The World’s Most Profound Health Challenge. In these exclusive interviews we speak to: Dr. Thomas Insel (Former Director of the National Institutes of Mental Health, NIMH – Neuroscientist at Verily, Google Life Sciences), Dr. Shekhar Saxena (Director: Department of Mental Health and Substance Abuse at the World Health Organisation, WHO), Paul Farmer CBE (Chief Executive of Mind, the world’s largest Mental Health NGO), Sergeant Kevin Briggs (Guardian of the Golden Gate Bridge), Marcus Trescothick (International Cricketer and Mental Health Campaigner) Professor Vikram Patel (Professor at the London School of Hygiene & Tropical Medicine and the Public Health Foundation of India), Professor Andrew Solomon (Writer and lecturer on politics, culture and psychology, a Professor of Clinical Psychology at Columbia University Medical Center, and President of PEN American Center) and Professor Green (rapper, singer, songwriter, actor and television personality). We look at the realities of mental health worldwide, understand the true burden on individuals, communities and countries and look at the opportunities to deal with our global mental health crisis.
Everything we are now, and will ever be, is contained within 1.5 kilos of matter- intricately woven into what, as far as mankind knows, is the most complex object in the universe- the mind. This cage provides a filter that allows us (as individuals) to make sense of the incomprehensible diversity of sensory noise that fills our world and the billions of other beings that we share it with.
It should perhaps come as no surprise therefore that an object this complex- and in many ways beautiful- comes at a huge price. The mind is the seat of our self, and with this amazing capacity comes the ability to cause us profoundly deep pain; illustrated by the fact that every 40 seconds, someone in our world commits suicide (around 1 million people each year).
It is estimated (conservatively) that 1.3 billion people around the world suffer from mental health disorders, with around 600 million people doing so severely enough to be disabled (in some capacity) by them; and losing many years of their lives to mental health related disability. Barely an individual exists on this earth that has not directly or indirectly been impacted by mental health in some way, perhaps fighting their own battles, or experiencing them by proxy through a friend, family member or colleague.
The burden of mental health also puts huge financial pressure on our world. By 2020 (less than half a decade from now) it is estimated that mental health will cost our world over U$6 trillion in lost-productivity and direct costs each and every year (a similar figure to the aggregate current global health expenditure). Yet- with this in mind- we find that mental health is underfunded, poorly understood, and abhorrently low down the social, political and economic agenda of our world.
In these exclusive interviews we speak to: Dr. Thomas Insel (Former Director of the National Institutes of Mental Health, NIMH – Neuroscientist at Verily, Google Life Sciences), Dr. Shekhar Saxena (Director of Mental Health for the World Health Organisation), Paul Farmer (Chief Executive of Mind, the world’s largest Mental Health NGO), Sergeant Kevin Briggs (Guardian of the Golden Gate Bridge), Marcus Trescothick (International Cricketer and Mental Health Campaigner) Professor Vikram Patel (Professor at the London School of Hygiene & Tropical Medicine and the Public Health Foundation of India), Professor Andrew Solomon (Writer and lecturer on politics, culture and psychology, a Professor of Clinical Psychology at Columbia University Medical Center, and President of PEN American Center)and Professor Green (rapper, singer, songwriter, actor and television personality). We look at the realities of mental health worldwide, understand the true burden on individuals, communities and countries and look at the opportunities to deal with our global mental health crisis.
Thomas R. Insel, M.D., is fomer Director of the National Institute of Mental Health (NIMH), the component of the National Institutes of Health charged with generating the knowledge needed to understand, treat, and prevent mental disorders. He is currently with Verily, Google’s Life Sciences division. His tenure at NIMH has been distinguished by groundbreaking findings in the areas of practical clinical trials, autism research, and the role of genetics in mental illnesses. Prior to his appointment as NIMH Director in the Fall 2002, Dr. Insel was Professor of Psychiatry at Emory University. There, he was founding director of the Center for Behavioral Neuroscience, one of the largest science and technology centers funded by the National Science Foundation and, concurrently, director of an NIH-funded Center for Autism Research. From 1994 to 1999, he was Director of the Yerkes Regional Primate Research Center in Atlanta. While at Emory, Dr. Insel continued the line of research he had initiated at NIMH studying the neurobiology of complex social behaviors. He has published over 250 scientific articles and four books, including the Neurobiology of Parental Care (with Michael Numan) in 2003. Dr. Insel has served on numerous academic, scientific, and professional committees and boards. He is a member of the Institute of Medicine, a fellow of the American College of Neuropsychopharmacology, and is a recipient of several awards including the Outstanding Service Award from the U.S. Public Health Service. Dr. Insel graduated from the combined B.A.-M.D. program at Boston University in 1974. He did his internship at Berkshire Medical Center, Pittsfield, Massachusetts, and his residency at the Langley Porter Neuropsychiatric Institute at the University of California, San Francisco.
Dr. Shekhar Saxena is Director of the Department of Mental Health and Substance Abuse at the World Health Organization (WHO). A Psychiatrist by training; with about 30 years of experience in research and programme management, service delivery and information systems in the areas of mental health and neurological disorders, especially in low- and middle-income countries.
Paul Farmer has been Chief Executive of Mind, the leading mental health charity working in England and Wales since May 2006. Paul is Chair of the NHS England Mental Health Patient Safety Board, he is an advisor to the Catholic Bishops on mental health and was on the Metropolitan Police commission on policing and mental health. He is a trustee at the Mental Health Providers Forum, an umbrella body for voluntary organisations supporting people with mental distress. Paul is also trustee at Lloyds Banking Foundation and Chair of the ACEVO board. In November 2012 Paul received an Honorary Doctorate of Science from the University of East London in recognition for achievements in promoting the understanding and support of mental health.
Kevin Briggs entered the United States Army in 1981, where he spent three years serving across the United States and Europe. In 1987, he became a correctional officer and worked at Soledad and San Quentin State Prisons. In 1990, he graduated from the California Highway Patrol (CHP) academy and worked predominately on the Golden Gate Bridge (GGB). This assignment proved to be very challenging, as the GGB produced an average of four to six suicidal subjects, multiple collisions, and dozens of other law enforcement “calls” each month. In 1999, he completed training at the CHP Motor School, and in 2008, was promoted to Sergeant. Having graduated from the FBI’s Crisis Negotiation Course, one of his duties was to train new CHP officers and GGB staff on crisis interventions/negotiations. Sgt. Kevin Briggs retired from the CHP in November, 2013, to promote Crisis Management, Leadership Skills, and Suicide Intervention/Prevention worldwide.
Marcus Trescothick is an international cricketer, regarded as one of England’s most outstanding batsmen of the modern age.
At 29, Marcus Trescothick was widely regarded as one of the batting greats. With more than 5,000 Test runs to his name and a 2005 Ashes hero, some were predicting this gentle West Country cricket nut might even surpass Graham Gooch‘s record to become England’s highest ever Test run scorer. But the next time Trescothick hit the headlines it was for reasons no one but a handful of close friends and colleagues could have foreseen. Marcus has since become one of the UK’s leading advocates for mental health awareness. He continues to play for Somerset, working as a commentator and analyst for Sky Sports in the off-season.
Vikram Patel is a Professor at the London School of Hygiene & Tropical Medicine and the Public Health Foundation of India. He is a co-founder of Sangath, a Goan NGO which works in many states of the country in the fields of child development, adolescent health and mental health. He is a Fellow of the UK’s Academy of Medical Sciences and serves on two WHO’s expert committees: for mental health, and for maternal, child and adolescent health. He has served on several Government of India committees including the Core Committee on Health of the National Human Rights Commission and the Mental Health Policy Group. He is a recipient of numerous international prizes, including the Chalmers Medal from the Royal Society of Tropical Medicine (UK), the Sarnat Medal from the US Institute of Medicine, an Honorary Doctorate from Georgetown University, and the Chanchlani Global Health Research Award from McMaster University. He was listed in TIME Magazine’s 100 most influential persons of the year in 2015.
Andrew Solomon, Ph.D., is a writer and lecturer on politics, culture and psychology, a Professor of Clinical Psychology at Columbia University Medical Center, and President of PEN American Center.
Solomon’s most recent book, Far and Away: Essays from the Brink of Change, collects Andrew Solomon’s writings about places undergoing seismic shifts—political, cultural, and spiritual. Chronicling his stint on the barricades in Moscow in 1991, when he joined artists in resisting the coup whose failure ended the Soviet Union, his 2002 account of the rebirth of culture in Afghanistan following the fall of the Taliban, his insightful appraisal of a Myanmar seeped in contradictions as it slowly, fitfully pushes toward freedom, and many other stories of profound upheaval, this book provides a unique window onto the very idea of social change. With his signature brilliance and compassion, Solomon demonstrates both how history is altered by individuals, and how personal identities are altered when governments alter.
