Introduction
The term ‘Stigma’ originated in ancient Greece, where it referred to individuals who were branded or marked as a means of punishment and disgrace. These inscriptions were indelibly inscribed onto the skin of so-called undesirables, including slaves, criminals, and murderers, by the wealthy and powerful using hot iron.1 Since then, the definition and scope of stigmatization have undergone profound transformations. Nonetheless, the fundamental elements of discrimination and isolation continue to be a cornerstone of stigma and are frequently employed as weapons against the feeble and vulnerable.2 For millennia, people have used the vulnerabilities due to underlying illness as a tool for stigmatization and discrimination. However, mental illness is subjected to a greater degree of stigmatization and condemnation than any other illness. Furthermore, the patients must contend with social exclusion and pervasive bias, in addition to the physical and mental challenges posed by their illness.3 This additional stigmatization adds an extra layer of burden among mental health practitioners to properly treat their patients. 4
The stigmatization of mental disorders is a worldwide occurrence; however, it is more prevalent in lower- and middle-income countries (LMIC) compared to developed ones.5 Additionally, they also bear a significant portion of the global burden of mental disorders, accounting for around 75% of the total burden.6 This added stigma can lead to a reluctance to seek care, which can worsen mental health and significantly reduce the quality of life for sufferers. This stigma is not limited to the general population alone; it can also infiltrate policy creation and lead to much less investment in psychiatric treatment compared to physical healthcare. According to a study conducted by the World Health Organization (WHO), there is a treatment gap of 76-90% for major mental illness in low- and middle-income countries (LMIC) compared to developed countries. This treatment gap is almost half of that in wealthy countries, which is estimated to be 35-50%.7
The South Asian Association for Regional Co-Operation (SAARC) is a regional organization consisting of eight nations in South Asia: Bangladesh, India, Pakistan, Sri Lanka, Nepal, Bhutan, Maldives, and Afghanistan. It was created in 1985 with the aim of enhancing regional economic and social development. 8 In 2019, SAARC represented 21% of the worldwide population, 3% of the world’s land area, and 4.21% of the global GDP.9 The limited resources available to meet the healthcare needs of this large population present a considerable problem, particularly in the area of mental health where stigmatization is quite prevalent. However, there is a lack of evidence examining the stigmatization of mental health within the SAARC region. This article seeks to address the lack of information by offering a comprehensive analysis of the existing stigmatization of mental health in this region, including its potential causes and potential solutions.
Methods and materials
Information sources and search The search was performed on March 24, 2024, using the MEDLINE and PubMed databases. We employed a database-specific restricted vocabulary and keyword phrases that are relevant to the stigmatization of mental illness in nations under the South Asian Association for Regional Cooperation (SAARC). The database was searched without any restrictions or criteria. The entirety of the records was downloaded and subsequently saved within a citation management software known as Mendeley. The search term included, ‘mental health’ and ‘stigma’ and ‘country name’. The ‘country name’ being the eight countries of the SAARC region. 11 articles were finally selected based on the criteria : (1) being an original article, (2) research whose primary objective was to focus on stigma related to mental health and (3) between 2000 and 2024.
Fig 1 : Selection process of appropriate articles.
Table 1: Major findings from the selected articles
| Reference | Country | Population and location | Sample size | Sample or population demographics | Study type | Findings on stigma |
| Sohel et al., 2022 10 | BD | University students suffering from mental illness in Khulna and their caregivers | 13 | University students and their caregivers, 8 suffering from mental illness and 7 were their caregivers | Qualitative | Labelling and stigmatization form all level of community for both the patient and their caregiver, isolation Community acceptance had positive effect |
| Faruk et al, 202311 | BD | South western Bangladesh | 325 | Mixed urban and rural population | Quantitative | Gender, age, geographical location, socioeconomic status and occupation had significant difference among the subscales of stigma with age, gender, mental illness treatment seeking, socio-economic status had good predictability for mental illness related stigma. |
| Giasuddin et al 201512 | BD | Dinajpur | 70 | Medical students | Quantitative | Education and socioeconomic status effected stigma, presence of self-stigma, negative treatment experience |
| Faruk and Rosenbaum, 202313 | BD | Rangamati | 349 | 5 tribes | Quantitative | No association with ethnicity, Female had higher level of stigma than males |
| Fernando et al,201714 | SL | Sri Lanka | 118 | Survey of outpatients and family carers attending two psychiatric hospitals in Sri Lanka | Quantitative | Stigma caused significant delay in health seeking behavior for both patients and their caregivers. Discrimination based on mental illness prevalent |
| Kaur et al, 202315 | In | Faridabad | 21 | A larger part of INDIGO partnership research program in Faridabad | Mixed method | Labelling through stigmatizing language, non-acceptance by community members. religious, traditional healers and faith healers, initial points of contact for all individuals seeking treatment for their mental illnesses. |
| Munisami et al, 202116 | In | Five states and their capitals of India | 100 | Physicians | Mixed method | Lack of awareness was the major contributing factor for developing stigma along with lack of skills and training about diagnosing and providing management. |
