Вы находитесь на странице: 1из 8


ISP60410.1177/0020764013490263International Journal of Social PsychiatryHarangozo et al.



International Journal of

Stigma and discrimination against Social Psychiatry

2014, Vol. 60(4) 359­–366
© The Author(s) 2013
people with schizophrenia related Reprints and permissions:

to medical services DOI: 10.1177/0020764013490263


J Harangozo,1 B Reneses,2 E Brohan,3 J Sebes,4 G Csukly,5

JJ López-Ibor,2 N Sartorius,6 D Rose3 and G Thornicroft3

Objective: To investigate whether people with schizophrenia experience discrimination when using health care services.
Methods: A cross-sectional survey in 27 countries in centres affiliated to the INDIGO Research Network, using face-
to-face interviews with 777 participants with schizophrenia (62% male and 38% female). We analysed the data related to
health issues, including health care, disrespect of mental health staff, and also personal privacy, safety and security, starting
a family, pregnancy and childbirth. Discrimination was measured by the Discrimination and Stigma Scale (DISC), which
consists of 36 items comprising three sub-scales: positive experienced discrimination; negative experienced discrimination;
and anticipated discrimination.
Results: More than 17% of patients experienced discrimination when treated for physical health care problems. More
than 38% of participants felt disrespected by mental health staff, with higher ratings in the post-communist countries.
Conclusions: Mental health service providers have a key role in decreasing stigma in their provision of health care,
and by doing more against stigmatizing and discriminating practices on the therapeutic and organizational level. This will
require a change of attitudes and practices among mental and physical health care staff.

Stigma, discrimination, schizophrenia, health services, integrated care, mental health services

Living with a mental disorder is related to a higher level of Thornicroft, Rose and Kassman (2007) have recently
stigma, which has a great negative influence on recovery reviewed the evidence related to the association between
and outcome (Lasalvia et al., 2013; Thornicroft et al., 2009) low rates of help-seeking behaviour of people with mental
and in other fields of social live (Major & O’Brien, 2005). disorders and the poor quality of the attention to their
People suffering from schizophrenia have a higher mor- physical health. The diagnosis of physical illness remains
tality compared with the general population (Brown, 1997;
Capasso, Lineberry, Bostwick, Decker & St Sauver, 2008;
Harris & Barraclough, 1998), as well as a higher risk of 1Centre for Community Psychiatry, Semmelweis Medical University,
physical illnesses (Fleischhacker, Meise, Günter & Kurz, Budapest, Hungary
2Instituto de Psiquiatría, Instituto de Investigación biomédica del
1994; Leucht, Burkard, Henderson, Maj & Sartorius, 2007).
Hospital Clínico San Carlos, Departamento de Psiquiatría, Universidad
Studies of comorbidity with metabolic and cardiovascular
Complutense, Madrid, Spain
diseases have been especially emphasized (de Hert, 3Health Service and Population Research Department, Institute of

Schreurs, Vancampfort & van Winkel, 2009; Saha, Chant & Psychiatry, King’s College London, UK
McGrath, 2007). The fact that physical diseases are even 4Department of Psychiatry, Bajcsy-Zsilinszky Hospital, Budapest,

more prevalent in people living in the community com- Hungary

5Department of Psychiatry and Psychotherapy, Semmelweis Medical
pared with those living in hospitals (Salokangas, 2007)
University, Budapest, Hungary
supports the idea that patients are less likely to receive ade- 6Association for the Improvement of Mental Health Programmes,

quate care, or even have difficulty accessing general medi- Geneva, Switzerland
cal services (Maj, 2009; Prince, 2007). A survey among 200
people with schizophrenia in Hungary showed that only Corresponding author:
B Reneses, Instituto de Psiquiatría, Instituto de Investigación biomédica
56% of patients had ever used a general practitioner (GP), del Hospital Clínico San Carlos, Departamento de Psiquiatría, Universidad
while 28% had wished to but did not receive that service Complutense, Av Prof. Martin Lago s/n 28040 Madrid, Spain.
(Harangozó, Döme & Kristóf, 2005). Email: blanca@reneses.es
360 International Journal of Social Psychiatry 60(4)

