The Health Collective 

Mental health

Understanding Tourette's Syndrome

February 22, 2018

By now, you would have seen the trailer of the upcoming movie Hichki, starring Rani Mukerji, in the role of a character who has Tourette’s Syndrome, who finally gets a job as a teacher. While we'll leave the reviews for the bonafide critics, Shruti Venkatesh takes a closer looks at Tourette’s Syndrome.



What is Tourette’s Syndrome?

Tourette’s Syndrome is characterised by brief, stereotypical but non-rhythmic “jerky” movements and vocalisations called tics.[1] Tics can be classified as motor or vocal: Motor tics are associated with movements, while vocal tics are associated with sound. Common tics include eye blinking, grimacing, jaw, neck, shoulder, or limb movements, sniffing, grunting, chirping, or throat clearing and the severity of such tics follows a waxing and waning pattern. 

A diagnosis is usually made only after verifying that the patient has had both motor and vocal tics for at least one year. 

How common is Tourette’s Syndrome?

Tourette’s, which was once considered to be a disorder of rare occurrence is now found to be a common genetic condition with its inception in childhood. [2]

Tourette’s occurs in people from all ethnic groups. Consulting psychiatrist, Dr Avinash DeSousa tells The Health Collective, “The prevalence in India is relatively less with an estimate of 1 in 1 lakh persons. However, in cases that are seen, history of epilepsy is common in patients with Tourette’s.”

Studies have found that males are affected about three to four times more often than females. [3] Symptoms of Tourette syndrome typically show up between ages 4 and 13, with the average being around 7 years of age. Approximately 10-15 percent of those affected have a progressive or disabling course that lasts into adulthood. [3] (The once understood rarity of its prevalence owes to when the disorder occurred only in 4.9 per 10,000 males and 3.1 per 10,000 females. It is now estimated that 200,000 Americans have the most severe form of TS, and as many as one in 100 exhibit milder and less complex symptoms such as chronic motor or vocal tics.)

ALSO READ: Understanding OCD

Associated Disorders

About 30 to 70 percent of patients with this disorder have substantial obsessive-compulsive (OC) symptoms [4] which may include symmetry, order, counting, and ritualistic repetition.

Attention-deficit hyperactivity disorder (ADHD) is also frequently diagnosed in children with Tourette’s, with a prevalence as high as 50 to 60 percent. [4] This comorbidity is associated with disruptive behaviours, such as aggression, inappropriate expression of anger, low frustration tolerance, adding considerable burdens to affected patients, including academic problems, peer rejection, and family conflict.

Individuals who suffer from Tourette’s also may report having depression or anxiety disorders, as well as other conditions which affect normal functioning that may or may not be directly related to Tourette’s. [5] Considering the range of potential complications, those with Tourette’s must receive medical care that provides a comprehensive treatment plan.

What causes Tourette’s?

The specific cause is unknown due to the complexity of the disorder but latest research points to abnormalities in certain brain regions, the circuits that interconnect these regions, and the chemicals in the brain responsible for communication. It was generally agreed that Tourette’s is genetically determined. However, more recently, a mixed model has been proposed in which it is suggests that infections and perinatal factors may also play a role. [6]

ALSO READ: Six Things to Know About Therapy

Can it be cured?

There is no “cure” to Tourette’s but people can lead a normal life and many don't need treatment when symptoms aren't troublesome.

Most patients experience peak tic severity before the mid-teen years with improvement for the majority of patients in the late teen years and early adulthood. Pharmacological treatment for the tics may not be needed unless they cause severe interference with social development. [7]

What are the available treatment options?

Medication has proven to be the most useful for tic suppression. However, the most common side effects include sedation, weight gain, and cognitive dulling. [3]

Dr DeSousa recalls the case of a 12-year-old boy with vocal tics (sounds similar to croaking) and sudden bursts of abusive language that were mistaken for poor behaviour at school in spite of the child’s report of it being uncontrollable and involuntary.

 Following the consultation with a neurologist and with the use of prescribed medication, the child’s symptoms drastically reduced in a month.

Dr. DeSousa advises, “The key to treatment for Tourette’s lies in a combination of long term medication and behavioural techniques in case of motor tics.” 

Habit Reversal Training and Awareness Training may be an effective treatment for tic reduction. [8] Cognitive-behavioral treatments, such as Exposure and Response prevention, continue to be a mainstay for the treatment of obsessive-compulsive disorder, especially when there is significant anxiety or phobic avoidance.

Stress has been proven to aggravate symptoms which can be improved with psychotherapy sessions. [9]  School adjustment, strong collaboration with school authorities, social coping and participation in extra-curricular activities can also help conditions. Advocacy groups focused on Tourette’s can educate and spread awareness for understanding the syndrome more accurately.

There has been significant progress in terms of research and pharmacology for Tourette’s in the last couple decades, however it is still not clearly understood. The best possible situation points toward correct diagnosis of not only the syndrome in itself but each associated comorbidity. Tourette’s requires the existence of a spectrum to avoid confusing debatable symptoms.


