Healthcare discrimination

People do attempt to relieve mental health problems other than by seeking mental healthcare. Many attend primary care, and even allowing for the small proportion of patients who disguise/somatise their mental distress, general practitioners (GPs) lack the time, means or inclination to label these as mental health problems. This is discrimination in the sense of choosing one option over another, but a good starting point to engage the psychiatrist sceptical of the effects of stigma is overt health service discrimination. The battleground here is the gap between aspiration and practice in delivering physical healthcare to people with severe mental illness within primary care. This has been previously discussed in this journal (Reference LesterLester 2005), and Thornicroft et al cite studies showing negative attitudes among GPs. Direct discrimination has been documented in organ transplantation (Reference ByrneByrne 2000) and in the investigation and treatment of people with severe mental illness who develop heart disease (Reference Hippisley-Cox, Parker and CouplandHippisley-Cox 2007). Reference Thompson and ThompsonThompson & Thompson (1997) listed widespread discrimination in health services, admitting that they had only scratched the surface: as laws tighten, discrimination becomes more subtle and covert. Clinician-focused analyses and solutions are well established (Royal College of Psychiatrists 2001), if largely unimplemented. The point here is that psychiatrists are well placed to challenge other clinicians' value judgements that make psychiatric patients the lowest priority (Fig. 1).

FIG 1 Levels of intervention by psychiatrists to reduce stigma-discrimination.

Levels of stigma

There has never been a full explanation of the findings of Reference PhillipsPhillips (1963) that public attitudes against people with mental health problems become progressively worse as the latter climb the mental healthcare referral ladder. Being a psychiatric in-patient is worse than seeing a psychiatrist, itself worse than consulting a clergyman about mental health problems. Is it that ‘inmates’ have lost control of themselves or that they are perceived to have lost their humanity? We do not know whether public antipathy to someone who has experienced psychosis would be less if they had home treatment rather than a brief hospital admission, albeit voluntary. Relevant to the Mental Health Act 2007 for England and Wales, Reference Link, Castille and StuberLink et al (2008) concluded that out-patient psychiatry by coercion is more stigmatising than psychiatry by collaboration and, by comparison, also reduces service users' quality of life and self-esteem.

The belief noted by Thornicroft et al that psychiatrists' diagnoses are cavalier and that they throw useless but harmful pills at people would, if psychiatrists were the main drivers of stigma, reduce public antipathy to people with mental health problems. However, the origins and perpetuation of stigma extend beyond the profession of psychiatry. Reference SchulzeSchulze (2007) offers clearer explanations of these complex interactions: mental healthcare professionals may stigmatise – with more than 70% of studies showing that their attitudes are similar to or worse than those of the general public – but they have become self-aware. Rather than psychiatrists' social embarrassments, there are other issues: that referral to mental healthcare by colleagues is as a last resort, our lack of funds relative to other specialties, and community resistance to discharging people with mental health problems after recovery.

Words then actions

Predominant in the recommendations made by Thornicroft et al is a call to abandon the old language of ‘chronic’ and ‘schizophrenic’. Language has always been problematic among professionals and in the wider public. We have words for racism, sexism, ageism, homophobia and so on, and near universal public acceptance that these are unacceptable belief systems. There is, however, no word for prejudice against people with mental health problems. Many service users resent the use of the word ‘stigma’ to describe their experiences, just as some colleagues resist the term ‘service user’.

Beyond language, no other branch of medicine has so many unresolved theoretical disagreements (Reference Estroff, Penn and ToporekEstroff 2004) and few authors have provided a sound theoretical basis to understanding stigma-discrimination. An honourable exception here has been Bruce Link. In one important review, he sets out key stigma-discrimination processes (Reference Link and PhelanLink 2001). Relationships that matter are about power: person A cannot stigmatise or discriminate against person B without a power differential. When we concede more equality in our doctor–patient relationships, reduce the infantalisation of the care programme approach (CPA) and challenge the poverty trap of the Disability Living Allowance (DLA), only then will we reduce stigma. Fittingly then, a focus of the final section of the article by Thornicroft et al is removing barriers to employment. We may have emptied the institutions but modern Western psychiatry's mind–brain dichotomy has neglected social dimensions and bequeathed asylum in the community.

Time to change

It is useful to understand attitudes but ultimately we need to examine and change behaviours. How do we engage all psychiatrists in anti-stigma activities? Thornicroft et al appeal to self-interest (low proportions presenting to mental healthcare, reduced funding, poor recruitment) and professional self-respect. We could also appeal to scientific sensibilities – the driving force for public prejudice is fear of violence (Reference Estroff, Penn and ToporekEstroff 2004) based on perceptions, not on reality – or to our sense of injustice (Reference Corrigan, Watson and ByrneCorrigan 2005). As clinicians, we strive to do our best for the patient sitting opposite and improving that person's social inclusion should be the benchmark of our every action. In the clinic, it's hard to see the bigger picture (Fig. 1) and harder still to conceptualise links between micro and macro (Reference Corrigan, Markowitz and WatsonCorrigan 2004). Many colleagues enjoy their role as educators and these activities could extend well beyond pliant medical students – the challenge is to promote multilevel actions by colleagues within and beyond the clinical arena (Fig. 1). In this, we have much to gain from collaborations with service users and carers, and many lessons to learn from contemporary anti-stigma initiatives (Reference Estroff, Penn and ToporekEstroff 2004).