Christopher Magoon, MD

This past year has been a watershed for public discourse around mental health. It is fitting, then, that representations of mental illness in popular culture are increasingly abundant, varied, and nuanced. Although each artist brings their own experience with mental health to their work, depictions of the mental health care system and mental illness are often sensationalized, demonizing, or grossly inaccurate. These misfires can further stigmatize patients with psychiatric disorders, and it is therefore important to highlight accurate representations of psychiatric issues and treatment. As psychiatrists and members of the Group for the Advancement of Psychiatry Committee on Arts and Humanities, we wanted to highlight some exemplary representations of mental health issues in film and television over the past year.

When perception diverges from reality, terror ensues. In 

, the viewer experiences the disorienting decline of Anthony (played by Anthony Hopkins) as he grapples with dementia. Anthony struggles to understand where he is, who he is, and who is around him. Director Florian Zeller deftly places the viewer into Anthony’s frame of mind as he experiences the horror of mistrusting his memories and perceptions. There is no overdramatization or embellishment. Zeller trusts that the stakes of this proud man—a well-off retired engineer—losing his faculties are high enough. As a result, the viewer is left feeling profound empathy. When a nurse hugs a crying and confused Anthony in the final scene, it feels genuinely cathartic to know he is comforted by human touch. The end of the film comes as a relief, as it does for many families with someone suffering with dementia. 

 an honest portrayal of the fragility of the mind, is well worth experiencing.

, an Israeli drama about a Haredi (ultraorthodox) family in Jerusalem, began streaming its third season this March. This series centers on Akiva Shtisel, an endearing but hapless son, brother, and father. Akiva is an oddity in his family and his insular religious community because of his artistic pursuits—he is a painter—and for his serial failures in love. In this season, we meet Racheli, a new love interest for Akiva, recently widowed and now a single father. Racheli, we come to learn, quietly suffers from what appears to be bipolar disorder. The touchingly human telling of their love story weaves Racheli’s psychiatric illness into the story seamlessly, neither glamorizing nor minimizing it, neither stigmatizing it nor ignoring its inherent cultural stigma.

There are other subplots touching upon mental health themes. Akiva’s sister and brother-in-law navigate their fragile marriage while watching their children strive to build families of their own. Akiva’s niece silently and courageously endures a complicated pregnancy. Through it all, Akiva’s father, widower Shulem, tries desperately to keep his family under his thumb while searching for companionship.

 gives viewers a fascinating glimpse into a world foreign to most, yet somehow simultaneously familiar. Although our day-to-day culture often either silences mental illness or sensationalizes it, 

fictional portrayal seems to bring us closer to reality than real life. That’s good TV.

 is an Australian documentary series that streamed its second season on Netflix in 2021. It is about young men and women with autism spectrum disorder who are looking for romance. The episodes are without commentary and with minimal intervention from the filmmakers and crew who chaperone dates. The otherwise high-functioning participants are behind the developmental curve in the worlds of sex and love, although they have touchingly supportive, loving, and nonjudgmental families (a series highlight).

There is little suggestion of mental health treatment, except for light coaching from a specialist—a mature, patient, and direct woman. She gives concrete advice on icebreaking, social conversation, and showing interest in the other, and she literally diagrams uncomfortable moments. The participants have structured dates and even speed-dating with a matching matrix. Sometimes they decide to be friends, and at other times, they get sidetracked by their single-minded focus on specific topics, as is common in individuals with autism spectrum disorder.

The series is remarkable for what is absent: insincere and staged competition, pathologizing, disability emphasis, and creepy voyeurism. While the characters are mostly straight, there are also gay and bisexual individuals integrated seamlessly by the filmmakers. The episodes are compelling, and we cheer on the participants. However, we return to reality with an understanding that these individuals face the same obstacles as everyone else. They suffer disappointment but show resilience. At least one couple married. For the viewer, 

 is uplifting and affirming in showing how intimacy and love are not out of reach for those on the spectrum. 

 stars Nicholas Cage as Rob Feldman, a former chef who makes a solitary living by truffle foraging with his beloved and talented pig. From the beginning, it is hinted that Rob is coping with tragedy, and as a result, is no longer interested in engaging in society. From time to time, Rob receives visits from Amir, who supplies truffles to high-end restaurants. One day, Rob’s pig is stolen by unidentified assailants. Rob, blaming Amir because he had spread word in town about the pig’s abilities, asks Amir to accompany him to Portland and find his pig. The duo goes through an odyssey with the hope of rescuing Rob’s lost love.

