A family whose son died was caring for his widow who happened to be schizophrenic.
Several treatment attempts were made to arrest the illness without success. Consequently, the daughter-in-law's behaviors were uncontrolled causing a number of problems. The patient's in-laws were unable to cope and finally sent her by train on a pilgrimage to Rishikesh in Uttarakhand state without the possibility of return. (Agarwal, 1998[3
Consequences of stigma can be life threatening and humiliating. It can deprive an individual from basic needs, marginalize and deprive them, potentially leading to their death by self-neglect or suicide. More than 40% of countries have no mental health policy, and over 30% have no mental health programmes. Existing health plans frequently do not cover mental and behavioural disorders at the same level as other illnesses, creating significant economic difficulties for patients and their families. One of the identified reasons for low support for mental health is the stigma attached to mentally ill individuals (World Health Report, 2001[62
]). Being mentally ill is still considered a shameful condition that causes the person or the family to lose face. In some cultures, to have a mentally ill relative could, by association, damage the possibilities of advancement of other family members, to an extent where it might harm the marriage prospects of a young daughter or sister.
It is important to understand that the nature, determinants and consequences of stigma vary across culture and region. For instance, according to a study by Murthy (2005[31
]), urban respondents in large centres try to hide their illness hoping to remain unnoticed, whereas rural respondents in smaller regions experience greater ridicule, shame and discrimination, as anonymity is more difficult. Also, Jadhav et al
]) reported that rural Indians showed significantly higher stigma scores, especially those patients with a manual occupation. Urban Indians showed a strong link between stigma and not wishing to work with a mentally ill individual, whereas no such link existed for rural Indians. A study by Switaj et al
]), reported reduced life satisfaction as a key aspect of the subjective experience of stigma. This cross-sectional study assessed the extent of stigma experienced by patients with schizophrenia to establish its clinical and socio-demographic predictors. The experience of stigmatisation was common among respondents who most frequently reported having concealed their illness (86%), witnessed others saying offensive things about the mentally ill (69%), were worried about being viewed unfavourably (63%) and treated as less competent (59%). Higher levels of stigma were related to lower subjective quality of life and younger age of illness onset. No significant associations were found between stigma and symptoms or level of social functioning.
Several studies have shown that patients feel rejection from family members. People with mental illness experience stigma during the course of their illness and treatment, and it is an important predictor for the relapse of symptoms and non-compliance to treatment. Despite experiencing stigma, one study showed that the majority experienced stigma in the form of lowered self-esteem (69%), which may be the result of their knowledge of the prejudices held by society, or from specific events. In this study many individuals also reported being ignored because of their illness, and overhearing offensive comments about mental illness (46%) (Adhikari et al
A 40 year old man who was treated for schizophrenia managed to find work. While going to the doctor he was seen by other patients who made him feel uncomfortable and ashamed. However, medications could only be dispensed from a doctor's clinic forcing him to continue the same routine that he found so humiliating. Nevertheless, he managed to circumvent the clinic by getting his medication from a local medical shop. This practice continued for three to four years. Unfortunately, he developed obvious tremors of the right hand that were visible to his coworkers. They then began to make fun of him, equating his condition to that of an old man. Specifically, they would tease him by saying he had Parkinson's disease. Consequently, he found it very difficult to manage serving tea in the office and as a result lost his job. (Principal Author's experience in practice).
Stigmatisation of the mentally ill leads to the selective isolation of people, whom society considers either physically flawed or behaviourally odd (Rinnerthaler et al
); Martin et al
]). Stigmatisation also deprives individuals with mental illnesses their full measure of human dignity and the opportunity to participate in society (Lauber et al
]). Consequently, the discrimination resulting from stigma leads to compromised social support and opportunities for treatment by individuals and institutions (Martin et al
]; Thornton et al
]). Negative attitudes exist not only amongst the members of society but also amongst health professionals (Read et al
). Stigmatization represents a chronic negative interaction with the environment that most people with a diagnosis of schizophrenia face on a regular basis.
The question that arises is why do people with mental health problems fail to engage in treatment (Goff et al
]; Franz et al
]; AbuMadini et al
])? Many among the general public assume that persons with psychotic disorders are unpredictable and incapable of being managed, even by the best efforts of the health care system, and therefore are considered a threat to the social order and to public safety (Kelly, 2005[20
]; Appelbaum et al
]). Society encourages and reinforces stigmatization through a host of mechanisms, e.g. public print and film media. In a Nigerian study, the most common descriptions reported were derogatory terms (33%). This was followed by abnormal appearance and behaviour (29.6%); physical illness and disability (13.6%), negative emotional states (6.8%), and language and communication difficulties (3.4%). The results suggest that, similar to findings elsewhere, stigmatization of mental illness is highly prevalent among Nigerian children (Ronzoni et al
]). Similarly, a Chinese study from Hong Kong examined the experience of stigma associated with psychiatric treatment for schizophrenia. In focus groups patients described stigma experiences related to clinic visits and the side effects of antipsychotic medications. Results showed that patients with schizophrenia were more likely to anticipate stigma, conceal illness, and default on clinic visits, than patients with diabetes. Medication-induced stigma occurred in 48% of patients with schizophrenia. It brought about the unwelcome disclosure of illness, workplace difficulties, family rejection and treatment non-adherence. Adverse experiences during hospitalization were also reported by 44% of patients with schizophrenia (Lee et al
The consequences of psychiatric stigma are fairly consistent across communities. They include negative labelling, discrimination, treatment avoidance, such menacing societal responses as ostracism and exclusion, and even violence and suicide. The original impact of stigma leads to discrimination which further increases discrimination, forming a vicious cycle . In non-Western communities, and in developing countries, psychiatric stigma is particularly severe. It is possibly due to ignorance and poor availability of care (Lee, 2002[25
]). The origin of psychiatric stigma is complex but research on the subject has frequently focussed on negative public attitudes (Schulze et al
]; Stuart et al
]). Mental illness is usually concealable. People who hold negative attitudes may not demonstrate discriminatory behaviour toward people who suffer from mental illness (Pinel, 1999[36
]). Common effects of stigma are low self-esteem and discrimination in family and work settings. Providing care and treatment are identified as the most common method of combating stigma.