The Southern Blues: Demystifying depression in South India

Kartik Bhardwaj and Shilajit Mitra

The new mental health bill is decriminalizing suicide, which happens to be India’s ninth most common killer, beating even malaria. With every 20th Indian suffering from depression — the primary cause of suicide — it’s time to demystify the closeted illness.

Speaking about the theme of the World Health day — ‘Depression: Let’s talk’, Prime Minister Narendra Modi said on his ‘Mann ki Baat’ radio show, ‘We are afraid to talk about it openly. We should change this and encourage people to come forward and share their burden.’

To understand what 350 million people worldwide are going through, let’s start with the basics.

What is depression?

According to the National Institute of Mental Health(NIMH), depression is a mood disorder that hampers how a person thinks, feels and handles daily activities like eating, sleeping or working. “Irregularities in sleeping and eating patterns are the initial signs,” says Amrita Arvind, a psychologist with Mindzone, a mental health clinic in Adyar, a locality in Chennai, “It further comes as fatigue and lack of interest in doing daily chores. Another sign is people not willing to do something they loved pre-depression.”

To understand the gravity of the problem, it’s important to stop using depression as a pop medical term. A number of blogs and sites trick readers into confusing their occasional blues with ‘being depressed’. “The first thing any patient says is that they feel depressed. We tell them that it is for us to decide. Depression is a medical term and such loose usage of it makes patients think of it as a not-so-grievous problem,” adds Amrita.

According to NIMH, there are six forms of depression:

· Major depressive disorder- Severe symptoms that affect the ability to work, sleep, study or eat. The depressive episode can occur only once in a lifetime or a person can have several episodes.

· Persistent depressive disorder- Where the symptoms of major or mild depression looms over a period of two years.

· Psychotic depression- Where the patient suffers with some form of psychosis like delusions and hallucinations along with depression.

· Postpartum depression- Suffered by women after childbirth, due to hormonal and physical changes or being overwhelmed by the new responsibility of taking care of the baby.

· Seasonal affective disorder- It is usually experienced during winters; light therapy is done to medicate such depression, alhough some patients require anti-depressants too.

· Bi-polar disorder- It is not exclusively a form of depression but people suffering from it can have episodes of extreme low moods(depression) and extreme high moods (mania).

Where does India stand in Depression?

According to an article by The Quint, there are only 3 psychiatrists per 10 lakh people in India and only 10% patients suffering from mental ailments get treated. India spends only 0.06% of its health budget on mental health which is even less than that of Bangladesh at 0.44%.

National Institute of Mental Health and Neuro Sciences(NIMHANS) data states that the prevalence of depressive disorders is higher in females(3%) than males(2.3%). People in their forties are the most depressed at 3.6%. Urbanisation has brought in work stress and depression, thus urban metro residents have a higher prevalence of depression at 5.2% than their counterparts.

Source:NIMHANS data

It’s important not to stigmatize people with depression. According to NIMHANS data, various derogatory terms are used in the country for mentally ill people. Terms like pagal, psychic, mental, screw dhila etc. are used in common parlance in various regions of the country.

Scenario in Tamil Nadu

15.1% of the urban south Indian population suffers from depression, alerts a report by the Chennai Urban Rural Epidemiology Study (CURES). Chennai — infamous as the suicide capital of India — alone accounted for 2274 suicides in the 2015 National Crime Records Bureau (NCRB) data. The co-relations are chilling and leave much for enquiry.

“The overall prevalence of depression in Chennai is associated with gender roles, age, low socio-economic status, lack of education, marital life and love affairs,” said Dr. Subramani Poongothai, ‎Research Head (Clinical trials) at Madras Diabetes Research Foundation who led the CURES study on Depression.

The main symptoms among the sample subjects were depressed mood, followed by tiredness, loss of interest and sleep disorders.

Let’s take a closer look at the some of the primary indicators.

Made using Canva

EDUCATION: Citizens with professional/post-graduation degrees have depression rates below 10% while illiterates have a count of 25.6%.

INCOME LEVELS: Income groups higher than Rs.20,000 witness a 7.1% depression while income-groups below Rs.5,000 are at 15.7%.

