TIME Mental Health/Psychology

Why Schools Should Screen Their Students’ Mental Health

kids students
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Two new reports argue for in-school mental health screenings

Schools should be a first line of defense for catching young people at risk for mental health issues from depression to ADHD, a pair of new reports says.

Kids and adolescents spend a significant amount of their time in school, yet providing mental health screenings and care is not an overarching requirement for many schools. “We need to think about how to embed mental health services so they become part of the culture in schools,” says study author Dr. Mina Fazel, a child psychiatrist at the University of Oxford. “It will take a commitment from health and education.”

The reports, published in The Lancet Psychiatry, looked at programs already implemented in both high-income schools and middle- and low-income schools. The authors made suggestions for both education systems. For instance, schools could conduct school-wide screenings by asking teachers to identify at-risk kids for further evaluation, or health counselors could be trained to spot both physical and mental issues by looking for visible signs like weight fluctuation or bullying. If treatments like cognitive behavioral therapy were included in a school’s health offerings, Fazel believes mental health problems could be caught early and treated.

“If we made mental health part of the usual health system of a school, then it becomes more normal…and hopefully it will then be easier to access it,” says Fazel. According to data presented in the reports (which is UK-specific but also looks at U.S. programming), about 75% of adults who access mental health treatment had a diagnosable disorder when they were under age 18, but in high-income countries, only 25% of kids with mental health problems get treatment.

Stigma is largely to blame for a lack of participation in mental health care. “[Mental health] is the service that people seem to know least about, seem to fear accessing most, and think they will be negatively viewed by their peers or their teachers or their families if they access those services,” says Fazel.

Some schools in the U.S. and abroad have had success with mental health screenings and programs, but implementation still hasn’t been made a standard, which Fazel thinks is a lost opportunity. By prioritizing mental health in a child’s early years, more people will get the treatment they need early on.

TIME mental health

Study Finds Antidepressants Change Brain Connectivity in Just a Few Hours

Researchers hope the findings will one day help to tailor individual therapy for those suffering from depression

A new study published in the journal Current Biology Thursday found that a single dose of some of the most widely used antidepressants change the brain’s architecture after only a few hours.

However, patients who take drugs to treat depression usually don’t report any improvement until weeks later, the L.A. Times reports.

Researchers hope their findings will allow doctors to determine whether or not a patient will respond to certain psychiatric drugs by way of a brain scan.

Low levels of the chemical transmitter serotonin in the brain are associated with depression. Antidepressants work by blocking how serotonin is reabsorbed into the brain.

The drugs are known as Selective Serotonin Reuptake Inhibitors, or SSRIs.

To conduct the study, researchers compared connections in the brain’s gray matter of patients who took antidepressants and those who did not, the Times reports.

“We just tell them to let their minds wander and not think of anything particularly dramatic or upsetting,” said neuroscientist Dr. Julia Sacher, a co-author of the study.

After mapping the connections researchers found that when more serotonin was present in the gray matter it meant a decrease in the brain’s functional connectivity.

But some areas of the brain didn’t follow this pattern.

“It was interesting to see two patterns that seemed to go in the opposite direction,” Sacher said. “What was really surprising was that the entire brain would light up after only three hours. We didn’t expect that.”

Sacher said more research was needed, but the findings of the study could help to tailor individual therapy for those suffering from depression.

[L.A. Times]

TIME Family

Why Not Having Kids Makes Some People Crazy

Ray Kachatorian—Photographers Choice

It's less about the children and more about thwarted dreams

The great, worldwide, international jury is still deadlocked over whether having children makes people happier or not. On the one side, there are chubby fingers and first steps and unbridled joy and on the other side, there’s sleep, money and time. But an intriguing new study from the Netherlands suggests that not having children only makes infertile women unhappy if they are unable to let go of the idea of having kids.

It sounds obvious, but here’s the twist: women who already had children but desperately wanted more had worse mental health than women who didn’t have kids and wanted them, but had managed to get over that particular life goal. So it’s not just whether they had kids that made people depressed or content, it’s how badly they wanted them.

