"Call Me Crazy": Lifetime's New Movie That Champions Hope and Resilience Around Mental Illness

*Warning: it was difficult to write this post without including a few small spoilers, but I hope you'll watch the whole film anyway.

On Saturday April 20th, Lifetime debuted "Call Me Crazy: A Five Film".  The film (which boasts a star-studded cast and director list) includes five short stories that examine the impact of mental illness from various perspectives.  Each story is named after the main character: "Lucy", "Grace", "Allison", "Eddie", and "Maggie".

In the first story, we are introduced to Lucy (played by Brittany Snow).  Lucy, a law student, has recently been admitted to a psychiatric institution after experiencing a schizophrenic episode.  She is struggling to see how she can live a "normal" life that includes relationships and a career.  Her clinician encourages her to finish law school because she has insight into something very few people understand (mental illness)- so who knows how many people she could help?

In "Grace", we meet a daughter who has been living with a bipolar mother for her entire life.  Grace is played beautifully by Sarah Hyland from "Modern Family"- I loved seeing her in a dramatic role.  We see the "highs" and "lows" of her mother's condition.  We also see the devastating impact that it has on Grace's life when it is not treated.  Grace often plays the role of caretaker- making sure her mother is safe.  We see her struggle to have her own life aside from her mother's illness.

"Allison" offers the viewers a twist.  She plays Lucy's younger sister.  So we step back from Lucy's view and we see how mental illness has affected her entire family.  Allison's childhood, her sense of safety, her relationship with her parents- were all changed as a result of her sister's illness.  She has bottled up a lot of anger and finds it difficult to support her sister through her recovery.

"Eddie" introduces the only male main character.  He is suffering from severe depression.  He has withdrawn from his wife and his friends.  He has stopped receiving help from his therapist.  We watch his wife intervene after discovering that he may be thinking about suicide.

Finally, "Maggie" introduces topics that (unfortunately) are all too common these days- post traumatic stress disorder (PTSD) and military sexual trauma among our returning veterans.  Maggie (played by Jennifer Hudson) was victimized during her time in the Army and its lasting impacts are threatening her ability to have a healthy relationship with her family.  Here we get another update on Lucy- she is now a lawyer and is representing Maggie in court.

While each story stands on its own, Lucy's story is woven throughout "Allison" and "Maggie" as well.  I really liked this strategy.  Not only because I became invested in her character during the first story...but also because seeing her evolve over time helped to demonstrate some key themes from this film- hope and resilience.

As Lucy says to Maggie: "I am living proof". [Of what?] "That there is hope".  In court, Lucy reminds Maggie's judge that having mental illness does not mean that you are a bad person or a bad mother.  She also reminds him about the importance of social support, "it is nearly impossible to get well alone".  Even though we see all of these characters at their lowest point- there is still hope that they can feel better, have strong relationships, and contribute positively to the world.

It seems fitting that Brittany Snow's character delivers these messages about hope and resilience, as she is a strong advocate for them in real life.  Together with the Jed Foundation and MTV, she founded Love is Louder.  Love is Louder is an inclusive movement that amplifies messages of love and support to combat negative messages resulting from bullying, loneliness, and stigma.  She has also publicly shared her own battles with anorexia, depression, and self harm.

As a health educator, I highly recommend this film as a resource for discussing mental illness, suicide, stigma, social support, and help-seeking.  Since each story is approximately 20 minutes, they can be broken down into segments or watched all together.  This film is a great example of Entertainment Education, which is an area of public health that acknowledges the strong impact that television and movies play in educating the public about health issues.

If you or someone you know is struggling with a mental illness, please reach out:
National Suicide Prevention Lifeline (1-800-273-8255)

"Girls" Tackles OCD: What I Hope IS NOT Happening In Our Emergency Departments

This afternoon I had the pleasure of having some downtime- so I used it to catch up on the three recent "Girls" episodes sitting on my DVR.  Having avoided spoilers, I was surprised and saddened to see Hannah (Lena Dunham) being consumed by Obsessive Compulsive Disorder (OCD).  We learn that she had a serious bout with the condition once before- in high school.  It was so serious that she sought professional help and medication at that time.  Flash forward to her post-college life and we see her plagued again...perhaps triggered by the stress of a recent break-up and a looming book deadline.

