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.

A Midwife’s Point of View: Breastfeeding

The contractions have ended and the only sound is the cry of the newborn little baby lying on her mother’s belly. The room becomes calm and relaxed as the family exhales and begins to recover. After a few minutes the little baby starts searching for her mother’s breast, pecking her little head back and forth, smacking her lips and making her very first sucking movements with her mouth. Using her legs to push herself upwards, she slowly moves towards her mother’s chest, and with the help of her mother’s gentle hand, her mouth finally reaches the nipple.

The breasts are well prepared. The first milk, known as colostrum, starts to be produced in week 18 of the pregnancy. It doesn’t feel like the breasts contain any milk. It takes approximately three more days until the real milk flows into the breasts. But this first milk is perfectly suited for the little baby. The baby’s stomach and intestines have only known the amniotic fluid and is now slowly but surely getting used to breast milk. This first milk contains substances that help the intestines adapt to a life outside the uterus and brings vital nutrients that the baby needs to grow.

The new mother is now holding her baby in her arms. The baby lies looking up at her mother, seeing her for the first time. They look at each other for a moment. The distance between them is just as long as the newborn’s small eyes may be capable of seeing and being seen is extremely important for the little baby’s continued psychological development. After looking at her mother for a while, the baby starts to cautiously and tentatively suck on her mother’s nipple. Being close, skin to skin, enables both mother and child to relax even more, as oxytocin, the natural, well-being hormone, flows like currents in their bodies. Oxytocin causes the heart rate, blood pressure, body temperature and respiration to stabilize in their bodies and causes the production of breast milk. This hormone also causes the mother’s uterus to contract, preventing her to bleed too much.

After sucking for a while on the breast, the baby falls asleep, exhausted but satisfied with both the birth and the first meeting with her family. Colostrum contains enough energy so that the baby now can sleep for a day and the new parents can rest.

The above scenario may be recognized by some women, but not by others. The description has been used to demonstrate the awesomeness of our bodies, and particularly, a woman’s body.

A peaceful breastfeeding start increases the chances of successful breastfeeding in the future.

As a licensed nurse and midwife, I meet women who breastfeed every day. Some do it with ease. Some fight through each feeding in pain, with babies who do not want to suck or babies who don’t want to stop sucking. Some women struggle without enough breast milk, while other women have too much milk. I also meet women who have chosen to partly breastfeed, or who, for various reasons, have chosen not to breastfeed. What is common for all women I meet is the incredible love they carry and the strong desire to do the best they can for their child.

It is imperative that we, as health professionals, are aware that our knowledge and treatment can be critical to how a mother succeeds in breastfeeding.

Becoming a parent generates a wide range of emotions: love, fear, anxiety, joy, sadness, loneliness, togetherness, uncertainty, fatigue, giddiness, and more. To breastfeed or not to breastfeed is not always an easy choice and to get breastfeeding to work or to stop breastfeeding may require professional help. My wish is that new mothers and their families receive the help and support they need, and are able to make informed and empowered choices, leading to results that works best for both the mother, the child and the family. Breast milk contains the best nutrition a child can obtain during the first 6 months of its life, but what is just as important is having a mother who feels well, is present, strong and confident.

Liza HenningThis is a guest blog post by Liza Henning, licensed Nurse and licensed Midwife. Liza works at the maternity hospital and the breastfeeding clinic in Malmö, Sweden.