 Good evening dear viewers. I am Dr. Vikram Arunachalam. I am a consultant psychiatrist with Manipal for the last eight years. Overall I am in the field of psychiatry for the last 15 years. So it's a great pleasure to be here today and discuss about an important public health concern which is depression and suicide. So we do have a question and answer session so you can come up with your questions in the comment box and try to answer them. This will be an half an hour Facebook live. So even otherwise I am available even after this session so you can raise up the questions which will be taken up. So today I have come up with few questions which some of my patients had asked me during my consultation time. So in fact we will try to answer this. So I am not going into the technical depth of depression and suicide. We will try to understand depression in terms of public health view. So let us look at the current scenario of depression globally in India as well as globally and as well as in India. So globally the study says that nearly roughly 300 million people are depressed. So that's a huge number. So it's almost five percent of the population in world are depressed. So when we look at top five countries which are depressed India comes at second. It's unfortunate. So China overtakes us in the most depressed privilege of depression followed by India then US then it's Brazil and Bangladesh. So since the start of this COVID-19 pandemic there has been an enormous amount of stress especially this unprecedented lockdown has led to stress and depression. So a recent study in India had also showed that there is 43 percent of Indians were depressed. So this is a study as per the National Mental Health Survey and predominantly women were more depressed than men. So the ratio was 2 is to 1. So depression is a global health problem, the disability worldwide and major contributor for disability associated life years. So also the commonest cause for suicide in the suicide is following depression. So many tend to ask when I talk about depression when I do mention about the signs and symptoms of depression. Everyone would say that I would have gone through the same case. So am I depressed? So there is a difference between what is depression and sadness. So is it the same? So let's see. So an healthy person goes through the variety of mood states including transient feelings of sadness. So this sadness is a temporary phase and it is not very much disabling the person. There is no impairment in the, it is not incapacitating and it is non-pervasive and it's okay to feel sad at times but it is not long lasting. Whereas when we talk about clinical depression it's more of a pervasive, sustained and more intensive problem. So when we say depression it has to be throughout the day, it has to be on most of the time for several days in a week. Ideally we would say continued symptoms for two weeks of time. So it might be accompanied by a sense of guilt, feeling helpless, wanting to hurt self, lots of thoughts about self harm. There might be other biological disturbances like appetite, sleep disturbances and it might significantly impair the person's functioning levels also. So to clinically diagnose as depression there are three core symptoms. When I say core symptoms these has to be there mandately to make a diagnosis of depression, pathognomonic of this condition. So when we say the core symptoms it is low mood, feeling, that is feeling of sadness, fatigability, that is feeling excessively tired and at times feeling lack of interest. What we technically say is anidonia, not feeling pleasure for previously pleasurable activities. For example the person was interested in interacting with friends, going out with friends, all of a sudden that behaviour has changed now. So these are the core symptoms. So not everyone presents with these core symptoms. Many times what happens is in our clinical practice we are taught about as a medical student as a postgraduate in psychiatry I would have learnt about this core symptoms. But over the years when I see patients not everyone presents with these kind of core symptoms. Most of the time people tend to have what we call as mask depression. So mask depression is something like they tend to present with chronic pain symptoms. Many would approach doctors with symptoms of chronic headache, chronic low back pain, migraine headache. In spite of repeated doctor visits the doctor would not find any organic etiology, almost all the investigation should be normal. So these person would have an underlying depression but they don't tend to present it in the classical way but they tend to present it in a more medical way. So some people present with sleep disturbances, some people present with sexual disturbances, sexual dysfunction, some present with a lot of interpersonal relationship problem. They tend to go for repeated medical visits and many people tend to report with reckless behaviors especially in child, child and adolescent depression. So the other question arises now. Most of them do ask me, do even have heard many of the talks in which some lay people would say that depression is a sign of mental illness. And they say that depression always occurs following a stressful event or a traumatic life event, which is not always true. So when I say depression, depression is a real problem, it is not an attitude, it is not a weakness, it is not a character problem, it is not a belief, it is not something by choice. Depression is a medical problem, it is just like another medical condition like people tend to have hypertension, people tend to have diabetes, people tend to have thyroid issues. So similarly depression is a medical problem. So what happens when I say it is a medical problem? For example when a person with a liver condition at an underlying liver pathology tends to