Discrimination in health care against people with mental illness

This paper discusses factors associated with low rates of help-seeking and poorer quality of physical healthcare among people with mental illnesses. Evidence is reviewed on the associations between low rates of mental health literacy, negative attitudes towards people with mental illness, and reluctance to seek help by people who consider that they may have a mental disorder. People with mental illness often report encountering negative attitudes among mental health staff about their prognosis, associated in part with 'physician bias'. 'Diagnostic overshadowing' appears to be common in general health care settings, meaning the misattribution of physical illness signs and symptoms to concurrent mental disorders, leading to underdiagnosis and mistreatment of the physical conditions.     

Toward a family-oriented treatment approach for consumers and carers of mental illness

In 2010–2011, a qualitative focus group study was commissioned by Australia’s beyondblue to explore the needs and experiences of consumers and carers of mental illness. Overall, it was found that their ‘stories’ are substantially different from one another, leading to high stigma within families. The aim of this article is to discuss these phenomena more deeply. In summary, the pervasive stigma associated with mental illness in society affects: people from gaining in-depth knowledge about it and therefore capacity to recognize symptoms early and provide the necessary empathy required; the capacity of health professionals to provide holistic treatment and not simply rely on a ‘medical model’; and the provision of adequate funding to ensure the formal mental health system has appropriate infrastructure to meet consumers’ needs. Stigma essentially hides mental illness from the community, placing pressure on families to provide support instead who may lack the expert knowledge that clinical consumers require. The ongoing and stressful nature of caring can cause carers to develop stigmatic attitudes and behaviors. These are intensified with misperceptions about consumers’ control over their mental illness, unequal distributions of attention within the household, and low consumer insight into the carer experience. It can also lead to the development of their own trauma that requires formal help. To address these complex issues, stigma is the foremost issue in need of redress. It can help reduce barriers to help-seeking in both consumers and carers, and ensure the provision of an informed and well-resourced ‘mental health response’ for families.     

How mental health literacy and experience of mental illness relate to stigmatizing attitudes and social distance towards people with depression or psychosis: A cross-sectional study

Background Evidence suggests that mental health literacy among the public is low, and stigmatizing attitudes are widespread. So far the effects of anti-stigma campaigns are small, and studies demonstrate that negative attitudes have been quite stable through recent decades. Aims To investigate the relationships between mental health literacy, experience of mental illness and stigmatizing attitudes/social distance towards people with depression or psychosis. Methods A cross-sectional study in which staff members from public services in Sweden (n?=?1027) completed questionnaires covering demographic data, self-reported experience of mental illness, identification of a vignette for depression or psychosis, beliefs about helpful interventions for the illness presented in the vignette, and attitudes and social distance towards people with the illness. Results About 50% of participants could identify depression and less than 40% psychosis. A higher degree of mental health literacy was related to less stigma and social distance but mainly towards people with depression. A similar relationship was shown for having personal or family experience of mental illness and attitudes/social distance. Negative attitudes and social distance were significantly higher in all aspects measured towards a person with psychosis than a person with depression. Conclusions A higher degree of mental health literacy relates to more positive attitudes and less desire for social distance towards people with depression. The differences between depression and psychosis should be taken into account in anti-stigma interventions.     

An admixture analysis of the age at index episodes in bipolar disorder

Similar to members of the public, people with mental illness may exhibit general negative automatic prejudice against their own group. However, it is unclear whether more specific negative stereotypes are automatically activated among diagnosed individuals and how such automatic stereotyping may be related to self-reported attitudes and emotional reactions. We therefore studied automatically activated reactions toward mental illness among 85 people with schizophrenia, schizoaffective or affective disorders as well as among 50 members of the general public, using a Lexical Decision Task to measure automatic stereotyping. Deliberately endorsed attitudes and emotional reactions were assessed by self-report. Independent of diagnosis, people with mental illness showed less negative automatic stereotyping than did members of the public. Among members of the public, stronger automatic stereotyping was associated with more self-reported shame about a potential mental illness and more anger toward stigmatized individuals. Reduced automatic stereotyping in the diagnosed group suggests that people with mental illness might not entirely internalize societal stigma. Among members of the public, automatic stereotyping predicted negative emotional reactions to people with mental illness. Initiatives to reduce the impact of public stigma and internalized stigma should take automatic stereotyping and related emotional aspects of stigma into account.     

