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Dancing in the Dark

A notable increase in college students seeking mental health services has been hailed by some as tangible evidence that efforts to de-stigmatize treatment have succeeded. Not so fast.
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A notable increase in college students seeking mental health services has been hailed by some as tangible evidence that efforts to de-stigmatize treatment have succeeded.

Not so fast.

While the work of organizations such as the National Alliance on Mental Illness (NAMI) may have reduced stigma associated with diagnosis and treatment, many sufferers remain reluctant to seek help due to embarrassment and shame. Maybe mostly men.

In his February 2016 New York Times article "Opening Up About Depression," Steven Petrow states that 6 million men in the United States suffer from depression. He then quotes Dr. Matthew Rudorfer of the National Institute of Mental Health (NIMH) as saying, "The true number is likely to be even higher." Nevertheless, whether male or female, the problem of depression is of staggering proportion. According to NIMH, "In 2014, an estimated 15.7 million adults aged 18 or older in the United States had at least one major depressive episode in the past year. This number represented 6.7 percent of all U.S. adults."

And the cost is enormous.

An article published by The Journal of Clinical Psychiatry states that the economic burden of major depression in the United States rose 21.5 percent between 2005 and 2010 from $173.2 billion to $210.5 billion. Among key cohorts nestled within these numbers are 15- to 24-year-olds, for whom suicide was the second leading cause of death in 2013, according to the Centers for Disease Control and Prevention.

The recent spate of suicides by high school students ranging from the community of Palo Alto in California to Fordham Preparatory School in New York makes clear we have our work cut out for us.

And that's before they get to college.

Emory Cares 4 U, an awareness and support program, reports that among college students the rate of suicide is between .5 and 7.5 per 100,000. More than 1,000 suicides occur on college campuses annually. And 10 percent of college students have made plans for suicide.

In a July 2015 New York Times article, Julie Scelfo, citing student suicides at the University of Pennsylvania, lays the blame on the "pressure of perfection" and overindulgence by parents pushing success and not allowing their kids to fail. In addition, Cornell University's director of counseling and psychological services, Gregory T. Eells, points to the role of social media in creating perceptions among young people that everyone else is doing fine. To the contrary, Eells says that when struggling individuals remark that everyone looks happy, he tells them: "I walk around campus and think, 'That one's gone to the hospital. That person has an eating disorder. That student just went on antidepressants.'" He goes on to say, "As a therapist, I know that nobody is as happy or grown-up as they seem on the outside."

For sure, many young people sublimate their need for treatment to their need to appear happy, healthy and successful. At Penn, Scelfo says, they call it "Penn Face" -- pretending all is fine even when it's not. While some practitioners of cognitive behavioral psychology may take a "fake it until you feel it" approach to therapy, it seems unlikely that is a durable, long-term strategy for chronic depression. Indeed, a task force convened at Penn in the wake of the suicides there concluded that a perception among students that they must achieve perfection in all areas of college life can leave them alienated, demoralized, anxious or depressed.

It is clear that stigma still exists.

A 2014 article in a U.S. edition of The Guardian reveals that not only hasn't the stigma of mental health problems gone away, but it's also more nuanced than we may think. Reporting on research from Sarah Clement and her colleagues, author Pete Etchells notes three distinct types of stigma.

1. Anticipated Stigma (how afflicted individuals believe they will be perceived or treated by others if their struggles become known)

2. Treatment Stigma (how they believe others will react to their seeking or receiving treatment)

3. Internalized Stigma (how they perceive themselves)

Etchells argues that to overcome stigmatization, we need to refine strategies to address all three types.

Ways to get around stigma, while also helping overcrowded collegiate counseling clinics, are programs such as those created by The Jed Foundation. Among them is ULifeline, an anonymous online resource that helps college students learn more about their thoughts and feelings and how to reach out for help if necessary.

Michael Lesser, M.D., a psychiatrist, former medical director of the New York City Department of Mental Health, and current executive director of Medical and Mental Health at RANE (Risk Assistance Network & Exchange), told me, "Stigma, even today in the U.S., remains a huge barrier for adolescents and their parents to seek timely and effective treatment for depression. It's essential for colleges -- and others -- to educate students and parents to recognize depression in all its manifestations and to create easy access to treatment."

Perhaps most salient in this important discussion is the ongoing role of silent stigma. Sadly, it leaves far too many young people living their lives behind a facade of normalcy, figuratively dancing in the dark.

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If you -- or someone you know -- need help, please call 1-800-273-8255 for the National Suicide Prevention Lifeline. If you are outside of the U.S., please visit the International Association for Suicide Prevention for a database of international resources.