develop jaundice. So similarly depression occurs when there is a malfunction of an organ, in this case the organ is a brain. So when the brain does not function well, so people tend to be depressed. So there is no way that the person can come out of depression on his own or the person can think positively when the brain is affected. So just like other condition of liver or any other organ which needs treatment, even this condition needs a treatment. So when we say that depression does not occur, only depression, the stressful events precipitate or trigger the depressive events. So it does not mean that they are the root cause for depression. So depression when we say about the reason, the etiology, the causes for depression, we would say that there are three cluster of factors which results in depression. So it is not one factor, it is an intermixed of all these three cluster group of factors which results in depression. So we call it as bio-psychosocial model, biological factors, psychological factors, social and environmental factors. So let us see what are these factors that results in depression. When I say biological factors, there are a lot of neurochemicals in the brain, neurotransmitters. When there are neurotransmitter abnormalities in the brain, when the neurotransmitter levels are altered, people tend to have depression. In some neurological conditions like multiple sclerosis, people tend to have depression. In some endocrinological abnormalities like thyroid condition, low thyroid levels, hypothyroidism, people tend to have depression. And in some cases, say 15 to 20 percent, people with a genetic, with a heredity history of depression, they tend to have depression. So sometimes it runs in the family. So with genetic pre-loading, people tend to have depression. So when I say this is about the biological factors, when I say psychological factors, so the personality of the person, the coping patterns, the temperament of the person and some early developmental factors like childhood trauma, childhood abuse can result in depression. So social and environmental factors are always overrated when compared to the psychological and biological factors. So definitely they do contribute a lot of stresses like losses, exit events, we call as exit events like the death of the beloved ones, unemployment, poverty, poor social support, all these can result in depression. So it is an inter-mixture of all these factors. So not one factor we cannot pinpoint that this is the reason for depression. So when we talk about depression, it is not a single thing. I mean, there are different types of depression. So there isn't what we call as unipolar, it is a major depression disorder. People, a person doesn't have any other symptoms except for signs of depression. Sometimes it can happen in bipolar-affective disorder. Personal bipolar-affective disorder can have a mania as well as depression. It is called as bipolar depression. And sometimes it can have a seasonal effect too. In certain seasons, people tend to become more depressed than other seasons. We call it as seasonal-affective disorder. Then there is something called as dysthymia. Dysthymia is persistent, depressive symptoms. It is a low-grade, very mild symptoms lasting continuously for more than two years or so. So it is called as dysthymia. And there is a condition which happens following a psychotic disorder. Psychotic condition is a different condition which is more of a thought disorder, thought process disorder. So people tend to have psychotic depression. And the most common these days what we are seeing is it happens in peripartum. That is mostly which happens during the pregnancy time. Which is called as postpartum depression. So these are different types of depression. Each type of depression needs an individualistic approach when it comes to management. So generally, we know what is depression. Most of them identify depression. We can identify depression in our colleagues. We can identify depression in our friends and the family members. But why people are generally reluctant to seek help? Not just depression. I have seen even in other mental health conditions, people don't voluntarily seek help. They are very reluctant to seek help. So why is this discrepancy when we compare this to physical condition? So when there is physical illness, I have hurt my finger. There is an headache. I have a fever. So I voluntarily go and approach the physician or any other general practitioner and talk about my illness. But when it comes to depression, there is another mental health condition. Still there is a lot of social stigma. People don't want to come up in open. They are not happy to discuss about their depression or any other mental health condition. Because there is a fear that the person might be branded as mentally ill. They might be having a fear that when I am mentally ill, nobody would marry my daughter or nobody would talk to my family members. They would try to isolate us. So all these kinds of perceived stigma is there. And also there is a lot of misconceptions about mental health issues and mental health treatment. So when it comes to treatment, people would have a lot of misbelief that notions about psychiatric illness and medication. They would feel that treatment is lifelong. I would be put on sleeping pills. And many times I develop side effects with the medication. It is not true. Maybe these were true two decades back. So almost in the last two decades, there has been leaps and bounds of advances in psychiatry. So we do not give sleeping pills unless and until it is an exclusive sleep disorder. So there are specific medications for specific disorders including depression. And also there has been leaps and bounds progress in the research. So the scientists have found out which lobe, which hormone, which neurotransmitter