Monday, May 13, 2013

Can Psychiatry Ever Really Get Rid of Stigma?

We all think stigma with mental illness is a bad thing.  Because mental disorders are stigmatized, people hide their psychic distress and don't get help, or they live in denial about their problems when the fact that they are mentally ill is obvious to others.  People live in pain, or they simply don't live up to their potential.  Stigma is only part of the problem, of course.  There is also the issue of access to care, access to good care, cost of care, dislike of the care that exists (mean psychiatrists, side effects from medications, lousy food or uncomfortable beds on inpatient units), and the fact that sometimes people lack the insight to be aware that they have a problem.  

Insurance companies, I believe, add to stigma, not because they want to stigmatize patients, but because this is a vulnerable group of people where they can avoid shelling out money.  Inadvertently, however, policies that exclude mental disorders or reimburse them differently, increase stigma.  Whatever the intent, the result is the same.

Some people like to compare mental illnesses to diabetes or hypertension: it's chronic, it's biological (we believe), it's an illness to treat like any other illness.  It's a lousy metaphor for a number of reasons: we don't know the biology behind the disorders, and psychiatric disorders are not predictably chronic.  Okay, actually, some people can get rid of their hypertension with weight loss, and then the disorders don't actually exist, but somehow once you're labeled with diabetes, it sticks (diet-controlled, even if you're not on a medicine, even if your blood sugar is normal).  

But aside from issues of insurance parity and certainty about the biological causes of psychiatric disorders, there is a reason I think that untreated or unresponsive mental disorders will always have  stigma.  In the world of "Reduce Stigma," this is going to be the totally politically incorrect thing to say.  Psychiatric disorders come with stigma because people in the throes of certain psychiatric illnesses sometimes behave in distasteful, frightening, unusual, and disturbing ways.  I think we've done a lot to decrease the stigma of depression and anxiety, and it's been immensely helpful that famous, brilliant, successful, beautiful, rich people have talked openly about their struggles with these disorders.  And while I think we've made progress identifying other disorders as problems/disorders/illnesses and not the 'fault' of the person, if a psychiatric problem makes it such that a person refuses to bathe, or becomes loud, irritable, and irrational in the work place, then no amount of reduce stigma campaigning will make it so that people will want to be next to someone who smells bad or whose behavior is erratic.   I, too, want to see stigma reduced.  But if someone is running down the street naked screaming about aliens, they have a bigger challenge to face than the person who quietly sits in the doctor's office and learns their blood pressure numbers are over a certain level.

The answer?  Better treatments, of course.  And more success stories from those with major mental illnesses.  I remain hopeful.