Friday, October 18, 2013

How to Combat Stigma, Part 1

The stigma associated with mental illness is something that leaders of the profession such as Dr. Jeffrey Lieberman, the current American Psychiatric Association president, often point to when fighting back against critics of psychiatry. Dr. Lieberman seems to believe that by moving psychiatry away from Freud's "brilliant fiction" and "into the mainstream of medicine," stigma will decrease and people will be more likely to seek treatment.

I think the truth is much more complicated. I believe that well-intentioned interventions can potentially have the opposite effect and increase stigma. I went to medical school in a city where HIV/AIDS was epidemic, and I was part of a medical student-run group that went to local middle schools to teach about HIV and AIDS. Our goal was not only to increase knowledge about the disease and how to prevent it, but also to decrease the stigma associated with HIV by having HIV-positive speakers meet with the students to share their stories. We also administered a quiz before the teaching and again a few months later, to assess for changes in the students' knowledge and their attitudes toward people with HIV/AIDs. Sadly, while their knowledge increased, their negative perceptions of people with HIV also seemed to increase.

An analogous situation is described by writer Ethan Watters in his 2010 book Crazy Like Us, which he excerpted in a NYTimes Magazine article:
In 1997, Prof. Sheila Mehta from Auburn University - Montgomery in Alabama decided to find out if the “brain disease” narrative had the intended effect. She suspected that the biomedical explanation for mental illness might be influencing our attitudes toward the mentally ill in ways we weren’t conscious of, so she thought up a clever experiment.

In her study, test subjects were led to believe that they were participating in a simple learning task with a partner who was, unbeknownst to them, a confederate in the study. Before the experiment started, the partners exchanged some biographical data, and the confederate informed the test subject that he suffered from a mental illness.

The confederate then stated either that the illness occurred because of “the kind of things that happened to me when I was a kid” or that he had “a disease just like any other, which affected my biochemistry.” (These were termed the “psychosocial” explanation and the “disease” explanation respectively.) The experiment then called for the test subject to teach the confederate a pattern of button presses. When the confederate pushed the wrong button, the only feedback the test subject could give was a “barely discernible” to “somewhat painful” electrical shock.

Analyzing the data, Mehta found a difference between the group of subjects given the psychosocial explanation for their partner’s mental-illness history and those given the brain-disease explanation. Those who believed that their partner suffered a biochemical “disease like any other” increased the severity of the shocks at a faster rate than those who believed they were paired with someone who had a mental disorder caused by an event in the past.
Of course, one study in college students is hardly conclusive, but I have had very many similar experiences with my own patients. Those who were told by previous doctors that they had biochemical issues going on in their brains often lost hope when the biological treatments did not help them feel better. I have had patients tell me that they felt like they were damaged or broken after they were told during psychiatric hospitalizations that they had "bipolar disorder" or "treatment-resistant depression."

I feel that many practicing psychiatrists are starting to come around, and I found hope in an unlikely place: the American Psychiatric Association's YouTube page. In particular, the following clip from this year's APA conference:

Below, I've summarized the responses of those interviewed:
  1. Chester Swett, MD: As public becomes better educated, emotional issues are more accepted as a part of going through life; a certain percentage of people may have more trouble than the average person, and that is when we diagnose anxiety, depression.
  2. Ravi Hariprasad, MD, MPH: Role model treating patients and families without stigma. Set a good example. Stigma is fought on individual one-to-one basis; best help is to help patients break their own stigma against themselves.
  3. Darshan Singh, MD: Help patients learn they are not to be blamed, it is a health issue. There is not one cause, mental illnesses are not like diabetes. People should be encouraged to talk to social workers, nurses, mental health agencies, pastors, etc. to learn that they are not alone in their struggles.
  4. Kerin Orbe, DO: Talk about psychiatry and psychological problems more naturally. Educate community about what mental illness means.
  5. Marcos Liboni: Share advances in psychiatry. Show psychiatry nowadays is very different from the past. Historically, psychiatry was linked to prisoners and torture. Now brain diseases can be treated; psychiatry is a medical specialty not far from medicine. 
  6. Laurie Wells, MD: Mental illness is universal, affects everyone. Treatment is whole treatment of mind and body, not just medication. Serving people we treat with respect and respecting autonomy de-stigmatizes them.
There is certainly a diversity of opinion, and I may not have captured the nuances of what each person was trying to convey. But what stands out to me is that only one of the respondents talked about biological advances in psychiatry, while several emphasized the importance of treating patients with respect and compassion. I think that's a good place to start.