How to Have a Better Conversation About Mental Illness

The public discussion about mental health has become too focused on moderate illnesses.


Comments: 102

  1. In California, Prop 63 was intended to provide funding for people suffering from actual mental illnesses. Instead, much of the money has gone to 'nonprofit' hospitals who run lucrative programs for the worried well. Disabled people need housing and actual medical treatment. Prop 63 should be repealed if it can't be managed to that end result.

  2. Go look at the amount of money distributed under the Mental Health Services Act. Millions and millions. Where did it go? Why do have so many psychotic homeless people on our streets? Pressure needs to be put on State and local officials to solve this problem.

  3. Thank you for addressing this issue. I have worked in behavioral health for 30 years, and
    I would like to make couple of points. Persons can have a personality disorder, as well as a co-occurring mood disorder. Oftentimes there may be a substance use disorder as well, so treatment can e complicated and prolonged. Not a simple problem...but one that definitely needs more attention..and compassion.

  4. It's a dichotomy that if you show up at the emergency room in physical distress, then they triage you to stabilization, and then you get some sort of out care. However if you show up at the emergency in mental distress, then you have to be flinging things about with a weapon, or a direct threat to harm yourself or others before they even look at you.

    Even then, it takes quite a lot to get that order of protection (usually 72 hours) otherwise everything below that line does not get treated (let alone talked about) unless you have some really good insurance. (even then)

    It's so hard to treat something you cannot see (overtly) and there are so many people taking up a lot of space within the little bit of system there is. (since everything is privatized)

    We can do better.

  5. Even in New Zealand, showing up at psychiatric emergency is a waste of time unless the patient is an imminent threat to themselves or others. In other words, psychotic.

  6. "They showed that the greatest levels of mental distress, suggestive of depression or anxiety, were experienced by those in the most socioeconomically deprived areas."

    Thanks to austerity and widening inequality, mental distress has increased in society, while mental health budgets can't keep pace with demand.

    Hospital treatment and outpatient psychiatrists are expensive, and can't treat the poverty issues and social status anxiety driving us mad.

  7. in the area of mental health our medical profession are not looking at real causes -- only tranquilizers.

    I have a close family member being helped now by Dr. Walsh and alternative health -- who uses integrative medicine -- such as lab tests to diagnose and treat chemical deficiencies (or surpluses); and improving food choices (reducing sugar and gluten to stop inflammation that can go straight to the brain.) Prescriptions may be still be required but can be greatly reduced.

    Summary -- MOST of our medical profession makes too much money with the pharmaceuticals to want to change. This is keeping most people with mental health -- literally in the Dark Ages.

    Unless funding is spent in the right areas, you are probably throwing it away!

  8. Medical professionals do NOT make money off of writing pharmaceutical prescriptions. That is both unethical and illegal. That said, evidence seems to be increasingly pointing to inflammation as an underlying problem in much mental illness, so your family member is lucky to have a practitioner who understands that.

  9. Finally, a voice of knowledge and experience speaking about mental illness in a way that may help people really understand. I have worked in public mental health as an RN for 13 years and NP for 8, treating children, adolescents and adults. I am acutely aware that the most important voices in mental health are not the ones speaking or being heard. It is most disturbing that mental illness usually only gets public attention when there is a mass shooting which has nothing to do with the critical issues facing people with mental illness.

  10. Severe treatment-resistant depression is an awful illness that seems (and may be) life-long. Someone who's got it knows that the customary tags for "call this to get help" are lies: there is no help.

  11. I think one of the main problems is that we use the word "depression" which is terribly misleading. It makes people think it is something like having a bad day, but just a bit worse--- and you should just think about butterflies and unicorns and get over it. We need a name that makes it clear this is a real disease of the brain that causes utter torment, destroys lives and, in a large percentage of cases, leads to suicide to escape the unbearable and continuous suffering, whether you are a celebrity or not.

  12. Thank you Lisa Prior.
    In my former clinical career, I experienced much of the same, but in time settled for helping the individual patient as much as possible rather than wishing that the mental health/illness system would ever change.
    The fragmentation of community-based care is perhaps the worst aspect of the status quo, so much so that referrers and concerned carers don't know where to turn for help.
    Competition for funding among providers can be counter-productive.
    Increased funding doesn't necessarily change delivery systems for the better.
    Yes, it comes back to diagnostics, something of a lost art.
    Frankly, I think some aspects of the old centralised state-based organisations worked better - but there will be no going back, for sure.

  13. Depression can lead to psychosis... And as per mania, we were taught in psychology in college (Clemson) that when a person is depressed enough out of self preservation their body goes into "extreme denial" of the "reality" of the depression and that's what the mania is... In other words, it's all the same thing.

  14. No, it is NOT all the same thing at all. That is the point of Dr Pryor's article.

  15. Since being diagnosed as severely depressed and also suffering from chronic social anxiety. I have not been shy to talk about my ailment openly. The struggles, the anxiety if I'm on a better path with the medications and if the right combination and dosage will work is a daily grind. But having people understand or be open to the idea of mental fortitude using a slide as a metaphor is not easy when they think that they can control every emotion and its their responsibility to not dump it on their families or loved ones. When they view emotions or psychic reaction that way its another form of repression which will be manifest. Conversations work, but we need more representatives in the media to view emotional qualities as not the purview of the older, wealthy and familial.

  16. Another factor that probably contributes to more privileged segments of society accessing mental health treatment more readily is that folks with lower socioeconomic can't afford it... even when treatment is subsidized, they can't afford the time (away from jobs without pay, for example).

  17. Does the treatment actually do any good? If not, we should not be concerned that access is unequal.

    One reads about people in "therapy" for years, sometimes decades, sometimes their entire adult lives. That is not what happens when the treatment cures a disease.

  18. Many psychiatric illnesses are chronic, just like diabetes, asthma or hypertension. All of these require ongoing treatment and we do not deny people care because they are not "cured" of them.

