Depression
Dr. Sayee Kumar sees students with depression rather frequently nowadays.
Parents often show up at the part-time therapist's office describing how their child's symptoms have become “quite disturbing to them or others.” The parents tell Kumar their child throws things, often expensive mobile phones, in moments of rage and talk about attempting suicide.
Dr. Kumar says children don't communicate the same way adults do when it comes to expressing emotional distress. The American Psychology Association says that youth of all ages, but especially younger children, find it difficult to recognize and verbalize distress. In his experience, if a child or teenager has depression, it generally goes unnoticed until an incident or group of incidents occurs. These are behavioral symptoms or behavioral problems, according to Kumar, who has over 30 years of experience as a therapist.
“So the moment the behaviors are changed, then the school and the family will take note of it and then they land up with us,” says Kumar. “Especially after some critical incidents. For example, if they talk about suicide or attempted suicide. Or if they develop any other kind of conversion symptoms.”
A conversion disorder is a psychological disorder that occurs when a person's internal stress and anxiety show up in strange behavioral ways that cannot be explained by a medical examination. In the town that caught Tourette's, many psychologists believe that it was a case of conversion disorder. So Kumar sees students who come into his office with involuntary movements caused by the physical expression of their internal anxiety.
Sayee Kumar
Kumar then takes their initial complaint and investigates further to figure out the underlying issue in order to treat them.
Another thing about depression that prevents it from making itself known to others or to society is that, because it's a mental health issue surrounded by a lot of stigma, it only expresses itself vividly or noticeably in cases of moderate or severe depression, according to Kumar.
Sanjay Gupta on Everyday Health said that symptoms of depression such as feeling hopeless, guilty or sad are not readily visible to others, unlike symptoms of physical illnesses.
But without many noticeable symptoms of a mental health disorder, cases such as depression often go without getting detected. Depression tends to prevent even the person affected by it from recognizing the problem, Kumar said.
“Mental health should not be considered only in terms of serious mental health problems,” Kumar said. “It should be considered as a normal problem that anybody can go through. But the problem is that everybody needs to know when it is going out of their control. But then that is a challenge because it is a decision-making ability of a person - that itself is impaired so how the person will be able to decide?”
This inability to recognize the problem is what led Divya Prabha, Kumar's daughter, to suffer with depression for years before she finally realized she needed to do something about it and seek help.
Contributing Factors
Psychology uses a multidimensional, integrative model to explain the causes of psychopathology. This means that it is a combination of genes, emotional and cognitive factors, social and environmental factors, and behavioral factors that influence the cause of a disorder. Discussed next are some of the major social, environmental and behavioral influences contributing to the depression experienced by the people I talked to.
Academic Pressure
“My parents were, like, pressurizing me to study a lot,” said Shruthilaya Hariharan, a second-year Bachelor of Engineering student at Anna University in Chennai.
When students reach their 10th and 12th standard years, the board exam years, it is common for academic pressure to build up. The pressure to get the highest possible marks in the board exams and get an acknowledging rank in your school or your whole state comes from parents, teachers, as well as from the student’s own goals and mindset.
Shruthilaya Hariharan
Switching boards and not meeting expectations
This pressure is not limited to the board exam years. In Hariharan’s case, she faced this during her 11th standard year as well.
“I was scared that I won't meet their expectations,” she said, the emotion of fear trickling into her voice. “I was scared I'm not meeting my own expectations of myself because I got really good grades in 10th. I felt like a failure for a lot of time because the first few months I was trying to cope up with state board thingy and all and I was not good at it. I got like comparatively less marks and I was feeling more anxious and all.”
Having switched from the Central Board of Secondary Education (CBSE) to State Board in 11th standard, Hariharan was already struggling with adjusting to the new curriculum pattern. This added stress and anxiety to her already present fear of not meeting expectations set for her both by her parents as well as herself.
There is already a stigma existing in Indian society that the depression students are experiencing is due to academic pressure and stress, which I observed may lead to a closed loop. However, it is important to note that while academic pressure is surely a contributor, the multidimensional model of psychopathology and the other factors discussed here show that stress is only one of many factors that influence the development of depression.
Calls to helplines spike around exam time
Connecting NGO, a suicide helpline in Pune, told the Times of India in February 2018 that they receive the most calls during exam seasons: February through March, and June through July, and the callers are usually 15 to 25 years old. This means that their callers are mainly high school and college students.
“Most, if you see the suicide record of students in Tamil Nadu,” Paveethran Ravichandran, a third-year engineering student at Anna University, said, “mostly it'll be because of their studies. Education. Because accordingly to people here, for them, those who score good marks, they'll go to a good college, like that. So if you didn't get enough mark or if you didn't get what you wanted, education wise, they attempt suicide.”
The phenomenon Ravichandran talked about happens every year during exam and results seasons. When students in India who didn’t perform as well as they wanted to or were expected to, they may attempt suicide.
The domino effect is very much understood by Indian society, in fact to a detrimental extent. The belief is that if you get good grades, you get into a good college or university, and that will lead you to land a good job. A good job means good pay, which means a happy and comfortable life in the future for you and your family. This end goal is what has historically led Indian parents to pressure their children into becoming doctors, engineers, or lawyers.
Whenever I tell Indian aunties and uncles that I am studying journalism, I am often met with surprised expressions. Once, when I told someone I am majoring in journalism, they exclaimed, “Oh, so you’re the atypical Indian!”
But due to the domino effect, students and society alike attribute bad grades in your board exams to affecting the rest of your life, which is a lot of pressure to put on 16 and 18-year-olds.
Loneliness
Hariharan switched boards after 10th standard. Moving to a new school was met with loneliness and a lack of friends.
“When I was in 11th, I didn't have any friends, she said. “New school and all. And I just felt lonely since I had no one.”
Not having anyone to talk to, on top of the stress, anxiety and fear from academic pressure she was dealing with, is what Hariharan said led to her depression.
Social Anxiety
Contributing to loneliness, the fear of talking to new people and making friends in a classroom full of strangers is something Ravichandran faced.
Ravichandran went to a school that had both CBSE and State Board syllabus in the same school for 11th and 12th standards, but on opposite sides of campus. When Ravichandran realized all his close friends who he had studied with since 6th grade were choosing to continue in CBSE for 11th and 12th, he tried to convince his parents to let him take CBSE too, but to no avail.
