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Understanding Stigma Surrounding
Depression and Mental Health Issues
There is a great deal of stigma that surrounds mental health issues. Stigma refers to a cluster of negative attitudes and beliefs that motivate the general public to fear, reject, avoid and discriminate against people with mental illness.1 These negative attitudes may cause discrimination, isolation, devaluing, and other problems for persons with mental illness. Having good mental health enables one to make good decisions and deal with life’s challenges in an appropriate manner. However, individuals who are mentally ill sometimes behave in ways that are atypical; that is, they may act and/or appear different than the norm and are perceived as mentally unhealthy. As a result, people are uncomfortable about mental health problems and stigmatize, or exclude, those perceived as mentally ill. Most times, people who react this way do not mean to be cruel – they simply do not understand.
One source of stigma is the different view in society of mental illness, compared to heart disease, cancer, or other physical illnesses. Inaccuracies and falsehoods have led people to believe that an individual with a mental health problem has a weak character or is potentially dangerous. This prejudice manifests in distrust, fear, embarrassment, anger and/or avoidance. Stigma isolates the mentally ill; others may avoid living and working with, renting to, or employing someone with a mental disorder, especially if severe, such as schizophrenia.1,2 For an individual suffering from mental illness, these kinds of reactions may lead to low self-esteem, loss of dignity, loneliness, and hopelessness. The stigma against mental illness also has a negative impact on attitudes related to care for the mentally ill. Society tends to be less compassionate towards those suffering from mental illness, compared to physical sickness, and thus is less willing to pay for treatment for mental illness.
Roots of Stigma of Mental Illness3,4
Stigmatization of the mentally ill has existed throughout history. Long ago, mental illness was attributed to demonic possession. Skulls several thousands of years old have been found with holes drilled into them, a practice called trephining. Archaeologists believe the skulls were drilled to allow the evil spirit to leave the body. More recently, mental illness was “treated” with exorcism and prayer. A “possessed” person was subjected to torture, boiling, fire, or flogging in an attempt to “unsettle” the demonic spirit.
In colonial times, individuals with mental illness were called “lunatics.” There was no public support for care of the mentally ill; the responsibility for their care fell to their families. It is believed that in the great witch-hunts of the 1500’s and 1600’s, many of the “witches” were actually psychotic, that is they suffered from a mental illness characterized by delusional thinking and hallucinations. Later, isolated asylums housed the mentally ill, but rarely provided any treatment. Early medical theory about mental illness included the idea that it was caused by an imbalance of body “humors” (substances assumed to fl ow within the body) or too much energy. Many individuals who were institutionalized because of mental illness were often chained and not treated at all. One such place, Bedlam Hospital in London (from which comes the term “bedlam” meaning chaotic or insane mass behavior), actually charged admission for the public to come and gawk at the patients.
By the late 19th century, mental illness was commonly explained as the result of a person having somehow violated the physical, mental and moral laws of nature. A popular belief was that when these laws were properly obeyed, the result would be not only the “highest development of the race, but the highest type of civilization.”5,6 Even today, these historical influences exert a significant influence on public perception of the mentally ill. Most people have their expectations about how a person with a mental illness is likely to behave but don’t realize where their opinions come from. Instead of being based on fact, current thinking about mental health issues is shaped by enduring misconceptions that are reinforced by today’s culture. We are surrounded by negative stereotypes: Popular movies5 depict killers as deranged. The news plays up stories about a horrific crime committed by someone believed to be psychotic.
Insensitive jokes use terms such as “psycho” and “crazy.” The prevailing assumption that all homeless people are mentally ill goes unchallenged. The news media, and especially the entertainment media, sometimes promote misunderstanding and an uncaring attitude about mental illness by characterizing its victims as aggressive, volatile, dangerous and unstable. As a result, mental illness has not received the sensitive media coverage that other health issues, such as cancer or diabetes, have been given.
