Depression, anxiety, psychological distress, sexual violence, domestic violence, and escalating rates of substance use are known to affect women more than men across different countries and different settings.

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According to World Health Organisation data, the age-standardized suicide rate in India is 16.4 per 100,000 for women (6th highest in the world) and 25.8 for men (ranking 22nd). In a country that has so many suicides every year, mental health is a detrimental factor and gender is another critical determinant of mental health and mental illness.

“Many of us have at one time or the other flirted with the idea of suicide, sometimes just as a fascination”, says psychiatrist Dr. Anirudh Kala. “But depressed patients do it seriously either out of perceived helplessness or because they are convinced the world is a miserable, wretched place and will always be. The latter is the driving thought when a mother includes a child in her suicidal plan (to save the child all the pain and misery in its later life)”.

Dr. Anirudh Kala is an Indian psychiatrist based in Ludhiana, Punjab. He had been an active participant in the Indian Psychiatric Society (IPS) for forty years and had raised awareness about mental health legislation and related issues among Indian psychiatrists. He is clinical director of The Mind Plus, an acute psychiatric care clinic in Ludhiana. Kala is the founding president of the Indian Association of Private Psychiatry and the founding president of Indo-Pak Punjab Psychiatric Society. The latter is a cross-border initiative forging links between mental health professionals of Indian and Pakistani Punjab provinces.

The Gender Factor In Mental Health

“Depression, anxiety, psychological distress, sexual violence, domestic violence, and escalating rates of substance use are known to affect women more than men across different countries and different settings,” he explains. “Pressures created by their multiple roles, gender discrimination, and associated factors of poverty, hunger, malnutrition, overwork, domestic violence, and sexual abuse, combine to account for women’s poor mental health.”

Gender differences are commonly found in mental disorders like depression, anxiety, and somatic complaints. Women predominate these disorders. According to WHO, depression is predicted to be the second leading cause of global disability burden by 2020, is twice as common in women because of the high prevalence of sexual violence to which women are exposed and the correspondingly high rate of Post Traumatic Stress Disorder (PTSD) following such violence. This renders women as the largest single group of people affected by this disorder.

Symptoms Of Depression

Depression is often accompanied by anxiety, a vague sense of foreboding, palpitation, a feeling of edginess. However, the core is the unexplained low feeling or a feeling of being emotionally drained, with clear sadness and disinclination to work or socialize. Sleep is often decreased but sometimes increased. Appetite too can be either decreased or increased. Physical symptoms are very common; heaviness of the head, indigestion, aches, and pains, this why a large number of persons first go to a physician. It is only when sadness lasts disproportionately long. And of course when there is sustained sadness without any stress to start with.

It is, for example, normal to be upset, sad, have low self-esteem for a couple of weeks after a breakup and even not go for work during the first week. However, if it lasts for three months, it could be depression. Or if a day after the event one swallows pills or cuts the wrist, help is certainly required for the emotional crisis, which may or may not evolve into depression.
Depression can occur at all ages from childhood (rare) to a very late age (not very rare). However, the peak age is 30-50 years and in that age group, women are twice as likely to have it as men. Famous women with mental health illnesses who died by suicide are Jiah Khan, Parveen Babi, Silk Smitha, Pratyusha Banerjee, Nafisa Joseph, Marlyn Monroe.

What kinds of depressions raise a red flag in women?

Sadness is a normal emotional response to an adverse event, an event about which the individual cannot do anything. Grief is a normal reaction to the loss of a loved one. All sadness and grief is certainly not depression.

“It is important to distinguish between the two because the treatments are different. Bipolar disorder has onset at a younger age, the peak being 20-30 years”, says Dr. Anirudh.

Clinical Depression commonly occurs as an episodic illness which may happen just once in a lifetime or several times with years of complete normalcy in between. Each episode typically responds well to treatment. Sometimes, it even resolves on its own but there is no way to tell in an individual case if it would and when- so each episode must be treated to avoid suffering and worse.

Depression can also exist for years as a chronic low grade variety called Dysthymia in which the person is functioning but has low mood and energy. You should ask your psychiatrist which variety you are closest to.

