Understanding Stigma as a Mental Healthcare Barrier

Despite the millions of patients managing a mental illness, very few are accessing treatment. Stigma and negative perceptions associated with mental illness are noted mental healthcare barriers for patients.

Former US Surgeon General David Satcher first addressed stigma as a pressing mental healthcare barrier in his 1999 publication Mental Health: A Report of the Surgeon General.

“Stigma surrounding the receipt of mental health treatment is among the many barriers that discourage people from seeking treatment,” Satcher said in the report. “Another manifestation of stigma is reflected in the public’s reluctance to pay for mental health services.”

Although Satcher – who is widely recognized as one of the first public health officials to shine a light on stigma as a treatment barrier – published his findings nearly 20 years ago, his words are still salient.

Data from the Substance Abuse and Mental Health Services Administration (SAMHSA) shows that in 2014, only 2.5 million of the 21.2 million individuals struggling with mental illness accessed treatment. The agency, as well as other public health officials, strongly contend that stigma is a fundamental barrier to care.

In the following primer, PatientEngagementHIT.com reviews how stigma affects access to mental and behavioral healthcare treatments and some of the current efforts to overcome those obstacles.

Stigma is a barrier for patients with mental health issues

The exact number of patients who cannot or do not access mental healthcare due to stigma is difficult to pinpoint. Patients who do not access mental healthcare fly under the radar and are underreported, making it difficult for researchers to provide an accurate picture of patients facing stigma obstacles. Therefore, measurements about stigma barriers to mental healthcare vary from study to study.

That said, most research concludes that perceived stigma is a considerable barrier to mental healthcare. In a 2014 study published in Psychological Science in the Public Interest, lead researcher Patrick Corrigan of the Illinois Institute of Technology reported that about 40 percent of the 60 million patients suffering from mental illness go without treatment.

Other researchers confirm that perceived stigma is a significant barrier for patients seeking mental healthcare. Other barriers include lack of knowledge about mental healthcare, inability to recognize symptoms in one’s self, and inability to identify adequate healthcare resources for mental health symptoms.

Corrigan’s study specifically looked at the various types of stigma facing patients with mental illness. Through a literature review, Corrigan et al identified public stigma, institutional stigma (health payers covering mental healthcare to a lesser extent than other care, for example), and self-stigma (lack of motivation to receive care – a “why try” attitude that discourages treatment access).

Stigma also serves as an obstacle in pediatric mental healthcare access. In addition to a provider shortage and billing issues, parents are not seeking mental healthcare for their children because of perceived stigma, according to research in the American Journal of Managed Care.

Parents are also reportedly concerned that accessing mental healthcare for their children will prompt onlookers to report parents to child protective services.

“Parents’ interest in treatment may be influenced by perceived stigma related to the mental health problem or their own experiences with the mental health system,” the researchers explained. “Provider stigma about mental health and concerns about a child being ‘labeled’ may reduce referrals as well.”

The military and the mental health stigma

Stigma as a barrier to mental healthcare is an especially pervasive problem in the military. According to a 2015 study, between 19 and 44 percent of returning Iraq and Afghanistan veterans have symptoms matching some mental health disorder, but few were accessing treatment.

A survey of 812 veterans revealed that 58 percent of veterans had accessed mental healthcare at least once. Care access was strongly correlated with the severity of a mental health disorder.

Likewise, mental healthcare access was negatively associated with perceived public stigma.

Interestingly, veterans perceived more public stigma than may have been necessary, the researchers reported. Forty-four percent of veterans believed they’d be viewed negatively if they sought mental healthcare. Conversely, only 12 percent said they would view another veteran negatively for seeking the same treatments.

The culture of strength and masculinity may be a contributing factor to high perceived mental health stigma, the researchers reported.

“Given that service members are expected to be ‘tough,’ to ‘shut down’ their feelings, and to do their best to cope by themselves with negative affect and difficult emotions, concern about being judged by others for seeking help, rather than for having mental health problems as such, may be reflective of military culture that emphasizes self-reliance and toughness,” the research team explained.

These problems are exacerbated because of the VA’s dearth of mental health services for veterans, according to a survey from the Wounded Warrior Project.

Although 75 percent of veterans suffer from post-traumatic stress disorder (PTSD), about one-third struggle with getting access to mental healthcare. Thirty-five percent of respondents said they were not comfortable with the VA’s treatment options, and 33 percent said they were concerned treatment would drudge up painful memories.

For their part, the VA is working on ramping up their mental healthcare options and reducing perceived stigma. The agency has recently forged a deal with the Veterans of Foreign Wars (VFW) and Walgreens to offer more educational materials to veterans experiencing mental health symptoms.

The VA has also launched the Make the Connection campaign, which shares stories from veterans who have experienced mental health issues and received treatment. The campaign also offers self-assessments, lists of symptoms, and potential resources.

How to reduce stigma, increase treatment access

While healthcare experts across the board call for an end to social stigma, the issue is still pervasive. And while public campaigns to overcome stigma could be effective in swaying healthcare consumers, industry professionals must also focus on what they can do to overcome perceived stigma obstacles with patients.

One such option is guaranteeing anonymity. While HIPAA and other privacy regulations require confidentiality regarding any type of medical care, research shows that completely anonymous screenings can be beneficial for overcoming stigma.

In 2011 research published in the Journal of the American Medical Association, anonymous screenings yielded two- to four-fold increases in response rates than screenings that included patient names.

Other healthcare professionals are integrating behavioral and mental healthcare into the primary care setting. At St. Joseph Health, a California-based health system, leaders say behavioral health integration helps reduce perceived social stigma attached to treatment access.

“We also need to make sure our health systems are designed to integrate mental health care into health care as a whole, and to free mental health patients from any shame about their conditions that they or their family may have internalized,” the health system said on its website.

“Anyone struggling with mental health… need our encouragement to break through the barrier of stigma and make the call,” the provider added. “They need to know that help is available without criticism or blame.”

Research shows that integrating behavioral health into primary care can reduce depression scores by up to 50 percent.

Cultural ideals amongst healthcare professionals also need to change, Corrigan and his colleagues asserted. Many medical professionals view psychologists differently than other medical doctors, perpetuating institutional stigma.

“Efforts toward changing attitudes have targeted the medical student, general public, and media,” Corrigan wrote. “Some studies with medical students showed that appreciation of therapeutic benefits combined with patient contact improved the image of psychiatry and enhanced its attractiveness as a career.”

Patient education strategies to improve mental health literacy can also have a positive effect, Corrigan pointed out.

“Mental health literacy seems to have a promising effect on care seeking,” the research team said. “Individuals who better recognize their mental illness and its manifestations, as well as treatment options to address its varied impressions, might better avail themselves of those options.”

Ultimately, it will take a multi-pronged strategy for healthcare professionals to encourage patients to seek mental health treatment. Through a varied approach and extensive research, the healthcare industry may be able to determine a dynamic solution to these obstacles.

“There is likely no simple or single panacea to eliminate the stigma associated with mental illness,” Satcher concluded in his trailblazing 1999 report.

“Stigma must be overcome. Research that will continue to yield increasingly effective treatments for mental disorders promises to be an effective antidote,” Satcher continued. “When people understand that mental disorders are not the result of moral failings or limited will power, but are legitimate illnesses that are responsive to specific treatments, much of the negative stereotyping may dissipate.”