Confronting Mental Illness Stigma

In the popular Netflix series The Crown, Princess Margaret is surprised to learn that she has two mentally disabled cousins who had, many years before, been hidden away and forgotten in a mental institution. Margaret, played by Helena Bonham Carter, voices the shock and anger many viewers experienced learning of this sad and, unfortunately, true story about the royal family. This was not such an unusual event, however. Hiding mental illness was once common practice for many families, who sought to avoid the shame and stigma associated with having such afflictions within the family.

Mental health stigma refers to prejudice against people with mental illness. The American Psychiatric Association describes three types of stigma: public stigma, self-stigma, and institutional stigma. Public stigma refers to the negative attitudes society has toward persons with mental illness. When an individual with mental illness internalizes the attitudes, they experience self-stigma. Institutional stigma is systemic and includes laws or policies from the government or other organizations that, intentionally or not, discriminate against those with mental illness. One glaring example is the disparity in insurance coverage for psychiatric treatment versus treatment for other medical illnesses.

More generally, stigma can be divided into prejudice and discrimination. Prejudice is the negatively biased thinking toward persons with mental illness. Discrimination is the unfair treatment of those persons due to such bias.

The consequences are tragic. In his historic report on mental health, former U.S. Surgeon General Dr. David Satcher wrote, “Powerful and pervasive, stigma prevents people from acknowledging their own mental health problems, much less disclosing them to others.” As a result, many avoid or delay treatment. Their fear is understandable, as we have heard many patients describe losing relationships or jobs after disclosing their mental illness. Such stigma can also lead to lower self-esteem, increased psychiatric symptoms, and more difficulties in relationships and at work. It can also affect treatment. For example, a 2017 study showed an association between higher self-stigma and poorer recovery from illness.

Fighting mental health stigma has always been a challenge, as persons with mental illness have been reluctant to speak publicly—understandably. One needs only remember Thomas Eagleton, who, in 1972, withdrew as a vice-presidential candidate after revealing he had (successfully) received electroshock therapy for depression.

However, over time, public figures began to bring awareness to mental illness. In the mid-’90s, the Oscar-winning actor Rod Steiger publicly discussed his battle with depression. Since then, many celebrities, including Demi Lovato, Michael Phelps, and Dwayne “The Rock” Johnson, have spoken about living with mental illness. At the same time, the federal government and many organizations have increasingly sponsored education campaigns to reduce the stigma associated with mental illness.

Do such approaches help? There is reason to believe so. For example, the Cochrane Library, perhaps the most respected source for evidence-based medical information, published an analysis of 22 studies looking at the effects of mass-media interventions on stigma. They looked at interventions in print media, recordings, radio, television, movies, mobile apps, and online publications. They found that most interventions did help decrease prejudice, with effects ranging from small to moderate. Unfortunately, the impact on discrimination was less optimistic, with fewer studies showing a reduction in discrimination.

However, something seems to be helping. Since 1996, the U.S. National Stigma Studies has tracked U.S. attitudes about mental illness. It found that, over time, mindsets are improving. For example, people are more willing to view mental illness not as a personal failure but as a medical illness with a scientific basis. In the past decade, people have become more comfortable working, socializing, and living with people with mental illness. This seems particularly true for those suffering from depression. Unfortunately, for severe mental illnesses like schizophrenia, there has been less improvement. This may not be so surprising, given the sensationalist statements made by political groups associating gun violence with mental illness, despite evidence to the contrary.

Still, the improvements in mental health stigma are promising. While it is commendable that celebrities speak out, we can all do our part. As with encountering other forms of prejudice, speaking out when we hear misinformation or disparagement of mental illness is essential. We can also ally with the many organizations working to combat mental illness stigma, such as Bring Change to Mind, Stamp Out Stigma, and Make it Okay. We can also work to educate ourselves and others about the realities of mental illness. Mental illness is a societal issue, as a society can improve or worsen mental illness and its effects on individuals. Therefore, as a society, we should all do our part to reduce stigma and help improve the lives of those suffering from mental illness.

About the Authors

Serena M. Weber, M.D., is a staff psychiatrist on Menninger's Comprehensive Psychiatric Assessment Service. Board-certified in general psychiatry, she is also an assistant professor in the Menninger Department of Psychiatry & Behavioral Sciences at Baylor College of Medicine.

Robert J. Boland, M.D., is chief of staff and senior vice president at The Menninger Clinic as well as vice chair of the Menninger Department of Psychiatry & Behavioral Sciences and the Brown Foundation Endowed Chair in Psychiatry at Baylor College of Medicine.