“The last great stigma of the twentieth century is the stigma of mental illness.”—Tipper Gore, wife of the former U.S. Vice President37
“Mentally ill people are nuts, crazy, wacko.” “Mentally ill people are morally bad.” “Mentally ill people are dangerous and should be locked in an asylum forever.” “Mentally ill people need somebody to take care of them.” How often have we heard comments like these or seen these types of portrayals in movies, television shows, or books? We may even be guilty of making comments like them ourselves. Is there any truth behind these portrayals, or is that negative view based on our ignorance and fear?
Stigmas are negative stereotypes about groups of people. Common stigmas about people who are mentally ill are
Each of those preconceptions about people who have a mental illness is based on false information. Very few people who have a mental illness are dangerous to society. Most can hold jobs, attend school, and live independently. A person who has a mental illness cannot simply decide to get over it any more than someone who has a different chronic disease such as diabetes, asthma, or heart disease can. A mental illness, like those other diseases, is caused by a physical problem in the body.
Stigmas against individuals who have a mental illness lead to injustices, including discriminatory decisions regarding housing, employment, and education. Overcoming the stigmas commonly associated with mental illness is yet one more challenge that people who have a mental illness must face. Indeed, many people who successfully manage their mental illness report that the stigma they face is in many ways more disabling than the illness itself. The stigmatizing attitudes toward mental illness held by both the public and those who have a mental illness lead to feelings of shame and guilt, loss of self-esteem, social dependence, and a sense of isolation and hopelessness.11, 44 One of the worst consequences of stigma is that people who are struggling with a mental illness may be reluctant to seek treatment that, in most cases, would significantly relieve their symptoms.
Providing accurate information is one way to reduce stigmas about mental illness. Advocacy groups protest stereotypes imposed upon those who are mentally ill. They demand that the media stop presenting inaccurate views of mental illness and that the public stops believing these negative views. A powerful way of countering stereotypes about mental illness occurs when members of the public meet people who are effectively managing a serious mental illness: holding jobs, providing for themselves, and living as good neighbors in a community. Interaction with people who have mental illnesses challenges a person’s assumptions and changes a person’s attitudes about mental illness.
Attitudes about mental illness are changing, although there is a long way to go before people accept that mental illness is a disease with a biological basis. A survey by the National Mental Health Association found that 55 percent of people who have never been diagnosed with depression recognize that depression is a disease and not something people should “snap out of.”34 This is a substantial increase over the 38 percent of survey respondents in 1991 who recognized depression as a disease.
Most people don’t think twice before going to a doctor if they have an illness such as bronchitis, asthma, diabetes, or heart disease. However, many people who have a mental illness don’t get the treatment that would alleviate their suffering. Studies estimate that two-thirds of all young people with mental health problems are not receiving the help they need and that less than one-third of the children under age 18 who have a serious mental health problem receive any mental health services. Mental illness in adults often goes untreated, too. What are the consequences of letting mental illness go untreated?
