Stigma of Mental Illness in Jordan

ABSTRACT

Background:   Local statistics in Jordan show that about 1.75 million people suffer from mental illnesses, which is equivalent to about 20% of the population ⁽¹⁴⁾.Mental health care and services in Jordan have greatly improved in quality and efficacy of management in the 21st century, although revolutions in psychiatry have not yet been able to reduce stigma.

Stigma is one of the risk factors leading to poor mental health outcome. It is responsible for the delay in seeking treatment, and reduces the likelihood of a mentally ill patient receiving adequate care. Clearly, the delay caused by stigmatization can have serious and dramatic results and effects. This study will discuss the stigma associated with mental illness, and its causes, results, and effects.

Objectives: The aim of the study is to identify and assess cases of mental health patients stigmatized after their first and second visits, as per the reports gathered from the Jordanian mental health care clinics' database.

Methods: All spontaneous reports of stigmatized mentally ill patients (2016-2017) related to delayed visitation, cessation of visits, noncompliance, and delayed improvement due to stigma were retrieved. A descriptive analysis was conducted using source, gender, age, and type of report, a retrospective cohort study using administrative healthcare data.

 The study will further identify the magnitude of this problem and the characteristics of the reactions and reviews, based on the current evidence. Therefore, attempts are made to answer the following questions: What are the clinical results and effects of stigma? Can stigma lead to increased duration of illness? Does stigma have an impact on life quality and socio-economic status?

Results:  From the mental health care clinics' database in Jordan, spontaneous reports of stigmatized patients (2016-2017) were assessed. These reports were related to delayed visitation, cessation of visits, non-compliance, and delayed improvement. Of the 115,616 patients with confirmed diagnosis (i.e., 6.6% of all patients in Jordan), 11,940 patients were assessed (10.32% of the 115,616), out of which 7639 were males (63.98% of 11,940) and 4301 females (36.02% of 11,940). With the overall stigma reporting frequency increasing over time for both cost-effectiveness and management and treatment, , which are associated with severely harming society, an analysis of the relative reporting ratios for delayed visit, cessation of visit, noncompliance, and delayed improvement ​​suggests that these adverse reactions were more frequently reported for mental patients. Of the total number of delayed visit, cessation of visit, noncompliance, and delayed improvement, it was found that 41.00%was due to stigma, 19.42% due to lack of insight, 13.58% due to financial problems, 12.83% due to side effects of medication, 9.34% due to improvement of previous symptom, and 3.83% due to lack of caregivers.

Conclusion: The present data suggest that stigma may be a cause for concern, especially in young patients. Hence, healthcare professionals should be vigilant about mental health care and provide psychological and pharmacological education in addition to activating the role of the crash team management. The government should also issue strict laws to protect stigmatized patients and enforce compulsory treatment in the event of delayed visit, cessation of visit, noncompliance, or refusing treatment against medical advice, regardless of the reason for refusal.

Keywords:  Stigma, Compliance, Relapse, Treatment.

RMS April 2020; 27(1): 10.12816/0055469

Introduction:

      Stigma is a broad and multi-faceted term which has been receiving increasing attention in psychiatric research and policy making. Stigma is a Greek word that refers to a type of marking or tattoo that was

burned into the skin of criminals, slaves, or traitors in order to identify them as morally bad people or outcasts. These marked persons were to be avoided, especially in public places. The common use of the word indicates shame or dishonor. In his book Stigma, Goffman defines the word as a feature that deeply distinguishes (1) “social definition”. Recent authors have used the term stigma in a wider sense that refers to the reaction of people or their attitudes and behaviors towards others.

   Today, the term stigma refers to any persistent trait of an individual or group that evokes negative or punitive responses. The diagnosis of mental illness comes with the additional burden of a negative label. Therefore, the quality and effectiveness of mental health treatments and services are negatively affected not only in Jordan but in many other places in the world. Compliance on medication and psychotherapy plays a vital role in psychological rehabilitation (2).

    Poor compliance on medication, psychotherapy, and psychosocial therapy among individuals with mental illnesses increases the likelihood of relapse and re-hospitalization (3, 4, and 5). Individuals with mental illnesses are stigmatized. A majority of those who visit mental health care clinics either do not utilize the services or do not fully adhere to treatment regimens because of stigma.

