Stigma and Quality of Life among People Diagnosed with Mental Disorders: a Narrative Review

INTRODUCTION

The concept of stigma originally referred to the mark, the sign made with red iron by powerful people in society disgusted by Greek slaves, murderers, or others.1 Since ancient times, this has been used to differentiate and label people from what are considered to be inferior social classes, leading to their social marginalization.2 Within the setting in which power is exerted, stigma is described as the co-occurrence of marking, stereotyping, isolation, loss of status, and discrimination.3 A number of authors have attempted to theorize the subject of stigma. Link and Phelan4 suggest that stigma is a complex phenomenon, which cannot be explained sufficiently by a single, unique definition. They describe four components they consider to comprise stigma, including distinguishing and labelling differences, the association of human differences with negative attributes, the notion of “us” and “them” as two distinct categories, and the loss of social status and discrimination leading to inequalities.4 These components are related to people’s habits of labelling others as different, associating differences with negative stereotypes, separating different people from the rest of the population, and stigmatizing the experience of discrimination based on labelling.

Today, stigma remains a fundamental problem, linking psychiatry, psychology, and public health,5 as its negative influence might be felt primarily by people suffering from mental disorders. Those with mental disorders are still the subject of public stigma, which includes discrimination, prejudice, and false perceptions.6 According to current research, different mental disorders are subjected to different levels of public stigma and trivialization. For example, schizophrenia is one of the most stigmatized of mental disorders due to an associated misperception of risk and unpredictability.7 Eating disorders and depression are also frequently stigmatized due to a loss of personal control.8,9 Another concept that exists within the context of public stigma is self-stigma. Self-stigma is defined as a process in which patients diagnosed with mental health disorders become aware of public stigma and internalize this by applying it to themselves.10 Self-stigma has been linked to the increased severity of symptoms, reduced treatment adherence, an increased rate of suicidality, and a significant deterioration in quality of life.11 It is important to note that quality of life indicators have been linked to patients’ judgements of their own neurocognitive impairments rather than physicians’ assessments of their conditions. For optimal outcomes, clinicians may need to measure patients’ views of neurocognitive performance to further refine the understanding of the treatment process, which would also aid social function.12 The existing stigma towards mental health disorders is a key barrier to successful treatment and rehabilitation of mentally ill people.13,14 In order to increase the quality of life of patients suffering from mental health disorders, it is important to find the most effective measures to raise awareness of the negative influence surrounding stigma.15

Against this background, the current study aims to review the available literature regarding the impact of stigma on the quality of life of people diagnosed with mental disorders. In particular, this review is focused on gaining a clearer understanding of how psychiatric patients are treated by society and the extent of the stigma towards them.

MATERIAL AND METHODS

The following two electronic databases were searched: PubMed and the Web of Science. This narrative review is based on scientific literature published between 1999 and 2021. Search terms included keywords such as "stigma", "mental disorders", "discrimination", "psychiatric patients", "rejection", and "social marginalization". Studies were eligible if they evaluated the impact of stigma on the quality of life of adults diagnosed with mental disorders. Studies in which patients had other stigmatizing conditions, such as HIV and obesity, were excluded. A descriptive analysis was employed to synthesize the obtained data. The study findings were recorded in English.

RESULTS

The results of the current review will be presented in three parts. Firstly, the impact of public and self-stigma on patients’ quality of life will be presented. Secondly, the consequences of stigma on patients’ access to healthcare will be discussed. Finally, the particular ways in which stigma can be addressed will be highlighted.

Impact of public and self-stigma on patients’ quality of life

Public stigma against people with mental disorders is a complicated phenomenon that can affect any aspect of a person’s life, including their ability to secure housing and jobs, pursue a career, access benefits, and receive equal care from the justice system and social public services.16 As a result, public stigma affects the prospects of people with mental disorders in terms of meeting life aspirations, finding sustainable jobs, and living comfortably in a healthy and secure household.4 There is a widespread belief that people who suffer from psychiatric disorders are to blame for their disease. The stereotype that people with mental disorders are dangerous and unpredictable is perhaps the most damaging. This leads to avoidance and withdrawal, two of the most troublesome discrimination practices. People with mental disorders are ignored by the general population in order to prevent their possible abuse.6,17 Wahl et al., in a study involving over 1400 participants, concluded that patients diagnosed with mental disorders experience social exclusion as they are not called or visited by their friends once their psychiatric diagnosis has been revealed.18 Thus, prejudice and discrimination may be used to exclude psychiatric patients in two ways: directly through discriminative attitudes, and indirectly through marginalization.19

