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It is the absence of positive emotions rather than presence of negative emotions that is related with morbidity - Dr. Russell De’Souza
Helplessness and hopelessness has a higher correlation with suicide than being depressed
Traditionally clinical research was always kept in the ivory towers of academic
institutions in the West but now it is moving to developing countries

LONDON: Prof. Russell D’Souza is a Director of Clinical Trials Research and Bipolar programme at Northern Psychiatry Research Center of Melbourne University Australia. He is also Vice President of South Asian Forum on Mental Health and Psychiatry which  has seventeen chapters around the world starting from South Asia extending up to North America and Australia. He is also treasurer for the section on Development of psychiatry in developing countries of World Psychiatric Association besides being on the Executive for section on Disaster intervention which is an important section. Dr. Russell D’Souza was recently in UK to participate in the Midland Psychiatric Research Group’s annual meeting held at Covnetry.  During the conference he talked to Mr. Shaukat Ali Jawaid Chief Editor of Pulse International and discussed a wide range of issues. Given below are the excerpts from the conversation:

Dr. Russell De’Souza

From where and when did you graduate and how your professional love affair started with psychiatry?

I had my undergraduate medical education in India and graduated from Madras Medical College in 1977. I have been in Australia since 1982. Originally I was thoracic physician specializing in tuberculosis and chest diseases at Madras Medical College Hospital. I came to Australia and could not get a position in that field. I got a job and found my way in to Psychiatry. Did DPM from Melbourne University and then did my Masters in Psychological Medicine and had my training in psychiatry in Australia. I had subsequent qualifications in psychiatry from USA besides having graduate diploma in clinical trials management which is a part of what I do now which is regulatory research.

My entry into psychiatry was just by accident. But having come into this field I have realized the importance of psychiatry, psychological understanding and under pinning of human psyche which brings satisfaction in people’s lives in illness and health. It is an extremely important branch of medicine that ultimately helps bring meaning and purpose but also helps human beings in most developmental tasks of mortality that we all have to succumb.

Photographed during the Midland Psychiatric Research Group meeting from (L to R)
are Mrs. Pedro, Prof. Pedro Ruiz President APA, Prof. Russell De’Souza
and Mr. Shaukat Ali Jawaid

What is your special interest in psychiatry? You talked about positive emotions. Would you like to throw some light on that?

My area of interest has been bipolar disorders. The real issue has been again coming from my personal experience in 1998. I was busy like every body else and went for a routine check-up which I did not had for five years. I just went for ECG.I ran up and had ECG and was running out when I was stopped and called out and told to come in. I thought they were making a mistake. In fact I was infracting. Instead of referring to a specialist, I was put into a wheelchair, sent straight to coronary care unit and there goes the story of dramatic shift from in control to out of control. That incident made me think again. That was the time I moved away to an Australian  remote country town and set up a research center. It was here looking at the original aborigines Australian how they confronted  difficulties  including  suicide of one of their child, how they were able to call upon the spirits of their forefathers and  find coping whereas we were going to offer de-briefing and techniques that we were used to. When I stood back what I found and watched the age old traditional way of dealing with significant loss of twenty-one years old grandson jumping off while he was admitted in our hospital. That struck me that there are coping strategies every culture had and we should be using that or adding value but not completely removing it and saying that  what we know is the best. So that was the start of what I started doing in 2000 bringing focus on spiritual issues for patients and for human beings. Living in a country like Australia where it is a taboo, I did the first survey on patient’s attitude and needs which was done for the first time in Australia. It was published in 2002 and it surprised every one because 79% of the patients surveyed said that it was very important or important.  They also said that their belief system whether it is spiritual or religious help them cope with psychological pain. Almost 70% of the patients surveyed said that it was helping them cope with pain. And yet they came to see us and we never asked about coping strategy. I did another survey with doctors and psychiatrists who were treating this population. Only 10% of doctors said it was important as opposed to 79% of the patients. So I then coined the term “spiritual gap”. That is the first time this terminology was used. I thought psychiatrists in Australia might be having a spiritual gap with their patients. If we have to help the patients then we cannot be so far apart, something which is so important to the patients but not to the doctors. It does not matter what the doctor feels .When I asked the 10% doctors who said it was important whether they have ever asked about it to their patients, I was astonished to know that only one out of those 10% had asked it. The remaining 90% said they knew it was important but they did not know how to ask them. They had asked them about sexual history, alcohol history but not about spirituality. Then we called it the practical gap that the doctors had. From then on there was a debate about its important. We drew a model how to take spiritual history that was sensitive, ethical besides fulfilling the requirements without any breach of ethics. From there on came the spiritually augmented cognitive behaviour therapy. I developed along with my multidisciplinary team, aboriginal leaders, elders and we developed what became known as “Spiritually augmented cognitive behavioral therapy”. It included sixteen sessions which focused on acceptance, hopes, looking at different types of hopes, finding meaning and purpose in one’s life and traversing the dimensions of forgiveness. People went through it. On the behavioral side we had some very good techniques. I used different types of meditations. We also brought in prayers. The patient had a religious ritual to whatever religion he or she belonged. This religious ritual was incorporated into the treatment. We encouraged the patient to do what they were doing. Every day they prayed and filled a form which was called the virtual monitoring sheet. After rituals they were asked to take their medications and note from one to five how they felt after praying. How they felt after taking medications, how this ritual has helped them, side effects of that medication and how it helped them with hope. These were predominantly patients who were demoralized. Demoralization takes place when the people are not only depressed but also feel helpless. They go into despair. We may not see depression but we see demoralization. We did four randomized controlled trials and showed it to be statistically and clinical superior to the controls even comparing it with CBT. While there was no difference in depressive symptoms, there was superiority in quality of life. That is how the concept of well being came in. Now there is lot of literature and scientific data on fostering well being. We found that well being and spirituality are intertwined between some of the spiritual exercises. Both of these deal with positive emotions.

