Monday, July 29, 2013

Side Effects: A Cure for Stigma and Call to Arms in Psychiatry

It is the rare film that takes something I’m already excited about and makes it even more exciting. But Side Effects achieves this: it is a Da Vinci Code for psychiatry, a whirling adventure that takes the viewer through the psych ER, the clinic and the hospital. I must tip my hat to its director, Steven Soderbergh, for he even made a literature review a thrilling, plot-changing scene. He demonstrates that modern psychiatry has all the ingredients of a high-adrenaline thriller: high stakes (pharmaceutical profits), complex character motivations, and a lot of ambiguity. With beautiful cinematography and masterful use of light and focus, the whole movie looked like an antidepressant commercial.

The thriller genre draws the audience along and succeeds in educating them “by the way.” Viewers see the many faces of modern psychiatry, including everything from pharmacotherapy counseling sessions to electroconvulsive therapy, and the attentive layperson can leave the theater with basic knowledge of depression and SSRIs, along with their side effects and what it’s like to be on them.

Psychiatry is an easy field to oversimplify. But Side Effects avoids both witch hunting psychiatrists and propagandizing SSRIs. Its critique of psychiatry is oblique. In 1975, Milos Forman aimed for psychiatry’s chest and unloaded both barrels with Nurse Ratched in One Flew Over a Cuckoo’s Nest. Side Effects used the facts of modern psychiatry as a mostly accurate (if somewhat exaggerated) background; it is a great film set against the intriguing tapestry that is modern psychiatry.

Side Effects seems to cover all the sticky issues in Psychiatry. Lesser movies would simplify the issues. Side Effects keeps them sticky, and uses the stickiness to make the plot gripping. It is uniquely able to do this because of its genre. In a non-thriller, the good guys and bad guys are usually pretty clear; the viewer’s sympathies rarely shift. In Side Effects, Soderbergh is able to give the viewer sympathy for good and bad psychiatrists, good and bad patients, and everyone in between; it is truly a full-spectrum emotional experience. The viewer gets to feel the deep sadness and isolation of depression, despair of suicidality, shame at having to see a psychiatrist, discomfort at a doctor’s “frivolous” prescription, hope that an antidepressant is actually working, and frustration at intolerable side effects. The viewer sympathizes with the psychiatrist’s guilt from a terrible patient outcome, anger at the malingerer, tiredness from overwork, and stress about finances. The viewer sees even the patient’s partner’s perspective, feeling their frustration and powerlessness.

The film powerfully combats stigma against those with psychiatric illness, and it does so by not combating it. In the late 1980’s, Jay Winsten and the Harvard Alcohol Project convinced popular TV shows (e.g. Cosby, Cheers) to donate several seconds of their scripts to including a “designated driver.” Without much finger-wagging or public education, the concept caught on and dramatically reduced the stigma of arranging to have someone drive you home. Side Effects does a similar thing with psychiatry. It doesn’t do much finger-wagging; it simply shows the pain caused by stigma and judgment and the dark road a depressed patient must walk down. The audience actually feels empathy for someone struggling with depression and the pain of judgment. Such empathy is very difficult to generate, especially for people who are “crazy.”

Despite its being a thriller, the film also touches on the deep philosophical question: who are we? A psychiatric patient is defended from a crime by claiming she was a, “victim of circumstance and biology.” The film asks us all, “Are we all victims of circumstance and biology?” Various high-performing not-mentally-ill characters seek medication to help improve their performance which, as one character explains, makes it, “Easier to be who you are.” Are we truly ourselves only when on our medications? And are medications the only defense we have against sadness and stress? In a poignant scene, a depressed character begins crying at a party. Her friend comes as if to console her, but ends up only offering a drug recommendation. The party guests look on the crying woman with embarrassment, unable to comfort or accept her, and she runs out of the party, ashamed.

The most important theme of the movie, and the crux of the plot, deals with diagnosis. The central tensions of the thriller are the daily questions of the psychiatrist: Who is really sick? Did this pill cause that? What should I, the doctor, do? These everyday uncertainties become matters of life and death, fame and disgrace. In the film, the stakes are very high for knowing if the symptoms are real. This fictional story reminds us that for patients, these are always matters of life and death. A correct diagnosis may well change a patient’s life.

In the film, one of the psychiatrists points out that the cardiologist can see the heart attack coming because he has tests, and then asks, “What test there is for sadness?” I hope that this is the last decade that such a film can be set. “The Sting,” a film set in the 1930’s, shows a central dupe which required the protagonists to delay telegraph information. When I saw it, I smiled at the quaint idea of slow information. I hope that our children can look at Side Effects and remember the quaint time when mental illness could not be diagnosed except by interview.

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