The study looked at more than 7,000 Dutch women who had had fertility treatments between 1995 and 2000. They were sent questionnaires about how they were doing and what caused the infertility and whether they had kids. Most of them were doing fine, except for about 6% who still wanted children even a decade or more after their last infertility treatment.

“We found that women who still wished to have children were up to 2.8 times more likely to develop clinically significant mental health problems than women who did not sustain a child-wish,” said Dr Sofia Gameiro, a lecturer at the School of Psychology at Cardiff University in Wales. True, the women who had kids but had undergone fertility treatments for more were less likely to have mental health issues than those who didn’t have kids, but they were still there. The kids hadn’t cured them. “For women with children, those who sustained a child-wish were 1.5 times more likely to have worse mental health than those without a child-wish,” wrote Gameiro. “This link between a sustained wish for children and worse mental health was irrespective of the women’s fertility diagnosis and treatment history.”

The women most likely to be laid low by wanting a child were those with less education and thus probably fewer options for fulfillment. Similarly, if the fertility issues were on the husband’s side or if they were age related, women were more likely to be able to get over it, possibly because they felt there was nothing they could have done. Those most set back by their inability to conceive were those who had started young and found that the problem was with their reproductive system, not their spouse’s, women who in the ancient days might have been called “barren.”

“Our study improves our understanding of why childless people have poorer adjustment. It shows that it is more strongly associated with their inability to let go of their desire to have children. It is quite striking to see that women who do have children but still wish for more children report poorer mental health than those who have no children but have come to accept it,” said Gameiro.

The paper, which was published online on Sept. 10 in Human Reproduction, recommends sustained psychological counseling for people who did not conceive after fertility treatments and a lot of frank talk about the possibility of failure during the treatments. The author also throws some shade on those “I-can-do-anything-if I-try” types (cough, Americans, cough). “There is a moment when letting go of unachievable goals (be it parenthood or other important life goals) is a necessary and adaptive process for well-being,” said Gameiro. “We need to consider if societies nowadays actually allow people to let go of their goals and provide them with the necessary mechanisms to realistically assess when is the right moment.”

TIME Parenting

ADHD in Adulthood: To Prepare for a New Baby, I Had to Prepare My Mental Health

The author with his son Jack.
The author with his son Jack. Courtesy Timothy Denevi

Soon enough we’ll find ourselves short on sleep and patience—in anticipation I’ve been trying to make the necessary preparations

This fall I’m expecting the birth of my second child, a daughter. Over the past months she’s grown from the size of a kumquat, to the size of a banana, and recently achieved the esteemed gradation of cabbage. From what I can tell the final step is cantaloupe—and then, having triumphed through the full prenatal catalog of produce, Sylvia Denevi, the newest member of our family, will be here.

For now the focus is on preparation. My wife and I live in a suburb of Washington, D.C., with our seven-year-old son, Jack. Together we’ve begun to make the expected adjustments. The guest room is now a nursery. The garage has been searched and reorganized, its assortment of baby gear emerging again like relics from a previous life.

I see my preparation for Sylvia’s arrival as love: the first opportunity I have to tell her I love her, that she’s precious to me, that I’ll do whatever it takes to be the best father I can be. I’ve also been taking the steps to prepare myself, within the context of mental health, for the change that’s about to come.

Growing up in the 1980s and 90s, I was part of the first generation of Americans to be diagnosed with Attention Deficit-Hyperactivity Disorder. There was never really a question of whether or not I had ADHD, and after years of being the most active, over-sensitive, and impulsive person in the room—after a childhood of psychiatric and psychological treatments, some of which helped, others making things worse—I graduated from college and entered the workforce, at which point my personality no longer seemed as exaggerated and out-of-whack as it had once been. In the end I figured that whatever ADHD was, it was a part of the past.