patients. So particular medications are given. So the most important aspect in psychiatry is early identification and treatment of the condition. The more it is prolonged, the more the treatment gap is more and the treatment is also much prolonged. So we need to identify the condition early. To identify the condition early, we need to come out of these stigma and notions about psychiatric illness. And we need to discuss about these things. We need to come up in the open forum. So off late, there has been instances where many Bollywood actresses like Deepika Podukone who is a Brand Ambassador for Indian Psychiatric Society have acknowledged about our problem, acknowledged that she had depression and suicidal ideas. She came up in open. She started her own foundation, Lea Lowlough Foundation which is catering to many adolescent and other people with the depressed disorder. So let's see. So we have understood what are the clinical features of depression, what are the reasons that cause depression. We have seen the different types of depression. We understood why people are reluctant in seeking depression. So now we will try to understand what will be the impact of depression on any person. So depression is not a single entity. So when the person is depressed, it can affect the family in the longer and it can affect the society in the longer and it can affect the entire country as well. So it impairs functioning, it impairs physical health and it lowers the quality of life. When we say physical health, so depression and physical illness run hand in hand. So most physical illness has an underlying stress hypothesis. So many people with depression tend to have or have comorbid cancer, hypertension, diabetes, malates, thyroid condition, dementia, multiple sclerosis and many other neuropsychiatric condition as well. So there has been a lot of studies in international studies as well as studies in India which says that there is a risk of diabetes is a two-fold increase in people with depression. And similarly when a person with diabetes, sorry, an vice versa, person with depression have a two-fold risk of having diabetes and person with diabetes have a two-fold risk of having depression as well. So for example also even the cardiovascular conditions, when two person had an heart attack, myocardial infarction, so imagine one person died. So the psychological autopsy and researches on this person has shown that that particular person pre-morbidly before we develop the cardiovascular condition had a depressive disorder. So the depression and depressive disorder just like other medical condition has lot of mortality and morbidity increases the rate of other medical condition as well as increases the death rate. So risk of diabetes, risk of cardiovascular condition, everything is increased and in the longer run it can affect the, it can lower the quality of life. So many people with depression do tend to feel suicidal but is it true that all suicides are because of mental health issue or depression? This is not true. So suicidal behavior indicates deep sense of unhappiness but not necessarily mental disorder. People with mental disorder or not all mental disorders do feel suicidal and vice versa. So it's true that most suicides happen suddenly without warning which is not true. So most of the majority of suicides have been preceded by warning signs. The warning signs might be verbal and behavioral as well. So of course there are some suicides which can happen very impulsively but most of the time what we do when we do a psychological autopsy on a person with suicide. So we would all find that the person would have directly or indirectly indicated about his suicidal wishes. So death wishes to relate you to a close friend or to a family member or maybe to the general practitioner. So we should be as a general public, as a medical fraternity, as other specialists, even the layman has to understand some of the risk factors or high risk factors in suicide, especially in a country like India. So why we are emphasizing more about suicides in India? The suicide due to depression has tripled in India almost after this pandemic. And the most scary thing is people are talking about the pandemic of depression and other mental health issues which can be much more severe than the COVID pandemic. So it is important to understand what are the warning signs and look out for this in people. When people come and talk to you, don't underestimate their suicidal thoughts, don't underestimate, don't advise them before listening to them empathetically. So suicide, as I told you, it is very common among the age group of 15 to 29. It can happen across all the age groups, but most common in India is between the age group of 15 to 29, the risk is very high. And unfortunately India is known to be infamously called as a suicide capital in Asia and it is going to be going beyond Asia also. And I am right now in Bangalore. Bangalore is also called the currently surpass Chennai and other cities to be known as the suicide capital of India. So it is our duty to know about the warnings and just like in hypertension or diabetes, when people try to educate that for example the COVID situation pandemic, people tend to explain the medical pattern, when you are having cough, when you are having fever, when you are having body pain, loss of smell, loss of taste, these are symptoms of COVID. Similarly, there are some symptoms where you can identify that the person has a high risk for suicide. So nobody commits suicide just out of the blue. So most of them have a direct or express a direct or indirect cue. So when we tend to learn these warning signs, we can easily help them and prevent this suicide in most of the cases. So this suicide can happen in any of our family members, can happen to our colleagues or any other person. So be aware of