According to the World Health Organization, “mental illness results in more disability in developed countries than any other group of illnesses, including cancer and heart disease.”
Yet most of us haven’t a clue what we’re really talking about when we casually throw around such phrases as “I’m feeling schizophrenic,” “She’s crazy,” “Go to the looney bin,” or “Take a chill pill.” Clichéd images of haunted mental institutions, straightjacketed patients who have “gone off their meds” and evil doctors performing electroshock therapy pervade our cultural imagination.
So it’s time for a reality check. We spoke with David Hamilton, MD, a UVA psychiatrist, to clear up some of society’s main misunderstandings and outdated perceptions about mental illness.
#1 Where the Iconic Mental Asylum Went
You know the type we’re talking about: Cartoons memorialize them as scary and thunderous, and many an early 20th century novel features these museum-sized buildings where people were once “locked away” and forgotten about. Although people still get persistent mental illnesses that require long-term, inpatient treatment, these iconic institutions, known for prison-like environments, have largely disappeared from the landscape.
So, what happened? President John F. Kennedy signed the 1963 Community Mental Health Act to reform this deeply flawed system. The act shifted care from public institutions to private organizations and to comprehensive community mental health centers. The hope: to keep people with mental illness in their communities and offer cheaper and more effective treatment.
This approach has facilitated the development of advanced treatments and largely met other goals. However, long-term mental healthcare remains a need, and it often goes unmet.
#2 Electroshock Therapy Happens, and It’s Not Torture
You’ve probably seen the scenes from “One Flew Over the Cuckoo’s Nest” or other such Hollywood films: The suffering mental patient strapped down to a stretcher and dramatically blasted with electricity.
This image, Hamilton says, is completely overblown. ECT, he says, “is still the gold standard for the treatment of severe depression – for people who are mute, cannot feed themselves or toilet properly,, and cannot get out of bed. ECT is also used often with spectacular results, for patient who have refractory schizophrenia where medicines don’t seem to be working,” and other extreme situations.
Administered in the hospital, ECT requires general anesthesia. “All you see is that a toe twitches,” Hamilton says. “Relative to what the movies would have us expect, it’s pretty anticlimactic..”
The main risk? Long-term memory impairment, which occurs in 0.6 percent of the population. Moving the electrodes to the front, and to one side minimizes even that small chance.
#3 There’s a New Kid on the Block: TMS Therapy
In 2008, the FDA approved the use of TMS therapy to treat depression. While effective, this approach remains largely unfamiliar to most people.
The difference between a depressed brain and a normal brain are stark.
Fewer neurotransmitters in the depressed brain mean fewer brain connections and circuits between the areas of the brain responsible for mood. The goal of depression treatment: To increase the communication between these nerve centers.
Neurons are electrochemical cells. Medication stimulates their growth chemically, TMS electrically.
TMS stands for transcranial magnetic stimulation, as it uses magnets, similar to an MRI, to produce electromagnetic currents that focus energy on the area on the outside part of the brain that controls the deeper limbic brain, the part of the brain where our emotions lie.
TMS at UVA
Learn more about TMS therapy.
In contrast to medications, which enter the blood system and thus have the ability to cause side effects throughout your body, TMS has the advantage of targeting only the specific part of your brain responsible for depression. Which is why Hamilton suggests TMS as a possible alternative for pregnant women concerned about the effects of antidepressants on their baby.
And compared to ECT, TMS does not require anesthesia, nor does it have the risk of impacting memory, as the magnetic currents go nowhere near the brain’s hippocampus, the part of the brain believed to be responsible for the formation of new memories.
Also unlike other therapies, TMS does not require lifelong treatment. TMS does require a time commitment of 5 days a week for at least 4-6 weeks, but improvement often shows up at about three weeks in, and once done, you’re done.
#4 Why People Go Off Their Meds
Not all mental illness feels bad.
In fact, bipolar disorder, labeled in the past as “manic depression,” has its perks, as well as its risks.
Of course, anyone would want to avoid the negative symptoms of the bipolar continuum – depression, psychotic breaks in reality, paranoia, delusion and irritability.
But Hamilton points out that the symptoms on the flipside can feel extremely positive: “People feel highly energized, creative, elated, high and can stay up for days without feeling fatigued.” Often, patients who are manic engage in risky behaviors that may have long-lasting negative consequences.
This productive, invigorating state can be hard to give up. “’Why can’t I just have this part?’” people ask Hamilton. “That’s when they don’t want to take medication, and we need to help them to develop insight that you cannot have the highs without the crushing lows.”
The Crush of Side Effects
The other reason people go off their meds? Because of the side effects.
