India: Model for a New Psychiatry?
WHY YOU SHOULD CARE
Because mental health is a global crisis — and might need a few new approaches.
By Sanjena Sathian
The following article contains information about depression and suicide that may be triggering for some readers.
It was the kind of television event that dominates dinner conversations for days, like the time Bruce Jenner became Caitlyn during a sit-down with Diane Sawyer. In this case, the star was Bollywood actress Deepika Padukone. Her interviewer was nationally famed NDTV anchor Barkha Dutt, and the topic of discussion: depression. In a coming-out of sorts, Padukone, the sweetheart of India’s Hindi film bubble, told the world that she had suffered from depression for 15 years.
Padukone was not on camera alone. She sat next to her mother; her counselor, Anna Chandy; and her psychiatrist, Shyam Bhat.
Which American film star would cart her therapists and her mom to a major TV interview? The trio of guests made for a bold narrative in Indian society: Depression is real, it’s not just sadness, it’s OK to ask for help. And parents, are you listening? Getting family on board to wipe away the stigma of mental health was crucial — but Indians also needed to hear from a doctor. Especially one with good looks and a cosmopolitan accent who was there to champion a cause. It was a distinctly Indian approach to psychiatry, drawing on ancient Hindu texts, yoga and the strength of family — and standing in clear opposition to the school of Western individualism. (Padukone could not be reached for comment via her mental-health-awareness organization, Live Laugh Love.)
“Either you are depressed or you know someone in your family who’s depressed. It’s that common,” Bhat told Dutt, who cited the statistic that almost 40 percent of the country had depression. “In my opinion, this is the result of a fast-changing society, and if we don’t start learning how to prevent this or treat this, we are in for a huge problem in about 10 or 20 years.” Out came the numbers arguing that this is an epidemic, not mere malaise: India, with its massive population of young people — in 2020, demographers estimate, the average age there will be 29 — has the world’s highest suicide rate in the 15-to-29 age bracket.
As India attempts to rethink medical notions of the mind, could it introduce an alternate model for mental health around the world?
Staring down such an urgent timeline, and with a growing chorus of mental-health practitioners in Asia and the diaspora insisting the “Western way” just doesn’t fit, Bhat and a cohort of psychiatrists, researchers, spiritualists and therapists are digging into the cultural context surrounding mental health. New York–based psychiatrist Neil Aggarwal, for one, has studied Ayurvedic and Islamic medicine, which often tie health to diet, the humors and geography. He dislikes the binary of East/West, seizing instead on the intellectual heritage of psychiatry and psychology, which, he explains, “emerged from a secular, post-Enlightenment tradition where we really believe there are five empirical senses that allow us to perceive reality, and our sense of self is infinitely entwined with our ability to define reality amid those five senses.” Padukone’s therapist, Chandy, who is not an M.D., is more succinct: ”I think it’s very important to stress that all the medical interventions have come from the West.”
But what exactly can these epistemic rejiggerings do to change society? On a macro level, the Indian government has stepped in, pushing to revive centuries-old medical practices like those Aggarwal’s investigated. The budget for the department supporting research and training in homeopathy, naturopathy and Ayurveda got a $30 million boost this year, bringing it to a healthy $200 million.
In practice, psychiatrists like Bhat and Aggarwal apply cultural sensitivities when evaluating, rather than pathologizing, say, a twentysomething kid still living at home (reasonable enough in Asian society). They may, in response to patients’ wishes, refrain from medical intervention: “Across the board, South Asians experience depression and anxiety as interpersonal stressors rather than genetic or biological results,” Aggarwal says. The psychiatrists may encourage open discussions around spirituality or practices that utilize meditation and yoga alongside cognitive behavioral therapy. Chandy uses body massage and refers to the Mahabharata or to Hindu concepts of leela, nondualistic notions of the self, when treating someone in crisis. And Bhat, for his part, has developed a practice called Integral Self Therapy, which incorporates meditation and spirituality into psychotherapy.
Advocates of the new wave can sometimes sound indistinguishable from Western therapists who know their downward dog and deep breathing. Nations beyond India are increasingly gravitating toward so-called “mind-body” concepts of the self — spawning a $3.4 trillion market, from healthy diets to alternative therapies. Could these musings of South Asia and its diaspora stretch beyond the country of 1.4 billion, plugging into global discussions about the role of medicine versus therapy, human relationships versus prescription pads, and whether our existential angst, neuroses, distraction and discontent stem from modernity and isolation … or from the inescapable biology of our brains? As India attempts to rethink medical notions of the mind, could it introduce an alternate model for mental health around the world?
Statistics point to rocketing rates of mental illness: According to an April report from the Centers for Disease Control, the last 15 years saw a 24 percent uptick in the number of suicides in the U.S. — climbing at an even faster rate since 2006. The World Health Organization estimates around 450 million people in the world suffer from mental illness; by 2030, depression will create the second-highest financial burden on health systems in middle-income nations and will show up as the third-highest strain in low-income nations. Pair those findings with WHO data indicating that, in 2014, 45 percent of people worldwide lived in a country with fewer than one psychiatrist per 100,000 residents.
