Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-0116bDepression in the Indian SubcontinentVikram PatelLondon School of Hygiene and Tropical Medicine, London, UK, and The Sangath Society, GoaCommon mental disorders, such as depression in late life, are notwell understood or acknowledged by either the community or themedical profession in India, for three important reasons. First,recognition of common mental disorders as a psychiatric problemin general is relatively poor. Most patients present with somaticsymptoms. While many patients and health providers acknowledgethe non-organic basis of these symptoms, neither group iscomfortable with labels that imply a relationship to psychiatry.Indeed, terms such as ‘‘depression’’ and ‘‘anxiety’’, when used todefine diagnostic categories of psychiatric disorder, have noconceptual equivalent in any Indian language. Ethnographicstudies have shown that symptoms of depression are attributed totension, family conflict and lack of family affection, rather thanbeing seen as a biomedical psychiatric problem 1 . The secondreason for low recognition is that the relative proportion of eldersis less than 5% for most Indian communities. This is bound tochange in the future, with falling birth-rates and rising longevityleading to predictions that, over 20 years, this oldest sector of thepopulation will exceed 100 million. The implications are grave, forIndia has no systematic social welfare system for the aged, and isfaced with the gradual breakdown of traditional extended familysystems that have formed the bulwark for the care of the disabledand chronically ill 1 . The third reason is:the fatalistic attitude toward aging in India, which mandates thatelderly persons accept their physical and mental condition as anormal part of old age. Not only are elderly persons with mentalillnesses rarely brought to a physician, but those with treatablemedical conditions also often receive no medical attention 2 .There are few epidemiological studies of common mentaldisorders in elders in India and no published studies, to date,that have used structured psychiatric interviews. Prevalence ratesfor depression in a community sample of elders have varied from6% in southern India 3 to over 50% in rural West Bengal 4 . Thecommon presenting complaints are tiredness, sleep complaints,aches, tingling-numbness in the hands and palpitations. Onenquiry, however, most depressed elders will admit to cognitiveand emotional symptoms typical of depression. The hallmarkcognitive feature is anhedonia, or loss of interest. Suicidal feelingsand agitation are also common 3 . The suicide rate in the 50+ agegroup (12/100 000) is nearly twice the national average (7/100 000).Co-morbidity with physical ill-health is common; by someestimates, more than 90% of elders with a psychiatric disorderalso have some physical disorder 3 . Risk factors for depressioninclude low education, poverty, social isolation and family discord.The latter is on the rise as a result of the breakdown of traditionalcommunity structures resulting from the massive migration of theyounger productive members of families to urban areas andreduced economic activity in rural areas. The commonesttreatments in primary care are symptomatic. Thus, benzodiazepinesfor insomnia and vitamins and ‘‘tonics’’ for tiredness areamongst the commonest prescriptions for common mentaldisorders in general health care, while antidepressants orpsychotherapy are rarely offered 5 .The rising rates of recognized risk factors, relatively lowrecognition of depression and even lower rates of appropriateinterventions should cause considerable concern to public healthpolicy and planning in India. One major limitation in influencingpolicy and practice is the lack of systematic evidence of theepidemiology of depression, and the efficacy and cost-effectivenessof treatments for depression, in elders in India. Research into themental health needs of elders in India is clearly an important areafor future psychiatric research. Health education should aim toeducate health workers and the community to recognize thatanhedonia and insomnia are not the expected price of growingold, but the result of a common, disabling and treatable illness.Removing stigma may require integrating the subject of depressioninto training programs for community and general healthworkers, and collaborating with non-governmental organizationsthat are pioneering programs to empower the elderly, supportfamilies with a mentally ill elder and provide health care sensitiveto their needs. Working with the existing manpower and healthand social service infrastructure is likely to be more successful inmeeting the mental health needs of elders in India than developingspecialized psychogeriatric services throughout the country.REFERENCES1. Patel V, Prince M. Ageing and mental health in developing countries:Who cares? Qualitative studies from Goa. Psych Med 2001; 31: 29–38.2. Chandra V. Cross-cultural perspectives: India. Int Psychogeriat, 1996;8(suppl 3): 479–81.3. Venkoba Rao A. Psychiatry of old age in India. Int Rev Psychiat 1993;5: 165–70.4. Nandi PS, Banerjee G, Mukherjee S. A study of psychiatric morbidityin an elderly population in a rural communty in West Bengal. Ind JPsychiat 1997; 39: 122–9.5. Patel V, Pereira J, Fernandes J, Mann A. Poverty, psychologicaldisorder and disability in primary care attenders in Goa, India. Br JPsychiat 1998; 172: 533–6.Principles and Practice of Geriatric Psychiatry, 2nd edn. Edited by J. R. M. Copeland, M. T. Abou-Saleh and D. G. Blazer&2002 John Wiley & Sons, Ltd