118 years of trust

Wednesday, October 7, 1998


Human rights of the ill in mind
By Dr N. N. Wig

ON October 10 this year once again people all over the world will observe World Mental Health Day. It is a solemn occasion to ponder over the importance of mental health in our lives and also to rededicate ourselves to the cause of helping the unfortunate victims of mental illness in the community.

Rights of your child
By Savita Malhotra
A CHILD too is a citizen of the State: It’s time to acknowledge his rights! The 20th century has been said to be the century of the child. During this period, several psychological and psychodynamic theories of development have focussed our attention on the importance of childhood, and on the child, in what he was rather than what he would become.

New anti-obesity drug
A new anti-obesity drug has been launched by the Knoll Pharmaceutical Company in the USA.

World Mental Health Day falls on October 10

Human rights of the ill in mind
By Dr N. N. Wig

ON October 10 this year once again people all over the world will observe World Mental Health Day. It is a solemn occasion to ponder over the importance of mental health in our lives and also to rededicate ourselves to the cause of helping the unfortunate victims of mental illness in the community.

World Mental Health Day was established by the World Federation of Mental Health and is cosponsored by the World Bank Organisation (WHO). The year 1998 marks the fiftieth anniversary of both these organisations. The theme chosen for this year is “Human rights and mental health.”

Good mental health is one of the greatest gifts which nature has bestowed upon human beings. Unfortunately, we realise it only when we temporarily lose it — when we are mentally upset over something; when we are angry, or sad, or anxious, or worried. For most of us, it is only a temporary aberration but a large number of people suffer from much longer states of mental ill health every year.

Epidemological surveys done in India as well as in many other parts of the world have amply confirmed that at any given time one to two per cent of the population suffers from serious mental disorders like psychosis, severe depression, mental retardation, dementia etc while 10 to 15 per cent suffer from so-called common mental disorders like anxiety, depression, fear, obsession somatic symptoms due to tension, alcohol and drug abuse, etc. Women seem to be more prone to anxiety and depression while men seem to misuse alcohol and drugs more often. Even children are not free from mental disturbances. Surveys done on school children in Indi have found that five to 10 per cent of the school children suffer from various kinds of psychological and emotional problems.

In the past, in the field of health, our mind has been preoccupied with communicable diseases because they were the biggest causes of death in the population. These diseases have partly been conquered by modern medical science. Mortality due to plague, cholera, malaria, tuberculosis, typhoid fever and pneumonia has sharply declined over the years. The life expectancy of an average Indian at birth, which was around 30 years in 1947, is now over 60. This is a remarkable achievement but it has brought in a new set of problems — that is, the burden of non-communicable diseases like cancer, heart diseases, arthritis, hypertension, strokes and, above all, mental disorders of various kinds.

Researches at the Harvard School of Health and the WHO, in alliance with more than 100 collaborators from around the world, have compiled the first comprehensive picture of the world’s health care needs. Their findings have been reported in a book, “The Global Burden of disease” edited by Christopher Murray and Alan Lopez.

The following information is quoted from this landmark publication:

  • The burden of mental illnesses has been seriously underestimated by traditional health statistics that take account only of death and not disability. While psychiatric conditions are responsible for a little more than one per cent of death in the world, they account for over 11 percent of of the disease burden worldwide!
  • The study shows that the burden of psychiatric conditions has been heavily underestimated in the past. At present, of the 10 leading causes of disability worldwide (measured in terms of eyars lived with disability) five are psychiatric conditions like depression, alcohol dependence, schizophrenia and obsessive-compulsive disorder.
  • In coming years, the disease burden in the world will further shift towards psychiatric disorders. In 1990, three leading causes of the disease burden, in descending order, were pneumonia, diarrhoeal diseases and conditions related to child birth. In 2020, the three leading causes of the burden of disease are expected to be heart disease, depression, and traffic accidents, in the same descending order. So, judged by any standard, mental disorders are one of the biggest causes of human suffering and as the years go by, it seems that these problems are going to increase further.

