The stigma associated with schizophrenia is pervasive, both in the community and among healthcare workers, and forms a real barrier to optimal recovery from the illness.
The negative consequences of stigma include discrimination in housing, education and employment, and increased feelings of hopelessness in people with schizophrenia.
Health professionals have a responsibility to improve their own attitudes and behaviour towards people with schizophrenia so they do not contribute to the stigma.
Educational campaigns aimed at people in the community and media personnel could help to demystify mental illness and reduce the portrayal of offensive stereotypes of people with schizophrenia.
People with schizophrenia put up with a lot more than their illness. Stigma, from both the community and from health professionals, contributes yet another major stress they can well do without.
Many people with schizophrenia say that the stigma and prejudice associated with their illness is as distressing as the symptoms themselves. In a recent Australian survey, people with mental illness and their families said "less stigma" was the number one thing that would make their lives better.1 They wanted healthcare workers who "treated them with more respect", who "would appreciate just how far a little kindness goes", and a community that "would understand that we are not lazy or weak" and that recovery is not simply a matter of "pulling yourself together".
Stigma contributes to loneliness, distress and discrimination against people with a mental illness and their families. Indeed, more than 40 negative consequences of stigma have been identified,2 including discrimination in housing, education and employment and increased feelings of hopelessness. The end result is that many people are reluctant to seek help, less likely to cooperate with treatment, and slower to recover self-esteem and confidence. Tragically, this leads many to suicidal behaviour. It is important, therefore, for clinicians and other healthcare workers to appreciate that stigma and its associated prejudice form a very real barrier to recovery and may even be fatal.
As health professionals we have a responsibility to put our own house in order first, to look at ways to improve the attitudes and behaviour of many healthcare workers. Norman Sartorious (Professor, Department of Psychiatry, University of Geneva), who, with the World Psychiatric Association, has initiated a global program against stigma and discrimination associated with schizophrenia (the Open the Doors program3), has coined the phrase "iatrogenic stigma".4
The aims of the Open the Doors program are to
increase the awareness and knowledge of the nature of schizophrenia and treatment options;
improve public attitudes to those who have or have had schizophrenia, and their families;
generate action to prevent or eliminate stigma and discrimination.
Sartorious believes that medical professionals, especially psychiatrists, contribute to stigma through both the careless use of diagnostic labels and through treatments that produce significant side effects (such as extrapyramidal signs), which mark the person as having a mental illness more so than the original symptoms. Discriminatory behaviour by doctors in general can also be implicated in the excessive premature death rate among people with mental illness (particularly from cardiovascular disease5) — there is a tendency to ignore these patients' general health problems or discount them as being delusional. Early diagnosis of physical illness in people with schizophrenia must also be followed up effectively to ensure true equity in healthcare. Longer-consultation fees and new mental-health item numbers (available from 1 July 2002) are being accessed by general practitioners with the required training, and should make this a more realistic possibility.6
The challenge is also to develop strategies to bring about systemic change so that the rights of people with mental illness are respected. They and their families need to be consulted and treated with respect and kindness within the healthcare system. My own view is that overworked, under-resourced healthcare workers are at particular risk of stigmatising people with mental illness.
In recent years, our understanding of how to improve community attitudes to mental illness has become more sophisticated. There is now awareness that we need long-term strategies to combat stigma by disengaging mental illness from associated fears and anxieties and by improving knowledge and attitudes. Two important ways of doing this are improvement in "mental health literacy"7 and stopping the constant reinforcement of stigma by the media.
Jorm and colleagues7 have demonstrated widespread community misunderstanding about mental health problems and their treatment, highlighting the need for improvement in mental health literacy. Programs such as the Compass Strategy in Victoria8 are being set up to improve mental health literacy in young people. Carefully designed cinema advertisements, supported by posters and postcards, are distributed in places where young people get together, in association with school and parent education programs. The intent is that, as mental illness becomes demystified, young people will better understand the early signs of mental illness and feel able to get help for themselves or their friends.
The media are essential players in any movement for change, as they have an important role in determining public attitudes to mental illness.9,10 Myths and misconceptions about schizophrenia are continually reinforced by stereotypical and often destructive media images — for example, people with schizophrenia are almost exclusively depicted as violent, and inaccurately and quite pervasively characterised as having a "split personality" (as recently offensively portrayed in the film Me, Myself and Irene [20th Century Fox, 2000]). Programs are now in place to encourage the media to report mental illnesses such as schizophrenia responsibly. In Australia, the Federal Government has taken a lead through its Mindframe National Media Strategy, which has supported several positive initiatives, including a media kit on responsible reporting for journalists, "ResponseAbility" education resources for journalism students, and expansion of the SANE StigmaWatch program.11,12
In an era when it is rightly acknowledged that it is better for people with schizophrenia to be treated, wherever possible, in the community,13 we, as a society, have a clear responsibility to reduce the stigma they face. The sad reality is that, for most people with schizophrenia, living in the community does not mean being part of the community.14 We need to ensure that the treatment package includes not only access to good clinical care, a range of community accommodation and rehabilitation programs, family education and support, but also health professionals and communities who are respectful and welcoming.