EDITORIAL: Stigma of mental illness and us
PROGRAM DIRECTOR: “What do you think about this residency candidate?”
MEMBER OF THE SELECTION COMMITTEE: “This candidate is problematic. According to his personal statement, he had an episode of mental illness and has a strong family history of mental illness.”
PROGRAM DIRECTOR: “So, should we take him?”
MEMBER OF THE SELECTION COMMITTEE: “No, we should not unless you would like to have a ‘special’ project.”
— A fictional but realistic discussion among members of a psychiatry resident selection committee
This fictional discussion is an example of the stigmatization of mental illness within a community of mental health professionals who should be theoretically devoid of such beliefs and should actually play a strong role in destigmatizing mental illness. It suggests that psychiatrists are part of the problem because they may not be completely devoid of stigmatizing mental illness, even among their peers. Could this be true?
Stigma toward mental illness has likely been around since humans first recognized mental illness. In ancient Greece, the word stigma (meaning “brand”) was used to mark slaves or criminals, and throughout history, the word has been used as a mark of disgrace or infamy. Mental illness became one such mark, and people with mental illness have been stigmatized and mistreated ever since. As Rössler1 wrote, “For millennia, society did not treat persons suffering from depression, autism, schizophrenia and other mental illnesses much better than slaves or criminals: they were imprisoned, tortured or killed.”
Modern psychiatry and medicine are known to fight the stigmatization of mental illness, along with organizations such as the National Alliance on Mental Illness. Nevertheless, this stigma is alive and well among physicians and, to a certain degree, psychiatrists. How many psychiatrists remember the disbelief and discouragement from other physicians when, as medical students, they announced their choice of specialty? How many times have we heard negative remarks about people with mental illness, and even about psychiatrists, while walking through hospital corridors? And how many of us remember negative remarks about a fellow psychiatrist with a known mental illness?
The stigmatization of mental illness and psychiatry by the general public and other medical specialties is a common, yet poorly studied phenomenon. In a systematic review that examined attitudes toward people with mental disorders among primary care physicians (PCPs),2 the authors concluded that these stigmatizing attitudes are common, particularly among older and more experienced PCPs. Only a few studies have focused on stigma toward psychiatrists and psychiatry as a profession. For instance, in an international study, Gaebel et al3 showed that psychiatrists perceive themselves as being stigmatized to at least a moderate degree.
The actions of licensing boards also contribute to the perpetuation and fear of stigma among physicians and psychiatrists.4,5 In a powerful testimony on the stigmatization of mental illness, Hill6 eloquently wrote: “It’s ironic that mental health conditions are so stigmatized in the medical profession, given that physicians long fought to categorize them as medical diagnoses…. When mental health conditions come too close to us, we tend to look away—or to look with pity, exclusion, or shame. We may brand physicians who’ve had mental conditions, while fostering environments that impede their ability to become and remain well. When, recently, I moved to a new state and disclosed my history of mental health treatment, the licensing board asked me to write a public letter discussing my treatment—an archaic practice of public shaming.”
Little is known about how psychiatrists stigmatize mental illness. Interestingly, in a study of the attitudes of Polish psychiatrists toward people with mental illness, Kochan´ski and Cechnicki7 found that “despite their education and professional mission, Polish psychiatrists present similarly stigmatizing attitudes toward the mentally ill as does the general population.” In a study from Brazil,8 psychiatrists had a stronger prejudice toward schizophrenia than the general population. These disquieting findings suggest that psychiatrists are part of the problem, stigmatizing mental illness in their patients.
To our knowledge, no studies have examined psychiatrists who stigmatize mental illness among their psychiatric colleagues. However, we believe that, as illustrated by our fictional discussion among members of a psychiatry residency selection committee (which we believe is not unique), this stigmatization exists.
How do we fight the stigma that our patients face if we stigmatize even our physician and psychiatrist colleagues who have mental illness? As Rössler1 noted, stigma can be described in 3 conceptual levels: cognitive, emotional, and behavioral. Stigma of mental illness is, in a way, a phenomenon similar to antisemitism or racism. It is difficult to address the emotional level of these phenomena. However, we can address cognitive and behavioral aspects more easily. As Gaebel et al3 recommend, we need to target mental health professionals and medical students with anti-stigma measures, raise trust in mental health care services and those providing mental health care, and improve the image of psychiatry. Many other anti-stigma measures are discussed in the literature. However, we believe that the fight against the stigma of mental illness should start with fighting stigma within our own profession. The fight against stigma has to start with us.
Richard Balon, MD
Departments of Psychiatry and Behavioral
Neurosciences and Anesthesiology
Wayne State University
Tolan Park Building, 3rd floor
3901 Chrysler Service Drive
Detroit, MI 48201 USA
1. Rössler W. The stigma of mental disorders. A millennia-long history of social exclusion and prejudices. EMBO Rep. 2016;17:1250-1253.
2. Vistorte AOR, Ribeiro WS, Jaen D, et al. Stigmatizing attitudes of primary care professionals towards people with mental disorders: a systematic review. Int J Psychiatry Med. 2018;53:317-336.
3. Gaebel W, Zäske H, Zielasek J, et al. Stigmatization of psychiatrists and general practitioners: results of an international survey. Eur Arch Psychiatry Clin Neurosci. 2015;265:189-197
4. Gold KJ, Shih ER, Goldman EB, et al. Do US medical licensing applications treat mental and physical illness equivalently? Fam Med. 2017;49:464-467.
5. Gold KJ, Andrew LB, Goldman EB, et al. “I would never want to have a mental health diagnosis on my record”: A survey of female physicians on mental health diagnosis, treatment, and reporting. Gen Hosp Psychiatry. 2016;43:51-57.
6. Hill AB. Breaking the stigma – a physician’s perspective on self-care and recovery. N Engl J Med. 2017;376:1103-1105.
7. Kochan´ski A, Cechnicki A. The attitudes of psychiatrist toward people suffering from mental illnesses [in Polish]. Psychiatr Pol. 2017;51:29-44.
8. Loch AA, Hengartner MP, Guarniero FB, et al. The more information, the more negative stigma towards schizophrenia: Brazilian general population and psychiatrists compared. Psychiatry Res. 2013;205:185-191.