Iatrogenic stigma of mental illness

BMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7352.1470 (Published 22 June 2002) Cite this as: BMJ 2002;324:1470

Begins with behaviour and attitudes of medical professionals, especially psychiatrists

  1. Norman Sartorius (Norman.Sartorius{at}hcuge.ch), professor
  1. Department of Psychiatry, University of Geneva, CH-1205 Geneva, Switzerland

    The stigma attached to mental illness, and to the people who have it, is a major obstacle to better care and to the improvement of the quality of their lives.1 The World Psychiatric Association has recently initiated a global programme against stigma and discrimination because of schizophrenia.2 Twenty countries are participating in the programme, and others have expressed their interest in joining.3 The programme of the World Psychiatric Association is different from others in three ways. Firstly, it begins by an examination of experiences that patients and their families have had since the illness started. The analysis of accounts of their experiences in relation to society serves to select targets for interventions that will aim to reduce stigma and its consequences. Secondly, it involves different social sectors—for example, health ministries, social welfare services, labour ministries, non-governmental organisations, and the media. Thirdly, the programme is not a campaign but a long term engagement. Because of the strategy adopted for the programme, its focus differs from one place to another. For example, in Canada, one of the first targets of the programme was a change in procedures used in emergency departments that discriminate against people with mental illness. In Italy, the attitudes of shopkeepers were the target and in Germany, the reporting about mental illness in the media. Certain themes and sources of stigmatisation, often neglected, emerge as worthwhile targets in most places. Among them are the behaviour of medical professionals (psychiatrists in particular4) and the contribution of the people with the disease who, for a variety of reasons, lose their self confidence and self respect, which changes their relationships with others and their way of life.

    A most obvious source of stigmatisation is the careless use of diagnostic labels. Diagnoses are useful tools in medicine because they summarise the information about a patient's illness and facilitate communication among members of the profession. They become less helpful in communication with other professions and can be harmful when used by non-professionals who are not familiar with the original definition of the term. Even doctors must communicate by diagnoses in a careful and restrained manner. The public and health professionals often have negative attitudes to people with mental illness and will behave accordingly once they are told that a person has an illness about which they have prejudices. Health systems that require that medical decisions be based on diagnoses without having resources that would ensure appropriate protection of diagnostic information about the patient are also to be blamed. Being conscious of the power of diagnosis and of the labelling process might contribute to a wiser use of diagnoses, but removing the diagnosis by itself would not eliminate stigma.

    Iatrogenic stigmatisation unfortunately does not stop at labelling. Treatment of symptoms of mental illness may produce side effects (for example, extrapyramidal signs), which will mark the person as having a mental illness more than the original symptoms of illness did. Governments sometimes support the use of cheaper treatments even when the side effects are profoundly disturbing or painful. Medical practitioners accept such policies, although it is clearly their duty to fight such regulations and ensure that their patients receive the best treatment, which is often not the cheapest.

    Psychiatrists and other mental health staff also stigmatise patients in other ways. Until recently psychiatrists in some European countries and elsewhere were requesting longer holidays and a higher salary than other doctors because they had to work with mentally ill patients who are dangerous, while arguing, at the same time, that mental illness is no different from other illnesses. Psychiatrists are among those who recommend separate legislation for people with mental illness to protect some people with mental illness, often unaware of the effect that such legislation might have on all other patients. They should certainly continue to do whatever is necessary to protect their patients; but it would help if they also advocated the notion that the rights and duties of people with mental illness should be decided by their behaviour and capacities in the same manner as for other people rather than by the diagnostic label alone.

    Directors of institutions and hospitals in which people with mental illness are treated or find shelter rarely insist that their clients should be given an opportunity to participate in elections or other voting. The installation of ballot boxes in mental hospitals is still a rarity even in countries where there is much awareness of the need to protect human rights and social rights of those with mental illness. How should we convince others that most people with mental illness retain many of their capacities and that their rights are often not respected if we do not show the way by our own behaviour? General healthcare staff only rarely joins psychiatrists in requesting equal provisions for the care of people with mental illness. Alison Gray in a recent review article urges medical professionals to consider their own attitudes and become aware of them, to involve service users in the development of services, and to stand up against discrimination because of mental health problems wherever it might occur. Hopefully health professionals will be influenced by her views.5

    The above examples are listed to remind us that we psychiatrists and other medical professionals are not sufficiently engaged in fighting stigma and discrimination related to mental illness; what is worse, we may be contributing to it in various ways. It would be useful if all of us were to examine our own behaviour and actions and change them where necessary to reduce stigma. Stigma remains the main obstacle to a better life for the many hundreds of millions of people suffering from mental disorders and their consequences. We must make our contribution to eliminate stigma and fight it in every way possible.


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