Media release

From: The Lancet

The Lancet: ‘Worse than the condition itself’ - experts call for radical action to end stigma and discrimination against people with mental health conditions globally

• Stigma can cause social exclusion and disempowerment of people with mental health conditions leading to discrimination and human rights violations, including problems in accessing healthcare, challenges in securing employment, and increased likelihood of health complications leading to early death.
• The Lancet Commission on Ending Stigma and Discrimination in Mental Health, launching on World Mental Health Day 2022, recommends ambitious actions to end mental health stigma and discrimination globally, including decriminalising suicide, providing mental health training for healthcare staff, and developing guidelines for accurately depicting mental health in the media.
• The Commission includes a comprehensive review of the evidence for effective stigma reduction interventions and finds social contact between people with and without lived experience of mental illness is the most effective way to reduce stigma and discrimination.
• Experts say we know how to end stigma and discrimination in mental health and, with the global rise in rates of mental health conditions during the COVID-19 pandemic, there is an even greater need to act now. 

With radical action we can end stigma and discrimination against people with mental health conditions and their families globally, says The Lancet Commission on Ending Stigma and Discrimination in Mental Health, which sets out key recommendations to achieve this goal.

Recent estimates suggest one in eight people, nearly one billion people globally, are living with a mental health condition [1], this rises to one in seven 10-19 year olds [2]. These people experience a double threat: the impact of the condition itself and the damaging social consequences of stigma and discrimination.

The COVID-19 pandemic helped to shine a light on the urgent mental health situation globally, and there was an estimated 25% rise in the prevalence of depression and anxiety in the first year of the pandemic [3,4]. However, despite the high incidence of mental health conditions around the world, mental health-related stigma and discrimination is also widespread [5], leading to exclusion of individuals from society and the denial of basic human rights, such as job and education opportunities and access to healthcare, including mental health care.

The new Lancet Commission is the result of work by over 50 contributors from across the world, notably including people with lived experience of a mental health condition. Containing testimonies and poems from people with lived experience [6], the Commission reviews the evidence on effective interventions to reduce stigma and calls for immediate action from governments, international organisations, employers, healthcare provider and media organisations, along with active contributions from people with lived experience, to work together to eliminate mental health stigma and discrimination.

“Many people with lived experience of mental health conditions describe stigma as ‘worse than the condition itself’. There is now clear evidence that we know how to effectively reduce, and ultimately eliminate, stigma and discrimination. Our Commission makes eight radical, practical, and evidence-based recommendations for action to liberate millions of people around the world from the social isolation, discrimination and violations of human rights caused by stigma” says Commission Co-Chair Professor Sir Graham Thornicroft from King’s College London. [7]

Co-author Charlene Sunkel, Founder / CEO of the Global Mental Health Peer Network, South Africa and a person with lived experience of schizophrenia, says, “The COVID-19 pandemic has resulted in higher numbers of people experiencing mental health conditions and urgent action is needed to ensure these individuals don’t also experience the potentially severe consequences of stigma and discrimination. We must empower and support people with lived experience of mental health conditions to play active roles in stigma reduction efforts and for this reason our Commission includes voices which whisper, speak or shout about their experiences in poems, testimonies, and quotations.” [7]

The consequences of stigma violate basic human rights

Stigma related to mental health conditions has many forms which lead to a myriad of often underestimated consequences. The Commission reviewed evidence on the impact of stigma and discrimination as well as completing its own survey of people with lived experience of mental health conditions from over 40 countries worldwide. The Commission finds that people with lived experience of mental health conditions very often encounter stigma and discrimination which have a profoundly negative impact on their basic human rights in all aspects of life and worsens their mental health.

For example, people with mental health conditions experience stigma and discrimination in educational and work settings which leads to reduced employment opportunities and income. The relationships between mental health conditions and poverty are especially destructive in low- and middle-income countries. Additionally, people with mental health conditions may be denied the right to vote, to get married and/or to inherit property.

Stigma and discrimination are substantial issues in healthcare: healthcare professionals themselves do not always know how best to diagnose and care for people with a mental health condition; and people with mental health conditions usually have a lower life expectancy than the rest of the population. Investment in mental health is on average only two percent of total health spending; and mental health conditions are frequently excluded altogether from health insurance schemes, unlike most physical health conditions.

