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Life in Conflict: Characteristics of Depression in Kashmir

Authors:

Abstract

Background: Mental, physical and social health, are vital strands of life that are closely interwoven and deeply interdependent. Mental disorders affect people of all countries and societies, individuals at all ages, women and men, the rich and the poor, from urban and rural environments. Depression is more likely following particular classes of experience – those involving conflict, disruption, losses and experiences of humiliation or entrapment. Many people living amidst the rages of conflict suffer from posttraumatic stress disorder. Objective: To determine the characteristics of depression in the population in Kashmir where a low-intensity-conflict has been going on for the last seventeen years. Methods: The non-combatant civilian population was surveyed. The Centre for Epidemiological Studies Depression (CES-D) Scale was used to measure symptoms of depression in community populations. Results: Due to continuing conflict in Kashmir during the last 18 years there has been a phenomenal increase in psychiatric morbidity. The results reveal that the prevalence of depression is 55.72%. The prevalence is highest (66.67%) in the 15 to 25 years age group, followed by 65.33% in the 26 to 35 years age group. The difference in the prevalence of depression among males and females is significant. Depression is much higher in rural areas (84.73%) as compared to urban areas (15.26%). In rural areas the prevalence of depression among females is higher (93.10 %) as compared to males (6.8%). Conclusion: Mental health is an integral part of overall health and quality of life. Effective evidence-based programs and policies are available to promote mental health, enhance resilience, reduce risk factors, increase protective factors, and prevent mental and behavioural disorders. Innovative community-based health programmes which are culturally and gender appropriate and reaches out to all segments of the population need to be developed. Substantial and sustainable improvements can be achieved only when a comprehensive strategy for mental health which incorporates both prevention and care elements is adopted.
International Journal of Health Sciences, Qassim University, Vol. 3, No.2, (July 2009/Jumada II 1430H)
203
Life in Conflict: Characteristics of Depression in Kashmir
Syed Amin and Khan A.W.
Department of *Accident & Emergency, **Psychiatry
Sher-e-Kashmir Institute of Medical Sciences, Srinagar – 190011 (India)
Abstract:
Background: Mental, physical and social health, are vital strands of life that are closely interwoven and deeply interdependent.
Mental disorders affect people of all countries and societies, individuals at all ages, women and men, the rich and the poor, from
urban and rural environments. Depression is more likely following particular classes of experience – those involving conflict,
disruption, losses and experiences of humiliation or entrapment. Many people living amidst the rages of conflict suffer from post-
traumatic stress disorder.
Objective: To determine the characteristics of depression in the population in Kashmir where a low-intensity-conflict has been
going on for the last seventeen years.
Methods: The non-combatant civilian population was surveyed. The Centre for Epidemiological Studies Depression (CES-D)
Scale was used to measure symptoms of depression in community populations.
Results: Due to continuing conflict in Kashmir during the last 18 years there has been a phenomenal increase in psychiatric
morbidity. The results reveal that the prevalence of depression is 55.72%. The prevalence is highest (66.67%) in the 15 to 25
years age group, followed by 65.33% in the 26 to 35 years age group. The difference in the prevalence of depression among
males and females is significant. Depression is much higher in rural areas (84.73%) as compared to urban areas (15.26%). In
rural areas the prevalence of depression among females is higher (93.10 %) as compared to males (6.8%).
Conclusion: Mental health is an integral part of overall health and quality of life. Effective evidence-based programs and
policies are available to promote mental health, enhance resilience, reduce risk factors, increase protective factors, and prevent
mental and behavioural disorders. Innovative community-based health programmes which are culturally and gender appropriate
and reaches out to all segments of the population need to be developed. Substantial and sustainable improvements can be
achieved only when a comprehensive strategy for mental health which incorporates both prevention and care elements is
adopted.
Correspondence:
Professor S. A. Tabish
Sher-e-Kashmir Institute of Medical Sciences
Srinagar – 190011 (India).
Email: amintabish@hotmail.com
Syed Amin and Khan A.W.
204
Introduction
Mental, physical and social health, are vital
strands of life that are closely interwoven
and deeply interdependent. Depression is
more likely following particular classes of
experience those involving conflict,
disruption, losses and experiences of
humiliation or entrapment. World Health
Organization has ranked depression as the
fourth among the list of the most urgent
health problems worldwide and has
predicted it to become number two in terms
of disease burden by 2020 overriding
diabetes, cancer, arthritis etc.
