Few other conditions in the history of medicine have attracted such social stigma as mental illness. One can have a broken leg, suffer from diabetes or cancer; but one is mental. You become the illness or put differently, the illness defines who you are, which only further reinforces stigmatisation and the fact that such people are somehow “different” from everyone else, damaged goods if you will.
Stigmatisation of the mentally ill has a long tradition. For millennia, society did not treat persons suffering from depression, autism, schizophrenia and other mental illnesses (defined in the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association) much better than slaves or criminals: they were imprisoned, tortured or killed. During the Middle Ages, mental illness was regarded as a punishment from God: sufferers were thought to be possessed by the devil and were burned at the stake, or thrown in madhouses where they were chained to the walls or their beds and simply forgotten. During the Enlightenment, the mentally ill were finally freed from their chains and institutions were established to help sufferers. But alas stigmatisation still persisted and at times the cruellest and most inhumane treatments re-emerged. The Nazi regime in Germany, not known for its humanity, murdered or sterilised thousands of mentally ill people in the name of eugenics.
In the post-war era, treatment of mental patients only improved marginally as attested by various works of art, literature and film. How could we possibly forget Jack Nicholson’s brilliant performance in the iconic film “One flew over the Cuckoos Nest”. They were electrocuted, lobotomised and mostly kept under sedation. Other treatments were relatively rare. The mentally ill were kept for long-periods, sometimes years, buried and forgotten in asylums and hospitals, hidden away from the rest of the world.
Today the level of stigmatisation has abated, but I would venture to say that it is probably the illness that still attracts the highest stigma and about which the general public is least informed. Using phrases like “she/he is crazy” does not help in the least. Nor does the entertainment media, where the villain is often a character with a mental illness and is depicted as a violent, deranged person; a recent example being the protagonist of the film The Joker, with its 11 Oscar nominations in 2019. In reality, people that suffer from mental disorders are more often victims of violence then its perpetrators.
Why such stigmatisation? Since mental illness affects our behaviour, it defines who we are more than any other illness. Yet mentally ill patients are much more than their illness. Should we reduce Van Gogh, T. S. Eliot, Leo Tolstoy, Ernest Hemingway and hundreds of other artists, poets and playwriters, who have enriched our cultural heritage, to their bouts of severe depression, bipolar and psychotic episodes? Was Churchill, or Roosevelt, world leaders that have defined our history mere expressions of their mental challenges? Surely their essence was much more than that. Being mentally ill does not define you morally. In fact, it often gives you greater insight and sensitivity to the human condition and to those around you. People that suffer from chronic depression or anxiety and continue to do their best everyday to function and relate to those around them, should be celebrated for their resilience, not diminished by their condition.
It is true that mental illness distorts what we would consider “normal”. Often, we are embarrassed by our inadequacy in dealing with it. We can’t see the person behind the disease. So, we stigmatise them. Call them “crazies”, “lunatics”, “psychotic”, “sick in the head”. But that is our problem, not theirs.
This stigma and discrimination trap people in a cycle of illness. They fail to seek professional help or even reach out to friends and loved ones who could support them. This only fuels feelings of shame, hopelessness and isolation, already associated with many of these pathologies. Not getting the requisite treatment often results in unemployment, poverty, drug and alcohol addictions, suicide and homelessness. Stigma denigrates the value of people who have a mental illness, by treating them as “damaged goods”. Curiously enough, it is not just the general population that has these attitudes. Many mental health professionals have themselves been identified as part of the problem. Too often, treating their patients as if they were “crazy”.
Stigma and widespread lack of knowledge (if these weren’t bad enough already) engender a whole host of bad public policies. Governments dedicate few resources in helping the mentally ill. Our social welfare system has hardly any resources to deal with mental illness, and psychiatric services are still largely concentrated in large centralised institutions, with little or no coordination between these and primary care givers. We need mental health services that together with evidence based treatments foster elegance and aesthetics.
Portugal has some of the best specialists in the world in mental health policies and services organisation. Our National Mental Health Plan, has existed since 2008, yet is still to be fully put implemented due to the decrease in investment in our national health services and low priority given to mental patients. It’s about time the government woke up to this problem.