What is mental health?: It is wrong to talk of mental health as something separate from physical health. Health is indivisible. It is a part of the European philosophical tradition, following the writings of Rene Descartes in the sixteenth century, to separate bodily functions from mental functions. It is an arbitrary division because body and mind are inter-dependent. Health has defined by the WHO., is not merely the absence of disease but a state of total well-being of the individual — physically, mentally and socially.

The World Federation of Mental Health — the sponsors of World Mental Health Day —has suggested the following three points in the definition of mental health:

* 1. Are you comfortable within yourself?

* 2. Are you comfortable with other people?

* 3. Are you able to meet life’s demands?”

If the answer to all the three questions is “yes,” you can assume yourself to be mentally healthy.

The plight of the seriously mentally ill: Patients suffering from serious and chronic mental disorders are one of the most neglected groups in our society. Often they are found in prisons without having committed any crime, or forced to stay continuously in mental hospitals even when they have recovered because no relative is willing to take them back.

Many of them are kept locked or even chained by their families. Much worse, many of them are seen wandering on the roads like stray cattle, totally abandoned, unwanted and uncared for — without food, clothes or shelter. In the ultimate analysis, how civilised a country is can be judged by how it treats its weaker sections, particularly those who are disabled by physical and mental illness. By that standard, India is still a very uncivilised country. On the occasion of World Mental Health Day (October 10), let us remember the plight of the mentally ill who have temporarily lost the precious gift of mental health. Many of them, with serious mental illness, can no longer enjoy the ordinary pleasure of life like smiling, laughing or enjoying the company of their near and dear ones. They are suffering terribly because of their distorted thinking and feeling caused by mental illness.

They deserve our sympathy and understanding and not ridicule. They are human too and deserve to have the same human rights as any one of us.

The human rights of the mentally ill: The General Assembly of the United Nations recently considered the question of the rights of the mentally ill. In a resolution adopted in December, 1991, it laid down important principles for the protection of persons with mental illness and the improvement of mental health care. The following points are from the first principle, namely,” Fundamental freedoms and basic rights of the mentally ill,” as passed by the UN General Assembly and accepted by all nations of the world:-

1. All persons have the right to the best available mental health care which shall be part of the health and social care system.

2. All persons with a mental illness shall be treated with humanity and respect for the inherent dignity of the human person.

3. All persons with mental illness have the right to protection from economic, sexual and other forms of exploitation, physical and other abuse and degrading treatment.

4. There shall be no discrimination on the grounds of mental illness.

5. Every person with a mental illness shall have the right to exercise all civil, political, economic, social and cultural rights as recognised by the Universal declaration of Human Rights.

Let us resolve on this occasion to treat the mentally ill with the same compassion and understanding as we have for a person with physical illness so that the mentally ill can also live their lives with dignity and self-respect.

Dr N.N. Wig, a pioneering psychiatrist of international fame, is Professor Emeritus of Psychiatry at the PGI, Chandigarh, and a former Regional Adviser in mental health to the WHO.Top


Rights of your child
By Savita Malhotra

A CHILD too is a citizen of the State: It’s time to acknowledge his rights!

The 20th century has been said to be the century of the child. During this period, several psychological and psychodynamic theories of development have focussed our attention on the importance of childhood, and on the child, in what he was rather than what he would become. Advancements in the medical field assured that a much larger number of children would be born normally, and would live and survive.

The school system and education became available and obligatory. The recognition of the specific needs of children and the facilitation of optimum development became an ideal and a necessary for the family and parents to accept and pursue.

Society and the State brought in several regulations and enactments concerning child protection and welfare such as the abolition of child labour, the end of exploitation and abuse, the making of education as a basic right and so on. The culmination point was the announcement of the International Declaration of the Rights of Children in November, 1990, by the United Nations Organisation.

