In the Heart
by Dr Mudasir Firdosi MBBS, MD, MRCPsych, Consultant Psychiatrist, South West London and St George’s Mental Health NHS Trust London
Kashmir is a picturesque valley wedged between India, Pakistan and China. I trained and later worked as a psychiatrist at the only psychiatric diseases hospital of the valley which is based in the capital city of Srinagar. I remember the walk-in clinics, where at times we had up to 300 patients waiting eagerly to have few minutes with a psychiatrist despite the huge stigma associated with mental illness. The number of people seeking help for emotional problems grew exponentially after the armed conflict started in 1989. One of our studies reported the lifetime prevalence of exposure to the trauma of about 59%[1]. A recent survey by Medicines Sans Frontiers (MSF) reported that about half of the population is suffering from some kind of mental illness, with 50% women and 37% men suffering from a depressive illness[2]. During my research on PTSD patients, depression was again the most common comorbidity in more than 80% of the study sample[3].
One can argue that the diagnostic criteria as suggested in the ICD and DSM may not fully hold true in the local cultural context for the diagnosis of depression or even other disorders. Asking the golden question, ‘How is your mood?’ usually gets a blank response. People often talk in the context of ‘heart’ when talking about their emotions and feelings, rather than the mind. Typically, someone with depression would come saying, ‘My heart is not good’, usually pointing to their chest. I remember asking, ‘How is your heart?’ more often than ‘How is your mood?’ Even the people from middle class and educated backgrounds would find it hard to discuss mood. The same is true about anxiety disorders with palpitations and other somatic symptoms often being taken as a symptom of physical illness.
People usually do not come to the doctor with an idea that they will get treatment for depression or even that they may be depressed. It is usually the physical symptoms like tiredness, pain, palpitations, memory difficulties, medically unexplained symptoms, and weakness in limbs and headaches that bring them to the doctor. Conversion symptoms are the most common presentations to the A&E department, typically a teenage girl not able to talk, move a limb or being unresponsive. This has a great cultural significance and is protective. If a woman reports feeling low to her husband, she would hardly be taken seriously and probably get told off for being lazy. However, when someone reports pain or physical symptoms, it is often taken seriously and considered a valid reason to seek help from a doctor.
Depression and other mental health problems form the biggest group of illnesses and burden of disease in the local population. With such a variable presentation of symptoms, patients often go to all kinds of specialists, quacks and faith healers. This results in unnecessary costs, inadequate or wrong treatment and, at times, iatrogenic harm. There is a need for training doctors and other health professionals in better identification and treatment of depression and other mental health disorders. There has been some awareness both among the doctors and the general public in seeking right help for mental health problems. Finally, medication still remains the sole therapeutic modality, keeping in view the lack of allied professionals like psychiatric nurses, psychologists and therapists.
[1] Margoob, M. A., Firdosi, MM, Banal, R., et al. (2006). Community prevalence of trauma in south Asia: Experience from Kashmir. JK-Practitioner, 13(Supplement 1), S14-S17.
[2] Medicine Sans Frontiers (Doctors without Borders) ‘’Kashmir Mental Health Survey 2015’’ https://www.msfindia.in/sites/india/files/research_summary.pdf
[3] Firdosi, M.M., Margoob, M.A. (2016) Socio-demographic profile and psychiatric comorbidity in patients with a diagnosis of Post Traumatic Stress Disorder–A study from Kashmir Valley. Acta Medica International.3(2):97-100
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