  19. There are many chronic diseases that can be controlled with treatment. Perhaps we should think of some mental illnesses like that. Probably many if not most of the more severe forms of mental illness can't be 'cured'; and just like diabetes or arthritis, will require a lifetime of ongoing monitoring and supportive treatment.

  20. In addition to many if not most mental illnesses having a chronic component which can’t be cured, MANY diseases have treatments which improve the patients quality of life, even if the underlying condition isn’t fully “cured “. There is a lack of full understanding of disease if cure or total elimination of the disease is the only measure of success! Long term therapy may be keeping someone ALIVE and not suicidal, which may allow their child to grow up with that parent. Chronic heart disease, many cancers, the list goes on and on, are treated so the patient can have a shot at life, not just to be cured.

  21. Most "mental illnesses" are not mental illnesses. All of us suffer from time to time from anxiety, depression, or psychological trauma such as being separated from parents, or losing a loved one. True mental illnesses are diagnosible medical disorders, including schizophrenia and bi-polar disorder. They have clear indicia, such as delusions, hallucinations, paranoia,disorganized speech. or major depression.

    By noting these signs and symptoms, one can classify the illnesses and predict with some accuracy the course of the disease, and decide on what treatments to give---whether, psychotherapy, drugs, or most often some combination of both.

  22. First of all, with the exception of a few diagnoses such as arsonist and pedophilia where injury is done to others, all the other DSM-5 diagnoses require that the symptoms significantly interfere with the person's ability to function. Do you really believe that 25% of the population fits this?
    And can you tell me what states allow anybody to be hospitalized against their will by the police or anybody else simply by saying they need it. In every state I am aware of it is required that the person be of imminent danger of harming themselves or another person to be hospitalized against their will. And nowhere is the decision to hospitalize someone made by the police. All states require a medical professional and in most states including New York where you say you are, this means not only one but two physicians attesting to the need for hospitalization.

  23. Somehow we can pay for high costs surgeries for people with low SES and they're able to take time away from jobs that these may require but this doesn't fit when it comes to mental health care.
    Perhaps you can explain this to me other than society's prejudice against mental illness.

  24. Just a question: Ms. Pryor (and why isn't she Dr. Pryor?) is described as "a doctor who works in mental health."
    Can anyone explain to me just what this means.
    Does it mean that she doesn't have training in it that would qualify her to be called a psychiatrist which is what most doctors who work in mental health are.

  25. Thank you for this. If anyone doubts that mental illness is a global problem, consider the situation of West African sufferers shackled and treated only with prayers: https://www.nytimes.com/2015/10/12/health/the-chains-of-mental-illness-i...
    Liberia has exactly one psychiatrist. The sickness and the stigma connected with it are worldwide, and there are many extremely ill Americans whose situation is not far from those in shackles. Kate Spade, Anthony Bourdain, and Robin Williams were charismatic, attractive and endlessly likable. This is not true of people whose illnesses make their behavior strange, paranoid, and, especially to those with no intimate experience of these ailments, shockingly inappropriate. I have such deep respect for clinicians who devote themselves to treating and studying these people. But at this point there is no excuse for the ignorance and fear surrounding their suffering.

  26. If I ever win the lottery, most of the proceeds will go to the care of the mentally ill.

    We have billionaires meddling in public education bc they ultimately stand to profit in some way (Gates) when what we really need is lifelong care for the small percentage of adults among us who need maximum supervision and help, as well as the larger percentage of adults who need moderate supervision and help.

    Severe mental illness literally robs a human being of their own mind and their ability to pursue life, liberty and happiness. We might not be able to fix it, but we can at least care for them.

  27. @honeybee

    I appreciate your comment because I would do very much the same if I were to be so lucky. (Having a billion dollars, or multiples thereof is obscene as well - which is a whole other argument)

    Anyways, we all know society is judged by how we treat our least well off. We barely support the poor or the sick, but it seems like if you have a mental illness (deadly if on top of the above) then we neglect those afflicted and leave them out in the cold.

    That has to change.

  28. As a teacher, I also thank you for telling the billionaires to stop thinking they know ANYTHING about education! Thank you!

  29. Not sure what to make about a 'nuanced' discussion; we have here in the United States a managed care system that pays executives many millions while creating misery for many millions of Americans who can barely gain access to care. We see this 'system' manipulate costs and make it nearly impossible to understand the limits of in and out of network mental health benefits. We have an epidemic of homeless mentally ill right here in a city that will provide water to city pets before it will provide public showers for those with serious and persistent mental illness. We used to see the PSA (public service announcements) in our subways that would speak to care for the mentally ill. This is no more. We trip over them in the streets, we ignore them and make haste to avoid the smells. How about a discussion about the economics of providing basic services, as they now have in the San Francisco area, in the form of a Lava Mae converted bus, to provide a toilet and a shower? Never mind the cost of warehousing the mentally ill in prisons and the cost of the medications to sedate the mentally ill, the rise in suicides inside such settings we rarely hear about?

  30. Removing stigmas is important to proper care being delivered. My idea (I am an MD) is to stop using "mental illness", which has a negative connotation. "Mental" refers to the mind, which is thought, feelings, emotions; that is, things you should be able to control (not that that is true all the time, but it is commonly thought to be so).
    I think it is relatively clear that these conditions have a biological basis. So, in my practice, I call them brain diseases (akin to lung disease, kidney disease, heart disease). For those who would cede that to neurology, I would disagree. Even in neurology there are multiple causes and multiple symptoms for the same diseases. Many are deficiencies in or alterations in neurotransmitters (Parkinson Disease and myasthenia gravis leap to mind), which is at least some of the etiologies of this class of brain diseases; this just adds another wing to the house. The brain is complex enough to have many representations of disease within in.
    Will "brain disease" get a negative connotation, also? With all the things that can fall under "brain disease", it would be more difficult. Will it relieve the stigma? Will it result in better care?
    I say it is worth the try.