| Trani et al, 201517 | In | Delhi | 1294 | 674 case of schizophrenia and 647 control | Case control study | Poverty was strongly associated with stigma, employment and income major contributor. Multidimensional poverty had higher association with stigma. Females with severe mental illness or people of severe mental illness from lower castes were more likely to be poor due to stigma than males or other castes |
| Raghavan et al, 202318 | In | Kerala | 204 | Patients, caregivers and community members | Qualitative | Stigma against mental health greatly disrupted social life including marriage proposal, lack of social supports for both patients and caregivers. Presence of self-stigmatization. |
| Dijkxhoorn et al, 202319 | In | South India | 29 | Caregiver | Qualitative | Caregivers faced the fear of being stigmatized, embarrassment and losing honor. Caregivers restricted sharing experience with others despite longing to be accepted by the community. There was also reduced social interaction and loneliness as dominant themes. Some caregivers identified lost opportunities of life while caring for the patients resulting in despair or loneliness in the end or growth from the experience towards more empathy and compassion. |
| Hussain et al, 202020 | PK | Karachi | 1470 | Physicians, healthcare students and general population | Quantitative | There was higher prevalence of stigma towards mental illness than physical illness. General population demonstrated higher level of stigma than other two groups. Females had lower levels of stigma compared with males. |
BD = Bangladesh, In = India, PK= Pakistan, SL = Sri Lanka
Results and discussion
Out of 11 articles 5 were from India, 4 were from Bangladesh, 1 from Sri Lanka, and 1 from Pakistan. The researchers were unable to obtain appropriate titles from Nepal, Maldives, Bhutan, and Afghanistan.
Characteristics of participants
The 11-article comprised of 3993 participants in total. 5 articles followed a quantitative approach to categorize stigma. The study group included individuals suffering from mental illness, their caregivers, healthcare workers, medical and university students. One study looked into greater general population.
Prevalence and manifestation of stigma
Labelling using stigmatizing language
Individuals suffering from mental illness can face myriad of stigmatizing language by the community, including “paagal” (mad), “aalsi” (indolent), “moti-buddhi” (fat-headed), “bewkoof” (idiot), “dimag khisak gaya” (lost of mind)’ 10,15. People from all background and age participated in the labelling and even perpetuated false rumors which caused severe distress to both the mentally ill and their caregivers.21
Discrimination based on stigma
Mental health stigma was directly associated with discrimination personal, professional and social fields. Participants were encouraged to hide their mental illness, for fear of discrimination and isolation by community. These discriminations encroached in all personal, social, and professional fields. The problem was more prevalent among female participants with stigma toward mental health leading to early marriage, domestic violence, loss of personal freedom among others. 14,15
Health seeking pattern due to stigma with mental health
Stigma had significant association with delay in help seeking behavior.14 Patient initially contacted religious, traditional and faith healers, initially for years before they sought professional help.15 Lack of healthcare resources prevents the dissociation of stigma related to mental health and people keep seeking help from these alternative sources, which can have devastating effect on the mental health of the patients. Caregivers also delayed seeking help due to the stigma associated with negative speculation.10 Two studies which explored healthcare personnels’ stigma also found high prevalence of mental health related stigma. Lack of knowledge and proper training were the contributing.
Stigma against the careers of those with mental illness
In all studies, the caregivers of mentally ill also faced stigma and discrimination by both family and coworkers. Along with additional stress, this also strained the caregiver’s relationship with the cared. The revelation of suffering from mental illness had significantly disrupted their family and public image and life.21 One study exclusively explored the experience of the caregiver while caring for the mentally ill . They were embarrassed to lose their honor, fearful that their relative was possessed by evil spirits, avoided sharing their thoughts in fear of ostracization, limited their social interaction and developed loneliness. All these accumulated in developing feeling of lost opportunities.19 However, positive experience, like acceptance from the community had net positive effect in their mental health and managing the struggle10, emphasizing the importance of understanding and empathy for better management.
Self-stigmatization
Some individuals developed self-stigmatization, blaming themselves for their family’s and caregiver’s suffering. The mentally ill individuals internalized the stigma which they or their family faced and developed feeling of shame.18
Factors affecting stigma
The factors which were found to be consistently associated with stigma included age, gender, socio-economic status, education.11 Female individuals, individuals with low socio-economic status faced higher instances of stigma.17
Conclusion
Stigma related to mental illness can have devastating effect among the mentally ill and their caregivers, driving them further into isolation and exacerbating their conditions. Identifying the factors affecting the stigma and their manifestation is necessary to design optimum intervention against the stigma. An empathetic and understanding approach is essential to ensure not a single individual does not face discrimination and can have equal opportunity to grow and recover.
Authors of this article
1. Dr. Faisal Chowdhury, MBBS, Chittagong Medical College.
2. Dr. Panchanan Acharjee, Associate Professor and Head of Department, Department of Psychiatry, Chittagong Medical College Hospital.
3. Dr. Sheikh Sabbir Ahmed, MBBS, Holy Family Medical College.
Reference
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