concealed probably due to the attribution of complaints Slovenia, Tajikistan) and other countries (Cyprus,
about physical condition to a mental illness. Also no clear Finland, France, Germany, Greece, India, Italy, Malaysia,
consensus exists as to which physician should be in charge Netherlands, Norway, Portugal, Spain, Switzerland, UK)
of the prevention and care of comorbid physical illnesses, and between different forms of health care (inpatient, out-
which leads to the fragmentation of medical care patient, home care, day care) were analysed. Discrimination
(Fleishhacker et al., 2008). was measured by the validated Discrimination and Stigma
Studies about stigma in mental health professionals Scale (DISC), which consists of 36 items comprising three
show several data that point out stigmatizing attitudes fac- sub-scales: positive experienced discrimination; negative
ing patients with schizophrenia and other mental illnesses experienced discrimination; and anticipated discrimina-
in different cultures and countries (Arvaniti et al., 2009; tion. The scale was administered by an interviewer who
Des Courtis, Lauber, Costa & Cattapan-Ludewig, 2008; asked the participants, for a series of domains, whether
Hori, Richards, Kawamoto & Kunugi, 2011; Lauber, Nordt, they have experienced discrimination because of their
Braunschweig & Rössler, 2006; Loch et al., 2012; Nordt, mental illness; what the direction (positive or negative) of
Rössler & Lauber, 2006; Ucok, Sartorius, Erkoc & Atakli, such discrimination is; and how severe it is. The domains
2004; Wahl, 1999). Stereotyped attitudes and attitudes of address key areas of everyday life and social participation,
prejudice from health care staff towards patients with including work, marriage, parenting, housing, leisure and
schizophrenia regarding their health may contribute to religious activities.
increased self-stigmatization, having at the same time a Statistical analyses were evaluated by SPSS (version 15)
negative impact on the help-seeking behaviour for their and SAS (version 9.2). Frequency tables were analysed by
health problems (Björkman, Angelman & Jönson, 2008; χ2 test and Fisher’s exact test (if more than 50% of the cells
Horsfall, Cleary & Hunt, 2010). had counts less than 5). Associations between variables
There are scarce studies that have looked on how people were analysed by Spearman rank correlations.
with mental disorders experience stigma in health settings.
They report that a negative discriminative attitude prevails Results
towards patients with schizophrenia (Lawrie et al., 1998;
Liggins & Hatcher, 2005; Wahl, 1999). Because these stud- Descriptive results
ies are limited, it is necessary to explore in a more detailed Most of the participants (537 out of 718) reported that they
and standardized way, how patients perceive stigma and were not treated differently compared to other people for
discrimination in medical services. physical problems. Among those who reported different
The main objective of this study is to investigate whether treatment, 47 (8.1%) experienced advantages and 123
people with schizophrenia experience discrimination or (17%) disadvantages (Table 1).
anticipated discrimination when using health care services. Only 55 patients had received a disadvantageous experi-
We hypothesized that discrimination by health profession- ence when treated with dental problems; a further 70 expe-
als and services exists and that this may contribute to the rienced advantages and 569 reported that they had not
fact that patients underuse health services. experienced any discrimination.
Approximately every fourth subject (183 out of 738)
reported disadvantageous experiences in the field of per-
Methods sonal privacy, only 22 experienced advantages and a further
A cross-sectional interview study was conducted in 27 533 did not report any discrimination.
countries, led by G. Thornicroft in centres affiliated to the The results were rather worse in the field of personal
INDIGO Research Network, by use of face-to-face inter- safety and security: 92 patients experienced strong, 59
views with 732 participants with schizophrenia (62% moderate and 53 slight disadvantage. Most of the partici-
male and 38% female) in 2006. The main findings of this pants (473 out of 686) reported no discrimination in per-
research project and the detailed description of the meth- sonal safety and security and only 12 experienced
odology have already been published (Thornicroft et al., advantages (see Table 1).
2009). Also in 2006, further data were added from The question ‘Have you ever been treated differently
Hungary (n = 20) and Japan (n = 25), which increased the when wanting to start a family?’ was answered by only half
sample to 777 patients. of the subjects, namely 388 out of 777. However, 216 did
In the current study we analysed the survey data that not report any discrimination, 153 experienced strong (62),
related to health issues, including health care and dental moderate (47) or slight (44) disadvantage, while 19 had an
care, disrespect by mental health staff, and provision con- advantageous experience (Table 1).
cerning personal privacy, safety and security, starting a Even fewer patients had any experience with preg-
family, pregnancy, childbirth and avoidance by others. In nancy and childbirth: only 64 out of 777 answered the
addition, differences between post-communist countries question. More than every fourth subject (17 out of 64)
(Bulgaria, Hungary, Lithuania, Poland, Romania, Slovakia, had a disadvantageous experience (strong: 11; moderate: 5;
Harangozo et al. 361