The best-selling Far From the Tree: Parents, Children, and the Search for Identity (Scribner, 2012), tells the stories of families raising exceptional children who not only learn to deal with their challenges, but also find profound meaning in doing so. Far from the Tree has received the National Book Critics Circle Award for Nonfiction; the J. Anthony Lukas Award; the Anisfield-Wolf Award; the Wellcome Book Prize; the Books for a Better Life Award of the National Multiple Sclerosis Society; the Green Carnation Prize; the National Council on Crime and Delinquency’s Distinguished Achievement Award in Nonfiction; and the New Atlantic Independent Booksellers Association (NAIBA) Book of the Year Award for Nonfiction, among others. Far from the Tree was chosen as one of the New York Times Ten Best Books of 2012, and a best book of 2012 by Publishers Weekly, the Boston Globe, the San Francisco Chronicle, Salon.com, Kirkus Reviews, TIME, and Amazon.com; it has also been named a Book of the Year by the Economist, the Cleveland Plain-Dealer, and BuzzFeed. Far from the Tree has been translated into Dutch, German, Italian, Norwegian, Portuguese, and Spanish, with numerous other translations forthcoming.
Solomon’s previous best-selling book, The Noonday Demon: An Atlas of Depression (Scribner, 2001), won the 2001 National Book Award for Nonfiction, was a finalist for the 2002 Pulitzer Prize, and is included in the London Times One Hundred Best Books of the Decade. The Noonday Demon has been published in twenty-four languages. It was named a Notable Book by both the New York Times and the American Library Association, and was recognized with the Books for a Better Life Award from the National Multiple Sclerosis Society; the Ken Book Award from the National Alliance on Mental Illness of New York City; the Mind Book of the Year; the Lambda Literary Award for Autobiography/Memoir; and Quality Paperback Book Club’s New Visions Award. Following publication of The Noonday Demon, Solomon was honored with the Dr. Albert J. Solnit Memorial Award from Fellowship Place; the Voice of Mental Health Award from the Jed Foundation and the National Mental Health Association (now Mental Health America); the Prism Award of the National Depressive and Manic-Depressive Association (now the Depression & Bipolar Support Alliance); the Erasing the Stigma Leadership Award from Didi Hirsch Mental Health Services; the Charles T. Rubey L.O.S.S. Award from the Karla Smith Foundation; and the Silvano Arieti Award from the William Alanson White Institute. In June 2015, a second edition was published with a new chapter outlining recent developments in the science and treatment of depression.
A native New Yorker, Andrew Solomon attended the Horace Mann School, graduating cum laude in 1981. He received a Bachelor of Arts degree in English from Yale University in 1985, graduating magna cum laude, and later earned a Master’s degree in English at Jesus College, Cambridge. While at Cambridge, he received the top first-class degree in English in his year, the only foreign student ever to be so honored, as well as the University writing prize.
In 1988, Solomon began his study of Russian artists, which culminated with the publication of The Irony Tower: Soviet Artists in a Time of Glasnost (Knopf, 1991). In 1993, he was invited to consult with members of the U.S. National Security Council on Russian affairs. His novel, A Stone Boat (Faber, 1994), the story of a man’s shifting identity as he watches his mother battle cancer, was a national bestseller and runner-up for the Los Angeles Times First Fiction prize; it has since been published in five translations.
From 1993 to 2001, Solomon was a contributing writer for the New York Times Magazine; he has also written for The New Yorker, Travel & Leisure, ArtForum, and many other periodicals, and has authored essays for many anthologies and exhibition catalogs. His journalism has spanned topics as wide-ranging as Chinese art, the cultural rebirth of Afghanistan, Libyan politics, video art, puppetry, and interior design. In 2003, his profile of the diarist Laura Rothenberg, “The Amazing Life of Laura,” received the Clarion Award for Health Care Journalism and the Cystic Fibrosis Foundation’s Angel of Awareness Award. In April 2009, “Cancer & Creativity: One Chef’s True Story” was recognized with the Bert Greene Award for Food Journalism by the International Association of Culinary Professionals; the story was also a finalist for the 11th Annual Henry R. Luce Award. Solomon’s reminiscence on a friend who committed suicide, “On an Aesthete Dying Young,” received the Folio Eddie Gold Award in 2011.
In August 2013, Solomon was awarded a Ph.D. degree in Psychology by Jesus College, Cambridge, Faculty of Politics, Psychology, Sociology and International Studies, working on maternal identity under the supervision of Prof. Juliet Mitchell.
Solomon has read and lectured widely at universities, professional conferences, and literary festivals, including the National Book Festival, the Hay Festival, the Hay Festival Cartagena, the FLIP Festival, the Edinburgh Book Festival, the Sydney Writers’ Festival, the Jaipur Literature Festival, and the PEN World Voices Festival. He is a frequent storyteller at The Moth, and has been featured on several episodes of National Public Radio’s Moth Radio Hour. Videos of Solomon’s TED talks, “Love No Matter What,” “Depression: The Secret We Share,” and “How the Worst Moments in Our Lives Make Us Who We Are,” have garnered over ten millions views, with viewer-contributed subtitles translated into more than twenty-five languages.
Solomon has made numerous appearances on television and radio, and is frequently called upon by the media for commentary on mental health, family, and disability issues.
Solomon is an activist in LGBT rights, mental health, education, and the arts. He is founder of the Solomon Research Fellowships in LGBT Studies at Yale University; a Special Advisor on Lesbian, Gay, Bisexual, and Transgender Mental Health to the Yale School of Psychiatry; a member of the boards of directors of the National Gay and Lesbian Task Force; and a participant in the Proud2Be Project. His articles on gay marriage have appeared in Newsweek, The New Yorker, The Advocate, the London Times, and Anderson Cooper 360. His July 2007 marriage to John Habich was reported in the New York Times, the London Sunday Times, Tatler, and Newsweek. The wedding ceremony that Solomon and Habich wrote for that occasion has been used as a sample text in a University of Pennsylvania Law School course on privacy and civil rights law.
In addition to his position with Columbia University, Solomon is a Lecturer in Psychiatry at Weill-Cornell Medical College. He is a member of the boards of directors of the University of Michigan Depression Center and Columbia Psychiatry; a member of the Board of Visitors of Columbia Medical School; and a member of the advisory board of the Depression and Bipolar Support Alliance. In recognition of his contributions to the field of mental health, he has been awarded the Society of Biological Psychiatry’s Humanitarian Award; the Brain and Behavior Research Foundation’s Productive Lives Award; Yale University’s Research Advocacy Award; the GRASP Friend and Benefactor Award; the Fountain House Humanitarian Award; the Mike Wallace Award of the University of Michigan; the Columbia Psychiatry Gray Matters Award; the Ackerman Institute Partner Award; the Erikson Institute Prize for Excellence in Mental Health Media; Cold Spring Harbor Laboratory’s Double Helix Medal; and The Bridge’s Partners in Caring Inspiration Award.
In March 2015, Solomon was elected President of PEN American Center; he has been a member of the organization since 1994. He also serves on the boards of the Metropolitan Museum of Art; the World Monuments Fund; the artists’ community Yaddo; and The Alex Fund, which supports the education of Romani children. He is a member of the Library Council at the New York Public Library; a fellow of Berkeley College at Yale University; and a member of the New York Institute for the Humanities and the Council on Foreign Relations.
Solomon lives with his husband, John Habich Solomon, and son, George Solomon, in New York and London and is a dual national. He also has a daughter with a close college friend. Habich Solomon is the biological father of two children with lesbian friends in Minneapolis; those children are also part of the family.
“Born 27th November 1983, I wandered the world for 18yrs till i completely lost my way and began making music, rap music; or talking music as my Nan likes to call it.” – Professor Green
Firmly established as one of the crossover superstars of British music, the Hackney born and raised rapper Professor Green (aka Stephen Manderson) has released two Top 3 albums (‘Alive ‘Till I’m Dead’ and ‘At Your Inconvenience’) and nine consecutive Top 40 singles – including hits Read All About It (#1), I Need You Tonight (#3), Just Be Good To Green (#5) and Lullaby (feat Tori Kelly) (#4).
Professor Green’s all-conquering music career has seen him amass over 500,000 album and 2 million single sales in the UK alone; embark on four headline tours in addition to performing on the main stages of countless festivals such as Glastonbury, V Festival and Wireless; and be nominated for a plethora of awards including the Brits ‘Best Male’ over and above earned NME and MOBO awards. Not to mention a high profile underlined by huge social media statistics – 1.7+ million Facebook Likes, 2.1+ million Twitter followers.
No stranger to TV – after his journey was documented by Channel 4 in a six episode TV series (Professor Green Unseen and Professor Green Unseen: After Hours) – the past eighteen months has seen Green present three BBC documentaries (Professor Green: Suicide and Me; Professor Green: Hidden and Homeless; and Professor Green: Dangerous Dogs), and co-host Channel 5’s ‘Lip Sync Battle’ series. Since the release of his most recent, third album ‘Growing Up in Public’, he has also published his autobiography ‘Lucky’.
After signing to Relentless Records, Autumn 2016 sees Professor Green return to music with arguably his freshest material to date.
Q: How serious is our global mental health crisis?
[Professor Vikram Patel] If we look only at the numbers of people affected by mental health problems, at any one time, a conservative estimate of 5 percent of the world’s population is affected. This translates to an astronomical figure of several hundred million people.
However, it is not the numbers which is the crisis. Mankind has dealt with health problems of even greater magnitude, such as HIV/AIDS which affected almost one third of the entire population of some countries. It is our response to health problems is important, and this is the real scandal when it comes to mental health.
Q: What is the state of mental illness?
[Dr. Thomas Insel] Mental illness has been with us for centuries, perhaps forever.
We try to capture the public health significance of an illness by looking at mortality and morbidity. Mortality- when you think about it – is driven by heart disease, cancer, and to some degree infectious diseases. Morbidity – or disability- is quite another thing.
