In recent decades, societal conceptions of mental health and mental illness have evolved significantly. Compared to prevailing attitudes of the early 1900’s, the general public and scientific community alike have become much more aware and knowledgeable of mental illness: its causes, severity, prevalence and treatments [1]. With increased basic and clinical research into the fields of mind, brain and behavior, more effective and accessible treatments for all types of disorders may soon be realized.

However, all the efforts and successes of the scientific community are critically undermined by the presence of a persistent, widespread societal stigma against mental illness. An afflicted individual suffers the additional burden of being stereotyped as violent, different from “normal” people, unstable, unreliable, beyond medical help, weak, or responsible for his or her condition [2, 3]. In the 1999 report on mental health by the U.S. Surgeon General, stigma was identified as the single largest barrier to future progress in reducing the disease burden of mental illnesses [1].

The impact of stigma upon individuals with mental disorders is multi-faceted and devastating. To begin with, negative perceptions of the mentally ill discourage these individuals from seeking help in the first place, out of embarrassment or fear of becoming permanently labeled. It’s been estimated that nearly two-thirds of people with mental illness do not receive professional treatment [1], a public health tragedy considering that, of 30,000 yearly suicides in the US, about 90% are committed by individuals with mental disorders [4]. Even a hesitation in the choice to get help can have serious consequences: research has shown that early intervention in the progress of mental diseases correlates with an improved success of treatment. Eradication of the stigma associated with mental illness would likely mean that not only would more people seek help, but also that they would get it earlier.

If the perception of stigma doesn’t prevent an individual from seeking help in the first place, it may influence him or her to prematurely end professional treatment, as shown in a study of patients with major depressive disorder and their adherence to antidepressant drug therapy [5]. As psychosocial and pharmacological treatments for mental disorders increase in number and efficacy, it is critical the compliance rate be increased so that benefits from these treatments can be reaped.

Stigmatization also contributes to the isolation of the mentally ill from the people around them. Authors of a recent paper demonstrated that for individuals with bipolar disorder, elevated concerns about stigma directly correlated with a lower degree of integration into social circles outside the family [6]. In turn, this poorer social adjustment will inhibit recovery of mental health. Even within the smaller and more intimate sphere of family relations, the perception of stigma can be damaging. Relatives of a person with mental illness often feel shame and worry about stigma against the family as a whole; this distress will negatively impact the ill family member and may exacerbate symptoms of the mental disorder [6].

Another serious effect of stigmatization is its potential to erode the self-esteem of individuals with disorders. When an individual expects and fears rejection by society, feelings of self-esteem and self-worth will be compromised, and one research study empirically proved a connection between the level of stigma perceived by individuals with disorder and their feelings of self-esteem [7]. The authors concluded that a reduction in stigma should have the therapeutic effect of improving self-esteem.

All these harmful effects of stigma may seem rather obvious and undeniable, yet there exist layers of complexity to the issue which must be considered. For one, the stigma is not the same for all types of mental illness: public opinions concerning schizophrenia are more extreme than those relating to depressive disorders, for example [8]. Another study showed that the general public can distinguish about seven different types of disorder, and that the nature of their negative perceptions varies by illness [3]. The implication is that perhaps destigmatization efforts should be focused upon specific forms of mental illness differentially, rather than grouping all of them together under the broad concept of “mental illness.”

Another complication is that stigma varies in nature across the global population. People display different attitudes towards mental illness based on their age, gender, education level, cultural background, and amount of previous contact with people with mental illness [5, 9, 10]. This would imply that destigmatization may require methods which are as varied as the people who hold the stigma.

Also, there can be a discrepancy between the perceived stigma experienced by an individual as compared to the actual stigma [6, 11]. For example, a person who has been hospitalized for an illness and is preparing to reenter mainstream society may fear that he will never be able to find meaningful employment because of the prejudice of employers. This perceived stigma may be more extreme than the reality of the situation, but it is the discrimination perceived by the affected individual that would give rise to feelings of hopelessness and lowered self-confidence. Both sides of stigmatization must be recognized, addressed by research, and ultimately reduced.

Finally, because the effects of stigmatization and the symptoms of the disorder itself are so similar, it can be difficult to resolve the two factors [10]. Feelings of paranoia, distrust, fear and low self-worth are all core symptoms of various mental disorders and, at the same time, effects of stigma and discrimination. Because of the interrelationship of the two causes, they can give rise to a “vicious cycle” effects of stigmatization aggravate mental illness, which in turn increases stigmatization of an individual, and so on [11].

As the Surgeon General insisted in the 1999 report, it’s imperative that the stigmatization of mental illness be combated and, ideally, eliminated [1]. It is not yet clear, however, how this goal can best be realized. One group of researchers found, to their surprise, that people with greater medical knowledge about mental illness tend to display increased social distance from the mentally ill [9]. These results indicate that transmission of knowledge of mental illness alone may not be destigmatizing.

