Unless an adolescent learns coping skills, there is a high risk of depression in this age group

In conversation with Dr Swati Bhave

As per WHO estimates, globally 10-20% of children and adolescents experience mental disorders. Half of all mental illnesses begin by the age of 14 and three-quarters by mid-20s. But most cases are undetected and untreated. If not tackled early, their impact extends to adulthood, impairing both physical and mental health and adversely affect the adolescent’s development, education and consequently their potential to live fulfilling and productive lives.

The World Mental Health Day, observed on 10^th October has also focused on adolescent mental health with its theme as “Young people and mental health in a changing world”.

I spoke to Dr Swati Bhave, who is a renowned expert in adolescent health, for her views on mental health issues in adolescence.

Dr Swati Bhave is Executive Director AACCI, Adjunct Prof in Dr DY Patil Medical College and Dr DY Patil Vidyapeeth in Pune and Head of Adolescent Clinic, Jehangir Hospital Pune. She is also the Editor of our Asian Journal of Paediatric Practice.

Here are the 10 salient points on adolescent mental health.

1.    In the past, it was thought that at 18 years the brain is fully mature and hence driving, voting etc. were permitted at this age.

2.    Now it is known by MRI and functional MRI, PET etc. adolescent brain is under development right up to 25 years.

3.    The “emotional brain” or the limbic system is normally under control of the “thinking brain” i.e. the prefrontal cortex and the impulsive behavior is controlled in adults.

4.    In adolescents, the limbic system is well-developed, while prefrontal cortex matures much later. This is the reason adolescents are prone to high risk behavior and experimentations like drinking, smoking, substance abuse, driving under alcohol influence.

5.    They are also very prone to labile emotions and need help to stabilize and handle failures or rejections.

6.    This is done by proper parental, teacher or other adult guidance.

7.    WHO has a program called the Life Skill Education (LSE). This is also under UNFPA and UNICEF. The ten life skills empower adolescents to deal with all problems, they can face during normal adolescent development.

The ten core life skills are: Self-awareness, empathy, communication skills – interpersonal relationships, decision making, problem solving, critical and creative thinking, coping with stress and emotions and negotiating skills.

8.    Unless an adolescent learns the coping skills, there is a high risk of depression in this age group. Severe depression leads to high rates of suicides in this age group on very trivial triggers. We need to empower adolescents to prevent suicides by becoming resilient.

9.    The dopamine reward pathway is also very highly developed in adolescents, which makes their brain very vulnerable to substance abuse, tobacco and alcohol. Children who start smoking and drinking below age 12 years are more likely to be adult-addicts.

10. NCDs or noncommunicable diseases are increasing globally. WHO has identified four behavioral risk factors in adolescent age group: Consumption of junk food, increased sedentary lifestyle, tobacco and alcohol. If these behaviors are checked in adolescence, we will prevent adult-onset NCDs.

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

Depression among doctors is a growing problem: Genesis of depression

Dr KK Aggarwal

Mail Today recently featured a cover story of how mounting stress level due to work pressure is taking a toll on the mental health of doctors at All India Institute of Medical Sciences (AIIMS), Delhi. Some of them are admitted in the psychiatric ward of the institute and are undergoing treatment, the story further said.

Depression among doctors is a growing problem and it is now increasingly being reported. According to a study published in JAMA (JAMA. 2015;314(22):2373-2383), between 20.9% and 43.2% of trainees screened positive for depression or depressive symptoms during residency.

As per quantum physics matter can be sequentially broken into atoms and then to subatomic particles (protons, electrons and neutrons), photons, quantum and wave. A photon is both a wave and a particle at the same time (wave particle duality). The human body is also a particle and a wave at the same time. In terms of science, this duality exists as a balance between sympathetic and parasympathetic states.

According to the Vedas, thoughts arise from our consciousness. Thoughts lead to action. Every action leads to a memory, which in turn leads to a desire. A cycle of action, memory and desire is subsequently set into motion. Fulfilled desires result in actions to realize that desire again or fulfil a new desire. Repeated fulfilment of desires leads to habits, addictions and behavior. Unfulfilled desires lead to anger, which can be expressive anger or suppressive anger.

