Serious mental illness is debilitating, confusing and overwhelming. As a society, one might imagine our response to mental illness might model the response to other public health challenges like heart disease, diabetes or breast cancer. Sadly, the opposite seems to be the case. Take the time to Google “mental illness is” and you find “mental illness is a myth” is the top search result, and “it does not exist” is the third result.

Prisons as providers of mental health treatment

In the 1950’s, there were more than 500,000 inpatient state hospital beds in the U.S. Without going into too much detail, suffice it to say that this system suffered from underfunding, mismanagement and abuse. Lawsuits were brought to reform the system of mental health treatment and did succeed in shutting down numerous facilities that provided substandard care.

Presently, there are 50,000 public hospital beds in the U.S. available for inpatient care. Judging by the decrease in these beds since the 1950’s, one might conclude that serious mental illness has been eradicated in America. But the truth is that the vast majority of such cases are now treated in outpatient clinics, intensive outpatient programs, support groups, etc. (Keep in mind that the U.S. population has effectively doubled in the same timeframe.)

If one were to imagine the most inhumane and ineffective way to address the ongoing issue of mental illness in America, incarcerating people with mental illness would surely be near or at the top of our hypothetical list. Yet the largest mental health facility in the country is the L.A. County Jail; the second largest is the Harris County Jail in Houston.

Just to be clear, the largest treatment providers for mental illness in the U.S. are jails.

Jails, prisoners and mental illness

The U.S. Department of Justice statistics (from September 2006) are grim:

• 43 percent of state prisoners and 54 percent of jail inmates met criteria for mania
• 15 percent of state prisoners and 24 percent of jail inmates met criteria for psychotic disorder
• state prisoners were twice as likely to have been homeless in the year prior to their arrest compared to those without mental illness (13 percent vs. 6 percent)
• inmates with mental health problems were three times as likely to report physical and sexual abuse in the past (24 percent vs. 8 percent).

Keep in mind that the overall incidence of serious mental illness in the U.S. population, according to statistics from the National Institute on Mental Health, is about six percent. If we just look at symptoms and not full-blown diagnostic criteria, a staggering 60 percent of county jail inmates, 49 percent of state inmates and 40 percent of federal inmates had symptoms of major depression, mania or psychosis in the 12 months prior to incarceration.

More than half of those incarcerated who met criteria for a serious mental illness also met criteria for a dual diagnosis, that is, a psychiatric illness AND substance abuse or dependence. Nearly one in three inmates with mental health diagnoses receive treatment while incarcerated and that number has been rising during the last few decades.

The cost of caring for inmates with mental illness

According to the National Alliance on Mental Illness, the cost to house – and, in one-third of cases, treat – prisoners with mental illness is at least $9 billion dollars per year. This illustrates a basic and fundamental reality: Mental illness does exist, and there is a cost associated with it that cannot be avoided.

As a society, we can relegate serious mental health treatment to jails, or we can choose to shift those responsibilities back to hospitals, clinics, providers and support groups. The cost to provide community support and mental healthcare on an outpatient basis is significantly less than the cost to treat a prisoner with mental illness. A novel study by the University of South Florida examined the highest users of mental health services in the criminal justice system in Miami. What the researchers discovered was that 97 individuals, mostly people suffering from schizophrenia, were arrested a whopping 2,200 times, spent 27,000 days in jail and cost the county $13 million over a five-year period.

The preceding comments have generally been approached from a pragmatic perspective. However, it might be useful to avoid eschewing morality altogether. If you think of the mentally ill as a subset of the needy, then I think comedian Stephen Colbert framed it quite aptly; just take a look at this clip:

Editor’s note: Five years ago, Stacey Freedenthal, PhD, LCSW, a professor at the University of Denver, wrote a guest commentary in response to the mass shooting at Virginia Tech, where Seung-Hui Cho killed 32 people. Its message rings just as true today in response to the Aurora, Colorado, movie theater shooting in which 12 people were killed and 58 wounded by accused gunman James Holmes. With Dr. Freedenthal’s kind permission, we repost her commentary, which originally appeared on www.denverpost.com:

Treating mental illness

In 1999, when two teenagers shot 13 people to death at Columbine High School and then killed themselves, a memorial was proposed for all the victims – including the shooters.

