Flat World Psychiatry

Earlier this year, I was in Bangalore on a brief vacation, eager to see India’s recent economic progress first hand. I was not disappointed—new flyovers, crowded shopping malls, gleaming glass buildings—the city was almost unrecognizable. One pleasant evening, I was sipping a particularly tart Mojito at one of Bangalore’s many new nightspots.

The place was packed—confident and hip young things milled around the place, laughing, flirting, dancing, drinking, as a DJ in the far corner mixed house music. It was about 9 o’clock on a Friday. I had paid 1000

rupees—about $25—as cover charge; a cocktail was $8, and food started at $20 an entrée. People sat on low-lying beds arranged around a pool in the center, reminiscent of lounges in South Beach.

“Bangalore’s changed a lot, man,” I remarked. “This is more like Miami than Miami itself.”

Anand, an old school friend of mine, now a successful architect, nodded, waved his hand around, “Yeah, but don’t let it fool you. These guys aren’t really happy. Everyone’s stressed out of their minds. I mean, did you ever hear of divorces in India before? Now almost everyone I know is divorced!” With a start I realized that 3 out of the 5 at our table had been through a divorce.

“How’re things at work?” I asked Mahesh, a high school classmate who was now the marketing head of an American company with opera-tions in India.

“Busy, man. Very busy. Next week I’m off to Singapore, then to London, and DC in August. It’s crazy.” He grinned. “But the real stress is not work but my love life.”

I had attended his wedding almost 10 years previously, when he married his high school girlfriend against his parents’ wishes. They had divorced recently, and he was now dating again.

“I thought you were seeing that journalist?”

He shook his head. “I almost miss my ex, it’s that bad. They’re too independent these days. This girl, she doesn’t want to have kids, she doesn’t want to get married. She doesn’t want any kind of commitment, man. Get this. She tells me, ‘We both have busy lives. When we are free, we’ll hook up. Just don’t get sentimental on me.’ ”

He shook his head and smiled, managing to look regretful and proud at the same time.

A few days later, I was driving my father-in-law’s new sedan through peak Bangalore traffic. My wife was sitting next to me, trying to stifle her gasps as I edged past the cars and bikes, buses, and autorickshaws.

My son sat in the car seat at the back, blissfully unaware of the drama outside. The distance from my in-laws’ to my parents’ was only 10 miles, but it had already taken us more than an hour.

“Almost there,” I said to Ashwini.

One more traffic light, a last stretch, and we would be home. A space about 4 feet wide opened up, but as I tried to squeeze past a small Suzuki on the left, we heard a scraping sound over the din of traffic. The other driver, a big swarthy man with a large moustache, began to scream obscenities, threatening dismemberment because I had scratched his car.

I reacted in the time-honored way, shouting back a few obscenities of my own. He gesticulated wildly, indicating that I should pull over, but I couldn’t do that with the traffic coursing all around us, and besides, his demeanor wasn’t exactly reassuring. I motioned for him to follow us and continued through the traffic. It was a sign of progress, I thought, that no one had taken the slightest notice of our skirmish. This was vastly different from the India of the past, where the slightest altercation on the road would draw, within minutes, a large enough crowd to fill a small concert arena.

The Suzuki followed us through the traffic, and I could see the man in the car, still shouting and shaking his fist, agitated and sweating, while his wife and children sat in silence. Maybe I’d been away too long, or maybe I’d spent too much time practicing psychiatry, but I found myself thinking: Why is the man so angry? What was it exactly that this man was so angry about?

I stopped the car at the side of the road, and he screeched to a halt, a good 50 feet ahead. “You bloody fellow!” he shouted. “You buy big-big car and you don’t even know how to drive. Come here and look what you did.”

“Before I do that, please calm down. What’s the problem? Why are you so angry?” I said, as if in some surreal clinical encounter, where I was ineffectually trying to calm an agitated patient.

He blinked for a moment, his rhythm thrown, then recovered enough to shout, “Problem? You are the problem. Rich fellows driving without looking.”

I felt a sudden anger in the pit of my stomach. Therapeutic approach be damned—he wasn’t my patient. “You better learn some decency—”

“Decency?!” He charged toward me. “I will show you decency.” He pushed me hard, and I staggered a step back.

His son, who was sitting in the car, shouted, “Appa!”

I reacted instinctively. Furious, I made a motion to push him back, when the absurdity of the encounter struck me, and I stopped myself.

We stared at each other for a few seconds, and then I broke the silence. “Look,” I said in my less-than-fluent Kannada. “This is not worth fighting over. I will take care of the damages.”

“It’s your fault. You should have looked where you were going,” he said belligerently.

“That’s right; it’s my fault.”

That seemed to deflate him, and by the time we exchanged insurance information, the mask of anger had dropped and I saw him for what he was—a family man, on his way home, burdened by the stress of living in a city where a new wave of young software engineers and entrepreneurs flaunted their money, trivialized his values, and diminished his self-worth.

The following week, I called a friend at a local hospital. She’s a psychiatrist, one of only about 50 in Bangalore, a city of 6 million people. “Lots of depression and anxiety, but people still don’t like to go to psychiatrists,” she told me.

“So who treats them?”

“If they go to a doctor at all, it’s usually to a general practitioner, who will often prescribe some Valium.”

Now that I was looking for it, I could see portentous signs everywhere: hardworking corporate couples who spent very little time together, tales of rampant affairs at the workplace, reports of suicide in the newspaper almost every day, road rage, escalating violent crime.

I looked up the statistics online. They were appalling. India has the highest suicide rate among young people— more than 10 times the average suicide rate in the Western world.1

On our flight back, I looked out of the window at the sparkling lights of Bangalore that extended in every direction, announcing India’s arrival as a major economic force. It is a flat world now, as Tom Friedman writes2 globalization is here to stay. But on this visit, I realized that globalization extends not just to the economy and business, but to social change, and therefore to psychopathology as well. Two-fifths of the world’s population are facing an unprecedented challenge to their sanity, as everything that defines them—social norms, institutions, values, modest aspirations—is dismantled by the flat world. Unfortunately, the flat world analogy does not extend to access to psychiatric services, or to awareness about mental illness, and those suffering have to manage largely without the help of mental health professionals— India has only 3000 psychiatrists for a billion people.3

This is the flat world of psychiatry. Across the globe, people are richer, but unhappier. They carry an iPod in one pocket, and a Valium in another.

 

REFERENCES

1. Aaron R, Joseph A, Abraham S, et al. Suicides in young people in rural southern India. Lancet 2004;363:1117–1118

2. Thomas Friedman. The World Is Flat: A Brief History of the Twenty-First Century. New York, NY: Farrar, Straus and Giroux; 2005

3. Das M, Gupta N, Dutta K. Psychiatric training in India. Psychiatr Bull 2002;26:70–72