Stigma and Discrimination in Schizophrenia - Essay Example

Swarna1 ID 5448 Order # 134258 19 October 2006 Study On Stigma And Discrimination Due to Schizophrenia AMRESH SHRIVASTAVA Mental Health Foundation of India, Mumbai, India GOPA SARKHEL IYER SUNITA Correspondence: Amresh Srivastava, Mental Health Foundation of India, Mumbai, India Declaration of Interest : None ABSTRACT Background People with schizophrenia suffer from stigma and discrimination. Aims The study aims to analyze the extent, causes, and impact of stigma due to schizophrenia and effective anti-stigma measures for better mental health care. Method A semi structured proforma was given to 300 family members of schizophrenics and the responses were analyzed statistically using randomized block design. Results The stigma and discrimination due to schizophrenia was found to be more with families than that of personal life. Unawareness and illness were the main reasons for stigma and discrimination due to schizophrenia in addition to drug usage. Effective strategies and measures were identified for minimizing the stigma and discrimination due to schizophrenia that will aid in efficient nursing. Conclusions The effective anti-stigma measures will certainly aid in mental health care for schizophrenics globally. INTRODUCTION Stigma is generally defined as a mark or token of infamy or disgrace. It also refers to a negatively perceived defining characteristics used to set individuals and groups apart from the normalized social order (Khaka Deepika, 2003) and is also assiciated with discrimination. Discrimination may be defined as the action or treatment based on stigma and directed towards the Stigmatized (Bunding, 1996). Stigma and discrimination are highly associated with the Schizophrenia as it is a psychiatric condition that describes a mental disorder characterized by deviation in the expression of truth and / or by significant social or occupational dysfunction. Stigma and discrimination resulted by schizophrenia is mainly due to unawareness among the people about the disease. Some investigators found that the stigma operated by schizophrenia may result in deviated behaviour and violence which is very dangerous (Link et al., 1992; farrington, 1994; Link &Stueve, 1995; Appelbaum et al., 2000). Schizophrenia is reported to afflict 1% of the worlds population (U.S. Department of Health and Human Services, 1991), where as schizotypal personality disorder afflicts 2–3%. The stigma and discrimination caused by schizophrenia was confirmed by several research workers (Poulton et al, 2000; Cannon et al, 2002). Earlier studies and reviews of worldwide-published research mainly compared the incidences of the stigma and discrimination due to illness in urban and rural geographical regions (Haroutunian et al., 2006, Paz et al, 2006 and Skosnik et al., 2006). However the past studies didn’t focus much on multifaceted stigmatization of schizophrenia and hence the present investigation has been performed to analyse the stigma and discrimination associated with schizophrenia in more integrated manner. This was planned to answer the following questions. 1. What is the main cause for stigma? 2. What is the extent of negative effect caused by stigma and discrimination on schizophrenia treatment? METHOD Study setting and design The sample size of the population (N) is 300. The family members of the schizophrenics residing in Mumbai, India were interviewed on nature and causes of stigma, most common forms of stigma, common source, removal probability, consequences, common management strategies, method of information about schizophrenia to relatives, common attitude of relatives, impact of stigma, and measures to reduce the stigma and discrimination. The people were asked to answer either “yes” or “no” to the specific factors resulting in the stigma. The factors were prioritized. Statistical analysis The arithmetic mean and coefficient of variance (C.V) of all the samples have been estimated. In addition, standard error of mean (SEM), standard error of deviation (SED) and critical difference (CD) at 5% have been estimated for better analysis of the collected data. One factor anova has been done under randomized block design (RBD). The data was collected in two replications and the average pooled data has been shown in the tables. NPRCSTAT package has been used for the statistical analysis. RESULTS The results can be depicted under following sub heads. Nature and causes of stigma The response indicates that stigma was observed to be highest in family (81%) and social life (73%) and lowest in marital life (35%). Similarly 69 % of the respondents felt that stigma is associated with the personal life also (Table 1). The statistical analysis of data has shown remarkable deviation from the general mean (55.3) which is reflected by higher value of coefficient of variation 9.6 %. Discrimination felt in marital life was also noticed by Weiss et al., 2001. 