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Stigma of Mental Illness Continues to Impede Early Diagnosis and Treatment of Affective Illness in the United States

ABSTRACT

Social stigma continues to impede the early diagnosis, specialist care referral, evidence-based treatment, and funding parity of mental illness.
Health care professionals, including many mental health providers, mirror prejudicial attitudes about the unpredictability and unmanageably of psychotic disorders, and the willfulness of addictive illnesses.
Stigmatization delays or preempts altogether care seeking among the mentally ill, and engenders ineffectual care of treatable conditions whose annual economic burden in established market economies is 15% of the overall burden of disease, more than the combined disease burden of all cancers.
In the United States alone, fewer than 30% of persons with psychiatric illness seek care and more than 40% of those who seek treatment receive sub-therapeutic care. Social stigma of mental illness is the preeminent impediment to care seeking.
General practitioners are uniquely positioned to screen for mental illness and to offer specialty referral. However, in the United States primary care providers fail to detect approximately 50% of all cases of depression. Similarly in the United States, nearly one-third of co-morbid mood and anxiety disorders that present at primary care and obstetric settings go undetected or are misdiagnosed, and primary care providers significantly under-utilize evidence-based treatment.
Similarly, psychiatric specialist practitioners lacking advanced sub-specialty expertise fare only marginally better in the early diagnosis and effective treatment of some mental illnesses, as for example bipolar disorder, a chronic and devastating condition which afflicts nearly 2 million Americans, or about 1% of the population age 18 years and older in any given year illnesses with a lifetime prevalence of attempted suicide of 25-50%.

A 70% initial misdiagnosis rate for bipolar illness among psychiatric care providers has remained essentially stable in the decade preceding 2004, as has a staggering 10 years average delay among one third of bipolar patients between first presenting for care and proper diagnosis of the condition, a disparity that one would har

dly imagine tolerated in the management of cardiac illness, or diabetes, or cancer.
Curiously, anti-stigma education alone has been shown to have the counter-intuitive result of encouraging further stigmatization and social isolation of the mentally ill, whereas education combined with increased exposure to individuals with mental illness increases tolerance as it is much harder to disregard an illness that has a face and a name.

Barriers to Mental Healthcare Delivery

The unwell mind, rationalized by medical theory, codified by the DSM, and managed with ever-refined symptom-specific molecules, continues to unsettle the general public and engender prejudicial discrimination among medical practitioners who either knowingly, or careless and unaware, deny illnesses of the brain and of the mind the same non-judgmental regard that medical custom, medical ethics, and current practice afford maladies of the flesh.
Despite an abundance of evidence-based interventions (1), the vast majority of people worldwide who are afflicted with psychiatric illness do not seek treatment (2), and many, if not most who do seek treatment will fail to receive adequate care (3) such that the available knowledge to address a particular diagnosis is grossly at odds with treatments that actually are administered to the psychiatric populace within the United States alone (4), a country that in several significant regards rightly boasts the preeminent medical community on the globe (5). Several factors, including the socially congruent reluctance of patients to recognize and acknowledge emotional disequilibrium (6-8), the limited professional training of non-psychiatric specialty practitioners to identify and address prodromal and clinical mental illness (9), and not least, the financial disincentive among political and financial stakeholders across the business landscape of free market medicine to heed good science and sound business practice. This associates preventive and remunerative treatment of psychiatric illness with increased economic productivity and improved outcomes in the prevention and care of physical, which is to say “non-psychiatric” illness (10).
Borne by fear and ignorance, and not unlike the shackle of individual mind and communal spirit that vilified pre-modern victims of medical scourges that now are routinely and with clinical disinterest rendered inconsequential in clinics throughout this country, fear borne of ignorance engenders stigmatization of mental illness. It encourages denial among the mentally ill and many who are committed to their best interest (11); it unduly cautions victims of mental illness against seeking and abiding proven treatments (12,13); and it discourages well-intended and otherwise highly-qualified practitioners from addressing a debilitating medical condition with clients who may have no other realistic point of contact with the medical establishment, than for example, a primary care provider.

