The April 2022 issue of Academic Psychiatry has several papers that demonstrate the continuing presence and cost of the stigma of mental illness. Psychiatric patients experience a burden of social marginalization and internalized shame that adds to the weight of the illnesses they bear. And the stigma of mental illness continues to deter medical trainees from seeking help when indicated. Addressing stigma is a crucial responsibility for all academic psychiatrists. The papers included here suggest several potentially fruitful ways to make a difference.

In order to assess attitudes toward self-harm, Joiner and Kaewchaluay [1] analyzed the content of focus groups with first and final year medical students in the UK. Though necessarily limited by small numbers at one medical school, the findings are nonetheless suggestive. It is not surprising to find stigma around this topic. Medical students early in training described negative and morally judgmental attitudes about self-harm, including that it is primarily attention seeking and that help is futile. This perception was coupled with ideas picked up from the hidden curriculum that self-harm is not important and not a medical condition. Nonetheless, final year students expressed more appreciation of the value of compassionate conversation with patients who self-harm. The authors call for more content in the formal curriculum on this topic, and instruction to teachers and staff to enhance their awareness of role modeling dismissive attitudes.

A valuable letter from Miah and colleagues [2] adds further depth to the picture. The authors are UK medical students who affirm that they experienced negative messaging from supervisors in emergency settings about the importance of mental health issues and the value of engaging with patients who self harm. However, in contrast to Joiner and Kaewchaluay’s findings [1], they report that learning about self-harm was a priority to them, as they knew that it would be emphasized on the Objective Structured Clinical Examination. They highlight the importance of examinations in having a very real impact on what students attend to, “Irrespective of their personal attitudes.”

Lo, Balasuriya, and Steiner [3] provide an encouraging report of a rotation that engaged residents with a marginalized and stigmatized population—the unsheltered homeless. Through a “street psychiatry” rotation, residents were brought into direct contact with patients in their lived environment and subsequently reported greater empathy for their experience and more appreciation of the structural obstacles that individuals experience when seeking care or attempting to adhere to health care plans.

Kunkle and colleagues [4] also emphasize the value of direct contact. They found that 69% of the preclinical medical students who took their introductory psychiatry sequence reported a decrease of bias and stigma toward those with mental illness. While it is impossible to say with certainty what element of the course was effective, it is intriguing that many of the volunteer patients with mental illness who are interviewed are employees on campus. Contact is thought to be most effective at reducing stigma when it brings people together in a situation of collaboration toward shared goals and more equal status. Such conditions are more likely to be met in the scenario Kunkle describes than in a psychiatric emergency setting or inpatient unit.

Posada, Potvin, and Cookson [5] share wise advice on the subject of “open notes” that has similar potential to decrease stigma. Psychiatrists are now required to provide ready access for patients to their mental health treatment notes. This new transparency requires the clinician to rethink the tone and wording of documentation. As the authors’ examples in Table 1 illustrate, this transparency may lead clinicians to replace terminology that unintentionally reinforces the stigma of psychiatric conditions, including “malingering,” “attention seeking,” and “denial.” Teaching more neutral and supportive language to trainees has the potential to “humanize notes and the patients they describe” [5].

Stigma of mental illness is not only an impediment to engagement and empathy with patients. Phillips et al. [6] demonstrate that it remains a deterrent to medical students seeking care for themselves. A survey of students at three Ohio medical schools identified 388 students who reported a perceived need for help. Those with higher scores on the Self-Stigma of Seeking Psychology Help scale were significantly less likely to obtain treatment. Asian identity was also found to decrease the odds of obtaining care, while the sole factor increasing the odds was being told by others to seek help.

Attention to respectful language, fostering opportunities for positive contact with people with mental illness, and confronting hidden curriculum messages disparaging of mental illnesses—all are valuable interventions that psychiatric educators can teach trainees as they approach their patients. We can offer something additional to medical students whose self-stigma may deter them from treatment. Those of us who have benefited from psychiatric treatment can share this experience with our students. (Such communication with students should not be confused or equated with self-disclosure to patients.) By demonstrating that we can accept ourselves as doctors who nonetheless are human, can become ill, and can recover, we may—gradually, incrementally—erode the stigma of psychiatric illness.