The stigma that surrounds mental illness continues to be strong, despite intensive public education efforts to overcome it. Disability and access issues affecting the mentally ill persist despite laws passed in the past 25 years (e.g., Individuals with Disabilities Education Act [IDEA]; Americans with Disabilities Act [ADA];
Mental Health Parity Legislation) to create rights and protections for persons with mental illness.
This prejudice is rooted in fear: People with mental illness, especially those with psychosis, are perceived to be more violent.7 But are people with mental disorders truly more violent? This is a serious concern that has been the subject of considerable scientific study. The consensus among researchers to some extent does support the popular view that violence and mental illness are linked, but almost exclusively as the result of co-occurring substance abuse, not mental illness. In such cases, violent behavior is primarily attributed to either the effect of substance abuse or the patient’s failure to take his or her prescribed medication.8,9
In those exceptions when substance abuse was not a factor, paranoid psychosis was associated with violence, but even those occurrences have been rare.7,9,10 In actuality, the probability that a mentally ill person will become violent is very small, and most instances of violent behavior are initiated by individuals without a diagnosable mental illness.11
In the rare instance when a mentally ill person becomes violent, the act almost always is directed at a family member or acquaintance. In fact, the risk is extremely low of a stranger being harmed by an individual with a mental disorder.9 But because the average person does not know how to judge the behavior of someone who is acting erratically, the natural tendency is to be cautious and distrustful. This common reaction only further isolates the mentally ill, which is unfortunate, given that the overall risk they pose to society is exceptionally small.7
In contrast to the few mentally ill persons who may act in overtly different or erratic ways at times, most persons with a mental disorder are not likely to behave differently than others. In fact, most people are unaware that everyday they encounter persons with mental health problems. Only when a crisis occurs does a problem become apparent. A 1996 study probing public perceptions of mental illness revealed beliefs and attitudes that varied with diagnosis. The public was more likely to consider an individual with schizophrenia as mentally ill than an individual with depression, but respondents’ desire to socially exclude both groups was the same.12
What Are the Effects of Stigma?
Everyday people with mental illness must endure stigma that affects all areas of their lives. Stigma is one of the greatest barriers to their enjoying a complete and satisfying life, often blocking access to adequate housing, health insurance, a loan or a job. Perhaps the greatest consequence is the impact on getting treatment. Polls show that most people believe that medical care for mental illness should be improved, but they are unwilling to pay for it by increasing either insurance premiums or taxes. Mental health still ranks below somatic disorders as a health insurance priority.1,13,14
The costs and stigma associated with mental illness discourage nearly two-thirds of the people suffering from a mental disorder from seeking treatment.15,16,17 Most people will delay getting help for themselves, their spouse or child because they fear the consequences of disclosure. This fear is not unfounded. Diagnosis and treatment of mental illness can often lead to more isolation, rather than a return to a normal life, as the sufferer encounters fear and rejection from others. Recent research refers to this as “self-stigma.”1 In contrast, when a person with cancer seeks medical help, others generally respond with support and sympathy, and if treatment is successful, life afterwards returns to normal. Rarely do others perceive the former cancer patient in negative terms. For a variety of complex reasons in many societies, mental disorders such as depression are not regarded the same as other organ disorders such as heart disease, breast cancer, or spinal cord injuries resulting in paraplegia.17,18
Stigma and shame associated with mental illness carry a profound effect in certain racial and ethnic minority groups.14,19 For example, Asian Americans are far less likely to access mental health services than non-Hispanic whites and, a major reason seems to be the social stigma that is associated with mental illness within the culture of Asian American families. This stigma offers one possible explanation for why Asian Americans score higher on symptom scales compared to members of other racial groups: They delay seeking treatment until their problems reach more serious levels. The reasons for this are complex and need research to be fully understood.