Positive emotions mean being happy, optimistic and joyful. Negative emotions include anger, anxiety and frustrations. What we are seeing is very clear. Now evidence suggests that absence of positive emotions has got a higher correlation with morbidity leading on to mortality.  It is the absence of positive emotions rather than presence of negative emotions that is related with morbidity. Helplessness and hopelessness had a higher correlation with suicide than being depressed. We know from studies that some one who feels hopeless has much higher chance of killing himself than some one who feels depressed.

Positive emotions can be fostered as it is associated with well being.  There is some new evidence by Prof. Robert Cloninger from Washington. He is working totally in well being. They have found that there is a temperament characteristic inventory that can actually look at character which shows higher correlation with wellbeing. We talk of three things one of them is transience being able to go higher than oneself. The other is sense of cooperation which is looking at such things as virtues and compassions. Some of these factors are areas where we can train our patients. We can teach general public to enhance what we call temperament characteristic inventory. If we can increase that then we have a chance that we are working towards positive well being. It has now become very important that we are not only fighting to keep disease out but  it is more important to look at well being and what this reflects on self motivation and general positive emotions. Despite set backs we seek physical, financial, psychological, social coherence or a sense of equibilirium.

It is almost a ritual that after consulting a doctor the patient is handed over a prescription containing medications. What about the acceptability of a prescription or advice which does not include drugs as treatment modality?

There is evidence that patients are also seeking about well being and total holistic care. We know that from 1955 till to date we have brought into psychiatric practice many psychotropic medications. We have manualized psychotherapy. While it has helped in the acute stage there is rapid relapse and recurrence.  After all that we have done, the improvement in patients in general wellbeing is marginal because most of these patients while may have some remission in symptoms, they have no remission in their functions. One of the studies recently showed that in first episode schizophrenia patients,  the drug was very powerful atypical as regards remission of symptoms. Twenty five years later more than 50% of them did not even have a partner which shows how their function has been impacted on in terms of psychosocial and in terms of occupation. So all medications, including psychotropics are doing a very small part of the job. There are two dimensions when people get unwell. One is illness and we seek to cure the illness although we don’t succeed always in curing. Medical profession has been trained to seek to cure. There is another horizontal impact that is what does that illness does to the person. Like if some one has myocardial infarction, it is threat to life. The fact is that he cannot do things which he could do before. Even the jury cannot bring back infarction. That is the horizontal play which is called healing. Healing is the important aspect of total care. We know people come out of MI, they are stable and they take beta blockers, lipid lowering drugs, regulate their diet and have regular exercise. But they are failing to be a husband, a father. They are shattered and they have to deal with demoralization. That is where the healing takes place. There are very powerful healing arts associated with our culture. We have to bring in that concept of healing from different religions into the biomedical force. We have ignored these aspects and concentrated on curing at the cost of healing and the patient has to ultimately seek this elsewhere. Unfortunately in the process of seeking this avenue out we may get pathology spiritualized. Hence it is so vital that we as doctors  must be able to understand the spiritual needs of our patients. If we pathologize that as something not acceptable, they will still seek that and many go into wrong hands where their pathology will be spiritualized. This is a factor which impacts on poor endurance of treatment and ultimately no one gets better. This is another factor why we are beginning to see patients going for Non-Evidence Based Therapy. In other words we are finding evidence based scientific methods to be too true to be good.

Stigmatization of psychiatry even within the medical profession as well as public still remains a problem. What is the situation in Australia?