Stigmatization of Mental Illness
The Oxford-Unabridged Dictionary defines “stigma” as a mark of “infamy, disgrace, or reproach”; in Middle English -- a “brand”; derived from Latin -- “tattoo, indicating slave or criminal status”; originating ultimately from stizein, the Greek word for “a recognizable sign made by burning or cutting a part of the skin of a less valued member of society with an aim of distinguishing him/her from the rest of the members” (14).
With the advancement of Christianity, the word stigmata, through a most ironic derivation (i.e. the physical disfigurement of one who was to be emulated rather than shunned, someone in the Biblical account who shunned no one), nonetheless came to reference a physical condition, an overt recognizable mark or disfigurement, as the blisters on the palms of the hands and feet -- the “Christ’s spot” (15,16).
Nathaniel Hawthorne’s The Scarlet Letter (17) is a cautionary tale for modern readers of society’s lingering propensity, perhaps indeed an inalienable compulsion to “mark” the social pariah, in the case of Hester Prinn quite literally a scarlet insignia inviting scorn for her divorce from normative morality:

But Hester Prynne, with a mind of native courage and activity, and for so long a period not merely estranged, but outlawed, from society, had habituated herself to such latitude of speculation as was altogether foreign to the clergyman. She had wandered, without rule or guidance, in a moral wilderness. . . . The scarlet letter was her passport into regions where other women dared not tread. Shame, Despair, Solitude! These had been her teachers,—stern and wild ones,—and they had made her strong, but taught her much amiss.

Second World War Jews not only were tattooed with serial numbers, but also were made to wear yellow armbands to identify their devalued heritage and social status (18). Within the Nazi concentration camps, homosexual Jews additionally were marked with pink armbands to signify their undesirable sexual identity (19). Countless similar examples litter the historical record of human existence from the seqer-ankh of ancient Egypt (20), to punishments for adultery and other challenges to Sharia law that still are observed in parts of the Arab world (21).
Stigmatization of the mentally ill continues a long history of selective isolation of persons whom society considers flawed by a discernable characteristic of physical appearance or behavior, characteristics curiously that may be celebrated in other social settings (22,23). Stigmatization deprives victims of mental illness their full measure of human dignity and participation in wider society (13,24) by undermining social support and compromising opportunity for treatment. And it does so by individual and institutional discrimination resulting from misconceptions (25), prejudicial stereotypes (26) and negative public and professional attitudes about mental illness (27).
Widely shared prejudicial attitudes about schizophrenia, alcoholism and other substance dependence disorders continue to stigmatize victims of those illnesses (28). And though such negative attitudes may be somewhat less widely held by psychiatric care providers, studies indicate significant negativism among health care professionals, including many with advanced training in the care of psychiatric illness (29-32).
Many among the general public assume that persons with psychotic disorders are unpredictable and incapable of being managed, even by the best efforts of the health care system, and therefore are considered a threat to the social order and to public safety (33). Persons suffering from substance abuse/dependence disorders suffer the additional widely held presumption, shared as well by many who provide treatment to this client population, that patients with these diagnoses, in whole or in part, whether for lack of character, or willpower, or basic social skills to cope with the routine challenges of adult life have brought affliction upon themselves (2,13,34).
Society encourages and reinforces stigmatization through a host of mechanisms. The film media, whether unwitting, or knowingly feeding, and profiting from the societal compulsion to stereotype and ostracize selected groups, encourages stigmatization by the dramatization of psychiatric illness through distorted and exaggerated (35) and thereby presumably more “interesting” and salable depictions of mental illness (36). Print media similarly select as featured coverage psychiatric incidents that reinforce the most egregious, the most titillating, and ultimately, the most marketable product for their business (35), yet also the most damaging to the image and overall understanding of psychiatric illness. Public judgment is thereby directed subjectively at the symptoms of mental illness, magnifying and overemphasizing the disparity between normative behavior and the aberrant actions of the mentally ill, inciting the very fear and prejudice that reinforces stigmatization of persons who have scant opportunity to challenge neither the veracity of the depictions nor the morality of the process (37). Entertainment television exerts a pernicious influence on children, who develop an understanding of the world unthinkingly from their social context, which increasingly includes passive participation in confabulated realities transmitted through television and computer screens that portray stigmatizing constructs of mental illness (16,24,38-40).
Stigmatization of mental illness may be understood to confound care of the mentally ill by two distinct processes. First and foremost, the stigma of mental illness prevents care seeking among the psychiatric population; and secondly, it interferes with the rational treatment of mental illness when mental illness when it presents to the medical community, often resulting in prejudicial treatment and ineffectual care.