  1. American Psychiatric Association. Diagnostic and Statistical Manual, Fourth Edition Text Revision. Washington, (DC): American Psychiatric Association Press; 2000. pp. 108–16. (DSM-IVTR)

  2. Ludolph AG, Roessner V, Münchau A, Müller-Vahl K. Tourette syndrome and other tic disorders in childhood, adolescence and adulthood. Dtsch Arztebl Int 2012; 109: 821–288

  3. Tourette Syndrome Fact Sheet. (2012, January). Neurological Institute of Neurological Disorders and Stroke

  4. Theodore, D. D. (n.d.). Textbook of Mental Health Nursing (Vol. 2)

  5. Other Concerns & Conditions. (n.d.). Centers for Disease Control and Prevention

  6. Robertson, M. M. (march 2000). Tourette syndrome, associated conditions and the complexities of treatment. Brain, 123(3), 425-462

  7. Fernandez, H. (n.d.). Tics & Tourette Syndrome. International Parkinson and Movement Disorder Society

  8.  Tourette's Disorder: Habit Reversal Training - Topic Overview. (n.d.). WebMD

  9. Cohen S.C., Leckman J.F., Bloch M.H. Clinical assessment of Tourette syndrome and tic disorders. Neurosci. Biobehav. Rev. 2013;37:997–1007. doi: 10.1016/j.neubiorev.2012.11.013

Disclaimer: Material on The Health Collective cannot substitute for expert advice from a trained professional

About the author:
Shruti Venkatesh is an aspiring Clinical Psychologist and Research Assistant at De Sousa Foundation, currently in her fourth year as a student of Psychology. She has been trained in REBT, TA, Forensic Psychology and Clinical Psychotherapy, and volunteers at NIOS and SPJ Sadhana.


Carers: What You Need to Know

February 18, 2018


Ask the Experts with Dr Achal Bhagat



When we talk about caring for somebody with a mental health problem, the most important thing is not to be judgmental.

People can have all kinds of problems. What might be easy for you to solve might be very, very difficult for someone to solve. See if from that point of view, think like them, feel like them and then you will feel the immense nature of the difficulty that they’re experiencing.

Don’t be directive, don’t say pull up your socks, don’t trivialise their difficulty, don’t come up with an immediate solution…Don’t overwhelm them with solutions, what the person expects from you is space, so they can talk about what they are going through; or what the person expects from you is understanding so they can talk about their weaknesses and their limitations. They are not looking at their strengths at this time so your repeatedly talking about their strengths at this time is actually makes them feel unheard.

So do not judge, do not direct…Feel from their point of view and be patient.

But more importantly caring is a very, very difficult task, take space out for yourself as well… If you’re caring for someone who is going through a difficult time, sometimes you need respite for yourself to care for yourself as well.


The Health Collective


Sometimes it’s very important that you are able to go and debrief with somebody else about what you’re experiencing so caring is also about looking after yourself, if you do not look after yourself you are bound to get angry or impatient with the person you are caring for.

ALSO WATCH: Understanding Mental Health with Dr Achal Bhagat


As mental health professionals it's very important that we seek supervision -- we are also carers and we also live our lives parallel to people that we care for and we have difficulties in our lives ourselves. We are not superhuman in any way…so everybody can be vulnerable and this is to our core professionals that it’s alright to seek help as professionals with each other. Sometimes we act too brave and we miss the point.


Tweet us @healthcollectif with your comments and to share your stories


Disclaimer: Material on The Health Collective cannot substitute for professional advice by a trained expert


We Walk Among You

February 11, 2018

1 in 4 people will have a mental health problem this -- and every -- year

Kishore Mohan/ Health Collective
Art by Kishore MohanHealth Collective

6 Things to Know Before Entering Therapy

February 9, 2018

By Kamna Chhibber

People frequently equate therapy with ‘simply talking’, just like you would with a friend or a family member. To us therapists, it is far more than that. A therapeutic setting creates the environment for you to explore experiences, thoughts, feelings and ways of responding within the context of your life, your work and relationships. The process with the therapist – a neutral, unbiased, non-judgmental observer – enables you to explore aspects of yourself and your life which you may not think to look at.

If you decide to embark on this journey, there are facets of therapy you need to know of. Multiple times in my years as a therapist I have crossed paths with clients seeking therapy harbouring notions that are far from the truth. What follow are my thoughts on the quintessential things you should be aware of as you prepare to embark on this journey.

  1. There is no quick fix. Often when people come for a first session and I enquire about what brings them to therapy, they share a simple problem statement, something like: “I am having panic attacks. I need you to make them go away”. Before they leave my chamber their final question is “In how many days will I be fine?”

    I help them understand there is no quick, easy way to make things better. Therapy requires a lot of work. There is nothing prescriptive about it. It is a process of working through a lot that was and is going on, things you anticipate may happen and factors you think may cause them to happen. It takes time. The first session is for us to situate you within the context of your life. The real work starts after we know you, understand you and have an understanding of where you come from. It can take us weeks, sometimes months and then even years to resolve, work through and close the loops with you.

Also Read: Ask the Experts: Understanding Therapy

  1. The past catches up. Everyone likes to steer away from the past, even if they recognise the role it played in getting them where they are today. We work through difficult situations by moving past them as quickly as possible, but this does not eliminate them from our mind. There are fewer things in our conscious awareness than what exists within the deep recesses of our minds –- the unconscious. These unconscious aspects play a significant role in shaping our views, thoughts, feelings, responses, reasoning and anticipation. When getting into therapy, be prepared to look at the ‘things of the past’, not because the therapist wants to but because your mind will push you to.

    Photo by Daniel Chen on Unsplash

  2. You must develop a bond. A crucial factor determining the success of therapy is your comfort and relatedness with your therapist. A realistic assessment of how your therapist understands you, helps you articulate thoughts and identify feelings is critical to the trust you develop which will help you resolve issues.
    The questions to ask yourself at the end of the first session are: “Did I feel comfortable? Was I able to express myself with ease?” As you progress through therapy you need to ask yourself: “Do I feel understood and are my feelings identified accurately? Is there movement with respect to the problems I approached therapy with?”

