TIME On Our Radar

See the Lives of China’s Mentally Ill

Ian Parry scholarship winner Yuyang Liu documents the dire reality of mental disease in China.

To live with mental illness in China is to live in an invisible world.

Of the more than 100 million victims living with some form of mental illness in China, 16 percent are classified as severe, according to a 2009 report by China’s National Center for Mental Health. Yet, inadequate psychiatric care and social stigmas have pushed many out of the public sphere, denying family members the much-needed support they need.

This year’s Ian Parry scholarship recipient, 23-year-old Chinese photographer Yuyang Liu, has set about illuminating this invisible world. He recently documented families crippled by mental disease across the southern province of Guangdong, one of China’s wealthiest regions. “It is often the case that one family is impoverished because of a family member’s illness,” Liu tells TIME.

The project, At Home With Mental Illness, which aims to highlight the inefficient government efforts, won him his scholarship.

Liu first became aware of the issue when he received a newsletter from a Chronicle Disease Prevention Center in a small town, which mentioned its effort in helping those struggling with mental health issues and their families. “I was blown away,” Liu says. “[I realized] that although the patients are largely invisible in the society, they and their families do live a real life.”

With leads provided by local NGOs and online forums, Liu gained access to six houses, photographing the interactions among the mentally ill, their families and the larger society. “I don’t want to photograph how miserable they are even though some of the pictures will inevitably convey that, but I want to focus more on the support between them and their families, and capture the viewers’ attention that way,” Liu says.

Among them, the Xiao family’s situation is especially grim. With a mother suffering from severe mental illness at home, Xiao, a father of two, has to work every morning. Before leaving, he used to tie his five-year-old daughter with a rope attached to a wooden stake so she wouldn’t be able to wander off. When social workers discovered the girl, she did not wear any pants. The father had thought that since no one could untie her to use a bathroom, it would prevent her from wetting her clothes.

Liu immediately partnered with Chinese Internet and technology giant, Tencent, after photographing the Xiao family’s situation, and raised 4,000 RMB ($645) for the child. But he hoped that the fundraising would benefit more than one family and that he would be able to raise awareness for the socially disadvantaged group as a whole, he says. Now with the scholarship’s support of £3,500 ($5,450), Liu plans to expand his coverage to other regions in China.

The scholarship, named after photojournalist Ian Parry, who died while covering the Romanian revolution in 1989, is given every year to an aspiring photographer under 24, the age Parry died. “[The prize] is a great encouragement for me personally,” Liu says. “There’re so many amazing photographers as my predecessors, and I’m really happy to be included in the family.”

Early this year, Liu had contemplated going into commercial photography for a better income, but soon dismissed the idea, and winning the award serves as a major encouragement for him to push through a short period of hesitancy.

“The judges felt this was an outstanding and brave body of simple, honest images,” said the jury in a statement. Along with Liu, Hosam Katan of Syria was highly commended this year. Hashem Shakeri of Iran, Isadora Kosofsky, who was published on TIME LightBox last year, and Salahuddin Ahmed of Bangladesh were also commended. Each of them will receive a cash award of £500 ($780). “Every single portfolio selected for this year’s scholarship has human interest at its heart, and that’s why this award is so special,” said Don McCullin, combat photographer and a trustee on the scholarship’s board.

See Isadora Kosofsky’s winning story below.

Ye Ming is a contributing writer to TIME LightBox. Follow her on Twitter @yemingphoto and Instagram.

TIME Mental Health/Psychology

More Than 200,000 Vietnam Vets Still Have PTSD

American flag Vietnam Veterans Memorial
Getty Images

New research reveals considerable PTSD in some vets, even decades after war

Many veterans who served in the Vietnam War still have war-zone-related post-traumatic stress disorder, according to a new study published in JAMA Psychiatry.

