Co-Author Linda Yau, M.D., F.A.C.P.
August 13, 2014
This book review is many months in the making and was scheduled to be published this week when the sad news about Robin Williams broke. My reaction to the death of Williams reminded me of my reaction when I first read about Iris Chang, another genius who is the subject of this book and who also succumbed to a suicide that was shocking and unfathomable. I had heard of her only in passing, as someone who wrote international bestsellers and was surely an ancient historian. It turns out she was not an ancient historian, but actually a celebrated author, publishing The Rape of Nanking : the Forgotten Holocaust of World War II at age 29. She was happily married, with a very supportive family and a young son.
Why was this well-known historian dead at age 36? This book, written by Chang’s friend, Paula Kamen, helps to answer this question by examining unlikely factors like her Asian American background, infertility treatment and journalism career. Chang was an incredibly successful author, on whirlwind book tours and working long hours. She was a hero to many of the victims of World War II because her book The Rape of Nanking brought to light the gruesome story of the Japanese atrocities in China during the war. She published 2 other books and was researching the Bataan Death March when she died. Her gripping story with a tragic ending can teach us all lessons about mental illness, specifically Asian American mental illness, and how to possibly help those who develop these difficult diseases.
The book chronicles the early years of Iris Chang, born in Princeton, New Jersey, to immigrants who came from Taiwan. Her parents were both professors at University of Illinois/Urbana-Champaign, and she grew up in the university town attending the prestigious University Lab School. She met her good friend, Paula, while writing for the U of I paper as an undergraduate. To Paula, “Iris Chang” quickly became a verb. “Iris Changing it” meant striving for something big and achieving it. Paula marveled at how Iris automatically assumed she could become an editor of the college newspaper. Iris set her goals and then achieved them in quick order, even being elected to the homecoming court as a junior. After graduating, her career skyrocketed, with the publication of her first book Thread of the Silkworm at age 27 in 1995 and The Rape of Nanking in 1997 at age 29. She appeared on national talk shows, did whirlwind book tours and appeared with famous celebrities. She met President Clinton and asked him to champion obtaining reparations for victims of the Japanese atrocities in World War II. She boldly confronted the Japanese Ambassador to the United States on the McNeill/Lehrer News Hour and asked for an apology on national television from him to the Chinese people for Japanese military war crimes.
From the outside, Iris Chang had the perfect life. The horrible mystery to the author of this book, her friends, very supportive family and the wide circles of international admirers, was why Chang was found dead of a self- inflicted gunshot wound to the head in her car in the early morning hours of November 9, 2004 at the age of 36. In investigating her friend’s death, Kamen discovered some important lessons for all of us in dealing with psychiatric disease. Iris was diagnosed with bipolar disorder with reactive psychosis in the last few months of her life. Bipolar disorder means that patients have both manic and depressive symptoms. In classic mania symptoms, patients have elevated mood, increased self-esteem, grandiose ideas, high energy levels, pressured and excessive speech, reduced need of sleep, and excessive indulgence in risky behaviors (excessive gambling, shopping, or sexual behaviors). Psychosis means that patients can be paranoid, believing they are being persecuted or followed and may also have hallucinations or hear voices that are not there.
