Home   |  Issues  |  The Daily Star Home | Volume 5, Issue 94, Tuesday, December 8, 2009

 

 

Dusk

In ten minutes when the sky turns red some of you will go home. Dusk will fall into the laps of those riding home in rickshaws, the rickshawala will cycle the evening to your doorstep. You will step down, look through your wallet and find the dirtiest bill and give it to the rickshawala. He won't make a fuss. You will smell like salt and sunset.

You will knock on your door; the little boy that works in your home will open it up for you, avoiding eye contact. You will rush in, go to your room and look for your wife who will be in the next room showing your four-year-old her A, B, Cs. You will feel a sense of peace even though a few honks from the street will roam around the floor of your drawing room.

Your wife will look up at you and scream at the maid to make tea. You will not think she is beautiful, you will just think you can't imagine the world without her. She will have on a sari unlike her usual kameeze. You will steal a glimpse of her exposed stomach, you will want to steal even more and then the next second you will think you are being silly, how can you steal what's yours?

You daughter will interrupt your thoughts and ask you to pick her up. She will then give you a warm kiss with her body scented with jasmine and lavender. She will have on a frock you bought for her during your visit to Singapore, the only time you ever got to leave the country.

Your daughter would then put her head on your chest, you will think of the hair on your chest, some of which have turned grey in the last few years. She will call you Baba and tell you a thousand little stories. Your wife will smile at you and ask you how your day went.

In the shower you will spend ten extra minutes, preparing yourself for relaxation, and wondering why such a thing like relaxation would need any preparation. You will wonder about your health, about the way your tummy is growing, how your knees aren't as strong as they use to be. You will think of having another child, a second one before you are too old. And you will think of your pay cheques, cash and balances, think about if you will ever be able to purchase a car.

You will think Friday is still two more working days away and about your cubicle at work and the smell of morning shingaras and tea at your office. You will think of your co-workers and the layers of work politics, gossip and some bad jokes that each of your days consist of. You will think of the first day you learnt to control your tears and when you broke your best friend's nose fighting over your first crush.

And then the evening will no longer be the shade of red or blue. By the time you will come out of the shower everything will appear pitch black. The neon lights from the neighbourhood store will play tic-tack-toe on your bedroom wall, you will hear your wife telling the maid to make roti instead of rice for dinner, you will listen to your daughter sing Tagore with her little broken voice “kothau amar hariye jawar nei mana mone mone,” and then, precisely right then, you will surrender to life just like that every dusk.


November 10, 2009
Dear doctor,
I am writing about a serious problem of one of my friends. She is 28 years old. In the year 2007, she was suddenly diagnosed with a serious mental disorder. She faced symptoms like insomnia, paranoia, inattention, general distrust of people and would often burst into crying etc.

Her disease was termed as psychosis in medical terms. Doctors also advised involvement in work, exercise and socialising.

In the meantime she joined a job and got married at the end of 2007. But her medicine continued. Her doctor advised that her disease is comparable with diabetes and blood pressure. So to keep well she will have to continue medication for an unlimited time.

Now she takes one Perkinil (5mg) and one Eripra (15mg) everyday, which she has been taking for the last one year. Now she is thinking about discontinuing her medication and plan for pregnancy.

Will it be a wise thing to do? Can she go through pregnancy with her existing medication or will she have to stop taking any medicine? Is there any chance that the child will be born with mental disorder or any other such problems? Please help.
- Sania Afroz

Dear Sania,
These are very relevant questions but I'm aware of the hidden risk of breaching the confidentiality of a particular person's medical record. Exact diagnosis, prognosis, drug history, and risks on pregnancy - these are one's very personal information. Fighting against social stigma about mental illness is an uphill battle; assessing any chance of victimising the person with the medical information is an ongoing challenge in case management.

In order to ensure compliance to medicine, it is essential that there is satisfactory communication between all parties. A patient has every right to ask relevant questions to the concerned doctor, and the doctor owes the patient a reply no matter how busy she/he is.

Symptoms you have mentioned here (insomnia, paranoia, inattention, general distrust of people etc.) are not enough to be conclusive about any particular diagnosis.

Psychosis is a pretty broad term and is more likely to be used as a preliminary diagnosis. It is more indicative of the nature and intensity of symptoms manifested during the episode.

