Skip to main content
Acta Bio Medica : Atenei Parmensis logoLink to Acta Bio Medica : Atenei Parmensis
. 2021 Oct 1;92(Suppl 6):e2021442. doi: 10.23750/abm.v92iS6.12235

Stigma, mental illness, and COVID-19 from a frontline clinician perspective: a way to go against the grain?

Francesco Branca 1, Elena Macchiarulo 1, Alessandra Costanza 2,, Julia Ambrosetti 3, Andrea Amerio 4,5, Andrea Aguglia 4,5, Gianluca Serafini 4,5, Mario Amore 4,5, Roberto Merli 1
PMCID: PMC8851007  PMID: 34739466

Abstract

A well-known insidious obstacle for patients with mental illness is stigma, linked to feelings of incomprehensibility, incurability, and dangerousness. The COVID-19 pandemic represented a relevant additional barrier for these patients, which contributed to their marginalization, quality of life reduction and diminished treatments feasibility. As part of a cross-sectional multidisciplinary project conducted in the psychiatric service of Biella, a northern Italy province, preliminary data were collected by frontline clinicians during the COVID-19 first wave regarding the vicious cycle that may have been created between stigma and psychiatric patients in COVID-19 time. Therefore, we tried to frame the observed changes not in the dual literature paradigms stigma-mental illness or stigma-social consequences in COVID-19 time, but in the mental illness-stigma-COVID-19 three-way paradigm. The protection of this vulnerable segment of population, including a rapid access to COVID-19 vaccination, needs to be recognized as a real public health priority. The role of mental health services in providing information and activating supportive interventions for patients with mental illness is also crucial. Particularly, a multidisciplinary therapeutic team including mental health providers, general practitioners, hospital physicians, and social services would be needed to ensure adequate networks and cares continuity. Actions to contrast stigma can be arduous and exhausting because they must counteract the gravitational pull of customs, prejudices, and ingrained cultural beliefs, and may therefore appear to be moving in an “unnatural” direction, like the water in Escher’s lithograph entitled “Waterfall”. Nevertheless, there is no less strenuous way to go against the grain.

Keywords: COVID-19, stigma, mental illness, mental health


A well-known insidious obstacle for patients with mental illness is stigma, linked to feelings of incomprehensibility, incurability, and dangerousness. In addition to having experienced discrimination (experienced stigma), patients with mental illness sometimes also feel being discriminated against, even when no discrimination has occurred (anticipated stigma). Stigma perceived by patients becomes reinforced through a vicious cycle, which gradually lead them to avoid relationships/places and renounce action. This in turn reinforces their marginalization with respect to society, reducing their quality of life and rendering potential treatments less feasible (1).

The 2019 coronavirus disease (COVID-19) pandemic represented a relevant additional barrier for patients with mental illness. As part of a cross-sectional multidisciplinary project conducted in the psychiatric service of Biella, a northern Italy province, preliminary data were collected by frontline clinicians during the COVID-19 first wave with regard to the vicious cycle that may have been created between stigma and psychiatric patients in COVID-19 time.

We observed three different typologies of patients who less used psychiatric services (face-to-face outpatient visits) during the COVID-19 first wave compared to 2019: 1) male subjects, 74% lesser, 2) seniors over 65, 88% lesser (in contrast to an increase in youth aging 18-25 of 80% in the later phases of the first COVID-19 wave), 3) patients with severe anxious disorder, 72% lesser (in contrast to an increase of 82% in suicidal crises among young adults in the later phases). Most discontinued psychopharmacological treatments were represented by clozapine, 45% lesser, and long-acting injectable antipsychotics (LAI), 20% lesser. Limitation to outpatient visits (54%), the fear of contagion, including delusions (72%), and the perception of one’s condition as less of a priority than the ongoing health emergency (84%) were the three main reasons responsible of the decrease of face-to-face outpatient psychiatric visits. The three more severe consequences of eluding contacts with mental health care providers were the worsening of the course of the mental illness, the accumulation of physical co-morbidities and the prolonged isolation, which likely played a role in triggering the suicidal crises increase among youth in later phases of the pandemic.

In light of our preliminary data, we tried to frame these changes not in the dual literature paradigms stigma-mental illness or stigma-social consequences in COVID-19 time (2, Italian Ministry of Health 2020: https://www.salute.gov.it.imgs/C_17_notizie_4149_0_file.pdf), but in the mental illness-stigma-COVID-19 three-way paradigm. Although this topic remains still understudied, given the available scientific evidence some observations can be made.

A recent multicenter study (3) based on the working experience of psychiatrists from different countries explored the infectious disease outbreak related stigma and discrimination during the COVID-19 pandemic. Using the Health Care Stigma and Discrimination Framework (HSDF), they found that, irrespective of the country, stigma was associated with similar factors, namely: certain drivers (e.g., fear of infection or quarantine), beliefs (supernatural or religious), blame (both oneself and others) for contracting the disease, guilt, and shame (3). They also suggested that the infection was more likely if: (i) individuals were unaware of the existence of anti-discrimination laws in their country (lack of education), (ii) the respective country did not have any anti-discrimination laws or policies in place, or (iii) laws and policies existed but were not enforced (3). The unprecedented wave of research and publications following the rapid spread of the pandemic (“infodemic”) acted as a driver and a facilitator of the COVID-19-related stigma (4). In some cases, the reinforcement of negative stereotypes and prejudice, plus social processes of labeling, further fueled already existing social inequalities, which were then reinforced by public health enforcement measures (e.g., arresting people for quarantine violations) (3).