The portrayal of Rob, who shows traits of autism spectrum disorder, like impaired social skills and a restrictive pattern of interests, is laudable. His fixation on cooking and food makes him the best chef and truffle forager in town. Rob copes with his loss with support from an unlikely friend. Despite being very different, like Rob, Amir is also coping with the loss of an important figure in his life. As such, a peculiar bond and attachment is formed between the two, and this human connection across differences has a healing power. 

An American football coach, Ted Lasso (Jason Sudeikis), is hired to run an English Premier League soccer team without any knowledge of how to play the game. He has tremendous confidence and an optimistic attitude toward the human condition. He evokes a positive response in others—undaunted by their negative responses to him—bringing them along to elevate their own personal experiences. Happily, a new star player, Danny, appears, whose credo is “football is life.” When Danny accidentally kills the team’s mascot dog with a penalty kick, he is traumatized and becomes quite depressed. His new motto becomes “football is death.”

When the coach is not able to help pull Danny out of his depression, the team brings in a therapist who helps him move forward. After seeing the therapist’s success with Danny, many other, often macho, members of the team engage her services. They realize that by simply talking about what is on their minds, they are able to feel better and move on in their lives. Ted also reluctantly seeks her services when he has to leave the sidelines because of a panic attack during a critical match. When knowledge of Ted’s panic disorder becomes public, he challenges the media to look at the treatment of mental health in sports.

Although the show later depicts unrealistic boundary violations after the therapist suffers from a biking accident, the two agents of change, Ted Lasso and the therapist, are complementary in advancing the inner lives of the team members. Much of the success of the series is due to the viewer also being exposed to the possibility that positive change can occur with optimism, self-confidence, and good therapy. 

The movie version of the Broadway musical, 

, is populated with mental health issues. In this story, both teenagers and adult parents present their guarded, inauthentic selves to the world. As often happens in worthwhile musicals and operas, when characters sing, their true selves blast out of mental shackles. “Why should I play this game of pretend?” asks Evan, the protagonist, played by young actor Ben Platt, who originated the Broadway role. He painfully stutters incoherent phrases, retracting and contradicting every word, avoiding eye contact with his world. He is on a trio of psychiatric medications. His single-parent mother unconsciously imprisons him by considering him “sick.”

A schoolmate’s mother embraces the pathologically shy Evan, mistakenly believing he was intimate friends with her son, Connor, who recently died by suicide. In fact, the only moment of contact between the boys was when Connor bullied Evan. However, Evan not only perpetuates the lie—he develops a fantasy of his and Connor’s friendship, using Connor as an idealized transitional object, a teddy-bear of warmth. As long as Evan is immersed in the lie, Connor’s family welcomes Evan into an accepting family he never had, and his awkwardness fades. Eventually, his lie thrusts him onto the world stage as an icon for adolescent mental health. Evan appears a star, but inevitably, the lie is revealed and Evan’s world crashes. Will traumatized Evan fall from grace or transform into maturity? Can real-world actions and emotions match truths that once were only sung in songs? Sometimes in therapy and the outside clinical world, disillusionment leads to growth. 

 is a coming-of-age comedy whose second season launched this July. 

central protagonist, Devi Vishwakumar, is a 15-year-old Indian-American girl. Less than 5 minutes into the first episode, narrator John McEnroe (yes, thatJohn McEnroe) tells us that Devi’s parents immigrated to the United States in September 2001 (“Not a super-chill time to be a brown person in America”); her father died of a sudden heart attack during her freshman year; she developed functional paralysis in her legs shortly thereafter; and the paralysis resolved suddenly 3 months later while she was straining to get a look at her crush. Devi is an overachieving nerd struggling with the unprocessed grief of her father’s death, her complicated relationship with her mother, and her cultural identity. The conflict of the show hinges on Devi’s vows to improve her social status and experience “normal” American teenage life.

The show’s pacing and occasionally over-the-top performances set the tone for its comedic content, but also mirror aspects of the adolescent experience that can be confusing, chaotic, clumsy, and replete with drama. While not all the psychiatric themes feel authentic (eg, the paralysis resolution), the underlying struggles of the teens generally do, and the show tackles issues including grief, coming out, family dynamics, and, briefly, anorexia. Similarly, Devi’s exchanges with her therapist (played by Niecy Nash) are often too compressed and laden with wit to serve as a how-to for supportive therapy, but they do provide a far more important positive, destigmatizing depiction of a helpful therapeutic relationship. On its surface, 

 is a typical teen rom-com, but at its core, it has a lot of heart. 

 is a fellow of the Group for the Advancement of Psychiatry Committee on Arts and Humanities. 

is chair of the Group for the Advancement of Psychiatry Committee on Arts and Humanities. Other committee members include Anish Ranjan Dube, MD, MPH; Fernando Espí Forcén, MD, PhD; Donald C. Fidler, MD; Andrew Lustbader, MD; Christopher Snowdy, MD; Kenneth J. Weiss, MD; and Helena Winston, MD, MPhil, MS.

