THE LOUDSPEAKER - DEPRESSION

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Summer 2015

Amplifying the voice of mental health

DEPRESSION 18

ABC

29

of Antidepressants

Helping in

Hallucinations

8 City life and

MENTAL HEALTH

6

Overcoming Forgetfulness

Help in Grief

29

...Plus Our Regular Features

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Amplifying the voice of mental health

Editor Dr. Prabha S. Chandra

Editor’s Note

Professor of Psychiatry Coordinator, NIMHANS Centre for Well Being

Sub Editors

P

Dr. Prasanthi Nattala

One moment the sun is shining and you think all is well with the world, when suddenly the dark clouds gather and before you know it, there is torrential rain, throwing your life completely out of gear. All the plans go awry, you don’t know when the rain will end and sometimes you may not even find shelter to protect yourself. I thought this was an apt description of a condition that affects so many people but continues to be undetected and untreated in society.

Dr. Meena K.S.

eople who have gone through depression describe it in various ways.

The most recent description that I heard was that it was like this year’s Bangalore rains. They come unexpectedly and create chaos in your life.

This issue of Loudspeaker focuses on Depression. We have advice from psychiatrists and psychologists, about sadness and depression, about how to help someone who is grieving, how to care for someone with depression and basic information on antidepressants and the `talking cures’.

We also have stories and the lived experiences of people who have faced and conquered depression (at least for the time being). In addition there is latest scientific knowledge on why people have hallucinations, how the mind deals with pain, simple tips on improving your memory and what city life does to our mental health.

We were a bit apprehensive about people’s response when we released the first issue of Loudspeaker. However, there has been an overwhelming feedback and acceptance from patients and their families and from the public. We have had demand for more copies and more issues.

We hope you gain from reading this issue as much as we gained and learnt from putting it together.

We would like to know more about what works for our readers.

Which articles do you like and what more do you want from us?

Please write to us at nimhans.wellbeing@gmail.com with your questions and ideas.

Associate Professor of Nursing NIMHANS

Assistant Professor of Mental Health Education NIMHANS

Smt D. Padmavathy In-charge Staff Nurse NIMHANS Centre for Well Being

Editorial Board Ms. Archana Nath Mr. Manoj Chandran Ms. Nagashree Ms. Namratha Nagaraja Mr. Prabhu Dev Ms. Tarannum Taj Ms. Shruthi Rajalakshmi Conceptualised and produced by NIMHANS Centre for Well Being Cover photos: Sunita Chakraborty Photo Credits:

Please look for all the Loudspeaker articles on the NIMHANS website under the Patient Education section.

Printing of the Magazine funded by: Dr. Ramachandra N Moorthy Foundation for Mental Health and Neurological Sciences

National Institute of Mental Health & Neuro Sciences

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Amplifying the voice of mental health

Contents

Overcoming day to day forgetfulness Dr. Roopesh BN

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Elderly people may experience difficulty in remembering names, address, routes, and in extreme cases, the faces of their family members.

Finding a way out of depression Depression is not a disease but a condition and you should seek immediate help if there are any signs of depression.

6 Mental Health in the City Ms. Shoba Raja In India every day hundreds of thousands of people migrate to Mumbai, Delhi, Bangalore and other cities in search of a better life.

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When does sadness become depression?

Dr. Santosh K.Chaturvedi & Dr. Abhinav Nahar “I had worked very hard for my final exams, but, failed in two subjects. For the next few days, I felt extremely low, and would cry whenever thoughts of the result crossed my mind.

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Beating depression; with a 4-pronged stick!

Chances are the person isn’t even listening to you, and just wants a space where he/she can share thoughts that are frightening, often taboo, and terribly hard to admit to.

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How can I help my family member with Depression Dr. Sabina Rao Individuals with depression cannot “just snap out of it” or “get over it”.

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Dance your way to good mood............................... 11 Ms. Shruthi Rajalakshmi The word “dance” seems to bring with it a sense of enthusiasm and pleasure.

The Science of Hallucinations................................. 26 Dr. G. Venkatasubramanian MD, PhD,

Talking cures for depression Dr. Paulomi M. Sudhir & Ms. Systla Rukmini Psychological therapies are popularly called “talking cures” based on the understanding that they involve a dialogue between a client and a therapist/ counsellor.

During these dreams, we see things and hear sounds with a feeling that they are real.

Helping in Grief...................................................... 29 Dr. Kavitha Jangam It is also important not to judge how people exhibit their emotions about the loss, as it can vary from person to person.

White Swan Foundation for Mental Health............ 37 We spoke to Manoj Chandran, CEO of White Swan Foundation for Mental Health about the need for information to be spread in the mental health space and why the conversation on mental health issues should be in the public domain.

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ABC of Antidepressants Dr. Srikanth Miriyala & Dr. Naveen Kumar C

How does the mind handle physical pain Dr. Geetha Desai

Depression and anxiety disorders result from an imbalance in neurotransmitters such as serotonin, norepinephrine, dopamine, etc.

When asked about her emotional wellbeing she said she was fine except for the pain

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Overcoming day to day forgetfulness You can train your brain to be less forgetful

Memory problem or forgetfulness is a common complaint among the elderly and even among adolescents. Some common examples of forgetfulness are misplacing mobile phones, laptops, goggles, keys, TV remote or documents; forgetting an assignment, appointment or other vital events on the calendar; being doubtful about whether we have locked the door or vehicle; forgetting an important item that we were supposed to buy from the grocery store; being unable to recall recently learned information and so on. Some of us are concerned about the extent of the problem and suspect it happens only to us and that these events maybe be indicative of an underlying illness.

Elderly people may experience difficulty in remembering names, address, routes, and in extreme cases, the faces of their family members. Are these normal? Can these instances be passed off as absentmindedness or are they early signs of dementia?

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To understand how to differentiate between forgetfulness and dementia, we must understand how memory is created. Our memory operates in stages. Information enters into Short Term Memory (STM) and then passes on to our Long Term Memory (LTM). The term used for the storage of information in the LTM is called encoding. Most of the information/ situations that we encounter in our daily lives are not necessary or important enough to pass on to the long term memory and most of it is forgotten. Forgetting is an important function to keep our brain from an information overload.

However, it becomes imperative to differentiate simple everyday memory lapses from the serious ones such as dementia.

One of the ways to determine this is to ask or know whether the forgetting is attention related?

For anything to be encoded into your memory for successful recall, the information has to be properly

attended. If a person is not attentive while learning it or while doing a task, then there is bigger chance of forgetting. For example, if you have not paid attention to where you kept your keys while placing it, there is a high chance that you won’t recall where you placed them, unless they were kept in their usual place. Similarly, not paying attention to your spouse when listing out grocery items might make it difficult to recall the list. Being preoccupied with many things or paying attention to many things at a time might also make it easy to forget. Likewise, when students do not use a proper reading techniques and if they do not revise at adequate time intervals, it might be difficult to recall information during an examination.

Apart from these there can be various other reasons for everyday memory lapses. Forgetfulness can occur due to stress, fatigue, boredom, anxiety, depression, sleep deprivation, vitamin B12 deficiency, thyroid problems, dehydration, side effects of some prescription medications, alcohol and drug abuse and age related lapses. It is only in extreme cases that forgetfulness occurs due to dementia.

One important way of differentiating everyday memory lapses from the more serious ones (e.g. dementia) is by asking oneself if the memory problems are affecting everyday functioning. Is it happening too often? Is it difficult for you to recall whom you met yesterday/day before or what you spoke with that person? Do you have difficulty recalling recently learned information, even when cues are provided? If the answer to any of these questions is ‘yes’, then you need to consult with a mental health professional or a neurologist.

The key to good memory lies in appropriate techniques which help in better encoding and storage along with proper conditions for recall. The techniques can be divided into those that are directly related to the way we learn information and those that help in better storage.