In September 2000, the U.S. surgeon general held a conference on children’s mental health. The former surgeon general, Dr. David Satcher, emphasized the importance of mental health in children by stating, “Children and families are suffering because of missed opportunities for prevention and early identification, fragmented services, and low priorities for resources. Overriding all of this is the issue of stigma, which continues to surround mental illness.”45
The consequences of mental illness in children and adolescents can be substantial. Many mental health professionals speak of accrued deficits that occur when mental illness in children is not treated. To begin with, mental illness can impair a student’s ability to learn. Adolescents whose mental illness is not treated rapidly and aggressively tend to fall further and further behind in school. They are more likely to drop out of school and are less likely to be fully functional members of society when they reach adulthood.45 We also now know that depressive disorders in young people confer a higher risk for illness and interpersonal and psychosocial difficulties that persist after the depressive episode is over. Furthermore, many adults who suffer from mental disorders have problems that originated in childhood.44 Depression in youth may predict more severe illness in adult life.27 Attention deficit hyperactivity disorder, once thought to affect children and adolescents only, may persist into adulthood and may be associated with social, legal, and occupational problems.14
The high incidence of mental illness has a great impact on society. Depression alone causes employers to lose over $23 billion each year due to decreased productivity and absenteeism of employees.46 The Global Burden of Disease Study, conducted by the World Health Organization, assessed the burden of all diseases in units that measure lost years of healthy life due to premature death or disability (disability-adjusted life years, or DALYs). Over 15 percent of the total DALYs were due to mental illness.26 In 1996, the United States spent more than $69 billion for the direct treatment of mental illnesses. Indirect costs of mental illness due to lost productivity in the workplace, schools, or homes represented a $79 billion loss for the U.S. economy in 1990.44
Treatment, including psychotherapy and medication management, is cost-effective for patients, their families, and society. The benefits include fewer visits to other doctors’ offices, diagnostic laboratories, and hospitals for physical ailments that are based in psychological distress; reduced need for psychiatric hospitalization; fewer sick days and disability claims; and increased job stability. Conversely, the costs of not treating mental disorders can be seen in ruined relationships, job loss or poor job performance, personal anguish, substance abuse, unnecessary medical procedures, psychiatric hospitalization, and suicide.3
A diagnosis of mental illness is rarely simple and straightforward. There are no infallible physiological tests that determine whether a person has a mental illness. Diagnosis requires that qualified healthcare professionals identify several specific symptoms that the person exhibits. Each mental illness has characteristic signs and symptoms that are related to the underlying biological dysfunction. The following sections describe the symptoms and outcomes of three mental illnesses that are highlighted in this curriculum supplement: depression, attention deficit hyperactivity disorder, and schizophrenia.
Depression, or depressive disorders, is a leading cause of disability in the United States as well as worldwide. It affects an estimated 9.5 percent of American adults in a given year.28 Nearly twice as many women as men have depression.25 Epidemiological studies have reported that up to 2.5 percent of children and 8.3 percent of adolescents in the United States suffer from depression.22
Depression is more than just being in a bad mood or feeling sad. Everyone experiences these feelings on occasion, but that does not constitute depression. Depression is actually not a single disease; there are three main types of depressive disorders.23, 27 They are
While some of the symptoms of depression are common during a passing “blue mood,” major depressive disorder is diagnosed when a person has five or more of the symptoms nearly every day during a two-week period.27 Symptoms of depression include
When people have depression, their lives are affected severely: they have trouble performing at work or school, and they aren’t interested in normal family and social activities. In adults, an untreated major depressive episode lasts an average of nine months. At least half of the people who experience an episode of major depression will have another episode of depression at some point.44
In children, depression lasts an average of seven to nine months with symptoms similar to those in adults.44 Symptoms in children may include
Children and adolescents with depression are more likely than adults to have anxiety symptoms and general aches and pains, stomachaches, and headaches. The majority of children and adolescents who have a major depressive disorder also have another mental illness such as an anxiety disorder, disruptive or antisocial behavior, or a substance-abuse disorder. Children and adolescents who suffer from depression are more likely to commit suicide than are other youths. As in adults, episodes of depression are likely to recur.44
Dysthymia is less severe than major depressive disorder, but it is more chronic. In dysthymia, a depressed mood along with at least two other symptoms of depression persist for at least two years in adults, or one year in children or adolescents.22 These symptoms may not be as disabling, but they do keep affected people from functioning well or feeling good. Dysthymia often begins in childhood, adolescence, or early adulthood.25 On average, untreated dysthymia lasts four years in children and adolescents.44
A third type of depressive disorder is bipolar disorder, also called manic-depression. A person who has bipolar disorder alternates between episodes of major depression and mania (periods of abnormally and persistently elevated mood or irritability). During manic periods, the person will also have three or more of the following symptoms:
While in a manic phase, adolescents may engage in risky or reckless behaviors such as fast driving and unsafe sex.