While there are several disturbing issues in the most recent episode "On All Fours" (you can see the comments in Alan Sepinwall's review for those details), I want to focus specifically on Hannah's trip to the local emergency department (ED).

I was very upset watching this scene and I'll tell you why:

We know that emergency room providers are key gatekeepers for those who are suicidal and/or suffering from mental illness.  Research tells us that 1 in 10 suicides are by people seen in an emergency department within 2 months of dying.  Acknowledging the importance of this gatekeeper role, leadership organizations in suicide prevention have created a variety of toolkits and resources to educate and train emergency department personnel to identify patient warning signs and assess their risk.

In "On All Fours", Hannah visits the ED after obsessively sticking a Q-tip in her ear, getting it stuck, and experiencing pain.  After lying to her parents by saying she has "12-15 good friends" to accompany her to the ED, she goes alone.  The scene opens with the doctor telling her, "Well, you must be feeling pretty silly."

As the doctor examines her injured ear, Hannah says:

"I've just been having a little trouble with my mental state."
"I have a lot of anxiety and I didn't think stress was affecting me but it actually is."
"I'm not saying this was an accident, but I was just trying to clean myself out."

At no point does the doctor respond to any of these statements.  He is all business, telling her to follow-up with a specialist if she is still experiencing pain in a few days.  As Hannah lays down so he can put antibiotic drops in her ear, she pleads with him to look at her other ear.  He snaps at her "there is nothing wrong with the other one."  Hannah cries on the bed because it (the drops? her situation?) hurts so bad.

He discharges her and she walks home alone.  In just a t-shirt and no pants.

Now I'm not saying that Hannah was acutely suicidal or verbalized such a threat in the ED.  However, I am saying that she made several clear statements about her mental health that should have been treated with concern and respect by a competent medical provider.  Her demeanor and her appearance deserved a kind ear, a social worker's visit, someone to ask if she was all right.

These recent episodes have been applauded for their accurate portrayal of OCD.  I hope that a future episode will show a portrayal of a caring and skilled provider using the public health prevention and education tools that are available to assist someone in desperate need of help.

For any readers that may need help:

• The National Suicide Prevention Lifeline:  1800-273-TALK
• Substance Abuse & Mental Health Services Administration: (SAMHSA) Mental Health Treatment Finder

Facebook Revisited: Does the Platform Help or Hurt Users (or Both)?

The benefits and challenges of social media for public health are a frequent topic on Pop Health.  For example, I've explored the influence of these platforms on emergency response, increasing the number of organ donors, and health activism.  However, one of the debates that I hear the most among public health colleagues relates to Facebook.

Does it isolate users?  Does it connect users?  Does it do both?

Earlier this year, my colleague Elana Premack Sandler explored this debate as it relates to loneliness.  Inspired by a feature in the Atlantic Magazine, Elana asks key questions like, "Is Facebook part of the separating or part of the congregating?"  She also mentions concerns about how Facebook (and other social media platforms) affect our social skills and therefore our friendships.

I thought of Elana's writing as I read a new post on the Atlantic website today, "Are Your Facebook Friends Stressing You Out?  (Yes.)".  This post highlights a new report out from the University of Edinburgh Business School.  The report caught my eye because it identified a very specific cause of stress for Facebook users.  The more groups of "friends" a user had (e.g., family, real life friends, co-workers, etc), the more anxiety they had because there was a greater chance of offending someone with their posts.  The report stated that the greatest anxiety came from adding parents or employers as Facebook "friends".  As Megan Garber writes so eloquently in her Atlantic post, the stress comes from Facebook forcing users to "conduct our digital lives with singular identities".  The way we speak or act around family or friends or co-workers must jive on Facebook, or we run the risk of offending someone.  I'm sure many of us saw this conflict a few weeks ago when political and election posts ran rampant on Facebook!

