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

Depression: The Silent Majority

Aliases: depression

At first glance, depression might seem an odd choice for May’s theme (language), but it’s a perfect example of what happens when words fail us. It is hard to describe and hard to define, making it easy to confuse with sadness or grief. Depression is staggeringly common, but it is often overlooked; it has one of the highest rates of under-diagnosis in the developed world3,4. It is misidentified, misunderstood, and, all too often, silenced by stigma.

As of 2004, depression was the third most important cause of disease worldwide: 8th in low-income countries, and 1st in middle and high-income countries1. One out of every six people in the developed world will suffer from major depression during their lifetime, 15% of men and nearly a quarter (24%) of women3. The majority will be misdiagnosed, or receive inappropriate or inadequate treatment, if they are treated at all4.

That oversight comes at a huge cost. To state the obvious, depression is bad for your health; in addition to its symptoms, it is associated with negative health behaviors, like smoking and inactivity1, as well as an increased risk of suicide4. Without treatment, it is likely to become chronic, because the more you’ve been depressed, the more likely you are to be depressed; after experiencing one episode there is a 50% chance of having a second, and experiencing another raises the likelihood of a third, etc. And the effects of depression are not limited to the patient; it takes a toll on interpersonal relationships, and deeply affects the family and friends of the sufferer1.

Depression also puts a massive burden on society. In addition to its incalculable personal costs, depression is one of the most expensive illnesses in the US. As of 1997, depression was estimated to cost $43 billion per year; $12 billion in direct costs (usually health care costs), and $31 billion in indirect costs, with $8 billion due to premature death and $23 billion due to absenteeism from work and lost productivity4. That amount has almost certainly increased in the past 20 years. Silence and stigma have a price, and it’s high.

depression
Ugh.

Cause: Depression is a disorder that affects the parts of the brain involved in mood, thinking, sleep, appetite, and behavior (i.e. basically everything). The causes of depression are complex and not well understood; it is thought to be caused by a combination of genetic, environmental, biological and physiological factors (i.e. basically everything). There are several forms of depression; some appear to run in families, some appear to be caused by genes interacting with the environment, and others seem to be triggered by trauma1.

Consequence: Depression’s wide range of symptoms are misleading; they include things that are routine, like sadness, but depression is an intense experience that interferes with daily life2. Symptoms include depressed or sad mood, decreased interest in activities that used to be pleasurable, fluctuation in weight, inappropriate feelings of guilt, difficulty concentrating, fatigue, psychomotor agitation or retardation, and recurrent thoughts of death (things that affect… basically everything). Patients must experience at least 5 of the above continuously for at least two weeks to be diagnosed with depression1. Depression can also have persistent physiological effects, such as digestive problems like cramps, that do not ease with treatment2.

Cure: The most common treatments are medication and psychotherapy (a.k.a. talk therapy), and the earlier treatment begins, the more effective it is. Antidepressants that affect the neurotransmitters serotonin and norepinephrine, selective serotonin reuptake inhibitors (SSRIs), like Zoloft and Prozac, are the most commonly prescribed medications. SSRIs are preferred because they have fewer serious side effects compared to older generations of antidepressants, tricycles and monoamine oxidase inhibitors (MAOIs), though these are still used. Unfortunately, though they can be very successful, antidepressants can also have serious side effects, including increased thoughts of suicide. When other treatments prove ineffective, electroconvulsive therapy (ECT) and other brain stimulation therapies are sometimes used2.

References

  1. Depression. Centers for Disease Control and Prevention. 14 May 2015. Web. 4 October 2013.
  1. Depression. National Institute of Mental Health. 14 May 2015. Web.
  1. Falagas, M.E., K.Z. Vardakas, & P.I. Vergidis. 2007. Under-diagnosis of common chronic diseases: prevalence and impact on human health. International Journal of Clinical Practice, 61:1569-1579.
  1. Hirschfeld, R.M.A., M.B. Keller, S. Panico, B.A. Arons, D. Barlow, F. Davidoff, J. Endicott, J. Froom, M. Goldstein, J.M. Gorman, D. Guthrie, R.G. Marek, T.A. Maurer, R. Meyer, K. Phillips, J. Ross, T.L. Schwenk, S.S. Sharfstein, M.E. Thase, & R.J. Wyatt. 1997. The National Depressive and Manic-Depressive Association consensus statement on the undertreatment of depression. Journal of the American Medical Association, 277:333-340.

Image source: Creative Commons, http://commons.wikimedia.org/wiki/File:Paris_Tuileries_Garden_Facepalm_statue.jpg