Estigma Suicidio

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r e v c o l o m b p s i q u i a t . 2 0 1 5;4 4(4):243–250
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Artículo de revisión
El complejo estigma-discriminación asociado a

trastorno mental como factor de riesgo de suicidio
Adalberto Campo-Arias a,∗ y Edwin Herazo b

a Grupo de Investigación del Comportamiento Humano, Investigaciones y Publicaciones, Instituto de Investigación del Comportamiento
Humano (Human Behavioral Research Institute), Bogotá, Colombia
b Grupo de Investigación del Comportamiento Humano, Instituto de Investigación del Comportamiento Humano
(Human Behavioral Research Institute), Bogotá, Colombia
información del artículo r e s u m e n
Historia del artículo: Introducción: Se propone el concepto “complejo estigma-discriminación asociado a trastorno
Recibido el 7 de octubre de 2014 mental” (CEDATM) para englobar los términos usados en la teoría de la atribución: estigma,
Aceptado el 14 de abril de 2015 estereotipo, prejuicio y discriminación. El CEDATM (el internalizado y el percibido) es un
On-line el 30 de mayo de 2015 fenómeno frecuente que puede explicar un porcentaje de los casos de suicidio.
Objetivo: Revisar los factores que pueden explicar la asociación existente entre CEDATM y
Palabras clave: suicidio y postular posibles mecanismos implicados subyacentes.
Estigma social Resultados: Se identificaron artículos en MEDLINE con los descriptores en inglés para
Discriminación social “estigma”, “trastornos mentales” y “suicidio” o “tasa de suicidio”. Se incluyeron artículos
Suicidio publicados entre enero de 2000 y junio de 2014. No se consideraron revisiones del tema y
Revisión estudios de casos. Los dos estudios incluidos mostraron que el estigma incrementa el riesgo
de comportamientos suicidas. Se evidenció que las personas con estigma internalizado rea-
lizaron más intentos de suicidio y que la tasa de suicidio en población general es más alta
en los países con mayor estigma percibido. Se consideró que la relación entre CEDATM y sui-
cidio se establece por mecanismos interrelacionados: un mecanismo “directo” que incluye
el CEDATM percibido y se configura como barreras de acceso a servicios y acciones en salud
mental, y un mecanismo “indirecto” que involucra el CEDATM internalizado y que incre-
menta la vulnerabilidad a episodios depresivos y comportamientos autolesivos repetidos
que pueden terminar en suicidio.
Conclusiones: El CEDATM impacta negativamente en la calidad de vida de las personas que
reúnen criterios de trastornos mentales y da cuenta de un número importante de suicidios.
Una primera vía se relaciona con el estigma percibido, que se configura como barrera de
acceso a servicios y acciones en salud mental, y una segunda ruta que incluye comporta-
mientos autolesivos repetidos que reducen la autoestima e incrementan el estrés percibido.
Se necesitan investigaciones que profundicen en el conocimiento de esta asociación.
© 2014 Asociación Colombiana de Psiquiatría. Publicado por Elsevier España, S.L.U. Todos
los derechos reservados.
Autor para correspondencia.

∗
Correos electrónicos: campoarias@comportamientohumano.org, campoarias@gmail.com (A. Campo-Arias).

http://dx.doi.org/10.1016/j.rcp.2015.04.003
0034-7450/© 2014 Asociación Colombiana de Psiquiatría. Publicado por Elsevier España, S.L.U. Todos los derechos reservados.
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244 r e v c o l o m b p s i q u i a t . 2 0 1 5;4 4(4):243–250
The Stigma-discrimination Complex Associated With Mental Disorder as

a Risk Factor for Suicide
a b s t r a c t
Keywords: Background: The concept stigma-discrimination complex associated with mental disorder
Social stigma (SDCAMD) is proposed to encompass the terms used in the attribution theory: stigma,
Social discrimination stereotype, prejudice and discrimination. SDCAMD is one of the most frequent disorders
Suicide worldwide. Internalized and perceived SDCAMD may explain a number of suicide cases.
Review Objective: To update the factors that may explain the association between SDCAMD and
suicide, and postulate possible underlying mechanisms.
Results: Articles were identified in MEDLINE using the descriptors for “stigma”, “mental
disorders” and “suicide” or “suicide rate”. Articles published between January 2000 and
June 2014 were included. Reviews and case studies were not considered. The two inclu-
ded studies showed that stigma increased the risk of suicidal behaviors. It was evident that
people who meet criteria for mental disorder and reported high self-stigma made a grea-
ter number of suicide attempts, and countries with high stigma in the general population
have a higher suicide rate. It was considered that the relationship between SDCAMD and
suicide is established by a set of interrelated mechanisms. A “direct” mechanism invol-
ving perceived stigma and is configured as a barrier to access mental health services, and
an “indirect” mechanism involving the self-stigma, which increases the vulnerability to
depressive episodes and repeated self-injurious behaviors that ultimately end in suicide.
Conclusions: The SDCAMD impacts negatively on the quality of life of people who meet cri-
teria for mental disorders, and accounts for a significant number of suicides. One way is
related to the perceived stigma that is configured as a barrier to access mental health servi-
ces and, the second one includes repeated self-injurious behaviors that reduce self-esteem
and increases perceived stress. Further research is required to increase the knowledge of
this association.
© 2014 Asociación Colombiana de Psiquiatría. Published by Elsevier España, S.L.U. All
rights reserved.
sobre los trastornos mentales, acercar y promover la asistencia