Some techniques that help in better memory on a day to day basis l

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Get proper sleep. Sleep helps consolidate whatever has been learnt into your long term memory.

Lead an active life. Regular exercise, playing outdoor/indoor games help.

Eat healthy foods. Healthy diet form the biological foundation for a good memory system.

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Keep your stress levels moderate. Too little stress (e.g. when you are not bothered about your exams at all) as well as too much stress (e.g. when you can’t focus), are shown to be harmful for good memory.

If you are stressed out, talk to friends, or learn some relaxation techniques such as meditation, yoga, tai chi etc.

Tips to avoid everyday forgetting l

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Have a regular schedule.

Pay attention to what you are doing. For example, while locking the door, be mindful about the activity.

Have a regular place to keep things. For example, keys can be kept in the same place, your vehicle can be parked at a regular spot when you go shopping. If you can’t have a regular space to park your vehicles when you go shopping, make sure you register the row or slot where the vehicle is parked. Remember landmarks when you go to a new place. Make sure that you remember the landmark from the opposite direction, as you will be driving back.

Make a list of what you are supposed to do. You can also make use of some of the apps available in your mobile phones to create to-do lists.

Set reminders in your mobile.

Use post-it notes and stick them at well frequented places.

Inform somebody to remind you about the activity that needs to be done.

Remember, there is no shortcut to good memory.

It is the result of staying mentally active, including physical activity in your daily routine and practicing a few tried and tested memory building exercises.

Dr. Roopesh BN Assistant Professor Dept of Clinical Psychology NIMHANS

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Mental Health in the City In today’s increasingly interconnected world, over half of the world’s population (54 per cent) lives in urban areas, according to a latest United Nations report. The coming decades will bring further profound changes to the size and spatial distribution of the global population. The proportion of the world’s population living in urban areas is projected to rise, touching 66 per cent by 2050.

Is that a good thing or a bad thing?

The lure of the city

The mass demographic movement to cities is already well underway, and is bringing chaotic changes to people’s lives. The lure of the city is often to do with the multitude of opportunities and options available.

In India every day hundreds of thousands of people migrate to Mumbai, Delhi, Bangalore and other cities in search of a better life. This migration has picked up scale and speed in the last decade with the opening up of the Indian economy to global markets.

Life in a city

Like most things in life, what a city offers is neither all good nor all bad.

Compared to rural areas, cities have more hospitals, schools, colleges, jobs and avenues for organized socio-cultural activities. New transport systems have transformed urban mobility. Technology has broken barriers of class and caste by providing wide access to services such as mobile phones, banking etc. Rise

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in the number of working women has made dual income families a common phenomenon. Increased purchasing power of young families combined with easy availability of credit cards and loans has made it possible to own bikes, cars, homes early in life and attain a good standard of living.

Technology stops people from conversing

These very features of the city, which make it attractive, are also leading to city populations becoming vulnerable to stress and mental health problems. Grossly inadequate infrastructure, traffic snarls, noise, pollution, crowded living spaces with poor water supply, are some of the common factors that contribute to chronic stress.

While overall living standards have gone up, expectations have increased and expanded manifold. Suicide, especially among young people, often for seemingly trivial reasons, has assumed alarming proportions. For those in their 50s or 60s, new dimensions of life are unfolding with children having flown the nest often to faraway places.

Challenges posed by the growing elderly population is still seen as a family burden, and not recognized as a problem of a society in transition.

The impact

Debashish (name changed) who came to Bangalore to join a BPO from a small town in Bengal says: “I cannot feel close to anyone as city people are busy and very businesslike.”

Kanimuzhi (name changed) from rural Tamil Nadu who works as a construction worker in Bangalore says: “I worry all the time about my children. There are so many cars and buses moving, and so many strangers, not all of them will be good so I am afraid my children may come to harm…….”

Ripin (name changed) moved to an IT job after working briefly in his father’s small company and says: “Earlier I was bored, my routine seemed dull. When I wanted to move, my father wasn’t happy…..but one year in this job and I have gained so much of self-confidence, I have confidence to speak to anyone. I am planning a startup company with 3 colleagues soon…..”

Debashish, Kanimuzhi and Ripin have one thing in common. They all live in a big city.

While cities potentially offer opportunity, stimulus and options to all, not everyone is able to take equal advantage. The multilayered complex dimensions of city life affect different people in different ways depending on their personal situation, experiences and coping styles.

As reported frequently in the news, young ‘techies’ are facing many succumbing to the combined stress

of work pressures and their own loneliness. The World Health Organization highlights stress as one of the major health challenges of the 21st century.

Urban living is believed to be quickly developing as a major contributor to this. A key narrative of stress in the city is related to what is termed as social stress.

Put simply, this is the interplay of typical urban ‘density’ (e.g. noise, pollution, crowds etc) with a pervasive sense of anonymity, the isolation. German researcher and clinician Dr. Mazda Adli called it the theory of ‘loneliness in crowds’.

Isolation can be an especially relevant theme for migrants who also face the social and psychological effects of migration. If there is insensitivity or resentment from ‘locals’ it can deepen their sense of alienation. Recent attacks in Bangalore and Delhi on young people from the North East revealed dangerous race tinged hatred in urban India.

Women almost always face the brunt in a bad situation.

Research shows that increase of nuclear families in urban society has led to increase in violence against women in general. Domestic violence is also more widely prevalent in urban areas. A study across 8 urban areas located in developing countries showed that the mental and physical abuse of women by their partners was distressingly common.

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What can we do?

Of course all this does not mean everyone living in cities is heading towards a mental health crisis. The majority seem to adapt and move ahead. However a great many are unable to cope. It is possible that they were ‘high risk’ individuals to start with, but the fact is that they are a sizeable number. With urban living set to become the norm it is critical that the high risk of mental disorders is tackled urgently to prevent ‘before’ rather than treat ‘after’.

In this context, it may be more important to tackle the intangible social emotional aspects of city life.

Ways to address these could range from seeking out and joining common interest groups to taking up stress busting activities (e.g. new hobbies, jogging, yoga etc.) to seek support, such as counseling, from trained professionals.

Research is adding to our understanding of the connection between city living and mental health.

There is evidence emerging of the higher risk for schizophrenia, anxiety disorders and mood disorders among city dwellers. Research findings also suggest that continuous exposure to stress for long periods affects the brain, making the brain region that regulates emotions such as anxiety and fear, more active.

People living in cities can and should leverage the advantages that stem from their urban environment.

To do this to maximum potential it is important they become aware of the risks to their mental health, recognize the signs of stress or isolation if they occur, be informed about what can be done and reach out appropriately for action.

Ms. Shoba Raja Special Advisor, Basic Needs.

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Dance your way to good mood Dance - what occurs to the mind when you hear this word? Joy, fun, celebration - all of these or perhaps more! The word “dance” seems to bring with it a sense of enthusiasm and pleasure. We find ourselves dancing when we rejoice in a success, when we hear happy news, when at a friend’s wedding, a get-together, or sometimes even when there’s good music playing nearby. Dance has been a way of expression (mostly joy) and a means of celebration from as long as the beginning of human existence.

What do we mean by ‘dance’?

We are familiar with dance through different forms - classical, folk, contemporary, Western, and so on.

They all follow a certain format, and one needs to undergo training to be able to learn and execute the various styles of dance. It may require some talent, skill, and interest too, along with training.

In this article, along with trained dancing, we include jumping, rolling, sliding, turning, bending, twisting and any movement you can think of, under

the umbrella of ‘dance’.

The “feel-good” factor

Dance is an effective de-stressing technique. A stressed mind can do well with some good dancing.

It helps to feel calm and light in the head. It can also easily brush away boredom, dullness, low mood, and make a quick way to feel better.

It is more or less the same with physical exercise or brisk walking. After all, these too involve extensive movement. However, what makes dance different from these is its synch with music, its variety in movement, whether free or learnt, and scope for creativity, expression and exploration.

This makes dance refreshing physically as well as psychologically.