Internalized stigma or self-stigma is the way in which a person with a mental disorder adapts to the stigmatizing beliefs held by certain members of the community to which they belong.20,21 One of the most common consequences of self-stigma is a lack of self-esteem and self-efficacy.22 Currently available research shows that almost one-third of psychiatric patients experience self-stigma, worsening their ability to have a normal life and complete recovery, and leading to a low subjective quality of life.23,24 Cavelti et al. assessed the insight, self-stigma, and demoralization of 145 patients with schizophrenia spectrum disorders. This study concludes that high levels of insight were correlated with high levels of demoralization when they were followed by self-stigmatizing attitudes. However, this was not the case or, indeed, was exhibited even to a low level when these patients were not in this situation. Therefore, self-stigma can be considered to be a moderator between the patient’s insight and his/her feeling of demoralization.25 Other studies have shown that self-stigma combined with insight is a significant predictor for symptoms of demoralization, such as hopelessness, low self-esteem, depression, and reduced quality of life.26,27 In general, there are three main ways in which self-stigma may affect the quality of a patient’s life. Firstly, it exacerbates the severity of a psychiatric disorder and contributes to social isolation, causing difficulties in daily life;28 secondly, self-stigma decreases a patient’s willingness to find help and has a negative impact on compliance with treatment;29 and thirdly, self-stigma is linked to inadequate recovery attitudes, a greater incidence of disabilities, and a higher economic burden.30

Consequences of stigma for access and care quality

Stigma has been labelled a “fundamental trigger” of health inequality as it restricts access to health services and influences a variety of health outcomes.31 The impact of stigma on help-seeking behaviour is one of its most important consequences. According to the existing literature, more than 70% of patients with mental health issues around the world either do not seek, or will refuse or delay their treatment.32 People with mental disabilities are less likely to seek treatment if they think their disease is stigmatized.33,34 Expected discrimination from healthcare professionals has been reported as a factor in patients’ reluctance to pursue mental health treatment.35 Individuals who have dealt with a psychiatric disorder report feeling undervalued, ignored, and dehumanized by a large proportion of the health providers with whom they interact.30 Furthermore, patients with severe mental disorders have a high mortality rate and die on average 25 years earlier than people suffering from other preventable medical conditions, such as heart disease.36 This imbalance in mortality has been increasing in recent years, demonstrating the existence of barriers in patient access to mental healthcare.37 Stigmatizing behaviour in the form of social distancing from people with mental disorders leads to difficulties in the recognition of emergencies and provision of help, particularly for patients who are less aware of their own condition.38 In general, limited access to healthcare, reduced life expectancy, social isolation, various disabilities, hunger, homelessness, and interactions with criminal justice systems have all been recognized as consequences of the stigma surrounding mental health issues.39

Ways to address stigma

The media is a valuable source of knowledge regarding mental health and plays a significant part in shaping public attitudes and stigma.40 The majority of such television coverage offers portrayals of mental disorders that conjure up images of dangerous, abusive people who are almost invariably potential murderers.41 Characters are often depicted as unstable, antisocial, incapable, duplicitous, losers, and social outsiders.42 In the same way as the media perpetuates myths in relation to psychiatric conditions, it may also serve to improve mental wellbeing by encouraging or otherwise supporting the societal battle against the stigma associated with mental illness. This can be achieved by disseminating public awareness programmes in order to provide factual knowledge on mental disorders and promote volunteering programmes, thus helping patients suffering from mental illness.43

Furthermore, educational anti-stigma programmes are required to provide accurate facts relating to stigmatized conditions.44 Educational programmes may be created on any scale, from local to global. Based on the currently available evidence, anti-stigma educational programmes delivered at the school level are proven to be the most effective.45 According to a study of European anti-stigma services, young people have shown major changes in their values and behaviours as a result of anti-stigma education.46 In an American national poll, young people who had received anti-stigma education were more likely to seek help in relation to their mental health in comparison with adults over the age of 55 who had not received such training.47

It is also important to teach families and caregivers how to help their loved ones overcome their guilt and seek or receive treatment. The creation of trained teams in psychiatric hospitals is required who can help families and informal caregivers to provide care for patients with mental health issues. These trained teams should be involved in patient treatment after the patient has been released from the patient unit, ensuring their continuity of care.51 Social support for people with mental health issues should be viewed as essential, not just for the family, but also for relatives, neighbours, and the whole community. Moreover, empathy and support should exist for every patient, especially as psychiatric symptoms might be caused by more serious pathologies, such as tumours.48-50

CONCLUSIONS

Public and self-stigma are widely recognized as barriers to various mental disorders. They are obstacles to seeking treatment and can disrupt adherence to recommended therapy. Stigma has a negative influence on all aspects of life and impedes rehabilitation, making it difficult to overcome mental health barriers and leading to psychiatric rehospitalization.

Regarding the management of people with mental disorders, stigma continues to be an important challenge. It has proved to be very difficult to change stigmatizing beliefs and habits. Stigma-reduction techniques frequently fall short of their goals, or worsen the problem. Due to the nuanced, multifaceted nature of stigma and discrimination, as well as challenges related to seeking help, diverse strategies are needed to eliminate stigma.

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