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ramblings of an unknown psychiatrist

Archive for the ‘suicide’ 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.

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

“Why don’t you just leave your husband?”

Posted by Dheeraj Kattula on November 6, 2009

“Why don’t you just leave your husband?” Yes, this is what I said a couple of days to a patient of mine. How could I suggest such a thing? Leaving a marriage is not consistent with my worldview. Suggesting things is not consistent with psychological therapeutic practices. Then how on earth was I moved to do such a thing.

She had come into the hospital having eaten a crushed Oleander seed, a common method to kill oneself in this part of the world. She was 32 years old. She is married for 18 years, with an alcoholic man.  He beat the hell out of her everyday. He sold all the articles of the house to feed his habit of drinking. She had no ornaments of any kind, not even plastic stuff. He sold everything except the clothing upon her.Her husband never visited her, even when she was admitted into the Hospital. She worked hard as a daily wage laborer to feed her husband, son and herself. What she gets in return is slaps, punches and kicks.

She has tried her best to get justice. She thought the village elders would counsel him and stop the mindless violence at home. The elders of the village were men who enjoyed alcohol. Domestic violence is not an issue for them. In fact they supported him as he occasionally bought drinks for them. She had gone to her parents’ house to get some support. Her husband came to their house and dragged her out and took her back to his village. It was his right, after all she was ‘his’ wife. Her parents had complained to the local police station. The police told them that it was not their business to interfere in domestic problems of their house-hold. Her 16 year old son had already started drinking alcohol and was joining his father in violating her.

The woman I am talking about was not just another dumb illiterate woman. She was quite functional. She had saved a couple of women, who had attempted suicide by consuming Oleander seeds by taking them to the hospital. She knew Oleander seeds were deadly. She had high intention of her death. She survived by God’s grace.

Why is it that she was pushed to this extreme? She had tough life and had no hope. The system was against her. What else could she do? Escape! Where? From life…this is what she thought. I too think she should escape…not from life but from husband. I wish we had good police and legal aid for such women. The NGO’s are faaaar away from her.

She had never considered running away from the rogue husband of hers. She could easily work as a maid servant in a caring household and live comfortably. She did not know that it is possible. May be I was paternalistic in suggesting it. Whatever…it gave her hope. She decided to search for work somewhere. She is now living with her parents. Her husband is not bothered about her now as he feels she is weak and useless, especially as she had a recent hospital admission. She hopes to have a better life. At least she does not want to die now.

I wonder how contexts can change the way we view what is good. Socially, leaving a marriage is justifiable on basis of sexual infidelity. If a person has right to sexual purity of the partner, don’t they have for maintaining their own physical and mental integrity from the partner? If it is acceptable to leave a spouse if there is a trespass in sexual norms, why not it be acceptable to leave a spouse who violates physically and mentally?

I do not know the answers. You can help…just comment.I am busy thesedays, but could not help writing this.

Posted in distress, ethics, gender, indian society, marriage, social, suicide | Tagged: , , , , | 8 Comments »

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:-

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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 »

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)

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

” I could not tell him that he is HIV positive for two weeks ! “

Posted by Dheeraj Kattula on May 3, 2009

He was young and suave.  Like many educated metro-Indians, he spoke English more fluently than his mother tongue. I could see bandages around his wrists, which he tried to cover with a full sleeves shirt. His grandpa arranged his appointment a day before. He wanted to share things regarding the grandson in private. He did not want to reveal ‘personal’ things in front of the grandson to avoid embarrassment for everyone.redribbon

Basically his grandson had become a ‘drug addict’ and was using intravenous drugs. He was not seen in his college or the neighbourhood for a couple of days, when someone intimated the grandpa. His grandpa rushed to his college immediately on a taxi. The patient was found lying unconscious in his room. He was ALIVE! He was taken to a nearby hospital and was treated for sepsis with intravenous antibiotics. He had developed a major infection. All the points from which he had shot drugs were swollen and were oozing pus.

