From the Editor

Stigma. Suicide prevention.

This week we consider these weighty topics with two excellent papers.

The first, written by Patten et al., looks at the perception of stigma in those receiving mental health care in Canada. The second is a “viewpoint” that asks what we need to do to reduce suicide rates – which, across the West, has not decreased in the past decade.


Stigma and Our Patients

“Perceived Stigma among Recipients of Mental Health Care in the General Canadian Population”

Scott B. Patten et al., The Canadian Journal of Psychiatry, 18 March 2016 Online First

Stigmatization refers to a negative social response to people who have a mental illness, resulting in prejudice, discrimination, and social exclusion. Addressing stigma has been the target of national initiatives in many countries. Fighting stigma was prioritized in the Canada’s ‘Changing Directions, Changing Lives’ mental health strategy and is one of the pillars of the Mental Health Commission of Canada’s activities through its Opening Minds Initiative.

Stigmatization interferes with mental health care on many levels, such as by discouraging help seeking. Consumer surveys indicate that stigma and discrimination are perceived from family and friends, employers, and also from health professionals. A report from the Mood Disorders Society of Canada forcefully expressed concerns about stigmatization in health settings, stating that people with mental illness ‘feel ignored in emergency rooms and treated disrespectfully by family physicians.’ However, stigma is most often understood as public or personal stigma, a term that refers to prejudice and discrimination directed at people with mental illness by members of the population. Self-stigma refers to the internalization of such attitudes, resulting in feelings of shame, blame, and diminished self-worth. Perceived stigma involves perceptions (of those with a mental illness) of stigmatizing attitudes held by others and internalization of perceived stigma plays a role in the emergence of self-stigma. This is especially true for those who perceive legitimacy in extant social hierarchies.

Dr. Scott Patten

So opens an important, new paper written by Scott B. Patten et al. from The Canadian Journal of Psychiatry. (Dr. Patten, you will remember, is also that journal’s editor.) Drawing from a mental health survey, Dr. Patten and his co-authors attempt to quantify how common is the perception of stigma.

Here’s what Patten et al. did:

· They drew data from the 2012 Canadian Community Health Survey: Mental Health and Well-Being. Stats Canada conducted this nationally representative survey of Canadian households, interviewing one representative in selected homes (age 15 or older). For the record, the 2012 CCHS had 69% response rate and a final sample of 25,113.

· The CCHS included a Mental Health Experiences scale, developed by Queen’s University’s Dr. Heather Stuart. Considering people who had experienced a mental health problem in the past 12 months, they were asked if “anyone held negative opinions” or “treated you unfairly” because of “your past or current emotional or mental health problem.” If there was perceived stigma, people were asked to rate how it affected them on a scale of 0 to 10 across various domains: “family relationships, romantic life, school or work life, financial situation, housing situation, and accessing health care services for physical health.”

· The survey also included other measures of mental health, such as perceived mental health, a distress scale, self-reported diagnosis and a structured diagnostic interview.

· The survey also asked people if they had discontinued treatments and, if they had, asked why. One of the options was “discrimination / unfair treatment / embarrassment.”

· Statistical analyses were done.

Here’s what Patten et al. found:

· The (weighted) percentage of women in the sample was 50.7%. The mean age was 45.7 years.

· 17.9% of respondents reported that they had received mental health care, with about half of them (46.5%) reporting treatment in the preceding 12 months. The analysis is based on the experiences of an estimated 8.3% of the Canadian household population.

· “Overall, 24.4% of this group reported encountering prejudice or discrimination because of their mental health…” (!!)

· The highest impact was in the areas of work/school and family and romantic relationships. (See graph below.)

· Perceived stigma was higher in people with diagnoses. (!!) See graph below.

· The authors also looked at having a disorder and perceived mental health status. “As expected, there is a strong relationship between having a disorder and perceived mental health status, but they do not assess exactly the same thing. Approximately 25% of those with a disorder reported very good or excellent mental health and 4.4% of those without any of the disorders covered by the CIDI reported only fair or poor mental health.”

· In terms of discontinuation of treatment, common reasons included “felt better” and “not helping;” “discrimination/unfair treatment/embarrassment” was the reason given by just 2.0% and 6.4% of participants, respectively.