Bring back the child in you!

Ever noticed how a baby behaves when happy, and when not? The child’s body is usually quite still while crying (or any other not-so-positive emotion) and on

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the other hand, the child is vigorously moving his/ her hands and legs while happy. We have the same tendency even after we grow up. We have all been babies once. We learn and unlearn so many things over the years, consciously and unconsciously. One of the things that slowly changes from babyhood to adulthood is free and spontaneous movement to learnt and socially acceptable movement.

We can understand from this behaviour in babies, that free movement is naturally associated with joy.

Dancing without inhibition and “letting go” gives a sense of happiness that can be understood only by doing and experiencing. Hence, by dancing freely, we can induce the joy of free movement, and for a few moments, be a child again!

The “Happy Hormones” therapy

Research has shown that dance (or any form of sufficient physical activity) stimulates the release of neurochemicals in the brain called “endorphins.”

These chemicals are responsible for inducing pleasant emotions. Hence tapping your feet to some good music gives your brain some food to feel happy!

All these inherent qualities in dance make it a unique tool for “therapy.” Dance/movement therapy is used to help persons with various emotional problems overcome their barriers to a happy life, and help cope with emotional ups and downs better. This form of therapy works around the concept that mind and body are connected, a concept well established over the years. This connection leads to the understanding that the body can be used as a medium to understand the mind better, hence making the effect of therapy more deep and intensive.

Rounding it all up, one can say that dance is an unfailing tool for improving your mood and shaking off any lethargy or heaviness in the mind.

So Dance Away.. And Be Happy!

Here are some ways you can help yourself with dance ●

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Play some music that you enjoy, then move and dance in whichever way you feel like. You could imagine sequences and enact those in your dance.

If you find it difficult to create your own movements, you could play the video along with the music and dance as you watch the movements in the video.

You can call a group of friends once in a while, make a list of fun songs, play it and dance away together.

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You could learn a dance sequence of a favourite song and dance it whenever you feel like. You could also invite some friends to join you for this if you are comfortable. If not, no problem, you are enough to make yourself happy!

Join a dance class of any style you like. That way, you’ll be doing your favourite dance every week regularly, and of course, you can practise what you learnt in class at home too.

Ms. Shruthi Rajalakshmi

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When does sadness become depression?

Sadness

“I had worked very hard for my final exams, but, failed in two subjects. For the next few days, I felt extremely low, and would cry whenever thoughts of the result crossed my mind. I was very low on confidence. However, my sleep and appetite were undisturbed. I would feel better interacting with friends and family, and discussing things other than results, like sports. Gradually I felt better, and I once again started preparing for my exams in a week’s time and was hopeful about my future.”

Sadness or downswings are part of everyday life and may be usual reactions to disappointments or setbacks. Though people use the term ‘depression’ to describe such feelings, depression means more than the usual sadness.

When sadness progresses to depression

“The breakup with my girlfriend was difficult for me to deal with. I would feel sad whenever I visited places where we had been together or when I came across pictures from during our happier times. However, I was able to work, sleep and have food on time. I felt comforted and overcame my loneliness by spending time with close friends initially.

Gradually, my sadness worsened. I felt sad even about things unrelated to her. I stopped going out of my house, did not want to meet my friends, had difficulty getting sleep, and had no interest in any previously enjoyable activities like watching movies, etc. I felt that this was the end of my life and I would never be able to come out of this situation”.

In depression, a person is continuously sad for a minimum of two weeks. This sadness engulfs his whole day and is pervasive i.e., present in all situations. This interferes with a person’s ability to study, work, and sleep. Depression makes it tough to function and enjoy life like you once did. Patients may also have intense feelings of helplessness, hopelessness, and worthlessness, with little relief.

When to diagnose depression

The symptoms of depression vary from person to person but there are some common signs and symptoms which when present, increase the possibility of diagnosis? of depression in the patient.

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•

•

• • • •

Often symptoms may not be overtly evident and may be hidden in person’s day to day activities. But when the symptoms are disabling, depression is diagnosed. It can present at any age, even in children, elderly, as well as in pregnant or postnatal women.

Some of the symptoms of depression are: •

Low/sad mood is present for most part of the day and in most situations. In some patients with

• •

• •

•

more severe varieties of depression, symptoms worsen during the morning hours.

Decreased interest/loss of interest in activities which were previously pleasurable, like watching sports, sex, cooking, adventure trips etc.

Feelings of helplessness in which a patient feels that whatever he may do, he will never come out of this situation, he feels that he is a burden on others and feels no one else can help to overcome the situation.

Decreased energy where a patient feels fatigued even with minimal or no activity.

Forgetfulness and decreased concentration Changes in weight and appetite Sleep disturbances during sleep. Or difficulty in initiating or maintaining sleep. Some may have difficulty in the later part of the sleep and they tend to wake up early in the morning.

Feelings of having done something terribly wrong.

Decreased work performance, loss of interest in work, reduced interest in interacting with people.

Irritability and anger outbursts Unexplained new onset or increased severity of previously present physical complaints like headache, backache etc.

Death wishes: Expressing wish that it would be better off being dead than living.

Take home message If any relative or friend of yours is showing signs of depression • • • • •

Encourage him/her to visit a mental health professional.

Listen to the patient and let him express his/her feelings.

Offer emotional support and reassure him/her that things will improve.

Do not ignore thoughts/ feelings of ending life, report it to the therapist/psychiatrist.

Keep a thorough watch on the patient especially if he/she repeatedly expresses suicidal ideation.

Dr. Santosh K. Chaturvedi Professor Department of Psychiatry NIMHANS.

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If you are depressed: • • • • •

•

Discuss your feelings with someone close to you.

Keep yourself active and busy.

Spend more time with people.

Visit a mental health professional as soon as possible.

If you repeatedly get thoughts of suicide, discuss it with a friend or relative and visit a doctor immediately.

Don’t expect immediate results. It will take time to improve but you will definitely come out of it with professional help.

Dr. Abhinav Nahar Senior Resident Department of Psychiatry NIMHANS.

Finding a way out of depression I worked a way out of depression

I am sixty-two years old and I am retired. I have had four episodes of depression. The first in 1998 at the age of forty six, the second in 2009 at the age of fifty seven, the third in 2012 at the age of sixty, and the fourth in 2013 at the age of sixty one. In my case, genetics played a big role in this predisposition to bouts of depression.

was only when I was given permission for early retirement that I started feeling better and started to get back to normal.

I had a seizure in the midst of a very exciting assignment and this led to my second episode of depression, which was treated by anti-depressants.

The exact dosage and medication was arrived at after a fair amount of trial and error.

For those of you who have experienced depression, you would know what it means to be depressed: a heavy/sinking feeling in your chest, loss of interest in life and things that you like to do, not wanting to socialise, poor concentration, being tired all the time, postponing tasks, etc. However, depression could manifest itself in different ways for different people, and the severity can vary.

My first episode of depression was very severe. It happened because I wanted to leave my organisation and take early retirement but was not given permission to do so. This led to anxiety, insomnia, lack of interest in any activity, etc. I was prescribed anti-depressants and was even administered five rounds of Electroconvulsive therapy (ECT) but it

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One should try and understand the triggers that cause depression. CBT helps you identify your triggers and your therapist will help you build techniques to deal with them. Stress was a major trigger for me and simplifying my lifestyle helped me. While this may be seen by others as slowing down, it is important that you know what is best for you.

It is very important to take your prescribed medication and be regular with your therapy session. You must inform your psychiatrist of all medications you are taking (for BP, diabetes, seizures, etc.), so that there are no drug interactions with anti-depressants.

It is quite depressing for family members to have a “depressed person at home”. In my case, my spouse has been a pillar of strength and support right through. She has always looked at things positively and encouraged me to keep busy with activities, social life, etc. My other family members have also been very supportive. I am also lucky that I have somebody in the family who is a leading psychiatrist who has guided me all along.