97% of the respondents opined that unawareness and nature of illness create stigma; 54% identify behavioral symptoms and 27% concluded that drug related complications also create stigma (Table 1). The difference in the factors affecting the origin of stigma was found to be significantly superior as it is higher than the critical difference. Most common forms of stigma and discrimination Majority people (69 %) felt that the most common form of stigma due to schizophrenia is lowering self esteem followed by that of discrimination in family (50%). Discrimination at job or work place, inconvenience for marriage, and poor sexual performance were also agreed upon as the common forms of stigma (Table 2). Barring the difference between the suffered discrimination in work place and not coping up with marriage, all other differences are found to be statistically significant (CD (0.05) =5.3). Over hearing offensive comments about their illness, hurtful news at mass media and non preference at the time of marriage proposals are among the other crucial forms of stigma due to schizophrenia. However, there has been no statistical significance among the factors except seeing the hurtful things in mass media as the difference is lower than CD (0.05) (21.4). Common sources of stigma The highest number of respondents (69%) felt that general community is primarily responsible for schizophrenia (Table 2) due to lack of awareness. The stigma and discrimination was also assigned to misleading information about mental illness by media (Stuart & Arboleda-Florez, 2001). The data has shown tremendous significance as the CD (0.05) (6.2) is lower than the difference among the treatments. It is followed by co workers (46%), family members (42%), mental health care givers (15%), medical personnel (15%) and other sources (8%). Majority of them (58%) opined that the stigma due to schizophrenia can be avoided successfully by implementing the awareness campaigns frequently. Attitude of family members and relatives It is heartening to note that majority of the family members of schizophrenics (81%) positively opined that stigma due to schizophrenia can be reduced significantly. However considerably larger size of respondents (35%) opined in favor of guilty feeling for having schizophrenic patient at their home. The family members (77%) preferred to declare it as mental illness that requires treatment, 42 % of the respondents opined to disclose openly to their relatives. However 23% of the interviewees favored disclosing only when the schizophrenic patient turns violent (Table 3). Tremendous significance among the information styles has been noticed as the difference among the treatments is lower than CD (0.05) (7.7). 15% of the respondents preferred disclosing of schizophrenia only when the patient attempts to commit suicide and 8% opined to completely hide the stigma in all circumstances. On the other side, the attitude of relatives towards schizophrenic patient is some how encouraging as 62% of them agreed to accept schizophrenics socially and they expressed willingness to assist them. 23% and 19% of the interviewees came forward to provide financial help and medical help respectively. The positive attitude of public towards schizophrenia is highly crucial in anti-stigma programmes (WHO, 1996). The worrying part is to find 23% of the respondents having attitude of keeping the schizophrenics at a distance in isolation and 19% of them were in the mood of discarding schizophrenics that reflects higher extent of stigma. This trend of maintaining social distance with mentally ill people was also investigated by Angermeyer and Matschinger (1995) and Penn et al., (1994). Consequences of stigma and discrimination The marital and social lives get affected due to presence of schizophrenic patient as a family member, according to 65 % respondents which is alarming. The presence of stigma is also reflected as 46% of the interviewees felt that their family reputation gets beaten owing to the presence of schizophrenic