Case managers' attitudes to the physical health of their patients

OBJECTIVE: To examine the attitudes and practices of case managers working in Area Mental Health Services (AMHS) towards the physical health of people with chronic mental illness. METHOD: Case managers at four AMHS in Melbourne participated in focus groups and completed a survey questionnaire. RESULTS: Case managers generally believed that mental illness, psychotropic medication and lifestyle factors contributed to the poor physical health status of their patients. Although many case managers attempted interventions aimed at improving physical health, there was inconsistency regarding the areas targeted. Preventive health measures were often neglected. Overall, there was a sense of pessimism around whether improved physical health was possible for people with chronic mental illness. CONCLUSIONS: Lack of coordination among health professionals and the health system may contribute to the poor general health of people with mental illness. Patients often have difficulty accessing general practitioners and the culture within the AMHS can exclude considerations of physical health. Case management should include aspects addressing the physical health issues of AMHS clients.     

Attitudes Towards the Mentally Ill: A Study with Health Workers at a University Hospital in Rio de Janeiro

As there are few studies about evaluation of attitudes of health care workers to people with mental disorders in Brazil, a cross-sectional study was carried out to assess the health professionals’ attitudes working in a university hospital in Rio de Janeiro and also examine the proportion of negative and positive attitudes endorsed by healthcare professionals in Brazil towards people with mental illness in comparison with other parts of the world. Data were collected using the Community Attitudes towards the Mentally Ill (CAMI) in a random sampling frame of health professionals (n = 246) working in a University Hospital in Rio de Janeiro between April 2013 and June 2013. The CAMI consists of four sub-scales: Authoritarianism, Benevolence, Social Restrictiveness and Community Mental Health Ideology. The results showed attitudes that range from neutral to positive, with the Benevolence and Social Restrictiveness sub-scales showing the least stigmatizing results. The following individual characteristics were associated with negative attitudes: lower levels of education and less clinical experience. In general, health workers attitudes towards service users are characterized as positive when compared with other international studies. However, educational programs for health workers should be reinforced to further promote pre-existing positive attitudes towards people with mental health and the implementation of Brazilian Mental Health Policies.     

Implicit and explicit stigma of mental illness: links to clinical care

This study examined implicit and explicit measures of bias toward mental illness among people with different levels of mental health training, and investigated the influence of stigma on clinically-relevant decision-making. Participants (N = 1539) comprised of (1) mental health professionals and clinical graduate students, (2) other health care/social services specialists, (3) undergraduate students, and (4) the general public self-reported their attitudes toward people with mental illness, and completed implicit measures to assess mental illness evaluations that exist outside of awareness or control. In addition, participants predicted patient prognoses and assigned diagnoses after clinical vignettes. Compared with people without mental health training, individuals with mental health training demonstrated more positive implicit and explicit evaluations of people with mental illness. Further, explicit (but not implicit) biases predicted more negative patient prognoses, but implicit (and not explicit) biases predicted over-diagnosis, underscoring the value of using both implicit and explicit measures.     

Do people with mental illness deserve what they get? Links between meritocratic worldviews and implicit versus explicit stigma

Meritocratic worldviews that stress personal responsibility, such as the Protestant ethic or general beliefs in a just world, are typically associated with stigmatizing attitudes and could explain the persistence of mental illness stigma. Beliefs in a just world for oneself (“I get what I deserve”), however, are often related to personal well-being and can be a coping resource for stigmatized individuals. Despite these findings in other stigmatized groups, the link between worldviews and the stigma of psychiatric disorders is unknown. We measured just world beliefs for self and others as well as endorsement of the Protestant ethic in 85 people with schizophrenia, schizoaffective or affective disorders and 50 members of the general public. Stigmatizing attitudes toward people with mental illness (perceived responsibility, perceived dangerousness, general agreement with negative stereotypes) were assessed by self-report. Using a response-latency task, the Brief Implicit Association Test, we also examined guilt-related implicit negative stereotypes about mental illness. We found a consistent positive link between endorsing the Protestant ethic and stigmatizing self-reported attitudes in both groups. Implicit guilt-related stereotypes were positively associated with the Protestant ethic only among members of the public. Among people with mental illness, stronger just world beliefs for self were related to reduced self-stigma, but also to more implicit blame of persons with mental illness. The Protestant ethic may increase (self-)stigmatizing attitudes; just world beliefs for oneself, on the other hand, may lead to unexpected implicit self-blame in stigmatized individuals. Public anti-stigma campaigns and initiatives to reduce self-stigma among people with mental illness should take worldviews into account.     

Attitudes Toward Community Mental Health Care: The Contact Paradox Revisited

Contact with people with mental illness is considered to be a promising strategy to change stigmatizing attitudes. This study examines the underlying mechanisms of the association between contact and attitudes toward community mental health care. Data are derived from the 2009 survey “Stigma in a Global Context—Belgian Mental Health Study”, using the Community Mental Health Ideology-scale. Results show that people who received mental health treatment themselves or have a family member who has been treated for mental health problems report more tolerant attitudes toward community mental health care than people with public contact with people with mental illness. Besides, the perception of the effectiveness of the treatment seems to matter too. Furthermore, emotions arising from public contact are associated with attitudes toward community mental health care. The degree of intimacy and the characteristics of the contact relationship clarify the association between contact and attitudes toward community mental health care.     