Bipolar Depression is the name given to the depressed phase of Bipolar Disorder which presents in the individual, some time as depression and sometimes as the opposite as elation and excitement with long phases of normalcy in between. It is much less common than Unipolar Depression which is what is meant when we just say depression. Genetic factors are more important in BPD. Antidepressants may not work very well in women suffering from Hypothyroidism or low functioning thyroid hence psychiatrists often order thyroid tests especially in women.

Perimenopausal and Menopausal Depression in women without any past depression in earlier life is not common and is more of a hype. Most women, even those who have hot flushes may not have depression. Perimenopause (the transition into menopause experiencing abnormal periods, problems sleeping, mood swings, and hot flashes are common symptoms but feeling depressed is not. However, if depressive feelings persist, medical intervention is needed. Also, the so-called post-retirement depression is mostly a feeling of being at a loose end and is more common in men; women may still have a lot to do at home.

There is a less common, more severe form of PMS – Premenstrual Dysphoric Disorder (PMDD). Is a serious condition with disabling symptoms such as irritability, anger, depressed mood, sadness, suicidal thoughts, appetite changes, bloating, breast tenderness, and joint or muscle pain.

In new moms, the birth of a baby can trigger emotions, from excitement and joy to fear and anxiety. This “baby blues” after childbirth include mood swings, crying spells, anxiety, and difficulty sleeping. These may last for a few days or a couple of weeks. But some new moms experience a more severe, long-lasting form of depression known as Postpartum Depression which is another rising trend of suicide in women. Fatigue, sleep deprivation, and stress could be signs of suicidal ideation and are a red flag when these emotions accompany constant crying, irritability, and the inability to find joy in life even after the birth of a baby.

Negative ideation (‘yeh na ho jaaye, vo na ho jaaye’) feelings of inadequacy (cannot do the chores, although she does), self-deprecation, guilt (‘I have done nothing for my children’ even when she has), and later even thoughts of suicide (why not finish it all) supervene in untreated cases. Still later, ideas about the possible mode of suicide start taking shape. That is another level and should raise red flags. In older patients ideas of nihilism can manifest as – ‘there is no food in the house’, ‘there is no money left’, ‘what if the water in the tank is finished’, etc.

Dos And Don’ts For Friends, Family And Caregivers

Well-meaning efforts by friends and family can be irksome for a person undergoing depression and may sometimes worsen it.
Back slapping exhortations to be happy, be positive and man up is counter-productive.
Coaxing them to sit before a TV or take them to a movie or for shopping does not help.
The person should not feel crowded around nor should a severely depressed person ideally be all alone.
A couple of drinks to cheer up is another bad idea because when alcohol level recedes, the person gets up at 3 am, feeling restless and full of dark thoughts
Going away to a hill station ‘for a change’ is another not to do a thing
Dismissing it as mood swings or hormonal fluctuation.
Do not make any important decisions while depressed.
There are few things more dispiriting (and symbolic) for a person who is thinking of giving up on the world than a ‘no-reply’ on a suicidal helpline.
It holds true for relationships too at that critical time, but even an unknown bystander willing to listen can tilt the balance in a person having suicidal thoughts.

Setting up a suicide helpline is crisis intervention of the greatest order. It is a work of great empathy but also of tremendous responsibility and organization.

If you or someone you know is suffering from above symptoms, please reach out for help. Some suicidal helplines are listed below:

AasRa Mumbai +91 98204 66726

Parivarthan, Bangalore 91 76766 02602

COOJ, Goa +832 2252525

Sneha Foundation India, Chennai 044-24640050

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Infano brings to you 10 Days Of Mental Health in collaboration with The Logical Indian in lieu of World Mental Health Day on October 10. Sonam Manoj, a Pain Psychologist tells us how chronic pain and mental health illnesses are interlinked and methods to treat them.

Chronic pain could be heart-wrenching and so is depression, anxiety, and other mental health challenges. Research shows that pain shares a biological similarity with depression and anxiety. The same play of neural pathway is observed in chronic pain as it is observed in depression, anxiety, and grief.

When a person undergoes pain for a long period of time, it is observed that the brain can fuse the experience of these two occurrences, often making it difficult to distinguish between the two.

