Stigma of Mental Illness & HIV: Causes & Strategies
Monday, July 20th, 2009This article has been written as part of the partnership between The Lancet Student and Asian Medical Students’ Association International. The 30th Asian Medical Students’ Conference will be held next week in Taiwan on the theme of ‘Stigmatised Illnesses: To understand, to accept, and to change’. We look forward to hearing about the conference, look out for the conference blog and podcast next week! Alistair Hustig, the Secretary of Academcis – Asian Medical Students’ Association International, has written this fantastic article on the theme.

‘Stamping out Mental Health Stigma’, NHS.
Stigma. This one word often represents the most crucial element effecting people living with a wide range of illnesses. It negatively impacts efforts to treat and prevent disease, and adversely affects individuals’ quality of life. Many illnesses have a high prevalence of stigma including mental illnesses, cancer, leprosy, and sexually transmitted diseases. However, the type of stigma varies with different conditions. This article highlights some causes and differences of stigma associated with mental health and HIV, as well as successful strategies of reducing its impact.
Definitions of stigma encompass social identity (deviance from what is normal), power discrepancies (that allow discrimination), and discrediting attributes that result in devaluation of people living with illnesses, such as those above (1,2,3). This often manifests itself in an external sense as discrimination, hatred, intolerance, rejection, and exclusion. However what is often under-recognised is the internal aspect of stigma. Internal manifestations can include self-loathing, shame, and self-blame, all of which are preyed upon when someone stigmatises (3,4). Stigmatisation can also extend to family, friends, and even to institutions and clinics which themselves perpetuate stigma. As a result anyone associating with patients, or visiting centres, can be dragged into the net of stigma.
People living with Mental Illness
People who have depression, schizophrenia, and other mental illnesses, commonly report stigma from both community and health professionals. Depression is a leading cause of disability effecting 121 million people worldwide (5). Schizophrenia affects millions of people. Of these, only 25% of those with depression, and 50% of those with schizophrenia who are in need of treatment are receiving appropriate therapy (5). These figures suggest that stigma, at least in part, may be having an affect on treatment of mental illness. The perception of depression as a weakness rather than an illness (6); or people with depression are dangerous, and ‘schizophrenics’ are violent (6,7) remains embedded in public opinion. These views are less shared with other common illnesses for example cardiovascular disease. Unlike mental illnesses, cardiovascular disease is less stigmatised at least in part because the aetiology, pathophysiology, and successful treatments are well known. The fear of the unknown may therefore contribute to stigma being ingrained in an illness. As a result people with the illness are afraid of disclosing to family and friends, and do not seek help where it would be of benefit (6). Health practitioners, even those in the field of mental health can also stigmatise through intensive use of language and labelling. Some are more empathic and understanding of the nature of the illnesses, but some practitioners continue to define their patient by their illness. The difference in language is powerful – a ‘schizophrenic’, whose behaviour defines them, versus a ‘person living with schizophrenia’, whose illness causes altered behaviour (7). This labelling may plague the patient as a ‘life sentence’ (7) reducing self-esteem, withdrawing social opportunities, and creating ongoing employment difficulties (8), ultimately ruining any chance of normality.
People living with HIV
It is estimated that around 33 million people worldwide are infected with HIV, with the majority in low- and middle-income countries (9). Of these, only 3 million were receiving appropriate anti-retroviral therapy as at December 2007 (9). Again one of the biggest issues preventing uptake is stigma. However, the stigma signature associated with people living with HIV is different to that explained for mental illness. Bos and colleauges (10) propose a model for stigmatisation of people living with HIV. They describe how perceived contagiousness (everyday contact, not just sex), perceived seriousness (life-threatening), personal responsibility (unsafe sex) and norm-violating behaviour (e.g. male-to-male sex, and intravenous drug use) contribute to increase fear and anger while decreasing pity for people living with the disease. Stigma also surrounds certain groups at increased risk, such as homosexuals, intravenous drug users, and sex-workers. This further stigmatises people living with HIV leading to amplified discrimination and negative social responses. As a result, people living with HIV have a decreased quality of life and are less likely to seek testing, treatment, and counselling, or disclose their status to potential support providers. This can result in advanced presentations with high viral loads, low CD4 counts, and opportunistic infections.
Strategies for Reducing Stigma
The need to address stigma is paramount in order to reduce prevalence and thus burden of illness (e.g. curbing the HIV epidemic), and increase treatment uptake. For mental illnesses, in particular depression, Barney and colleagues (6) suggest that blaming, avoiding, and labelling people living with mental illnesses must be addressed. Accurate knowledge and portrayals of survival and recovery, as well as the true risk to the community for these health conditions needs to be expressed by all means possible, especially the media.
