COMMENTARY

This is an interesting and well designed study on the subjective experiences of stigma in schizophrenia. The tripartite nature of the respondents (patients, families and mental health professionals) makes it comprehensive. Although using focus groups allows only small numbers of participants, the depth and richness of data compensates for this. Indeed, the depth of information available from qualitative studies is often unequalled by that elicited using quantitative methods. As such, qualitative and quantitative methodologies should be combined whenever possible in order to enhance the evidence-base in mental health.

In this study, Schulze and Angermeyer suggest that reduced social contacts, problems with social identity, the need for secrecy, problems with work, and adverse effects from medication all contribute to the experience of stigma. These factors have been recorded in earlier studies. What is striking, and may impact on the planning of health services for the mentally ill, is the perceived low priority accorded to mental health services and the allocation of resources for people with schizophrenia and their carers. Increased awareness of rights and resources and the proliferation of support groups in recent years may have contributed to this perception among those directly affected by the illness, but there is also supporting quantitative evidence. For instance, WHO’s 2001 World Health Report collated figures of health budgetary allocation to mental health in various countries. In many countries, spending on mental health was miniscule.¹

When interpreting the findings of studies, it is important to place them in their social and cultural context. This study was conducted in Germany, but the descriptions of stigma could well have been from families and patients in developing countries. One difference may be the importance of marriage as a stigmatising experience.² In many developing countries, marriages are still arranged by families. The stigma attached to mental disorders may limit the marriage choices available to people and have a negative impact on others in the family. On the other hand, in the developing world there is some recourse to traditional and religious methods of healing disorders of the mind. These healing methods may serve to mitigate the stigma attached to formal mental healthcare systems.

Stigma is a ubiquitous and universal experience of pain, discrimination and marginalisation cutting across all cultures and societies. While an attitude change is critical, this may be difficult to fashion. Planning better mental health services, improving access and encouraging more positive attitudes in the professionals manning them may be steps towards this goal. Similarly, improving the orientation of general practitioners and other healthcare providers and enhancing the mental health curriculum in undergraduate medical education may augur for a gradual diminution of stigma throughout the world.