Ill-Fated Mental Illness

Several investigators have determined that persons who suffer from psychiatric disorders do not seek treatment in an effort, typically a futile effort, to avoid being “labeled” with a condition that is understood to result in devaluation, social distance, or outright rejection, and which may have a powerfully negative influence on a person’s overall quality of life (38,41,42,43 (Sokratis & Stevens, 2004). Stigmatization contaminates equally effectively from the center outward as evidenced from the personal accounts of persona afflicted with mental illness who have internalized social devaluation, giving credence to societal misperception of their condition as “other than purely medical” affliction, and believing they are wholly or in part to blame for their condition, they therefore are undeserving of assistance or should struggle alone, utilizing whatever limited personal resources at their disposal to overcome the “character flaw” that is the root cause of their distress.
Societal perception of depression and the overall efficacy of the medical industry to treat the disease exemplify the corrosive influence of stigmatization. Employing a standardized epidemiological assessment, disability-adjusted life year (DALY), the Global Burden of Disease Study (GBD) determined that Unipolar Depression is the fourth leading specific cause of global illness (44). The financial burden of depression in the United States alone is estimated in excess of $40 billion annually (45). The toll in human suffering is incalculable. Recent studies indicate general health care costs are between 50 to 100 percent higher among those who suffer from depression and anxiety disorders compared with those who do not and the increased costs have been linked to a disproportionately higher utilization of primary care and emergency services rather than specialty psychiatric health care (46). The burden of mental illness on productivity in the United States and throughout the world has long been underestimated. Data from the Global Burden of Disease study conducted by the World Health Organization, the World Bank, and Harvard University reveal that in established market economies such as the United States, mental illness, including suicide, accounts for over 15 percent of the burden of disease, more than the disease burden caused by all cancers (47).
Multiple barriers to effective psychiatric treatment have been studied. The Epidemiologic Catchment Area Study (48) and the National Comorbidity Survey (49), nationally representative mental health surveys that employ fully structured research diagnostic interviews to assess the prevalence and comorbidities of DSM-III-R disorders, indicate that fewer than 30 percent of persons with psychiatric disorders seek care, and more than 40 percent of those who pursue treatment receive sub-therapeutic care. Corrigan (12) posits stigma as the major barrier to seeking or full participation in psychiatric health care services. Other researchers concur, noting higher levels of guilt and shame in families of individuals who suffer from psychiatric or substance dependence disorders were associated with longer treatment delays and less family collaboration, despite overwhelming evidence of significantly improved outcomes with family involvement. Other studies demonstrate similarly improved patient outcomes associated with minimal delay between the onset of psychiatric symptoms and the inception of treatment (50,51).
Narushima and Robinson (52) demonstrate the imperative of early psycho-pharmacotherapy in the recovery of post-stroke depression, reporting a significant improvement in the performance of activities of daily living (ADL) among patients who began antidepressants within thirty days post-stroke as compared with patients who started antidepressant therapy later than one month post-stroke. The ADL recovery and remission rates of post-stroke major depression associated with early antidepressant treatment were sustained throughout the two-year study period (52). Depression occurs in 40-60% of people who have suffered heart attack, and those with major depression have a 3-4 times greater risk of dying within the subsequent six months (53).

Primary Care – A Failed Psychiatric Care Delivery Paradigm

The World Health Organization defines primary care as “essential health care based on practical, scientifically sound, and socially acceptable methods and technology made universally accessible to individuals and their families” (54). In North America and Australia, the majority of psychiatrically ill persons who attempt to engage in “essential health care” treatment do so through primary care practices. And African-American utilization of primary care for mental health complaints is disproportionately higher than Caucasian utilization (55). Further research would enumerate the unique barriers to care among minority populations in the United States (54,56). Yet why the vast majority of the mentally ill seek initial treatment at primary care facilities, and more significant, why primary care providers evince a diminished rate of specialty referral for psychiatric presentations as compared with other specialty illnesses, is unaddressed in the literature and poorly understood. Possible explanations include 1.) greater patient familiarity and comfort with a general practitioner; 2.) a compelling motivation to avoid the stigmatization of being labeled mentally ill; 3.) the social and medical industry expectation that primary care providers “should care for the emotional needs of their patients” (54); 4.) the presumed adequacy of academic background and clinical training among many general practitioners in the treatment of psychiatric disorders, even regarding more complicated cases that practitioners with advanced training would deem outside the scope of practice of the generalist practitioner; and 5.) prolonged delays for psychiatric consultation endemic to rural or remote settings (46,54-56).
Although primary care professionals play a pivotal role in recognizing and managing patients with psychiatric illness, they often provide neither accurate diagnosis, nor adequate documentation, nor effective treatment of mental illness (54). The United States Preventative Services Task Force reported that depression was undetected in approximately 50 percent of all cases in primary care settings (46). Other researchers suggest that up to one-third of patients who present to primary care or obstetric clinics with somatic complaints have co-morbid mood or anxiety disorders that go undetected or misdiagnosed with subsequent detrimental consequences, including under-medication or mis-medication (57-59).