Also Read: Relationships, Happiness and Living the Life You Want

  1. You will arrive at the answers. The methodology of therapy is assumed to be a process of questions and answers – questions put forth by the client and answers provided by the therapist. In reality, the role of a therapist is to facilitate skill development and enhance coping strategies. Fostering dependency by becoming your personal crisis interventionist is not the goal. Your therapist will help you arrive at solutions

  2. Things might get worse before getting better. A dilemma in therapy is that often things get worse before they get better. The reason involves the necessity of looking at the much avoided past which can leave a blemish on the present. Additionally, working through uncomfortable issues is a burden likely to make clients experience a worsening of symptoms. However, as therapists it is our responsibility to ensure that things are not out of control and making you feel shattered or distraught.

  3. Share what you feel about your therapist. We often elevate people who help us to a pedestal which can prevent sharing of thoughts about them or how they are with us. It is a misnomer that clients cannot share things about their therapist. In contrast, it is a key to enabling therapist effectiveness in therapeutic interactions. Flexibility to adapt to each client is an essential skill of being a therapist and your feedback is instrumental in ensuring it.


About the Author:
Kamna Chhibber is a Clinical Psychologist, Heading the Department of Mental Health and Behavioural Sciences for Fortis Healthcare. She is a cognitive behaviour therapist, with a particular interest in relationships, trauma, abuse and the impact of personality-related variables on mental health. She has been in practice for the past decade.

Feedback is welcome: Tweet @Kamna_Chhibber @healthcollectif


Disclaimer: Material on The Health Collective cannot substitute for expert advice from a trained professional.

Mental Health and You: The Work From Home Dilemma

January 22, 2018

By Vandita Morarka

I work from home on several days through certain months of the year, owing to the nature of my work and multiple commitments. It’s generally not been for longer than a week at a time, though, which is perhaps why I’ve always found it convenient. Of late, though, I’ve had to work from home for over a month, which certainly brought the negatives front and centre.

This seems to mirror mixed findings from studies. For example:

This article examines various studies that show the downside of working from home on mental health. It points to studies like this one that looks at the effects of work from home on societal structures and inter-personal relationships.

Work from Home and Mental Health: A Survey

The Health Collective conducted an informal, small survey amongst individuals working from home. We surveyed 40 respondents, all of whom work from home, either sometimes or always, and while this is by no means a statistically significant number, it does yield some interesting insight, hopefully even paving the way for more in-depth studies and potentially an improved work experience.

Where to Find Help: Contacts and Helplines

About our survey: Of the 40 responses, 28 came from persons identifying themselves as female, 11 from persons identifying themselves as male and 1 from a person identifying themselves as non-binary. The respondents came from a variety of professional backgrounds, with a higher concentration of those working in the development sector and those in writing and marketing streams.

Respondents were spread across age groups: 13 (18-25), 16 (25-35), 10 (35-55) and 1 (55+).


Image Courtesy Raw Pixel

Why do our respondents work from home?

A better work-life balance, said several respondents, primarily when they had younger children to take care of, or health issues that made travel cumbersome.

Others stated that the reason they worked from home was simply because either an office space didn’t exist or the company rules preferred work from home for its employees. Here the gender dynamic was strongly felt: most females stated that they preferred work from home because of younger children, whereas males and others stated varying reasons.

Would they rather work at an office instead of at home?

Fifty percent said yes. Reasons included building networks, peer learning, more motivation, and having a more organised and structured environment. Some felt that working from home entailed daily engagement in all household tasks in addition to office work.

Those who would prefer to work from home cited flexibility, time lost in commutes, and care-giving as major reasons for their choice. Compared to older respondents, younger respondents seemed to prefer working from home, appreciating the freedom, but worried about missing out making connections during the initial, formative years of their career.

Effects of work from home on mental health

Twenty nine of 40 respondents stated that working from home increased feelings of social isolation; younger respondents seemed to feel more that working from home negatively affected their mental health. On the flip side, the positive mental health effects of work from home stated by respondents were reduced stress due to lessened commute, higher independence in working style and better productivity.

Raakhee S, a respondent told The Health Collective, “The flexibility and freedom is the best thing about working from home. It allows one to work when most productive and take breaks when feeling tired. And no unnecessary interruptions from ‘official time-wasters’. You feel great when you finish your daily work quota early or exceed it without being delayed by unnecessary meetings that plague office productivity.”

There’s no issue of travel time, either. “It also removes the need for long and unpleasant commutes that disrupt productivity and add to mental strain, stress and tiredness. As long as you maintain some form of social contact loneliness and isolation is not always part of working from home. And getting far from the madding crowds is a boon for introverts.”

Also Read: Reporter’s Diary: Workplaces and Mental Health

Sahana Rai of Glocal Brand Solutions found the work from home concept a welcome one for parenting. “We see majorly that children will grow up being more secure and happy and would probably not complain about not seeing enough of their parents,” she told The Health Collective.

Most respondents though stated that the work from home increases feelings of loneliness, depression, social anxiety, isolation and reduced motivation and interest in work. Additionally, it could become a case of reduced work-life balance as the lines between home and office blur.

One of our respondents felt: “Completely negative. I lose motivation to work when I'm at home and my home doesn't allow for the kind of space where I can have a working area. I'm lucky if I get an hour of silence on any given day. I'm sure work from home works for some people but when offices offer that as the only option without any facetime, I can vouch it reduces productivity and promotes feelings if self doubt and a complete lack of interest.”

Technology today makes possible collaborative working over large remote distances, but can it act as a substitute for the human needs for social interaction and engagement?


We asked respondents for the three adjectives that came to their mind when they thought of working from home, this word cloud represents those responses - the larger the word displayed, the higher the frequency of that response.

