Thinking and writing about the complexity of mental health issues has jogged several memories. When I was in graduate school a fellow student tried to take his own life. He had a brilliant academic record, was doing well at school, and was Indian. Fortunately, a quick-thinking response made the attempt unsuccessful. After the incident, the entire extended group of fellow Indian students were all left wondering as to why he had chosen to call a non-Indian acquaintance for help from the emergency room, when it was apparent that he spent most of his barely existent ‘free time’ with one of us. Once he returned to the academic routine, he restricted his interactions to a select few, citing embarrassment. Depression was simply not something to be advertised. Several years later, another colleague frequently recalled his previous advisor’s words with gratitude. Years earlier, she had told him that there was no shame in seeking professional treatment for depression saying that it was necessary to leading a healthy life, just like resetting a broken bone.
Although the stigma related to the diagnosis and treatment of mental illnesses is universal, it may be felt more acutely within the Indian and the larger South Asian population. Immigrant Indian-American families have a laser focus on academic and professional success, and they feel the acute need to appear as being a part of a model-minority group. Women in these immigrant groups face a double burden as they are isolated from the larger network of extended family members and relatives/friends which they commonly enjoy in India. The need to avoid any exposure of personal weakness and the pressure to present a stoic appearance to the outside world does not permit a discussion of these problems with the gravity that they merit.
In fact, a 2001 report from the US Department of Health and Human Services (DHHS) remains pertinent to the present day when it mentions that “Mental illness is highly stigmatizing in many Asian cultures. In these societies, mental illness reflects poorly on one’s family lineage and can influence others’ beliefs about how suitable someone is for marriage if he or she comes from a family with a history of mental illness.” Harvard Medical School published a study in 2010 on mental health problems in the workplace, citing depression as being the costliest health condition, with anxiety ranking fifth on the same list.
Cultural factors impinge on Mental Illness
A combination of three factors is required for mental health deficits to manifest:
- Biological and genetic factors;
- Psychological factors including individual psychological thresholds, perception and interpretation.
- Social factors including environment, family and friends.
Looking at the three factors, we realize that for immigrant families, social and cultural milieu turns out to be an integral part of this complex equation. First, it has a bearing in the manner in which treatment is sought, i.e., through a religious leader, social worker, traditional healer, psychiatrist, psychologist, family support, etc. In close-knit cultural communities, including some immigrant communities, some of these alternative treatment options may be explored in preference to a more mainstream doctor or counsellor. Secondly, in cultures where there is excessive stigma attached to mental illness, patients may first present somatic symptoms which are physical (also called ‘somatization’), and describe psychological symptoms only upon further investigation. Additionally, other obvious social factors are language barriers in immigrant populations, and affordability of care.
Cultural norms may also decide which emotional and subjective concerns are considered significant. In specific instances mental illnesses can be concentrated in certain communities, but this is dependent on whether genetic or social factors have a greater impact on this indication. For example, schizophrenia correlates with genetic factors, but depression, anxiety and suicide rates may be more dependent on cultural and societal factors.
Mental Health versus Mental Illness
Mental health and mental illness are points on a continuum, not a pair of opposites. Although mental illness is better understood since it has symptoms related to aberrant functioning of mood, behavior and thinking which cannot be ignored, good mental health is more than just the lack of an identifiable illness. It includes emotional and psychological well-being, the ability to perform productive mental activities, have fulfilling relationships, have the ability to cope with adversity and change, and is admittedly difficult to define precisely as its definition is biased by individual and cultural value judgements.
Mental illnesses range from the better-defined diseases of schizophrenia, bipolar disease, and obsessive compulsive disorder (OCD) to phobias, personality disorders, depression, and anxiety. As expected, there is greater awareness of the former group of defined illnesses than the latter. Depression is the most common mental health disorder, and it is estimated that it will be a leading cause of disability by 2020.
Thus, mental health is increasingly being considered a public health issue, and initiatives are being created to promote mental wellness in all age groups especially amongst students in universities and also amongst other age groups within professional organizations. The importance of good diet, regular physical activity, sleep, relaxation, meditation/mindfulness, and healthy peer interactions are stressed.
