Williams’ death reminds us that a patient’s relief might be a warning sign

By
H. Steven Moffic, MD

One
of my favorite movie moments is when Robin Williams signs on as an edgy D.J. by
exclaiming "Good Morning, Vietnam" from the 1987 movie of the same name.
Sometimes, I played the audio over and over, as if it could promise a good day.
As he did so often, he found a way to not only lighten the sadness, but to do
it in such a way that might be constructively critical.

Surely,
the real life mornings were not often happy ones, as so many of our troops died
or ended up with post-traumatic stress disorder (PTSD) from that war. It is a
lesson we are still learning, so that movie and his role is worth seeing again
soon.

Now,
after his reported suicide, that good morning seems more like a final good
night.

Although
he is probably best known for his manic comedy, he also played many serious
roles. Most ironically now, he won an academy award in 1997 for playing an
empathic therapist in the film “Good Will Hunting.”

Indeed,
beloved entertainers like Robin Williams have a therapeutic role of sorts for
society in the sense that they provide some relief—even if briefly—for the
grief and stress of everyday life. For playing that societal role, such people
become a repository for our hopes, dreams and demons. As we know for so many
famous entertainers, it is not easy for them to have a successful private
life—a private life that the public also tries to invade, as if they were
related to us.

What
we do know publicly is that Williams suffered from chronic depression and
intermittent substance abuse. It is reported that he received treatment,
including entering rehab just last month. Obviously, money to get the best
treatment was not an issue, though how good the treatment was will remain
unknown. We do know, however, that wealthy VIPs often receive treatment just as
poor as low-income folks without resources. We also know that occasionally
depression is a terminal illness, though that ending is not predictable.

Beyond
the public information, and despite the understandable curiosity, this is not
the time, nor should it ever be the time, to speculate about his diagnosis and
reasons for committing suicide. In fact, the so-called "Goldwater
Rule," called that for the inappropriate professional speculation about
presidential candidate Barry Goldwater, ethically prohibits such speculations
on the part of psychiatrists like myself.


Given
this professional ethical principle, as well as the family's request for
privacy, is there anything we can still learn from this apparent tragedy? The
most intriguing detail that caught my attention was his last tweet and
Instagram on July 31. Reportedly, he had wished his daughter a happy 25th
birthday.

Why
might this positive communication be of importance to us?

It
reminded me of the only patient I ever had who committed suicide, long ago,
when I was a resident in training. In the second session, the depression of
this elderly man seemed to be less severe, but after that session he walked
into Lake Michigan and drown. In the psychological autopsy, I never forgot the
warning that when a depressed patient starts to seem better, they actually can
be at higher risk for suicide.

Risky
time

Why
is that time of apparent improvement a risky time? The person can have more
energy, then plan and complete a suicide. They may also feel relief at their
decision, causing others to paradoxically feel relief. That is one of the
reasons why it is so common to hear of the genuine surprise that the suicide
occurred, as the person seemed to be happier.

What
this means, not only for professionals, but for the public, is not to take at
face value if a depressed person seems better. Be sure there is a sound
explanation for the apparent improvement. 

Our
only consolation must be that entertainers like Robin Williams keep on living
in the form of their life’s work, like the movie “Good Morning, Vietnam,” that
is so ubiquitously available nowadays. Even so, it would not be surprising if
at the times we laugh once again at Robin William's humor, that the laughter
will also be accompanied by some tears of grief.

Bio

H. Steven Moffic, MD, is a Life Fellow of the APA. Currently, he blogs regularly for Psychiatric Times, Behavioral
Healthcare, and The Hastings Center's Over 65.



This blog was originally published in Behavioral Healthcare.
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Spreading Hope!

By Matt Goldenberg
D.O.

@docgoldenberg 

“You treat a disease, you win, you lose. You treat a person,
I guarantee you, you'll win, no matter what the outcome.” 

I whole-heartedly agree with that statement. However, I
cannot take credit for those words. Those are the words of Robin Williams, or
more specifically, the words of his character in Patch Adams.