“I was like, ‘I'm going to take CBSE,’” Ravichandran said, “and they told that, ‘No, it's not a good option’.”
The main difference between CBSE and state board is that CBSE requires the students to apply their knowledge whereas state board exams require the students to write word-for-word whatever the textbook says on their answer paper to get marks. The results for state board exams come out earlier than CBSE exam results, which affects student’s ability to get admission in college because seats start filling up quickly after state board results are out.
“So taking State Board is the best idea,” Ravichandran said. “So I had no other choice, so I took State Board and I had no friends. I was so alone.”
Paveethran Ravichandran
Studies indicate that social support is an important factor in one’s resilience to stress and maintaining physical and mental health. In periods of high stress and pressure, such as the board exam years, having a support system of friends can be crucial.
When I asked Ravichandran whether he attempted to make friends in his new class, he said he didn’t.
“I'm socially awkward,” he said. “I didn't want to talk with any one of them. Because I didn't know any - It was scary to me. They had… I just - whenever I see them, they… I felt like they are staring at me. So I was like, 'Oh my god, what is this’?”
He went on to say that this isolation was the biggest contributing factor to his depression.
“Most of the time I felt alone,” he said. “That's the thing that's coming to my mind. I was alone and I just hated everything, whatever that was going on to me. Like, whenever I go to school, I was like, 'When this day is going to end?’ That'll be the only thing that's running in my mind. So I'll just continue the day because I had to go. I had no other options. So I just stayed there. I don't know what to do and then... I was just there.”
Physical Illness
The trouble started with a single mosquito. It changed Anton Abilash Netto’s entire life.
When Netto was in 10th standard, he was suddenly diagnosed with dengue, and not expected to live. He said doctors were astonished he was even able to stand when his parents brought him to the hospital.
Netto survived the dengue, but he was left with rheumatoid arthritis, an autoimmune disease, and a life full of pain in every joint in his body.
“Actually every day I have to push through my limits and suffer - I have to suffer for everything.” Netto said. “And because of pain, I get depressed.”
Anton Abilash Netto
Chronic pain and suicidal ideation
The constant pain and not knowing how to control it has even led Netto to suicidal thoughts.
“Even one time, I went to the terrace and thought, ‘Why should I live?’” he said. “That one second, if I think that I should end my life…”
His voice trailed off.
“You didn’t, but, you don’t,” I said.
“I don't, because I don't want to lose to this world,” he said. “Because if I die, I lose myself. That's all.”
And now his only wish is to live a single day without any pain.
“There's only one wish for me,” Netto said. “At least a day, single day, without pain. I don't hurt, I have to enjoy with my friends, walk freely without any pain.”
Inability to Accept Failure
Netto’s life was going great until the dengue and resultant rheumatoid arthritis hit. A star student, he said he was expected to achieve the state first rank in 10th standard.
However, due to the hospitalization and the following recovery process, he was forced to be held back a year and repeat 10th standard.
Not wanting to let the arthritis take over his life, Netto worked hard to achieve a score of 495/500 in his 10th standard board exams. Scoring 99% is difficult enough already, and I was absolutely blown away by the fact that Netto was able to score that, given his circumstances.
But even that felt like failure to him.
“I don't accept failure because I don't go back on my word,” the avid anime fan smiled as he quoted Rock Lee from the famous anime and manga series “Naruto”.
Even as Netto told me his story in that Cafe Coffee Day shop, I saw his eyes well up and him hold back tears multiple times. I realized even crying, showing that emotion, acknowledging that pain, feels like accepting failure for him, which he later confirmed.
Family Problems
Netto mentioned that family problems are also a major cause of depression. He described a news story where a boy in Tirunelveli who was preparing for his NEET examinations committed suicide after being upset over the frequent arguments with his reportedly alcoholic father, despite multiple attempts over five years by the boy to convince his father to give up alcohol.
Netto also mentioned problems within his own family.
He talked about his uncle, who survived a serious train accident, and multiple accidents and deaths in his family. Stressful events like that are contributors to Netto’s depression.
Family History
The multiple accidents and deaths in Netto’s family lead to his mother being depressed for many years, he said.
According to a paper on NCBI, numerous twin studies, linkage studies and association studies show that genetics play an important factor in the development of Major Depressive Disorder. The seventh edition of the “Essentials of Abnormal Psychology” textbook states that having a family member with depression has shown to increase the likelihood of you experiencing a major depressive episode.
In fact, Kathleen Hall on Everyday Health stated that having a parent or sibling with MDD makes you two to three times more likely to develop depression than someone with no family history.
So the fact that Netto said his mother clearly suffered with depression for years put him at a higher risk for depression as well.
Suicide or Attempted Suicide by a Close Relative
“My cousin said she wanted to suicide,” Hariharan said. “She actually brought a knife to her wrist and then she was like, 'I’m gonna cut my hand,’ and then her mother apparently convinced her not to do it.”
Family history of suicide is another known risk factor for depression and suicide. While Hariharan’s cousin did not go through with it thanks to the intervention of her mother, Netto was not so lucky.
Netto said his older cousin, his aunt’s daughter, was like him. He said she was depressed even at the young age of 10.
Netto described how his cousin was a very timid girl and that her parents never seemed to care about her. He said that despite having a lot of money, his cousin’s parents never wanted to spend money on her.
Because of this, his cousin was very close to Netto’s mother instead. Netto and his mother would go visit his cousin whenever she was in town.
“She just hugs my mother and she'll cry a lot and she'll say, ‘No one is caring me,’ like that,” Netto said.
Anton Abilash Netto
In January 2017, during the Pongal holidays, Netto’s mother asked him to text his cousin, who they hadn’t seen in two years. His cousin worked in Trivandrum and often wouldn’t tell her family when she came to visit, choosing to stay at friend’s houses instead. Netto’s mother told him to tell his cousin that their grandmother is on her deathbed, hoping that will give her the incentive to come visit.
At the time, Netto said there was an ongoing quarrel between his father and his aunt. However, Netto stressed in his messages to her that they didn’t want anything to do with that ongoing argument.
But she didn’t respond to texts or calls. Frustrated, Netto asked her if it’ll kill her to call back. One week later, he received the news.
“Treena is dead,” Netto said, the helplessness evident in his voice. “I was speechless. I don't know what to do at that time.”
