Iatrogenic stigma of mental illness

sir,not very long ago we used to criticize the society and relatives
of psychiatric patients,not only for lack of any kind of sensitivity,but
also for a strange kind of racism.This kind of racism created a great deal
of social isolation for the patients resulting to their permanent stay
away from any kind of social life and inside an indifferent environment of
a psychiatric asylum.It is about time we recognised that in many cases
there has been hiding,fairly well indeed,a growing iatrogenic stigma
towards these patients.This stigma has unfortunately come not only from
physicians and health personnel,but also from many psychiatrists,who
themselves ought to have kept a different attitude towards psychiatric
patients.If we want things to change we should start showing some
different aspects of behaviour,similar to the one we seem to show to any
other kind of patients.Only this way it is possible that a gradual change
of approach towards psychiatric patients will be followed by society and
mass media in order to improve the quality of life and the standards of
medical and nursing treatment of psychiatric patients.

Competing interests:  
None declared

Dear Sir,
It is important to look at the attitudes of professionals involved in the
care of mentally ill people but also unfair to blame them for perpetuating
the stigma of the mentally ill. By definition anything that marks one out
as different from others can be considered to be a stigma. This is already
part and parcel of illness as a whole and in particular mental illness,
and has been for many milleniums. However some illnesses are more
stigmatised than others. A prime example is AIDS. Even psychiatrists are
stigmatised both by the medical profession and by society. We are not
perceived to be "real Doctors" and many expect us to be "weird" ourselves.
Even my Grandmother is quite concerned about 'the path' that I am taking.
I do not expect much improvement in society's attitudes by trying to get
people to be more accomodating and more tolerant of what they fear and
don't understand. Perhaps we should be helping society to realise that
people with mental disorders are just like the rest of us and, anyone of
us can have a mental illness but remain a valuable member of society.

Reference:
1.Norman Sartorius
BMJ 2002; 324: 1470-1471

Dear Sir,

Norman Sartorius’ editorial “Iatrogenic Stigma of Mental Illness”
(BMJ 2002;324:1470–1) addresses an uncomfortable issue: the extent to
which doctors, and particularly psychiatrists, might be responsible for
the stigma and discrimination experienced by people with mental health
problems. While his views presumably reflect a global perspective, I
believe they present a misleading picture of UK psychiatry.

Psychiatrists are well aware of the need to accurately diagnose the
illness, while not “labelling” the person. Of all health professionals,
psychiatrists are surely the least likely to misuse diagnostic terms. This
is a point well made (though presumably inadvertently) by GP Dr Andrew
Ashworth. Responding to Dr Sartorius’s Editorial, he makes the crass
statement “it is better to be a junkie than a loony”, encapsulating in a
few unthinking words the attitudes and prejudices that the RCPsych has
worked so hard to change.

Clinical decisions about the suitability of older, cheaper
antipsychotic drugs versus the more expensive atypicals are more complex
than the editorial suggests. For example, while atypical drugs may cause
less movement disorder, other side effects- such as sedation, weight gain
and hypersalivation- can be just as “stigmatising”. Furthermore, money
spent on drugs may mean that less funds are available for other forms of
treatment- such as expensive psychological therapies. After a lengthy
review, NICE only gave a cautious welcome to the new drugs last month.

It is not true that British psychiatrists “recommend separate
legislation for people with mental illness to protect some people with
mental illness, often unaware of the effect that such legislation might
have on all other patients.” The case against separate mental health
legislation has been made by psychiatrists in this journal,(1) and
Scottish psychiatrists also argued for a non-discriminatory general
“Incapacity Act” during the Millan Committee’s consultation about the
revised Mental Health (Scotland) Act. The Committee did not accept the
proposal.

Similarly, the UK Government has retained powers to detain people
with “severe and dangerous personality disorder” in the proposed English
Mental Health Act despite the adamant opposition of the Royal College of
Psychiatrists.

The World Psychiatric Association’s (WPA) global programme against
stigma and discrimination is welcomed and supported by the Royal College
of Psychiatrists. Like the WPA programme, College-supported antistigma
campaigns in Scotland and the UK as a whole have emphasised the importance
of multi-agency involvement. This is not because others are needed to make
sure that psychiatrists don’t stigmatise- but because we recognise that
psychiatrists are not able to change discriminatory cultures and systems
on our own.

