Erasing stigma needed in mental health care

Scientists, politicians, clinicians, police officers and medical workers agree on one thing: The U.S. mental health system needs a big fix. Too few people get the help they need for mental ailments and emotional turmoil that can destroy livelihoods and lives.

A report in the October JAMA Internal Medicine, for instance, concludes that more than 70 percent of U.S. adults who experience depression don’t receive treatment for it.

Much attention focuses on developing better psychiatric medications and talk therapies. But those tactics may not be enough. New research suggests that the longstanding but understudied problem of stigma leaves many of those suffering mental ailments feeling alone, often unwilling to seek help and frustrated with treatment when they do.

“Stigma about mental illness is widespread,” says sociologist Bernice Pescosolido of Indiana University in Bloomington. And the current emphasis on mental ills as diseases of individuals can unintentionally inflame that sense of shame. An effective mental health care system needs to address stigma’s suffocating social grip, investigators say. “If we want to explain problems such as depression and suicide, we have to see them in a social context, not just as individual issues,” Pescosolido says.

Stigma as a mark of disgrace that taints someone in others’ eyes goes back several millennia. Sociologist Erving Goffman wrote in 1963 of stigma as a “spoiled identity” caused by society’s negative attitudes toward conditions such as mental illness. New evidence supports the idea that stigma about psychological problems runs surprisingly deep. What’s more, it filters through families and communities in different ways.

Many depressed people experience their condition primarily as a family predicament, not a brain disease, says a team led by UCLA psychiatrist and medical anthropologist Elizabeth Bromley. Those who seek treatment from primary care physicians feel tremendous shame about depression-related problems, such as being unable to work, that put a burden on their families. They hide their depression and any treatments, fearing rejection by those closest to them, Bromley and her colleagues report in the October Current Anthropology. Even if antidepressants ease symptoms such as insomnia and fatigue, depressed individuals describe the treatment as a Band-Aid stuck on unresolved family fractures, which can include a violent spouse or drug-addicted child.

Bromley’s team examined data from 46 people, representing various ethnic backgrounds and economic classes, identified in primary care clinics in 1996 as having depression. After their diagnosis, participants completed surveys every six months for two years, then at the five-year and nine-year marks. Interviews about symptoms, treatments and coping occurred at a 10-year follow-up.

Only two people described the depression treatment they received as helpful and appropriate to their situation. Both had family and friends who had noticed their depression symptoms and encouraged them to seek help.

The remaining 44 people spoke of depression as a threat to their closest relationships and family standing. They kept treatment secret to avoid intensifying family conflicts and for fear of rejection. Shame and emotional distance from family members remained even if depression treatments had positive effects. Participants commonly spoke of not wanting to burden their families with their condition. Several said that being singled out for treatment, which only required that one take antidepressants or, say, learn relaxation techniques, made them feel more estranged than ever from already fragile families and, what’s more, did nothing to resolve underlying family troubles.

“Individually focused, biomedical approaches can feel stigmatizing to many people with depression,” Bromley says.

Her team’s findings fit with previous observations that stigma discourages many people from discussing depression with their doctors for fear of breaking frayed family ties, writes psychologist Rob Whitley of Montreal’s McGill University in the same issue of Current Anthropology.

Excessively close ties among a network of families can also stoke stigma, researchers find. It can flourish in a wealthy, well-manicured community where everyone knows everyone else, if not in person than by word of mouth, say sociologists Anna Mueller of the University of Chicago and Seth Abrutyn of the University of Memphis.

In one such town, given the fictional name Poplar Grove by the researchers to protect privacy, teenagers struggle mightily under the weight of an “overactive grapevine of gossip.” Parents and peers constantly monitor whether teens live up to a community-wide standard of high academic achievement, the researchers report in the October American Sociological Review. Hard work is admired, but only if it yields superior grades with no signs of extra effort, such as using tutors. Academic struggles, anxiety and depression are stigmatized as signs of imperfection. As a result, most young people fear to seek any help from adults, including parents and teachers. That situation contributed to a rash of 19 suicides among current students and recent graduates of the town’s high school between 2000 and 2015, Mueller and Abrutyn propose.

The pair conducted interviews and focus groups in 2014 and 2015 with 110 volunteers, including teens who grew up in the town and lost a friend to suicide, parents whose children killed themselves, mental health workers in the town and high school teachers and counselors. In public forums held afterward, residents were surprised to hear from Mueller that one of Poplar Grove’s strengths — strong ties among neighbors concerned about the welfare of everyone’s kids — had a dark side. Parents talked about the shame they felt if a child experienced emotional problems and of feeling like bad parents when word got around. Teens expressed intense fear of failing to ace schoolwork and make it seem effortless. Students who had killed themselves were described by friends as having emotionally wilted under those pressures.

Bromley’s and Mueller’s findings underscore the need for mental health services that reach people where they live, Pescosolido says. Local services stand the best chance of getting troubled individuals to see help-seeking as acceptable behavior with the potential to change one’s life for the better.

Possible approaches include training pastors and other religious leaders in how to assist those with mental disorders and establishing public self-help groups and high school clubs devoted to open discussion and support. Local centers housing teams of social workers and counselors able to coordinate care for serious mental disorders would be a big advance, she says.

Job No. 1, Mueller says, involves getting beyond the popular assumption that mental illness and suicide arise solely in individuals. It’s long been known, for example, that chaotic communities where people feel isolated push suicide rates higher. But as Poplar Grove demonstrates, really tight-knit communities can have the same effect. “Deep psychological pain often has family and community sources,” she says.