Beyond any definition, stigma has become a marker for adverse experiences. First among these is a sense of shame. Mental illness, despite centuries of learning and the ‘Decade of the Brain’, is still perceived as an indulgence, a sign of weakness. Self-stigmatization has been described, and there are numerous personal accounts of psychiatric illness, where shame overrides even the most extreme of symptoms.

The question arises as to just what all this shame and secrecy is about. Negative cultural sanction and myths combine to ensure scapegoating in the wider community. The reality of discriminatory practices supplies a very real incentive to keep mental health problems a secret. Patients who pursue the secrecy strategy and withdraw have a more insular support network. Discrimination occurs across every aspect of social and economic existence.

The starting point for all target groups and at every level is education: to date, the Changing Minds campaign has succeeded in its requests to medical journals to publish articles on stigma. These articles, including the excellent Lancet series have provoked discussion within professional circles, and beyond. Psychiatric Services and the UK-based Journal of Mental Health have been major forums for research and debate on this subject, and more recently the Psychiatric Bulletin has featured a number of key articles.

If every psychiatrist left rehabilitation to the rehabilitation team, there would be no rehabilitation. Equally, if every psychiatrist leaves “the stigma issue” to the Changing Minds campaign, there will be no enduring change. Psychiatrists should address stigma as a separate and important marker in its own right. Because of the nature of stigma, patients are unlikely to bring it directly to the attention of the mental health team. Clinicians should ask about the nature of adverse experiences, discrimination, the extent of social networks, self-image, etc., and incorporate these issues into the treatment plan. Acknowledging the existence of prejudice is an essential first step, and is no more “dangerous” than inquiry into suicidal ideation.

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