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National Strategy for Suicide Prevention:
Goals and Objectives for Action

GOAL 3:
Develop and Implement Strategies to Reduce
the Stigma Associated with Being a Consumer
of Mental Health, Substance Abuse, and Suicide
Prevention Services

Suicide is closely linked to mental illness and substance abuse and effective treatments exist for both. In fact, 60 to 90 percent of all suicidal behaviors are associated with some form of mental illness and/or substance use disorder (Harris & Barraclough, 1997). Despite the fact that effective treatments exist for these disorders and conditions, the stigma of mental illness and substance abuse prevents many persons from seeking assistance; they fear prejudice and discrimination. About two thirds of people with mental disorders do not seek treatment (Kessler et al.,1996). The stigma of suicide, while deterring some from attempting suicide, is also a barrier to treatment for many persons who have suicidal thoughts or who have attempted suicide.

People who have a substance use disorder also face stigma, because many people believe that abuse and addiction are moral failings and that individuals are fully capable of controlling these behaviors (Murphy, 1992). Rather, many mental health professionals, consider mental disorders, alcohol abuse, and drug abuse disorders not as signs of weakness, but as disorders that require professional assessment and clinically appropriate treatment (U.S. Department of Health and Human Services, 1999).

While the stigma attached to mental illness and addiction prevents persons at risk of suicide from seeking help for treatable problems, the stigma of suicide itself may also reduce the number of people who seek help, while adding to emotional burdens. Family members of suicide attempters often hide the behavior from friends and relatives, since they may believe that it reflects badly on their own relationship with the suicide attempter or that suicidal behavior itself is shameful or sinful. Persons who attempt suicide may have many of these same feelings. Those who have survived the suicide of a loved one suffer not only the grief of loss, but the pain of isolation from a community that may be perplexed and uninformed about suicide and its risk factors.

Historically, the stigma associated with mental illness, substance use disorders and suicide has contributed to the inadequate funding available for preventive services and to low insurance reimbursements for treatments. Until the stigma is reduced, treatable substance use and mental health problems–including those strongly correlated with suicide– will continue to go untreated, and services tailored to persons in crisis will continue to be limited. As a result, the number of individuals at risk for suicide and suicidal behavior will remain unnecessarily high.

Stigma has been identified as the most formidable obstacle to future progress in the arena of mental health (U.S. Dept. of Health and Human Services, 1999). It is a key reason that certain ethnic groups are particularly disinclined to seek treatment for mental illness or substance abuse (Sussman et al., 1987; Uba, 1994). Stigma is intense in rural areas (Hoyt et al., 1997) and it is implicated in the low percentages of youth and the elderly with mental disorders–both groups at high risk for suicidal behavior– who receive mental health services (Kazdin et al., 1997; U.S. Department of Health and Human Services, 1999).

Over the past 25 years, a principal goal shared by mental health consumer and family advocacy groups is to overcome the stigma of mental illness. These groups include The National Alliance on Mental Illness and the National Mental Health Association. Other mental health advocates, such as the American Psychological Association and the American Psychiatric Association, have also worked to reduce stigma. The publication of Mental Health: A Report of the Surgeon General represents a milestone in the Federal government's effort to reduce stigma by dispelling myths about mental illness and by providing accurate knowledge.

The objectives established for this goal are designed to create the conditions that enable persons in need of mental health and substance abuse services to receive them. There are many reasons why individuals may not receive such services, but stigma is an important factor. Stigma dissuades people from seeking mental health or substance abuse services. It is both a contributing cause and a result of society's collective devaluation of mental and substance abuse illness as compared to physical illness, such as heart disease or diabetes. The stigma of mental illness and substance abuse has resulted in the establishment of separate systems for physical health and mental health care; one consequence is that preventive services and treatment for mental illness and substance abuse are much less available than for other health problems. Moreover, this separation has led to bureaucratic and institutional barriers between the two systems that complicate the provision of services and further impede access to care. Destigmatizing mental illness and substance abuse could increase access to treatment by reducing financial barriers, integrating care, and increasing the willingness of individuals to seek treatment.

Due to the historic bias and prejudice against those with mental illnesses, health care, mental health care, and substance abuse treatment have traditionally been viewed as separate types of treatment; persons who need mental health care or substance abuse treatment avoid seeking it, and insurance companies often do not pay for it. As our Nation moves towards viewing mental illness and substance abuse disorders with the same concern and understanding as it views other illnesses, there will be a concomitant change in the importance attached to effective and available care, along with increased political support for "parity" (the financing of mental health care and substance abuse treatment on the same basis as that of other health services).

Behavior associated with mental disorders is still viewed by many persons as evidence of a character flaw rather than an illness. Consequently, disease that is treatable remains untreated because it is not perceived as disease. When people understand that mental disorders are not the result of moral failings or limited will power, but are legitimate illnesses that are responsive to specific treatments, much of the negative stereotyping may dissipate; more persons will seek treatment and the suicide rate will be reduced.

When the act of seeking services for mental health concerns is normalized, and when such care is reimbursed, a larger number of persons at risk for suicide will receive treatment. Such a change in perspective might also lead to a better integration of the separate systems of care that now exist–one for mental health, one for substance abuse, the other for primary and specialty health care.

Research indicates that suicides are more likely early in the course of certain severe mental illnesses and that persons who have required hospitalization for severe mood disorders have a substantially increased lifetime risk of suicide compared to individuals with less severe illnesses. Yet, only a minority of persons with those mental or substance use disorders seek professional help. The literature suggests that up to two-thirds of those who die by suicide are not receiving mental health or substance abuse treatment at the time of their death and that half had never seen a mental health professional (Jamison & Baldessarini, 1999; U.S. Department of Health and Human Services, 1999). Older people, for whom depression is quite prevalent and who have the highest rates of suicide in the U.S., are especially unlikely to utilize mental health services (Conwell, 1996; Hoyert et al., 1999). They tend to seek and receive health care in primary care settings, where it has been found that depression is frequently undiagnosed and untreated (Caine et al., 1996).

Members of some ethnic groups may also be reluctant to seek professional mental health care. Few treatment providers in the U.S. are knowledgeable about effective combinations of Western health care and culture- specific remedies that may enhance utilization of mental health services. Moreover, mental health services may not be available from persons who speak the language of individuals from particular ethnic groups or who understand the meaning of mental illness in the culture. Persons from many ethnic and cultural groups encounter additional barriers to access, such as lack of health insurance. Since effective treatments now exist for the major depressive disorders, and since these disorders are implicated in such a high proportion of suicides, ensuring treatment for these illnesses should reduce the suicide rate. Mood disorders are very prevalent among individuals who complete suicide, with 36-70 percent of individuals having a mood disorder at the time of death (Barraclough, Bunch, Nelson, & Sainsbury, 1974; Henriksson et al., 1993; Foster, Gillespie, McClelland, & Patterson, 1999; Rich, Young, & Fowler, 1986). Schizophrenia, certain personality disorders, and anxiety disorders in combination with other illnesses carry increased risk for suicide (Harris & Barraclough, 1997). An individual who suffers from one of these mental illnesses–especially if he or she has severe symptoms or a co-existing addictive disorder–is at increased risk of suicide (Angst et al., 1999).

Reducing stigma related to mental illness and substance abuse will increase the number of persons from all groups who receive appropriate treatment for mental disorders associated with suicide.

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