Elsevier

The Lancet Psychiatry

Volume 1, Issue 6, November 2014, Pages 467-482
The Lancet Psychiatry

Review
Mental health-related stigma in health care and mental health-care settings

https://doi.org/10.1016/S2215-0366(14)00023-6Get rights and content

Summary

This Review considers the evidence for mental-health-related stigma in health-care and mental-health-care settings. Do mental-health-care and other health-care professionals stigmatise people using their services? If so, what are the effects on quality of mental and physical health care? How can stigma and discrimination in the context of health care be reduced? We show that the contact mental-health-care professionals have with people with mental illness is associated with positive attitudes about civil rights, but does not reduce stigma as does social contact such as with friends or family members with mental illness. Some evidence suggests educational interventions are effective in decreasing stigma especially for general health-care professionals with little or no formal mental health training. Intervention studies are needed to underpin policy; for instance, to decrease disparity in mortality associated with poor access to physical health care for people with mental illness compared with people without mental illness.

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

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,

References (116)

  • K Fraser et al.

    Nurses' confirming/disconfirming responses to patients diagnosed with borderline personality disorder

    Arch Psychiatr Nurs

    (1993)
  • PW Corrigan et al.

    Mental health stigma and primary health care decisions

    Psychiatry Res

    (2014)
  • M Samuelsson et al.

    Training program in suicide prevention for psychiatric nursing personnel enhance attitudes to attempted suicide patients

    Int J Nurs Stud

    (2002)
  • RE Cosgray et al.

    A day in the life of an inpatient: an experiential game to promote empathy for individuals in a psychiatric hospital

    Arch Psychiatr Nursing

    (1990)
  • A Ucok et al.

    Anticipated discrimination among people with schizophrenia

    Acta Psychiatr Scand

    (2012)
  • J Gabbidon et al.

    Development and initial validation of the questionnaire on anticipated discrimination (QUAD)

    BMC Psychiatry

    (2011)
  • OF Wahl

    Mental health consumers' experiences of stigma

    Schizophr Bull

    (1999)
  • A Lasalvia et al.

    Global pattern of experienced and anticipated discrimination reported by people with major depressive disorder: a cross-sectional survey

    Lancet

    (2012)
  • E Corker et al.

    Experiences of discrimination among people using mental health service users in England 2008–11

    Br J Psychiatry

    (2013)
  • C Thornicroft et al.

    Impact of the “Like Minds, Like Mine” anti-stigma and discrimination campaign in New Zealand on anticipated and experienced discrimination

    Aust N Z J Psychiatry

    (2014)
  • BG Link et al.

    On describing and seeking to change the experience of stigma

    Psychiatr Rehab Skills

    (2002)
  • PW Corrigan et al.

    Self-stigma and the “why try” effect: impact on life goals and evidence-based practices

    World Psychiatry

    (2009)
  • BG Link et al.

    On stigma and its consequences: evidence from a longitudinal study of men with dual diagnoses of mental illness and substance abuse

    J Health Soc Behav

    (1997)
  • DE Clarke et al.

    Emergency department from the mental health client's perspective

    Int J Ment Health Nurs

    (2007)
  • J Harangozo et al.

    Stigma and discrimination against people with schizophrenia related to medical services

    Int J Soc Psychiatry

    (2013)
  • J Gabbidon et al.

    Discrimination Attributed to Mental Illness or Race-Ethnicity by Users of Community Psychiatric Services

    Psychiatr Serv

    (2014)
  • K Wahlbeck et al.

    Outcomes of Nordic mental health systems: life expectancy of patients with mental disorders

    Br J Psychiatry

    (2011)
  • D Lawrence et al.

    The gap in life expectancy from preventable physical illness in psychiatric patients in Western Australia: retrospective analysis of population based registers

    BMJ

    (2013)
  • B Schulze

    Stigma and mental health professionals: a review of the evidence on an intricate relationship

    Int Rev Psychiatry

    (2007)
  • O Wahl et al.

    Attitudes of mental health professionals about mental illness: a review of the recent literature

    J Comm Psychol

    (2010)
  • Equal treatment: closing the gap. A formal investigation into physical health inequalities experienced by people with learning disabilities and/or mental health problems

    (2006)
  • S Clement et al.

    Mental health stigma and access to care: a systematic review of quantitative and qualitative studies

    Psychol Med

    (2014)
  • BJ Goosby et al.

    transgenerational consequences of racial discrimination for African American Health

    Sociology Compass

    (2013)
  • T Band-Winterstein

    health care provision for older persons: the interplay between ageism and elder neglect

    J Appl Gerontol

    (2013)
  • I Tuffrey-Wijne et al.

    Preventing ‘deaths by indifference’: identification of reasonable adjustments is key

    Br J Psychiatry

    (2014)
  • X Cai et al.

    Are AMI patients with comorbid mental illness more likely to be admitted to hospitals with lower quality of AMI care?

    PLoS One

    (2013)
  • B Happell et al.

    Negative attitudes towards clients with drug and alcohol related problems: finding the elusive solution

    Aust N Z J Ment Health Nurs

    (2001)
  • DD Mendez et al.

    Institutional racism, neighborhood factors, stress, and preterm birth

    Ethn Health

    (2014)
  • P Carr-Walker et al.

    Attitudes towards personality disorders: comparison between prison officers and psychiatric nurses

    Leg Criminolog Psychol

    (2004)
  • G Thornicroft

    Shunned: discrimination against people with mental illness

    (2006)
  • AJ Commons Treloar et al.

    Targeted clinical education for staff attitudes towards deliberate self-harm in borderline personality disorder: randomized controlled trial

    Aust N Z J Psychiatry

    (2008)
  • TS Rogers et al.

    Nurses' responses to people with schizophrenia

    J Adv Nurs

    (1998)
  • L Magliano et al.

    Beliefs of psychiatric nurses about schizophrenia: a comparison with patients' relatives and psychiatrists

    Int J Soc Psychiatry

    (2004)
  • C Nordt et al.

    Attitudes of mental health professionals toward people with schizophrenia and major depression

    Schizophr Bull

    (2006)
  • S Hamilton et al.

    Discrimination against people with a mental health diagnosis: qualitative analysis of reported experiences

    J Ment Health

    (2014)
  • R Henderson et al.

    Viewpoint survey of mental health service users' experiences of discrimination in England 2008–12

    Soc Psychiatry Psychiatr Epidemiol

    (2014)
  • KM Gallo

    First person account: self-stigmatization

    Schizophr Bull

    (1994)
  • JB Ritsher et al.

    Internalized stigma of mental illness: psychometric properties of a new measure

    Psychiatry Res

    (2003)
  • JP Calicchia

    Differential perceptions of psychiatrists, psychologists, and social workers toward the ex-mental patient

    J Comm Psychol

    (1981)
  • JP Calicchia

    Attitudinal comparison of mental health and non-mental health professionals toward ex-mental patients

    J Psychol

    (1981)
  • Cited by (426)

    • Le défi de l'obésité dans les maladies psychiatriques

      2023, Nutrition Clinique et Metabolisme
    View all citing articles on Scopus
    View full text