Usually a complete psychiatric assessment - which comprises of history taking and mental state examinations, medical investigations with or without an observational period - often enables the psychiatrist to draw a more definitive clinical diagnosis according to DSM or ICD. Once, the final diagnosis is made by eliminating other possibilities, it becomes easier to come up with a long term treatment plan and predict the possible outcomes of continuing or discontinuing the medications.

Some cases of mental illnesses need to be medicated for a long time and can be compared with any other chronic physical illnesses (Diabetes, Hypertension etc.) where people have to take medications at a maintenance dose for an unlimited period of time. It makes sense that your friend would be treated with an anti-psychotic if her initial diagnosis was indeed psychosis.

I'm not familiar with the brand name “eripra” (the generic name is universal but the brand names vary from country to country). “Perkinil” is often prescribed with anti-psychotic drugs to prevent side effects.

From your description, it appears that your friend has been functioning quite well with this medication for about a year. It is not an uncommon practice to taper off the dosage after 6-12 months of full remission to see if the symptoms start creeping back or not.

It is very tricky on my part to make a comment on the treatment plan without seeing the patient directly or knowing her full background. I believe her doctor is renowned for a reason and is competent enough to deal with this case. So be assertive in asking questions directly about what he means by unlimited time in this particular case.

I strongly recommend that she doesn't discontinue medication without the permission of her doctor. If necessary, take a second opinion. It is best to avoid all kind of medications at least during first 3-4 months of pregnancy given the fact that there is limited data available on the safety of anti-psychotic drugs in pregnancy.

Congenital anomalies (like neural tube defect) in babies of mothers taking conventional anti-psychotics are rare. Some reports suggest that the neonate may suffer from symptoms like drowsiness if the mother was taking conventional anti-psychotic drugs throughout pregnancy.

However, no increased risk with atypical anti-psychotic medication in pregnancy has yet been reported within my knowledge. I'm not aware of any case of a baby being born with mental illness (besides there is no way to diagnose a mental illness in a neonate!).

Before a planned pregnancy it would be wise to talk to her doctor, the benefits of continuing medicine has to be carefully weighed against the unknown risks of taking it during pregnancy.

I won't be comfortable putting someone through so many major life changes (mental illness, marriage, new job, pregnancy, child-birth, and parenting) in such quick succession. Every major life event brings new stress in life, which can be quite challenging for any average person not to mention someone who has experienced psychotic symptoms in recent times.

What is the reason for this hurry? Your friend is only 28 years old and got married only in the end of 2007. What's wrong if she starts planning about pregnancy after couple more years of stability in life?


Dear Dr. Khan,
I have some black spots on my front tooth but no pain. It seems to have remained the same size for the last 10 years. Is this dental caries? What is your opinion? Should I go for filling or wait? Tell me about dental caries.
- Sadek Hossain

Dear Mr Hossain,
I think you should go for dental filling. Destroyed tooth structure (black spot) does not regenerate. However, the progression of cavities can be stopped by treatment. The goal is to preserve the tooth and prevent complications.

In filling teeth, the decayed material is removed (by drilling) and replaced with a restorative material such as silver alloy, porcelain, or composite resin; Inlay and Onlay Crowns (cap) are used if decay is extensive and there is limited tooth structure. A root canal is recommended if the nerve in a tooth dies from decay.

'Caries' is Latin for 'rot' or 'rotten'. Dental caries or cavity is the most common of all oral diseases, and the average individual has his first experience with this disease in childhood. It is recommended that between 1½ -2 years of age, children must have their first check-up before any extensive cavities are established.

Dental caries very often appear as a white chalky area on the enamel. It later softens and then the tooth structure breaks down. If not treated in the initial stages, it progresses towards the pulp and will then require extensive treatment to save the tooth.

Prevention
Oral hygiene is necessary to prevent cavities. This consists of regular professional cleaning (every 6 months), brushing at least twice a day, and flossing at least daily. X-rays may be taken yearly to detect possible cavity development in high-risk areas of the mouth.

Sticky foods (such as dried fruit or candy) are best if eaten as part of a meal rather than as a snack. If possible, brush the teeth or rinse the mouth with water after eating these foods.

 

 

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