The magnitude, suffering and burden in
terms of disability and costs for individuals,
families and societies are staggering (1-3).
Mental disorders are universal, affecting
people of all countries and societies,
individuals at all ages, women and men, the
rich and the poor, from urban and rural
environments. Mental functioning is
fundamentally interconnected with physical
and social functioning and health outcomes
(4,5). The mental health is influenced by
displacement through conflict and war, by
stresses on families, and by economic
adversity. For the many persons who face
uncertain futures (including those by conflict
or disasters), the burden of serious
emotional and behavioural disorders afflicts
their lives. Many people living amidst the
rages of conflict suffer from post-traumatic
stress disorder (6,7).
At the dawn of a new millennium,
communities and societies increasingly face
situations of armed conflict. While this trend
is apparent in different parts of the world, it
is of particular concern to the South Asian
region.
Violence is a phenomenon intrinsic to
class-based societies which are inherently
unequal and oppressive. Violence here may
either take implicit forms in the manner of
institutionalized oppression and inequality,
or a more explicit form of state oppression
through the use of state sanctioned
institutions, such as the police, the military
and courts. It could even assume a more
direct form, whereby civilians manage the
task of a weakened state through militia
groupings. Large-scale violence may also
take the form of mass uprisings against the
oppression of dominant classes. Civilians
are increasingly being targeted in these
episodes of contemporary violence. To
reduce military casualties, civilians are used
as protective shields; torture, rape and
executions are carried out to undermine
morale and to eradicate the cultural links
and self-esteem of the population. Most
civilians witness war-related traumatic
events such as shooting, killing, rape and
loss of family members. The extent of
psychosocial problems that results from this
mass exposure to traumatic events can
ultimately threaten the prospects for long-
term stability in society.
Despite growing evidence over the
past two decades of the terror both of the
physical and mental dimensions of war
upon civilians much of post-conflict
activity tends to concentrate on physical
reconstruction roads, bridges and
buildings. Moreover, even though
psychological and psychic injuries can have
more damaging, long-term consequences
as other injuries from a situation of conflict,
they remain undetected and distanced from
any plans for rehabilitation. Partly this is
because these injuries are difficult to fathom
in terms of the enormity of scale and the
delayed manifestation of symptoms which
can sometimes take years to surface.
Physical violence may be easier to identify,
name and quantify than psychic or symbolic
violence.
Kashmir has been regarded by many
as heaven on earth. Its splendid beauty and
hospitable population is legendary. Over the
past 18 years Kashmir became associated
with violence.
The objective of this study was to
determine the characteristics of depression
in the non-combatant civilian population of
Kashmir where a low-intensity conflict has
been going on for more than 18 years.
Study was conducted during 2005-06.
Life in Conflict: Characteristics of Depression in Kashmir 205
Security concerns are amongst the
dominant themes in the minds of people
living in Kashmir. This owes to the fact that
death, injury, destruction of property is the
notable features of life here due to conflict,
disturbances and turmoil for the last 18
years. Many have suffered tragic incidents
of a war-like situation, which by their nature
are beyond the endurance of common man.
Many are witness to bloodshed that is
characteristic of such situation. Thousands
of people have lost their lives or limbs, and
thousands have been rendered orphans and
widows. Scores have disappeared. A
colossal damage to property is evident.
Many educational and healthcare
institutions have suffered damages. Those
who have survived all this, continue to be
reminded of their vulnerability through the
media of killings that make the headlines
almost daily. Moreover, with disruption of
development works consequent upon war-
like situation, added concerns are
unemployment, poverty, relationships etc.
A vicious circle of events has been
created comprising torture, disappearances,
displacement, killings, ballistic trauma, etc.
paralleled by a state of mind wherein
grieving, insecurity, oppression, poverty,
uncertainties of career and relationships
etc. are the major themes.
The situation in Kashmir can best be
described as a “low-intensity conflict”. What
predominates in such conflicts is the use of
terror to exert social control, if necessary by
disrupting the fabric of grassroots; social,
economic and cultural relations; the main
target of the combatants is often the
population rather than the territory and
psychological warfare is a central element.
As can be expected, the consequences for
mental health can be substantial. Kashmir is
not merely a law and order problem but
there are social, emotional, political and
psychological aspects involved.