The researchers, led by Dr. Charles R. Marmar, of the New York University Langone Medical Center, wanted to look at the prevalence of PTSD over time. Thanks to the National Vietnam Veterans Longitudinal Study, a study of PTSD in Vietnam vets done more than 25 years ago, they had historic data on the prevalence of PTSD; they conducted a follow-up to the study by gathering new data from the 1,450 veterans who were still alive and willing to participate in another round of PTSD assessments. From 2012-2013, researchers gathered from each vet a self-report health questionnaire, a telephone health survey or a clinical interview by phone. (Some vets participated in two or all three of the measures.)

MORE: Meet 15 Extraordinary Wounded Warriors Who Are Stronger Than Ever

The team determined that even now—40 years after the war ended—about 271,000 Vietnam vets have full war-zone-related PTSD plus war-zone PTSD that meets some diagnostic criteria. More than a third of the veterans who have current war-zone PTSD also have major depressive disorder.

MORE: “Hidden Wounds”: Battling PTSD With Music

Men who served in the Vietnam war had a war-zone-related PTSD prevalence of 4.5%; when factoring in vets who met some of the criteria, that number climbed to almost 11%. For women veterans, those prevalences were about 6% and 9%, respectively.

“An important minority of Vietnam veterans are symptomatic after four decades, with more than twice as many deteriorating as improving,” the study authors write. “Policy implications include the need for greater access to evidence-based mental health services; the importance of integrating mental health treatment into primary care in light of the nearly 20 percent mortality; attention to the stresses of aging, including retirement, chronic illness, declining social support and cognitive changes that create difficulties with the management of unwanted memories; and anticipating challenges that lie ahead for Iraq and Afghanistan veterans.”

TIME Mental Health/Psychology

These Antidepressants May Be Riskier For Pregnant Women, Study Says

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Alfredo Ausina—Getty Images/age fotostock RM

Treating depression properly is important, but a new analysis found a link between certain SSRIs and birth defects

In a study published in the BMJ, researchers conducted the most thorough study to date looking at how popular SSRI antidepressants taken by pregnant women affect their unborn children.

Previous studies, most of which investigated individual medications and their potential effects on the still-developing fetus, have resulted in conflicting results; some have found associations between the antidepressants and birth defects, while others have not.

In the BMJ study, Jennita Reefhuis, team lead in the birth defects branch at the U.S. Centers for Disease Control and Prevention, and her colleagues analyzed data from six existing studies of selective serotonin reuptake inhibitors, called SSRIs—a class of antidepressants—and their relationship with birth defects, as well as the National Birth Defects Prevention Study, which collected birth defect information from hospitals in 10 U.S. cities. The added data from nearly 18,000 mothers who had children with birth defects provided more power to the analysis that Reefhuis and her team performed.

MORE: Therapy and Antidepressants Work Better Together Than Just Pills Alone

Overall, they found that two SSRIs—fluoxetine (Prozac) and paroxetine (Paxil)—were linked to seven specific birth defects, including those involving heart structures, abnormal brain formation and the growth of the intestines outside of the body. The other SSRIs studied—citalopram (Celexa), escitalopram (Lexapro), and sertraline (Zoloft)—did not show strong associations with birth defects.

The researchers don’t yet know exactly why these SSRIs were linked to birth defects, and Reefhuis stresses that the risks she uncovered are small. For example, a heart structural defect occurs normally in about 10 per 10,000 births, and for women taking paroxetine, that risk doubled to 24 per 10,000. “But two times a small number is still a small number,” she says.

MORE: Why Some Antidepressants Make You Feel Worse Before Better

Still, the results should provide better information for doctors and women who want to start families about how to balance the benefits of antidepressants like SSRIs in treating depression and the potential risks the medications can pose to the baby. “I think our data points in the direction that maybe they could choose an SSRI that has not been shown to be associated with, or has been associated with fewer, birth defects,” she says. But more studies like this are needed to confirm and expand on what we know about how specific antidepressants are linked to specific birth defects. “This information is most helpful in trying to unravel this mystery,” says Reefhuis. “I really hope it provides options for treating women who need treatment for depression during pregnancy.”

