Kashmir: The continuing war in Kashmir is literally driving people there mad, reports David Orr from Srinagar.
Conflict in Kashmir is taking a terrible toll on the mental health of the population. There has been a marked increase in the number of people with psychiatric disorders and in the number of suicides.
Doctors say this trend can be directly related to the ongoing violence in the contested Himalayan state.
"We're seeing more and more patients all the time," says Dr Mushtaq Margoob of the Government Psychiatric Diseases Hospital in Srinagar.
"Most of them are suffering from depression or some form of post- traumatic stress disorder, mostly chronic. It's clear the present situation in Kashmir is contributing significantly to the increase in psychiatric morbidity."
The situation to which the doctor refers is a complex web of attrition and counter-attrition between Islamic insurgents and the Indian armed forces.
All too often, it is the civilian population that is caught in the middle. Remote villages have been all but wiped out in raids by militants. Families and children have been blown up in explosions and grenade attacks, and a shocking catalogue of human rights abuses has been visited on the people by the Indian security forces.
"Almost every family knows someone who has been killed in the conflict," says Mr Martin Sloot of the aid organisation Médecins Sans Frontières (MSF). "There's a lot of stress and tension in the population. So many people need help but there's only one psychiatric hospital and not enough trained professionals. That's why we're here."
MSF Holland has set up the state's first counselling centre and helped refurbish two wings at the Psychiatric Diseases Hospital in Srinagar. The hospital's new facilities were officially opened last week by the state's chief minister, Mufti Mohammed Sayeed.
"We're getting about 10 referrals a day to the counselling centre and hope to be able to see more soon," says Mr Sloot. "There's a lot of stigma attached to mental health problems here but already people seem to be opening up to the idea of counselling."
In 1989, the year the insurgency started in the Indian-held part of Kashmir, 1,300 outpatients visited the Psychiatric Diseases Hospital. By 1994, that number had jumped to 17,500. Last year, doctors saw 48,600 outpatients.
"At first, we mostly saw people with anxiety disorders," says Dr Margoob. "Then in the mid-90s, we started getting people who had tried to commit suicide, particularly girls. In recent years, we're seeing more people suffering from depression.
"Of course, some people are more susceptible to depression than others but the conflict can be a trigger which sets it off. Someone witnesses a shooting or a family member is arrested and disappears, that is all it takes."
The conflict in Kashmir is believed to have claimed 35,000 lives since 1989. Those who have died include militants, members of the Indian security forces and Kashmiri civilians. Many others are injured, arrested without charges or simply disappear.
The mental trauma inflicted on the population is harder to chronicle but the signs of suffering are there to see. The Sher- I-Kashmir Institute of Medical Sciences (SKIMS), one of the two main general hospitals in Srinagar, sees between three and five attempted suicides a week.
"There is growing depression among the young in this climate of fear and violence," says a senior SKIMS doctor. "Most of those taking their lives or attempting to do so seem to be young, literate, urban women. Most of them choose poison."
A typical case involves a 19- year-old college student who, within the space of a short time, witnessed two shootings near her home. Soon afterwards, she started complaining of nightmares. She became listless and lost interest in her studies. After a minor altercation with her sister, she swallowed pesticide.
Some 250-350 people visit the outpatient clinic of the Psychiatric Disease Hospital every day. Many travel long distances from their villages in the Kashmir Valley or up in the mountains to seek help - and, still, doctors believe they are not seeing the full picture.
"Children are suffering from the same disorders as the adults but we don't see them," says Dr Margoob. "Children's problems manifest themselves in a different way. They become aggressive, irritable or impulsive, but their problems are not getting enough attention."
To cope with the growing need, MSF Holland is planning to open another counselling centre in the town of Kupwara and to launch outreach services for villages in the Kashmir Valley.