Addressing Mental Illness Biases Should Start Early in Training

Heidi Combs, M.D., M.S., a highly accomplished medical educator, points out that psychiatric training of medical students who go into primary care and other medical specialties can be a powerful tool to addressing the stigma associated with mental illness. —Jürgen Unützer, M.D., M.P.H.

For just a moment, I want you to pretend that you have been diagnosed with cancer. Would you tell your colleagues? I would imagine most of you would.

Now pretend you have been diagnosed with depression. Would you tell your colleagues? According to available research, the answer is probably not. Studies indicate that physicians suffer from depression at a rate significantly higher than those in other professions. Moreover, physicians attempt and complete suicide at rates significantly higher than the general population. Why wouldn’t a physician seek help?

Social stigma is a powerful force that shapes all of us, including those of us in the field of medicine. Many believe that mental illness is within the control of the individual and can be fixed with attitudinal and behavioral changes. Others consider mental illness a kind of character flaw. Studies show that the stigma of mental illness leads directly to our inclination to punish or discriminate against those with mental illness. Physicians are not immune from these attitudes.

In the early phases of medical training, depression is often perceived as a sign of personal weakness. A study by Wimsatt and colleagues found that among medical students who reported a previous depression diagnosis, most indicated they would be embarrassed if they were depressed and classmates knew. Many felt revealing their depression could negatively affect their professional advancement or cause them to be devalued. Interestingly, students with no prior depression associated depression and depressed individuals with inferior functioning and performance. Studies have found medical students also have negative beliefs about patients with other mental illnesses, including substance use and schizophrenia.

Stigma toward mental illness doesn’t end in medical school. Given that most patients receive mental health care from a family practitioner, the negative impact of existing stigma could be significant. Studies looking at general practitioners’ attitudes toward patients with mental illness compared with those without have found the most positive attitudes were held toward patients without a diagnosis of mental illness. Negative attitudes may be contributory to the physical health disparity between patients with comorbid mental illness.

Although the data are mixed, providers who work with patients with mental illness are also prone to stigmatizing patients. How can we expect better of other physicians if psychiatrists themselves struggle with stigmatizing these patients? The key may lie in focusing attention early in medical education.

Education has been found to be an effective approach toward reduction of stigma. As clerkship director, I emphasize to medical students the importance of appreciating the challenges faced by people with mental illness and the inspiring resilience of these individuals. I want my students to understand the suffering associated with mental illness as well as the person behind the diagnosis as a way to reduce stigma.

A contributor to the stigma is the perceived unpredictability of mental illness. This is anxiety provoking and can engender negative feelings toward the patient and their prognosis. Another factor is the impotence that trainees can feel about their inability to “fix” or “cure” a patient with a severe mental illness. This feels like failure. The bias that patients are in control of their experience and could “pull themselves up by their bootstraps” can result in students’ feeling judgmental toward patients.

I find it’s helpful to put mental illness in perspective. Patients with diabetes, cancer, heart disease, rheumatoid arthritis, and so on fail treatment, yet somehow it’s easier to ascribe this to the illness rather than the individual struggling with the illness. Helping students to understand this bias can allow them to develop a different attitude toward patients with mental illness and can reduce stigma.

Finally, helping students to see the person behind the illness can be very powerful. We promote the progression of students from focusing on the symptoms that patients are exhibiting to connecting with the people behind the symptoms. This allows them to understand their suffering and promotes empathic attunement. I feel I have succeeded when my students reflect on how they feel about patients and how mental illness has impacted their patients’ lives.

Efforts to reduce the stigma associated with mental health early in medical education can have a powerful effect downstream, particularly for those students who go on to practice in primary care, as most of my students do. Greater empathy for mental health can shape the attitude of primary care physicians as well as their practice. By starting mental health treatment in primary care, physicians send a strong message to their patients that mental health is part of overall health and that they are in the right place to get help.

As medical students move through training and become the next generation of physicians, we should aim to reduce stigma toward mental illness, amplify empathy and understanding, and ultimately provide better care for persons with mental illness. ■