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ramblings of an unknown psychiatrist

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Archive for the ‘adjustment disorder’ Category

Lost everything & gained a new life: Turnaround in three days of Hospital Admission

Posted by Dheeraj Kattula on November 28, 2009

She was an 18 year old young lady. Orphaned at an early age, she was brought up by her maternal grandparents and uncles. Her dad deserted her to remarry a woman of his choice. A couple of years ago, she dropped out from school and joined a cotton factory. She was hard working. She had savings of about Rs 35,000/- within about 3 years of work. She was attracted to a nice co-worker of hers and desired to marry him. He too reciprocated her love.

All her maternal uncles were alcoholics. They wanted to dispose her off cheaply. They arranged her marriage with a man who was already divorced and was twice her age. She was not interested in this proposal at all. The groom asked her in private if she was interested. She agreed. She knew that her uncles were listening. One of her uncles had threatened to poison himself if she did not consent for the marriage.

The marriage was over within hours. It was time for the ‘first night’. She told her husband that she would not allow him to touch her. Both of them had arguments throughout the night. Of course she managed to protect herself.  By the way even if he had raped her, it would have been legal in India. Here marriage indicates permanent consent for sex. She created a scene the next morning telling everyone that she cannot live with him. The groom’s family was aghast. They had spent Rs 1,50,000/- on the marriage. They had borne all the expenses as it was not easy for him to get proposals because of divorcee status.

They took her to a Police Station. The relatives of the girl were there too. They gave in writing that she had given a consent. They also wrote that they will have nothing to do with her, if she walks out of the marriage. They did not want  any voice in her favor to surface. One of her uncles beat up his own father with a thick stick and bruised him in areas that cannot be seen easily. He kept the old man away from the Police station. Few other uncles thought it was good to take her to a psychiatrist, so that he can change her mind. That is how she landed in my office.

I admitted her to separate her from stressful zone. She was under pressure from all sides. Her grandfather stayed in the hospital as a caretaker. She came to know that all the money she had saved during her 3 years of work was used up by one uncle. When he took the money, he had told her that he would buy her golden jewelry. She had lost almost everything now.

Her newly married husband pursued her in the hospital. He paid her grandfather money to foot the bills. She was angry with her grandpa for accepting help from that guy. She knew that it could become a liability and restrict her freedom. Poverty and want pushed her grandpa to receive the money. He began to counsel her to change her mind. After all the groom was a benevolent man! They shared their room with a patient with Schizophrenia. The mother of the patient was a 70 year old lady who had faced much difficulties in life. She too started counseling her to reconsider her decision. She was of opinion that it is better to get married to a rich man who did not have vices (whatever be his age) than remain unmarried.

The girl was fed up with all these inputs. In the hospital she had respite from torture of her uncles. She began to think more clearly. I listened to her and gave her support. I gave her little advice to remain calm and not lose her temper when her husband came. We knew he would come. We knew if he walked away from marriage then all problems would be over. Next time when her husband visited her, she remained calm and chatted with him. She explained to him that he would not be happy with her, as she liked someone else. She told him that she respected him and felt bad about what he has gone through. He tried to convince her that they could start afresh. With time he realized that it was futile to try it if she has absolutely no feelings for him. He agreed for a divorce. I do not know if it can be called a divorce. What had happened was hardly a marriage. What ever be the semantics, she would have a new life.

She was afraid of her uncles. She could no longer live in the same village. She told her grandpa that she was willing to take care of him, if he followed her. She was a skilled worker and she could easily find a job in cotton industry. He agreed. He wanted to bid good bye to few people in his village. If he were to do it, he could inadvertently give away the plans to his sons. He decided to move to a new location soon after discharge from the hospital. He would begin a new life. His grand daughter would be his care giver.

