The most common mental disorders are anxiety, depression and substance abuse. The comedian and actor Robin Williams was affected by all three — although he had no drugs or alcohol in his body when he chose to take his own life, as the results of his autopsy showed when released last week.
There was much public discussion in the days and weeks after Williams’s death about mental illness, and depression in particular. Details of his suicide and speculation about the pressures he faced went into lurid and undignified detail. Commentators — both professional and amateur — weighed in on the validity (or not) of the image of the tragic clown, and the ‘demons’ that got the better of him. Then the debate switched to stigma and its reduction (or not). Even to have such a conversation was enough for some. Society was able to give itself a pat on the back for being so open about mental illness.
But how much of that well-meaning discussion focused on the reality that people with depression, and other mental illnesses, face every day? For lack of a better way to put a terrible thing, there seemed to be more focus on the glamorous tragedy of the end, and not so much on the chronic debilitating (and recurring) struggle that came before it. Frankly, it seems that the death of someone with depression is easier to talk about than the life of someone with depression. That needs to change.
Mental illness hits people with a double-whammy. There is the agony of the symptoms themselves: the paralysis of depression, the frustration of psychosis, the panic of anxiety; and then there is the way in which those symptoms interfere with how the person would otherwise like to live his or her life. (Physical illness and injury, too, can bring this secondary effect, of course — see the effect on a sports star kept out of action with a broken leg.)
Better understanding of mental disorders and honest discussion and acceptance of them can help to reduce these secondary effects, but there is further to go here than even the most optimistic advocate would admit. The stigma of living with depression and other mental disorders may have been reduced in recent years, as more people describe their experiences, and wildfire social-media campaigns stamp down on any public statements that could give offence, but the stigma, for example, of being treated for these conditions is harder to shift. Don’t agree? Then where are the popular media and political campaigns for fairer and better access to drug and psychological treatments? How come new cancer drugs are heralded as miracle cures, whereas antidepressants and antipsychotics are still whispered about in many countries as part medicine, part magic? Who talks about a struggling diabetic as being ‘off her meds’?
The main focus of science and research is to address the symptoms of mental illness. And as this special issue shows, the need to make progress on this goal, for depression in particular, is colossal. Measured by the years that people spend disabled, depression is the biggest blight on human society — bar none. Research has struggled to lift the fog. And as a result, more than 350 million people still battle with the disorder every day.
“Neuroscientists and psychiatrists alike must remain open-minded.”
Only in the past decade or so have the genomic and brain-imaging tools emerged to enable significant progress on the physical and molecular features of illnesses such as depression. As a result, long-term agendas are shifting, with the US National Institute of Mental Health leading the attempt to partition mental disorder into component symptoms as a way to examine neural mechanisms. Supporters and critics trade ferocious rhetoric about the promise and pitfalls of this approach. And whether it will capture the most important determinants of mental illness, or enough of them to justify shifting the bulk of research resources, is a legitimate question. There is much criticism that the approach overlooks cultural, social and societal factors. True, but productive study of those — within or outside neuroscience — in ways that translate into clinical benefit has not been cracked with the existing approach either.
Neuroscientists and psychiatrists alike must remain open-minded. Genetic and neuroscience techniques to probe circuits will surely make progress. The fruits of this research will come too late for many people with depression. But, these people still have a crucial part to play. As more people are willing to talk about their experiences of mental illness — and the trend there seems positive — then important insights about the most relevant behaviours and factors will emerge. Discussion of mental illness must continue to grow, and to include the lives of sufferers as well as their deaths.
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