Mental Health — the hidden pandemic

Photo credit: Dan Myers

Part 1 — Enigma and stigma

“There is a slot, I am going to book it”, I yelled out. Within a few seconds, I was furiously thumping the table shouting “How on earth can 150 slots get booked in less than 30 seconds?” Over the last few days, I have spent approximately 5–6 hours per day in front of the computer logging in repeatedly, entering OTPs, and scouting the Telegram app for slot alerts. Add to it the incessant news feed about the ever-rising Covid cases, shortage of oxygen, beds, mismanagement, vaccine production etc. that pops up on my phone and you have a setting that breeds stress and anxiety.

The lockdown plays its part too; we are almost completely cut off from in-person interaction with friends and family that is so crucial to one’s well being and sanity. I generally pride myself in my ability to stay calm and even tempered amidst chaos. When I, who is someone blessed with a fantastic support system and fairly robust mental health, find myself rattled fairly often in these trying times, I wonder how people with mental health issues are coping.

Mental health has almost always come a distant second to physical health when it comes to the importance we accord it. The pandemic, which has thrown our lives off gear, has made us re-look at anxiety, depression, post-traumatic stress and many other mental health aspects that have often been forgotten and brushed under the carpet. Our stressful lives have already contributed significantly to the spectrum of mental health disorders. Unfortunately, the lack of awareness and the stigma surrounding mental health have ensured that people rarely open up and continue to silently suffer. Not only does this lead to individual crises but can also quickly balloon into a massive challenge for the families, workplace and society itself.

Having spent a fair bit of time over the last few years consuming quality content about the brain & mental health, I have realized that complexity of the brain, the design/working of the neurotransmitter circuits and emotional regulation can perhaps never be understood in its entirety. However, over the last 2–3 decades, we have made significant advancements in our understanding of genetics, gene-environment interaction and brain functioning. We certainly have a long way to go before we talk about the functioning of the brain and ‘mental health’ conditions with the same confidence as we do about ‘physical health’ conditions such as diabetes, blood pressure etc.

Although majority of the evidence points to the role of hormones such as serotonin, dopamine etc. in many mental health conditions such as depression and bipolar disorder, the pathways are not yet clearly understood. Many studies have also pointed to links between blood sugar & thyroid levels with mood. Why then, do we continue to give a lot more importance to physical health and not as much to mental health conditions that clearly have the potential to inflict a lot more long-term and wide reaching damage?

Part 2: Many questions, few answers

To try and get an answer to the above question and seek an opinion on how we can boost mental health awareness and improve our society’s understanding, I decided to run a survey. Although the sample size was not large (~50), it was a fairly eclectic mix (both Indian and foreign residents) of doctors, researchers, IT engineers, business professionals, entrepreneurs etc. This sample, I believe, provides a fairly comprehensive and diverse set of viewpoints about mental health and reduces bias. While some (by virtue of their qualification/profession/interest) of the respondents were quite knowledgeable about the topic, it was interesting to observe that almost everyone cared about mental health and had valuable inputs. This perhaps suggests a growing interest in mental health given the current circumstances.

Why is the importance given to mental health less than that given to physical health?

This is quite an important question to ask ourselves. The responses were interesting, too. While a small proportion of responses (10%) suggested that the enigmatic nature of the brain and lack of time (in our stressful lives) are reasons, the majority (~70%) seems to believe that it is mostly to do with the lack of awareness and (right) education about mental health while we were growing up. Further, many respondents felt that our inability to differentiate between ‘normal’ and ‘not so normal’ behavior adds to the confusion. Nearly half the respondents pointed out that this is perhaps because we have never quite cared enough to understand and appreciate the value of sound mental health. Scary, but true, I suppose.

What is our level of awareness when it comes to mental health?

This is a question that warrants a definition beforehand. What is awareness in this context? For a subject as vital as mental health/wellness, awareness is sorely lacking in the vast majority of the population. We may never know the exact cause or the physiology/biology associated with the condition but we can do our bit by recognizing that most mental health conditions are a complex interplay between genes, the environment, and the chemicals/hormones. Nearly 70% of the respondents believe this. More than 50% of the respondents believe they have some knowledge of a few mental health conditions but feel they do not know enough to offer a viewpoint or help someone understand.

