Mental Health in India’s Adolescent Girls

At ten years old, at the delicate intersection of childhood and adolescence, I lost my father.

The sudden, swift loss of a loved one left my family with a vacuum that felt insurmountable. Fear, inordinate sadness and hopelessness enveloped our home. Our South Asian family was heavily steeped in cultural norms. Showing one’s wounds to others was viewed negatively.

Crying was looked down upon, and seeking help would be an impermissible acknowledgement of weakness. Therapy was not a word in our vocabulary.

As I was expected to, I placed invisible bandages over my pain and suffering. I walked to school one week later with a forced smile pasted on my face. When asked how I was feeling, I quickly redirected the conversation, replying, “I’m okay.”

This external reticence surrounding my feelings and emotions continued throughout my adolescent years. While I experienced intermittent jolts of sadness and depression – likely as result of all that I had concealed and bottled up – I never once considered the option of therapy.

Now, as a pediatrician, I recognize the need to end the stigma and silence surrounding mental health in South Asian communities.

I have seen again and again the multi-generational consequences of mental illness, particularly depression. I co-founded Girls Health Champions, a non-profit training adolescents as peer-to-peer health educators, because I have seen firsthand that young people have significant unmet needs surrounding mental and physical health.

We know from both anecdotal and empirical evidence that adolescent depression and mental illnesses are on the rise, specifically for young women. Girls are over three times more likely than boys to experience depressive symptoms. The extent and complexity of mental illness among youth in India continues to be understudied, and the support for young people is stagnant.

Our suicide rate is a public health crisis – India accounts for 36.6% of suicides globally. Additionally, among Indian women and teenage girls aged 15–19, suicide has surpassed maternal mortality as the leading cause of death.

We have ample evidence to show that frank discussion and dialogue must start early and occur frequently. However, addressing the mental health of adolescent girls requires a thoughtful, multi-pronged strategy.

We must address cultural attitudes when approaching girls’ mental health education.

We know that South Asians, including young people, share a cultural resistance towards legitimizing mental health as a medical need. According to Dr. Nidhi Kosla, a mental health provider, South Asians “fail to report their [emotional] pain to avoiding burdening others or being seen as weak.” This might explain why many South Asians do not utilize resources such as therapy or psychiatric care, even if they are aware of them.

Additionally, in India, mental illnesses such as depression have often been equated with words such as “pagal”, or crazy. This language intensifies the shame and stigma young people experience. As a result, discussions of mental health must not only focus on awareness raising, but also on addressing and overcoming prevalent stigmas.

Mental health remains an underdeveloped and understaffed field in India’s medical practice. It is time to start building India’s mental health infrastructure.

Out of the 936,000 doctors in India, there are only roughly 4,500 psychiatrists to serve a population of 1.3 billion. In comparison, the USA, with a population a quarter the size of India’s, has 7,000 psychiatrists of Indian origin and 28,000 overall. 

India’s mental health infrastructure is also severely limited, with only 43 government mental health hospitals across all of India to provide services for the estimated 70 million people living with psychosocial disabilities.

In addition, most general practitioners and pediatricians are not adequately trained in identifying or managing mental health illnesses. These are often the people who serve as the first medical ‘touch points’ for young girls. Many providers may even hold negative attitudes towards mental health conditions themselves. Investment in training for frontline health workers is essential.

In both my experiences as a pediatrician and with Girls Health Champions, I have learned that a majority of young girls do not feel they can turn to their parents when it comes to discussing mental health-related issues. 

Parents play a critical role in providing a supportive climate around mental health.

We must educate them to have understanding, empathy, and awareness of mental health-related issues. Parents should develop the capacity to identify potential issues in their children and recognize when it would be appropriate to seek help.

I want our young people to know that it is okay to feel, to reach out for help, or even to say, “I am not okay”.

Day after day, I diagnose young girls with mental illnesses, including depression. During these visits, we often talk about the importance of removing the invisible bandages. We talk about the fact that ultimately, opening up is a sign of strength.

Silence is not Strength. Silence is Deadly.

Content note: this post refers to abuse

I used to think silence was a reflection of strength, respect, and intellect. A lot was going on in my life, but the fear of breaching what I thought of as strength kept me tight-lipped about my experiences.

