When Chiara de Blasio, daughter of New York City Mayor Bill de Blasio, openly discussed her past struggle with a mood disorder, it was hailed by many as a triumph for fighting the stigma of mental illness. In 1999 the U.S. Surgeon General labeled stigma as perhaps the biggest barrier to mental health care; this stigma manifests particularly in a phenomenon known as social distancing, whereby people with mental issues are more isolated from others. Eradicating the stigma and social distancing of people with mental illness must be a top public health priority in order to improve worldwide mental health and reduce economic burden.
According to the World Health Organization (WHO) and the World Economic Forum (WEF), mental illness represents the biggest economic burden of any health issue in the world, costing $2.5 trillion in 2010; this burden is projected to cost $6 trillion by 2030 with two-thirds of these costs attributed to disability and loss of work. And yet shockingly, of the 450 million people worldwide who suffer from mental health conditions, the majority (60 percent) do not receive any form of care, with 90 percent of people in developing countries receiving no form of care.
Research suggests that the majority of people hold negative attitudes and stereotypes towards people with mental illness. From a young age children will refer to others as “crazy” or “weird”; these terms are used commonly throughout adulthood as well. Often the negative stereotypes involve perceptions that people with mental illness are dangerous. This perception is fueled by media stories that paint violent perpetrators as “mentally ill” without providing the context of the broad spectrum of mental illness. This bias is not limited to people who are either uninformed or disconnected from people with mental illness; in fact health care providers and even some mental health professionals hold these very same stereotypes.
These negative attitudes often manifest as social distancing with respect to people with mental illness. In particular, when people feel that an individual with mental illness is dangerous, that results in fear and increased social distance. This social distancing may result in the experience of social isolation or loneliness on the part of people with mental illness. This stigma and social distancing have the potential to worsen the well-being of people with mental illness in several ways. First, the experience of social rejection and isolation that comes from stigma has the potential for direct harmful effects. It has long been understood that social isolation is associated with poor mental and physical health outcomes and even early mortality – “the lethality of loneliness.” Further, social isolation predicts disability among individuals with mental illness. For example, a Swedish study of 53,920 women and men followed for 12 years found that social isolation predicted disability, and that this effect was particularly pronounced among individuals with mental illness.
More, people with mental health issues recognize and internalize this stigma to develop a strong “self-stigma.” This self-stigma will often undermine self-efficacy, resulting in a “why try” attitude that can worsen prospects of recovery. Further, as people begin to experience symptoms of their mental health conditions such as anxiety or depression, stigma may cause some people to try to avoid, separate from or suppress these feelings, all of which have been linked to the worsening of well-being.
This stigma doesn’t just worsen outcomes on a personal level, but also complicates the care and resources available to people with mental illness. In its “Attitudes Towards Mental Illness” report, the Centers for Disease Control (CDC) noted that stigma can result in a lower prioritization of public resources and poorer quality of care. One research review of 22 studies that focused on barriers to care and mental illness determined that stigma and embarrassment were the top reasons why people with mental illness did not engage in medication adherence. The effects of stigma work both ways – mental health conditions are not typically screened in most health care settings, losing an important opportunity for care.
Further, the discrepancy between the cost of mental health disorders as compared to the funding of research is striking, and is believed to be caused by the stigma associated with mental health issues. For example, in the United Kingdom, mental health accounts for 23 percent of the economic burden, but only receives 13 percent of the funding. Worse, this stigma and need for social distancing may influence what has become the criminalization of people with mental illness. People with mental illness are 10 times more likely to be in prison than in psychiatric facilities, leading some to call prisons “The New Gulags for the Mentally Ill.” Many consider this a human rights violation that contributes to the cycle of prison, poverty and homelessness for many mentally ill people.
What can be done?
Overall, increased awareness is probably one of the most important things that can be done to counteract stereotypes. For years groups such as the National Alliance for the Mentally Ill and the Rosalynn Carter Foundation have fought to reduce stigma. More recently, Molly Knight Raskin, who has received the Rosalynn Carter Fellowship for Mental Health Journalism, is developing a movie, “Still We Rise,” to bring awareness to the epidemic of global mental illness. Knight Raskin told me, “To me, there’s only one thing standing in the way of our ability to care for mentally ill people in this country, and around the world: stigma.”
It is also crucial that those on the front lines of working with people with mental illness receive the education and support needed to help manage bias. Programs need to be developed to teach health care professionals to identify and manage their biases toward mental illness so as not to interfere with clinical care. Training more people across the medical field in mental health issues creates the possibility of integrating mental health screening in primary care settings. For example, in a review of 14 studies, the U.S. Preventive Services Task Force has determined that screening for depression in primary care settings improves outcomes.
Finally, recent legislation holds promise that people with mental health issues will receive care comparable to those with physical health issues. For example, The Affordable Care Act of 2013 expanded upon the Mental Health Parity and Addiction Equity Act of 2008, providing more possibility that mental health conditions will be covered on par with physical health conditions.
Mental Illness will be the definitive public health priority in the decades to come. Unlike many conditions, we actually have empirically supported treatments in the form of medication, psychotherapy and lifestyle behavioral programs that have demonstrated efficacy and cost effectiveness in treating mental illness. The stigma of mental illness is perhaps the greatest barrier to care. It is preventable, and doing so would radically reduce suffering, disability and global economic burden.
As Knight Raskin told me: “I often wonder if we’ll live to see the day when we can talk about issues like suicide or addiction in the aisles of the supermarket with concerned neighbors without speaking in hushed tones, as if we have something to be ashamed about.”
Dr. Mike Friedman is a clinical psychologist in Manhattan and a member of EHE International’s Medical Advisory Board. His opinions are his own. Follow Dr. Mike Friedman on Twitter @DrMikeFriedman and EHE @EHEintl.