family members; 23% of the people expressed their feeling about schizophrenics as a social liability (Table 4). But the statistical analysis indicated that the superiority of effect on marital and social life of family members is not significant to that of effect on family reputation as it is lower than CD value (0.05) (25.1). Due to the presence of stigma, significantly higher number of respondents (38%) preferred avoiding the disclosure of their mental illness at the place of their work or job. The strong desire of people to keep themselves away with schizophrenics was also reported by Angermeyer &Maschinger, 1997 ; Link et al., 1999). Similarly 27% of the well qualified schizophrenics were found to be disqualified because of this stigma. The worrying trend is that 31 % of the respondents felt that they were not accepted wholeheartedly even in their families. The extent of stigma is so intense that the Schizophrenics were pushed in to unacceptable social condition (27%), social exploitation (23%) and sexual harassment (4%) (Table 4). Social exploitation, unacceptable social situation and lonely living have not shown any significant difference among themselves as the consequences of stigma, where as all these factors are significantly superior to that of sexual harassment (CD (0.05)=10.1). Common strategies to cope up with stigma and discrimination The most effective strategy for removing the stigma and discrimination due to schizophrenia as opined by the majority respondents (77%) is a strong and committed public awareness and public involvement. Involvement in advocacy (62%), selective disclosure about the patients (38%) and empathic understanding and giving other diagnosis (35%) are other strategies to cope up with stigma due to schizophrenia as opined by the respondents (Table 5). Measures to reduce stigma and discrimination Relapse prevention programme was considered to be the most effective measure to reduce the stigma and discrimination (88%), followed by complete treatment (85%), educating community (Table 5), providing better treatment and rehabilitation (81%) and early identification (77%). However it is significantly superior to that of all other factors except educating community, better treatment and early identification (n=300 and CD(0.05)=11.8). Educating community would certainly reduce the stigma due to schizophrenia as the educated people have shown higher level of stigma (Davidson, 2002). Similarly social integration (65%), realization (62%) and improving productivity (60%) are other viable options for controlling the stigma due to schizophrenia as opined by the respondents. The social integration of schizophrenics with society was already established by some researchers (Nawkai and Reissi, 2002)) as effective anti-stigmatic measure. DISCUSSION Nature of stigma and discrimination The highest prevalence of stigma and discrimination due to schizophrenia recorded with the familial life and social life might be due to the more probability of identifying the symptoms of stigma due to frequent contacts and social mobility. It was also revealed that stigma and discrimination due to schizophrenia may come at any time during the life and cognitive behavioral therapy plays a crucial role in management of stigma. Even though some investigators could not give a clear picture (Cormac et al., 2002) the present study results favoring cognitive behavioral therapy are in coincidence with the findings of Zimmerman et al., 2005. Causes and management of stigma and discrimination Unawareness in community about the disease as felt by the majority of the respondents is probably the prime reason for severe extent of stigma and hence imparting basic knowledge to people on symptoms of schizophrenia will certainly reduce the stigma and discrimination to a greater extent. Similar trend was also noticed by Lauber et al., (2005) who reported a wide variability in mental health literacy in educational elite group. The common form of stigma was identified as lowering self esteem and suffered discomfort at both job and at home. As it leads to the split personality, schizophrenics have been facing problems like lack of marriage proposals, being avoided by the people while interaction at work etc. The remarkable percentage of respondents identified general community and family as the cause of stigma due to its linkage with some genetic factors (Harrison & Owen 2003). The reason for hiding the fact about presence of schizophrenics (8%) might be