A third of respondents believe that they are above average awareness/knowledge wise while around 15–20% feel they are well ahead of their peers. It is, however, quite clear that this sample is drawn out of a certain strata of society that is highly educated, well travelled with excellent exposure to numerous topics. It is imperative that we do our bit to spread the awareness and knowledge among friends, family, fellow professionals, our extended social circle, and finally the larger community.

Why is it difficult to open up about mental health?

Let us face it — nobody likes to be judged. In the context of mental health, it is almost impossible to escape prejudice and misinterpretation. All of us have been there. I, certainly, have been guilty in the past for believing that people going through depression were just plain ‘lazy’ and that the lack of motivation and energy had nothing to do with the condition. Almost 70% of the responses suggest that we have a long way to go before people can open up without fear of judgment. Mental health continues to be taboo in many places and where it is not, it is still misunderstood. Around 25% of the respondents are positive about today’s environment — they believe things have changed and families and workplaces are more encouraging. At this point, however, we can hardly claim we have the understanding and empathy similar to what we have for physical health conditions.

What about the treatment/management?

This is perhaps the single biggest difference between physical health and mental health conditions. The certainty and confidence we associate with treatment of physical health conditions is not quite there when it comes to mental health. Many conditions take years to manifest and are extremely complex to understand and diagnose accurately. For example, there are numerous similarities yet major differences between the depression seen in major depressive disorder versus the depression associated with bipolar disorder. Genome wide studies have suggested that many conditions are co-morbid and some common genes could be implicated. Brain scans may reveal a lot of details but do not perhaps infuse enough confidence to influence the course of treatment. Psychiatrists have to engage, discuss and observe the behavior of patients long enough before deciding on the approach.

There is no guarantee that the medicines will work, though. To add to the challenge, even when medicines work, dosage adherence is a massive problem. Many patients, especially those going through some phases of mood or thought disorders, find that their creativity and productivity is significantly enhanced and refuse treatment/medication since they fear the ‘high’’ phase may end. It is crucial that caregivers work closely with the patients, identify any changes early, and discuss with the medical fraternity/psychologists to ensure correct medication and dosage adherence. We should be extremely thankful that there are extremely high-quality pharmacological interventions available today to ensure a more ‘normal’ life for people with otherwise crippling mental health conditions.

The effectiveness of psychotherapy/counselling is impossible to measure but research does suggest that medication, in conjunction with therapy, seems to yield the best long-term results. More than 80% of the responses in the survey believe it too.

Often, as in case of certain physical health conditions, early diagnosis of mental health issues can be extremely beneficial. Not only does it help in better and more focused treatment but it also represents the best possible chance of recovery. How can we surmount the extraordinary challenge of unmasking conditions such as depression, anxiety and personality disorders that are lurking below the surface of a rather ‘normal’ external demeanor? The answer, again, perhaps lies in early education and awareness.

Can mental health disorders be prevented?

Given we haven’t understood the biology well enough and have a very rudimentary knowledge of the genetics behind mental health conditions, it is quite apparent that the environment is the only component we can influence to some extent. By fostering a very transparent, supportive setting at home, parents will be able to address this bit. While a child may be born with a genetic predisposition to a mental health condition (for example, bipolar disorder and schizophrenia are highly heritable conditions) the chances of the condition manifesting itself later in life may depend a great deal on the childhood environment and stressors one encounters growing up.

An overwhelming majority (80%) of respondents believe that a positive childhood environment is likely to play a massive role in reducing the chances of developing a mental health condition. It is interesting to observe that less than 10% of the respondents actually believe that we have the knowhow to identify and fix the biological/genetic cause to prevent an occurrence.

What can be done to boost awareness/understanding of mental health?

Although the brain has been a fascinating topic of study for a long time, we have only recently started encouraging initiatives that aim to increase awareness and de-stigmatize mental illness. Undoubtedly, thousands of people from previous generations must have suffered silently without treatment fearing backlash and judgment from close ones and society. Despite numerous medical and technological advancements, the modern world is grappling with its own set of stressors and we are now faced with an explosion of mental health related challenges.

