A Prejudice That Kills
Lost at sea, an apparent suicide. The death of Philip Merrill, 72, should shake us out of our complacent stupor in the face of this leading killer. Because of his stature as a publisher and former diplomat, Merrill's disappearance and death dominated the news. How could this happen to a man known, according to a family statement, for his "lifelong optimistic outlook"?
The question reflects our own fears and prejudices. Our shock is another veil of denial, a way to keep the horror at bay. So powerful and repressive is the tyranny of stigma.
First is the stigma of suicide. We don't talk about it. We don't look at it on television; we delight in watching bang-bang murder mysteries -- but shrink from the idea of a bang-bang suicide mystery. Yet many more people in the United States kill themselves than are killed by someone else. Suicide, which claims about 31,000 lives a year, is more prevalent than homicide by a ratio of about 3 to 2.
Second is the stigma of mental illness. To be sure, not all suicides can be understood against a background of mental illness. Each suicide is complex, with a unique set of circumstances and risk factors. But the majority of suicides -- perhaps about 75 percent -- are linked to depression or other mental disorders. Despite public campaigns to de-stigmatize mental illness, disorders of the brain and behavior remain in a medical and social twilight zone compared with disorders of the body and physiology.
Third is the stigma of growing old. As long as older men and women represented a small proportion of the population, they could be kissed off with Hallmark greeting card nostalgia for being the cute rocking-chair folks. But the dramatic shift to a graying population is challenging the forever-young mystique of our relatively young country.
All three stigmas combine in a kind of Triple Crown of prejudice, creating a personal crisis for millions of older Americans and a public crisis for a nation unprepared to meet general mental health needs or confront the demographic challenges of an aging society.
These stigmas have a synergistic effect: The highest suicide rates, for example, occur in older people -- particularly in white men over 65. Do we think that suicide is somehow rational for those who have supposedly replaced the impulsivity of youth with the stability of wisdom? Or does society's prejudice go deeper? Perhaps we can't imagine having a meaningful life after a certain age -- which makes suicide in an older person understandable.
Maybe we even suspect that going a little ga-ga is a normal part of aging! If an older person is sad and withdrawn, stigmas kicks in with the view: Hey, if I had arthritis or cancer or had lost a spouse or been eased out of the workplace, I'd be depressed, too! Vicious bias ends up dismissing a vicious disease. Ugly ageism translates into bad medicine. "To feel down and have a sense of loss is normal," says psychiatrist Stephen J. Bartels of the New Hampshire-Dartmouth Psychiatric Research Center. "To be depressed over a period of time is not normal."
Mental illness in older men and women often goes undetected -- and untreated. One misconception is that severe disorders such as schizophrenia and bipolar depression only develop in younger adults. But researchers now know that 20 percent of schizophrenia cases occur after age 45 -- and in 10 to 12 percent of patients with bipolar depression, the onset of episodes begins after age 55.
Many older men and women can also develop a mental illness in combination with medical disorders such as cancer, diabetes and heart disease. Patients who undergo heart surgery may be at risk of developing depression. Dementias can be exacerbated by depression. Drug interactions and substance abuse are frequent problems. Some 20 percent of older patients with bipolar depression, for example, also abuse alcohol or drugs.
About one in four older Americans has a significant mental disorder. By 2030, an estimated 15 million people over 65 will have a major psychiatric illness. Without a national initiative to address their needs, "future generations of young and old Americans will tragically bear the economic and social costs of excess disability, diminished quality of life, and a healthcare system overwhelmed by an epidemic of mental disorders of aging," concludes the 2003 report of the president's mental health commission.
There are some signs of progress. The White House Conference on Aging has placed mental health among its top 10 priorities. A federal initiative is coordinating special outreach and treatment programs for men and women over 55 in 25 states.
But the biggest barrier is the Triple Crown. "Without addressing stigma, systemic reforms . . . are unlikely to be successful," states the commission report.
Philip Merrill's well-publicized death -- for all the unanswered questions in his case -- is a public challenge to address stigma and start dealing with the realities of the human condition in an era of longevity. ?