due to the perception that this stigma will affect their family reputation and marriage proposals. Once it comes to the matter of their safety the fact will be revealed by them which reflected in their favor of disclosure of either during violence or attempting suicide. The similar attitude of public maintaining social distance towards mentally ill people due to their perception of association between stigma and violence was also reported earlier (Pescosolido et al., 1999 and Thornton and Wahl, 1996). However increased awareness and educational counseling might have resulted in the reasonably good percentage of respondents tilting towards acceptance of schizophrenics and stigma management. Successful anti-stigma programmes like the Boulder anti-stigma campaign which is a pilot project of the World Psychiatric Association global program have to be taken as models (MHCBC, 2005). Research efforts must be directed to intensify these trials so that schizophrenics will be assured genuine and integrated treatment and stigma and discrimination can be minimized. The remaining fraction of population that is unaware about the basics of schizophrenia responded negatively in the form of guilty feeling and liability perception which reflected higher extent of stigma. Overall, the main reason for stigma proves to be violence associated with it and the negative extent of stigma and discrimination was found to be remarkably higher on medical interventions and nursing for schizophrenics. By reducing the incidents of violence by schizophrenics through assisted treatment (O’Keef etal., 1997 and Swartz et al., 1998), the stigma due to schizophrenia can be minimized. Practical importance of the present study and conclusions The stigma associated with schizophrenia becomes a strong challenge for effective mental health care. Hence the solution for minimizing this stigma through anti-stigma programmes is highly essential that necessitates the collection and analysis of complex information and the present study has significantly contributed a lot in this direction by measuring the extent of negative effect caused by stigma and all the significant parameters affecting stigma have been presented in Table 6. It is concluded that violence is the major cause for stigma and by reducing the violence through counseling and educational campaigns; the stigma can be managed successfully. This will certainly act like an ideal model for large scale implementation of anti-stigmatic plan for schizophrenia that would reduce the stigma and facilitate efficient mental health interventions ACKNOWLEDGEMENTS REFERENCES Andreasen NC, Daoud SZ, Conley R, Roberts R, Bustillo J, Perrone-Bizzozero NI (2006) Increased expression of activity-dependent genes in cerebellar glutamatergic neurons of patients with schizophrenia. Am J Psychiatry. 163(10):1829-31.Paz RD,. Angermeyer, M.C. & Matschinger H. 1995.Violent attacks on public figures by persons suffering from psychiatric disorders: their effect on the social distance towards the mentally ill. European Archives of Psychiatry and Clinical Neuroscience 245: 159-164 Angermeyer, M.C. & Matschinger H. 1997. Social distance towards the mentally ill: results of representative surveys in the Federal Republic of Germany. Psychol Med. 27:131–141. Appelbaum, P. S., Robbins, P. C. & Monahan, J. (2000) Violence and delusions: data from the MacArthur violence risk assessment study. American Journal of Psychiatry, 157, 566 -572.[Abstract/Free Full Text] Bunting, S. M. (1996). Sources of stigma associated with women and HIV, Advanced Nursing Science, 19:64-73 Cannon, M., Caspi, A., Moffitt, T. E., et al (2002a) Evidence for early, specific, pan-developmental specific, pan-developmental impairment in schizophreniform disorder: results from a longitudinal birth cohort. Archives of General Psychiatry, 59, 449 -457.