A Conversation with Dr. Evan Fox

The assistant director of Hartford Hospital’s Institute of Living tackles misconceptions surrounding mental illness

By Judie Jacobson

Dr. Evan Fox

HARTFORD – Dr. Evan Fox is a psychiatrist who serves as assistant medical director of Hartford Hospital’s Institute of Living (IOL). A resident of Farmington, he joined IOL in 1992 as a fellow.

Fox manages and directs the consultative service at Hartford Hospital, overseeing the behavioral consequences of medical and surgical illnesses.

In 2012, he was the recipient of Hartford Hospital’s John K. Springer Humanitarian Award, which recognizes members of the medical community for their compassion, civility, vision, and integrity.

Fox was part of a panel of renowned experts and community members who took part in a panel discussion centering on mental health awareness, sponsored recently by Jewish Family Service of Greater Hartford and Tara’s Closet.

Recently, the Ledger spoke with Dr. Fox about issues surrounding mental health awareness.

JEWISH LEDGER (JL): What exactly are we talking about when we talk about “mental health”? What constitutes mental health?

EVAN FOX (EF): In general, we are talking about a balance of what others might consider psychological well-being or, at the very least, the absence of a mental illness or diagnosis. And so, when you think of balance you’re looking at probably three areas that others might call a holistic definition: one’s emotional state, one’s cognitive state, one’s behavioral state. The balance of those three things in concert is what I guess we call in everyday terms “normal.” But I would suggest that the diversity of ‘normal’ is greater than it ever has been, and so we continue to define both what is acceptable and what isn’t acceptable regarding thought, mood, emotional responses and behaviors in our particular society currently. Ultimately this all leads to what I think every human being wants, which is to be adaptive, to be resilient.

JL: On the flip side, what kinds of things constitute a lack of mental health?

EF: It’s interesting. If you were to go to the site of the World Health Organization and looked up mental health, you would see that it talks about “mental health” and then it talks about ‘mental health illnesses.’ It presumes that we may all have mental health and then something happened. We don’t say that about any other medical illness. I don’t have “diabetes health illness.” I don’t have “normal blood sugar illness.” So it’s a bit confusing. In a way that could be a very subtle way of representing the stigma: that is, “I don’t want to talk about it, and when I do, I don’t know how to talk about it.”

JL: So how do you define it?

EF: The whole science of the brain is still in its infancy, but far beyond where it was even before 1980 – before the so-called biological movement of psychiatry began. So, when you think about the brain and its function as an organ and then its capacity to interact with both the internal influences and the external environment, it’s extraordinary. But it’s not just the brain that does that, our bodies are doing that, with the brain being the main center that hopefully coordinates and creates this balance that we’re talking about.

Using the balance/imbalance model, illnesses arise when the brain cannot accommodate what we’ll call the balance between internal and external stressors that cause aberrant thoughts, behaviors and moods that are part of a symptom complex in which one might develop an affective disorder – like a depression, an anxiety disorder or a thought disorder like schizophrenia. These are all imbalances. Everybody has a different tipping point and some people are able to compensate. Unfortunately, those who can’t are very vulnerable to things that you and I might be able to adjust to and be perfectly fine. Someone else though on an ongoing basis might perceive whatever we’re talking about to be a stressor – both internally and externally. That contributes to the imbalance that leads to a mental illness.

I don’t have a problem with us currently calling depression, anxiety and schizophrenia the three basic examples that most of the public understands to be mental illnesses; because until we get to the point in our society where we realize that these things happen and there is treatment beyond just medication that includes other interventions, we’re not seeing these phenomena and these illnesses for what they are. More importantly, as a consequence of our blindness and our own denial we are missing cues where intervention may be very helpful early on. Consequently, children, adolescents, young adults, and so on – including adults – are being treated later and later. We’re definitely learning now that early intervention is very helpful.

JL: Are we currently seeing an increase in any of these mental health issues among certain groups of people? For example, it seems as if we’re seeing an increase in teen suicide – but is there actually an increase or are we simply recognizing that there is a problem?