The patient’s only concern was to find out if he had to continue antibiotics or not. We could connect well. He was young , English speaking gentleman, who felt no one is interested in him and I was a person interested in all aspects of his life if not personally at least professionally :-).  I asked him to do a couple of blood tests. He readily agreed. I asked the lab technician to also do the HIV test. I had reasons to suspect a immuno-compromised state in him and also had the responsibility to protect our staff involved in his care.

I did not do the pre-test counseling or tell him about which tests were done. Reason- I did not want to rake up a emotionally disturbing issue in the beginning of a therapeutic relationship. I thought once I develop rapport and stabilized him, I would bring the topic, re-do the test and then declare the result to him.

Following this, I had a couple of sessions with him. His childhood experiences, his brought up under his mother after a painful divorce from the father, his troubled school life, his grief when his mother was diagnosed of cancer, bereavement  when she died, his lost love during college years, his one night stands and his encounters with the ‘drugs’. He was a talented man. He had a scrap-book full of songs he had written during intoxicated states. They resembled the songs written by rock stars. They lyrics were full of emotion, even if devoid of rhyme and reason 🙂

I had few sessions with his grand father too. He was an old man of about 75 years. His wife had died when he was relatively young. He brought up three children. The eldest was a nurse, mother of the patient. She had a troubled marriage with an alcoholic man. She found peace in divorce. She brought up her son all alone and sent him to a metro city for his graduate level education. She was diagnosed of cancer and subsequently died.  The old man had a paraplegic son who was dependent on him. The third child was a responsible one, who was single and worked in another part of the country. Grandpa had a comfortable pension, which was in addition to the pension the patient received. Their family income exceeded the salary of a consultant doctor of the hospital!

He came on a regular basis for two weeks. In the third week, I mustered courage to tell what had to be inevitably told.

I asked him,” What do you know about HIV?”

‘A bad disease.’

“How do you think it spreads?”

‘When a person is not careful during…’

“Ok” ,I added “also a child can get it from a HIV +ve mother during birth and people who share needles when they take drugs”. I could see anxiety in his eyes.

“Is there a possibility that you could get HIV?”

‘No, I cant get it.’

“I am saying if there is a slight possibility, as you have said already that…”

‘Yes, possible.’

“Would you like us to test you for it? The result would be between you and us. That is all”

‘Ok. Where can I do it?’

” Here itself. You can give a blood sample  now. We will tell you the result tomorrow. That should be Ok. Can you tell me what would you do, if you were positive?”

with a smile,  he said”Just live till I die.”

“I have some good news for you. Nowadays with newer medicines life expectancy in nearly equal to not having the disease if the person who is HIV +ve takes regular medicines. If you are +ve would you take these medicines?”

‘Sure, sir. Where will I get them?’

“Let us first do the test.Ok?”

Test was done. I already knew the report.

“What do you think is the result?”

long pause.

I nodded my head slowly. He understood. He did not mind me sharing this with grandpa.

” What should we do now?” they asked.

I told them all the details I had gathered from CMC, Vellore’s Department of Medicine ( and Infectious Disease ). They planned to go to the nearest centre for T4 cell counts within a week. I never saw them since then. Our staff told me that they had come, when I was on vacation. It seems he was looking much better nourished. Thank God, he is still alive…

I still wonder, why is it that I did not ‘break bad news’ for two weeks!!! It looks so simple now 🙂 Was it my own anxiety that he being unstable, might do something drastic like commit suicide or less lethal step of relapsing into drug use? Was it my psychological voyeurism to understand a ‘case’ with multiple problems from many dimensions?  Was it my fear to loose a psychotherapy client due to distress caused by a medical diagnosis? Was it me buying time to get the best information possible for his further management?

I do not know and might never know my own fears and motivations… I went by ‘gut’ and probably, was right. I feel timing was right in breaking bad news in this case. The reason is that the manner in which it happened and it’s outcome was smooth, predictable and under control.