MARITAL STATUS: Divorced men tend to be less depressive (7.7%) as opposed to divorced women (22%). Widowed men and women both have high rates of depression (29.1% and 26.6% respectively).

Bookings of mental specialists, finds a report by Practo titled ‘Healthcare Map of India’, have increased rapidly. More than 70% of mental health doctors and patients were below 30 years of age. 62% of these patients had complaints of depression and anxiety.

“People living in urban cities have been seeking medical help for major depressive disorder (MDD) which often has symptoms such as loss of interest and enjoyment in practically every aspect of life. Added to this are physical symptoms such as heavy headache, backache, insomnia, difficulty in concentration, restlessness, stomach disorders, heaviness in the chest, weakness and blurred vision,” said Dr Aarti Jagannathan, Assistant Professor, Department of Psychiatric Social Work/ Psychiatric Rehabilitation Services, National Institute of Mental Health and Neurosciences (NIMHANS) to the Economic Times.

Depression in adolescents

Among the top five suicide-prone states listed by the NCRB, three are from south India: Tamil Nadu, Karnataka and Telangana. The union territory of Puducherry had the highest suicide rate in India in 2014.

The age-group most vulnerable to suicides in our country is between 15–29 years. The WHO estimates that every year, around 40 youngsters per one lakh Indians commit suicide.

The leading causes for such a high suicide rate, enlisted by the NCRB, are family problems, drug abuse/addiction, love affairs, failure in examinations and unemployment.

“People fall into abuse drugs or alcoholism to relieve symptoms of depression, anxiety or other mental health conditions. The rate of major depression among addicts is always four times higher than the general population,” says Dr. Mini Rao, a Chennai-based psychologist.
Photo credit- Kartik Bhardwaj

Speaking from her experience, Dr. Amrita Arvind of Mindzone said, “The major issue we have always seen in the city is the struggle to establish oneself. Some people find it very difficult to chose what they want in the careers.”

A complicated romantic life — characterized by successive break-ups within short spans of time, multiple partners and sexual promiscuity — is another major problem among the urban youth. “People often complain of relationship failures. Failed romance often leads them into drugs or harming themselves. Relationship issues are mostly identified with moderate depression,” says Arvind.

The link between depression and academic pressure is also striking. In 2016, the Asian Journal of Psychiatry published a study conducted among 717 students from various Indian universities. The research revealed that 37% of the students suffered from moderate depression, followed by severe (13%) and mild (2%) depression.

In South India, school students in classes IX, X, XI and XII face shocking conditions of depression. A 2015 research by the SRM Medical College and Research Institute, Tamil Nadu revealed that 25% school students (aged between 14–17 years) were grappling with depression.

31% students in class X were suffering from severe depression. Moderate depression was found among 59% students in class XII.

“Adolescence is when youngsters start experimenting with relationships, alcohol and drugs. We start assessment by looking into their behavioural issues at school: were they able to perform academically? Were they able to follow instructions?” says Amrita.

‘Sensitivity’ as a part of an adolescent’s personality also invites depression, according to Amrita. “Highly sensitive people (HSPs) are always vulnerable to depression. An imposing living environment, a higher emotional intelligence, excessive empathy for people’s feelings… such conditions often push HSPs into depression,” she says.

Amrita recalled an incident where bullying and peer pressure had pushed one of her patients into severe depression. Pratik (name changed), a class XI student, was constantly humiliated by his classmates in his new school in Chennai. He was made to stand on his desk while other students gathered around in a circle and laughed at him, without explaining why. This affected his personality deeply — he refused to go to school or any social gathering where he feared his friends might show up. He was diagnosed with moderate depression along with anxiety and insomnia.

Depression in Children

When Rohan(name changed), an eight-year-old kid, otherwise a bright student started scoring bad at school, his parents were worried. He showed irritability and sadness and had stopped doing his favorite pursuit, cycling. When his behavior didn’t change for over a month, his parents decided to take him to a psychiatrist.

