We searched Medline, PsychINFO, CINAHL, AMED, and the Social Science Citation Index databases to identify full-text, peer-reviewed, data-based studies and reviews (editorials and opinion pieces were excluded). Articles in any language were included from Jan 1, 1980 to April 9, 2014. Articles were included that we judged to represent health-care professionals' (counsellors were excluded) attitudes or opinions towards, or stigmatisation of, individuals with mental health disorders (dementia,
ReviewMental health-related stigma in health care and mental health-care settings
Introduction
The evidence that professionals working in all areas of health care including mental health stigmatise and discriminate against people with mental illness is increasingly compelling. Recent progress in two areas of research has re-emphasised the need to consider how stigma related to mental health manifests in health-care settings, and how to address it effectively. First, the specialty of stigma research increasingly encompasses exploration of what the people who are the targets of stigma perceive,1 anticipate,2, 3 and directly experience4, 5, 6, 7, 8, 9 from various sources of stigma, and how they feel and respond accordingly.5, 10, 11, 12 Health care is one of the contexts in which this research is most actively developing.5, 13, 14 The frequencies of discrimination reported by respondents to surveys in these studies range from 16%9 to 44%15 in a mental health-care setting and 17%7, 14 to 31%15 in a physical health-care setting. Second, epidemiological research shows a mortality gap in people with severe mental illness in high-income countries of around 20 years for men and 15 years for women compared with the general population,16, 17 which puts mental illness at the top of the list of variables associated with physical health inequality. The conclusion that severe mental illness itself explains this mortality gap should be avoided; instead, the reasons for the mortality gap need to be investigated and addressed. We therefore extended the scope of this Review beyond mental health professionals and stigma18, 19 to include all types of health professional.
Stigma in a health-care context probably contributes to the disparity in life expectancy,20 compared with the general population, but before this can be tackled effectively, careful consideration of what stigma means in health care is needed. We used a theoretical framework and separated mental health services from other health services, because the effect of stigma might vary in these contexts. We then addressed the questions: do mental health professionals stigmatise people using their services; and do other health-care professionals stigmatise people with mental illness? If health professionals do stigmatise people with mental illness, what are the effects on quality of mental health care and physical health care? We then considered the evidence that stigma and discrimination in the health-care context can be decreased. To focus this Review on health professionals, we excluded the literature in which health-care students were the only study group. Neither did we address the question of the extent to which stigma is a barrier to health professionals seeking help for their own mental illness.21
Section snippets
A framework for considering stigma in mental health care
In the context of service provision, it is useful to consider stigma as operating on three inter-related levels: structural, interpersonal, and intrapersonal.22 Structural stigma refers to discriminatory social structures, policy, and legislation,5, 22 which contribute to health disparities for some populations, such as African Americans,23 and to low quality care for elderly people.24 In health care for people with mental illness, structural discrimination can be seen in the disparity between
Professional experience
Table 1 summarises the studies identified by our search that address this question. The first studies of mental health professionals' attitudes came after recognition of the negative public response to deinstitutionalisation and community care. Calicchia43, 44 compared psychiatrists, psychologists, and social workers with each other, and against mental health students and a sample of non-mental-health professionals consisting of teachers, lawyers, and engineers. He used five dimensions to
Do attitudes of general health professionals differ from those of mental health professionals?
Many of the surveys mentioned compared mental health professionals' attitudes with those of general hospital professionals, general practitioners, or medical students. Compared with psychiatrists (but not psychologists), general practitioners in Australia were more optimistic about treatment outcome,45 but both groups of doctors had greater optimism with increasing age. The decreased stigmatisation of patients by mental health professionals with increasing experience46 was shown in surveys that
Health professionals' attitudes towards patients with physical versus mental illness
Fewer studies have examined the effect of patients' mental illness on health professionals' attitudes compared with a physical illness, even though this comparison closely addresses whether discrimination is more likely to occur in the general health-care setting. Minas and colleagues68 showed that in Malaysian hospital professionals, stigmatising attitudes towards people with mental illness were common. Respondents to a mental illness vignette scored significantly lower on ratings for care and
What are the effects of stigma on the quality of mental health care?
Surveys of mental health professionals' attitudes, and assessments of training interventions are done under the assumption of a relation between attitudes and behaviour and do not measure behavioural outcomes. Few studies in our search strategy measured behavioural outcomes. In 1965, Ellsworth71 did surveys of psychiatric inpatients, and the nurses and aides working with them after screening the patients for their ability to recognise the professionals. He found that restrictive attitudes,
Quality of care
Studies83 show that people with mental illness and substance misuse disorders receive lower quality treatment for various physical illnesses including cardiovascular disease, diabetes, HIV, hepatitis, and cancer than do people without mental illness. Less is known about the role stigma has in the decreased quality of care. Corrigan and colleagues84 showed a correlation between attitudes and treatment intentions in mental health and primary care professionals working for the US Veterans Health
Interventions to decrease stigma in mental illness
Apart from studies about people with specific diagnoses, we identified two on mental illness. Both used internet-based interventions. In one study109 psychiatrists in Turkey were randomly assigned to receive an instructional email about stigma; controls received a questionnaire on social distance. The intervention group had significantly lower scores for social distance than the control group. No baseline assessment was done, however, and the response rate was 41 (22%) of 205, and there was a
Conclusions
In view of our framework, clearly very few studies address more than one level of stigma, and almost all focus on interpersonal stigma. We suggest that future work should address all three levels of stigma and the relations between them. We postulate that organisational culture and structural stigma might moderate the effectiveness and durability of any effects of interventions directed solely at health professionals to decrease stigmatisation of patients, and suggest the need for long-term or
Search strategy and selection criteria
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