Evidence Be Damned

Research establishes that even when psychiatric disorders are detected, primary care providers significantly underutilize evidence-based treatment (60,61), relying instead on improper use of benzodiazepines (62), pharmacotherapy for mild conditions best managed with psychodynamic interventions, pharmacotherapy alone when best treatment outcome studies indicate combined medication and psychodynamic therapy, and sub-therapeutic dosing and insufficient duration of psychotropic medication, all of which contribute to unrelieved symptomology, in particular physical and emotional distress, occupational and educational impairment, interpersonal and inter-relational dysfunction, and suicide (46,56,60,61,63-65 (van Os, van der Brink, Tiemens, von der Meer & Ormel, 2004), risking potentially dire consequences not only for the recipient of inadequate care, but also for their dependent minors and other family members (58).

Blame the Victim

A family history of suicide and a personal history of attempted suicide stigmatize persons with mental illness who otherwise would be motivated to recognize symptoms of the condition and seek treatment early in the course of their illness. Familial survivors inherit the stigma, impeding their recovery from the loss, and diminishing their prospects for better managing the consequences of an illness with demonstrated heritability (66,67).
Stigmatization is the primary instigation for hostility directed against a family member afflicted with mental illness (67). The mentally ill family member is at greater risk of ineffective treatment or failed recovery if in hopelessness, the family considers the afflicted member a threat to the family’s freedom to live a “normal” life. These feelings inevitably lead to increased social isolation, and particular family members may “unconsciously” wish for, or accept suicide of the ill member as the best outcome in the face of a seemingly impossible circumstance (67).

Punish the Victim
This sense of fatalism has been studied among health care providers who treat patients with psychiatric disorders, with some research suggesting that failure to recognize suicidal gesture and suicidal ideation is common among professionals who themselves are emotionally vulnerable to thoughts of suicide, or conversely to those who are well enough, yet emotionally disengaged, and who also may “unconsciously” accept their patient’s death wish as an acceptable solution to a pernicious illness (68).
Repeated longstanding documentation establishes suicide as the primary cause of premature death in persons with schizophrenia. A 1992 survey of individuals with schizophrenia and bipolar disorder reported that 19 percent had threatened or attempted suicide within the previous year (69). The Epidemiologic Catchment Area Study reported 28 percent of individuals with schizophrenia having attempted suicide (70 - Robins, 1991). Estimates of the completed suicide in schizophrenia range between 10 to 13 percent (71), a range that is in excess of four times normalized average estimates from studies between 1913 and 1960, inclusive, indicating that suicide rates among this psychiatric population have risen dramatically since, and quite likely consequent to, deinstitutionalization (72).
Psychiatric illness, especially depressive disorders and multiple associated risk factors including deteriorating physical health and other end-of-life stressors also markedly increase the risk of suicide among the elderly (73 - NIMH Website, 2006). In a study of suicide among elder populations in the United States, Great Britain, and Finland, more than 70 percent of subjects who committed suicide had been seen by primary care providers within 30 days of their deaths. And though anxiety disorders were diagnosed infrequently in this population, benzodiazepines were among the most commonly prescribed classes of medications across study groups, suggesting the global scope of the deficit in properly treating psychiatric illness (61).
A University of South Florida comparison of elderly married men who committed suicide with elderly men who had committed murder-suicide documents clinical evidence of depressive symptomatology among not less than 50 percent of the study subjects in the weeks prior to their deaths (74). Postmortem toxicological examination furthermore confirmed the presence of benzodiazapine molecules, benzodazepine-derivatives and alcohol in approximately 15 percent of each subject group. Either substance is known to lower inhibitions, or paradoxically to cause agitation in elderly patients, adverse reactions that isolated or in combination are known risk factors for suicide. Toxicology tests failed however to provide evidence that antidepressants or psychotropic medications had been administered, suggesting a pattern of hesitation to refer to specialty care, despite a longstanding and well documented tradition among psychiatric care providers educating general practitioners in the recognition, initial management, and referral protocols for proper care of psychiatric illnesses. Of equal concern is the popular perception of anxiolytics as a more benign and less stigmatizing treatments than antidepressant medication.
By the onset of World War II, in an effort to address the shortage of psychiatric care for U.S. military personnel, and throughout the late 1960s, the American Psychiatric Association mandated basic education in psychiatry for medical practitioners and ongoing training for specialty psychiatric care providers, such that by the end of the 20th century continuing education requirements for primary care physicians was established as an incontrovertible part of the mission equally for general medical health care institution as for mental health care specialists. An obvious but generally overlooked practical reality given the organization of most primary care settings, is that the practice of psychiatry within a primary care model is grossly incongruent with the industry standard fifty-minute psychiatric assessment (54,63). In other words, despite the laudable intentions and best institutional effort of primary care facilities and family care practitioners, neither is well suited to the unique clinical challenge of addressing illnesses that demand not only specialized diagnostic attention, but also and equally significant, require specialized treatments with proactive follow-up care.