That understanding changed when Jack was born. At the time I was 27. All at once I found myself surrounded by an enormous amount of conflict—the same kind I used to experience, growing up, when my behavior would drive the people around me crazy. It was uncanny: my wife would say something, and I’d overreact, and she’d say something else, and then I’d be shouting, and glaring, and shouting again. We argued constantly over the new demands: diaper changes, midnight feedings, who got to take a midday nap and who had to do the grocery shopping. Soon enough our lives began to resemble a ledger. I did this and you didn’t do that. My time is just as important than yours! You want to go to the gym for an hour but I can’t play softball tomorrow night? Instead of finding a way to share the new amount of work that was required of us, we spent hours fighting.

My wife is a scientist, thoughtful and logical, traits that have always fit well with my more energetic demeanor, and up until Jack was born our relationship was steady. But now it seemed as if our personalities had switched; at the end the day she’d be yelling at me and I’d turn sullen and depressed.

I felt overwhelmed. Like I couldn’t do the simplest things. It was as if I was underwater, gazing up toward a normal reality—one in which every other new parent seemed to deal well enough—while I was the abnormal one, a failure, once again a problem for the people who loved me. It was the most distant I’d felt from my wife since we’d been together.

“You’ve never been like this,” she told me. And while there were other variables involved—we’d moved across the country right after Jack was born, were at precarious points in our careers, and didn’t have extended family around to help—it was clear that if I didn’t act soon I’d run the risk of damaging my relationship with my family in a way that couldn’t easily be undone.

Eventually I went to see my family doctor, and then a psychiatrist. When I explained my moodiness and agitation they said the same thing: ADHD, even in adulthood, tends to make you much more sensitive than other people to your surrounding environment. If you’re constantly feeling restless and impulsive, you might react to demands in a disproportionate way—and there are few things more destabilizing than the birth of a child.

There wasn’t one thing I could do to magically make things better, they told me—that’s not how mental illness works. Instead, they recommended a series of steps. For the first time I started exercising regularly; I paid careful attention to my sleeping and eating habits; I even went on a low dosage of Adderall, which helped to make everything seem less drastic and overwhelming.

Eventually things improved, but not right away. It was a genuinely hard stretch for my wife and I—part of the reason, no doubt, we’ve waited a while to have another baby. But now, seven years later, as the summer turns to fall and Sylvia continues in her ascension through an aisle at the grocery store, we can take solace in the fact that we both have a much better idea of the changes to expect.

Soon enough we’ll find ourselves short on sleep. And time. And stamina. I’ll be less resilient in terms of mood and patience. In anticipation I’ve been trying to make the necessary preparations.

I started psychotherapy, visiting a psychologist regularly both by myself and with my wife. I’ve set up my exercise schedule with an emphasis on cardiovascular activities like running and tennis, the most beneficial to mental health. I’m trying to cut down on social events and alcohol—two things I very much enjoy. And I find myself making observations about my own sleeping and eating that are usually directed at seven-year-olds: Do you really think it’s a smart decision to start another television show this close to bedtime? If you’re sweating and your stomach already hurts, maybe that fifth piece of pizza isn’t the best decision…

I’ve also talked with my psychiatrist about the possibility of making a medication adjustment. (I hate being on medication anyway, and prefer to take as low as dose as possible.) The Adderall I’m on is the instant-release kind; my current approach is to take it ahead of time when I know I’m about to find myself in situations that are especially overwhelming or agitating—a birthday party for one of Jack’s friends at Chuck E. Cheese; driving through an unfamiliar snarl of D.C. traffic—but what happens when the foresight necessary for such an approach is already eroded by a lack of sleep and/or a screaming infant? I can try a time-release version, or a new medication.

One of the most difficult aspects of mental illness, especially within the context of parenthood, is finding a way, when it comes to your life and its influence on the people you love, to do more good than harm. In the end you can’t possibly predict what’s really coming: the moment in the future that will dislodge you from the balance you’ve worked so hard to achieve. It might be a random calamity, or one you’ve personally brought about. But the incredible truth is that it’s already on the way. And against such a prospect, what good can something like a therapist or exercise or a low-dosage pyschostimulant actually do?

This isn’t to dismiss the idea of effort. In fact it’s the opposite: imagining all the things that could go wrong or right for my family, I can’t help but find solace in action. I’m lucky that there are steps I can take, and that often enough they do tend to help. What matters is the act itself: an expression of love for the most important people in my life. After all, there are many ways to show how you feel; is it so terrible that one of mine happens to take the form of self-preparedness?