Introducción
a los servicios en salud mental y colocar el tema en la agenda
pública, acciones todas muy positivas y convenientes9,12 . Sin
Estigma, estereotipo, prejuicio y discriminación son conceptos embargo, esta manera tradicional de abordar el estigma hacia
altamente imbricados, producto de una compleja dinámica las personas con trastornos mentales deja de lado los con-
sociocultural1–4 . El estigma se configura en el momento que textos particulares y la mirada holística que una situación
un estereotipo o una idea preconcebida frente a un atributo tan compleja requiere, con el riesgo de acentuar la patolo-
o rasgo1 toma una connotación negativa (prejuicio)2,5 y que gización y medicalización de la salud mental, al alejarla del
valida la cultura hegemónica en las situaciones en que niegan bienestar social, de modelos de calidad de vida que no estén
algún derecho (discriminación) a los miembros del grupo con regidos primordialmente por el consumismo y la acumulación
la característica estigmatizada6 . de capital y de la necesidad que deberían tener las sociedades
Tradicionalmente, desde la teoría de la atribución, el de eliminar las inequidades13 .
estigma, el estereotipo, el prejuicio y la discriminación se Por lo insuficiente que resulta la explicación lineal estigma-
conciben como una secuencia lineal de estigma-estereotipo/ estereotipo/prejuicio-discriminación, los autores del presente
prejuicio-discriminación7–10 . Aunque este modelo de enten- artículo proponen el uso del constructo complejo estigma-
der el estigma es congruente y convincente, en la vida real discriminación (CED) para agrupar estos conceptos asociados
son conceptos cuya separación no es posible y, por el contrario, e inseparables. La presente revisión se ocupa del CED hacia
puede resultar funcional para el diseño de acciones y políticas las personas con trastornos mentales, por lo que se utiliza
públicas que, con el objetivo de reducir o eliminar el estigma, la denominación complejo estigma-discriminación asociado
terminan por reforzarlo a través de la invisibilización de los a trastorno mental (CEDATM) entendido como una secuen-
asuntos fundamentales, con la consecuente perpetuación del cia compleja, indivisible y en espiral de los cuatro términos,
estigma11 . Para mayor claridad puede tomarse como ejemplo como otros autores han propuesto recientemente sin dar una
el estigma hacia las personas con trastornos mentales. Se han denominación particular14–16 . No obstante, se puede ampliar
expedido normas y políticas públicas para la reducción o eli- a otros rasgos frecuentemente estigmatizados tan evidentes o
minación del estigma hacia estas personas mediante planes, manifiestos como étnico-raciales, sexuales, por discapacidad
programas, estrategias y actividades que buscaron informar física y sensorial u otras condiciones que pueden disimularse
r e v c o l o m b p s i q u i a t . 2 0 1 5;4 4(4):243–250 245
u ocultarse, como la orientación sexual o la infección por el que el CEDATM se configura por sí mismo en un factor que
VIH17–19 . considerar en personas con comportamiento suicida55 . Sin
También es importante diferenciar dos formas del embargo, el rol directo o indirecto del CEDATM en estas perso-
CEDATM. La primera es la modalidad percibida, que implica nas no se ha estudiado ampliamente.
el ejercicio de etiquetamiento y exclusión que perpetran otras El objetivo de este trabajo es proponer los conceptos de CED
personas y la sociedad a las personas que reúnen criterios y CEDATM, revisar los factores que pueden explicar la aso-
de trastorno mental2,20–22 . La segunda, la internalizada o el ciación existente entre el CEDATM y el suicidio y postular los
autoestigma-discriminación, que alude a que las personas que posibles mecanismos implicados subyacentes.
reúnen criterios de trastorno mental asimilan o aceptan como
ciertas las opiniones negativas acerca de estas condiciones Desarrollo del tema
humanas2,23 .
Lo que se propone como CEDATM es frecuente en el Algunas investigaciones exploran la asociación particular
mundo y supera en prevalencia a los relacionados con la entre estigma y discriminación relacionada con trastorno
orientación sexual y la infección por el VIH24,25 . No obs- mental y suicidio. Para conocer el estado del conocimiento
tante, tanto el CEDATM como los complejos asociados a específico, se buscaron los artículos disponibles en MEDLINE
otras características varían de acuerdo con el momento his- a través de PubMed. Se usaron los descriptores en inglés para
tórico y las diferencias culturales, económicas y sociales de “estigma” (stigma), “trastornos mentales” (mental disorders) y
las sociedades. Igualmente, la frecuencia de CEDATM guarda “suicidio” o “tasa de suicidio” (“suicide” or “suicide rate”). Se
asociación con el trastorno clínico específico implicado; por incluyeron artículos originales publicados desde el 1 de enero
ejemplo, según la forma de medición, hasta el 72% de las de 2000 hasta el 30 de junio de 2014. No se consideraron para
personas que reúnen criterios de trastornos depresivos y este análisis las revisiones del tema y los estudios de casos. Es
algo más del 85% de las personas con trastornos del espec- importante anotar que se usaron especificadores del tipo de
tro de la esquizofrenia son víctimas de alguna forma de diseño de los estudios (observacional, ecológico o transversal)
estigmatización-discriminación26,27 . para limitar aún más.
El suicidio es un fenómeno clínico complejo relacionado En la búsqueda inicial se identificaron 49 artículos; sin
con un conjunto diverso de factores de riesgo individuales, embargo, la inclusión de cada uno de los tipos de estudios
familiares, culturales, históricos, políticos y por la determina- redujo entre 0 y 5 el número de títulos posibles, por lo que se
ción social28,29 . El suicidio es un desenlace fatal que se asocia desestimó el uso de estos especificadores. De los 49 títulos,
en aproximadamente el 90% de los casos a la presencia de un se seleccionaron seis resúmenes sugestivos de las investiga-
trastorno mental30 . ciones formales. No obstante, fue necesario descartar cuatro
En general, se observa que los trastornos mentales de ellos después de la lectura, dado que dos no exploraron la
incrementan de manera estadísticamente significativa la posi- asociación de interés56,57 , uno era un estudio relacionado con
bilidad de un episodio autolesivo. El riesgo de suicidio en estigma distinto de trastorno mental58 y otro era una revisión
presencia de trastorno mental puede multiplicar de 4 a narrativa59 .
25 veces el que se observa en la población sin trastorno men- En la revisión se identificaron dos investigaciones que
tal, con excepción del trastorno del desarrollo de la capacidad exploraron la asociación entre estigma, discriminación y com-
intelectual y el deterioro cognitivo mayor31 . Los trastornos portamientos suicidas. En la primera, Assefa et al60 , en un
depresivos, del espectro de la esquizofrenia, bipolares, de grupo de 212 personas que reunían criterios de esquizofrenia
ansiedad y de personalidad explican un número importante (el 65% varones; el 72% sin pareja estable; el 71% desemplea-
de los diagnósticos formales que reúnen este grupo de perso- dos) cuantificaron estigma internalizado con la Escala para
nas, en particular, los casos en que hay comorbilidad28,30–32 . Estigma Internalizado (alfa de Cronbach = 0,92) y la historia de
A la fecha, algunos investigadores han observado que las intento de suicidio con una pregunta (¿Alguna vez se ha sen-
personas que reúnen criterios de trastornos mentales pre- tido tan desesperado/a que incluso ha intentado hacerse daño
sentan más riesgo de mortalidad temprana no solo debido o quitarse la vida?) e informaron que el 71% de los pacientes
a comportamientos suicidas, sino también relacionadas con tenían alto autoestigma y el 45% informó al menos un intento
enfermedades respiratorias, cardiovasculares, neoplásicas y suicida alguna vez en la vida; quienes presentaron alto auto-
por condiciones que afectan a la realización del proyecto de estigma mostraron el doble de riesgo de intento suicida (odds
vida de las personas o su papel en la familia, en los grupos ratio [OR] = 2,3; intervalo de confianza del 95% [IC95%], 1,3-4,1).
sociales a los que pertenece, en la comunidad en general o en En la segunda investigación, Schomerus et al61 llevaron a
el ámbito educativo y laboral33–44 . cabo un estudio ecológico con información del año 2010 de
No obstante, las variables que explican la mayor mortalidad 24 países de la Unión Europea, y cuantificaron “aceptación o
por suicidio entre las personas con trastorno mental se cono- rechazo social” como medida de estigma percibido, con la res-
cen parcialmente en número, extensión y profundidad27,30 . puesta a una de dos preguntas (¿Podría resultar difícil hablar
En los años recientes se ha prestado mayor atención al con alguien con un problema de salud mental? y ¿No tendrías
estigma asociado a trastornos mentales y su impacto en la ningún problema en hablar con alguien con un problema de
calidad de vida45–48 . Se plantea que las actitudes y acciones salud mental?), y la tasa de suicidio (lesiones autoinfligidas y
relacionadas con el CEDATM, como en otros complejos de suicidios, según los registros de la décima versión de la Clasifi-
estigma-discriminación, las víctimas las perciben como ame- cación Internacional de Enfermedades). Los autores omitieron
nazantes, como otro estresor, y se traduce en una respuesta la información sobre la frecuencia de estigma y las tasas de
fisiológica, psicológica y comportamental49–54 . De tal suerte suicidio; no obstante, mostraron que el estigma se relacionaba
directamente con la tasa de suicidio (coeficiente beta estan- internalizado, y con ello la posibilidad de intentos de suicidio
darizado, ␤ = 0,46). El beta estandarizado indica que, por cada y suicidio consumado69,72 .
unidad que se incrementa el estigma, la tasa de suicidio en la Adicionalmente, los pacientes con historia de intentos de
población aumenta en 0,46. suicidio suman un nuevo complejo estigma-discriminación,
En resumen, estas investigaciones mostraron que el ahora relacionado con el intento o los intentos de suicidio
