Destigmatizing Mental Health

At Eternity’s Gate by Van Gogh

There has never been a more apt time to talk about mental health. Nothing much has changed in our discourse on mental health since the last few decades. In India, mental health continues to remain a stigma. What shocks me today is that journalists,whom one would expect to know better, are positively contributing to the perpetuation of stereotypes. “Does he look depressed?” they ask on national news programs while flashing videos of an actor who allegedly committed suicide due to mental health problems. How does a depressed person look? This is not a hard question to answer. Here’s how a depressed person looks:-

The image is of Linkin Park’s lead singer Chester Bennington clicked just days before he committed suicide. He struggled with clinical depression his whole life. His wife shared a video of him 36 hours before his death, smiling and having fun with his family.

Chester wasn’t an outlier. The singer Chris Cornell too suffered with clinical depression. He committed suicide in 2017 just hours after performing his last show.

Society’s perception of mental health stems from a lack of awareness and understanding about what it actually is. There are many who are educated yet hell bent on denying the existence of mental health. Consider the instance of a Bollywood filmmaker who pondered whether depression,bipolar disorder and “Multiple Personality disorder”(no longer known by that name) are just “fancy words”. He further argued that “families are the best psychiatrists”. This line of thinking is obviously problematic. However, I don’t want to base my article on a low resolution strawman version of mental illness denial. We’ll see why this filmmaker is wrong but I’ll also attempt to steelman his sentiments.

Mental illness denial has a long intellectual history. Psychology as a field of scientific inquiry in its contemporary form was popularized by the likes of Sigmund Freud and Carl Jung. Even though they helped popularize the field,their theories are now largely discredited. The problem as such is not that psychology is a relatively new field. The problem is its implications. Evolutionary biology is relatively new as well. However, it doesn’t impact us at an individual level in the same manner. Psychology/psychiatry, on the other hand, deals with patients and attempts to cure them.

Foucault

The form of mental illness denial which is prevalent today was first articulated by the French philosopher Michel Foucault. His scepticism of mental illness as a concept emerged from a general distrust of institutions. In Madness and Civilization, Foucault carves a history of mental illness. There is no doubt that his thesis on history of mental illness(that madness has been used by institutions to abuse individuals) is correct. However, his argument is more complex than this. According to Foucault, mental illness exists “only within a culture that recognizes it as such.” He argues that psychology’s failure to formulate a unified theory of personality makes it markedly different from physiology. “Mental pathology” is abstract while “organic pathology” has achieved a form of “psychosomatic totatility”. The lack of a totalizing objective description of human nature leads Foucault to conclude that science of the self is futile.

Thomas Szasz

Almost a decade after Foucault’s attack on psychology, Thomas Szasz published his seminal work “The Myth of Mental Illness”. Almost immediately after its publication, it garnered widespread attention. Unlike Foucault, Szasz was trained as a psychiatrist and remained a professor of psychiatry for most of his life. His critique of psychiatry/psychology was motivated by his libertarian beliefs. Mental illness refers to “problems in living”. It is merely a metaphor, if Szasz is to be believed. As such, it is no different than “belief in witches”. The absence of biological attributes meant that mental illness was not a disease in the sense that cancer is a disease. The mind is non-existent,unlike the brain. Psychiatrists, according to him, were religious-polititical leaders. The psychiatrist-patient relationship was one where the former had the upper hand and used her/his power to manipulate the latter. A major difference between Szasz’s and Foucault’s critique is Szasz’s belief that individuals control their behavior. Foucault believed that mental illness was merely the product of a disoriented society. The popularity of Szasz’s critique was partly the result of the prevalence of involuntary admission into mental asylums and lobotomy. These practices has experienced a significant decline since then. Szasz was also one of the earliest proponents of gay rights. His denunciation of mental illness extended to the DSM’s classification of homosexuality as a disease. It was only in 1973 when this was formally removed from the DSM.

Szasz and Foucault were writing at a time when the bulk of psychology was actually unscientific. Apart from barbaric practices, Freudian speculations were accepted as the truth. This was succeeded by a general acceptance of Skinner’s Behaviorism. We know now that both of these school of thoughts were severely flawed. This is not to say that they were never correct. Indeed they had their moments. But the small victories of Skinner and Watson were taken as evidence of the accuracy of behaviorism in general. While the critics were right to point out the excesses of these school of thoughts, they were wrong to denounce the field of psychology/psychiatry itself as nothing more than pseudoscience.