A few weeks ago, when Jack was looking through the toys in his closet and trying to guess which, if any, his future sister might enjoy, he turned to me and said, “Daddy, I have a question.”

I could tell by the line of his mouth that it was something he’d been considering for a while. “Yeah?”

“What do you think Sylvia will be like?”

Briefly the image of a pumpkin with very long eyelashes flashed into my mind, but in the next instant was something outside the parameters of size and shape: an emotion similar enough to anticipation. “A little like you,” I said. “And like Mommy. A little like me, too, I think.”

He nodded.

“That’s the exciting part,” I added. “Whoever she’s going to be, she’ll be herself.”

Hyper, by Timothy Denevi Courtesy Simon & Schuster

Timothy Denevi is the author of Hyper: A Personal History of ADHD, out this week from Simon & Schuster. He received his MFA in nonfiction from the University of Iowa. He lives near Washington, DC and teaches in the MFA program at George Mason University, where he’s a visiting writer.

TIME health

What Americans Can Learn From Obama on Mental Health

US-POLITICS-OBAMA-AMERICAN-LEGION
President Barack Obama greets members of the American Legion after speaking at the American Legion's 96th National Convention in Charlotte, North Carolina, August 26, 2014. SAUL LOEB—AFP/Getty Images

We must broaden the scope of our efforts beyond the military and veteran community

President Obama addressed the American Legion’s 96th National Convention on Tuesday and outlined five priorities to “fulfill our promises to service members, veterans, and their families.” These priorities include: delivering the quality health care veterans have been promised, ensuring all veterans have every opportunity to pursue the American Dream, providing the U.S. Department of Veterans Affairs with the resources our veterans deserve, protecting the dignity and rights of all veterans and eliminating the decades-old disability claims backlog.

From early in his administration, our President has demonstrated his concern for and commitment to our military and veteran families. He has made numerous speeches at military installations, praising the sacrifices of our troops and pledging his support. He has acknowledged his respect and admiration for those who wear the uniform during his State of the Union Addresses, often inviting injured service members and their families to join the First Lady in the Capitol to watch the address. In 2012 he issued an Executive Order titled “Improving Access to Mental Health Service for Veterans, Service Members and Military Families,” which paved the way for greater communication and coordination among government agencies while creating several specific initiatives and programs to increase access to care and improve the provision of services. And in June 2013, a primary focus of his National Conference on Mental Health was on the unique mental health challenges facing our military and veteran community.

Our First Lady shares the President’s commitment. In the spring of 2009, five months into the administration, I was invited to a meeting at the White House hosted by the First Lady and Dr. Jill Biden. The purpose of the gathering was to learn about the issues affecting our service members, veterans and their families from the organizations that support them and to ask for suggestions regarding how the First Lady and Dr. Biden might best use their platform to assist these worthy men, women and families. This meeting, and several that followed, provided the foundation for what would become the First Lady and Dr. Biden’s Joining Forces initiative, which focuses on three key areas of support for military families: employment, education and wellness.

Tuesday’s speech by the President made reference to several new executive actions designed to serve the military and veteran community – many of which focus on improving the mental health and wellness of those who struggle, those who suffer and those who are at risk of suicide. During perhaps the most inspiring moment of the speech, President Obama proclaimed:

“And maybe most of all, we’re going to keep saying loud and clear to anyone out there who’s hurting, it is not a sign of weakness to ask for help; it is a sign of strength. Talk to a friend. Pick up the phone. You are not alone. We are here for you. And every American needs to know if you see someone in uniform or a veteran who is struggling, reach out and help them to get help. They were there for America. We now need to be there for them.”

Our President has done an excellent job of setting the table for us. He has provided leadership and directed resources. He has made it clear that the mental health and wellness of those who serve and their families is a priority for his administration and for America. His staff has consistently reached out to the community of organizations that engage and support our military and veteran community, asking for feedback and seeking opportunities for partnership and collaboration. Some might suggest that this has all been politically motivated – sadly so much of what seems to happen in Washington these days certainly is – but to those of us who have had the honor of working alongside our colleagues at the White House over the years on these issues, it has been clear from early on that that this sustained effort is genuine.