Gateways to Mental Illness Discourse: Tools for Talking with Teenagers

The existence of mental health discrimination is well-documented, and research suggests that negative attitudes to mental illness are particularly prevalent among adolescents. While recent years have seen much activity aiming to reduce this discrimination, little of it has been targeted at young people or based in schools. The first stage of targeted anti-discrimination enterprise must be to understand the current views of the target group. However, research into how young people construct and occupy mental illness discourse is sparse. In this qualitative study, the ways in which adolescents construct understandings of mental illness are explored, using an innovative photovignette technique. Eighteen young people aged 14—18 participated. The photo-vignette method enabled participants to engage with figurative narratives of mental illness, and responses indicated that life history explanations for mental illness helped young people adopt non-discriminatory positions. These findings are considered in relation to the development of strategies for reducing mental health discrimination through education.     

Characteristics of Vietnamese patients attending an anxiety clinic in Australia and perceptions of the wider Vietnamese community about anxiety

This article examined the causes underlying low utilization of mental health services by Vietnamese immigrants in Australia. Study 1 examined cases of Vietnamese patients who had attended an anxiety disorders clinic, while Study 2 surveyed Vietnamese people in the community on their knowledge and attitudes towards common mental problems. Results from Study 1 showed that Vietnamese patients had significantly higher attrition rates, and presented with a larger number of nonanxiety disorders than their Australian-born counterparts. Study 2 results indicated that many Vietnamese people did not differentiate clearly between the terms 'stress', 'anxiety' and 'depression'. Additionally, many participants felt that there was a generally negative cultural attitude towards people suffering from these problems and the mental health system itself. These outcomes suggest the importance of education for ethnic communities regarding available mental health facilities and treatments offered, as well as specific information on mental illness to help remove stigma.     

‘Individualism-Collectivism’ as an Explanatory Device for Mental Illness Stigma

The aim of this study is investigate whether the cross-cultural value paradigm ‘individualism-collectivism’ is a useful explanatory model for mental illness stigma on a cultural level. Using snowball sampling, a quantitative questionnaire survey of 305 individuals from four UK-based cultural groups (white-English, American, Greek/Greek Cypriot, and Chinese) was carried out. The questionnaire included the ‘Community Attitudes to Mental Illness scale’ and the ‘vertical-horizontal individualism-collectivism scale’. The results revealed that the more stigmatizing a culture’s mental illness attitudes are, the more likely collectivism effectively explains these attitudes. In contrast, the more positive a culture’s mental illness attitudes, the more likely individualism effectively explains attitudes. We conclude that a consideration of the individualism-collectivism paradigm should be included in any future research aiming to provide a holistic understanding of the causes of mental illness stigma, particularly when the cultures stigmatization levels are particularly high or low.     

Mexican Psychiatric Trainees’ Attitudes Towards People with Mental Illness: A Qualitative Study

Despite their training, psychiatrists have been found to have negative attitudes towards people with mental illness, including the patients they treat. Similarly, studies focused on service users have identified psychiatrists as a source of stigma. Even though negative attitudes in psychiatrists have been identified in different countries and settings, in Mexico the attitudes of these professionals have never been assessed. Because of this, we invited psychiatric trainees from a hospital in Mexico to participate in individual interviews to describe their opinions regarding mental health-related stigma, to evaluate their attitudes towards people with mental illness and to identify factors that could be influencing their attitudes. Interviews were audio recorded, transcribed and analysed using thematic analysis. A total of 29 trainees participated in the study. The results suggested that trainees recognised psychiatrists can have negative attitudes towards people with mental illness, such as poor empathy, judgement and labelling, and mainly towards patients considered difficult and with borderline personality disorder. Participants recognised these attitudes can influence their relationship with patients, and considered it is necessary to develop interventions to improve their own attitudes and reduce mental health stigma. From this study we concluded Mexican psychiatrists are not free from stigma towards people with mental illness. However, Mexican psychiatric trainees are interested in improving their attitudes and reactions towards their patients.