The largest words that come up are Lonely and Flexible/Flexibility.  

While working from home provides a certain flexibility, is better for the environment, and allows for a greater work-home balance, it can be a deterrent if you live in a space not conducive to act as a workspace.  Individual personality styles greatly vary, in turn affecting how different people fare in a work from home setting. The nature of the work is also important, while tech-based workers can easily work remotely, other industries might require more “facetime” for higher productivity and efficiency.

ALSO READ: Epic Fail: Transport Woes and Stress

Co-working spaces are offering an in-between solution.

Krutika Katrat, Cofounder, tells The Health Collective, “I work at a co-working space, but I work with my team here. More than flexibility, what makes it a good place to work is that we get an opportunity to gel up with different set of people, from different backgrounds and skill sets. There have been occasions when resource hiring and peer-sharing on work matters has been rewarding owing to a good mix of people we have…”

And let’s not forget about the socialising. “Also, the office parties get more interesting as well. I think this is a little different from a formal to the T, typically authoritarian setup, giving more creative space and bandwidth to an individual to grow within and outside of the organisation. Also, when you work alongside others I feel there is a sense of healthy competition to grow which keeps the motivation to succeed at work, alive.”

Motivation is something that Japleen Pasricha also highlights, along with the importance of a routine.

“Working from office or a co-working space brings a sense of routine and schedule. You get up in the morning and have the motivation to take a bath, get dressed and go to work, as opposed to just slouching the entire day in your pyjamas. It also clearly demarcates office and personal timings which are very fluid when you're working from home. I like working from my bed once in a while, but definitely prefer an office space and a daily schedule,” Pasricha, Founder-Director of Feminism in India tells The Health Collective.

“It also gives a sense of community where you meet and work with like-minded people as opposed to working alone without any social interaction which can take a toll on your mental health.”

There is a difference between having the flexi-work option for a few days a month, and only having to work from home. From personal experience, while I enjoyed work from home when it was a few days a month, working from home continuously, for a long period of time, has not been conducive to my psychological well being.

If you’re newly entering the work from space as an employee, it is important for you to pre-evaluate how well you can work in such a setting and also check in on what support your workplace provides to its work from home staff. For employers providing a work from home option, here’s a possible checklist of questions:

  • Is technology being used to build personal connections between employees and to drive engagements?
  • Are efforts being made to facilitate additional offline meetings amongst employees to boost personal connections and reduce isolation?

  • If the home setup is not conducive to the employee working out of that space, do you provide alternatives?

  • What additional online and offline mental health support facilities do you provide for your employees? (This is a question for all workplaces)


Share your comments and feedback right here or tweet us @healthcollectif




Ask the Experts: What's Stressing Out Indian Kids?

January 20, 2018

Ask the Experts with Dr Amit Sen


Amrita Tripathi, Founder-Editor, The Health Collective
We’re in conversation today with senior psychiatrist Dr Amit Sen to take us through some of the most common stressors when it comes to child and adolescent mental health.

Dr Amit Sen, Founder, Children First
I think in India, one stressor that runs across all of childhood and adolescence is academics: education or the way education is viewed in our country. Schooling starts very early and a lot of our kids are not ready neuro-developmentally to engage with it in the way they are expected to by schools, by teachers, parents. A lot of these kids spend large amounts of their time trying to learn things, which perhaps they’re not ready for; at the expense of play time, building bonds, relationships, just being free and having fun. The pressure and expectations they keep rising as kids go from Nursery, KG to primary school.

The pressure starts very early, and even when a 3 year old is not able to do what they are expected to by a teacher, alarm bells start ringing. Parents start worrying, will start by disciplining or scolding the child. At the end of it, they might to really begin to worry about their future and take them to specialists and so on. It start very early. The system is to blame.

In our country, we start with academic learning way too early, and a large part of expectations is driven by rote learning. Hardly any flexibility and we see this right across primary school and as they get into secondary, middle and senior school, the expectations are higher.

Although the manifestations of that pressure is not seen so much in primary school — though sometimes they are, sometimes we see children for anxiety and behaviour disturbances only for academic pressure in primary school, but more often than not, they keep piling up. It’s like a dam bursting when they reach adolescence, and that’s when you begin to see depression and anxiety and a range of other issues, like substance misuse, so-called oppositional defiant disordered behaviours.

So it’s a relentless and eroding, oppressive system that we put our children through.

Also Watch: Ask the Experts: Dr Vikram Patel on Mental Health and Illness


Relationships no doubt are key and the cornerstone of emotional and social development of any child. Again, because of some of the other demands which are placed on children, sometimes we see the parent-child relationship begins to be affected very early, in primary school.

The time that parents might have had to just be with their kids or play with their kids or be without pressure and anxiety is simply diminishing. As they grow up, other kinds of relationships become important, peer relationships, relationships through social media of various kinds. And those become extremely complicated and warped at times.

Although social media is a great thing, you find that for young people it becomes a central thing in their lives. How many thumbs up they’ve got, how many likes they’ve got… What kind of person they are able to project, who is bullying whom in social media, who is getting ostracised and so on. A large part of their waking hours are being spent just engaging with that.

And those relationships are so complex. And adults, because we have so little knowledge about this whole dynamic of the social media are hardly able to guide them; adults come down very heavily, take away gadgets of young people or admonish them. We have to accept that young people know so much more, has such a mastery over it that we can't stop them from getting into it unless we come on the same side and try and understand it.

