Stigma and bipolar disorder: A review of the literature

Abstract

Background

Psychiatric stigma is pervasive injustice that complicates the course of illness and reduces quality of life for people with mental illnesses. This article reviews the research examining stigma towards bipolar disorder (BD) with a view to guiding the development of stigma reduction initiatives and ongoing research.

Methods

PsychInfo, Medline, and Embase databases were searched for peer-reviewed studies addressing stigma in BD.

Results

Stigma is a serious concern for individuals with BD and their families. Stigma occurs within affected individuals, families, social environments, work and school environments, and the healthcare industry. With stigma often come a loss of social support and occupational success, reduced functioning, higher symptom levels and lower quality of life. BD stigma is comparable to that of other severe mental illnesses, such as schizophrenia. Few interventions are available to specifically target stigma against BD.

Limitations

Most studies have used explicit, attitude-based measures of stigma without controlling for social desirability, which may not translate into real-world stigmatizing behaviors. Furthermore, many studies have not clearly delineated results in a manner consistent with the conceptual framework of stigmatization.

Conclusions

Stigma toward BD is ubiquitous and has insidious consequences for affected individuals and their families. Stigma reduction initiatives should target individuals living with BD, their families, workplaces, and the healthcare industry, taking into account the experiences and impacts of BD stigma to improve social support, course of illness, and quality of life.

Introduction

“Psychiatric stigma” refers to systemic and internalized stereotypical negative attitudes against people labeled as mentally ill (Corrigan et al., 2011). It is a social injustice that goes hand in hand with discriminatory behaviors, causing direct harm to the individuals affected. Negative, stigmatizing attitudes common in today's society include beliefs that mental illness is a sign of personal deficit, weakness, deviance, low intelligence, unreliability or incompetence and that people with mental illness are violent and unpredictable (Harrison and Gill, 2010, Putman, 2008). This type of prejudice is found throughout society—in the general public, within the families and social circles of people with mental illness, among healthcare professionals, and even among affected individuals themselves (Sartorius et al., 2010).

The theoretical framework of stigma describes three intersecting levels: structural, social, and self-stigma. Structural stigma refers to the policies and practices of institutions, in positions of power, that systematically restrict the rights and opportunities for people living with mental illnesses (Corrigan et al., 2004, Herek, 2007, Livingston and Boyd, 2010). Social stigma refers to the process whereby large social groups endorsing stereotypes about people with stigmatized condition and act against them (Corrigan et al., 2005). Lastly, self-stigma refers to the internalization of societal attitudes and discriminatory practices (Crocker and Quinn, 2000, Major and O'Brien, 2005). Self-stigma is defined as a subjective state “characterized by negative feelings (about self), maladaptive behaviour, identity transformation, or stereotype endorsement resulting from an individual's experiences, perceptions, or anticipation of negative social reactions on the basis of their mental illness” (Livingston and Boyd, 2010). Self-stigma has serious impacts on the lives of individuals with mental illnesses and their families. It can be associated with withdrawal, social exclusion, and a reduced quality of life (Harrison and Gill, 2010). In some cases, internalized or self-stigma prevents treatment seeking (Eisenberg et al., 2009) or poses a barrier to optimal treatment provision (Verhaeghe and Bracke, 2011).

Bipolar disorder (BD) is no exception when it comes to stigma. BD is a severe mental illness characterized by episodes of major depression and mania (BD-I) or hypomania (BD-II) (American Psychiatric Association, 2001). People with BD tend to experience multiple affective relapses (Schaffer et al., 2006), substantial residual or inter-episode symptoms (Benazzi, 2004, Paykel et al., 2006), and high suicidality (Judd and Akiskal, 2003). With these symptoms come a myriad of impacts on psychosocial functioning, self-esteem, and quality of life (Blairy et al., 2004, IsHak et al., 2012). BD also imposes a considerable burden on families and caregivers (Van Der Voort et al., 2007).

Stigma is assessed in a variety of ways. A large body of research examines stigma using qualitative techniques. This approach has many advantages in examining stigma, as it allows researchers to explore the subtle, personal meaning that stigma has for different individuals. Quantitative self-report tools have also been developed. Among the commonly used tools is the Mental Illness Stigma Scale (MISS; Day et al., 2007), a general scale that can be administered to any adult population and that breaks the construct of stigma down into factors such as contact anxiety, hygiene, treatability, and the feasibility of recovery. Additional tools have been developed to assess stigma among specific populations. Examples include the Mental Illness Clinicians’ Attitude Scale (MICA; Kassam et al., 2010) and the Opening Minds Scale for Health Care Providers (OMS-HC; Kassam et al., 2012). Self-stigma is assessed with similar questionnaires that can be adapted to the disorder in question. A popular example is the Internalized Stigma of Mental Illness scale (ISMI; Ritsher et al., 2003), which looks at self-stigma from various angles, such as the sense of alienation, perceived discrimination, and social withdrawal. In an attempt to move away from attitudes-based assessment, Link et al. (1999) proposed a brief scale to measure the desire for social distance from individuals with mental illness, viewed as a proxy for stigmatizing behavior. Other methods of measurement include the use of vignettes to accompany assessments and implicit measures that seek to bypass social desirability. Methods of assessing stigma are more thoroughly reviewed elsewhere (Link et al., 2004, Stier and Hinshaw, 2007).

Through a program of community-based participatory research, the Collaborative RESearch team to study psychosocial factors in BD (CREST.BD) has identified stigma as a major concern for people with BD and their families (Michalak et al., 2011, Suto et al., 2012). CREST.BD is a multidisciplinary, cross-sectoral network dedicated to fundamental research and knowledge exchange on BD (Michalak et al., 2012). Based on its early findings, CREST.BD has established stigma reduction as a priority area for its work. However, a unified, effective campaign to fight BD-related stigma requires a clear understanding of the relationship between stigma and bipolarity. To this end, we conducted a review of the literature addressing the psychiatric stigma associated with BD.