In general, it all brought in an element of preference to the interests of children.

How have all these developments translated into reality? What is the state of children in real life?

The needs and the rights of children are relegated to lower levels of priority in most societies. The promotion of positive mental health and psycho-social development of children, which is so crucial to adult personality and mental health and to the character of the future society, is neglected during the most important phase of life when it is possible to intervene.

There are several situations in the everyday life of children where their rights and needs are not acknowledged, leave aside respected. The physical environment, social and cultural practices and value systems, attitudes and morals, all influence the dynamic interaction between the child and the world he is born into and lay the foundation of his or her personality.

A child at birth is totally dependant on adults for survival and then has to go through a prolonged period of dependency on his family. Since he, due to his immaturity and insufficient capacity, is unable to speak for himself, it is the adults who should speak for the child. Infants in Latin, (infant in English,) is one who does not speak. In highly traditional authoritarian families, a child remains a child forever, who never knows as well as parents, and hence should not be allowed to speak. It is apparent when parents tell children. “Don’t ask questions, don’t talk at the table, speak only when you are spoken to”.

Teachers use this method to deal with children in classrooms. It is much easier to stop a child from talking than it is to encourage him to speak. If a child has to express what he thinks and feels, one must first create an atmosphere in which speaking is possible.

Most adults do not allow freedom of speech to children for reasons of inner insecurity, fear of erosion of authority or of injury to their narcissistic feelings. During the period of the child’s immaturity and dependency, it is assumed and expected that the parents should have the right, authority and pleasure of speaking for their children and assert their rights. But what happens when the parents’ actions are contrary to the child’s interests. In situations of maltreatment, physical, emotional and sexual abuse, neglect and deprivation, child labour and employment in hazardous conditions, denial of the basic rights to education, medical treatment, play and recreation etc, occur within the family set-up. This is a paradox in the lives of children where the “protector” and the “provider” in the family becomes the “perpetrator” of what can be termed as crime against humanity. Obviously society and the State must intervene.

Traditionally child development has been a matter limited to the family and the jurisdiction of the state ended at the family’s door-step. But now society’s and the State’s intervention is possible in extreme situations of child maltreatment and neglect. The child is taken into the ambit of protection and social services in several countries in the world at the earliest indication of abuse and neglect.

There are telephone helplines where children can call when in distress.

In India, the Constitution provides that the government would ensure that “the children are given opportunities and facilities to develop in a healthy manner in conditions of freedom and dignity and that childhood and youth are protected against exploitation and against moral and material abandonment” (Article 39). The Juvenile Justice Act of 1986 provides for the care of neglected and delinquent juveniles. Nevertheless, these enactments alone can’t improve the lot of children in real life until society as a whole wakes up to the importance of the issue.

Children’s education in the past was entirely a private matter with parents where they decided on the need and the type or education, such as in “shastra” or “shaastras”, they wished to impart to their child and arranged for suitable teachers. Of course, this was based on the system of familial occupations and castes. Now education has been regarded as a fundamental right of all children, obligatory on the part of parents and the State. Thus child care and child development are becoming a collective responsibility of society rather than an individual responsibility.

In a manner similar to that for education, many more rights are and should be recognised and granted to children. Research in medical sciences and child development have gathered an enormous amount in information in recent years that deals with issues of prevention of diseases, promotion of health, including mental health, and enhancement of optimum development.

Anything that is unquestionably required for children to grow and develop their full potential will have to be considered their legitimate right and society’s responsibility. It may include the right to speak, to learn, to play, to be cared for, to be loved. Ironically, in the present-day society where technology and industry are in tremendous competition for production of high-quality goods, and where “quality” is the buzz word linked to success and achievement, we pay little attention to the quality of the human race.

In fact, adults are too busy with themselves and parents have left the care of children to several extra-familial agencies, such as creches, nurseries, servants, neighbours and older children. All the alternatives to a family system where parents, particularly biological parents, and children live together are far from satisfactory. Parenting should be viewed as an important task and should be adequately supported by the State and society.