estigma, tanto el internalizado como el percibido, puede ser repetidos81–83 . Este complejo estigma-discriminación se con-
una variable intermedia o mediadora en la asociación obser- figura como barrera de acceso a servicios de salud mental
vada entre trastorno mental y los comportamientos suicidas e incumplimiento del plan terapéutico63,64 . Los obstáculos
y el suicidio consumado. incrementan, sin duda, el riesgo de suicidio en este grupo de
personas16,24,71 . El modelo para estos mecanismos se muestra
en la figura 1.
Es preferible considerar el conjunto estigma-estereotipo/
Discusión prejuicio-discriminación como un “complejo”, más que con-
ceptos interrelacionados. Por una parte, existen diferentes
Según el resultado de los estudios analizados y al retomar la aproximaciones, no mutuamente excluyentes, para precisar
propuesta de los autores de que el estigma visto en forma ais- el origen del complejo: constitucional, económico, psicoló-
lada no dice mucho sobre la realidad que viven las personas gico, institucional o evolutivo84 , y por otra, el complejo incluye
que sufren discriminación, como consecuencia del estigma y varios componentes: cognitivo, afectivo y conductual, con una
el estereotipo/prejuicio, sino que son un complejo (CEDATM), base biológica que los explica, dentro de un contexto social y
en el que sus componentes son inseparables física, emocional cultural particular49–53,84,85 .
e históricamente, puede afirmarse que el CEDATM está aso- Aunque se acepta que los CED asociados a diferentes
ciado a la presentación de comportamientos suicidas y es un características socialmente degradadas comparten algunos
factor de riesgo de suicidio. puntos de convergencia o similitudes20,22,23 , es necesario
Las observaciones anteriores permiten postular un par tener presente que el CEDATM muestra algunos matices
de posibles mecanismos involucrados en la relación entre distintivos, particulares y relevantes4 . El CED es mayor si
el CEDATM y el suicidio. Sin duda, estos mecanismos están el rasgo, la situación o la condición señaladas como inde-
ampliamente interrelacionados, con estadios comunes o com- seables son muy evidentes o visibles, se piensa estar bajo
partidos. el control voluntario del señalado o si se percibe como
Primero se propone una vía expedita o mecanismo peligroso4,22,23 .
“directo”, que implica que el CEDATM percibido conlleva una En un número importante de personas que reúnen crite-
pérdida de estatus y suele afrontarse con aislamiento social, rios de trastorno mental, en especial los llamados trastornos
deterioro en las redes de apoyo y reducción de oportunidades mayores, la visibilidad de la condición es alta, por los sínto-
laborales, sociales, etc. Se configuran así barreras de acceso mas en sí mismos o los efectos secundarios de la medicación
a servicios en salud mental62,63 . Las personas sintomáticas utilizada para controlarlos4,25 .
o sus familiares con frecuencia ocultan el sufrimiento oca- De la misma forma, el conjunto de imaginarios y repre-
sionado por los trastornos mentales y, con ello, se retrasa la sentaciones sociales de los trastornos mentales da cuenta
consulta a profesionales de la salud mental64 . Estas demoras de que las personas no pueden controlar los síntomas y, en
incrementan de manera importante la gravedad del episodio consecuencia, se califican como perezosas, manipuladoras o
y, en consecuencia, se acrecienta el riesgo de suicidio28,30–32 . afectadas de una deficiencia en la personalidad26,27 . Es fre-
Asimismo, una vez las personas asisten a valoración médica cuente que las personas legas e incluso los profesionales de la
es habitual el rechazo del diagnóstico formal y los posi- salud con poca experiencia en salud mental no consideren que
bles factores etiológicos que llevan al incumplimiento del los “trastornos” mentales sean condiciones objeto de aten-
plan terapéutico, ya sea psicoterapia o farmacoterapia62–64 . El ción para el sistema de salud, a diferencia de las “verdaderas
incumplimiento terapéutico es la principal causa de recaídas, enfermedades” (físicas), por lo que persisten las explicacio-
recurrencias y rehospitalizaciones de personas que reúnen nes mágicas o pintorescas y la fragmentación del concepto de
criterios de trastorno mental65–67 . La falta de adhesión a las salud4,11,22 .
recomendaciones profesionales reagudiza los síntomas y, con Finalmente, el CEDATM guarda relación con la alta peligro-
ello, se eleva el riesgo de suicidio. El suicidio es la peor con- sidad que se endilga a las personas que reúnen criterios de
secuencia del incumplimiento terapéutico58,68 y también del trastorno mental. Por lo general, se relacionan erróneamente
CEDATM69 . los trastornos mentales con mayor frecuencia de comporta-
Segundo, se plantea una ruta más intrincada, un meca- mientos violentos, hacia otras personas y contra sí mismos,
nismo “indirecto” que involucra el CEDATM internalizado que que cuando no hay diagnóstico formal de trastorno mental, lo
incrementa la predisposición de los pacientes a reunir cri- que posiblemente se relacione con el origen histórico de la psi-
terios de un episodio depresivo mayor70,71 . Los pacientes quiatría, vinculada al sistema judicial como un componente
con alto CEDATM internalizado expresan con mayor fre- de las evaluaciones forenses para determinar la responsabili-
cuencia ideas de minusvalía, baja autoeficacia, desesperanza, dad criminal o legal21,26,86–88 .
deterioro social, desempleo y dificultades para iniciar o man- Estas peculiaridades de los trastornos mentales se arti-
tener una relación de pareja si así lo desearan, es decir, un culan para negar la solidaridad a las personas que reúnen
deterioro general de la calidad de vida72–78,46,79,80 . A mayor criterios y la poca respuesta de las instituciones o de la socie-
número de episodios depresivos, se eleva el nivel de CEDATM dad en general (capital social)89,90 para mostrar benevolencia y
Trastorno mental
Complejo
estigma-discriminación
relacionado con
trastorno mental
Estigma percibido Estigma internalizado
Baja autoestima
Pérdida de estatus
Aislamiento
Pobre red de apoyo
Escasas oportunidades Episodio depresivo Deterioro
Comportamientos
autolesivos
Complejo
Barrera de acceso estigma-discriminación
a servicios y acciones relacionado con
de salud mental comportamientos
suicidas
Suicidio
Figura 1 – Modelo de la asociación entre el complejo estigma-discriminación relacionado con trastorno mental y suicidio.
atender las necesidades de estos colectivos, con la persistencia consolidación de la medicalización de la vida cotidiana y de
del CEDATM91 . la salud mental101–103 . La medicalización ha tenido un efecto
Actualmente, la prevención del suicidio es un proceso com- contraproducente, pues se ha convertido en otra fuente de
plejo y desalentador92–94 . La estimación y la cuantificación CEDATM. El mero conocimiento de la implicación de facto-
del riesgo son inexactas e imprecisas95,96 , dado que pocas res biológicos en la presentación de estos padecimientos no
acciones en salud pública han mostrado efectos positivos en modifica sustancialmente los mitos y otros imaginarios o
la prevención del suicidio, la educación del personal sanita- representaciones sociales negativas101,102 .
rio, especialmente médico, en el diagnóstico y el tratamiento Es indiscutible la necesidad de conocer la frecuencia y las
adecuado de los episodios depresivos, el control del acceso a variables asociadas al CEDATM, internalizado y percibido, ya
métodos suicidas, el seguimiento adecuado de personas con que la presencia de un estigma potencia otros estigmas104 . En
intento suicida reciente y la regulación de los medios de comu- países en vía de desarrollo, como Colombia, se debe conocer el
nicación en el manejo informativo de los eventos suicidas en desempeño de los instrumentos disponibles para la cuantifi-
la comunidad son fundamentales97–100 . cación de este fenómeno en personas que reúnen criterios de
Por su lado, la respuesta institucional orientada a reducir trastornos mentales y en la población general como una forma
el CEDATM se ha centrado en dos puntos fundamentales: el eficaz de detectar la situación problemática105 . Se esperaría
continuo proceso de cambios en la nominación, el uso lin- observar una alta prevalencia de este fenómeno en América
güístico del concepto de trastorno mental, para minimizar el Latina106,107 .
estigma (por ejemplo, el cambio entre el DSM-IV-TR y el DSM-5 Asimismo, una de las principales medidas en la preven-
de retraso mental por trastorno del desarrollo de la capacidad ción del suicidio debe ser la comprensión y la reducción del
intelectual y demencia por deterioro cognitivo mayor31,85 ), y CEDATM internalizado, dado que supone un estresor para las
la insistencia en llamar a estos sufrimientos humanos “tras- personas que reúnen criterios de trastorno mental9,12,13,108,109 .
torno” y no “enfermedades”, dados la poca claridad y el
escaso conocimiento de las verdaderas naturaleza y causas
de estos padecimientos101,102 . La segunda se ha centrado en el Conclusiones
manejo de la información sobre los trastornos mentales, en
poner al alcance de los colectivos y comunidades las pers- El estigma, el estereotipo, el prejuicio y la discrimi-
pectivas y los hallazgos en neurociencia, en un proceso de nación relacionados con los trastornos mentales deben
considerarse como un “complejo”. La visibilidad de los sínto- 12. Parcesepe AM, Cabassa LJ. Public stigma of mental illness in
mas, el supuesto control que se puede tener de los síntomas the United States: a systematic literature review. Adm Policy
y la percepción de peligrosidad son características distintivas Ment Health. 2013;40:384–99.
13. Saxena S, Thornicroft G, Knapp M, Whiteford H. Resources
del CEDATM.
for mental health: scarcity, inequity, and inefficiency.
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Stigma as a cause of suicide
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B R I T I S H J O U R N A L O F P S YC H I AT RY ( 2 0 0 3 ) , 1 8 3 , 1 7 0 ^ 1 7 5
Correspondence differential diagnosis. British Journal of Hospital