But while the President’s leadership is absolutely critical for success, we will need more than his commitment if we hope to ensure the mental health and wellness of those who serve and their families. We must broaden the scope of our efforts and look beyond the military and veteran community. The stigma associated with mental illness is a huge problem within our society – a problem that we must address if we hope to reduce the number of service members and veterans who choose suicide every day. How can we expect those who serve – given their training on self reliance, their value on mental toughness and their focus on serving others – to step forward and ask for help if they are depressed, anxious or suicidal when so few among us in the civilian community do so comfortable or openly. It was a little over two weeks ago that Robin Williams’ suicide sent shock waves and overwhelming sadness across our nation. Robin Williams – who was so beloved, so talented, so smart – was unable to ask for help in his darkest hour. He was unable to let those he loved know that he was in danger. How horribly sad and lonely he must have felt – how terribly distressed and alone so many in our nation feel every day.

We must change our culture if we are to succeed in saving lives and ending suffering. We must come to accept that mental health and mental illness are elements of the human condition – just as physical health and disease are – not just within our military culture but for all Americans. We must use opportunities like the one that the President has given us to harness support, roll up our sleeves and do the heavy lift required that will change the conversation in America about mental health. Perhaps one positive outcome of the last 13 years of war can be an end to the stigma associated with mental health and mental illness. Perhaps our service members and our veterans will once again lead America and serve as examples of courage, acceptance and compassion for self and others.

Barbara Van Dahlen, named to the TIME 100 in 2012, is a licensed clinical psychologist and the founder and president of Give an Hour. A notable expert on the psychological impact of war on troops and families, Dr. Van Dahlen has become a thought leader in mobilizing civilian constituencies in support of active duty service members, veterans and their families.

TIME Mental Health/Psychology

1 in 7 People Suffer From Being ‘Sleep Drunk’

Alarm clock
Getty Images

Severe disorientation while waking up or falling asleep could be a real problem

It’s a scene familiar to about 15% of us. Your alarm goes off in the morning, but instead of waking up alert (if not especially chipper), you’re entirely confused by what’s going on. You may be disoriented, not know where you are, and you may even try to answer your alarm as though it were a phone call.

If that’s happened to you, it’s because you’re sleep drunk.

According to a new report published in the journal Neurology, sleep drunkenness—which is having trouble coming to full wakefulness after sleep, accompanied by intense confusion and disorientation, and even sometimes violent reactions and amnesia—is a serious and surprisingly common problem.

Researchers at Stanford University School of Medicine interviewed 19,136 people ages 18 and older about their sleep behaviors, mental health, and medication use and found that about 15% of the participants had experienced a sleep drunkenness episode in the last year, with over half of those people reporting experiencing an episode a week. Further data suggests there may be a connection between sleep drunkenness and other factors, including mental health.

Among those who had reported sleep drunkenness episodes, 84% also had either a sleep disorder, a mental health disorder or were taking drugs like antidepressants, which suggests that sleep drunkenness could be a symptom of—or a red flag for—other problems that could disrupt sleep quality.

The researchers say that even though sleep-related problems like sleep drunkenness get less attention compared to behaviors like sleep walking, they can be just as dangerous, and more research should be done to determine the best ways to treat it.

TIME Mental health/Psycholog

4 Signs Your Body Image Isn’t Healthy

woman-holding-shoulder
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Last week, Tallulah Willis—daughter of Bruce Willis and Demi Moore—bravely shared her struggles with body dysmorphic disorder in a video for StyleLikeU. “I’m diagnosed [with] body dysmorphia,” Willis, 20, told the fashion blog. “[My biggest insecurity] is my face. That’s where my diagnosis came into play. Because of the position I was born into, I would read these things on the Internet and I was like, well, Why would someone write that if there wasn’t some basis for truth out there?”