Lest the reader think we are talking of a minor problem in society, let’s take a look at some statistics pre – Covid. The Portuguese Society of Mental Health reports that nearly 1 in 4 Portuguese have suffered from some form of psychiatric problem (22,6 percent to be exact). Portugal has the second highest number per capita of psychiatric disorders in Europe, beaten by a whisker by Northern Ireland – not a record to be proud of! Only a quarter of patients with mental disorders seek help in advanced economies, and only 10% have access to help that is considered adequate. These numbers alone should be a powerful wake-up call for the pressing need to raise public awareness, de-stigmatise these conditions and advocate for better health care.
But if this still isn’t convincing enough, let’s take a look at the costs to society. Across the United States, serious mental illness causes $193,2 billion in lost earnings each year and it is estimated that depression and anxiety disorders cost the global economy over $1 trillion in lost productivity annually. People with depression have a 40 percent higher risk of developing cardiovascular and metabolic diseases than other people. The rate of unemployment is far higher and high school students with significant symptoms of depression are more than twice as likely to drop out of school compared to their peers. Suicide is the second leading cause of death among people aged between 10 and 34. But suicide is only part of the picture; many adolescents and young adults – our future workforce – will resort to substance abuse and self-harm.
These depressing numbers have only increased with Covid 19. Adolescents depend on their friendships to maintain a sense of self-worth and to manage anxiety and depression. We all do, young and old. SnapChat, TikTok, WhatsApp, and Instagram do not substitute for socialisation. As stressful as adolescent relations can be, they are essential for the formation of personal identity. Spending too much time in your “own thoughts” is unbearable. As one adolescent I spoke to said: “When I can’t see my friends, I feel the world is caving in.”
Children and adolescents are feeling the stress and uncertainties about the future of their parents. Some worry that they are increasingly falling behind on their school work by not having access to the same conditions as more privileged children. By keeping our schools closed longer then any other European State, the current government showed how reckless they have been with the mental health of future generations.
Adults have also been affected, and how. Health professionals are showing signs of burn-out, with the added risk of growing levels of anxiety and depression. Those who have lost their jobs, face an unknown future. Almost all of us, especially parents with younger children, are finding it hard to juggle working from home and family life. Anxiety, depression and problems associated with increased consumption of alcohol and drugs have increased dramatically. Post-Traumatic Stress Disorder (PTSD) is likely to be a lasting effect of social isolation and economic stagnation. The coronavirus pandemic posses the greatest threat to mental health since the Second World War, with the impact being felt for years after the virus has been brought under control.
There is however a piece of good news. Mental wellness has at last made headlines in the media. Political parties like Iniciativa Liberal and the Juventude Social Democratica (JSD) have introduced programmes in Parliament to mitigate the effects of Covid-19 on mental illness. The Government has finally introduced a hotline that people can call in their hour of desperation. The number of psychologists in the National Health Service will be increased to deal with the rising demand. But this is far from enough and it should not end once Covid is over.
The priority should be to promote quick access to mental health care, close down the big psychiatric hospitals and reintegrate persons suffering from mental disorders back in the community. This has two huge advantages. First, it gives people suffering from mental disorders better access to care, while still maintaining their family relations, friendships, and in many cases jobs during their treatment. Help is provided earlier and rehabilitation is easier and quicker. Secondly, they are allowed to live in an environment that is conducive to getting better, there is greater protection of human rights and ultimately less stigma.
Priority should also be given to informing society and to educating children in schools about mental illness. Many of us tend to be quick to judge. Mental illness is seen almost as a character flaw, a weakness or a threat to society. We should be careful about such judgements, as depressions or anxiety disorders can hit us all, at one time or another during our life-time. So, when next someone reaches out to you, for God’s sake don’t lecture them on “how many wonderful things they have in their lives” and “how they should just get over it”. That’s equivalent to telling a paraplegic to stop complaining and just run the marathon. Listen to them, support them, try to get them some help but most of all accept them for the incredible and unique individuals they are. After all, we all have our share of “quirkiness”.
Mahatma Gandhi once said that “A nation’s greatness is measured by how it treats its weakest members”. It certainly defines its moral character. We cannot afford as a society to ignore this “inconvenient problem” any longer.