Medicine,
Medicine, 53,
53, 582^586.
Romanucci-Ross, L., Moerman, D. E. & T Tancredi,
ancredi, D.
EDITED BY STANLEY ZAMMIT (1991) The Anthropology of Medicine: From Culture to
Method.
Method. New York:
York: Bergin and Garvey.
Contents & Explanatory models in psychiatry & Ethnic differences in prisoners:
describing trauma and stress & Specialistcare
Specialist care for prisoners? & Consent and treatment in K. Bhui, D. Bhugra Department of Psychiatry,
prisons & Amisulpride-induced mania in a patient with schizophrenia & Changing use of Barts and the London, Medical Sciences Building,
Mile End Road, London E1 4NS,UK
ECT & Inappropriate use of psychostimulants & Stigma as a cause of suicide & Social
capital and mental health v. objective measures of health inThe Netherlands
Ethnic differences in prisoners:
describing trauma and stress
Explanatory models in psychiatry disease, it should not be hindered. Dein I read with interest the two articles by Coid
appears to show contempt for a territory et al (2002a
(2002a,b) but was puzzled by the use of
Dein (2002) comments on our editorial on in which psychiatrists are not expert (pos- the term ‘post-traumatic stress’ to describe
explanatory models (Bhui & Bhugra, session and exorcisms: see Pereira et al, al, the psychiatric response of prisoners who
2002), but fails to apprehend the conceptual 1995), and certainly does not show the had experienced adverse or negative life
flaws in his assertions, promotes a compla- respect for cultural beliefs that is part and events. The authors use the term post-
cent attitude to the challenges of cultural parcel of a scientific or anthropological traumatic stress without specifying whether
psychiatry, and is threatened by a patient’s study of healing, let alone clinical practice. they are referring to the specific diagnosis of
explanatory model that differs from his His approach smacks of a patriarchal con- post-traumatic stress disorder (PTSD), a
own. Dein agrees with us that explanatory viction that the diagnosis is more than a recognised psychiatric condition in the
models are not stable, and are dynamic, theory, and that psychiatric interventions DMS–IV (American Psychiatric Associa-
complex, shifting entities, making more re- are not to be questioned. To diagnose is tion, 1994) or simply a vague amalgam of
search necessary for any consistent theory to classify and to predict a course and treat- neurotic symptoms which the authors infer
about their role in routine clinical practice. ment based on the vagaries of statistics and are a consequence of the various stresses
None the less, their role in improving experience: it is to take what can be a the prisoners experienced in their lifetimes.
understanding of patients’ cultural world serious risk (Romanucci-Ross et al,al, 1991). The confused terminology in this respect,
views has not previously been in dispute Although he cites a single example, it is which is present in both papers, is unhelpful
(American Psychiatric Association, 2002). not the case that the evidence base of tra- in assessing what precisely is psychiatrically
Although Dein gives greater weight to ditional healing approaches are researched wrong with these prisoners. A Criterion A
behavioural expressions of explanatory to the levels of esoteric knowledge found trauma, that is a trauma that may precipi-
models, he does not question whether ex- in biomedicine, except for, perhaps, acu- tate PTSD in some individuals, is specifi-
planatory models can or should be con- puncture and Ayurveda where there is a cally defined and described in the DSM–IV
sidered as a psychological construct of growing literature. People will always be as an event in which the person experiences,
the individual, or as a group or social– keen to try anything that helps them, bio- witnesses or is confronted with an event or
behavioural phenomenon, or both. Each of medicine or culturally sanctioned tradition- events that involves actual or threatened
these conceptualisations is certainly dis- al therapies. Surely he does not mean that death or serious injury to the self or to
torted by theorising more concrete, but we as psychiatrists have nothing to learn others, and to which the individual responds
more easily understood, expressions of about treating illness from the traditional with intense fear, helplessness or horror.
explanatory models. Contrary to the histor- and complementary sector. Our view is The experiences that were screened for in
ical anthropological paradigm, it is not we have plenty to learn and research. Elicit- the original study by Singleton et al (1998)
useful to psychiatric practice if valuable ing explanatory models is a beginning of would not normally be considered to repre-
anthropological critiques simply ignore psy- the process in consultations and offers an sent a Criterion A event, but merely nega-
chological and non-behavioural data. More easily understandable method of learning tive or adverse life events which have no
worryingly, Dein assigns a patriarchal role about a patient’s culture. However, Dein’s specific aetiological links with any distinct
to the psychiatrist, a role that cannot lead view appears to be that we know enough, clinical diagnosis. The experiences included
to a collaborative therapeutic relationship. and need not discover more. We are by the authors in their screening include bul-
It seems Dr Dein is not prepared to accept surprised at this view and cannot agree. lying and marital separation, which do not
that a patient may pursue his or her own constitute Criterion A events for the pur-
explanatory model and associated inter- American Psychiatric Association (2002) Cultural pose of making a PTSD diagnosis. Similarly,
ventions, alongside those recommended by Assessment in Clinical Psychiatry.Washington,
Psychiatry.Washington, DC: many other traumatic experiences were not
American Psychiatric Publishing.
the psychiatrist. A fuller discussion of these apparently screened for by the authors, such
alongside the psychiatrist’s own models Bhui, K. & Bhugra, D. (2002) Explanatory models for as rape or adult sexual assault, combat,
allows for a shared vision of treatment and mental distress. Indications for clinical practice and being assaulted in the street (although vio-
research. British Journal of Psychiatry,
Psychiatry, 181,
181, 6^7.
recovery. lence in the home or at work are included).
Why is an exorcism problematic for the Dein, S. (2002) Transcultural psychiatry (letter). British Thus, the selection, definition and descrip-
psychiatrist? It is not in the realms of psy- Journal of Psychiatry,
Psychiatry, 181,
181, 535^536. tion of these events as traumatic is mislead-
chiatric knowledge or skills, and if helpful Pereira, S., Bhui, K. & Dein, S. (1995) Making ing, while the inclusion of negative life
for recovery from illness, rather than sense of ‘possession states’: psychopathology and events that are clearly more traumatic
17 0
CO
ORR R E S P ON
ONDD ENC E
makes the interpretation of any resulting Hospital Medical School, Jenner Wing,Cranmer
Wing, Cranmer with the Prison Service has set out, in detail,
phenomenology extremely difficult. Terrace, London SW17 0RE,UK good practice guidelines for providing care
It is also clear from the original publica- to both competent and incapacitated adult
tion by Singleton et al that no specific prisoners. These outline circumstances in
assessment for PTSD was carried out, Specialist care for prisoners? which prisoners who lack capacity can
although validated and reliable instruments In his recent editorial on mental health in receive treatment. We have found this
for this exist (e.g. the Clinical Assessment prisons Dr Reed (2003) urges, understand- very helpful in developing protocols for
for PTSD, Blake et al (1995) or the ably and in most cases correctly, that the treatment in the prisons we visit.
Posttraumatic Stress Symptoms Interview quicker that patients with psychosis are The development of policies and proto-
(PSSI) or Posttraumatic Stress Symptoms transferred to specialist psychiatric care, cols will assist in establishing who, when
Self-Report (PSS–SR), Foa et al (1993)). the better. and in which circumstances incapacitated
The authors did a partial screen for a few However, there are prisoners with prisoners may be treated and allow us to
recognised PTSD symptoms, such as re- schizophrenia, willing to take medication, be more confident when making these
experiencing and avoidance, but there was who survive reasonably comfortably in the difficult decisions.
no systematic assessment of the condition prison milieu. Their great fear is that they
that would have allowed them to diagnose will be transferred to a special psychiatric
Department of Health (2002) Seeking Consent:
the full disorder. It should be recognised hospital; ‘nutted off’ in prisonspeak. They Working with People in Prison.
Prison. London: Department of
that PTSD is a major psychiatric disorder have reason to fear a transfer, for it effec- Health.
that constitutes a serious burden for the in- tively exchanges a finite sentence for an in-
dividual and for society (Kessler, 2000). A definite one. In the case of those serving a Earthrowl, M., O’Grady, J. & Birmingham, L. (2003)
diagnosis of PTSD has implications in terms life sentence, it means their fate is in the Providing treatment to prisoners with mental disorders:
of assessing the individual’s risk and in hands of a mental health review tribunal
development of a policy. Selective literature review and
expert consultation exercise. British Journal of Psychiatry,
Psychiatry,
terms of treatment recommendations. It is rather than the Parole Board, the latter, 182,
182, 299^302.
important that the term post-traumatic they believe, being less cautious in recom-
stress should not be confused or conflated mending discharge. As an ex-member of I. Qurashi Gulid Lodge,Whittingham Lane,
with the term ‘post-traumatic stress dis- both organisations, I would agree with Preston PR3 2AZ,UK