My mother passed on when I was about 8 months old. My father followed when I was 12 years of age. I felt their absence in my life immensely, but I thought that I had to be strong. I did not want to weigh my siblings down with my emotions because I could see that they were battling with their own.

My parents raised me with so much love. However, in my childhood and adolescence I had my own battles to deal with. For starters, I was abused at 5 years of age. I did not speak to anyone about it.

As a result, I unknowingly adopted a lifestyle that led me down a path of depression, immorality and deceit. It was not until 2017 that I eventually opened up to my family and a few close friends. I gave them a glimpse of what had happened to me, from what I could remember. You can imagine the sombre atmosphere in the air that day.

My family immediately embraced me with love and encouragement. After hearing my story, they did all they possibly could to support me.

Seeing them heartbroken and despondent, I regretted staying silent for so many years about this traumatizing experience. It is something that has greatly affected my life in all aspects, including my relationships with those closest to me.

I write this to tell you that silence can be deadly.

Oh, how my thoughts consumed me and my mind in ways I cannot even explain. What I can say is that the impact was devastating and abhorrent to the point that it almost lost me all the truly important things in my life.

Today is different, and I am different. I urge everyone to SPEAK UP. It can be out loud or written down. However you choose to do it, let it all out and make your voice heard. Confide in people in your life you can trust. Allow them to listen to you and help you. Accept their help and support.

Do not let fear or shame hold you back.

I would say to anyone reading this and suffering in silence – try to acknowledge all that happens in your life, both the good and the bad. And most importantly of all, never ever think that you are beyond repair.

Depression

Sitting in his passenger seat
Enjoying chocolate ice cream in the scorching heat
I felt my heart pound
Like I was being drowned.

This feeling, so strong
Like everything was wrong
Taking my breath away
As though it was my last day.

Opened the window, gasping for air
Suddenly lost in regret and despair
He didn’t notice what I was going through
How could he? It came out of the blue.

I didn’t know what it was
I thought loneliness could be the cause
Ignoring the symptoms like nothing happened
I never knew depression could make me so saddened.

Now I stay awake for countless hours
Struggling to sleep under beautiful stars
I think of that day in his passenger seat
Enjoying chocolate ice cream in the scorching heat.

Read more of Fatima’s poetry

One Woman’s Experience of Workplace Anxiety

After almost three years of working multiple near-minimum wage jobs, a seemingly great job opportunity finally fell into my lap.

Happy ending? Not entirely.

The emotional scars from working 14-hour days, still stressing over rent, and having a male employer who didn’t respect me began to take their toll.

Some say everything happens for a reason. Now that I’m doing better, I can perhaps agree more with that sentiment. I quickly realized I wasn’t the only woman to have experienced workplace anxiety, which made me passionate about sharing what I learned with others. Here are four lessons I took away.

1. Women still aren’t equal in the workplace

Legally, employers can no longer discriminate on the basis of sex, but in reality, behaving exactly the way men do at work can cost women their jobs. I’ll never forget my former boss hearing a male coworker literally screaming very inappropriately at a customer on the phone and just walking by. But should my own frustration lead to so much as asking for some assistance, I’d receive responses like, “It’s not rocket science, honey.” 

Anyone who watched the confirmation hearings of Brett Kavanaugh witnessed the way that men who display emotion are frequently rewarded, while women who do the same are derided and dismissed. Dr. Christine Blasey-Ford maintained perfect composure during incredibly harsh questioning and was disbelieved. Kavanaugh sat on the stand alternately hollering and crying and earned a Supreme Court appointment.

2. Anxiety takes many forms for women

Everyone worries now and then. Those with anxiety disorders differ in that the feeling doesn’t fade even when no external stimuli warrant the worry. Those suffering from general anxiety disorder often see the worst possible outcomes when making workplace decisions. Others may experience panic attacks, and those with PTSD react disproportionately to certain triggers.

In a world where women are frequently labeled as “too emotional”, “hysterical” or “crazy”, I’ve learned to manage my anxiety disorder in ways men may not have to worry about. I’m certain this varies widely depending on the situation, but my own experiences still hold true.