Also Watch: Ask the Experts: Dr Achal Bhagat on OCD 

For more do tweet us @healthcollectif or share your comments and feedback right here

Where to Find Help: Contacts and Helplines


Disclaimer: Material on The Health Collective cannot and does not claim to substitute for expert individual advice from a trained professional



Understanding ADHD/ ADD

January 17, 2018

By Devina Buckshee

What comes to mind when you think of Attention Deficit Hyperactive Disorder (ADHD) or Attention Deficit Disorder (ADD)?
“Unfortunately a child who has ADHD is always imagined/perceived as a child who has excess energy, fidgety and most probably bored and in my mind an under-utilised child,” says Janki Mehta, Co-founder Mind Mandala.

When we think of ADHD, we think of hyperactivity. We think of disruptive behaviour, and we are most often imaging a young boy fidgeting, shouting or causing a scene.

“His idle mind often is a devil’s workshop and yet again I’m only commenting on his energy and we are at fault, we have not found a way to use his energy productively. These children often when guided well emotionally can excel in something just finding a way beyond this regular schooling system will help,” Mehta tells The Health Collective.

Art by Kishore MohanHealth Collective

Our thinking pattern aligns with research that says ADHD is a hyperactive, impulsive condition.The hyperactivity associated with ADHD is more often seen in boys, with other symptoms like inattentiveness, distraction and disorganisation, reportedly often being missed, in girls.

“It would be harder to diagnose girls than boys. One of the reasons being cultural norms where girls are taught to behave themselves at all times whilst boys are allowed to act in an outward manner,” Havovi Hyderabadwalla, Co-founder Mind Mandala tells The Health Collective.

Undiagnosed in childhood, girls can grow into women with untreated or unmanaged ADHD, with potentially severe repercussions to their mental health and well-being. ADHD tends to manifest later in girls than in boys, according to this piece in Quartz, it manifests in puberty for girls. The tumultuous, confusing time of puberty is when girls anyway see a dip in their self-esteem.

Child and Adolescent Psychiatrist Dr Amit Sen tells The Health Collective that ADHD/ ADD is one of the most common disorders in childhood, though he acknowledges that there is still ongoing debate and controversy on whether it’s over-diagnosed in some countries.

“However, if you see the scientific literature and wide-scale studies by the WHO across the world including in centres in India, you will find that the prevalence of ADHD is as high as 5% at least, whereas in some Western countries, it’s thought to be 10%,” Dr Sen tells The Health Collective.


ADHD is a neuro-developmental disorder and there are widely thought to be 3 main types:

  • Predominantly hyperactive

  • Predominantly inattentive (ADD)

  • Combined inattentive-hyperactive

Common signs would include being distracted, having poor concentration, interrupting, talking and fidgeting and difficulty staying focused.

“To a lay person, ADHD children tend to come across as 'difficult', 'badly behaved' or 'purposely' behaving in a particular manner. From a professional point of view, we understand that these children suffer from a neuro-chemical imbalance in the brain which leads them to behave the way they do. Most of these children suffer from a lot of emotional turmoil and have a hard time developing a secure sense of self. They require great amount of patience and nurturing from their family and different social support systems like peers and teachers to help them grow,” says Havovi Hyderabadwalla, co-founder Mind Mandala.

ALSO READ: Ask The Experts: Child and Adolescent Mental Health

The India picture seems varied. We welcome your stories, comments and feedback -- share with us right here or tweet @healthcollectif.

Further reading: ADHD in India: A Complex Condition in The Swaddle

*COMING SOON: More from Dr Amit Sen on ADD/ ADHD in our ‘ASK THE EXPERTS’ VIDEOS*


Disclaimer: Material on The Health Collective cannot substitute for expert advice from a trained professional.


What is Love?

January 15, 2018

Relationships 101 with Dr Achal Bhagat 

One of the commonest questions I’m asked is: What is this thing called love?

I say to people and it’s not about falling in love it’s about working on a relationship; it’s about working in love you’re always standing and working in love. Love and relationships are about care, respect, responsibility and knowledge. If you fall in love it’s an impulsive decision… it’s more like infatuation than love. 

Love is about care, respect responsibility and knowledge: You need to know the person that you love... You need to know what they think, what they feel, the small things in life. Not in an intrusive kind of manner, but in a manner that you can care for them in a better way, that you can respect them as they wish to be respected… that you do not humiliate them act responsibly towards them, that you do not intrude upon them,  you do not take for their lives,  you do not neglect them, do not distrust them.  

ALSO READ: Breaking Up and Moving On: A Psychologist's Perspective

GENDER WAR: Unfortunately the commonest problem that happens in relationships in India is a gender war. It’s like we are 5,000 years back when the relationship gets into a problem.  My family thinks like this, your family things like this. Men are supposed to do this, Women are supposed to do this. We make assumptions about each other’s families, we make assumptions about  each other. We forget that these assumptions impact each other very negatively.

TREAT EACH OTHER WELL: So the first step is to get out of this gender war and start treating each other as human beings and start empathising with each other. Again empathy is not the proverbial ‘put yourself in somebody else’s shoes’. It is about trying to get to understand their feelings, their thoughts  and not waiting either for them to mind read or for you to mind read them...Mind reading doesn’t happen...Conversations do.

COMMUNICATE BETTER: Life is about having conversations with each other…about communicating with each other and we need to learn to communicate with each other if we need to solve our problems.
So in the relationship if your patterns are becoming unhelpful, if you are spending more than the usual time only solving problems, if you’re using words like always, never, should, must not, must…
If you are humiliating the other person or if you are feeling humiliated yourself and definitely if it’s bordering on to violence you must seek outside help.
Even the threat of violence is violence. Never be in a relationship and stay and bear the violence. Violence is about control. We need to move away from violence, we need to move towards communication, towards caring for each other. If you are distressed in a relationship do talk to your partner and seek out for help. 