Facts you need to know:

*One in four people in the world suffers from mental illness (6), where in Jordan, about 1.75 million people suffer from mental illnesses, which equals to about 20% of the population (14).

* It is likely that we will all deal with mental illness at some point in time, whether in family members, colleagues, or ourselves.

* Stigmatizing affects everyone (stigmatizers or stigmatized). 

* People who have experienced mental illness suffer as much from other people’s responses and expectations as from the symptoms of the illness itself.

* Stigmatization has a long history and is a multicultural ubiquity (7).

Methods

      All spontaneous reports of stigmatized mentally ill patients (2016-2017) related to delayed visitation, cessation of visit, noncompliance, and delayed improvement due to stigma were retrieved. A descriptive analysis was conducted using source, gender, age, and type of report, a retrospective cohort study using administrative healthcare data.

 The study will further identify the magnitude of this problem and the characteristics of the reactions and reviews, based on the current evidence. Therefore, attempts are made to answer the following questions: What are the clinical results and effects of stigma? Can stigma lead to increased duration of illness? Does stigma have an impact on life quality and socio-economic status?

Results

     From the database of mental health care clinics in Jordan, spontaneous reports of stigmatized patients (2016-2017) related to delayed visit, cessation of visit, noncompliance, and delayed improvement were found. These reports included 115,616 patients with confirmed diagnosis (6.6% of the total patients in Jordan). We assessed 11.940 patients (10.32% of 115,616) out of which 7639 were males (63.98% of 11.940) and 4301 were females (36.02% of 11,940) (Tables I and II).With the overall stigma reporting frequency increasing over time for both cost-effectiveness and proper management and treatment which respectively, associated with severely harming society.

 The analysis of proportional reporting ratios for delayed visit, cessation of visit, noncompliance, and delayed improvement due to stigma values seems to indicate that these adverse reactions were more frequently reported for mental patients. Of the total number of delayed visit, cessation of visit, noncompliance, and delayed improvement, it was found that 41.00% was due to stigma, 19.42% due to lack of insight, 13.58% due to financial problems, 12.83% due to side effects of medication, 9.34% due to improvement of previous symptoms, and 3.83% due to lack of caregivers (Table III).

Table I: Distribution of patients by gender.

Table II: Distribution of patients by age.

Table III: Distribution of patients by reason of delayed visit, cessation of visit, noncompliance, and delayed improvement

Discussion

     If stigma is a delay factor in the search for, and sustainability of, treatment, it has been shown that specific measures to reduce stigma in a variety of mental illnesses can achieve highly positive and highly effective therapeutic progress. This will allow smoother integration of patients in the society where social barriers are reduced due to bias. However, the integration of stigma-coping strategies in clinical practice remains a challenge. Stigma is likely to lead to severe direct deficits and indirect economic effects.

Stigma reduction may be a cost-effective means of reducing risk relapse and poor outcome results by chronic exposure to the environments of stigma. In addition, this may result in significant gains in quality of life if all patients with mental illness routinely receive information about stigma and are taught to use simple strategies to increase resilience to negative environment and stigma.

It is clear that more efforts need to be made to identify interventions that will address the barriers to treatment and thus improve the quality of life of individuals suffering from mental illness.

     The fact that stigma is a global phenomenon and not just limited to Jordan, cannot be overlooked, because of its effect, the achievement of the therapist, the therapeutic outcome of the patient and the medical economy in general. The question arises whether the nature, results, and effects of stigma are similar in all mental disorders. Surprisingly, there is no clear and consistent evidence which states that stigma varies depending on the disorder, mostly because of the lack of research and studies on this subject. In general, it is said that stigma is related to disorders that show behavioral or intellectual disorders or what is contrary to social custom ⁽¹⁵⁾.