This book reveals many lesser known risk factors for mental illness and suicide. In fact, 90% of all suicide victims have a form of mental illness. Too often the disease is undiagnosed, not treated effectively or treated at the eleventh hour. In the case of Iris Chang, there are several factors that may have contributed to her illness:
One factor that is not widely discussed is her race. Mental illness in Asian societies is a shameful secret, a taboo that frequently is hidden. It is likely that Iris had longstanding bipolar disorder that was unrecognized because of her ethnicity. It turns out that the Asian range of behavior is much narrower than those of other races. Often Asian patients will not exhibit the classic spending spree or hypersexual behavior but their mania may only result in working long hours or having long conversations. “As a result, Iris’ “excitable” behavior which would have seemed in the range of “normal” for a white person, butcould signal spiraling mania for a typically less expressive Asian…And even when white people do recognize extreme behaviors in Asian friends or coworkers, such as nonstop work for days, they may accept that as a normal characteristic of the Asian super achiever or “model minority”…compounding inaccuracy of diagnosis, even for trained professionals, is an extreme lack of clinical research into nonwhite subjects and how they experience mental illness.” (210-211) Many patients such as Iris actually like the high energy of being manic and may not want to treat it, as those with mania can be highly productive in work. Suicide is much more common in Asian American women compared with women of all other races, especially between the ages of 15 and 34 and those above 75. For unclear reasons, it turns out that Asian American women born in the U.S. (like Iris) are much more likely to commit suicide than immigrants.1
Another risk factor for her worsening mental illness may have been Chang’s infertility treatments. It has been found that estrogen levels can be ten times higher than normal on certain drugs that stimulate ovulation. Patients who have an underlying bipolar disorder are much more sensitive to hormonal shifts that may induce their moods to cycle through mania and depression on a fast cycle. 70% of women with bipolar disorder can have post-partum depression, compared to 10-15% of those in the general population. Often fertility clinics do not have time to do in depth investigation into a woman’s past psychiatric history, especially if it is mild or unrecognized, as in Iris’ case. Kamen wondered if Iris suffered from postpartum depression; however, in a shocking revelation near the end of the book, Iris’ husband reveals that Iris was never pregnant with her son because a chromosomal abnormality caused multiple miscarriages. Therefore it was more likely that the fluctuating hormones from being pregnant, miscarriage and then fertility drugs over 2 years may have influenced her moods. So not only was she struggling with a mental illness, but she also had extensive hormonal treatments that may have worsened her mania and depression. 2
A third factor in Chang’s illness was that she extensively and intensely researched very difficult topics in World War II which involved genocide and severe trauma. She immersed herself in writing about gruesome acts of violence to hundreds of thousands of civilians while writing The Rape of Nanking, and then was starting difficult interviews with many U.S. servicemen’s torture during the Bataan Death March. According to Kamen, journalists are not trained to deal with the impact on researching, interviewing and writing about trauma on a regular basis and may suffer from a form of post-traumatic stress disorder from reading, thinking and writing about excessively violent subjects. Journalists need to learn about self-care when reporting on horrific crimes and understand that the difficult nature of the subjects they write upon may affect their mood. While it is well known that creative type people are more likely to suffer from mental illness (think Vincent Van Gogh), the stresses of journalism are not often spoken about.
This book offers good advice on helping others with depression or bipolar disorder that are suicidal. “Family members should not hesitate to take away credit cards, car keys and checkbooks. Have the person committed to a hospital is he or she is in serious danger. Then give the patient ample time for recovery, knowing that suicide attempts are very likely in the weeks after a hospitalization.” (273) It is key that the person have a great relationship with a mental health professional that can help with proper medication, psychotherapy and monitoring progress. Hopefully there will be more research on the varied ways mental illness can manifest in individuals and how we can be alert and vigilant for signs of depression or mania in others. Listed below is the number for the National Suicide Prevention Lifeline as well as the website for the American Foundation for Suicide Prevention which has many facts and advice on helping people in crisis.
References
- American Foundation for Suicide Prevention: Excellent website with resources and advice on risk factors and warning signs: http://www.afsp.org/
- If you are in crisis or helping someone with suicidal thoughts, call the National Suicide Prevention Lifeline: 1‑800‑273‑TALK (8255)
- Depression in Asian Americans: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071741/
- Infertility and Mental Health: http://womensmentalhealth.org/posts/infertility-increases-risk-of-serious-psychiatric-illness/2
http://www.sciencedaily.com/releases/2012/07/120702134442.htm?utm_source=feedburner&utm_medium=email&utm_campaign=Feed%3A+sciencedaily%2Fmind_brain%2Fpsychiatry+%28ScienceDaily%3A+Mind+%26+Brain+News+–+Psychiatry%29 - Postpartum Depression:
http://www.nytimes.com/2014/06/16/health/thinking-of-ways-to-harm-her.htmlaction=click&contentCollection=Health&module=RelatedCoverage®ion=Marginalia&pgtype=article
http://www.nytimes.com/2014/06/17/health/maternal-mental-illness-can-arrive-months-after-baby.html?src=mv
1Correlates of Suicide Behaviors in Asian Americans