Articles

The Group for the Advancement of Psychiatry Committee on Arts and Humanities highlights some exemplary representations of mental health issues in film and television.

Top 7 Screen Portrayals of Mental Health Issues in 2021

Our mental health system is facing something of a perfect storm. The stress of the 

 contagion, the civil strife and social disruption, and economic insecurity is causing an increased demand for mental health treatment.

 Yet, government agencies and health care institutions are incurring budget deficits, and without government funding to cover these losses, existing treatment programs are in jeopardy. 

 have already announced reductions in mental health care funding, and other states are expected to follow.

The simultaneous increased demand and decrease in available services could generate a second phase of the 

 crisis. This is particularly true for racial and ethnic minorities and those in lower socioeconomic groups, who faced an 

 of psychiatric disorders before the pandemic and have been hardest hit by the virus.

 For children, the situation is more dire. Mental health services were deficient for this patient population prior to COVID-19 and are now worse. In the context of the pandemic, the rates of mental illness can be expected to rise precipitously.

This country has been struggling with mental health care problems even before COVID-19. Deaths from suicide, drug overdose, and alcohol-related liver disease, 

 the combined mortality of all infectious diseases combined in the United States.

 According to recent projections, we can expect up to 

 from suicide and addiction as a result of COVID’s ripple effects without additional interventions.

We were caught unawares by the COVID-19 pandemic, and we are suffering the consequences. We cannot afford a repeat failure.

The good news is that there are evidence based, cost-effective interventions to address public mental health needs.

 But let us start with what we should not do. We should not—as we repeatedly do out of habit—continue talking about our “mental health system.” The truth is that we do not have a system but rather a patchwork or mosaic that is far from comprehensive and not close to being adequate. The same is true for all of health care; there are many systems, organizations, clinics, and practices delivering mental health services under many auspices (from governments to nonprofits to for profit investor-owned). However, these neither meet all health care needs nor provide the requisite evidence-based services or ensure uniform quality of care. Given the wide range of stakeholders and the lack of leadership and political will, it is doubtful we will see one system emerge from the COVID-19 crisis. Yet, we can use this opportunity to accelerate the coordination of services for communities, including adequate mental health services that will provide a template for post-COVID care.

Accountable care organizations, medical homes, and Medicaid waivers have all inched coordinated care forward. We have also seen expanded use of telehealth due to the elimination of regulatory and reimbursement barriers. Virtually overnight, this resulted in unfettered adoption of online mental health treatment. We can do the same for coordinated care by removing regulatory barriers and offering payments that incentivize hospitals and their services, community-based organizations, and local primary care providers to create a no-wrong door, seamless continuum of mental health and substance abuse services.

This is our vision for the Northern Manhattan Mental Health Initiative, targeting one of the most severely affected areas by the COVID-19 virus. It gives health care providers and communities the opportunity to strengthen existing relationships, build new partnerships, and create a safety net for patients.

Other systemic problems can be addressed to meet the increasing demand for mental health care. For example, there are 

 The inpatient bed is the ICU of mental health care: for the most severe cases, it can be the difference between life and death. Well-meaning but flawed deinstitutionalization policies in the second half of the 20

 century left many people with serious mental illness on the streets, in homeless shelters, or incarcerated. Deinstitutionalization policies, compounded by 

, incentivized hospitals to close inpatient units and created a critical bed shortage.

 As a result, patients can wait in emergency departments for days—or 

In the midst of this pandemic, many inpatient beds, including those in our institution, have been converted to medical units to meet the deluge of patients with COVID-19, and it is unclear when or how they will return.

While such developments are regrettable, they are incentivized by the health care financing system that provides far higher reimbursements for procedural interventions than for preventative health measures like mental health. For example, according to the Centers for Medicare & Medicaid Services Physician Fee Schedule, payment for an emergency hour-long session by a psychiatrist with a patient who is acutely suicidal, homicidal, or floridly psychotic is only $147, while a 10 minute skin biopsy and 20 minute cataract surgery are reimbursed at rates of $150 and $765, respectively.

 These disparities are 1 reason there are so many surgery centers with an average profit of $2 million profit per year are popping up, while nearly half of patients with mental health disorders go without treatment.

 Leveling the playing field with reimbursement will incentivize health systems to emphasize mental health treatment.