     

Mental health literacy among young people in a small US town: recognition of disorders and hypothetical helping responses

Aim: Mental health literacy may be a factor in early detection and prompt treatment for mental, emotional and behavioural disorders among young people. Building on previous research in Australia, this study assessed aspects of mental health literacy among adolescents in classrooms in a small town in the eastern USA. Methods: The students were provided brief, hypothetical, gender-matched scenarios about adolescents experiencing negative emotions and exhibiting related behaviours; some scenarios depicted diagnosable disorders. The respondents were asked to characterize each scenario as describing a mental health problem or other teen problem and indicate how they would respond to a peer who had such a problem. Results: Overall levels of recognition of mental disorders were low (27.5% identified anxiety and 42.4% identified depression as ‘a mental health problem or illness’). However, the respondents who recognized a disorder were three to four times more likely than those who did not to say they would take some helping action, such as telling an adult about the problem (depression: odds ratio 3.27; CI 1.43–7.46, anxiety: OR 4.43; CI 2.23–8.79). Few students (27.7%) remembered in-class discussions of mental health, a mandated health topic for schools in their area. Conclusions: There appears to be substantial room for improvement in mental health literacy among young people, and the development of interventions to enhance mental health literacy among students may be justified.     

Semen-loss syndrome: a comparison between Sri Lanka and Japan

In some cultures semen loss is associated with illness, anxiety, and loss of energy and power. Thirty-five nonpsychotic patients attending a psychiatric clinic in Sri Lanka during one month, attributed their complaints of sexual dysfunction, lethargy, thinness, and miscellaneous aches and pains to semen loss resulting from masturbation or nocturnal emissions. Similar complaints are rare among psychiatric patients in Japan. A survey questionnaire designed to measure negative attitudes and beliefs regarding semen loss was used to measure such attitudes in a patient population and a general university population in Sri Lanka and Japan. The survey disclosed that unlike in Japan, people in Sri Lanka consider semen loss to be detrimental to mental and physical health. Attitudes regarding semen loss were the most negative in the patient population. These results indicate the possibility that culturally held negative attitudes and beliefs may contribute to the high incidence of semen-loss complaints in Sri Lanka, and suggest that attitudes and beliefs may play a role in the way patients express psychopathological symptoms in different societies.     

Attitudes of mental health professionals toward people with schizophrenia and major depression

Several studies reveal poor knowledge about mental illness in the general population and stigmatizing attitudes toward people with mental illness. However, it is unknown whether mental health professionals hold fewer stigmatizing attitudes than the general population. A survey was conducted of the attitudes of mental health professionals (n = 1073) and members of the public (n = 1737) toward mental illness and their specific reaction toward a person with and without psychiatric symptoms ("non-case" as a reference category). Psychiatrists had more negative stereotypes than the general population. Mental health professionals accepted restrictions toward people with mental illness 3 times less often than the public. Most professionals were able to recognize cases of schizophrenia and depression, but 1 in 4 psychiatrists and psychologists also considered the non-case as mentally ill. The social distance toward both major depression and the non-case was lower than toward schizophrenia. However, in this regard, there was no difference between professionals and the public. The study concludes that the better knowledge of mental health professionals and their support of individual rights neither entail fewer stereotypes nor enhance the willingness to closely interact with mentally ill people.     

Experiences of stigma among people with severe mental illness. Reliability, acceptability and construct validity of the Swedish versions of two stigma scales measuring devaluation/discrimination and rejection experiences

Stigma has been identified as one of the most important obstacles for a successful integration of people with mental illness into the society. Research about stigma has shown negative attitudes among the public towards people with mental illness. Studies so far have, however, put little emphasis on how these negative attitudes are perceived by the mentally ill persons. The aim of the present study was to investigate acceptability and internal consistency of the Swedish versions of two stigma scales, the Devaluation and Discrimination scale and the Rejection experiences scale. Forty individuals were subject to an interview, which also comprised assessments of needs for care, quality of life, therapeutic relationship and empowerment. The results showed that both the Devaluation and Discrimination scale and the Rejection experiences scale had a good internal consistency and acceptability. Stigma in terms of perceived devaluation and discrimination was found to be most markedly associated with empowerment and rejection experiences was found to be most associated with the number of previous psychiatric admissions. It is concluded that the Swedish versions of the Devaluation and Discrimination scale and the Rejection experiences scale may well be used in further studies of stigma among people with mental illness.     

Factors associated with stigmatization of persons with mental illness

Stigmatization of individuals with mental illnesses is widespread and serves as a major barrier to treatment. In a survey of 116 undergraduates, the authors examined the impact of diagnosis, attitudes about treatment, and psychiatric terminology on stigma associated with mental illness. Stigmatization of schizophrenia was significantly higher than stigmatization of depression. More positive attitudes toward treatment were associated with significantly less stigma. However, psychiatric terminology had no impact on attitudes toward mental illness. Significantly less stigmatization of mental illness was found among females than among males. Reducing the stigmatization of mental illness continues to be an important goal for mental health professionals.