Psychiatry for all

2025-08-21T22:25:00.000-07:00

Looking Back, Looking Within: A Journey Through Bhutan’s Mental Health Landscape

I began my journey as a medical doctor in 1989, a time when Bhutan’s health system was still in its early stages of development. As a young medical officer, I moved across five different postings over 13 years. Those years shaped my identity as a doctor and taught me the value of service, resilience, and humility. Yet, when I look back on that period, one thing stands out with a quiet but unsettling weight: I do not recall ever treating a patient for the psychiatric conditions that now dominate my daily practice.

It was only later, after training and returning as Bhutan’s second psychiatrist, that I began to question this silence. Did mental illness not exist in those days? Or did we, as medical professionals, fail to recognise it?

In my memories, I can still see “odd” figures wandering the streets — men and women who behaved strangely, muttered to themselves, or lived in hidden corners of the community. They were the ones people avoided, the ones children were warned against as potentially dangerous. At the time, we had no framework to understand them. Mental illness was not part of our diagnostic vocabulary. Alcohol use, meanwhile, was dismissed as a weakness of character and a lack of discipline. We had no tools, no interventions, and no hope to offer.

Our focus in those days was elsewhere. We were young doctors serving in a young nation, where communicable diseases, maternal and child health, safe drinking water, sanitation, and nutrition were our urgent priorities. Public health campaigns — immunisation, malaria control, iodine deficiency, leprosy eradication, and family planning — consumed our attention and rightly so. Hospitals were places people turned to only when local healers and shamans could not provide relief. Our task was to win their trust in modern medicine, to prove that science and compassion could complement tradition.

Yet, beneath this progress, a hidden suffering remained unaddressed. Only years later, after serving as a psychiatrist for more than two decades, do I recognise how much we might have missed. Mental illness was there — in silence, in stigma, in shadows — but it went unseen, unnamed, and untreated.

Today, the picture is very different. Thousands of people come forward seeking psychiatric help, each story unique, each pain deserving of recognition. Families, schools, and workplaces are more open to conversations about mental health. Awareness campaigns, training programs, and media discussions have brought the invisible into the light. Sometimes, though, I wonder if in our effort to destigmatise mental health, we may have swung the pendulum too far in the other direction.

I find myself reflecting on whether we have created a kind of over-reliance — a belief that every stress, every worry, every difficulty must be solved by professionals like us. While clinical care is essential, I firmly believe that true mental well-being also requires personal responsibility, resilience, and community support. People must learn not only to seek help when needed but also to nurture their own coping skills and inner strength.

After 36 years in Bhutan’s health sector — 23 of them as a psychiatrist — I remain humbled by the journey. From days when mental illness was invisible to today, when it is openly discussed, we have come a long way. Yet the work is far from over. We must continue to expand services, reduce stigma, and strengthen care. But equally, we must empower individuals to take ownership of their mental health, to recognise that healing is not only in hospitals and clinics but also within families, friendships, and the choices we make every day.

As I reflect on this path, I realise that the greatest lesson of all has been to look beyond symptoms and statistics, and to see the human being in front of me — vulnerable, complex, yet resilient. That, perhaps, is where true healing begins.

SUICIDE

2018-08-14T22:21:00.003-07:00

Introduction:

In Bhutan, suicide deaths rank among the top six leading causes of deaths after alcoholic liver disease, other circulatory diseases, cancers, respiratory diseases, and transport deaths. Suicide deaths outnumber the combined deaths due to TB, malaria and HIV. In a five-year review of suicide cases from 2009 ‐2013 in Bhutan, a total of 361 suicide deaths were documented by the Royal Bhutan Police. This is an average of 73 suicide cases in a year or six suicide deaths in a month. The death by suicide rate in Bhutan is 10 per 100 000 population slightly lower than the global rate of 11.4 per 100 000 population per year. The proportion of suicide deaths among all deaths is 4.5% higher than the corresponding proportion of 1.4% in the low middle-income countries. Suicide occurs among the most productive age groups; 87% of deaths occurred within the age group of 15‐40 years. Although the global suicide rate has seen a drop, suicide rates in Bhutan have remained steady and rather increased particularly in the recent years.

Globally for every suicide death, many more people attempt suicide. In Bhutan, for every 4.5 suicide deaths,, there is one suicide attempted case recorded, indicating gross under-reporting of the attempted cases. The Health Management Information System (HMIS) of the Ministry of Health has been collecting data on “intentional self-harm” since 2010. Cases of intentional self-harm reported in the health facilities ranged from 502‐682 cases while only 3‐5 deaths due to intentional self-harm which is likely suicide deaths were recorded in health facilities during 2009‐2013. This shows that suicide attempt cases end up in health facility care. Suicide attempts result in an enormous cost to the healthcare, family and individuals due to injury and disability.

Causes:

There’s no single reason why someone may try to take their own life, but certain factors can increase the risk. Someone may be more likely to attempt suicide if they have a mental health disorder. About 90 per cent of people who commit suicide have a mental illness at the time of their death.

The most common causes of suicide are:

1. Depression

2. Psychosis

3. Impulsive behaviours

4. Crying for help

5. Philosophical desire to help

6. By mistake

Depression is the top risk factor, but there are various other mental health disorders that can contribute to suicide, including bipolar disorder and schizophrenia.

In Bhutan, some of the major contributing social factors identified were lack of job opportunities, the percentage of broken families, and a high rate of domestic violence.

Elsewhere, aside from mental illnesses, there are several risk factors that may contribute to thoughts of suicide, attempted suicide, and actual suicide. They include:

· previous suicide attempts

· substance abuse

· incarceration

· family history of suicide

· poor job security or low levels of job satisfaction

· history of being abused or witnessing continuous abuse

· being diagnosed with a serious medical condition, such as cancer or HIV

· being socially isolated or a victim of bullying

· being exposed to suicidal behaviour

Those who have been shown to be at a higher risk for suicide are:

· men

· people over age 45

People who have suicidal thoughts are often so overwhelmed by feelings of sadness and hopelessness that they think they have no other option. While it can be hard to know how someone is feeling on the inside, there are various behaviours that can indicate suicidal tendencies. It’s important to recognize these warning signs so you can help a family member or a friend who may be experiencing suicidal thoughts.

Signs and symptoms of suicidal behaviour

· feeling of hopeless

· feeling trapped

· feeling alone or lonely

· feeling anxious or agitated

· feeling as if there is no reason to go on living

· thinking of suicide as a way out

· experiencing mood swings

· abusing alcohol or drugs

Signs That Someone May Attempt Suicide

You can’t see what a person is feeling on the inside, so it isn’t always easy to identify someone who is having suicidal thoughts. However, some outward warning signs that a person may be contemplating suicide include:

· talking about feeling hopeless

· talking about having no reason to go on living

· making a will or giving away personal possessions

· searching for a means of doing personal harm, such as buying a gun

· sleeping too much or too little

· eating too little or eating too much, resulting in significant weight gain or weight loss

· engaging in reckless behaviours, including excessive alcohol or drug consumption

· avoiding social interactions with others

· expressing rage or intentions to seek revenge

· showing signs of anxiousness or agitation

Causes for increased suicide risk

Many factors increase the risk for suicide. These factors are separated into three categories: biopsychosocial, environmental, and sociocultural.

Biopsychosocial

Biopsychosocial causes account for most suicides and attempted suicides. These causes include mental health disorders such as:

· depression

· bipolar disorder

· schizophrenia

· anxiety disorders

· personality disorders

Additional biopsychosocial causes include:

· substance abuse

· childhood abuse or trauma

· the family history of suicide

· previous suicide attempts

· having a chronic disease

Environmental

Environmental factors that increase the risk for suicide often occur due to a stressful life event. This may include the loss of a person, pet, or job. Other causes include:

· social loss, such as the loss of a significant relationship

· access to lethal means, including firearms and drugs

· being exposed to suicide

· being a victim of harassment, bullying, or physical abuse

Sociocultural

One of the main sociocultural causes of suicide is the feeling of being isolated or of not being accepted by others. Feelings of isolation can be caused by sexual orientation, religious beliefs, and gender identity.

Other possible suicide catalysts in this category include:

· difficulty seeking help or support

· lack of access to mental health or substance abuse treatment

· following belief systems that accept suicide as a solution to personal problems

· exposure to suicidal behaviour

Diagnosing and assessing people who are at risk for suicide

Mental health professionals, such as Psychologists, Psychiatrists, counsellors etc will be able to assess people who are at risk for suicide. It is very important for anyone who experiences suicidal thoughts to visit professionals to seek help. The first point of contact can be a school counsellor, doctors in the hospitals or other health workers.

Assessments may include:

Mental health conditions: In many cases, thoughts of suicide are caused by an underlying mental health disorder. If the health care provider suspects that a mental health disorder is contributing to suicidal thoughts, they will refer them to a mental health professional. A mental health professional can provide an accurate diagnosis and appropriate treatment.

Substance abuse: Alcohol or drug abuse can often contribute to suicidal thinking and acts of suicide. It’s important to tell inform the health care provider about any alcohol or drug use, such as binge drinking or using drugs on a daily basis. If substance abuse is causing the suicidal thoughts, getting treated for this in a detoxification unit or a rehabilitation program is a better option.

Medications: The use of certain prescription or over-the-counter drugs can also trigger thoughts of suicide and suicidal behaviour, therefore, it is important to inform the healthcare provider about any medications that are being taken at the moment.

Treatment for people who are at risk for suicide

Treatment will depend on the underlying cause of your suicidal thoughts and behaviour. In most cases, however, treatment consists of talk therapy and medication.

Talk Therapy

Talk therapy, also known as psychotherapy, is one possible treatment method for lowering the risk of committing suicide. Cognitive behavioural therapy (CBT) is a form of talk therapy that’s often used for people who are having thoughts of suicide. It teaches how to work through stressful life events and emotions that may be contributing to the suicidal thoughts and behaviour. CBT can also help in replacing negative beliefs with positive ones and regain a sense of satisfaction and control in life.

Medication

If talk therapy isn’t enough to successfully lower your risk, medication prescribed for that purpose can ease symptoms caused by certain physical and mental health conditions. Treating the underlying cause of symptoms can help reduce the frequency of suicidal thoughts. Generally, one or more of the following types of medication may be prescribed:

antidepressants
antipsychotic medications
anti-anxiety medications

Lifestyle Changes

In addition to taking medication and participating in talk therapy, risk for suicide can be reduced by making certain adjustments to the lifestyle. These include:

Avoiding alcohol and drugs: Abstaining from using alcohol and drugs is critical, as these substances can increase the frequency of suicidal thoughts.

Exercising regularly: Exercising at least three times per week, especially outdoors and in moderate sunlight, can also help. Physical activity stimulates the production of certain brain chemicals that make people happier and more relaxed.

Sleeping well: It’s also important to get at least six to eight hours of sleep each night. Getting help for sleep is very important.

