Discrimination and social stigma against people with mental illnesses in Argentina

Abstract

Background:

Individuals with mental and neurological illnesses face stigma and discrimination every day. There are only a few studies regarding the degree of discrimination in the comparison between the illnesses, and no recent research has been found in Argentina about this topic.

Aims:

The aim of this research is to study and compare stigma and discrimination toward people with mental illnesses (schizophrenia, substance use disorder, and bipolar disorder) and with neurological disorders (epilepsy) in Argentina, while analyzing the social distance toward them. The level of responsibility attributed to individuals with these disorders were also assessed and compared.

Method:

Individuals from Buenos Aires, Argentina, were surveyed in order to measure the social distance given to people with mental illnesses and a neurological disease. For that purpose a modified version of the Bogardus scale was used, with a sample of 500 individuals contacted online in January 2021.

Results:

Social distance toward people with mental illnesses was higher than those with a neurological disorder (epilepsy). A significant difference was found in the level of responsibility attributed to people with substance use disorder in comparison to the other illnesses. On the contrary, there were no significant differences of discrimination according to age or sex. Finally, the research outcomes showed that people with substance use disorder are the most discriminated against and stigmatized.

Conclusion:

A significant level of discrimination was found against individuals with mental disorders and, specially, toward people with substance use disorder. Moreover, they are perceived as responsible for their disorder. For this reason, anti-stigma campaigns should be directed to end the misconceptions toward the most discriminated groups. More support is needed to counteract the stigmatization and exclusion of individuals with mental and neurological disorders in our society.

Keywords

Stigma discrimination bipolar disorder schizophrenia epilepsy substance use disorder

Introduction

Stigma and discrimination are issues that have been affecting humanity throughout history, but when referring to people with mental illnesses or neurological disorders the degree of stigmatization increases exponentially (Corrigan & Watson, 2002; Ross et al., 2019). Based on this, the overarching aim of this research is to analyze the stigma surrounding schizophrenia, bipolar disorder, substance use disorder, and epilepsy, in order to provide a brief overview of the existing social distance of these groups of people in Argentinian society.

Naturally, ‘stigma’ is understood as a set of behaviors, mostly negative, that are maintained toward people who have stereotyped characteristics regarding some distinctive trait that differentiates them. As a result, a negative perspective is adopted, causing their downgrading and social exclusion (Goffman, 2006). Establishing labels and stereotypes leading up to the division of society into two large groups: one referring to the ‘normal’, which includes those who fit within the accepted sociocultural parameters; and the other one, the ‘stigmatized’, which includes those who are considered different, who are turned into a social imaginary, usually associated with evil, danger, and weakness (Corrigan et al. 2015; Goffman, 2006). In this sense, the term ‘they’ refers to those who are deemed different, while the concept of ‘we’ is considered correct and accepted (Link & Phelan, 2001). For example, it is common to refer to a person as ‘schizophrenic’ instead of ‘a person with schizophrenia’, which results in immediate separation from the group (Baumann, 2007; Corrigan & Watson, 2002; Rüsch et al., 2005).

Nevertheless, this is not the case with people who suffer from physical or neurological illnesses. A person suffering from cancer will remain one of ‘us’ since this illness is considered an attribute, while the ‘schizophrenic’ becomes one of ‘them’ since they inherit a condition that makes them undeniably different from the rest (Frable, 1993; Rüsch et al., 2005). In addition, people with a mental illness are often blamed for causing their own illness, accentuating the discrimination (Rüsch et al., 2005). Although stigmatizing attitudes are not limited only to mental illnesses, society in general seems to discriminate against people with psychiatric disorders to a greater extent than people with physical disorders (Corrigan & Watson, 2002). Furthermore, the distinction between neurological and psychiatric disorders is unhelpful, all of them should be classified as disorders of the nervous system, due to the fact that the separation between them gives a rise to discrimination, this is why changing the classification will contribute to reduce the discrimination toward people with psychiatric disorders (White et al., 2012).

