Wednesday 17 January 2018

Exploring the connection between stigma and Suicide

A culture which stigmatises mental illness may lead to an increased suicide rate. (stock photo)
A culture which stigmatises mental illness may lead to an increased suicide rate. (stock photo)

Patricia Casey

Death by suicide is a terrible tragedy and it is something that we associate with older teenagers and young adults. We forget that the elderly population is also at significant risk.

Research into aspects of suicide that are of interest to the general public continue to emerge and one important aspect relates to stigma. A common mantra is that we need to destigmatise suicide and that as a consequence there will be a reduction in the number dying in this manner.

It is unclear what the mechanism for this change will be, but presumably the belief is that it will lead to people being more receptive to seeking help.

An interesting editorial in the British Journal of Psychiatry asked a related question - to what extent do stigmatising attitudes to mental illness lead to suicide? The author Nicolas Rusch from the University of Ulm in Germany draws on what little information we have on the relationship between stigma and suicide from scientific studies. One of these was a study from the Netherlands, where the suicide rate is relatively low, compared to Flanders, where the rate is higher.

In the Netherlands there was a positive attitude to both professional and also informal help seeking for emotional problems, while the opposite was the case in Flanders.

A more recent piece of research examined attitudes to mental health problems in 25 European countries and found that national suicide rates were negatively correlated with social acceptance of mental illness, so that rates were higher in countries with negative attitudes to mental illness.

In both of these investigations the attitudes to mental health seemed to be the key factor associated with suicide.

Suicide is linked to certain aspects of the person's life, such as mental illness and isolation. In these studies it is possible that those who were at risk of suicide because of mental illness did not seek help because they or their culture stigmatised such illnesses. Likewise, the isolation that accompanies mental illness may have tipped some of these people into ending their lives. In other words the pathway from mental illness to suicide may have been strewn with attitudes that made the person fearful of reaching the point of seeking help or may have isolated them from supports.

Imagine if your friends and family told you that you would never get better, or that the medications used might damage rather than heal you or that those treating you were 'all mad'.

Stigma can operate at several levels. Structural stigma can disadvantage people with mental illness, as for example, when funding for services is poor relative to other specialties or when recruitment problems are unheeded. Neglect of buildings and an impoverished mental health infrastructure are further examples.

Social stigma, another variant, is toxic because it can permeate the wider society into endorsing negative stereotypes. Employers may discriminate against people who have a history of mental illness, the public may shun them through fear, for example, of violence ultimately causing isolation and colleagues may see their treating doctors, psychiatrists, as eccentric or 'odd'.

As somebody said to me when I said I wanted to become a psychiatrist 'why don't you do proper medicine instead?'

At a personal level, self-stigma is the most poignant since it seeps to the core of how the person sees himself or herself. It saps self-worth and turns it into blame, shame and guilt. It is a phenomenon in which the patient internalised the myths, stereotypes, prejudices and social rejection that the public has about mental illness.

It works by engendering feelings of hopelessness, helplessness and self-loathing. The person assumes they will be unable to work outside the home or have children.

One of the most significant effects is to reduce willingness to accept a diagnosis of mental illness, whether it be at the mild end, such as generalised anxiety disorder, or severe such as schizophrenia and problems with treatment adherence are consequent upon this.

There is no study assessing the value of destigmatising suicide itself or of its influence on the suicide rate. It is likely that the link between positive attitudes to mental illness and lower suicide rates is that well-resourced psychiatric services is a given in society, rather than because suicide has been normalised.

So, one of the tasks in Ireland, if we truly want to reduce the suicide rate, is to tackle structural, social and self-stigma. But above all, we should tirelessly fight for the rights of the mentally ill to proper services and evidence-based treatments. Only then will our suicide rate begin to fall.

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