How to prevent suicide

To help prevent suicidal thoughts, you should:

Talk to someone. Talking to someone about the suicidal feeling is helpful; it is not good to try to manage suicidal feelings by oneself. Getting professional help and support from loved ones can make it easier to overcome any challenges that are causing suicidal thoughts or behaviour.

Take medications as directed.

Take medications prescribed for the mental health problem regularly. Stick to the prescribed dose and never change your dosage or stop taking your medications unless the health care provider stops the medication. Suicidal feelings generally come back if not treated optimally and the symptoms may return. If there are negative side effects of the medication inform the treating doctor or health care provider.

Pay attention to warning signs. Learn about the possible triggers for suicidal feelings from the healthcare provider. This will help you recognize the signs of danger early on and decide what steps to take ahead of time. It can also be beneficial to tell family members and friends about the warning signs so they can know when to provide help.

Eliminate access to lethal methods of suicide. Get rid of any firearms, knives, or dangerous medications if you worry that you might act on suicidal thoughts.

How to help someone who may be feeling suicidal

If you suspect that a family member or friend may be considering suicide, you should talk to them about your concerns. You can begin the conversation by asking questions in a non-judgmental and non-confrontational way. You may ask them:

Have you ever thought about committing suicide?
Have you ever taken steps to commit suicide?
Have ever attempted to commit suicide in the past?

If they answer “yes” to any of those questions, then they are at a high risk of trying to commit suicide and they should get professional care immediately. Calling 112 or going to a hospital emergency room are good ways to prevent a suicide attempt.

If your friend or loved one isn’t in immediate danger but is having suicidal thoughts, then you can simply speak to them about the challenges they may be facing. During the conversation, make sure you:

· Stay calm and speak in a reassuring tone

· acknowledge that their feelings are legitimate

· offer support and encouragement

· reassure them that suicidal feelings are temporary

· tell them that help is available and that they can feel better with treatment

You should never minimize their problems or shame them into changing their mind. Listening to them and showing your support is the best way to help them. You can also try encouraging them to seek professional care. Offer to help them find a health care provider or mental health professional, make a phone call, or go with them to their first appointment.

It’s critical to act if you're in a position to help. Starting a conversation and risking your feelings to help save a life is a risk worth taking.

Suicide prevention

If you think someone is at immediate risk of self-harm or hurting another person:

· Call 112 or your local emergency number.

· Stay with the person until help arrives.

· Remove any guns, knives, medications, or other things that may cause harm.

Listen, but don’t judge, argue, threaten, or yell.

Sources:

1. National Suicide Prevention Lifeline and Substance Abuse and Mental Health Services Administration

2. https://en.wikipedia.org/wiki/Suicide_in_Bhutan

3. http://www.searo.who.int/bhutan/suicide_action_plan.pdf?ua=1

4. Dorji, Gampo & Choki, Sonam & Jamphel, Kinga & Wangdi, Yeshi & Chogyel, Tandin & Dorji, Chencho & Nirola, Damber. (2017). Policy and governance to address depression and suicide in Bhutan: The national suicide-prevention strategy. WHO South-East Asia Journal of Public Health. 6. 39. 10.4103/2224-3151.206163.

5. http://www.health.gov.bt/wp-content/uploads/moh-files/2017/03/Suicide-survey-report.pdf

Illness Anxiety Disorder [Hypochondriasis]

2018-07-30T23:13:00.001-07:00

What is illness anxiety disorder (IAD)?

Illness anxiety disorder (IAD) is a recent term for hypochondriasis, or hypochondria. People diagnosed with IAD strongly believe they have a serious or life-threatening illness despite having no, or only mild, symptoms. Yet IAD patients’ concerns are to them very real. Even if they go to doctors and no illnesses are found, they are generally not reassured and their obsessive worry continues. IAD can also trigger worries in people who do have a physical illness that they are sicker than they really are. The disorder is not about the presence or absence of illness, but the psychological reaction.

How long can illness anxiety disorder (IAD) last?

IAD may occur once, multiple times, or continuously. The first signs of it are usually seen in early to middle adulthood (ages 25-35) but can come on at any age. It can wax and wane in intensity, but rarely goes away completely.

What are the symptoms of illness anxiety disorder (IAD)?

Symptoms of IAD may include:

Excessive worry over having or getting a serious illness.
Physical symptoms are not present or if present, only mild. If another illness is present, or there is a high risk for developing an illness, the person’s concern is out of proportion.
High level of anxiety and alarm over personal health status.
Excessive health-related behaviours (e.g., repeatedly checking body for signs of illness) or shows abnormal avoidance (e.g., avoiding doctors’ appointments and hospitals).
Fear of illness is present for at least six months (but the specific disease that is feared may change over that time).
Fear of illness is not due to another mental disorder.

What causes illness anxiety disorder (IAD)?

The cause is not known, but certain factors may increase the risk of developing IAD:

Major life stress
A severe symptom believed to threaten one’s health (e.g., chest pain, memory issues)
History of childhood abuse (physical, sexual, emotional) or neglect
History of childhood illness
Having another mental disorder (e.g., major depression, anxiety, obsessive compulsive disorders, psychotic disorders)

Case study

A 45-year-old white male engineer presents to a primary care clinic armed with multiple internet searches on the topic of cancer. He states that he “just knows” he has a GI cancer, "probably the colon or maybe the pancreas." When asked how long this concern has bothered him he says "for years I have been concerned that I have cancer." You ask about relevant symptoms and he is a bit vague, saying "I get some pain or pressure right here (he points to the left upper quadrant) but it is not there all the time." Upon asking about prior workups he says “I have had ultrasounds and colonoscopies but they couldn't find anything. I was initially relieved but a couple of weeks later started to think that they must have just missed something.”

When you ask about the patient's goals for today’s visit he is emphatic. "I think what I really need is another colonoscopy and abdominal CT scan." His examination is unrevealing. When you suggest a less invasive approach, he brings up error rates of the other evaluations and shows literature endorsing how abdominal CT is the criterion standard. He is anxious at baseline and increasingly irritable when you propose less invasive evaluation. He ends the encounter by stating that he will “find another doctor who sees my point and will get me what I need.”

References:

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013.
Anxiety and Depression Association of America. DSM-5: Changes to the Diagnostic and Statistical Manual of Mental Disorders Accessed 6/25/2015.
American Psychiatric Association. DSM-5 Fact Sheets: Somatic Symptom Disorder (PDF) Accessed 6/25/2015.
https://my.clevelandclinic.org/health/diseases/9886-illness-anxiety-disorder-beyond-hypochondriasis (accessed on 31/07/2018)
https://emedicine.medscape.com/article/290955-overview (accessed on 31/07/2018)

SUICIDE in children and adolescents

2013-08-19T22:34:00.003-07:00

Suicidal ideation and behavior are among the most frequent psychiatric emergencies in childhood and adolescence.

Although successfully completed suicide is virtually non-existent in children under 5 and rare in children 6-12, the suicide rate in adolescence is significant and is rapidly increasing. In the 15- to 24 year-old age group, suicide is the third leading cause of death. Girls attempt suicide three times more as frequently as boys; however, boys complete suicide two to three times as frequently as girls.

Any child who attempts suicide usually does so as a last resort. Even if the suicidal behavior is seen as a gesture and not genuine effort to end life, it must always be seen as a desperate attempt on the part of the child and must always be taken seriously. It is important to remember that a proportion if children who attempt suicide later go on to commit suicide. A suicidal gesture is a psychiatric emergency.

Suicidal ideation and behavior in childhood usually reflect serious and chronic problems within the family. Children who contemplate suicide have frequently had early separation from their parents or inadequate mothering, sometimes including physical and emotional abuse. Often these children present as depressed, empty, and lonely, with an accompanying sense of themselves as expendable.

Often the child of latency age or younger may threaten or attempt suicide without understanding the nature of death, its permanence, and its irreversibility. For children of this age death may mean removal from unpleasant situation to a happier one; it may also be an attempt to gain love from unresponsive parents or to join a parent or loved one who has died.

In a recent study of suicidal behavior in children ages 6 to 12, it was found that a child’s suicidal potential correlated significantly with a sense of depression, hopelessness, and worthlessness; with parents’ depression and suicidal behavior; and with a belief that death is temporary and pleasant.

Suicidal adolescents understand the meaning of death. Usually these youngsters are seriously troubled. They frequently present with depression or with antisocial behavior (turning their aggression outward as a defense against their depression). Most have very low self-esteem. Prior to their suicide attempts there are may be difficulties in other areas of life (such as failure in school, trouble with law, or the end of a romantic relationship) that further lower self-esteem. The adolescent may feel overwhelmed and desperate. Most attempts represent the child’s or adolescent’s effort at extrication from impossible situation resulting either from internal or external stress.

Source: Manual of Clinical child Psychiatry: Emergencies by Judith Robinson, MD

ILL EFFECTS OF ALCOHOL

2013-06-08T06:56:00.000-07:00

Brief History:

Although the exact date when alcohol was produced remains elusive, from archeological discovery of late ‘Stone Age Beer Jugs’ points to the fact that intentionally fermented beverages existed as early as the Neolithic period.

Alcoholic drinks were an intricate part of most civilization ranging from China and India and Western Asia to Europe. In India alcoholic beverages appeared during the Indus Valley Civilization, In Hindu Ayurvedic texts both the beneficial and detrimental effects of alcohol have been outlined. Distilled spirits originated in India and China around 800 B.C. the distillation process emerged in Europe around the eleventh century.

We have no records when alcoholic beverages appeared in Bhutan but from our rituals, cultural practices and customs we can safely make a guess that drinking of alcohol must have been there since long. People from all the ethnic groups in Bhutan know the process of brewing alcoholic beverages. Prior to 1976, until the establishment of Army Welfare Project which started manufacturing modern liquor, most people used to drink home-brewed alcoholic beverages such as Bangchang, sinchang, and ara.

Since most of the people worked in the fields and used limited quantity of the alcoholic beverages during their work hours, there was perhaps not much severe physical harm to them then. May be most of the alcohol they consumed would have got ‘burnt out’ faster due to hard physical labour. However, our old habits carried to our modern lifestyle have been showing a different picture now. Due to abundance of several brands and makes of alcoholic drinks in modern day Bhutan, there are many people addicted to alcohol. The most common cause of death in Jigme Dorji Wangchuck National Referral Hospital is Alcoholic liver disease.

Physical effects of alcohol:

Alcohol is a central nervous system depressant because of this it impairs judgment, speech and muscular coordination. It slows down the reaction time and causes the person to make some risky decisions that would normally be avoided; it thus impairs the ability to drive.

Alcohol use over time can cause serious physical ailments. Alcohol causes inflammation of the liver leading to increase in size called alcoholic hepatitis. There will be deposition of fat in some areas of the liver leading to fatty liver. Fatty liver decreases the amount of liver tissue. Overtime the swelling will be replaced by scar tissue developing into cirrhosis. The liver ultimately loses healthy tissue until it can no longer function. The signs of severe liver disease are abdominal swelling and pain, nausea, vomiting, jaundice and mental confusion. Some people might bleed easily especially inside the digestive tracts that can go unnoticed resulting into death.