ALSO SEE: Ask the Experts: What is OCD

Disclaimer: Material on The Health Collective cannot substitute for expert advice from a trained professional

We Need to Talk: Suicide and Suicide Prevention

January 13, 2018

By Amrita Tripathi

A recent article in the Times of India highlighted that in India, a student takes his/her own life every hour. Every hour. Every year, we talk about exam stress, often ignoring relationship stress, the magnitude of pressure on the young, and certainly overlooking the fact that – as senior psychiatrist and co-founder of Children First, Dr Amit Sen tells The Health Collective  suicide is the single largest killer of young Indians. 

We’ve seen considerable commentary and attention paid to the gruesome Blue Whale challenge in the media, but not as much attention, perhaps, paid to the scale of the issue when it comes to young people taking their own lives.

Art by Kishore Mohan
Dr Sen tells The Health Collective:

“The furore over the Blue Whale Challenge has suddenly brought into sharp focus the widespread and endemic nature of suicide in our country, a fact that we as clinicians, have been painfully aware of for years. A landmark article in the Lancet puts it as the number one cause of death in the youth (10 to 24) in India, ahead of Road Traffic Accidents
 and other illnesses.”

The bigger, underlying question is why, of course? What is going so terribly wrong? As many adults keep forgetting, adolescence is a hugely complicated minefield to navigate sometimes. Should we be paying more attention to underlying issues?

Also Read: The World is My Mirror: A First Person Account of Surviving

Dr Vikram Patel, renowned psychiatrist and co-founder of Sangath, points us to his article in in The Indian Express, where he articulates very eloquently:

That young people are developmentally primed to take risks and behave impulsively is well-recognised; it is the result of a unique combination of biological events (such as changes in the brain and puberty) and social expectations (such as those related to completing education and finding a partner) which occur during this period of life. 

His work, documented in The Lancet* looks at a nationally representative survey on Suicide Mortality in India, with this interpretation:

Interpretation: Suicide death rates in India are among the highest in the world. A large proportion of adult suicide deaths occur between the ages of 15 years and 29 years, especially in women. Public health interventions such as restrictions in access to pesticides might prevent many suicide deaths in India.

*(Suicide mortality in India: a nationally representative survey; Vikram Patel, Chinthanie Ramasundarahettige, Lakshmi Vijayakumar, J S Thakur, Vendhan Gajalakshmi, Gopalkrishna Gururaj, Wilson Suraweera, Prabhat Jha, for the Million Death Study Collaborators, 2012) 

While this study was done before suicide was de-criminalised in India, it also points out the high incidence of death by poisoning – indeed across South Asia, there has been a call for restricted access to pesticides. In an earlier interview, The Health Collective asked Professor U Vindhya of TISS, Hyderabad, about studies and findings published in the monograph Suicide in SAARC Countries**, which states:

A striking feature of the occurrence of suicide in developing countries is that the relationship between mental illness and suicide is not as pronounced as in the west where nearly 90% of suicides are said to be associated with some form of mental illness.

**(Galab, S., Vindhya, U. and Revathi, E. Suicide in SAARC countries: Multidisciplinary perspectives and evidences. Centre for economic and social studies, Hyderabad, 2010)

She told The Health Collective,

“While suicide is of course a personal, individual act, there is a long-standing debate on what is the responsibility of societal factors that drive individuals to choose this option. The magnitude of the problem in developing countries and in India in particular is a pointer to systemic factors. This finding places the onus on structural inequalities and the distress and frustrations that such inequities unleash on people. A case in point is the large scale suicides of farmers.”

Also Read: Understanding Suicide in India: Do We Need a New Approach to Prevention

Even if we wrap our heads around the scale of the problem, are we any closer to understanding what's causing this "epidemic"? 

Dr Sen tells us:

“More than two thirds of young people completing suicide suffer from a mental illness, most commonly Depression. Substance misuse, trauma and abuse, domestic violence, suicide in family, bereavement and breakdown in relationships can contribute to it. In India, academic expectations, failure in exams and emotionally loaded responses from parents & schools are major precipitants of suicide, as borne out by the numerous cases that are reported soon after exam results come out each year.”

There are multiple factors, and they are clearly varied and complex  one can't presume to speak on behalf of anyone who chooses to take this ultimate, drastic step. But surely we need to understand, or make an effort to understand just what is going wrong. We can’t afford to ignore some of these societal and structural inequities and pressures. Our conversations on Mental Health and Mental Illness cannot only be restricted to a few sensationalised cases, or even skew only towards to urban over rural, or hang on to taglines rather than digging deeper.


For our colleagues in the Media, please note that with every article and story reported on suicide, there are some best practices including by the WHO and Samaritans. You can read the guidelines right here; and keeping in mind the "copycat" or Werther effect, you could do an incredible amount of good and avoid doing immeasurable harm, by avoiding the "sensationalised" sort of reporting we've gotten used to, there's nothing to be gained by reporting on the method of suicide, for example. Let's all aim for responsible reporting.

Also Read: The Media Portrayal and Understanding of Suicide

And finally, for parents and educators, what are signs to look out for?

“The signs of suicide are varied and complex,” Dr Sen tells us, but breaks down some common signs to look out for.

“There can be signs of depression, hopelessness and despair, embarrassing experiences with feelings of humiliation and shame, notes and messages expressing the same, previous attempts at self harm and becoming socially cut off. Many a times, such expressions are interpreted as attention seeking behaviours, and therefore neglected, with tragic consequences.”

Most importantly, perhaps:

“Young people should be encouraged to approach anyone who listens, understands and is willing help.”

