I Sense a Stigma

On October 30, 2017, the president of the University of Pennsylvania held a campus forum to discuss mental health. It was touted as the “first conversation of its kind.” Six students of the university have died since August 2017. Fourteen students have committed suicide since February 2013. These deaths draw attention to the prevalence of mental illness on campus, and the prevalence of mental illness everywhere. Many students suffer from mood disorders during the entirety of their college career. Junior Samuel Brooks is one of these students.

“I much prefer being drunk to being Sam,” he says.  He sits on his bed, hunched over, pressed against the wall, languidly smoking marijuana from a vaporizer. He considers weed to be negative coping mechanism, but it helps with his depression.

Sam suffers from social anxiety and major depressive disorder.  He sees his mental illness as a character flaw. In his words, “it’s not embarrassing, but it’s a weakness.” He’s talking to me because he trusts me. I also suffer from anxiety, and I have since seventh grade.  He does not confide in many people, and his name has been changed because he does not want to be identified as being mentally ill. He feels comfortable talking with me and with his roommates, John and Sebastian. Sebastian created a support group for people suffering from mental illness, and John struggles with anxiety. Sam has talked to his girlfriend of a year and a half about his disordered thinking only because she once asked him about his pills. I am conducting my interview with him in his bedroom behind a closed door in a low tone even though his roommates are the only other people in the apartment.

Social anxiety is characterized by having a persistent, irrational and intense fear of being judged, negatively evaluated, or rejected. This manifests itself in both tangible and intangible ways. Panic attacks are common, as is an increased heart rate, nausea, and sweating.  Sam does not typically experience any of the physical symptoms, but finds the disorder’s more intangible aspects to be debilitating.

When Sam was a senior in high school, he was terrified to go to class every single day. He felt ostracized, but he had friends. He was afraid of being disliked, but he had friends. He was afraid of falling into the gaps between different cliques, none of which he was really a part of, and he had friends. When I asked him what it was like coming to college, he said he was convinced that everyone thought he was an asshole when they first met him. He said it was hard for him to connect with people because he thought he came off as arrogant. He said he was always drunk.  Sam puts downs his vaporizer so he can juggle a foam soccer ball and takes a minute to muse about his current friendships with his roommates. “You’re asking them what they think of me, right?” He looks at the ground, pauses, and squeezes his ball for comfort. “I bet John will say, ‘Yeah he’s pretty weird. We’re just friends with him so he doesn’t off himself.’ And Sebastian will be like ‘Oh Sam’s the fucking worst.’”

I visit John during a lull in his office hours in an engineering building. We sit alone at a table in a crowded room. Sam is attending class across campus.  “What was your first impression of Sam?”

“He was a nice, jovial guy,” says John. “He gave off a good first impression. Then we spent more time together at Penn Apps, and now he’s probably my best friend here.”

Living with social anxiety and depression is exhausting. Fatigue and sleep deprivation emerge with both illnesses. Depression comprises a loss of interest and lack of motivation.  Obsessive and disruptive thought patterns accompany anxiety, as does paranoia.

I ask Sam if his mental illnesses have affected his future plans. “Yeah,” he said. “My long term goal is my mental health. It makes it harder to accomplish things. I want to start a company and have a happy marriage, but I don’t think I can commit to anyone, or anything, unless I love myself.”

Unlike Sam, Elena has no qualms about speaking candidly about her major depressive disorder. It’s loud and crowded in the Starbucks on the corner of 34th and Walnut Street where I sit at a small table for two with my laptop opened in front of me. Elena Brown-Soler is a sophomore at the University of Pennsylvania. She sits across from me, avoiding eye contact and jiggling her legs nervously, her knees crashing into the wooden table top.

She wants people to know that depression is not the same thing as feeling sad. It doesn’t just go away. “When I’m in a good mood, it’s there. It’s like clouds that can always move into position to block out the sun. It’s a heavy weight. There may be days when the sun peeps through, but it’s still a gray day. People don’t understand. They always tell me to ‘think happy things!’ That’s not how it works.” She rolls her eyes and fidgets.