Netto then said he felt like he heard voices that day when he asked Treena if it would kill her to call him back. He said he ignored those voices, thinking it was strange. The way he described it, it felt like he was feeling responsible for Treena’s death.
“Even after a month, I was like, thinking that if I called her, she would be alive,” he said. “ If she comes, we can do something.”
Netto stated that Treena’s death was part of the reason for his depression. However, it didn’t make him consider suicide himself because he considers it a cowardly act.
Normalization of Self-Harm
Divya Prabha, a third-year sociology student at MOP Vaishnav College for Women, talked about a troubling behavior that caused her to not be able to recognize her own problem throughout her school life. The normalization of anxiety, depression and self-harm.
“I mean like, if you ask around, you'll probably notice that there are a lot of kids, and like, self-harm is a very common thing here,” Prabha said. “Like that’s something people don't even take seriously. So as a result, really bad things like having anxiety, depression, or self-harming behavior, or manipulative behavior, something that could be potentially harmful, it's normalized. And it's not recognized in other people. Either for lack of awareness, or it's because people aren't comfortable with confronting that something might actually be wrong.”
Divya Prabha
Prabha, who went to a Kendriya Vidyalaya school, mentioned that it’s something she noticed is more common in government schools and schools with people from a socially backward background.
She recalled a time when she regularly talked to her cousin brother, who lives in Kumbakonam, when he was in 9th or 10th standard. She said he used to talk about things like his friends cutting themselves pretty normally, and that was very disturbing.
“And the thing is even I was normal about it - it's only now that I see how problematic that was,” she said.
Although she’s not sure how widespread this problem is, Prabha said the reason for this is that students don’t even consider self-harm as something that is wrong, problematic, or as something that warrants concern.
Experiences
During depression, there are a number of things people experience that are common as well as unique to the experience of students in India.
Learned helplessness
One of the psychological factors that affect depression is the emotional assault on oneself, according to Kumar. He said that when someone with depression doesn't have a positive attitude toward themselves or a healthy personality, they end up being unable to find a meaningful way out of their situation. They develop learned helplessness. They end up feeling helpless to the extent that they find it threatening to make any kind of change to their lives and get over their depression.
“They feel it is better to suffer than to struggle and then survive later,” Kumar said.
Sayee Kumar
Psychologist Martin Seligman suggested that people become anxious and depressed when they decide that they have no control over the stress in their lives, leading to the development of the learned helplessness theory of depression.
For such people, Kumar says that learned helplessness becomes more of a coping mechanism and is one of the important psychological factors contributing to depression.
Double depression
What's more, he said that this can even result in double depression sometimes, which is when a person has persistent depressive disorder, and then has major depressive episodes occur on top of that.
To put it into perspective, Kumar explained that it's like having a fever, and then diabetes at the same time.
According to Kendra Cherry on Very Well Mind, learned helplessness can worsen depression, anxiety and loneliness.
Loneliness: being avoided
Hariharan already said loneliness contributed to the beginning of her depression. Loneliness also played a role in her experience.
Besides the fact that she said she had no friends in her class, people also avoided her like the plague.
“Having someone to talk to would have been nice,” Hariharan said. “And people knowing that it's not some illness or something, it's not a communicable disease or something - I wish they would have known. I wish my friends knew that it's not some disease or something like that. They avoided me like I had some malaria or something.”
Hariharan said that even when a handful of people, including her best friend, tried to talk to her, they didn't seem to know how to help her. All they could do was make small talk. She felt like there was no one she could really reach out to, mentioning frequently that she didn't have anyone to talk to when I interviewed her.
Shruthilaya Hariharan
Wanting to keep sleeping
Hariharan also said she didn't want to leave her bed when she was experiencing depression. She said she just wanted to keep sleeping because she didn't want to talk to people or interact with anyone.
Prabha, who is undergoing treatment for her clinically diagnosed depression, also experienced the same thing and had copious amounts of sleep.
“I spent hours sleeping,” she said. “And it wasn't the kind of fulfilling sleep, it was just sleeping because I didn't want to do anything else.”
Crying and being unable to reach out to her parents
Hariharan also said that she noticed she spent a lot of time crying without knowing the reason.
“I was crying half the time and I didn't know why,” she said.
Hariharan described how her parents chalked all her behaviors up to just a teenage phase. But whenever someone said that she'd get over it soon, Hariharan said she got more stressed out, wondering what would happen if she actually doesn't get over her depression.
Whenever Hariharan did try to talk to her parents, they talked more about the effects of her behavior on her academics than her general well-being.
Ravichandran said he didn't even try talking to his parents about it because he didn't want them to worry or get stressed out about him.
“My parents,” he said, “all they wanted was me to get good marks. So I didn't want them to get stressed by saying that I am depressed. I just kept it to myself.”
Ravichandran also recalled that he didn't even talk about it with his older brother, who he said he's normally comfortable with. He just kept thinking it'll get over soon and didn't talk to anyone about it.
Only talking about it when it finally went away
It was only a couple years later when Ravichandran started college that he finally opened up about his depression. He said that by that time, he didn't feel depressed anymore.
“After 12th, when I started meeting new people in college, I started talking about that I was depressed and, I don't know, I felt comfortable after I came out of the depression,” Ravichandran said. “Because I crossed that, so I felt that now talking about depression might make me feel even more better.”
He said he feels that talking about his depression from the point of someone who has dealt with it might give people comfort and hope to have the willpower within them to fight it.
Functional when busy, but not when she had free time
For Prabha, college was the turning point in her experience with depression.
High functioning depression is a kind of depressive disorder described in the fifth and current version of Diagnostic and Statistical Manual of Mental Disorders, popularly known as the DSM-5. The DSM-5 is used by psychologists in the United States to diagnose psychological disorders (internationally, psychologists use the ICD-10). As the name suggests, it is a form of depression where the person is still able to carry out their day-to-day activities without much effect from the depression.
Prabha said that in school she was functional to a certain level. It didn’t stop her from going to school or performing well in exams. School kept her busy.
“But college, it took a really weird turn,” she said. “Because I had a lot of time on my hands and I didn't know what to do and like I actually started feeling things.”
Comorbidity with anxiety and a toll on her functionality
Another thing Prabha experienced was anxiety.
Due to the similar nature of the symptoms for depression and anxiety in the DSM-5, there is a lot of comorbidity, or the presence of two psychological diseases at the same time in a person.