Mental illness accounts for 26% of all years lost to disability. It trumps virtually all other sources of disability- and this is for two reasons. Firstly, mental illnesses are highly prevalent. In the USA, nearly one in five adults had a diagnosable mental illness in the past year. More important, around 4-5% of the population is disabled by a severe mental illness- nearly 1 in 20 adults. Moreover, what makes mental conditions different from heart disease or cancer is that these disorders start very early in life- 75% before the age of 25. The current estimates are that depression is the single largest source of years lost to disability. That’s extraordinary to think that depression is globally a leading source of disability — this would not be on most people’s lists of public health challenges.
[Dr. Shekhar Saxena] The state of worldwide mental health is a cause for very serious concern, not just for governments but also the World Health Organization. There are a very large number of people with mental disorders, but a huge number who also have mental and psychological symptoms (not amounting to disorders) who need support. Although some people require care and services, many require help to take care of their mental health, to prevent future disorders.
We are talking about a huge population; not just people who have diagnosed disorders and require treatment, but all of us – you and I – who need to pay more attention to our mental health.
3-5% of people in any given population, at any moment in time, have a mental disorder with substantial disability. 10% of people in any given population, at any moment in time, have a mild mental disorder. Overall, in 1 in 4 families there is someone with a mental disorder, and that’s without including disorders related to alcohol and substance abuse.
What causes us great concern is that the attention paid to mental health by policy-makers and health services at large is extremely small. There is a large need, and not enough attention. The World Health Organization’s mental health programme is called the mhGAP – the Mental Health Gap Action Programme – which signifies the gap between the needs and availability of resources in this sector.
[Paul Farmer] We know that 1 in 4 of us will experience a mental health problem at any one given time- by which we mean people who will need help for their mental health. In broader terms however, we all experience mental health challenges- and one of the most important parts of our work is to think of mental health in context of the whole population as well as those specific individuals who do experience mental health problems.
[Sergeant Kevin Briggs] Mental illness in society today is more serious then ever before, in my opinion. According to the World Health Organization, there are approximately 800,000 suicides in the world each year. And, for each completed suicide, there are 20-25 attempts. We are still learning about the brain, how it operates, and how it is affected by mental illness. The key to reducing the stigma surrounding mental illness is education and an open mind. Take stress/mental illness in the workplace for example. They tend to remain near the top of the list for time lost from work. I believe if there were more training in the area surrounding this issue, particularly on how to recognize/approach a person suffering from mental illness/anxiety/stress, there would be a significant amount of money saved in lost time at work, thus reducing workmen’s compensation. People would also in fact be happier and contribute more to the success of their company.
Q: What is the state of mental health in the developing world economies?
[Professor Vikram Patel] The developing world is incredibly diverse, and you can never capture the truth of all countries in a single answer.
Let us consider community based care, which is the core of mental health care, where you have comprehensive services for mental and physical health needs, and where the mental health component includes medical as well as psychosocial interventions. If you take that as the goal of a good mental health system, then it would be fair to estimate that the proportion of people in the developing world who have such access is less than 1 percent.
Q: How does the mental health of a population impact their ability to respond to change?
[Andrew Solomon] The highest rates of anxiety disorders and depression tend to be in societies that are undergoing rapid transformation. In the same way that you get high rates in people who are displaced from one country to another, you also get high rates when a country is displaced from one system of values to another. Places where industrialisation is occurring show a big increase in depression and anxiety; places going from dictatorship to democracy do too. Societies that have been isolated find huge mental health challenges when they’re being integrated into the larger world.
Depression arises when a genetic vulnerability is triggered by external circumstances. If you have a very high rate of vulnerability, you need only minor circumstances to trigger it – and if you have a low rate of vulnerability, you need fairly major circumstances to trigger it.
Societies that are in transition are forcing people away from everything that is familiar to them, into a new way of thinking, being and understanding themselves. The result of this is that the people who have even moderate vulnerability to depression are triggered.
Q: How are our lifestyles impacting our mental health?
[Professor Green] Life is high pressure, and the stresses we are all under are getting more and more.
We’re only designed to have two responses to stress, fight or flight- and that’s because we evolved from our ancestors- the hunter gatherers. Now? we have relationship stress, work stress, stress about our friends, about our families, financial stress, mortgage stress, stress about our food. There’s a lot that people need to cope with now, and people don’t take time to deal with the stress they’re going through, even though that stress can cause serious health problems now, and in the future.
We have to look out for our communities too, social depravation and mental health issues go hand in hand, and that only furthers the link between stress and mental health issues.
Q: What was your experience of mental health challenges?
[Marcus Trescothick] If I look back, mental health impacted my life more back in 2006- when I was away playing in India, and became too much of an issue to deal with… which is why I returned from there and began the process of dealing with it, understanding it, and learning how to live your life with it.
In truth, it had been underlying for quite a long period of time. It had always been there and I hadn’t perhaps given it the credibility it warranted. I used to suffer quite a bit from homesickness from an early age- around 11- and the symptoms were very similar back then to how they are now still. At the time you think it’s just homesickness and you learn to cope with it for that period of time and it moves on. It’s only really at the time when it became more severe, that I understood what it was- and the reasons why. It became more of a ‘problem’ once I acknowledged what it was!
Mental health impacts everything. When I’m playing cricket, I could immerse myself in the game and what I had to do. I could distract myself and manage it more easily- and that’s part of the problem where if you’re not doing a great deal, you can sit with it, dwell on it, and it can become a bigger problem. My challenges certainly did have an impact on my job, but I learned to manage it to carry on and still deliver- and do what I need to do- even if I don’t feel 100% or as good as I would normally do on a daily basis.
[Professor Green] I’ve suffered with anxiety as far back as I can remember. It’s something that’s always been there, a feeling that sits in the pit of my stomach. As a child, I realised that I experienced ‘fight or flight’ a lot more than other people, and that’s quite a typical starting point for people with anxiety.
My Dad taking his own life played a huge impact on my life too. I became a lot more aware of things I perhaps wasn’t before. After my Dad took his life, I stopped smoking weed and did the opposite to what you see most people doing in situations like that. Instead of turning to things as crutches, I decided I wanted to feel everything and to deal with it. Even that wasn’t enough- and all this years on, that event has a huge impact on my life- and it’s something that’s taken a long time to come to terms with.
Q: How did you realise you were ‘depressed’?
[Andrew Solomon] In retrospect, I can say that I had some depressive episodes of a minor kind earlier in life. It was really when I was going through the trauma of losing my Mother however, that it escalated. In the years after she died, I struggled quite a lot and then I published a novel that was loosely based on her illness and death. In part because of the publicness of the book, and in-part because finishing it meant saying a final goodbye, I found myself feeling sad—and then that sadness gave way to nullity. It was a gradual substitution of negative feeling with the absence of feeling.
In The Noonday Demon, I wrote that the opposite of depression is not happiness, but vitality. It was vitality that was seeping away from me. I kept thinking I was going to ‘tough it out,’ that I would be able to deal with this on my own. Finally, I began feeling less and less able to do anything, and I became overwhelmed by the prospect of making myself a meal, doing laundry, taking a shower; I became paralysed by dread at the thought of leaving the house. It got to the point where I felt utterly overwhelmed by all aspects of life. And then the anxiety! I had this constant, burning terror but didn’t know what I was terrified of.
I eventually felt so physically paralysed, that I thought I had had a stroke. One day I lay in bed for many hours, unable to lift a hand to make a call even though I knew I required help. The phone finally rang, and I managed to answer it. It was my father. I told him there was something very wrong with me, and that he needed to come and see me.
It was at that point that I began seeking treatment for depression.
Q: What is the relationship between masculinity and mental health?
[Professor Green] When it comes to mental health, men feel as if they shouldn’t, they shan’t, they mustn’t…. It’s how masculinity is sold to us as children… We start with action men… and we’re told that being a man is about being ‘strong,’ and anything less isn’t being a man.
There’s a real misconception around the difference between being strong and being a hard man. Being aware of your vulnerabilities and admitting them, is a bigger strength than any kind of front you can put on.
Media portrayals of masculinity go back to society’s vision of the ‘archetypal male’ the superhero, the hunter gatherer. Men are expected to be everything in every situation; it’s something women experience too. You are expected to bend or mould to fit any situation- and that’s an impossible task.
Men aren’t very good at saying they’re not sure, or that they can’t do something, or can’t take something. That sense that we must have a ‘stiff upper lip’ is still so prevalent, and doesn’t seem to be changing- but the stresses we encounter are growing.
If you don’t get better at handling your stresses, there’s only, really, one result….
Q: How did your depression play a role in the lives of those around you?
[Andrew Solomon] People surprised me as I was going through my depression. Some people I had thought of as my oldest, nearest, dearest friends, people I had always assumed would be with me through any crisis, really couldn’t deal with it and disappeared from my life. There were other people, however, with whom I had thought I had quite a light, surface-level relationship who, to my great surprise, were right there with me through my difficulty.
My friends were mostly incredibly present and attentive. I remember having a conversation with one friend where I said that if I were ever feeling terrible, could I call him and come over? He said he might not know how to deal with me in that state, and that it perhaps wasn’t a very good idea. I was deeply hurt by that, but came to realise that different people have different capacities and what one person can give is not necessarily what another can give and my being in the state I was in was more threatening to some people than to others.