“When I asked him to write how he felt on a piece of paper, he wrote ‘I don’t feel like going out. When I do and look at the clouds, I feel like they have turned black. Everything appears to be sad and black. I see colors but I am not able to appreciate their beauty’,” said Ramya Srinivasan, a psychiatrist with Billroth Hospital, Chennai, “Children are unable to verbally describe how they feel, unlike adults. Hence, it becomes important to closely notice any change in their behavior.”

Urbanisation and changing family structures are leading to increased stress amongst children. According to Srinivasan, children in Chennai are forcibly enrolled in various classes to make them ‘all-rounders’. “Nobody asks the child if he or she is interested in music, dance or any other co-curricular activities. Parents are in a hurry to make them excel at everything. Nobody asks the child if he or she is interested in the activity or not.”

“Children these days are looking for instant gratification,” says Srinivasan,” With both parents working, the child is always in need of attention and thus he or she makes unnecessary demands. The parents also fulfill them immediately. Mobile phones and gaming consoles also veil them from the realities of the world.”

It’s important to understand that depression is not entirely a psychological problem but also biological. The decline in serotonin (a neurotransmitter in the brain that channels brain signals) can lead to depression. According to Srinivasan, imbalance in the serotonin which influences brain cells related to mood and sexual desire can cause both anxiety and depression.

“We need to understand that depression can also be a genetic problem. If either of the parents have depressive disorders, the child can also be prone to such disorders,”
-Ramya Srinivasan

Among other reasons of depression in children is sexual molestation. “I attended to a visually impaired girl who was molested at school. She started getting nightmares and didn’t let any male member of her family touch her. She was going through a severe case of depression,” recalls Srinivasan.

According to Dr. Vimal Doshi Virappan from the Department of Psychiatry, Institute of Child Health, Madras Medical College, Chennai, these are some initial symptoms of depression in school going children.

· Sadness, irritability or general dullness.

· Inability to enjoy oneself

· Easy crying

· Fatigue

· Low self-esteem

· Diminished or weak school performance

Depression in Women

Reema(name changed), a middle aged woman living in Bihar had a happy family. She lived with her in-laws. She had a loving husband and two children. Then one day she suddenly left home and got on a train, never to return.

“A lot of women we rescued at are immigrants from other states, especially Uttar Pradesh and Bihar. They just get on any random train and eventually end up in Chennai.These women face a lot of hardships, from being desolate to sometimes being forced into trafficking,” says Dr. S.Priyadarshini, a psychologist with Banyan, an NGO dealing with the mental health of women. “Their mental health further deteriorates in a strange state.”

Family also pays an important role in the mental condition of women. “A lot of times in rural families, due to illiteracy, they do not understand what the woman is going through. If she is not working or being irritable, they think she doesn’t respect her elders. This sometimes leads to domestic violence and that worsens their condition,” explains Priyadarshini.

According to the CURES study of the urban South population, out of a sample of around 25,000 subjects, 3847 people were found depressed. Females had a lead over males by 347.

According to a study titled Depression in women in Indian context by Neena Bohra, Shruti Srivastava and M.S Bhatia in the Indian Journal of psychiatry, 75% of working women suffer from depression or general anxiety disorder. Death of a loved one, or trauma after a mishap are also reasons for depression in women.

“Among the general cases of work pressure and dissatisfaction from work, the working woman suffers from a lot of relationship problems. In most cases break-ups without closures lead women into depression,” adds Priyadarshini.

Depression and stress can sometimes lead to certain psychosomatic(relating the mind to the body) effects. “In one of the cases,” Priyadarshini remembers, “a 23-year-old girl pursuing her PhD had a condition of constantly bleeding from her nose. After analyzing her, we concluded that the reason of her ailment was not admitting the problem. When you don’t address the disorder directly, it can take a toll on your body.”

It’s important to understand that depression is a major problem in India. Most of the time, people don’t understand what a depressed person is going through. Here are some tips from an article by the News Minute on how to talk to people who are depressed.

· Listen to them, don’t criticize

· If they talk about suicide, it’s not attention seeking behavior

· Be empathetic

· Try to get them professional help

After the recent suicide of Arjun Bhardwaj, a 23-year-old who jumped off the 19th floor of a Mumbai hotel, it’s high time we realize that depression is not a ‘phase’ and if not treated timely, it can have major repercussions.