Alcohol is an irritant to the gastrointestinal tract and can inflame the lining of the oesophagus and the stomach. This inflammation causes chronic gastritis and at times even ulceration. Chronic inflammation of the stomach also prevents absorption of vitamins such as folic acid and thiamine which are necessary for good health. Alcohol can also damage the pancreas, which is an organ that manufactures certain enzymes for digesting proteins, carbohydrates and fats. The body’s metabolism is also affected when the pancreas is damaged by heavy drinking.

Alcohol is bad for people who suffer from diabetes as alcohol will keep glucose that exists in the liver from being released into the bloodstream. This in turn will increase the chances of developing low blood sugar, also called hypoglycemia.

High blood pressure and damage to heart muscle can be precipitated by alcoholism. People are thus put at risk of suffering a stroke or having a heart attack. Kidney disease has also been known to develop in people who consume excess amounts of alcohol.

Erectile dysfunction (failure to achieve erection of penis) in males and interruptions in women's menstrual cycle have also been associated with the effects of alcohol. Pregnant women who are addicted to alcohol have high risk for miscarriage. Even if they attend full term pregnancy, the chances of children being born with foetal alcohol syndrome is very high. Alcohol affects bone mass, causing thinning of bones so that fractures are much more likely to occur. Numbness in the feet and hands, dementia, and an increased prospect of developing cancers such as cancer of the liver, throat, and colon are other possible physical effects of alcohol addiction.

Psychological Effects of Alcoholism

Alcohol is a highly addictive substance that can carry with it numerous short- and long-term effects. While it can be physically damaging to our health, it can also be mentally damaging to our psyche

Short Term Effects

Short-term effects of alcohol, say from one night of drinking with friends, can range from slurred speech, difficulty balancing, impaired decision making, lowered inhibitions and memory loss, depending on the amount of drink. Blackouts are also a short term result of drinking and occur when a person drinks alcohol quickly and the blood alcohol level rises swiftly. Black out means loss of memory of events that take place while drinking, that is, the person will not be able to remember anything that ensues during the bout of drinking.

Long Term Effects

In people who drink heavily and regularly, alcohol causes depression, anxiety and many other dysfunctions of the brain.

1. Depression

Many people believe that alcohol can treat depression and make someone happier, but on the contrary, alcohol can lead to depression, or greatly increase the symptoms of depression in a person diagnosed with depression. Taking alcohol to treat depression can lead to severity of symptoms at times leading to suicidal attempts and suicides.

2. Anxiety

Much like depression, alcohol can also lead to serious anxiety issues, especially in a person diagnosed with an anxiety disorder. Alcohol can cause or increase anxiety by depressing the nervous system and leading to irritation and fatigue. Often the hangover effect caused by drinking alcohol can increase feelings of anxiety. Excessive alcohol consumption can also increase heart rate and blood pressure, a physical aspect that can lead to greater anxiety and panic attacks.

3. Brain dysfunction

Overtime, with heavy drinking, alcohol has been found to lower the cognitive functions of the brain such as ability to learn new information and remember things. This happens because alcohol kills the brain cells and brain cells once destroyed do not regenerate.

4. Wernicke-Korsakoff Syndrome

Wernicke-Korsakoff syndrome is a severe brain disorder resulting from thiamine (Vitamin B1) deficiency, which is often a result of long-term heavy drinking. WKS causes poor coordination, muscle movement, confusion, an inability to learn and remember things and disorientation. While early stages can be treated with administration of thiamine, if left untreated it can lead to a permanent condition that can cause coma or death.

Signs and Symptoms of alcoholism:

Drinking is woven into the fabric of many societies. Sharing a bottle of wine over a meal, going out for drinks with friends, celebrating special occasions with champagne etc. are commonly accepted norms in many societies. Since alcohol is such a common element in many celebrations and activities, it will be hard to realize when one progresses from social user to a problem drinker. However, if someone consumes alcohol simply to feel good, or to avoid feeling bad, this could become problematic.

Drinking problems are due to many interconnected factors, including genetics, upbringing, and the social environment and one’s emotional health. People who have a family history of alcoholism or who associate closely with heavy drinkers are more likely to develop drinking problems. People who suffer from a mental health problem such as anxiety, depression, or bipolar disorder are also particularly at risk, because alcohol may be used for self-medication.

Since drinking is so common in many cultures and the effects vary so widely from person to person, it’s not always easy to figure out where the line is between social drinking and problem drinking. The bottom line is how alcohol affects the individual. Therefore, if your drinking is causing problems in your life, you have a drinking problem.

You may have a drinking problem if you...

Feel guilty or ashamed about your drinking.
Lie to others or hide your drinking habits.
Have friends or family members who are worried about your drinking.
Need to drink in order to relax or feel better.
“Black out” or forget what you did while you were drinking.
Regularly drink more than you intended to.

Substance abuse experts make a distinction between alcohol abuse and alcoholism (also called alcohol dependence). Unlike alcoholics, alcohol abusers have some ability to set limits on their drinking. However, their alcohol use is still self-destructive and dangerous to themselves or others.

Common signs and symptoms of alcohol abuse include:

Repeatedly neglecting your responsibilities at home, work, or school because of your drinking. For example, performing poorly at work, failing in the examinations, neglecting your kids, or skipping out on commitments because you’re hung over.

Using alcohol in situations where it’s physically dangerous, such as drinking and driving, operating machinery while intoxicated, or mixing alcohol with prescription medication against doctor’s orders.

Experiencing repeated legal problems on account of your drinking. For example, getting arrested for driving under the influence or for drunk and disorderly conduct.

Continuing to drink even though your alcohol use is causing problems in your relationships. Getting drunk with your friends, for example, even though you know your wife will be very upset, or fighting with your family because they dislike how you act when you drink.

Drinking as a way to relax or de-stress. Many drinking problems start when people use alcohol to self-medicate for relief of stress. Getting drunk after every stressful day, for example, or reaching for a bottle every time you have an argument with your spouse or boss.

The path from alcohol abuse to alcoholism

Not all alcohol abusers become full-blown alcoholics, but it is a big risk factor. Sometimes alcoholism develops suddenly in response to a stressful change, such as a breakup, retirement, or some other loss. Other times, it gradually creeps up on you as your tolerance to alcohol increases. If you’re a binge drinker or you drink every day, the risks of developing alcoholism are even greater.

Signs and symptoms of alcoholism (alcohol dependence)

Alcoholism is the most severe form of problem drinking. Alcoholism involves all the symptoms of alcohol abuse, but it also involves another element: physical dependence on alcohol. If you rely on alcohol to function or feel physically compelled to drink, you’re an alcoholic.

Tolerance: The 1st major warning sign of alcoholism

Do you have to drink a lot more than you used to in order to get drunk or to feel relaxed? Can you drink more than other people without getting drunk? These are signs of tolerance, which can be an early warning sign of alcoholism. Tolerance means that, over time, you need more and more alcohol to feel the same effects.

Withdrawal: The 2nd major warning sign of alcoholism

Do you need a drink to steady the shakes in the morning? Drinking to relieve or avoid withdrawal symptoms is a sign of alcoholism and a huge red flag. When you drink heavily, your body gets used to the alcohol and experiences withdrawal symptoms if it is taken away. These include:

· Anxiety or jumpiness

· Shakiness or trembling

· Sweating

· Nausea and vomiting

· Insomnia

· Depression

· Irritability

· Fatigue

· Loss of appetite

· Headache

In severe cases, withdrawal from alcohol can also involve hallucinations, confusion, seizures (fits), fever, and agitation. These symptoms can be dangerous, therefore, it is advisable to take help from a doctor or health worker if you are a heavy drinker and want to quit.

Other signs and symptoms of alcoholism (alcohol dependence)

You've lost control over your drinking. You often drink more alcohol than you wanted to, for longer than you intended, or despite telling yourself you wouldn't.

You want to quit drinking, but you can’t. You have a persistent desire to cut down or stop your alcohol use, but your efforts to quit have been unsuccessful.

You have given up other activities because of alcohol. You’re spending less time on activities that used to be important to you (hanging out with family and friends, going to the gym, pursuing your hobbies) because of your alcohol use.

Alcohol takes up a great deal of your energy and focus. You spend a lot of time drinking, thinking about it, or recovering from its effects. You have few, if any, interests or social involvements that don’t revolve around drinking.

You drink even though you know it’s causing problems. For example, you recognize that your alcohol use is damaging your marriage, making your depression worse, or causing health problems, but you continue to drink anyway.

Drinking problems and denial

Denial is one of the biggest obstacles to getting help for alcohol abuse and alcoholism. The desire to drink is so strong that the mind finds many ways to rationalize drinking, even when the consequences are obvious. By keeping you from looking honestly at your behaviour and its negative effects, denial also exacerbates alcohol-related problems with work, finances, and relationships. For example, you may blame an ‘unfair boss’ for trouble at work or a ‘nagging wife’ for your marital issues, rather than look at how your drinking is contributing to the problem. While work, relationship, and financial stresses happen to everyone, an overall pattern of deterioration and blaming others may be a sign of trouble.

If you find yourself rationalizing your drinking habits, lying about them, or refusing to discuss the subject, take a moment to consider why you’re so defensive. If you truly believe you don’t have a problem, why do you feel the need to cover up your drinking or make excuses? Is it possible that your drinking means more to you than you’re ready to admit?

If you have a drinking problem, you may deny it by:

Drastically underestimating how much you drink
Downplaying the negative consequences of your drinking
Complaining that family and friends are exaggerating the problem
Blaming your drinking or drinking-related problems on other

Treatment:

Alcoholism is considered a disease and treatment helps in quitting alcohol and remaining sober. Since alcoholism is a lifelong problem, the main objective of treatment is to achieve sobriety for lifelong.

Treatment consists of different phases; even though benefit of going through all the phases is much more than one single phase, it is not mandatory for everyone to go through all the phases.

Detoxification (detox for short) literally means the physiological or medicinal removal of toxic substances from a living organism. In treatment of alcoholism, the person abstains from drinking alcohol and medicines which prevent development of withdrawal symptoms are prescribed for a period of ten to twelve days. Detoxification can be done on domiciliary basis or in a hospital setting depending on the severity of alcoholism.

Counselling: Through counselling the person is educated about the harmful effects of alcohol, methods of coping with urges and trigger, time management etc. Counselling in Bhutan is provided in the Drop-in-centres, hospital and the rehabilitation centres.

Rehabilitation: Through cognitive behaviour therapy and other psychological exercises the person is prepared to live an alcohol free life. People who have lost jobs due to alcoholism are taught some skills which they can use later in life. A typical Rehabilitation Program last from three to six months. The Nazheon Pelri Treatment and Rehabilitation Centre for Drug and Alcohol Dependence at Serbithang is one such centre in Bhutan and the program is for 3 months.

Support groups: Support groups, such as “Chithuen Phendey”, alcoholic anonymous and Al-anon try to help the recovering alcoholics and their family members cop up with problems that could result due to alcoholism, teach skills to handle cravings, and provide continued support prevention of relapses.

