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Mental Health, Stigma and Barriers to Care 11 2 Mental Health, Stigma and Barriers to Care Ronald C. Kessler, Ph.D. DR. KESSLER: There are a couple of reasons, at least, for studying stigma. One is, of course, that we are interested in discrimination, the behavioral implications of stigma, for example, discrimination in housing and jobs and in research. I do not know how many of you have seen Ben Druss’ interesting paper in Health Affairs which had a rank ordering of the societal burdens of different classes of illness and a rank ordering of how much money is given to research on those illnesses. The biggest discrepancy is mental disorders. Quite a bit of interesting work has been done in diverse ways concerning behavioral implications and discrimination. Rich Hogan, who is one of my former students, has done this fascinating work on the question of, “How do the community mental health centers decide where to put a group home” Essentially, what happens is that it is done in the middle of the night by stealth. When they discover that a group home is going to be put at the end of the block, communities mobilize, go and get their local councilmen and lobby against it. Over the years there have been a number of efforts by community mental health people to meet with the neighborhood and tell them how mental illness is not really an illness and not really dangerous. What researchers have discovered through considerable practical research on this topic is that when they provide education to the community in advance it only helps the neighborhood mobilize against them more quickly. They discovered the best thing to do is rent the place, get in before anybody knows, and then fight people off after it is too late. That is the practical implication of the perceptions of mental illness in the community. The aspect that I have been most interested in has to do with the other side of it. That is, people who have mental illnesses know that other people feel this way about people living with mental illnesses. One of the implications is that people have a great deal of reluctance to go for treatment. This is nowhere more true than in the armed forces where the ethos is, “I don’t need help. I can handle things myself.” There is good reason to think that embarrassment is an important cause of failure to get treatment and an important cause of dropping out of treatment prematurely. Premature dropout is a massive problem and I will discuss some data on that in a
12 Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism little while. This embarrassment is based, at least in part, on the perception of the stigma associated with emotional disorders, the idea that it is shameful to have a mental illness, and that it is a character flaw. There is reason to think that some of these attitudes might be changing. For a number of years now the General Social Survey has been monitoring attitudes about mental illness and has documented an increase in the perception that mental illness is attributable to biological causes, rather than a character flaw. There has been an increase in the perception that biological treatment is likely to be the most effective kind of treatment. Part of the reason for this, presumably, is that there has been a massive increase in public information about mental illness since the early 1990s when Prozac became the first prescription drug to be advertised on TV. I do not know how many of you are familiar with this but it is really not coincidence that in the last 15 or 20 years there has been this boom in understanding of mental illness. I was, as it so happens, working as a graduate student at the National Broadcasting Company in New York at the time that it became illegal to advertise cigarettes on television. The television networks in their eagerness to improve public health and also, as an aside, to get a little bit more money, decided that it was a terrible thing that prescription drugs could not be advertised on television and started something called the Prescription Drug Advertisement Coalition. They came together with a bunch of pharmaceutical companies to lobby to make it legal to advertise prescription drugs on television. As it turns out there is some interesting economic evidence about this. Advertising on TV for eyeglasses, which also require a prescription, is illegal in some states. It turns out that when you look at the states where you can advertise prescription eyeglasses on TV, the cost of eyeglasses is only about 60% as high as in the states where you cannot advertise. The result is that all of these eyewear shops only go into the states where they can advertise because they make their money on volume. In fact, being able to get this information out has a positive impact on getting people access. That is not always the case, though. If you look at over-the-counter medications, like Bayer aspirin versus aspirin, the companies that spend most on advertisement raise the prices of their products more. It is not always true that giving people more information is a good thing. For one reason or another, the networks and the pharmaceutical industry combined to convince the FDA that there should be direct-to-consumer advertisement for prescription medications. It just so happened that ruling occurred at exactly the time that Eli Lilly developed Prozac, the very first drug that was advertised direct-to-consumer. As you know, Prozac had this unbelievable uptake. The idea that depression is an illness and that treatment was available was compelling. We now know that the effectiveness of SSRIs and SNRIs is not that much greater than TCAs. There is a side effect profile advantage. But the dramatic change in the number of people who were getting treatment for depression was really unprecedented. It is hard to know which was the horse and which the cart. It is true that direct-to-consumer advertising of Prozac coincided with front page feature stories about Prozac on the covers of Time and Newsweek, and all of a sudden we became inundated with Prozac. Subsequently, we have had many front covers of Time and Newsweek that have talked about PTSD, stress, trauma, and suicide in the Army. Various famous people have gone on the Tonight Show to talk about their depression and their drugs and how they overcame it. There are lots of tell-all books, etc. If you look at the mass media archives, the number of stories about mental illness in the past 15 years has
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