Senior psychiatrist Dr C J John has been at the forefront of mental healthcare for four decades. Known for his empathetic approach and commitment to holistic wellness of patients as well as society, he is often seen as a socio-medical crusader. Dr John is a member of the State Mental Health Authority and is one of Kerala’s earliest anti-suicide campaigners. He speaks to TNIE about Kerala society, depression, parenting and more.
At a time when psychiatry was a niche subject in India, what made you choose the stream of medicine?
Psychiatry has a thrill element from an outsider’s point of view, right? Like everyone else, I was also intrigued by the subject, especially while watching films. I still recall director K G George’s Swapnadanam... Watching the film, I wondered how amazing it would be to read, analyse someone’s mind (smiles).
What are the major changes that you have observed in mental healthcare over the years?
Earlier, mental health centres were nothing but a place to keep those mentally unstable people away from others, they were like asylums. Human rights violations were quite common. Now, mental health has become mainstream, but stigma still exists. According to a study, about 9% of Kerala’s adult population has common mental health disorders such as anxiety and depression. There is a gradual improvement when it comes to seeking help. In a way, Kerala now has an understanding that there is no health without mental health. But, we still have a long way to go.
Could you elaborate on that?
One of my patients, a Class 9 student, has depression. One of the first symptoms was school refusal. We gave her adequate treatment and there was a time when she needed medicines. Once she started going to school, teachers began noticing that she was drowsy at times. They took her to the school counsellor, who was informed by the parents that the student had been on medication. The counsellor did an online search about the medicines and advised the child to stop taking them – the girl was told such medicines were taken by lunatics. Naturally, the student stopped taking the medicines, and all symptoms reappeared. We are living in a world where even people we assume to be knowledgeable act irrationally and spread misconceptions. It’s a sad reality.
‘Depression’ has become a word that we hear in our daily conversations these days. Is this because of better awareness or a rise in cases?
Many mental health terms such as depression, mood-off, borderline personality, bipolar disorder, and ADHD pop up then and now. That doesn’t mean seeking help has increased. Many people use these words without even understanding their scientific meaning. Some use these words, perhaps, because they find them fashionable. It is just a contemporary change in our vocabulary. Also, there’s a fine line between feeling sad and being depressed.
Will you explain that difference?
The degree, duration and how it is affecting one’s daily activities are the primary parameters to diagnose depression. If a sad or low feeling lasts beyond two weeks, and if the person doesn’t find joy in anything, is unable to sleep, doesn’t want to socialise and has suicidal thoughts, there’s a clear probability of clinical depression.
When should one seek professional help?
If the condition starts affecting daily routines, and one starts withdrawing from social connectivity, feels one is not worthy enough to live, loses appetite… one should seek professional help. There are instances of people losing up to 10kg of body weight just because of depression. For a person with a genetic history of mental health, stress could just be a trigger for depression. Mental health issues are a result of an unhealthy symphony between psycho-social and biological factors.
Some people belonging to earlier generations tend to trivialise issues such as depression, which they view as a new-generation or Western concept...
Human beings, after all, are universal. The cultural shift that has undergone has made humans more lonely. And a lonely individual is likely to experience depression. It is a human predicament. There is no East or West in that experience. Take the Bhagavad Gita… Arjuna was down with depression. And Bhagvan Krishna gave him something like what you call cognitive behavioural therapy (smiles).
There are two categories in society today — those who label all problems as a result of depression, and those who are yet to acknowledge that such a thing as depression exists. How do you address this polarisation?
We need a comprehensive public health campaign. This is a common problem, a problem that can cause morbidity. Even mortality. There’s a 15% risk of mortality due to depression (suicide). In Kerala, where you have an escalating suicide rate, a public health approach is the need of the hour.
How do you identify those who are experiencing depression?