[Abstract/Free Full Text] Cormac I, Jones C, Campbell C. (2002) Cognitive behaviour therapy for schizophrenia. Cochrane Database of systematic reviews, (1), CD000524. Davidson,M. 2002. What else can we do to combat stigma? World Psychiatry. February; 1(1): 22–23. Farrington, D. P. (1994) Early developmental prevention of juvenile delinquency. Criminal Behaviour and Mental Health, 4, 209 -227. Harrison PJ, Owen MJ. (2003) Genes for schizophrenia? Recent findings and their pathophysiological implications. Lancet, 361(9355), 417–9. Haroutunian V, Katsel P, Dracheva S, Davis KL. (2006). The Human Homolog of the QKI Gene Affected in the Severe Dysmyelination "Quaking" Mouse Phenotype: Downregulated in Multiple Brain Regions in Schizophrenia. Am J Psychiatry.163(10):1834-7. Kay S.R, Fiszbein A & Opler LA. (1987). The Positive and Negative Syndrome Scale for schizophrenia. Schizophr Bull. 13:261-276 Khakha, Deepika c. (2003). Discrimination in health care to patients living with hiv / aids. Nursing Journal of India. Dec 2003. FindArticles.com. 11 Oct. 2006. http://www.findarticles.com/p/articles/mi_qa4036/is_200312/ai_n9321219 Link, B. G., Andrews, H. & Cullen, F. T. (1992) The violent and illegal behavior of mental patients reconsidered. American Sociological Review, 57, 275 -292. Link, B. G. & Stueve, A. (1995) Evidence bearing on mental illness as a possible cause of violent behavior. Epidemiological Reviews, 17, 172 -181. Link B.G., Phelan J. & Bresnahan M. 1999. Public conceptions of mental illness: labels, causes, dangerousness, and social distance. Am J Public Health. 89:1328–1333. Louise Arseneault, Mary Cannon, Richie Poulton & Avshalom Caspi (2003). Childhood origins of violent behaviour in adults with schizophreniform disorder. MHCBC. 2005. The mental Health Centre Serving Boulder and Broomfield Counties in Colorado http://www.mhcbc.org/anti-stigma.htm. O’Keefe C, Potenza DP, Mueser KT. 1997. Treatment outcomes for severely mentally ill patients on conditional discharge to community-based treatment. Journal of Nervous and Mental Disease 185 : 409-411. Penn D.L, Guynan, K and Daily, T. 1994. Dispelling the stigma of schizophrenia: what sort of information is best? Schizophrenia Bulletin 20: 567-577. Pescosolido B.A, Monahan J and Link B.G. 1999. The public’s view of the competence, dangerousness, and need for legal coercion of persons with mental health problems. American Journal of Public Health 89 : 1339-1345. Petr Nawka1 & Charlene M Reiss1. 2002. Integrating people who are stigmatized: the tetralogue model. World Psychiatry. February; 1(1): 27–28. The British Journal of Psychiatry (2003) 183: 520-525 © 2003 The Royal College of Psychiatrists. Poulton, R., Caspi, A., Moffitt, T. E (2000) Childrens self-reported psychotic symptoms and adult schizophreniform disorder: a 15-year longitudinal study. Archives of General Psychiatry, 57, 1053 -1058. Robins, L. N., Cottler, L. O., Bucholz, K. (1995) Diagnostic Interview Schedule for DSM-IV. St Louis, MO: Washington University School of Medicine. Skosnik PD, Krishnan GP, Aydt EE, Kuhlenshmidt HA, ODonnell BF. (2006). Psychophysiological evidence of altered neural synchronization in cannabis use: relationship to schizotypy. Am J Psychiatry.163(10):1798-805. Stuart H. Arboleda-Flórez J. A. 2001. public health perspective on violent offenses among persons with mental illness. Psychiatr Serv. 52:654–659. Swartz M.S, Swanson J.W and Hiday V.A. 1998. Violence and severe mental illness: the effects of substance abuse and nonadherence to medication. American Journal of Psychiatry 155: 226-231. Thornton J.A. and Wahl O.F. 1996. Impact of a newspaper article on attitudes toward mental illness. Journal of Community Psychology 24 : 17-24. U.S. Department of Health and Human Services (1991). The Cost of Schizophrenia. Schizophrenia Bulletin: National Institute of Mental Health, 17(3). http://www.answers.com/topic/schizophrenia Weiss, M.G., Jadhav, S. & Raghuram, R. 2001. Psychiatric stigma across cultures: local validation in Bangalore and London. Anthropol Med.8:71–87. World Health Organization. 1996. Guidelines for the promotion of human rights of persons with mental disorders. Geneva: WHO. Zimmermann, G., Favrod, J., Trieu, V. H., & Pomini, V. (2005) The effect of cognitive behavioral treatment on the positive symptoms of schizophrenia spectrum disorders: a meta-analysis. Schizophrenia Research, 77, 1-9. Table 1: Nature and causes of stigma seen in Schizophrenia Nature of stigma Causes of stigma Category Percent of people with Yes Percent of people with No Category Percent of people with Yes Percent of people with No Personal 69 * 31 Unawareness in community 97 * 3 Social 73 * 27 Nature of illness 73 * 27 Familial 81 * 5 Faith in supernatural power 0 0 Occupational 62 * 10 Behavioral symptoms 54 * 46 Marital 35 17 Drug related complications 27 73 Others 12 88 Mean 55.3 50.2 C.V. 9.6 % 5.9 SEM 3.7 2.1 SED 5.3 3.0 CD (0.05) 13.7 * significance with Marital life 8.3 * Significance with drug related complications Table 2 : Most common forms and sources of stigma Most common form : category 1 Most common form : Category 2 Common