The opening scenes of the Silver Linings Playbook view like a trailer with a rapid sequence of events. The protagonist, Pat, a high school teacher, has been admitted to a psychiatric inpatient facility which the viewer later finds out is due to a violent outburst when he finds his wife, also a high school instructor, in the shower with another man. While at the inpatient facility, Pat attends regular group session therapy and is administered medication which he promptly spits out of his mouth. After receiving eight months of inpatient treatment, Pat's mother unexpectedly shows up to check her son out of the court-ordered treatment despite his doctor's protests. During Pat's first outpatient psychiatrist visit, the viewer learns about Pat's violent eruption where he viciously assaults his wife's lover, a fellow teacher at the same high school. At this visit, it is also revealed that Pat suffers from “undiagnosed bipolar disorder with delusional thinking.” Pat reports that one week prior to the incident, he imagined that the history teacher (his wife's lover) and his wife were plotting against him and embezzling money from the high school. He also reports that he does not need medication for his illness and that the medication makes him “foggy.” Lastly, it is during this therapy session that the title of the film is explained. Pat expresses his outlook on life being that as long as one works hard and perseveres, there is always a silver lining. Throughout the movie Pat is obsessed with reconnecting with his wife, who appears to want nothing to do with Pat after filing a restraining order against him. Pat's obsession brings him together with Tiffany, an emotionally traumatized character with various personal issues, who lost her husband in a tragic roadside accident for which she blames herself. Tiffany promises Pat that she will pass a letter to Pat's wife, Nikki, in exchange for his partnering with her for a dance competition. Despite all odds, Tiffany and Pat are able to work through their own illnesses together to find love and companionship in one other by the time the movie ends.

The combination of Pat and Tiffany, who both suffer from mental illness, allows the film to bring up and candidly discuss issues facing those who suffer from mental illness. Pat and Tiffany compare notes when discussing the long list of medications that both have tried. Pat states that he was on a regimen of lithium, Seroquel, and Abilify but reports that he doesn't take these medications as they make him “foggy-headed and bloated.” Tiffany then reports that she was on Xanax and Effexor but then states that she stopped therapy, as she “wasn't as sharp.” They both laugh in agreement that Klonopin makes you so out of it that you are not sure what day it is and that trazodone “flattens you out” and “takes the light right out of your eyes.” The viewer sees Pat struggling with medication adherence several times: spitting the medication out at the psychiatric inpatient facility, reporting to his therapist that he does not need medication, and the conversation mentioned previously. In this way, the film highlights the difficulty of adhering to a psychiatric medication regimen and, more importantly, identifies several causes behind this struggle. The movie accurately depicts how patients are often noncompliant because they do not believe they need medication or because the side effects brought on by drug therapy are too bothersome and interfere with normal functioning. A common adverse effect reported in the movie is cognitive dysfunction or the “foggy-headed” and “not as sharp” feeling. Unfortunately, this is a side effect associated with many of the medications used for the treatment of bipolar disorder. Clinicians hope to decrease this and other side effects through careful selection and titration of drug therapy. As seen through Pat and Tiffany's conversation, it may take several trials of various drug therapy combinations before an optimal therapy associated with the least adverse effects is found. In order to determine this optimal regimen, the patient's self-report of side effects and symptom control are invaluable to the clinician. It appears that at the turning point of the film, Pat becomes adherent to his medication therapy, which includes Seroquel and lithium. After this point, Pat does appear to be emotionally more stable and no side effects are detectable. In keeping with the film's central theme of silver linings, while medication therapy does pose significant side effects, the overall benefits realized by therapy are numerous. The contribution of medication adherence to Pat's overall improvement and control of his bipolar disorder is overshadowed by the notion that it is his relationship with Tiffany and their budding romance that allows for his improvement. This leads to the cliché idea that “love conquers all.”

The film also touches upon the stigma associated with mental illness. A neighborhood boy is constantly showing up at Pat's parents' house (where Pat lives) in an attempt to interview Pat for a school report on mental illness. The principal at Pat's high school, where Pat once taught, acts fearful of him and does everything she can to try and move away from him. Pat is introduced to his brother's friends during a tailgate and one of the first things asked to Pat is, “What is this I hear about you just getting out of the loony bin?” Pat also tries to distance himself from mental illnesses by essentially labeling Tiffany as the “crazy one” during one of their first encounters. So often, people just see Pat's mental illness and allow this disease to define him. This is problematic as it may prevent patients from seeking treatment or adhering to their medication regimen. In general, many feel that mental illness is still a taboo subject and making it known that a person has a mental illness may leave one open to judgment. In relation to this, the film tries to underscore the point that many people suffer from some degree of mental illness. The father in the film (Robert DeNiro) shows an obsession and unusual superstitions regarding the Eagles. Pat's friend Ronnie may have some degree of anxiety as he admits to Pat that sometimes he feels like he can't breathe and someone is choking him.