the warning signs, understand and help the suicidal person. So there is no, there is nothing called as a typical suicide victim. We cannot say that this person, he or she will commit suicide. It can happen to young, it can happen to old person, it can happen to rich, it can happen to poor. Fortunately these warning signs are there which when acted upon can save lives. So let's see what are the warning signs. A person might be suicidal if he talks about committing suicide repeatedly. He has trouble in biological symptoms, repeatedly sleep disturbances, continuously having eating disturbances. There is a drastic changes in the behavior, the behavior. Suddenly the person becomes withdrawn, doesn't interact with family members, doesn't interact with friends or relatives. And all of a sudden experiences high, very feeling energetic, feeling very high. All these are also sudden changes in behavior or risk factors for suicide. He withdraws from friends and social activities. There is loss of interest in his usual hobbies, loss of interest in work, loss of interest in school, especially in children we would see. And many a time people tend to prepare for the death by making a will or even final arrangement. They would say that they would give their personal belongings. The person in normal times would not even share anything. But during this kind of a suicidal tendency, people tend to share their prized position. And when a person has attempted suicide in the past, the risk factor is high. So he takes unnecessary risks. He has had a recent severe losses in finance. All these are risk factors. He is preoccupied about death and dying, always exposed on the internet or Google checks what are the ways to die without pain or something like that. He talks to people, talks to friends about death, watches more of death news. So all these are risk factors. And the person tends to be withdrawn from everyone. He tends to lose interest in self-care. There is an increase of a person might be using alcohol or drug or tobacco. All of a sudden there is an increase in use of alcohol and smoking. All these are risk factors and warning signs for suicide. So when we understand about these warning signs, we can easily help people to seek help and prevent the suicidal tendency. So we have understood about warning signs and suicide does not happen out of the blue. So people would have directly or indirectly given a clue about their suicidal tendency. And now how to reduce this risk? We have talked about all the warning signs. So there are a lot of measures to prevent the suicide as well. So there are a lot of protective factors. Just like this risk factor, just like the negatives, there are some positives also. Protective factors to prevent suicide. So the foremost is the belief that it is okay to seek somewhere. An early identification and early intervention is the best method. And good problem solving skills in the person, good coping skills in the person. An optimistic outlook, feeling always optimistic, having a positive attitude and ready and eager to seek help from others. So when I mean eager to seek help, it need not be a psychiatrist or any other mental health professional or even the medical fraternity. You can seek help from near and dear and friends and relatives, talk about their problem, come up in the open, discuss about their problem. See most of the time what happens is when we talk about the problem itself, we feel that when we are heard by the other person, most of our problems get addressed. So at least initially we feel reassured and we do not go for this extreme step. So we need to try to increase the person to talk about his problems. And obviously a positive family and good social support and studies have even shown that good spiritual support is a protective factor. Against suicide and other depressive conditions. So these are the protective factors which can prevent against suicide. So also there are, we would like to emphasize on the health helpline in our country. We have a health helpline 104. So 104 also catered as a suicide helpline. So it is 24 bar 7 into 365. So it can be for person feeling restless, having this kind of thoughts about feeling helpless. So when I say helpless, they tend to have a triad of symptoms. People tend to feel helpless about this situation, feels hopeless about future, feeling worthless and feeling burden on others, family members or relatives or friends. So when he expresses these kind of thoughts, when he feels that there is no one to discuss, he can immediately dial toll free number 104 and talk about his conditions. So we have seen what are the risk factors and what are the protective factors for suicide. So finally we will discuss on how depression and other mental health conditions are treated. So when it comes to treatment of mental health conditions or depression, so there is nothing as a trailer made treatment, trailer made treatment approach. There is nothing as a common pill, one pill works for everyone. So it is an individualistic approach. So each, it has to be holistic, holistic means it is the multiple things are involved in addressing depression or any other mental health condition. So the most common is medications and talk therapy. When I say medications, medication target the altered biology. Medicines for depression are as important as giving a talk therapy. Talk therapy targets the altered psychology. So when I say medications, there are a varied medications. So like earlier the medications were like two decades back, we didn't have much of medications. So a lot of sleeping pills were given. So which was incapacitating the person, the person was unable to work. Sleepy, sleepy, drowsy, but these days we have specific medication given for a short period of time. Once the symptoms tend to remit, we can gradually taper and stop the medication