The authors note:

“This study helps to quantify the stigma perceived by Canadians accessing mental health care. Although the frequencies are high (in the range of 30% to 40% for those with the various disorders assessed), the experience of stigmatization was not universal. Interestingly, although the sample was restricted to those receiving mental health services in the past year, not all of the respondents had evidence of a disorder, either as discerned by the CIDI or by self-report. Some people seek mental health care for reasons other than mental disorders per se (such as stress management, marital problems), and such individuals appear to perceive stigmatization less often than those with a diagnosis.”

A few thoughts:

1. This is an important paper.

2. Like the Patten et al. paper that looked at the treatment of depression (considered in a Reading a few weeks ago), this paper draws its data from the CCHS, and asks practical questions and gets practical answers.

3. This paper is deeply troubling. The paper finds that many people with mental health problems perceive stigma.

4. The reality is probably worse. As the authors point out, a limitation here is that people were surveyed if they received treatment within the year prior to the survey – thereby losing those who had stopped treatment as a result of past perceived stigma. Would a different methodology have yielded a higher rate? That’s possible. A UK survey, as Patten et al. note, reported a higher frequency – though it was plagued by a low response rate.

5. For a great discussion of stigma and mental illness, check out the recent presentation by Dr. David Goldbloom for the Walrus Foundation (as part of the “Walrus Talks” series). I’ve put his written comments on my webpage – where I archive past Readings, by the way. Here’s the link:


Moving Forward on Suicide Prevention

“Changing the Direction of Suicide Prevention Research: A Necessity for True Population Impact”

Helen Christensen et al., JAMA Psychiatry, 16 March 2016 Online First

Suicide rates in most Western countries have not decreased in the last decade, a finding that compares unfavorably with the progress made in other areas, such as breast and skin cancers, human immunodeficiency virus, and automobile accidents, for which the rates have decreased by 40% to 80%. Preventing suicide is not easy. The base rate of suicide is low, making it hard to determine which individuals are at risk. Our current approach to the epidemiologic risk factors has failed because prediction studies have no clinical utility—even the highest odds ratio is not informative at the individual level. Decades of research on predicting suicides failed to identify any new predictors, despite the large numbers of studies. A previous suicide attempt is our best marker of a future attempt, but 60% of suicides are by persons who had made no previous attempts. Although recent studies in cognitive neuroscience have shed light on the cognitive ‘lesions’ that underlie suicide risk, especially deficits in executive functioning, we have no biological markers of suicide risk, or indeed of any mental illness.

“For those who seek help, current treatments can be effective but are not optimal. Novel treatments through repurposing drugs such as ketamine hydrochloride may provide new opportunities. However, people at risk of suicide do not seek help. Eighty percent of people at risk have been in contact with health services prior to their attempts, but they do not identify themselves, largely because they do not think that they need help.

Helen Christensen

So opens a paper by Christensen et al. from JAMA Psychiatry, which argues that big changes are needed to address suicide.

There is often a schism between the treatments offered in medical settings and the interventions delivered through the community.

Indeed, looking at current community interventions, they find great limitations. (See graph below.)

They continue, advocating a bigger approach: “We need larger studies at country or state levels to prove that these interventions have statistically meaningful results with regard to suicide rates.”

Christensen et al. emphasize the potential of technology. They see technology as a way to connect with people (for example, “Digital footprints left on Twitter can be examined in real time using machine learning”) but also as a way to offer real-time interventions (like the peer support of Facebook, or an app immediately useable by someone at risk).

How to make these ideas into more of a reality? They suggest large-scale experimentation (like at a national level), and they suggest robust support from government.

Is this agenda too big? “The biggest risk in suicide research is that we simply continue the approach taken over the last few decades. Suicide rates are potentially reducible worldwide, but we need a new ambitious approach combining technology with trials on a scale that has not been seen before, together with the realization that suicide prevention research must change.”

My final thought: this is a well-argued commentary and worthy of consideration. The opening statistic – that suicide rates haven’t declined in the last decade across the West – is extraordinary and unacceptable. I’m bullish on technology and appreciate the argument about big data; I’m also mindful of the fact that when we aren’t sure what to do, people often float the potential of technology.

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