Robin Williams is dead. Is this a shock? No. Is it a tragedy? Absolutely. Without knowing any of the details about his psychiatric treatment, from a purely statistical standpoint Mr. Williams had a number of risk factors that are often identified ‘after the fact’ in suicidal patients – he suffered from a serious mood disorder, addiction to drugs and alcohol and he had open-heart surgery which is well-known to be associated with severe depression even years later. Now we are finding out that he suffered from early stage Parkinson’s Disease. To the general public his comedic veneer and successful acting career probably made it seem like he was impervious to the ravages of depression and addiction – clearly a falsehood.
It’s fascinating that in the wake of his death, one of the immediate reactions among pundits and medical professionals is that “we hope that Mr. Williams’ death brings to light issues about depression and addiction and helps end stigma so that people come forth and get help.” The implication is that those who are too ashamed to ask for help for depression and/or addiction suffer the consequences. While we are all in support of ending the stigma associated with mental illness and addiction, the fact is that Robin Williams was totally open about both of his struggles not only with depression but also addiction. Without knowing any of the details about his illness or his treatment, it is difficult, if not impossible to speculate about exactly what happened to him. Yet it is possible that he survived as long as he did because he was open about his problems and received a good deal of help for them. The sad fact is, that people who have multiple risk factors for early death often die young. This is true for those suffering from illnesses like diabetes, cancer and heart disease, and it is also true for those who suffer from certain mental illnesses – primarily mood disorders and psychotic disorders – and certainly addiction.
While the field of psychiatry has its limits, one thing we know well is that the risks and consequences of major mental illness are real and severe, and are clearly exacerbated by the use of drugs and alcohol. We know that Robin Williams suffered from a mood disorder, either Bipolar Disorder or Unipolar Depression complicated by addiction – a combination that is possibly the most catastrophic of all the major mental illnesses. Whether or not he actually suffered from Bipolar Disorder or just “Unipolar” Depression is irrelevant – we will probably never know the exact details of his psychiatric treatment.
Bipolar disorder, otherwise known as Manic Depression is a disease of the brain characterized by major shifts in mood that vacillate between high energy manic states, periods of relative calm, and very low mood depressive and often suicidal feelings – it is a major mental illness that is almost entirely treated with medication. People who suffer from Unipolar Depression experience periods of severe depression, sometimes resulting in suicidal thinking that lasts for days to weeks or even months, followed by periods of relatively normal mood. The good news is this: with medication, therapy and avoidance of drugs and alcohol, many patients who suffer from both Bipolar Disorder and Unipolar Depression can keep the symptoms check and live a relatively stable life. The bad news: Many patients who suffer from these mood disorders are at a heightened risk of a number of tragic problems including suicidal behavior, substance abuse, violence, job loss, relationship problems and serious health issues.
The statistics are impressive: About 2 million Americans suffer from bipolar disorder with an equal distribution between men and women. Depression probably affects upwards of 20% of Americans at some point in their lives. In 2012, 16 million adults over 18 (6.9% of the population) suffered at least one Major Depressive Episode in the prior year. Up to 50% of patients who suffer from Bipolar Disorder make a suicide attempt at some point in their lives and about 10-15% succeed in killing themselves. Life stress, addiction, broken relationships, social isolation, physical health problems and medication non-compliance all increase the risk of suicide.
One of the major challenges patients suffering with Bipolar Disorder face is the need to continually take “mood stabilizing” medications despite that fact that they can cause feelings of “dullness”, and emotional blunting. They even need to take the medication during times of “euthymia” (normal mood). Many patients complain that “normal” living feels like depression to them – they enjoy and often thrive on the highs associated with manic behavior – which is often a source of creative and/or athletic genius. Many Bipolar patients stop medication despite their doctors telling them that they need to continue taking them, even when they are stable and doing well. They like being manic. Further complicating the picture is the fact that for many people, manic episodes, while ominous, can be a source of major creative and intellectual inspiration.
The fact is, Mood Disorders are chronic, relapsing, remitting diseases of the brain that require on-going treatment and monitoring by mental health professionals. Studies clearly show that every time a person suffers from an episode of mania or depression, the brain becomes somewhat de-stabilized which results in a more insidious course of the illness. That is, future episodes last longer, are more severe and come more frequently – thus the recommendation to treat these illnesses early and aggressively with medication, psychotherapy and cognitive behavioral therapy.
A final point about suicide: despite decades of serious research and study, predicting suicide, and other violent behaviors remains a difficult task since it is a relatively rare, though tragic problem. The problem is that while people who commit suicide almost always demonstrate a number of risk factors, the overwhelming majority of people with the same risk factors as Robin Williams, will never attempt or commit suicide or other violent behaviors.
We need to take depression, addiction and all mental illness seriously as diseases that require treatment. The behaviors associated with these illnesses are not simply “bad choices”, but manifestations of chronic brain problems that we are still trying to understand.
— Scott Bienenfeld, M.D.