My father was very frightened and distressed, but I felt he also carried a great sense of failure at having not cured my mother of cancer—not that he could have done so, but he had tried so hard to get the right doctors and right treatments for her, and it didn’t work. In a strange way, while it was difficult for him to deal with me during my depression, he has since said it was very gratifying to face a problem that did have a solution.
People say one quarter of the world’s population will experience the symptoms of depression in their lifetime, but if you gather all the people who are affected by depression, in family members and friends, it’s closer to 100 percent of the world’s population.
Q: What is the social, economic and political burden of mental health on the community?
[Dr. Shekhar Saxena] Mental disorders have an impact on a number of levels. First, there is the health impact; they cause deaths and a huge amount of disability. More than 10% of the world’s Disability Adjusted Life Years lost is due to mental and psychological problems. This is huge. We mustn’t forget though that lives are lost. People frequently identify mental illnesses as causing disability, but not death; but that’s not correct. Around the world over 800 000 people lose their lives to suicide each year, and a large number of people with mental disorders die significantly earlier than the general population as they ignore their health needs and may not therefore get treatment for tuberculosis, cardiovascular disease, respiratory disease, cancers and so on. Unfortunately mental illness are often ignored by the health system; and they get much less attention in the hands of policy makers and health-care providers.
The social burden of mental illness is huge. Mental health problems give rise to absenteeism in the workplace, marital discord, child maltreatment, neglect and abuse, and also violence. I don’t want to feed the misconception that mentally ill people are violent, that’s absolutely not true. People with mental health disorders are more often at the receiving end of violence. Both people with mental health disorders, and their families, often suffer from stigma and discrimination. Sufferers are often denied access to social services, the jobs market and even social and cultural activities. This is extremely hard to measure in monetary terms, but is hugely significant.
The economic impact of mental health disorders is also very large. Working populations may experience reduced productivity, greater absenteeism and even ”presenteeism” where the person is at the job but not performing at well. You also find economic burden within the justice system as a result of drug and alcohol usage. A very large proportion of the prison population all over the world, but particularly in North America, has mental health disorders. In effect, the state spends more money on the indirect effects of mental health on society than actually treating the disorders in the first place.
The cost of mental health on society is not measured in millions or billions, but in trillions of dollars. This scale is largely unrecognised by policy makers.
The best voices to highlight these concerns are the people with the mental health disorders themselves, and their families; the advocacy organisations in this sector are not just few in number, but weak in stature. There is a lot of self-advocacy for HIV, cancer and so forth, but not so much for mental health. The people who suffer the most have the quietest voice – not just because of the illnesses themselves – but because of the stigma. This is one of the reasons why mental health issues do not get the attention they deserve.
[Paul Farmer] Mental health can be seen as a continuum. Many people manage their mental health well, and are able to live the lives they want to- and there are numerous examples of people who have achieved fantastic, incredible things whilst living with mental health problems… others have more complex and enduring problems that impact every aspect of their lives… ultimately and very sadly, there are also 6,000 people in the UK alone who take their own lives- and that is the ultimate impact of someone’s poor mental health.
Q: What is the toll and impact of suicide globally, and what is the challenge of suicide prevention?
[Dr. Shekhar Saxena] Over 800 000 people die by suicide each year, and the numbers are almost certainly under-estimated; a significant number of suicides are reported as natural or accidental deaths. For each death by suicide, there are over 20 attempts. These attempts leave a great deal of mental and physical disabilities. For each death by suicide, there are family members, friends and colleagues that are affected, and who sometimes blame themselves. It’s a huge problem that countries need to discuss. This is beyond health; it is a cross-sectoral issue.
We must recognise mental disorders at an early stage and provide proper care so that suicides can be reduced. We must also make sure that people at the front-end of services (such as medical staff, together with those working in the law enforcement and judicial systems) are trained to ask the right questions to detect people with suicidal tendencies early. Most people who eventually commit suicide and die have sought help within the previous 12 months, but did not receive appropriate help. We must also ensure that the means of committing suicide, such as pesticides and firearms, have restricted access. It’s genuinely believed that if a person is bent on suicide, that they will do but this is not true. Suicidal tendencies are often transitory and if you can prevent the person from taking their own life for a few hours or days, they may often never do it. We must also look at the fact that alcohol is very closely linked to thoughts of suicide and death by suicide. Reducing the amount of alcohol consumed in society will have a very positive impact on preventing suicide.
We believe that there is no acceptable rate of suicide, that each and every suicide is one too many and that each and every country has a responsibility to act on this issue.
Q: What are your views on our cultural perceptions of suicide?
[Andrew Solomon] Suicide is something we don’t discuss enough, but it’s important to note that discussing it too much can have toxic effects. So we need to be careful not only of whether we talk about it, but also of how we talk about it.
In the aftermath of major famous suicides such as Marilyn Monroe and Robin Williams, there’s an up-tick in suicides because the choices of those famous people seems so normalize the act.
There are prevention strategies for suicide that can be very effective, but I also believe that people have a right to suicide if they really have tried everything they can to get better, and cannot do so. There are very few people for whom it is the right decision, but there are some.
In the United States, we have an appalling problem with gun violence, caused in large part by our lack of gun control laws. The rate of suicide by gun is significantly higher than the rate of homicide by gun; so more than half of people who die by gun in the United States are dying by suicide. If you removed the means of their self-destruction, many would survive; there is clear evidence that when it’s harder for people to kill themselves, fewer of them do it.
People often talk about physical health being urgent and immediate, and mental health as being something of a luxury. Foreign Policy just ran an article about refugee camps in Iraq for Kurds who had returned from conflict. The people running them said that they were fully occupied keeping people safe, and didn’t have time for the luxury of dealing with their mental health. These are people who have post-traumatic stress and extreme depression and high anxiety—as most of us would after going through what they’ve endured. The notion that their mental health is a luxury, akin to giving them freshly baked goods for breakfast, is so misguided. In fact, many of them may die from their psychiatric challenges.
The enormous suffering people go through during, and even in the lead-up to major depression is has costs in terms of the overall level of happiness on the planet, and in terms of the economic cost of all these people who are unable to function. It would be not only humane but also economically wise to provide better treatment to more people.
Q: Why do you think people see suicide as a final way out?
[Sergeant Kevin Briggs] This of course is just my opinion with regards to why people become suicidal. This is based on my own observations of the many folks I have dealt with. With mental illness comes shame. In most of the world, mental illness is looked upon as a sort of made up concoction is one’s head. You dare not speak about, for fear of loosing family, friends, even your employment. So, people suffer for years with getting treatment. Even those who face this head on can struggle greatly, due to the severity of the illness at times. Some of those who suffer, even after seeking help, become so ashamed and incapacitated by their illness, they believe they simply cannot go on. They feel they are a burden, and are actually doing everyone a favour by their demise. Then they are the one’s who have committed criminal acts, such as lewd acts with children. When they are discovered, they shame and embarrassment is too much. As many ways as there are to loose one’s life to suicide, are that many reasons to do it.
As far as a cry for help, there are those that start to do an act, say, come to the Bridge and go over the rail because they know they are going to get attention. It is my belief that most do not do this for attention. We do have our “frequent guests” so to speak, but each and every time they are handled with respect and as if it was their first time on the Bridge. You just never know what is really going on in a person’s mind, so it is important to take each case with the utmost care and concern.
Q: What were the reasons why people had decided to make attempts at taking their own lives on the Golden Gate Bridge?
[Sergeant Kevin Briggs] There are a multitude of factors why people think suicide is their only way out of the pain/loneliness they are suffering. The vast majority of the time years of suffering from mental illness have occurred. Mental illnesses like Depression and Bi-Polar disorders wreak havoc on a person. Some do very well with therapy and medication. Others loose their way and decline steadily, over the years, emotionally, financially, and finally loose their ability to cope. Once is a while a person will loose their life to show another person what they have done to them. It is a retaliatory action based on what a loved one, business partner, or person close to them has done.
Q: What was the mental state of those you observed on the Golden Gate Bridge?
[Sergeant Kevin Briggs] Most of the people I have encountered over the rail did in fact suffer from a diagnosable mental illness in one form or another, and varying degrees of severity. Alcohol and drugs was observed in many, as this helps to alleviate pain and give them courage for the task at hand. Two of the people I dealt with directly were in fact not under the influence of alcohol/drugs. They had been suffering from mental illness for years. Their demeanour was generally calm and collective. Both were extremely polite, and seemed as if they were ok with what they intended to do, and had made peace with it.
Q: What was the impact you saw from suicide?
[Sergeant Kevin Briggs] The impact of what occurs when we observe a suicide is difficult to fully explain. If we have spoken to the person for some time, it is like loosing a friend. The bond created just before one’s death leaves an emptiness in your heart and guilt in your soul. “Could I have done better?” We ask this of ourselves each and every day. But this is just the tip of the iceberg. The family and friends can be affected so deeply that it may trigger other suicides. I have seen parents simply give up on life after their child has lost his/her life to suicide. The guilt can be tremendous. Although they may, and probably did, do everything to the best of their ability, a suicide has ripple affects that lasts a lifetime.
Q: How did suicides impact you (personally) and the officers/personnel you worked with?
[Sergeant Kevin Briggs] The suicides that we do witness will forever be ingrained in our minds. It is very personal, and each of us deals with it differently. We (the California Highway Patrol) have what’s called an Employee Assistance Program (EAP) where we can see a psychologist seven times a year. This has helped many of us.