Overall, the film does not show an accurate depiction of bipolar disorder. The viewers only see the manic side of bipolar disorder. The depressive phase of bipolar disorder is not displayed during the film. The first night of his release, we see that Pat does not sleep, has pressured speech, and flight of ideas. This is evident when he reads Ernest Hemingway's A Farewell to Arms and is so disturbed about the ending that he throws the book out of the window, wakes his parents up and rants about how the book was so disturbing to him. Distractibility, another target symptom of mania, is shown in two key instances: first, when Pat sees the vice principal of the school, he is obsessed with finding out about Nikki, but when she comments on his weight loss he completely switches to being very thankful about the compliment and secondly, when he comments on his friend, Ronnie's, unhappiness, Ronnie changes the subject by presenting Pat with an iPod, and again he quickly switches to being thankful, while forgetting about the previous conversation.

In conclusion, the movie seems to take a somewhat Hollywood view of bipolar disorder. The movie does show that individuals with mental illness may have poor insight and often refuse their medications. It also touches on the stigma associated with mental illness. In the end, however, our opinion is that the movie makes it appear that love and exercise is the cure to both Tiffany and Pat's mental disorders. Although critically acclaimed and entertaining, we would not recommend the movie for educational or therapeutic purposes.

The new film Silver Linings Playbook can most basically be described as a heartfelt, feel-good romantic comedy about two people suffering from mental illness. The film has effortless pacing, excellent direction and Oscar nominated performances from Bradley Cooper, Jennifer Lawrence, Robert DeNiro, and Jacki Weaver, not to mention a nomination for best picture. However, as pharmacy students, we are not qualified to voice opinion on any of that. All we can say about the nuances of film-making are whether we enjoyed our two hours in the theater or not (and we most certainly enjoyed these two hours). We are, however, able to critique the portrayal of mental illness and the medications used to treat it. Being close to the end of our schooling we can base most of our critiques on what we have learned in class and whether or not it correlates with what is portrayed in this film.

All throughout school we were taught that psychiatric medications are not the cure-all, but rather just another tool in a patient's tool box for mental wellness. Cooper's character during most of the movie believed that he should be able to work through his illness on his own, without the help of any medications. He even alludes to the idea that he was embarrassed to have to take medication. This sort of social stigma can adversely affect medication adherence and treatment outcomes.1 It is important to find a balance between taking medications regularly yet not depending on them alone for improvement. Relying on medication too much can create unrealistic expectations for patients, yet too little medication compliance can make the lifestyle changes they wish to make much more difficult. It was interesting to watch Cooper's character struggle with allowing medications to be part of his toolbox.

The movie opens with Cooper's character being given his daily medication in the hospital. We see him put the capsule in his mouth and appear to swallow it, only to later see him spit it out on the floor. This tactic, well known to healthcare providers, is called “cheeking”. Though not a good example to patients receiving medication therapy, it is a true depiction of the difficulty often faced with getting patients to take their medications. Something we are taught in school regarding these medications is that consistent dosing is important to maintain symptomatic control making adherence very important. Cooper's character is a well groomed, seemingly intelligent person and it may surprise some to see that, yes, even he can be noncompliant.

There is also a scene around the dinner table, where two of the characters share their feelings on different psychiatric medications they have tried. This will seem familiar to many who have sat in a medication discussion group or counseled a patient. Many patients are good at remembering what they have tried and what side effects they have experienced. They often enjoy discussing them with others who have had similar experiences. This scene gave accurate drug information and also pointed out that side effects are one of the leading reasons patients may discontinue their medication. While side effects can be a big issue, it would have been nice for the beneficial aspects of medication use to be highlighted as well. Cooper does eventually agree to continue his medications while he begins the process of recovery, but the medication's role in his improvement is not mentioned again in the movie.

There are certainly going to be issues with any film trying to entertain us with a person's struggle against mental illness but it is also important to point out that this film uses the condition for some dark humor but never becomes a caricature of the illness. It portrays these people as normal human beings who are simply working through a difficult time in their lives. The medication related scenes in this movie proved to be real life struggles that many patients and practitioners face and could relate to. We found the medication aspects of this film to not only be accurate, but also correlate with the information we were taught in school.

Stigma as a barrier to recovery: Perceived stigma and patient-rated severity of illness as predictors of antidepressant drug adherence
Psychiatr Serv
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