Outrage ensued. Many parents of the teenagers killed by Eric Harris and Dylan Klebold argued that the boys were murderers, not victims. I can understand their outrage. A memorial for the murdered should inspire loving memories and cleansing grief.

That said, a sad fact remains: People who kill while in the throes of mental illness are victims themselves. Seung-Hui Cho, the shooter at Virginia Tech, stole 32 lives, but it is clear that his life, too, was stolen years ago. I cannot diagnose a stranger from news accounts, but definitely there are signs that he was deeply depressed and probably psychotic, too.

The overwhelming majority of people with mental illness, including those with exceptional disturbances such as paranoid schizophrenia or psychotic depression, do not ever become violent toward others. In fact, violence toward oneself is a larger problem, with more than 30,000 people in the United States dying by suicide every year. But when people with mental illness do kill others, the question becomes not so much who is at fault, but what?

When I have worked with suicidal clients, I have warned them that their minds can play tricks on them. Diseased and untreated (or inadequately treated), the mind can tell outrageous lies. I had a teenage client once who firmly believed that her parents would be happier if she killed herself, and that her suicide would be a gift to them. Imagine! Her parents were not abusive or neglectful monsters. Indeed, the teenager believed her parents would be better off with her dead precisely because they cared so much about her.

For whatever reasons, Seung-Hui Cho’s brain, with its toxic lies, led him to believe that he had to slaughter innocents.

Feeling compassion for a mass murderer does not mean excusing his actions, or necessarily sparing him punishment. It does not mean forgoing feelings of hatred, anger and incalculable grief. It does mean directing feelings of anger at their proper causes: mental illness and the barriers to treating it effectively. Gun proliferation and our culture of violence also undoubtedly contribute, but the underlying problem remains the brain’s uncontrolled impulses and false rationalizations to initiate violence in the first place.

By remembering that mental illness ultimately wrought this tragedy, we can be empowered to create at least one good consequence. As a society, we need to make it easier for people to ask for help with emotional problems, to provide that treatment, and to receive inpatient psychiatric hospitalization when necessary.

So far, we do none of those things. Young people do not seek help for emotional problems, possibly because of the stigma attached. We as a society can send the message that seeking help for emotional problems is no less acceptable or necessary than for the flu.

Other barriers to receiving effective help include a dearth of psychiatric hospitals; difficulties being admitted to a psychiatric hospital or staying beyond a few days; mental health professionals who rely on treatments with no documented effectiveness; insurance companies that provide few benefits for mental illnesses; insurance companies that require doctors to select medications based on costs rather than individual needs of patients; and lack of health insurance altogether.

We cannot change what Cho did at Virginia Tech. We can, however, do what we can to prevent it from happening again. Doing so requires that we keep several things in mind:

Mental illness, though not always curable, is treatable.

Stigma and lack of resources make it difficult for people to receive sufficient, effective treatment or any help at all.

The more we ignore the needs of people with mental illness, the more they will suffer – and, sadly, the more society will suffer, too.

What’s a parent to do?

The recent Newsweek cover story on psychological hazards of Internet use and other “screen time” activities (such as texting and playing videogames) leaves one wondering whether to cut all electric power to one’s home or just wait till the next study comes out contradicting what we think we now know.

I can only imagine how most parents feel. I’m confused, and I’m a psychologist. And a researcher! 

The Newsweek article is definitely worth a read. To summarize: Various forms of screen time have been linked to depression, ADHD, obsessive-compulsive disorder and diaper rash (OK, that last one’s not true, but the rest are).

More alarming to me, as a father of two boys born with silver joysticks in their hands (sorry, another slight exaggeration), there is also brain imaging research showing changes in the brains of heavy Internet users that resemble those of drug addicts. A separate study showed that the brains of non-users began to resemble those of heavy users after only five hours of Internet use (this I am not making up). 

