Shrink's Views

ramblings of an unknown psychiatrist

Archive for the ‘grief’ Category

Religion,Depression and Suicide:an Observation

Posted by Dheeraj Kattula on July 26, 2009

Kandhamal district of Orissa is stunningly beautiful. In the peak of winter there is a place here where it snows. It is surrounded by mountains and is covered with thick forests. The air is pleasantly cold. The canvas of it’s beauty was marred by violence that struck its heart in August 2008.You may read about what happened here.

It is sad that I have not seen Kandhamal in its best of times. I have been there on two occasions.Once it was as a Medical Officer from Red Cross to look into health issues in Nuagam Relief Camp in November 2008. Recently I went with a team of other doctors and conducted camps in four different sites in the district.

A carpenter looks for nails everywhere. I, a novice carpenter of the mind looked for stress related mental disorders. I expected to see PTSD, Severe Depression, Anxiety disorders, Insomnias, complicated grief and suicidal ideation. What else do we expect in a group of people who have lost all their assets and have no clue what the future had in store for them?

I was wrong.I did not find even one PTSD case in about 1000 consultations that I had in the Relief Camp. Of course people were concerned about their future and were sad about the persecution they faced,but they had enormous faith in their God,who they felt allows suffering but is in control. I found that they had tent prayers everyday.

Situations have changed. The situation now is not at all as bloody as it had been. There may be tensions. There may be animosity, but the situation is now in control.The Governments are trying their best. In this state of peace, I recently went to Kandhamal again.

In this visit I  saw about 250-300 patients. I did find people with depression. I found a couple of them quite severely depressed. When we mental health workers probe about very personal thoughts and behaviors, we usually ask open ended broad questions and slowly zero-into specific areas.

In case of depression,we usually enquire if the patient feels himself to be useless & worthless, then ask if he feels lonely and helpless, then ask if he thinks that things are going to improve in future. If he says yes to these then we tell him,”when life feels so difficult many people feel it is better to die,have you ever felt like that?” If patient says yes, then we ask regarding suicidal intent,which will have a bearing on how we would manage the patient by asking ” Have you ever felt like killing yourself?”

I have seen a many people in Tamil Nadu, easily consider the thought of killing themselves when overwhelmed with stress. In a study in Vellore,the average annual suicide rate was 95 per 100 000 for the years 1994-99. The rates in adolescent males and females and those over 55 years were 148, 58 and 189 per 100 000 respectively.(The British Journal of Psychiatry (2006) 188: 86.)

In Kandhamal I had a shock.I did not find even one person consider suicide despite overwhelming adverse life events and financial distress.Individual cases were depressed clinically, but they were not feeling ‘hopeless’.Many reflected their view to be like,”Yes I feel bad.I have nothing left.I do not know what I will happen tomorrow.I wish to go back to my village to start a new life.I hope they allow me to start again.I feel sad,but I know God is there.He has helped us till now.If it were not him,I would not be here today.He will continue to take care of me and my family.Why would I kill myself and hurt God?Things will improve.We are praying.”

The pattern forced me to think if indeed religion and faith protected people from suicide and mental illness in general. Why is it that I did not find a single case of PTSD in a relief camp after a spate of bloody violence?What makes them stronger than American war veterans from Vietnam!!?

Harold G Koenig’s review in Candian Journal of Psychiatry 2009;54(5): 283–291  concludes stating that “In general, studies of subjects in different settings (such as medical, psychiatric, and the general population), from different ethnic backgrounds (such as Caucasian, African American, Hispanic, and Native American), in different age groups (young, middle-aged, and elderly), and in different locations (such as the United States and Canada, Europe, and countries in the East) find that religious involvement is related to better coping with stress and less depression, suicide, anxiety, and substance abuse.”

Considering suicidality in specific, an article in Journal of Affective Disorders reports that its results suggest that religious attendance is associated with decreased suicide attempts in the general population and in those with a mental illness independent of the effects of social supports.

Indeed, research validates my observation that religion does help in coping stress and prevent mental illness and decrease suicidality.

References:

1.In the name of God.

