Social Stigma
Historically, many cultures associated mental illness with demonic possession, sin, or weakness of will. In cultures influenced by Christianity, widespread beliefs in a holy soul housed by a material body contributed to conceptualizing mental illness as a spiritual affliction, different from other forms of physical illness. In Enlightenment philosophy, this notion was secularized as a bifurcated sense of physical and mental life often tagged “Cartesian dualism,” in reference to its iconic articulator, 17th century French philosopher Rene Descartes. With rationality replacing the soul as the perceived essence of humanity, mental illness continued to be stigmatized as a culpable deficiency perceived as more dehumanizing than other mortal conditions.
The notion of a mind-body dichotomy has been thoroughly debunked by modern science and social science. Genetic and biochemical pathways profoundly impact vulnerability to many mental illnesses, depression, and substance abuse. Human experience such as either loving support, or traumatic abuse or neglect impact, impact the brain, nervous system, and immune system. Many forms of chronic illness and mental health challenges tend to co-occur and to exacerbate eaçh other.
Yet many aspects of contemporary social framing of mental illness belie the modern understanding. Indeed, the continued designation of “mental health” as a separate category of healthcare for training and insurance purposes ignores state-of-the-art scientific insights.
Fear of continuing social stigma may discourage people from seeking treatment. Lingering stigma creates greater access barriers to mental health care which often entails additional layers of insurance review and regulation. Some patients decline covered services for fear an insurance record of mental health treatment could hurt them in the future. Electronic medical records and “big health data” offer the potential for better coordinated care for patients with mental health challenges, but these emerging technologies also increase the risk that sensitive health information shared with a health professional may not be fully confidential and may become known to people or institutions the patient did not intend.
Patient perceptions of the danger of stigma are all too often accurate. For example, many licensure processes require answering questions about mental health history that can result in rejection even if past problems were successfully treated, including medical, law, foster parenting, and adoption applications.
Licensure issues may be one of many factors underlying elevated levels of mental health duress and suicidality among health professionals and trainees, compared to the population at large. Other factors may include a stoic medical culture that portrays ideal providers as unflappable heroic rescuers. High rates of undiagnosed and untreated depression, addiction, contribute to professional burnout and high rates of suicidality in this population. Male physicians are 1.4 times more likely to die by suicide than other men in the general population, and women are 2.3 times more likely. Increased mental health distress often begins in medical school. Studies suggest not only that medical students experience depression and other mental health conditions at a higher rate than the general population, but that their mental health tends to decline over the course of their medical training. Behind accidents, suicide is the most common cause of death among medical students. Professional and public attention to trauma suffered by first-line responders in the ongoing Covid-19 pandemic is piquing renewed discourse about mental health support for healthcare workers (May 2020).
Features of medical curriculum can worsen or alleviate stigma of mental illness that is subconsciously perceived and perpetuated by health professionals. Evidence suggests the earlier in medical training serious mental illness is addressed, the more comfortable trainees become diagnosing and communicating with people who have significant mental health challenges. Yet often in medical rounds, case studies, and textbooks, people with mental health conditions are described as “needing help” (though of course all patients do), being “unpredictable” and “volatile.” At the same time, less general curricular time may be spent relaying stories of successful mental health treatment, or briefing the higher chronic disease burden and mortality of those with serious mental illness. These factors can contribute to a “physician bias,” overly negative attitudes among medical staff regarding the prognosis for patients with serious mental health challenges. The profession with a special obligation to reduce stigma itself struggles with both mental illness and institutionalized stigma.
There are now concerted social efforts to combat stigma. Many of these efforts encourage people to talk about mental health challenges, aiming simultaneously to offer a healing narrative while destigmatizing public discussion. The U.S. Mental Health Parity and Addiction Equity Act of 2008 prohibits insurers from having lower-dollar annual or lifetime caps for mental health services than other services. Many mental advocates consider it a first legislative step toward fuller parity for mental health benefits. The Affordable Care Act of 2010 expanded on the Mental Health Parity Act, requiring that as of 2014 certain mental health and addiction benefits be required in the essential benefits packages of insurance plans in the ACA market exchange.
The devastation wrought by the subsequent opioid epidemic increased political interest in better integration of addiction and mental health services, resulting in numerous programmatic innovations. The mental health stresses associated with the social and economic upheaval of the Covid-10 pandemic (as of May 2020) likely will increase those political pressures.