order’. The description of post-traumatic them.
stress made by Coid et al cannot be evalu- So, while prison is obviously bad for
ated without deconstructing more precisely people with mental illness, hospital is
what this means. As there are now well-re- sometimes worse. Authors’ reply: We fail to understand Dr
cognised instruments to assess PTSD and
Qurashi’s comment that ‘separate legisla-
lifetime experience of traumatic events in Reed, J. (2003) Mental health care in prisons. British
tion is therefore unnecessary’. Our paper
a range of settings, without these being Journal of Psychiatry,
Psychiatry, 182,
182, 287^288.
sets out a policy for providing treatment
used then terms such as post-traumatic
A. Gibson correspondence c/o the British Journal to people with mental disorder based on
stress should be avoided.
of Psychiatry,
Psychiatry, 17 Belgrave Square, London SW1X common law (Earthrowl et al, al, 2003). We
8PG,UK are not proposing separate legislation.
American Psychiatric Association (1994) Diagnostic
and Statistical Manual of Mental Disorders (4th edn) Dr Qurashi also mentions that we ap-
(DSM ^ IV).Washington, DC: APA. Consent and treatment in prisons pear to have overlooked recent guidance
D., Weathers, F., Nagy, L., et al (1995) The
Blake, D. D.,Weathers, from the Department of Health (2002).
I read the article by Earthrowl et al (2003)
development of a clinician administered PTSD scale. The Department of Health guidelines were
Journal of Traumatic Stress,
Stress, 8, 75^90.
with interest. The issue of providing treat-
produced in July 2002, after our paper
ment to prisoners, who are frequently in-
Coid, J., Petruckevitch, A., Bebbington, P., et al was accepted for publication.
capable of consenting, will not be
(2002a) Ethnic differences in prisoners. 1: Criminality
(2002a These guidelines provide guidance on
and psychiatric morbidity. British Journal of Psychiatry,
Psychiatry, unfamiliar to psychiatrists providing men-
establishing capacity but, in our opinion,
181,
181, 473^480. tal health care in these establishments.
they do not tackle the practical issues relat-
(2002b) Ethnicdifferencesin
_ , _ , _ , et al (2002b Ethnic differencesin prisoners. Although the authors correctly state that
ing to the management of prisoners with
2: Risk factors and psychiatric service use. British Journal there is no legislative framework for pro-
of Psychiatry,
Psychiatry, 181,
181, 481^487. mental disorder in any great detail, they
viding treatment for mental disorders in
do not deal with the ethical issues sur-
Foa, E. B., Riggs, D. S., Dancu, C.V., et al (1993) prisons, this may be slightly disingenuous.
rounding the provision of an equivalent ser-
Reliability and validity of a brief instrument for assessing The current legislative framework that pro-
posttraumatic stress disorder. Journal of Traumatic Stress,
Stress, vice in prisons adequately and detailed
vides for the treatment of mental disorders,
6, 459^473. guidance on making a concerted effort to
namely the Mental Health Act 1983, is
Kessler, R. G. (2000) Posttraumatic stress disorder: the obtain treatment under the Mental Health
clear that prison health-care wings are not
burden to the individual and to society. Journal of Clinical Act in hospital before proceeding with
Psychiatry,
Psychiatry, 61 (suppl. 5), 4^12. hospitals. It follows that any treatment that
treatment under common law is lacking.
is administered forcibly must be consistent
Singleton, N., Meltzer, H. & Gatward, R. (1998) In our view, these are serious omissions.
with common law. Separate legislation is
Psychiatric Morbidity Among Prisoners in England and
Wales.
Wales. London: Stationery Office. therefore unnecessary.
They also appear to have overlooked Declaration of interest
G. Mezey Forensic and Personality Disorder recent guidance on this matter. The Depart- J.O. is a member of the Department of
Group, Department of Psychiatry, St George’s ment of Health (2002) in collaboration Health Prison Expert Group.
171
C O R R E S P ON D E N C E
Department of Health (2002) Seeking Consent: No other concomitant medication was therapy (ECT) use not mentioned by Eranti
Working with People in Prison.
Prison. London: Department of
used. The delay in development of overt & McLoughlin (2003) in their recent
Health.
manic symptoms may reflect having to editorial.
Earthrowl, M., O’Grady, J. & Birmingham, L. (2003) overcome a baseline SANS score of 68. The use of ECT without consent has
Providing treatment to prisoners with mental disorders:
development of a policy. Selective literature review and The mechanism of action of mood not declined at all since 1985. There were
expert consultation exercise. British Journal of Psychiatry,
Psychiatry, changes induced by atypical antipsychotics 3362 people given ECT without their con-
182,
182, 299^302. is unknown, with speculation centring ex- sent under section 58 of the Mental Health
clusively on a 5-HT2a : D2 economy. Lane Act 1983 in England and Wales in the 2-
L. Birmingham, J. O’Grady University of et al (1998) argue that a higher ratio will in- year period 1985–87, 4454 in 1987–89
Southampton School of Medicine,Community crease frontal dopamine release, whereas and 4463 in 1999–2001, with little change
Clinical Sciences Research Division, Ravenswood
others point to the combined blockade en- in the years between (Mental Health Act
House, Medium Secure Unit,Knowle, Fareham,
hancing the ability of 5-HT1a to release Commission, 1988–2002).
Hampshire PO17 5NA,UK
frontal dopamine (Ichikawa et al, al, 2001). It was the 1970s that saw the greatest
These theories do not explain the manico- decline in ECT use, from an estimated
genic effects of amisulpride, which has no 60 000 courses in Great Britain in 1972 to
Amisulpride-induced mania in a serotonin affinity. I propose that the ability 30 000 in 1979 (Pippard & Ellam, 1981).
patient with schizophrenia of low doses of amisulpride to differentially The decline in ECT use over the past 20
Numerous case reports of atypical antipsy- block presynaptic D2 and D3 autoreceptors years or so has been marked by regional
chotics inducing hypomanic/manic symp- enhances dopamine transmission in the variations. While in England ECT use fell
toms have been published; most concern frontal cortex and can lead to the develop- fairly steadily during the 1980s, in Scotland
the use of risperidone and olanzapine ment of manic symptoms in susceptible it remained fairly constant during the 1980s
(Aubry et al,
al, 2000), but quetiapine (Benaz- subjects. Presumably this mechanism con- and early 1990s and then fell by about a
Author:
zi, 2001) and ziprasidone (Lu et al,al, 2002) tributes to its antidepressant efficacy, for half in the mid-1990s (Freeman et al, al, Col. 1:
written
have also been implicated. A literature which it is used in many countries. The the- 2000). In the East Anglian region ECT use permission
for
search using Medline and PubMed revealed ory implies induction of manic features at actually increased during the 1980s Sanofi-Synthe-
labo needed
no such reports associated with amisul- low doses only. (Pippard, 1992).
pride. Although the manufacturer has accu- I think it is hard to reconcile these facts
mulated a small number of reports of manic Declaration of interest with the authors’ suggestion that new
symptoms developing during amisulpride B.P.M. works for ORYGEN, which has drugs, improvements in patient care and
treatment, a recent internal review con- received an unrestricted educational grant better appreciation of the indications for
cluded that no causality could be from Sanofi-Synthelabo. ECT are responsible for the decline in
established (Sanofi-Synthelabo, personal ECT; although this would be the most re-
communication, 2002). I report a case of Andreasen, N. C. (1982) The Scale for the Assessment of spectable explanation for the decline in
amisulpride-induced mania. Negative Symptoms.
Symptoms. Iowa, IA: University of Iowa. use of a treatment which is still described
A 17-year-old female with a 4-year his- Aubry, J.-M., Simon, A. E. & Bertschy, G. (2000) as safe, effective and life-saving – especially
Possible induction of mania and hypomania by olanzapine
tory of schizophrenia was commenced on and risperidone: a critical review of reported cases.
since the textbook indications for its use
amisulpride for persistent negative symp- Journal of Clinical Psychiatry,
Psychiatry, 61,
61, 649^651. have changed little over the past two or
toms. It was cross-titrated with olanzapine, Benazzi, F. (2001) Quetiapine-associated hypomania in three decades. Is it really the case that fewer
over a 4-week period, to 400 mg. She con- a woman with schizoaffective disorder. Canadian Journal people need ECT nowadays – or was it gi-
of Psychiatry,
Psychiatry, 46,
46, 182^183.
tinued taking citalopram 20 mg, which ven needlessly to large numbers of people
Ichikawa, J., Ishii, H., Bonaccorso, S., et al (2001)
had been started 6 months previously on in the recent past? Since no research into
5-HT2a and D2 receptor blockade increases cortical
the basis that her negative symptoms could DA release via 5-HT1a receptor activation: a possible the reasons for the decline in the use of
be secondary to a masked depression. On mechanism of action of atypical antipsychotic-induced ECT has been done, it remains impossible
commencement of amisulpride her negative cortical dopamine release. Journal of Neurochemistry,
Neurochemistry, 76,
76, to answer this question with any certainty.
1521^1531.
symptoms, as rated on the Scale for the As-
Lane, H.Y., Lin,Y. C. & Chang, W. H. (1998) Mania
Chang,W. Eranti, S.V. & McLoughlin, D. M. (2003)
sessment of Negative Symptoms (SANS; induced by risperidone: dose related? Journal of Clinical Electroconvulsive therapy ^ state of the art. British
Andreasen, 1982), rapidly and linearly im- Psychiatry,
Psychiatry, 59,
59, 85^86. Journal of Psychiatry,
Psychiatry, 182,
182, 8^9.