We are building out and sharing a list of contacts and helplines on our page here, do reach out for help, if you or someone you know share signs of concern, discuss ending it all, or feel overwhelmed. As Dr Patel tells us in another interview,

“There is nothing brave about struggling alone, and if you have got mental health experiences that are very distressing, speak to someone. It could be a friend, it could be a family member, a counsellor, it could be a mental health professional. But don’t just lock it up inside yourself.”

Please don't ignore any signs of distress or play it down, and if you're struggling, please do remember you are not alone. 

ALSO WATCH: Hidden Illness: Dr Vikram Patel in Conversation with The Health Collective


Disclaimer: Material on The Health Collective cannot substitute for expert advice from a trained professional.

If you would like to share your thoughts or stories, do reach out to us by email or tweet @healthcollectif. You're #NotAlone
If you have helplines or contact you'd like to submit to the database, please do email us

Hidden Illness: The Dr Vikram Patel Interview

January 9, 2018

As part of our series, Ask the Experts, The Health Collective is delighted to share PART TWO of this interview with renowned psychiatrist Dr Vikram Patel, the Co-Founder, Sangath.

Also Watch: Part One of the Interview



Amrita: Dr Patel, just to pick up a little bit from what we’re talking about in terms of the lack of trained resources, the work you’re doing with your organisations is showing that it’s imperative to have community participation and intervention, can you take us through what you were saying about Indian attitudes to psychotherapy and how you’re seeing trained resources there.

Dr Patel: Sure, you know earlier I had mentioned the National Mental Health Survey of India reported that only about 10% of Indians with a mental disorder in the last 12 months had sought or received help. 

But actually if I ask the question, what proportion of Indians had received psychological therapies, which are amongst the most effective of all medical interventions for any health condition, psychological and social interventions for mental, substance use disorders, the figure would be 100% have not received, with the small exception of very affluent, urban folks who are able to pay for private psychotherapy, the vast overwhelming majority of Indians do not have access to these therapies. 

That is because many people assume Indians don’t like talking therapies, they prefer pills. I’ve heard doctors say when a patient comes to my clinic, they want a pill, they want an injection. Well, our experience has been exactly the opposite, our work has largely focused on challenging the myth that Indians don’t like talking therapies. We now have shown time and again that very high proportions of those who are offered psychotherapies engage with them and complete the treatment. We also challenge the myth that psychological therapies require extremely expensive, highly trained, people to deliver it. 

Our work has shown that you can use lay people in the community, we can train them, and with adequate training and supervision, they can effectively deliver scientifically sound psychological intervention with very large clinical economic and social benefits to those who are affected by a range of conditions, ranging from autism to drinking problems, depression, psychosis etc.

Can you give us a few examples even anecdotally of the work you’ve been doing? 

Sure, one of the more recent programs of work that I’m really excited about is our demonstration that in about a 6-8 session psychotherapy delivered over 2-3 months based on the psychological theory of behaviour activation -- that is to say, to get someone to actually engage with rewarding and pleasurable activities -- is a very effective treatment for severe depression when delivered by lay people in routine primary health care settings.

I’m also excited that this particular treatment that we call The Health Activity program is now being tried out in Nepal, Uganda, Zambia. It’s also being tested in other parts of India, and so could be genuinely be an innovation that’s developed in India and has value and application in many other parts of the world. Very pleased about that. We’ve done similar work on drinking problems, producing 2-4 session treatment for harmful drinking called the Counselling for Alcohol Problems, and a particular area of work that I’m currently engaged in? Is to develop digital training intervention and supervision interventions to scale up these psychological therapies. 

Also Watch: Part One of the Dr Vikram Patel Interview

Imagine for example, that a few years from now, anyone who wanted to learn these therapies, all they had to do is to go online, access our training program, complete it, complete the online supervision, and then be equipped with the skills to deliver this intervention in their community.

And you’re seeing this success cases, when they go out, and interventions?

Well that would be a success story, yes. At the moment, the success is that we’ve designed this intervention and shown it works in a clinical trial, and are now engaged in scaling it up.

That’s incredible. I want to ask you a little bit about … I mean our attempt is to be a safe space for conversations, and completely take your point that you are talking to people of incredible amount of privilege when you are talking to largely urban audiences, you’ve brought in the need to involve the community. We do see -- and I want to ask you about the work that It’s Ok to Talk is doing -- because we do see with younger people more of an openness to discuss some of the issues, and how they can make a change. Can you take us through any insights?

I’m glad you brought up It’s Ok to Talk - that’s a website, actually, and the name tells you what it’s all about… it’s about encouraging young people in particular to disclose their own experience of mental health and mental health problems, and the idea is that through disclosure, much the same way with celebrity disclosure, but ordinary young people, that we will challenge some of the stigma and the shame around mental health and mental health problems.

It’s part of a larger initiative of engaging young people -- we’re also using other methods like theatre, film, other kinds of media interactions, and this in itself is part of a bigger program, where we are developing a psychological program for students in secondary schools in Delhi and Goa...that includes a very strong component of self care as well as an app-based delivery of psychological therapy for young people with anxiety or mood or behavioural problems.  

To come back to the need to talk about things and help erase the stigma in that way, you’ve shared your story, part of your story, on the site, talking about your mother being one of the 40 million Indians who suffered depression. It was so interesting -- and thank you for sharing that, I think it was a very powerful account -- coming back to the fact that most people don’t get treatment, you say, there’s no X ray or blood test to determine depression, can you take us through a little bit of of your personal story and how it resonates with other people?

