Counselling for depression: A journey within

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Psychotherapy could not be more unlike the many psychometric tests that are administered to evaluate a person’s aptitudes and skills. The process pertains to the acquisition of  the competencies required for a realistic self-appraisal of one’s emotional state of being. It is intended to help a person take charge of himself  through enhanced self-awareness.

The judgement whether one needs greater self-awareness and the decision to actively seek specialised intervention is itself subjective. A person who feels he needs to stay connected to himself avails of the service of a psychotherapist. Somebody  who finds his daily life directionless, unsuccessful, unfulfilling and unworthy in other ways should consider consulting a counsellor because these mental states can be corrected permanently through developing the requisite emotional coping skills. Conversely, they could prove extremely counterproductive, even debilitating, if allowed to persist over a long period. After all, whether you recognise it or not, how you feel influences what you think and what you think determines what you do or do not do.

Many of us grow up believing that we did not cause the miseries we live through and therefore cannot alter them. Therapy offers an alternative route wherein you begin to differentiate between matters that are within your individual control and those that lie outside your purview of influence. You thus actively address the former and stop agonising over the latter.

A therapist is not somebody who pretends to propose solutions to your problems. Instead, he is one who helps you find your own solutions.Very early in my therapy sessions, the counsellor drew my attention to an important comparison concerning  contemporary life. We discuss current affairs, sport and entertainment with anybody and everybody, he noted. But when it comes to  matters of the mind, meaning our emotions, we treat them, he observed, as entirely and extremely private affairs and consequently give them far less attention and consideration than they merit. These latter are sought to be addressed in therapy.

A therapist is not somebody who pretends to propose solutions to your problems. Instead, he is one who helps you find your own solutions. He is a facilitator of this journey of self-discovery. Its effectiveness or otherwise is entirely contingent upon how you, as a client, approach your interactions with the therapist.

In a typical session, a frank, open and honest articulation of one’s troubles or anxieties often produces the most fruitful results. For one thing, such ventilation is an end in itself. That is to say, it instantly relieves a huge emotional baggage, which is invaluable in its own way. Once cleared of the toxic feelings, the mind automatically begins to focus attention on the problem in a dispassionate and clinical manner. Ventilation is, in that sense, also a means to an end.

It is relatively easy to express one’s anger, sorrow, a sense of betrayal and so on. Conversely, it is that much harder to face up to one’s own shortcomings, flaws, dishonesty, deceit and other aspects of one’s personality. But in the end, somebody who can be honest in relation to both the above aspects stands a better chance of getting a hold over his emotions.

The release of emotions in a therapy session is a structured process of acknowledgement or stock-taking of  what  has happened. A therapist actively listens to what is being expressed. The word active is important here. Unlike family and friends, he does not sit in judgement over what he hears. He is a disinterested party to the conversation. He does not react immediately with statements to the effect that this is right and that is wrong. By lending his ear, he facilitates clarity on the issues that confront a person. One day soon, you will make all those judgements independently, comfortably and confidently. That benefit is something to be felt and experienced first-hand; and over a duration of time.

The benefits spelt out in the above paragraphs, even when they become apparent, do not accrue to your account instantly. They rise to the surface and recede just as quickly as the waves on the oceans. You come out of a session feeling on top of the world. You go back into the next one again with the same seemingly intractable dilemmas. It is hence important to persist in the conversation, session after session, with a view to learn how to  accept the highs and the lows with equanimity.

A competent therapist never becomes involved in the life of a client; he merely engages with the issues that are presented before him. An ethically scrupulous professional is seldom seen chasing clients for the next appointment. That is usually the latter’s call.

The rewards from psychotherapy are both instantaneous and long-term. That is the secret of its efficacy and appeal to those who have the patience to persevere. More important, it is not driven by a time-bound or deadline-dictated programme that a client is expected to complete. It is rather an exercise the individual in question initiates and carries forward at his own pace. Happy therapy.

(The author wishes to remain anonymous)

Depression: The fault lies in classification

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The World Health Organization estimates that more than 300 million people across the world are living with depression. “But that does not mean that all the 300 million people would need medical intervention,” says Vikram Patel from Harvard Medical School and the Delhi-based Public Health Foundation of India. The reason: the current binary classification of depression that distinguishes people as either “well” or “sick” is fundamentally flawed. The binary model is “unsuitable” for depression as there is no clear line that differentiates the miseries of daily life from the disorder that can be treated through medical intervention.

Levels of depression

In the absence of a biomarker that neatly distinguishes healthy and depressed people, the binary model relies on symptoms of emotional well-being — feeling miserable, losing interest in things, unable to sleep, idea of self-harm and feeling profoundly fatigued — and assesses the duration and impact of these symptoms to arrive at a diagnosis.

“The binary model uses the answers to a list of questions and then applies a complicated set of rules to arrive at a diagnosis for depression,” says Prof. Patel. “It uses a set of symptoms without recognising that there might be stages through which the symptoms graduate to a full medical disorder.”