“One Sunday, I was sitting in the sixth floor of Van Pelt and I was trying to do work, but I couldn’t. I couldn’t do work. I just sat there and stared at my computer screen and I tried to care, but I didn’t.” She wipes her tears away with hands covered by sweatshirt sleeves. “I left and I walked down to Franklin Field. I just sat there on the track for four or five hours. Then I went to my friend’s house. I looked at him and I said, ‘Sean, I’m not okay.’ He just sat and was there for me as I broke down into tears and collapsed on his couch.”

She starts to cry harder. She tells me the only reason she won’t commit suicide is because she knows it would destroy her little sister.

I ask her the same question I asked Sam, about how depression affects her vision of the future. She looks around, clasps and unclasps her hands, and starts to cry again. She responds, “I’ve lost a sense of what I want to do. Depression blocks my ability to concentrate and focus on long term goals. Some days it’s hard to function. I’m more focused on just getting through the day than what I’m going to be doing in the next five years.” Inability to focus and indecision are common side effects of depression. These symptoms can be exacerbated during college, a time where people feel forced to make important life choices. Some people experience the worst effects of their mood disorders while in school.  Psychology Professor Dr. Melissa Hunt explains, “University life involves a great deal of sleep deprivation which can make many illnesses worse. It also elevates stress levels. Being at Penn is probably harder on someone’s psyche than working a 9-5 job that isn’t particularly demanding.”

In August, Elena started taking her antidepressants, and in January of his sophomore year of college, Sam started taking his medication. Both of them floundered in their mental illness for several years prior to coming to the University of Pennsylvania.

I asked both of them what made them decide to get help. Elena resisted seeking a specialist until she couldn’t get out of bed one day. It was too much effort. Then she waited, until that day became a week. Then she got help. Sam waited until he started to feel lonely even when he was with people, until he lost all motivation for schoolwork, and until he started to have suicidal thoughts. Then Sam waited until he realized he was staying awake until 4 or 5 every morning to finish work he procrastinated on. When Sam seemed reluctant to get help, his dad called him and said half-jokingly, “You should see a therapist. It may help some idiots like you.” Sam got help.

Sam waited to get help, he said, because he’s “stubborn.” He thought he could cure his own depression through exercise and healthy eating. If he just worked a little harder at improving his physical health, his mental health would naturally follow. He didn’t want to admit something was seriously wrong with him.

The dictionary definition of stigma is a “mark of disgrace associated with a specific quality, circumstance, or person.” A study published in 2015 by the National Bureau of Economic Research on Aging and Health reported that the negative effects of stigma surrounding mental illness could be as dangerous to a person as their actual mental illness. It is the “main barrier to mental health care.” The article continues, “Hence, stigma could prevent individuals from seeking care, leading to more intense (and perhaps less successful) and more expensive treatment options later.”

During our interview about Sam, I asked John about his own mental health issues. He told me he’s started to have intense anxiety attacks about once or twice a month. This onslaught of panic began a year ago. The frequency and the intensity of these anxiety attacks have gotten worse. He knows when they are coming now, his teeth chatter, he shakes, and he can’t tolerate being around the noise and energies of other people. He begins to think in “mental loops” and all of his attention is focused on ending the anxiety attack, usually through deep breathing and attempts to meditate. He will not seek treatment because he doesn’t think this condition justifies therapy-the anxiety attacks are too sporadic. He fears that if he seeks treatment, he will be over prescribed Xanax and become a casual user. This is ironic, since to cope, he has started taking Klonopin. He scavenges this drug from his fraternity brothers. Klonopin and Xanax are both benzodiazepine anticonvulsants. They are stronger and more addictive than other drugs that are more commonly prescribed. They start working within half an hour and inhibit the GABA neurotransmitters, effectively shutting down neural impulses. These drugs are also used to treat seizures. Many people, including John, who are reluctant to see a psychiatrist fear “emotional numbing,” which Dr. Hunt agrees is a possible side effect of benzodiazepine anticonvulsants, but is never the goal. She also explained that this side effect is exclusive to the benzodiazepines, and not to other anxiety medications. He is not seeking professional help, and John says, he will not be telling his parents about these problems. John’s family is from Russia and “mental health just isn’t something that is mentioned in the Soviet Union.”

