The portrayal of mental illness in film has been a favorite topic of discussion on the College of Psychiatric and Neurologic Pharmacists listserv for many years. This movie review compares and contrasts two such films, one a classic (One Flew Over the Cuckoo's Nest) and the other (Shutter Island) a relatively new addition to the filmographic registry of the psychiatric genre. Further, this review is provided from two different perspectives-that of a veteran psychiatric pharmacist and a fourth year Pharm.D. student.Spoiler Alert- if you have not seen these pictures, some significant aspects of the plot lines of both movies are revealed below.

Jerry McKee PharmD, MS, BCPP

Psychiatric Pharmacist Perspective- One Flew Over the Cuckoo's Nest is a sometimes comedic drama filmed in 1975, based on the 1962 novel of the same name by Ken Kesey. The film stars a very young Jack Nicholson, Danny Devito, and Louise Fletcher. It depicts the psychiatric inpatient hospitalization of a prisoner McMurphy (Nicholson) looking to serve out his sentence in the relatively stress free confines of the “mental hospital” by malingering. Upon arrival at the hospital, the brash rebel (Nicholson) rallies the patients together to take on the oppressive Nurse Ratched (Fletcher), a woman more a dictator than a nurse, who rules the ward with little medical supervision. The action is seen through the eyes of a physically imposing American Indian called “Chief” Bromden.

The film was the second to win all five major Academy Awards (Best Picture, Actor in Lead Role, Actress in Lead Role, Director, and Screenplay) and is listed as number 20 on the American Film Institute's 100 Years... 100 Movies list. It was shot at Oregon State Hospital in Salem, Oregon, which was also the setting of the novel. Oregon State Hospital is the primary state-run psychiatric hospital in the state of Oregon. The film's director had the cast view the Titicut Follies prior to beginning filming, in order to get an idea of what life was like inside a psychiatric hospital. The only American film banned from release for reasons other than obscenity or national security, 'Titicut Follies' was filmed in 1967 inside the Massachusetts Correctional Institution at Bridgewater, a prison hospital for the criminally insane.

Student's Perspective: The 1975 film adaption of Ken Kesey's Novel One Flew Over the Cuckoo's Nest has remained to this date, a favorite of viewers and movie critics alike. Set in a state mental institution, the film focuses on the charismatic, free spirited and rebellious RP McMurphy. Following conviction for statutory rape, McMurphy fakes mental illness and is admitted to the mental ward for evaluation. There he meets his gang, which includes patients like Cheswick who throws temper tantrums, Harding who is suspicious of his wife's infidelity and in denial of his own sexual incompetence, and the Chief who is thought of as “deaf and dumb”. He also meets Nurse Ratched, the head nurse who presides over the ward with an iron fist. Almost immediately, there is conflict. Nurse Ratched is constantly provoked by McMurphy's antics as he entices the others to follow in his path which results in some amusing situations. McMurphy soon learns of the power Nurse Ratched holds over the others by using humiliation and guilt as her weapons. The film shows the vulnerability of the human mind and questions the meaning of sanity and insanity. Nurse Ratched is portrayed as the embodiment of all things sane. However, what is sanity? Is it conformity? Or is it a free bird like McMurphy? Not only is the film good entertainment, it also provides food for thought. As to McMurphy, what becomes of him? What changes will he bring to the ward? Will he escape? Will the others follow him? It remains to be seen.

Serene George, Pharm.D. student- Nova Southeastern University

Preceptor: Joshua Caballero, PharmD, BCPP

Psychiatric Pharmacist Perspective- Thirty-four years later, Shutter Island 2009 was filmed. This is an old-fashioned thriller with a stunning plot twist, starring Leonardo DiCaprio and Mark Ruffalo. Many viewers were confused by this twist, to the extent that since the film was released in March, the blogosphere's been filled with debate about what actually happens in the final scene. Martin Scorsese's film is based on a best-selling novel by Dennis Lehane. Set in the period just after World War II, the film's protagonist, Teddy Daniels (DiCaprio), who's apparently a US marshal, turns out to be Andrew Laeddis, a demented killer. He's a patient in a mental hospital who's been encouraged by his psychiatrist to act out his delusion in the hope that this will dispel it. The role play fails and after a brief recovery, Andrew relapses into insanity and is therefore taken off apparently to be lobotomized.

Like One Flew Over the Cuckoo's Nest, Shutter Island was filmed at a historic state psychiatric hospital. Medfield State Hospital is an historic mental hospital in Medfield, Massachusetts. The hospital was built in 1892. At its height it included 58 buildings, on a property of some 900 acres, and a capacity of 2,200 patients. It raised its own livestock and produce, and generated its own heat, light and power. Added to the National Register of Historic Places in 1994, the property was closed in April 2003 and was shuttered, and has recently been reopened to the public.

Student's Perspective: Edward “Teddy” Daniels (Leonardo DiCaprio) and his partner Chuck Aule (Mark Ruffalo) are US Marshals sent to the psychiatric facility on Shutter Island to investigate the disappearance of a patient. Amidst the complicated interplay between Teddy's flashbacks to both his wife's untimely death and his participation in the liberation of Dachau, and his ever-growing list of conspiracy theories that includes mind-control experiments and the sinister machinations of the House of Un-American Activities Committee.

The movie suggests Teddy's underlying pathology is that of a highly functioning male suffering from delusions brought on by post-traumatic stress disorder. The “defense mechanisms” motif is hammered throughout the film, and Teddy's creation of a distorted, alternative reality appears to be a coping mechanism for the traumas of his actual reality.

Dr. Cawley represents the transition between the old world of psychology and the new. He wants the profession to leave behind certain old practices (lobotomizing patients) and treat patients with new antipsychotic drugs. Although seemingly devoted to helping his patients avoid an unseemly surgery, Dr. Cawley's choices complicate the issue of whether his actions are completely altruistic or designed to benefit his legacy. He puts his entire staff of guards, nurses, and orderlies at risk by allowing his patient, “the most violent man at Shutter Island”, to engage in the elaborate role-play. The ethics of Dr. Cawley's pioneering approach are highly questionable as he even allows other patients to participate in the experiment.

One of the film's best achievements is the ironic upending of the conflict verbalized by Rachel Solando, one of Teddy's allies: “If you're not crazy but people have told the world you are, then all your protests to the contrary just underscore their point.” While “sane” Teddy emphatically agrees, fearing the application of that very paradox to his own situation, the patient's fate rests not with insistence on his sanity, but rather, on the acknowledgement of his possible delusions.

Brett Hensley, Pharm.D. student-Nova Southeastern University

Preceptor: Joshua Caballero, PharmD, BCPP

Psychiatric Pharmacist Perspective- The two films share some common themes. The lead characters in both films receive therapies which were accepted practice at the time, but are no longer in vogue. Both were filmed at historic state inpatient psychiatric facilities, giving them the appropriate “period” feel. These historic inpatient facilities are rapidly dwindling in number. One Flew Over the Cuckoo's Nest creates a more sympathetic view of persons with serious mental illness, while Shutter Island depicts an element of danger, suspicion, and suspense surrounding these individuals. Both films serve, to some extent, to depict (in a Hollywood version at any rate) the world of psychiatric inpatient treatment in the 1950s, in the years prior to the development of modern psychopharmacologic therapies and are “must see” for psychiatric pharmacists interested in the history of mental illness and its treatment.