  31. Can you prove these are brain-specific? For example, neurotransmitters (serotonin, dopamine, etc.) are made in the gut, maybe they're gut diseases?

  32. A brilliant srticle. One thast addresses the mainstream of mental health issues facing the 21st Century World.

  33. people may resist a psychotic label because it might affect driving privileges.

  34. And employment, child custody... The list goes on - if you’re “high functioning” you suffer, often in silence, because the consequences of being open about your illness are life altering. So we stay silent and do the best we can. I have “good” insurance ($80 copay per visit w psychiatry and $70 per counseling visit) and I’m struggling. What about those who are left with the scraps of what our system - broken, uncoordinated and hard to access - will offer? For those who have not experienced intrusive suicidal and/or menacing thoughts as you try to be a functional productive citizen, you are blessed. It is hell.

  35. The two suicide victims in my life who I was very close to both seemed to have resulted from easily understandable circumstances that made perfect sense to me. Why do we have to keep calling suicide a mental illness? It’s very disrepectful to my dad and cousin who went through hell before they got around to it. To me they both seemed crazy to have put up with all that they did first.

  36. Done properly, treatment of mental disorders is time consuming and expensive. Many insurance plans have limits that don't begin to pay for effective treatment. And there is another aspect to it: mental disorders usually impair an individual's earning potential. Many end up in the casual labor market where they earn low wages and receive no healthcare benefits. Pressure on providers is great, so treatment is frequently just a hastily written prescription. We can do better than this.

  37. As a person who has lived with bipolar disorder for nearly 40 years, I do not think you are on the right track either. I accept your seriousness and your strong desire to improve the lives of those with "mental illness." The first and most important problem is the use of the term "mental illness."

    Based on the current state of medical and neurological science it is clear that certain illnesses such as severe depression, bipolar disorder and scizophrenia are genetically based and are physical illnesses. By that I mean that they are brain diseases, just as there are heart, liver and kidney diseases. The first step towards destigmatizing these diseases is to refer to them as "brain diseases" and to consign the term "mental illness" to the graveyard of "thou art"s.

    With that accomplished the public and the medical profession can begin to treat these brain diseases as physical illnesses. This would be a tremendously important development. Today a person with advanced lung cancer who smoked 2 packs a day for 50 years receives more sympathy from the general public and general medical community that a sufferer of bipolar disorder whose only sin was to be born with certain genetic mutations. This has to stop as soon as possible.

  38. Perhaps mental illnesses should be those treatable by therapy alone and brain diseases should need other treatments as well?

  39. Note that the difference in the two statements is that she concludes the greater funding also needs to be targeted at the people who need it the most.

  40. "Suffering is compounded when the groups that are most in need of treatment for mental illness are the very groups who are less likely to receive it."

    As these groups do not command much political or economic power, then they are at the mercy of those who do. Insurance companies are not known for their altruism. Treating mental illness, in their terms, for those who need it is a very bad investment.

    And for the politicians? What do they get from helping or spending public monies on this?

    "Greater funding is needed, and it needs to be targeted at the greatest suffering."

    This however is always "nuanced" with or balanced by political considerations.

  41. There are many people whose mental illnesses are under control with treatment and medication and who have advanced educational degrees and professional abilities. These people need work accommodations and extra training just as much as employees with physical limitations in order to obtain and keep employment in their fields. But in NYC, what should be considered a medical condition becomes, in the case of mental illness, a bar to employment in any professional position.

  42. Mental illness takes a toll not only on the diagnosed individual but also on his or her family members. Since these disorders often begin in adolescence and young adulthood, it is often the parents -- who were anticipating their "golden years" with young adult children safely launched, and the joy of grandchildren -- who find themselves instead with the financial and emotional burden of advocating for, and paying for, their son or daughter's treatment, often while continuing to provide shelter to that son or daughter in their home, which can be very disruptive for all concerned.

    The author, as an Australian, may not know about NAMI, the National Alliance for Mental Illness, a US organization which provides support groups, training courses, and many other resources for the families of people with mental illness. Everyone who is caring for a family member with severe depression, suicidality, a personality disorder or psychosis should know about this organization and make use of its resources.

  43. Acute mental disorders exist, but the larger problem remains overreach. Now almost every personal problem is mental illness (yours!). Inevitably, psychiatry is social control (of deviance or precarity). Its ubiquity betrays privatizing depoliticization.

    By the definitions legislated in the diagnostic manual, the DSM-5, 25% or more of the populace is sick, and so their thinking, feeling, and behavior are wrong. Medication is management (of "symptoms"). Insight-based talk therapies (like psychoanalysis) have been abandoned for discursive techniques of self-management. They use rational discourse to aim not at happiness but less misery. Implied is that if you are unhappy, it's you: change your thinking (or attitude).

    Psychiatric hospitalization in many states no longer requires a finding of danger, but only a vague declaration that the person "needs" it. In my case, it was decided by the police, who said they were concerned about my being a writer and my political views.

    Hospital wards are places of neglect and abuse; patients are harassed by nurses, punished (e.g., with isolation) if they complain, or refuse (their legal right) medication. Like cops, nurses worry mostly about themselves. You are separated from every thing and person in your life, outside contact prohibited. No therapies. These wards are for punishment, and warehousing for the useless.

    We are all morally imperfect. But where the arts were, now there is only policing.

  44. Good article. I like how the author distinguishes that the less advantaged are not getting the help they need. I am a peer support worker at a crisis residential for a non profit. Clients come to us after major psychiatric events (5150) after receiving treatment in locked facilities. With us they are stabilized on meds, receive support, benefits, and then usually independent living placements at licenced and unlicensed board and cares in the area. I've seen a few of these board and cares and more often than not the conditions are deplorable. Clients frequently aren't able to stay long and bounce back out on to the streets to face greater risks. I write this that in my humble opinion more resources should be available on some community level so those in recovery be given a chance to live independently in conditions more respectable, and comfortable-- more favorable for success. In an area of wealth and hyper- economic growth(Silicon Valley) it doesn't seem like much is being done, at least in this instance. I'm not saying that it's a multi-billion dollar tech company's job to take care of those in recovery, but something could be done... It's just what I've observed. The system seems broken on this level. Not only do they deserve help but better living conditions once on their own.