sources of stigma Category Yes No Category Yes No Category Yes No Suffered discriminations in jobs/work place 42 * 58 Overhearing offensive comments about mental illness 46 54 General community 69* 58 Suffered discriminations in family 50 * 50 Seeing or hearing hurtful things in the mass media 32 68 Family 42* 58 Lowering self esteem 69 * 31 Being avoided because of their illness 61* 39 Co worker 46* 54 Cannot cope up with marriage 44 * 56 Do not get proposals for their marriage 42 58 Mental health care givers 15 85 Poor sexual performance 7 93 Medical personnel 15 85 Any other 3 97 Any other 8 92 Mean 36.0 45.2 32.5 C.V. 5.7 14.8 7.4 SEM 1.4 4.7 1.7 SED 2.0 6.7 2.4 CD (0.05) 5.3 * Significance with Poor sexual performance 21.4 * Significance with seeing hurtful things in mass media 6.2 * Significance with medical personnel Table 3 : Style of information and attitude of family members and relatives towards schizophrenics Style of information of family members Attitude of relatives Category Yes No Category Yes No Say it openly to the relatives 42* 58 Acceptance 62* 38 Try to hide it 8 92 Discard 19 81 Inform only when patient is violent 23* 77 Isolation 23 77 Inform when there is suicide attempt 15 85 Help 62* 38 Say it is mental illness needing cure 77* 23 Cooperation 77* 23 Any other 4 96 Financial support 23 77 Offering medical support 19 81 Any other 8 92 Mean 28.0 36.6 C.V. 10.7 12.4 SEM 2.1 3.2 SED 3.0 4.5 CD (0.05) 7.7 * Significance with “Try to hide it” 10.8 * significance with “offering medical help” Table 4: Impact and consequences of stigma and discrimination due to schizophrenia Impact of stigma Consequences Category-1 Consequences Category-2 Category Yes No Category Yes No Category Yes No Do you see them as a liability 23 77 Avoid disclosing their mental health histories on jobs / applications 38 62 Living alone 27* 73 poor nutrition given to them 4 96 Had been turned down for a job inspite of being qualified 27 73 Pushed into unaccepted social situation 27* 73 Do marital & social life of other family members get affected 65* 35 Unaccepted in the family 31 69 Sexual harassment 4 96 can the stigma result into isolation of patients or is there a fall in family reputation 46* 14 Social exploitation 23* 77 Any other 0 0 Mean 34.5 32.0 16.2 C.V. 22.9 16.7 22.5 SEM 5.5 3.7 2.5 SED 7.9 5.3 3.6 CD (0.05) 25.1 * Significance with “poor nutrition given to them” 23.0 No significance among the treatments. 10.1 * Significance with sexual harassment. Table 5 : Common strategies and measures to reduce stigma and discrimination due to schizophrenia Common strategies Anti stigmatic Measures Category Yes No Category Yes No Involvement in advocacy 62* 38 educating community 81* 19 immediate challenge of stigmatizing remarks 27 73 providing better treatment 81* 19 Concealment or selective disclosure Of patients 38* 62 early identification 77* 23 involvement with other consumers (like M.Rs) 15 85 reducing complications (suicide, violence) 69* 31 public involvement to remove the stigma 77* 23 improving productivity 50 50 empathic understanding & giving other diagnosis 35* 65 social integration 65* 35 Any other 4 96 complete treatment 85* 15 realization 62* 38 rehabilitation 81* 19 relapse prevention program 88* 12 Any other 4 96 Mean 36.8 67.3 C.V. 17.8 7.8 SEM 4.6 3.7 SED 6.5 5.2 CD (0.05) 16.1 * Significance with “involvement with other consumers” 11.8 * Significance with improving productivity Table 6: Most significant parameters relating to stigma due to schizophrenia Stigma nature Significant parameter Percent of people with “Yes” Percent of people with “No” CD (0.05) value at 95 % probability Nature of stigma Familial life 81 * 5 13.7 Cause of stigma Unawareness in community 97 * 3 8.3 Most common form (Category 1) Lowering self esteem 69 * 31 5.3 Most common form (Category 2) Being avoided because of their illness 61* 39 21.4 Common source of stigma General community 69* 58 6.2 Style of information of family members Say it is mental illness needing cure 77* 23 7.7 Attitude of relatives Cooperation 77* 23 10.8 Impact of stigma Do marital & social life of other family members get affected 65* 35 25.1 Consequences Category 1 Avoid disclosing their mental health histories on jobs / applications 38 62 23.0 Consequences Category 2 Living alone / Pushed in to unacceptable social condition 27* 73 10.1 Common strategies public involvement to remove the stigma 77* 23 16.1 Anti stigmatic measures relapse prevention program 88* 12 11.8 Read More