also. And in severe depression, we have a most effective means of treatment called as electroconvulsive therapy. So it is a very safe treatment even in pregnancy and even in childhood. Children's electroconvulsive treatment has been effectively given without any kind of complications. So as I said, it's an holistic approach. Medications would be the mainstay. Along with medications, simultaneously we would do this talk therapy. Therapy is more structured. So we have a lot of therapy, supportive psychotherapy, interpersonal therapy. What we commonly use in depression is what we call as CBT, cognitive behavior therapy. So cognitive behavior therapy addresses the thoughts, emotions and actions of the person. So this is a structured therapy done by a psychologist. So it has to be done on an average of six to eight sessions. It again depends on the individual's problems. So along with that, there is an emphasis on family therapy also. So when a person is depressed and when a person is suicidal, it doesn't affect the individual alone. It can have an impact on the other family member, especially more commonly the spouse. There is a caregiver burnt out in most of the mental health condition. So family approach also, family scoping skills has to be enhanced. Family, the relaxed family person, the spouse has to be taught relaxation procedures. So in the longer run, so the family issues is also addressed. The person's outcome recovery also will be much better when the spouse is more understanding and accepting the person's medical and the psychiatric condition. So we have understood what is how depression is treated. So medication would be the mainstay. When we initiate the medication early, it can be tapered and stopped early also. So just like we understood the protective factors in suicide, there are some ways we can prevent depression and also some mental and other mental health condition like the anxiety spectrum disorders. So we need to effectively enhance our coping skill strategies. The most commonly advocated, just like in physical condition, the most commonly advocated in most of the psychiatric conditions are exercises, having a regular exercise regime, bringing about lifestyle changes, getting adequate sleep. We do talk about good sleep, hygiene sleep is very, very essential just like as we eat our food, sleep is very essential. And diet also, we need to keep a watch, some of the diet can alter our physiological, bring up our physiological changes, can increase our stress hormone levels and predispose us to depression. So this is about depression, this is about suicide, how we can identify depression, how we can identify suicide, how we can treat depression and how we can prevent depression. So just given an overview about this, in detail if you want we can share the materials also available through our platform. So let's see, we can take up some of the questions from the comment section. So there is a question on how does anti-depressant help cope up with depression. So as I told you, it is a depression, a lot of biological changes does happen when a person is depressed. So the neurotransmitter levels gets deranged. So when I say depression, there is an hormone called a serotonin which is an happiness hormone, serotonin, dopamine gets deranged. So most of the time we tend to give serat, SSRA, serotonin, selective serotonin, re-uptake inhibitors which regulates the serotonin levels in the brain and it helps the person with depression. So most of the melancholic biological depression can be addressed with anti-depressants. So there is a question on how to deal with people who have multiple personality disorders because it is difficult to deal with people having multiple personality disorders. And this could lead to depression, I think the depression in caregiver and mental challenges for people around them. So we need to evaluate, so personality issues is a different component. So personality problems has to be evaluated in depth. We need a psychologist, a psychological evaluation for a personality issues and the person has to be addressed based on the kind of personality. We have three clusters of personality, cluster A, cluster B and cluster C which has a different behavioural manifestation. So definitely it can be addressed. That is a different topic so it can be discussed later. So a message from Sundar, thank you for sharing knowledge of prevention of depression and symptom. Thanks Sundar. So I hope it was informative. So we are ready to take up any other questions. So can depression be masked without the course in them? Yes, obviously. So I did mention that many, especially in Indian scenario people don't openly come to invest in world. We see that people are open and happy to talk about their mental health issues, especially depression. They do come and say, I am feeling sad, I am unable to cope with it, I feel like crying, I am feeling suicidal. But depression and mental health is still a taboo subject in India. So people don't tend to openly express about depression. So it tends to be submerged inside and people tend to express their psychological problems in terms of somatic symptoms, that is bodily symptoms. So what we commonly see as psychiatrists is people tend to come with chronic pains, chronic low back pain, chronic headache, sexual disturbances, interpersonal disturbances, behavioural disturbances. So all these things are symptoms of mask depression. So as a mental health professional, when we sit and evaluate about other symptoms, signs and symptoms of depression, we can diagnose depression. I don't think I don't see any other questions. If there are no more questions, I think we can end the session now. So thank you all. Thank you. So if there are any other doubts, you can write down this email id we would be sharing. So we can clarify your doubts. Thank you.