How Medical Psychiatry May Worsen Mental-Health Stigma

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In the 1980s and 90s, an emerging theory was that mental disorders like depression, bipolar disorder, or schizophrenia were due to faulty brain chemicals, and ultimately, faulty genes.

This message was popularized by books like Nancy Andreasen’s 1985 The Broken Brain, Solomon Snyder’s 1986 Drugs and the Brain, and Jon Franklin’s 1987 Molecules of the Mind.

In this view, schizophrenia was due to dopamine imbalances. Depression involved serotonin imbalances. Bipolar disorder involved lithium imbalances. And drugs like Prozac worked by reversing these imbalances.

While simplistic versions of many of these theories were disproven, the “chemical imbalance” metaphor still has a powerful grip on the professional and public imagination.

Journalists, doctors, and activists thought that this messaging would help end stigma by showing that you’re not to blame for your mental health problems, any more than you’re to blame for breast cancer.

New research, however, is calling this received wisdom into question. This research is showing that medical framings of mental health problems actually make some kinds of stigma worse, not better.

Challenging the Received Wisdom

Over the last decade, a group of psychologists have investigated new questions about mental health stigma.

For example, if I think that your mental illness is caused by your brain or your genes, how does that affect my desire to interact with you? This is known as the desire for social distance.

Similarly, if I think that your mental illness is caused by your brain or your genes, how does that affect my belief that you will recover? This is known as prognostic optimism.

The upshot of this research is that biological explanations of mental illnesses have their own dangers. They tend to increase people’s desire for social distance. If I think your mental illness is caused by your brain or genes, I’m more likely to see you as potentially dangerous and unpredictable, and to want to keep my distance from you. They also decrease prognostic optimism: If I see your mental illness as having a biological cause, I have less hope that you’re going to recover.

On the plus side, these mindsets do reduce the perception of blame: If I think your schizophrenia or depression is caused by your genes, I’m less likely to blame you for it.

One of the most troubling findings in this new research is that, by several measures, stigma towards schizophrenia has actually gotten worse over the last 30 years, not better. This may be related to the greater acceptance of the medical paradigm.

Making Stigma Worse?

Research carried out last year, while confirming those main findings, raised new puzzles of its own. This research was led by sociologist Marta Elliott of the University of Nevada, Reno and published in August, 2023 in Psychiatric Services [1]. Elliott sought to better understand what happens when conditions like schizophrenia, depression, or addiction are presented as having a genetic, versus an environmental, cause. Her team also wanted to know what happens when we combine different sorts of explanations, such as biological and environmental ones.

As they put it, “to our knowledge, this study is the first of its kind to manipulate multiple attributions and treatability and to test their independent and interactive effects on stigma with a large sample representative of the U.S. adult population.”

To this end, they recruited over 1,600 participants and presented various hypothetical scenarios to them (“vignettes”). In one vignette, a man consults a physician and is told his mental disorder is genetic. In another, he is told his mental disorder is caused by trauma. In yet another, he is told his mental disorder is caused by both genes and trauma.

The participants were then asked questions, such as how willing they would be to spend an evening socializing with the man or making friends with him.

Predictably, biological explanations increase the desire for social distance, regardless of which mental illness is in question. The desire for social distance was far stronger for schizophrenia and addiction than for depression.

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New Puzzles

Elliott's research, however, raised two new puzzles. First, she found no negative impact on public stigma when mental illness was presented as caused by life trauma. If I see your depression as the result of, say, profound grief, I’m just as likely to want to socialize with you or be friends with you. Knowing that your mental health problems stem from negative life events seems to have a powerful humanizing influence on how people think about those who suffer from mental illnesses.

Second, when offered an explanation that combined life trauma with genetics, participants’ desire for social distance increased almost as much as it did when the biological account was presented alone. It’s as if the “genetic” part of the explanation cancels out the humanizing impact of the traumatic event.

It seems to me that one possible explanation for these findings is that if I see your mental illness as a meaningful response to the problems of life, I’m less likely to see it as defining your very identity.

The authors note that these results may have implications for how psychiatrists and other mental health professionals, as well as the media, discuss mental illness: “Portraying mental illness in exclusively genetic terms may perpetuate stigma, encourage discrimination, and harm the mental health of people living with psychiatric diagnoses.”

As psychologists Eleanor Longden and John Read put the point, when it comes to mental illness, it may be time to start seeing “people with problems” rather than “patients with illnesses.”