Reconsidering the Paradigm

This predicament is not unlike the challenge, widely recognized and routinely abided among general practitioners of the imperative to identify clinical presentations that demand specialty intervention, and the equivalent ethical and legal expectation of the primary care provider neither to conduct specialty diagnostics nor to perform specialized treatments post-diagnosis. “Just as you wouldn’t want a primary care physician to do coronary bypass surgery, you wouldn’t want one to treat severe or complicated depression” (75). One may have to admit the impracticality, and perhaps as well the significant risk of some clients doing without psychiatric care altogether within the current medical care delivery system in discouraging primary care practitioners from identifying and treating mild depression, even though one should acknowledge that the criteria for mild depression are poorly differentiated from clinical presentations of more severe forms of the illness. Yet precisely for this reason does reliance on non-specialist differentiation only further beg the question whether primary care settings are appropriate venues or can be reconfigured as appropriate venues for treating psychiatric disorders.
Perhaps a more realistic standard of practice should be considered for non-psychiatric care providers, one that requires training in facilitative provider-patient communication together with routine incorporation of venue-appropriate screening and early detection protocols for psychiatric disorders with the understanding that the purpose, and indeed the requirement of discerning these disorders by any such method and standard of practice is to refer the client to specialty care (46,54,65 (van Os, et al., 2004),76).
Over the past decade, mental health practitioners and scientific researchers have been instrumental in educating the primary care industry and related professions about psychiatric symptomology and diagnostics with the mission of reducing the stigma attached to mental illness and improving the quality of overall care that is administered to psychiatric clients who present at general practice settings with medical complaints as well as those seeking psychiatric care directly. Consequently, primary care providers are faced with a greater degree of responsibility in front-line recognition, diagnosis, coordination of treatment, and referral of psychiatric illness to specialty trained clinicians. The World Health Organization does not support the assumption of sole responsibility by primary care providers in the identification and treatment of psychiatric illnesses and is actively developing referral protocols for primary clinicians as well as secondary and tertiary care providers (77). A dermatologist, a gastroenterologist, a gynocologist, an oncologist, an endocrinologist, a pulmonologist or a cardiologist, equally for example, according to an evolving World Health Organization standard of care should be both qualified and expected to recognize psychiatric symptoms in their patients and refer those clients for specialized care. Despite a burgeoning literature about the consequences of stigmatizing mental illness and an expanding awareness of the relationship between stigma or any other mechanism of discrimination and the willingness of the afflicted to seek or to accept care, research continues to document reluctance among the mentally ill to pursue treatment, and near equivalent reluctance among non-psychiatric specialist providers to circumscribe their role in mental health care to the close monitoring and early referral of suspected psychiatric disorders to specialty care (13,46,78).

Bipolar Medical Malfeasance

Treatment of bipolar illness at primary care settings, and for that matter, by practitioners lacking advanced sub-specialty diagnosis and medical management training regardless the care delivery venue, illustrates the pernicious influence on the overall quality of care for psychiatric client populations when treatment for these diagnoses is diverted via stigmatization to non-“psychiatric” venues or to non-specialist psychiatric care providers.
Prevalence estimates of bipolar illness in western populations range between one and nearly seven percent. Early estimates of more than 2 million American adults with the illness, or about 1 percent of the population age 18 and older in any given year (79,80), were based on screening methods that may have been insufficiently sensitive to refute more recent prevalence estimates. A Mental Health Resource Center report, published in 2000 by the National Mental Health Association estimated 2.3 million Americans have bipolar disorder (80 - NMHA, 2000). Additional studies of a broader spectrum of bipolar illness establish a lifetime prevalence of between 2.6 and 6.5 percent (82). Nearly 10 percent of patients screened at a general medicine clinic in an urban area were found to have a history of bipolar disorder, according to a 2005 study in the Journal of the American Medical Association (83).
Bipolar Illness is not a benign disorder. The lifetime prevalence of attempted suicide among patients diagnosed with bipolar illness is 25–50% of patients with bipolar disorder attempt suicide during their lifetimes (84,85). The illness is chronic and devastating (86), and according to the World Health Organization, is the sixth leading cause of disability-adjusted life years among people aged 15–44 years. Misdiagnosis and inadequate or inappropriate treatment of bipolar illness are potentially life-threatening (87). Yet national surveys (88) and recent studies (89) have demonstrated that 48% of subjects in a National Depressive and Manic Depressive Association (NDMDA) study reported consulting with three or more mental health professionals before receiving a diagnosis of bipolar illness, and that on average it took eight years of clinical treatment before the diagnosis of bipolar illness was made correctly among subjects in all clinical settings. In a related study, by examining the charts of inpatients prospectively diagnosed with bipolar or schizoaffective disorder by a psychiatrist with expertise in affective disorders, researchers demonstrated that 40% of study subjects previously misdiagnosed as having unipolar depression were diagnosed with bipolar illness.
The rate of misdiagnosis has remained essentially stable in the decade prior to 2004 according to two studies that indicate a nearly 70 percent rate of initial misdiagnosis of patients with bipolar illness, with more than one third reporting a delay of 10 or more years between first seeking treatment and accurate diagnosis of bipolar illness (88,90).
One is reluctant to concede that the medical community, or indeed society would tolerate a comparable disparity, more than a decade extant as documented, between misdiagnosis/misadministration of care for instance, of patients with cardiovascular disease, diabetes mellitus II or any number of treatable forms of cancer. Yet the literature is more replete with explanations of the technical/systemic factors related to the phenomenon – poor or uneven patient self-reported histories, diagnostic complexity vis-à-vis psychiatric comorbidity, complexity of medical comorbidities and medical rule-outs, and misdiagnosis consequent to symptom lag/periodicity (91-94), than with considerations of societal factors, including the stigma of psychiatric illness (95) that contribute to the de facto relegation of this particular field of specialty medicine to primary/non-specialty care.