For a population of approximately 1,
10, 70,000, presently Jammu & Kashmir
state has around 3800, 5000, 12300 health
institutions, doctors and hospital beds
respectively. Population of Kashmir
Province is 57, 13,509 (2001 census) out of
which 27, 07,837 are females. Kashmir
province has 11 hospitals associated to
Medical Colleges, 8 District Hospitals, 47
Community Health Centres, 661 Primary
Health Centres/Allopathic Dispensaries,
1105 Sub Centres, 184 Indian System of
Medicine (Unani) dispensaries and, 21
other healthcare institutions (Table 1,2).
Health care is supported by the private
sector hospitals, nursing homes, poly
clinics, GP clinics, faith healers, quacks,
etc. Quacks play havoc with the lives of
people because of lack of implementation of
regulations mechanisms. Moreover, the
exodus of health care professionals from
Kashmir during the early 1990s created a
vacuum adversely affecting the basic health
services.
The already inadequate health care
infrastructure further added to the miseries
making the people vulnerable to health
problems and other forms of deprivation. This
exodus coupled with poor governance led to
malfunctioning of health sector in general but
rural health facilities in particular.
Women’s health has not received
proper attention for policy makers as there
is a single maternity hospital catering to
whole population of Kashmir.
Mental health has been neglected for
far too long. In spite of eleven fold increase
in psychiatric diseases due to ongoing
conflict, tremendous stressful conditions,
overwhelming fear and uncertainty during
the last 18 years, not much attention is
being paid to expand and modernize the
present infrastructure.
Looking after the health of the
population of the state which resides in a
widely scattered mix of 6652 villages and
around 75 towns, at a mean elevation of
1800 meters above sea level occupying a
variegated landscape, enduring long winters
and severe summers, can never be a
simple task, even if we have all the
resources and time as J&K is unique in
more ways than can be fully explained (4,5).
Syed Amin and Khan A.W.
206
Table (1). Socio-demographic parameters of J&K and India.
[Data from Census-2001 & NFHS-II] $ as per SRS vol.37 no. 2 October 2003
Table (2). Details of healthcare facilities in Kashmir.
District
Medical
Colleges/
Associated
Hospitals
District
Hospitals SDH/
CHC PHC/
ADs MAC/
SC
ISM
Dispen
sary Others* Total District
Srinagar 11 1 3 49 80 26 7 177 Srinagar
Budgam 0 1 9 54 115 26 1 206 Budgam
Anantnag 0 1 8 68 207 40 3 327 Anantnag
Baramulla 0 1 7 74 149 22 2 255 Baramulla
Pulwama 0 1 6 55 132 48 2 244 Pulwama
Kupwara 0 1 7 39 195 20 1 263 Kupwara
Leh 0 1 3 22 123 1 1 151 Leh
Kargil 0 1 4 13 104 1 4 127 Kargil
*Mobile Medical Units, TB centres, FP centres, Leprosy centres, Leprosy control units and Amchi centres
Key: [SDH=Sub-District Hospital, CHC=Community Health Centre, PHC=Primary Health centre, AD=Allopathic
Dispensary, ISM=Indian System of Medicine, MMU=Mobile Medical Units, SC=Sub Centre]
Life in Conflict: Characteristics of Depression in Kashmir 207
Within the spectrum of mental health
interventions, prevention and promotion have
become realistic and evidence based,
supported by a fast growing body of knowledge
from fields as divergent as developmental
psychopathology, psychobiology, prevention,
and health promotion sciences (1-3).
Many depressed patients with somatic
complaints may be overlooked as ones
having no real illness, once medical illnesses
are evaluated and ruled out. Even in the
most advanced countries more than 50
percent of the depressed individuals are
neither diagnosed nor treated by their family
doctors. The adequate recognition and
treatment of depression is hampered by
negative public attitude and gaps in
professional expertise (14).
The social institutions and cultural
practices have a major influence in structuring
experience and in giving meaning to human
lives and may be reinforced and supported by
social networks that may have been severely
fractured and dislocated during conflict. Social
structures may provide and allow meaning in
human lives. The situation in Kashmir requires
prudence and modesty.
This study is an attempt to define a
prevalence of mental health problems in a
community exposed to conflict with special
reference to characteristics of depression.
However, intervention that might be used to
help this population has not been studied
which needs further research.