“It was something I never wanted to say out loud because it was so painful.” Willis goes on to talk about how hearing mean comments about her face drove her to dress provocatively and lose a lot of weight, thinking she could draw the attention to her body instead. “I started starving myself,” she says. “I got down to 95 pounds.”

Health.com: 10 Signs You May Have OCD

This is exactly why body dysmorphic disorder (or BDD) can be so difficult to diagnose, explains Health contributing psychology editor Gail Saltz, MD. “Disordered eating can be a symptom of it, but there is no surefire sign. What body dysmorphic disorder really means is that you are so preoccupied with either a real (but slight) or imagined imperfection that you become consumed by it.”

Plenty of healthy people have a body hang-up or two that makes very little sense (mine’s my fat ankles, full disclosure), so how do you know when someone you love is really struggling? Here are four ways to recognize body dysmorphia.

They always need reassurance about that one thing

“Most people who have body dysmorphia are not going to talk about it openly because they feel a lot of shame,” Dr. Saltz says. “But sometimes, it’s a friend who keeps asking you repeatedly for reassurance about this one body part.” If supportive comments like “No, your arms aren’t fat, really!” or “No, your nose is beautiful” don’t seem to make them feel even a little better, that could be a red flag.

Health.com: 12 Signs You May Have an Anxiety Disorder

They dress in a way that doesn’t make sense

Obviously, you don’t have to agree with every style choice your friends make, but think twice if she’s dressing in a way that suggests she’s trying to compensate for that one thing. “For example, she’s putting on a tent of a dress and saying it’s to hide her belly that doesn’t exist,” Dr. Saltz says. Or in the case of Tallulah Willis, she mentioned that she would wear short-shorts and push-up bras in a bid to shift attention away from her face.

Health.com: 12 Ways We Sabotage Our Mental Health

They go to extremes

“Dysmorphia fits in with this constellation of anxiety disorders like obsessive compulsive disorder,” explains Dr. Saltz. “It’s a compulsion that gets in the way of your life.” So in the same way that no amount of hand washing satisfies a person with OCD, no amount of “fixing” seems to help people with BDD. Some patients may even get plastic surgery, and then still think they need more work done after they’ve healed, while others try a progressively restricted diet to lose, say, an imagined double chin.

Health.com: 7 Strategies to Love the Way You Look

They’re hiding out

“The thing separating a normal insecurity from a problem with body dysmorphia is how much it affects your ability to function,” Dr. Saltz explains. If you notice that that she’s not going out as much, or she doesn’t want to date, or maybe she’s turned down a promotion because she doesn’t want to have to give presentations, those are signs her body issues are getting in the way of her life.

Amelia Harnish is an Associate Editor at Health.

This article originally appeared on Health.com.

TIME Mental Health/Psychology

Robin Williams’ Parkinson’s: The Link Between the Chronic Disease and Depression

Robin Williams
Tracey Nearmy—EPA

Williams' widow reveals actor was battling early Parkinson's

Receiving a positive diagnosis for Parkinson’s can be devastating. It’s a chronic disease that progressively worsens, causing formerly competent men and women to gradually lose control of their own bodies, and it’s the second most common neurodegenerative disorder after Alzheimer’s. As revealed on Thursday by his wife, the late actor and comedian Robin Williams was privately battling the early stages of Parkinson’s on top of his more public struggles with anxiety and depression.

The National Institutes of Health (NIH) acknowledges there is a link between Parkinson’s and depression, though the association is not always biological. It’s estimated that about half of all people with Parkinson’s will experience depression at some point during the disease. For some, depression can be spurred as a result of receiving the diagnosis, learning that the new ailment may turn their mind against their body.

Other research has shown that depression may be the result of biological factors that the two diseases share and that a chemical imbalance in the brain could contribute to both. For instance, changes in levels of hormones and neurotransmitters in the brain, like dopamine and serotonin, caused by Parkinson’s may increase the likelihood that a person will also develop depression, since both are involved in mood regulation. But it should be noted that Williams’ depression and anxiety were likely established separately from his Parkinson’s.