proved. Her mood, however, continued to Lu, B.Y., Lundgren, R., Escalona, P. R., et al (2002) Freeman, C. P. L., Hendry, J. & Fergusson, G. (2000)
rise and by 3 months she had developed a A case of ziprasidone-induced mania and the role of National Audit of Electroconvulsive Therapy in Scotland.
Scotland.
5-HT2a in mood changes induced by atypical Edinburgh: Scottish Office.
manic episode without psychotic features. antipsychotics. Journal of Clinical Psychiatry,
Psychiatry, 63,1185^1186.
63,1185^1186.
She exhibited insomnia, hyperactivity, dis- Mental Health Act Commission (1988^2002) Biennial
Reports (2nd to 9th). London: Stationery Office.
tractibility, disinhibition and an abnor- B. P. Murphy Early Psychosis Prevention and
mally and persistently elevated mood that Pippard, J. (1992) Audit of electroconvulsive treatment
Intervention Centre,ORYGEN Youth Health, Locked
in two National Health Service regions. British Journal of
continued despite the immediate cessation Bay 10 (35 Poplar Road), Parkville,Victoria, Australia Psychiatry,
Psychiatry, 160,
160, 621^637.
of citalopram. There was no evidence of 3052
_ & Ellam, L. (1981) Electroconvulsive Treatment in
substance misuse or akathisia. These fea- Great Britain 1980.
1980. London: Gaskell.
tures improved after halving the amisul-
pride to 200 mg and re-introducing Changing use of ECT S. Kemsley Address supplied; correspondence
olanzapine 15 mg. They fully remitted I would like to point out a couple of facts c/o the British Journal of Psychiatry,
Psychiatry, 17 Belgrave
within days of stopping the amisulpride. about the decline in electroconvulsive Square, London SW1X 8PG,UK
17 2
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ORR R E S P ON
ONDD ENC E
Authors’reply: Sue Kemsley has raised some Inappropriate use adolescent disorders? British Journal of Psychiatry,
Psychiatry, 182,
182,
284^286.
important issues regarding ECT. The use of of psychostimulants
ECT without consent has not declined in Rey & Sawyer (2003) ask ‘Are psychosti- Runnheim,V. A. (1996) Medicating students with
absolute numbers since 1985 but, as dis- emotional and behavioural disorders and ADHD: a state
mulant drugs being used appropriately to survey. Behavioural Disorders,
Disorders, 21,
21, 306^314.
cussed in our editorial (Eranti & McLough- treat child and adolescent disorders?’ –
lin, 2003), the total number of patients the answer is no. Like most articles on psy- Timimi, S. (2002) Pathological Child Psychiatry and the
receiving ECT has substantially fallen dur- Medicalization of Childhood.
Childhood. Hove: Brunner-Routledge.
chostimulants, they avoid discussion of the
ing this period. Little research has been di- fundamental question that needs tackling S. Timimi Child and Adolescent Mental Health
rected at understanding this change in the for their conclusions to have any mean- Services, Ash Villa,Willoughby Road, Sleaford,
pattern of ECT use. One possibility is that ing – is attention-deficit hyperactivity dis- Lincolnshire NG34 8QA,UK
there exists a core group of patients with order (ADHD) a valid medical disorder?
severe depressive illness and possible psy- The answer is no (see Timimi, 2002). This
chosis that requires treatment with ECT, disorder is best understood as a cultural
while the decline in use predominantly oc- Stigma as a cause of suicide
creation. Rey & Sawyer illustrate how
curs in people with less severe illness. So deeply practice in this area is influenced We read with great interest the article by
why has the use of ECT declined in this by cultural dynamics. They show how Eagles et al (2003) in which, among the
latter group? there are large variations in the way diag- various interventions discussed to prevent
As we have already suggested, we be- nostic criteria are used both between coun- suicide, it was suggested that according to
lieve that this is due to historical changes tries (not surprisingly, they only mention patients’ opinions there should be a de-
in general psychiatry, especially psycho- Western ones) and within them. They show crease in the stigma attached to psychiatric
pharmacology. One has to bear in mind that there are also large variations in the illness. We share that opinion and suggest
that, following its introduction in 1938, way psychostimulants are used. that another goal of suicide prevention is
ECT was one of the first truly effective Children are already the losers here. the reduction of the stigma attached to
treatments for severe debilitating psychi- There are reports of some primary schools suicide.
atric disorders and thus its use rapidly be- where nearly 40% of the students were tak- The term stigma refers to a mark that
came widespread (Fink, 2001). We are ing psychostimulants (Runnheim, 1996). denotes a shameful quality in the individual
currently investigating trends in ECT prac- Rates of diagnosis of ADHD and subse- so marked. Mental illness is widely consid-
tice over the past 50 years in the Maudsley quent medication use continue to rise alar- ered to be such a quality, an assumption
and Bethlem Royal Hospitals in south Lon- mingly in most Western countries. This is supported by a number of beliefs such as
don. Its use peaked in 1956 when 34% of a massive, dangerous and scandalous ex- the association between mental illness and
admissions were treated with ECT. This periment in which millions of children are irrational and unpredictable violence as
rate fell steadily thereafter to 30% in being exposed to highly toxic, addictive portrayed by the media and the notion that
1959, 21% in 1968 and 5% in 1987. It is and brain-disabling drugs whose medium- mental illness is not a ‘true’ illness like or-
interesting to note here that imipramine and long-term efficacy and safety have not ganic disease. And yet, people do fear men-
was introduced in 1958, coinciding with been established (Breggin, 2002). The only tal illness and do not know how to avoid it
the beginning of this decline in use of winner is the profit margin of the by following the types of precautions and
ECT. Similarly, ECT use further declined pharmaceutical industry. guidelines available for so many organic
after the introduction of fluoxetine, the first I realise this is emotive language, but disorders.
of the selective serotonin reuptake inhibi- then the business of what values we hold Not only does the stigmatisation of
tors, in 1988, such that by 1991 2% of ad- when it comes to children is too important mental illness prevent people from seeking
missions received ECT. Currently, less than to allow us to hide behind dry, detached, treatment, which in turn exposes them to a
1% of admissions are treated with ECT and academic pretence. We live in a culture that greater risk of suicide, but also suicide can
nearly 90% of these have a diagnosis of has a deep intolerance for children. This is appear to be the best solution for a stigma-
major depressive disorder, which is well- at the heart of why we are labelling physi- tised individual. A number of environ-
established as being the main indication cally healthy children with fictional medical ments can be traced where this process
for contemporary ECT (Carney et al, al, disorders. Doctors become a symptom of takes place. In the family, the family mem-
2003). this intolerance, not part of the solution. bers’ relationship to the patient may affect
This is all so unnecessary. For years I the extent to which the patient’s stigma is
Carney, S., Cowen, P., Geddes, J., et al (2003) Efficacy
and safety of electroconvulsive therapy in depressive have been working with these children transferred to the family members, as in
disorders: a systematic review and meta-analysis. Lancet,
Lancet, and their families using diverse perspectives the case of schizophrenia (Phelan et al, al,
361,
361, 799^808. 1998). In such extreme cases, difficulties
based on a more humanitarian value system
Eranti, S.V. & McLoughlin, D. M. (2003)
(Timimi, 2002). Not only are my clients in dealing with a chronic disease, which
Electroconvulsive therapy ^ state of the art. British
grateful for this, they often recommend often results in relapses, hospitalisations
Journal of Psychiatry,
Psychiatry, 182,
182, 8^9.
others to come and see me. and social impairment, leads family mem-
Fink, M. (2001) Convulsive therapy: a review of the
first 55 years. Journal of Affective Disorders,
Disorders, 63,
63, 1^15. bers to stigmatise the patients. They be-
have in a way that may lead the patient
Breggin, P. (2002) The Ritalin Fact Book.
Book. Cambridge,
S.V. Eranti, D. M. McLoughlin Institute of to assume that suicide might be a solution
MA: Perseus.
Psychiatry, Section of Old Age Psychiatry,Box PO70, for their situation. Family members may
De Crespigny Park, Denmark Hill, London SE5 8AF, Rey, J. M. & Sawyer, M. G. (2003) Are psychostimulant also unconsciously believe that suicide
UK drugs being used appropriately to treat child and might be a solution. In the hospital, staff’s
17 3
C O R R E S P ON D E N C E
attitudes towards patients who are at risk Phelan, J. C., Bromet, E. J. & Link, B. G. (1998) Data were part of a three-level structure
Psychiatric illness and family stigma. Schizophrenia
of suicide deserve consideration. Accep- with height and weight measurements at
Bulletin,
Bulletin, 24,
24, 115^126.
tance of a patient’s suicide as a solution different ages nested within children, and
Sawyer, D. & Sobal, J. (1987) Public attitudes toward
to problems, wishes that a patient would suicide: demographic and ideological correlates. Public
children nested within neighbourhoods.
commit suicide as a solution to his or Opinion Quarterly,
Quarterly, 51,
51, 92^101. Growth curves were estimated using a
her problem, fear of the patient and diffi- Smith, B. I., Mitchell, A. M., Bruno, A. A. et al (1995) multi-level random-effects regression model
culties in dealing with suicidal individuals Exploring widows’ experience after suicide of their (including age and age2). The outcome mea-