Sam and Elena waited to seek treatment because they magnified the stigma they thought they detected from the outside world. They just wanted to be normal.  They didn’t want to admit that something was wrong. They didn’t want to feel weak. In Sam’s words, “Anxiety is like having an embarrassing disease that nobody else really knows about, like having really bad breath or IBS. Every time you feel it affecting you, you feel worse about yourself because ‘normal people’ don’t have to deal with this stuff.”  According to Sam, “normal people” are “neuro-typical” people who are not chemically imbalanced. Sam believes that people who are not diagnosed with mental illness are comfortable within their own minds. He assumes that “neuro-typical” people have a tendency to be happy and explains, “When people who don’t have depression feel sad, it’s not that serious. It’s like the equivalent of stubbing a toe. They’ll be able to forget about it shortly and move on with their lives. When someone who has depression feels bad and their thought processes already naturally tend toward sadness, they won’t be able to forget about something bad, no matter how small, and just move on with their day. People without depression aren’t able to relate to people with it.”

Stigma is more prevalent and far-reaching than people realize, or want to admit. Many students were underwhelmed by the campus conversation Gutmann hosted on October 30, 2017. The forum, held in the Zellerbach Theater on Penn’s campus, was broken into two parts. The first part comprised Michelle Xu, Undergraduate Assembly President and representative of Penn’s student body, interviewing President Amy Gutmann and Provost Wendell Pritchet. The second part was a panel discussion on mental health. The panel of speakers included Psychology professor Angela Duckworth, Perelman Psychiatry Professor Jody Foster, University Chaplain Rev. Chaz Howard and Perelman Professor and Chair of Psychiatry Maria Oquendo. After the panel discussion there was a 10-minute question and answer session with members of the audience.

Gutmann and Pritchett did not address the administrative policies that current students are struggling to understand and deal with, most notably the long wait times associated with the arduous referral process of Counseling and Psychological Services. They discussed personal stressors in their life and what they’ve learned through coping with these stressors. The overarching message was that you should be forthright with your peers because they will be helpful and accepting. Neither Gutmann nor Pritchett shared stories about personal experiences dealing with mental illness. Their conversation centered on dealing with death, grief, and other unprecedented challenges. After the conversation, Gutmann sent an email to the undergraduate student body which outlined a plan for improving the Counseling and Psychological Services of the university.

To give her credit, Gutmann was reaching out to relate to students, but she also brought attention to a common misunderstanding about mental illness. Stress can exacerbate mental illness, but stress is not a mental illness. The idea that the stress is equivalent to depression or anxiety is irritating, harmful, and dangerous to people suffering from mental illness. It dilutes the conversation around an important issue. During my interview with Elena, Elena spoke about this problem. Although she never felt stigmatized at Penn, she said that she did notice people use the term “depression” too often and too loosely. “Everyone says that they are depressed, but they are not depressed. They are just stressed. I try to correct my friends whenever they use the word incorrectly. Recently, I’ve noticed that Penn has been trying to address mental health issues, but the issues are still stigmatized.” She becomes increasingly frustrated and fidgety as she reflects on some of her personal experiences. “You’re welcome to talk, but people [the administration] don’t want to say ‘suicide.’ People [the administration] always say that they’re here to help, but they don’t help.”

Elena is not the only person to feel this way. An article published on October 29, 2017 by The Daily Pennsylvanian addressed the university’s reluctance to provide the undergraduate population with details regarding student deaths. The Vice Provost for University Life, Valerie Swain-Cade McCoullum is quoted in the article, explaining that the lack of specificity and detail in the emails addressing these incidences is out of respect for the family of the deceased. The administration is also reluctant to call suicide by its name because of fear of the “cluster effect,” a spike in suicides after one person takes their own life. They do not want to exacerbate the mental illness of others who are already struggling.

