Suicide is a leading cause of premature death and disease burden worldwide. 1 Although suicidality is often a direct consequence of mental disorders and their symptoms, Reference Cavanagh, Carson, Sharpe and Lawrie2 people with mental illness face a two-fold problem. Besides their symptoms, they belong to a stigmatised group Reference Schomerus, Schwahn, Holzinger, Corrigan, Grabe and Carta3 and experience frequent discrimination in their daily lives. Reference Lasalvia, Zoppei, van Bortel, Bonetto, Cristofalo and Wahlbeck4 Here we discuss the stigma and discrimination associated with mental illness as modifiable factors that may contribute to suicidality, but can be targeted by interventions. The link between stigma and suicidality is well known for other stigmatised groups, for example individuals from ethnic or sexual minorities, Reference Goldston, Molock, Whitbeck, Murakami, Zayas and Hall5 but has not received the same research attention for people with mental illness.
Consequences of stigma and discrimination
Three main types of stigma can be distinguished that may contribute to suicidality. First, public stigma occurs when members of the general public endorse negative stereotypes and discriminate against people with mental illness; typical consequences of public stigma are social isolation and impaired social networks when members of the public distance themselves from people labelled as mentally ill. Public stigma can lead to unemployment if employers endorse negative stereotypes and can affect several other domains such as education and housing. Stigma and discrimination are typically experienced as social defeat, which in turn is associated with suicidality. Reference Taylor, Gooding, Wood and Tarrier6 Second, societal regulations can systematically disadvantage people with mental illness, which is called structural discrimination; for example, relatively poorer funding of mental health services as compared with physical health services can lead to poorer quality of care and reduced access to mental health services.
Third, self-stigma refers to people with mental illness who internalise negative stereotypes, leading to shame, social withdrawal and demoralisation. As a consequence of self-stigma individuals with mental illness may feel they are not worthy or able to pursue their life goals (‘why try’). Reference Corrigan, Larson and Rüsch7 Two additional consequences of experiencing stigma are important in this context. One is hopelessness or the feeling that one’s situation will not improve. Individuals with mental illness who hold their own group in low regard - conceptually similar to self-stigma - are more likely to report hopelessness after adjusting for depressive symptoms. Reference Rüsch, Corrigan, Wassel, Michaels, Olschewski and Wilkniss8 Research has shown that, as a last stage of coping with ostracism, individuals can enter a resignation stage that is dominated by hopelessness. Reference Wesselmann, Williams and DeWall9 A second potential consequence of facing stigma is the cognitive appraisal of stigma as a stressor or the perception of stigma as a threat that exceeds one’s coping resources. Increased stigma stress is associated with social anxiety, shame and hopelessness. Reference Rüsch, Corrigan, Powell, Rajah, Olschewski and Wilkniss10 Finally, all three forms of stigma can be barriers to help-seeking for mental health problems. Reference Clement, Schauman, Graham, Maggioni, Evans-Lacko and Bezborodovs11
Risk factors and models of suicidality
It follows from the previous paragraphs that many consequences of stigma and discrimination are also factors associated with suicidality. Reference Pompili, Serafini, Innamorati, Lester, Shrivastava and Girardi12,Reference Wray, Colen and Pescosolido13 Although a comprehensive discussion of suicide models is beyond the scope of this paper, two conceptualisations are pertinent here: interpersonal and stress-diathesis models. First, the interpersonal theory of suicide posits that suicidality stems from a combination of perceived social isolation, or thwarted belongingness, and perceived burdensomeness, or the perception that one is a burden on others. Reference van Orden, Witte, Cukrowicz, Braithwaite, Selby and Joiner14 This is consistent with stigma as a risk factor, since public stigma typically leads to social isolation; perceived burdensomeness can be understood as a facet of self-stigma when the person with mental illness has internalised negative stereotypes. Second, according to a stress-diathesis model of suicidality, the co-occurrence of biological or psychological vulnerabilities and psychosocial stressors can trigger suicidality. Reference van Heeringen and Dwivedi15 Stigma is a stressor with negative effects already present during the at-risk stages of mental illness; Reference Rüsch, Corrigan, Heekeren, Theodoridou, Dvorsky and Metzler16 stigma stress is associated with hopelessness Reference Rüsch, Corrigan, Powell, Rajah, Olschewski and Wilkniss10 and thus can be conceptualised as contributing to suicidality according to stress-diathesis models. Finally, low rates of help-seeking for mental disorders are associated with higher suicide rates. 1
Stigma and suicidality - empirical findings
