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There are different types of mental health professionals. What is the difference between psychologists and psychiatrists?

Psychologists and psychiatrists are both professionals who treat mental illnesses. The difference is in the training and the predominant treatment modality they use. Psychologists would primarily use a treatment modality called psychotherapy whilst a psychiatrist would primarily use medication. Both of these treatment modalities have a place in the treatment of depression.

Why does a person get a depressive disorder?

There can be many reasons. For instance, if an individual has undergone significant life trauma, (such as rape, abuse or experience of violence), or had experienced some long term difficulties, that may lead to a depressive disorder. Some people on the other hand, may not have experienced any significant traumas in life, but may still get a depressive disorder. This latter type of depression maybe largely biological whilst the former types maybe largely psychological.

It is up to the clinician to decide the reason a particular patient has got depressed. Depending on the reason, s/he would then decide on the treatment modality – psychotherapy versus medication, or a combination of both of these.

What is a traumatic event that might lead to depression?
We know that there are certain situations that are generally traumatic for most human beings. Being abused in childhood, raped, tortured, or living in a family or community where violence (physical and/or psychological) is common, all have significant impact on a person. All of these can be considered as traumatic life situations. However, we do come across people who have gone through such traumatic life situations but they do not get clinically depressed. They are quite functional and coping well with life. There are others who are wealthy, had relatively loving parents, intelligent, and good looking, but they may have a depressive disorder.

This indicates to us that some people are more resilient and able to handle stressors or traumatic life situations better than others. People might think, the moment you have experienced a traumatic life incident, one may automatically get depressed. It is not only the outward experience that makes one depressed, bit one's internal (or mental) perspective of the situation too is crucial. Two people can face the same experience, but cope completely differently because of their outlook on life.

What role do parents play in raising their kids such that the possibility of a diagnosis of depressive disorder is reduced?

It is very important that parents offer their children life opportunities such that they become mentally resilient. For example, in school, they may face bullying. A teacher may not be very kind to them. The child may not be as intelligent as other children and may not be performing well in studies. The child may have a disability. It is very important that the parents make such children resilient and coach the child to handle these situations appropriately. Those strategies that they teach the child, will be there when the child becomes an adult. Thereafter if and when a traumatic experience occurs in his or her life, the person may have psychological resources to cope with it. This then would reduce the possibility of depression. For instance, a child may tell a parent: "Nobody talks to me, I feel cornered. In the interval time I am alone. When I go to the play area nobody calls me for the group game. Some kids call me names." Upon hearing this, some parents might get very anxious and complain to the teacher, and may suggest to the teacher to 'force' others to get friendly with their child. Or, the parents may tell the child that his/her problem is too trivial a thing to sort out and hence not take it seriously. Or, parents might completely ignore the incident, thinking it might sort itself out. Or, they might think its good for the child when these things happen, that it would strengthen the child. As if the mere occurrence of such events would build psychological resilience. All these views are not correct. What is better is for the parent to understand what the child is talking about and to be aware that it is worrying and bothering the child. Brushing it aside is not going to help at all. The parents should allocate some time, to sit with the child, and get a clear picture as to what is actually happening in this school situation. The parent needs to understand why this child feels that others are intimidating him/her. They should find out the real reason the child is having this problem. Is the child a sensitive child? Does the child not know how to make friends? Or is there actually a bully in the class, who is picking on the child or jealous of the child?

The parents should be able to discuss with the child, to find out the reason and give the child techniques on how to overcome it. This process makes the child very mature in handling life problems because in his/her childhood itself, the parents are giving the child capacity/tools to handle problems. So when bigger things happen to the child (when he grows up), s/he will be able to use that capacity to handle it, and may not be predisposed to a depressive disorder.

Is there anything specific in Sri Lanka that people get depressed for, or is it just  general events that you mentioned?