Methods
Brief psychiatric symptom scales are useful
as screening instruments, because the rationale
for most disease screening procedures is to
provide a fast, economical method of detecting
cases of suspected or potential illness in the
general population. One of the most popular
such scales is the Centre for Epidemiological
Studies Depression Scale (CES-D Scale). This
scale was developed to measure symptoms of
depression in community populations (8-10). It is a
self-report scale; respondents are asked to rate
the frequency, over the past week, of 20
symptoms by choosing one of four response
categories ranging from “rarely” or “none of the
time” to “most or all of the time”. Scores range
from 0 to 60, with a score of 16 or above
indicating impairment. The reliability and validity
of the scale have been tested on clinical
populations and on community samples (8-13).
A cross sectional study of general
population was conducted to determine the
characteristics of depression in Kashmir. A
total of 2728 subjects were selected from
different areas (both urban and rural) of
Kashmir.
In order to ensure participation of different
groups of people, samples were drawn from
persons with different age, gender, occupation;
marital status, geographical location (rural,
urban), literacy, socioeconomic status, etc. All
the districts (excluding Ladakh) were included
in the survey. Some groups (like students)
were more readily accessible than others, and
the number of these participants was more in
the sample than others because of their
catered location in the community. Similarly,
mobile persons were more accessible than
those in households.
Six surveyors (four resident doctors
undergoing postgraduate training and two
school teachers) were assigned the job of
conducting this survey individually. All were
given two-week’s training of how to conduct
the survey. Two school teachers who worked
as surveyors for this study had an advantage
of being postgraduates in educational
psychology with theoretical background as well
as genuine interest in such an exercise.
Three educational institutions (one each
in Srinagar, Anantnag and Budgam districts)
were selected including two Higher Secondary
Schools (+2) that would give representation to
adolescents (> 16 years of age) by conducting
survey on 50 students from each school. One
Srinagar-based Women’s College provided
sample from a higher age group (18 plus). In
addition to these three institutions, 50
university going students
(coming from both rural and urban areas)
were also included in the sample to give fair
representation to the youth with different
academic pursuits and aspirations to exclude
bias that could arise from the pursuit of more
competitive branches at school and college
level studies. Most of the respondents being in
the young and productive age group are
representative of the targeted samples.
The questionnaire was administered to
the young persons after a proper explanation
to them to seek their consent. Respondents
were generally forthcoming and the response
Syed Amin and Khan A.W.
208
was encouraging. There were no refusals from
the participants and everybody cooperated in
completion of the questionnaire. The number
of people not located and not available was
insignificant. Children below 16 were ineligible
for this survey.
Similar exercise was done in other
population groups. However, in these groups
the approach required modification. Most of the
male respondents were contacted at their work
places or public places. Many women
respondents were contacted at their homes or
work places. The initial contacts with women
were from kinship networks of the surveyors
and those would further broaden the network
of respondents. Such an exercise was time-
consuming and laborious and took 12 months.
The study was conducted in a phased manner
and at times discretely to avoid any undue
attention resulting from extracting information
from otherwise strangers.
Results
The results reveal that the prevalence of
depression is 55.72%. The prevalence is
highest (66.67%) in the 15 to 25 years age
group followed by 65.33 % in the 26 to 35
years age group. Females have an overall
prevalence of 60 per cent while as males have
51.34 per cent. Significant difference in the
prevalence of depression among males and
females is in the age group of 36 to 45 years
and 46 to 55 years who have p values of 0.005
and 0.013 respectively. Females have a higher
prevalence of depression in all the age groups
than males and it is highest in the age group
26 to 35 years (68.66%). Females in the age
group of 15-25 years also have similar
prevalence rate of depression (68.64%). In
males prevalence of depression is highest in
the age group of 15-25 years (64.61%)
followed by 62.65% in the age group of 26 to
35 years (62.65%). (Table 3, 4).
Table (3). Age-, Gender-wise percentage of depression.
Age group (years) Gender No. of respondents
No. %
Depression
(Score > 16)
No. %
2
X
15-25 M
F
T
380 28.19
472 34.20
852 31.23
244 35.06
324 39.13
568 37.27 1.862
26-35 M
F
T
332 24.63
268 19.42
600 21.99
208 29.88
184 22.22
392 25.72
2.263
36-45 M
F
T
224 16.62
252 18.26
476 17.45
92 13.22
136 16.42
228 14.96
7.904
46-55 M
F
T
184 13.65
192 13.91
376 13.78
76 10.92
104 12.56
180 11.81
6.229
56-65 M
F
T
120 8.90
124 8.99
244 8.94
40 5.75
48 5.80
88 5.77
0.764
> 65 M
F
T
108 8.01
72 5.22
180 6.60
36 5.17
32 3.86
68 4.46
2.269
Total M
F
T
1348 49.41
1380 50.59
2728 -
696 100
828 100
1524 100 20.750
M: Males; F: Females; T: Total
Life in Conflict: Characteristics of Depression in Kashmir 209
Table (4). Characteristics and statistical significance of depression.
