Query

Figure. Photo by: Anson Liaw

The longer I work in general practice, the more I wonder about the stigma attached to mental illness. When I suggest a diagnosis of depression to an obviously depressed patient, a typical reaction is, “Who, me? No! I'm sick, not mental. Find something else wrong with me.” Denial is a powerful force, but I'm beginning to believe it is strongest when it alights on mental illness. As per popular conception, people don't want to be mad, nuts, bonkers, loony, batty, insane or crazy. Come to think of it, it's that last word most people get stuck on.

I've dealt with the cardiac case in denial who insists on working just as hard as he did twenty years ago when he was just starting his career. I've dealt with the denial of adolescent diabetes, the refusal to believe there is a problem despite several life-threatening bouts of diabetic ketoacidosis, the umpteen admissions, and my repeated attempts to counsel and educate. And I once treated a man who refused to believe he had HIV; he felt too strong, he said, too healthy.

Yet all these conditions have one redeeming feature: they are medical, medical, medical, not mental, mental, mental. Or so my patients seem to believe and behave. It is as if having depression and needing an SSRI were less worthy — and by that token, even less desirable — than being a cancer patient and needing chemotherapy.

Once the diagnosis has been broached, significant time has passed, and a healthy amount of acceptance had been gained, further barriers must be brought down. There's the “Do I really need medication?” barrier, in which patients see the necessity for medication as some kind of moral failing or, to put it as they do, a “failure at life.” And once medication has been accepted and my depressed patients are feeling somewhat better, the invisible nature of mental illness spurs them to think they never had a problem at all, and so didn't need the medication in the first place. And so they stop taking the drugs that have been starting to make them feel better. The almost invariable result is a return of the original symptoms, making the diagnosis and need for medication even plainer. Then there's the “Do I need medication even when I've been feeling good for months?” barrier. My preference is to keep patients on antidepressants for at least six months once they are feeling well. But patients see feeling well, not taking medication, as the goal; once they have achieved their goal, they lose esteem for the treatment that brought them that far.

I know that the same behavioural phenomena arise in other diseases, but in my observation mental illness is the most difficult to contend with. This is not only because of patients' reluctance to accept therapy, but also because there just isn't the same physical representation of the illness — a broken bone, say, as opposed to feelings of hopelessness. And there's a tendency for others to blame the person with mental illness, while the patient with a fractured leg is sent Get Well Soon cards and bouquets of flowers in sympathy for their unfortunate accident.

It's a shame that my patients with mental illness don't realize they're the most courageous patients I have. When I tell them that, they look at me as if I'm crazy. And that's yet another barrier: getting them to understand how much integrity they have in trying to get well.

— Dr. Ursus