Shrinks (40 page)

A few short generations ago, the greatest obstacles to the treatment of mental illness were the lack of effective treatments, unreliable diagnostic criteria, and an ossified theory of the basic nature of the disease. Today the single greatest hindrance to treatment is not any gap in scientific knowledge or shortcoming in medical capability but the social stigma. This stigma, unfortunately, has been sustained by the legacy of psychiatry’s historic failures and its enduring reputation—no longer justified—as the unwanted stepchild of medicine.

Though we live in a time of unprecedented tolerance of different races, religions, and sexual orientations, mental illness—an involuntary medical condition that affects one out of four people—is still regarded as a mark of shame, a scarlet letter C for “crazy,” P for “psycho,” or M for “mental.” Imagine you were invited to a friend’s wedding but unexpectedly came down with an illness. Would you prefer to say that you had to cancel because of a kidney stone… or a manic episode? Would you rather offer as your excuse that you threw out your back… or suffered a panic attack? Would you rather explain that you were having a migraine… or were hung over from having gone on a bender?

I encounter evidence of this shame and sensitivity nearly every day. Many of the patients seen by our faculty prefer to pay out of pocket rather than use their health insurance, for fear of their psychiatric treatment becoming known. Other patients choose not to come to see our doctors in the Columbia
Psychiatry
Clinic or visit me in the New York State
Psychiatric
Institute, preferring a private medical office without any signs indicating the identity of the medical specialty inside. Patients frequently fly here to New York from South America, the Middle East, or Asia to consult with us just to make sure nobody from their country finds out that they’re consulting a psychiatrist.

A few years ago, I gave a talk at a luncheon in midtown Manhattan about mental illness to raise funds for psychiatry research. Afterwards, I circulated among the attendees—smart, successful, and outgoing people who had all been personally invited to the event by Sarah Foster, a prominent socialite whose schizophrenic son had committed suicide some years ago while a senior in high school. They chatted over poached salmon and Chablis, openly praising Sarah’s selfless efforts to raise awareness about mental illness—though none of them admitted any direct experience with mental illness themselves. Instead, mental illness was treated like the genocide in Sudan or the tsunami in Indonesia: an issue highly deserving of public attention, but one quite distant and removed from the patrons’ own lives.

Several days later, I received a call at my office. One of the attendees, an editor at a publishing company, asked if I could help her. It seemed that she had lost interest in her job, had trouble sleeping, and frequently become very emotional, even tearful. Was she having a midlife crisis? I agreed to see her, and eventually diagnosed her as suffering from depression. But before she made the appointment with me, she insisted I keep it completely confidential—and added, “Please don’t say anything to Sarah!”

The very next day I got a call from another attendee. This woman worked at a private equity firm and was concerned because her twenty-something son had dropped out of graduate school to start his own company. Though she admired his entrepreneurial spirit, his grandiose idea for a new software application to end world poverty was conceived during a period of erratic and sleepless behavior. After evaluating her son, my initial suspicion was confirmed: He was in the incipient stages of a manic episode.

Over the next few weeks, I received more calls from Sarah’s invitees seeking help for spouses with addictions, siblings with anxiety, parents with dementia, young children with attentional problems, and adult children still living at home. Over time, fully half of the people who attended Sarah’s luncheon reached out to me, including the owner of the restaurant where the event was held.

These were all educated and sophisticated people with access to the very best health care money could buy. If they had trouble breathing or suffered a prolonged fever, they likely would have obtained help from their personal physicians, or at least sought out the best possible referral. Yet because of the stigma of mental illness, they had avoided seeking medical attention for their issues until they fortuitously met a psychiatrist at a fund-raiser for mental illness. And amazingly, even though they had been invited to the fund-raiser by a friend who devoted herself to raising awareness about mental illness after the tragedy of her son’s death, none of them wanted Sarah to know about their own problem.

It’s finally time to end this stigma—and, now, there is good reason to think we can.

Bridging the Gap

Receiving a diagnosis of mental illness can scar your self-image as if the doctor has seared an ignominious brand onto your forehead for all the world to see—every bit as pernicious as the historic stigmas affixed to other medical conditions once considered loathsome, such as epilepsy, leprosy, smallpox, cancer, and AIDS (and more recently, Ebola). In times past, victims of these maladies were shunned as pariahs. Yet in each case, scientific advances eventually revealed the true nature of the illnesses, and society came to understand that it was neither a moral failing nor a divine scourge. Once medical science discovered the causes and began to deliver effective treatments for these diseases, the stigma began to dissipate. Today, we’ve reached a point where players in the National Football League wear pink during games to express support for victims of breast cancer, every major city has a fund-raising walk for AIDS research, and we have a national autism awareness day. This dramatic shift in public attitudes came about as people began to talk openly about stigmatized conditions—and, perhaps most important, began to have faith in medicine’s ability to understand and treat them.

Our first real opportunity to eliminate the stigma shrouding mental illness has finally arrived because most mental illnesses can be diagnosed and treated very effectively. Yet the stigma has persisted because the public has not become aware of psychiatry’s advances in the same swift way that it became aware of advances in heart disease, cancer, and AIDS treatment. Or, perhaps more to the point, the public does not yet
believe
that psychiatry has truly advanced.

Today, psychiatrists are well integrated with the rest of medicine and approach mental illness as they do any other medical disorder. They may prescribe medication or apply ECT to treat a disorder, while simultaneously providing proven forms of psychotherapy. They may recommend evidence-based changes in diet, sleep, exercise, or lifestyle to reduce the risk of developing an illness or to reduce its effects. They communicate openly and frequently with other medical specialists, and they may delegate some components of a patient’s treatment to allied mental health professionals, such as psychologists, social workers, psychiatric nurses, and rehabilitation therapists. They engage with their patients in a direct and empathic manner. And they get good results.