Age group (years) Gender Depression % p - value
15-25 M
F
T
64.21
68.64
66.67
0.172
(NS)
26-35 M
F
T
62.65
68.66
65.33
0.124
(NS)
36-45 M
F
T
41.07
53.97
47.90
0.005
46-55 M
F
T
41.30
54.17
47.87
0.013
56-65 M
F
T
33.33
38.71
36.07
0.382
(NS)
> 65 M
F
T
33.33
44.44
37.78
0.132
(NS)
Total M
F
T
51.34
60.00
55.72
0.0001
M: Males; F: Females; T: Total; NS: Not Significant
The difference in the prevalence of
depression among males and females is
significant; p <0.05 (Table 5). Depression is
much higher in rural areas (84.73%) as
compared to urban areas (15.26%). In rural
areas the prevalence of depression among
females is higher (93.10 %) as compared to
males (6.8%). The difference between
prevalence of depression in urban and rural
areas is significant i.e. p <0.05 (Table 6).
Table (5). Prevalence of depression according to marital status.
Marital
status No. of respondents
No. % Score > 16
No. frequency
Percentage X2 p-value
Married
Single
51.47
1324 48.53
696 46.77
828 53.23
53.56
64.65
20.750
34.639
0.0001
Table (6). The sex differences across urban and rural areas among individuals with depression (score >16).
Sex Score >16 Rural Urban X2 p value
No. % No. %
Male 692 676 97.6 16 2.31
Female 828 612 73.91 216 26.08
Total 1520 1288 84.73 232 15.26 164.74 0.0001
Syed Amin and Khan A.W.
210
Discussion
Traumatic events can have a profound
and lasting impact on the emotional, cognitive,
behavioral and physiological functioning of an
individual. No age group is immune from
exposure to trauma, and its consequences.
The effects of trauma in terms of
psychopathology are well understood in the
case of adults, while as in the case of children
they have only recently begun to be
understood. In a turmoil situation, civilian
casualties have been found to outnumber
military casualties by 3:1 (14). The most
common traumatic event experienced is
witnessing the killing of a close relative,
followed by witnessing the arrest and torture of
a close relative.
Our study reveals that there is a gender
difference with regards depression by locality -
with men higher in rural areas / women in
urban areas. The number of women suffering
from depression is more (60%) as compared to
men (51.34%). Women have a higher
prevalence of depression in all the age groups
than males and it is highest in the age group
26 to 35 years (68.66%). Women in the age
group of 15-25 years also have similar
prevalence rate of depression (68.64%).
Women are an integral to all aspects of
society. The multiple roles that they fulfill in
society render them at greater risk of
experiencing mental problems than others in
the community. Women bear the burden of
responsibility associated with being wives,
mothers and carers of others. Increasingly,
women are becoming an essential part of the
labour force and in one-quarter to one-third of
households they are the prime source of
income (WHO, 1995). Women are more likely
than men to be adversely affected by specific
mental disorders, the most common being:
anxiety related disorders and depression.
Women in Kashmir have been closely
associated with political mobilizations and
continue to be victims in the ongoing cycle of
violence and abuse. They continue to confront
and cope with psychological and physical
violence, dislocation and disillusionment of a
situation of war - as women and as members
of a community. Yet their voices or experience
of the conflict remains absent. The invisibility of
women's voices vis-à-vis the conflict emerges
from the presumption that women are external,
far removed from the scene of actual combat
between militants and security forces. The
false dichotomies of home vs. warfront were
appropriately highlighted during the Kosovo
conflict which brought home the social,
economic and psychologically traumatic
consequences of the conflict for women.
The difference in the prevalence of
depression among males and females is
significant; p<0.05 (Table 5). Depression is
much higher in rural areas (84.73%) as
compared to urban areas (15.26%). Lower
socioeconomic status including unemployment
is one of the important factors. With single
people reporting higher levels of depression,
locality is not a factor in rural or urban areas.
There is only a marginal difference between
the genders or age of married / single people.
To live in a community of total 6 million
people, having more than a million depressed
patients and more than 100,000 of them
thinking in terms of ending their lives is a
matter of great concern and a big challenge for
any medical professional, working in Kashmir.