“Everyone with a mental health condition is affected by stigma and discrimination, but it’s especially important to acknowledge how young people and their caregivers are impacted. One in seven of 10-19 years olds experience a mental health condition. Misunderstandings about mental health and lack of acceptance continue to be a significant challenge for far too many young people worldwide. We see that stigma still has an adverse effect on children and young people: it can prevent them from getting the support they need; negatively impact their relationships with family and peers; and result in social exclusion from schools, sports, and society.” Says Zeinab Hijazi, Senior Mental Health Technical Advisor at UNICEF and an author on the report. “We know that adolescents with mental health conditions can be deterred from seeking help if they are afraid of experiencing stigma and misunderstanding from their family, teachers and peers. It’s crucial that we reduce, and eventually eliminate, stigma surrounding young people with mental health conditions so they can experience life without discrimination.” [7]

Reducing stigma through social contact

The Commission’s analysis stresses that forms of social contact (in person or remotely) between people who do, and who do not, have lived experience of mental health conditions is the most effective evidence-based way to reduce stigma and discrimination. Furthermore, the Commission highlights the need for people with mental health conditions to be strongly supported to lead or co-lead interventions that use social contact to reduce stigma and discrimination.

“We found that social contact, where the lived experiences of people with mental health conditions were shared with people who did not have such conditions, successfully reduced stigma when appropriately adapted to different contexts and cultures. It is crucial that we see more organised social contact, whether via in-person discussions, video calls, or through theatre or film, between people with and without lived experiences of mental health conditions if we are to end stigma and discrimination.” Says Dr Petr Winkler, Director of the WHO Collaborating Center for public mental health research and service development, Czech Republic. “Our Commission also shows that anti-stigma interventions around the world are most effective when they directly involve people with lived experience in all aspects of their production. We must put the voices of people with lived experience of mental health problems centre stage.” [7]

Writing in a linked Comment, Edwin Mutura and Claudia Sartor, Global Mental Health Peer Network, who were not involved in the study, say: “The role of persons with lived experience in global advocacy work is the way forward. Persons with lived experience, are experts in their own right. Their experience is unique because through their personal experience and by navigating challenging issues such as stigma, their input and participation in anti-stigma campaigns is encouraged. It is therefore important for all stakeholders to appreciate persons with mental health conditions as an integral part of such programmes and their inclusion should be non-negotiable. It is crucial to note that we need to move from a ‘we need to help them’ attitude to an inclusive attitude devoid of tokenism.”

Now is the time to act to end mental health-related stigma and discrimination

In order to end mental health-related stigma and discrimination, the Commission calls on all governments, international organisations, schools, employers, healthcare, civil society and media to take action now and gives specific recommendation for each group.

For governments and international organisations, the Commission recommends:

• Governments to implement specific policies, and international organisations to issue guidance, that aim to reduce and eventually end stigma and discrimination. Specifically, it is recommended that all countries take action to decriminalise suicide, therefore reducing the stigma around suicide and leading to fewer occurrences.

For employers:

• Employers to take evidence-based action to promote full access to educational opportunities, work participation and return-to-work programmes for people with mental health conditions, as set out by the 2030 Objective 3 of the WHO Comprehensive Mental Health Action Plan [8] and in WHO guidelines [9].

For health and social care providers:

• National training courses for all health and social care staff should include mandatory training sessions on the needs and rights of people with mental health conditions, co-delivered by people with such conditions

For schools:

• School curricula to include sessions for students on evidence-based interventions to improve understanding of mental health conditions.

For the media:

• All national and international media organisations to systematically remove stigmatising content and issue policy statements and action plans, based upon the findings of this Commission, on how they will actively promote mental health and consistently contribute to reduction of stigma and discrimination in mental health.

“Our Commission showcases the devastating impact that stigma and discrimination against people with mental health conditions can have on their human rights. Mental health affects us all, whether directly or indirectly, and now is the time for organisations and individuals to implement our recommendations to end stigma and discrimination for good. To truly realise this, it is critical that people with lived experience are key partners in anti-stigma initiatives.” Says Guadalupe Morales Cano, Director of Fundación Mundo Bipolar, Madrid, Spain, [6].

A linked Editorial published in The Lancet says, “The onus is on all of us to act in our personal and professional lives to improve the mental health of ourselves, loved ones, friends, and colleagues. Ending mental health-related stigma is a goal that must be pursued.”