All things considered, the present research compared a neurological disorder (epilepsy) with multiple mental disorders (schizophrenia, bipolar disorder, and substance use disorder) in order to test whether there was any difference in the stigma between them. Thus, it was assumed that if mental disorders were explained as biological or genetic diseases, stigmatization would occur based on two assumptions; firstly, attributing the cause of a mental disorder to genetic factors would reduce the assumptions of responsibility and blame to those affected, since this would be beyond their control, and secondly, that if people were less responsible for their condition, they would experience less rejection by their social environment (Angermeyer et al., 2011). That is why people with mental illnesses, unlike people with physical disabilities, are perceived as being in control of their illness, since they are responsible for its cause (Souza y Machorro & Domingo Lenin, 2008). It is important to highlight that epilepsy is within the neurological diseases with an increased percentage of suicide rate (Eliasen et al., 2018). The constant discrimination suffered by people with epilepsy brings them significant psychological alterations, such as depression, low self-esteem, anxiety, among others (Centurión et al., 2013). Some studies proposed that the reason why the rates are so high is due to the fact that compared to the management of physical symptoms, there is less attention to the psychological consequences of living with a neurological disease (Eliasen et al., 2018).

Although the notion of stigma is the same and exists all over the world, its effects vary according to the cultural environment in which they appear (Agrest et al., 2015; Hartini et al., 2018). Recent studies in Argentina regarding stigma in mental illnesses have shown that there are some methodological contradictions and limitations about the perception of the stigmatized communities depending on their international context. In this way, the level of self-esteem experienced in Argentina by people with mental illnesses is not as low as others in other parts of the world (Agrest et al., 2015). Those negative psychological results affect the mental health of stigmatized people and influence the behavior of their surroundings (Lolich & Leiderman, 2008).

Despite the cultural, social, or economic differences, when referring to people with mental illnesses, there are some characteristics, labels, or stereotypes around the globe (Semrau et al., 2015). For example, people with schizophrenia, alcoholism, and substance use disorder receive more negative opinions compared to depression, eating disorders, and anxiety (Crisp et al., 2000; Grandóna et al., 2017; Haghighat, 2001). As we know, stigmatization occurs as a cause of ignorance of the pathology and a lack of contact with people who suffer from disorders. This is why, contrary to other mental illnesses, patients diagnosed with bipolar disorder are less likely to suffer from stigmatization than patients with schizophrenia or substance use disorder, due to popular knowledge about it (Mileva et al., 2013). This does not mean they are free of discrimination, the existence of stigma attached to the well-known symptoms of bipolar disorder are associated with the belief that these individuals, along with individuals with other disorders, are unpredictable and dangerous (Lolich & Leiderman, 2008). Additionally, people who suffer from a substance use disorder are also victims of stigmatization. It is thought that such people show poor control of emotions and weakness, they are unable to cope with everyday stressors, and, on top of that, they are perceived as being unpredictable and consequently dangerous and/or violent (Cassiani-Miranda et al., 2019; Nieweglowski et al., 2019).

In 2006 a study conducted in Canada found similar results as a research conducted in 1996, in the United Kingdom, in which mental illnesses were analyzed. Schizophrenia was found to be one of the most stigmatized illnesses in the general population, as it is associated with violence and aggression (Stuart, 2006; Wolff et al., 1996). Following studies conducted in 2008, in the United Kingdom, found that depressive disorders tend to produce more positive responses from family, friends, and co-workers, compared to the negative reactions given to schizophrenia and bipolar disorder (Putman, 2008).

Studies carried out in the United States concluded that the perception of stigma has an influence in the time of recovery and social reintegration, making them avoid social interaction for fear of rejection (Link et al., 2004). Likewise, a study in 2015 in some Latin American countries analyzed the main characteristics of stigma toward people with mental disorders and the psychological and/or social variables with which they have been associated (Mascayano Tapia et al., 2015). The results showed that the most outstanding characteristic is the belief of dangerousness, due to the fact that they are perceived as individuals who can become aggressive and violent. This perception is highly prevalent when it comes to substance use disorder and schizophrenia (Mascayano Tapia et al., 2015).