Chronic pain and mental health

Patients suffering from depression, anxiety, PTSD often complain about physical pain. Similarly, when one is undergoing a phase of chronic pain, the immobility one experiences and the inability to function normally, right from doing their daily tasks to being unable to take part in their preferred hobbies can affect one’s self-regard and esteem.

This loss of involvement in the usual pleasure-giving activities often leads to distress and the first thing that changes are, undoubtedly, the behavior of the person. These behavioral changes slowly start to affect the relationships of the patient, both personal and professional, further leading to hampering some close-to-heart inner circle and social networks, thereby leading to damage in the mental and emotional state of wellbeing. One leads to the other and there is no end.

My experience as a Pain Therapist

As a psychologist and a pain therapist, I have very closely observed that patients suffering from depression or stress disorders exhibit more severe pain than other people. It becomes harder to work on these patients than people who come in with regular pain conditions.

Some of the most common mental health issues that we find in chronic pain patients are insomnia, depression, stress disorder, and anxiety. It is also observed that these conditions can further hamper the chronic pain condition that already exists. It is like a vicious cycle, one leading to the other in a loop.

The other dimension to the pain-related mental health issues also is long assistance and dependence on strong pain killers. This dependence on the high potent medication especially opioids starts to hinder the normal cognitive processes or thinking of a person. Again, one would observe a chain reaction of unending distress and uncomfortable experiences in this case. To treat a case like this becomes very challenging for a therapist.

Focus on pain can camouflage the presence of mental health disorder

Psychogenic pain

Sometimes these pain flare-ups can also pass off as Psychogenic pain, a short-term or a long-term pain condition that is associated with a psychological or emotional condition and not a physiological one. You must have heard of patients complaining about neck and shoulder pain or lower back pain, heading for clinical screening and coming back with no specific physiological diagnosis. This is what we call psychogenic pain.

Tension Myositis Syndrome

A very common syndrome that we come across in patients with psychogenic pain is the TMS, Tension Myositis Syndrome, which is a psychological condition causing physiological symptoms like chronic back pain, gastrointestinal problems, and fibromyalgia. In some cases, one would also observe the presence of chronic headaches and sleep disturbances.

The symptoms have no explainable cause and pass off like that from a psychogenic origin. The patients whom I have come across with this syndrome have usually had a history of trauma of some sort, loss of a loved one at an early age, abuse – physical and sexual, accident with no physical injury, etc.

Pain Management

Now, the good news is that it is possible to cope with this pain by implementing a holistic approach to the treatment. There is a slow yet promising rise in pain clinics in the country that deals with the multidisciplinary and wholesome approach to pain management, which involves equal interventions from pain specialists or orthopedics, pain psychologists, physiotherapists, and nutritionists.

Also, many of these treatments can be practiced independently after initial guidance from the health care professional or the pain specialist.

Psychotherapies for pain management

In patients with mental health conditions, there are various established psychotherapies that can be used for pain management which can be combined with medication.

Cognitive Behavioural Therapy is one of the oldest and most established non-pharmacological treatments for pain management. It helps one with adding resources into their wellbeing bag, that would help them cope with the pain rather than victimize themselves. This can be combined with relaxation training, talk therapies, counselling sessions, and movement therapy.

Co-occurrence of pain and mental health conditions is very common and is best worked on with a tailor-made multi-disciplinary approach.

If you are suffering from pain or depression, go seek a pain therapist or a pain medicine specialist before it worsens. Living a quality-filled and pain-free life is your right!

This article has been authored by Sonam Manoj, Consultant Psychologist & Pain therapist at Cloudnine Hospitals & Alleviate Pain Clinic.

Sonam holds her Masters in Clinical Psychology She is a Ph.D. research scholar, rigorously researching in the field of Pain Medicine and Neuropsychology. She has also earned a Post Graduate Diploma in E-Pain Management from NHS, United Kingdom. She holds a Diploma in Counselling and a Postgraduate Diploma in Life Skills, Reproductive Health and Personal Safety from Christ University, Bangalore.
Sonam Manoj is an active member of the International Association of Pain Research, USA.
She is known for tailoring therapies for patients suffering from stress-related pain, fibromyalgia, pain challenges in children with needs, sportspersons, and also works on ‘Geriatric pain management programs.

You can reach her at sonamjagasia1@gmail.com