Why did they then stop following up??? !!! I do not know, and I have no guesses. I hope that he is following up in the center which gives them Anti- Retro-viral Drugs and that they a managing his psychological and substance abuse related problems.

What do you think?

Posted in challenge, distress, drug therapy, emotion, ethics, psychotherapy, substance abuse, suicide | 2 Comments »

psychotherapy beyond boundaries

Posted by Dheeraj Kattula on April 28, 2009

He was allotted to me as I could speak Bengali. He was slow in his movements and in speech. He used words which I did not understand and spoke with a accent difficult for me to comprehend. I had many cases to see that day and I had reasons to feel irritated. I listened to him. He was depressed. He had seen psychiatrists in Europe, Bangladesh and in India. He had received many drugs from many people. He had lost hope in everything.

He should be admitted as an in-patient with the level of hopelessness and suicidal ideation. One cannot be admitted into the Mental Health Center, Vellore without a accompanying relative. So, If I wanted to help him I would have to treat him on an OP basis. I had many OP psychotherapy appointments and I had my hands full with full quota of IP patients too. I gave him a time slot for an afternoon session with him. That day I saw him sitting in front of my room right in the morning. He greeted me humbly, understanding my busyness, not expecting to be seen immediately.

I liked this guy’s commitment to therapy. I decided to give my my best. His visa was for 30 days and few days are already gone. I had to hurry. I squeezed in some time even during my duty days to see him on a regular basis. I remember I had a session with him between 9.00 and 10.00 pm! I struggled to communicate with him. He understood that I was struggling. He tried to be helpful ! I started him on a rapid modified Cognitive Behavioral Therapy (CBT). I failed miserably to even communicate what an automatic negative thought was. So I focused on behavioral issues.

His diagnosis was Dysthymia with Depression. We had also started him on an antidepressant called Imipramine. As he and I struggled together, I remember on one occasion I shouted so much at him that it was audible outside my consultation room. This was because he was nodding in that session as if he was understanding so as to not displease me! But to me the time was FULLY wasted, a reason to feel displeasure.

My therapy was primarily supportive, as my glorious plan of CBT failed. There were many issues he discussed with me. His anger over his brother, who had cheated him of all his savings for 5 years, his sexual problem after being married thinking marriage would lift him out of depression, his poor supports in Europe, treatment failures everywhere and many other things.

I was listening patiently. In a sense, buying time for the time tested Imipramine to work. He was on a pretty good dose of 175 mg.The time for his going was nearing. I took an opportunity to ask if it was possible for him to forgive his brother unilaterally. He said it was impossible. I prayed with him once. I gave him a exercise for my last session. He had to make a ‘mixture’ using puffed rice, onions, tomatoes, some sweets and boondi.

I will never forget the last meeting. He came in unexpected on a day I had to leave to another campus to see patients. Every minute with him would crunch my lunch time. The expression on his face made me skip lunch. I ate the ‘mixture’ he had bought. Told him that it was very good. I took him to my supervisor and told of his improvements. I wrote letters to the psychiatrists, who might have to follow him up. I gave my personal email ID and mobile number. This is usually not done in our set up. I did it as I felt he might not be able to send a email himself but if he ever required help I could offer it over telephone.

A year later I received a phone call from him. I was having my final PG exams. I could not give him much time. I told him ‘DO NOT STOP medicines. Show my letters to psychiatrists there and follow their advice.’ I had written long term treatment plans in the letter.

I received another call 6 months later. I was in Baripada. My Tamilnadu mobile is roaming. I use it for sms only. I picked it as it was an international call thinking it was my aunt calling. He told me that 6 months ago when he had cal led had  I told  him to follow up locally. They had changed the   medicine. The changed Imipramine to a newer drug. He slowly slipped into depression again. He had stopped work. He wanted to come, wherever I was for getting treated! I gave him my address.

