Broken,not beaten

“It takes a village to raise a child, and I’m glad I had that village,” smiles new mommy, 33-year-old Pankti Desai, who has a beautiful and healthy baby boy. Pankti had her fair share of struggles with maternal depression. Her robust family support system, a japa nanny, and counselling for her mild postpartum depression ensured hers was an unremarkable pregnancy.

However, studies state that most Indian women combat post-partum and perinatal depression. Shockingly, new mothers in India have no compulsory test to diagnose Post-Partum Depression (PPD), mandated in several countries in the West, and no proper data to fall back upon. “Surprisingly, India does not have a mechanism to check the level of depression in PPD,” states Anshu Mittal, a mother-to-be.

According to Dr Sundarnag Ganjekar, additional professor and consultant, Perinatal Psychiatry Services, Department of Psychiatry, Nimhans, “Predominantly, one in five women suffer from PPD. Past history increases risk. Lower-income groups are treated at government hospitals by an overworked obstetrician who sees close to 100-150 patients a day; it’s a challenge to screen new mothers on mental health, especially with no mechanism to test them.”

Putting protocols in place

Nimhans explored mental health protocols by adding questions for perinatal women — in its pilot, implemented in Karnataka and Telangana. Dr Ganjekar stresses that recognising and treating PPD is at a grossly nascent state in India. He cites the Edinburgh Post Natal Depression Scale, included in the American Obstetrician guidelines, a 10-question tool to assess the mental health of a pregnant woman — compulsory in the West, not in India. 

“Women should be assisted in depression and anxiety — during trimester checks, the OB/GYNs should be trained to ask routine mental health questions. This does not happen in India. Nimhans, in their latest Maternal Child Protection — Thayi Card (for lower-income pregnant and lactating mothers) should include anxiety, depression, and past history,” explains Dr Sundarnag, adding, “Rural women can seek help at Asha clinics, however, early identification of such symptoms from the government with screening by way of a mental health tests on the MCP card, should be the norm.”

The World Health Organisation’s systematic review of PPD found that the prevalence of common mental disorders in the postpartum period in low- and lower-middle-income countries was 19.8 per cent. It recommended placing greater importance on maternal mental health to improve maternal and child health. During Covid, for instance, about 46 per cent of women who sought help through a Nimhans helpline showed signs of postpartum psychosis. Older women also tend to have severe symptoms — the case of a mother who brutally killed her son in Goa, to prevent visitation from her estranged husband comes to mind. A few years ago, another case where a woman strangulated her baby also sent shock waves. “Perinatal tests should be mandatory. Slowly, pre-natal testing became a norm, similarly, if mental health tests are made compulsory, it will address this gap,” says Dr Taniya Khanum, consultant OB/GYN at a prominent city hospital.

Lack of support, marital conflict, a history of psychiatric illness, intimate partner and domestic violence, and a slew of biological changes can take a huge toll on a perinatal woman’s mental health and may lead to depression, psychosis and suicidality. Female infanticide, wanting a boy child, not a girl, lack of a mother-infant bond, etc., can also increase the risk. 

Sensitising men

Sleep disturbances are a huge risk, and can disturb equilibrium. “If the mother pumps breast milk, a family member can feed the baby, and she can get enough sleep. Such gender transformative interventions are needed,” explains Dr Sundarnag.

Depressive bouts also cause subtle shifts in the brain. “Neurologically, each depressive episode is neurotoxic. If we measure the break response and do a Cerebrospinal fluid analysis of an individual with depression, we would find chemicals that can damage the brain. The changes may seem subtle at first, but over some time, repeated depressive episodes can cause a shift.”

On the upside, various NGOs are working towards empowering women dealing with PPD at the grassroots level. For instance, the Centre for Health and Social Justice is working to sensitise men and families. Ekjut helps pregnant mothers to prioritise the health of their babies. 

The way ahead

The stigma and social taboos against speaking out often dissuade women as such mental health conditions are still shrouded in shame. Many experts feel including mental health protocols must be made a mandatory part of consultation, something that is currently left to the discretion of gynaecologists and obstetricians. 

For Angie Hope, pregnant with twins after two unsuccessful IVFs, the trauma of years of fertility and hormone treatments, and becoming pregnant at 40 was a nightmare. For over two years, she battled severe PPD. “I was crying and had no interest in the twins. After I fed my boy, I didn’t have the strength to feed my daughter or enough milk. I had no support from my husband as in India, traditionally, men do not help,” says Angie who sought therapy and medication.

A difficult pregnancy, miscarriage, the baby not latching on to the breast, or lack of milk can evoke depressive episodes. “Often a depressed mother is unable to feed the baby. If the baby is not putting on weight, then it’s a red flag. In affluent families, there is more awareness, and when I see signs, I refer them to a psychiatrist,” explains Dr Khanum. Often, mothers with mild symptoms do not report distress, which can go unseen and create more issues.

