In the history of medicine, many conditions have been associated with stigma. In the past, epileptics were thrown into fire during the dark ages as they were believed to be possessed by Satan or evil spirits. Patients with leprosy were despised and exiled to far away islands because of the disfigurement due to disease. Even now this fear of lepers (!) lingers on in the society. I had occasion to live near a leprosy hospital. People used to hesitate to buy land near that compound. I have heard of many people who abandoned their plans to buy land only for of this fear even recently.People infected with Syphilis and other sexually transmitted diseases have also suffered a similar fate. Fate of HIV infected persons - how the community treated them, even small kids - is still fresh in our memory. Why does this happen ? Fear of a disease may be due to the ugly disfigurement it causes, or because it is fatal / incurable, or because it produces unpredictable behaviors as in the case of mental illnesses. Moralistic beliefs could also shape our attitudes to illnesses.Stigma can have individual and social effects. The plight of the individual affected with a stigmatizing illness is all too familiar. But the social effects may not be always easy to appreciate. I am aware of the stigma in the professional community. It is indeed shameful that even professionals (doctors and nurses) internalize such stigmatizing attitudes. This could be one reason why psychiatry is unpopular among doctors. Things have reached a state where such wrong attitudes are causing public health problems. For example the number of qualified psychiatrists in the Kerala Government Health Services is steadily declining. Many government funded programs for treating mentally ill are feeling the squeeze. We are unable to get qualified psychiatrists. This is another effect of stigmatizing attitude of the society.As I said in my earlier post we cannot wish away mental illnesses. Concerted effort of mental health professionals, media, N G O activists and the Government is needed to change this situation.
Mental illness is the most important underlying cause for many suicides. Approximately 15% of depressed patients ultimately kill themselves. For schizophrenia the risk is lesser, but still significant. Majority of such cases of depression go undetected. There is evidence to show that teaching general practitioners how to identify and treat depression is a very effective strategy to reduce suicide rate. Majority of these depressed persons self medicate themselves with alcohol or drugs. Many flock to alternative treatments. Some fail to gain emotional insight into their problem and adhere to treatment. I remember a female who was my neighbor earlier for some time. She was a graduate, employed lady who used to visit many physicians; mostly she consulted gastro enterologists with complaints of 'gas, indigestion, occasional loose stools etc'. Several investigations were done, but drew a blank. Her diagnosis was 'Irritable bowel syndrome'. She used to come to me and discuss about her medical problems as a neighbor. On evaluation I found that she had most symptoms of depression, but was not wiling for treatment. She used to insist that she had no depression, but only some anxiety. Later i could persuade her to take some medication and also consult a psychologist. After some time I lost track of her; later she told me she is seeing another psychiatrist. I asked her to continue that. Then again she disappeared. Again I met her incidentally and with persuasion she continued drugs given by the other psychiatrist. I taught her some relaxation methods as well. After a few months when her husband and only child were away, she closed all doors and windows and consumed poison. Somehow all her physicians, psychologist and the two psychiatrists (including me) failed to convince her about the need for treatment. She had a habit of arguing about the diagnosis. As my consultations were of a casual nature, she was free with me in expressing her disagreement about what mental health professionals thought about her problems. What prevented her from accepting her diagnosis was the stigma associated with mental illness. Ultimately her husband lost her; her child lost its mother.Stigma of mental illness is real. It causes undetected suffering. We cannot wish away mental illnesses. The only way out is proper recognition of the problem and treatment. If people prefer to consult non psychiatrist doctors, we have to train them suitably.
This model was proposed by an American psychiatrist - George Engel, to explain mental health. It is derived from the General systems theory. This theory looks at the universe at different levels - from the level of subatomic particles to the macro cosmic universe, including living organisms. each level is more complex than the lower level. Bio-psycho-social model proposes that mind is emerging from the brain's unique organization. The body is organized as cells, which aggregate to form tissues. Collection of tissues with similar function form organs (e g: liver is formed by a collection of specialized cell called hepatocytes). Organs with related functions are grouped together as organ systems. For example liver, stomach, intestines etc together form the gastro intestinal system. Brain is viewed as the highest level of organization of all the organ systems. All the other systems like heart and blood vessels, kidneys and urinary bladder etc are there to support the brain. The property of consciousness emerges at the level of brain. But at the same time social and psychological factors can influence the way we live in this world and relate to our fellow human beings. Social factors operate at the interpersonal level. Psychological factors operate within our subjective world - our own private fears, doubts, fantasies, feelings etc. Brain is the final common pathway for all these experiences to enter our mind. The electrical and chemical processes taking place in the neurons and their connections give us our subjective world. But how does the physical events get transcoded as our rich internal world ? Neuroscientists are still working on this. It will be the ultimate mystery of nature. Will man be able to solve this riddle ?