It is an interesting question. There was a study done in Australia by Australian National University. They did two surveys. In one they took two thousand people on the roads and asked them if they had depression, what they will do and they gave them a list of interventions. Psychiatrists were on No. 28. This is after so many years of education and training. Australia has spent millions of rupees on educating public on depression. Ironically we are second highest users of anti-depressants in the world after United States and we still are having an epidemic of depression. This study is important because it reflects what people feel. This survey showed that if a person is depressed, he or she will try twenty seven other interventions before consulting a psychiatrist. And surprisingly spiritual persons were ranked at No. 11.  At No. 1 was eat good food, exercise, have family and friends. In the second study they looked at what was the prognosis of someone who had schizophrenia. Again ironically the best prognosis and least stigma came from public on the road whereas lowest came from the psychiatrists. The mental healthcare professionals rated that they had no hope. This is a very interesting finding which was published and the main investigator got award for this landmark study. This study is very interesting because it tells you where it starts. This study showed that the most negative thoughts about schizophrenic patients were at the level of psychiatrists. As a matter of fact these psychiatrists and their views about psychiatry is a problem that we face in both developed as well as developing world. Stigma continues to remain a problem. The importance of psychosocial rehabilitation specially in the West  cannot be over emphasized because we have lot of medications, patients are given costly medicines, they are forced into having medications but the true needs of the human being is not there because  there is no family and no need for work. So they are getting unemployment or are on pension. As against this I saw a patient in one of the remote villages in India who had schizophrenia. At times this fellow gets psychotic, at times he goes out of his head and rest of the time he was kept in the hut with his wife and he was doing work along with his children. Sometimes they told me that he was even chained up. Even in that chained conditions, his needs were better met as he was fulfilling the role of being father, cooking for his child and when he got sick, that chain was there to hold him down but rest of the time he was getting what is so important the human requirements to keep him going. When such a change comes into the society and these people are accepted, it will reduce stigma.

What about the Association of Clinical Research Professionals.

That is a very interesting area. I am Secretary of Section on Research for Psychiatry in developing countries. One of the things I have been looking at research per say is what are the priorities for research in mental health in developing countries? The questions being asked in the developing world are different. Presently developed world is doing lot of research. That is being translated and being accepted or not accepted. But there is lot of things in developing world which needs to be researched and brought back. I am talking about cross fertilization wherein we have people from the developed world taking part in collaborative research in the developing world.

Regulatory research is a very vital form of research. It is this research which brings new molecules onto the registration process. Just imagine if we did not have some of the medications for schizophrenia or depression, where we would be? Traditionally this was always kept in the ivory towers of academic institutions in the West.  Recently this has been moving out and these studies are governed by legislation in every country. Two major forces are the American FDA and the European Drug Authority.  We now see a big move towards the developing countries for many reasons i.e. the quality of research has improved a lot, some of them talk English and they have lot of patients which they can recruit unlike in the West. It also brings with it lot of finances. Each study costs between thirty to forty million dollars and it is initiated in thirty forty countries simultaneously. Developing countries must take part in this research activity which is regulated research activity under legislation. It is governed by high ethical requirements. Informed consent process is very rigorous, confidentiality, autonomy to continue and to withdraw from research. This will bring in requirements of good clinical practice which is helpful both for patients and academic medicine. In the past all the drugs in clinical trials used to be tested on patients in the developed world but now patients in the developing countries will also be included and we know that there may be some differences. Some drugs cleared in the developed world as safe had some problems in the developing countries. We will also get a core group of good research staff and some of them might take it up as a career. It will also offer opportunities to those interested in clinical research to join pharmaceutical companies as Clinical Research Associates. Safety and efficacy of the drug is carefully monitored in the trials.

What has been the contribution of South Asian Forum on Mental Health and Psychiatry?

This is an amazing concept which Dr. Afzal Javed and his colleagues started and I along with him have been passionately following. All these regional countries are being treated as important in their own right and all of them have something to offer. We are not going to wait for bodies like WHO and WPA to come and do certain things. With good will and fortitude and following the concept of brain circulation we will contribute whatever we can. Many of the South Asian psychiatrists are leading and occupying important positions in USA, UK, Europe and Australia. There are over fifty thousand Indian physicians in United States. In addition there are eleven thousand medical students in United States who are of Indian origin. So far it was said it is brain drain. In the era of globalization no one can stop the economic pull. We in the South Asian Forum came up with the idea of brain circulation. We believe that you are free to go but if you come back and give some thing to the place which trained you, it will be appreciated. We have been able to harness from America and UK some of the leading medical personalities to come to India, Pakistan and Colombo, make presentations and do some teaching and training. We ask every body to come back as they will also find something to learn from here despite the fact that they are working in the West. South Asian Forum on Mental has been able to do it besides improving psychiatry across the borders. Recently fifteen academic professionals from South Asian Forum went to Bangladesh and contributed a great deal to teaching and training activities. We had similar programme in Sri Lanka, we wish to do similar programme in Singapore, Malaysia and Nepal. All this is being done with a sense of commitment in a team work. This way South Asia will not only become self reliant but it will also bring us respect in the world. Discipline, Unity and Faith are the three building blocks of South Asian Forum and we have consistently used three pillars. We are determined to make a difference in this world.