In an essay published in PLOS Medicine on April 4, Prof. Patel proposes a continuum of stages to define depression. At one end of the spectrum are people who are well and do not have any distressing emotional experiences. “But many people have depression-like symptoms in reaction to the trials of everyday life, for example when there is the death of a dear one,” he says. A significant proportion of people now diagnosed as suffering from depression have only mild to moderate symptoms and most often do not need clinical intervention. What such people need is advice on how to help themselves recover and support from friends, community-based workers or the Internet.

IMG_0488When to step in

The next stage is when the distressing experience lasts longer — at least two to four weeks — and severely impacts day-to-day social functioning. This condition needs medical intervention — antidepressants, brief psychological treatments or both, though most of this can be provided through primary care physicians and community health workers. At the extreme stage are the recurrent or refractory depressive episodes where patients do not respond to existing treatments or suffer from relapse. “This constitutes only a small fraction and they need to see a psychiatrist or clinical psychologist,” he says.

Since the model of various stages would dramatically reduce the number of people with depressive symptoms who need medical intervention, the focus of specialists can be to treat severe cases.

Staged model in India

There is a body of evidence to show that with appropriate training and supervision, front-line community health workers can effectively deliver psychological treatments for moderately severe to severe depression, such as the Healthy Activity Program, a six- to eight-session treatment; the results of the study were published in December 2016 in The Lancet.

In the VISHRAM (the Vidarbha Stress and Health ProgRAM) programme in 30 villages in the Amravati district in Vidarbha, central India, the staged model was implemented by providing care for mild stages by community agents, while more severe stages were treated by lay counsellors working in collaboration with primary care physicians and visiting psychiatrists. This led to a huge reduction in treatment gap for depression, according to a paper published in January this year in The Lancet Psychiatry.

Following the study, all the 30 villages have a community health worker “who is trained to detect depression, provide low-intensity psychosocial interventions, and refer the patient to the public health system for further management”.

Published in The Hindu on April 8, 2017

People seeking mental healthcare increased six-fold

DepressionThe proportion of people with depression who sought care increased six-fold from 4.3 to 27.2 per cent in 30 villages in the Amravati district of Vidarbha. The proportion of people who accessed mental healthcare was the same across sex (53 per cent males and 47 per cent females), education, income and religion. As a result, the prevalence of depression among nearly 1,900 participants dropped from 14·6 to 11·3 per cent during this period. The results were published on January 5 in the journal The Lancet Psychiatry.

The prevalence of suicidal thoughts reduced by about 50 per cent — from 5.2 to 2.5 per cent. The actual reduction in the prevalence of suicidal thoughts was only small and was not the primary objective of the intervention, says Prof. Vikram Patel from the Public Health Foundation of India (PHFI), Delhi and the senior author of the paper.

The Vidarbha region has witnessed a large number of suicides in recent years. While other benefits have been extended to people in the region, access to mental care has not been provided. The intervention was carried out by VISHRAM (the Vidarbha Stress and Health ProgRAM), a grass-root community mental health program that has been designed to address the mental health risk factors for suicide (depression and alcohol use disorders).

There were just eight counsellors providing advanced psychosocial care and 39 community workers who helped increase awareness about mental health in the 30 villages. A baseline survey was conducted on nearly 1,500 participants who were randomly selected and another survey was carried out on nearly 1,900 randomly chosen people at the end of 18 months.

“The pilot study has shown that the programme can be expanded to cover the entire State,” says Dr. Rahul Shidhaye rom PHFI and the first author of the paper. “A similar approach pilot tested in one district in Madhya Pradesh under PRIME (programme for improving mental health care) was scaled up last year to cover the entire State.”

In India, 2-3 per cent (13 million people) adults suffer from depression. Yet, only about 4.3 per cent access mental care and nearly 90 per cent do not.

Even lower stress levels can increase risk of cardiovascular deaths, says study

Published in The Hind on August 1, 2012

People suffering from even low, subclinical levels of psychological stress are at an increased risk of death from external causes and cardiovascular diseases, says a study published today (August 1) in the British Medical Journal (BMJ).

The increased risk of death from both external causes and cardiovascular diseases is 29 per cent each

In both cases, a strong evidence of a dose-response effect was seen, and it remained valid even after taking into account factors such as age, sex, body mass index, systolic blood pressure, physical activity, smoking, drinking and diabetes.

Though stress did cause cancer deaths, only higher levels caused mortality. “Psychological distress in highly symptomatic patients was associated with 41 per cent increased risk of cancer deaths,” the authors say.

“The main finding of this study was a dose-response association between psychological distress and mortality from cardiovascular disease, and external causes… even in people who would not usually come to the attention of mental health services,” they write. “A similar association with cancer was seen at higher levels of psychological distress.”