The anxiety described above is interesting, because ideally what we would hope is that Facebook provides a source of social support to users.  Social support occurs when one is cared for by others (via emotional, tangible, or informational support).  The presence or absence of social support is a factor related to public health issues, such as suicide.    

So after reading through the various posts/articles, what do I think about my opening questions about Facebook?

Does it isolate users?  Does it connect users?  Does it do both?

I think it does both.  I have seen it do both.  For example:

Isolation:  I have spoken to friends and colleagues who feel terrible about themselves or their lives after scrolling through their Facebook news feed.  A friend with chronic illness feels isolated hearing about the latest vacation or new job taken by her "friends".  A friend suffering from infertility can't bear one more picture of a "friend" and their newborn.  I think much of this results from the "whitewash" that many of us put on Facebook.  We often paint a picture for our Facebook friends, full of engagements and babies and fun events.  

Connection:  Earlier this year I watched a suicide intervention unfold on Facebook via the comment section under a post.  A friend of a friend posted a suicidal message on their Facebook wall.  Within minutes, "friends" reached out in the comments.  However, not only did they "speak" to the person, but they interacted with each other and followed up in real life.  One comment read, "Did someone go to his house?"  The next comment read, "I went to his house and I called his parents".  After he was taken to the hospital, a comment was posted to inform all the friends that he was safe.  As a public health practitioner that worked in suicide prevention for years, I was amazed with what I saw. 

So what can we do to reduce the isolation/anxiety and increase the connection?  You can certainly start by exerting your control over your Facebook account.  For example:

• Create a policy about "groups of friends" that you accept into your circle.  I know lots of people that do not accept requests from co-workers or parents.  They make it clear to the individual that it is nothing personal, they just have minimal friends with which they share intimate information.
• Use the privacy settings!  You can control who can see your posts.
• Find and use the unfriend button!  I have done this frequently.  If someone posts messages that are offensive or disrespectful regarding something that I've posted- I get rid of them quickly.
• Take a break from Facebook.  If you realize that Facebook is making you feel bad about yourself, take a break or disable your account.  Use that time to connect with your in real life (IRL) friends or family.

Tell me what you think!  

• Does Facebook isolate and stress us?  
• Does Facebook connect us?
• What other strategies can help to reduce the isolation and increase the connection on Facebook or other social media platforms?

The bipolar disorder pendulum: Depression as a compensatory adaptation

As far as explaining natural phenomena, Darwin was one of the best theoretical researchers of all time. Yet, there were a few phenomena that puzzled him for many years. One was the evolution of survival-impairing traits such as the peacock’s train, the large and brightly colored tail appendage observed in males.

Tha male peacock’s train is detrimental to the animal’s survival, and yet it is clearly an evolved trait ().

This type of trait is known as a “costly” trait – a trait that enhances biological fitness (or reproductive success, not to be confused with “gym fitness”), and yet is detrimental to the survival of the individuals who possess it (). Many costly traits have evolved in animals because of sexual selection. That is, they have evolved because they are sexy.

Costly traits seem like a contradiction in terms, but the mechanisms by which they can evolve become clear when evolution is modeled mathematically (, ). There is evidence that mental disorders may have evolved as costs of attractive mental traits (); one in particular, bipolar disorder (a.k.a. manic-depression), fits this hypothesis quite well.

Ironically, a key contributor to the mathematics used to understand costly traits, George R. Price (), might have suffered from severe bipolar disorder. Most of Price’s work in evolutionary biology was done in the 1970s; toward the end of his life, which was untimely ended by Price himself. For many years he was known mostly by evolutionary biologists, but this has changed recently with the publication of Oren Harman’s superb biographical book titled “The Price of Altruism: George Price and the Search for the Origins of Kindness” ().