The situation has become grim due to a very
high percentage of chronic post traumatic
stress disorder presenting with co-morbid
depressive illnesses (14).
The burden of depression is rising,
affecting both the working and social lives of
individuals. In India, a meta-analysis of 13
psychiatric epidemiological studies (n=33
572) yielded an estimated prevalence rate of
5.8% (15).
Post Traumatic Stress Disorder (PTSD)
is highly prevalent in general population in
Kashmir. Most patients (67%) had co-morbid
depression out of which 64.51% were males
and 69.04% females (16). According to
another study (17) majority of the PTSD
cases had a co-morbid psychiatric disorder
most commonly depression.
A hospital-based study conducted for
depression (18) revealed that depressive
disorders is increasing (1971: 16%, 1980: 14%
and in 1989: 32%) among the patients
(N=3486) admitted in the Outpatient
department of the Psychiatric Hospital of
Kashmir. However, the present study reveals
much higher prevalence (55.72%) among the
community. The increase of depressive
disorders is primarily due to continuing conflict.
However, the possibility of the elevated stress
in daily life as possible origin for the increase
of depression can not be ruled out. Violence is
Life in Conflict: Characteristics of Depression in Kashmir 211
seen as the root of all evil. It does not only
dislocate the life of many individuals also social
and community life is affected for many rituals
and events are banned for security reasons. A
lingering generation conflict seems to be
triggered by the violence. Family structure
changes, habits disappear and respect for
tradition is diminishing. The protective belt
usually formed by family is eroded. Especially
in the rural areas all expressions of
psychological suffering are summarized by the
expression of having 'tension'. The resilience
of individuals, community and culture is
expressed through coping and self help
mechanisms.
Civilian stressors in general and conflict
stressors in particular include torture, beatings,
rape, life-threat; being targeted, shot at,
threatened or displaced; being confined to
one’s home; losing a loved one or family
members; financial hardship; and having
restricted access to resources such as food,
water and other supplies. In addition to
depression other psychiatric disorders like
substance misuse and suicide among young
adults are on a rise.
Mental health staff is scarce. There is a
single 100-bedded hospital of psychiatric
diseases in Kashmir. The state of Jammu &
Kashmir has only eight psychiatrists in public
service and no clinical psychologists. The
absences of services on primary and
secondary level cause a heavy strain on the
tertiary level.
There is scientific evidence that
depression is 1.5 to 2 times more prevalent
among the low-income groups of a population
(4,5). Poverty could be considered a significant
contributor to mental disorders, and vice-versa.
The two are thus linked in a vicious circle, and
affect several dimensions of individual and
social development. Moreover, employed
persons who have lost their jobs are twice as
likely to be depressed as persons who retain
their jobs. Studies have shown a significant
relationship between the prevalence of
common mental disorders and low educational
levels (19-21).
A study conducted demonstrates that,
while coping strategies were to a large extent
determined by social variables, there was a
differential impact of violence upon civilians
experiencing mass terror. For the Lebanese
groups, the greater the understanding of the
reason for the war the easier was the coping
strategy. For Palestinians, on the other hand,
the belief that their entire history was one of
facing the threat of annihilation (‘for us the war
has never ended’) rationalised the frequent
violent assaults upon their community as
inevitable and, despite higher levels of physical
injury and death, enabled better coping than
among Lebanese civilians. Among both
groups, combatants had high rates of
depression but lower levels of traumatisation.
In the long term social relations were much
more fractured among the Palestinians than
among the Lebanese since large numbers of
the former were expelled from Beirut following
the Israeli invasion of 1982, fracturing once
vibrant primary networks (22).
Because of the nature of social conflict in
Asia, peace psychologists working in this
region should focus on active nonviolent
political transformation, healing protracted-war
traumas, beliefs supporting economic
democratization, social voice and identity,
culture-sensitive political peacemaking, and
psychopolitical aspects of federalizing to
address a territorial conflict. The people of
Kashmir must be assisted in achieving peace
and safety in their own homeland. Counselors
and psychologists can play a role in bringing
about peace using worldview research.
There is a need for collective response
from the members of all walks of life to evolve
multipronged strategy with provision for
immediate, short-term and long-term objectives
for addressing these problems. Mental
illnesses do not have only materialistic but also
more powerful divine and spiritual solutions.
Spiritual leaders (priest, learned scholar, etc.)
should communicate with masses about the
ground realities and approach to tackle issues
such as social problems, drug addiction,
suicide, unemployment, etc. by quoting the
perfect models of prevention and control.
