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Mental illness stigma as a quality-of-care problem
Reducing the stigma associated with mental illnesses
in health-care settings is becoming an increasingly
important focus for research, programming, and intervention.1–3 A systematic review2 published in The Lancet
Psychiatry in 2014 articulately described the growing
body of evidence on mental-illness-related stigmatisation
in health care and its consequences, including negative
attitudes and stereotypes, prognostic negativity,
diagnostic overshadowing, insufficient skills of healthcare providers, discriminatory behaviours, and perceptions
of unfair treatment among consumers of mental health
services.2 The stark mortality gap in high-income countries
between people with severe mental illnesses and the
general population—20 years for men and 15 years for
women—has been argued to be at least partly related to
the problem of stigmatisation.2 These issues suggest that
several important quality-of-care concerns exist for people
with mental illnesses.
Opening Minds (OM), the anti-stigma initiative of
the Mental Health Commission of Canada, identified
health-care providers as one of four key target groups
in its stigma reduction strategy.1 OM’s strategy involves
seeking out existing anti-stigma programmes, identifying
what works and why, then sharing this knowledge so that
effective programmes, instruments, and best practices
can be broadly implemented.1 Thus far, OM’s research
has identified several effective programmes4–5 and key
ingredients for maximal stigma reduction in health-care
environments, which include such elements as social
contact and an emphasis on, and demonstration of,
recovery.6
Yet, implementation of anti-stigma initiatives in
health-care settings can be difficult. The problem of
stigma is an unperceived learning need for many healthcare organisations and professions, and engagement is
limited by competing priorities, time constraints, and
low perceived need.2–3 Indeed, emerging findings from
a qualitative component of OM’s research suggest that
achieving desired levels of buy-in and participation is a key
challenge for many anti-stigma programmes, especially
those explicitly marketed as being about stigma.
To address this challenge, we suggest that applying
a quality-of-care perspective to the problem of
stigmatisation might be of particular benefit to achieve
greater organisational and provider buy-in and uptake.
www.thelancet.com/psychiatry Vol 2 October 2015
Quality of care is a structural priority, continually at the
forefront of concern of health-care organisations and
professions7,8 and most have established quality-of-care
standards and processes through which to assess, measure,
and improve patient care. Instead of framing stigma as
a problem in and of itself to be solved (ie, by focusing on
stigma reduction as the primary outcome through the
design and delivery of interventions explicitly marketed as
being about stigma), we suggest greater traction could be
gained through a view that understands the problem of
stigmatisation in health-care settings, at least in part, as a
core attitudinal and behavioural barrier to quality of care
(panel).
Applying a quality improvement lens to the problem of
stigmatisation in health care could also provide additional
benefits. For one, viewing stigmatisation through a
quality improvement lens would help ensure emphasis is
placed on achieving higher level Kirkpatrick results,9 such
as behaviour and practice change and improved patient
Panel: Addressing stigma through quality of care—a hypothetical case example
Scenario
Patients with a history of mental illness present to emergency departments with various
complaints and symptoms, but are prematurely referred for psychiatric consultation and
admission without full consideration, assessment, or treatment of physical symptoms or
concurrent or pre-existing disorders.2 Patients spend lengthy periods without care in the
emergency room as providers disagree about which service should assume responsibility
for the patients’ care.
Traditional approach to reduce stigma
An evidence-based programming approach focuses on encouraging emergency
department staff to become aware of the reality and consequences of diagnostic
overshadowing though education and consumer-based personal testimonies. The
intervention does not focus on changes to workflows or processes. Attendance is low to
moderate with limited engagement, in view of time and resource constraints and
prioritisation of various service needs. Outcome measures are attitudinal-based and
satisfaction-based.
A care quality approach to reduce stigma
A quality-of-care perspective enhances educational programming by focusing on patient
outcomes. Gaps in best practice for triage and emergency room care are identified
through the use of quality improvement tools such as cause–effect and driver diagrams.
Critical incident ranking11 prioritises the quality concern, leveraging administrative
resources and leading to a change in workflow or process—eg, the implementation of a
checklist screening tool for medical stability,12 improved triage, new algorithms or care
requirements for patients with mental health presentations, or the development and
monitoring of new quality indicators for the emergency care of patients with a history of
mental illness. The prioritisation of diagnostic overshadowing as a human risk factor for
quality-of-care issues enhances uptake and participation of contact-based educational
interventions.
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Comment
outcomes, over attitudinal and knowledge improvements.
It would also drive greater attention to the problem
of stigmatisation as a structural issue, allowing for the
identification and prioritisation of changes to systems
and care procedures, a need not typically addressed
through knowledge and social-contact-based intervention
approaches.2 (By social contact, we refer not to regular
patient–provider interactions, but rather to recovery-based
personal testimonies and other similar interactions with
people who have or have had a mental illness, for which
the nature of the contact is also in keeping with Allport’s
four criteria, including that of equal status between
parties.3–6)
The US-based Institute of Medicine, for example, argues
for a redesign of mental health services to adequately
address what it describes as the quality chasm, ie,
pervasive deficiencies across the six main dimensions of
quality care (safety, effectiveness, patient centeredness,
timeliness, efficiency, and equitable care), many of
which are also negative outcomes of the process of
stigmatisation.2,8 Framing stigma, at least in part, as a
quality-of-care concern would allow the conceptualisation
and measurement of different forms of stigmatisation
across these main quality indicators, as performance and
structural deficits. Common quality improvement tools
could easily help to map the relation between problematic
practices and quality-of-care outcomes (panel).
As we see it, applying a quality improvement frame
to the problem of stigmatisation provides a way of
strategically colluding10 with and leveraging already well
accepted processes and priorities for health-care providers
and organisations. It is a logical idea that would benefit
from receiving greater attention in the stigma literature.
In our view, it provides a promising strategic enhancement
through which to pursue anti-stigma agendas that can
easily incorporate existing evidence-based ingredients
864
and strategies for stigma reduction,6 while also helping to
address specific key challenges, including securing those
all-important yet still-elusive desired levels of participation
and buy-in.
*Stephanie Knaak, Scott Patten, Thomas Ungar
Opening Minds Anti-Stigma Initiative, Mental Health Commission of
Canada, Calgary, AB, T2C 3G3, Canada (SK, SP); Department of
Community Health Sciences, Department of Psychiatry and
Mathison Centre for Mental Health Research and Education,
University of Calgary,Calgary, AB, Canada (SP); Department of
Psychiatry, North York General Hospital, and Faculty of Medicine,
University of Toronto, Toronto, ON, Canada (TU)
sknaak@mentalhealthcommission.ca
We declare no competing interests. Our research was made possible through
funding from the Mental Health Commission of Canada (MHCC). The work of the
MHCC is supported by a grant from Health Canada. We thank the Opening Minds
research team for their helpful comments on previous versions of this draft.
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