Ir Med J. 2005 Feb; 98 (2): 37


Thirty years ago, in 1975, Fantasy Films released a film version of Ken Kesey's celebrated novel 'One Flew Over the Cuckoo's Nest.'¹ The film was hugely popular in both the United States and Europe, and went on to win five major Academy Awards. The story centres on the experiences of Randle P. McMurphy, a petty thief committed to a state mental hospital in the United States, for a period of assessment. Following his committal, McMurphy proceeded to challenge almost all of the procedures and protocols of the psychiatric ward, with disruptive and disturbing consequences for staff and patients alike.

It is known that cinematic and media portrayals of mental illness have a particularly strong impact on public opinions of psychiatry.² In the thirty years since the release of 'One Flew Over the Cuckoo's Nest,' however, it has become clear that this particular film has had an especially strong and enduring effect on public perceptions of mental illness and its treatment.³ The character of Nurse Ratchett, for example, has entered popular folk-lore, and the film's vivid portrayal of electroconvulsive therapy, delivered without anaesthetic and for punitive reasons, has remained as affecting and powerful as it was first released. Today, electroconvulsive therapy is used only for therapeutic reasons; is given with a general anaesthetic; and is subject to detailed guidelines from the Royal College of Psychiatrists.⁴

Nonetheless, and despite considerable changes in psychiatric practice in recent decades, myths, misperceptions and stigma persist. A stigma is defined as a mark of shame or discredit, and the stigma associated with mental illness is often related to a poor understanding or limited experience of issues related to mental health and illness.^5,6 There is strong evidence that stigma has negative effects on the physical and mental health of individuals with mental illness and can also have a deleterious effect on help-seeking behaviour.^7,8

As part of the Royal College of Psychiatrists' 'Changing Minds' anti-stigma campaign, Crisp et al performed a survey in Britain to determine public opinion about seven different mental illnesses: severe depression, panic attacks, schizophrenia, dementia eating disorders, alcoholism and drug addiction.⁹ They found that people with any of these illnesses were generally seen as hard to talk to, and that people with schizophrenia, alcoholism and drug addiction were seen as unpredictable or dangerous.⁹

The Royal College of Psychiatrists commissioned a similar survey in Ireland, interviewing 1400 adults at 70 points throughout Ireland in May 1999 (www.irishpsychiatry.com/survey.html). This survey found that 74% of those interviewed indicated they knew nothing or very little about schizophrenia and 56% indicated the knew nothing or very little about depression - despite the fact that depressive disorders have a prevalence of up to 12.3% in urban areas and 7.9% in rural areas of Ireland.¹⁰ On the positive side, relatively few people thought that 'pull yourself together' was an appropriate response to illnesses such as schizophrenia (7%) or depression (23%).

The opinions of mental healthcare professionals in relation to mental illness have also been studied. In a survey of psychiatrists in Britain, for example, Kingdon et al found that psychiatrists' attitudes compared favourably with those of the general population, and that psychiatrists tended to believe that the risk of dangerousness was over-emphasized.¹¹ Interestingly, there was also evidence, especially in relation to schizophrenia, that increased direct personal contact with individuals with mental illness leads to improved understanding of mental illness.¹¹ It is often pointed out that the media plays an important role in shaping public attitudes towards mental illness.² As part of its 'Open the Doors' anti-stigma programme, the World Health Organization arranged several anti-stigma initiatives, including some aimed at improving the accuracy of media reports in relation to mental illness (e.g. the initiative in Canada described by Stuart¹²). Interestingly, one Irish study of newspaper coverage of psychiatry-related issues found that Irish newspapers were not generally hostile to psychiatry, and that there had been an improvement in coverage over the preceding five years.¹³ Nonetheless, the authors identified a need for psychiatrists to develop a greater involvement in the media, with a view to shifting the focus from coverage of forensic issues to more informative articles.¹³

The stigma associated with mental illness is a complex, ongoing and changing phenomenon that requires a multi-level, ongoing and flexible approach by all stake-holders. The provision of clear and accurate information is critical, and a number of websites now offer information and guidance about mental health matters; these include the websites of the Irish College of Psychiatrists (www.irishpsychiatry.com), the Royal College of Psychiatrists (www.rcpsych.ac.uk), Schizophrenia Ireland (www.sirl.ie) and Aware (www.aware.ie).

Anti-stigma campaigns also have a continuing role to play, and recent years have seen a renewed focus on campaigns such as the 'Changing Minds' campaign organized by the Royal College of Psychiatrists. Their 'Changing Minds' website offers a range of materials for both professionals and the public to download, including information leaflets about mental illness, special leaflets for children and young people, and the anti-stigma video, '1 in 4'

(www.rcpsych.ac.uk/campaigns/cminds). Media reporting of mental health matters also remains crucial in shaping public opinion, and media guidelines for the reporting of mental health issues have been produced. For example, a 'Guide for Journalists and Broadcasters Reporting on Schizophrenia' was formulated in 1999, by several groups of stake-holders in conjunction with the National Union of Journalists.

Finally, the provision of effective mental health services forms the bed-rock of all efforts to address issues related to mental illness, including the issue of stigma. If mental health services are to be truly effective, efficient and acceptable to service-users, it is important that services are structured and resourced in a fashion that is appropriate to regional needs; recent evidence indicates that this is not the case in Ireland.¹⁴ Clearly, the provision of appropriate mental health services is critical, not only in order to meet population mental health needs, but also in order to address the multiple problems presented by stigma.

Brendan D Kelly
Department of Psychiatry, Our Lady's Hospital,
Navan, County Meath, Ireland.
Tel.: + 353 (0) 46 9072 676,
Fax: + 353 (0) 46 9072 357,
Email: [email protected]

References

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3. Gabbard GO, Gabbard, K. Psychiatry and the Cinema (second edition). Washington DC: American Psychiatric Press 1999
4. Royal College of Psychiatrists. The ECT Handbook. London: Gaskell, 1997
5. Goffman E. Stigma: notes on the management of spoiled identity. Englewood Cliffs (NJ): Prentice-Hall, 1963
6. Byrne P. Stigma of mental illness and ways of diminishing it. Advan Psychiatr Treat 2000; 6: 65-72.
7. Miller CT, Major B. Coping with stigma and prejudice. In: Heatherton TF, Kleck RE, Hebl MR, Hull JG (editors). The social psychology of stigma. New York: Guiulford Press, 2000
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13. O'Connor A, Casey P. What it says in the papers: an audit. Ir J Psychol Med 2001; 18: 68-71.
14. O'Keane V, Jeffers A, Moloney E, Barry S. Irish Psychiatric Association survey of psychiatric services in Ireland. Psychiatr Bull 2004; 28: 364-7