Longstanding issues of racism and discrimination toward minorities also contribute to stigmatization and present barriers to accessing mental healthcare. The history of officially authorized racism and discrimination against African Americans, Native Americans and immigrants of other ethnic minority groups in the United States foreshadows the specter of mental health problems in these populations. Studies have shown that experiences of racial bias and discrimination are psychologically stressful events, and this stress may increase the risk for poorer health and mental health outcomes in minority populations.19
Research on African American populations, for example, has revealed that the stress from incidents of self-reported racism or discrimination can negatively influence physical health issues such as hypertension and mental health factors such as psychological distress and well-being.20, 21 Symptoms of depression have also been linked to perceived discrimination in a study involving 5,000 children of Asian, Latin American, and Caribbean immigrants.22 In addition, findings from research studies published in 1999 and 2000 reported a strong relationship between perceived discrimination and depressive symptoms in a group of adults of Mexican origin and among Asians.23,24
Taken collectively, recent research demonstrates a significant association between the effects of racism and discrimination in minority populations and greater levels of stress, thus putting minorities at risk for depression, anxiety and other mental disorders.20, 25 This association does not imply causation, but just as the need exists for more research into the impact of social and cultural influences on mental health, the stigmatizing effects of racism merit further study.26
How Do We Erase Stigma?
We can only start to erase the stigma that surrounds mental health issues when we first have facts. There is no single solution. Professionals and consumer groups have long thought that stigma would decline as public knowledge of mental illness increased, but even though information about mental illness is more available, stigma in some ways has intensified over the past 40 years.1,2 Apparently, the facts alone are not enough. Current research indicates that furnishing practical information about mental illness and violent behavior can help dispel negative perceptions about severe mental disorders. Other approaches to stigma reduction involve programs that offer advocacy, public education, and contact with persons with a mental illness through schools and other societal institutions.1,18
Some mentally ill persons, their families and friends, as well as some mental health providers, are taking proactive measures to reduce stigma. In the past two decades, they have joined with consumer and advocacy groups (e.g. NAMI – National Alliance for the Mentally Ill, Federation of Families, and Bazelon Center for Mental Health Law) and government agencies (e.g. NIMI – National Institute of Mental Health and SAMHSA – Substance Abuse and Mental Health Services Administration) to make the plight of the mentally ill a mainstream political issue. As a result, persons with mental illness and their families have been empowered, and society’s attitudes about mental illness are slowly changing.
Stigma must be overcome if persons with mental illness are to live as full citizens, with opportunities to contribute to society and pursue happiness. When people finally believe that mental disorders are not the result of some moral failing or personal weakness but are medical conditions that warrant specific treatments and a commitment to research, much of the negative stereotyping may dissolve. As stigma subsides, people will be more willing to seek treatment, and as the costs are assimilated into the health care system, it will be more affordable. In turn, support for public funding for research into mental illness will increase, enhancing the hope for even the most severe disorders.13,16
No matter how a person develops a mental illness, there is a treatment that can bring some improvement and lead to a more fulfilling life. But to help all those who need care, society first must understand that mental wellness is integral to being healthy and our health care system should help, not exclude, those who need treatment.
The National Mental Health Services Knowledge Exchange Network http://www.mentalhealth.samhsa.gov/stigma/ This government website contains many free resources on stigma and mental health.
Southern Poverty Law Center
This site has a wealth of links and resources for teens and teachers, including grant opportunities for teaching tolerance in the schools.
American Psychological Association Help Center http://helping.apa.org Search site for “stigma” for links to many useful articles.
American Mental Health Awareness Campaign http://www.nostigma.org For many excellent materials, click on “Teens,” then “Stigma.”
U.S, Surgeon General’s Report on Mental Health http://www.surgeongeneral.gov/library The Surgeon General’s Report on Mental Health has an informative section, “Roots of Stigma.” For more on how stigma affects minority populations, check out the supplement to the report, titled “Culture Race and Ethnicity.”
NAMI – The Nation’s Voice on Mental Illness http://www.nami.org/Content/NavigationMenu/Take_Action/Fight_Stigma/Fight_Stigma__ StigmaBusters.htm
This organization’s website contains great information about StigmaBusters, a program to dispel stigma.