Of course, mental health, like physical health, does not exist in a vacuum. When people’s basic needs are met, they are healthier in mind and body. The previously noted interventions will be most effective if we do all we can to address social determinants of health, including nutrition, housing, education, community safety, and employment. Being poor is bad for your health. This certainly holds true in New York City, where black and Latinx people are disproportionately vulnerable to the coronavirus.

Given our awareness of the looming mental health repercussions of the COVID-19 pandemic, we cannot remain idle in the anticipation of 75,000 excess deaths from the complications of mental disorders. It is morally wrong to condemn those who have the least to suffer the most, and it is irresponsible for us not to plan for a public mental health initiative to stem this imminent crisis.

 is a resident in psychiatry at the New York Presbyterian Hospital, Columbia University Irving Medical Center. 

 is assistant professor of medical sociology at Columbia University Vagelos College of Physicians and Surgeons and past president of the National Council for Behavioral Health. 

 is chairman of psychiatry at Columbia University Vagelos College of Physicians and Surgeons, past president of the American Psychiatric Association, and the author of 

The coronavirus pandemic is pushing America into a mental health crisis

https://www.washingtonpost.com/health/2020/05/04/mental-health-coronavirus/

Doctors urge governor to reconsider cuts to maternal mental health care.

 KQED. May 15, 2020. Accessed August 25, 2020. 

https://www.kqed.org/news/11818800/doctors-urge-governor-to-reconsider-cuts-to-maternal-mental-health-care

Some mental health resources could be cut from Colorado's budget because of COVID-19.

 9news.com. May 15, 2020. Accessed August 25, 2020. 

https://www.9news.com/video/news/local/next/some-mental-health-resources-could-be-cut-from-colorados-budget-because-of-covid-19/73-cb8ab247-76d7-46d2-a371-7a0d17284e64

Budget cuts to hit schools, colleges, mental health services hard

. April 23, 2020. Accessed August 25, 2020. 

https://www.dailypress.com/government/local/dp-nw-budget-20200423-u3puda5or5cl3dwyrh6f4qynu4-story.html

5. Kivimäki M, Batty GD, Pentti J, et al. 

Association between socioeconomic status and the development of mental and physical health conditions in adulthood: a multi-cohort study “Deaths of despair”: The deadly epidemic that predated coronavirus

. 2020 Mar;5(3):e140-e149. Accessed August 25, 2020. https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(19)30248-8/fulltext

“Deaths of despair”: The deadly epidemic that predated coronavirus

. April 15, 2020. Accessed August 25, 2020. https://www.vox.com/2020/4/15/21214734/deaths-of-despair-coronavirus-covid-19-angus-deaton-anne-case-americans-deaths

Deaths from infectious diseases drop in United States

 March 30, 2018. Accessed August 25, 2020. 

https://www.pharmacytimes.com/news/deaths-from-infectious-diseases-drop-in-united-states

The COVID pandemic could lead to 75,000 additional deaths from alcohol and drug misuse and suicide.

 Accessed August 25, 2020. https://wellbeingtrust.org/areas-of-focus/policy-and-advocacy/reports/projected-deaths-of-despair-during-covid-19/

Draft menu of cost-effective interventions for mental health.

 September 2, 2019. Accessed August 25, 2020. 

https://www.who.int/mental_health/WHO_Discussion_Paper_Draft_Menu_of_cost-effective_interventions_for_mental_health.pdf?ua=1

10. Arango C, Díaz-Caneja CM, McGorry PD, et al. 

. 2018;5(7):591-604. Accessed August 25, 2020. https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(18)30057-9/fulltext

How the loss of U.S. psychiatric hospitals led to a mental health crisis

November 30, 2017. Accessed August 25, 2020.

https://www.npr.org/2017/11/30/567477160/how-the-loss-of-u-s-psychiatric-hospitals-led-to-a-mental-health-crisis

12. National Council for Behavioral Health. 

The psychiatric shortage: causes ad solutions. National Council Medical Director Institute.

 March 28, 2017. Accessed August 25, 2020. 

https://www.thenationalcouncil.org/wp-content/uploads/2017/03/Psychiatric-Shortage_National-Council-.pdf?daf=375ateTbd56

Teenager in psych crisis waits 25 days in ED for admission

 January 7, 2020. Accessed August 25, 2020. 

https://www.medpagetoday.com/special-reports/exclusives/84236

https://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx

 Becker’s Hospital Review. Accessed August 26, 2020. 

https://www.beckershospitalreview.com/asc-turnarounds/100-surgery-center-benchmarks.html

American Psychological Association Monitor

. April;49(4). Accessed August 26, 2020. https://www.apa.org/monitor/2018/04/datapoint

The COVID-19 pandemic reveals existing weaknesses in the mental health system, but also presents opportunities for reform. 

Christopher Magoon, MD

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