  45. Absolutely. And with increased funding for peers and a recognition that peers should not be relegated to peer positions. People with lived experience with serious mental illness should be actively recruited for decision-making and policy positions.

    Of the population for the population. People with serious mental illness are the only marginalized population not in key decision-making positions within the field entirely about and for their population. That one change could change everything.

  46. Thank you for doing the work you do, and for this thoughtful and insightful comment.

  47. Part of the problem is that you conflate neurotic with psychotic conditions.

    Both are worthy of help and can have a serious impact. But it is questionable whether most of the personality disorders are actually illnesses, or even disorders as opposed to unlikable qualities.

    By way of contrast, illnesses like schizophrenia and major depression are uniquely life destroying. It is the people with these conditions who are the people who are most in need of help, and yet many psychotics are dumped unceremoniously on the street to become addicted to drugs, end up in prison, or die.

  48. As a psychiatrist in private practice I can attest to the extreme economic disparity in mental health treatment, compared to medical treatment, even in my relatively affluent and social-service endowed state. If you do not have the means to pay out-of-pocket for treatment, or if you do not have a very good insurance plan with out-of-network mental health benefits (increasingly rare or nonexistent), you are subject to the insurance industry's draconian rationing of care, lack of access, and substandard treatment from at times less well-trained or even poorly trained clinicians. This happens in medical care too, but much less so than in mental health care. Psychiatrists are increasingly only paid to prescribe medicines and sidelined or discounted with regard to comprehensive treatment planning, when they are theoretically trained to do much more. No wonder there is a mental health crisis in this country.

  49. While I appreciate the author's ultimate aim, I think she misses something pretty basic.

    The fact that mental illnesses aren't treated as real health problems, generally, is *one* of the reasons why mental health treatment is overlooked in international aid and development efforts and why it is so difficult to access for poor people in this country.

    Although this isn't fair, emphasizing that mental illness *can* strike anyone, and sharing the stories of admired public figures who have struggled with these illnesses and benefited from proper treatment, are probably the *best* ways to get people to view mental illnesses as real health problems.

    Once mental illnesses are viewed as real health problems, mental health treatment will become a little more accessible for *everyone*--though of course, the (domestic and global) poor will continue to face more obstacles to proper treatment than will the rich--just as they face more obstacles to accessing so much else.

  50. We need to "rebrand" common mild mental illness (any combination of depression, anxiety, gastro issues, pain) as likely Serotonin Deficiency Disorder. First, it's more scientifically accurate. Depression and the others are symptoms, not the underlying problem. Secondly it's vastly less stigmatizing to blame a chemical, not a person. Finally people are much more likely to seek and comply with the treatment if it's something intuitive like "you are likely low on serotonin and this medication will help increase it." It makes this condition more like any other medical condition for which you prescribe medication.

  51. Please read Johann Hari's wonderful book, Lost Connections - Uncovering The Real Causes of Depression - And The Unexpected Solutions (https://thelostconnections.com/)

    Your opinions will most likely be strongly shifted. It's a wonderfully researched and written book.

  52. If only things were only as simple as you portray them.

    But unfortunately, the theory that depression & other mental disorders you mention are caused entirely, primarily or even largely by a deficiency of serotonin as you say has not been substantiated by scientific, scholarly research. In fact, it's been largely debunked.

    Before & since Prozac & all the other Selective Serotonin Reuptake Inhibitors - SSRIs - started to be marketed in the 1980s, a whole lot of Big Pharma money & a great deal of effort have been devoted to proving the serotonin deficiency theory - without success.

    Yes, a lack or imbalance of serotonin can contribute to some forms & symptoms of depression. But in most cases of depression, it's not been found to be the primary cause or even a major cause. This helps explain why rates of depression & the other maladies you mention have not diminished - in fact, they've increased - as SSRIs have been prescribed to an exponentially growing & now huge percentage of the US population.

    The lack of validity to the serotonin theory of depression can be verified by a look at the professional literature via Google Scholar or in the database of the US National Library of Medicine/National Institutes of Health.

    www.ncbi.nlm.nih.gov/pmc/articles/PMC4471964/

    The popular press has covered it too.

    BTW, gung-ho embrace of the serotonin theory of depression was pretty much restricted to the US. The medical community in Europe & elsewhere never bought into it.

  53. I appreciate the writer making this point. It isn't a necessarily popular position and it took a bit of courage to put it out there.

    As some others have commented, "mental illness" has expanded to include quotidian disturbances and episodes that can be gotten through with counselling, temporary medication, a change in circumstances, or other modifications to life or coping skills. Depression isn't having a bad day because one's husband grumbled about burning the toast. (Not that anyone is justified in grumbling about burnt toast under any circumstances.)

    While I have compassion for anyone going through tough times, the broadening of the tent may have actually had the effect of minimising the gravity of severe, chronic afflictions rather than bringing more effective attention to them. "Oh, you're on Prozac, too, huh?"

    I don't detect any significant change in the stigma about mental illness. One may mention that they're diabetic or arthritic over lunch with coworkers, but it's far less likely that they will volunteer that they have a serious mental illness, even if they are perfectly functional. It could be a career killer.

    More money for treatment is certainly needed to address the magnitude of the issue. But much of the impetus for that is in the hands of policy makers and insurance companies. I don't know about you, but I have very little faith that they will rise to the occasion.

  54. We spend tons of money on the moderate to severely mentally ill. Unfortunately, it is by Departments of Corrections pressed into being the only consistent care this country provides for the mentally ill. In short, for most citizens, you need to be labeled a criminal to get care, even if it is poor and mostly inappropriate care. But least, they are out of sight of the lesser "walking wounded" and those lucky enough to have the sort of disorders like trump whose illness is felt most by others rather than himself.