     In one study, 200 college students completed scales that gauged their beliefs on depression and schizophrenia. Specifically, they measured their perceptions of the relevant social norms and their preferred level of social distance from a person with schizophrenia or depression. The desired social bias measures were also completed. The study highlighted that the percentage of variance in the preferred social distance almost doubled when the perceived criteria was added to the beliefs on the disorder in the regression equation ⁽¹⁵⁾. Cognitive social norms are an important contribution to the social distance of an individual from those suffering from mental illnesses. Messages designed to influence perceived social norms may help reduce the stigma of mental patients ^{(8, 9)}. The serious results and effects of stigma may risk or threaten the life of a patient in general, and his/her social life in particular. This process deprives the patient of basic needs, which may lead to death by self-neglect or suicide. This means that the immediate psychological effects, which made the society dislike them, and their anger, shyness, sadness, and terror, leads to social rejection, and this cause's diminished self-efficacy, then social withdrawal or an acceptance of the low opinions of others, which make them give up and leads to hopelessness and increased suicide rate. Despite the society having moved a long way from the large Victorian asylums, and with the effectiveness of treatments now allowing recovery and reintegration of mentally ill people into society, the WHO reported in 2001 that more than 40% countries do not have a mental health policy, and more than 30% do not have a mental health program. Mental health is not covered economically and morally, and is not treated by the hospitals at the same level as other diseases, which leads to great financial difficulties for patients and their families. The reasons for the almost insignificant support for mental health are cost-effectiveness of therapy and the stigma attached to individuals with mental illness ⁽¹⁰⁾.The stigma of mental illness affects the chances of a person in gaining employment or leads to job discrimination. It also affects housing and the marriage prospects of not only the mentally ill person but those of his/her relatives, such as a young daughter, sister, or other relatives, in Jordanian cultures and countries where being mentally ill is still considered a shame. Therefore, it is necessary to understand that the nature, determinants of stigma, and the results and effects of stigma vary from one region to another. Murthy’s study shows that urban patients and their caregivers in large centers try to hide their illness hoping to remain unnoticed, whereas rural patients and their caregivers in smaller regions experience greater ridicule, shame, and discrimination, as anonymity is more difficult ⁽¹¹⁾.

     The extent of schizophrenic patients who develop clinical, social, and demographic predictions has been assessed in a cross-sectional study, the results of which indicate that stigma is common in patients and is associated with reduced quality of life and the onset of the disorder at a younger age but found no link with significant symptoms (Table IV) ⁽¹²⁾.

Table IV: Results of the cross-sectional study by Switaj et al..

     On the other hand, many studies have revealed that patients feel ignored and rejected by family members. During their illness and treatment, stigmatized people with mental illness show an important predictor of relapse or increased duration of relapse and lack of adherence to treatment, even moving to noncompliance. Also, a study has shown that low self-esteem is a form of stigma, which may be related to pre-conceived ideas held by society or specific events. In this study, many patients also reported their illnesses being ignored and receiving abusive comments about mental illness. Therefore, public education and protests on this matter can be international, national, or locally based. Current international projects include the World Psychiatric Association’s global program to fight the stigma and discrimination that arise from schizophrenia ⁽¹³⁾.

    Our study provides us with a deeper overview of the stigma problem through delayed visit, cessation of visit, noncompliance, and delayed improvement from the perspectives of those affected by stigma in Jordan. Patients reported the boosted effect of stigma due to a combination of their daily activities and other social life. Different factors (e.g., lack of education on mental health care, pharmacists' psychotropic awareness, and economic prospects during remission) complicate the role of medical staff in Jordanian communities. The lack of insight, financial problems, and side effects of medication in addition to the stigma and shame associated with mental illness, facilitates patients to discontinue regular visits and become noncompliant, which leads to socio-economic impairment.

Conclusions

       The present data seems to suggest that stigma may be a cause for concern, especially in young patients where results showed that people with mental illness face a great amount of public stigma in Jordan. Our findings also indicated that several factors (labeling symptoms as "mental illness", attributing biological causes, perceiving dangerousness and socio demographic factors) are associated with stigma. A positive role of personal experience with mental health problems on stigma was not observed. It would be great to draw conclusions for anti-stigma interventions to reduce public stigma in our context from these results. Hence, healthcare professionals should be vigilant about mental health care and provide psychological and pharmacological education in addition to activating the role of the crash team management. The government should also issue strict laws to protect stigmatized patients and enforce compulsory treatment in the event of delayed visit, cessation of visit, noncompliance or refusing treatment against medical advice, regardless of the cause for refusal, because the cost of stigma is high. It prevents many people with mental health problems from living normal lives, and it deters people from seeking help when they need it, so to consider provision of medico-legal and ethical aspects.

       However, the meaning of mental illness is a social, and therefore changeable, construction. Adequate information may demystify mental illness and help to reduce the fear and prejudice surrounding it.

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