On the other hand…

We see a story in TechNewsDaily about a new study from the University of Wisconsin showing that prior research findings of a “Facebook depression” effect may not be as dire as previously thought. They monitored 190 undergraduates over the course of a week; after dividing the sample into groups of low (less than 30 minutes per day), medium and high Facebook users (more than 2 hours per day), they found no differences in depressed mood. 

What’s a parent to do? Here’s where the media often overreact, suggesting, for example, that if eating eggs is shown to be not quite as deadly as previous studies indicated, then perhaps all health-related research is a bogus game of flip-flopping in response to the fad of the day. But we can do better than that.

So, short of throwing out both baby and bathwater, here are some thoughts, admittedly delivered with only a modicum of confidence (probably more in role of father than psychologist):

1. Most studies of effects of electronic activities, from violent videogames to Facebook activity, show increased risk of harmful effects, not one-to-one correspondence. One implication is that it is the at-risk kids, those already on the margins due to adverse histories and challenging living conditions, that we should be most worried about. As one of the researchers in the Facebook study commented, “Parents don’t have to be overly concerned [as long as] their child’s behavior and mood haven’t changed, they have friends and their school work is consistent.”
2. If your child is at-risk – struggling socially or academically – particular attention needs to be paid to addressing that child’s needs, including significant monitoring of screen time. Studies show, for example, that economically disadvantaged children tend to spend more time engaged in electronic activities than their more affluent counterparts.
3. Even if your child has all the advantages of economic security, stable home life and good adjustment at school, you’re still not off the hook as a parent. It is impossible to read the Newsweek article (not to mention actually watching a young person at a computer) without becoming convinced that various forms of electronic entertainment, from videogames to online pornography, have significant addictive properties. Excellent resources are available from such sources as the American Academy of Pediatrics or SafeKids.com, providing guidance for parents. Foremost among safe practices is parent involvement, including having the computer and other electronic gear in a public area such as your den, where you can easily monitor what your child is up to (this is sometimes quite interesting, by the way).
4. Insist that your children spend at least as much time in the real world (face-to-face conversation, shooting an actual basketball through an actual hoop, etc.) as in the virtual world (expect mainly contempt in reply, at least until the first swish of the basketball net).
5. This last point brings up an important issue (caution: psychologist hat now firmly in place). Children’s electronic activities are highly rewarding (behaviorally reinforcing), not just for children, but also for parents. Child activities that are otherwise annoying, intrusive and inconvenient (such as actually wanting to talk to you) drop to negligible levels when the child’s mind is absorbed in a virtual environment (often interacting with someone across town or even on the other side of the globe). This peace and quiet can, in itself, become quite addictive to parents; but, in large quantities, it is a definite no-no to anyone interested in the child’s mental health, not to mention a reasonable relationship with said child.

I will be interested to see comments in response to this post. If someone has better answers than these (a fairly likely scenario), then my time engaged in this particular session of screen time will have been well worth it.

The pro's and con's of disclosure.

In my previous job as a vocational rehabilitation counselor, I helped individuals with psychiatric disabilities transition back into the workforce and witnessed firsthand the difficulties faced by those re-entering the work place after a significant mental health setback. In my current position as a clinical interviewer, which involves conducting diagnostic assessments with hospitalized patients – many of whom are professionals – my previous experience has been reinforced.

While many disabilities are observable, and thus generally accepted by employers as requiring accommodations on the job (e.g. in the form of assistive technology, duty modifications and medical devices), mental illness is not obvious. In fact, it’s sometimes referred to as “the invisible disability.”