I had enormous joy in dealing with her and her grand father. They had real life problems. They had no money. They were surrounded by crooked relatives, who could not be trusted. They were on the verge of giving up. The girl had suicidal ideation and man had no idea of what was going on. A timely admission and supportive therapy filled them with hope and helped them decide what was good for them. I learnt that at times, apart from allowing ventilation of distress, all we need to do is to offer a platform for mindful thought on choices and their consequences.


Posted in adjustment disorder, alcohol, distress, indian society, marriage, psychotherapy, suicide, women's issues | Tagged: , , , , , , | Leave a Comment »

The Cultures of Depression

Posted by Dheeraj Kattula on October 21, 2009

Here is an article written by my teacher Prof KS Jacob. It is a well articulated argument for need for a wider perspective on depressive illness.This article appeared in newspaper “The Hindu” on the 18th of October 2009.Here is the link and the article follows:-


Diverse models of depression have been proposed and debated. Much of the confusion that exists in this area is because of disputes about the nature of mental illness. The confusion is compounded by the fact that core depressive symptoms, such as sadness and feelings of hopelessness and helplessness, are also found in medical diseases, as reactions to stress and as part of normal mood.

Medical model: The medical model considers psychiatric disorders as diseases, supposes brain pathology, documents signs and symptoms and recommends treatments. The disease halo reserved for the more severe forms of depression is also conferred on people with depressive symptoms secondary to stress and poor coping skills. The focus for diagnosis of depression centres on symptom counts without assessment of context, stress and coping skills. The provision of support by health professionals mandates the need for medical models, labels and treatments to justify their input. Insurance reimbursement also necessitates the use of disease labels. Consequently, psychiatric culture now tends to view all depression and distress through the disease/medical lens.

Perceptions in primary care: Patients visit general practitioners (GPs) when they are disturbed or distressed, when they are in pain or are worried about the implication of their symptoms. Bereavement, marital discord, inability to cope at work and financial problems also lead people to seek help from their doctors. In this context, the major challenge is to distinguish between distress and depression. Depression in patients encountered by GPs is often viewed as a result of personal and social stress, lifestyle choices or a product of habitual maladaptive patterns of behaviour. Consequently, GPs often subscribe to psychological and social models of depression.

Population perspectives: Social adversity is often seen as a cause of depression by the general population. Under such circumstances, people are reluctant to consult their GPs, counseling is the preferred treatment and antidepressants are viewed with suspicion by patients as they are considered addictive. Religious models are also popular. The general population seems to simultaneously hold multiple (and often contradictory) models of illness. They seek diverse treatments from assorted centres offering healing. The protracted course of depression secondary to chronic stress, lifestyle and poor coping results in people shopping for varied solutions.

Pharmaceutical approach: The pharmaceutical industry has espoused the cause of the medical model for depression. It has aided and abetted the medicalisation of personal and social distress to its advantage. Sponsoring educational activities and professional psychiatric and user meetings and conferences have helped shape medical and patient opinions. While pharmaceutical companies play a major role in the development and testing of new treatments firmly rooted in the medical model, in actual practice theirs is a culture driven by profit rather than by science.

Competing cultures: The medical model is defended by the powerful biological psychiatry movement within the specialty of psychiatry and by the pharmaceutical industry. But the other models and cultures of depression emphasising psychological and social issues are equally valid in the contexts of primary care and the community, but lack the academic clout and financial resources to present their points of view. The different ‘cultures of depression’ and the pressures from these divergent perspectives need to be acknowledged.

The issues which need to be re-examined include: (i) the heterogeneity of the concept of depression, (ii) the (in)adequacy of a single label of depression, relying solely on symptoms counts, to describe the diverse human context of distress, (iii) the need for clinical formulations which clearly state the context, personality factors, presence or absence of acute and chronic stress and extent of coping, (iv) the fact that antidepressant medication is not the solution to mild and moderate depression and should be reserved for severe forms of the condition, (v) re-emphasising the need to manage stress and alter coping strategies, using psychological treatment for people with such presentations, (vi) de-emphasising medicalisation of personal and social distress and, (vii) focusing on other underlying causes of human misery including poverty, unmet needs and lack of rights.