Does mental illness have any biological markers? Is it purely socially constructed as its critics claim?

Let’s try to understand this by first looking at one of the most common mental disorders- Depression. People often confuse depression with sadness. For them, the answer to the “why” question must be external or societal. They’re baffled when seemingly successful people or celebrities are diagnosed with clinical depression. What could possibly have gone wrong in their lives? This is perhaps the most common misconception about depression. Depression is not “sadness”. Sadness has an external reason and can be resolved. Consider this scenario:-

“Richard nervously looked at his grades. They were terrible. He was on the verge of tears. As Richard checked again, he realized that this wasn’t his report card at all. His teacher had made misplaced his report card with a fellow classmate.”

Richard felt sad when he saw the report card. This feeling suddenly transformed into relief as he found out that the report card wasn’t his own. The solution here was external. Good grades would make Richard happy. Its not that simple for those diagnosed with depression. They often do not have an external reason. They could be extremely successfully yet feel suicidal. A diagnosis of depression is made when an individual shows symptoms for at least 2 weeks. What are these symptoms? Self injury, grief, guilt, Anhedonia ,psychomotor retardation, loss of apetite, insomnia etc.

Anhedonia is the loss of interest/pleasure in things/activities that one usually enjoys. For a musician, it is the loss of interest in music. For a writer, it is the loss of interest in writing. For a foodie, it is the loss of interest in food. This is essentially what depression is. A general loss of pleasure. The “inability to appreciate sunsets” in Robert Sapolsky’s words. It also has a strong biological marker. The dopaminergic pathways activate tegmental neurons, which in turn leads to the release of dopamine. Stress reduces the stimulation of dopamine neurons, leading to anhedonia.

Ophelia by John Millais

There are many environmental factors influencing depression:- loss of a parent in childhood, family problems etc. Nevertheless, the susceptibility of an individual to succumb to these environmental triggers often depend on biological markers. For instance, the excess of prenatal glucocorticoids(a stress hormone) makes the adult individual more susceptible to environmental triggers.

When all forms of therapy i.e. behavioral therapy, medications etc. are tried on an individual with major depression without any trace of success, clinicians resort to a surgical procedure. This is known as cingulotomy, where the anterior cingulate, responsible for regulations of abstract emotions, is removed.

Depression isn’t the only mental disorder with genetic components. Schizophrenia also has strong biological markers. Recent research on dyslexia suggests the prevalence of cortical abnormalities among dyslexics. Panicogens (sodium lactate, caffeine) play a major role in triggering panic disorders. Szasz’s claim of an absence of observable pathology is not just wrong but also a terrible standard by which to define illness. We can’t observe migraine visually the way we can observe a tumor. Fortunately, no one denies the existence of migraine due to this. Moreoever, neuroimaging now makes it possible for us to observe what happens inside the brain of individuals with mental illness(unsurprisingly, they’re different from normal brains).

What does this entail? Isn’t it only going to make us treat individuals suffering from all forms of mental illness as “mad”? Wouldn’t it only ostracize them more? Not necessarily. People do not empathize with individuals who are depressed because they think it’s their fault. They treat depression as individual failure. They attribute it to mere pessimistic outlook. This allows them to make absurd statements like “dont be depressed” or “You won’t be depressed if you stop thinking negatively”. What they fail to understand is that depression isn’t in anyone’s control. Imagine saying “dont be diabetic” to someone who has diabetes.

Accepting mental illness as a serious biological dysfunction(which it is, as we have seen) leads us to emphatize with others better. It leads us to recognize that our thoughts aren’t in our control. It leads us to understand that depression can happen to anyone, rich and poor, successful and unsuccessful, young and old etc. Yes, we are going through a mental health epidemic. But we are also going through a mental health denial epidemic. People rightly feel scared of opening up about their feelings. Seeking psychological treatment continues to be a stigma. Individuals suffering from mental illness need more than just emotional support. They need psychiatric intervention. Mental illness denial corrodes the lives and happiness of individuals in a way in which we can only imagine. We will never know how many lives were irreparably damaged because they weren’t able to get emotional support and psychiatric intervention. The evidence is clear. It is the lack of awareness which is the problem. We need to aim for a compassionate and understanding society where its okay to be not okay.