Economic impact

The impact of mental illness is often minimized in work settings despite statistics that demonstrate one of the greatest costs to employers is unaddressed psychiatric illness. “In the United States, the annual economic, indirect cost of mental illness is estimated to be $79 billion. Most of that amount — approximately $63 billion — reflects the loss of productivity as a result of illnesses.”¹ According to the Harvard Mental Health Letter, “The indirect costs of mental health disorders — particularly lost productivity — exceed companies’ spending on direct costs, such as health insurance contributions and pharmacy expenses.”²

Mental illness might not seem to qualify as a “true disability” because of the colloquial use of the terms “depression” and “anxiety” and the sometimes flippant conversations about “taking a mental health day,” which detract from the significance they hold for those with diagnosable mental disorders. For those suffering from anxiety or mood disorders, to be depressed or anxious might mean struggling to get out of bed every morning due to paralyzing anxiety or debilitating depression; striving to focus at work while trying to hold the panic at bay; or exhausting efforts to maintain the façade that everything is OK in order to evade questions or comments from coworkers or supervisors.

Additionally, coworkers and employers who are unfamiliar with psychiatric disabilities can have difficulty tolerating the limitations such disorders can present on the job, in part because the person looks otherwise “normal.” The assumption that a healthy physical appearance equates to a healthy mind is problematic for individuals with significant psychiatric illnesses. The result can be limited patience on the part of the employer when problematic symptoms begin to cause concerns or interfere with work. When individuals start coming in late or struggle with productivity, their managers may believe the person is lazy or irresponsible. As a vocational rehabilitation counselor, I also educated employers on the potential limitations of mental illness in the workplace, suggested reasonable accommodations and provided data suggesting that people with disabilities are more likely to stay with a job longer than individuals without disabilities.³

Disclosure: how and when?

Hello, I'm the new guy here.

Another component of my previous position was counseling individuals with disabilities on how and when to disclose their disability. Everyone has the right to keep their psychiatric conditions confidential; however, it is important to consider how they may interfere with work performance. In such cases it may be in the individual’s best interest to disclose to their employer so that the appropriate  accommodations may be provided. These can go a long way toward minimizing disruptions due to poor job performance, excessive absences and possible termination.

There are potential downsides to disclosing disabilities to one’s employer: the fear of termination, lessened workload leading to delay in advancement or the possibility of a breach in confidentiality. The upside to open and honest communication with an employer is the possibility for accommodations which can help employees feel more confidant and secure, while potentially  minimizing absences and possible job turnover due to symptom exacerbation. If employers do not have prior knowledge of a person’s need for accommodations, they may have grounds for termination if that person cannot adequately perform the job duties of their position.

Despite many employers’ best efforts to act ethically and professionally when managing employees with mental health issues, uninformed employers may reveal a stigmatized view on mental illness. The concept of “pulling oneself up by the bootstraps” is frequently associated with mental illness in the workplace: It is seen as something within the person’s control, a matter of will power. Yet extensive research documents the biological basis of mental illness such that, like hypertension or diabetes, the illness is not entirely within the individual’s control.

Acknowledging limitations

However, it is also important to acknowledge the employee’s role in understanding, and at times accepting, the limitations their mental illness may present in a work setting. It is the employee’s responsibility to acknowledge if and when positions or responsibilities are beyond their ability. Good self-care involves knowing limits as well as strengths.       

Mental illness can create significant problems in a work setting beyond the typical “mental health day” that some people might need in order to recalibrate. If mental illness is not properly addressed and accommodated by both the employer and employee ahead of time, then potentially avoidable stressors might not only impair job performance but also exacerbate the psychiatric illness.

1. U.S. Department of Health and Human Services. Mental Health: A Report of the Surgeon General. Rockville, Md., U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services,1999, pp. 408409, 411. 
2. Harvard Mental Health Letter. “Mental health problems in the workplace.” February 2010.
3. Benefits of Employing People with Disabilities. October 15, 2009.

May is Mental Health Awareness Month.

The Menninger Clinic family of staff and patients recently experienced one of life’s stressful events: moving.

Even though we all love our wonderful new facility, the process of preparing for the move, making the move and settling in have created stress that is challenging for us all. During Mental Health Awareness Month, one of the areas of focus for the month is stress and how it affects health.

