Mental health stigma: A global scourge

It is no surprise now that one in seven people living in low resource countries do not receive treatment for depression. Mental health stigma is one of the key barriers when it comes to seeking care. One can argue that despite its devastating effects, COVID-19 could dramatically reduce stigma, especially when it comes to seeking care for mental health problems.

But let us first understand what mental health stigma is. The term “mental” or “mad” is used in a derogative manner to refer to individuals with mental health issues. In 2019, a Hindi film titled Mental Hai Kya?, which translates to “Are You Mad?”, triggered outrage amongst health professionals, with calls to change the title.

Our team recently interviewed Graham Thornicroft, a practising psychiatrist, who is extensively and deeply involved in mental health stigma research at the Institute of Psychiatry, Psychology and Neurosciences at King’s College London. He divided stigma into three components – knowledge, attitude and behaviour. The last – behaviour – emerges from social isolation, such as what we are experiencing during the pandemic, as well as exclusion from mainstream activities and citizenship. Debarring people with mental illness from these basic human rights, he believed, is fundamentally wrong. This led him to consider, first and foremost, how to reduce and eventually eradicate stigma. Subsequent exploration led him to perform much work in low- and middle-income countries, including India, while also attempting to discern whether stigma is static or variable and evolving, in advanced and developing countries. He noted that it is certainly manageable in broader sections of communities.

Studies across 30 to 40 countries have concluded that stigma is “universal” – for example, being reported by about 90 per cent of people with schizophrenia across the world. It may appear in the form of variable social exclusion – for example, adversely affecting marriage prospects in India, while, in China, it may be a source of “embarrassment”. Stigma rates in higher-income countries may be greater than those in other countries, perhaps because of the pressure to excel.

In low-income countries, one can be unwell and still play an active social and productive role somewhere as there are many such roles to play within the family and in society. Fear of failure plagues some people with mental illness, which can become a reason to not even apply for jobs. Moreover, fear of failure in intimate relationships may also stall people with mental illness from attempting or initiating such an arrangement. How do we then address this microaggression towards people living with mental health problems?

We know that enhancing contact with people who have experienced mental health problems is the best way to reduce stigma. To date, most people with mental illness remain silent about their condition, avoiding discussing their problems for fear of losing face, damaging their reputation or jeopardising their family status. Having a space where they may be welcomed and listened to, rather than judged, will go a long way towards enabling them to share their experiences.

In a small part of rural Andhra Pradesh, researchers used posters, pictures, drums, and a short street play, as an intervention technique to reduce mental health stigma. An actor portrayed a person’s journey through mental health crises and setbacks before receiving support and showing hope, improvement and recovery. People assembled around the stage, willing to talk about and discuss what they saw, even two to three years after the event. The main aim of the play was to manifest, deliver and culturally adapt and train society for the benefit of those fenced on its fringes.

We often get asked if rural and urban areas differ in responding to interventions for social contact between people with mental health problems and society at large, to curtail stigma for people with schizophrenia and other mental disorders? We do not know these answers yet.

The entertainment industry is flush with poor portrayals and interpretations of mental health, contributing to mental health stigma. The media exploits mental illness in order to create sensationalised headlines and easily captivate readers’ attention.

The lack of genuine sympathy or concern with the problem prevents the subject of mental health from being explored or saved from neglect. Mentally ill people are often criminalised and covered as murderers and killers in the media as the result of some isolated incidents. Print media content is but a reflection of this fascination and stigma, propped up by false mythical beliefs spread around the illness, yet offering only some contemporary examples and instances of violent crimes committed under the duress of illness. As such, it becomes common to generalise despite the inaccuracy that comes with doing so.

Meanwhile, one recent development is that of celebrities disclosing and revealing their struggles with mental illness. The anti-stigma movement is, thus, effectively becoming endorsed by famous and influential figures.

Ten to 15 years ago, the stigma was even more stifling, with biased stories being titled and reported sensationally, with words like ‘schizophrenic killer’, ‘mad killer’, ‘mad maniac’ and ‘psychotic’ being used freely. In some ways, during the pandemic we have seen this negativity being replaced with more responsible, sensitive and honest coverage of related stories by both print and electronic media. Indeed, there seems to be a concerted effort to bring about a shift in public and personal sensibilities in relation to mental illness.

Family members and friends of people living with mental health problems often face a lot of challenges while caring and also earning their living. These combined responsibilities are very real and can be very daunting.

Another interesting perspective is that people with schizophrenia often blame family members as being the biggest source of stigma. On the other hand, those recovering claim the obligation and support of their families helped them to escape from their illness. The person with the illness, even if more or less cured, feels the need for freedom from their families – who are often overprotective. Meanwhile, the caretakers’ excuse to retain a leash on their recovering family members is grounded by the possibility of a relapse and overall fear. This concept, known as ‘mollycoddling’, which keeps people from being able to live normal and fulfilling lives, is disabling, according to Thornicroft. Mental health professionals have worried that this conundrum exacerbated during the pandemic which was apparent by the sheer number of families who have reached out for online support.

In light of this conflict, families should be encouraged to be attached without being over-involved, giving the family member with mental illness space of their own to continue their improvement efforts and pursue their interests. Families should remain close enough to ward off their difficulties, but also let them learn from their errors and stand up on their own again. Moreover, they must support them always and protect them. Love, empathy, compassion and companionship are humanitarian methods that go a long way in the healing process.

Similarly, families should not shy away from seeking the support of psychiatrists, psychologists, physiotherapists, nutritionists, etc,

COVID-19 is likely to affect our psychological health and wellbeing for various reasons, including enforced social distancing, long term side effects of COVID-19, and inability to access care for other health conditions. Concerns over social isolation have already contributed to increased feelings of distress in the general population. The long term economic effects of the pandemic however are more frightening. In order to keep people out of poverty, particularly those who are the most vulnerable due to serious mental illness, extensive mitigation strategies should be planned.

Working through the COVID-19 pandemic has led mental health professionals to understand the need to connect with people and provide assessment and treatment support via technology. We have already encountered a paradigm shift to our treatment delivery methods, which means that technology will play a larger role in clinical service provision in the future. But not everyone, especially older family members, has access to this technology, and neither do all healthcare professionals feel confident to use it with their service users. All of this will need to be considered for wider upscaling of technology-driven solutions for treating mental health problems.

However, as previously mentioned, a collateral advantage of the COVID-19 pandemic could be a sense of a new normality, which can help people to feel less stigmatised whilst seeking help. This evidence may take some time to grow, but we can start by developing new ways to enhance social interaction with people who have mental health issues. This can be achieved by offering them a secure, even if virtual, space for self-expression. COVID-19 has surfaced the much neglected mental health issues in our societies, as well as the stigma associated with them, while also allowing us to focus on and make sense of the lives we care about.

The writer is a carer and mental health researcher at King’s College, London. Acknowledgements: Professor Graham Thornicroft, Alka Singh, and Anil Vartak