Sunday, November 08, 2015

10 Steps to Change the Stigma of Psychiatric Disorders for Better or for Worse with some Surprises

It's someone's mantra: the number one barrier to getting mental health treatment is stigma.  Maybe it's true and I'm not looking at the research, I'm writing from my own impressions (It's my blog...)

I'm going to suggest that the barriers to getting mental health treatment are
~1) Access.  Half of all counties in the US don't have a mental health professional (I saw that on Twitter, so it must be.)  That's any mental health professional, not just psychiatrists.
~2) Access.  If there's somewhere to go there may be many weeks to wait.  People don't like to wait and some of those people just won't make appointments far off; some will feel better before they actually get in and won't show up.
~3) Cost.  Over half of psychiatrists don't participate with insurance, the upfront cost of care is very expensive, and insurance companies vary in how well they reimburse out-of-network care and won't tell you what they reimburse before you file the claim which they may or may not lose or reject.
~4) Shame or embarrassment,  so stigma.
~5) The urgings of others who disapprove of the use of medications, don't believe in psychiatrists, don't want to foot the bill for relatives, don't want to take off work to drive a relative to appointments.
~6) Distrust of psychiatrists and the pharmaceutical industry

Somehow, we've become a culture that believes that if you say "End Stigma" you're doing something to end stigma.  Or that if you come out and announced all the awful things your mental illness has led you to do, that this ends stigma.  Bill boards are big.  Or that if you're a politician who says "We need to end stigma" while passing stigmatizing laws, that you're ending stigma.

So what decreases stigma.
1) When successful celebrities announce that they've struggled with mental illness, particularly if they have not made a spectacle of themselves and if they haven't led chaotic lives.  When Andrew Solomon talks about his struggles with depression, as he rakes in his many writing awards and gives his incredible TED talks, that's destigmatizing.  Brittany Spears -- not so much.

2) When regular people talk about their struggles with mental illness: especially if they are employed, married, and living productive lives.

3) This won't be popular but: Television commercials for pharmaceutical agents and direct-to-consumer advertising.  It's everywhere -- someone must be taking those medications and the ads normalize it.  It may be bad for all sorts of other reasons, but in terms of decreasing stigma, they help.

4) Parity for insurance so that mental health treatments aren't different/less than 'real' medical conditions.

What Increases stigma:
1) Anything that alters civil rights based upon the existence of a mental health diagnosis in the absence of a troublesome behavior.  So laws that restrict the purchase of guns by people with a mental health diagnosis, even if they've never done anything dangerous or threatening.  Or proposed laws that want to say that people with a diagnosis of a psychiatric disorder should be the only people who can't forbid their treatment team from releasing their diagnostic and treatment information to their family/caretaker.

2) Comments about keeping guns out of the hands of crazies.  ('nuff said).

3) Linking mental illness with mass murder.  I think.  I actually have never had a patient who has expressed any sense that being in psychiatric treatment in any way associates them with someone who does heinous things.  But it can't be a good association.

4) Fears of being made/coerced into to take medications when you don't want to take them and the concern that one's autonomy and individual decisions won't be respected.  Who wants to sign on for that?

5) The side effects of our medicines.  There's nothing desirable about being overweight, having metabolic syndrome, being sedated, having a tremor, or having other movement disorders.  

6) The devastation associated with untreated mental illness -- unmet potential, sometimes unemployability, homelessness (or being stuck in a parent's basement), incarceration, poor hygiene, odd behaviors.

So what did I miss?  I'm skeptical about the idea that Modern Family's Halloween episode with scary 'mental patients.' actually increases stigma -- it's a historical stereotype and it's too outrageous to feel like anything accurate -- but I certainly do understand that this is very offensive (I'm just not sure that all that is offensive is  stigmatizing).  By all means, feel free to correct me here.  And feel free to add to the list.

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