Is the Internet making you ill?

It's a valid concern in the attention economy we live in - Who is drawing this attention? What emotions are they evoking? What product are we being warmed up to buy? Essentially, who is capitalsing our attention?

Consider the frequency with which mental illness terms are hurled at us as we scroll Instagram or the social media platform of the minute. Most of us are likely to identify with at least three out of the five symptoms listed. We are constantly vigilant for "triggers" and have decided we are ‘ADHD' on Thursday and ‘Borderline' by Sunday. Mondays are for anxiety attacks.

The concern is exacerbated by the fact that towards the end of his days, Dr Keith Conners expressed misgivings about how loosely the label ‘ADHD' (Attention Deficit Hyperactivity Disorder) was being applied to children in the United States, leading to liberal medication for it. Conners devised the 39-item questionnaire - called the Conners Rating Scale - for diagnosing and treating ADHD. It has become the worldwide standard for assessing the severity of the disorder that's characterised by trouble paying attention and controlling impulsive behaviours.

As the popularity of the scale grew in the late 1980s, psychiatric drugs such as Adderall and Concerta were widely prescribed to the point of an epidemic of overmedication. They became study aids for any striving student, diagnosis or not.

Dr Zirak Marker

The Indian psychiatric drug market, though small, will be the second fastest growing market up to 2023, expanding at an annual rate of 13.4 per cent. In 2019, the market was valued at around $1.6 million; by 2023, it is estimated to be worth $2.5 billion (as per The Business Research Company).

Are we headed to an epidemic of overmedication too? Not yet, say mental health professionals. "It's not just the mental health industry," says psychologist Salma Prabhu, "The pharmaceutical lobby jumps into benefit from any and all perceived illnesses. However, luckily in India, when I see articles or advertisements by them on the Internet, they link the browser to a mental health professional they can connect to. That is a better option."

Dr Neeraj Ravani, a neuropsychiatrist, points out a crucial detail: Pharma companies can't sell psychiatric drugs directly to patients; they have to be prescribed by a qualified doctor. "If a patient comes to me and says, ‘Doctor, I took a test on the Internet and I have ADHD, please give me medication', I would use my clinical judgment, run some tests and get details from parents, if possible, about the patient's childhood," he says. "S/he may have anxiety and I write a prescription accordingly. Just anxiety could also shorten attention span and cause memory difficulties."

The first step of psychological diagnosis is rating the severity of the disorder on the DSM-5 scale. The Diagnostic and Statistical Manual of Mental Disorders is a tool and reference guide to diagnose, classify, and identify mental health conditions. "The measures are Mild-Moderate-Severe," says Prabhu, "Only a qualified doctor can prescribe appropriate medication; much can be managed by a change in lifestyle and dietary changes, as well REBT [Rational Emotive Behaviour Therapy]. I don't even accept learning difficulties - most children can be integrated into mainstream education using play therapy or changing their diet, if caught early."

Salma Prabhu

Prabhu resists "labelling" any mental discomfort promptly. "We assess the patient's reliance on escape mechanisms such as impulsive shopping or eating, and daily functioning abilities," she says.

But we're not in the clear yet. Perceived symptoms of mental illnesses do drive us towards impulsive consumption. "When you are playing Candy Crush and winning," says Prabhu, "you experience the rush of dopamine release." The neurotransmitter cultivates an intense feeling of reward; it's in our nature to prolong this rush, which shopping, eating or just smelling freshly-baked bread can do. Our RAS [Reticular Activating System] also comes into play here. You know why you feel a surge of relaxation when someone kneads the base of your neck?" asks Prabhu. "That's where the RAS is. It filters incoming stimuli and keeps you motivated to behave in a certain way."

Back to your last life on Candy Crush: "Then pops a message saying you can get six more lives just by watching an advertisement. Most likely, the ad will be about something you have recently been browsing, and of course, you will buy it."

Not just dopamine, architects of consumerism also efficiently utilise negative emotions. You see posts validating your stress or "hard day"; it could have a list of symptoms that you identify with, not because you have the disorder, but because they are normal life challenges. Then come posts promoting self-care through a beauty regimen or a cupcake. "You tell yourself ‘I deserve at least this much'," Prabhu says. "Food, especially, gives instant gratification. Even more so after the pandemic because there are so many new colour kitchens and home chefs, and delivery services. You tell yourself you deserve ‘at least this much' because you work so hard; but don't question why you work so much."

According to her, a real self-care process is acknowledging the problem, identifying and reducing exposure to triggers, and making a plan that includes rest, a therapeutic activity such as painting or dancing and stress-reduction techniques such as breathing exercises.

On the whole, mental health professionals are glad for conversation about mental health and the reduction of associated stigma in society. "When I started my practice 22 years ago," says Ravani, "A patient would turn back from the waiting room if s/he saw someone s/he knew. Now, patients are told by family, partners, colleagues, and friends to seek help and given references."

Eventually, the proof of the pill is in the relief. "So many molecules [medicines] do well in research but die out in the market," says Ravani, "because they don't work in real-life scenarios. If my patient does not feel better week on week, I have to change the prescription. Eventually, the molecule will die out."

Another reason we are not at peril of being over medicated yet like in the West, is the difference in how pharma companies woo doctors in the USA and here. Dr Zirak Marker, who works with children and adolescents, trained for two years in New York City, before building a 20-year practice in Mumbai. "They really court you aggressively there. They wine and dine you, fly you to free seminars and workshops. In India, they sit in the waiting room until you give them five minutes. They have just enough time to give you relevant information: Tell you about the new molecule, what clinical trials have proven, whether it is FDA-approved and what it can be used for. We take the literature and go do our own research," Marker says about pharma sales representatives.

We don't have the fulcrum of health insurance policies that the US has, to tilt the scales in favour of pharmas. A New York Times article dated July 13, 2017 lays out how the reckless prescription of stimulant drugs made ADHD look like an epidemic, much to Dr Conner's regret. "In 1991, the United States Education Department made students with ADHD officially eligible for special education, which accelerated rates of diagnosis, and drugmakers have aggressively marketed their products to parents, doctors and adults who think they have attention deficits.

But in a 2013 interview with The New York Times, Dr Conners… expressed dismay that some 15 per cent of high schoolers reported having been given an ADHD diagnosis… This is a concoction to justify the giving out of the medication at unprecedented and unjustified levels."

India, fortunately, is not aping the West in this case yet. "Most of us old doctors," says Dr Marker, "are conservative about prescribing medication. I can't meet a patient for five minutes, diagnose, label and prescribe medication. I need at least 45 minutes, and most of us have a holistic approach. If medication is needed, we list out the pros and cons and address fears of dependency, side-effects such as weight gain and addiction. Depression needs at least six to nine months of medication; I explain that it's just like taking tablets for Vitamin D3 deficiency; it works on the symptoms but does not take the underlying disorder away. That needs therapy and life-style changes and management."

Self-diagnosis is quite common, he admits, especially among the youth. "They ask their parents to take them to a psychiatrist after filling out a multiple choice quiz online," he says, adding this is why he is grateful for our habit of a second or third opinion. He cites the example of a 17-year-old patient who had been prescribed medication for bipolar disorder after a 15-minute consultation with another psychiatrist. We decided not to put her on medication and relied only on psychotherapy and is on the mend. After all, one can't change one's reality. But a holistic approach to mental health equips us with the tools to control our reaction to it.

13.4
Annual rate at which the Indian psychiatric drug market is expanding according to The Business Research Company