Unfortunately, we are too involved with the present and do not care to think about the future. Children should be seen as assets and a nation’s wealth which should be protected, guarded and nurtured.

Dr Savita Malhotra is the Additional Professor of Psychiatry at the PGI, Chandigarh.Top


New anti-obesity drug

A new anti-obesity drug has been launched by the Knoll Pharmaceutical Company in the USA.

The drug called sibutramine hydrochloride monohydrate or meridia, is used along with a reduced-calorie diet for obesity management which includes weight loss and its maintenance, reports Diabetes Forecast.

Meridia does not work like previous weight management drugs like redux. Earlier drugs increased the level of serotonin — a chemical inside the brain that regulates appetite — by entering the cells where serotonin is stored and forcing the chemical out.

Meridia, on the other hand, belongs to a drug class called “neurotransmitter reuptake inhabiters, which work outside the cells, slowing down the time it takes for naturally released serotonin to be reabsorbed, and thus prolonging the full, satisfied feeling patients have after eating a meal.

Taken once a day without regard to meals, it is available in doses of five, ten or 15 milligrams, so that doctors can tailor therapy according to their patients’ needs.

The most common side-effects associated with meridia are minor and include dry mouth, headache, constipation and insomnia. It should not be taken by persons having controlled or poorly controlled high blood pressure as it substantially increases blood pressure in some patients. People with well-controlled high blood pressure may use it.

The drug should not be used by patients who take drugs called monoamine oxidase inhibiters (MAOIs) that are used for depression. Parkinson’s disease and other disorders to avoid serious reaction.

It should not be taken by patients taking prescription drugs, over-the-counter (OTC) medications and herbal products, those who have coronary artery disease, angina (heart-related chest pain), arrhythmias (irregular heart beats), prior heart attack, severe liver of kidney disease, stroke or its symptoms and have loss of appetite.

Other non-users include pregnant or lactating women, people having a history of epilepsy and children under sixteen.

Approved by the Food and Drug Administration (FDA), meridia has not shown carrying the risk of causing damage to heart valves like redux, an earlier drug.

Research has also shown a low likelihood of addiction or physical dependency. Long-term studies are now under way as part of routine surveillance and monitoring procedures.Top


Headaches — III
Managing migraine
By Prof K.C. Kanwar

The classic migraine comes with a warning signalling that the attack is imminent and nearing. Promontory symptoms comprise feeling of elation, excessive energy, thirst, drowsiness, hunger and sometimes even craving for sweet foods. In certain sufferers premonition comprises depression instead. Such premonitions last for an hour or so and fade to be followed by a severe headache. It one takes precautions and uses appropriate drugs right away, it is possible to ward off the attack or at least minimise its intensity.

A patient may suffer from both common and classic migraines at different times. Over and above, it is not uncommon for migraine sufferers to have tension headaches in between migraine attacks. Soon after premonition, tingling, weakness or numbness may be felt in the lip area, one side of the face which may slowly involve arm and (rarely) the leg on the side mimicking a minor stroke. A severe attack of migraine leaves the sufferer confused and incoherent. He may experience difficulty in speaking.

The early symptoms generally fade away with the passage of time but severe throbbing headache persists specially on the opposite side of the head where initially numbness had been felt.

Though migraine can be sited anywhere in the head, it commonly involves the temples or forehead region. Characteristically unilateral at the onset, migraine may spread to the whole skull and may also even involve neck. Such headaches are worsened by physical or mental exertion or even by blazing lights but are eased by solitude, and a quiet and dark environment — and lastly by sleep. The episodes last for 12-48 holes. But durations are briefer in children or young adults. Rest lessens the pain and sleep heralds recovery.