The mental health first aid concept has three parameters — look, listen and link. We can find hints of depression if someone is not being as active as before, not engaging enough, is withdrawing from activities, dressing shabbily, has no initiative, no laughter, makes out-of-sync statements, displays sluggish body language… Usually, it is a life event that triggers this. Often, we note these signs only in retrospect after someone takes drastic measures. This has to change. For instance, if a child is going through a problem, there might be changes in his/her behaviour. S/he may not study well, and tend to cry easily when scolded. A teacher should be able to understand such changes. If s/he has loss of appetite, or suddenly stops playing with friends, the parents should intervene. The second step is to listen. The near and dear ones should give one a platform to open up. Never be judgemental or impatient. An empathetic approach can help those in need. The problem may not be solved, but this link is a significant step.
How much of a role does genetics play?
If a person has a genetic vulnerability or a history of mental disorder in the family, the probability of developing a mental disorder is only 10%. Building resilience, learning to cope with the situation or modulating the reactions through meditation or yoga, etc., can protect people with genetic vulnerability to a certain extent. If both parents have a history of mentally illness, the risk may increase to 30%. Even then, there are psycho-social elements that can protect.
Lohithadas’s Thaniyavarthanam comes to mind…
I would see the film as a depiction of the fear of people, rather than as a doctrine. It is depicted from the perspective of a victim of stigmatic social response. Unfortunately, the film gives a negative message as well in the end. We cannot say there will be an absolute transmission from one generation to the next. It is an unnecessary fear.
There used to be a lot of secrecy about consulting psychiatrists. Has there been a change in approach over time?
It is definitely changing in Kerala. After my MD, I had decided that I would sit only along with other specialists in hospitals. Hence, for long, I worked only in general hospitals, and may have even lost money because of my principle. But it carried a message. Now, people don’t hesitate to come or even bring their to mental health facilities for consultation like before.
Are people more willing to accept if you diagnose them with a condition?
Yes, it is easier now. However, there still exists a resistance to medication. For instance, patients who are prescribed antidepressants suddenly stop taking the medicine due to the opinions of strangers, or because they feel better. This undoes all the efforts till then. No other specialities will hear questions and resistance about medicines, right from the first consultation. I always inform those who ask about side-effects. But then, if one day you get cancer and are advised to go through chemotherapy, will you decide not to take it due to extreme side effects? See, mental health care is also about life. If you don’t treat depression properly, in future, the patient may turn suicidal and later succumb to death. Psychiatric medicines have a latent period of action. It’s not paracetamol, once you take it the temperature goes down within minutes. Psychiatric medicines will take time.
Is this fear factor because of the fact that the mind is still an undefined entity, which doesn’t have a physical manifestation?
The mind is a function of the brain. No doubt about it. Especially now, with technologies such as functional MRIs, we can see how parts of the brain respond to different emotions. For instance, we can see some parts glowing when one is angry, another one when one is happy. So there is evidence that certain parts of the brain are the ones that modulate your emotions and thinking.
Is it true that long-term alcohol addicts lose empathy and sympathy even towards their family?
Long-term alcohol abuse will severely damage the prefrontal cortex of the brain. This is the part that decides our judgement, will power, etc. That is why after a limit, alcoholism becomes a pathological brain disorder. That is why we say that early detection is paramount when it comes to alcohol and drug abuse.
Is Kerala, as a society, happy? Where would you place the state in the context of happiness?
It is a challenging question. With the help of certain social and mental health indices, we can arrive at some inferences. If we look at suicide rates, divorce rates, and domestic violence data, these are escalating. There is also penetration of synthetic drugs in Kerala, evident in the crimes committed by the youth and the rising violence. We are shifting to a money-driven, pleasure-focused perspective. Based on these factors, we have to generally say that something is wrong here.
Here we have seen several communists or atheists turning very religious in the later stages of life. What triggers these extreme shifts?
It is not particular to Kerala. An atheist can change to a believer. There is a basic insecurity in human beings. It is a survival game, and people shift loyalties all the time (smiles).
What has been the psychosocial impact of Covid on our society?
Many people are still struggling with the economic burden caused by Covid. It affected the business and livelihoods of many middle-class people. They are struggling to meet both ends. This financial distress has certainly caused depression in many.
How important is one’s emotional quotient (EQ)? Often emphasis is laid on intelligence quotient (IQ)...