Anti-Stigma Re-education and Recommendations

Anti-stigma programs are informed by the widely-held presumption of the positive relation between disseminating theories of mental illness that emphasize purely biological causes of psychiatric disorders, and social acceptance of the mentally ill. Angermeyer (2) and Brockelman (38) conclude from independent study results however, that this strategy has promoted rejection of the mentally ill and has intensified the public’s interest in institutional responses to mental illness that tend to segregate persons with a psychiatric label from the public at large. The research demonstrated nonetheless, that much like the enhanced tolerance that results from increased exposure for instance, across racial groups, personal stories tend to be a compelling adjunct to stand-alone facts about mental illness. Education regarding the causes, course, and treatment outcomes, separated from exposure to the living human face of mental suffering eventuates, rather ironically a diminished tolerance for mental illness and increased public impetus to distance itself from the mentally ill (2,38,96). “While facts about mental illness are valuable, it is more difficult to disregard a name and a face” (38).
Additional measures for consideration should include: 1.) on-site psychiatric specialty services provided alongside other specialty services at general practice locations; 2.) psychiatric specialty screening and referral services at K-12 and post-secondary educational institutions; 3.) establishment as current standard of care the referral to a psychiatric MD or a psychiatric Nurse Practitioner, to rule out biological etiology and initiate early psychopharmacologic intervention as medically indicated for all mental health presentations; 4.) mandatory psychiatric MD or psychiatric NP assessment and periodic review of non-the medical treatment of mental illness, care provided by PhD psychologists, MSWs, LCSWs, licensed marriage and family counselors, and drug and alcohol addiction counselors; 5.) eventual establishment as optimal standard of care the combined psychodynamic and psychotropic treatment by a single provider, rather than the current market driven model of brief intermittent medication management and segregated psychodynamic care, often at a disparate location.

Reconditioning the Human Condition

The propensity of the human animal to stigmatize a minority of its own is endemic throughout the written record of humankind. Theorists of human group dynamics postulate furthermore, an inherent advantage to survival of the species, whether constructed and cognizant, or subconscious, in delimiting “maladaptive” diversity through stigmatization. To the extent group behavior theorists have described an unalterable fact of human intercourse (97) rather than an episodic situation-specific occurrence, which regarding the stigmatization of mental illness in contemporary Western culture one might expect to resolve with a well-considered societal intervention, stigmatization threatens a perpetual resurgence in medicine as in other professional venues, a reality that whatever the biophysical or social dynamic impetus will necessitate vigilant, ongoing monitoring (24,97-100).
A silver lining in this otherwise dire acknowledgement of homo sapiens as a social animal, is that any individual’s susceptibility to the compulsion to participate in stigmatization shifts and changes as one’s knowledge and personal experience with the injustice of the process grows (101,102). And although humankind cannot recast the template of its social identity, modern Man does arguably boast abundant, perhaps as well sufficient resources of intellect, spirit and technical accomplishment to remain vigilant at checking primordial impulses that we must continue to acknowledge are at odds with an evolving world increasingly informed by rationalism and compassion.

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38. Brockelman KF, Olney MJ, Williams SS. Social distance in response to psychiatric labels. Int J Rehabil Res 2002;25(4):253-59.

39. McKay D. Stigmatising pharmaceutical advertisements. Br J Psychiatry 2000;177:467-68.

40. Wilson C, Nairn R, Caverdale J, Panapa A. (2000). How mental illness is portrayed in children’s television: a prospective study. Br J Psychiatry 2000;176:440-43.