TIME Mental Health/Psychology

How Fireworks Can Trigger PTSD

Fireworks will be going off with a bang all weekend, but for some, they cause more anxiety than celebration

You may see the signs popping up around your neighborhood this July 4—red, white and blue notices that indicate the home of a vet with the request to “Please be courteous with fireworks.”

The signs are the work of a Facebook-launched nonprofit, Military With PTSD, begun by Shawn Gourley, whose husband, Justin, served in the Navy for four years and returned with post traumatic stress disorder (PTSD). Sudden and loud noises can trigger episodes of PTSD, bringing veterans back to traumatic experiences they have lived through during their service. According to the U.S. Department of Veteran Affairs, up to 20% of military personnel who served in Iraq or Afghanistan experience PTSD each year.

The signs are posted on the lawns of veterans’ homes to alert people to be more considerate when setting off fireworks in the area. According to Gourley, who spoke to CNN, the group has mailed 2,500 signs, some of which were paid for by donations and others by the vets themselves, while 3,000 people remain on a waiting list.

The signs are not meant to quash any Fourth of July celebrations, but to raise awareness that the explosive sounds, flashes of light and smell of powder may trigger unwelcome memories for some. “If you are a veteran, on the one hand July 4th should be one of the most patriotic holidays that you feel a part of,” says Dr. John Markowitz, professor of psychiatry at Columbia University. “On the other hand, the rockets’ red glare and the bombs bursting in air are likely to evoke traumatic memories, and you might want to hide. It’s a tricky one.”

Having advanced knowledge of a fireworks display can help some people with PTSD to better prepare and cope with any symptoms they may experience. “A big component of the startle response and PTSD is the unexpected,” says Rachel Tester, program director of the Law Enforcement, Active Duty, Emergency Responder (LEADER) Program at Harvard Medical School’s McLean Hospital. “When people are able to anticipate, they are able to put into place mechanisms they have to cope ahead of time.”

That might include things such as relaxation techniques or being able to see the fireworks show and therefore know that they’re coming, as well as having headphones, music or other distractions at the ready.

Such strategies may not work for every PTSD patient, but being more aware that the explosive celebrations of the holiday might affect those with PTSD is an important step toward ensuring that everyone can enjoy the holiday without fear, anxiety or pain.

TIME Crime

U.S. Police Killed Someone in Mental or Emotional Crisis Every 36 Hours This Year, Report Says

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Getty Images

In most cases, police were called not because of a crime but by a concerned bystander or loved one

Reporting released by the Washington Post on June 30 depicts an apparently stark reality when it comes to confrontations between police and people with mental illness in the U.S. The article draws from the newspaper’s tracking of every fatal police shooting in the country in the first six moths of 2015 — 462 in all — to present an in-depth look at those confrontations involving disturbed or distressed individuals.

During that time, police killed someone in mental or emotional crisis every 36 hours, including three men within 10 hours on April 25, the Post reports.

In most of those cases, the paper says, officers were not called to the scene because of reports of a crime but were rather responding to concerned bystanders or loved ones. Out of the 124 shootings examined in the report, 50 involved explicitly suicidal individuals. In 45 cases, police were explicitly asked for medical assistance or called after the individual had attempted to get medical assistance elsewhere. Nearly a dozen of those killed were veterans, and several suffered from PTSD.

Many of the responsible police agencies do not train their officers adequately to deal with distressed people, the article concludes. According to the Police Executive Research Forum, officers in training spend up to 60 hours learning to handle a gun and only eight hours each learning to neutralize taut situations and interact with mentally ill individuals. In fact, many of the tactics learned in training, such as shouting commands, can worsen the situation for already fragile people.

“This a national crisis,” Chuck Wexler, executive director of the Police Executive Research Forum, told the Post. “We have to get American police to rethink how they handle encounters with the mentally ill. Training has to change.”

Read more at the Washington Post

TIME Innovation

Why Women’s Soccer Is a Feminist Issue

The Aspen Institute is an educational and policy studies organization based in Washington, D.C.

