“Depression”, wrote the American novelist William Styron in his remarkable little book Darkness Visible: A Memoir of Madness, “is a disorder of mood, so mysteriously painful and elusive in the way it becomes known to the self — to the mediating intellect — as to verge close to being beyond description. It thus remains nearly incomprehensible to those who have not experienced it in its extreme mode.”
Despite this, perhaps more than anyone before or since, Styron captured the terrifying reality of what someone suffering from clinical depression goes through. (The essay that was later expanded to form the book, is here.) It is an illness defined best, paradoxically, by what it is not. “The madness of depression is, generally speaking, the antithesis of violence”, writes Styron. To that one may add that it is not, emphatically not, the ordinary garden-variety sadness. One cannot simply “snap out of” depression. Although psychiatric medicines supposedly target the symptoms by making available more of certain neurotransmitters in the brain, its underlying biological causes remain a mystery.
As debilitating as depression is, it is made worse for the sufferer by the stigma — having a mental illness is seen as a weakness, a failure of the will, a character flaw. The stigma can be powerful enough to prevent people from acknowledging their own mental health problems. And sadly, some people do not think much of passing pejorative comments because mental illness is, after all, all in the mind. It is, unlike physical disability, not visible to others and is therefore much less acknowledged, even as the WHO estimates that depression will be the second-leading cause of global disability burden by 2020. Thus, the unrelenting despair, the devastating psychic pain, the all-pervading dread, the withdrawal from social contact, the total loss of energy, the general hopelessness and the loss of self-esteem that a sufferer experiences is easily ignored or misunderstood by others.
Here again, Styron puts it best: “One does not abandon, even briefly, one’s bed of nails, but is attached to it wherever one goes. And this results in a striking experience — one which I have called, borrowing military terminology, the situation of the walking wounded. For in virtually any other serious sickness, a patient who felt similar devastation would by lying flat in bed, possibly sedated and hooked up to the tubes and wires of life-support systems, but at the very least in a posture of repose and in an isolated setting. His invalidism would be necessary, unquestioned and honourably attained. However, the sufferer from depression has no such option.”
One of the most effective ways to combat depression, as shown by clinical trials, is a form of psychotherapy called cognitive behavioural therapy, or CBT. In combination with antidepressants, it works for all but the most severe cases.
Dr. Prabakar Thyagarajan, consultant psychiatrist at the Institute Hospital here, is a practitioner of CBT. He consults at the Apollo and Billroth Hospitals and has previously practised in the U.S. and U.K. He spoke to me about depression and mental health in the backdrop of the recent suicide on campus.
Of the students who consult you here at the IIT Hospital, what fraction of them would you say have been diagnosed with depression?
I would say 75%.
So depression is the most common diagnosis among the students here.
Absolutely. I would expand on that a little and say mood disorders. Mood disorders are the commonest.
You mean depression along with anxiety?
Yes. Depression associated with anxiety, or depression as part of a bipolar spectrum. So, mood disorders form about 75%.
(Note: Bipolar disorder is an illness wherein episodes of restlessness, or mania, alternate with episodes of depression.)
How would you compare the prevalence of depression or anxiety among students here at IIT with the same age group in general? I know it’s difficult to put a number on that.
I wouldn’t hazard that. Because one would really need to study that, in terms of figures. But I would say that there is a lot of stress, a lot of loneliness, a lot of undiagnosed depression. And I think, accessing that and allowing people access to services would be a very, very important solution. And the presence in the Hospital of those of us who work to serve you.
To what extent would you say the academic pressure and the environment here contributes to these disorders?
Enormously. Enormously. Because I’ve worked in Boston, where it was a very similar kind of profile at the Massachusetts Institute of Technology, MIT. You had the same issues very often. Part of the problem, as you very well know, is that the people who are very extraordinary in their educational institutions and their homes — and who achieve entry into IIT — when they come into IIT, they find that they’re no longer extraordinary because they’re amongst other people who are equally extraordinary. So that makes it very difficult to take. They’re very competitive and very confident of their abilities — their very superior abilities — but they suddenly find that they’re not at the top. That can be very difficult for a lot of people. There’s also the question of students from outside their own states facing difficulties with language, with cultural barriers.
Homesickness as well, I guess.