41. Cooper AE, Corrigan PW, Watson, AC. Mental illness stigma and care seeking. J Nerv Ment Dis 2003;191(5):339-41.

42. Graf J, Lauber C, Nordt C, Rüesch P, Meyer PC, Rössler W. Perceived stigmatization of mentally ill people and its consequences for the quality of life in a Swiss population. J Nerv Ment Dis 2004;192(8):542-47.

43. [Sokratis & Stevens to be inserted here]

44. Murray CJ, Lopez AD. Global mortality, disability, and the contribution of risk factors: Global Burden of Disease Study. Lancet 1997;349:1436-42.

45. Stewart WF, Ricci JA, Chee E, Hahn S, Morganstein D. Cost of lost productive work time among US workers with depression. JAMA 2003;289:3135-44.

46. Robinson DW, Geske JA, Prest LA, Barnacle, R. Depression treatment in primary care. J Am Board Fam Pract 2005;18(2):79-86.

47. NIMH Website (2008). Available from: URL:http://www.nimh.nih.gov/health/statistics/index.shtml

48. United States Department of Health and Human Services. Epidemiologic Catchment Area Study. National Institute of Mental Health; 1980-1985.

49. National Comorbidity Survey: Baseline (NCS-1). Department of Health Care Policy, Harvard Medical School., Institute for Social Research, University of Michigan., Section on Developmental Genetic Epidemiology, National Institute of Mental Health; 1990-1993.

50. Kaas MJ, Lee S, Peitzman C. Barriers to collaboration between mental health professionals and families in the care of persons with serious mental illness. Issues Ment Health Nurs 2003;24:741-56.

51. Okazaki S. Treatment delay among Asian-American patients with severe mental illness. Am J Orthopsychiatry 2000;70(i):58-64.

52. Narushima K, Robinson RG. The effect of early versus late antidepressant treatment on physical impairment associated with post-stroke depression: is there a time-related therapeutic window? J Nerv Ment Dis 2003;191(10):645-52.

53. NIMH Website (2007). Available from: URL:http://www.nimh.nih.gov/nimhhome/index.cfm

54. Hodges B, Inch C, Silver I. Improving the psychiatric knowledge, skills, and attitudes of primary care physicians, 1950-2000: A review. Am J Psychiatry 2001;158:1579-86.

55. Snowden LR, Pingitore, D. Frequency and scope of mental health service delivery to African Americans in primary care. Ment Health Serv Res 2002;4(3):123-30.

56. McManus P, Mant A, Mitchell P, Britt H, Dudley J. Use of antidepressants by general practitioners and psychiatrists in Australia. Austral and New Zealand J Psychiatry 2003;37(2):184-89.

57. Culpepper, L. Generalized anxiety disorder in primary care: emerging issues in management and treatment. J Clin Psychiatry 2002;63(8):35-42.

58. Smith MV, Rosenheck RA, Cavaleri MA, Howell HB, Poschman K, Yonkers, KA. Screening for and detection of depression, panic disorder, and PTSD in public-sector obstetric clinics. Psychiatr Serv 2004;55(4):407-14.

59. Splete H. Specialists more likely to spot ADHD co-morbidity. Clin Psychiatry News 2001;29(7):1.

60. Unutzer J. (2001). Two-year effects of quality improvement programs on medication management for depression. Arch Gen Psychiatry 2001;58(10):935-42.

61. Yeates C, Lyness JM, Duberstein P, Cox C, Seidlitz L, DiGiorgio A, et al. Completed suicide among older patients in primary care practices: a controlled study. J Am Geriatr So 2000;48(1):23-9.

62. Kisely S, Linden M, Bellantuono C, Simon G, Jones J. Why are patients prescribed psychotropic drugs by general practitioners? Results of an international study. Psychol Med 2000;30(5):1217-25.

63. Roy-Byrne PP, Wagner A. Primary care perspectives on generalized anxiety disorder. J Clin Psychiatry 2004;65(13):20-26.

64. Schwenk TL, Evans DL, Laden, SK. (2004). Treatment outcome and physician-patient communication in primary care patients with chronic, recurrent depression. Am J Psychiatry 2004;161(10):1892-1901.

65. van Os, van der Brink, Tiemens, von der Meer & Ormel, 2004 – (need this citation)

66. Eagles JM, Dawn PC, Begg A, Naji SA. Suicide prevention: a study of a patient’s view. Br J Psychiatry 2003;182:261-65.

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69. Steinwachs DM, et al. Family perspectives on meeting the needs for care of severely mentally ill relatives: a national survey. School of Public Hygiene and Public Health, Johns Hopkins University; 1992.

70. [Robins, 1991 here]

71. Caldwell C, Gottesman I. Schizophrenics kill themselves too: a review of risk factors for suicide. Schizophr Bull 1990;16:571-89.