What’s known about the connection is that having depression on top of Parkinson’s can negatively influence the outlook for the disease. People who have both depression and Parkinson’s have higher levels of anxiety and trouble moving, according to the NIH, compared to people who have just one or the other. Similarly, individuals with both diseases may have greater difficulty concentrating than people who suffer from depression alone.

Williams’ death, by an apparent suicide earlier this week, is a reminder of the weight that people with both diseases carry. As Williams’ wife said, “It is our hope in the wake of Robin’s tragic passing, that others will find the strength to seek the care and support they need to treat whatever battles they are facing so they may feel less afraid.”

TIME psychology

Robin’s Pain: The Mystery of Suicide — and How to Prevent It

Sad Goodbye: Where Robin Williams once stood, flowers now lay
Sad Goodbye: Where Robin Williams once stood, flowers now lay Paul Archuleta—FilmMagic/Getty Images

Robin Williams was just one of 39,000 Americans who take their lives each year. The long-standing puzzle is why anyone arrives at so tragic a place. Increasingly, there are answers

The great paradox of the human brain is that it can’t feel pain. The organ that is the seat of all joy and worry and love and sorrow and whimsy and fear is itself insensible to injury. It’s the reason brain surgery can be conducted on conscious patients without their being any more physically aware of the cutting than if a garment they were wearing were being violated the same way.

But the pain the brain can cause — the bottomless well of grief, the psychic blackness of depression — is something else again. There is both presumption and a certain pointlessness in trying to explain the awful convergence of sorrow and circumstance that drove Robin Williams to end his life. Williams himself may not have known, and if he did, the secret died with him. That doesn’t stop others from trying to make sense of it, of course — and so we hear that he was suffering from clinical depression or bipolar disorder, or that his battles with substance abuse finally claimed him.

Williams was publicly sanguine about his mental state, telling NPR in 2006, “No clinical depression, no. I get bummed, like I think a lot of us do at certain times. You look at the world and go, ‘Whoa.’ Other moments you look and go, ‘Oh, things are O.K.’” But after his death, his representative released a statement saying he had been “battling severe depression of late.”

The only thing that can be said with certainty is that Williams arrived at the same terrible place 39,000 other Americans reach each year, and like them, he concluded that the only way to annihilate a terrible despair was to annihilate the self. All anyone can do responsibly is reason back from there — reverse engineer the tragedy — and see what that might reveal.

The numbers can tell you something — sort of. Up to 90% of all people who commit suicide have been diagnosed with depression or some other form of mental illness in their lives. About one third of people with serious depression have had struggles with drugs and alcohol, perhaps as a result of trying to medicate their pain chemically. About 25% to 35% of people who commit suicide have a chemical substance in their blood at the time of death.

But there are plenty of depressed or chemically dependent people in the world, and while their struggles are real, their stories — and their lives — don’t end the way Williams’ did. The difference appears not just to be pain, but pain of a particular valence.

“It’s intolerable, unbearable anguish that can’t go away,” says psychologist Dan Reidenberg, executive director of Suicide Awareness Voices of Education (SAVE) and U.S. representative to the International Association of Suicide Prevention. “No matter what people have tried — treatment, medication — it doesn’t help. Logic becomes unreal. Attention and focus fall apart. The brain is just an organ and at some point it says, ‘I can’t take the pain anymore. I must take myself out.’”

But that doesn’t happen overnight. There’s a certain ambivalence and a strange kind of deal-making that can go on before a decision to die is actually reached. Suicidal scenarios may be considered, even planned, taken off the shelf and toyed with as a possibility. “This starts to play certain tricks on the mind,” says Reidenberg. “People think, ‘If someone smiles at me today I’m not going to do it. I’m going to have my last meal and if that goes well, I won’t do it.’”

Not all suicides creep up so slowly — or at least they don’t seem to. Situational despair — the kind that comes from the death of a loved one or a sudden bankruptcy — can, anecdotally, precede a suicide, but this happens less than is popularly believed. All of those investors who leapt to their deaths when the stock market crashed in 1929? Those were mostly a myth — though there were some isolated suicides in the days and months that followed the crash. And even in those cases, there was likely an underlying depression or mental illness that was exacerbated by circumstance. If tragedy were the threshold requirement for suicide, a spectacularly successful and globally celebrated person like Williams — or Kurt Cobain or Ernest Hemingway or Marilyn Monroe — would never have ended things as they did.