Bipolar disorder is a condition characterized by disruptive mood swings. These swings are between manic and depressed states, and are analogous to the movement of a pendulum in that they alternate, seemingly gravitating around the "normal" state. See the figurative pendulum representation below, adapted from a drawing on Thinkquest.org.

Bipolar disorder is generally associated with creative intelligence, which is a very attractive trait (). Moreover, the manic state of the disorder is associated with hypersexuality and exaggerated generosity (). So one can clearly see how having bipolar disorder may lead to greater reproductive success, even as it creates long-term survival problems.

On one hand, a person may become very energetic and creative while in the manic state. This could be one of the reasons why many who suffer from bipolar disorder have fairly successful careers in fields that require creative intelligence (), which are many and not restricted to fields related to the fine and performing arts. Creative intelligence is highly valued in most knowledge-intensive professions ().

On the other hand, sustained acute mania or depression are frequently associated with serious health problems (). This is why the clinical treatment of bipolar disorder often starts with an attempt to keep the pendulum from moving too far in one direction or another. This may require medication, such as clinical doses of the elemental salt lithium, prior to cognitive behavioral therapy. The focus of cognitive behavioral therapy is on changing the way one sees and thinks about the world, particularly one’s “social world”.

Prolonged acute mania, usually accompanied by severely impaired sleep, may lead to psychosis. This, psychosis, is an extreme state characterized by hallucinations and/or delusions, leading to hospitalization in most cases. It has been theorized that depression is an involuntary compensatory adaptation () aimed at moving the pendulum in the other direction, out of the manic state, before more damage ensues ().

Elaborate approaches have been devised to treat and manage bipolar disorder treatment that involve the identification of mania and depression “prodromes” (), which are signs that a full-blown manic or depressive episode is about to start. Once prodromes are identified, cognitive behavioral therapy techniques are employed to prevent the pendulum from moving further in one direction or the other. The main goal of these techniques is to change one’s way of thinking about various issues (e.g., fears, pessimism). These techniques take years of practice to be used effectively.

Identification of prodromes and subsequent use of cognitive behavioral therapy seems to be particularly effective when dutifully applied with respect to manic episodes (). The reason for this may be related to one interesting fact related to bipolar disorder: manic episodes are not normally dreaded as much as depression episodes.

In fact, many sufferers avoid taking medication because they do not want to give up the creative and energetic bursts that come with manic episodes, even though they absolutely do not want the pendulum to go in the other direction. The problem is that, if depression is indeed a compensatory adaptation to mania, it seems reasonable to assume that extreme manic episodes are likely to be followed by extreme episodes of depression. Perhaps the key to avoid prolonged acute depression is to avoid prolonged acute mania.

As someone with bipolar disorder becomes more and more excited with novel and racing thoughts (a prodrome of mania), it would probably make sense to identify and carry out calming activities – to avoid a fall into despairing depression afterwards.

Certain mental disorders may have evolved as costs of attractive mental traits

I find costly traits fascinating, even though they pose a serious challenge to the notion that living as we evolved to live is a good thing. It is not that they always deny this notion; sometimes they do not, but add interesting and somewhat odd twists to it.

Costly traits have evolved in many species (e.g., the male peacock’s train) because they maximize reproductive success, even though they are survival handicaps. Many of these traits have evolved through nature’s great venture capitalist – sexual selection.

(Source: Vangoghart.org)

Certain harmful mental disorders in humans, such as schizophrenia and manic–depression, are often seen as puzzles from an evolutionary perspective. The heritability of those mental disorders and their frequency in the population at various levels of severity suggests that they may have been evolved through selection, yet they often significantly decrease the survival prospects of those afflicted by them (Keller & Miller, 2006; Nesse & Williams, 1994).

The question often asked is why have they evolved at all? Should not they have been eliminated, instead of maintained, by selective forces? It seems that the most straightforward explanation for the existence of certain mental disorders is that they have co-evolved as costs of attractive mental traits. Not all mental disorders, however, can be explained in this way.