Sam and Elena both take psychiatric medicine and attend weekly therapy appointments. Sam takes an SSRI, a Selective Serotonin Reuptake Inhibitor, and an NDRI, a Norepinephrine-Dopamine Reuptake Inhibitor, while Elena just takes an SSRI. SSRIs work by leaving the chemical serotonin in the synaptic cleft for a longer period of time and creating more receptive vesicles for serotonin in the brain. People with anxiety and depression are thought to have less serotonin than people without these afflictions. NDRIs work in a similar way, but instead affect the neurotransmitters norepinephrine and dopamine. Despite the proven chemical reasons for taking medicine, psychiatric medication tends to be even more stigmatized than mental illness on its own. If stress is the equivalent of depression, and everyone is stressed, shouldn’t everyone also be able to deal with depression without medication?

I sat on the cream-colored faux leather couch in my therapist’s office. I crossed my legs in front of me and I rubbed my fingers against the indent in my palm created by my class ring (I also have OCD), and the meaty part of my arms. I looked over the head of my therapist, Dr. John Guerry, to the crayon drawings his younger patients had made for him. There’s a canvas painting featuring a swirl of pink with a mess of green on the bottom and a blanket of blue on top. Written in sharpie is the phrase “My Pink Tornado.” I am drawn to this because my fifth grade teacher used to call me “her favorite hurricane.”  I keep my gaze on that and tell Dr. Guerry that I think I would like to be medicated. This is my second appointment with him. I’m not sure how he’ll react. I know he’s opposed to psychiatric medicine. He told me that when I was first being evaluated, but I didn’t want medicine then.

I didn’t want medicine because the first time a therapist recommended that I take medicine was when I was in seventh grade, and my parents yelled at her, and at me for wanting it. They told me my anxiety was not that bad. They told me I was “normal” and that everyone felt uneasy sometimes. They told me I should “suck it up” and try to find something that “normal kids do” and make that a coping mechanism. My parents were trying to help, and didn’t want me to be drugged unnecessarily. They consider medicine to be only a temporary solution, a crutch to use until the “happy thoughts” manifest naturally. My parents wanted me to find strength within myself, and they didn’t want me to fall into the trap of using mental illness as an excuse not to be ok. They enrolled me in tennis camp.

I didn’t want medicine because my grandfather took medicine for his depression and then he gained weight, and stopped talking, and all of the sudden he didn’t care about the small things that he used to care about anymore. He became less detail-oriented, he didn’t clean up after himself, and he stopped playing with my sister and me. He had days where he did nothing but lie on his bedroom floor with his head in the closet. My Pops is doing better now, though. He bought himself a toy hamster and named it Little Louie. They watch TV together.

I didn’t want medicine because when I was in eighth grade, my friend’s father committed suicide after he started taking antidepressants, and that is not uncommon. Side effects of many psychiatric medicines include an increased risk for suicidal thoughts and behaviors. Anti-depressants may act by giving people suffering from depression enough energy to execute a plan for taking their lives.

I didn’t want medicine because over the summer when I came back from college, I asked my friend Madison what she thought and she said “You’re really not that bad. Everyone overthinks and obsesses over things.” And when I asked my friend Michael what to do he said, “No. Don’t take it. It’ll ruin your personality. You’ll be a zombie. You don’t need it. You’re pretty normal.”

I didn’t want medicine because my therapist didn’t believe in medicine and neither did my doctor. My doctor is nearing retirement age and has written only 20 prescriptions for Prozac. I am one of those.

I didn’t want medicine because I was convinced that I was strong enough without it. I was diagnosed with anxiety, depression, and OCD in seventh grade. I was on suicide watch for two years. Throughout parts of grade school and high school, I had a pass that allowed me to go to the guidance counselor’s office whenever my system flooded itself with adrenaline and my mind ventured on its own little uncontrollable joy ride from hell. I saw six therapists, most of them unhelpful. I survived days where I couldn’t function. I survived weeks where I couldn’t eat, and had consequently lost around fifteen pounds. I survived innumerable sleepless nights and anxiety attacks. And despite this, I thrived. I spoke in front of my class during high school graduation, I flew to Mexico with my friend for a week-long vacation. I moved to college and made new friends and received decent grades. I was too strong for medicine. I didn’t need it. If I took it, I would be giving up on myself. I didn’t want to be a quitter. I considered myself to be an expert on my mental illnesses because of all my experience, the readings I did, and the classes I’ve taken (I’m minoring in neuroscience), and I thought I could defeat my “demons” on my own.

