Mental illnesses are the leading causes of disability in the United States, with bipolar disorder and major depressive disorder affecting 2.6% and 6.7% of American adults respectively. But despite this prevalence, the struggles of those who suffer from mood disorders have long been avoided in public discussion (1). Recently, however, increased publicity both from high-profile sufferers of mood disorders and discussions about violence in our society have brought this issue and the importance of their treatment into the limelight. The number of people whose mental health issues have been misdiagnosed, mistreated, or simply not monitored, signifies the need for urgent action. Next to Normal, a 2009 musical about a suburban mother named Diana Goodman who struggles with bipolar disorder, provides a framework through which its audience can examine the status and implications of mental health care within our society. Such an examination elucidates clear goals for the future, including a destigmatization of mood disorders, more sympathetic public policy, an interdisciplinary approach to psychiatric research, and a greater focus on the families of the mentally ill, in order to create a system that better responds to the needs of those who suffer from depression, bipolar disorder, and other mental illnesses.
“What makes you think I’d lose my mind?
I’m no sociopath,
I’m no Sylvia Plath” (2).
In this scene from the musical, Diana lashes out at her doctor, angrily refusing the therapy he recommends; she cannot relate to the popular images of mental illness, and therefore cannot accept that she has one. The character’s denial highlights the way stigmatization and stereotyping of mental illness have prevented people from seeking the treatment they need, with both social and professional stigmas continuing to reinforce such feelings of shame and guilt over mental illness. A recent study on bipolar disorder found that over 50% of Argentinean patients believed that the public was afraid of persons with bipolar disorder (3). In another study, a third of patients across seven Western countries reported being discriminated against because of their mental illness (4). In yet another survey, 66% of people with bipolar disorder agreed with the statement “I feel ashamed of my mental illness,” and many of the public (29% across America) believed that people with mood disorders were “not normal, even when treated.” Only 17% of patients with bipolar disorder reported being able to speak with their employer about their mental illness (5). And despite the importance of law enforcement having an understanding of mental disorders, a study revealed that 60% of police officers believed the mentally ill to be more dangerous than the rest of the population, and 67% believed they should be permanently hospitalized (6). Such statistics reveal a strong presence of stigma against people suffering from mood disorders.
Unfortunately, race continues to play a large role in whether or not an individual receives mental health care. Asian American teenagers, especially girls, suffer the highest rates of depression in their age group, and yet they are the least likely to seek treatment for that disorder (7). And as reported by the Center for Disease Control, 19% of Asian American teens contemplate suicide, compared to 16% of teens across ethnic groups (8). University of Pennsylvania psychiatrist Dr. Zheya Yu explains that much of the gap between the rates of depression and treatment stems from the cultural stigmatization by parents, who feel that a child with depression could reflect poorly on them and their family. Asian parents, who typically expect high achievement from their children, may not want to accept that there is a problem with their child. This can manifest in refusal to seek help or even in refusal to complete treatment, in cases where the parent and/or child are aware of the mental illness. The cultural gap between the East and West with regard to mental illness is illustrated further by the criminalization of attempted suicide in India, with survivors facing up to a year of imprisonment. However, a new Indian Mental Health Care Bill introduced in August seeks to remove this penalty, which seems to indicate progress in the perception of mental illness in Asian cultures (9).
Prominent voices in the media continue to spread false information about mental health and mental health services, contributing to the confusion of those suffering from disorders and those who surround them. As recently as June 2013, an article in The Daily Caller asserted that what psychologists call “anxiety” and “depression” are really just “stress” and “sadness,” and suggested “stoicism, hard work, marriage, prayer and personal initiative” as alternatives to psychiatric treatment (10). Such misinformation can easily add to the guilt and shame experienced by people who find that those traditional coping mechanisms do not alleviate the symptoms of their disorder. But the reasons Americans do not utilize mental health services run deeper than just stigma. According to the 2013 report by the U.S. Substance Abuse and Mental Health Services Administration, over 50% of Americans cannot afford treatment, even with insurance (11). It is important to note that the high costs of mental health services actually hurt the economy; as early as 2000, the World Health Organization noted that in terms of productivity loss, mental disorders cost 4% of a developed country’s GNP, which in the U.S. would be approximately $636 billion (12).
“The memories will wane, the aftershocks remain.
You wonder which is worse, the symptom or the cure” (13).