Lo Behold ! In a month’s time he was in Baripada. He shocked our staff and our town people, who heard this. He got admitted. I restarted him on Imipramine. He improved in 2 weeks and went back. Last month he called from Europe. He told me that he is doing well and has also got a promotion. I congratulated him. I was happy for him and for myself too !

I was wondering what is it that has brought him from thousands of miles to get treated from a young psychiatrist like me? It would have lessons for me to learn and be consistent about. It was :-

1. Willingness to take up extra work despite a lot of busyness, if that is the only way another person can be helped.

2.Willingness to invest time and energy, without looking for rewards.

3.Looking at a person as a whole not as a label.

4.Being really committed to well being of a person, even if minor departure from protocol.

5.Using time tested medicines.

6.Being available.

It was not that the doctors, who saw him were incompetent. They could not give him hope at a personal level. To them he was a case, who was treatment resistant. To me he was MY patient who has problems. I do not deny that failures on his part would not have affected me, with this sort of an attachment, but at times it is that attachment only that holds a person who is sinking.

There was two things that he told me in this Baripada admission that I would never forget.

‘Sir, I have forgiven my brother fully. I hugged him and cried. My relationship with him has been restored, but this depression has not left me.’ He need not tell this as I had never pushed him to it. I had just suggested it. Traditionally psychiatry is neutral regarding forgiveness etc, but I sense some of those things matter a lot to people.

‘Sir, If you had not given me an appointment soon after you saw me to explain me the treatment plan and the time required to improve, I would have gone and slept  on a railway track in Vellore itself.’

I realize there are many opportunities which come our way to make a difference in people’s lives, if we are patient enough to respond.

May God give us such patience at all times.

Posted in depression, drug therapy, psychotherapy, suicide | 3 Comments »

lesser the better

Posted by Dheeraj Kattula on April 26, 2009

She was 26 years old. A mother of a three year old child. She was well dressed and well kempt. An old patient of ours brought her to our OPD ( out patient department ) for vague somatic complaints that she had been having for the past 2 years. She was not keen expressing her problems as well. I usually enquire regarding stressors even in a general OPD. To me young hesitant woman ususally means- domestic problems with husband or mother-in-law.

She lived in a nuclear family and her husband was very loving. As I probed into her more deeply, I realized that the patient was quite severly depressed and was also having suicidal ideation. I encouraged her attender to admit as soon as possible indicating high suicidal risk. She wanted to come the next day. A hospital admission is not that simple.

Patient’s families have to hand over their cows and hens to others to care for. They should arrange for someone to take care of their feilds. They also need to arrange for cash. Most payments are out of pocket in rural India. They need time to go and bring utensils, rice, dal and oil to cook nearby. Most importantly they should arrange for someone to stay as an attender.

She came the very next day for admission with her husband. I could see her in detail. She revealed that she had been hearing voices that others could not for the past two and a half years. She had also been suspecting few relatives of doing witchcraft against her. She was barely able to do her household work. She was managing well, due to her extremely suportive husband. Clearly her diagnosis was Paranoid Schizophrenia- continuous course.

I started her on antipsychotic Risperidone 2 mg. In the evening hours I spent time with her husband regarding her illness, its nature, course, treatment strategies, prognosis and outcomes. The voices in her ears came down within 3 days. I had planned to go up on the dose to 4 mg before discharge. I decided against it. Many a time we go up on the dose rapidly expecting results quickly. Thoogh many patients might respond at lower doses.

She bacame aware of her problem as an illness. She feels there is no reason to die if her voices go away. She has hope that treatment is helping her. Why go up on the dose? The patient is not going to run away anywhere. If she does not respond with 2 mg over 2 weeks then I would go up.

By increasing her dose to 4 mg would I not double her treatment cost? It she develops extra pyramidal side effects (tightness and rigidity), she would require medicines to control that. This would triple her cost. By being conservative in a relatively safe situation benefits are fewer medications, better compliance, lesser cost, lesser side effects and probably better effectiveness.

Posted in drug therapy, economics, schizophrenia, suicide | 1 Comment »