Silver Linings Sometimes Come in Pill Bottles

Although the movie Silver Linings Playbook has been widely and positively reviewed, there has been little discussion of its depiction of the realistic and difficult path many patients with severe mental illness traverse before accepting psychiatric care. Through this depiction, the movie is heartening to psychiatrist viewers as well as to patients and their families.

In the first 10 minutes of the film, we are introduced to protagonist Pat (Bradley Cooper), who is checking his medications while a patient at Baltimore State Psychiatric Hospital. Pat is shown to be in near constant motion with pressured speech and an affect that quickly alternates from euphoric to rageful. With a tangential thought process, Pat’s thought content reveals both grandiose and erotomanic delusions. For the psychiatrist audience member considering different possible diagnoses, the mystery ends when Pat shares that he has gone several years with unexplained difficulty in thinking because of undiagnosed bipolar disorder.

Under the impression he has been taking the medications prescribed by his psychiatrist, Pat’s mother (Jacki Weaver) decides that after 7 months in the hospital with little in the way of improvement, it is time for Pat to come home to live with her and Pat Sr (Robert DeNiro). Against medical advice but hopeful as only a mother can be, Pat’s mother signs him out of the hospital.

Pat returns home from the hospital and he refuses to take the medications he was simulating taking in the hospital. Freed from having to simulate medication compliance, Pat explains he will not take the pills because they make him “bloated” and “foggy.” Pat’s parents, and I imagine most viewers, cannot fathom why Pat gives more weight to the seemingly minor side effects of the medications than to his illness, which leads him to violate a restraining order, trespass, destroy property, and act in an out-of-control manner that brings unwanted attention from neighbors and law enforcement. Each of these actions is followed by a recognition that he does not wish to behave in these ways but does not feel able to stop himself.

The movie shows another factor that can help patients choose against medication compliance. In one scene, Pat has dinner with a woman who also has mental illness. The two compare notes on all of the medications they have taken along with all of the undesirable side effects they have experienced from them. The shared understanding of the two is that the medications will prevent you from being yourself rather than help you achieve that essential subjective sense.

When Pat’s behavior reaches a nadir and hope of recovery seems to be most remote, he has another appointment with his psychiatrist, Dr Patel (Anupam Kher), who steadfastly reminds Pat that he cannot expect to get better if he does not take his medication. The whole downward trajectory of Pat’s life begins to change when Pat begins to do so.

Following this scene, Pat’s behavior becomes less erratic and his thinking more linear. While he remains somewhat oddly related, he is able to make decisions and follow through on his plans. The medications do not take a severely mentally ill man and make him perfect, but they do place him squarely within the spectrum of imperfection that includes us all, whether or not we carry a DSM diagnosis.

Although a romantic comedy, Silver Linings Playbookdoes not romanticize mental illness for the patient or for the family. Likewise, it does not gloss over the side effects that the most effective medications for severe mental illness carry. What the film does display, though, is that the medications available are much more likely than not to be effective if they are taken as directed and that a life with mental illness effectively treated can be filled with meaning, happiness, and love.