In this podcast, Chris Lambert, FNP-C, DNP, and Pradeep Manudhane, MD, discuss stigma as an obstacle to the diagnosis of and treatment for mental illness and identify ways to approach bias in order to improve patient care.
CL: Hello and welcome. I am Chris Lambert, a family nurse practitioner, and today I am joined by Dr Pradeep Manudhane, a psychiatrist.
PM: Thanks, Chris. It’s great to see you. I am happy to join you here today to discuss a very important topic that we as mental health practitioners should keep in mind while caring for our mental health patients, and that is stigma.
CL: Absolutely. Let’s jump right in.
CL: More than half of people with mental illness don’t receive treatment, and one of the reasons for this is stigma surrounding mental health and mental disorders.1,2 Stigma can also be an obstacle to diagnosis and can result in people delaying or avoiding seeking help in managing their condition.3 In the 2020 National Survey on Drug Use and Health, approximately 14 million people with any mental illness and about 18 million people with a serious mental illness said they did not receive mental health services because it might cause their neighbors or community to have a negative opinion of them.4 Similarly, about 10 million people did not receive services because they did not want others to find out that they did so.
CL: We’ve made progress as a society in understanding mental illness, but there is still a lot of work to be done around stigma on the patient level. For example, a survey from the American Psychological Association found 33% of American adults feel “scared” of people with mental disorders, and 39% said they would view someone differently once learning that person has a mental disorder.5 Stigma can come in several different forms, such as stereotypes, prejudices, and discriminatory behavior.3
PM: Yes, Chris. I agree, there are many types of stigma. For example, patients with mental illness may have their own stigmas—such as feeling ashamed that they have a mental illness or believing that people who take medication for bipolar disorder are “inferior.” These self-stigmas also are a barrier to treatment. In a review of the effects of self-stigma among people with mental illness, individuals with more self-stigma were less likely to adhere to treatment.6 Healthcare professionals too can exhibit stigma, such as thinking patients with mental disorders can never get better and lead productive lives.7 One way of combatting stigma is to educate patients and healthcare professionals on the biomedical model of mental illness. Based on this model, mental disorders are considered as brain diseases that may be caused by neurotransmitter dysregulation, and they should be treated like any other physical illness or injury.8
PM: Thinking about illnesses or injuries to other body parts and using analogies can be effective at leading patients to a more open mindset about mental illness—one of, “This is a medical issue, not a judgment of you” or “This is not your fault.” For instance, you wouldn’t tell someone with a physical illness not to seek treatment. You wouldn’t blame yourself if you had bad vision and needed glasses. And even runners can exercise but still have high cholesterol; they might have a genetic condition. Addressing issues with psychiatric conditions is no different—maybe their brain has an imbalance in neurotransmitters.
CL: Absolutely, Dr Manudhane. Mental health stigma is layered and complex. It can be exhibited in many different ways—some obvious, like shaming and blaming, and others less so, like microaggressions.9 Numerous factors may contribute to stigma. Because of this, stigma needs to be approached individually for each patient, and not in a “cookie cutter” fashion. There is no single approach or conversation that will work for all patients to help them overcome stigma and break down barriers that result from stigma.
PM: So, Chris, what are some contributors to stigma? In this country, there is still a lot of guilt, shame, and fear associated with having a mental illness, and these contribute to stigma. Cultural norms and values can also influence the way we think about mental illness and can lead to stereotypes and other stigmatizing beliefs and behaviors.10 And the way a person thinks and feels about the healthcare system, healthcare professionals, and taking medication could also be self-stigmatizing, causing them to avoid seeking help.11,12
CL: Agreed. Additionally, research has shown that the length of time it takes for an initial visit with a health care provider can lead to negative outcomes, like a lower likelihood of attending additional appointments.13 It might be that, in some instances, waiting for care leads to self-stigma. For instance, if a patient has thoughts of self-harm and has to wait for weeks for an appointment, it could lead to thoughts like, “No one cares. No one can help me. It’s going to be like this forever.” The patient has negative thoughts about their diagnosis before even seeing their healthcare professional for the first time.
CL: Healthcare professionals can play a critical role in fighting bias and discrimination. They should ask themselves, “What am I doing to combat mental health stigma with my patients?” Healthcare professionals, NPs and physicians alike, need to intentionally look for sources of implicit bias and stigma early on. Be sure to spend some time educating patients—as well as caregivers—about mental illness. Stigma is sometimes the result of simply not understanding the disease, its causes and effects, and possible treatments.
PM: Yes, Chris, it is so important to educate our patients and their support systems. To help address stigma, healthcare professionals need to better understand where patients are coming from, what life experiences they have had, and what family experiences shaped them. Spend some time during intake talking with patients about their sociocultural backgrounds. Look for sources of resistance they faced before seeking help, like negative beliefs about mental illness treatment or negative attitudes by those in their family or social circle. Patients may say they have no family history of mental illness, but perhaps it just wasn’t talked about or recognized. Maybe there was stigma about saying the word “bipolar” out loud. Asking questions about a patient’s family can unearth clues about stigma that paint a different picture.
