I clearly recall seeing a young woman in the clinic during my psychiatry placement as a fourth year medical student at Shifa International Hospital in 2012. She was attending with her mother in law, who kept lamenting at the fact that “Sab kuch hai iss kay paas. Ghar. Gaari. Paisa. Mera beta khyaal bhi bohot rakhta hai. Par yeh khush he nahi hoti.” (Translation: She has everything.  A house.  A car. Money. My son takes good care of her too. But she is still unable to feel happy.) I remember glancing at the woman, who seemed so embarrassed of feeling the way she felt as if she had voluntarily chosen to feel low, anhedonic and hopeless. The silver lining of this experience was probably the fact that her mother in law had supported her to see a psychiatrist rather than a spiritual healer before just labelling her as an attention seeker. Sometimes we just have to celebrate the small wins.

Eight years down the line, working as a psychiatry registrar, in a time where transcultural psychiatry is actually a thing and the perceptions of mental illness in different societies is important enough to warrant a separate special interest group within the Royal College of Psychiatrists, I am still amazed at how crucial a role one’s ethnicity plays on their experiences of mental illness and its management all over the world.

When someone starts showing symptoms of a mental illness, they are often misinterpreted as black magic, the evil eye or hidden under the guise of a physical ailment. Everyone is quick to judge and label, because the concept of mental illness is deemed foreign and dangerous. As if it’s a justification for someone being unable to be a contributing and productive member of the society. Due to this, there is a high risk of patients becoming socially isolated if they do choose to share their difficulties with those around them instead of following the lessons of internalizing, tolerating and staying silent about adversities in life that have been handed down from generation to generation. When the symptoms are no longer able to be contained, the causality is linked to supernatural, religious or magical phenomenon. The response to this is contingent on the socioeconomic background and level of education as mental health professionals are mostly located in urban areas, which creates difficulty in seeking help and contributes to the stigmatization of the mentally ill.

Common misconceptions about the treatment of mental illness are deeply rooted and often difficult to challenge. Psychotropic medication is expensive and sometimes not readily available. In a country where benzodiazepines can be easily obtained and consumed like smarties, people easily lose faith in drug treatments that take longer. You often come across people who have become tolerant to high doses of benzodiazepines and therefore see little benefit in trying anything else, which is not as quick acting or sedating. Psychiatrists are seen as doctors, who want to keep their patients hooked onto medication that is expensive and does not work. The desire for a “quick fix” undermines the importance of psychotherapy. Going to a therapist on a weekly basis is hard work, logistically and financially. It is seen as a luxury rather than as treatment of a medical condition.

The stigma surrounding mental health is omnipresent. It is more so in developing countries due to the enmeshment of religious and cultural concepts of health and well being. It is easier to hide behind somatic symptoms rather than admit that one’s feeling vulnerable or overwhelmed as it’s seen as a sign of weakness or indolence. People suffering with mental illness are ostracized and shunned by society. In a society that strongly links treatment outcomes with the patient’s propensity to get married or divorced, there is widespread skepticism about mental health diagnoses and treatment.

And what about the South Asian immigrants settled abroad? Cultural and religious values travel with them to wherever they go. We as a society have been conditioned to keep our head down, be grateful and humble. These qualities can be great, but can also put us at a disadvantage as we can find ourselves internalizing stress and manifesting signs of chronic burn out without even realizing. Immigrants that are unable to express themselves eloquently in English might be misunderstood by services and their struggles misinterpreted or dismissed altogether. Common culturally acceptable coping mechanisms might be seen as deviant or pathological such as praying, fasting or observing other religious obligations etc.

The dialogue about the impact of racism on mental health has recently gained momentum. History and studies both prove that the concepts of pathological and non-pathological have been purely based on one race, with little attention given to variations of normal and pathological phenomenon in other races and ethnicities. These are difficult conversations that need to happen to challenge and change status quo.