I knew that I needed to take medicine because I didn’t feel comfortable being with my best friends anymore. I didn’t feel happy. I was dissociating, I would watch myself interact with others from afar. I lived as a shadow of myself. I had more conversations inside of my head than I did with the people around me. I was doing things that would normally make me feel happy, and I knew I should feel happy, but all I felt was worry. Whenever I was more than hour away from home, I suffered anxiety attacks that left me quaking and vomiting. I wasn’t alive.

Sam didn’t want to take medicine because he “did his research”. He knew risks were involved, that 1 in every 10 people suffers adverse effects because of biology. In people not already diagnosed with bipolar disorder, antidepressants can act as the catalyst for the manifestation of the illness, and even in patients without bi-polar disorder, anti-depressants can cause mood swings and suicidal behaviors. There is also the risk that the medication will not help to alleviate depression, and the patient will experience all of the side effects, like dry mouth, headaches, drowsiness, hyperactivity, insomnia, and constipation, without any of the benefits. This is especially common with Prozac, where the side effects begin before the drug starts working.

Sam didn’t want to take medicine because he was afraid that he’d lose his personality, and wouldn’t recognize himself. He thought the medicine would blunt his thoughts, prohibit him from thinking deeply and clearly. Sam decided to take medicine because his sister takes medicine, and she is the same person now as she was before. Sam decided to take medicine because his parents insisted on it.

Elena didn’t want to take medicine because she didn’t want to be dependent on chemicals to make her feel better. She wanted to learn how to be happy on her own. Elena decided to take medicine because she’s in college now. She doesn’t have the time to be depressed.

All of us who have started medication feel considerably better now. Because of medicine, Sam worries less about what strangers think of him, he feels less alone, and has more energy. Elena doesn’t miss her nagging clouds of sadness. I feel as though I am back in my body. However, there’s a tradeoff.  Sam’s sex drive and performance have decreased considerably. When he drinks, he gets drunk almost immediately and becomes belligerent, and he still gets nervous to have dinner with his girlfriend, Lissa. Elena feels flat, “I can laugh and jump around, but I don’t feel anything. It’s better than being sad, though.” Elena also suffers insomnia, hyperactivity, and nausea as resulting side effects. I have lost motivation, I have insomnia somedays and hypersomnia other days, and I care less about things that were once important to me. It’s harder for me to focus on my schoolwork and grades. I also don’t read or write nearly as much as I used to, and I find that it’s difficult for me to make time for my therapy appointments on days when I am feeling ok. I view these side effects as minor annoyances compared to the feelings of panic that once plagued me regularly. In fact, I like my medicine so much that sometimes I daydream about a pill that could take away all of my emotions without any side effects. I wouldn’t be happy, but I wouldn’t be depressed. Is that why people become addicted to drugs?

I’m sitting with Sam in his apartment on his Ikea couch facing the wall projector that’s standing in for the broken television. We’ve each had a beer and are talking loudly, making jokes about how free we feel since we’ve started taking antidepressants. You become much more sexually liberated when you’re not tethered to your pesky emotions. You also gain a lot of self-confidence, which is a big deal for us former bullied nerds.  We talk about our lives, families, pubic hair, and travel plans. As I get ready to leave, he looks at me and tells me that he’s had a rough week, the roughest that he has had in a while, but he’s glad we’re in this together, and just sitting together playing video games and making jokes has helped.

I became friends with a freshman in the College named Avneet Randhawa because of this expose. Avneet and I both write for the student-run satire magazine, The Pennsylvania Punch Bowl. Avneet showed up to our initiation night thirty-five minutes late and was smoking a cigarette. We were instructed to stand outside in the cold and wait to be summoned by the juniors and seniors in the magazine. I brought up this project because I was looking for more people to interview about their experience coping with mental illness. Avneet offered up her story and we met the next day at a Starbucks. She had no qualms speaking openly because “most people view body disorders as private, and people dealing with body disorders feel like others will judge them.” She went on to say, “People can speak so openly about depression, but not about this. It’s misunderstood and people think that we are just vain.”

