In our line of work, there are some statements which we keep hearing. Virtually, not a single day of my working life has gone without hearing any of the following statements which I quote below:
l “Doctor, my father has stopped taking your medicines because he does not want to take sleeping pills. He worries he will become dependent on them.”
l “I do not want to take antidepressants. Can I try counselling and other natural ways to feel better?”
l “My husband does not want me to take antidepressants. He feels it will harm me.”
Cogito, ergo sum
In one of my favourite Hollywood movies, Groundhog Day, the protagonist relives the same day repeatedly. It serves as a catalyst for his personal growth and self-awareness. I have always likened my reaction to hearing these words repeatedly from patients or their relatives to the experience of Phil, the central character of the movie. It has enabled me to develop a deeper understanding of the stigma related to seeking help from our profession, and more specifically, the fear of taking medicines for mental illness.
In the past 10-15 years, more people are opening up about suffering from mental illnesses. The perplexing thing though is the reluctance to take medicines for their mental illness has not decreased or perhaps, it has increased amongst a certain section of society. Taking an antidepressant is still not accepted as a ‘legitimate’ modality to ameliorate the complex and soul-destroying illness like severe depression.
The stigma against drug treatment of mental illness has its roots in history. Most people do not hesitate to take drugs for hypertension, diabetes, asthma or the favourite ailment of the Bengalis, the “gas problem”. But the same people shy away from taking pills for depression.
I believe that one of the sources of stigma is the way we understand what the mind is. The roots of the confusion lie in the history of how the mind was begun to be conceptualised.
Rene Descartes, a French philosopher, proposed in early 1600 AD that mind and body are separate, a concept termed Cartesian Dualism by philosophers. His views gained significant traction and hold sway even now. He theorised that there is existence of two distinct substances: the mind and the body. This dualism is rooted in his famous dictum “Cogito, ergo sum” (“I think, therefore I am”). He concluded that the mind is an immaterial substance that engages in various activities such as rational thought, imagining, feeling, and willingness. In contrast, the body is a material substance that conforms to the laws of physics and is governed by mechanical principles.
By separating the mind from the body, he inadvertently removed the functioning of the mind from the functioning of the brain. Therefore, we have become oblivious of the fact that maladies of the ‘mind’ are in fact nothing but maladies of the brain. Like any other organ in our body (heart, kidney or liver etc), the brain too can be afflicted with disease. The symptoms of the brain disease are manifested as psychiatric or neurological illnesses. This division between what is now thought of as a psychiatric illness and neurological illness too has roots in the history of how modern medicine has evolved over the past 200 years. But that is a story for another day.
What is mind?
The answer is complex. Susan Greenfield, an eminent British neuroscientist, provided an answer which is relevant to the context of what I am discussing today. According to her, the mind is best understood as a “personalised brain”. Mind is a unique entity, whose physical substrate lies in the individual’s brain. Siddhartha Mukherjee, a Pulitzer Prize-winning author, who wears many hats, in his book Songs of the Cell, quotes Emily Dickinson, a Nineteenth-century poet, to describe the complexity of the brain: “The brain is wider than the sky, the brain is deeper than the sea.” He describes brain as the repository of memory, consciousness, temperament, sensation and feelings. Love, hatred, envy and compassion and everything we include as facets of our mind, are reposed in the tangled neurones, which constitute our brain.
While our brains are largely similar, our minds are uniquely different. Our experiences, our environment, our learnings and the infinite sequence of multi-sensory inputs we receive while going through life leave an imprint on the brain. It changes the micro-architecture of the brain. As the brain changes, so do our minds. The fact that our brain changes constantly should not come as a surprise. It is like any other organ of our body, which also changes in response to our life experiences, ageing and illnesses.
Separation of mind from the brain, as a consequence of Cartesian Dualism, has camouflaged the fact that mental illnesses are brain disorders. The social factors do affect the expression of mental illnesses. The reality is that all social and environmental factors, like poverty, bullying, abuse, screen time, nutrition etc leave an impact on the brain. Ultimately, social and environmental factors have an impact on the neurons of the brain. They change the microarchitecture and functioning of the brain. The social and environmental factors, along with the influence of our genes, cause what we know as mental illnesses.
Addressing the stigma
A major determinant shaping the reluctance to take medicines for mental illness partly lies in how mental illness is conceptualised. The way we feel about physical illness is completely different compared to the way we feel about mental illness.
A person does not feel guilty if their thyroid gland is not working properly and they develop hypothyroidism. The same person or their family members would feel guilty if their brain was afflicted and they had depression. Many of us believe that suffering from depression is a choice, it is a matter of a bad, indolent and selfish lifestyle.
“Go out, get a job, be with your family, be grateful, increase your willpower” are amongst the variety of advice given by gurujis, life coaches and memes on social media.