The social aspects of suicide were discussed in the previous post. There are many other factors. For example it is found that suicide is more common in some families. Both genetic factors and shared environment could be behind this. Studies have been done to clarify more on this. There is some evidence to say that genetic factors may be operating independent of the environment. Environment also has its share. There are many studies showing that levels of a brain chemical called serotonin (a neurotransmitter acting as messenger between nerve cells) is low in the brains of suicide victims. Further it is also shown that still lower levels are seen if the suicide is by a violent method (jumping before train for example). It is also known that people with low serotonin tend to be highly impulsive in their behaviors. They are also prone to develop depression. It can surmised from the above that serotonin plays a key role in regulating our mood, ability to control our emotions and behaviors etc. It may not be possible to explain everything about suicide (or complex human behavior in general) with a single theory. This is why psychiatrists advocate the bio-psycho-social model of illnesses.
The famous sociologist Emil Durkheim has divided suicides into three categories. These are Altruistic, egoistic and anomie types. Altruistic suicides occur when a person is too much integrated in to an ideology (which may be a correct or wrong choice). The psychology of suicide bombers and martyrs belong to this type. Here a person sacrifices himself for a cause which he believes is important.Egoistic suicides occur when a person is too much engrossed with his own ideas and fails to integrate himself with the rest of the society. Such suicides are infrequent. One example I can think of occurred in Kerala around 5 years ago. A retired school teacher called Thomas master ended his life at Pavaratty in Thrissur district of Kerala. He had earlier filed a petition before the High Court of Kerala seeking permission to end his life. His children had grown up and were living separately. After the death of his beloved wife, he became increasingly lonely and decided to end his life. But as suicide is a crime in Indian law, this former teacher did not want to break any law; hence his petition in the court. But the honourable court refused permission and he decided to kill himself. His last note stated that he is finally 'ending his life like a coward, and that he is ashamed at his plight, but says he had no other choice as courts did not understand him'. Imagine the plight of a catholic, living among other staunch believers, and requesting permission to kill himself. His fellow catholics and the church were unsympathetic to him and deserted him after he filed the petition. This is a case of egoistic suicide. It had struck me very much; as a mental health professional and as a human being;hence I am able to narrate all this from my memory. Anomie is a state of social disintegration. Suicides become common in such a state as people lose faith in the existing system and even the social values. I think the epidemic of suicide among farmers belong to this category. Farmers are left out of the main stream of social fabric, though leaders shed crocodile tears for them from their rooftops. They might be feeling that the existing economic system helps only to make them huge debtors. whatever relief measures materialise after long delays. This is why many commit suicide.One should also bear in mind the fact that whatever be antecedent causes, many persons who ultimately kill themselves are in a state of clinical depression. If some interventions or mental health care was provided at this stage, at least some of these deaths could have been avoided.
Why do people in Kannur join political parties and kill each other? Is it for ideological reasons ? I think majority of the killings are done by professional execution squads. These are organized by local leaders of the major political parties. These leaders infuse their followers with hatred for each other. But why can't people think for themselves ? Why do they act as they being controlled by someone else ? It is said that the killer squads are protected by their masters. Usually unrelated persons are purposefully arrested. Thus the evidence will be flimsy and the accused are acquitted. Psychiatrist working in Kannur have narrated tales of the emotional problems faced by school children after their teacher was assassinated in front of them in the class room. But later we also happened to hear about killings done by the same political group. The parties only aim is to get public sympathy. They know how to get this sympathy into votes. I think there may be a high prevalence of Post Traumatic Stress disorder in Kannur district. It will be worthwhile to conduct a study.A description of the clinical syndrome of Post Traumatic stress disorder is given in an earlier post on "Emotional trauma and dissociation".