The tendency to label mental illnesses negatively turns the drug or substance dependent into a different and inferior being, which leads to the belief that they are antisocial, marginal, and dangerous subjects (Fanton, 2011). There are two ways of thinking about substance use disorder: firstly, it is understood as a disease (the person is a victim of a disorder that weakens their values and good intentions) and secondly, it is conceived as a free choice (the person is the responsible agent who commits acts of violence against themselves) (White, 2001). More often than not, it is considered that this disorder is self-induced, resulting in the outcome of personal decisions and, consequently, a highly avoidable health problem (Cassiani-Miranda et al., 2019). It was also found that the public attribution of responsibility toward those suffering from a mental disorder is mostly established when it refers to people with substance use disorder, such as alcohol dependence, as opposed to people suffering from depression or schizophrenia, where it is much lower (Mascayano Tapia et al., 2015). In Argentina, as in many other countries, the stigmatization around substances segregates their users from the rest of society, turning them into ‘the other’, someone totally unequal (Morales, 2009). Similarly, they are considered as sick people, who must be cured and rehabilitated (Napiarkorvski, 2019). The stigmatization of a family with a substance user undermines the ability to support the individual and maintain their well-being. Family members prefer to keep it as a secret, minimizing contact with others, due to a lack of knowledge and empathy toward this condition, which causes the problem to worsen (Pascual Molla & Pascual Pastor, 2017).

Other studies developed in Germany, Japan, Brazil, and India showed that stereotypes related to self-responsibility and being dangerous and unpredictable stand out in people with substance use disorders over the other mental disorders analyzed (Angermeyer et al., 2011). In addition, a 2006 Canadian study analyzed what happens to people suffering from a mental disorder in relation to their work environment. The study concluded that unemployment rates among people with a schizophrenic disorder are extremely high, between 80% and 90% (Stuart, 2006). In other words, researchers discovered that having a mental illness is an insurmountable barrier when obtaining or keeping a job because of the social association made between the disorder and aggression (Magallares Sanjuan, 2011).

On the other hand, in 1993, research done in Germany, using a modification of the Bogardus scale, found that the level of social distance increases with the level of intimacy in the relationship for all the disorders studied (schizophrenia, depression, substance use disorder, and anxiety disorders). When it comes to social distance, it was found that there are significant differences depending on the type of disorder: people with substance use disorder and schizophrenia are more strongly rejected than those with a depressive or anxiety disorder (Angermeyer & Matschinger, 1997; Jorm & Griffiths, 2008). In addition, research done in the United States found that in terms of avoidance behaviors, the results were strongly endorsed for schizophrenia in comparison to anxiety disorder and depression which received a lower average avoidance score (Grishma, 2021).

Methods

The study was carried out in January 2021. It consisted of 500 adult volunteers, who did not receive any type of remuneration and who accepted to be part of the research by means of an informed consent form and whose data have been kept confidential. The subjects were contacted online, 56.8% (n = 284) were women and 43.2% (n = 216) were men. Likewise, the average age was 36.8 years (SD = 15.4) ranging from 18 to 81 years – as shown in Table 1. This research was approved by the Ethics Committee of the Universidad de Palermo.

Table 1.

Questions used in the survey for each of the studied disorders.

Questions	Possible answers
Would you be scared to talk to someone with . . .	Definitely yes/probably yes/probably no/definitely no
Would you move next door to a person with . . .	Definitely yes/probably yes/probably no/definitely no
Would you work with a person with . . .	Definitely yes/probably yes/probably no/definitely no
Would you marry a person with . . .	Definitely yes/probably yes/probably no/definitely no
Would you trust your children to a person with . . .	Definitely yes/probably yes/probably no/definitely no
Would you feel ashamed to have a person with . . . in the family	Definitely yes/probably yes/probably no/definitely no
How responsible do you think someone is about his/her . . .	Much/quite a lot/a little/not at all

Regarding residence, 73.2% (n = 366) lived in the city of Buenos Aires and 26.8% (n = 134) in the suburbs of Buenos Aires. In terms of educational level, 2.2% (n = 11) had completed only primary school, 36.4% (n = 182) had completed only high school, and 61.4% (n = 307) had attained a complete tertiary/university education.