  55. Most human beings are only one serious trauma away from severe mental illness. We are vulnerable and fragile. All of us.

  56. Most Americans are only one serious illness away from medically induced bankruptcy. It's enough to drive one crazy.

  57. I am twenty-eight years old, and have had a diagnosis of bipolar disorder for ten years. A few reflections. In the last decade I have witnessed a staggering decline in the quality of psychiatric care available to people like me who are living with severe mental illnesses. When I first sought treatment, I was able to get hour-long appointments with a psychiatrist, about once per month, paid for by my family's very good health insurance.

    A few years later, I was able to see an elderly psychiatrist in a large practice for about half an hour at a time. When he retired at the age of ninety, I was shunted off to a different psychiatrist in the practice, who would see me for no more than ten minutes at a time, several months apart, and who would read off the same list of questions ("Have you gained weight? Are you suicidal?") from his computer screen at each appointment.

    Currently, I "see" a psychiatric nurse practitioner (supposedly supervised by a psychiatrist I have never met), by phone, for fifteen minutes at a time, every month or so. I would like you to imagine trying to discuss the most intimate details of your life by phone on the sidewalk outside your place of work: does that seem like a good idea?

    The state of New York - and the rest of the country - needs Medicare for All and a guaranteed right to treatment for the most vulnerable patients, before managed care "manages" us all out of the ability to see a doctor.

  58. God speed, young one.

  59. I am a psychologist in NYC and read this article with little insight as to the point the author is making, aside from:

    “But ultimately, raising awareness, that impotent entreaty of our time, is not enough. Greater funding is needed, and it needs to be targeted at the greatest suffering.”

    But earlier she said greater funding didn’t necessarily help because it doesn’t reach the right people. The aim of this article is unclear and I’m not sure why it passed the litmus test for publication. Unless I’m just tired. If anyone (including the author) can clarify for me, I’d be happy to reconsider.

  60. No, I don’t think you’re just tired. The article would have benefitted from some more active editing as it is indeed somewhat contradictory.

  61. I will gladly agree to raising my taxes to pay for the care that Dr. Pryor advocates if she will agree to criminally prosecute those who are gaming the system. It'll be wash, in my opinion. Better outcomes for the truly ill and good riddance to the charlatans who are taking us for fools.

  62. Could the NY Times expand on this
    problem and provide an analysis of
    where the Money to treat Mental Health
    comes from and goes and what provisions
    are there to help those who carry such a
    terrible and soul destroying burdren every
    moment of their lives.

  63. The money stopped with Regan.

  64. Too often discussions of mental health are centered on relatively minor conditions, trivial misfortunes and elevate ordinary human unhappiness into some grand diagnostic puzzle

    For example, years ago wealthy people used to go to Freudian psychoanalysts because it was the chic, cultivated thing to do. Now, everyone seems to think they have depression and they clamor for anti depressants.

    And the author is right: The people who really need help are disregarded, disparaged and disdained because, as Bob Dylan said, "Money doesn't talk, it swears." The pampered denizens of Park Avenue, I have read, will see a therapist because they are miffed by their mediocre tennis game. I knew a law student who got a psychiatrist to say that he had a "processing defect" which made it take longer to solve problems; he was given extra time for exams.

    Meanwhile, in the streets and in the gutters we can see the wretched refuse who were clobbered in the game (or is it the war?) that is life. The schizophrenics, filthy, homeless, with sores all over their body and everything about them exuding defeat and resignation.

    But then again does it matter. The consumption of anti depressants has gone up dramatically over the past 20 years --- and suicides have risen too. After all, psychiatry is much vaguer and imprecise than "regular" medicine. We can see and palpate an inflamed appendix; we can't see a vengeful superego or rebellious id.

  65. I had to laugh about this because if one has read The Times' coverage of mental illness going back years, one would think that virtually all of mental disorders just involves coping with the normal problems of daily living and not severe issues such as psychosis related to schizophrenia or bipolar disorder or to severe depression. None of its so-called mental health correspondents seem to have interest in this (I remember that its first one spent most of his time writing about emotional intelligence) and its medical correspondents such as Lawrence Altman seemed to have believed that mental illness was not something real doctors should concern themselves with as they never wrote about it. And if people do have severe mental disorders, according to The Times it only occurs in football players and then it's always due to head trauma.
    Also, readers of The Times would take away the message that psychotropic medications are worse than worthless and that they are prescribed by venal psychiatrists who are in the pocket of Big Pharma.

  66. Thank you for your article as it brings light to horribly misunderstood neurological illnesses.
    My son battled schizophrenia for 15 years fighting visual and auditory hallucinations while trying to maintain some semblance of a normal life, until he could fight no longer.
    We traveled all over searching for the newest meds and treatments, that only brought about horrible side effects and very temporary relief.
    There’s so many issues to address here, but if I had to choose one it would be to devote more money for research, like we do for cancer, diabetes, Alzheimer’s, etc.
    Schizophrenia is cancer of the brain and is treated like a curse. My son was a gentle soul who fought his own war like the bravest soldier. He was my hero.

  67. Your son does sound very brave. I am sorry for your loss, especially that it occurred despite your joint quest to get him the help he needed. His life, though too short and having too much suffering, was better for having you there beside him whenever you could be.

  68. Sorry for your loss. I too lost a loved one to this terrible and terribly misunderstood disease.

  69. The unevenness of distribution is even worse...

    Many mental illnesses (of all severity levels) arise in the aftermath of traumatization, neglect, or pathological parenting in very early life. The flashbacks, self regulation problems, dissociation, lack of any affirming inner voice typical of many mental afflictions often result from early trauma. So the mentally ill suffer lifelong consequences of a very early traumatic pain.

    We must correct the public's understanding of etiology of mental illnesses, so people understand there are ways of preventing them in the next generation.