In Next to Normal, Diana responds negatively to electroconvulsive therapy (ECT), one of the most effective current treatments for depression and bipolar disorder; while it successfully mitigates the effect of her trauma, the memory dysfunction– a key side effect of ECT – leaves her feeling empty. But whether or not the benefits of ECT outweigh the risks has been a matter of contention since the 1980s, partially because the mechanisms of depression – and its treatment – are still not completely clear. The traditional perspective on depression has been that low serotonin levels cause depression, and thus scientists believe that antidepressants function by raising serotonin levels. However, recent research suggests this is not the case, that an imbalance of neurotransmitters cannot be the sole cause of depression; for example, patients with depression were not found to have consistently lower serotonin levels (14). However, lowering serotonin levels had a significant effect on the mood of people with a family history of depression, suggesting a strong genetic component to the disorder. The mechanisms behind antidepressants have been further called into question by Irving Kirsch’s 1997 experiments on the placebo effect in depression, in which he observed that 75% of the antidepressant effect could be achieved with a placebo (15). Together, these studies showed that those who responded positively to antidepressants often had milder forms of depression, and serotonin seemed to play a large role for these patients. In the 1980’s, Fred Gage approached the problem from a different angle when he found that the adult brain produces new neurons in the hippocampus, a part of the brain involved in memory and, to a certain degree, emotion. Later experiments on mice found that Prozac worked only with the production of new neurons within the hippocampus, and when this production was blocked, Prozac had no effect; the experiments, when replicated in 2011 with monkeys, achieved the same results (14). So how might the new information about the hippocampus be connected with what we know about serotonin? The answer may lie in the subcallosal cingulate, an area of the brain connected with the hippocampus and rich in serotonin transporters, which regulates responses to emotional stress (16). Electric stimulation of this area was reported to cause a powerful mood change in 75% of depressed patients. All this suggests that serotonin may actually change the circuitry of the brain itself, affecting how the subcallosal cingulate regulates a malfunctioning hippocampus. To fully understand how depression works, and to come to a proper conclusion about its treatment, scientists will have to combine the studies of cognitive psychology, neuroscience, and genetics, but until that occurs, patients must choose between the available treatments – including ECT – using the information they currently have.
Although its side effects and high relapse rate make many patients wary of the treatment, ECT has been shown to mitigate severe cases of depression on which antidepressants have had no effect (as antidepressants work in only 30% of cases) (17). Recent studies, however, may illuminate the mechanisms behind ECT’s effects, possibly opening research pathways for alternative therapies. In fMRI scans of depressed patients who received ECT, the treatment appeared to reduce the connection between brain regions associated with emotion and those associated with cognitive function (18). While such an explanation addresses the involvement of neural circuitry, research has not yet extended this finding to a connection with serotonin levels. Either way, it doesn’t seem that the fears surrounding ECT will disappear anytime soon; an FDA panel recently refused recommendations that ECT be reclassified as a Class II medical device, which would decrease restrictions and regulations on its production and use (19). Instead, ECT will retain its designation as a Class III procedure – one with the highest risks. With more knowledge of the biology behind both depression and its treatments, scientists may be able to either improve the function of ECT and antidepressants, or develop a replacement therapy with greater benefit and fewer risks.
“With you always beside me to catch me when I fall,
I’ll never get to know the feel of solid ground at all” (20).
The scene where Diana leaves her family, citing her need to recover on her own, represents the climax of the familial struggle central to the musical and illuminates the greater need for counseling and support of families of people with depression and bipolar disorder. The negative impacts of stigma and ineffective treatment of Diana’s disorder are only exacerbated by the familial dysfunction in her home; meanwhile, Diana is unable to respond to her daughter Natalie’s feelings of alienation from her family or her husband Dan’s attempts to remain optimistic in the face of their troubles. Often, family members are not involved in diagnosis, despite being twice as likely as the patient to recognize manic symptoms (21). Families of violent patients have also expressed helplessness in connecting with their family member’s treatment or finding support for their family. The need for both patient privacy and family support makes the situation difficult to resolve. For example, while many of the laws that block parents from interfering with their children’s mental health treatment were intended to enable children to receive treatment more easily, they can actually have the opposite effect in more severe cases, when the parent is the one seeking help for their child (22). In addition, coming to terms with the tragedy of a patient’s suicide can be extremely difficult for families who are unable to obtain answers about what happened from their family member’s doctor. A balance must be achieved between allowing patients agency and safety in their treatment and enabling families to feel confident about their loved one’s treatment.
Due to their major implications for community and economy, mood disorders and their treatments must be treated as a major public health issue in order to promote global emotional health, well-being, and productivity. With the situation as problematic as it is both socially and clinically, it is easy for people with these disorders, as well as their friends and family, to feel discouraged about the future. But campaigns and programs for destigmatizing mood disorders, interdisciplinary research, and increased lobbying have begun to move the cause in a better direction. After all, while pointing out the flaws in the system and society, the musical Next to Normal ends on an inspiring note: with the hope that we will “find the will to find our way, knowing that the darkest skies will someday see the sun… There will be light” (23).
Contact Navya Dasari at NAVYA.DASARI.email@example.com
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2. A. Ripley, “Didn’t I See This Movie?” Tom Kitt. Next to Normal: Original Cast Recording (2009).
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13. A. Tveit, “Aftershocks.” Tom Kitt. Next to Normal: Original Cast Recording (2009).
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20. A. Ripley, “So, Anyway.” Tom Kitt. Next to Normal: Original Cast Recording (2009).
21. H. E. Marano, Depression: A Family Matter (2002). Available at http://www.psychologytoday.com/articles/200303/depression-family-matter (17 September 2013).
22. G. Fields, Families of Violent Patients: ‘We’re Locked Out’ of Care (2012). Available at http://online.wsj.com/news/articles/SB10001424127887323463704578495154217291958 (17 September 2013).
23. Next to Normal: Original Broadway Cast, “Light.” Tom Kitt. Next to Normal: Original Cast Recording (2009).