are some of the most important sources spouse. Journal of Psychosocial Nursing and Mental Health sures were height, weight, and body mass
Services,
Services, 33,
33, 10^15.
of stigma in mental health environments. index (weight/height2), and all variables ex-
Also, following an attempt many indivi- cept for age were considered fixed factors.
M. Pompili, I. Mancinelli, R. Tatarelli
duals feel isolated or ignored by health When neighbourhood variables and indivi-
Dipartimento di Scienze Psichiatriche,Universita'
professionals (McGaughey et al, al, 1995). ‘La Sapienza’,Via Panama 68, 00198 Roma, Italy dual level confounders were added to the
In the military environment, stigma to- models, results showed that none of the so-
wards mental illness is very strong and cial capital measures was associated with
military personnel tend to deny any form Social capital and mental health any of the outcomes.
of mental disorder unless they are hoping v. objective measures of health Therefore, we conclude that neighbour-
to get another job. This exposes such a inThe Netherlands hood measures play a role in mental health,
population to the risk of suicide. but that effects are more readily expressed
McKenzie et al (2002) reported that social
Yet suicide is, itself, a source of stigma in the psychological rather than the phys-
capital in the neighbourhood may be bene-
as anyone with suicidal ideation is consid- ical domain, in children living in The
ficial for health and mental health in adults.
ered weak, shameful, sinful and selfish, Netherlands.
We have reported associations between
which prevents these individuals from seek-
neighbourhood social capital and mental
ing treatment early in the suicidal process. Drukker, M., Kaplan, C. D., Feron, F. J. M., et al
health service use in children (Van der Lin-
These judgements are often shared by ac- (2003) Children’s health-related quality of life,
den et al,
al, 2003). We wished to investigate neighbourhood socio-economic deprivation and social
tive churchgoers (Sawyer & Sobal, 1987),
whether such effects on mental health were capital. A contextual analysis. Social Science and
teachers and parents. Also, parents and wi- Medicine,
Medicine, 57,
57, 825^841.
accompanied by similar effects on physical
dows of victims of suicide are stigmatised,
development, and investigated sensitive, cu-
which makes recovery from this type of loss McKenzie, K., Whitley, R. & Weich, S. (2002) Social
K.,Whitley,
mulative objective measures of child health, capital and mental health. British Journal of Psychiatry,
Psychiatry,
particularly difficult (Smith et al, al, 1995).
height and weight at different ages, in rela- 181,
181, 280^283.
Destigmatisation should be addressed to
tion to the neighbourhood environment.
mental illness as well as suicide. Increasing Van der Linden, J., Drukker, M., Gunther, N., et al
We recorded all height and weight data
the stigma associated with having suicidal (2003) Children’s mental health service use
registered regularly in the Municipal Youth neighbourhood socio-economic deprivation and social
feelings will increase the suicide rate. Inter-
Health Care Centre from birth up to the capital. Social Psychiatry and Psychiatric Epidemiology,
Epidemiology, in
ventions among families, mental health press.
baseline measurement of our cohort study
professionals, military personnel and
of 1009 children aged approximately 11
church activists aimed at decreasing the M. Drukker, N. Gunther Department of
years living in the 36 neighbourhoods of a
stigma associated with mental illness and Psychiatry and Neuropsychology, Maastricht
Dutch city (response rate of both child
suicide may contribute to the reduction of University,
University,The
The Netherlands
and one parent of 54%) (Drukker et al, al,
deaths by suicide.
2003). This study on the effects of neigh- F. J. M. Feron Youth Health Care Divison,
bourhood variables also included family- Municipal Health Centre, Maastricht,The
Eagles, J. M., Carson, D. P., Begg, A., et al (2003) Netherlands
Suicide prevention: a study of patients’ views. British
level and child-level measures, such as
Journal of Psychiatry,
Psychiatry, 182,
182, 261^265. family socioeconomic status. In addition, J. van Os Department of Psychiatry and
social capital dimensions of (a) informal Neuropsychology,Maastricht University,POBox 616,
McGaughey, J., Long, A. & Harrison, S. (1995)
social control and (b) social cohesion and 6200 MD Maastricht,The Netherlands, and Division
Suicide and parasuicide: a selected review of the
literature. Journal of Psychiatric and Mental Health trust were measured in a community survey of Psychological Medicine, Institute of Psychiatry,
Nursing,
Nursing, 2, 199^206. and aggregated to neighbourhood level. London,UK
One hundred years ago
Epileptic colony, Ewell, Surrey was opened by H.R.H. the Duchess of purposes, and on which the Manor Asylum
Fife and the Duke of Fife, K.T., Lord (for 700 female lunatics) and the Horton
ON Wednesday, July 1st, the first rate- Lieutenant of the County of London. Asylum (for 2,000 lunatics) have already
supported epileptic colony in this country, Situated on the north-eastern corner of been erected, it has a demesne of 112 acres,
founded by the London County Council the Horton Estate (facing the Epsom to be devoted to colony purposes, separated
for the epileptic insane of the metropolis, Downs), purchased in 1896 for asylum from the rest of the estate by a public road.
17 4
1 0 0 Y E A R S AGO
The buildings, consisting of an administra- the eight villas (named after trees – Holly, The lighting is by electricity throughout.
tive block and eight villas have been erected Lime, Pine, Elm, Chestnut, Hawthorn, Telephones connect all the buildings, and
upon the most elevated part of the ground, Walnut, Beech) in which all the colonists, an electrical fire alarm places the villas
some 200 feet above the sea level. A corri- with the exception of the 32 females to be and the centre in communication.
dor leads from the administrative centre – accommodated in the admission ward at The estimated cost of the buildings, in-
wherein are offices for the medical superin- the administrative centre, will be housed. cluding fixtures, fittings, and equipment, is
tendent, assistant medical officer, matron, . . . Each villa is similarly arranged, and £98,000, which with its provision for 326
clerk, etc., apartments for some of these of- has a south-eastern aspect, and the roads patients (60 females and 266 males) gives
ficers, and quarters for the resident subordi- giving access to them enclose a space to a total cost per bed (exclusive of the cost
nate staff – to a group of buildings be laid out by the colonists, and used as a of land) of £300. The plans of the buildings
consisting of stores, main kitchen, and a cricket and recreation ground. Each villa were designed by the Asylums Committee’s
hall for recreation and dining purposes. is arranged to accommodate 38 patients, Engineer, Mr. William Charles Clifford
The boiler house, workshops, and water and will be under the charge of a resident Smith, M.I.C.E.
tower are situated between the stores and married couple. The interiors are designed Dr. Charles Hubert Bond (D.Sc., M.D.,
the female admission ward, the latter being to enable the individual patients to have Ch.M.Edin.), Senior Assistant Medical
a portion of the central block. On the other the maximum amount of freedom under Officer at the Heath Asylum, Bexley,
side of the corridor, immediately opposite supervision. The verandahs and spreading formerly Assistant Medical Officer at
the boiler house, a laundry will shortly be porches to the villas are important features, Banstead Asylum, and Clinical Assistant
erected. The dining and recreation hall has enabling the colonists to be in the open in at the National Hospital for Epilepsy, and
seating accommodation for 326 persons, all weathers. The method of warming is at the Wakefield and Morningside
the number of colonists to be received. by double fireplace stoves arranged in the Asylums, has been appointed Medical
Here it is intended that all whose condition centres of the rooms. Superintendent. For this officer a detached
permits their being present shall assemble The ventilation is by means of fresh-air residence has been appointed conveniently
for dinner, the other meals being taken in inlets at floor level and outlets through the near the administrative buildings.
the several wards. It is so arranged as also ceilings into the roof space, the necessary
to serve as the chapel. At one end of the hall upcast movement being obtained by the
a platform has been provided for entertain- heat from the hot-water storage tank which REFERENCE
ments. The hall will be well lighted, and is placed at the base of a shaft leading into
its heating (which is by means of steam- the open air. Four of the villas are built in
heated radiators) and ventilation are very red brick with artificial stone dressings, as British Medical Journal,
Journal, 4 July 1903, 43.
completely arranged for. are also the administrative buildings. The
Within the 20 acres of land on the east stores and the remaining villas are faced Researched by Henry Rollin, Emeritus Consultant
side of the administrative block are dotted with rough case. All the roofs are tiled. Psychiatrist, Horton Hospital, Epsom, Surrey
Corrigendum
Early intervention service for non-abusing (p. 69), published norms (col. 3) for the internalising sub-scale: referred¼14.6,
referred 14.6,
parents of victims of child sexual abuse. Child Behavior Checklist should read: total non-referred¼6.3;
non-referred 6.3; externalising sub-scale:
Pilot study. BJP,
BJP, 183,
183, 66–72. Table 1 score: referred¼52.1,
referred 52.1, non-referred¼23.1;
non-referred 23.1; referred¼17.5,
referred 17.5, non-referred¼8.2.
non-referred 8.2.
17 5
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Document downloaded from http://www.elsevier.es/, day 09/09/2019. This copy is for personal use.