    Every single person I know who struggles with serious mental illness was abused, traumatized, or neglected in childhood. There may be cases where the "assault" is biological or genetic as well -- a neurotoxin, etc. But the lion's share can be explained by ACEs. (acestoohigh.com)

    Our country needs to face that early childhood practices are not providing the amount of nurture kids need to thrive.

    And yes, it's much worse when poverty or racism are present as well.

  70. In terms of funding, my shrink stopped accepting. insurance about 10 years ago. The insurance companies paid him so little that he had to run a volume business. Now he gives us extra time without extra cost. I pay about $120/mo. for More time than I used to get Innovative charging worked greatl for me.

  71. I’m a little unclear about how your doctor’s system works but am very glad to hear you’re getting the help you need.

  72. A serious and excellent piece. As the author says, it is far past time to begin a serious and informed conversation about brain diseases. As the comments illustrate, one does not have to agree with her entirely to partake in the conversation. Due to the associated stigma, and deep misunderstanding by the general public as to what brain diseases really are, we are far behind where we should be in addressing them in the appropriate medical and societal ways that we address other serious illnesses.

  73. I have schizophrenia which has been successfully treated for many years. I am attending school and generally moving forward with my life. I have had to conceal my illness from the vast majority of people I encounter for fear of being misunderstood, which I am a little sad about seeing as how depression and anxiety are gaining widespread acceptance. I want people to try to understand and accept schizophrenics the same way we now try to understand and accept people on the autism spectrum. The social difficulties are very similar in some respects (missing social cues; trouble reading faces). Most of us are quirky rather than unpleasant (provided we adhere to treatment). Why not put a schizophrenic character in a TV show? ... one who is not wielding a chainsaw but is portrayed as just one of the guys. This is the age of showing how "the rest of us" live in the media. Let's expand that to include the rest of the rest of us.

  74. Actually, there was a TV show on for three seasons not too long ago called Perception whose lead character had schizophrenia. Eric McCormack played a professor of neuroscience, Dr. Daniel Pierce, who helped an FBI agent with her cases. It presented his struggles with the condition both sympathetically and, for TV anyway, realistically. It’s still available on Hulu and iTunes.

    And more power to YOU for coping as well as you are with what can be a really debilitating situation.

  75. The author makes some important points but I have been around a few more years than Dr. Pryor and I can therefore provide a bit of encouragement about the reduction in stigma that HAS occurred for even severe forms of mental illness. I work at a university and I am constantly amazed at how honest many young people are about their struggles with mental illness. This is a change for the better as compared to when I was in college in the early 1980s. Just as important, my students are invariably compassionate and supportive towards their classmates who are suffering. On a different point one person who posted a comment on this article more or less illustrated Dr. Pryor's point about the fallacy of mental illness being an equal opportunity offender. The poster stated something to the effect that "we are all one trauma away from mental illness." I believed the same thing before I had read more literature on PTSD. Actually--as counter-intuitive as it may seem--many people undergo severe traumas and don't develop PTSD while others may develop PTSD after a less severe trauma. In general, prior functioning before the trauma is a much better predictor of PTSD than the actual severity of the trauma. Even in childhood many kids bounce back after one short-term trauma without therapy etc. On the other hand, kids who grow up in chronically dysfunctional environments are much more likely to develop a variety of psychological problems as a response to chronic victimization.

  76. A friend who works with PTSD and substance abuse in veterans—he is board certified as a psychiatrist in these illnesses—made a similar observation to me 25 years ago. The security and resilience of a person before trauma are strong predictors of their ability to encounter trauma and survive without disabling sequelae.

  77. May be we need more study on the resilience gene? To better understand those who escape "dysfunctional" childhoods and become capable content adults.

    And, we need to do better in distinguishing suffering from clinical depression and situational depression from which individuals may recover "prior functioning" as the triggers are removed. To explain to all involved that clinical depression can be driven by our DNA and may require replacement chemicals like serotonin.

    Members of the Internatl Society of Biological Psychiatry are MDs first. They assess biology first. They prescribe and manage individuals with informed use of drugs--first. Once the biology and drug regimens are settled, they move to talk therapy, understanding that the latter--alone--cannot be effective without first managing prescription medications needed for underlying biological functioning.

    Last, our older cadre needs to pay attention to our neighborhood kids. Watching and listening without judging raises awareness and costs nothing. We must find those two-of-three teens with clinical depression that have not yet been diagnosed and get them into the care of physicians who understand their brain is still developing to at least age 25. The American Academy of Pediatrics says that is our neighborhood challenge: 66% of teens continue to struggle without professional help. We can silence critics and be these kids bridges to a better quality of life.

  78. Another thing missing from discussions of mental health is the fact that the privacy of the person with a debilitating psychiatric disorder is more highly valued than the person's effects on family members. My mother was diagnosed with a personality disorder decades ago. We children were not told anything or helped in any way as she continued to rage and punish us. She blamed us and other family members for all of her problems, and none of us were helped to understand or deal with her. The collateral damage is continuing into a fourth generation.

  79. I am diagnosed with three of the ten personality disorders: borderline, obsessive-compusive, and avoidant. As well, I am a depressive, have PTSD and ADHD (not diagnosed until ten years ago). I am a 71 year-old woman and because I am Australian and covered by our health system, have been able to access regular psychotherapy since I was 17 years old, either at no or minimum cost. This has enabled me to lead a relatively normal life and have a career as a university academic. And yes, during that career, I believe I did fulfil a socially useful role as a very effective teacher and researcher. I do live alone which some of you may seem as a failure but in fact I rather like my life like that. I have never told anyone about my rather long list of diagnosed mental disorders. I hate to think what my life would have been like without the constant support afforded by a psychotherapeutic relationship - I assume it would most likely have ended years ago in suicide. Presumably, this is what would happen to someone like me if she were to have been born in the 'great' United States of America - Heaven help her!