Procedures and instruments

In order to carry out this research work, a survey was done via Google Forms (an online modality). Due to the epidemiological context a virtual format allowed the logistics to be more flexible, in that costs were not a barrier to obtaining information and the range of individuals was greater due to the good control of response management, while the anonymity of those who responded to the survey could be preserved as it was impersonal (Evans & Mathur, 2005; González-Sanguino et al., 2019). Mental illnesses are better assessed with an online modality rather than an in-person interview. (Henderson et al., 2012).

This survey was divided into three sections: the first section consisted of questions related to the sociodemographic characteristics of the population. The second section involved the modified Bogardus scale of social distance. The Bogardus scale, which was used in other studies (Husain et al., 2020; Rüsch et al., 2005; Rusch et al., 2008), measured the level of desirable contact with members of other groups (Bogardus, 1933). In this case the survey was aimed to study and compare the social distance from people with mental and neurological disorders. The questionnaire consisted of Likert-type questions, with a score ranging from 0 to 3, being 0 definitely yes, 1 probably yes, 2 probably no, and 3 definitely no; the higher the value, the greater the social distance. The sum of this score divided by the number of respondents reflected the degree of social distance of the individuals (mean discrimination score [MDS]). In this way, it has been found out that the minimum and maximum of this score is 0 and 18, respectively. Afterwards, a general discrimination score was used to compare the level of distance between the mental illnesses and the neurological disorders. For this purpose, the average of the MDS of the three mental disorders was compared to the MDS of the neurological disorder. In order to analyze if the level of discrimination increases with the level of intimacy, the questions in the second section were divided into two groups. The first three questions (see Table 1) were less intimate, and the other three were more. The results (the sum of the scores) were compared in general and for each disorder in particular. Finally, the last section was a question about the level of responsibility attributed to each person according to their disorder. The responses had a Likert-type pattern, ranging from 0 (not at all) to 3 (very much); the sum of this score divided by the number of respondents constitutes the Mean Responsibility Score (MRS).

Statistical Analysis

Subsequently, the data obtained was transferred to an Excel spreadsheet to be analyzed using the SPSS Statistical Software. Pearson’s correlation coefficients were obtained to establish associations between the different variables. An analysis of variance (ANOVA) was performed to compare groups and to determine the relationship between the responses of these groups and the variable to be studied. A post hoc analysis was then performed to establish the relationships between the groups and the variables analyzed, which included sex, age, and level of education.

Results

Mean Discrimination Score

The degree of discrimination of the subjects toward people with different pathologies was significantly different (repeated measures ANOVA F(3) = 505.2; p < .001). Pairwise post hoc analyses showed that there were significant differences (p <.001) between all types of discrimination, with the greatest discrimination against people suffering from substance use disorder (MDS = 8.8) and then, in a decreasing scale, schizophrenia (MDS = 7.6), bipolar disorder (MDS = 6.7), and epilepsy (MDS = 3.9).

Comparison Between Mental Disorders and a Neurological Disorder

The average of mental disorders MDS was compared with the neurological disorder MDS. The results showed that the social distance of individuals toward mental disorders was significantly higher than the one toward epilepsy (mental disorders average of MDS 7.7 ± 2.5 versus epilepsy MDS 3.9 ± 2.9, t (449) = 34.9; p < .001).

Discrimination Based on Sociodemographic Variables

In general, no significant differences were found in the degree of discrimination against people with mental and neurological disorders according to sex. Only in the case of the degree of discrimination toward people with substance use disorder, there was a statistically significant difference, where women had higher social distance (men MSD 8.2 ± 3.1 vs. women MSD 9.3 ± 3.2 [independent sample t-test t (498) = 3.7; p < .001]).