3. High-achieving women often suffer internally 

My performance at work matters greatly to me and I’ve always gone above and beyond. Hearing about my achievements can make some people skeptical that I’d suffer insecurity and anxiety.

The truth is, high achievers suffer from anxiety disorders at alarming rates, as they thrive on external stimuli like earning the top bonus tier or a big promotion.

The therapist I could finally afford spent several sessions teaching me how to honor myself without comparing myself to others. I’ve come a long way, but it’s important to note that I’ve always worked in creative fields, which are known for being friendlier toward women. I can only imagine what high-achieving women in grievously gender-imbalanced fields feel when they have to constantly compete with and compare themselves to their overwhelmingly male peers.

It’s also interesting to note that in a US-study, 88% of women reported in 2018 that they frequently compare themselves to others. Half of those then said that the comparison generally comes out unfavorable in their eyes. Meanwhile, only 65% of men reported regularly comparing themselves to others, with 37% deeming the comparisons frequently unfavorable.

Additionally, another 2018 study found that men tend to have higher opinions of themselves than women do. Is comparison a uniquely female trait? Not altogether, but our society puts significant pressure on women to look and act in certain ways, and the resulting anxieties in women speak volumes.

4. Anxious women also suffer depression

Many women experiencing workplace anxiety have a comorbid diagnosis of depression. It makes sense. After all, no matter how good you are, someone is always better, a fact that drives anxious people to despair.

Interestingly, the same neurotransmitters influence both anxious and depressed mental states. As such, antidepressant medications often do double duty by helping to balance these brain chemicals. It’s unfortunate, though, that our culture can drive so many to develop depression and anxiety disorders they may not have otherwise had, but now have to learn how to treat.

Breaking Free

It took a lot of work, but today, I can sleep through the night instead of lying awake replaying every professional interaction in my head. While I still strive to excel, I’ve learned to forgive myself when I have an off day.

Anxious working women would do well to examine the many factors that could be at play in their workplace to ensure that they are being valued as they deserve to be.

Tips for Supporting Someone Experiencing Depression

After I shared a list of the tools helping me handle depression, I started to think about what my experience has taught me about helping other people.

Do you know someone suffering from depression? If you do, it can feel difficult to know what to say or what to do. Based on what I’ve learnt so far, here are my tips for supporting someone you care about.

Dont…

…tell them to toughen up. Believe me, they are already trying their best. Being told to “fight back” or “be stronger” only makes you feel much, much worse. It is difficult to trust someone who clearly believes that you are not trying hard enough or that you are just ‘pretending’ to be miserable.

…judge them for taking medication. You can be sure that they have discussed doing so with professionals and made an informed decision. They don’t need you to decide whether or not their pain is ‘important’ enough. Someone once shouted at me and said she didn’t think I could be ‘unwell enough’ to need pills. Luckily for her, she was not in my head, so she could not feel my pain. None of us can really know what is best for someone else. 

…force them to go out, party or cheer up. Some days, it is simply impossible to fake it. So, unless you want to see them break down in tears in front of everyone at the party, drop it. Let them choose to hide for a while, be gentle. Just show them you are listening to them and there for them no matter what.

Do…

…be patient. Accept that they will have bad days, that their mood might change, and that they might refuse to tell you anything for now.

…pay attention and ask questions – gently. Check if their appetite has gone up or down, ask them about their sleep – a lot of symptoms are invisible. No one around me could ever even imagine that I have had suicidal thoughts, but I have. Try not to make assumptions about your friends, some people are really positive and enthusiastic, but it doesn’t mean they are at peace within themselves. Some of us have become masters at hiding pain.

…remind your friends to take some ‘self-care’ time and do it with them. Sometimes watching a movie, sharing nice food and going to bed at 9pm with your friend is just perfect.

…encourage them. Congratulate on every little step. Sometimes getting up in the morning is so hard. Opening up about their pain and feelings is hard. So if they trust you enough to open up to you, be grateful and proud of them.

…remember you don’t have to say anything. It’s very hard to find the right words to comfort someone. Sometimes it can be ok just to listen and be present.

…break the stigma. Every time you hear any of the followings, please speak up. For the sake of everyone, let’s make these false statements stop: “people who are depressed are weak”, “depression is a white person’s problem”, “you must experience difficult or traumatic external conditions for your depression to be valid”

One final point – remember to check on the men and boys around you. They feel pain too but gender norms and inequalities might be making it very difficult for them to open up about it!