Reference:

http://www.ehow.com/about_5557931_psychological-effects-alcohol.html#ixzz1JJk63iFx
http://www.awp.com.bt/brief_history_awp.php
http://www.ehow.com/about_4827654_physical-effects-alcohol-addiction.html
http://pubs.niaaa.nih.gov/publications/aa63/aa63.htm
http://helpguide.org/mental/alcohol_abuse_alcoholism_signs_effects_treatment.htm
http://visual.ly/how-alcohol-travels-through-body

Ill effects of substances abused in Bhutan

2013-06-08T06:35:00.001-07:00

There are various substances abused in Bhutan. Even though ‘hard drugs’ such as Heroin, amphetamine, methamphetamine etc., have not been very prevalent, we have been seeing a typical pattern of drug use in Bhutan. Teenagers start experimenting with drug by using volatile substances, later progressing to cannabis (marijuana) and pharmaceutical products like smasmoproxyvon (SP), relipin (RP), cough mixer (Corex), and Nitrazepam (N10).

While ill effects of alcohol are generally well known to many, the side effects and the danger of abusing other substances are not very well understood. This chapter will therefore try to explain the ill effects of substances that are commonly abused in our country.

Volatile substances:

Volatile substances are chemical compounds that give off fumes at room temperature. They are also called ‘inhalants’ in recognition of their route of administration. Volatile substance use (VSU) is the ‘practice of deliberately inhaling (“sniffing”, “huffing”, “bagging” or “chroming”) substances that are vaporous at ambient temperatures for the purpose of becoming intoxicated’.

Volatile substances are central nervous system depressants which produce an immediate and intense intoxication. The onset of effect is rapid because the extensive capillary surface of the lungs readily absorbs the vapour causing blood levels to peak within minutes of use.

Volatile substances[i] can be in form of intoxicating fuels for vehicles (petrol), butane gas (lighter fluids), aerosol paints and sprays (spray paint), glue (Dentrite), correction fluids etc.

Physical effects of volatile substance use[ii]:

The psychoactive effects of inhaling volatile substances occur rapidly but only last for a short time (5 to 45 minutes after ceasing use). However, because of the fat soluble nature of volatile substances, they can be stored in neurological tissues and can have a prolonged effect on the level of consciousness for a much longer period of time.

Many of the harmful physical effects from VSU are reversible, especially in infrequent users. The damage is cumulative in chronic VSU, and is associated with an increased likelihood of permanent brain damage.

There are short-term and long-term physical effects of VSU:

Short-term physical effects	Long-term physical effects
§ a feeling of wellbeing § fatigue § headache § blurred vision § slurred speech § nausea and vomiting § increased risk-taking and loss of inhibition § agitation and aggression § confusion § hallucinations § loss of coordination § abdominal pain § heart palpitations § loss of consciousness § death	§ red, watery eyes § nosebleeds § lack of energy § indigestion § dizziness § frequent cough § shortness of breath § tinnitus (ringing in the ears) § angina (temporary chest pain) § stomach ulcers § chronic headache § sinusitis (inflammation of the area around the nose) § attention, memory and problem solving issues § depression § loss of hearing and sight § ataxia (lack of coordination of muscle movements) § seizures and epilepsy § reduced bone density § damage to the heart, lungs, liver and kidneys

Short-term physical effects

Long-term physical effects

§ a feeling of wellbeing

§ fatigue

§ headache

§ blurred vision

§ slurred speech

§ nausea and vomiting

§ increased risk-taking and loss of inhibition

§ agitation and aggression

§ confusion

§ hallucinations

§ loss of coordination

§ abdominal pain

§ heart palpitations

§ loss of consciousness

§ death

§ red, watery eyes

§ nosebleeds

§ lack of energy

§ indigestion

§ dizziness

§ frequent cough

§ shortness of breath

§ tinnitus (ringing in the ears)

§ angina (temporary chest pain)

§ stomach ulcers

§ chronic headache

§ sinusitis (inflammation of the area around the nose)

§ attention, memory and problem solving issues

§ depression

§ loss of hearing and sight

§ ataxia (lack of coordination of muscle movements)

§ seizures and epilepsy

§ reduced bone density

§ damage to the heart, lungs, liver and kidneys

Sudden sniffing death

Some inhalants can indirectly cause sudden death by cardiac arrest in a syndrome known as ‘sudden sniffing death’. The hydrocarbon gases present in the inhalants appear to sensitise the heart muscle to adrenaline (a type of hormone). In this state, a sudden rush of adrenaline (for example, from a frightening hallucination or intense physical activity) can cause a fatal heart irregularity (Cardiac arrhythmia). Sudden sniffing death can occur after a single use and is associated with the inhalation of butane, propane, and the chemicals found in aerosols.

Asphyxiation

People who inhale petrol can die as a result of asphyxiation. The oxygen in the lungs is displaced by the inhaled petrol vapour which may stop the user from breathing. Inhaling petrol from a bag or in a confined space (such as under a blanket) increases the risk of death from asphyxiation. Spraying volatile substances directly into the mouth is thought to cause asphyxiation since the cooling agents in the aerosol propellant freeze the larynx.

Cognitive and neurological impairments

Cognitive impairments

Cognitive impairments from VSU include a reduced attention span, short-term memory deficits, difficulty in solving problems, and impairments to visual-spatial skills. The severity can range from mild impairment to severe dementia.

Neurological impairments

Some forms of neurological disorders, including Parkinson’s disease, are thought to be linked to volatile substance use. The neurological damage due to cumulative and chronic, long-term use is more likely to cause permanent brain injury or death. Early studies suggested that brain injury associated with VSU was permanent, but recent evidence suggests that significant recovery from the effects is possible where abstinence occurs prior to the development of cerebellar atrophy.

Exposure to volatile substances during pregnancy

Volatile substances can cross the placental barrier, and prenatal exposure is associated with: spontaneous abortion; low birth weight; prematurity; developmental delays; neurobehavioral problems; physical malformations; and behavioural issues later in life.

Social effects of volatile substance use

VSU is associated with a variety of social problems that involve the individuals who use volatile substances, their families, their communities, and wider society.

Common social issues are:

poor school attendance and performance
loss of opportunities to learn cultural knowledge
inability to obtain employment
alienation and isolation from social support (family, friends, community)
social stigmatisation
increased likelihood of involvement with the police
increased likelihood of being homeless
damage to spirit
fear of violence in the community (caused by volatile substance users)
increase in antisocial behaviour (fighting, vandalism, etc.)

Spasmoproxyvon/Relepin/Corex:

Spasmoproxyvon [SP] and Relepin [RP] are analgesics, pain medicines, which are generally prescribed for relief of mild to moderate abdominal pain. These substances contain a small amount of synthetic opioid called dextropropoxyphene, along with dicyclomine and paracetamol (acetaminophen) or acetylsalicylic acid. Corex is a cough mixture which contains a small amount of codeine which suppresses dry irritating cough.

A person who abuses SP and RP also consumes a large quantity of paracetamol. Even though paracetamol is one of the most commonly prescribed medicine for fever and pain, if taken in large quantity it is highly toxic to the liver. In general the recommended maximum daily dose of paracetamol for healthy adults is 4 grams (8 tablets). Higher doses lead to increasing risk of toxicity. In adults, single dose above 10 grams or 200 mg/kg of bodyweight, whichever is lower, has the likelihood of toxicity in the form of liver and kidney failure.

Opioids, such as dextropropoxyphene and codeine, by itself have lots of side effects. Common side effects of include sedation, dizziness, nausea, vomiting, constipation, and respiratory depression. Less common side effects may include delayed gastric emptying, hyperalgesia (abnormally heightened sensitivity to pain), immunologic and hormonal dysfunction, muscle rigidity, and myoclonus (Spasmodic jerky contraction of groups of muscles).

Opioid addiction is a disease of the brain[iii]. Repeated use of an opioid leading dependence causes long-term changes in both the structure and the way the brain functions (the biochemistry of the brain). The most important structural or architectural change takes place in the circuitry of the brain, particularly in the wiring of the reward pathway. Our brains are wired to ensure that we repeat life-sustaining activities, such as drinking water and eating food, by associating those activities with pleasure or reward. Whenever this reward circuit is activated, the brain records that experience making us likely to do it again. Memories that have an intense emotional component (such as pleasure) may be permanently ‘hard-wired.’ Therefore, the person with opioid dependence is tricked by the brain into believing that an opioid is as necessary for survival as food and water. The effect of such a powerful reward motivates people to repeat that behaviour again and again, even when it is clearly harmful to do so. Repeated use of an opioid has a profound impact on the intellectual portion of the human brain that is involved in judgment and decision-making.

Cannabis/Marijuana:

Marijuana is the most commonly used illicit drug in Bhutan. It is consumed in various forms, but the most common way is by smoking, generally mixed with tobacco. When smoked, it begins to effect users almost immediately and can last for one to three hours. When it is eaten in food, such as ‘bhang’, ‘pakora’, baked in brownies and cookies, the effects take longer to begin, but usually last longer.

Short-Term Effects[iv]

The short-term effects of marijuana include:

· Distorted perception (sights, sounds, time, touch)

· Problems with memory and learning

· Loss of coordination

· Trouble with thinking and problem-solving

· Increased heart rate, reduced blood pressure

Sometimes marijuana use can also produce anxiety, fear, distrust, or panic.

Effects on the Brain

The active ingredient in marijuana, delta-9 tetrahydrocannabinol or THC, acts on cannabinoid receptors on nerve cells and influences the activity of those cells. Some brain areas have many cannabinoid receptors, but other areas of the brain have few or none at all. Many cannabinoid receptors are found in the parts of the brain that influence pleasure, memory, thought, concentration, sensory and time perception, and coordinated movement.

When high doses of marijuana are used, the users can experience the following symptoms:

· Hallucinations

· Delusions

· Impaired memory

· Disorientation

A number of studies have shown an association between chronic marijuana use and mental illness. High doses of marijuana can produce a temporary psychotic reaction (involving hallucinations and paranoia) in some users, and using marijuana can worsen the course of illness in patients with schizophrenia. Some studies have also shown a link between marijuana use and later development of psychosis[v]. There are also studies which suggest that there are associations between marijuana use and other mental health problems, such as depression, anxiety, suicidal thoughts among adolescents, and personality disturbances, including a lack of motivation to engage in rewarding activities.

Effects on the Heart

Within a few minutes after smoking marijuana, the heart begins to beat more rapidly and the blood pressure drops. Marijuana can cause the heart beat to increase by 20 to 50 beats per minute, and can increase even more if other drugs are used at the same time.

Because of the lower blood pressure and higher heart rate, it is found that the risk for a heart attack is four times higher within the first hour after smoking marijuana in comparison to the general risk of heart attack when not smoking.

