Sunday, October 20, 2013

SNL Keeps the Stigma Going

I suppose I was one of millions of disappointed viewers who tuned in to Saturday Night Live last night. One of the skits was to show the first used car commercial.  The commercial uses the familiar "crazy" motif, implying that the business uses an irrational pricing strategy that favors the customer.  Practically every television market has a business that uses this approach for selling cars, appliances, stereos, you name it.  I suppose that some comedians would suggest that this is commentary on these commercials as a rationale for the video.  In the same show there was a skit about a drunk uncle.  At one point the drunk uncle introduces meth nephew - portrayed by an actor for the AMC series Breaking Bad.  I can recall the comedic placement of an alcoholic dating back to The Andy Griffith Show's Otis.

Associating comedy with mental illness is stigmatizing.  That is not an original thought and I am sure that some people have written about it before.  I am sure there is a thesis somewhere submitted for degree requirements that looks at the rationale and the pros and the cons.  For me the straightforward analysis is that it is a reflection of the disproportionate noise in the media about psychiatry and mental health.   That is closely followed by the fact that  there are no similar comedic approaches to other diseases.  Where are the skits about an uncle with cirrhosis, chronic pancreatitis or cancer?  Or the uncle in prison for vehicular homicide while intoxicated?

I also can't help but notice if you were not laughing at the Tina Fey character in the commercial what were you thinking?  I was thinking about a situation where a family might notice a personality change or a change in thinking like the one described in this skit and what they would do about it.  There are no clearly defined public health approaches to these problems.  People get concerned, they get very uneasy, they don't know what to do about it, and complications happen.  They may actually bring their relative down to the local Emergency Department only to find that they are declared "not imminently dangerous" and discharged with a number to call for an outpatient appointment.  If their family member is in need of medical detoxification from alcoholism, they may be discharged with a bottle of lorazepam and instructed on how to detox them at home.  I was thinking about the millions of Americans out there who have had this happen, have inadequate treatment, and never recover.  Their role in the family is permanently altered or disrupted.

I was thinking about the legal approach to some of these problems and the issue of criminal responsibility.  That dovetails with the lack of a public health approach because one of the possible complications is that a crime gets committed during an episode of mental illness.  Of course it is a crime based on the assumption that the person is able to appreciate what they are doing and that it is unlawful.  In the majority of cases it is not likely that a severe crime will be understood that way and the defendant will typically get psychiatric treatment in prison or a county jail.  The civil legal approach is as problematic.  An actual or practical "imminent dangerousness" standard for treatment leaves huge numbers of people untreated and acutely mentally ill.

For all of these reasons, these skits were not funny to me.  I like Tina Fey and think that she is a comedic genius, but I didn't crack a smile.  I think it will be a test of mental health advocacy groups everywhere to see what they say about this.  Some have criticized SNL before but I have not seen anything about this skit so far.  All of the discussions about the problems with the lack of adequate mental health treatment in this country and the associated public health disasters have no traction as long as we continue to think of mental illnesses and addictions as comedy.

George Dawson, MD, DFAPA

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