Statistically, while women have been more prone to depression and associated conditions, they have also been more forthcoming in seeking help. Men often grow up in a setting that discourages discussing emotions openly (read — it is not okay for men to and tend to hide their challenges. Intervention in almost all these cases is too late. How do we change this?

Almost everyone who responded to the survey feels that we have to start in high school. Our curriculum, which is currently focused more on human physiology and anatomy, must be expanded to cover mental health. It is crucial, more than ever before, for children to understand the nuances of mental health and illness before they embark on their professional journey. Nearly 90% of the respondents also believe that a congenial setting plays a significant role in encouraging transparency and promoting open discussions on mental health challenges/issues.

Several startups have sprung up in the mental health space over the last few years and many of them offer one-on-one counselling, corporate tie-ups and awareness sessions etc. Nearly 50% of the respondents believe that we must encourage more such startups and facilitate interactive expert-led sessions in large companies and apartment complexes. In addition, quality media resources (books, movies, documentaries and videos) need to be made available in easily accessible repositories.

What does the future hold?

Evidence suggests that we are doing better now than we were five years back and the trend will continue. Nearly 50% of respondents believe that gene identification, new pharmacological discoveries and improved treatments may be a possibility considering the exceptional progress we have made in the last 1–2 decades. While there has been some acceptance on the health insurance front, top insurance providers must revisit their policy definition to expand coverage to pre-existing mental health conditions.

Perhaps, more crucially, 75% of respondents believe that as a society we will become more aware and accepting of mental health thus encouraging people to be more open about their challenges. A large proportion of respondents (~70%) also feel treatment and therapy will be far more accessible. Although a minority, the pessimistic view does exist — they believe we are at least a generation away from a paradigm shift in thinking in the context of mental health. It is squarely our responsibility to setup a learning environment that nurtures a well-informed, empathetic generation that is not only willing to talk more openly about mental health but is also focused on passionately driving awareness.

What next? We can perhaps start encouraging more discussions — both one-to-one and group. Engage experts to deliver sessions. Work closely with individuals who are more knowledgeable and aware to boost our understanding of this vast topic. Read more, watch relevant videos and documentaries and access resources that will help us build empathy. Let us understand that while mental health conditions/illness are complex and seemingly incomprehensible, they can be treated and managed extremely well if diagnosed early. Undeniably, early diagnosis is possible only if the individual feels encouraged to open up to his/her social circle without the fear of judgment or stigma. We owe this to the millions who have suffered and continue to suffer from this ‘hidden’ pandemic.

Useful resources

Over the last few years, I have taken a few courses and accessed various books, websites, & videos/documentaries to enhance my understanding of mental health. As is always the case, one stands to learn the most by discussing with experts and other interested folks. Here is a short list of resources I found very useful.

Books

1. An Unquiet Mind by Kay Redfield Jameson — Simply put, one of the most fascinating writing I have ever come across. The quality of writing is exceptional, the emotion is raw and the optimism amidst the gloom shines through. Highly recommended.

2. Against Depression by Peter Kramer — From the man who wrote ‘Listening to Prozac’ — this is a very in-depth look at depression and the associated challenges

3. The Gene by Siddhartha Mukherjee — highly readable introduction to genetics

4. Behave by Robert Sapolsky

5. Books by Oliver Sacks and V. Ramachandran — more from a perspective of understanding the brain and its functioning

Courses (all on Coursera)

1. Social Psychology

2. Behavioral Genetics

3. Genetics and Evolution

Videos/documentaries

1. Troubled Minds — the discovery of Lithium as a treatment for bipolar disorder

2. Robert Sapolsky’s Stanford class videos

3. Decoding Depression — Harvard Mini Series

Web resources

1. American Psychological Association

2. American Psychiatric association — publish the Diagnostic and Statistical Manual of Mental Disorders (DSM) — a reference guide to improve diagnosis and treatment

3. Web MD

4. Healthline

5. Mayo Clinic

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