I look at it a couple of different ways. One is that fact that I believe we help many more then we loose. The other are words a Rabbi from New Jersey told me once after I spoke to a young man, just 32 years old, who flew out to the Bridge from New Jersey and jumped after I spoke with him for an hour. I was feeling extremely guilty and very down on myself. The Rabbi told me, “Kevin, if you ever stop feeling the way you do right now, get out of the business.” He explained it is the compassion and thoughtfulness that’s helps so many, and that even though we try with all our heart and soul, some folks just cannot be reached.
Q: In your role; how would you try and diffuse the situation(s) and talk-down individuals?
[Sergeant Kevin Briggs] I use active listening skills in the hopes of generating conversation to find out what is going on in their life. Honesty is huge. I in no way advise them their life will be a piece of cake if they come back over the rail, but I do relate the importance of their life, their self worth, their responsibilities, and try and install hope. Listening is critical. Many times, all a person needs is someone who will listen, without an agenda or argument.
Q: What is the state of attitudes towards mental health?
[Dr. Thomas Insel] There is a lack of understanding about mental illness.
In the developing world, mental illnesses tend to be viewed as a first-world problem. In the developed world, it’s often seen as a private family issue and is rarely a priority for people who set the public health agenda. Mental health oddly has been carved away from the rest of medicine as being a social-services problem rather than a medical or public health problem. That’s a critical part of the difficulty we’ve had bending the curve for mortality and morbidity as they relate to mental illness; we’ve not been able to get traction in the world of medical practice.
The World Health Organisation reckons that around 3% of healthcare dollars are spent on mental disorders, yet these disorders account for 26% of years lost to disability. It’s a huge gap between investments and costs.. Patients receive the equivalent of less than $2 per person per year in this space- and that’s incredible considering the disability associated with mental illness. It’s not simply a question of disability – mortality is also a concern. The WHO global suicide report cites conservatively that there are more than 800,000 suicides in the world each year, 90% of which can be attributed to mental disorders and 75% of which are in low and middle income countries. Mental health is not only a first-world problem, and the suicide data demonstrate that, when neglected, this a problem with fatal consequences.
In the USA we have around 12 suicides per 100,000 people each year- a rate which is about average for an OECD country. Note that the deaths from suicide are more than double the deaths from homicides each year: the USA has around 16,000 homicides each year, and 39,000 suicides! In the USA, there is an immense focus on homicides, it’s a lead story in each and every newspaper but you rarely read about suicide which is twice as prevalent. In fact… homicides have come down around 50% whereas suicides have only trended upwards.
There’s a remarkable neglect for suicide. Around the world we have people accountable for reducing medical deaths, road traffic accidents and so forth, but it’s difficult to find who’s accountable for preventing suicide in most countries.
[Dr. Shekhar Saxena] The stigmatisation of, and discrimination against, those with mental health disorders is found all over the world.
The stigma is not just due to a lack of knowledge, but attitudes. It’s easy to change knowledge, but hard to change attitudes and behaviours.
One of the reasons self-advocacy is weak, and we are experiencing a policy hiatus, is because policy makers don’t like to think or plan around mental health because of the stigma. The public discourse in developed countries is changing, but it’s far from adequate ̶ and in much of the world, the discrimination is rampant.
There is also a very clear link between mental health disorders and human rights violations. These violations occur in mental institutions and in the community. Almost 70% of psychiatric beds are in mental hospitals and not general hospitals. Mental hospitals, by their definition, are isolated and often far from cities. They have conventionally been more of a place to keep people with mental disorders away from society, rather than for treatment and services; this unfortunate reality continues in the present day in both the developed and the developing world. Human rights violations are rampant and because of a lack of transparency and accountability, these violations are able to occur both within and outside the law. In many countries, there are laws that deprive people with mental disorders of their basic civil rights such as voting, driving, property ownership and so forth. Laws aside, we see frequent abuse of people with mental disorders; they are deprived of their liberty, and sometimes locked-up in institutions for life. Even basic physical needs, such as food, clothing, shelter and basic healthcare, are often denied.
It’s not just within healthcare settings that these abuses occur. Communities frequently violate the human rights of their citizens who are suffering with mental health disorders. We hear stories about people being chained and locked-up in their houses for years ̶ this is indicative of the way society treats people with mental disorders. This is not just illegal, it’s immoral.
Mental disorders are disorders like any other, but they are stigmatised and deprive people of their human rights. Society must do something about this.
[Paul Farmer] There is no doubt that mental health stigma remains a huge challenge to overcome. For generations, we’ve ignored the issue of mental health, and those with mental health problems have been literally kept out of sight, out of mind. Let’s not forget that it wasn’t that long ago that people were locked-up in long-stay institutions! That was the way that society viewed mental health!
We are beginning to see progress… For the first time, partly as a result of the Time to Change campaign, that we run with ReThink Mental Illness we’ve seen an improvement in public attitudes to mental health. In specific areas, attitudes are changing quite quickly. In the workplace for example we know that many employers are recognising the importance of improving well-being for employees, and supporting people who need it. We also still know that many people feel they can’t disclose their mental health problems to their employer or colleagues.
It’s important for leaders to be open about their experiences, and that’s not something that happens very often. It makes a huge difference. There’s been a lot of work around how leaders can be open about their mental health challenges, as it can often be doubly-difficult in a workplace. If you’re a member of staff, it’s hard enough going to your manager – but if you’re in charge? Who do you talk to and how!?
[Marcus Trescothick] I [personally] don’t see this perhaps as much as it’s reported in the media, but I can only really judge it on my own circumstances and a few friends in the profession who’ve been through it. Whether we’re just lucky and people allow us to carry on playing the game? …it doesn’t affect us too much. It doesn’t affect the decisions made on us, we’re still allowed to carry on and do as normal. You do hear a lot about it in other areas.
Even now however, I know lots of people who still don’t want to admit to their boss or team-mates what they’re going through. That’s people within the game, but also from other walks of life.
People still believe there’s an issue or stigma… but it’s not until it’s a major problem that people go, ‘sod it, I’ll just tell everyone….’ And that made it a lot easier for me!
[Professor Vikram Patel] It’s often easy to blame people at the grass-roots for the myths and negative ideas around mental health, but it’s my belief that these start at the top, with the policy makers and rich foundations who may argue that mental health problems are not real, or that they are intractable or not treatable.
At the community level, the biomedical framing of mental health problems is by no means acceptable for the vast majority of people. An approach that tries to force psychiatric or biomedical paradigms will also fail. We have to adopt an approach that incorporates people’s understandings of mental health problems, in particular for conditions like depression or anxiety. For example, we need to use narratives of suffering in the context of social-disadvantage instead of psychiatric labels. This approach will help us connect with the community more effectively and lead to greater openness to discuss these conditions and to seek appropriate care.
Q: How do attitudes about mental health affect access to care?
[Professor Vikram Patel] In many communities, people feel that mental health problems can be dealt with by tightening your belt and being strong. Of course, you would never say that to someone who had cancer! Whilst I do believe that mental health conditions are ‘health’ conditions, I think they are different from physical conditions, such as cancers for example. You have cancer as something that is external to your being. You do not connect your cancer with who you are as a person. Mental health conditions, particularly depression, are embedded deeply in your life and your sense of who you are- they are often triggered by things that are happening in your life and inseparable from it. The very different ways in which people view mental health problems need to be acknowledged if we are to address these barriers to improving access to care.
Q: How much importance is given to mental health in India?
[Professor Vikram Patel] In India, mental health is forever in the news. It’s one of the biggest political issues of the country, but it’s not referred to as a ‘mental health issue.’ At the moment, there are two good examples of this which have been central themes in elections: the suicides of farmers and alcohol abuse (linked to prohibition). In most parts of the world, these two issues would be addressed from a public mental health perspective. But in India, entire elections are being fought by parties around these issues, but without mentioning mental health. The reason is partly because policy makers equate mental health in this caricatured way as the ‘pagal’ (literally meaning ‘mad’) person, someone wandering dishevelled in the street whilst being very, very unwell. The idea that drinking heavily is a mental health problem or that contemplating and acting on suicidal thoughts are a mental health problem are simply not part of the conversation.
Q: Why is mental health shrouded in taboo?
[Andrew Solomon] Taboo and stigma are very overused words in this context.
People experience shame from the outside; people are frightened by depression and express prejudice towards it. Often, the people who exhibit the most prejudice are subject to depression themselves, are terrified by its contagion, and don’t understand its true sources. This fear is part of the general human tendency to dislike weakness; depression is still seen as a weakness.
The internal shame arises because one of the symptoms of depression is not liking yourself much, and if you don’t like yourself, it’s difficult to display your authentic self out in the open.
It’s possible for me to be very open about having had depression, but when I have the occasional slight relapse and have to cancel something? I find myself saying I have food poisoning, or concocting some other false explanation. Even as I’m making that excuse, I am thinking to myself how ridiculous that is. I’ve written a book on depression, everyone knows that I suffer from depression, but even so, when I am depressed, I feel that admitting I am depressed is a further failure, and I am ashamed all over again. In fact, that shame is a symptom of the disease.
Q: What are your views on the taboo around medication and counselling?