Bipolar disorder frequently begins during adolescence or young adulthood. Adults with bipolar disorder often have clearly defined episodes of mania and depression, with periods of mania every two to four years. Children and adolescents with bipolar disorder, however, may cycle rapidly between depression and mania many times within a day.29 Bipolar disorder in youths may be difficult to distinguish from other mental illnesses because the symptoms often overlap with those of other mental illnesses such as ADHD, conduct disorder, or oppositional defiant disorder.
Depression, like other mental illnesses, is probably caused by a combination of biological, environmental, and social factors, but the exact causes are not yet known. For years, scientists thought that low levels of certain neurotransmitters (such as serotonin, dopamine, or norepinephrine) in the brain caused depression. However, scientists now believe that the interplay of factors leading to depression is much more complex. Genetic causes have been suggested from family studies that have shown that between 20 and 50 percent of children and adolescents with depression have a family history of depression and that children of depressed parents are more than three times as likely as children with nondepressed parents to experience a depressive disorder.44 Abnormal endocrine function, specifically of the hypothalamus or pituitary, may play a role in causing depression. Other risk factors for depressive disorders in youths include
Scientists have studied changes in the brain associated with depressive disorders. Imaging studies using PET have shown that brain activity in certain areas is substantially decreased in a depressed individual whereas activity in other brain regions is increased compared with the same individual after successful treatment.13 PET imaging has also shown that depressed patients have lower neurotransmitter receptor binding potential in some areas of the brain.48 Scientists looking at changes in the brains of bipolar patients found decreases in the size of the cerebellum (the part of the brain that regulates balance and controlled movements), changes in the metabolism of some chemical compounds, and a decrease in the activity of specific brain regions (prefrontal cortex) during the depression phase.42
A variety of antidepressant medications and psychotherapies are used to treat depression. The most effective treatment for most people is a combination of medication and psychotherapy.23
Many of us are aware that medications are available to treat depressive disorders—we see the ads on television and in magazines. Up to 70 percent of people with depression can be treated effectively with medication.44 Medications used to treat depressive disorders usually act on the neurotransmission pathway. For example, some medications affect the activity of certain neurotransmitters, such as serotonin or norepinephrine. Different depressive disorders require different medication therapies. For example, individuals who have bipolar disorder are often treated with a mood-stabilizing drug, such as lithium, during their manic phase and a combination of mood-stabilizer and antidepressant medications during their depressive phase.
Medications usually lead to relief from the symptoms of depression within six to eight weeks. If one drug doesn’t relieve symptoms, doctors can prescribe a different antidepressant drug. As with drugs to treat other mental illnesses, patients are monitored closely by their doctor for symptoms of depression and for side effects. Patients who continue to take their medication for at least six months after recovery from major depression are 70 percent less likely to experience a relapse.1
Psychotherapy helps patients learn more effective ways to deal with the problems in their lives. These therapies usually involve 6 to 20 weekly meetings. These treatment plans should be revised if there is no improvement of symptoms within three or four months.44
The combination of medications and psychotherapy is effective in the majority of cases and represents the standard care; however, doctors can employ other methods. One therapy that is highly effective when antidepressants and psychotherapy are not effective is electroconvulsive therapy (ECT), or electroshock therapy.23 ECT is not commonly used in children and adolescents. When ECT is performed, the individual is anesthetized and receives an electrical shock in specific parts of the brain. The patient does not consciously experience the shock. ECT can provide dramatic and rapid relief, but the effects usually last a fairly short time. After ECT, individuals usually take antidepressant medications.
