Authors' reply

Takei et al give salient examples of how psychiatrists and psychiatric treatment contribute to the stigmatisation of individuals with schizophrenia in Japan. We discuss similar and other related instances of such treatment-related stigma in a separate paper (Lee et al, in press).

Compared with stigma in most social situations, treatment-related stigmatisation exhibits two features that render its impact on patients particularly poignant. First, whereas patients can conceal their illness from friends, colleagues or even family members, total secrecy within the psychiatric treatment system is nearly impossible. Nor can they distance themselves from psychiatric treatment without running the risks of being labelled as ‘non-compliant’ or ‘lacking insight’, and having a relapse of illness. Second, patients often experience unconscious stigmatisation by mental health staff. Instances such as those described by Takei et al frequently occur in the course of routine clinical management by psychiatrists and nurses.

However, even when there is no conscious intent to stigmatise, certain institutional practices in psychiatry that cause stigma are examples of structural discrimination (Pincus, 1996). This arises less from personal prejudice than a combination of causes such as poor quality of health services, inadequate budget allocation and neglected rights of patients.

Psychiatrists have routinely blamed negative social attitudes for the stigmatisation of people with schizophrenia. Public health campaigns have sought to reduce the stigma associated with mental illness by increasing public knowledge. Without doubting the benefit of attitudinal shifts among the general population, we believe that programmes aimed at reducing stigma must be informed as well as evaluated by patients’ lived experience of psychiatric treatment. Tackling structural discrimination and the resulting power difference is at the root of such a change.