Depression is not a disease but a condition and you should seek immediate help if there are any signs of depression. Don’t worry about what relatives, friends or society will say. It is your body and you have the right to feel good about yourself. Always remain positive, take medication regularly (not withstanding side effects) and tell yourself “this too shall pass”. The depression will lift and when that happens, you experience a wonderful feeling of lightness.

I am not sure what the trigger for my third episode of depression was. This time, I was asked to try Cognitive Behaviour Therapy (CBT) at NIMHANS along with medication. I started CBT immediately and found this to be a very positive experience.

It involves talking about your condition in great detail after which you are assessed for your level of depression, the way you think about yourself and whether there are any distortions in your thinking process. In my case, CBT involved fifteen sittings of one hour each with the therapist over a period of fifteen weeks. I started feeling progressively better after each session. I strongly vouch for CBT in addition to consultations with psychiatrist. Along with making me feel less sad, CBT also helped be more social, enthusiastic and interested in life.

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To summarise, these are the things that have worked for me in finding a ‘way out of depression’ (and the same can work for you too): • • • • • • •

Seeking immediate help Taking medication regularly and giving correct feedback during reviews with my psychiatrist Remaining positive and saying to myself that “this will also pass” Undergoing CBT (Cognitive Behaviour Therapy) Exercising regularly Recognising what causes stress Keeping busy with different activities, socialising and hobbies

The writer has been a high performer in his career

Beating depression; with a 4-pronged stick!

To be depressed is to begin each day with a heavy heart. To live the perfect life but to have a nagging anxiety that something is amiss. That something will go wrong. It is to be in the midst of a well meaning, ever-supportive family but to feel painfully alone. It is to worry about things that others shrug off ever so easily. It is, to welcome each morning with lethargy and apprehension. To be depressed is to find minor tasks insurmountable. It is to be in pain. Pain that is seems immune to exercise, to medication, to relaxation.

It is to weep for nothing, and yet, for everything. It is to feel inadequate almost every waking minute. It craves sleep. It tints reality; casting a grey, gloomy and weary picture of a life that was effortless, cheerful and jaunty. Most importantly, it is be unforgiving of oneself. It is unrelenting and ruthless, and makes you believe that you are no good. And that you never will be. It makes you second guess all that you say, all that do and everything that you think.

I could go on about what depression does to one’s life and the trenches that it throws you into. But I want this to be about how to get oneself out of that pit that seems so perversely comforting. I struggle with this. Every time I feel I have reached level ground I find myself back where I began. It is exhausting, frustrating and oddly desensitising. But I take heart in the fact that there are things that have worked.

The most important thing to do is to talk. If you are reading this as someone supporting a person with depression, then the most helpful thing you can do is to listen. And to listen without jumping in with suggestions, or consolations, or promises that it will get better. Chances are the person isn’t even listening to you, and just wants a space where he/she can share thoughts that are frightening, often taboo, and terribly hard to admit to. If you are feeling depressed, make sure that you are heard out. Repeat yourself, if that’s what it takes.

Try finding one person you can trust. I am blessed to have a few people I can trust with my life. They are the ones I go to when I doubt myself, at work or at home.

This article is as much for them as it is for you.

Exercise. Believe me, I know when exercise is the last

thing you feel like doing. Getting out of bed is hard enough, leave alone dragging yourself to a gym. But it helps. If nothing else, it tires you out and silences those havoc creating thoughts that you trust. It paradoxically energises you. A sport helped me more than the gym.

Play a sport, take a brisk walk, do some jumping jacks at home, skip; whatever seems least daunting.

See a psychiatrist. There will be people around who won’t, and possibly cannot fathom the gravity of how miserable you feel. They feel it will pass. That it is okay to feel this way. And that everyone occasionally has the blues. Please hear yourself over them. They might mean well, but only you know how you really feel.

You know that there is a lot more than you admit to.

A psychiatrist can help. Be honest with the doctor. The odds are that he doesn’t have time to ask questions.

You owe yourself the right to getting better. Hard as it might be to share the most intimate thoughts with a stranger, do it. Keep a record of the treatment and keep your doctor abreast. The first line of treatment may not work, but something will. Just as insulin works for diabetes, or paracetamol works for a fever.

Above all else, remind yourself that this is the condition and not you. Write it up somewhere and read it over and over again. In all likelihood this will be the hardest to work through. I know it has, and continues to be so for me. I keep wondering… Is this the person I have become? Is this who I will always be? Will I ever be the happy-go-lucky person I used to be? Will I ever be free of the weight of the worries that I carry around? While these are questions that remain, I see glimpses, on good days, of the person that I used to be. Yes, they are fleeting images but I am hopeful of them permeating through my life.

Write down when you have had a good day, or when you did something that trivial as it may seem, was hard to do. Ask people around you what they see. They are likely to see the real you, while you are seeing the less desirable you. Believe them. They truly care and want the best for you always.

Remember, depression isn’t who you are; it is a part of your life. And this too shall pass.

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A pill box to take medicines on time

ABC of Antidepressants ABC of Antidepressants

Antidepressants are a popular treatment choice for those with depression. They are among the most common prescriptions issued by psychiatrists and other medical doctors. Considering the increased prevalence of depression, it is important to have basic knowledge of antidepressants and the treatment procedures.

1. What are antidepressants?

First of all, we need to understand that our brain consists of various circuits (connections between different areas) that are responsible for expression of our mental states, be it fear, anxiety, etc. Proper functioning of these circuits is essential for healthy expression of these mental states. Neurotransmitters are chemicals in the brain which are a critical part in the functioning of these circuits. They help in transmitting the electrical impulses between the nerve cells in brain circuits. Once these neurotransmitters act upon their targets, many downstream activities take place inside brain cells resulting in optimal emotional expression.

Depression and anxiety disorders result from an imbalance in neurotransmitters such as serotonin, norepinephrine, dopamine, etc. Antidepressants are a group of medications which help to restore these

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imbalances inside the brain. Antidepressants are classified and named either after their functions, or their chemical structures. For example, tricyclic antidepressants (TCAs) are drugs named after their chemical structure. On the other hand, Selective Serotonin Reuptake Inhibitors (SSRI), Monoamine Oxidase Inhibitors (MAOI), Serotonin Norepinephrine Reuptake Inhibitors (SNRI) are based on their function. Some common individual antidepressants are given in Table-1.

2. When are antidepressants used?

Antidepressants are widely used in treating a variety of mental disorders where emotional dysregulation is an important feature. Some of these are: a. Depressive disorders b. Anxiety disorders a. Panic disorders, social phobias, specific phobias, Generalized Anxiety Disorders, etc c. Obsessive Compulsive Disorders d. Adjustment disorders e. Pain disorders f. Impulse control disorders

3. How long should antidepressants?

one

take

There is no one fit answer to this question. As

Table-1: Commonly used antidepressants SSRIs Citalopram (upto 80 mg/day)*

TCAs Amitriptyline (upto 300 mg/day) *

SNRIs Duloxetine (upto 120 mg/day) *

Escitalopram (up to 20 mg/day)

Clomipramine (upto 250 mg/day)

Venlafaxine (upto 225 mg/day

Fluoxetine (upto 80 mg/day)

Doxepin (upto 300 mg/day)

Milnacipran (upto 200 mg/day)

Fluvoxamine (upto 300 mg/day)

Imipramine (upto 300 mg/day)

Paroxetine (upto 50 mg/day)

Nortriptyline (upto 150 mg/day)

MAOIs Moclobemide (upto 600 mg/day *

Others Mirtazapine (upto 45 mg/day)

Sertraline (upto 200mg/day) * doses mentioned pertain to the maximum permitted level

mentioned above, antidepressants are used for a variety of disorders, and the duration of treatment varies according to the disorder. For example, for a first episode of depression that is not severe, antidepressants are generally prescribed for about a year. If the depression is recurrent, the duration of treatment is much longer and perhaps indefinite.