No statistically significant correlation between age and degree of discrimination was found: schizophrenia (r = −.03), substance use disorder (r = −.13), epilepsy (r = −.09), and bipolar disorder (r = −.004). For the purposes of this study, the sample was divided into three age groups: firstly from 18 to 34 years (n = 284) accounting for 56.8%, then from 35 to 64 years (n = 183) accounting for 36.6%, and finally those over 64 years (n = 33) accounting for 6.6% of the sample. The ANOVA statistical test was performed for ‘discrimination’ as the dependent variable and ‘age range’ as the independent variable. No relevant statistics for discrimination by the age group indicated were found.

No significant differences were found with respect to educational level and the degree of discrimination toward the different disorders at a general level. Post hoc analysis specifically showed that people with bipolar disorder are more likely to be discriminated against by those with lower educational level analysis (F(2) = 4.2 p = .01) demonstrating the following results: group 1, primary educational level (MSD = 9.27) versus group 2, secondary educational level (MSD = 6.51) versus group 3, and tertiary-university educational level (MSD = 6.78).

Level of Discrimination Based on Intimacy

Significant differences were found in terms of distance in intimacy attributed to individuals with mental illnesses and neurological disorders. It was corroborated that the closer the proximity, the greater the discrimination. The results showed general MDS 10.1 ± 5.1 in the less intimate and 17 ± 5.2 in the more intimate [t (499) = 35.9; p < .001)]. Moreover, social distance toward people with the mentioned disorders showed that the more intimate the questions were, the greater the social distance attributed to them (see Table 2).

Table 2.

Comparison of social distance by level of intimacy.

	MSD intimate	MSD non intimate	Paired t-test	p-Value
General	17.05 ± 5.29	10.1 ± 5.18	t (499) = 35.9	<.001
Schizophrenia	4.65 ± 1.49	2.99 ± 1.7	t (499) = 22.4	<.001
Substance use disorder	5.42 ± 1.67	3.44 ± 1.94	t (499) = 26.6	<.001
Bipolar disorder	4.27 ± 1.75	2.47 ± 1.7	t (499) = 26.0	<.001
Epilepsy	2.7 ± −1.78	1.19 ± −1.48	t (499) = 22.2	<.001

Note. Results of paired t-tests. MSD = mean social distance.

Mean Responsibility Score

Significant differences were found to exist in terms of the responsibility attributed to individuals according to disorder (repeated measures ANOVA F(3) = 153.6; p ⩽ .001). The degrees of responsibility attributed to the individuals with the different disorders studied were: substance use disorder (MRS = 1.61), schizophrenia (MRS = 0.84), bipolar disorder (MRS = 0.83), and epilepsy (MRS = 0.8). Post hoc studies showed that the responsibility attributed to people with addictions was greater than to people with schizophrenia, bipolar disorder, or epilepsy.

Responsibility and social distance correlation

The correlation between the social distance and the degree of responsibility attributed was analyzed. A significant correlation was found in addictions (r = .12; p = .007), in bipolar disorder (r = .09; p = .030), and in epilepsy (r = .07; p = .011), but not in schizophrenia (r = .02; p = .5).

Discussion

The overarching aim of this research was to analyze the social distance toward individuals with mental illnesses (schizophrenia, bipolar disorder, and substance use disorder) and with a neurological disorder (epilepsy) as it is known that the mentioned disorders suffer from stigma and discrimination. It was confirmed that people with a mental illness suffer a higher degree of discrimination than those with a neurological disorder. These results replicated those shown by Mascayano Tapia et al. (2015) which exhibit that society discriminates and rejects more markedly those who are considered responsible for their disease (as in substance use disorder) over people who are not (as in epilepsy) or those who are considered dangerous (as in the case of schizophrenia).

The pandemic context generated an increase in social inequalities, therefore, it is a possibility that the results obtained in the present research are altered. Some people with mental disorders suffer a greater risk when exposed to COVID-19, this may generate social stigmas such as the concept of ‘weakness’. Also due to the COVID-19 context, the well-being and psychological reactions of the participants could have affected their normal behavior, causing emotional distress or defensive responses. Due to all the pandemic effects mentioned, the survey may be affected (Cullen et al., 2020).