When under pressure, we all experience similar feelings, such as fatigue, irritability and a decreased ability to cope. We may experience headaches, stomachaches or other physical manifestations of tension. However, there is a difference between common stress and abnormal stress. With common stress, the symptoms are temporary, and emotional and physical equilibrium are re-established once the stressful stimulus is over or has significantly lessened. When the symptoms of reaction to stress persist and compromise functioning, it can indicate mental illness.

Sometimes a simple change such as deep breathing, taking a walk, talking with a friend or having a cup of tea can help relieve some of the feelings generated as a reaction to stress. As clinicians, we need to appreciate that we may experience the effects of the strains of everyday life and that simple techniques may be adequate to help us get through periods of difficulty.

Yet our patients come to us with emotional challenges that make them more susceptible to the negative symptoms of the pressures they face, and their response to stressors may evoke maladaptive behaviors. It is our task to do more than provide support and care to help them get through short-term stresses like moving. We must teach coping skills that will help them not only survive stress but prevail over its often deleterious and pervasive effects on their lives and their health.

I guess the answer to that question depends on whether you are asking about understanding mental disease or mental illness. Just to clarify: Disease is a diagnostic term used to classify a pathological condition. Illness is more contextual. An illness is the subjective experience that arises from living with a disease. There are many published accounts of illness narratives written by people who live with a disease, but I don’t believe I have ever heard of a disease narrative. So back to the question: How well do we understand mental illness?

Through the written word 

Tom Ellis, PsyD, ABPP, recognized how noted psychologist Marsha Linehan courageously publicly disclosed her experiences with living with mental illness and suicidality. He called our attention to others in the field who have written eloquently about their own experiences with mental illness, such as Kay Redfield Jamison (An Unquiet Mind) and Norman Endler (Holiday of Darkness).

Many others also have shared their mental illness experiences,including Pulitzer Prize-winning author William Styron (Darkness Visible: A Memoir of Madness), poet Sylvia Plath (The Bell Jar), actress Brooke Shields (Down Came the Rain), attorney Terry Wise (Waking Up: Choosing to Die, Deciding to Live) and writers Joanne Greenberg (pen name, Hannah Green) (I Never Promised You a Rose Garden) and Julie Hersh (Struck by Living), to name a few.

David Lovelace (Scattershot: My Bipolar Family), Michael Greenberg (Hurry Down Sunshine), Patrick Tracey (Stalking Irish Madness: Searching for the Roots of My Family’s Schizophrenia) and Christopher Lucas (Blue Genes: A Memoir of Loss and Survival) have given us views into families’ experiences with mental illness.

Through the arts

Self-portrait with Bandaged Ear, 1889, by Vincent van Gogh

This is merely a partial listing of mental illness narratives. There are also many other genres that are readily available to help us understand the experience of living with mental illness. Who has not gazed upon a Van Gough self-portrait and not recognized distress and known it in a slightly new way? The photographer Michael Nye (Fine Line: Mental Health: Mental Illness) has given us a photo voice exhibit that profoundly captures the lives of some of the most vulnerable, poor, desolate people with mental illness.

Learning from the arts

The question is: How do we use these media to really understand mental illness? After all, it is in understanding something that it becomes less taboo, that the stigma is reduced.

I have a couple of ideas about this. First of all, what would happen if medical, nursing, psychology and social work educational programs made understanding the illness experience a core part of the curriculum? Programs that include courses in narrative medicine are aimed at training interdisciplinary clinicians in the art of using patient and family illness narratives to provoke reflection, empathy and compassion in the service of patient-centered care.

Second, what would happen if researchers applied narrative analytic methods to the published illness narratives? Lt. Cmdr. John Fleming, a psychiatric nurse practitioner in the U.S. Navy, and his colleagues conducted such a study of Michael Nye’s exhibit. Reports from such studies have the potential to stimulate future research in understanding how to incorporate the patient and family experience into clinical practice.

Next, what would happen if narrative medicine were included as a core component of continuing education programs? Such a development could help enhance the development of the therapeutic alliance by providing an additional lens through which to interpret the patient’s perspective. 

Regardless of the approach, the call to patient-centered care is a call to understand the illness experience. I believe in doing so we will be better informed about mental illness.