[Andrew Solomon] The resistance to medication for depression frequently comes from people who think they should wage their battles on their own. If the person had diabetes, you wouldn’t tell that person to avoid insulin injections; if someone had pneumonia, you wouldn’t persuade that person to go off antibiotics.
People’s idea that antidepressants aren’t natural contributes to the resistance to medication, but we have plenty of interventions in our life that are not natural yet are important; brushing your teeth for example. The natural thing would be for them to fall out by the time you’re thirty, but no one militates against toothpaste.
Life is short, and if you are really depressed for this whole year? Guess what? You will never get this year back again. If there’s some medication you can take that will allow you not to be depressed for this whole year, there is no moral advantage to avoiding it. There is no scorekeeper out there giving you extra credit for “fighting on your own.”
You need to do whatever you need to live as well as you can.
If you take medication, and you don’t like it? You can stop. People have this misguided impression that taking medication is a Rubicon they will cross, from which there is no turning back from. It’s not so.
People often say it was brave of me to talk about my experience of depression, and my medication. But I grew up as a gay person, very much in a closet. I decided when I got out of that closet, that I was not going to be getting in any more.
Don’t ever make yourself or others feel ashamed about taking medication. We all have illnesses and vulnerabilities. Don’t be a slave to your or anyone else’s notion of what healthy means. This is your voyage of discovery.
[Professor Green] People don’t want to appear vulnerable, and there’s a sense that if you go for counselling or take medications, that you’re showing a vulnerability.
These thoughts even spread into careers… If you think about two people who are going for the same job in a workplace, if one of them was honest about their mental health, they may think they were at a disadvantage, or think they are weak.
You know what, I understand the fear around medication. The first time I went to see my doctor about my anxiety, they gave me a prescription. I’ve never taken medication; that’s not to say there’s a case for them, and that’s not to say they’re not important for some people; but it’s not good that antidepressants are handed out quite easily when routes such as talking therapy can be just as effective for a lot of people, and without the side effects.
Q: Is there a link between high performance careers and mental health?
[Marcus Trescothick] From what I see, I think there probably is. There’s a lot of demand put on yourself – you push yourself through hours and hours of work; that could be hours of training at the gym, practice, on the pitch, travelling and being away from home. The England team for example spend around 270 days a year away from their families and homes- that’s pretty demanding.
There must be some correlation between demanding lives and mental health… that said, I know many people that suffer these problems who don’t have those same life challenges. Everyone’s issues are relative to how their brain operates- they still have the same stresses and worries that we all do.
Q: What is the state of treatment for mental illness?
[Dr. Thomas Insel] We think of treatment in two big buckets. One is medications. The medications we have today, around 30 anti-depressants and 20 anti-psychotics, are not strikingly different from the drugs we had 40 years ago. That’s not to say they’re not effective; they’re actually quite useful and may be essential for those who are severely ill.
Medication isn’t sufficient however… you need a series of non-pharmacological interventions deployed with medication. In much of the developed world, people get medication but not much of anything else. The second bucket includes the range of non-pharmacologic treatments, from psychotherapies to devices, including mobile health apps. There is a lot of innovation right now in the development of inexpensive, accessible treatments that can be used in low resource environments.
Medications can treat the symptoms, but may fail to address the core of these illnesses, which are often cognitive. In the developed world, we’re too singular in our approach- focusing on medication or cognitive therapy but rarely combining treatments to get optimal outcomes.. In many developing world, patients don’t- in many cases- even have access to the medication! The WHO estimates that 85% of people in the developing world receive no treatment whatsoever! All these medicines are generic and incredibly cheap, and could be available everywhere to everyone. It wouldn’t be enough of course, but antidepressant and antipsychotic medications should be in every formulary in the world.
[Paul Farmer] There is a very long history of mental health being continuously underfunded as a result of which, only 25-35% of people with mental-health problems receive treatment at all. There’s an enormous treatment gap between the number of people who need help and support and the number of people who get help and support.
Evidence suggests if we invest systematically in mental health, not just at the treatment-end, but also with early interventions and appropriate crisis care, that it can be clinically and economically effective. There isn’t any reason why these investments can’t be made now, especially given the savings that could be made in acute hospitals and primary care; lots of people who go to their Doctor or A&E; have mental-health problems, and many people on acute wards have some mental health problem. There’s a really good opportunity to change the way that mental health services are provided, and in our manifesto for the next government, we’re encouraging this to be at the heart of thinking.
Q: What are the most promising areas of science in mental health?
[Dr. Thomas Insel] At the NIMH we think a lot about how we get better at diagnosing and treating these disorders. Much of what we do today, and have done for the past several decades has been focussed on symptoms rather than the underlying cause or strategic treatments. The hypothesis we have here is that mental illness is related to something going on in the brain, just as chest pain is usually related to something going on in the heart or the lungs. We don’t know enough about these illnesses as brain disorders, but if we apply the extraordinary tools of modern neuroscience- there’s great potential. Modern genomics and neuroscience could transform how we think of mental disorders and provide us with new diagnostic tests and treatments. Just as an example: in the era where pharmacology was the main foundational science for mental disorders, there was a tendency to think of the brain as a black-box and to consider an illness as a chemical imbalance- as if depression meant you were a quart low in serotonin. The new perspective views depression as a problem with circuits in the brain that aren’t operating properly- something more like an arrhythmia in the heart. The task of treatment is to get the circuit synchronised in the right way- Medications can help but circuit tuning may require cognitive psychotherapy or targeted brain stimulation. It’s becoming increasingly clear also that depression is many different disorders that impact brain circuitry, as much as fever comes from many different causes- neuroscience should give us the assays to understand depression in this way.
Science is taking us in a new transformative direction for mental illness.
Q: What are the key determinants of mental health?
[Dr. Shekhar Saxena] Mental health disorders have many causes. I can say upfront that we don’t fully understand the causes of all mental disorders, although for some we have a very good idea.
The causes of mental health disorders vary from biological to social, and also psychological. Biological causes are to do with brain functioning, neurotransmitters, genetics and even structural lesions within the brain. The psychological and social causes are due to stress factors, and the risk factors that exist as a result of inequality, conflict, wars and so-forth.
There are avertable causes, and also non-avertable causes, but we do know that rapidly changing societies, and those going through upheavals caused by conflict and natural disaster for example, predispose their populations to a higher incidence of mental disorders; and we can do something about that through anticipatory action and the right interventions post-event.
Q: How do demographics impact mental illness?
[Dr. Thomas Insel] One of the things that is so unique about mental illness is its prevalence in children. A fascinating question has come up about the genetics of conditions ranging from autism to schizophrenia and bipolar to ADHD. It turns out that the genetics are very similar across them all, indicating there may be a common vulnerability. Some disorders occur more in children, some more in men than women. Autism and ADHD are 4 times more common in boys for example, while depression and eating disorders are more common in women. Is there something about the fundamental mechanisms of these diseases that causes some to occur by aged 2-3 (such as autism) and some much later (such as schizophrenia) which emerge in the early 20’s. Could the age of symptoms reflect the development of relevant brain pathways? Do the gender differences represent hormonal influences that are protective?
It is also possible that age and gender alter the presentation of these disorders. One line of thinking today argues that the same disorder looks like anxiety at aged 8, depression at 28, and dementia at 68. It can be the same biology and may require the same treatment. We know that men and women with the same disorder have different presentations. For instance, women with depression more often present with the sadness and gulit; men often exhibit irritability and hopelessness.
[Paul Farmer] At Mind we’ve been thinking about how we can support the resilience of those who are most at-risk of developing mental health problems. We’ve been doing quite a lot of work thinking about mental health in a public health concept in much the same way as people look at smoking or obesity. There’s also benefit in identifying groups who are at specific risk; for example- older people who are at risk of isolation, mums-to-be, who are at risk of post-natal depression, unemployed men in particular due to the elevated risk of mental health problems in those who are not at work, vulnerable migrants, people from the African and Afro-Caribbean community, and also those with long-term physical health problems- they are all at greater risk of developing mental health problems. We want to work with public health teams at a local-level to put in place strategies that allow people to have the resilience they need to deal with mental health problems.
[Sergeant Kevin Briggs] Most of the time it is white males, ranging from 18 to 45 years old that jump from the Bridge. They differ in socio-economic levels. There really are no patterns to suicide on the Bridge. Some years have more age groups then others and sometimes more in the spring and after school begins, but really, suicide from the Bridge crosses all races and economic borders.
Q: Who are the highest risk groups?
[Professor Vikram Patel] If we consider depression and anxiety, which are the most common forms of mental illness, we find that these conditions are more commonly identified in women, and much more strongly associated with a variety of social disadvantage such as living in relative or absolute poverty, having lower education, or belonging to a marginalized group or having been exposed to trauma and conflict.
Q: How do the justice system and our political framework deal with mental health?
[Paul Farmer] We have three cornerstones in legal terms when thinking of mental health. The Human Rights Act is an incredibly important part of the support and safeguards that people with mental health problems have, and so too is The Equalities Act. Since mental health is perhaps the only situation where someone can be forced to receive treatment against their will, The Mental Health Act and The Mental Capacities Act provide those legal policies and frameworks to safeguard and define any state intervention in someone’s life.
We are detecting a greater degree of political interest in mental health as an issue, and all of the [UK] political parties are taking it a lot more seriously. There is still a long road to travel down before mental health is embedded into government policy-making, and that’s really what we would like to see.