“So it's just that one thing affects the other,” Prabha said. “So my anxiety could make my depression worse, and vice versa. So I realized that I was reacting badly to situations that really didn't warrant the reaction in the first place. And I spent hours sleeping. And it wasn't the kind of fulfilling sleep, it was just sleeping because I didn't want to do anything else. And I didn't shower, like my personal hygiene was really bad and I had to cut off my hair because I didn't wash my hair for weeks, stuff like that. It basically took a toll on my functionality.”
Suicidal ideation
One of the other major things Prabha experienced was having suicidal thoughts, although she said she didn’t try anything.
According to Ishita Goeal from The Indian Express, depression is one of the leading causes of suicide in India.
“I've had thoughts to a point where it's just, like, impossible for me to do anything else except think about that,” Prabha said. “And sure, thank God I didn't really have the courage to do something… whatever. But having the thoughts is really bad.”
Parent’s Reactions
Lack of appetite
“Like I'll be eating and I'll be like, 'What if I don't eat for 10 days?’” Hariharan said, describing how she went through phases of losing her appetite and not eating when she experienced depression. “And then I'll actually do that because I just wanted to try it out.”
When I asked her how her parents reacted to that, she said her parents talked to her about it, but in a way that emphasized the effect it would have on her ability to study well, which made it seem to her that her parents didn’t really care about her.
“They'll be like, ‘If you're not eating well, you can't study,’” Hariharan said, “which will be like, ‘Okay, you don't care.’”
Prabha too got away with not eating most days. She spent most of her day at school, so she had both breakfast and lunch outside of home, with no one to monitor whether she was eating or not. The only meal she had at home was dinner, which is generally a lighter meal for people in India.
Prabha’s parents too noticed that she wasn’t eating, but they didn’t try to talk to her about it. Instead, they associated it with being just a teenage phase rather than a mental health issue.
“I think they just thought it was something that kids do and something they have to put up with,” she said. “They thought I was exclusive from the whole mental health situation.”
Self-harm
Prabha also engaged in self-harm when she was in 10th standard.
“I remember I was really really angry and helpless - I was super helpless,” Prabha said. “And for some reason I thought that harming myself would be a release of some sort, I guess? I don't know.”
Self-harm involves purposely inflicting pain on oneself, and one of the most well-known methods is cutting with a blade or knife.
Prabha said that people try self-harm for various reasons.
For some, it is a coping mechanism. People who attempt self-harm have control over the pain they are inflicting on themselves, and that helps them regain a sense of control and predictability over their lives. Losing a sense of predictability actually causes a number of psychological disorders.
Prabha also said that some use self-harm to compensate for a lack of attention. But for her, the reason was anger and pure impulsivity.
“For me, it was more like I was really really angry and I just wanted to like find a release,” she said. “And I know for a fact that like once I finished doing it, I regretted it. So it was like a very impulsive thing.”
Divya Prabha
I asked Prabha if she ever thought about the fact that she is causing herself more pain when she is slashing herself, to which she said no, she never thought about that.
But did her parents notice?
Prabha said it was pretty obvious that she had wounds on her hand, but her parents never said a word. They either didn't notice it, or they noticed and chose not to react to it.
This leads to another problem Prabha still faces today: talking to her parents about depression.
Talking about depression
Prabha said that although she and her parents still function as a family, they aren’t actively supporting her and it’s still weird for her to have this conversation with them. Her parents make sure that she is comfortable and make sure they don’t do anything that make her feel bad, but depression is still an uncomfortable topic in her home.
“We function as a family and everything,” she said, “but we never talk about this kind of personal stuff out open with each other.”
At Schools
No one to talk to
Both Hariharan and Ravichandran described loneliness and having nobody to talk to at their school. They both said there were no counselors in their school they could open up to.
“It's something like general knowledge,” Hariharan said. “Like, it's common, and if people are experiencing about it, they should come out and talk. And when people do come out and talk, we have to listen to them, because that's one thing we all want it. When I was depressed, I wanted someone to listen to me. And I realize that no one was there to listen to me, to my fears and everything. So it would be nice if someone was there.”
Shruthilaya Hariharan
In Prabha’s school, the PT teacher was made the counselor, so although Prabha said his intentions were good, he was unable to provide professional help.
Schools are unfamiliar with the concept of mental health and normalization
“To be honest, most of the schools here, people aren't even familiar with the concept of mental health, let alone recognize the symptoms and provide help,” Prabha said, which prevented her from even being able to realize that she and her friends had problems when they were in school.
Not knowing about mental health or what depression even is, the experiences and symptoms felt by Prabha, Hariharan, Ravichandran and Anton all tend to be normalized in schools, with students taking it as the norm, like Prabha described in her school. This is bad because it can prevent students from seeking out and getting the help they need.
“Throughout my school life,” Prabha said, “I thought that I was normal, and I didn't have much of a problem.”
When They Realized They Had Depression
When I was in school, I felt like depression was almost like a rite of passage. I didn’t even know what depression was until 11th standard.
Hariharan didn’t realize she had experienced depression until it went away, and she didn’t get a clinical diagnosis of depression. Looking back, she said she always thought she just felt sad, but now thinks she was a little too sad for it to be considered normal sadness.
According to the diagnostic criteria, if a person experiences a depressed mood and/or a loss of interest or pleasure in activities, and at least 3 of the other symptoms listed in the DSM-5 for a continuous period of two weeks, they can get a diagnosis of depression.
Although Ravichandran was also not clinically diagnosed, he said he realized he had depression when he was in school, when he saw that he was lonely but also too scared to approach his new classmates to make friends with them.
Paveethran Ravichandran
It’s not easy to go see a therapist or psychiatrist about depression in India, what with all the stigma, which is why it is not uncommon for people like Hariharan and Ravichandran to go through their experience with depression without ever getting a diagnosis or seeking treatment.
Kumar said that even if a person doesn’t get a clinical diagnosis of depression, it is important to take them seriously.
“It is important because they are making an act of self-disclosure no?” Kumar said. “So that’s important for others to make a note of it, people who are in surroundings and friends and family and relatives. That’s important.”
The Stigma
Even if someone knows they have depression, they face a battle with the stigma.
“Stigma - social stigma - has got a very long history,” Kumar said, tracing it back to when people with physical illnesses like leprosy, tuberculosis or HIV, or social issues like poverty and prostitution were isolated from society due to the heavy stigma. “It's quite easy for the society to instantly label, if you go through many of the social psychology theories, how isolation occurs forcibly by the society for the another person. So it seems well explained that social stigma is something quite very important for the topic of mental health.”