University of Chicago Center for Psychiatric Rehabilitation
This is the home page for a leading research center on mental illness and stigma.
1. Corrigan PW, Penn DL. Lessons from social psychology on discrediting psychiatric stigma. American Psychologist. 1999;54:765-776.
2. Penn DL, Martin J. The stigma of severe mental illness: some potential solutions for a recalcitrant problem. Psychiatric Quarterly. 1998;69:235-247.
3. History of mental illness. Available at http:// www.bipolarworld.net/Diagnosis/Mental_Illness/ history.html Accessed September 8, 2003.
4. Roots of Stigma. Surgeon General’s Report on Mental Illness. U.S. Department of Health and Human Services, 1999. Available at http://www.surgeongeneral.gov/library/mentalhealth/chapter1/sec1.html
Accessed September 8, 2003.
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6. Grob GN. From Asylum to Community: Mental Health Policy in Modern America. Princeton, NJ:
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9. Eronen M, Angermeyer MC, Schulze B. The psychiatric epidemiology of violent behavior. Social Psychiatry and Psychiatric Epidemiology.
10. Swartz MS, Swanson JW, Burns BJ. Taking the wrong drugs: the role of substance abuse and medication noncompliance in violence among severely mentally ill individuals. Social Psychiatry and Psychiatric Epidemiology. 1998;33(suppl 1):
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14. Sussman LK, Robins LN, Earls F. Treatmentseeking for depression by black and white Americans. Social Science and Medicine. 1987;24:
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of patient attitudes and preferences regarding treatment of depression. Journal of General Internal Medicine. 1997;12:431-438.
16. Regier DA, Narrow WE, Rae DS, Manderscheid RW, Locke BZ, Goodwin FK. The de facto US mental and addictive disorders service system:
Epidemiologic Catchment Area prospective, 1-year prevalence rates of disorders and services. Archives of General Psychiatry. 1997;50:85–94.
17. Kessler RC, Nelson CB, McKinagle KA, Edlund MJ, Frank RG, Leaf PJ. The epidemiology of co-occurring addictive and mental disorders: implications for prevention and service utilization. American Journal of Orthopsychiatry.1996;66:17-31.
18. Burrell D. Eliminating stigma of mental health. In:
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19. U.S. Department of Health and Human Services.
Mental Health: Culture Race and Ethnicity – A Supplement to Mental Health: A Report of the Surgeon General. Rockville, Md: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services; 2001.
8-7 University of Arkansas, Board of Trustees © 2002. All rights reserved.
20. Clark R, Anderson NB, Clark VR, Williams
DR. Racism as a stressor for African
Americans: a biopsychosocial model. American Psychologist.1999;54:805-816.
21. Williams DR, Yu Y, Jackson JS, Anderson NB.
Racial differences in physical and mental health:
socio-economic status, stress and discrimination.
Journal of Health Psychology. 1997;2:335-351.
22. Rumbaut RG. The crucible within: ethnic identity, self-esteem, and segmented assimilation among children of immigrants. International Migration Review. 1994;28:748-794.
23. Finch BK, Kolody B, Vega WA. Perceived discrimination and depression among Mexicanorigin adults in California. Journal of Health and Social Behavior. 2000;41:295-313.
24. Noh S, Beiser M, Kaspar V, Hou F, Rummens J.
Perceived racial discrimination, depression and coping: a study of southeast Asian refugees in Canada. Journal of Health and Social Behavior. 1999;40:193-207.
25. Williams DR. Race, stress, and mental health.
In Hogue C, Hargraves M, Scott-Collins K, eds. Minority health in America. Baltimore, MD: Johns Hopkins University Press; 2000:209-243.
26. Williams DR, Williams-Morris R. Racism and mental health: the African-American experience. Ethnicity and Health. 2000;5:243-268.
Sponsored by the UAMS College of Medicine, Department of Psychiatry Partners in Behavioral Health Sciences program which is made possible by support from a Science Education Partnership Award (R25 RR15976) from the National Center for Research Resources at the National Institutes of Health.