The Power of Stigma: Say It Ain’t So

Some things we don’t talk about. Some issues are too fraught to put into words; others are simply too shameful. When disease veers from the disconcerting to the disgusting, it ventures into the realm of the taboo and intersects with the powerful influence of stigma.

Stigma is the result of social disgust. If a person or group differs from the perceived norm in a way deemed unacceptable or socially deviant, that behavior can elicit disgust in others and shame in themselves3. Stigma is insidious; it impacts the stigmatized through a variety of means, including discrimination, and threats to their personal and social identity. In our daily lives, we are constantly trying to evaluate the responses of people around us, picking up social cues about our social position. When we feel stigmatized, we can feel like our social identity (how others see us) is in jeopardy, which can trigger involuntary stress responses, affecting our physical and mental health7. Although on some level stigma affects everyone, it is at it’s most dangerous when social, economic or political power is leveraged against a stigmatized group2,3,4.

What’s in a name?

Not only does stigma directly affect our health by causing stress, it can also indirectly impact our well-being by deterring us from seeking help. The heavy stigma around mental health issues have had a huge impact: in the US and Europe, 52-74% of people with a mental health condition are not treated, and the number is even higher in low and middle-income groups. A massive review of 144 quantitative and qualitative studies found that stigma has a small to medium-sized negative effect on help-seeking. Men, ethnic minorities, and people in the military and health professions are disproportionately dissuaded by stigma. Of the various forms of stigma, internalized stigma (disgust that the stigmatized feel toward themselves) and treatment stigma (stigma about the treatment of a condition) are the most likely to impede help-seeking. While stigma itself is only the fourth greatest barrier to help-seeking, the issues that trump it, like fear of disclosure (ranked first), are likely influenced by it4.

stigma
You can’t get there from here.

A way with words

Combatting stigma is complex, and can sometimes backfire. Biogenetic explanations for mental disorders, meaning an understanding that mental disorders are biological, and not a sign of a weak or deviant character, have been promoted as a way of addressing stigma against the mentally ill. Unfortunately, while people who believe biogenetic explanations for mental disorders tend to blame the affected people less for their condition, they also perceive them as more dangerous and want to have greater distance between themselves and the ill. And although belief in biogenetic explanations reduced blame, it only weakly reduced stigma5. But it’s not all bad news! There are other promising interventions for reducing stigma at all levels, including therapy, sharing positive stories about the stigmatized, and contact-based training and education programs for professionals who interact with the stigmatized, such as medical students6.

Stigma’s relationship with public health is also complicated. Public health interventions, such as quarantine, can reinforce or even create stigma. The AIDS crisis is a perfect example of the devastating power stigma can have on the ill; it layered the isolation and indignity of an unknown and terrifying disease on top of the social backlash against the gay community, further marginalizing an already vulnerable group and contributing to the spread of the virus. But while stigma can certainly threaten public health, it may not always. After the negative health effects of smoking became widely known in the 1960s and 70s, there has been a series of campaigns against it. Many of these efforts depend on making smoking socially unacceptable for non-smokers and inspiring guilt in smokers: all the makings of stigma1.

Wielding the shame of stigma is a dangerous game, even when done for the best reasons. Stigma threatens what matters most: our place in the community around us, our relationships with those we love and admire. It is a brutal force. Is it any wonder it hurts so much?

References

  1. Bayer, R. 2008a. Stigma and the ethics of public health: not can we but should we. Social Science & Medicine, 67:463-472.
  1. Bayer, R. 2008b. What means this thing called stigma? A response to Burris. Social Science & Medicine, 67:476-477.
  1. Burris, S. 2008. Stigma, ethics and policy: a commentary on Bayer’s “Stigma and the ethics of public health: not can we but should we. Social Science & Medicine, 67:473-475.
  1. Clement, S., O. Schauman, T. Graham, F. Maggioni, S. Evans-Lacko, N. Bezborodovs, C. Morgan, N. Rüsch, J.S.L. Brown, & G. Thornicroft. 2015. What is the impact of mental health-related stigma on help-seeking? A systematic review of quantitative and qualitative studies. Psychological Medicine, 45:11-27.
  1. Kvaale, E.P., W.H. Gottdiener, & N. Haslam. 2013. Biogenetic explanations and stigma: a meta-analytic review of associations among laypeople. Social Science & Medicine, 96:95-103.
  1. Livingston, J.D., T. Milne, M.L. Fang, & E. Amari. 2011. The effectiveness of interventions for reducing stigma related to substance abuse disorders: a systematic review. Addiction, 107:39-50.
  1. Major, B., & L.T. O’Brien. 2005. The social psychology of stigma. Annual Review of Psychology, 56:393-421.