“Young people can’t be depressed”
Netto described that people in India tend to think young people don’t, or shouldn’t, experience depression. He said he’s heard people say that only married people go through depression.
“They say, ‘Indha vayasile unakku enna da depression,’ like that. (At this age, what depression do you have?),” Netto said. “They are not even considering that we are also humans, we too go through depression.”
Anton Abilash Netto
But Kumar said that depression should be considered as something normal that everyone goes through. They shouldn’t be isolated because of it.
“You shouldn’t talk about depression”
Even opening up about depression is a challenge because it’s considered something so dark that people don’t, or shouldn’t, even talk about, everyone said when I talked to them.
Ravichandran didn’t even talk to his friends about his depression. I asked him why.
“I don't know, maybe,” he laughed, “I was too like, ‘Talking about depression is not a good thing,’ and just maybe I think like that, maybe because of the society? I don't know.”
So he didn’t even open up to his friends because he felt like it was something he shouldn’t talk about.
“It’s just a phase, stop seeking attention”
Hariharan heard a lot of people tell her it was just a phase. She said that when people talk about depression in India, it’s not taken seriously. Especially if you try to talk to adults.
People tend to say things like, “Just get over it,” “It’s not that important,” and “You don’t need to focus on that; focus on your career and life goals and the depression will automatically go away.”
One of the problems associated with depression is calling people who try to talk about their experiences as attention-seeking. This is problematic because Prabha said that, besides never really feeling comfortable talking about it, she didn’t feel like she even could talk about concerns for her mental health within her circle of friends.
Depression can affect a student’s ability to perform well in school, because symptoms in the DSM-5 include a diminished or absence of pleasure in activities as well as a difficulty in concentration. But when depression starts to affect a person’s academic performance, it is often mislabeled as simply slacking off.
To adults, Hariharan said depression is like it's something that young people invented by themselves when they are not sad and satisfied with our life.
“If someone says that they're depressed, the first thing what youngsters would do at this age will be like, 'Are you okay? Do you want to talk about it?’ they'll ask,” she said. “But if we talk to people who are older than us, they'll be like, 'It’s common. The more you grow up, the more you'll experience sadness in your life. So you'll get used to it.’ Which doesn't exactly cheer up a person.”
And if a person gets past the stigma of opening up and talking about it, they face the next challenge: seeking treatment.
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NDTV video "Let's Talk About Depression"
“If you take medicine, there’s something wrong with you”
While plenty of therapists are available to diagnose and treat people with depression, the idea of having to take medication for it is met with resistance due to the stigma associated with it. Hariharan described that if you take medicine for something, there’s something wrong with you.
“And I don't want people who are depressed to think there's something wrong with them because it's normal,” Hariharan said.
The World Health Organization’s India branch cited the National Mental Health Survey in a document about depression in India, saying that one in 20 people in India over 18 years of age have suffered from depression at least once in their lifetime. Despite depression being something so many people experience in their life, it clearly isn’t easy to talk about it or make the decision to seek medication.
Prabha said she’s sure she never felt comfortable talking about her mental health situation, but that was only part of the problem. The other part was the environment.
“So I think it's both,” she said. “Like the environment isn't very receptive to people like this, and because people grow up in such an environment they themselves are closed off to sharing stuff.”
Coping with Depression
Hariharan, Ravichandran and Netto all refused to seek professional help for their depression. Hariharan and Ravichandran said they got over it after they started college, but Netto is still dealing with it.
So how did Hariharan and Ravichandran cope with it when they felt depressed?
Reading: an escape from reality
Hariharan said she spent a lot of time reading books. A huge bookaholic, she loved to enter the world of a book she was reading and drown away in this world so removed from her own. It was her escape from reality.
Hariharan also said she confided in her best friend Priya. But that didn’t really help.
“The thing is that she knew I was depressed, but she didn't know how to help me and cheer me up,” Hariharan said, “so I used to just find a lot of time alone.”
Talking to friends
Whenever she did try to talk about depression, she and her best friend didn’t have deep conversations. Hariharan said she acted like she was normal, that she was okay, and she didn’t have depression, when she was around Priya. She said this was because she actually believed she was okay when she was with her best friend, talking about books and music.
Netto has two close friends he said he talks to. He said he sometimes tells them he can’t do it and is thinking about how he’s going to live his life with all the pain he is feeling from the rheumatoid arthritis.
“So they always say, “Okay, no problem, don't hesitate to call. If want to you say something, please, we are here to hear you. Please don't hesitate to tell anything,” they will say, but I think…,” Netto’s voice trailed off.
He didn’t want to feel like a burden to his friends. That’s why Netto tries his best not to talk to them too much about his depression.
Anton Abilash Netto
Although Ravichandran said he didn’t talk to anyone about his depression, having his best friend, who switched from CBSE to state board two months after school started, helped. His friend didn’t know he was helping Ravichandran.
“I didn't talk to him that I was depressed or sad or anything,” Ravichandran said. “It's just, his presence gave me a… He just made me, ‘Okay, I have someone right now. I'm not alone.’”
Just knowing that there was someone Ravichandran felt like he could talk to if he wanted to helped him cope with his depression.
Grandma’s love
In a similar way, Hariharan’s grandmother also helped her without knowing.
“My grandmother used to talk a lot, but then she didn't know I was depressed,” Hariharan said. “She's a bit old and in their generation there was no depression and all. She just thought I was sad and all.”
But her grandmother was still very supportive of Hariharan, and often made her favorite food for her.
However, Hariharan, Netto and Ravichandran all refuse to seek professional help or take medication.
The Refusal to Seek Help and Take Medication
Believing they’d get over it
“I didn't think going to a therapist was a necessary thing,” Ravichandran said. “I felt like I know I'll come over it, I'll get over it.”
Hariharan also said she felt like she’d get over her depression, which is why she too refused to seek professional help and talk to a therapist or someone.
Believing they’d get over it was probably the only positive reason I heard people give in response to why they refused to seek help or take medication for their mental health. One of the biggest trends I saw in the reasons people gave was not wanting to be a burden to their friends and family.
Not wanting to burden or scare people away
Unlike Hariharan, who confided in her best friend, Priya, Ravichandran said he didn’t talk to anyone about his depression. Not his best friends, not his parents, not even his older brother whom Ravichandran said he’s very close to.