CL: I love that you stress the importance of talking to patients to uncover potential barriers to care. I myself approach treatment discussions from a shared decision-making approach. Ask patients how they feel about medication, psychotherapy, and other treatments and services, like peer services or mutual-aid support groups. Consider their thoughts on which treatments and services they’d like to avoid or have had negative experiences with. Shared decision making not only can help reduce stigma but may also improve engagement and compliance with treatment decisions.14
CL: To summarize, there is a need to take an individual approach with each patient to find common ground, better understand them, and reduce stigma around mental illness and mental health treatment. To do this, take the time to learn about their life experiences and sociocultural influences.
PM: Yes, Chris. Taking an informed medical-based approach by thinking and talking about mental illness as you would any other medical illness, using analogies to make the subject of mental health more relatable and less taboo, and using shared decision-making can all help reduce stigma as well as patient resistance to appropriate diagnoses and management.
PM: In some cases, you might need to refer the patient elsewhere for care. This does not mean you’re engaging in stigma. When you have reached the limits of your scope of practice or available treatments you can offer, the patient may need treatment elsewhere. Imagine, for instance, a female patient with bipolar disorder and a history of trauma tells you she prefers a female healthcare professional with experience in such cases. If you don’t meet those qualifications, you might need to connect her with a healthcare professional who does.
PM: Stigma has many layers that need to be broken down. How healthcare professionals approach bias and take steps to address stigma early on with patients during intake can play a key role in improving patient care.
CL: I agree that building strong relationships with patients truly does begin at the first meeting. Reducing the stigma burden on patients by normalizing mental health and treating mental illness like any other illness, working to eliminate barriers, modeling being open to talking about mental health, and helping improve access to care—all of these efforts can help reduce stigma surrounding mental health.
PM: On behalf of Chris and myself, thank you for joining us today for this important discussion of stigma and its impact on mental health patients. We hope you have a wonderful day and encourage you to use other helpful resources available on the NP Psych navigator website.
- Mental Health America. The State of Mental Health in America. 2022. https://mhanational.org/sites/default/files/2022%20State%20of%20Mental%20Health%20in%20America.pdf
- American Psychiatric Association. Stigma, prejudice and discrimination against people with mental illness. 2020. https://www.psychiatry.org/patients-families/stigma-and-discrimination
- Thornicroft G, Mehta N, Clement S, et al. Evidence for effective interventions to reduce mental-health-related stigma and discrimination. Lancet. 2016;387(10023):1123-1132.
- James SL, Castle CD, Dingels ZV, et al. Global injury morbidity and mortality from 1990 to 2017: results from the Global Burden of Disease Study 2017 [published correction appears in Inj Prev. 2020 Sep 28;:]. Inj Prev. 2020;26(Supp 1):i96-i114.
- American Psychological Association. Americans Becoming More Open About Mental Health. 2019. Accessed October 24, 2022. https://www.apa.org/news/press/releases/apa-mental-health-report.pdf
- Livingston JD, Boyd JE. Correlates and consequences of internalized stigma for people living with mental illness: a systematic review and meta-analysis. Soc Sci Med. 2010;71(12):2150-2161.
- Knaak S, Mantler E, Szeto A. Mental illness-related stigma in healthcare: Barriers to access and care and evidence-based solutions. Healthc Manage Forum. 2017;30(2):111-116.
- Deacon BJ. The biomedical model of mental disorder: a critical analysis of its validity, utility, and effects on psychotherapy research. Clin Psychol Rev. 2013;33(7):846-861.
- Crespo-Ramos G, Cumba-Avilés E, Quiles-Jiménez M. "They called me a terrorist": Social and Internalized Stigma in Latino Youth with Type 1 Diabetes. Health Psychol Rep. 2018;6(4):307-320.
- Abdullah T, Brown TL. Mental illness stigma and ethnocultural beliefs, values, and norms: an integrative review. Clin Psychol Rev. 2011;31(6):934-948.
- Dixon LB, Holoshitz Y, Nossel I. Treatment engagement of individuals experiencing mental illness: review and update [published correction appears in World Psychiatry. 2016 Jun;15(2):189]. World Psychiatry. 2016;15(1):13-20.
- Fung KMT, Tsang HWH, Corrigan PW. Self-stigma of people with schizophrenia as predictor of their adherence to psychosocial treatment. Psychiatr Rehabil J. 2008;32(2):95-104.
- Gallucci G, Swartz W, Hackerman F. Impact of the wait for an initial appointment on the rate of kept appointments at a mental health center. Psychiatr Serv. 2005;56(3):344-346.
- Slade M. Implementing shared decision making in routine mental health care. World Psychiatry. 2017;16(2):146-153.
NP Psych Navigator is sponsored by AbbVie Medical Affairs. The contributors are paid consultants for AbbVie Medical Affairs and were compensated for their time.
This resource is intended for educational purposes only and is intended for US healthcare professionals. Healthcare professionals should use independent medical judgment. All decisions regarding patient care must be handled by a healthcare professional and be made based on the unique needs of each patient.
Sponsored by AbbVie Medical Affairs
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