All of which confirms that depression isn’t a developed-country, white-person problem. A 2013 study showed that while Westerners were likelier to experience anxiety, depression had a higher prevalence in Asia and the Middle East. Soma Ganesan, clinical psychiatrist at the University of British Columbia in Vancouver, treats lower-middle-class immigrants and refugees in a city where nearly half the population doesn’t speak English at home, according to Canadian government data. It’s tempting to treat their troubles as distinct from the issues facing clients willing to pay $200 for an hour of psychotherapy — but “if we don’t understand their cultural contexts, we would deal with them in a biological side only,” he says
The current edition of the Diagnostic and Statistical Manual (DSM V), the psychiatric bible, lists almost 300 conditions — nearly triple the number in the first volume. This DSM, published in 2013, covers familiar illnesses like eating disorders and schizophrenia. But it also refers to what psychiatrists call “culture-bound syndromes,” like the Malaysian and Indonesian experience of amok (the basis for the English phrase “running amok”) — a furious and sudden emergence of anger (usually in a male), occasionally resulting in mass violence. Other culture-bound syndromes mentioned in the DSM include Korean shinbyeong, characterized by melancholy and loss of sense of self, and Haitian maladi moun, which refers broadly to mental troubles like depression or anxiety caused by interpersonal friction.
Bhat, who trained in India, the U.S. and the U.K. and practiced in America before returning to his motherland, has seen some of these conditions up close. He describes an early day of his psych rotation in medical school when he witnessed a case of “possession” at a government hospital. The patient had arrived with her husband, who, it transpired, drank every day and hit her occasionally. He’d slapped her when his dinner arrived cold, and she’d responded by chanting lines from the holy Bhagavad Gita — and blessing him. Was she a goddess? He thought so — and treated her accordingly — for a few days, until she in turn slapped him … which brought them to the doctor. The husband reasoned she was a demon, not a goddess, and required an exorcism. Bhat watched as the attending doctor prescribed a muscle relaxant for the woman, to ease out the “devil,” and told the husband that women are kind when treated well and horrid when treated poorly. No lying on the couch to discuss feelings. In, out, and off they went.
Schizophrenics in California, Ghana and India each heard distinct types of voices.
Even for global disorders like schizophrenia, we have seen evidence of specific cultural contexts: A 2014 study by Stanford psychological anthropologist Tanya Luhrmann found that schizophrenics in California, Ghana and India each heard distinct types of voices — in general, Americans experienced threats, Ghanaians heard sounds of the divine and Indians spoke casually with their ancestors and deceased family members. But many fear a respect for the vernacular nature of the mind is fading. Bhat is, in some ways, standing athwart history shouting “Stop!” as the tech workers in his cosmopolitan home city of Bangalore cart rapidly Westernizing ideas into his office.
Speaking to 37-year-old Rohan Sabharwal over coffee one afternoon, I thought things looked bleak. The mordant-witted, pierced and tattooed filmmaker has been diagnosed with a soup of conditions since he was a teen, but mostly he seems to suffer from bipolar disorder. He’s OK right now. But not always.
He’s spent time in mental hospitals, where the medication gave him diarrhea and he couldn’t go to the bathroom without an orderly present. He’s seen his parents shell out for overpriced rehabilitation facilities. He’s undergone elective electroconvulsive therapy and, as a result, says he can’t remember anything that happened to him in 2014. He’s seen some 15 shrinks and even tried hypnotherapy, which was basically an expensive nap. (Bhat notes that a lack of cultural awareness regarding mental health can leave Indians vulnerable to snake-oil peddlers.) Sabharwal swallowed rat poison and had it pumped from his stomach. He bears scars from when he locked himself in his apartment and slashed his arms nearly to the bone. His partner has the key to where knives are kept at his house, and she forbade him from moving into an apartment on the tenth floor. “I feel like killing myself a lot,” he says. “It’s been the No. 1 thing on my Google search for the past eight or nine years.”
After years of living through and meeting others in the belly of India’s mental-health system, Sabharwal refuses to adopt the mantra of family first. He’d rather take Western individualism over parents who don’t talk to their kids about sex, force them to marry by 24 and believe they can flush homosexuality out of them. “In India, we have this notion of the family being the center — but I feel honestly that all our problems are rooted in the family.” Asked about Padukone’s appearance on national TV, he’s willing to acknowledge there’s been a shift in the conversation since she spoke up. But he’s quick to follow with a caustic reference to the “1,000-word statuses people post on Facebook about mental health.… Everyone’s romanticizing it.”
India is undergoing a romantic era of rewriting its identity, one in which the intellectual narratives of mental health could fit, for better and worse. The nation is nearing 70 years from independence and decades from economic liberalization. At last, much of the country seems interested in, if not eager to define itself on, its own terms — from Narendra Modi’s government harkening back to the glory of Vedic times to the wave of left-wing activists resisting what they see as Western-imported capitalism.
Perhaps India could offer the world some new models for governance in the Gandhian tradition, for integrating science and religion, for concepts of the mind. Listening to Bhat, who quotes Émile Durkheim, Plato and Hindu Vedanta, that hope seems more promising to many — in the East and West alike — than a Prozac prescription.
An earlier version of this story misspelled Rohan Sabharwal’s name.