The disease of depression is not a choice or a matter of poor willpower. If one believes so, they have not sat face to face with a person whose whole heart is filled with pain and chaos. They have not fathomed what it might feel to be a person who believes that everything in her life is meaningless, and death is preferable.
Depression is a health condition just like heart disease or diabetes, which needs scientific evidence-based treatment and not unscientific platitudes. Simply put, one does not choose to be depressed and suffer because the person is “weak”.
No one (I hope) recommends someone with diabetes stop taking insulin. That could be fatal. Unfortunately, many people tell persons struggling with their depression to “try to be happy” and stop their medicine, because it is not a “natural” way to get better. This inappropriate cliche only reinforces the stigma of reaching out for help and accepting legitimate treatment.
The other major myth is that all psychiatric medicines are addictive. They are not. There are many different kinds of medicines used in psychiatric illnesses. The ones that are most commonly used are antidepressants.
Antidepressants are not sleeping pills. Sleeping pills (the scientific name for which is hypnotic drugs) can be addictive if taken without supervision. Hypnotics are a completely different class of drugs from antidepressants. It is worse than equating apples with oranges. Therefore, advising a person who is taking anti depressants that she will become dependent on them is wrong and detrimental.
The other lie is that anti depressants are just a quick fix. Quacks on social media advise us against their use. They are not. It takes weeks or months for anti depressants to work and in many situations, it requires painstaking and personalised dose titration to get it right. Using medicines to alleviate depression is not a synthetic cure. It does not “change” the person or alter their personality. It merely removes the pall of gloom, which has shrouded one’s personality.
We live in a different era now
In reality, anti depressants are another powerful tool for improving our well-being, if we are significantly depressed. They are not “happy pills” or “uppers” that you pop one and you are instantly in a party mode. Other lifestyle measures like improving self-care, exercising and improving social connectedness contribute, too, in alleviating depression.
Taking antidepressants does not mean the person is “crazy” (whatever the term means). It only means your mind, which is seated in the brain, is not functioning at its optimum level and taking the medicine is a part of the recovery process. A few years ago, a man no less than Tom Cruise criticised Brooke Shields for taking anti depressants. Shields came back with a brilliant response, asking him to “stick to saving the world from aliens” and mentioned that his statement was a disservice to many.
Another significant part of the stigma comes from how popular media, especially in the past, have depicted treatment. Treatment of depression has come a long way from a time when uncooperative patients were given electric shocks without proper precautions (as shown in the cult film One Flew Over the Cuckoo’s Nest) and parts of their brain was being removed to make violent patients docile. Till even 60 years ago, lobotomy was practised as a modality of treatment in psychiatry. The person who developed the treatment, Edgar Moniz, was even awarded a Nobel Prize for his work in 1949.
A variety of popular films, books and personal narratives of persons with mental illness have shaped the dread many of us feel when we think of receiving treatment for a mental illness. It often feels less scary to go for a root canal treatment!
Finally, however much we (the psychiatrists) point fingers at others, we cannot absolve ourselves of the blame. We have, through our acts of omission or commission, perpetuated the stigma and fear of psychiatric treatment.
It would be a lie to paper over the human rights abuse of patients with mental illness. For decades they have been chained and coerced into treatment, without any legal recourse until recent times. These real scenarios have contributed to the stigma. Times have changed and the psychiatric establishment has been forced to change for the better, due to the protests by its critics. The protests against psychiatric practices are known as the anti-psychiatry movement.
I find the term used to describe this fight for justice against abuse of the mentally ill, as “anti-psychiatry movement” rather myopic. It was and is a much bigger movement to shake up years of injustice, which had been institutionalised by the state, religious bodies and medical establishments, including psychiatrists. It was and is a fight for social justice.
We live in a different era now. The pressure from civil society including self-advocates, supplemented with staggering advances in neuroscience and genetics has led to major breakthroughs in providing safe, effective and humane treatment.
My plea is that we need to open our minds and accept antidepressants and other psychiatric drugs as legitimate and science-based treatment methods. Decades of painstaking research go into drug development. Each medicine, irrespective of which disease it treats, is allowed to be used on real sufferers of the disease, after rigorous clinical trials. The medicine use is monitored by multiple agencies and some drugs are even withdrawn from the market, if found problematic.
Harbouring unnecessary fears about drug treatment of mental illness costs lives, prolongs suffering and destroys the lives of many families. My hope is that we learn to give science, and not prejudice, a chance.
Dr Jai Ranjan Ram is a senior consultant psychiatrist and co- founder of Mental Health Foundation (www.mhfkolkata.com). Find him on Facebook @Jai R Ram and on Instagram @ jai_psychiatrist