Reading of the Week: Better with Time? The New JAMA Paper on Stigma; Also, Dr. Steuber on Real Doctors – and Real Stigma (Academic Psych)

From the Editor

“To say that I didn’t know my great-uncle, Wolfe Levine, would understate things. I didn’t even know of such an uncle, brother of my mother’s father (a grandfather with whom I was close). In retrospect, it’s clear that my great-uncle was simply unmentionable.” In a long essay, writer Howard Husock notes that his great uncle, who suffered from mental illness, was never mentioned.

Society’s view of mental illness has changed much in recent years (good), but some stigma still exists (not so good). How have the public’s views shifted over time?

In our first selection, drawing from JAMA Network Open, we look at a new paper by Bernice A. Pescosolido (of Indiana University) and her co-authors. Reviewing attitudes and beliefs over 22 years, they find that: “this survey study found the first evidence of significant decreases in public stigma toward depression.” That said, not all the results are encouraging. We look at the paper and its clinical implications.

In the second selection, Dr. Elizabeth R. Steuber (of Johns Hopkins University) writes about the stigma faced by those in mental health care. Dr. Steuber, who is a resident of psychiatry, discusses the comments of a patient. She contemplates her work and the potential to change ongoing stigma: “I am hopeful that by leading through example on the medical floors, psychiatry trainees will continue to reshape how the field is seen by society at-large, even if it is only one patient at a time.”


Selection 1: “Trends in Public Stigma of Mental Illness in the US, 1996-2018”

Bernice A. Pescosolido, Andrew Halpern-Manners, Liying Luo, et al.

JAMA Network Open, 21 December 2021

Stigma, the prejudice and discrimination attached to devalued conditions, has been consistently cited as a major obstacle to recovery and quality of life among people with psychiatric disorders. Stigma has been implicated in worsening outcomes for people with serious mental illness, with nearly 40% of this population reporting unmet treatment needs despite available effective treatments. Although some psychiatrists claim that stigma has decreased or is irrelevant, stigma remains concerning to health care professionals, patients, advocacy groups, and policy makers. Research has not supported claims of a decrease in stigma. Moreover, national levels of public stigma have been associated with treatment-seeking intentions and experiences of discrimination reported by people with mental illness. Findings on antistigma interventions also reflect the persistence of stigma; the unclear, limited, or short-term effectiveness of both large-scale messaging and small-scale interventions; and the lack of scalability of many such programs. Herein, we examine US public stigma over a 22-year period to provide a detailed assessment of changes in the nature and magnitude of public stigma over 2 decades for major mental health disorders.

So begins a paper by Pescosolido et al.

Here’s what they did:

  • They used data collected from the US National Stigma Studies (US-NSS). This included face-to-face interviews (!) conducted in 1996, 2006, and 2018.
  • “US-NSSs used a survey experimental design using vignettes describing a fictitious person with behaviors meeting Diagnostic & Statistical Manual of Mental Disorders, Fourth Edition criteria for schizophrenia, major depression, alcohol dependence, and a daily troubles control… The vignette character’s psychiatric condition as well as their self-reported sex (man or woman), race (African American, Hispanic, or White), and educational level (eighth grade, high school, or college) were randomly varied and assigned as experimental characteristics in the stimulus.”
  • These interviews were chosen with multistage sampling techniques.
  • Respondents were aged 18 years or older.
  • “Measures included beliefs about underlying causes (attributions), perceptions of likely violence (danger to others), and rejection (desire for social distance).”
  • Statistical analyses were done, including model regression models.

Here’s what they found:

  • 4 129 individuals were interviewed in the surveys – to be specific: 1996 (n = 1 438), 2006 (n = 1 520), and 2018 (n = 1 171).
  • Demographics. Respondents tended to be women (54.6%) and the majority were White, with a mean age of 44.6.
  • “In the earlier period (1996-2006), respondents endorsing scientific attributions (eg, genetics) for schizophrenia (11.8%), depression (13.0%), and alcohol dependence (10.9%) increased.”
  • “In the later period (2006-2018), the desire for social distance decreased for depression in work (18.1%), socializing (16.7%), friendship (9.7%), family marriage (14.3%), and group home (10.4%).”
  • “Change appeared to be consistent with age and generational shifts among 2 birth cohorts (1937-1946 and 1987-2000).”