Effects on the Lungs

Smoking marijuana, even infrequently, can cause burning and stinging of the mouth and throat, and cause heavy coughing. Scientists have found that regular marijuana smokers can experience the same respiratory problems as tobacco smokers do, including:

· Daily cough and phlegm production

· More frequent acute chest illnesses

· Increased risk of lung infections

· Obstructed airways

Most marijuana smokers consume a lot less cannabis than cigarette smokers consume tobacco, however the harmful effects of smoking marijuana should not be ignored. Marijuana contains more carcinogenic hydrocarbons than tobacco smoke and because marijuana smokers typically inhale deeper and hold the smoke in their lungs longer than tobacco smokers, their lungs are exposed to those carcinogenic properties longer, when smoking.

Other Health Effects

Researches indicate that THC impairs the body's immune system from fighting disease because of which a wide variety of health problems can occur

Effects of Exposure during Pregnancy

Several studies have found that children born to mothers who used marijuana during pregnancy exhibit some problems with neurological development. According to those studies, prenatal marijuana exposure can cause:

· Altered responses to visual stimuli

· Increased tremulousness

· Problems with sustained attention and memory

· Poor problem-solving skills

Finally, marijuana use has also been linked in a few recent studies to an increased risk of an aggressive type of testicular cancer in young men, although further research is needed to establish whether there is a direct causal connection.

Benzodiazepines

Nitrazepam is a benzodiazepine which is a medicine typically prescribed for sleep problem such as insomnia. N10 is a brand name of nitrazepam 10mg tablet and is not prescribed by physicians in Bhutan. It is seen that many people addicted to drugs such SP or RP add a few tablets of N10 to heighten the effect of these drugs.

Benzodiazepine Abuse Symptoms and Signs[vi]

Benzodiazepine is a central nervous system depressant and has a very similar action to that of alcohol. At normal or regular doses, benzodiazepines relieve anxiety and insomnia. They are usually well tolerated but sometimes, people taking benzodiazepines may feel drowsy or dizzy. This side effect can be more pronounced with increased doses.

High doses of benzodiazepines can produce more serious side effects. Signs and symptoms of acute toxicity or overdose may include the following:

ü Drowsiness

ü Confusion

ü Dizziness

ü Blurred vision

ü Weakness

ü Poor judgment and decision making

ü Slurred speech

ü Lack of coordination

ü Difficulty breathing

ü Coma

ü Death from respiratory arrest (ceased breathing)

Signs of chronic drug abuse can be very nonspecific and include changes in appearance and behaviour that affect relationships and work performance. Warning signs in children include abrupt changes in mood or deterioration of school performance. Chronic abuse of benzodiazepines can lead to the following symptoms that mimic many of the indications for using them in the first place:

o Anxiety

o Insomnia

o Anorexia

o Headaches

o Weakness

Despite their many helpful uses, benzodiazepines can lead to physical and psychological addiction. Dependency on benzodiazepines can result in withdrawal symptoms and even seizures when they are stopped abruptly. The symptoms of withdrawal can be difficult to distinguish from anxiety. Symptoms usually develop at three to four days from last use, although they can appear earlier with shorter-acting varieties.

[i] http://www.health.nt.gov.au/alcohol_and_other_drugs/volatile_substances/index.aspx

[ii] http://www.healthinfonet.ecu.edu.au/health-risks/volatile-substance/reviews/background-information

[iii] http://psychcentral.com/lib/2011/opioid-dependence-and-withdrawal/

[iv] http://alcoholism.about.com/od/pot/a/effects.-Lya.htm

[v] http://www.drugabuse.gov/publications/drugfacts/marijuana

[vi] http://www.emedicinehealth.com/benzodiazepine_abuse/page3_em.htm#benzodiazepine_abuse_symptoms_ and_signs

Alcoholic hallucinosis (Alcohol induced psychotic symptoms)

2010-10-02T07:26:00.000-07:00

Case history:

Mr. X, 41 years old unemployed, unmarried, educated man from Paro came with the following history.

Four years ago when he woke up from sleep some time at midnight he saw nine cats in cowboy hats and boots dancing. He, sort of, enjoyed the dance though he was a little surprised. This was just a single instance and he was not bothered further.

Seven days before coming to the hospital he saw a man at the window of his house who planted device on his head with the help of a gun and started controlling him. He had to obey to the command and do whatever he wanted. The person also told him that he was webbed, that is, he was now connected to that person’s internet. Following this he felt that there was someone always at his right ear talking to him.

This invisible person guides him, gives valuable suggestions and at times sings and tells jokes to him. The patient feels that this person is much more intelligent and smarter than himself. He also has to eat for him for he keeps demanding for odd food, like ‘puri’. He, however, says that this person doesn’t like alcohol and complains a lot if the patients is about to drink alcohol. But the patient sometime defies the order of the voice and drinks alcohol and later finds that the person goes off to sleep peacefully and doesn’t bother him much. The patient is somehow used to this ‘person’ and basically enjoys his company.

Three days prior to coming to hospital, while he was alone at his room a girl came to him and said she was in love with him. Before he realized, this girls turned out to be a ‘vixen’ (A cat-woman). She started seducing him and he got very scared. The voice kept telling him that if the cat-woman succeeded in inserting her whiskers inside his nostrils he would succumb to her. He tried his best to get rid of her but he was finally pinned down. However, she failed to insert her whiskers in his nostrils and she left. This was quite worrying for him. Later, this same cat-woman came with vengeance and ‘castrated’ him. He said that the experience was very painful. Subsequent to the castration he became paranoid thinking that he had now no place in the society. He wanted to run away to some other country but instead he went and requested one police personnel to lock him up in order to escape from the wrath of the neighbours and the community. When this request was not entertained he came to Thimphu. He said the voice also advised him to go to Thimphu.

After reaching Thimphu, while he was taking bath he noticed that he still had his genitalia, and to his pleasant surprise he was not castrated. This made him even more confused. After this he seemed to have gained some insight and thought that there was something He then started having doubts about his delusions. He thinks he must be having some ‘audio-visual’ hallucinations and has come to the hospital to seek help.

He is known to take alcohol off and on but he told me that he was not drinking for the last two years. However, he smelled of alcohol at the time of interview and he accepted having taken alcohol that morning.

Mental state examination:

Patient was appropriately dressed but not kempt. There were no abnormal behaviour and rapport was well established and sustained. He was well oriented to time, place and person. Speech was coherent and he could relate the history vividly. No formal thought disorder was evident. He described his mood as normal but he appeared to be a little anxious. He still believed that he had the invisible person with him near his right ear but he was not bothered by ‘him’ during the interview. He said he was no more bothered by the vixen as well. He was not sure whether he was having hallucinations or all those experiences were real.

SUICIDE

2010-08-19T07:52:00.000-07:00

Development has lots of social evils and one such evil is the “rat race” all of us have to participate in! Our younger generation is facing lots of challenges these days; they have to excel in classrooms, they have to get a slot for scholarship, they have to be selected for a job etc. etc. When things are unfavourable for them they get hopeless and helpless and resort to suicide. It is also believed that media coverage on suicide has some detrimental effect on people’s psyche. When people are in distress they tend to believe that suicide is the only alternative because they hear a lot about several other people resorting to it!

In most countries, women attempt suicide more often than men, but men tend to complete suicide more often. The frequency of suicides for young adults has been increasing in recent years because of single marital status, unemployment, low income, mental illness, a history of being physically or sexually abused, a personal history of suicidal thoughts, threats or behaviours, or a family history of attempting suicide.

Over 90 percent of people who die by suicide have a mental illness at the time of their death. The most common mental illness is depression. Untreated depression is the number one cause for suicide. Other mental illnesses such as bipolar disorder, schizophrenia, alcoholism, substance abuse and other chronic mental disorders may also lead to suicide.

Some people are genetically predisposed to depression, and thus they may not appear to be undergoing any negative life experiences, yet still become depressed, and may die by suicide because of a depression that was caused by genetics. Sometimes we hear of people dying by suicide without exhibiting any overt symptoms of depression or other mental disorder. It is believed that genetic factor plays important role in this type of people.

It is difficult for us to pinpoint one single cause for suicide many people die by suicide because depression is triggered by several negative life experiences, and the person does not receive treatment – or does not receive effective treatment – for the depression. (Some people need to go through several treatments until they find one that works for them.)

Risk factors for adults who commit murder-suicide include male gender, older caregiver, separation or divorce, depression and substance abuse. In children and adolescents, bullying and being bullied seem to be associated with an increased risk of suicidal behaviors. Another risk factor which renders children and teens more at risk for suicide compared to adults is that of having someone they know commit suicide, which is called contagion or cluster formation.

The common means of suicide depends from place to place. For example, more than 60% of people who commit suicide in the western countries take their lives by firearms. In our country most people seem to use rope or other such object for hanging and this is simply because they are easily accessible and practical in our settings. Few people have attempted suicide by consuming prescribed medicines.

Warning signs that an individual is imminently planning to kill himself or herself may include the person getting his or her affairs in order, suddenly visiting friends or family members (one last time), a sudden and significant decline or improvement in mood, or writing a suicide note. Contrary to popular belief, many people who complete suicide do not tell their therapist or any other mental-health professional that they plan to kill themselves in the months before they do so. If they communicate their plan to anyone, it is more likely to be someone with whom they are personally close, like a friend or family member.

Individuals who take their lives tend to suffer from severe anxiety, symptoms of which may include moderate alcohol abuse, insomnia, severe agitation, loss of interest in activities they used to enjoy, hopelessness, and persistent thoughts about the possibility of something bad happening. Since suicidal behaviors are often quite impulsive.

Generally, the absence of mental illness and substance abuse, as well as the presence of a strong social support system, decrease the likelihood that a person will kill him- or herself. Having children who are younger than 18 years of age also tends to be a protective factor against mothers committing suicide.

Effective interventions

Strategies involving restriction of access to common methods of suicide, such as firearms or toxic substances like pesticides, have proved to be effective in reducing suicide rates; however, there is a need to adopt multi-sectoral approaches involving many levels of intervention and activities.

There is compelling evidence indicating that adequate prevention and treatment of depression, and alcohol and substance abuse can reduce suicide rates, as well as follow-up contact with those who have attempted suicide.

Challenges and obstacles

Worldwide, the prevention of suicide has not been adequately addressed due to basically a lack of awareness of suicide as a major problem and the taboo in many societies to discuss openly about it. In fact, only a few countries have included prevention of suicide among their priorities.

Reliability of suicide certification and reporting is an issue in great need of improvement.

It is clear that suicide prevention requires intervention also from outside the health sector and calls for an innovative, comprehensive multi-sectoral approach, including both health and non-health sectors, e.g. education, labour, police, justice, religion, law, politics, the media.

Source: Suicide.org, http://www.medicinenet.com, http://www.who.int/mental_health/prevention/suicide/suicideprevent/en/,

Steroid induced psychosis:

2010-07-12T09:45:00.001-07:00

19 year old boy, a known case of epilepsy who had poor seizure control even though he was on 3 anti-epileptic drugs (AEDs) was referred to us recently. We confirmed that he was indeed a case of epilepsy, generalised tonic clonic type. We also confirmed that he was taking his medication regularly. However no CT or MRI was ever done. As such we requested for MRI and it was found that he had 2 neurocysticercus cysts in the brain. Along with the AEDs he was then put on albendazole 400mg b.i.d and prednisolone on tapering dose, starting with 40mg per day. On the tenth day of treatment he was brought to the emergency with history of recurrence of seizures with abnormal behaviour for a whole day. At the time of admission the patient was found to be confused, irritable, agitated and violent. There were no seizures.