Image source: http://starrfmonline.com/1.1966021

Schizophrenia: The Cost of Care

Aliases: schizophrenia

For the theme of economics, it made sense (cents?) to write about the most expensive suite of diseases: mental illnesses. Of these, schizophrenia may be the costliest4. The total overall cost (the cumulative cost, not annual) of schizophrenia in the US in 2002 was estimated to be $62.7 billion, encompassing 2.5% of US healthcare spending3. This astronomical sum is the result of a multitude of causes, the most obvious of which is the large number of people that the illness affects. About 1% of American adults have schizophrenia1; as the US adult population is approximately 241,838,562, this amounts to about 2,418,386 people.

Schizophrenia is chronic, an ailment that persists or recurs throughout life. Because of the early age of onset (most commonly in the late teens or twenties), the illness results in decades of continuous care. The long duration and pervasive social impact of the disease is reflected in the breakdown of the overall cost. While direct health care costs, such as medication and long term care, are high, totaling to approximately $22.7 billion in the US in 2002, the majority of the expense is due to indirect costs (approximately $32.4 billion), with direct non-health care costs, such as living offsets, making up the difference (approximately $7.6 billion)3.

Indirect costs quantify the affect of schizophrenia on society. As it turns out, the single costliest aspect of this illness is not what it demands from the community (i.e. care), but what it withholds. People burdened with schizophrenia are often unable to work, and unemployment, what economists call productivity loss, is the greatest driver behind the rising cost of schizophrenia, both in the US and abroad2,3,4. Of course these facts, like so many of their ilk, are simplistic renderings of a more complex reality. They do not account for the emotional costs incurred by those most affected by schizophrenia: the friends, families and, most importantly, the ill.

schizophrenia
Care: it’s not exactly dollars and cents.

Cause: The underlying causes of schizophrenia remain unclear, but it most likely results from a combination of genetic and environmental factors, meaning the disease requires a genetic predisposition that interacts with the surrounding environment (i.e. prenatal exposure to a virus) to result in illness. Imbalanced brain chemistry, specifically in the neurotransmitters dopamine and glutamate, and abnormal brain development and structure may also play a role in the development of schizophrenia. People are most commonly diagnosed between the ages of 16 and 30 (when symptoms usually develop), and rarely after 45. Men and women are equally susceptible1.

Consequence: People suffering from schizophrenia exhibit three types of symptoms: positive, negative and cognitive. Positive symptoms are behaviors that are not seen in healthy people, and include hallucinations, delusions, and thought and movement disorders. Negative symptoms are more subtle and may be mistaken for depression. They include disruptions to normal emotions and behaviors, such as a flat affect and a lack of pleasure in everyday life. Cognitive symptoms such as poor “working memory” (the ability to use information right after learning it), are even more difficult to identify, and are usually only detected by psychological testing1.

Cure: The treatment of schizophrenia addresses its symptoms (as its causes are not well understood), and relies on antipsychotic medications, which suppress hallucinations and other psychotic symptoms, and psychosocial approaches. Psychosocial treatments include an array of methods, ranging from cognitive and behavioral therapy to social and vocational training1.

References

1. Schizophrenia. National Institute of Mental Health. Web. 1 April 2014.

2. Somaiya, M, S Grover, A Avasthi, & S Chakrabarti. (2014). Changes in cost of treating schizophrenia: Comparison of two studies done a decade apart. Psychiatry Research, 215:547-553.

3. Wu, EG, HG Birnbaum, L Shi, DE Ball, RC Kessler, M Moulis, and J Aggarwal. (2005). The economic burden of schizophrenia in the United States in 2002. Journal of Clinical Psychiatry, 66(9):1122-1129.

4. Zhai, J, X Guo, Min Chen, J Zhao, & Z Su. (2013). An investigation of economic costs of schizophrenia in two areas of China. International Journal of Mental Health Systems, 7:26

Image source: https://momsincharge.wordpress.com/2012/02/