“Nutrition, sex education, planning a pregnancy, awareness, and sensitising family members is key. The support from the partner and family is crucial,” stresses Dr Sundarnag. A combination of Cognitive Behaviour Therapy (CBT), psychotherapy, counselling, and when required, prescribed drugs are suggested. Often CBT and interpersonal therapy are structured for up to 12-15 sessions. “In the UK, trained nurses help the mother before and after the delivery, a practice still nascent in India,” adds Dr Khanum.

Key interventions include yoga, meditation, eating nutritious food, familial support, exercise and counselling. In severe cases, medications are prescribed with consensus from the perinatal team. “Today, most medicines are safe, even if secreted in the breast milk, the effects are minimal,” adds Dr Sundarnag, citing studies that show no major developmental problems. “Each visit before, during and after delivery, the doctor should ask questions to assess the mother and infant’s health. This also helps us get data to amp up vigilance,” adds the doctor, whose team at Nimhans is trying to strengthen the system by training doctors and medical officers. More regional studies will bolster data which will then help bring about policy changes, he says.

Suruchi Kapur Gomes

Bipolar disorder: The misdiagnosis hurdle

“It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity.”

Charles Dickens' famous opening lines from his novel A Tale of Two Cities, which compare and contrast radical opposites, seem like a metaphysical rendition of the symptoms of Bipolar Disorder (BD). BD is an ailment that refuses to get boxed and thus remains misunderstood, misdiagnosed and stigmatised, despite increasing awareness and open conversations around mental health — much more than ever before. 

The misconceptions around BD become more stark when we examine its onset in youngsters. The mean age of onset of bipolar disorder varies from 17 to 30 years. European data suggest a mean age in the late 20s, whereas the United States data suggest a mean age in the early 20s. Like most other psychiatric disorders, BD has its onset at a time when an individual is expected to be academically productive. The subsequent illness trajectory can pose a significant emotional burden on the individual with BD.

Unfortunately, there is often an interval between the onset of mood episodes and when help is sought (an average of 8-10 years!). This is why often, the clinician evaluating the person with BD would miss inputs from reliable informants such as family and friends. Furthermore, because of these information gaps, an overwhelming 20 to 40 per cent of bipolar patients are initially misdiagnosed with unipolar depression.

Misdiagnosis in children and adolescents is widespread because the symptoms frequently overlap between mania and attention-deficit hyperactivity disorder (ADHD). ADHD symptoms such as hyperactivity, inattention, and impulsivity are seen in mania as well. Likewise, periods of intense anger and irritation, which may reflect irritable mania, may get missed altogether. Adding further complexity, BD in children and adolescents has substantial co-morbidity in the form of ADHD, oppositional defiant disorder, anxiety, and substance-use disorders. A person in hypomania may even enjoy the slightly elevated mood and may refuse to count it as a part of the illness spectrum.

No one-size-fits-all

Like other chronic medical conditions, such as diabetes, hypertension, and cardiovascular disorders, BD is a readily treatable disorder. Following the chronic disease management model, a balance has to be struck between evidence-based guidelines, and an individualised tailored approach. There’s no one-size-fits-all strategy.

Evaluation should take into account the number of previous mood episodes, the average length of episodes, the average time between episodes, the level of psychosocial functioning between episodes, previous response to treatment, family history of psychiatric disorders including suicide, and the current or past use of alcohol or drugs.

With the advent of novel and effective neuropharmacological interventions, we would do well to remember Dr John Cade’s words, ‘’I believe the brain, like any other organ, can get sick and it can also heal’’.

Alok Kulkarni

The author is a senior interventional neuropsychiatrist at the Manas Institute of Mental Health and Neurosciences at Hubli. He has been awarded the IMH Marshall Fellowship in Mood Disorders by the University of British Columbia, Vancouver.

Not just 'creative madness'

In 2016, Amsterdam's Van Gogh Museum hosted a symposium of over 35 mental health professionals who debated about the mental health of the post-Impressionist artist and many concluded that since he experienced periods of high energy followed by episodes of extreme fatigue, he may have suffered from BD. Bipolar disorder, historically, has been indulgently (and dangerously for the sufferers) referred to as 'creative madness' or dismissed as 'artistic temperament'. Appealing as such notions are, most people with BD would rather live a life free from the unpredictability of mood swings, which most of us take for granted. Chameleon-like in its presentation, the symptoms may vary from one episode to the next, within the same patient. The ‘bipolar’ nature of the illness is evidenced by symptoms alternating between two diametrically opposite. An individual may also oscillate between high and low moods without having a significant manic or depressive episode.