Patient was admitted in the psychiatric ward with a provisional diagnosis of steroid induced psychosis. The steroid was stopped immediately and injection haloperidol was given. Patient settled down behaviourally after the injection. He didn’t need to continue taking any anti-psychotic medication thereafter.

Corticosteroid treatment, especially with high doses, can alter mood and behaviour early in treatment—the patient can become confused, irritable and suffer from delusion and suicidal thoughts. These effects can also occur when corticosteroid treatment is being withdrawn.

Schizophrenia

2010-05-17T09:56:00.000-07:00

A 17 year old male, class 12 student presented to the OPD. His family reported that, about 7 months ago, the patient began to show evidence of odd behavior such as needing to arrange his clothing, books and shoes in a very specific manner and would become highly upset if any of these were out of order. About a month prior to coming to the clinic, he started to feel that his friends were talking about him and trying to harm him in some unspecified way. He started to isolate himself at home, spending many hours in his room by himself. He became increasingly wary of friends and family and feared that they might rob him of his ‘Self’ and make him disappear. He also started hearing voices telling him to avoid his friends. He was no longer able to focus on his school work, whereas he had been at the top of his class just months before.

Schizophrenia is a severe mental disorder characterized by disturbances in thought, perception, emotion and behaviour.

EPIDEMIOLOGY

The incidence is 1 in 100 people in their lifetime, worldwide. The onset is usually in late adolescence or early adulthood.

TYPES OF SCHIZOPHRENIA: Paranoid, Disorganized, Catatonic, Undifferentiated and Residual

CAUSES

Biological factors arising from physiology, biochemistry and genetic makeup.

Psychological factors including upbringing, emotional experience and social experiences.

Social factors are associated with the person’s present life situation and socio-cultural influences.

Bio-psycho-social model encompasses the genetic, environmental, and neuro-developmental aspects as well as, drug abuse and biochemical factors.

CLINICAL FEATURES ARE DIVIDED INTO CATEGORIES

Positive symptoms: such as delusions and/or hallucinations, disorganized thinking, disorganized behaviour, catatonic behaviour, incongruent mood

Negative symptoms: such as social withdrawal, loss of motivation and drive, loss of feeling or ability to express emotion or affect, poverty of speech and disorganized behaviour.

POSSIBLE COURSE OF A SINGLE SCHIZOPHRENIC EPISODE

· A single acute psychotic episode before having a partial or full recovery.

· A severe acute psychotic episode characterized by periodic exacerbations and remissions.

· A continuous illness with either a progressively worsening course or levelling out, then remaining relatively stable.

GENERAL COURSE OF A SINGLE ACUTE EPISODE:

Prodromal phase - Most people exhibit non specific symptoms before the onset of an acute psychotic episode. The symptoms appearing are mainly negative e.g. social withdrawal, difficulty concentrating, eating less, loss of interest in work etc.

Acute phase – The person experiences severe psychotic or symptoms of disorganization and may also have negative symptoms. The positive symptoms generally respond well to treatment.

Stabilizing phase - The acute psychotic symptoms begin to reduce in severity in the stable phase. Individuals in this phase can be either symptom free or have non- psychotic symptoms such as anxiety, depression, tension or insomnia. Positive symptoms are of milder form, if present.

Prognosis - 25% experience full recovery, 40% experience a recurrent episode with some degree of social disability and periods of unemployment, 35% experience long term schizophrenia.

FACTORS ASSOCIATED WITH A FAVORABLE OUTCOME

· Abrupt onset,

· An absence of pre-morbid disturbances,

· Later onset,

· Appropriate early assessment and intervention,

· Presence of acute and resolvable life stressor,

· Family history of affective disturbance,

· Living in a developing country,

· Presence of social support and favourable attitude from family members,

· Being employed,

· Presence of mainly positive symptoms,

· Absence of blunted or flat affect,

· Absence of alcohol or other drug abuse and

· Absence of co-morbid conditions.

INVESTIGATIONS

Laboratory examination: Routine blood, urine and other bio-chemical tests to rule out any organic basis of disorder and to establish a baseline record.

MANAGEMENT

Psychopharmacology:

As most schizophrenic patients do not have insight and therefore are reluctant to take their drugs regularly, medication should be closely monitored and supervised by health workers or family members. Something like the DOTS method for tuberculosis treatment would be preferable if possible.

Medications:

§ Tablet chlorpromazine 100 – 300 mg bedtime per orally

§ Tablet Risperidone 2 mg tid per orally

§ Injection chlorpromazine 50 mg IM stat if patient is refusing oral medication or violent

§ Long acting depot Fluphenazine decanoate injection 25 mg deep IM stat (if available), repeat dose if required after 2 – 4 weeks if oral drug compliance is poor

§ Injection haloperidol 10 mg IM SOS, if aggressive and violent

§ Tablet Trihexyphenidyl (Pacitane) 2 mg tid per orally if there are severe adverse symptoms to anti-psychotic drugs such as Parkinsonism and extra-pyramidal symptoms.

Source: Bhutan Mental Health Manual 2010 (Unpublished)

ANXIETY DISORDERS

2010-05-10T07:45:00.000-07:00

What is anxiety?

When you are anxious you feel fearful and tense. In addition you may also have one or more unpleasant physical symptoms. For example: a fast heart rate, palpitations, feeling sick, shaking (tremor), sweating, dry mouth, chest pain, headaches, a 'knot in the stomach', fast breathing.

The physical symptoms are partly caused by the brain which sends lots of messages down nerves to various parts of the body when you are anxious. The nerve messages tend to make the heart, lungs, and other parts of the body 'work faster'. In addition, you release 'stress' hormones (such as adrenaline) into the bloodstream when you are anxious. These can also act on the heart, muscles and other parts of the body to cause symptoms.

Anxiety is normal in stressful situations, and can even be helpful. For example, most people will be anxious when threatened by an aggressive person, or before an important race. The burst of adrenaline and nerve impulses which we have in response to stressful situations can help us to 'fight or flight'.

Anxiety is 'abnormal' if it:

is out of proportion to the stressful situation, or
persists when a stressful situation has gone, or the stress is minor, or
appears for no apparent reason when there is no stressful situation.

What are anxiety disorders?

There are various conditions ('disorders') where anxiety is a main symptom. You may have an anxiety disorder if anxiety symptoms interfere with your normal day-to-day activities, or if worry about developing anxiety symptoms affects your life. About 1 in 20 people have an anxiety disorder at any one time. The following is a brief overview of the main anxiety disorders. Some people have features of more than one type of disorder.

Reactions to stress

Anxiety can be one of a number of symptoms as a reaction to stressful situations. There are three common types of 'reaction' disorders.

Acute reaction to stress (sometimes called 'acute stress reaction')

'Acute' means the symptoms develop quickly, over minutes or hours 'reacting' to the stressful event. Acute reactions to stress typically occur after an unexpected life crisis such as an accident, bereavement, family problem, bad news, etc. Sometimes symptoms occur before a known situation which is difficult. This is called situational anxiety. For example before: an exam, an important race, a concert performance, etc.

Symptoms usually settle fairly quickly, but can sometimes last for several days or weeks. Apart from anxiety, other symptoms include: low mood, irritability, emotional ups and downs, poor sleep, poor concentration, wanting to be alone.

Adjustment reaction

This is similar to the above, but symptoms develop days or weeks after a stressful situation as a reaction or 'adjustment' to the problem. For example, as a reaction to a divorce or house move. Symptoms are similar to acute reaction to stress but may include depression. The symptoms tend to improve over a few weeks or so.

Post traumatic stress disorder (PTSD)

This condition may follow a severe trauma such as a serious assault or life-threatening accident. Symptoms last at least one month, often much longer. Anxiety is only one symptom which may come and go. The main symptoms of PTSD are:

Recurring thoughts, memories, images, dreams, or 'flashbacks' of the trauma which are distressing.
You try to avoid thoughts, feelings, conversations, places, people, activities or anything else which may trigger memories or thoughts of the trauma.
Feeling emotionally 'numb' and feeling 'detached' from others. You may find it difficult to have loving feelings.
Your outlook for the future is often pessimistic. You may lose interest in activities which you used to enjoy.
Increased 'arousal' which you did not have before the trauma. This may include: difficulty sleeping, being irritable, difficulty concentrating, and increased 'vigilance'

Phobic anxiety disorders

A phobia is strong fear or dread of a thing or event. The fear is out of proportion to the reality of the situation. Coming near or in contact with the feared situation causes anxiety. Sometimes even thinking of the feared situation causes anxiety. Therefore, you end up avoiding the feared situation as much as possible, which can restrict your life and cause suffering.

Social phobia

Social phobia (social anxiety disorder) is possibly the most common phobia. With social phobia you become very anxious about what other people may think of you, or how they may judge you. Therefore, you fear meeting people, or 'performing' in front of other people, especially strangers. You fear that you will act in an embarrassing way, and that other people will think that you are stupid, inadequate, weak, foolish, crazy, etc. You avoid such situations as much as possible. If you go to the feared situation you become very anxious and distressed.

Agoraphobia
This too is common. Many people think that agoraphobia means a fear of public places and open spaces. But this is just part of it. If you have agoraphobia you tend to have a number of fears of various places and situations. So, for example, you may have a fear of:

Entering shops, crowds, and public places.
Travelling in trains, buses, or planes.
Being on a bridge or in a lift.
Being in a cinema, restaurant, etc where there is no easy exit.

But they all stem from one underlying fear. That is, a fear of being in a place where help will not be available or where you feel it may be difficult to escape to a safe place (usually to your home). When you are in a feared place you become very anxious and distressed, and have an intense desire to get out. To avoid this anxiety many people with agoraphobia stay inside their home for most or all of the time.

Other specific phobias

There are many other phobias of a specific thing or situation. For example: claustrophobia (fear of confined spaces or of being trapped); fear of certain animals; fear of injections; fear of vomiting; fear of being alone; fear of choking and there are many more.

Other anxiety disorders

Panic disorder

Panic disorder means that you get recurring panic attacks. A panic attack is a severe attack of anxiety and fear which occurs suddenly, often without warning, and for no apparent reason. The physical symptoms of anxiety during a panic attack can be severe and include: a thumping heart, trembling, feeling short of breath, chest pains, feeling faint, numbness, or pins and needles. Each panic attack usually lasts 5-10 minutes, but sometimes they come in 'waves' for up to two hours.