  80. Hi KIC, I am heartened to hear your experiences obtaining affordable treatment for your mental health issues. I do wonder if the public funding goes far enough. I note that under the 'Mental Health Care plan' (a part of Australia's universal health care system Medicare), people can get up to 10 subsidised sessions with a psychologist per year (appointments with a psychiatrist are always subsidised). The subsidy is in the region of $130, however the Australian Psychological Society's recommended rate for a one hour consultation is $250. The gap is significant and for someone who requires weekly sessions the subsidised sessions run out quickly!

  81. Mental illness?

    I've had to go the hospital a couple of times for mental illness. What I suffer from has never really been clarified. Paranoid schizophrenia? Bipolar disorder? What I do know is my view of life is rather dark. Religion tells us there is a good God (monotheism). Science says often there is no God and that nature is merely "indifferent".

    But I wonder if there is a malignant intelligence behind life. Take the scientific view of life, the organic, against an inorganic background: For life to evolve, move especially to higher states of complexity and consciousness, it has to derive its sustenance, nutrition, by feeding on itself. It's incredibly cruel this process whereby the price of higher complexity and consciousness is essentially a zero sum game of life feeding on itself. Can we really speak of an "indifferent nature" when essentially life forms are pitted against each other automatically? You would think if nature were really only merely indifferent life forms would be allowed to derive their sustenance from the inorganic, like a person being able to eat rocks or run on electricity. Artificial Intelligence is interesting because here the possibility exists of intelligence, consciousness, running on an inorganic platform and being able to derive its energy needs from the inorganic.

    What I do know is science, technology, has to work a lot harder on grasping the life situation and ameliorating the problems involved with being alive, conscious beings.

  82. It seems that conflating mild emotional setbacks with mental illness has harmed the definition of the latter. Having a bad spell in your life and suffering through a loss (job, spouse) is what we need to be taught to endure, that is life and life is randomly cruel and randomly wonderful.
    Early traumatization is far too prevalent in this country. Way too many people have children that they are completely unable to care for and so the trauma and neglect merry go round continues at great ost to all those involved.
    Serious mental illness is a whole other ballgame and should be treated as thus. People with diagnosable pschotic issues should be cared for and medicated.
    We are all here together, and all subject to the vagaries of this life.
    Be kind.

  83. I think part of the problem here is understanding the interaction between societal issues and intrinsic brain issues. Life is full of challenges, hard decisions, setbacks, etc. Technology has made us dull more knowledgeable about everyone else’s life. There is riding uncertainty, rising income and wealth inequality and simultaneous loss of a social safety net.
    Some people deal with all this with remarkable ease. Other deal with it poorly and manifest constant anxiety, avoidance, and depression. They feel that “if only I had made that decision...; if only I had the courage to do X...; etc etc...).
    People are stressed, depressed, and anxious about real things. Some people, despite all the societal pressures, are much better able to deal with the world than others.
    But are these differences “illness”? Are people who respond poorly to life stresses “sick” or do they have more insight into the modern world? Are happy people mentally healthier? Or less insightful about the world we live in?
    People with psychotic illness are nit living in reality - they hallucinate, cannot think right, etc. people with, say, anxiety and depression may be having a perfectly rational response to the world. Perhaps not a response that leads to mental peace, but a rational response nonetheless.
    So, what is illness here?

  84. Severe and chronic mental illness is heartbreaking. There are often no solutions only coping alternatives.

    When discussing an acceptable level of care for these patients, I believe the full-time elder care environment is more relevant for comparison rather than the model provided by general medical insurance. That's perhaps why the medical community continually comes up short when treating severe and chronic mental illness.

    These patients don't just face severe healthcare concerns, they also face income, housing, life skills, and social isolation issues that require immense resources. Their issues go well past the resources of healthcare insurance. Indeed well beyond the
    medical community - let's be honest here, these concerns require either lifetime disability insurance for the 1% or a full spectrum of social service for the rest of us.

  85. Up here in the Tropical Far North of Queensland, before we escaped to the northern beaches, I used to see the effects of mental illness, substance abuse, and personality disorders almost every time I went out for a run along the Cairns Esplanade.

    One busy Saturday afternoon, tourists everywhere, I stepped in to help a small German man, a tourist minding his own business, who was being beaten by a six foot five Torres Strait Islander who must have weighed three hundred pounds, all of it muscle.

    During the day, this man shared a dosshouse, a high-set Queenslander, on the corner of Lake Street, now gone, where he and his bros would hang out, drink, smoke weed, pop crystal meth.

    He'd had a bad argument with his wife. Rather than beat her, he’d gone out looking for prey. At one point, he took a swing at his victim so fast, so powerful, his fist whistled through the air. He missed, and his momentum caused him to slip, lose his footing on the grass, and fall. For a couple of seconds, he lay there on his back, kicking his legs like an enormous beetle, before he leapt back to his feet as if he weighed just a hundred pounds.

    No one would intervene. No one would ring the cops. I was disgusted with them, but that's par for the course up here.

    I intervened in many such incidents, alone, unarmed, wearing just a pair of shorts and running shoes, up against very large, very aggressive, extremely violent men imbued in the cruel warrior culture of the Torres Strait.

  86. The headline trumpets, but the article only touches upon, the fact that certain Relatively mild psychiatric disorders, such as depression and anxiety, have become socially acceptable, even fashionable, while more severe problems, such as schizophrenia and bipolar disorders still cause one to be a social pariah. Because of this, folks with more serious problems still hide in the shadows, and even avoid seeking medical treatment. Too bad that the author chose to dodge this issue.

  87. Immigrants who grow up to be severely disturbed adults who live near their extended families may not be able to get a paying job, but they are given a job to do. They take care of the babies or the great grand parents or the pets or clean house or clean the yard and the cars. They are not alone. They do not feel stigmatized by the world. They do not even have time to think about how the world views them because they have jobs to do that help out their family.

    They are with the family every day and, even if they are not earning any money, their life is purposeful. They do not feel stigmatized. They feel loved. They eat dinner every night with their parents and grandparents and brothers and sisters and all the kids -- every day -- not once a year on Thanksgiving. They are not alone.