Since we work in a government hospital, typically, we see a lower economic strata of society. In some dysfunctional family situations, the husband maybe abusive and the wife has to look after almost all aspects of the home front: looking after children, looking into their school work, making sure they go to school, doing the household work, holding a job, whilst the husband may be out there drinking and even abusing her. After some time all these may take a toll on her. She may plummet into a depressive disorder or even a sub-clinical version of it. We also see young people, who may not be having depressive disorder but they feel like harming themselves.

Is this a recent occurrence or is it something that has been there for some time?

We have had high suicide rates from the 1990s, and at one point we had the highest rate. But these high rates, as compared to other countries, have now come down. It seems we as a country our in a better position, in terms of suicides, though a lot still needs to be done to improve the current rates. Suicidal ideation are a symptom of depression. If you are happy you will not want to kill yourself. There are two types of suicide. One is planned suicide which involves planning one's suicidal attempt well then and carrying it out. The other type is the impulsive variety. In a planned suicide, people think about it. They may be depressed, where they feel life is not worth it, and they might contemplate the ways they would commit suicide. They may even ask people ways to commit suicide. In respect of impulsive suicides, the person may not have planned their suicide in advance. They may do this to seek attention or because they are in the throes of an emotional state, but it can go wrong and even though they may not have intended to actually kill themselves, they can die or they can do significant harm to themselves. Several suicides are impulsive suicides by teenagers and young adults. They give into the impulse of wanting to die because they feel that they cannot cope with life problems.

Is this their own fault, or has the education system or the family played a role in it?

Both the education system and their family may have played a part. If the parent/teacher taught the child different strategies to manage life's problems, periodically or whenever the child had a small problem, then when the child becomes an adolescent/adult and has a problem s/he may know how to cope successfully.

A Lack of strategies means the family has not trained them in life skills, or maybe the family feels that they expect the school to train the kids on how to handle problems, and the school has not trained them either. Now has that situation changed, where the families are more involved or is it still the same?

I dont think it has changed much. I dont see a significant shift in our family where parents spend more time with children. Parents want to do a lot of other things which are not necessarily bad things. Young parents, take their children to school, they go off to work, the children are looked after by domestic helpers, they come home by about 6 or 7 in the evening, some of them are doing their professional courses/degrees, so they dont actually have time to spend with their children. Children are part of their lifes' package but dont get as much attention as maybe required to ensure that the child's psychological needs are fully met. Hence, when parents spend less time with children, the opportunities to impart life skills to them become lesser.

So how do you suggest we address this issue?

At a young age, you give them the strategies of coping with lifes' problems. Rather than telling them what to do, or ridiculing their little concerns, if you sit down and talk to them, and address and develop the child's problem solving capacity that would go a long way. Help the child to formulate a problem, to understand a problem, and to be patient with their problem. This whole process will help the child inculcate life skills. So when this child faces a bigger problem in later life he may have the skills to manage it. Even if the parents are not there, he can be patient, not be impulsive, and think things through.

Is there some mechanism to implement things in your opinion? Can schools train them in these tools, or is it more of the parents' role? If so, how do we activate the parents to do that?

I dont think there can be a formal mechanism. That would be too artificial. If parents and teachers can be empathetic with the young people that would be very important. When the young people have a problem adults should make it a high priority to give them an ear, which means their time. Their time availability is the problem here. Most adults are actually concerned. But when it comes to giving time, it is hard for them. So, some adults tend to skim over the opportunity to teach their children (or students, in the case of teachers) life skills in solving problems that occur in their life. Parents may have other priorities. Socialising, office work, looking after aged relatives etc. These may get precedence. They may think that providing the child with gifts and holidays would suffice. Of course these are important, but what is more important in the time spent with the child and most crucially, time spent teaching the child to solve lifes' problems. In the case of modern day teachers, some of them may need to get ready for their next class, or to look into matters of their personal life. These are their needs and they come first. That's very natural. After all, adults too have their needs. And they need to be met. But, instead, if the adults can also look into the needs of the children (which at some point would need to make the adults' needs secondary) too, that would be the ideal scenario.

At which age should this life skills (i.e. helping a child solve his/her problem) training start?