Our education system has become highly IQ-oriented now. I never was a topper in my academics (laughs). However, I have been a happy person all through. I have faced many situations of stress and have been able to overcome them. But I have seen many toppers failing to cope with stressful situations. Why do we see suicides at IITs and IIMs? IQ is not the only thing that matters. If you have a strong EQ, you will survive better.
Could you tell us about the mental health issues seen among today’s children?
Firstly, a lot of issues have crept into parenting in today’s world. A simple example, children are not made to understand how difficult it is to earn money. Instead, the parents try to provide a living status way beyond their limits. This corrupts them, and, at a later stage, they tend to become more demanding and aggressive.
Gadget addiction among children is a major concern for parents…
There is a conflict happening between the children, who are the digital natives, and the parents, who are digital immigrants. Parents should enforce a digital discipline as a child grows up. Instead, most parents enforce curbs when the child reaches, say, Class IX. The attempt is likely to fail. What usually happens is that parents use the mobile phones as babysitters. Also, there is the role model factor. How will parents, who themselves are always immersed in their mobile phones, effectively convince children to regulate gadget use? Socialising is very important for children. There should be balanced activities, Parents have to draw up rules that include the time for gadgets, socialising, physical activity and studies. And this has to be enforced with love.
Is drug abuse among children rising?
Now, the drug mafia tactfully depicts synthetic drugs as recreational drugs. They claim that when you have a sleepover, birthday party or other celebrations, these drugs enhance pleasure. The children, who are brought to us, argue that there is nothing wrong with using these drugs once in a while. They are made to believe so.
There have been several debates about physical punishment to correct children. What is your take?
Earlier, we had a very intimate bond with the person who punished us. They gave us space for communication as well. Now, parents don’t have time for all this. In such a scenario, many children have no clue why they were punished. Physical punishment should not be parents taking out their anger on children. We always recommend psychologically effective tools – like denying a favourite food item or TV show – rather than physical punishment.
Parenting is now perceived as a stressful endeavour…
Effective communication between parents and children is essential. Knowing, understanding one’s child is important. Children should feel free to share everything with their parents. The lack of such a connection may hinder them from reporting incidents of child abuse. Understanding your child is crucial. One has to grow with the child. Also, initiating discussions about sexuality at an early stage is essential, given the abundance of explicit content on social media and OTT platforms. Engaging in conversations about web series and current news is necessary.
Gender and sexual orientation are in much focus nowadays. How receptive are parents about concepts such as homosexuality?
There are occasions when youngsters bring their parents to me to discuss such issues. I explain to them about it, make them understand that it’s just a normal variation of sexuality. I advise parents to allow children to live as per their orientation. Some parents accept this; the majority of them don’t.
There are several centres that offer ‘conversion therapy’, which is illegal…
They don’t work. How would a heterosexual person feel if subjected to a treatment for converting into a homosexual? It is the same case the other way around.
There are differing views on how parental separation affects children. What’s your take?
In my opinion, a physically broken marriage is far better than a psychologically broken marriage. If there is a problem in the relationship, it is better to get a divorce, considering the children’s future and their security. But there should be no lapse in parental responsibility. A psychologically broken marriage cannot be repaired, hence divorce is the better option. If one continues in a trouble marriage due to societal concerns, it will eventually backfire. And children growing up in such an environment may develop narcissistic or borderline personality disorders, or antisocial personalities.
How do films affect society? Director Ranjith, in a previous edition of Express Dialogues, asserted that films do not influence society...
We cannot say there is no influence. Many films have a positive influence. You can change some people’s attitude towards certain things. Similarly, there can be negative influences. In the case of aggression, there are clear-cut studies showing that if people with personality problems or similar issues are fed regularly with visuals or films that contain aggressive content, they tend to show aggressive behaviour in similar real-life situations. It’s like disowning the media and its strength when we say that cinema has no influence. Not everyone gets influenced, but there is a vulnerable population.
TNIE team: Cithara Paul, Rajesh Ravi, Anu Kuruvilla, S Neeraj Krishna, Mahima Anna Jacob, Sanesh A (photos), Pranav V P (video)