Expressive anger (anger-out), or uncontrolled outbursts of anger, becomes evident as aggressive behavior and/or violence. Suppressive anger (anger-in), can be acute or chronic. Acute suppressed anger can manifest as acute heart attack, acute asthmatic or anxiety attack. While, chronic suppressed anger may lead to depression in due course of time.

Non fulfilment of desires, expectations and aspiration over a period of time therefore is the main cause of depression.

The desires are need-based. Human behaviour is governed by needs, which can be at the level of physical body, mind, intellect, ego or the soul. These needs result in desires, expectations and aspirations.

These can be in the form of respect, recognition and prestige, once the basic physical needs of food, clothing etc. are satisfied.

The feeling of discontent may also be a result of humiliation from seniors/faculty, exam pattern, hurt ego (by patients and/or their families), the daily trauma of dealing with sickness/death, long gruelling shifts, sleep deprivation, social isolation topped with the perennial sword of litigation.

As a way to deal with this stress, some are pushed to self-destructive habits and addictions (alcohol and substance abuse) and some may even resort to the ultimate step of taking one’s own life.

Become a doctor demands lot of self-sacrifice. The extreme stress tests one’s fortitude and perseverance every day.

Overworked and exhausted doctors are bound to mistakes as happened in the case of Dr Bawa-Garba, NHS in UK. She was convicted of manslaughter by gross negligence following the death of a 6-year-old boy with Down syndrome. Her name was erased from the medical register following an appeal from the GMC. Missing the diagnosis of sepsis and thus delaying initiating antibiotic treatment was one among several charges of negligence levelled against her. The charge of manslaughter against their colleague will also adversely affect the morale of other doctors.

Depression therefore is an outcome of the chronic suppression of emotions or need-based desires or their non-fulfilment, particularly for those who have high expectations or high aspirations.

HCFI Update: Depression and Diabetes

Depression is implicated in diabetes said Padmashri & Dr B C Roy National Awardee, Dr K K Aggarwal, President Heart Care Foundation of India and MTNL Perfect Health Mela.

For many years it was thought that depression was a complication of diabetes. More recent research, however, points to depression as a possible trigger.

A Kaiser Permanente study of 1,680 subjects found that those with diabetes were more likely to have been treated for depression within six months before their diabetes diagnosis. About 84 percent of diabetics also reported a higher rate of earlier depressive episodes.

A 2004 Johns Hopkins study tracking 11,615 initially non diabetic adults aged 48-67 over six years found that "depressive symptoms predicted incident type 2 diabetes."

According to an evaluation of 20 studies over the past 10 years, the prevalence rate of diabetics with major depression is three to four times greater than in the general population. While depression affects maybe three or five percent of the population at any given time, the rate is between 15 and twenty percent in patients with diabetes, according to the American Diabetic Association. Women, in particular are at greater risk.

Whether a cause or an effect, the combination of diabetes and depression can be deadly. Because of physiologic and behavioral interactions between diabetes and depression, each becomes more difficult to control, increasing the risks of cardiovascular disease, diabetic retinopathy causing blindness, neuropathy and other complications.

Obesity is a risk factor for macrovascular disease. Depressed people tend to eat more and exercise less, which results in weight gain and sabotages efforts at controlling blood sugar levels. Depressed adults with diabetes have significantly higher body mass indexes than nondepressed adults with diabetes.

Depression in diabetics is a greater risk factor for heart disease than high blood sugar.

If depression can trigger diabetes or make it much worse, it stands to reason that effectively managing one's depression can help bring one's diabetes under control.

The take home message is

1. If you have diabetes get screened for depression

2. And if you have depression get screened for diabetes

Dr KK Answers: What is the link with depression?

Screening for depression in patients with dementia is recommended because depression is a common treatable co-morbidity that may also masquerade as dementia.