Psychiatry has made serious errors in the past- what Byrne bluntly
refers to as “dumb ideas in psychiatry”.(2) This has led to a situation
where our profession experiences some of the marginalisation, ridicule and
rejection experienced by people with mental health problems in their own
lives. Yet most of the “dumb ideas” were rejected before younger
consultants like myself were even born.

21st Century British psychiatry seeks to be open, inclusive and
pragmatic- and has arguably made more progress in user consultation and
involvement than any other medical specialty.

We remain alert to our deficiencies, and are seeking to correct them.
But we cannot control legislation, health policy, or the attitudes of
others on our own- nor should we be scapegoated for our failure to do so.

Yours sincerely,

Dr. Michael Smith

Chairman, Public Affairs Committee,
Scottish Division of the Royal College of Psychiatrists

Reference List

1. Holloway F,.Szmukler G. Public policy and mental health
legislation should be reconsidered [letter]. BMJ 1999;318:1354.

2. Byrne P. Stigma of mental illness and ways of diminishing it.
Advances in Psychiatric Treatment 2000;6:65-72.

Dear Sirs,

Thanks for this editorial about a very neglected field for the
medical profession, but even more for authorities and patient
organizations. As a sufferer and thus an involuntary specialist in
schizophrenia, I am very pleased with the general message of this
editorial, although I do not fully agree with everything in it.

It is important, when discussing schizophrenia to remember that today
almost 50 % recovers according to WHO:s Fact Sheet for Mental and
Neurological Disorders. Psychiatrist are not visited by the recovered and
thus they often might have a too pessimistic view of the outcome of the
disease today. Thus many people labelled earlier as schizophrenics can't
be discriminated by the psychiatrists anylonger, but the diagnosis can
still be a great problem for the individual, if it is known by people in
his/hers neighborhood. For the majority of sufferers the general public is
probably the main culprit in discrimination and stigmatization, which is
my own experience.

Personally, my contact with the psychiatric care is 1 hour each year
to renew prescriptions, which is 0.01 % of my time, whereas each day I
spend about 3 hours outside my flat. This makes the attitudes of the
general public 1000-times more important for me. Thus the chances for the
care to discriminate me is minimal and I have always been very well
treated, although twice objections I had about the pharmacotherapy was not
respected (later it appeared, that I was right). It is, however, very
probable that I have been much better treated than the average sufferer.
However, I believe that today only a small part of people with
schizophrenia (20 % ?) that have daily or more regular contact with the
care.

What is not mentioned in the Editorial, but is very interesting is
that schizophrenia in developing countries seem to have a more benign
course and a better outcome (Schizophrenia and public health, Barbato, A,
WHO page 8). The reason for this is not known, but the stigma in
industrial countries has been discussed as one of many factors. This
suggests that environment factors in our society contributes and makes
people with schizophrenia sicker that they actually should be. This
further supports the stigma as discussed in the editorial as a mayor
threat against the health and well-being for people with schizophrenia.

When discussing stigma, I feel one important detail is always
missing. All people with schizophrenia have always once been healthy and
thus then they probably got the identical prejudices about the disease as
the general public. How this affects the course of the disease, I have
never seen discussed and I welcome any information in this area. This also
indicates I think together with the often early onset of the disease that
pupils and students are the most important targets for information about
the disease.

In the near future, I can see that the number of recovered will
slowly increase, as improved drugs, patient education and cognitive
behavior therapy is fully implemented in the care. The most dramatic
change should probably caused by a drug with a novel mechanism of action,
that would have effect on drug therapy resistant cases and the need of
todays institutional care.

Naturally, it would be excellent too, if we could fight the
prejudices and discrimination, which would maybe give us the treatment
results of todays developing countries. However, it is important to
remember as more and more recover that the general public will be an even
bigger problem in the future and the discrimination by the care of less
importance. Also, the stigma and discrimination is a general problem in
society and maybe the most efficient way to combat it is to inform in
media like TV and newspapers, which does not need the engagement of the
already hard working local psychiatrists. Personally, I am more
disappointed at the patient organizations than the psychiatrists in the
lack of progress today in the fight against the stigma.

Yours

Sir Nil

Founder of the site:
Whisper - about schizophrenia
Information source, Meeting point, Whistle-blower
http://hem.passagen.se/sir.nil/