I want to discuss the disease called depression. I will start by first
discussing the diagnosis and the signs and symptoms of depression. I will then
follow up with my thoughts on the various treatment options for depression and
the strategies I employ with my patients to improve their outcomes. None of my
thoughts and suggestions should serve in place of a formal consultation with a
mental healthcare provider. However, I hope shedding light on mental health
diagnoses like depression will lift the veil and social stigma on these chronic
diseases that impact so many people.



Psychiatry has come a long way in the last decade. This is a time of continued
discovery and increasing public awareness. The leaders of our professional
organization, the American Psychiatric Association (APA), have suggested that we
as mental health professionals are under a microscope. I agree that we are
and I also strongly believe that we are up for the challenge. School shootings
and celebrity suicides and overdoses have increasingly put a focus on mental
health. Psychiatry has significantly improved the outcomes, treatment options
and the prognosis of patients with mental illness. However, we still are unable
to decrease the prevalence of the diseases we treat or prevent them. We know that
the brain changes during an episode of depression and our treatments help it to
return to normal (see the image below). Although we are getting closer, we
still currently do not have widely accessible blood or imaging tests that can
confirm our diagnosis or localize the area of disease.

I can say with certainty, however, we are able to accurately
diagnose patients. We are able to identify medications, psychotherapies and
other treatments that patients with a specific diagnosis or cluster of signs and
symptoms often benefit from. There is strong evidence that our treatments
decrease symptomatology and disability and improve quality of life, clinical
outcomes and a patient’s prognosis.



Psychiatrists are trained to view the patient as a “whole person”. Psychiatry
is a field of medicine whose assessment by definition includes all of the
biological, psychological and social aspects of a patient’s life. We listen for
the psychological and social factors that can contribute to disease.
Oftentimes, the “whole story” can be more telling than only focusing on
specific symptoms of a given disease. There is a saying, throughout all fields
of medicine, that “most patients have not read the textbook.” In other words,
patients usually do not present exactly as the textbook says they should.
Stress and psychological factors can mimic chest pain, shortness of breath,
gastrointestinal problems and a whole host of other diseases. If we do not step
back and get the whole story, we can miss the root cause or the exacerbating
factors of many manageable diseases which are of the mind.



Many of the diseases we treat, such as depression, are chronic illnesses which
require lifelong treatment. Our treatments can improve a patient’s mental
health and coping skills and decrease their symptomatology and substance use.
We know through decades of research that these are modifiable risk factors for
suicide. Therefore, Psychiatrists have the training and tools necessary to
decrease a patient’s risk of attempting suicide. Our treatments have the
potential to not only significantly improve the lives of our patients, but also
the lives of their families and everyone who comes into contact with them.
Anyone who tells you otherwise is misleading, misinformed or both.

I
hope this information and the blogs to follow will give you hope. Mental
illness can include symptoms which can be devastating and complications which
can be life-threatening.
However, it is important to state again, these are treatable diseases. If you
or someone you know, would like to talk to someone, call your primary care
doctor or your insurance company for a referral to a Psychiatrist. A true
multi-disciplinary team also includes therapists, psychologists, nurses and
social workers. You are never alone. You can call the national suicide helpline
24 hours a day, seven days a week (1-800-273-TALK (8255) or visit www.suicidepreventionlifeline.org).
There are also local crisis lines likely available in your area and are an
internet search away. If you are ever feeling unsafe, or fearing for the safety
of a loved one, you can call 911 or go to the nearest emergency department.

It is time for everyone to understand that there is no shame in getting help
for depression, much as there is no shame in getting help with diabetes or high
cholesterol. Even if you have never suffered from depression, there is
a lot you can learn.

Together we can raise awareness and spread truth and hope. I know that if we
spread knowledge, and ignore the misinformation, we will overcome the
complacency and ignorance that is so pervasive today. That is how we can best
honor those we have lost. That is how we can best prevent the next death from
mental illness and addiction.

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