A few years ago, the herbal supplement St. John’s wort received great attention in the media as an over-the-counter treatment for mild to moderate depression. However, many of the claims did not have good scientific evidence to back them up. The effectiveness and safety of St. John’s wort remain uncertain, and its use is generally not recommended.31
People who have depression (or another depressive disorder) feel exhausted, worthless, helpless, and hopeless. These negative thoughts and feelings that are part of depression make some people feel like giving up. As treatment takes effect, these thoughts begin to go away. Some strategies that can help a person waiting for treatment to take effect include
A potential, tragic consequence of untreated depression is suicide. In 1997, over 30,000 people in the United States died from suicide, and suicide was the third leading cause of death among 10- to 24-year-olds.22, 25 Over 90 percent of these people had a mental illness, typically either a depressive disorder or a substance-abuse disorder.25 Research from the National Institute of Mental Health estimates that as many as seven percent of adolescents who develop a major depressive disorder become victims of suicide.22
Danger signs that a teen may be considering suicide include
Children and adolescents who are suicidal report feelings of depression, anger, anxiety, hopelessness, and worthlessness. They feel helpless to change frustrating circumstances or to find a solution for their problems. In addition to depression, family conflicts and suicidal death of a relative, friend, or acquaintance are risk factors for suicide among children and adolescents.44 In the case of another person’s suicide, children or teens may need intervention to prevent feelings of guilt, trauma, or social isolation. Programs offered by school professionals that address these concerns can be extremely helpful for identifying grieving youths who may need help.
Public health approaches to preventing suicide include establishing telephone crisis hot lines, restricting access to suicide methods (for example, firearms), counseling media to reduce “copycat” suicides, screening teens for risk factors of suicide, and training professionals to improve recognition and treatment of mood disorders. Research about the effectiveness of these methods indicates that the screening and training strategies are more helpful for preventing suicides among young people than the other methods are.44
Attention deficit hyperactivity disorder (ADHD) is the most commonly diagnosed behavioral disorder of childhood. In any six-month period, ADHD affects an estimated 4.1 percent of youths ages 9 to 17. Boys are two to three times more likely than girls to develop ADHD.25 Although ADHD is usually associated with children, the disorder can persist into adulthood.19 One researcher6 estimated that as many as two-thirds of the children he evaluated with ADHD continued to have the disorder in their twenties, and that many of those who no longer fit the clinical description of ADHD nonetheless had significant problems at work or in other social settings.
The three predominant symptoms of ADHD are impaired ability to regulate activity level (hyperactivity), to attend to tasks (inattention), and to inhibit behavior (impulsivity).19 Individuals who have ADHD may display predominantly hyperactive/impulsive behavior, predominately inattentive behavior, or a combination of both. Children and adolescents with ADHD
The DSM-IV5 specifies several conditions in addition to the symptoms listed above before making a diagnosis of ADHD. For a diagnosis of ADHD, the behaviors must
The diagnosis of ADHD can be made reliably using well-tested diagnostic interview methods. However, as of yet, there is no independent valid test for ADHD.
Among children, ADHD frequently occurs along with other learning, behavior, or mood problems such as learning disabilities, oppositional defiant disorder, anxiety disorders, and depression.
The exact causes of ADHD are unknown; however, research has demonstrated that factors that many people associate with the development of ADHD do not cause the disorder. For example, ADHD is not caused by minor head injuries, damage to the brain from complications during birth, food allergies, excess sugar intake, too much television, poor schools, or poor parenting.7, 19 No single cause of ADHD has been discovered. Rather, a number of significant risk factors affecting neurodevelopment and behavior expression have been implicated. Events such as maternal alcohol and tobacco use that affect the development of the fetal brain can increase the risk for ADHD. Injuries to the brain from environmental toxins such as lack of iron have also been implicated.
Scientists have investigated the role of the neurotransmitter dopamine in the development of ADHD because this neurotransmitter plays a key role in regulating movement, increasing motivation and alertness, and inducing insomnia. The observation that ADHD tends to run in families strongly suggests that the disease has a genetic component. Children who have ADHD usually have at least one close relative who also has the disorder.24 One group of researchers found that a child whose identical twin has ADHD is 11 to 18 times more likely to develop the disorder than a nontwin sibling.