Yeah, you know it’s one of the reasons I believe that one of the most important reasons that mental health problems are often missed, is because they are hidden. And what is hidden will obviously be harder to find. There is no blood test, there is no objective, pathological sign that you have a mental health problem, and certainly not one that is of commercially any value, and so there is no commercial incentive either to doctors or to auxiliary service like a pathology lab to actually screen people for mental health problems.

What you need to do is to ask people questions, you need to ask them a set of different questions that explore a set of mental health issues, and then assemble all that in order to arrive at an understanding about their mental health. This is too time-consuming, it’s too vague, there’s no money in it. And therefore to be honest, I”m being blunt, a lot of medical practice is driven solely by commercial value. If there is money in it, there will be more of that done. That’s why you have so many blood tests and X-rays. But this has no value in it, at the moment at least, therefore mental health problems go undetected.


Dr Vikram Patel on The Health Collective
The Health Collective


And if there’s anything to end on -- was there anything cathartic for you in sharing that story? Has anyone come up to you after you shared that -- it’s been 20 years of course and more that you’ve been talking about mental illness. Is there anything you feel that sharing your own story personally that connects with others?

 I think sharing your own story always connects you with others. If I was giving a talk to students or a scientific audience, I would typically give a dry, science-based lecture, because that’s what I’m there for. But if I’m talking to a general audience, a community, to invoke my own personal story connects me to people. It connects my story with theirs. And of course because I can also bring in the expertise as a psychiatrist, as a researcher, that also adds value.

Certainly with my mother’s story, perhaps the most telling lesson for me was that I myself missed my mother’s depression for many years. It was when her diabetic doctor pointed out, hey Vikram, you’re a psychiatrist, can’t you see that your mother’s diabetes is out of control because she’s depressed. It was only then that I paused and did a clinical interview with her and discovered my goodness, my mum was very severely depressed.

So again, going back to the point, it’s so well-hidden from view, that even someone like myself who is fully trained as a mental health professional, couldn’t see it in my own mother.

Dr Patel, to ask you, if there were two or three things you wished everyone in India to know about mental illness what would that be?

First of all, mental health is not just the absence of mental illness.

Secondly, that each and every one of us has a very unique life story that determines our mental health. That life story is a product of our genetic inheritance and of the social environments that we’ve experienced, particularly in the early years of our life, from very early childhood to young adulthood. The implication of this is that for all of us in society who are concerned with mental health, our primary emphasis for prevention and promotion must be the early years to ensure that environments for young children, whether at home or schools or in communities, are nurturing, because this is the most powerful prevention that we can actually ensure the healthy development of the brain, and thus mental health in adulthood.

And finally, that the best guardian of your own mental health is yourself. Be equipped with knowledge and skill on how to protect and promote your own mental health, but equally remember that there is nothing brave about struggling alone, and if you have got mental health experiences that are very distressing, speak to someone. It could be a friend, it could be a family member, a counsellor, it could be a mental health professional. But don’t just lock it up inside yourself.

Amrita: Thank you so much.

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What It's Like to Live With Anxiety and Depression

Do check out this incredible comic (created by Nick Seluk of The Awkward Yeti). I first saw it on Upworthy and was blown away by it -- like so many others have been. It is reproduced here with the kind permission of The Awkward Yeti.



This incredible comic was created by Nick Seluk, creator of The Awkward Yeti, based on a story told by Sarah Flanigan, and published on 

It is reproduced here with kind permission from The Awkward Yeti


Adolescents, Relationships and Stress

In India, year after year, we are almost inured to stories of students driven to extreme stress by board exams. At times, in the absence of learning coping mechanisms or other ways of releasing these incredibly high levels of stress, a significant number of them choose, tragically to cut short their young lives.


The National Crime Records Bureau report looking at Suicides in India (2004-2014) analyses the 'Percentage Distribution of Suicide Victims by Profession during 2014' to find that 6.1% of suicide victims in 2014 were students. (Another shocking statistic: 15.3% of suicide victims were found to be housewives; find an analysis of the data and concerns about under-reporting here on IndiaSpend)

There doesn't seem to be enough attention paid to causes of suicide -- often a web of causes, not just one simple cause.

Nonetheless, many counsellors I had spoken to over the years, including some manning exam helplines for Indian students, mentioned that frequently callers dial in to talk about relationship issues and relationship pressures. It's not just the stress of exams/ Board exam results and the massive pressure we've been socially conditioned to accept as normal, that is.


Noted child and adolescent psychiatrist Dr Amit Sen had told me years ago, about how kids are in relationships at ever younger ages -- think tweens or pre-tweens -- and aren't always able to navigate the complications of this; often relationships of course are due to peer pressure.

 Dr Amit Sen's own words on the context in India: 

"For the longest time we have found correlations between exam stress and rising depression in adolescents. There is no doubt in my mind that study and exam pressure takes a heavy toll on the minds and well being of teenagers in India. It robs them of other experiences that are vital for adolescent development. Paradoxically, as they begin to slip under the pressure, the system exerts even more pressure.

More recently, we have become increasingly aware of the close relationship between romantic relationship and depression. And indeed, as the article suggests, it is not only to do with break ups but also ongoing/"serious" relationships that often become too complicated for the mid-teens to handle. The cause and effect relationship is,however, not always clear. Its also true that depressed teenagers make themselves more vulnerable and tend to get into messy relationships more easily. A lot depends on the readiness/maturity of the person and clarity about what the relationship means and where the boundaries lie. In India, and perhaps in all places, teenagers often get widely conflicting messages about romantic relationships. This is where life skills and sex education (that is sustained and ongoing) might be preventive/protective of the many ills that plague our children today."

-- This was in response to this article in The Huffington Postwhich, among other things, raised some key points from a startling survey of more than 8,000 American adolescents on issues of depression and romantic relationships.




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