Cultural and religious beliefs which discourage
substance misuse or suicide and support self-
prevention measures that enhance protective
factors can play a key role in prevention of
several mental disorders. Spiritual approach
can be combined with evidence-based
scientific methods of management of most
mental illnesses. Health education in
educational institutions regarding mental
illnesses is essential. Programmes that support
and sustain protection need to be in place.
Syed Amin and Khan A.W.
212
Mental illness is not a personal failure.
Science and sensibility are combining to bring
down real and perceived barriers to care and
cure in mental health. Strengthening mental
health and resilience not only reduces the risk
of mental and behavioural disorders, but also
contributes to better physical health, well-
being, productive life, social capital, safer
environments, and economic benefits. Proper
planning is at the heart of successful public
policy advocacy initiatives.
Conclusion
Due to continuing conflict in Kashmir
during the last 18 years there has been a
phenomenal increase in psychiatric morbidity.
The prevalence of depression is 55.72%.
Mental health is an integral part of
overall health and quality of life. Effective
evidence-based programs and policies are
available to promote mental health,
enhance resilience, reduce risk factors,
increase protective factors, and prevent
mental and behavioural disorders.
Innovative community-based health
programmes which are culturally and
gender appropriate and reaches out to all
segments of the population need to be
developed. Substantial and sustainable
improvements can be achieved only when a
comprehensive strategy for mental health
which incorporates both prevention and
care elements is adopted. Health services
should be able to provide the much-needed
treatment and support to a larger proportion
of the people suffering from mental
disorders than they receive at present:
services that are more effective and more
humane; treatments that help them avoid
chronic disability and premature death; and
support that gives them a life that is
healthier and richer a life lived with
dignity. Investing in mental health today can
generate enormous returns in terms of
reducing disability and preventing
premature death.
Acknowledgements
Authors are grateful to Dr. Farooq A. Jan
and Dr. G. H. Yattoo of SK Institute of Medical
Sciences Srinagar, for extending their help in
data collection.
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The impact of events going on in kashmir over more than past 15 years has led to a phenomenal increase in mental disorders .Given the longstanding inadequacy of resources and expert manpower in mental health care area of developing world in general, the urgency to address mental health care needs in a crises situation under such circumstances can not be overemphasized. Mobilizing all possible resources at individual and collective levels to meet the grossly increased demands has remained one of the foremost necessities during these prolonged trying times of traumas, despair, disorders and disasters in Kashmir. A more active role for physicians in screening for mental health needs and providing services at least to less severe cases was envisaged by this author as a possible means of multiplying hands to ameliorate the distress of masses at a large scale. Survey of non psychiatric clinician's during 90's by Margoob et al demonstrated that most practitioners felt inadequately trained to identify and treat the common mental health concerns of patients , so every year a number of activities related to different facets of intervention in mental health care area including traumatic stress and its associated issues have continued to be carried out by this author and his team. A passing reference to a few of such activities may not be out of context here: To live in a community of total 6 million people, having more than a million depressed patients (Margoob et al, 2002) and more than a lakh of them thinking in terms of ending their lives is a matter of great concern rather a big challenge for any medical professional, working in Kashmir. The situation has become all the more grim due to very high percentage of chronic post traumatic stress disorder presenting with co morbid moderate to severe depressive illness (Zafar, Magoob et al 2000) .Correct diagnosis and effective management of depressive disorders is emerging as a dilemma all over the world. World Health Organization (WHO) has ranked depression as the 4th among the list of the most urgent health problems worldwide and has predicted it to become number two in terms of disease burden by 2020 overriding diabetes, cancer, arthritis etc. Among women, depressive disorder is going to b the number one disease in this regard. I guess this has already started happening here in Kashmir. Since human beings react to external and internal events by initiating a series of thoughts, feelings and actions, distinguishing the normal emotion of depression that is virtually experienced by everyone at times in their lives, is difficult from a depressive illness that requires medical treatment and is often problematic for the clinicians not trained in mental health sciences. The widespread misconception among common people that psychiatric disorder like depression is not a disease but a deficiency of will, that can be overcome with effort is, based on misinformation and lack of knowledge. This misconception can extend into primary care settings where patients present with unexplained physical symptoms to express emotional distress. Many depressed patients with somatic complaints may be overlooked as ones having no real illness, once medical illnesses are evaluated and ruled out. Even in the most advanced countries like the US and UK more than 50% of the depressed