Stigma and mental health: overcoming barriers

INTRODUCTION World Mental Health Day, which falls on 10 October, provides an opportunity for all stakeholders involved in mental health issues to discuss their work and identify further actions needed to make mental health care accessible worldwide. Stigma is one such ubiquitous issue, often impacting those with a mental health condition throughout their journey. It also affects those providing care to a person with a mental health condition, either through affiliate stigma (stigma evoked as a consequence of associating with stigmatised persons) or by causing distress and frustration as they struggle to support their loved ones who feel overwhelmed by stigmatising attitudes.[1] The pervasiveness of this stigma extends to even healthcare workers, leading to the value of their profession being minimised by the general public and peers.[2] HISTORICAL CONTEXT OF STIGMA The term ‘stigma’ originates from the ancient Greek word ‘στίζω’, which means “to carve, to mark as a sign of shame, punishment or disgrace”.[3] Goffman[4] defined stigma as “an attribute that is deeply discrediting” that reduces an individual “from a whole and usual person to a tainted, discounted one”. Link and Phelan[5] expanded the concept, describing stigma as a multifaceted social process involving labelling, stereotyping, separation, status loss and discrimination within a power context. Such stereotyping and prejudice lead to the rejection and discounting of diverse groups, including people experiencing homelessness,[6] individuals with excess body weight[7] and those with mental health conditions.[8] IMPACT OF STIGMA ON INDIVIDUALS WITH MENTAL HEALTH CONDITIONS The stigma surrounding mental illness affects individuals in multiple ways. Firstly, it discourages people from seeking help.[9] Fear of being labelled as mentally ill can lead individuals to downplay or hide their symptoms, delaying diagnosis and treatment.[10] This reluctance to seek help can exacerbate the burden of mental health conditions, leading to more severe symptoms, the development of comorbid conditions and poorer outcomes.[11] Secondly, self-stigma or internalised stigma, which occurs when people with mental health conditions are aware of the negative stereotypes of others, agree with them and internalise them, is associated with suboptimal health outcomes.[12] Self-stigma can also lead to lower self-esteem, diminished sense of self-worth, and impaired social and occupational functioning.[13] Thirdly, public stigma may result in social isolation, as friends, family and colleagues might distance themselves due to misconceptions and fear.[14] At the workplace, stigma may result in employers and coworkers harbouring biases and believing that individuals with mental health issues are less capable or reliable, leading to discrimination, such as not being offered a job, being overlooked for promotions or assigned less-demanding tasks, regardless of the individual’s capabilities.[15,16] EFFORTS TO COMBAT STIGMA There have been several efforts to address the stigma surrounding mental health conditions in Singapore, ranging from interventional studies to nationwide campaigns and legislative changes. Leveraging education and the contact theory, researchers from the Institute of Mental Health, Singapore, collaborated with a local university to pilot an intervention — Advancing Research To Eliminate Mental Illness Stigma — to improve mental health literacy and reduce stigma towards depression.[17] The authors found that the intervention was effective in improving knowledge on depression and reducing social distancing and personal stigma from pre- to post-intervention as well as from preintervention to 3-month follow-up. Tan and Mankiewicz[18] evaluated the efficacy of a randomised controlled trial comprising (a) a brief video contact-based intervention (90 s) in which a woman described her experiences and recovery from psychosis, (b) a transcript intervention, which was a verbatim of the video, and (c) an active control arm comprising a brief video of a woman describing her recovery from breast cancer. They found no significant differences in declared stigma between the three arms. Surprisingly, social distancing attitudes worsened postintervention and, even more so, at follow-up. Although other stigmatising attitudes improved significantly postintervention, they subsequently returned to baseline levels at follow-up. A concerted effort to address stigma and promote social inclusion of people with mental health conditions was initiated by the National Council of Social Services, Singapore. The campaign, known as ‘Beyond the Label’, was a nationwide movement initiated in 2018, and the second phase of the movement, termed ‘Beyond the Label 2.0’, was launched in 2022. In 2021, the Health and Wellbeing team of the National University of Singapore (NUS) spearheaded a campus-wide ‘#AreuOK’ mental health campaign that aimed to destigmatise mental health conditions and promote early help seeking among the students and staff of NUS. Increasingly, people with and without mental health conditions are advocating for greater support of people with mental health conditions and raising awareness of stigma and its impact on society. Literary works like Praying to the Goddess of Mercy and A Philosopher’s Madness demystify and destigmatise mental illnesses while showcasing the resilience and courage of the authors who have shared their journeys. In a first for Singapore, more than 20 members of parliament spoke on ways to improve care and raise societal acceptance in a debate on advancing mental health in the parliament on 6 February 2024. Many shared candidly on the challenges faced by those with mental health conditions and how Singaporeans can do more to support them. Legislation and policies are equally vital in combating stigma. The Tripartite Committee has recommended that legislation should prohibit workplace discrimination towards those with disability and mental health conditions. As part of the Workplace Fairness legislation, this would cover all stages of employment, that is, pre-employment (e.g. recruitment), in-employment (e.g. promotion, performance appraisal, training) and end-employment (e.g. dismissal). HEALTHCARE PROFESSIONALS AND STIGMA Healthcare professionals have a significant role to play in reducing mental health stigma. Unfortunately, research shows that the stigmatising attitudes of healthcare providers result in poorer quality of physical care for persons with mental health conditions.[19] Many factors may contribute to it, including ‘seeing the illness ahead of the person’,[20] which can lead to the use of language that may be perceived by people with mental health conditions to be disrespectful or dismissive of them and their unique strengths. Therapeutic pessimism is acknowledged as another contributory factor. Healthcare providers tend to hold pessimistic views about the reality and likelihood of recovery, which may lead to low prioritisation or even lack of care for people with mental health conditions,[21] and physical health symptoms being dismissed or not taken seriously.[22] However, local research is scarce in this area, with one study reporting considerable stigma towards those with alcohol use disorder. Furthermore, as compared to the general public, healthcare workers held more stigmatising views towards patients with alcohol use disorders.[23] The stigmatising attitudes and behaviours often lead to unwillingness to seek care or early disengagement of services, which impacts the physical and mental health of those with mental health conditions. There is a need to train healthcare workers to recognise and address their own biases and ensure that they provide compassionate, non-judgemental care to individuals with mental health conditions. We need to develop and evaluate culturally acceptable interventions that can reduce stigma in healthcare settings. It may well be that the best intervention is a colleague speaking up and educating the team on the impact their words and behaviours can have on a person with a mental health condition. HOPE FOR A BETTER TOMORROW As I pen my thoughts on stigma for this commentary — a subject to which my colleagues and I have been dedicated for the past decade — the words of a young boy at a focus group discussion came to me: “I think it is better to have cancer than a mental illness”. On hearing this, the rest of the group supported him with self-deprecating words such as, “We would get some sympathy”, “They would not say it is our fault or that we are making it up”, and most poignantly, “Do you know there is a cure for many cancers?” When the focus group discussion ended, I emphasised to the participants that things were changing in the mental health field, that it was better than a decade ago and recovery was possible. They acknowledged that things were changing and humbled me by gently telling me to have a good weekend with my family and not to worry too much about them. As they excitedly made plans with each other to grab a bite, watch a show or catch up later, I let myself hope that someday, stigma would not have the power to dull their laughter and zest for life. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.