Clinical presentations: The syndrome of depression includes depressed mood, loss of pleasure in almost all activities, poor concentration, fatigue, medically unexplained symptoms, insomnia, guilt and suicidal ideation. Three categories of depression can be identified from a clinical and treatment point of view. The first, called adjustment disorder, is a normal reaction to acute and severe stress in people with a past record of good coping. The magnitude of the stress would temporarily destabilise many people with good coping strategies. By definition, the condition is time-limited and people usually settle back to normal lives within a few weeks or months. There is an absence of a family history of depression or suicide. The self-limiting nature of the condition means that support is all that is usually required and results in good outcome.

The second type of depression is characterised by its chronic nature (called dysthymia). Stressors, usually mild and multiple, precipitate, exacerbate and maintain the symptoms. The onset of such depression is usually in early adult life and such people usually have a long history of depressive symptoms. Their moods fluctuate and are usually responsive to changes in the environment. They also have a history of maladjustment and poor coping in response to past stress. The mainstay of treatment is psychological interventions which focus on improved coping, changes in personality, attitude, philosophy and life style.

The third category is called melancholia. In addition to the basic syndrome of depression, symptoms of melancholia include a pervasive depressed mood with minimal response to environmental change, global insomnia, early morning awakening with low mood worse in the mornings, significant loss of weight and restlessness, agitation or slowed movements. Melancholia usually occurs later in life and there may be a family history of similar depression or suicide. Such presentations may be also part of a bipolar disorder (manic depression), which has extreme mood swings, or may be due to medical, neurological and endocrine disease. The treatment of choice is antidepressant medication, management of the underlying medical causes and hospitalisation.

Management: Clinicians and psychiatrists managing patients with depression should be able to hold multiple models of depression. They should be able to appreciate the diverse cultures of depression and choose appropriate treatment strategies. Clinically, there is a need to look beyond symptoms and explore personality, situational difficulties and coping strategies in order to comprehensively evaluate biological vulnerability, personality factors and stress. The treatment package for such presentations should include psychological support, general stress reduction strategies (for example, yoga, meditation, physical exercise, leisure, hobbies) and problem-solving techniques (for example, cognitive therapy) for subjects presenting with ‘depression’. Antidepressant medication should be reserved for the severe forms of depression with hospitalisation and electroconvulsive therapy for those with high risk of harm to themselves and to others. People can present with a mixture of clinical presentations requiring a combination of approaches. A psychosocial formulation of the clinical presentation, background and context will put issues in perspective.

The progressive medicalisation of distress has lowered thresholds for the tolerance of mild symptoms and for seeking medical attention for such complaints. Patients visit physicians when they are disturbed or distressed. Grief at loss, frustration at failure, the apathy of disillusionment, the demoralisation of long suffering and the cynical outlook of pessimism usually resolve spontaneously without specific psychiatric intervention. Distress and emotions should not be mistaken for pathology; fear and apprehension should not be labeled as anxiety, or sadness as depression.

The failure of individual models and cultures to explain all aspects of depression seen in diverse settings has led to the development and use of multiple models, which argue for the need to accept the many perceptions as partial truths. These models should be viewed as complementary rather than competitive, with some being more valid in a specific context than others. Patients present to physicians with their illnesses while doctors diagnose and manage disease concepts. The failure to bridge the gap between disease and illness and healing and cure is a major cause for the contemporary confusion in the diagnosis and management of depression. There is a need for more pragmatic approaches which move beyond the specific models of depression and narrow ‘cultural’ perspectives.

( K.S. Jacob is Professor of Psychiatry at the Christian Medical College, Vellore.)

Posted in adjustment disorder, depression, Diagnosis, mood disorders, psychiatry, psychotherapy, religion, social, suicide | Tagged: , , , , , , , | 2 Comments »