Q: Is there enough will to fight mental illness?
[Dr. Thomas Insel] We’re stuck in a situation where mental health has become hugely fragmented and misunderstood. Secretary Hillary Clinton recently spoke about the need to redefine mental health as a public health problem. She pointed out that in some countries, including the US, mental health has become a criminal justice problem- as more people with mental illness are in jails than in hospitals.
There’s a great need to educate policymakers as to the importance of this problem, and the need to address it. It’s not expensive! We’re not talking about high tech diagnostics and therapeutics for each ill-person, but re-organising resources to achieve better outcomes. In fact, we know how to do this. For example, NIMH supported scientists are about to publish the results of a large study to improve outcomes in individuals following their first psychotic break (usually in their early 20s). To reduce subsequent arrests, re-hospitalisations, and poor treatment compliance, this study bundled together treatments that have been available for three decades. We can do so much better without any new science; just by making sure we do what we need to.
Q: Who are the key stakeholders in mental health solutions?
[Dr. Shekhar Saxena] Mental health issues should be everyone’s business, starting from policy makers who have a responsibility to make national policies to prevent mental disorders and promote mental health, and service providers. The budget allocated to mental health in low- and middle-income countries is less than 2%, and less than 3% elsewhere in the world – but the burden of mental and neurological disorders worldwide is around 10% of the total disease burden.
Civil society has a huge responsibility to highlight issues and take action to make things better. Those with mental health disorders (and their families) have a responsibility to speak out and demand the services they need. The media also has a role to play. Many misconceptions about mental health are strengthened by inappropriate reporting ̶ meaning that people are given the picture that those with mental health disorders are abnormal, cannot be cured, are violent and aggressive, cannot take responsibility and more. All of these things are untrue. In the majority of cases, those with mental health disorders can become ‘normal,’ and work, marry, look after themselves and their families and have good lives. People with mental health disorders need the support of society, not the ridicule that is often heaped upon them.
Commercial organisations play a role. The healthcare sector (including pharmaceutical companies and researchers) have the responsibility to further research treatments of mental health disorders ̶ this is not just good business, but also in the public health interest. Employers must do a better job of looking out for the mental health of their employees. We have a large responsibility for mental health in the workplace, and that’s often ignored.
Even you and I are stakeholders in the mental health agenda. We need to be on the look-out for people who may need help, in our own families and among our friends and colleagues. Often, because of stigmatisation, those needing help do not get it in a timely way and may be at risk of suicide.
Q: How can communities play a role in improving the mental health of their citizens?
[Professor Vikram Patel] Psychiatric care will never reach everyone in the population. Even in the richest, most well-resourced countries, with the best healthcare systems and specialists where access to healthcare is publically funded around 50 percent of people with depression and anxiety do not see a psychiatrist or psychologist. We need to move away from the notion that mental healthcare is equivalent to psychiatric care. This is a simply not the case. You do need psychiatrists and psychologists, but they are needed for the more severe end of the spectrum of mental illnesses. The majority of people with depression and anxiety should be able to manage their problems through supported self-care (for example, through the internet and self-help books with remote support) and through community based workers in which frontline workers provide first-level psychological treatments based on empirical science and theory.
The community is central in improving access to mental health care. We recently completed a project in 30 villages in a region which is the epicentre of farmer suicides in central India. During my initial engagement with the community, the villagers heard I was a psychiatrist and so they paraded out all those epilepsy, schizophrenia and learning disabilities. By the end of 18 months of systematic engagement with community leaders and systems, the dialogue extended to include suicide, depression and alcoholism much more openly. A number of villages passed resolutions to demand mental healthcare from the state.
This experience confirmed that the engagement of the community in a participatory and democratic way was essential to improve access to care in a contextually sensitive way.
Q: What is the role of government and the private sector in mental health outcomes?
[Professor Vikram Patel] Mental health is everyone’s business.
Government should work to recognise that mental health is profoundly influenced by macro-economic and social policies and this should be taken into account when designing such policies. Just as one example, we now know that giving mothers adequate support after pregnancy, not least through fully paid maternity leave, not only prevents maternal depression, but supports early childhood development and improves those children’s outcomes as adults. That’s a good investment for mothers, their children and wider society, as well as being a high-level policy imperative.
Businesses must ensure that people’s rights are protected as part of their obligations to society, but they must also encourage an open dialogue around mental health in the workplace, and that sick-leave and benefits are equally accessible to those who are mentally-ill. Businesses must not disadvantage those who are experiencing mental illness. Workplace design, culture and environments are also extremely important to maintain the mental health of our workforce.
Q: Will we see a world free of mental health problems?
[Dr. Thomas Insel] The community of people involved with mental health have really never sought a cure, the way advocates have campaigned for cures for cancer, heart disease, and AIDS. Mental health advocates are developing a culture of recovery — their most ambitious aim is to make sure that everyone can recover. That is fine, but prevention and cure need to become part of our vision when we think about autism, severe depression, and schizophrenia.
People are now starting to talk about prevention, recovery and cure in their agendas. We need to look at this in similar terms to heart-disease. We need early detection- rather than waiting for someone’s first psychotic break at 22, we need to detect the prodromal problem at aged 8, 12 or even 15. In the USA, we have around 100,000 people who have their first psychotic break each year, we want to reduce that by 50% through early detection and intervention. This field simply hasn’t had a vision of prevention and cure – which will require better science. We’ve been mostly about provision of services. Better services are critical but will this reduce morbidity and mortality? It’s a real challenge for us to realise that maybe what we have to offer today is not good enough and that we need to do something better to prevent psychosis and suicide.
[Dr. Shekhar Saxena] I don’t see a world in the foreseeable future that is free from mental health disorders, but I do see a world with greater attention given to mental health, and a world where people are encouraged to promote their mental health and to effectively take care of disabilities and conditions if and when they occur. I also see greater participation of people in society within the mental health agenda, and the mainstreaming of mental health into policy making. This is a realistic goal. We are not seeing the end of cancers in the foreseeable future for example, but we have a better understanding of prevention, care and services, and this is what we want for mental health.
The World Health Assembly Resolution on Mental Health was passed by all the health ministers in 2013. I see this as a major advancement in the recognition of mental health, and a commitment by the world. It was remarkable that all 194 Member States of the World Health Organization, committed themselves to the same vision, objectives and targets for mental health. This gives me a lot of hope about future actions and achievements in improving the lives of people suffering from mental health disorders and their families.
Q: What is the role of education as it relates to mental health?
[Paul Farmer] There is a serious need to give young people a good grounding in mental health. In the Time to Change campaign, we take mental health messages directly into schools and work with teachers, pupils and support staff. When our team leave, we hope that people are able to ask the right kinds of questions and talk around these issues. Formally and informally, there’s a huge job to be done…
We’ve also seen positive evidence around supporting mental health right back in the 0-2 year old group where you can do a lot to build positive resilience through positive parenting programmes for example.
Q: How is technology impacting mental health?
[Paul Farmer] Accessing information and support has helped people with mental health issues tremendously. For example, our Ele-Friends peer-support community is a fantastic example of what you can do in a positive way using online empowerment. We are also seeing the emergence of access to online therapy, and the use of apps to monitor mood and so forth.
There’s also a strange-paradox where people may feel that technology can make them more isolated rather than less isolated; so despite the fact that we have may ways of communicating perhaps we’re doing it less in quality terms.
We have to keep a close eye on the impact of modern technology on the mental health and mental wellbeing of any society, but on the whole we see it as a force for good.
Q: What would be your view of the future of mental health?
[Paul Farmer] We are living through a key-part of mental health’s journey. We are coming out of the shadows, and mental health issues are now much more visible in a positive way. The next 10 years or so could hold a great opportunity to reach a tipping point in public attitudes to mental health in the same way that attitudes have changed towards gender, sexuality or race. With that will come a significant increase in demand for help, and so it’s important that the support services are in place to absorb that demand.
In a really optimistic way, I think there’s an opportunity for a real significant sea-change, and we are on an inexorable path towards that.
Q: What was the greatest lesson you learned in your time as a guardian on the bridge?
[Sergeant Kevin Briggs] I have learned so many things since I began working on the Bridge, not only about people in general, but about myself also. My professional career has been primarily in “macho” jobs (military, corrections, CHP). This path had hardened me somewhat, making me emotionally shut down. To see what we see in this business and still be able to go back and do see the same thing the next day, you need to be able to put the bad away and move forward in a fast manner. What has really struck me is the empathy you show can really make others shine, no matter where that be. Everyone of us has emotions, and when confronted by obstacles in our life that can seem overwhelming, all it can take is just one caring individual to really make a difference. That little amount of time you spend with someone can make a lifetime’s worth of hope for them.
Q: What is the role of resilience?
[Andrew Solomon] People can be resilient to their own depression or resilient in the face of shifted and changed societies.
There is an interplay between illness and personality. Some people seem to have greater inherent resilience; they can adapt better even to a condition that undermines many people’s ability to adapt. Beyond native capactiy, however, resilience comes from the personal and social level of reckoning with whatever those specific triggers are. It comes from refusing to ignore your own problems or to sweep them under the carpet. It comes from integrating the story of your own depression into the larger story of your life.
Of the countries that I’ve visited and written about in Far and Away, South Africa has gone through the most successful transition. There have been issues, of course, with the ANC, and there’s a lot to be worried about, but it is essentially a better place now than it was under apartheid. The fall of apartheid was the elimination of something evil and wrong that gave way to something better. The entire population went through the essentially psychotherapeutic process of the Truth and Reconciliation Commission.