EF: That’s a really good question – and there is no one answer. Statistically, suicide is the third leading cause of death among teens; and it’s predicted that in the next 10 years it will be the second. So that’s been on the rise. Simultaneously, let’s be aware that as these things occur and we become more aware of it there have been countermeasures. In the last year or so, there’s been a new movement nationally among academic centers – and the Institute of Living happens to be one of them – that is working on what is known as the Zero Suicide Project. The project is an opportunity to actually take something like suicide, which few have wanted to talk about – there have been plenty of people studying it if you will in labs but society has not developed a conversation about it and about mental illness in general and so this whole project is really to look at all the ways in which to the degree – and examine the gaps in both care and in our awareness, not just in treatment centers, but in the community. If you look at the content of social media, at various TV series and movies, there’s been more attention on the theme of mental health.

Twenty percent of youth between 13 and 18 years of age have a mental illness; 11 percent probably have some kind of mood disorder; another 10 percent some kind of conduct disorder; and another eight to 10 percent, anxiety.

The lifetime prevalence of mental illness in general between ages 14 and 24 is about 50 percent by age 14, and 75 percent by age 24. That means that during the course of a lifetime it’s thought that one in every two will have one mental health diagnosis. If you look at different cultures and demographics, probably half of those people – or less than half of those people if you’re African American – will not get treatment.

JL: Why don’t more people get help?

EF: At first you don’t even think you have a mental illness you think that someone else has a problem. And, before you come to realize that the thought and feelings you’re having are not consistent with your peers or someone’s brought it to your attention, then there’s further investigation that’s necessary. That’s not to say that everybody who has a bad thought or a depressed moment has a mental health problem. That’s important to know: a lot of people don’t differentiate depression as an illness with being depressed. Those are two very different concepts: one being a compilation of any symptoms that actually create morbidity, the other being a transient thing that can lead to a depression, but often is just a reaction to something that’s happened.

JL: We tend to focus on young people when it comes to mental illness. But isn’t it true that senior adults often suffer from depression?

EF: Probably around 15 percent of the population of people 65 years of age and older have had depression and are at risk. Actually, they are at higher risk, just like young adults and adolescents, for higher rates of suicide. The generation of people who lived through the Depression and through World War II don’t necessarily relate to the word “depression.” So, a lot of time when you use those words with older people they deny it because it’s actually a word that represents something very different and a great deal of humiliation and shame. It doesn’t mean they don’t have depression, they just don’t relate to the word so often you have to use different language.

JL: What should a family member or friend do if they see a loved one exhibiting the signs of a mental illness or disorder?

EF: Let me ask you this question: If you have a friend who all of a sudden wasn’t returning your phone calls as frequently or, when the friend did, he or she sounded odd. Maybe they’re thinking is a little slower, or some of their thoughts seem to be more negative than usual, and then they start complaining about not getting much sleep, not eating well, missing work, etc. What would you do?

JL: Good question.

EF: We don’t know because we want to be respectful. Even in your hesitation to the question – which makes perfect sense – we don’t want to believe that it’s happening, even if it’s so obvious.

This morning, a patient came into my office and said “I didn’t know how messed up my husband was but he finally went to a doctor and came back with a piece of paper that defined his mental illness.” That was pretty striking. The point is, for 15 years of their marriage she’s living as if this is his norm – which I guess it was, relatively speaking. But now he’s coming back and saying, “See, I told you I had a problem.” This, of course, raises a whole other set of issues, but nonetheless now it’s attached to something called “treatment.” So, she went from “should I stay in this marriage” to “maybe something can help.” What an incredible shift within literally 24 hours. He understood there was something wrong, but didn’t want to admit it. To go to a doctor and admit there’s a problem takes a lot of courage.

JL: Especially when it comes to those with drug and alcohol problems, they often say the person has to hit “rock bottom” before he or she will seek or can benefit from help. True?