Public disclosure of HIV status has been shown to have a beneficial impact to both the individual and the surrounding community (11). Individuals are often very scared and describe this as the most difficult and dangerous thing to do. Post-disclosure they feel empowered, released from a heavy secret, and less isolated and withdrawn, taking back control of their lives (11). To help facilitate this appropriate training and support needs to be given before disclosing to prepare for potential negative reactions from community members. However, public speaking regarding one’s positive living helps to make the community more aware and dispel myths around HIV, thus reducing stigma. This is echoed by studies involving public speaking by people living with HIV (11) and mental illness (12), which have shown improved attitudes among high school students to those living with the illness. Uniting all people with stigmatised illness would provide a voice that would be far too loud to ignore.
Access to relevant treatment that communities understand is effective and essential in any stigma reduction programme. The case of universal access to HIV therapy in Botswana (which has the 2nd highest prevalence), implemented in 2002, provides clear evidence of reducing stigma (13). Wolfe and colleagues (13) demonstrated pre- and post-implementation that only 31% of people had disclosed positive HIV status to family, and 5% to friends in 2001, compared with 90% and 55% respectively in 2004. Other examples of reduced stigmatising attitudes include an increase in the number of people that would care for a person living with HIV, accept them as a teacher and buy food from a shopkeeper with HIV.
Conclusion
Stigma and its consequences affect the course of illness for many millions of people worldwide. It provides an enormous barrier to all attempts to help people living with stigmatised illnesses. Stigma affects all, it endures, and it compromises survival and recovery of those most in need. We must strive to find new ways to abolish stigma, and thereby allow access to treatment and empowering positive living.
Alistair Hustig, hust0007@flinders.edu.au
Secretary of Academics – Asian Medical Students’ Association International
Australian Medical Students’ Association Councillor
Graduate Entry Medical Programme Year II – Flinders University, Adelaide, South Australia
Bachelor of Medical Science – Flinders University, Adelaide, South Australia
References
1. Joint United Nations Programme on HIV/AIDS (UNAIDS). Reducing HIV Stigma and Discrimination: a critical part of national AIDS programmes. [Online]. 2007 [accessed 20 June 2009]. http://data.unaids.org/pub/Report/2008/JC1521_stigmatisation_en.pdf.
2. Reidpath DD, Chan KY, Gifford SM, Allotey P. ‘He hath the French pox’: stigma, social value and social exclusion. Sociology of Health & Illness 2005; 27(4): pp. 468-489.
3. Courwright AM. Justice, Stigma, and the New Epidemiology of Health Disparities. Bioethics 2009; 23(2): pp. 90–96.
4. Cameron E. Witness to AIDS. Cape Town: Tafelberg Publishers Limited; 2005.
5. World Health Organization. Mental Health: Disorders Management. [Online]. 2009 [accessed: 21 June 2009]. www.who.int/mental_health/management/en/.
6. Barney LJ, Griffiths KM, Christensen H, Jorm AF. Exploring the nature of stigmatising beliefs about depression and help-seeking: Implications for reducing stigma. BMC Public Health 2009; 9(61).
7. Flanagan EH, Miller R, Davidson L. ‘‘Unfortunately, We Treat the Chart:’’ Sources of Stigma in Mental Health Settings. The Psychiatric Quarterly 2009; 80: pp. 55-64.
8. Corrigan P. How Stigma Interferes with Mental Health Care. American Psychologist 2004; 59(7): pp. 614-625.
9. Joint United Nations Programme on HIV/AIDS (UNAIDS). Report on the global HIV/AIDS epidemic. [Online]. 2008 [accessed 20 June 2009]. http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/2008_Global_report.asp
10. Bos AER, Schaalma HP, Pryor JB. Reducing AIDS-related stigma in developing countries: The importance of theory- and evidence-based interventions. Psychology, Health & Medicine 2008; 13(4): pp. 450-460.
11. Paxton S. The paradox of public HIV disclosure. AIDS Care 2002; 14(4): pp. 559-567.
12. Spagnolo AB, Murphy AA, Librera LA. Reducing Stigma by Meeting and Learning from People with Mental Illness. Psychiatric Rehabilitation Journal 2008; 31(3): pp. 186-193.
13. Wolfe WR, Weiser SD, Leiter K, Steward WT, Percy-de Korte F, Phaladze N, Iacopino V, Heisler M. The Impact of Universal Access to Antiretroviral Therapy on HIV Stigma in Botswana. American Journal of Public Health, 2008; 98(10): pp. 1865-71.


The college principal inaugurating the NMCRCYC board
Patients in the free health camp
Flood victim relief material being handed over to secretary of the Red Cross Kathmandu Chapter