Contemporary psychiatrists hold a pluralistic view of mental illness that embraces neuroscience, psychopharmacology, and genetics—but also wields psychotherapy and psychosocial techniques in order to understand patients’ unique histories and treat their conditions in an individualized way.

In the past, it was widely believed that medical students went into psychiatry to solve their own problems, a conviction espoused even within the medical profession. And it’s true psychiatry sometimes ended up as the safety net for medical students who were too weak to compete in other disciplines—as it still remains in some Asian and Middle Eastern countries to this day. But times have changed.

Psychiatry now competes with other medical specialties for the top trainees. In 2010, we were trying to recruit a talented MD/PhD named Mohsin Ahmed, who was considering applying to the Columbia psychiatry program. He had completed his PhD in neurobiology under a celebrated neuroscientist who proclaimed him one of the most talented graduate students he ever had. Ahmed was a prized recruit and had his pick of any program in the country. Although he had signaled his interest in psychiatry, it was clear he harbored some reservations.

I made it a point to talk with Ahmed on several occasions during his interviews and did my best to convey the excitement in my field—how it was being transformed by neuroscience while still enabling its practitioners to maintain personal involvement with patients. When the results of the annual process of matching graduating medical students with training programs came out, I was thrilled to see that he had selected psychiatry after all and was coming to Columbia. But midway through his first year, he started having second thoughts about his choice of specialties and told our training director he wanted to switch to neurology.

I promptly arranged to meet with him. He told me he was fascinated by the daunting complexities of mental illnesses but disappointed by the clinical practice of psychiatry. “We still base diagnoses on symptoms, and assess the effectiveness of treatments by observing the patient rather than relying on laboratory measures,” Ahmed lamented. “I want to feel like I have some real sense of why my patients are sick and what our treatments are doing in their brains to help them.”

How could I argue with him? Ahmed’s concerns were a common refrain—echoed by everyone from Wilhelm Griesinger to Tom Insel—and were entirely valid. But I explained that even though we were still bridging the gap between psychological constructs and neurobiological mechanisms, it was entirely possible to embrace both, as Eric Kandel, Ken Kendler, and many other world-class psychiatric researchers have done. The most exciting psychiatry research in the twenty-first century is linked to neuroscience, and all the leaders in our field now have some kind of biological or neurological training. At the same time, there is still steady progress in psychotherapy. Cognitive-behavioral therapy, one of the most effective forms of psychotherapy for depression, has recently been adapted by psychodynamic pioneer Aaron Beck to treat the negative symptoms of patients with schizophrenia—a remarkable achievement at any age, but a stunning accomplishment for an indefatigable researcher in his nineties.

I told Ahmed that his generation would be the one to finally close the gap between psychodynamic constructs and biological mechanisms—and given his own abilities and passions, he could lead the way. Ahmed is now one of our top psychiatry trainees and is conducting an innovative project on the pathophysiology of psychotic disorders. Ironically, despite maintaining his focus on neuroscience research, he has shown himself to be a most empathic and skilled psychotherapist, with a real knack for connecting with patients. To my mind, he personifies the twenty-first-century psychiatrist. No longer an alienist, shrink, pill-pusher, or reductionist neuroscientist, Mohsin Ahmed has become a compassionate and pluralistic psychiatric physician.

From Psycho to Silver Linings

Now that the field of psychiatry has acquired the scientific knowledge and clinical capability to manage mental illness effectively and is attracting some of the best and the brightest talent into the profession, changing popular culture and society’s attitudes toward psychiatry and mental illness has become the final, and perhaps most challenging, task of all.

The Hollywood stereotype of the homicidal maniac was indelibly emblazoned in the public’s mind by the 1960 Alfred Hitchcock film
Psycho
. The protagonist, Norman Bates, is a psychotic motel proprietor who channels his deceased mother in drag before viciously murdering his guests. Needless to say, this lurid fictional portrayal wildly exaggerates clinical reality. But ever since
Psycho
’s commercial success, there has been a parade of psychotic murderers in cinema, from
Halloween
’s Michael Myers to
Nightmare on Elm Street
’s Freddy Krueger to
Saw
’s Jigsaw.

The motion picture industry also has a long tradition of portraying psychiatrists and other mental health workers as weird, ignorant, or cruel, starting with such films as
Shock
(1946) and
The Snake Pit
(1948), which depict the horrors of asylums, and continuing through
One Flew Over the Cuckoo’s Nest, The Silence of the Lambs
(featuring a manipulative, arrogant director of a mental institution),
Girl, Interrupted
(featuring a mental ward for young women where the staff are oblivious to the true problems of their patients),
Gothika
(featuring a creepy mental institution with a sadistic, murderous director),
Shutter Island
(featuring a creepy mental institution with staff who appear manipulative, arrogant, and violent),
Side Effects
(featuring manipulative psychiatrists and greedy pharmaceutical companies), and even
Terminator 2
(portraying the staff of a mental hospital as cold and foolish rather than compassionate and competent).

But in recent years, Hollywood has begun to present another side of mental illness. Ron Howard’s film
A Beautiful Mind
tells the moving story of economist John Nash, who suffered from schizophrenia yet went on to win the Nobel Prize. Another example is the hit TV series
Homeland
, featuring a brilliant CIA analyst (played by Claire Danes) who suffers from bipolar disorder and is supported by her smart, caring psychiatrist sister. Apart from the interesting plot and fine acting, the series is remarkable for its authentic and accurate portrayal of both the effects of the protagonist’s mental disorder and its treatment—while showing that mental illness need not limit someone from attaining a high level of professional competence.