Some anti-stigma campaigns have been centered upon the idea that the genetic bases for mental disorders should be firmly established and highlighted in the eyes of the public [12]. The argument is that if mental disorders are fundamentally biological in nature, not the result of weaknesses in character or poor upbringing, then individuals with mental illness could not be held responsible for their condition or expected to simply “pull themselves together.” At least one study has shown that less stigma is exhibited by people who perceive the illness to be the result of factors not controlled by the individual [4].

However, critics of this theory warn that overemphasizing the genetic causes of mental illness may have the exact opposite effect for several reasons. For one, the portrayal of ill individuals as inherently flawed on the genetic level could add to the negative perceptions which already give rise to stigmatization. Also, to emphasize that disorders are genetic in origin would imply that people with mental illness and their relatives are carriers for highly undesirable traits, a consideration which would certainly impact choices made in marriages and other intimate relationships [13]. This debate underscores the fact that destigmatization campaigns must be designed carefully; to do so, more research into what type of education efforts have the most positive effects is warranted.

Some recent studies have shown that a sense of optimism about treatment options can serve as a powerful anti-stigma device by discrediting the idea that disorders are permanent and incurable [8]. Therefore, the general public should become more educated about the growing number of effective treatment options available to help individuals achieve mental health and stability. This could be achieved, in part, by disseminating research news beyond the academic and clinical communities and out to the general public.

One specific and deeply troubling form of stigma is that exhibited by health care professionals themselves, and some anti-stigma campaigns have been specifically aimed at physicians, nurses and other health care providers [14]. A patient would be less likely to seek and/or adhere to treatment when he or she does not trust the professionals administering the treatment. Additionally, health care professionals can advocate for public policy changes that might assist and support the mentally ill in places of employment, health care institutions, schools and other arenas of public and private life. Reduction of stigma within the medical community hopefully would encourage this type of political action [4].

If the stigmatization of mentally ill individuals is not countered and eliminated, progress towards improving the overall mental health of our society will always be hindered. The first steps might be increased research into fully understanding the nature of stigma, the factors which determine degree of stigmatization, and the effects of stigma upon the mentally ill: some experts in the field express doubt that research performed to date has adequately addressed these issues [10]. Better research methods for assessing the effectiveness of anti-stigma programs certainly would help as well, especially because there exists debate about what type of program is best. In the end, efforts to end stigmatization will require sustained and persistent work on the part of the medical community, policy makers, the popular media and general public altogether.

References

1. Mental Health: A Report of the Surgeon General. Washington, DC, US Department of Heath and Human Services, 1999.

2. Link BG, Phelan JC, Bresnahan M, et al: Public conceptions of mental illness: labels, causes, dangerousness and social distance. American Journal of Public Health 89:1328-1333, 1999.

3. Crisp AH, Gelder MG, Rex S, et al: Stigmatisation of people with mental illnesses. British Journal Psychiatry 177:4-7, 2000.

4. Halter MJ: Stigma and help seeking related to depression: a study of nursing students. Journal of Psychosocial Nursing and Mental Health Services 2:42-51, 2004.

5. Sirey J, Bruce ML, Alexopoulos GS, et al.: Perceived stigma and patient-rated severity of illness as predictors of antidepressant drug adherence. Psychiatric Services 52:1615-1620, 2001.

6. Perlick DA: Special section on stigma as a barrier to recovery: introduction. Psychiatric Services 52:1613-1614, 2001

7. Link BG, Struening EL, Neese-Todd S, et al: The consequences of stigma for the self-esteem of people with mental illnesses. Psychiatric Services 52:1621-1626, 2001

8. Mann CE and Himelein MJ: Factors associated with stigmatization of persons with mental illness. Psychiatric Services 55:185-187, 2001

9. Lauber C, Nordt C, Falcato L, et al: Factors influencing social distance toward people with mental illness. Community Mental Health Journal 40:265-274, 2004

10. Hinshaw SP and Cicchetti D: Stigma and mental disorder: conceptions of illness, public attitudes, personal disclosure, and social policy. Development and Psychopathology 12:555-598, 2000

11. Ertugrul A and Ulu B: Perception of stigma among patients with schizophrenia. Social Psychiatry and Psychiatric Epidemiology 39:73-77, 2003

12. See, for example, the website of the National Alliance of the Mentally Ill: http://www.nami.org

13. Phelan JC: Genetic bases of mental illness: a cure for stigma? Trends in Neurosciences 25:430-431, 2002

14. Bolton J: How can we reduce the stigma of mental illness? BMJ Career Focus 326:57, 2003

Report by: Christine Loftus
Writer, Global Neuroscience Initiative Foundation
Faculty, Seattle Central College

Commissioned by: Shaheen Lakhan
Executive Director, Global Neuroscience Initiative Foundation