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Outside the big cities of India, away from the wealthier neighborhoods, people will complain about experiencing tensions or anxieties. It may well be depression, and those suffering could be treated medically, but they often don't know that because there's little recognition of depression as a disease. Here's reporter Joanne Silberner.
JOANNE SILBERNER, BYLINE: Subhani Desai’s problems started with a specific event. Desai is in his early 50s and owns a photo shop at the top of an alley in the town of Sanquelim, India. Business is slow today. He's got time to reflect on what happened several years ago when he went to the local health clinic for help with his diabetes.
SUBHANI DESAI: And I saw there some old lady — came to me and asked me, are you taking alcohol, drinking? I say yeah.
SILBERNER: The lady gave Desai a short questionnaire about how he was doing. The answer? Not well. It wasn't just the alcohol, he felt down, totally hopeless. He blames his feelings on an event so emotional that he switches to his native language to describe it.
DESAI: (Through interpreter) My eldest son — he suddenly left home.
SILBERNER: Desai doesn't know why his son, who was 19, left. Every time he looked at his son's photo, he'd take a drink and every night...
DESAI: When I'm going to my home directly, I'm going and take — watching that news program. I'm looking there.
SILBERNER: Looking there for news of his son. Desai was left with the unremitting feeling that life wasn't worth living, but that was not why he went to the clinic. Arpita Anand is a psychologist and part of a pilot program to deal with mental health issues. She says few people seek treatment for a mental disorder.
ARPITA ANAND: They very rarely talk about how they're feeling low, how they've been crying, how they have lost interest in activities, so the representation is more physical.
SILBERNER: For Desai, it was his diabetes. Others have a stomachache or physical pain or they'll talk about eating problems or sleeping problems or stress or tension or fatigue. For 28-year-old RajBai Jyoti, it was a post-surgery visit to a clinic near Sehore in central India. She and her husband work in other farmers' fields. They live at the edge of a bright, green field dotted with wild peacocks. She's sitting in her lean-to porch wearing a beautiful ivory dress covered by a chartreuse and magenta scarf. Her life has never been easy, but a couple of years ago things got even worse.
RAJBAI JYOTI: (Through interpreter) I couldn't sleep before, and I couldn't eat either.
SILBERNER: Her problem — she calls it tension — just appeared one day, and it wouldn't go away.
JYOTI: (Through interpreter) I felt that I was worrying unnecessarily. I felt that a couple of times.
SILBERNER: She wasn't sure she should take her tension seriously. Psychologist Arpita Anand says she often sees a gender difference.
ANAND: With women, they find it very difficult to focus on themselves and talk about how they're feeling, what they're going through because it's almost perceived as being selfish.
SILBERNER: Jyoti was in a way lucky. There's an estimate that 90 percent of Indians don't have access to mental health treatment. She feels better now.
JYOTI: (Through interpreter) I used to feel that all the time, but not anymore.
SILBERNER: Like Desai, Jyoti was seen at a clinic that was part of a pilot program designed to identify and treat depression in primary care clinics. They're comfortable talking about their conditions now and Desai has gotten word that his son is alive and well. But Anand says most people in India, especially poor people, will initially deny that they have a mental illness.
ANAND: The defense that usually comes up is that, oh, you don't understand what I'm really going through. That's not what I'm going through. That's not my problem.
SILBERNER: People just don't want to hear that they have a mental health problem, and they don't want their neighbors or family to hear it either. Near Jyoti's home, there's a primary care clinic headed by medical officer Wilfred Mirand. He says you can't just ask someone outright if they're depressed.
WILFRED MIRAND: If you were go — to go to some of these remote villages perhaps they would not know what you were exactly asking them. They would describe it as stress, tension. They would not know really what depression is.
SILBERNER: And you have to be very careful in what you tell patients.
MIRAND: The moment you relate that disorder to a mental illness or a psychiatrist then there would be a stigma for that.
SILBERNER: The stigma against depression appears to be lifting, at least in the big cities, helped in no small way when one of the most popular Bollywood actresses went public with her story. In more rural areas, there's something else that's fighting stigma — a program that's training local people to become mental health counselors. Several recent studies show this approach when properly done is both effective and inexpensive. For NPR News, I'm Joanna Silberner.