Generalized Anxiety Disorder (GAD)

If you have generalized anxiety disorder (GAD) you have a lot of anxiety (feeling fearful, worried and tense) on most days. The condition persists long-term. Some of the physical symptoms of anxiety (detailed above) may come and go. Your anxiety tends to be about various stresses at home or work, often about quite minor things. Sometimes you do not know why you are anxious. In addition, you will usually have three or more of the following symptoms:

Feeling restless, on edge, or 'keyed up' a lot of the time.
Tiring easily.
Difficulty concentrating and your mind 'goes blank' quite often.
Being irritable a lot of the time.
Muscle tension.
Poor sleep (insomnia). Usually it is difficulty in getting off to sleep, or difficulty in staying asleep.

Mixed anxiety and depressive disorder

In some people, anxiety can be a symptom when you have depression. Other symptoms of depression include: low mood, feelings of sadness, sleep problems, poor appetite, irritability, poor concentration, decreased sex drive, loss of energy, guilt feelings, headaches, aches, pains, and palpitations. Treatment tends to be mainly aimed at easing depression, and the anxiety symptoms often then ease too.

Obsessive-compulsive disorder

Obsessive compulsive disorder (OCD) consists of recurring obsessions, compulsions, or both. Obsessions are recurring thoughts, images, or urges that cause you anxiety or disgust. Common obsessions are fears about dirt, contamination, germs, disasters, violence, etc. Compulsions are thoughts or actions that you feel you must do or repeat. Usually a compulsion is a response to ease the anxiety caused by an obsession. A common example is repeated hand washing in response to the obsessional fear about dirt or germs. Other examples of compulsions include: repeated cleaning, checking, counting, touching, hoarding of objects.

What is the treatment for anxiety disorders and phobias?

The main aim of treatment is to help you to reduce symptoms so that anxiety no longer affects your day-to-day life. The treatment options depend on what condition you have, and how severely you are affected. They may include one or more of the following.

NON-MEDICATION TREATMENTS

Understanding
Understanding the cause of symptoms, and talking things over with a friend, family member or health professional may help. In particular, some people worry that the physical symptoms of anxiety such as palpitations are due to a physical illness. This can make anxiety worse. Understanding that you have an anxiety disorder is unlikely to cure it, but it often helps.

Counselling

This may help some people with certain conditions. For example, counselling which focuses on problem solving skills may help if you have generalised anxiety disorder.

Cognitive and behaviour therapy

Cognitive therapy is based on the idea that certain ways of thinking can trigger, or 'fuel', certain mental health problems such as anxiety and depression. The therapist helps you to understand your current thought patterns. In particular, to identify any harmful, unhelpful and 'false' ideas or thoughts which you have that can make you anxious (or depressed). The aim is then to change your ways of thinking to avoid these ideas.

Behaviour therapy aims to change any behaviours which are harmful or not helpful. For example, with phobias your 'behaviour' or response to the feared object is harmful, and the therapist aims to help you to change this. Various techniques are used, depending on the condition and circumstances. As with cognitive therapy, several sessions are needed for a course of therapy.

Cognitive-behaviour therapy (CBT)is a mixture of the two where you may benefit from changing both thoughts and behaviours. (Note: cognitive and behaviour therapies do not 'look into the events of the past'. They deal with, and aim to change, your current thought processes and/or behaviours.)

MEDICATION

Antidepressant medicines

These are commonly used to treat depression, but also help to reduce the symptoms of anxiety even if you are not depressed. They work by interfering with brain chemicals (neurotransmitters) such as serotonin which may be involved in causing anxiety symptoms.

Antidepressants do not work straight away. It takes 2-4 weeks before their effect builds up. A common problem is that some people stop the medicine after a week or so as they feel that it is doing no good. You need to give it time. It is best to persevere if you are prescribed an antidepressant medicine.
Antidepressants are not tranquillisers, and are not usually addictive.
There are several types of antidepressants, each with various 'pros and cons'. For example, they differ in their possible side-effects. However, SSRI antidepressants (selective serotonin reuptake inhibitors) are the ones most commonly used for anxiety disorders.
Note: after first starting an antidepressant, in some people the anxiety symptoms become worse for a few days before they start to improve.

Benzodiazepines such as diazepam

These medicines (sometimes called minor tranquillisers) used to be the most commonly prescribed medicines for anxiety. They usually work well to ease symptoms. The problem is, they are addictive and can lose their effect if you take them for more than a few weeks. They may also make you drowsy. So, now they are not used much for persistent anxiety conditions. A short course of up to 2-3 weeks may be an option for anxiety which is short term, or 'now and then' to help you over a bad spell if you have persistent anxiety symptoms.

Beta-blocker medicines

A beta-blocker, for example propranolol, can ease some of the physical symptoms such as trembling and palpitations. They do not directly affect the 'mental' symptoms such as worry. However, some people relax more easily if their physical symptoms are eased. These tend to work best in acute (short lived) anxiety. For example, if you become more anxious before 'performing' then a beta-blocker may help to ease 'the shakes'.

In some cases a combination of treatments such as cognitive therapy and an antidepressant may work better than either treatment alone.

Alcohol and anxiety

Although alcohol may ease symptoms in the short term, don't be fooled that drinking helps to cure anxiety. In the long run, it does not. Drinking alcohol to 'calm nerves' is often a slippery slope to heavier and problem drinking. See a doctor if you are drinking heavily (or taking drugs) to ease anxiety.

Source: http://www.patient.co.uk

Bipolar Disorder

2010-04-25T09:37:00.000-07:00

What is bipolar disorder?

Bipolar disorder, also called "manic-depressive" disease, is a mental illness that causes people to have severe high and low moods. People with this illness switch from feeling overly happy and joyful (or irritable), to feeling very sad. Because of the highs and the lows -- or two poles of mood -- the condition is referred to as "bipolar" disorder. In between episodes of mood swings, a person may experience normal moods.

The word "manic" describes the periods when the person feels overly excited and confident. These feelings can quickly turn to confusion, irritability, anger and even rage. The word "depressive" describes the periods when the person feels very sad or depressed. Because the symptoms are similar, sometimes people with bipolar depression are incorrectly diagnosed as having major depression.

Most individuals with bipolar disorder spend more time in depressed phases than in manic phases.

Symptoms

The dramatic and rapidly changing mood swings from highs to lows do not follow a set pattern, and depression does not always follow manic phases. A person may also experience the same mood state several times before suddenly experiencing the opposite mood. Mood swings can happen over a period of weeks, months and sometimes even years.

The severity of the depressive and manic phases can differ from person to person, and even in the same person at different times.

Symptoms of mania ("The Highs"):

Excessive happiness, hopefulness, and excitement
Sudden changes from being joyful to being irritable, angry and hostile
Restlessness
Rapid speech and poor concentration
Increased energy and less need for sleep
High sex drive
Tendency to make grand and unattainable plans
Tendency to show poor judgment, such as deciding to quit a job
Drug and alcohol abuse
Increased impulsivity

Some patients can become psychotic, seeing and hearing things that aren't there and holding false beliefs from which they cannot be swayed. In some instances they see themselves as having superhuman skills and powers, or think they are god-like.

The symptoms of bipolar depression are the same as those of major depression and include:

Sadness
Loss of energy
Feelings of hopelessness or worthlessness
Loss of enjoyment from things that were once pleasurable
Difficulty concentrating
Uncontrollable crying
Difficulty making decisions
Irritability
Increased need for sleep
Insomnia or excessive sleep
A change in appetite causing weight loss or gain
Thoughts of death or suicide

· Attempting suicide

What causes bipolar disorder?

A definite cause for any type of depression is difficult to determine but may include genetics, changes in the chemical make-up of the brain, and environmental factors like stress and major life changes. More research is being done to determine the relationship that these factors have in bipolar disorder, how they may help prevent its onset, and what role they may play in its treatment.

How is bipolar disorder diagnosed?

A diagnosis of bipolar disorder is made only by taking careful note of symptoms and their severity, length, and frequency. The most telling symptoms include severe mood swings (going from extreme highs to extreme lows) that don't follow a set pattern. Reviewing collateral history from close friends and family is often very helpful to distinguish bipolar disorder from major depression.

If you or someone you know is experiencing symptoms of bipolar disorder, seek the advice of your family healthcare provider or a psychiatrist. A referral may then be made to an appropriate mental health expert.

A thorough medical evaluation should be performed. Your doctor will ask questions about your personal and family history of mental illness. You may also be asked to complete a depression screening questionnaire -- a series of structured questions that you will be asked to answer verbally or in writing.

What are the treatments?

Bipolar disorder is a long-term illness that requires management throughout a person's life. People who have numerous (four or more) episodes of mood changes (rapid cycling) in a year can be much more difficult to treat. Medication is the primary form of treatment, but the additional use of psychotherapy or "talk" therapy is sometimes recommended to help prevent future episodes.

There are many medications available to treat bipolar depression.

What can I expect after treatment?

For most people, a good treatment program can stabilize severe moods and provide effective symptom relief. Treatment that is continual has proven more effective in preventing relapses and controlling cycling. Those who also have a substance abuse problem may need more specialized treatment.

Can bipolar disorder be prevented?

There is no known method to prevent bipolar disorder. Because its exact cause has not yet been determined, it is especially important to know its symptoms and seek early intervention. Some people who experience bipolar disorder may become suicidal. By knowing how to recognize these symptoms, there is a better chance for effective treatment and finding coping methods that may prevent long periods of illness, extended hospital stays and suicide.

A question to me...

2010-04-24T10:20:00.001-07:00

Dear Doctor,
I have a personal message requesting for your help to solve a problem of my relative. He has been suffering from a peculiar problem since October 2009.

He trembles in front of mandir and starts uttering words. He says that he is a Kul devta, kul devi, Drarma devta, and Pitri devta and he tells that he is disturbed by the evil force forced unto him by a person below his cast. Sometimes he starts shivering and uttering words saying that the kins in his clan have been careless and taking meat and all. Most of the time he looks disturbed. He has been taken to number of mandirs & Matas and Gurus. He says he is above all. I want to help him but I can not take him to doctors as he believes that God resides in him. At the same time he seems to be skeptic also.

He requires a good councelling and good mental training like meditation & relaxation. Can you please throw some light like whether it is a psychic problem and how he can be cured from this problem?
I shall be very grateful to you for your kind help.
With warm regards

B.R.Sharma

What is depression?

2010-04-24T09:29:00.000-07:00

Depression is a mood disorder characterized by loss of pleasure or enjoyment and/or decreased interest. It is also accompanied by physical and psychological symptoms. In order for depression to be considered as a clinical disorder, symptoms should be present for more than 2 weeks.

Depression is one of the most common mental illnesses in our country. At least 8 -12 % of men and 18 - 25 % of women will suffer major depression in their lifetime. Depression is more common among unemployed and divorced persons.

What causes depression?