Investigations of particular genes involved in ADHD have focused on a dopamine receptor gene (DRD) on chromosome 11 and the dopamine transporter gene (DAT1) on chromosome 5.44 Ongoing studies continue to examine these genes and others as factors in ADHD. Most likely, a combination of several genes and environmental factors determines whether a person has ADHD.
Imaging studies have shown differences in the brains of boys with ADHD compared with boys who do not have ADHD. Researchers found that certain parts of the brain are, on average, smaller in boys with ADHD.8 Other studies found that the total brain volume is smaller in girls who have ADHD than in control subjects; these results match similar findings about the brains of boys with ADHD.9 Scientists have speculated that the changes in the particular brain regions may be involved in the inability to inhibit thoughts, which is a symptom of ADHD.
A variety of medications and behavioral interventions are used to treat ADHD. The most widely used medications are methylphenidate (Ritalin), D-amphetamine, and other amphetamines. These drugs are stimulants that affect the level of the neurotransmitter dopamine at the synapse.40 Nine out of 10 children improve while taking one of these drugs.19
When used as prescribed by qualified physicians, these drugs are considered quite safe. Side effects associated with moderate doses are decreased appetite and insomnia. These side effects generally occur early in treatment and often decrease with time. Some studies have shown that the stimulants used to treat ADHD decrease growth rate, but ultimate height is not affected.
Interventions used to treat ADHD include several forms of psychotherapy, such as cognitive-behavioral therapy, social skills training, support groups, and parent and educator skills training. A combination of medication and psychotherapy is more effective than either treatment alone in improving social skills, parent-child relations, reading achievement, and aggressive symptoms.24
In addition to the well-established treatments described above, some parents and therapists have tried a variety of nutritional interventions to treat ADHD. A few studies have found that some children benefit from such treatments. Nevertheless, no well-established nutritional interventions have consistently been shown to be effective for treating ADHD.24
As the symptoms indicate, ADHD interferes with a person’s daily life. Treatment is available to help individuals and relieve the symptoms, but some simple strategies—including those listed below—can also help.
Schizophrenia affects approximately 1 percent of the population, or 2.2 million U.S. adults. Men and women are equally affected.25, 32 The illness usually emerges in young people in their teens or twenties. Although children over the age of five can develop schizophrenia, it is rare before adolescence.21 In children, the disease usually develops gradually and is often preceded by developmental delays in motor or speech development. Childhood-onset schizophrenia tends to be harder to treat and has a less favorable prognosis than does the adult-onset form.
There are many myths and misconceptions about schizophrenia. Schizophrenia is not a multiple or split personality, nor are individuals who have this illness constantly incoherent or psychotic. Although the media often portray individuals with schizophrenia as violent, in reality, very few affected people are dangerous to others.32 In fact, individuals with schizophrenia are more likely to be victims of violence than violent themselves.
Schizophrenia has severe symptoms. A diagnosis of schizophrenia requires that at least two of the symptoms below be present during a significant portion of a one-month period:
However, the presence of either one of the first two symptoms is sufficient to diagnose schizophrenia if the delusions are especially bizarre or if the hallucinations consist of one or more voices that keep a running commentary on the person’s behavior or thoughts.5
The DSM-IV specifies additional criteria for a diagnosis of schizophrenia:
The course of schizophrenia varies considerably from one individual to the next. Most people who have schizophrenia experience at least one, and usually more, relapses after their first psychotic episode.32 Relapses are periods of more intense symptoms of illness (hallucinations and delusions). During remissions, the negative symptoms related to emotion or personal care are usually still present. About 10 percent of patients remain severely ill for long periods of time and do not return to their previous state of mental functioning. Several long-term studies found that as many as one-third to one-half of people with schizophrenia improve significantly or even recover completely from their illness.44
Like the other mental illnesses discussed here, scientists are still working to determine what causes schizophrenia. Also like the other mental illnesses, genetic and environmental factors most likely interact to cause the disease. Several studies suggest that an imbalance of chemical neurotransmitter systems of the brain, including the dopamine, GABA, glutamate, and norepinephrine neurotransmitter systems, are involved in the development of schizophrenia.20, 36
Family, twin, and adoption studies support the idea that genetics plays an important role in the illness. For example, children of people with schizophrenia are 13 times more likely, and identical twins are 48 times more likely, to develop the illness than are people in the general population.44 Scientists continue to look at genes that may play a role in causing schizophrenia. One gene of interest to scientists who study schizophrenia codes for an enzyme that breaks down dopamine in the synapse.12 Investigations to confirm the role of this and other genes are ongoing.