Opinions and experiences published on girlsglobe.org are not medical advice. If you are struggling with your mental health, please seek professional help from a doctor. 

If you are experiencing suicidal thoughts, or if you know someone who is, please reach out for help immediately. Suicide Stop has a list of suicide hotlines worldwide, which you can find here

My Not-So-Easy Mental Health Recovery Journey

I’ve noticed that many of the stories I encounter about mental health tend to focus either on the darkest moments or on the triumphant ones – including the stories I’ve shared myself. In between those two opposites, however, there is a long road of treatment, recovery, and daily battles, as well as a lot of gray days that are neither too dark nor too triumphant.

Here is something I wished people knew about my mental health recovery journey so far…

If I say that I see a psychiatrist, take medication and have weekly therapy sessions, it does not mean that I’m always ‘well’ (much less ‘cured’).

I’ve had many people congratulating me for getting help and saying that they’re glad I am working with professionals to address my mental health conditions. But the truth is, doing these things doesn’t mean I’m always well. I still have bad (and even horrible) days, but treatment and recovery have helped me gain skills and tools to better deal with those days.

It may seem ‘easy’ to take medication and go to therapy. But what people who’ve never been on this journey may not know is that treatment for mental health conditions is very difficult, and it’s work — a lot of hard work.

It’s very ‘easy’ to take my three daily pills – one gulp of water and it’s done. But it’s not easy to deal with side effects, and medication changes, and how expensive they can get sometimes even with health insurance. And then there’s dealing with health insurance issues, and not being able to go out with colleagues after work because I have to stop by the pharmacy which is far away.

I have to keep tabs on my medications to make sure I never run out and organize them weekly into my medication container. I have to make sure I don’t forget to take them with me when needed and reach out to my psychiatrist when I need refills — all of which takes time and energy to do; and energy is not something I have much of when struggling with anxiety and depression.

I’ve changed medications several times and have experienced difficult side effects both starting and stopping medications: severe nausea, headaches, and increased anxiety that left me bed-bound for days.

I even had a pretty serious reaction to one of my medications that scared me – my provider couldn’t explain it. Because of how that experience destabilized me, there was even a moment when going into a psychiatric unit was a real possibility (which would have meant taking leave from my internship and master’s program).

Therapy has not been any easier. It’s expensive for me and a weekly commitment means having to say ‘no’ to more enjoyable activities. Therapy has been challenging and uncomfortable. It pushes me out of my comfort zone, which is hard to do even when my comfort zone has been harmful to me. It challenges my thoughts and behaviors. And in all therapy settings I’ve been in, I’ve always had some homework to do during the week (on top of all the work I have to do as a Ph.D. student).

I don’t regret getting help for my mental health, but I do wish someone had told me how long and difficult the journey of treatment and recovery could be.

Sometimes, I feel like quitting. I feel like never going to therapy again or canceling my next appointment with my psychiatrist, because the truth is, I’m tired and recovery is exhausting. I can’t make any plans or decisions without considering my treatment: how is it going to affect my therapy schedule? Will I have enough medication for this trip?

I will always encourage people to reach out for help if they are struggling with their mental health — it is important, and can be life-saving.

But I also believe it’s important that we start a conversation about what ‘getting help’ is actually like — and the truth is that it’s hardly ever easy.

It’s a sacrifice and for some, like me, it’s a life-long commitment. It’s challenging and uncomfortable. And through it all, we’re still experiencing our mental health conditions. It’s having a panic attack and going to therapy anyway. It’s going through a depressive episode and still getting out of bed for a psychiatric appointment.

Recovery for me has been still struggling but knowing I’m not struggling alone.

And though the journey is long and hard, treatment and recovery have given me hope and strength to carry on.

Opinions and experiences published on girlsglobe.org are not medical advice. If you are struggling with your mental health, please seek help from a doctor or mental health professional.

If you or someone you know is struggling with suicidal thoughts, please reach out for help immediately. In the United States, call 1-800-273-TALK (8255) or text TWT to 741741. For a list of international suicide hotlines, visit www.buddy-project.org/hotlines.