It should start as young as possible. I am not saying it is easy. It is difficult to work with children. Their intellectual capacity is still developing. We have to be patient, we have to reason, we also would get annoyed. Its a balancing act.

If the older one is hitting the younger one, what would you say is the way of dealing with it?

Depending on the age of the older one, how you handle it would change.

Let's say the kids are 5 and 4.

If its 5 and 4 you would tell the older one, "How would you feel if someone hit you? Can you remember in school, that girl hit you? How did you feel about it?" Then they will say something to show how they felt. Then you would tell the child "Now Nangi also feels the same way that you felt when that girl was hitting you." The child MAY realize that Nangi is feeling the pain that she felt. Its a dialogue. A dialogue of internalizing morals.

He talks to himself, realizes this is how I felt, so this is how the other person feels?

Yes. It's a process of talking. We want to teach the child reasoning. We want to teach the child empathy. This is only one example. It can be anything. The child sees a beggar. She has a ten rupee note in her hand. The mother says to the child "Why don't you give the ten rupee note to the beggar?" The child says "No". Then the parent starts a dialogue. "How would you feel like if you were outside in the hot sun? Maybe without food? Why dont you give it to him? After you give it, tell me how feel. Lets try." So its little things on a daily basis. Its a constant reinforcement of that message, with different messages. Over the years the child becomes patient, and learns to tell him/herself these same things that the parent/teacher/caregiver taught him/her

Let's say you have the talk and the child understood the mistake but went on doing it. Is it a case of repeating that message over and over or does at any point actual punishment or discipline come in?

Repeating the message is very important. Because children tend to take some time to learn about life. In fact even us adults take time too...Sometimes when a child doesnt listen to your repeated reasoning then disciplining maybe necessary. Its not punishment but discipline. Punishment has the connotation of hitting which we dont recommend in psychology. Hitting or any other type of physical force (such as caning, pulling the ear, pulling the hair) is not recommended, but there are other ways of disciplining. These would have to be enacted and reasoning would be the first line in this gamut of recommended disciplinary strategies.

Why is this?
Because reasoning builds knowledge and strategies in the child. It makes them resilient for future problems. Spanking is out, because spanking doesnt give the message to the child about what s/he did wrong. It communicates anger though it gives immediate compliance (because of fear). The child must first understand what he has done wrong if he is to reform himself for the future. Spanking or any other type of physical force doesn't lead to moral internalization.

Can children also be diagnosed with depressive disorder?
I would say, not when very young, but children of 13, 14, 15 years do have these symptoms.

Is there anything else you would like to add?

We should not use the word depression loosely. It is an illness. When someone is feeling unhappy or in a low mood, we should not automatically call it depression. There are symptoms of depression which a psychologist or psychiatrist would determine, and if the person falls within that entire gamut of symptoms, treatment would be given, medication or psychotherapy or a combination. The reasons for depression can be environmental factors or/and biological factors. Environmental factors would primarily need psychotherapy while biological factors would require medication or sometimes a combination. Two people may face the same event, one may be actually depressed, while the other may be unhappy but is getting on in life, and will bounce back. Its the internal psychological mind-set of the person that determines thee response to a traumatic event. This mind-set has to be inculcated at childhood and should be taught by adults. Mainly parents and teachers. When they learn this, the risk for long term psychological problems are reduced. Most of our government health services now have a Mental Health Unit. Private hospitals too offer mental health services. So, its now quite easy for a person to meet with a psychologist or a psychiatrist if s/he or a family member is having a depressive problem.

How do psychologists and psychiatrists ensure that their own mental health is safeguarded, where they dont take on any emotional or mental problems that their patients have and get affected by them, or where their own mental and emotional problems get transferred to the patient who already has a mental or emotional problem?

Some mental health professionals may get affected emotionally while treating a patient and this can be harmful. In some countries there is peer supervision where clinicians meet with each other regularly and discuss their professional issues. This assist them in handling the emotional impact of their work. These practices are now being introduced to Sri Lanka.

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