The differences in the discrimination toward subjects with the mentioned mental disorders were corroborated and the results obtained are consistent with the studies made by Cassiani-Miranda et al. (2019) and Mascayano Tapia et al. (2015). In said studies, the responsibility attributed to the condition and the degree of aggressiveness affect the level of discrimination. Both affect the level of discrimination differently, depending on each disorder. The reached results in this survey confirmed that the degree of discrimination is associated with the level of responsibility attributed to the person for their disease. The most affected were people with substance use disorder, with a higher attributed responsibility along with a higher degree of discrimination. It may be explained by the association of the problematic substance use with their lifestyle, in which people assume they could choose; and also by the lack of information or specific knowledge about this disorder creating in consequence prejudicial attitudes like blaming the individual for the problems they face (Henderson & Thornicroft, 2009; McGinty et al., 2018). Also our results showed that the more the presented situation implies social closeness, the higher the level of social distance, the same was found on a paper done by Lauber et al. (2004). When talking about schizophrenia, it could be inferred that the reason why responsibility is not attributed to this mental disorder as much as substance use disorder is due to the fact that it is accredited more to the genetic factors and that there is no choice about such a condition.

The research also showed that age did not have a difference when it came to discriminating. These outcomes replicated those reported by Wolska and Pietrulewicz (2008) who found no difference in attitudes toward mental illness linked to age. Similarly to those results, Angermeyer and Matschinger (1997) established no significant differences between age and degree of discrimination. At the same time, it was found that both women and men discriminate and stigmatize to the same extent. These findings support the work of Bradbury (2020) and Gonzalez et al. (2005) revealing no statistical significant interaction difference between age and gender for attitudes toward mental illnesses. This may be because of the cultural thought given to the distinction between genders and the concept of one gender being more discriminating than another, which is not representative in our population.

It was found that people with bipolar disorder were more likely to be discriminated against by those with a lower educational level, even though no significant differences were found in connection with education and the degree of discrimination toward the different disorders in general. This was corroborated by the study of Husain et al. (2020) in which the level of education was not significantly associated with stigma for either type of illness. According to the study by Cassiani-Miranda et al. (2019) and Rüsch et al. (2005), education is essential in order to understand stigma and discrimination in general. This is why emphasizing on proposing short educational mental health courses will help reduce stigmatizing attitudes.

The limitations of this study could be implicated by the context of COVID-19 pandemic; the data obtained in the surveys may have been affected by it. As a virtual format was the only option, the use of the online modality left out a large part of the population without internet access. At the same time, the use of the internet resulted in a target audience of relatively young age with a higher level of educational attainment. This over-representation of young people could have conditioned the data, resulting at the same time in a non-proportional number of results in the three age samples. Finally, this study was designed as a cross sectional, meaning the data is collected from the Argentinian population, at a specific point in time; in order to fully understand this topic another research should delve in the discrimination against mental disorders before, during, and after the pandemic.

Conclusions

This study is of vital importance due to the lack of comparison on discrimination between mental illnesses and neurological disorders in Latin America and, specially, in Argentina. It was found that the level of discrimination was higher for those disorders to which a greater degree of responsibility was attributed. The results showed that substance use disorder and schizophrenia were the most discriminated against, compared to bipolar disorder and epilepsy. These results allow us to focus on awareness campaigns directed to mental illnesses and neurological disorders. It presents value for the possibility of broadening knowledge on the subject. Based on that, anti-stigma campaigns should be directed about ending misperceptions and pointing to the involuntariness of the illnesses, taking into account the priority of intervention according to the level of discrimination toward the disorder. Further studies should be performed to confirm and explain the correlations between mental illnesses and the social negative impact produced by the stigma. It is important to acknowledge that larger groups of people need to be involved in the fight against stigma in order to fully include the mentally and neurological ill individuals in our society.

Footnotes

Acknowledgements

The authors would like to acknowledge Abigail Fallas for help in translation, Sophie Sztyglic, Francisco Saccomandi, Agustina Castro, and Paula Campillay for assistance in collecting data, and Nurit Mitrani for her help to draw up the initial ideas of the paper.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Mijal Mitelman

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