Additionally, one needs to consider other important clinical issues such as: severity and frequency of the illness episodes, the amount of distress and dysfunction caused by each episode, family loading of illnesses, response level to a particular antidepressant, risk of recurrences in cases where antidepressants are stopped, tolerability of a particular patient to a particular drug, interactions of antidepressants with other medical drugs, etc.

Once the person starts taking antidepressants, it takes about 2 weeks for the antidepressant action to set in. Once the action starts, patients improve gradually day by day. It is however important to take these medications regularly as prescribed, since they get metabolized and ultimately eliminated from the body. This is the reason why the medications should be taken regularly in order to maintain sufficient levels inside the brain for sustained action.

across all the above situations. Treating physicians would decide on the choice of antidepressant based on the patient profile, the drug’s side effect profile and other relevant factors, e.g. the patient’s age, frequency and severity of episodes, family history of depressive disorders, and other co-existing illnesses.

Table-2: Common side-effects of antidepressants

SSRI

TCAs SNRI MAOI

Nausea and vomiting, insomnia, sexual dysfunction (including loss of sex drive, difficulty in reaching orgasm, delayed ejaculation) Dry mouth, blurred vision, drowsiness, weight gain, constipation Like SSRIs, can cause high blood pressure Dizziness, drowsiness, dry mouth, constipation

some side affects –blurred vision

4. Are there any side effects with antidepressants?

As a rule, all drugs including antidepressants have side-effects. Some of the common ones are mentioned below in Table-2. However, some of the side-effects can be dangerous, particularly in cases of overdose.

Pregnancy and breast feeding are other conditions that merit caution before starting antidepressants.

There is no single solution that can apply universally

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5. What should be done when the patient wants to stop taking antidepressants?

It is always recommended that the doctor’s advice is taken before stopping antidepressants.

For instance, some antidepressants should not be stopped suddenly because they can cause withdrawal symptoms like feeling dizzy, irritability, sleep problems, vivid dreams, flu like symptoms (headache, sweating, chills), etc. Thus, it is important that proper decisions be taken regarding the continuation/stopping of antidepressants, only after a collaborative discussion with the treating doctor.

Dr. Srikanth Miriyala Senior Resident Department of Psychiatry NIMHANS

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6. What about food intake along with antidepressants?

Certain antidepressants increase sleepiness.

Some food items (that contain tyramine) are to be compulsorily avoided if MAOIs are prescribed.

These are: cheese, pickles, salted fish, overripe fruits and vegetables. Check with your doctor before starting antidepressants.

7. What about using antidepressants with the elderly?

The elderly experience more side effects with the intake of antidepressants. Hence, the doctor prescribes a lower dose of these medications for the elderly in order to avoid severe side effects.

Dr. Naveen Kumar C Associate Professor Department of Psychiatry NIMHANS

How can I help my family member with Depression?

Vishal’s story……

My brother, Vishal, now 36 years old, got married at the age of 28. We all thought things were going well until his wife called me one day in tears. She told me that he had attempted suicide by consuming an overdose of sleeping pills and was now in hospital.

I was shocked.

My brother is an engineer working in a well reputed multinational company. I could not imagine what would have made him do something like this to end his life.

Over the next few days, we got to know that Vishal started to get depressed about a year ago. His yearly assessment with his boss did not go well. He started to feel sad, tearful, and somewhat hopeless.

He thought he would snap out of it but felt worse every day. Over the next few months, his feelings of hopelessness grew. He started skipping work and avoiding his family. He felt guilty that he was not being a good husband and father. He felt helpless and was unable to fix it.

My sister-in-law noticed that he stayed in bed most days. She had to coax and at times threaten him to get to work. She thought he was just being lazy. She started to worry when his boss called and expressed concerns that her husband would lose his job if he missed any further days. My sister-in-law felt too ashamed to call me or anyone else in the family about Vishal.

Eventually, my brother took medical leave from the company. He was diagnosed with depression and was started on medications. He is still on medications and doing very well. He is back at work. My sister-inlaw says he is no longer withdrawn from the family.

He sees his doctor regularly and they have talked about slowly taking him off the medications, once he has learnt some skills on how to handle stress.

So, what is depression?

According to the World Health Organization (WHO), depression is the leading cause of disability in the world: 350 million people suffer from depression and 1 million people commit suicide as a result of the illness globally. However, very few seek and receive treatment.

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diagnosed with depression might think “why don’t they just get over it or snap out of it?” It can be draining for relatives of people with mental illness. The depressed person’s lack of motivation, energy, communication, can be frustrating. It can be confusing and frightening when a relative who was perfectly fine and actively participating in life, gradually or suddenly withdraws.

What can I do to help my ill relative?

Individuals with depression cannot “just snap out of it” or “get over it”.

It can go a long way if you understand that you family member is ill and needs some form of treatment. The most common treatments are therapy, medication or a combination of both. For the more severe forms of depression, there are other treatment options that you can discuss with the doctor.

Depression is more than just feeling sad for a few days. Depression is more than feeling tearful after a loss or negative event in one’s life.

It is a serious illness. It can affect men, women, and children of any age, socioeconomic status, and culture.

Individuals with depression, other than feeling low, sad; ● Do not enjoy the things they did before ● Feel unmotivated and tearful for several days, weeks and months ● Feel worthless, hopeless, and unusually guilty ● Feel tired, have difficulty sleeping ● Express difficulty with concentration ● Have suicidal thoughts, attempts might occur in the more severe types of depression.

How does it feel for a family member?

Family members of persons who have been

It will help you get a better understanding if you can look up information regarding the illness from reliable websites, books. Talking to your ill relative’s doctor/ psychiatrist definitely helps.

If the relative with depression has been advised to visit a counsellor or therapist, you might encourage and remind them to make it to the appointment. If the doctor has advised that he or she take medications, you could encourage and remind them to do so, on time every day.

Sometimes, depression may be so severe that your relative might not want to get out of bed, bathe or even eat on time. If you can be the motivator and encourage your relative to get out of bed and take care of his or her everyday needs, it will help in recovery.

For your unwell relative AND you, exercise, eating on time, eating healthy, will help.

Depression is treatable. Most people don’t know they are suffering from depression. Get help!

Dr. Sabina Rao Specialist Grade Psychiatrist Department of Psychiatry NIMHANS.

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Talking cures for depression What is depression?

Depression is one of the most common mental health concerns, affecting nearly 20% of the world’s population. It is a leading cause of disability worldwide and a major contributor to the burden of suicide.

Why should one seek help? What kind of help is available for depression? ● ● ● ●

Depression causes interference in work and physical health It affects relationships and the well-being of others While it may reduce over time, it is likely to recur in 60% of the people Learning skills through professional help can help prevent recurrence

Fundamentally, treatments for depression can be divided into two types: Medications/ pharmacological interventions and psychological therapy/counselling.

Medications or pharmacological interventions are often the treatments of choice when depression is severe or the individual is severely incapacitated due to the symptoms, or is suicidal. Psychological therapy

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or counselling is another widely recommended treatment option for depression.

What are talking cures?

Psychological therapies are popularly called “talking cures” based on the understanding that they involve a dialogue between a client and a therapist/ counsellor. Interestingly, the term ‘talking cure’ was first used by Josef Breuer, an Austrian physician in the early 19th century, to refer to the “verbal therapy” that he used with one of his clients, whose condition improved as she described the symptoms and traumatic experiences in detail. Sigmund Freud, a neuropsychiatrist, later adopted this in his work on psychoanalysis.

Today, talking cures refer to a wide variety of psychological therapies, involving the therapist attempting to understand the client’s perspective and come to a common agreement on what goals they want to achieve and how.

Healthy ways of coping

Treatment of depression often requires both medications and psychotherapy. At times only one of the approaches may be necessary. It is best to follow the recommendations of a mental health professional, about the most effective course of action. As not all talking cures are equally effective, a trained mental health professional will be able to guide you regarding which one will be the best for treating depression.