    Walk around Williamsburg and Crown Heights Hasidim. Walk around Richmond Hill among South Asian extended families. Maybe living with the extended family nearby is healthier for everyone, not just the disturbed.

  88. $$ spent in the current context of the "medical community" does not solve the problem of mental health. And there are many types of levels of disease obviously. Been there, done that. Sometimes people are totally nonfunctional -- danger to selves and others. Sometimes people appear functioning but aren't. Practitioners themselves can be horrible, and sometimes the patient has no choice. Once complaining about bullying by the social worker in a group, I was banned from the group. So far as I know neither the social worker - upset over my bringing cookies to the group "this is not a support group." -- It's for short term therapy -- participants had been in that group more than a decade. Funded by Medicare and for the training of young psychiatrists (some effective; others very needy "how do you like my office?" - words matter. Suicidal people are difficult to read -- and people often do not know why they have given up. The total lack of rationality of society and people around them? $$$ can't buy love or sanity. demonstrated daily in DC.) Where are the 24 hour libraries, community centers-- thank heavens for Starbucks -- even McDos kicks out customers after they consume. Why is decent group therapy so hard to find. Why are people so thoughtless?

  89. You could have deleted the first 8 paragraphs and had a much more coherent and educating editorial.

    What I understood from this epistle was that some nonspecific 'we' are bad for raising awareness incorrectly. We should note that its more of a poor person problem than we tend to think. Because the real problem about mental health is that 'greater funding' is needed to ensure the poor get mental health treatment. But! Its okay that the non-poor get it because in fact anyone can have mental illness. Its just that saying that doesn't mean anything because we really as a society need to make distinctions about illness at the individual level. Got it.

  90. What a meandering article. What is the takeaway from this? Of course we need to focus on severe mental illness. But, even if you have insurance, good luck finding a psychiatrist in your network who has availability. And if you do, they don't want to treat severe cases, which require much more time then they're allowed. Without insurance, you'll wind up over medicated and incorrectly diagnosed in a State facility. Further, psychiatric drugs are the least understood medication, all trial and error. We still do it know which medications will work for an individual. Getting proper treatment is a maze. What is the author trying to focus on here? Awareness isn't as big of an issue as proper treatment and resources.

  91. We need to invest in Community Mental Health Programs. Safe places were people can go during the day and participate in a Community of their peers. We are Social Animals. Isolation kills, especially if you have a chronic mental illness.

  92. We can't even talk about mental illness in this country because we all have to be super happy all of the time, no sadness or bad thoughts ever. Like living in a TV toothpaste advertisement. We don't even allow people or give them sufficient time to mourn deaths. You must instantly heal thyself and be all boot strappy. Just snap out of it, move on, ya know.

  93. I think too that ableism plays a big part in this conversation too. I accepted my diagnosis of schizo-effective and learning disabled enons ago, yet encounter ableism every day, from avoidence of telling people what i am for fear they'll react badly, to encountering myths that need to be struck down, that we're stupid, failures, that we think differently than everyone else, and it must be fun to have them since it does make you super creative, and be hip, as it's so hip to have a disability, according to hipsters, precisly becasue we're not 'normal.' All of which again, should be done away with ASAP, exactly as this writer is suggesting, and have a more common sensible outlook on disabilites of all types, severe and moderate.

  94. With an increasingly dysfunctional health care system in America - the ability to access (good) mental & physical health care is impacted by one's socio - economic standing. AN old saying is, "wealthy with crazy behavior you are labeled odd or "eccentric" - poor, with crazy - and you are ILL or CRAZY" waving at windmills on the street corner.

    Reading these comments bring up many thoughts - certainly one is that the insurance executives & politicians determining access to good care for all are doing a lousy job here in the states - with proper mental health care "hope" at least becomes a reality. Be kind to your neighbor

  95. I suffered an acute paranoid schizophrenic psychosis and was hospitalized for fifteen months as a result of a psychiatrist trying to cure my homosexuality. My first lover, who underwent the same psychiatric treatment, committed suicide. From the horrors of insanity, I learned two main lessons. The first is that Freud was right when he said that the cause of psychosis is repression, usually sexual repression and very often the repression of homosexual desires. The second lesson is that religious faith is good for mental health. I survived. You can read my story in my book What Rough Beast.

  96. The shooters aren't mentally ill. They are evil. Not the same thing.

  97. Excellent article. Not the usual drivel that Lisa references in her second paragraph. Makes me remember the old proverb (biblical?), "I moaned because I had no shoes, until I saw a man that had no feet.".

  98. A close family member is so disabled by mental illness that she can’t hold a job. Obviously it’s almost impossible for her to get the high quality care she needs.

  99. I noticed this very thing after I had severe postpartum depression with psychosis. Many friends would try to relate by mentioning how they understood the baby blues, and just how hard it can be after a baby is born. It took me 3.5 years, and 2 of those involving twice a week behavioral and exposure therapies, to undo the trauma I experienced in that hell. That place was drastically different to situational depression I’ve experienced, or even some of the severe anxiety I’ve had.

    Worlds apart. Very, very far apart. Different language was, and is needed for the varying degrees of mental illness.

  100. If only we could have a #Metoo-type awareness/movement for those of us who suffer from serious psychiatric illnesses! I believe that it must take close to the same absolute courage and self-acceptance to step up and say, Me too, I have one (or more) of these illnesses, this is who I am and, though I have suffered at this hands of this beast, I will persevere and overcome! I think it would change the lives of many who are now suffering in the dark silence of secrecy. If we could have this type of dialogue openly, you would be utterly shocked at how many people you interact with on a daily basis are affected by these illnesses.

  101. #Me Too freedom fighters must zealously advocate for their Bipolar Disorder suffering sisters dying on average (63) almost two decades earlier than typical woman.

  102. I wonder why the New York Times does not refer to "Ms." Pryor as Dr. Pryor, given that she is a medical doctor.