Stigma and mental illness in the community

Tai-pong Lam 林大邦

HK Pract 2007;29:81-82

According to the US Surgeon General, stigma is the number one barrier to mental health care and this has been supported by recent studies.1 There is similar evidence that stigmatizing opinions about people with mental illnesses are widely held in the UK.2 World Health Organization also emphasized the centrality of stigma to mental health and called for anti-stigma campaigns to combat mental illness stigma.3 Indeed, the phenomenon is universal and exists in the general population worldwide.

According to The Concise Oxford Dictionary of Current English (1995), stigma refers to "a mark or sign of disgrace or discredit; a distinguishing mark or characteristic; a visible sign or characteristic of a disease". Jones et al developed a definition of stigma as a "mark" that sets a person apart from others and link a person to undesirable characteristics, with six dimensions of stigma identified, namely concealability, course, disruptiveness, aesthetics, origin, and peril.4 Link & Phelan added the component of discrimination as experienced by a stigmatized person to Jones et al's definition and derived the concept of stigma in the consequence of interrelated components where the elements of labelling (i.e. identification of disparity), stereotyping (i.e. linking the bearer to undesirable characteristics), separation (i.e. separate "us" from "them" in distinct categories), emotional reactions (i.e. affect of stigmatizers and the stigmatized),6 status loss and discrimination co-occur.5

These stigmatizing opinions vary in nature and frequency for different mental illnesses. Li et al investigated the barriers to meeting the mental health needs of the Chinese community in the UK.7 They found that stigma associated with mental illness and limited knowledge in the community were the main causes for the widespread discrimination experienced by their participants. It is likely that such stigmatizing opinions exist in Hong Kong; however, relatively little is known about its level of intensity and the specific mental health conditions that they are associated with. This knowledge is of vital importance if we are to aim at reducing such stigmatizing opinions since studies have shown that people's attitudes towards psychiatric patients are susceptible to change.8 Interventions have been shown to have positive impact on participants' attitudes towards people with mental health problems.9

Family physicians and their team members are confronted endlessly by the challenge of mental disorder and related mental health problems in their patients.10 The primary care team often has the potentially precious advantage, diagnostically speaking, of knowing the ongoing psychological and social dynamics of the family background. One major explanation would be that their family physicians are their most accessible doctors as nearly 80% of individuals visits their family physicians at least once a year. Another important reason might have been that it carries no stigma to consult family physicians. In Hong Kong, many patients with minor mental health problems e.g. anxiety related illnesses, depression, are attending specialist psychiatrists, either private or public. Phongsavan et al reported that 64% of Australian general practitioners had found patients feeling uncomfortable being referred to psychiatrists.11 It is uncertain if attending psychiatrists carries sufficient stigma that would affect the readiness of some Hong Kong patients to seek care and to continue follow up for their mental health conditions. It is therefore of importance to investigate if care by family physicians would help to reduce such stigma,12 hence, affect the readiness of some Hong Kong patients to seek care and to continue follow up for their mental illnesses.

It has been predicted by World Health Organisation that depression, probably the most common mental illness in the community, will become the second most important cause of disability worldwide by 2020.13 Its prevalence is estimated to be between 5-10%. The care of these depressed patients will fall heavily on the family physicians because of its size. It is hoped that the reduced level of stigmatization and the improved skills of family physicians will help combat the hidden epidemic of mental illness in the community.