Any transmission of this document by any media or format is strictly prohibited.

El complejo estigma-discriminación asociado a

Adalberto Campo-Arias a,∗ y Edwin Herazo b

(Human Behavioral Research Institute), Bogotá, Colombia

información del artículo r e s u m e n

Autor para correspondencia.

Correos electrónicos: campoarias@comportamientohumano.org, campoarias@gmail.com (A. Campo-Arias).

244 r e v c o l o m b p s i q u i a t . 2 0 1 5;4 4(4):243–250

The Stigma-discrimination Complex Associated With Mental Disorder as

sobre los trastornos mentales, acercar y promover la asistencia

r e v c o l o m b p s i q u i a t . 2 0 1 5;4 4(4):243–250 245

246 r e v c o l o m b p s i q u i a t . 2 0 1 5;4 4(4):243–250

r e v c o l o m b p s i q u i a t . 2 0 1 5;4 4(4):243–250 247

Estigma percibido Estigma internalizado

248 r e v c o l o m b p s i q u i a t . 2 0 1 5;4 4(4):243–250

r e v c o l o m b p s i q u i a t . 2 0 1 5;4 4(4):243–250 249

250 r e v c o l o m b p s i q u i a t . 2 0 1 5;4 4(4):243–250

Stigma as a cause of suicide

Article in The British Journal of Psychiatry · September 2003

Maurizio Pompili Iginia Mancinelli

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