The telltale signs of a mental disorder that is likely to be a cost associated with a trait used in mate choice are: (a) many of the individuals afflicted are also found to have an attractive mental trait; and (b) the mental trait in question is comparatively more attractive than other mental traits that have no apparent survival costs associated with them.

The broad category of mental disorders generally referred to as schizophrenia is a good candidate in this respect because:
    - Its incidence in human males is significantly correlated with creative intelligence, the type of intelligence generally displayed by successful artists, which is an attractive mental trait (Miller & Tal, 2007; Nettle, 2006b).
    - Creative intelligence is considered to be one of the most attractive mental traits in human males, to the point of females at the peak of their fertility cycles finding creative but poor males significantly more attractive than uncreative but wealthy ones (Haselton & Miller, 2006).

The same generally applies to manic–depression, and a few other related mental disorders.

By the way, creative intelligence is also strongly associated with openness, one of the "big five" personality traits. And, both creative intelligence and mental disorders are seen in men and women. This is so even though it is most likely that selection pressure for creative intelligence was primarily exerted by ancestral women on men, not ancestral men on women.

Crespi (2006), in a response to a thorough and provocative argument by Keller & Miller (2006) regarding the evolutionary bases of mental disorders, makes a point that is similar to the one made above (see, also, Nettle, 2006), and also notes that schizophrenia has a less debilitating effect on human females than males.

Ancestral human females, due to their preference for males showing high levels of creative intelligence, might have also selected a co-evolved cost that affects not only males but also the females themselves though gene correlation between the sexes (Gillespie, 2004; Maynard Smith, 1998).

There is another reason why ancestral women might have possessed certain traits that they selected for in ancestral men. Like anything that involves intelligence in humans, the sex applying selection pressure (i.e., female) must be just as intelligent as (if not more than) the sex to which selection pressure is applied (i.e., males). Peahens do not have to have big and brightly colored trains to select male peacocks that have them. That is not so with anything that involves intelligence (in any of its many forms, like creative and interpersonal intelligence), because intelligence must be recognized through communication and behavior, which itself requires intelligence.

Other traits that differentiate females from males may account for differences in the actual survival cost of schizophrenia in females and males. For example, males show a greater propensity toward risk-taking than females (Buss, 1999; Miller, 2000), and schizophrenia may positively moderate the negative relationship between risk-taking propensity and survival success.

Why were some of our ancestors in the Stone Age artists, creating elaborate cave paintings, sculptures, and other art forms? Maybe because a combination of genetic mutations and environmental factors made it a sexy thing to do from around 50,000 years ago or so, even though the underlying reason why the ancestral artists produced art may also have increased the chances that some of them suffered from mental disorders.

A heritable trait possessed by males and perceived as very sexy by females has a very good chance of evolving in any population. That is so even if the trait causes the males who possess it to die much earlier than other males. In the human species, a male can father literally hundreds of children in just a few years. Unlike men, women tend to be very selective of their sexual partners, which does not mean that they cannot all select the same partner (Buss, 1999).

So, if this is true, what is the practical value of knowing it?

It seems reasonable to believe that knowing the likely source of a strange and unpleasant view of the world is, in and of itself, therapeutic. A real danger, it seems, is in seeing the world in a strange and unpleasant way (e.g., as a schizophrenic may see it), and not knowing that the distorted view is caused by an underlying reason. The stress coming from this lack of knowledge may compound the problem; the symptoms of mental disorders are often enhanced by stress.

As one seeks professional help, it may also be comforting to know that something that is actually very good, like creative intelligence, may come together with the bad stuff.

Finally, is it possible that our modern diets and lifestyles significantly exacerbate the problem? The answer is "yes", and this is a theme that has been explored many times before by Emily Deans. (See also this post, by Emily, on the connection between mental disorders and creativity.)

Reference
(All cited references are listed in the article below. If you like mathematics, this article is for you.)

Kock, N. (2011). A mathematical analysis of the evolution of human mate choice traits: Implications for evolutionary psychologists. Journal of Evolutionary Psychology, 9(3), 219-247.