These are today's best ideas

1. Women’s soccer is a feminist issue.

By Maggie Mertens in the Atlantic

2. Can community service journalism save local news?

By Steven Waldman in the Columbia Journalism Review

3. This 99¢ app connects kids to thousands of scholarships.

By Fitz Tepper in TechCrunch

4. America is more afraid of peace than war.

By Gregory A. Daddis in the National Interest

5. Here’s how the LAPD is addressing use of force on the mentally ill.

By Noelle Swan in the Christian Science Monitor

The Aspen Institute is an educational and policy studies organization based in Washington, D.C.

TIME Ideas hosts the world's leading voices, providing commentary and expertise on the most compelling events in news, society, and culture. We welcome outside contributions. To submit a piece, email ideas@time.com.

TIME Innovation

The High Cost of the American Dream

The Aspen Institute is an educational and policy studies organization based in Washington, D.C.

These are today's best ideas

1. We’re pricing the American Dream out of existence.

By Mechele Dickerson in the Conversation

2. Syria’s future might be like Somalia’s: Permanent anarchy.

By Aron Lund at the Carnegie Endowment for International Peace

3. The UN wants to share its sustainability goals with the world, so it’s turning to comics.

By Chris Arrant in Newsarama

4. Museums are doing a pretty bad job of connecting people to art.

By Michael O’Hare for Democracy Journal

5. Most kids with mental illness aren’t receiving treatment.

By Arielle Duhaime-Ross in the Verge

The Aspen Institute is an educational and policy studies organization based in Washington, D.C.

TIME Ideas hosts the world's leading voices, providing commentary and expertise on the most compelling events in news, society, and culture. We welcome outside contributions. To submit a piece, email ideas@time.com.

TIME Crime

Colorado Gunman’s Notebook of Ramblings Becomes Evidence

Holmes Shooting Notebook
AP A portion of Aurora shooter James Holmes' notebook, after it was presented as evidence in the Holmes murder trial on May 26, 2015, in Centennial, Colo.

Copies of a journal kept by the man on trial for the Aurora theater shooting have been distributed to the jury that will help determine his fate

A notebook containing James Holmes’s ramblings, sketches and thoughts on topics ranging from the meaning of life to murder was presented on Tuesday at his trial for the 2012 mass shooting in an Aurora, Colo., movie theater that killed 12 people and injured 70 others.

It’s a key piece of evidence for prosecutors trying to prove the 27-year-old plotted the killings and for defense lawyers who argue he was experiencing a psychotic episode on July 20, when he opened fire on moviegoers at a premiere of The Dark Knight Rises.

Holmes’s notebook reveals references to violence and death and is stepped in nihilism. He writes about a “self diagnosis of broken mind” and several pages are covered with the question “Why?” over and over again. “When mankind can’t find truth,” he mentions at one point, “untruth is converted to truth via violence.”

The former doctoral student in neuroscience is pleading not guilty by reason of insanity. Prosecutors are seeking the death penalty. Holmes sent the notebook to his University of Colorado psychiatrist, Dr. Lynne Fenton, eight days before the shooting, but the package was not discovered until several days after the massacre. Fenton had warned authorities that Holmes was a danger to the public.

Holmes describes in the journal a number of fantasies about different ways to kill, but quickly rules them out. He says a bomb is too regulated and suspicious, biological warfare requires extensive knowledge of chemicals and serial murder is “too personal, too much evidence, easily caught after few kills” before settling on a “mass murder spree.” He writes that he chose this method because it would provide “maximum casualties, easily performed with firearms, although primitive in nature. No fear of consequences, being caught 99% certain.”

At one point, he rules out certain venues, like airports, because he didn’t want his mass killing to be misinterpreted as a terrorist act. Airports have “too much of a terrorist history,” he writes. “Terrorism isn’t the message. The message is there is no message.” The journal also includes diagrams of different theaters within the movie complex, as well as pros and cons for each one.