A few thoughts:

1. This is a good paper – though not an incredible paper.

2. To summarize the results in a word: progress.

3. The biggest change was observed with depression and in recent years. The authors write: “The more recent period (2006-2018) documented, to our knowledge, the first significant, substantial decrease in stigma, albeit for one mental illness diagnosis: major depression. Fewer survey respondents expressed a desire for social distance from people with depression across nearly all domains, including work and family. Considered in the context of previous research, these decreases are statistically significant, substantively large, and persist in the presence of controls.”

4. But the survey results aren’t all good news. In fact, there was some regressive change: “Inconsistent, sometimes regressive change, was observed, particularly regarding dangerousness for schizophrenia (1996-2018: 15.7% increase…) and bad character for alcohol dependence (1996-2018: 18.2% increase…).” Ouch.

5. Why the progress in some areas and not others? Public mental health campaigns (like Bell Let’s Talk Day in Canada) have been impactful – should they focus more on areas like substance in the future?

6. Like all studies, there are limitations. The authors note several, including declining participation. “Decreasing response rates present a challenge to researchers who seek to model trends over time in attitudes or behaviors. As noted, GSS response rates decreased approximately 16% over the 22-year period in question.” Though the study gives us data, it’s also important to realize the fundamental limitation: participants offered their attitudes and views, but we don’t actually know about their behaviours in the real world.

7. What are the implications for clinical practice? Stigma continues to exist. When working with families and, perhaps, other providers, psychoeducation may be important. Also, in written notes and communications, we should avoid stigmatizing language. A past JAMA Network Open paper was excellent, and was featured in a past Reading:

8. Returning to the opening, Husock’s essay — which is worth reading – can be found here:

The full JAMA Network Open paper can be found here:

Selection 2: “Can I Have the Real Doctor?”

Elizabeth R. Steuber

Academic Psychiatry, December 2021

It was early into my intern year when I met Mr. J., a sixty-some year-old gentleman who had suffered a stroke immobilizing the left side of his body. I introduced myself as a doctor on the neurology team that would be caring for him during his hospitalization. Our introductory meeting was uneventful. Just as I neared the exit, however, Mr. J. asked to see my badge. I initially thought nothing of it since patients often forget my name in the hospital, and I returned to his bedside. As he read my badge, his brow furrowed. He sheepishly asked to see the badge a bit closer and then asked the actual question weighing on his mind: ‘Can I have the real doctor?’

At first, I was confused by Mr. J.’s request, even wondering whether this was a symptom of the neurologic insult he had endured. I again explained that I was a physician on the neurology team, taking care to put particular emphasis on the word ‘doctor.’ However, he glanced sideways and said again, ‘I know, you’re wonderful, but I just want the real doctor.’

So begins a paper by Dr. Steuber.

The psychiatry resident notes the problem: “It was at that moment I realized it was my badge that had come between us.”

She adds: “As a psychiatry trainee, my hospital badge says both ‘Psychiatry’ and ‘Doctor’ below my name. I typically view this as a badge of honor, a hard-fought prize for years of studies and hard work. However, my badge was now seemingly working against me – despite the big, bolded letters spelling ‘Doctor,’ he viewed me as something less than a true physician.”

She notes ongoing stigma: “Despite the scientific advancements in the field, the increased competitiveness, and the decreased stigmatization of mental health care, psychiatry still appears to be the ugly duckling of medicine. Psychiatric illnesses are still separated from ‘medical problems’ throughout much of the world. As such, psychiatrists do not often achieve parity as true medical doctors, despite their training to the contrary.”

Yet, psychiatry has a clear role: “Despite his request, what Mr. J. needed in that moment was a psychiatrist. His history revealed that he was desperately anxious about his trajectory and demoralized by his post-stroke loss of function. This event was a devastating blow to his identity and his self-esteem.”

Eventually, she connects with the patient. “Mr. J. left the hospital several days later. As he left, he called out to me in the hall, ‘Hey Doc, you’re not so bad… for a shrink.’ He then threw me one of his characteristic winks, and I grinned behind my mask.”

A few thoughts:

1. This is a nice essay.

2. We can all relate.

3. She notes the role of pop culture: “Caricatures of armchair psychiatrists unable to interpret basic lab results or archaic notions of psychiatry as the study of maternal imperfections continue to permeate public perceptions of the field, despite tremendous reductions in bias against mental illness over the past decades. As a result, the negative stereotypes perpetuated in popular culture fundamentally alter how psychiatry, and therefore psychiatrists, is perceived.” Thoughtful.

The full Academic Psychiatry paper can be found here:

Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.

1 Comment

  1. I’m hoping that there can be more investigations into potential problems with some stigma messaging. I discussed some of these problems in this article: