost as an afterthought with most graduating doctors having next to no knowledge about common psychiatric illnesses. This becomes a huge burden when these graduates go on to become practising doctors. Their lack of knowledge prevents them from recognising and treating these illnesses in their patients and even more tragically in their families and loved ones.
It is not uncommon for me to get frantic late night calls and messages from former students about their spouses, siblings, parents and other relatives developing acute emotional distress about which they are clueless. In many cases, all this suffering is tragically unnecessary. Appropriate treatment (which can include both medications and psychotherapy/counselling) can allow complete recovery in most cases.
In addition to depression, Pakistan, wracked by terrorist, religious and other types of violence is seeing a spike in cases of ‘Post-Traumatic Stress Disorder’, a specific illness which occurs after a life-threatening trauma (which can be a terrorist atrocity or even domestic abuse). This illness can include anxiety attacks, sleep problems, physical symptoms as well as depression.
While we celebrate mental health awareness every year, the activities usually remain confined to hospitals and departments of psychiatry and psychology in universities and colleges. The rising toll that depression and other mental illnesses are taking on our national health requires more from us.
These illnesses and their remedies need to be discussed and debated on media, in newspapers and in colleges, universities and workplaces around the country. Only then can we begin to break down the barriers of silence and help the afflicted begin to heal. Not much is required. The most valuable lesson that my patient “Joanna” taught me is that a sympathetic ear and an open heart is sometimes all that is required to help a person emerge from the depths of despair.