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Many with depression report discrimination
More than three-quarters of people with depression reported discrimination as a result of their illness, according to new study results. Respondents also reported having difficulty initiating close personal relationships and hesitated applying for work at some point because they expected to face discrimination.
“Previous work in this area has tended to focus on public attitudes toward stigma based on questions about hypothetical situations, but ours is the first study to investigate the actual experiences of discrimination in a large global sample of people with depression,” study researcher Graham Thornicroft, PhD, said in a press release.
Thornicroft, of the Institute of Psychiatry at King’s College London, and colleagues surveyed 1,082 patients being treated for depression in 39 sites across 35 countries. Discrimination and anticipation of discrimination were assessed using the discrimination and stigma scale, version 12.
The researchers found that 79% of participants reported experiencing discrimination. Depression had prevented 37% of participants from initiating a close personal relationship, 25% from applying for work and 20% from applying for education or training. Participants who experienced discrimination were less willing to disclose a diagnosis of depression (P<.001). However, Thornicroft and colleagues also found that participants who had anticipated discrimination did not necessarily experience it. Forty-seven percent of participants who had anticipated discrimination in searching for or keeping a job and 45% of those who had anticipated discrimination in their personal relationships did not actually experience any in those situations.
In a linked statement, Anthony Jorm, PhD, of the University of Melbourne in Australia, noted the importance of the study results, but said, “Further research could provide much needed input into the design of anti-discrimination interventions — such as public education about human rights and the effect of discrimination on the person with depression; action from health services to help overcome anticipated discrimination as a barrier to help seeking; and the incorporation into treatments such as cognitive [behavioral] therapy of techniques to address anticipated discrimination and symptoms.”
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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Lasalvia and colleagues’ recent study indicates a great burden of discrimination against people with mental illness — this is not surprising. However, the news here is that the authors chose not to look at the public’s attitudes, but rather at patients’ own perceptions of discrimination. Further, the illness in question was not one of the highly stigmatized and overtly behaviorally disordered syndromes like schizophrenia or substance use disorder, but rather the arguably more subtle (and perhaps more socially acceptable?) major depressive disorder.
The authors provide a thoughtful analysis of the data, and these are important findings — especially as they relate to public health, policy and education. While one might think that this study’s findings may have easily been anticipated, the results indicate an even more sobering and aversive picture of real and expected discrimination (from self and others) experienced by depressed patients around the world. This study adds an expectation of social-harm to even further intensify the other well-studied systemic barriers to care.
An important possible limitation mentioned by Lasalvia et al is that of depression itself affecting study results. The presence of negative views of the self, other and future commonly experienced by patients with depression (not to mention anger, resentment and loss) may have exerted large confounding effects on indices of perceived discrimination (ie, a negative affective/cognitive tone colors one’s perceptions). Further, the large percentage of subjects who reported anticipated discrimination in the absence of experienced discrimination may result from such negative cognitive distortions or affective projections. Though, of course, anticipated rejection may also be mediated by any patient’s well-founded and validated knowledge of societal stigma. However, even if the presence of cognitive/affective symptoms of depression was a confounding factor, I believe it would only serve to indicate that we have to work that much harder to help these patients out there in the world. There are many reasons why patients suffer, but self-stigma (whether originating from depressive symptomatology or internalized or experienced societal devaluation) is one we must address in order to both bring patients into and help them benefit from treatment to emerge into the social world.
As a final anecdotal note, the public (as well as the current DSM) tends to focus more on maladaptive behavioral manifestations of illness than on patients’ subjective experiences. This seems to highlight patients’ functional limitations in the world rather than foster a view of their more experiential and painful internal symptoms, thus creating an imbalance that may lead to worsened discrimination and impeded empathy and validation.