Homesickness, loneliness. All these things can certainly contribute. And then the work pressure. I think the pressure to perform is enormous. Another reason for depression is that, for five or six years, during their high school years — between, say, 7th or 8th standard and the 12th standard — they’ve been working so hard to get into IIT. But suddenly, having come in, it’s an anti-climax. Because what they’ve been pushing for all their lives is suddenly not there. There isn’t something in front of them that they need to achieve. And that kind of vacuum is sometimes very hard to adjust to. There’s a vacuum, there isn’t something to push forward to immediately and people kind of don’t quite know what to do with themselves. That’s the kind of situation they find themselves in.
And for a lot of people, of course, I think this is an age where romantic interests arise. They are a major part of a young person’s life. Romance can give you wonderful happiness. But it can also have a lot of disappointments and sorrow. So that can add to the pressure cooker that’s already there.
Would you say that their age — being teenagers or in their early 20s — exacerbates the problems?
Yes. Insofar as romance is something that blossoms at this age, insofar as that contributes, there is an age factor.
From what the students who consult you have been telling you, did their problems begin once they entered IIT, or does it pre-date their arrival here?
That’s a good question. For some of my patients, there’s definitely a pre-existing illness when they come in. For many of them, it is something that started after they came here and for a few of them, very clearly, the precipitant has been romance — disappointment in romantic relationships. For one or two others, it has been very clearly work pressure. For some, it has been a pre-dating illness too.
Does it have anything to do with the kind of students IIT attracts? Introverts maybe, bookish, who are very studious, don’t socialise much and they come here and find themselves in a new world.
Well, we have to be careful not to fall into stereotypes. But I’d say this: In the push to get into IIT, I think a lot of students are forced to become so narrow in their aims and so narrow in their goals — getting into IIT — for about five to six years in school, that a lot of things get sacrificed.
Would you say that their emotional development is sacrificed?
Yes, insofar as social relationships are curtailed as a way of focusing on academic performance and the goal of getting into IIT. Reality is social. Not being able to negotiate social relationships in a wide spectrum, have a wide spectrum of interests, be a well-rounded person, have the ability to sustain disappointments, have the ability to share, to help, or reach out — all of these things. They’re forced into a more blinkered kind of pursuit of academic success alone in the years prior to coming into IIT, and this can set you up to be unable to relate to people, to be unable to talk about it. A lot of people are unable to express themselves, unable to listen to another person’s problems. I think that maybe this becomes a major problem.
I believe you’ve practised in the U.S. and U.K. as well?
I have. Practised about five years in the U.K. and about fifteen years in the U.S. As I was saying, I happened to practise near Boston, I lived in Boston. But there was a very similar profile there at MIT. So I know that in institutions that attract brilliance, they do have this problem.
How does the MIT administration handle this? What systems do they have in place?
They do have an extensive system of professional help available to them. And that’s something that’s very American. Even high schools have a counsellor who’s always available to students. And all colleges too. They have a very comprehensive, professional system. And MIT also attempts to make people all-rounded. So they try very hard to have a lot of the arts. It’s part of the institution, they try to have people widen their skills: music, literature, a lot of things.
But they also, I think, make an attempt to have social programmes that can help students to socialise. And they have professional help with psychiatrists to focus on the students. I think we have a similar system here with Mitr. I think we need to be more proactive, perhaps, in accessing the students and explaining the help available to them.
There was a wonderful system I’d like to talk about. I studied medicine at Christian Medical College, Vellore. They had a system, in my MBBS days, where each staff family would take in one student from the college as a foster child. That was possible because it was a much smaller class. We were 60 students in a class, about 300 students in the entire college. So it was easier. The vulnerable students would then have a foster family, a home away from home. The ability to go some place and have a person who is wiser, older, have someone who is a father figure. That kind of a setup — a family setup — I think, is very wise at least for the more vulnerable students or those who opt for it.
What can we learn from how MIT deals with such issues? What are their best practices that the administration here at IIT-Madras could adopt?
I think it would be a very good idea if the administration here approaches the MIT administration with a view to learning more about the systems they have in place. Such information would be very useful to learn from.
We had this meeting where a few people got together to discuss recent events. Some felt that people have become more individualistic. Students here sit in front of their laptops all day, they are less social than people of their age group used to be. Would you say that’s true?