Cardiovascular death

Several stresses have been found to cause cardiovascular deaths. For instance, acute stress can alter cardiovascular physiology, which in turn can result in heart attacks even in those not suffering from any cardiovascular disease. Stress and depression could even result in dysregulation of the hypothalamus-pituitary-adrenal axis. Depression alone affects the body in multiple ways.

“Physiological and psychological responses to psychological stressors are designed to protect the organism but that the body’s response can also have harmful effects on health,” notes an accompanying editorial in the same issue of the journal. “It seems reasonable to hypothesise that not ‘coping’ with psychological stressors will lead to symptoms of depression and anxiety.”

While modifying the source of stress is one way of reducing risk, some people might actually go out seeking stressors. “Chang[ing] the psychological interpretation of stressors might reduce their biological impact,” notes the editorial.

The results are based on a meta-analysis of over 68,000 people aged 35 years and above from 10 large prospective cohort studies from 1994 to 2004. Psychological distress was measured using the 12-item General Health Questionnaire (GHQ-12) score and cause of death was extracted from the death certificate.

General Health Questionnaire is a “widely used measure of distress in population studies,” and captures stresses such as anxiety, depression, social dysfunction, and loss of confidence.

Depression: 15 % prevalence seen in Chennai

Published in the Hindu on October 1, 2009

Depression

Women were found to be more susceptible to depression as they grew older. — Photo: Wikimedia Commons

A study of more than 25,000 individuals above the age of 20 (median age 40) in Chennai found that nearly 15 per cent of them had depression. The results are published online in the Open Access journal PLOS One.

The study conducted by Dr. V. Mohan and others from the Madras Diabetes Research Foundation, Chennai, found that depression was more prevalent in females (15.1 per cent) compared with males (13.9 per cent).

“We studied the general population, and the results are a true representation of Chennai,” said Dr. V. Mohan, Chairman of Dr. Mohan’s Diabetes Specialities Centre, Chennai. “Other Indian studies were restricted only to certain populations, and were not true representations of the general population of both sexes. The number of subjects studied was also less [than 400].”

The study was based on 12 parameters. “A person is said to suffer from depression only if he or she answers ‘yes’ to at least 5 questions,” said Dr. Mohan. “And the individual is asked to quantify the period if his answer is ‘yes,’ to say, inability to fall asleep.”

The study found that nearly 31 per cent of the people studied suffered from depressed mood. This was closely followed by tiredness (30 per cent). Severe symptoms of depression such as suicidal thoughts (12 per cent) were less common.

Several associations

The study brought out several other associations. Depression was found to be inversely related to income and education. In other words, the prevalence of depression was higher among people who had less income and education.

Among women, the prevalence was higher among those who were divorced (26.5 per cent) and widowed (20 per cent) compared with those who were married (15 per cent). Many studies undertaken in developed countries have shown similar associations.

Age appeared to play a significant role. It was found that the chances of getting depressed increased as individuals grew older. Again, women were found to be more susceptible to depression as they grew older.

“Age, marital status, education, income etc are only associations and not causal factors,” said Dr. Mohan.

Unlike what was seen in studies conducted in the U.S., depression did not appear to dip in the middle age of 45 and then start rising again but kept increasing steadily with age.

The higher association between suicidal tendencies and depression (about 12 per cent) was based on the individual’s response to a question of “thoughts about death” than suicidal thoughts in particular.

The high prevalence, according to the authors, could be because unlike other studies that looked at suicidal plans or ideation, the questionnaire used in this study was restricted to “thoughts about death in general.”

“We could only ask ‘thoughts about death’ and not about the individual’s suicidal tendencies,” Dr. Mohan said.

The study did not look into any confounding effects that could affect the results.

Representative sample

People chosen for this study were recruited from the urban component of the Chennai Urban Rural Epidemiological Study (CURES) undertaken by Dr. V. Mohan of the Madras Diabetes Research Foundation, Chennai.

“This is the largest study undertaken in India to determine the prevalence of depression in the general population, and we looked at all strata of the society,” said S. Poongothai from the same Centre, and the first author of the study.

People chosen for this study were from ten zones representing 46 wards in Chennai. The subjects were selected following a set procedure that minimised any selection bias.

The 12 parameters used to study depression

The conclusions of the study were based on a questionnaire where individuals were required to either state ‘yes’ or ‘no’ to a set of 12 questions.

To reflect the conditions seen in India, the internationally used questionnaire was improvised and it contained 12 questions instead of nine. The questionnaire was validated and published in February this year in the Journal of Association of Physicians of India.

The 12 parameters

The 12 parameters used were: Feeling sad, blue or depressed; loss of interest or pleasure in most things; feeling tired or low on energy most of the time; loss of appetite or weight loss; overeating or weight gain; trouble falling asleep or staying asleep; sleeping too much; more trouble than usual concentrating on things; feeling down on yourself, no good or worthless; being fidgety or restless; moved or spoke so slowly that other people could notice; thoughts about death more than usual, either your own, someone else’s, or death in general.