For most of the doctors, it was a typical busy day at the hospital. However, the psychiatric center’s waiting area had two patients – a significant increase from the usual turnout of zero. Both patients apparently knew each other and, caught unawares, were utterly uncomfortable in admitting to their real intents. “I’m here for an eye check-up”, said one, “but their waiting area is crowded. Thought I would hang out here…”. “I’m accompanying my wife”, said the other, “she’s picking up some reports.” Unfortunately for them both, the junior psychiatrist chose that particular moment to bustle in and hand them each a questionnaire.
The incident I describe took place a decade ago in India, when I was interning at the hospital’s psychiatric department. Much time has passed, but I have seen little improvement in public perceptions of mental disorders. These are still taboo, and the stigma associated with admitting a problem and seeking help, often leads to cringe worthy and surreptitious behavior as I happened to witness that day. In fact, psychiatrists are considered unnecessary, and psychiatry itself, bogus.
This situation leads to unhealthy behaviors: patients rarely have access to metal health care facilities, in part because these services are scarce and expensive, and in part because the fear of stigmatisation prevents people from seeking help. There are a few commonly employed techniques to ‘manage’ mental health issues in my country: family members may ignore symptoms, insisting that they are temporary, or confine the patient indoors where no one can see them, or if the patient is single, arrange for them to be married (without informing the prospective spouse of their problems, of course) which grows out of the persistent belief that mental health problems are self-imposed and therefore will be ‘forgotten’ when the affected person is busy taking care of their family.
Having spoken to colleagues and friends of other nationalities, I realise now that such stigmatisation of mental health is widespread. I am surprised at the numbers of psychiatrists who admitted to being discouraged from training in psychiatry as junior doctors. And I am always surprised at the misperceptions of mental health and treatments. An elderly lady, during my doctoral studies in the Netherlands, remarked that my research on ADHD would lead to naught, as the disorder was an imaginary problem concocted by avaricious psychologists and could be easily managed if cell phones were to be banned.
It is odd that mental health is regarded in the same manner as other diseases were before the modern era. Partly, this is due to the complexity of these disorders, our inability to put our finger on the pathology, and our incomplete understanding of the black box that is the brain. Yet, much research in the past couple of decades has begun to reveal valid biological bases for such problems. Why then are we still unwilling to accept mental health disorders as critical public health problems, on par with diseases such as hypertension, diabetes, etc.? Perhaps, the evidence is not sufficiently convincing. Perhaps research output is too technical and too abstract to be comprehended instinctively. Or perhaps, we treat our brain differently: bodily pain is truly problematic, but any other issue that does not leave a physical mark is assumed to be ‘all in one’s head’.
Before the enlightenment movement spread throughout Europe and before the germ theory of disease was formulated, our approach to healthcare was erratic, superstitious, and ineffective… If not outright dangerous. The advent of systematic scientific inquiry changed everything. It proved that diseases were not caused by God’s displeasure or foul miasmas. Or perhaps that story gets things backwards: perhaps it was cultural changes that encouraged rationality which made those scientific investigations into the cause of disease possible in the first place. But neither rationality nor science, seem to be changing perceptions of psychiatry in our modern era.
I recently read an article claiming that psychiatric treatments are being handed out indiscriminately as acceptability of these disorders rise. Care has to be taken that unnecessary and incorrect labels are not applied, but greater damage is caused by under-recognition of mental health problems. However, concern about over-diagnosing actually reflects a different problem: difficulty in defining psychiatric disorders. As of now, there are no objective tests for psychiatric disorders (although there is a push towards developing such methods) and most diagnoses are assigned if someone fulfills a given number of subjective criteria. These criteria have been fine-tuned over the years and are based on research findings, yet are nowhere close to being as objective as say a blood test or an x-ray. Vague definitions mean that trust in psychiatric diagnoses, naturally, is low.
So how can stigma be reduced when the validity of mental health disorders is itself being questioned? It has to be conveyed that while the diagnostic guidelines are a work in progress, the existence of mental health problems cannot be denied. Many studies have explicitly looked into methods to improve perceptions and tackle stigmatisation of mental health problems. It seems that public education and personal contact with patients attenuates negative perceptions of mental health problems (see Corrigan et al.). While ensuring personal contact with patients as an effective counter to stigmatisation is difficult to employ on a mass scale, public education can be easily initiated.
I have always felt that scientific research into mental health will improve its acceptance. Given my background, that is a natural thought (or bias?). However, I realise that change does not occur automatically following scientific discoveries. Other strategies can and must be adopted in parallel. Public education is a noteworthy move in that direction. There is also another option, one that is either more or less appealing depending on your point of view: that of celebrity endorsements. We, the public, lap up all sorts of questionable life-style choices, provided these are endorsed by a singer, an instagram influencer, an actor, etc. So why not harness their ability to reach people and tackle the mental health crisis? (Making sure to clarify that science is not the same as scientology… see works of Tom Cruise et al. for reference). Upon chancing on this idea, I reflexively googled ‘effectiveness of celebrity endorsements’ and was rewarded with this recent meta-analysis. Such studies are insightful and will enable planning of any celebrity-based mental health awareness campaigns. What is also interesting is the finding that endorser brands maybe more effective than individual celebrity endorsements. While a Netflix/Apple/any other brand-based campaign to tackle mental health will be able to reach greater numbers of people, I wonder what may incentivise them to take up such a cause.
I would have liked to end this article by summing up the next steps in our plan of action, but unfortunately, we don’t have one. Mental health awareness is still an underexplored area. A combination of multiple strategies may work in eventually improving acceptance of mental health. Meanwhile, research must continue alongside other community-based efforts, be it education or celebrity endorsements. For the latter, we scientists may feel that it is outside of our purview. But, it is our voice that can urge for new policies; policies that tackle mental health stigmatisation. We must remember that silence is not always golden.