Countries that close their eyes to their history are under constant threat of that history recurring, just as peoplewho close their eyes to their own personal history are more likely to be fearsomely depressed.
Societies that examine themselves, examine their changes and understand their history, create a single fluid narrative and are frequently more resilient.
In the United States, in England and in Europe, we’re seeing a rise of populist extremism. People are made anxious by change and frequently, autocratic leaders appear to offer enormous stability. People who are unsettled will often be drawn to that perceived stability, even if it is accompanied by unattractive policies and bigotry. The great trick for governments is to teach people to tolerate the feeling of uncertainty, showing how uncertainty can be the precondition of striving for something better.
Q: How has your art played a role in your mental health journey?
[Professor Green] Thoughts can become a bit of a jumble and clutter your head, but when you put things on a page, they have structure. It could be a thought here or there, a line here or there, but eventually what goes on that page takes structure- a verse, a chorus. There’s something cathartic about that process, it helps deal with what’s happening in your brain.
Art is a form of expression. I didn’t have any form of expression until I wrote music, not artistically anyway. Anyone who’s fortunate enough to find a form of expression should embrace that- some people do it through boxing, some through painting, some through playing football, some from the gym, it can be anything.
Q: What would be your advice to those people with friends or family going through mental health struggles?
[Professor Green] Don’t ever feel like you can’t say anything, or that you should know the right thing to say. When people pluck up the courage that something’s wrong, they can sometimes start to feel even more isolated because the usual responses are, ‘come on, pull yourself together…’, ‘keep your chin up…’ or ‘don’t worry, you’ll be ok…’ – whilst those responses don’t come from a bad place, they don’t help. If you speak with the wrong person, if you speak to someone who doesn’t understand what you’re going through, you can’t expect them to empathise or have the answers to your problems.
The best thing for anyone to do is to point their friend or loved one in the direction of someone who can help them.
Q: What has been your greatest insight during your recovery journey?
[Marcus Trescothick] One of the most valuable lessons I learned was that you only start to learn how to cope with your problems when you acknowledge what they are. You then come to terms with what it is, learn about it, understand it – and start to improve yourself!
I had been hiding from my mental health problems for a long time, almost since I returned from India. You’re almost trying to cover your tracks, and cover your ‘secret’ – the best thing to do at that point was to tell everybody. It made it easier, it meant I didn’t have to lie to the media about the reasons why I was doing this or that – when you talk about it, you find that people understand what you’re going through and often are going through it too. The point where I was open and honest about my mental health was definitely an important turning point for me.
I didn’t have any preconceptions about mental health before then. You obviously hear a lot of people talking about how they’re depressed and so on; and I didn’t really realise what it was about – I thought maybe people were run down or worn out. You hear a lot of stories about people prejudging those with mental health issues, but you never really understand it until you go through it yourself.
Q: What has depression taught you about life?
[Andrew Solomon] I had to make a decision at some point as to whether I was going to keep going in my life, and I decided very strongly that I was. That was crucial. I found that I had to dig up whatever resilience was buried in my complicated character and bring it to the fore.
Having felt myself come unfurled like I did made me more sympathetic to the difficulties of other people in general. It made me aware that things can go awry, that people aren’t always in control of their frame of mind, their feelings, their ability to think clearly. It made me sympathetic to the vulnerability of being human, because I had experienced that vulnerability myself. It made me kinder, I ceased to see things with the rhadamanthine judgement that I used to exercise. I saw the susceptibilities in people that makes them act as they do. That understanding changed my friendships and my relationship to public life and the wider world.
It’s often difficult to understand the experience of being someone else. Depression has made it easier. In abstract, it’s easy to say we should be kind to those in need. If you’ve been in need yourself from time to time, that informs your inclincation to help others in need. I believe it was Seneca who said that the wounded doctor heals the best. You can be well-intentioned without ever having been wounded, but the wounding gives you an intimacy with other people’s experience that you can’t derive from any other source.
Q: What would be your message to those currently experiencing mental illness?
[Dr. Thomas Insel] I am hopeful but also I think we need to be realistic. The tools we have today are unprecedented, we have never been able to offer so much to so many…. however…. we need to admit that the quality of care in most places is not good and that, in contrast to much of medicine, diagnosis and treatment depends more on whom you ask rather than what you have.
All of us have family members who have been impacted by mental health issues, and many have done remarkably well, while for some it’s still a challenge. We need to be honest — we don’t have the treatments we need for autism, for many aspects of schizophrenia, and for dementia. I am hopeful that science will give us better diagnostics and therapeutics, but this is a long-term effort. We also need to recognize that we can do much better with the treatments we have today. For instance, creating toolkits with medication and evidence-based psycho-social treatments could make a big difference in the short term. And for the best outcomes, we need to involve families and patients to empower them to direct their own care. If we can do that, my message is that there is hope for recovery in the short-term and prevention and cure in the long-term.
[Dr. Shekhar Saxena] People with mental disorders can help change the world around them. By recognizing and articulating their needs, and by having a say in decisions made, they can not only improve their own lives, but make the world a better place.
[Paul Farmer] It’s important for people to realise that you are not alone. So many people who are developing a mental health problem feel very alone, isolated and even scared about seeking-help. We want to send a message to people saying that it’s OK, you’re not on your own, and that there’s a lot of help and support out there for you- formally and informally. We want to encourage people to seek-out and reach that help.
[Sergeant Kevin Briggs] To those who are suffering from mental health challenges, or just feeling low at times, which very much includes myself, I’d like to give you some advice that I use for myself. I know all too well how hard this illness can be in your life. At times there is extreme loneliness, lethargy, and even disgust with one’s self over what may be occurring in your life. At least this is how I feel at times. But, I also know there will be days when all just seems right with the world. When those days occur, write down how you felt, what you did, whom you were with (if anyone) and if anything assisted you in feeling better (sunlight, foods, walking the dog….). On your bad days, look at this and it will help you get through it, knowing it will pass.
[Marcus Trescothick] You have to seek help straight away; whether that’s a doctor or a psychologist. You have to try and get a bit of direction, and get to a point where you know how to start dealing with your mental health. You need to get to an area where things start to improve, and that takes time- but if you’re not asking or seeking the advice, then you’ll never get the clarity about how it’s going to get better.
If I broke my leg, I’d go straight to a hospital and they’d put a cast on me and give me a rehabilitation programme; but because you don’t see the physical problem, you move away from it, and think you can cope with it yourself.
Men are often guarded about what they’re feeling, and may perceive it as a weakness to ask for help. It’s often only when they have been through-it and experienced it that they realise this isn’t true. We [as men] can get help, we can ask for help, we’re just normal people at the end of the day.
[Professor Vikram Patel] We have to demand the right care and the right to a life with dignity. We have to press our elected representatives in particular, but also our doctors and our businesses, and demand that whoever is in control of healthcare resources give parity to mental health with physical health.
[Andrew Solomon] Depression is much more widespread than you think, and if you’re hiding it, you can safely assume that those you are hiding it from may be going through it themselves.
While depression is widespread, and appears to be growing more so, it is very treatable. Many people who have been very, very sick go on to leave lives of considerable worth and value. It’s imperative you seek the lifestyle changes and the treatment that can help you recover.
While you are living the depression, it feels like a barren and useless part of your life. It also feels like depression is what the rest of your life will be; that conviction is a symptom of the disease. I would tell you that later on, there will be things you will draw from this experience. You may never be grateful you went through this journey; you wouldn’t have chosen it; but it will help you grow in beautiful ways that you simply cannot envison at the time.
The experience of depression is part of the wide spectrum of human mood that makes the world an engaging and interesting place.
Depression is cyclical. It will remit, and when it does—and when you get to rebuilding your life—you will find that life has beauty and value. Life is short, but it’s worth living as fully as you can.
There is hope on the far side of this horror.
[Professor Green] Mental health problems can feel isolating, they consume you. When your thoughts ruminate, they grow and grow… and keeping things on the inside can become isolating.
You’re never going to be the only person going through something, there’s always someone else going through it with you. I’m not saying you take peace from someone else’s suffering, but I am saying that you should know that you’re not alone, and that things will change and get better.
It is perhaps appropriate for this author to conclude this piece by disclosing a rather personal interest in the subject matter.
I have lost more than one of my closest friends to suicide, and have spent decades at the torment of my own mind’s depressive states and, on occasion have come to understand- quite vividly- the depths of darkness that lead people to think- and do- the unthinkable.
I contend that I am me, and nobody else will ever know how I feel- and with that contention comes the realisation that the challenges of mental health are solitary unspoken battles between myself and my soul, with invisible wounds and selfish victories, which- in turn- create my greatest weaknesses and most profound strengths. It is this contention that means that I (and many more) fight alone….
… The truth is, I am not alone. Should humans be categorised by those with, and those without mental health challenges – I would be part of an immense family – and one desperately in need of a voice.
Mental health challenges kill over a million people each year, and cause profound levels of suffering to billions more. Given we have the technology and capability to treat the vast majority of mental health disorders, each and every life lost is a failure on our conscience- and each and every moment of suffering is an injustice at our hands.
I hope, dear reader, that you will join me in taking up arms – and speaking from the heart, on behalf of the mind.