Psychiatrists used to think schizophrenia resulted from dopamine shortages or imbalances in the brain. So the answer? Medication that Hamilton describes as “dropping dopamine-blocking bombs on the whole brain, which made negative symptoms worse, caused people to shuffle, have tremors.” And many people report feeling the drugs don’t do anything positive at all.
But about 15 years ago, researchers discovered that there’s a lot more going on than dopamine. Other neurotransmitters, such as glutamate, also play a role.
This new revelation about the causes and effects of schizophrenia led to the development of more effective and potentially less harmful medications.
#5 Diagnosis is a Long, Tricky Process
The typical time it takes to diagnose bipolar disorder? About 10 years.
There are several reasons for this:
- Episodes of mania and depression can come and go over a stretch of several years, making it difficult to track.
- The disorder can appear at any time of life—half occur before age 25, half after.
- Bipolar disorder presents symptoms typical of other illnesses, like depression, anxiety, schizophrenia, ADHD, post-partum depression, which can lead to misdiagnosis.
#6 Mentally Ill People Aren’t Violent
“It’s a popular misconception that people with schizophrenia perpetrate horrific acts,” Hamilton says, “But the statistics show people with mental illnesses are more likely to be the victims of violence, not the other way around.”
One caveat to that, however, is that substance abuse can increase a person with schizophrenia’s risk of violence. Alcohol and illicit substances disinhibit us. For a person with schizophrenia, the use of substances may also leads to disinhibition and may cause them to respond to their symptoms in a way that they could prevent if they were sober. Substances can also heighten a person’s experience of their symptoms. Psychotic symptoms can range from the extreme — thinking the TV is sending messages specifically to you, believing other people can read your thoughts or are putting thoughts in your head, delusions, hearing voices — to the more sedate signs, like a lack of interpersonal interactivity and decreased spontaneous production of speech.
In fact, most people with schizophrenia live fairly normal lives, a result, in part, from new understandings about how to treat the disease.
#7 Depression is Real and Culturally Specific
People casually say “I’m depressed” all the time. To Hamilton, this nonchalant use of the word can pose a real danger, diminishing the distinction of clinical depression. “We must be mindful that people going through a major depressive episode are really suffering a major medical illness,” he says.
The Depression Stigma
Nearly a quarter of Americans still incorrectly consider depression a sign of personal weakness. Get more facts.
Part of the problem? “It’s a quiet epidemic. More than 16 percent of the U.S. population will meet criteria for Major Depressive Disorder at some point in their lives, with at least 6 percent are experiencing major depressive episodes right now.”
Surprisingly, depression rates vary from country to country. These cultural variances fascinate Hamilton, though they complicate his work. While a kidney doctor may have to consider cultural shifts in diet, he says, psychiatrists have to go farther. They must consider cultural expectations about how people are supposed to behave and feel and how that affects the very pathology of their conditions.
The most depressed country is Afghanistan, where more than one in five people suffer from the disorder. The least depressed is Japan, with a diagnosed rate of less than 2.5 percent. See the map.
Hamilton adds that the understanding of how depression originates and works continues to change, and to some extent, “We still really don’t understand completely the neurobiology of depression. Psychiatry is a field that changes so fast,” he says. “Our definitions of depression have changed 2-3 times in the last 15 years, which can be frustrating when attempting to develop treatments for the disorder.”
But innovations in gene sequencing and neuroimaging hold a lot of promise for future treatments: “As the costs of gene sequencers and genetic testing drop, we get closer to cheaper methods for guiding how we choose medications” on an individualized, and therefore more effective, basis.
#8 Anxiety is Like an Emotional Appendix
Anxiety, from an evolutionary perspective, was once extremely useful. Hamilton explains that early humans developed reactions to threat, stimulating hormonal responses to help us survive. “If we saw a tiger, anxiety would help you get up, run and survive.”
In the modern world, anxiety doesn’t prove as useful, and yet, we still react at the same level of alarm: “The tigers are now inside of us,” Hamilton says.
A tendency toward anxiety seems heritable, meaning we can be born wired so our “circuits trip more easily.” But childhood development is also responsible: The effects of trauma can make a person prone to anxiety, with resulting physical conditions, like ongoing migraines or digestive problems.
#9 In Modern Psychiatry, Mindfulness is No Joke
Hamilton confirms the hype around mindfulness and meditation: “Mindfulness helps. They’ve known this absolutely in the East now for centuries.” And now Western science is proving it. Just this month, researchers have been able show that mindfulness meditation changes the brains of ordinary people; last year, studies showed that mindfulness prevented depression as effectively as medication.
So, along with various kinds of psychotherapy, medications and treatments like TMS and ECT, mindfulness offers yet another valid way for people to manage symptoms of mental illness.
At UVA, we offer mindfulness classes both to our providers and to the public. Sign up for a mindfulness class.
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