“Maybe talking about my depression will make him go away, I thought,” Ravichandran said about talking to his best friend about depression. He was scared his friend would get frustrated with him and think, “Why is he always sad like this?” and scare him away.
To Ravichandran, who said he was already socially awkward and felt scared to make friends with his new classmates, losing his best friend didn’t seem worth the effort to open up about his depression to him.
Netto, on the other hand, was able to talk to his two close friends about his issues, but he restricted himself from talking too much about it because he said he didn’t want to depress his friends by talking about his pain and constant fears for how he’s going to live his life with rheumatoid arthritis.
He also said he doesn’t show that he’s in constant pain to his family either. Till date, his mother believes Netto is cured of the pain.
“Because I don't want them to get depressed,” he said. “Already they have gone a lot - but she's now happy, my mother. That's what I want.”
When his relatives come over, Netto said they like to play cards. They sit in a circle on the floor and play. But for Netto, sitting in one place for a long time is difficult and painful, but he masks his pain with a constant smile. He loves playing cards, but he said he is torn between concentrating on hiding his pain from his relatives and concentrating on the game.
Anton Abilash Netto
“I told my mother I don't even want a marriage,” Netto said, saying a wife would have to go through the pain of having a husband with an autoimmune disease and depression. “And my mother went through a lot. So I don't want her to also be like that. And who is going to marry a man with a thing like this?”
Many counselors, but still no answer
However, Netto did say he talked to many counselors and retreat centers, asking why he can’t get over his perceived failure because he hates to lose. Every counselor said the same thing. They all praised him for his intelligence, hard work and strength. They all called him extraordinary and said there’s no need for him to beat himself up so much. And they told him he should just accept his condition.
“Everyone will say something like that, but I didn't get the proper solution to my question,” Netto said, who now doesn’t have faith in talking about his feelings or depression to people or hearing the solutions they give because he can’t seem to find the right answer to his question.
But Netto at least had the courage to talk to counselors, even though he feels like they didn’t really help. Many people are scared to even approach a counselor for fear of the stigma associated with it.
Feeling like something is wrong with them
Hariharan’s family saw a clash of opinions when one of her cousin brothers suddenly quit his job and came home, declaring that he was depressed and didn’t want to work anymore.
When her parents heard about this, her father immediately said they should go help and take her cousin to a counselor. But her mother disagreed.
“My mom, she was like, 'Let us not take him to a counselor because that'll make him feel more sad and psychotic about himself,’” Hariharan said.
Her mother felt that taking her cousin to a counselor to get professional help for his depression will make him think that there’s something wrong with him, and that he’s a psycho, so she was against the idea of taking him to go see a counselor.
Equating it to insanity
Prabha described that from what she has studied in sociology and observed from her dad’s colleagues and friends, most Indians are open to taking medication, even if they don’t have a full idea of what is wrong, if their doctor is supportive and assertive enough. They take the medicine hoping they’ll feel better.
“Some people, they're okay with it, actually,” Prabha said. “But the moment they realize what it actually is, like there's something to do with your mental health, they immediately equate it to insanity.”
Equating mental health problems to insanity or being psychotic isn’t the only reason people are afraid to take medication.
Relying on alternatives
Hariharan said she doesn’t believe people need to take antidepressants to get over their depression because it causes hormonal changes, and she doesn’t think that’s good.
Antidepressants work by increasing the serotonin and norepinephrine neurotransmitter levels in the synapses between neurons in your body. These help regulate your mood so you can feel happier.
But Hariharan said that instead of taking antidepressants, people can do something relaxing like taking a walk or doing something they love. She said her cousin brother loves riding his motorcycle, so he could’ve gone for a long drive.
People in India think that if you take medicines, there’s something wrong with you, Hariharan explained.
“And I don't want people who are depressed to think there's something wrong with them because it's normal,” she said. “So they can actually do stuff they really like because that helps a lot. And then talking to someone helps.”
Netto too said he believes he should get through it with his own strength only; no other help.
Not wanting society to know
Shibila Anbumani, an occupational therapist, said she has seen a lot of the parents of differently abled children who come to her battling depression. But because of the stigma, these parents don’t go see a psychiatrist. They don’t even want to be seen sitting outside the office of a psychiatrist.
“Like if you go to a psychiatrist or if you go to a counselor, people think this person is, you know, they will have some problem or he's mentally unstable or something like - even they don't want to go and sit outside the OPD (outpatient department) of a psychiatric doctor,” Anbumani said. “Because they think when I sit outside and somebody sees me, they think like ‘I am abnormal’. I have completed basic certification in mental health because I know there are many parents who are depressed.”
Shibila Anbumani
Anbumani said she uses her certification to counsel the parents who come to her, because she hopes that even if they don’t want to go talk to a therapist, at least they would feel a little more comfortable talking to her.
Prabha too has come across people who are scared of society knowing they have a mental health problem.
“I've come across people who are just like - like some people don't even want the diagnosis because they feel like if someone sees them outside the therapist's office, then people would think they're crazy, and they reject medications,” she said.
Of the people I talked to who faced or are still facing depression, Prabha was the only one who sought help and is taking medications.
Finally Getting
the Diagnosis
“I think I just took it for granted that since my dad is a therapist, my mental health wouldn't really be that much of a problem,” Prabha said.
Prabha said that her father, Kumar, and her mother probably didn’t catch all the signs, and it’s possibly because her father saw being a therapist as a different role from being a father.
“Or maybe he saw it and he was in denial,” she said, “I have no idea about that.”
Prabha said Kumar had, however, been bringing up the idea of going and talking to someone if she ever needed help, but he never really insisted on it because she was reasonably functional in school. Depression never stopped Prabha from going to school or doing well in exams.
“I didn't really have any academic pressure in school,” Prabha said. “So that should have been an indicator that I should probably go and get some help. Because like the thing that's supposed to stress me out isn't actually stressing me out. So what is causing this problem? But I never asked that question, and it didn't occur to anyone around me to ask that question either.”
When Prabha got to college, she saw her peers getting involved in lots of extracurricular activities while Prabha was struggling to even get out of bed in the morning. She said she felt dysfunctional, lazy and unwilling to work, but she thought that that was just the way she was. She never thought it could be attributed to a psychological problem.
Then social media came to the rescue.