What to expect in therapy?

Most talking cures (psychological therapies) range from 6-14 sessions depending on the goals of the therapy. Sessions are usually carried out on a weekly or twice weekly basis, lasting from 30 to 90 minutes, according to the type of therapy. The effects of therapy occur gradually and it is important to be regular in meeting the therapist. This will help the therapist monitor progress, offer alternatives in case of little or no improvement.

Unhealthy ways of coping

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How to choose the right treatment?

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Talking cures help by focusing on: ● Improving mood ● Reducing symptoms that interfere with work and social life such as inactivity, feeling tired, withdrawing from social life and negative thoughts. ● Learning skills to cope with stressors and consolidate existing skills in order to prevent recurrence of depression.

Problem solving skills training helps clients learn effective ways to overcome common problems that cause stress and depression. It teaches clients to work on problems in a systematic manner, generating alternative perspectives and solutions instead of feeling helpless and inadequate. Clients may learn to deal with financial problems, negotiate in relationships, and take decisions by using problem solving strategies.

However psychological therapies do not ● Give advice as to what to do about problems ● Provide an instant cure ● Directly remove stressful factors such unemployment, financial difficulties

Interpersonal Psychotherapy (IPT) is a widely used evidence based therapy. It assumes that depression is linked to stressful interpersonal events such as loss, death, sudden changes in roles (change in job, marriage, childbirth), conflicts with others or difficulties in maintaining interpersonal relationships. The therapist works towards helping the client understand biological and psychological causes of depression, work through emotions related to the stressful event, and learn the skills to deal with present and future stressors.

What are the different types of talking cures?

There are different types of talking cures for depression that are backed by sound research evidence. These are also called evidence based psychological therapies. Some of them are outlined below: Behavioural activation (BA) is a simple yet effective intervention involving gradual improvement of activity levels of the client. Many symptoms of depression such as social withdrawal, getting tired easily, and loss of interest interfere with routine activities and in turn maintain negative mood. By increasing activity levels BA breaks this cycle and is particularly useful in the initial stages of therapy.

Cognitive behavioural interventions: Cognitive behaviour therapy (CBT) is one of most widely recommended therapies for depression. CBT assumes that specific thought patterns precede negative emotions and behaviours. CBT requires collaborative participation by the client, who learns to recognize faulty thought patterns and skills to deal with them effectively.

Dr. Paulomi M. Sudhir Additional Professor Department of Clinical Psychology NIMHANS.

Supportive psychotherapy is applied when an individual is facing a crisis or stressful event which may have led to depression. It draws on the individual’s own resources to cope with stressors and uses a variety of techniques such as allowing client to ventilate, helping in identifying a network of social support, helping client change the environment to reduce stressors and to build alternate interests. It offers a non-threatening environment in which the individual can grow and rebuild coping resources.

Who can provide these interventions?

Talking cures or psychological therapies are provided by trained mental health professionals such as clinical psychologists, psychiatrists, psychiatric social workers and psychiatric nurses. Competence in delivering these therapies is very essential to facilitate effective treatment.

Ms. Systla Rukmini PhD Scholar Department of Clinical Psychology NIMHANS.

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The Science of Hallucinations What are hallucinations? How do they develop? And can I do something about them?

“All this started months before. I felt myself getting more exhausted and not feeling good. I had been having a strange inexplicable feeling – something was not right. One late night, I was returning home after a hectic and stressful day – walking all alone in a deserted street. Suddenly, I heard my neighbour’s voice, “Look! What he is doing?

He had a bad day at work! He complains of stress and excess work load. Is it an excuse for his faults at work?” I was shocked, I turned around, but could see no one; I felt nervous and continued to walk fast. Again, my neighbour started to talk to his son, “Let us call the police to get this fellow arrested! He has to be taught a lesson.” His son responded and called the police – I could hear the mobile ring and police siren. I was terrified and all of a sudden, everything became clear to me – they want to snatch my home by sending me to jail. All these months, they have been talking filthy things about me – I could not see them – my neighbour’s expertise in CCTV must have helped him to develop a special machine to monitor me and talk to me in ‘invisible mode’ even if I go to other cities.

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What are Hallucinations?

Hallucinations are perceptions (sounds, voices, images and similar other sensations) that happen in the absence of any stimulus. Almost all of us get dreams when we sleep. During these dreams, we see things and hear sounds with a feeling that they are real. However, once we wake up we realize that the experiences were unreal. On the contrary, people who have hallucinations get these experiences when they are awake and conscious; more often, they fail to recognize that these experiences are unreal and might attribute these experiences for a purpose along the lines of the above-mentioned anecdote.

Do normal people have hallucinations?

It is noteworthy that hallucination-like perceptions are experienced in a minor proportion of population without any other accompanying features to suggest mental illness. These hallucinations-like experiences (HLE) are commonly reported while getting into sleep (also called as hypnagogic hallucinations) or awaking from sleep (also called as hypnopompic hallucinations); rarely, HLE might involve occasional hearing of voice(s) when alone – however, such

experiences are very transient, occur rarely and most importantly the person will be able to appreciate the ‘unreality’. In contrast, hallucinations that accompany psychiatric disorders are persistent, and mostly unpleasant with associated behavioral disturbances.

How do hallucinations manifest?

Hallucinations can involve any sensory modality namely – auditory (sounds, voices, music), visual (images), olfactory (smell), tactile (touch, unpleasant “electric” or “pricking” sensation), gustatory (taste related sensation) and similar others. Certain psychiatric disorders tend to be accompanied by a specific type of hallucination more frequently than others; for instance, a person with depression is likely to experience hallucinations with nihilistic (a depressive delusion that the self, part of the self, part of the body, other persons, or the whole world has ceased to exist) content.

The Brain and Hallucinations

Dysfunctional brain regions are demonstrated to underlie the genesis of hallucinations. For instance, when we hear any sound, the sound signals reach the region of the brain that processes the sound signals – which is called as the auditory cortex. The processing of sound signals in the auditory cortex is associated with increased nerve cell (neuron) activity.

In patients who have auditory hallucinations,

spontaneous neuronal activity of the auditory cortex (in the absence of any external sound stimulus) during the hallucinatory experiences has been shown through brain research studies. Interestingly, such spontaneous, abnormal brain activations in these patients are shown to be associated with generation of inner speech.

Under normal conditions, our brain has the ability to differentiate our own thoughts / inner speech from the words that are spoken by us as well as the ones that we listen from others. Possibly, a deficit in the brain’s capacity to recognize inner speech as being produced by one-self might result in patients misattributing their own thoughts as external voices. This deficit might be secondary to several neurochemical aberrations involving neurotransmitters (chemicals that facilitate signal communication between neurons) like dopamine, gamma-amino butyric acid, glutamate and several others.

Treatments that help in controlling hallucinations

Medications that modify the dopamine abnormalities, namely antipsychotics, are the mainstay of treatment for hallucinations. For persistent hallucinations that are non-responsive to antipsychotics, very recently, optimized version of transcranial direct current stimulation (tDCS), a novel and safe treatment

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that involves application of weak direct current (2 milliamperes which is approximately equal to one-five-hundredth the amount drawn by a 100watt light bulb) to the scalp using saline-soaked sponges, has been found to result in striking clinical improvement. Interestingly, preliminary research studies at NIMHANS have shown that tDCS corrects the brain deficits that cause misattribution of selfgenerated words as externally generated ones.

Apart from these two Cs (chemical and current) based therapies, another C i.e. Cognition based therapy can also be effective in select patients. Cognitive Behavioral Therapy (CBT) for hallucinations involves several stages – initial stages focus on engaging the patient with aims to enhance the therapeutic relationship and develop a comprehensive understanding about the hallucinations (like detailed characteristics of hallucinations, experiences and behaviors that accompany the hallucinations in detail as well as the antecedents / consequences & behaviors, patient’s belief about the hallucinations and similar others).

