Nearly two-thirds of all people with diagnosable mental disorders do not seek treatment (Regier et al., 1993; Kessler et al., 1996). Stigma surrounding the receipt of mental health treatment is among the many barriers that discourage people from seeking treatment (Sussman et al., 1987; Cooper-Patrick et al., 1997). Concern about stigma appears to be heightened in rural areas in relation to larger towns or cities (Hoyt et al., 1997). Stigma also disproportionately affects certain age groups, as explained in the chapters on children and older people.
The surveys cited above concerning evolving public attitudes about mental illness also monitored how people would cope with, and seek treatment for, mental illness if they became symptomatic. (The term “nervous breakdown” was used in lieu of the term “mental illness” in the 1996 survey to allow for comparisons with the surveys in the 1950s and 1970s.) The 1996 survey found that people were likelier than in the past to approach mental illness by coping with, rather than by avoiding, the problem. They also were more likely now to want informal social supports (e.g., self-help groups). Those who now sought formal support increasingly preferred counselors, psychologists, and social workers (Swindle et al., 1997).
Stigma and Paying for Mental Disorder Treatment
Another manifestation of stigma is reflected in the public’s reluctance to pay for mental health services. Public willingness to pay for mental health treatment, particularly through insurance premiums or taxes, has been assessed largely through public opinion polls. Members of the public report a greater willingness to pay for insurance coverage for individuals with severe mental disorders, such as schizophrenia and depression, rather than for less severe conditions such as worry and unhappiness (Hanson, 1998). While the public generally appears to support paying for treatment, its support diminishes upon the realization that higher taxes or premiums would be necessary (Hanson, 1998). In the lexicon of survey research, the willingness to pay for mental illness treatment services is considered to be“soft.” The public generally ranks insurance coverage for mental disorders below that for somatic disorders (Hanson, 1998).
Reducing Stigma
There is likely no simple or single panacea to eliminate the stigma associated with mental illness. Stigma was expected to abate with increased knowledge of mental illness, but just the opposite occurred: stigma in some ways intensified over the past 40 years even though understanding improved. Knowledge of mental illness appears by itself insufficient to dispel stigma (Phelan et al., 1997). Broader knowledge may be warranted, especially to redress public fears (Penn & Martin, 1998). Research is beginning to demonstrate that negative perceptions about severe mental illness can be lowered by furnishing empirically based information on the association between violence and severe mental illness (Penn & Martin, 1998). Overall approaches to stigma reduction involve programs of advocacy, public education, and contact with persons with mental illness through schools and other societal institutions (Corrigan & Penn, 1999).
Another way to eliminate stigma is to find causes and effective treatments for mental disorders (Jones, 1998). History suggests this to be true. Neurosyphilis and pellagra are illustrative of mental disorders for which stigma has receded. In the early part of this century, about 20 percent of those admitted to mental hospitals had“general paresis,” later identified as tertiary syphilis (Grob, 1994). This advanced stage of syphilis occurs when the bacterium invades the brain and causes neurological deterioration (including psychosis), paralysis, and death. The discoveries of an infectious etiology and of penicillin led to the virtual elimination of neurosyphilis. Similarly, when pellagra was traced to a nutrient deficiency, and nutritional supplementation with niacin was introduced, the condition was eventually eradicated in the developed world. Pellagra’s victims with delirium had been placed in mental hospitals early in the 20th century before its etiology was clarified. Although no one has documented directly the reduction of public stigma toward these conditions over the early and later parts of this century, disease eradication through widespread acceptance of treatment (and its cost) offers indirect proof.
Ironically, these examples also illustrate a more unsettling consequence: that the mental health field was adversely affected when causes and treatments were identified. As advances were achieved, each condition was transferred from the mental health field to another medical specialty (Grob, 1991). For instance, dominion over syphilis was moved to dermatology, internal medicine, and neurology upon advances in etiology and treatment. Dominion over hormone-related mental disorders was moved to endocrinology under similar circumstances. The consequence of this transformation, according to historian Gerald Grob, is that the mental health field became over the years the repository for mental disorders whose etiology was unknown. This left the mental health field“vulnerable to accusations by their medical brethren that psychiatry was not part of medicine, and that psychiatric practice rested on superstition and myth” (Grob, 1991).
These historical examples signify that stigma dissipates for individual disorders once advances render them less disabling, infectious, or disfiguring. Yet the stigma surrounding other mental disorders not only persists but may be inadvertently reinforced by leaving to mental health care only those behavioral conditions without known causes or cures. To point this out is not intended to imply that advances in mental health should be halted; rather, advances should be nurtured and heralded. The purpose here is to explain some of the historical origins of the chasm between the health and mental health fields.
Stigma must be overcome. Research that will continue to yield increasingly effective treatments for mental disorders promises to be an effective antidote. When people understand that mental disorders are not the result of moral failings or limited will power, but are legitimate illnesses that are responsive to specific treatments, much of the negative stereotyping may dissipate. Still, fresh approaches to disseminate research information and, thus, to counter stigma need to be developed and evaluated. Social science research has much to contribute to the development and evaluation of anti-stigma programs (Corrigan & Penn, 1999). As stigma abates, a transformation in public attitudes should occur. People should become eager to seek care. They should become more willing to absorb its cost. And, most importantly, they should become far more receptive to the messages that are the subtext of this report: mental health and mental illness are part of the mainstream of health, and they are a concern for all people.
2 The Surgeon General issued a Call to Action on Suicide in 1999, reflecting the public health magnitude of this consequence of mental illness. The Call to Action is summarized in Figure 4-1.
No comments:
Post a Comment