“And finally, the last escape, mass murder at the movies,” he writes. “Obsession onset: > 10 years ago.”

Holmes describes his psychological struggles as “the real me is fighting the biological me,” and notes that work and romantic failures aren’t the reason for his action, although both are “expediting catalysts.” Instead, he claims, his “state of mind for the last 15 years” is to blame for his actions.

He notes a particular set of symptoms and behaviors that accompanied his self-diagnoses of a “broken mind,” including a “recurring return to mirror to look at appearance, particular attention focused on hair styling. 10+ times a day.” At the time of the shooting, Holmes’s hair was dyed a bright red-orange. He also describes at least one childhood accident that injured his genitals, which he alleges led to an “allergic reaction to sex.”

In one particularly chilling passage, Holmes alludes to the name of the movie he selected for the attack: “I was fear incarnate. Love gone, motivation directed to hate and obsessions, which didnt disapear for whatever reason with the drugs,” he writes. “No consequences, no fear, alone, isolated, no work for distractions, no reason to seek self -actualization. Embraced the hatred, a dark knight rises.”

TIME portfolio

Navigating a Mother’s Mental Illness Through Photography

Photographer Melissa Spitz spent the past six years documenting her mentally ill mother.

Melissa Spitz was only six when her mother Deborah was institutionalized for psychotic paranoia, while her father was away on an overseas trip, leaving Spitz and her brother at friends’ homes. Over the years, her mother’s diagnoses changed frequently—from personality disorder to alcoholism—eventually rupturing her family.

“My mother has caused our family a lot of pain over the years,” Spitz says. After her parents ended their 27-year marriage and her father left their home in St. Louis, and her brother Adam became more estranged because of his mother’s behavior, Spitz became the primary caretaker, traveling home every other week while juggling her photography studies at the University of Missouri in Columbia, Mo., and later during graduate work at Savannah College of Art and Design in Savannah, Ga. in her early 20s. Inevitably, her mother became her central focus.

“My [photography] background and this project are kind of blended, and it was this thing that happened in unison,” the 26-year-old photographer tells TIME.

Spitz did not think that documenting her mother could make a substantial body of work until she saw the similarly intimate and intriguing photographs of Richard Billingham, Nan Goldin and Tierney Gearon, who unapologetically exhibited the private lives of their loved ones in a public display. “I really wasn’t aware that that was something photographers did.”

Yet, to fully confront the moments of chaos and, at times, ugliness of life — emotions often concealed outside of close family circles — was a difficult journey. When Deborah was hospitalized after a car accident and begged Spitz to document it, she couldn’t raise her camera. “I remember telling her that this makes me feel bad, like I’m doing something wrong,” Spitz says.

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Melissa SpitzMom at MFA Thesis exhibition, 2014.

But as time went by and hospital visits stacked up, Spitz says that Deborah told her: “This is my life, Melissa. If you’re going to do this, you need to just go all in.” Since then, her mother has become more than just a subject; she’s a collaborator. The experience has served as an emotional and therapeutic bridge between the two, channeling a relationship that had long faltered. “Now I can’t think of a time that I haven’t photographed her, even when she’s been in hospital. I just try and let her have as much control as possible.”

Once, Spitz took her mother back to the high school where Deborah had been a popular cheerleader, and sat her down on the bleacher for a portrait. “She just started screaming and crying,” Spitz recalls, “It was really fake at first but she kept doing that, and all of a sudden [she] had this tone that was just so real and full of pain.” In that moment, Spitz’s own long-repressed emotions about her mother’s illness erupted. “That was when I knew that the work was a conversation that was not only me watching her but also an echo of how I feel about living and dealing with her.”

But as the world of photography opens doors to self-reflective and sensitive examination, accusations of exploitation also arise. And Spitz understands how turning the lens on her mother can affect Deborah’s behavior.

