Shrinks (41 page)

The Best Picture–nominated
Silver Linings Playbook
offered a realistic portrayal of appealing characters with mental disorders. They live purposeful lives in which their illnesses do not define them but instead are merely part of the fabric of their lives. When Jennifer Lawrence accepted her Best Actress Oscar for her role in the movie, she proclaimed, “If you have asthma you take asthma medicine. If you have diabetes you take diabetes medicine. But as soon as you have to take medicine for your brain, you are immediately stigmatized.”

Lawrence’s co-star, Bradley Cooper, who played a young man regaining his balance after a destructive bout of bipolar disorder, became an advocate for mental illness after the role. I’ll never forget what Cooper told me at a White House Conference on Mental Health in 2013, when I asked what motivated his advocacy. “Working on the film reminded me of an old friend who I knew in high school and was mentally ill. It dawned on me what he had been dealing with, and made me feel ashamed of how I offered him no support or understanding, only ignorance and indifference. Making this film made me wonder how many other people out there are similarly unaware as I was and that I can help bring them the same awareness that the film brought me.”

The actress Glenn Close embodies Hollywood’s improving attitude toward mental illness. Twenty-five years ago, she gave a riveting performance as a pet-killing, homicidal character with borderline personality disorder in
Fatal Attraction
. Today, Close has emerged as the most visible spokesperson for mental illness in the entertainment industry. She started the Bring Change 2 Mind nonprofit, whose mission is “to end the stigma and discrimination surrounding mental illness.” Close travels the country educating people about psychiatric research and treatments for mental illness. Her motivation is her family: Her sister Jessie suffers from bipolar disorder and her nephew Calen has schizoaffective disorder.

Numerous celebrities have been willing to talk openly about their own experience with mental illness. The mega-selling author Danielle Steel started a foundation to commemorate her son Nick Traina, who committed suicide after battling bipolar disorder. Talk show host Dick Cavett and
60 Minutes
anchor Mike Wallace bravely spoke out about their struggles with depression. Catherine Zeta-Jones revealed her hospitalization for bipolar disorder. Kitty Dukakis, wife of presidential candidate Michael Dukakis, wrote a book about the life-saving role of ECT in controlling her depression.

I have had the good fortune to become personally acquainted with Jane Pauley as the result of her own experience and public advocacy for mental illness. The former
Today
show anchor writes about the role bipolar disorder has played in her life in her books
Skywriting
and
Your Life Calling
. She recounts how in the small Indiana town where she grew up, no one knew about mental illness, much less talked about it. As a result, she never gave her frequent mood changes much thought, until she landed in the psychiatric ward at the age of fifty-one after a course of the steroid medication prednisone triggered a severe manic episode. This unexpected hospitalization finally compelled Pauley to come to grips with the suppressed history of mood disorders in her family—and the fact that she had unknowingly endured the symptoms of bipolar disorder for years. She could have chosen to keep her condition private, but instead Jane made the brave decision to speak out about it.

Other celebrities provoke public discussion of the stigma of mental illness only after they succumb to its effects. At the age of sixty-three, Robin Williams, one of the most talented comedians of his generation—famed for his frenetic, high-octane brand of humor—tried to slash his wrist, then hanged himself in his bedroom with a belt. Fans were shocked to discover that a man who shared so much joy and passion with the world had apparently struggled with severe depression most of his life. While his tragic suicide is an immeasurable loss, it was at least reassuring to find that most of the media coverage invited mental health professionals to address head-on the apparent paradox of a man who seemed to be so loved simultaneously feeling he had nothing to live for.

In another indication of how cultural attitudes are changing, a scion of America’s most famous political family has emerged as a passionate spokesperson for mental illness. Patrick Joseph Kennedy is the youngest child of Massachusetts senator Edward Kennedy and the nephew of President John F. Kennedy. He was the youngest member of the Kennedy family to hold political office when, at the age of twenty-one, he was elected to the Rhode Island House of Representatives in 1988. He was elected to Congress in 1994.

I first met Patrick at a fund-raiser held at a friend’s home in 2006. Though he was still in Congress, his admirable legislative record had become overshadowed by stories of intoxication and emotional instability. The previous May he’d crashed his car into a barricade on Capitol Hill. Shortly afterward, he went to the Mayo Clinic for detox and rehab. When I met him, despite his voluble and engaging political persona, he seemed a bit shaky and disjointed—symptoms of his bipolar disorder, I assumed.

Five years later, I encountered Patrick again at a meeting on mental health care in Washington, DC, and I was struck by how much he had changed. He was composed, focused, and responsive. When I inquired about this apparent change, he explained that he had received effective treatment for his bipolar disorder and substance abuse and was living a healthy lifestyle and feeling great. A year later I attended his engagement party in New York. After the toasts and congratulatory comments, Patrick pulled me aside and informed me that he had decided to devote the next phase of his career to being an advocate for mental illness and addictions.

Inspired by his decision, I made up my mind to run for the APA presidency the very next day. If I was fortunate enough to win, I thought Patrick would be the perfect partner in my own mission to eliminate the stigma associated with mental illness and educate people about psychiatry. Since then, Patrick and I have worked together on many psychiatry-related legislative initiatives, including the Final Rule of the Mental Health Parity and Addiction Equity Act, the Patient Protection and Affordable Care Act, and the Helping Families in Mental Health Crisis Act. We have also joined efforts to communicate the true state of affairs about mental illness, addiction, and mental health care to the public. Patrick has become perhaps the most visible, articulate, and effective spokesperson for mental illness in America—and the first politician to confront his own serious mental illness in such a public and positive manner.