Over the course of therapy, behavioral strategies that might potentially reduce the inner speech (for example humming, listening to music, reading & similar others) are taught to cope with the hallucinatory experiences. CBT sessions also attempt to examine the beliefs of the patients about the hallucinations and discuss the alternative possibilities related to the origins of the “voices” in the context of person-

specific approach principles (for instance, in some patients, we have observed that a simple modification of the term (from “voices” to “voice-thoughts”) used by the clinician has a profound impact on helping the patient to gain understanding of the alternative possibilities underlying the origin of hallucinations.

With further consolidation of improvement in hallucination through behavioral strategies & enhanced therapeutic alliance between the doctor and the patient, comprehensive insight facilitation is possible through systematic sessions. While CBT techniques are useful, it has to be emphasized that in most of the patients, these therapeutic strategies have been applied in addition to regular medications.

Thus, while there are several treatment approaches, antipsychotic medications continue to be the primary and most effective therapeutic avenue.

To facilitate person-specific therapeutic approaches for hallucinations, tailor-made treatment strategies that involve an optimal choice comprising of one or more of the ‘C’s (i.e. chemicals, current or cognition) are available through the InSTAR (Individualized Schizophrenia Treatment And Re-integration) Program of the Schizophrenia Clinic at NIMHANS (www.instar-program.org).

For further information related to schizophrenia work at NIMHANS please visit the following websites: o Clinical:http://www.instar-program.org/ o Research: http://www.transpsychlab.org/

Dr. G. Venkatasubramanian MD, PhD, Additional Professor of Psychiatry Schizophrenia & Metabolic Clinics Department of Psychiatry NIMHANS

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Helping in Grief

Offering Support and Solace – How can one help a person who is grieving?

Grief is an emotional reaction or response of a person to any loss. How grief is expressed and experienced varies among individuals. For a child, the loss of a favourite pet or an object can be a significant loss, whereas for an adult it may not be. Similarly, the thoughts of people who are affected by loss may vary from person to person. Some people may perceive a loss as unforeseeable circumstance beyond their control while some blame themselves for what happened. Some people feel angry and frustrated at the loss, whereas some feel hopeless, guilty and sad.

The grieving process is extremely complex. It can be troubling or soothing, and people in grief can bounce between different thoughts as they make sense of their losses. Grieving behaviours range from crying to laughter, and from sharing feelings to engaging silently in activities like cleaning, writing, or exercising. Some people find comfort in the company of others, particularly with those who may be similarly affected by the loss, while others may prefer to be alone with their feelings.

Support during the grieving process can mean a lot for a person affected by loss. Many times, other people find it difficult to share or express their feelings with the persons in grief. Sometimes, one might be scared of saying the wrong things which may even worsen the situation.

Mostly, people in grief try to look for validation of their feelings and thoughts. They want people to understand their feelings about the loss and what it meant for them even if it is a loss of a very old member of the family, or even a pet.

One may not be able to fill the loss, but one can become a much needed support for a person in grief.

One need not stay away from providing support to grieving persons with the fear that they might do something bad. Your very presence can mean a lot for a person who has experienced a loss. There are things which you can do, if you understand the process of grief and how to react to the situation.

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Ask how he or she feels, and don’t assume you know how the bereaved person feels on any given day.

Source: American Cancer Society

Helping people in grief:

Listen empathetically: Many times, people wish to share their feelings about the loss, and the best thing someone can do is to listen to them calmly. We might sometimes feel uncomfortable talking about death, but try not to stray away from the subject. Help the person express his/her feelings and thoughts about the loss in a candid way.

finding closure through their things and happy memories

Understanding grief:

Grief is a complex process and does not follow any particular order. Persons who have had a loss may exhibit different intense reactions varying from shock and numbness, to emotional outbursts. Also, no one can predict the time required for grieving.

Some people find it difficult to cope with the loss even after a reasonably long time, while some others accept their loss quite quickly. It is also important not to judge how people exhibit their emotions about the loss, as it can vary from person to person.

What to say to someone who has lost a loved one:

It is common to feel awkward when trying to comfort someone who is grieving. Many people do not know what to say or do. The following are suggestions to use as a guide.

Acknowledge the situation. Example: “I heard that your_____ died.” Use the words “died or passed away.” That will show that you are more open to talk about how the person really feels.

Express your concern. Example: “I’m sorry to hear that this happened to you.”

Be genuine in your communication and don’t hide your feelings. Example: “I’m not sure what to say, but I want you to know I care.”

Offer your support. Example: “Tell me what I can do for you.”

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Accept the feelings and emotions: Help the person express his/her feelings and emotions. Let the person know that it is ok to cry, express anger, break down. Expression of these feelings and emotions are required in the process of grief.

Offer reassurance without minimizing loss: Feelings associated with loss may not be same for everyone.

Each one may have a different meaning for their loss, therefore we must offer reassurance without minimizing the loss. Share your experience of loss if you had one, but do not tell the person that you know exactly what he/she is going through.

Comments to AVOID when comforting the bereaved: ● “I know how you feel.” One can never know how another may feel. You could, instead, ask the person to tell you how he or she feels. ● “It’s part of God’s plan.” This phrase can make people angry and they often respond with, “What plan? Nobody told me about any plan.” ● “Look at what you have to be thankful for.” They know they have things to be thankful for, but right now they are not important. ● “He’s in a better place now.” The bereaved may or may not believe this. Keep your beliefs to yourself unless asked. ● “This is behind you now; it’s time to get on with your life.” Sometimes the bereaved are resistant to getting on with life because they feel this means “forgetting” his or her loved one. In addition, moving on is easier said than done. Grief has a mind of its own and works at its own pace. ● Statements that begin with “You should” or “You will.” These statements are too directive.

Instead you could begin your comments with: “Have you thought about...” or “You might...”

Source: American Hospice Foundation Offering practical assistance: Grieving persons may feel uncomfortable in asking help from others. But, you can help them with making arrangements for food, after death rites and rituals, calling relatives, handling guests etc.

Provide ongoing support: Grief lasts much longer than most people expect. Grieving persons may need support for months or at times years as they find it difficult to deal with the memories of loss.

One must provide ongoing support over the long haul by meeting them regularly, making phone calls, sharing, and listening to them when they talk about the deceased person.

coping with grief can be an internal struggle or an external struggle

Watch out for warning signs: It is common for grieving persons to feel sad, anxious, confused or disconnected, etc. However, if these symptoms persist or worsen over a period of time, or if the grieving person often talks about ending his/her life, it should be considered as warning signs and you must encourage the person to take professional help to resolve the grief.

With your consistent support, concern and mindfulness, you can help someone pass through the grief process and emerge wiser and stronger.

Your presence matters more than your words!!

Dr. Kavitha Jangam Assistant Professor Dept of Psychiatric Social Work NIMHANS

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How does the mind handle physical pain?

A 30 year old school teacher has been experiencing pain in her arms and legs for two years. There has been little or no pain relief despite taking analgesics.

She has been consulting multiple doctors but there is no relief and the pain is getting worse. When asked about her emotional wellbeing she said she was fine except for the pain. During an assessment she was asked to note down when her pain increases.

She noticed that whenever she is worried, her pain increases and suffering goes up. Of late due to her

pain, she is unable to work or do things which she enjoyed earlier and has been feeling low and losing sleep. Since then her pain has further worsened. This raises an important question, what has pain got to do with emotions?

Pain is not a mere physical sensation!

When it hurts it really hurts!!

Pain is a very subjective experience. Over the years, pain has not remained a mere physical sensation but a complex phenomenon. International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage�. Pain is not just physical sensation but an emotional experience.

The signals sent to the brain get modified by various mechanisms that modulate the way the pain is perceived.

Emotions and pain

Let us say a person sustains a cut on his/her finger, the pain experienced by this individual depends not only on the extent of injury but the attention or focus, emotional state of the individual and also past experience with the pain.