A: Whenever I hear that phrase – “need to hit rock bottom” – like for instance with substance use disorders, I’m not really sure what that means. Because I’ve seen “rock bottom,” and it’s usually from the casket. But I do understand the concept, which is that there is a certain level at which the individual’s tolerance for who they’ve been actually reveals to themselves that they can’t continue this way. Hopefully that leads to them getting help. Of course, when I get help and I feel better there’s always another “rock bottom.” I’m feeling better and now I can actually repeat my former behavior hoping that I won’t get to where I was before, but eventually I do and that’s just another lesson.

So, I think that “rock bottom” is very individual. We all get to the point of acceptance in different ways, and we all hear the lesson in very different ways. Some of us literally have to be in the emergency room after having done something unfortunate or just prior to having done something that would have been unfortunate. And then it happens over and over again until there is a break in that denial because I’ve been hospitalized five times now for the same thing and it’s always related to telling me that I have this illness; and this is what’s necessary to treat it and I haven’t done that. Then there’s a transition to acceptance where I actually try it.

It’s not always successful the first time. This is a work in progress. But you need acceptance and engagement in order to change behavior and changing behavior is really challenging. Look at your own life: take any simple thing that you wanted to do and ask yourself why, as important as you thought it was, you haven’t done it yet.

Acceptance & Understanding:
A community conversation shines a light on the stigma of mental illness

By Stacey Dresner

Risa Sugarman

WEST HARTFORD – Risa Sugarman says she deals with the stigma of mental illness on a daily basis.

“It comes from the outside, and there are times when I see myself kind of creating it because it is so ingrained,” she said. “I think that stigma comes from misunderstanding or fear and if people have a better understanding of mental illness, they are not going to be so scared.”

Struggling with depression since she was an adolescent, Sugarman has endured episodes of severe treatment-resistant depression over the past couple of years. Hospitalized twice at Yale in the summer of 2014, she began electroconvulsive therapy (ECT), which she says, “helped to save my life and provide relief,” she says.

Since then, she has had two more depressive episodes.

“I am in one right now,” she said. “I’ve just been going through this cycle where I am well for like four or five months and then, about six weeks ago it just happened. So I am relying a lot on my treatment team right now.”

That treatment includes several daily medications, sessions with her therapist, and a weekly Dialectical Behavioral Therapy (DBT) group.

Sugarman shared her story at last week’s “Embracing Possibility for Mental Health Awareness: A Conversation About Compassion & Education,” a panel discussion held annually during Mental Health Awareness Month.

Held at Kingswood Oxford School in West Hartford, the program was presented by Jewish Family Service of Greater Hartford (JFS), partnering with Tara’s Closet, a JFS initiative that aims to bring mental illness out of the shadows and help those coping with it to seek treatment. Tara’s Closet was founded by Barbara Roth of West Hartford after her daughter, Tara Savin, lost her battle with bi-polar disorder.

“Mental health is as important as physical health and deserves the same level of attention and support. We must change the perception of mental illness and create transparency, acceptance and understanding. This conversation is a very important step in the process of education and awareness,” said JFS Executive Director Anne Danaher.

The event featured guest speaker, Jenna Bush Hager, NBC’s Today contributing correspondent and former first daughter.

“It is through the power of compassion, community support and educational opportunities that we can elevate the conversation about mental health, and show our commitment to ensure those who need help have access to the support, acceptance, and resources they deserve,” said Hager.

The JFS event featured local community members, like Sugarman, and Hartford Hospital/Institute of Living Assistant Medical Director Dr. Evan Fox, who discussed how to tear down misconceptions surrounding mental illness.

Mental Health Awareness Month (also referred to as “Mental Health Month”) has been observed in May in the United States since 1949, when it was instituted by the Mental Health America organization. This year’s theme, “Risky Business,” is designed to educate the public about behaviors that can “increase the risk of developing or exacerbating mental illnesses, or could be signs of mental health problems themselves…including “risky sex, prescription drug misuse, internet addiction, excessive spending, marijuana use, and troublesome exercise patterns.”

“The truth is that mental illness affects one in five, which basically means it affects everyone. It could be your cousin, it could be your best friend – it’s really is out there,” Sugarman said. “That is why I tell my story because I want people to have a little better understanding of mental illness.”