Causes: The indisputable truth about migraine is the sudden narrowing of arteries on one side of the head thereby affecting the cerebral blood supply on that side. This is related to the aura of well-being and elation felt initially before the onset of the attack. The headache follows when the same blood vessels dilate allowing greater blood flow. Cranial blood vessels, when they swell, irritate and inflame the neighbouring nerves and hence the pain. As to why the blood vessels should contract and then dilate to cause pain is elusive. A wide variety of factors can trigger migraine attacks.

Many believe that periodic constriction and dilation of the cranial vessels are not the real cause of migraine but merely its side-effects.

Many researchers are of the view that the sudden release of stress peptides in the brain precipitates a migraine attack. A host of other workers, however, relate migraine with the faulty chemistry of the brain. Serotonin — one of the chemical neurotransmitters that is essential for normal brain activity — seems to be either lacking or severely depleted in migraine patients. Serotonin is known to suppress the perception of pain apparently by blocking pain messages from reaching the thalamus. Thus, it is held, that when serotonin is depleted, signals of acute head pain are no longer prevented from reaching the thalamus.

Serotonin is also known to play an important role in the constriction of blood vessels within the brain. If the brain does not have enough of serotonin, the excessive swelling of the blood vessels would not be contained and hence the pain. The direct support to the theory that migraine sufferers have an abnormally low amount of serotonin comes from the fact that ergotamine — perhaps the only drug which eases migraine — helps boost the level of serotonin.

Some researchers even speculate that a defect in the functioning of serotonin could be inherited, and, if so, this explains as to why migraine runs in successive generations. Though the genetic factor operates in 70 per cent of the migraine sufferers, the pattern of heredity is not Mendelian.

Whereas certain rescues contraceptive pills cause or exacerbate migraine, pregnancy or for sure reduces the frequency as well as intensity of migraine attacks. Promises of remission at menopause are often ill-founded or exaggerated though the frequency and the severity of the attacks tend to lessen significantly with age. Since women are affected more than men and migraine often starts at puberty, various factors do suggest the ill-understood but important role of hormonal imbalances.

Just about anything and everything can set off a migraine attack in a person already prone to it. The consumption of Chinese food, caffeine, red wine, processed meat etc. may trigger migraine. Sex tension and even blank relaxation, emotional upheavals, physical and mental exertion, fatigue or a low blood sugar level can initiate an attack. Blurring music and blazing lights can also escalate as well as trigger migraine attacks. Even a sudden blow on the head can cause a migraine attack in a susceptible person.

“Prevention is better than cure” is more relevant in case of migraine. Avoid stress and tension, practise relaxation techniques and make special efforts to get enough sleep.

A regular but light exercise schedule may help. When under attack, try to be aloof, avoid conversation and take rest in a quiet dark place. Some believe that food too can be a triggering factor in a few cases and, if so, the worst offenders are alcohol (especially red wine), chocolates, cheese, citrus fruits, caffeinated drinks etc avoid these. Since low blood sugar can trigger an attack, it is advisable to maintain regular eating habits. Once the attack is in full swing, nothing seems to work; medicines are effective if taken right at the onset of the attack. Migraine sufferers should stay in good health, eat only what suits them and get into a regular sleeping routine.

Certain drugs which reduce and alleviate attacks of neuralgia and migraine available these days should be taken only under medical advice.

Migraine, except for the obvious distress it causes, produces no serious long-lasting side-complications. Between the episodes, the sufferers are perfectly normal.

Treatment: The causes and the treatment of migraine remains elusive. There is no panacea. There is possibly no permanent cure of this affliction. However, the severity of attacks can be minimised and patients comforted. Mild migraine attacks sometimes can be averted by taking aspirin or paracetamol in the early stages.

Since 1930, ergot is the drug of choice to abort the attacks but this should be taken only under medical advice and supervision since it can produce serious side-effects. The ergot-based drugs are strictly prohibited during pregnancy and also for those suffering from ulcers in the gut. Ergotamine works by constricting the dilated blood vessels and is risky for anyone suffering from angina.


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