There is an emerging literature to support the hypothesis that stigma variables contribute to suicidality. Reference van Orden, Joiner and DeWall17 First, in population studies, shame and self-stigma were lower in regions with fewer suicides as compared with high suicide rate regions, Reference Reynders, Kerkhof, Molenberghs and van Audenhove18 and public stigma levels were inversely related to suicide rates in different countries across Europe. Reference Schomerus, Evans-Lacko, Rüsch, Mojtabai, Angermeyer and Thornicroft19 In a qualitative study among people with mental illness and a history of suicidal crises, a majority reported that stigma had contributed to their feeling at their worst. Reference Eagles, Carson, Begg and Naji20 Quantitative studies found significant associations of suicidality with self-stigma among people with schizophrenia even after controlling for symptom levels, Reference Sharaf, Ossman and Lachine21 with shame, a proxy of self-stigma, among military personnel, Reference Bryan, Ray-Sannerud, Morrow and Etienne22 and with stigma stress among secondary mental health service users (details available from the authors on request). Suicide rates are higher when appropriate treatments are not available; Reference Rihmer and Kiss23 as mentioned above, reduced access to mental healthcare can be considered an index of structural discrimination, and stigma in general is a barrier to help-seeking. Reference Clement, Schauman, Graham, Maggioni, Evans-Lacko and Bezborodovs11
Nevertheless, the existing evidence is sketchy for several reasons. First, most studies that examined the link between stigma variables and suicidality were cross-sectional and thus cannot clarify the direction of causality between symptoms, suicidality and stigma variables; second, as a relatively rare event suicide is hard to study empirically, and examining suicidal ideation as a proxy has its limitations; finally, empirical investigations should distinguish between the stigma of mental illness as a risk factor for suicidality (the topic of this editorial) on the one hand and the stigma of the suicidal act itself on the other hand. The latter stigma could be harmful (for example, because it could delay help-seeking) as well as helpful (for example, because it could deter individuals from suicide).
Implications for research and interventions
In terms of research, we need longitudinal studies to produce evidence for the hypothesised link between stigma variables and suicide risk. These investigations should be theory based and examine hypotheses derived from, for instance, the interpersonal theory or stress-diathesis model of suicidality. Different forms of experiencing and reacting to stigma and their impact on suicidality need to be taken into account: anticipated and experienced discrimination by others; self-stigma and shame; and consequences of structural stigma such as poor quality of and reduced access to mental health services. These studies should consider direct effects of stigma variables on suicidality as well as effects mediated by depressive symptoms that in turn may be triggered by social rejection. Reference Witvliet, Brendgen, van Lier, Koot and Vitaro24 Finally, previous stigma research has mainly examined experiences of and reactions to stigma as trait variables, but future studies could use ambulatory assessments to capture situational or state variables and more immediate reactions, including the role of impulsivity.
The link between stigma and suicidality would have important implications for mental health policy and practice. In our view, though, we need thorough research first; on the basis of its findings, recommendations for policymakers and practitioners on how to tackle stigma and suicidality should be suggested later on. Such research will identify the most relevant consequences of stigma that are also risk factors for suicidality, informing interventions with the ultimate goal of reducing the number of suicides - a specific case of the more general agenda to address stigma and discrimination as barriers to prevention in mental health. Reference Rüsch and Thornicroft25 There is initial evidence for the efficacy of interventions to reduce public stigma Reference Corrigan, Morris, Michaels, Rafacz and Rüsch26 and self-stigma, Reference Mittal, Sullivan, Chekuri, Allee and Corrigan27 including stigma stress. Reference Rüsch, Abbruzzese, Hagedorn, Hartenhauer, Kaufmann and Curschellas28 However, it is unclear whether these interventions reduce suicidality. At a population level, the effect of broad anti-stigma campaigns on suicide rates should be examined and likewise the effect of more targeted programmes to reduce public stigma among, for example, adolescents on suicide rates in this group. In clinical settings, interventions that reduce self-stigma, stigma stress and shame might successfully reduce suicidality. The effects of better funding for mental healthcare, an index of reduced structural discrimination, on suicide rates should be examined. Furthermore, there is an ongoing discussion whether the new social media are a remedy for or rather a cause of social isolation, Reference Parigi and Henson29 and the internet as a potential pathway to increase social inclusion and to address stigma and suicidality should be investigated. Finally, increased help-seeking may mediate the effects of anti-stigma initiatives on suicidality.
In conclusion, we have initial evidence to speculate about stigma as a factor contributing to suicidality. Unlike other variables, stigma and discrimination - whether at the societal or individual level - are in principle modifiable risk factors. Therefore research on interventions in this domain is needed with the ultimate goal of reducing suicide rates.