“I am fully aware that my mother thrives on being the center of attention and that, at times, our portrait sessions encourage her erratic behavior,” Spitz says. “There are people who think I exploited my mom, and think that I’m doing something wrong, and then there’re people who think I’m doing something very important.”

“My hope for the [story] is to show that these issues can happen to anyone, from any walk of life and that there is nothing to be ashamed about,” she adds.

Now, Deborah, 60, works as a greeter at a Home Depot store in St. Louis, a job created by Missouri’s Social Security Disability Insurance program. She tells TIME that she hopes sharing her story could help de-stigmatize mental illness. For the photographer, the investment on a project, which already stretched half a decade and is still ongoing, is worth it. “I can finally take something I love doing and share it with my mom,” she says. “It’s been a mirror for both of us to see our lives.”

Melissa Spitz is a photographer who divides her time between the Midwest and New York. She plans to make a book about her mother’s project, You Have Nothing to Worry About. You can also follow her on Instagram.

Paul Moakley, who edited this photo essay, is the deputy director of photography and visual enterprise at TIME.

Ye Ming is a writer and contributor to TIME LightBox. Follow her on Twitter and Instagram.

Listen to the most important stories of the day.

TIME Healthcare

When Can a Person Be Forced to Receive Medical Care?

'We subscribe to the principle that people should get to make decisions for themselves almost all the time'

Last week, the case of a Connecticut teenager, identified as Cassandra C., 17, made headlines. Diagnosed with Hodgkin’s lymphoma, Cassandra wanted to forgo chemotherapy altogether—a decision her mother reportedly supported. But in early January, child services took the 17-year-old into custody and on Jan. 8 the state Supreme Court denied the teenager’s request to not receive the drugs.

The state’s interference in a personal decision about health care provides a rare lens into when and how health officials can mandate health care. Forced treatment is rare, but it happens when people, most often minors and the mentally ill, find themselves in extenuating circumstances.

“We subscribe to the principle that people should get to make decisions for themselves almost all the time,” says Paul S. Appelbaum, a psychiatry, medicine and law professor at Columbia University. “The exceptions to that rule are rare. What we’re seeing play out in Connecticut is really the exception, not the rule.”

Competent adults in the United States are almost always permitted to make their own health care decisions, even if that means forgoing a potentially life-saving treatment. Even in cases of highly infectious disease, state laws don’t typically allow forced medical treatment. Instead, sick individuals may be quarantined until they agree to comply with treatment procedures.

The most obvious exception to the principle applies to mentally ill patients deemed incompetent to make their own health decisions. Though laws vary for long-term involuntary treatment between states, most jurisdictions allow short-term hospitalization for individuals thought to be a risk to themselves or others.

Read more: Dangerous Cases: Crime and Treatment

Minors have no official say when it comes to decisions about their health care; parents or guardians are typically charged with making treatment decisions on their behalf. (Minors do have the right to petition the courts to show that they are “mature”—something Cassandra from Connecticut did—and therefore capable of making their own decisions. Cassandra’s petition was denied.)

If parents refuse a recommended treatment, the state typically works with parents to reach a mutually agreeable solution, says Appelbaum. If the parties still can’t agree, the case may go to the courts. “The legal principles here are fairly consistent, but their application is not necessarily straightforward,” said Appelbaum of the difficulty of resolving health care issues in court. “There is no algorithm.”

When brought to court, judges weigh a range of concerns, including the consequences of leaving an ailment untreated. Life-threatening conditions are much more likely to result in forced treatment than, say, a recommended cosmetic surgery, said Appelbaum.

“How long is a person actually supposed to live, and why? Who determines that?” Cassandra wrote in a op-ed in the Hartford Courant. “I care about the quality of my life, not just the quantity.”

The court, which had previously ruled Cassandra’s mother unfit to make decisions on her daughter’s behalf, rejected Cassandra’s explanation and ordered her to undergo chemotherapy.

“This is a curable illness, and we will continue to ensure that Cassandra receives the treatment she needs to become a healthy and happy adult,” said a statement from the Connecticut Department of Children and Families.

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