If the person is anxious or feeling depressed he/ she is likely to have increased perception of pain.

Each individual is likely to experience pain in

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different ways as pain is modulated by the factors mentioned above.

In the experience of pain, the body and brain communicate both ways. The brain receives signals of pain and sends out necessary message so as to initiate action from the body. The brain also diverts attention from pain so that one focuses on the external world. When this mechanism is not working properly, pain is more likely to become the center of attention. The neuro chemicals that are involved in pain pathways in the brain are also involved in the emotions. So when the regulation fails, pain increases along with sadness and anxiety. Suffering from long-lasting pain can also bring about changes in the brain itself which leads to perpetuating pain.

Chronic pain and mind

Pain is typically classified as either acute or chronic.

Acute pain is predicted response to an injury where the cause is often evident. Acute pain often resolves quickly with analgesics and treatment of the underlying cause. However chronic pain is pain that lasts beyond the time of healing. In chronic pain, often the cause is not evident and pain becomes a complex phenomenon. Worldwide, chronic pain is a common pain condition that significantly impacts individuals and families. It can result in poor work performance, loss of employment, and the individual can become susceptible to emotional problems. When depression and anxiety coexist with chronic pain, the individual is more likely to have increased perception of pain.

This is probably one condition where mind-body interaction can be easily understood.

Can mind treatments be used for treatment of chronic pain?

Although pain is felt in our bodies, the perception is modified by our mind. The mind and body have a connection - anything that affects the body affects the mind and vice versa. Hence by modifying the person’s emotional states like depression and anxiety, one can produce change in the body itself.

Strategies like distraction, relaxation and effective coping strategies have been used in the treatment of chronic pain. These therapies are often used as an adjunct with other treatments for pain. In managing chronic pain, if psychological and emotional issues are not addressed, one might be merely increasing the dose of analgesics and subjecting the person to potential side effects.

To conclude, emotions do play a role in experiencing of pain and hence this needs attention from the sufferer as well as the health professionals.

Dr. Geetha Desai Additional Professor Department of Psychiatry NIMHANS

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White Swan Foundation for Mental Health Knowledge is the first step forward

As psychiatry progresses in its ability to detect and treat mental health issues, patients continue to hesitate to seek help from the fear of being labeled. Most often, this is due to the lack of proper knowledge about mental health issues. Why is there such a wide gap between recognizing the symptoms of a mental illness and seeking expert help? We spoke to Manoj Chandran, CEO of White Swan Foundation for Mental Health about the need for information to be spread in the mental health space and why the conversation on mental health issues should be in the public domain.

What are the core challenges in the mental health space?

We are aware of the statistic that a staggering 20% of Indians will experience a mental health problem sometime in their lifetime. However, our services, legal and social infrastructures are not prepared to help those who experience mental health problems.

For a country of 1.2 billion people, we have less than 4,200 psychiatrists. The social acceptance of people with mental health problems is nearly absent. They do not receive the emotional, societal support that is so crucial for recovery in cases of mental health problems. The underlying challenge is that there is a near absence of access to information on mental health for the common man. Consequently, we are ill-informed or many-a-times misinformed about mental health and end up developing wrong perceptions and stigma about it.

Why is it important to acquire knowledge on mental health?

It is only through the acquisition of the right knowledge on mental health that we can take the right step forward. For a person in India who is suffering from a mental health problem, the road to seeking professional help is one that is full of challenges. They end up either in denial or hide the symptoms for as long as it is possible. However, access to knowledge and information can provide

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much-needed confidence to reach out and seek help, without bothering about the social challenges that exist.

Why should the common man know about mental health?

In the field of mental health, the role of the common man is very important. The common man forms the social circle that the persons suffering from mental health problems belong to and are influenced by. It is extremely important that people in these social circles are well informed about mental health so that they can play their supportive roles efficiently.

Conversations about mental health and related issues should be out in the open in the same manner that we discuss physical health issues. Each one of us has a role to play in creating a world where people suffering from mental health problems find support and care in their fight to recovery.

How is White Swan Foundation changing the perception of mental health among people?

What can the visitors expect from the portal?

White Swan Foundation for Mental Health is a notfor-profit organization created with the mission of delivering knowledge services in the field of mental health and wellbeing. The first task that we had at

hand was to create a unique knowledge repository on mental health that a common man can easily use to acquire the right knowledge in this field. We recently launched India’s first Internet portal on mental health at http://www.whiteswanfoundation. org . The portal has a rich trove of knowledge and information on mental health that will help remove the myths surrounding mental health. The portal not only provides information on the several mental health disorders but also informs the readers about the need to focus on mental wellbeing. We believe that by acquiring the right information, the people will better understand their role in society and in creating a more supportive environment for those who are suffering from mental health problems.

The team at White Swan Foundation does not have any expertise in psychiatry and its allied subjects. We bring in experience in communication and regularly seek advice from subject matter experts. In order to ensure the factual correctness of our content, each article is scrutinized by a subject matter expert.

Are mental health professionals associated with you? How are you associated with NIMHANS? The White Swan Foundation’s team of content creators works closely with subject matter experts to curate, create and whet the content before they are published on the portal. We are fortunate to have a strategic partnership with the National Institute of Mental Health and Neuro Sciences (NIMHANS) that provides us access to some of the reputed psychiatrists, psychologists and other practitioners in the field of mental health in the country. They not only guide us through the lifecycle of content creation but also help the communication experts from White Swan Foundation team to better understand the subject of mental health and wellbeing.

Is your work limited to content on your portal?

Even as we continue to strengthen the knowledge repository that we recently launched, we have also begun reaching out to the youth in colleges. We believe that there is a need to offer opportunities to the youth to engage in a dialogue on a taboo subject like mental health. We are in the process of collaborating with colleges to create such platforms.

It is through interactions and dialogue that the youth will air their apprehensions, doubts and nervousness and play a positive role.

What will be some of the things to look out for in the coming months?

In the next few months, White Swan Foundation portal will be available in Kannada, Bengali and Hindi, making the rich content accessible to millions more across the country. We will also add new features to the portal that will help readers access latest data on mental health service providers in the country.

There are so many Internet portals on mental health. How will White Swan Foundation portal be different?

Almost all the web sites on mental health are from outside India. They are largely created for readers of their respective countries. For such a sensitive subject as mental health, there is a strong need to contextualize the message, information and knowledge to our Indian audience. White Swan Foundation ensures that our content is relevant for readers and audiences from India. In addition to providing an understanding of mental health issues and mental wellbeing, you will also find several personal stories and narratives which talk about real experiences of patients and caregivers.

Additionally, White Swan Foundation content caters to the knowledge needs of the common man, who does not have any expertise in mental health.

Are you focusing on any particular illness or age group?

The White Swan Foundation portal at http://www. whiteswanfoundation.org and any other knowledge repository that we will introduce in the future will always provide well-rounded information about mental health. The repositories will not be restricted to providing knowledge on a few illnesses or problems but will look at the 360-degree views of all issues. In the first phase of our journey, we are targeting to fulfill the information needs of the youth staying in Tier 1 and 2 cities of India. However, in a phased manner, we will cater to the demands of every individual across all geographies of India.

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Youth Pro

Pro- active youth for pro-motion of positive mental health An initiative to engage youth volunteers:

For popularizing mental health; Working towards enhancing wellbeing amongst peers Fighting stigma & Spreading awareness that mental health matters For whom For youth between 16-35 years of age From any walk of life/any course How Attend an orientation- induction workshop Form Action groups Receive support to do your bit for mental health promotion in the youth community

Youth Pro is an NCWB-Positive Psychology Initiative.

To know about upcoming youth pro orientation programs: Mail to positivepsychology.nimhans@gmail.com

Printing of the Magazine funded by: Dr. Ramachandra N Moorthy Foundation for Mental Health and Neurological Sciences