Avneet is recovering from anorexia and struggles with body dysmorphia. She was diagnosed with anorexia when she was 12, and remained severely underweight until she was 16. This is the first time her weight does not label her as anorexic. To most people, this would be an accomplishment, but it serves as a double-edged sword for Avneet. She explains, “I don’t have anorexia anymore, but I still have an eating disorder. I’m not emaciated enough to be classified as an ‘anorexic’ and body dysmorphia is hard to diagnose. I am a failure within my own disorder.”

Avneet’s mental illness centers on her body image. She was late to meet us at The Punch Bowl party because she walked past a mirror and noticed that something was “off.” She spent half an hour adjusting and readjusting her clothing and hair, in small ways. She didn’t change her outfit, just pulled at her clothing until she felt that it fell perfectly and minimized any of her flaws. When Avneet is unable to distract herself with academics, the one thing she feels represents her self-worth and success, she spends the entire day obsessing over her figure. She said, “During the summer it consumed almost all of my time.  I wonder what I else I could have done if I didn’t have to think about my body. When I am walking down the street, I think about how other people have time to care about other things, do other things. I feel like I will never be able to escape my mind. I have to plan out my meals and make notes of outfits that I looked really good wearing. If I start thinking negatively about myself, I like to mentally revert back to a time when I looked really good. Sometimes I try to be kind to myself and not think about my appearance, but then I’ll walk past a mirror. I can’t look at myself in certain angles because I am reminded of my imperfections, and it’ll ruin my day or my week. This is why I am always late to things. I have to do multiple things to my face and body to feel ok.”

Avneet has a difficult time making and retaining friendships and relationships. Female friendships are especially difficult, because she finds herself constantly comparing her appearance to theirs. She is also hesitant about telling people about her insecurities because she doesn’t want people to see her as “the girl with the eating disorder.” She feels like having a conspicuous mental illness deters people from wanting to get close to her because it transforms her into a liability, a burden. She assumes, like Sam does, that “neuro-typical” people cannot relate to disordered thinking, but she also believes that it’s too much work for someone who isn’t mentally ill to befriend someone who is. She copes in social situations by drinking alcohol, smoking weed, and making out with random people.

Avneet does not talk to her parents about her mental health because they don’t believe it’s a real problem. They stigmatize her and then she internalizes this stigma and applies it to her peers. This is a common theme. I interviewed 15 “neuro-typical” people about their thoughts on psychiatric medicine, therapy, and mental illness, and all of them supported the use of psychiatric medicine and the ability to get help. They agreed that access to mental health care needs to be improved and that people should be comfortable and able to speak about their problems with their friends and family. They also agreed that the public stigma around mental health was disappearing.

The stigma surrounding mental health is so difficult to eradicate because it is this intangible thing lurking predominantly in the minds of the vulnerable people struggling the most, implanting seeds of doubt, of weakness and fear. I asked Dr. Melissa Hunt about this hypothesis. She explained, “We typically define ourselves and others by how we think, feel, communicate and interact with others.  Mental illness can affect all of those domains, challenging our core sense of who someone is and how we should understand them.” We project how we feel onto the people we interact with and assume they are analyzing the conversation in the same way that we are.  Society is becoming more accepting of these diseases, especially recently with the advent of scientific theories, that suggest that maladies like anxiety and depression are biologically rooted in the brain. This has led to a huge push to normalize mental illness in recent years. If mental health was still taboo, still universally seen as weak, there would not have been a campus conversation with Amy Gutmann, people would not have sat for these interviews, and it’d be a lot easier to get a therapy appointment. In order to change the way mental illness is viewed in society, we have to change the way that we view ourselves. We are not disordered people; we are people who have disorders. We harm ourselves more than any of our relatives or peers do. We are the ones who make ourselves feel weak or abnormal. We are the problem in this situation. We can change that by ceasing to compare ourselves to others, and by accepting our thoughts. We need to stop doubting the advice of doctors, and thinking that our independent research is more valid than their medical training. We must kill the stigma that exists within each of us. We can do it. It can’t be any harder than changing society’s mind.