I think people communicate more because there are actually more ways to communicate. So electronically, there is a lot of communication via Whatsapp, SMS, cell phones, e-mail, or social media. I think people do communicate quite extensively. But how effective that communication is, is worth thinking about. Because sitting across from someone, making eye contact, physical contact, having a relationship, talking to each other, I think insofar as it becomes easier — particularly for people who may be introverted — and more tempting to socialise via the internet, it cuts them away from those who are around.
So you could be a neighbour, somebody who is in the neighbouring room; twenty-five years ago, those kids would’ve gotten together and started talking and gone to the local tea shop. Today, both those children are alone in their rooms and they’re on their computers talking to other people. And I think that’s a problem. There is a lot more communication, it’s wider, but the quality and the extent to which it cuts them away from personal, physical, social contact, that is I think a problem.
You mean, earlier, people would’ve had deeper social relationships than what we have today?
Yes, I think being with someone, talking to them, making eye contact, laughing, talking, doing things together, that has come down. Communication via electronic media has gone up. But the quality of that communication is the issue.
How does one address the stigma of being diagnosed with a mental illness? It is generally perceived as something to be ashamed of, a character flaw, a weakness. What concrete steps would you suggest?
I think that’s a very important question. I would say that more education, more discussion of these issues would be helpful. Especially here at IIT, where you have such bright people, I think raising awareness is critical. It would also help if prominent people would come out and admit that they’ve had issues with their mental health. You could make a list of famous Indians who have gone through such experiences in their life, to show that it is very common and nothing to be ashamed of. People have to realize that this could happen to anybody. Mental illness and mental health lie on a continuous spectrum. They’re not discretized. All of us are neurotic to some extent in various circumstances. I think recognizing that is the key.
Mental illness is an invisible disability. People don’t appreciate that it is a disability because unlike physical disability, it is not readily apparent to people. Again, this is related to what I just asked you: how does one create awareness of this?
I think that’s a very good point. One does not generally accept someone as mentally ill, unless, you know, it becomes very apparent as in the case of psychosis and you’re roaming the streets and so on. And that is the picture that society has of mental illness. That needs to change. We’re all vulnerable.
And far from being a weakness, I think the disabled, whether physically or mentally, are heroes. They show the courage and strength of true heroism, those who battle on in life despite all their disabilities.
Having practised abroad, what would you say are the differences in how mental illness is perceived in the U.S. or U.K. compared to India?
I think the stigma is universal. That’s always there. But elsewhere, I think people are more ready to consult a professional as and when the need arises. It’s not seen as a weakness. People do it all the time when they’re experiencing even the normal ups-and-downs of life, or in times of distress. It doesn’t have to be a mental illness that compels them to consult a psychiatrist. So that difference is there.
If I’ve a friend who I think could be suicidal, what can I do to help? What are the warning signs?
There are warning signs, yes.
Yes, social withdrawal is definitely one aspect of it. Then there are some things the person might say casually, maybe half-jokingly, that you only realize later could have been a warning sign. He or she might say that I’m not going to be around to see this or that, or something like that. Such offhand remarks should be taken note of.
Do you think friends and family can help by keeping an eye out for social withdrawal and other warning signs? Someone who’s depressed may not have the initiative or inclination to consult a doctor. Should a friend take the initiative in taking someone to see a psychiatrist?
I think, yes. That’s very important. If you think someone you know is suffering and may be having suicidal thoughts, I think it’s important to let others know. You could have a network of friends who could keep each other informed about how one of them is feeling a bit down, for example. If you notice it, you must report it to the Warden even if it might turn out to be a false alarm. Maybe your friend was indeed joking when he made that casual remark. You may worry that reporting such things would destroy your friendship and offend him or her, but you must remember that it’s a person’s life we are talking about. I think it’s worth the risk. If it turns out not to have been a real alarm, you can always apologize later on and I’m sure he or she would understand.
There is a tele-helpline here which has been functioning for some time. Do you think such initiatives help? I mean, talking over the phone is not the same as meeting a doctor in person.
That’s true. But I think as a first step, it’s useful to have. One may not always be able to immediately see a doctor. As a first step, I think the tele-counselling is worthwhile. It shouldn’t be a substitute, of course, for an in-person consultation. It can’t be that you carry on with only tele-counselling for a long time. But as a first step, it’s good that it’s available to students here.