Stigma as a cause of suicide

We read with great interest the article by Eagles et al (2003) in which, among the various interventions discussed to prevent suicide, it was suggested that according to patients' opinions there should be a decrease in the stigma attached to psychiatric illness. We share that opinion and suggest that another goal of suicide prevention is the reduction of the stigma attached to suicide.

The term stigma refers to a mark that denotes a shameful quality in the individual so marked. Mental illness is widely considered to be such a quality, an assumption supported by a number of beliefs such as the association between mental illness and irrational and unpredictable violence as portrayed by the media and the notion that mental illness is not a ‘true’ illness like organic disease. And yet, people do fear mental illness and do not know how to avoid it by following the types of precautions and guidelines available for so many organic disorders.

Not only does the stigmatisation of mental illness prevent people from seeking treatment, which in turn exposes them to a greater risk of suicide, but also suicide can appear to be the best solution for a stigmatised individual. A number of environments can be traced where this process takes place. In the family, the family members' relationship to the patient may affect the extent to which the patient's stigma is transferred to the family members, as in the case of schizophrenia (Phelan et al, 1998). In such extreme cases, difficulties in dealing with a chronic disease, which often results in relapses, hospitalisations and social impairment, leads family members to stigmatise the patients. They behave in a way that may lead the patient to assume that suicide might be a solution for their situation. Family members may also unconsciously believe that suicide might be a solution. In the hospital, staff's attitudes towards patients who are at risk of suicide deserve consideration. Acceptance of a patient's suicide as a solution to problems, wishes that a patient would commit suicide as a solution to his or her problem, fear of the patient and difficulties in dealing with suicidal individuals are some of the most important sources of stigma in mental health environments. Also, following an attempt many individuals feel isolated or ignored by health professionals (McGaughey et al, 1995). In the military environment, stigma towards mental illness is very strong and military personnel tend to deny any form of mental disorder unless they are hoping to get another job. This exposes such a population to the risk of suicide.

Yet suicide is, itself, a source of stigma as anyone with suicidal ideation is considered weak, shameful, sinful and selfish, which prevents these individuals from seeking treatment early in the suicidal process. These judgements are often shared by active churchgoers (Sawyer & Sobal, 1987), teachers and parents. Also, parents and widows of victims of suicide are stigmatised, which makes recovery from this type of loss particularly difficult (Smith et al, 1995). Destigmatisation should be addressed to mental illness as well as suicide. Increasing the stigma associated with having suicidal feelings will increase the suicide rate. Interventions among families, mental health professionals, military personnel and church activists aimed at decreasing the stigma associated with mental illness and suicide may contribute to the reduction of deaths by suicide.