Divya Prabha
Facebook fandom group
Toward the end of 12th standard, Prabha joined a fandom group on Facebook that changed her life by bringing her a platform to discuss and learn about mental health.
“I met so many new people who had such progressive takes on things and that was literally the first time in my life that I came across discourse about mental health,” Prabha said.
She then started to read up more about depression and other mental health problems and talk to people in the fandom group who had problems like her, gathering other perspectives on it.
She said that until then, Prabha was completely unaware of the fact that discourse even existed about such a thing.
“So it was by completely random chance that I found out about this thing,” Prabha said, “and I luckily got into a group of acquaintances who made it a point to talk about things like this.”
Deciding to go to the doctor
Prabha was formally diagnosed in summer 2017.
When she decided things were getting out of hand and she needed to get help, she took her dad along and the doctor told her that it was a very clear case. The doctor said they’ll start treating it aggressively and see where it goes.
“But I realized, once I went to the doctors,” Prabha said, “I realized that I've been having it for a major part of my adolescent life. So like right from, say, 7th grade.”
Because she had been having depression for so long, Prabha said that it was a little difficult focusing on a kind of treatment for her.
But Prabha said identifying depression is just the beginning. There’s a lot of “emotionally taxing” work to put in after getting the diagnosis in order to get better.
Coping After Seeking Professional Help
“So imagine you've been living without any regulations and self-discipline and everything like that,” Prabha said. “You never showered, or you didn't wake up, you didn't eat or whatever. Now all of a sudden you're trying to be functional, trying to wake up in the morning, take your food.”
These are the lifestyle changes Prabha had to make after being diagnosed with depression.
Prabha recalled how she forgot to drink water for days and get extremely dehydrated.
“I don't know, I felt thirsty but drinking water wasn't a priority,” she explained when I asked how that’s possible. “It was that phase. So another thing is people don't really factor in the physical toll depression takes on you.”
People with depression often experience weight loss or weight gain. In Prabha’s case, she experienced weight loss because she mostly missed meals and didn’t get the nutrition she needed in her growing years. Her parents noticed she wasn’t eating, but equated it to a teenage phase.
Now she has family and friends constantly reminding her and making sure she drinks at least a couple bottles of water per day so that she doesn’t get dehydrated. However, despite the constant reminders, one year after the diagnosis, Prabha says it still hasn’t become a habit.
“So it's small things like these that take a huge toll - it's like a collection of small things like these,” she said, describing the emotional toll of depression.
Prabha is also taking medicine for her depression and anxiety, two psychological disorders that share high comorbidity. If you have one of them, you’re highly likely to have the other disorder as well.
She was taking Attenrol for her attention disorder, Clonax for anxiety, and two antidepressants, Bupropion and Pramipex at the time I spoke to her.
Taking these medications didn’t immediately cure her depression though.
Psychologists follow a rule of thirds for antidepressants: Antidepressants only work for one-third of the population, and for those that they work for, they only reduce one-third of the symptoms, according to Madeline Meier, who teaches abnormal psychology at Arizona State University.
“So the thing is it's a very slow process,” Prabha said. “This time last year is when I started my medicines, like May 2017. And initially I was having really terrible side effects and I thought my medicines are not helping.”
Side effects Prabha said she had included nausea, convulsions, extreme thirstiness, body aches, lots of headaches, and dizziness. She has convulsions even now, so she said she has tremors and can’t hold her hand straight.
Prabha said that since you’re introducing something foreign into your body, your body’s bound to react. But she feels that perhaps taking medication and dealing with these reactions is better than not taking medication and getting worse with her mental health.
Although she can’t pinpoint exactly when she started feeling better, Prabha said she is definitely way better now than she was last year. The key is patience, she said.
Prabha stressed that it is important to stick with the lifestyle changes, visit the doctor regularly for follow ups, and take your medicines on time. Eventually, when you compare yourself between two points of time, you’ll see a difference.
“Yes, it's really difficult to do that even now,” Prabha said, “but whatever I'm doing now is definitely better than not doing it at all.”
Current Condition
“I think that I’m awfully quite happy with what is happening in this context,” Kumar said about how people are talking about depression nowadays. “People are talking about it and then they’re coming open and the reason is that the technology has created many platforms of expression.”
According to Kumar, many people have been documenting their depression on social media like Facebook, Twitter and Instagram, and some people have even started self-help groups on Facebook. People are also using social media to talk about depression and discuss it, much like his daughter Prabha does now. Kumar also said that there are people who are making short films and movies.
Celebrities and their efforts
Celebrities have also come out about it, publicly discussing their depression. The most prominent example of this is Deepika Padukone, a famous actress who came out and told the world she suffers from depression on New Year's Day, 2015.
“So Deepika had been suffering from severe LTD depression, that is severe endogenous depression, bipolar disorder, for a long time,” Kumar said. “She was known to be treated by one of the psychiatrists known to me named Ganapathesh, so I remember that he has become a brand ambassador for Indian psychiatrics. Which was unthinkable earlier.”
Padukone has even started The Live Love Laugh Foundation six months later to help fight the battle against depression.
According to the TLLLF website, there are only about three psychiatrists for every million people in India, which is clearly problematic considering the rates of depression and suicide prevalent in the country.
“It's being talked by people who are really famous, that's really nice,” Hariharan said. “But then it's still not reaching the common people. Like there is a counselor at Anna University and there's like only one counselor for so many people.”
Padukone's TLLLF aims to train general practitioners in mental health, create a national database, develop helplines, fundraise, and collaborate with nonprofits to spread awareness about mental health.
The National Mental Health Programme
Kumar also mentioned that India has a National Mental Health Programme.
“That is a program that was conceived in the year 1982,” he said. “And then after that it went for many revisions and now they have found so much of money now that they have started District Mental Health Program.”
According to Kumar, the NMHP has three broad objectives. First, integrating mental health services into general health services. Second, achieving a mentally healthy India by the year 2000, but that date has been pushed back in subsequent revisions. Third, integrating mental health services and social welfare, education and many other services, and encouraging community participation in activities related to mental health.
Not enough progress
Despite these efforts, there is still not enough progress happening, and Prabha said that there needs to be special attention given to making sure progress happens in the right way.
“It's just that it's kind of really really sad because progress is happening, yes, but it's very very limited,” she said. “And it's important that awareness happens in the right way. So that's something we need to be concerned about.”