(http://www.tehelka.comstory_main40.asp?filename=Ne130908CoverStory.asp)

2. Manoranjitham et al.Suicide in India.

(http://bjp.rcpsych.org/cgi/content/full/188/1/86)

3.Harold G.Koenig.Research on Religion, Spirituality, and Mental Health:
A Review

(http://publications.cpa-apc.org/media.php?mid=793&xwm=true)

4.Daniel T.Rasic et al.Spirituality,religion and suicidal behaviour in a nationally representative sample.

(http://www.jad-journal.com/article/S0165-0327(08)00344-3/abstract)

Advertisements

Posted in anxiety, depression, distress, grief, mood disorders, philosophy, psychiatry, religion, spiritual, substance abuse, suicide, Uncategorized | 3 Comments »

“Normal”, “Abnormal” and “Label”

Posted by Dheeraj Kattula on June 26, 2009

Warning:

The post might have a lot of jargon,which you might not enjoy. It might be written in a fashion, which may make you feel that author and his thinking is complicated. Don’t worry. He is ‘normal’ only. If you want to stop reading the post mid-way, It might be absolutely ‘normal’. So, no problems with that too. If you call this post bad, I would say you are a ‘label-er’ but not ‘abnormal’. If you say this is written splendidly in Sanskrit, it is only then I could consider you abnormal. Assuming normalcy of some sort I invite you to read the post:

“Normal”, “Abnormal” and “Label”

There would always be debates on defining, what is ‘normal’. There are many models to define what is abnormal.

‘Statistical infrequency’ is one of the models to define what is abnormal. If some thing is rare then it is abnormal. If that be the case gifted people are abnormal as they are rare!

‘Failure to function adequately’ is another model to help not labeling gifted individuals as abnormal. But, who defines what is adequate and what is functioning? Is there a consensus?

‘Deviation from social norms’ is another such model. Social norms vary with culture, context, situation, age, gender, development and historical context (time).

Identifying parameters that are abnormal, considering the possible causes and treating them is a part of routine medical practice. In psychiatry, the parameters are more behavioral in nature.

Is “normal” a dichotomous construct (yes/no), a continuous construct (0-fully dysfunctional, 100-Mahatma Gandhi), or a dimensional construct (Einstein- professionally a genius, politically eccentric, interpersonally deficient)?

If we observe, we might find ourselves in different areas of the normal curve in different aspects. For example when I dance (as I sometimes do), people don’t see me in awe but rather laugh in amusement :-/ ( not so sadly :-)) Dancing Dheeraj

Or when I play cricket, I know the timing of my shots is awful. I might discuss the physics behind ‘reverse swing’ but would never be able to read its trajectory and time a ‘square-cut’ to the boundary. This just shows that I probably am low in Body Kinesthetic Intelligence. A not so sophisticated ‘labeler’ might call me ‘Kinesthetically Retarded’! (Ops! I labeled him a ‘labeler’ :-)) .The more specialized psychiatrists have even a diagnosis for it ‘Developmental Coordination Disorder’. “Diagnoses for all by 2025” seems to be the motto of some psychiatrists.

It is interesting that though we draw clear lines and cut across the parameters as normal and abnormal, most parameters are distributed normally. There are individuals very close to the line drawn but on different sides of it. They end up with different labels/ diagnosis and probably different treatments. Is this not quite terrifying?

Not just that, if the line is drawn somewhere close to the mean, then we have more problems. Take for example Complicated grief, Atypical PTSD (Post Traumatic Stress Disorder), High-functioning Asperger’s syndrome, Developmental Coordination Disorder etc. Besides, some conditions that are abnormal in a majority of settings become desirable in very narrow contexts. For example Anti-Social Personality Disorder in politicians and businessmen, Histrionic Personality in actresses and performers, Schizoid Personality in mathematicians and physicists and so on.

Good news is that most medical researchers consider these statistical issues before formulating guidelines and are not keen on labeling everything and everyone as abnormal. Most Clinicians go by patterns of symptoms, signs, laboratory results and diagnostics not isolated laboratory findings. Clinicians are not bothered, so thankfully not confused about statistical issues!

A good doctor picks up most of the abnormal parameters in his history taking, clinical examination and diagnostic work up, logically thinks through and explains these with the most judicious explanation, considers rarer possibilities and tries to rule them out or in and treats appropriately covering for most possible causes and always tries to relieve symptoms and is less bothered about the ‘label’ he gives to his patients.

Posted in Diagnosis, grief, medicine, personality, psychiatry, statistics | 4 Comments »