Many people tend to believe that we Bhutanese, by virtue of being the inhabitants of the "Country of Gross National Happiness" should not be depressed at all! However, we should never forget that we are from the same family of humanity possessing similar traits concerning susceptibility to stresses caused by life events; we have similar desires, same types of expectations and identical ways of getting frustrated. Therefore, the causative factors remain same in our setting as well. The following are the common factors attributed to cause depression:

Psychosocial problems: Recent bereavement, relationship and financial problems, unemployment or stress at work, moving to a new house or new environment, unstable relationships or divorce,
Infectious diseases especially after viral infections,
Chronic medical conditions such as cancer, HIV/AIDS, hypertension, diabetes mellitus etc.,
Alcohol and substance use disorders
Long term use of medications such as hypertensive drugs - H2 blockers, oral contraceptives, corticosteroids
Family factors: Family history of depression, parental deprivation
Others: Child birth or menopause

COMMON SYMPTOMS

Psychological symptoms:

Persistent sadness and/or low mood, loss if interest or pleasure, tearfulness, feelings of hopelessness, helplessness, worthlessness, feelings of guilt, low self-esteem, pessimism, poor concentration, poor memory, suicidal thoughts and/ or attempts, irritability

Physical Symptoms:

Reduced energy and fatigue, sleep disturbances, amenorrhea, appetite and weight changes, decreased libido, constipation, physical aches and pains, social withdrawal or restlessness. The symptoms have to be present for at least a two week period.

TREATMENT

First we need to asses the patient and decide whether the patient needs admission in the ward or can be managed in the community.

We have to secure safety of the patient as depressed patients are high risk for suicide.
Depressed patients are at high risk for dehydration and hypoglycaemia due to poor appetite, extreme psychomotor slowing and social withdrawal.
Maintain personal hygiene and sanitation of patient. Urinary catheter may be required for bed ridden patients to avoid soiling of bed. For severely depressed patients, change the position of the body every 2 hours to prevent bed sores.
Educate the patient and the family about depression and the plan of management so that they understand the disorder and cooperate with the caregiver. Reassure the patient and family that the patient will improve with treatment but that it will take at least a couple of weeks for the patient to show improvement. Explain the side effects of the medicine so that the patient does not get worried and stop the medication.
Medication consists of antidepressants such as Amitriptyline, and Fluoxetine.

This was what Abraham Lincoln had to say when he was severely depressed:

"I am now the most miserable man living. Whether I shall ever be better I can not tell; I awfully forebode I shall not; To remain as I am is impossible; I must die or be better."

Domestic Violence, one important cause for depression in women

2010-04-22T08:05:00.000-07:00

Today I was asked to see a woman who was admitted in the burn unit for depression. When I visited the ward I found a severely burnt woman of 25 years who had come for reconstruction surgery for her disfigured face from the Plastic Surgery team that is currently here in JDW NRH.

I took the history and I found out that she is a mother of two sons, 7 years and 2 years. She was two year old when her parents died. She is younger of two children from her parents and the elder brother lives in India at present. She was brought up during the early days by her uncle and aunt but as soon as she was big enough to do household chores she was hired out to people as domestic help. She did odd jobs until she got married 9 years ago. Her marriage was full of odds as her husband turned out to be an alcoholic and abused her physically all the while. In 2009 she thought enough was enough and consumed insecticide to end her life but she was taken to the hospital and survived. She wanted to run away from the abusive husband but each time she went and lived with her friends and relatives, the husband would go and get her forcefully. He challenged anyone who interfered telling them that he had all the rights to do whatever he wanted with his wife! Obviously the woman didn’t have any knowledge about the Women and Child Protection law and she believed that she was at the mercy of the husband!

One day in January 2010 she wanted to face her husband’s beating by drinking some alcohol but the husband discovered that and started beating her. When this happened, she challenged him by threatening to set herself on fire if he hit her further. To that the husband brought a can of kerosene and gave it to her but the can was empty. The woman got more frustrated and went to get the can which had kerosene in it and poured on herself. She found out that the kerosene itself hurt her body too much and did not have the courage to light the fire. However, the husband then started provoking further and kept insisting that she lit the fire otherwise he would do it. He thrust the matches to her after several altercations and persuaded her to ignite. She became absolutely desperate and alighted herself sustaining severe burn. She gave a statement to the police stating that it was her own mistake thus the husband is scot-free to this day.

Now she bears the unhealed burnt injuries with disfigurement on the face, chest, abdomen and both hands. She now realizes that the husband has no remorse about his act. He has cut off relationship with her as well as the children. She is totally helpless and hopeless but she insists that she will live for her children and regrets having ever married to the man who turned out to be a monster. In the eyes of the law the whole incident was reported as a suicidal attempt but no one realizes that this was a serious case of domestic violence, the Hindi Serial (Soap) style!

Depression

2010-04-20T07:01:00.000-07:00

A mother of 2 children had been visiting the hospital with frequent complaints of headache. She was given paracetamol every time she went there but it didn’t benefit her much. One day she came to me saying that she heard me talking in the television about depression and thinks that she must be depressed.

On taking careful history it was found that she was having low mood for about a month associated with helpless and hopeless feelings, she had lost interest in all the pleasurable activities she used to enjoy, cried often and even had suicidal thought. She also had early morning awakening and poor appetite. All the symptoms started after she found out that her husband was having extramarital affairs. She didn’t realize that these symptoms were important to her and kept complaining about the associated headache to the doctors.

She was diagnosed to have severe depression and is currently under medication. I met her recently and she looks cheerful even though her marriage had ended in a divorce.

Questions asked by The Journalist to me

2010-04-19T09:34:00.000-07:00

1. Figures show increasing number of young drug abusers in the country. Why are the youth lured toward drugs?

The transition of people from adolescence to young adulthood is a crucial period in life. During this period the young people experiment with illicit drugs and drugs have strong appeal to them. This is the time when they are in search of identity and have lots of curiosity and thirst for experience. They are under constant peer pressures and when their self esteem is generally low they tend to yield to the pressure even in terms of drug use.
The increasing trend we see in our country is that many youngsters are un-guided by parents and there is easy availability of drugs from across the border. Besides, urbanization has resulted in change is life style because of which most young people in cities have lots of time for leisure unlike in a village. When we were small we had to help our family in a number of household chores and hardly had much time to hang around with our peers.

2. What do you think is the bigger problem in Bhutan at the moment – alcohol or drugs? Why?

I think alcohol is a bigger problem in Bhutan than drug problem. Because of easy availability of alcohol, alcohol is considered a socially accepted drink our country. It is taken by people from all walks of life on a regular basis. We have been seeing an increasing number of them coming for help. Alcohol is also one of the important causes for domestic violence in our society.
However, among the youth drug abuse is becoming a serious problem and is likely to increase over the period of time.

3. Should the government have more stringent laws in place to tackle these two social threats?

It is high time we have an alcohol related policy in place. We have to restrict the sale of alcohol and impose more tax on the products. There should be strict monitoring of the regulations that are in place and new regulations should be formulated to deter civil servants from drinking alcohol during duty hours.
Regarding drug problem, I feel we have a lot to do in this aspect. More stringent laws should be in place for dealers and repeated defaulters.

4. Drug and alcohol can eventually lead to a bigger problem – mental illness. Given scarce resources and shortage of specialists in JDWNRH, does this not concern you as one of the only two psychiatrists in the country?

We are severely constrained with resources not only in terms of manpower but also in terms of infrastructure. Our small eight bedded ward is generally filled by alcoholics and drug users and at times we have difficulty admitting the severely mentally ill patients. It is a challenge but we are trying hard to strengthen our capacity to deal with this problem.

5. What are the most common youth-related mental health problems in Bhutan? And how are you handling them?

Besides substance abuse, most youth suffer from stress related mental problems such as anxiety disorders.
We have been trying to educate our youth through various means so that they can handle stress without succumbing to it. The school health programme is in place and life skill education is already addressing this issue. With the introduction of GNH curriculum in all schools, I hope we will empower our youngsters with enough mental strength to forge ahead in life.

6. Suicide is also increasing among the younger lot. Why is it so?

I definitely feel parents have the greatest role to play. If we can not guide our children in the right direction, it is futile to expect the teachers to do much for them. Many tend to believe in giving complete freedom to their children but I believe we have not evolved to that extent. Freedom should come with responsibility otherwise we will land up in a “catch 22” situation!

8. How can the media play a more proactive role in addressing the youth-related social ills?

Media’s role should be to guide youth in the right direction with right information. News and articles should focus on changing the behaviour of the youngsters in the correct way rather than to elaborate or glorify behaviours those are not socially acceptable.

Suicide

2010-04-19T00:02:00.000-07:00

There was yet another news about a young woman committing suicide in Simtokha. We have been hearing news about at least one suicide in a month lately. The media keep asking us reasons for such act and we have to keep giving the same answer to almost everyone. When it comes to numbers, the Royal Bhutan Police is the right authority to provide the information, but reasons for committing suicide generally remains the same every where.

Among the South East Asia Region Member countries, the suicide rate vary from 8 to 50 per 100 000 population (WHO, 2001); however, we don't have data about the prevalence of suicide in our country. Suicide is reported to the police and the forensic examination is conducted by forensic specialist in Thimphu and other health professionals (Doctors, Assistant Clinical Officer, or Health Assistants) in other parts of the country. Information related to attempted suicides are never reported or compiled by any agencies.

The exact cause for suicide has been an enigma since time immemorial. No one precisely knows the cause and those who survive an attempt give vague and unacceptable reasons. In our experience, people who are referred to us as a survivors of suicidal attempts are generally people with suicidal behaviours, at times inflicting injuries to self out of anger.

Some factors known to influence suicide are low frustration tolerance, severe hostility, life expectations and failures, interpersonal conflicts between family members and peers, mental health problems, behavioural problems of alcohol and drug abuse, suffering from diseases such as HIV/AIDS, and other environmental factors. Some people, however, act impulsively and we do not get a clue to what went wrong! (Suicide prevention: Emerging from Darkness, WHO, 2001).

COMMON BELIEFS VS FACTS REGARDING MENTAL DISORDERS

2010-04-16T22:32:00.000-07:00

Belief: Mentally ill people show bizarre behaviour

Fact: All mentally ill patients do not necessarily show bizarre behaviour

Belief: Mental health is not related to physical health

Fact: Mental illness can affect physical health and vice versa. For example, a person who is very anxious will develop fast heart beat, fast breathing. Likewise physical illness may manifest as anxiety, tension or depression.

Belief: The prevalence of mental illness is low in

Bhutan

Fact: What your mind does not know, your eyes do not see. The fact is, there are as many mentally ill patients in

Bhutan

as in any other country. Case records from the hospitals around the country show increasing trends of people with mental illness to seek treatment.

Belief: Mental illness once acquired is life long

Fact: There are different types of mental illnesses. Most are short term and treatable. Some like schizophrenia can be long term, but with adequate treatment, patients can remain well and functional as with other chronic illnesses.

Belief: Mental illness is something to be ashamed of

Fact: Mental illness is like any other illness which can be treated. With effective modern treatments, the prognosis for mental illnesses can be very good.

Belief: Mental illness is caused by supernatural power

Fact: Mental illness is not caused by supernatural powers. Rather, it is caused by a variety of factors such as changes in the brain function, genetic factors, childhood experiences, and life stressors.