Imaging studies have revealed differences in brain structure and function in individuals with schizophrenia compared with control individuals. Brain imaging studies show that young people who have schizophrenia have structural differences in their brains compared with individuals who do not have schizophrenia. These changes include a reduced total volume of the cerebrum (the upper portion of the brain, which is divided into halves), a reduced amount of gray matter (the tissue that makes up a majority of the brain and consists mainly of neuron cell bodies and dendrites), enlarged brain ventricles (the cavities, or spaces, in the brain that are filled with cerebrospinal fluid), and other abnormalities.38, 39, 41 PET scans of identical twins have revealed that the twin with schizophrenia has lower brain activity in the frontal lobes (the front section of the cerebral lobes) than does the twin who does not have schizophrenia.47 One group of researchers used MRI to periodically scan the brains of teens with childhood-onset schizophrenia and an age-matched control group over a five-year period. They found that teens with schizophrenia lose four times the amount of neurons in a specific region of the brain that teens in the control group lose.43
There is no cure for schizophrenia; however, effective treatments that make the illness manageable for most affected people are available. The optimal treatment includes antipsychotic medication combined with a variety of psychotherapeutic interventions.44
Since the 1950s, doctors have used antipsychotic drugs, such as chlorpromazine and haloperidol, to relieve the hallucinations and delusions typical of schizophrenia. Recently, newer (also called atypical) antipsychotic drugs such as risperidone and clozapine have proven to be more effective. Early and sustained treatment that includes antipsychotic medication is important for long-term improvement of the course of the disease. Patients who discontinue medication are likely to experience a relapse of their illness.32
People who manage schizophrenia best combine medication with psychosocial rehabilitation (life-skills training).17 Therapies that combine family and community support, education, and behavioral and cognitive skills to address specific challenges help schizophrenic patients improve their functioning and the quality of their lives.
As a teacher, you may occasionally have students who show symptoms of or who have significant risk factors for a mental illness. A first step for helping these students is to contact the school nurse or guidance counselor. These individuals should know the appropriate next steps to take, including directing the student’s parents or guardians to contact their physician or their city or county mental health services.
If you think a friend or colleague might have a mental illness, encourage him or her to see a physician. Physicians can make referrals to mental health specialists in the community. In addition, your state or county health departments may offer services for people struggling with a mental illness. The National Mental Health Association has an affiliate network throughout the country. The programs offered by the NMHA affiliates include support groups, public education and advocacy campaigns, rehabilitation, and housing services. You can access the NMHA’s affiliate network through its Web site: http://www.nmha.org/nav/section/affiliate.cfm.
The Additional Resources for Teachers section describes other online resources about mental illnesses.
a Relevant to Lessons 1, 2, 3, 4, and 5.
b Relevant to Lessons 4 and 5.
c Relevant to Lessons 2, 3, 4, 5, and 6.
d In this module, the term depression refers to major depressive disorder. We will use the terms dysthymia and bipolar disorder specifically when we are referring to those types of depressive disorders.
e Relevant to Lessons 1, 2, 3, 4, 5, and 6.