Role of Counseling
The role of counseling in the maintenance of mental health is not trivial. A sympathetic ear and professional advice is an important avenue to preserve mental health, and can potentially alleviate mental illness in early stages. In cultures where stigma prevents individuals from accessing early interventional professional help (Indians are known to be more inhibited in this matter than the general population), treatment is finally sought only when mental illness presents as a condition which cannot be ignored. To stress that seeking help is key to healing, “Maintaining patient confidentiality is of utmost importance with psychiatrists,” states Dr. Uma Nuthi, a practicing psychiatrist in Pennsylvania. This is not restricted only to patient information, she says, but also to the very basic fact that an individual is indeed a patient seeking these services. Mental health is as important as physical health, and needs to be maintained with the same effort and by giving it equal importance.
How can a parent help children stay mentally stable?
“A person’s a person, no matter how small.” This pithy sentiment of Dr. Seuss is echoed in the ACEs (Adverse Childhood Experiences) study that was conducted by the Centers for Disease Control and Kaiser Permanente. ACEs was initiated in 1995, and follows the long-term health outcomes of participants with respect to the association of ACEs with health and social problems over the entire lifespan. The incidence of high-risk behaviors in adulthood correlated with the number of ACEs, which also correlated with an increased incidence of serious illnesses including heart disease, cancer, and depression, along with an increased risk of attempted suicide. Even in those fortunate instances where ACEs are not an issue screen time may come into play, as we continue with our modern-day obsession with smartphones, tablets, computers, electronic games, and the now outdated television. While the long-term effects of young children being extensively exposed to screens is still emerging, there seems to be a correlation of length of screen time with changes in learning ability and sleep cycles.
To promote mental wellness, healthy interactions between family members are stressed and we also find that children often complain that parents are not available to them because they are constantly busy with their phones or computers. Notwithstanding such inter-generational issues, parents should be vigilant about aspects of their children’s life and habits such as their friends and peers, changes in performance at school and interactions outside of school, and changes in physical symptoms including appetite, sleep patterns, and nausea to name a few. If changes are noticeable and cause concern for several weeks, it may be prudent to explore a more concerted approach to address them.
Unfortunately, at the present time one isn’t able to perform a blood test that would serve as a positive diagnostic test to confirm a mental illness. However, a recent possibility is the development of one for stress, which could directly or indirectly bear upon indications such as anxiety and depression. Medistress, a spinout from Oxford University, believes it may have a novel blood test that measures the immune response to stress. This idea remains to be tested in various scenarios before one may be able to measure stress with an unbiased number, but research continues to push the boundaries of our knowledge of disease mechanisms, to test new hypotheses, and configure diagnostics and therapeutics for mental illnesses.
Simultaneously, efforts continue to increase awareness of mental health issues and remove the associated stigma. One such initiative is the DMAX Foundation. The Substance Abuse and Mental Health Services Administration (SAMHSA) is a DHHS public health initiative that provides information related to prevention hotlines, and is a good national and regional resource for researching options regarding treatments and funding options.
Bollywood celebrity, Deepika Padukone, recently made public the fact that she had suffered from depression, and recovered. Her interview on how she came to understand that she was suffering from depression is an eye-opener (https://www.youtube.com/watch?v=srGbyn8Ad5E). This kind of public discourse may encourage awareness that since these illnesses can be taken in stride with current medical modalities, it is high time that associated stigma be discouraged.
As the 2020 election campaigns ramp up, conversations related to health care, and specifically mental health issues, are very much in the forefront. Joe Biden reportedly wants to improve facilities for mental health care for children, Amy Klobuchar is focused on funding mental health research, and Bernie Sanders and Seth Moulton target mental health services for veterans. A non-partisan group called Mental Health for US which includes prominent mental health groups such as the National Alliance on Mental Illness, is pushing for the candidates to articulate their policies on mental health and addiction clearly. They intend to facilitate direct and informed interactions between voters and candidates in town-halls and other events.
In addition to increasing awareness by these public means, family and friends can help persons with mental illness by being aware and supportive. As mentioned, keeping a careful watch over behavioral changes, appetite, sleep patterns, and other physical symptoms including nausea, breathing problems, and palpitations will serve as an indication that the person needs to seek counselling and/or psychiatric help. Disturbing patterns in these parameters should be considered seriously. Taking the time to convince the potential patient that consulting with a counsellor/psychiatrist is important for their wellbeing could be the first step to treating the mental illness, and a path towards a healthy and productive life.
L. Iyengar has earned a Ph.D., and has been involved in research programs targeting human therapeutics in India and the USA. She is the author of White Blackmail, a work of fiction and a medical thriller. Links to her recent publications may be found at www.liyengar.com.