On those occasions that short-term pain does play a role in suicide, it’s likelier to occur among teens. That’s partly because the impulse control region of their brains have not fully come online yet — which is why even happy teens make such wildly poor decisions sometimes — and partly because they have such a flawed sense of the long arc of time. “The teenager cares about right now, what’s in front of me,” says Reidenberg. “They’re not looking at the next 60 years, they’re thinking about the next six minutes.”

The biggest thing working in the teens’ favor is that they often seem less than entirely certain about the wisdom of suicide, even after they’ve resolved to try it. “There’s a much higher rate of suicide attempts among adolescents than among other groups, but a much lower rate of actual death,” says psychologist John Draper, project director of the National Suicide Prevention Lifeline, which runs a website and 24-hour hotline (1-800-273-8255) for people in crisis. “A big part of them doesn’t want to die and the overwhelming majority get through those moments and are glad they’re alive.”

Indeed, says Reidenberg, both teens and adults who attempt suicide but survive often report that in the instant after they took the decisive step — swallowing the pills, leaping from the window — they began hoping that they’d survive the fall or be found alive before the drugs could do their work. Some never try again.

Stopping people short of that point — or pulling them back from the brink if they’ve reached it — can sometimes be a matter of simple preparation. For anyone who has flirted with suicide, Draper recommends putting together a safety plan that can be used in a time of crisis — a list of friends, family members and professionals to contact for help, as well as reminders of self-calming activities or short-term distractions that have worked in the past. Keeping the instruments of self-harm out of reach is important too. About 60% of the 33,000 gun deaths in the U.S. each year are suicides.

Making psychotherapy more widely available can help as well. Roughly 60% of the people who need mental health services in the U.S. each year do not get it, often beause of the stigma of seeking help, though just as often because of lack of insurance. The Affordable Care Act is changing that, with requirements that all policies cover mental, not just physical illnesses.

Early detection of people prone to suicide could make a difference, and one finding earlier this summer revealed that a gene known as SKA2, which is abundant in the prefrontal cortex, may play a role in helping people manage negative feelings and contain impulsive behavior — both important brakes on suicidal behavior. Handily, the gene produces blood markers that indicate its level of activity, providing a quick way of diagnosing potential problems long before they start. Talk therapy is important too, and medications may be an important adjunct, though just which drug is best depends on just which patient is being treated — antidepressants for the depressive, mood stabilizers for the person with bipolar disorder.

As with any deadly disease, of course, there is nothing certain about who will be lost to suicide and who will not. Williams himself seemed to understand the knife edge on which such mortal matters balance. In a 2006 TV interview, after completing two months of treatment for a relapse into alcoholism, he described how easy it is for a former drinker to pick up the bottle again. “It’s the same voice that … you’re standing at a precipice and you look down, there’s a voice and it’s a little quiet voice that goes, ‘Jump.’” This week, in his own way, Robin Williams jumped — and a little bit of all of us went with him.

TIME celebrity

WATCH: Hollywood Reacts to Death of Robin Williams

Comedians, actors and entertainers pay tribute to the late star

Like the rest of the nation, actors, comedians and entertainers were shocked by the sudden death of superstar talent Robin Williams. Celebrity reactions to his apparent suicide have flooded media both social and traditional, with many paying tribute to their own personal relationships with the late star.

Steve Martin referred to him as a great talent and a genuine soul. Kathy Griffin tweeted of how every moment shared with Williams was a pivotal one, and that it was a comic’s dream to be in his presence. Judd Apatow wrote about the lengths he went to simply be near the legendary comic, saying that he took an internship at Comic Relief at the age of 18 in order to work with Williams.

Billy Crystal wrote poignantly, “No words.”

Other comedians such as Jimmy Kimmel and Chelsea Handler marked the tragedy by attempting to raise awareness of depression, telling those in need of support to not be afraid to reach out for help, and to remain strong.

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