Patients with medical illness appear to have an increased risk of becoming infected by COVID-19 and developing more severe complications, for several possible reasons: (i) Their mental health difficulties may limit or delay perceptions of changes in the external environment and feelings of self-protection, thus negatively impacting on adherence to standard precautions for infection, (ii) Their somatic comorbidities may facilitate or aggravate the infection, (iii) Their interaction between psychic suffering and physical injuries, as for instance would be the case for neurologic diseases, may contribute to a worse course of the infection (5,6). They also find it more difficult to obtain adequate medical care specific for COVID-19 (3). Moreover, psychiatric boarding in emergency departments is associated with higher risk of hospitalization and thus longer stay in psychiatric wards not always equipped with high isolation standards against infectious respiratory diseases (3).

The protection of the mental health status of this vulnerable segment of population, including a rapid access to COVID-19 vaccination, needs to be recognized as a real public health priority (7). It is also emphasized the role of mental health services in providing information and activating supportive interventions for patients with mental illness (7). Particularly, a multidisciplinary therapeutic team including mental health providers, general practitioners, hospital physicians, and social services would be needed to ensure adequate networks and cares continuity (7).

It has been observed that both experienced and anticipated rates of stigma in patients with mental illness remain essentially unchanged over time (1). In fact, laws aimed at countering experienced stigma do not lead to appreciable results unless accompanied by interventions that increase patients’ self-esteem, thereby reducing anticipated stigma (1). This is particularly true in COVID-19 times, when both healthcare providers and patients perceive mental illness as “less serious” and “less priority” than the COVID-19 infection with a dangerous acceleration of the aforementioned vicious cycle and an increased mortality in patients with mental health illness.

Actions to contrast stigma can be arduous and exhausting because they must counteract the gravitational pull of customs, prejudices, and ingrained cultural beliefs, and may therefore appear to be moving in an “unnatural” direction, like the water in Escher’s lithograph entitled “Waterfall”. Nevertheless, there is no less strenuous way to go against the grain.

Acknowledgements:

This work was developed within the framework of the DINOGMI Department of Excellence of MIUR 2018-2022 (Law 232/2016).

Conflicts of interest:

Each author declares that he or she has no commercial associations (e.g. consultancies, stock ownership, equity interest, patent/licensing arrangement etc.) that might pose a conflict of interest in connection with the submitted article.

References

  1. Thornicroft G, Brohan E, Rose D, Sartorius N, Leese M, Group IS. Global pattern of experienced and anticipated discrimination against people with schizophrenia: a cross-sectional survey. Lancet. 2009;373(9661):408–15. doi: 10.1016/S0140-6736(08)61817-6. doi: 10.1016/S0140-6736(08)61817-6. [DOI] [PubMed] [Google Scholar]
  2. Bagcchi S. Stigma during the COVID-19 pandemic. Lancet Infect Dis. 2020;20(7):782. doi: 10.1016/S1473-3099(20)30498-9. doi: 10.1016/S1473-3099(20)30498-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Ransing R, Ramalho R, De Filippis R, et al. Infectious disease outbreak related stigma and discrimination during the COVID-19 pandemic: Drivers, facilitators, manifestations, and outcomes across the world. Brain Behav Immun. 2020;89:555–58. doi: 10.1016/j.bbi.2020.07.033. doi: 10.1016/j.bbi.2020.07.033. [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Odone A, Salvati S, Bellini L, et al. The runaway science: a bibliometric analysis of the COVID-19 scientific literature. Acta Biomed. 2020;91(9-S):34–39. doi: 10.23750/abm.v91i9-S.10121. [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Costanza A, Baertschi M, Weber K, Canuto A. Neurological diseases and suicide: from neurobiology to hopelessness. Rev Med Suisse. 2015;11(461):402–5. [PubMed] [Google Scholar]
  6. Costanza A, Amerio A, Aguglia A, et al. When Sick Brain and Hopelessness Meet: Some Aspects of Suicidality in the Neurological Patient. CNS Neurol Disord Drug Targets. 2020;19(4):257–63. doi: 10.2174/1871527319666200611130804. doi: 10.2174/1871527319666200611130804. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. De Hert M, Mazereel V, Detraux J, Van Assche K. Prioritizing COVID-19 vaccination for people with severe mental illness. World Psychiatry. 2021;20(1):54–55. doi: 10.1002/wps.20826. doi: 10.1002/wps.20826. [DOI] [PMC free article] [PubMed] [Google Scholar]

Articles from Acta Bio Medica : Atenei Parmensis are provided here courtesy of Mattioli 1885

RESOURCES