72. Dinos S. Stevens S. Stigma: the feelings and experiences of 46 people with mental illness. Br J Psychiatry 2004;184:176-81.

73. [NIMH Website 2006 inserted here]

74. Moon M. Elderly suicide risk often missed in primary care. Clin Psychiatry News 2001;29(6):1-2.

75. For depression, the family doctor may be the first choice but not the best. [cited 2005 May 22, 2005] Available from: URL:www.healthyplace.com/unapro/depression/prescribing_antidepressants.asp.com

76. Mojtabai R. Diagnosing depression and prescribing antidepressants by primary care physicians: The impact of practice style variations. Ment Health Serv Res 2002;4(2):109-18.

77. World Health Organization (WHO). [cited 2006]. Available from: URL:http://www.who.int/en

78. Grace GD, Christenson RC. Mentally ill need us all. Clin Psychiatry News 2003;31(10):1-2.

79. Tiemans BG, Ormel J, Jenner JA, van der Meer K, Van Os TW, van der Brink RH, et al. Training primary-care physicians to recognize, diagnose and manage depression: does it improve patient outcomes? Psychol Med 1999;29(4):833-45.

80. McQuaid JR, Stein MB, Laffaye C, McCahill ME. Depression in a primary care clinic: the prevalence and impact of an unrecognized disorder. J Affect Disord1999;55:1-10.

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83. Amar K, Das M, Olfson M, Gameroff MJ, Pilowsky DJ, Blanco C, Feder A, et al. Screening for bipolar disorder in a primary care practice. JAMA 2005;293:956-63.

84. Jamison KR. Suicide and bipolar disorder. J Clin Psychiatry 2000;61 Suppl 9:47–51.

85. Simpson SG, Jamison, KR. (1999). The risk of suicide in patients with bipolar disorders. J Clin Psychiatry 1999;60 Suppl 2:53–6.

86. Goodwin GM. (1999). Prophylaxis of bipolar disorder: how and who should we treat in the long term? Europ Neuropsychopharmacol 1999;9:Suppl. 4:125–29.

87. Ghaemi SN, Ko JY, Goodwin FK. "Cade's disease" and beyond: misdiagnosis, antidepressant use, and a proposed definition for bipolar spectrum disorder. Can J Psychiatry 2002;47(2):125-34.

88. Lish JD, Dime-Meenan S, Whybrow PC, Price RA, Hirschfeld RM. The National Depressive and Manic-depressive Association (DMDA) survey of bipolar members. J Affect Disord 1994;31:281-94.

89. Ghaemi SN, Boiman EE, Goodwin FK. Diagnosing bipolar disorder and the effect of antidepressants: a naturalistic study. J Clin Psychiatry 2000;61:804–8.

90. Hirschfeld RM, Lewis L, Vornik LA. Perceptions and impact of bipolar disorder: how far have we really come? Results of the national depressive and manic-depressive association: 2000 survey of individuals with bipolar disorder. J Clin Psychiatry 2003;64:161-74.

91. Simon NM, Otto MW, Wisniewski SR, et al. Anxiety disorder comorbidity in bipolar disorder patients: data from the first 500 participants in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). Am J Psychiatry 2004;161:2222-29.

92. Baethge C, Baldessarini RJ, Khalsa HM, Hennen J, Salvatore P, Tohe M. Substance abuse in first-episode bipolar I disorder: indications for early intervention. Am J Psychiatry 2005;162:1008-10.

93. Goldberg JF, Harrow M, Whiteside JE. Risk for bipolar illness in patients initially hospitalized for unipolar depression. Am J Psychiatry 2001;158:1265-70.

94. Perlis RH, Miyahara, S, Marangell, LB, et al. Longterm implications of early onset in bipolar disorder: data from the first 1000 participants in the systematic treatment enhancement program for bipolar disorder (STEPBD). Biol Psychiatry 2004;55:875-81.

95. Hayward P, Bright JA. Stigma and mental illness: a review and critique. J Ment Health 1997;6:4.

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Authors

Joan M. Landino, PMHNP-BC; MSN Columbia University 2005, MS Forensic Science University of New Haven 2001, Integrated Psychiatric Services, Inc., North Haven, CT John M. Roy, PMHNP-BC; MSN Yale University 2006, MBA Yale School of Management 2001, Integrated Psychiatric Services, Inc., North Haven, CT Jane M. Buckley, PMHCNS-BC; MSN Columbia University 2000, Integrated Psychiatric Services, Inc., North Haven, CT

Please direct further communication to: Jane M. Buckley 100 Broadway North Haven, CT 06473 203.234-0365

First Published June 2009

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