Former congressman Patrick Kennedy (right) with Vice President Joseph Biden and the author at the 50th Anniversary of the Community Mental Health Act at the JFK Presidential Library in Boston, October 25, 2013. (Ellen Dallager Photography, American Psychiatric Association, 2014)

Patrick Kennedy, along with Bradley Cooper, Glenn Close, and Jane Pauley, is joined by many other celebrities, including Alan Alda, Goldie Hawn, and Arianna Huffington, who are all beginning to use their visibility and influence to raise awareness about mental illness. This is a good start, but the truth is that we will only overcome the stigma of mental illness when the public is fully convinced that medical science understands mental illness and can provide effective treatment. Fortunately, even more impressive developments in psychiatry are just around the corner.

A Bright Future

Over the past two hundred years, the history of psychiatry has been characterized by long stretches of stagnation punctuated by abrupt and transformative changes—many of which, regrettably, were not for the better. But we have entered a period of scientific advances that will produce a stream of innovations more dazzling than any that have come before.

One of the most promising arenas of research is genetics. It is virtually certain that no single gene alone is responsible for any particular mental illness, but through increasingly powerful genetic techniques we are starting to understand how certain patterns or networks of genes confer levels of risk. These genetic signatures will lead to more precise diagnosis of patients. They will also permit earlier identification of persons vulnerable to severe mental illness, enabling preventive interventions.

Glenn Close’s family provided one of the first examples of the application of genetics in psychiatry. In 2011, her sister Jessie and nephew Calen volunteered for a research study at McLean Hospital in Massachusetts led by Dr. Deborah Levy, a psychologist at Harvard. A genetic analysis of Jessie and Calen’s DNA (using ROMA-like methods) revealed that they shared a rare genetic variant resulting in extra copies of the gene that produces an enzyme that metabolizes the amino acid glycine, which has been implicated in psychotic disorders (as it helps to modulate the activity of the excitatory neurotransmitter glutamate). Extra copies of this gene meant that Jessie and Calen were deficient in glycine, since their body overproduced the enzyme that metabolized glycine. When Dr. Levy gave them supplemental glycine, Jessie and Calen’s psychiatric symptoms markedly improved. It was like watching a patient’s fever decline after giving him aspirin. When they stopped taking the supplemental glycine, their symptoms worsened.

Using a genetic test on Glenn Close’s sister and nephew in order to identify a specific drug that could ameliorate their mental illness was one of the very first applications of personalized medicine in psychiatry. It holds the promise of revolutionizing the diagnosis and treatment of mental illness.

I believe we will soon have useful diagnostic tests for mental illness. In addition to the progress made toward genetic tests, there are several other promising technologies that could lead to tests that can aid in diagnosis and treatment selection, including electrophysiology (establishing an EKG-like test of brain activity), serology (which would produce a blood test similar to the tests for cholesterol or prostate-specific antigen), and brain imaging (using MRI and PET procedures to detect signature brain structures and activity). The FDA recently approved PET testing for Alzheimer’s disease, and we are getting very close to using brain imaging to aid in the diagnosis of autism. Then, instead of Daniel Amen’s spurious claims for SPECT-based diagnosis of mental illness, we will have scientifically proven methods of diagnosis using brain-imaging procedures.

Advances in psychiatric treatment are also occurring on other fronts. New drugs are being developed that are more precisely targeted in terms of where and how they act within the brain. Brain stimulation therapy (the treatment modality that began as ECT) is also undergoing remarkable progress. Researchers have devised two new forms of brain stimulation that are much less invasive than ECT: transcranial magnetic stimulation (TMS) and transcranial direct-current stimulation (TDCS). These therapies use magnetic fields or weak electrical current to stimulate or dampen brain activity in specific anatomic regions without inducing a seizure, and they are noninvasive and don’t require anesthesia. They can be used to target specific brain sites believed to be the source of symptoms of psychosis, depression, and anxiety.

For the most severe and intractable mental illnesses that don’t respond to medications or other forms of brain stimulation therapy, deep brain stimulation (DBS) offers new hope. DBS involves surgically implanting an electrode into a precisely defined neural structure. While this procedure is highly invasive and requires neurosurgery, as a treatment of last resort it has been used successfully to treat extreme cases of obsessive-compulsive disorder and depression, as well as neurological disorders like Parkinson’s disease and torsion dystonia.

One encouraging avenue of psychotherapy research is coming out of cognitive neuroscience, a field that studies the software of the brain. This work is beginning to elucidate the neural bases of mental functions that can be modified through talk therapy—and mental functions
not
amenable to talk therapy. We are starting to understand the specific neurobiological processes that are active during psychotherapy and can use this information to refine psychotherapy techniques, applying them only to conditions that they are most likely to help.

Other researchers are combining specific medications with talk therapy to enhance its efficacy. Antidepressants, antipsychotics, and anxiolytics are frequently used to reduce symptoms that interfere with a patient’s ability to benefit from talk therapy—it’s hard to meaningfully engage when you are having psychotic thoughts or hearing screaming voices, severely depressed, or paralyzed by anxiety. Drugs that enhance learning and neuroplasticity can increase the effectiveness of psychotherapy and reduce the number of sessions necessary to produce change.