So the problem is getting people talking, Prabha said. According to her and Hariharan, the stigma is still strong among people in India, though relatively less among the youth than in the older generations. People are still hesitant to talk about depression and mental health because it is still an uncomfortable and taboo topic.
Problematic views among the youth
But even among the youth, not all is perfectly progressive. Over coffee, when I asked Prabha if she watched "13 Reasons Why" and what she thought about it, she illustrated the problematic views among the youth about mental health.
It seems that besides normalization among people unaware of the problem, there is also romanticization among those who know about depression.
“I've noticed a lot of people who don't necessarily have the problem, but they leverage it to get things done and stuff like that,” Prabha said. “To get out of responsibility or accountability.”
We discussed how there are also people who think having a mental illness is cool or poetic in some way, not knowing the real struggles and ugliness that come with it. This leads to people talking about depression without being very knowledgeable about it.
“So it's really sad,” Prabha said, “because majority of Indian society is not aware that such a problem exists; a bunch of us know that it exists, and among that bunch, quite a lot of them tend to glorify it and romanticize it, you know. So there are only like very few people who are reasonable and objectively true about it.”
Prabha watched the first season of "13 Reasons Why", but she couldn’t bring herself to watch the second season that came out about a month before I talked to her. She said she disapproves of how Hannah Baker, the main character, leverages her suicide against all the people she had a grudge against in order to get revenge.
“So you need to be able to look at it and isolate the two things,” Prabha said. “One is suicide, and two is whatever she's doing is wrong, irrespective of the fact that she is suicidal or having depression.”
Basically, you can acknowledge that someone is depressed and is having problems making decisions, but that doesn’t make it okay for them to justify the bad decisions they’ve made with depression, according to Prabha.
“So it doesn't make it okay for you to do bad things intentionally,” she explained, “and use your mental health as an excuse, you know? That sort of thing.”
Prabha herself has come across people like that who hurt people and used their depression as an excuse. Prabha said she tried to talk to them about it but, unable to change their views, ended up cutting off their friendship in the end.
“See that is a thing, human beings really aren't that receptive to change,” Prabha said. “One of the most difficult things you can try to do is change a person's attitude or belief, because it's very complicated. And it's vital that if you're trying to change someone's views, that you do it right. And you need to make sure that you're equipped to do that, and you're equipped to handle the consequences if things don't go as you planned. And all this can be emotionally taxing as well.”
In the end, you need to make a decision of whether or not you still need to be around that person, which Prabha said can be a very hard choice to make if the “emotionally manipulative” person is a close friend or family member.
A Possible Solution
The Conundrum with Placing Enough Counselors in Schools
One of the ways India can improve the situation of mental health among students is hiring a counselor for every school. But that’s easier said than done.
One of the problems is the availability of adequate professionals. As referenced earlier, there are only three psychiatrists for every million people in India, according to TLLLF.
One of the criteria that India has to meet is training large number of manpower for this work,” Kumar said. “You don't even have enough number of people even to do normal severe mental health work, for the severe mental health problems like schizophrenia, severe depression, any other issues. You don't have enough number of people.”
One of the reasons for this is that psychological issues are not given a priority, according to Kumar.
In a hospital, who receives treatment first? Whoever’s dying fastest. So the critical and emergency care units are given more importance and more people prefer to work in those areas, Kumar explained.
Even if there are professionals available, another problem arises: affordability.
“Schools cannot afford it,” Kumar said. “Cannot simply afford it because counseling is a specialized skill and then you need a personable trained and committed to that.”
He suggested that one thing schools can do is share a counselor between two or three schools, or a district.
Schools can also get around this by appointing a regular staff member as the counselor. For example, in Prabha’s school, her PT teacher was the counselor. But that wasn’t very helpful.
“So, sure his intentions were good,” Prabha said, “but whatever help he was trying to do, they weren’t professional.”
She said this makes it difficult for the appointed counselor to earn the students’ trust. But that’s difficult for another reason: there’s no privacy in Indian schools, Prabha said.
One of the simplest examples Prabha gave for this was how teachers get students to confess to something.
“In schools a very simple threatening mechanism that is used is, ‘confess up or I'm going to call up your parents,’” she said. “But situations like this demand little bit of sensitivity and discretion basically. So they need to be sensitive to that. I think Indian schools have a long way to go in that regard.”
So the people appointed as counselors in schools need to work hard to convey that their door is always open for students to come in and talk, and that anything said in that room stays between the counselor and the student.
Bringing it into the Curriculum
Another way to increase awareness of mental health is to bring it into the curriculum.
Prabha frequently mentioned during our conversations that she wished she had the ability to identify that she had a problem. She wishes she and her classmates knew about mental health so that they didn’t normalize depression and self-harm.
It’s not just mental health that the curriculum needs to include, according to Prabha.
“I think the curriculum has, not just in terms of depression but any other mental health issues, or things that have a social influence but are also personal, you know,” Prabha said, “like right from sex ed to depression, mental health, and adult education, it needs to be included in the curriculum. And it's not just enough that you include it, you need to make sure that it's disseminated properly.”
In Prabha’s school, there was a class called the “Adult Education Program”, she said, but she still has no idea what that class was about. She also had really hesitant teachers talk about sex education in her school who talked to the girls and boys separately.
To prevent issues like that, it is important to make sure that a trained professional talks about the subject. So a PT teacher isn’t going to cut it.
The Role of Teachers
Hariharan and Ravichandran proposed another solution: training the teachers in the schools to identify and help students struggling with mental health issues and getting them to develop a close relationship with the students.
“So they'll just come, they'll teach, and go,” Ravichandran said about the teachers in his school. “We didn't have a good interaction with any of them.”
Hariharan said the teachers in her school only cared about whether or not the student performs well in the board exams. To her, it didn’t seem like the teachers cared about each individual person because they never talked or reached out to her even though they knew she didn’t talk to people in class.
“I'd like to ask teachers to talk to students,” Ravichandran said. “Because the job for teacher is not to just come and teach, just write on the board and then go. They should know each and every student, they should know what they're doing, they should actually observe them.”
What if mental health is brought into the curriculum? What if teachers develop a close relationship with students, identify students with mental health issues? What if those teachers then guide students to a trained professional appointed in the school as a counselor who can talk to the students with guaranteed privacy? Maybe then students in India will slowly take their mental health back in their own hands.