individual are neither diagnosed nor treated by their family doctors. The adequate recognition and treatment of depression is hampered by negative public attitude and gaps in professional expertise. This is the reason that the Royal College of Psychiatrists in collaboration with Royal College of General Physicians had to embark upon its most ambitious public/professional education campaign in its 30 year old history - the ‘Defeat Depression Campaign from 1992-1996’. This campaign was designed to improve professional recognition and treatment of depression and to increase public understanding of the features, extent, course and treatment of depression. Since most primary physicians in USA also do not receive much training in recognizing depression, which is why the National Institute of Mental Health had to launch its Depression Awareness Recognition and Treatment (DART) Programme to help doctors intervene more confidently and more successfully. The recognition and management of depressive disorders in developing countries including India, is still worse partly because till now no such significant mass campaign has been initiated. At places like Kashmir where there has been a phenomenal increase in the psychiatric morbidity in general and depressive disorders in particular (Margoob et al 2002) professional complacency would simply amount to allowing this disease explode into an unchecked epidemic. The need to intervene was getting further substantiated by the data emerging from more than half a dozen scientific studies from various clinical settings including from psychiatric clinical experts (Margoob et al 1999) as well as from the medical trainees (Margoob et al 2003). All these factors provided enough justification to do something worthwhile for evolving appropriate, preventive, curative and rehabilitative strategies and to make a start in this direction, at least. With a total of ten psychiatrists, almost all of them awfully busy and clustered at one or two places in the city of Srinagar only, such a gigantic task of imparting education for correct diagnosis and effective management of depressive disorders is simply impossible. With all these constraints in mind a very humble beginning was made by the undersigned in the year 1998 by trying to identify the main areas to be focused upon which emerged as 1) Non Psychiatric experts and primary physicians 2) Postgraduate trainees 3) Media. However expectations from such a programme, which started almost as a one-man affair in the beginning, had obviously to be very modest, but the overwhelming response made the fact that the outline of the speech as guidelines for treatment of depression in General Practice’, were published by the host pharmaceutical concern and distributed among the audience. The demand for such write-ups was so high that the copies had to be Xeroxed in hundreds to cater the demands of a beeline of practitioners from field and teaching Institutes. Since in my last lecture (Oct. 14, 2002) addressed to the large gathering of experts from different medical and surgical domains some of the questions had remained unanswered due to shortage of time, I had promised the concerned to reply their queries in a write up at some proper occasions. The present effort is a fulfilment of that promise and I have selected this occasion of the World Health week for it. I hope, that this humble attempt would add to efforts of helping this suffering community. One more equally important area of activity to combat depression, was developing professional skills and expertise, in trainees of the only Postgraduate department of psychiatry in the state of Jammu and Kashmir. The meritorious students who joined the department over the past few years have not only been associated with the routine clinical and teaching activities but were also involved in research and academic activities organized by various prestigious national institutes from time to time. This core group of new budding psychiatrists, if given chance and opportunity to work in the future, can be of immense help in carrying forward such missions with the zeal and zest, they have already shown. Focus on media has also been an important aspect of the Defeat Depression Programme over the years. Besides many interviews, a series of weekly or biweekly programmes on various aspects of depression, as psycho education for masses was run by both TV and radio. The print media also carried out write ups from time to time on the topic. Presently more than 60 TV programmes on awareness campaign and psycho education programme stand recorded on Psychiatric disorders, as a part of a six episode series, currently being telecasted. Similar radio programmes are also in the pipeline. Recently pharmaceutical industry has also joined public awareness and similar activities besides continuing medical education (CME) in a big way. I hope Defeat Depression activities would be continued and carried forward by others from now onwards, because as per previous plan my 5-year programme is ending now. It is to be followed by an equally important rather more disturbing, relatively less researched, and often more disabling and agonizing disorders related to post traumatic stress. If Defeat Depression programme has served some useful function in enhancing public awareness and improving professional recognition and management of depression, the credit for that will go to all the organizations and individuals who participated, cooperated and helped me from time to time. Obviously the blame for any shortcomings will fall on me, but one satisfaction which still will make me repeat such activities in future also is MAIN AKELA HI CHALA THA JANEBE MANZIL MAGAR (ALONE, I HAD BEGAN MARCHING TOWARDS GOAL) LOG AATAY GAYE AOUR KARWANN BANTA GAYA (PEOPLE KEPT ON JOINING AND THE CARAVAN INCREASED)