Table 1.  Stigma, self-stigma and discrimination related to health

issues (N = 777). Question Frequency (n) Percent of those
who answered the
Question Frequency (n) Percent of those question (%)a
who answered the Moderate disadvantage 22 9.6
question (%)a
Slight disadvantage 27 11.8
Ever treated differently for physical health problems No different treatment 123 53.7
Missing 59 N/A Slight advantage 1 0.4
Strong disadvantage 46 6.4 Moderate advantage 1 0.4
Moderate disadvantage 36 5 Strong advantage 3 1.3
Slight disadvantage 41 5.7 How much felt disrespected by mental health staff
No different treatment 537 74.8 Missing 14 N/A
Slight advantage 35 4.9 Not at all 465 60.9
Moderate advantage 12 1.7 A little 174 22.8
Strong advantage 11 1.5 A lot 124 16.3
Ever treated differently for dental problems How much been avoided by those who know about diagnosis
Missing 83 N/A Missing 18 N/A
Strong disadvantage 20 2.9 Not at all 333 43.9
Moderate disadvantage 15 2.2 A little 276 36.4
Slight disadvantage 20 2.9 A lot 150 19.8
No different treatment 569 82 How much feel need to conceal diagnosis
Slight advantage 31 4.5 Missing 12 N/A
Moderate advantage 19 2.7 Not at all 208 27.2
Strong advantage 20 2.9 A little 242 31.6
Ever treated differently in personal privacy A lot 315 41.2
Missing 39 N/A
Strong disadvantage 76 10.3 N/A = not applicable.
a100% = those who answered the given question.
Moderate disadvantage 51 6.9
Slight disadvantage 56 7.6
No different treatment 533 72.2
Slight advantage 11 1.5 slight: 1), 44 found no difference and only three felt posi-
Moderate advantage 4 0.5 tive discrimination.
Strong advantage 7 0.9
Among those, who experienced disadvantage when
Ever treated differently in personal safety or security
Missing 88 N/A
wanting to start a family, significantly more felt the need to
Strong disadvantage 92 13.4 conceal the diagnosis. Only 229 of the 777 subjects
Moderate disadvantage 59 8.6 answered the question ‘Ever treated differently in being
Slight disadvantage 53 7.7 able to act as a parent?’ and many (101) felt disadvantages
No different treatment 473 68.7 in this field.
Slight advantage 6 0.9 Need for concealing the diagnosis was reported by 557
Moderate advantage 4 0.6
(a little: 242; a lot: 315) and only 208 felt free to disclose
Strong advantage 2 0.3
Ever treated differently when wanting to start a family their diagnosis to others (Table 1).
Missing 389 N/A The question ‘How much did you feel disrespected by
Strong disadvantage 62 16 mental health staff?’ was answered by 763 of the 777 sub-
Moderate disadvantage 47 12.1 jects. More than half (465) did not feel disrespected, 174
Slight disadvantage 44 11.3 reported a little and 124 a lot, and 228 did not experience
No different treatment 216 55.7 disrespect by mental health staff at all (Table 1).
Slight advantage 5 1.3
Avoidance by those who know about the diagnosis was
Moderate advantage 9 2.3
Strong advantage 5 1.3 reported by 426 (a little: 276; a lot: 150) out of 759 (Table 1);
Ever treated differently during pregnancy and childbirth 333 subjects did not experience avoidance.
Not applicable 668 N/A Age group and gender had no significant effect on the
Strong disadvantage 11 17.2 answers to any of the above questions.
Moderate disadvantage 5 7.8
Slight disadvantage 1 1.6
No different treatment 44 68.8 Associations between discrimination related
Slight advantage 1 1.6 to physical health and discrimination related
Moderate advantage 1 1.6 to other life fields
Strong advantage 1 1.6
Ever treated differently in being able to act as a parent There was a significant association (p < .01) between disad-
Missing 548 N/A vantages related to physical health and disadvantages
Strong disadvantage 52 22.7 related to friendship, treatment by family, keeping a job,
(Continued) travel visas, welfare benefits and pension, opening a bank
362 International Journal of Social Psychiatry 60(4)

Table 2.  Association between discrimination related to physical health and discrimination related to other life fields (N = 777).

Question Correlation n p (two-tailed)

Ever treated differently making or keeping friends 0.17 701 < .01
Ever treated differently in relationship with neighbours 0.05 678 .23
Ever treated differently in intimate or sexual relationships 0.07 570 .11
Ever treated differently with housing 0.07 519 .13
Ever treated differently in becoming homeless 0.13 147 .1
Ever treated differently in education 0.09 439 .06
Ever treated differently when dating 0.07 511 .12
Ever treated differently in terms of marriage or divorce 0.12 256 .06
Ever treated differently by your family 0.12 708 < .01
Ever treated differently in finding a job 0.05 509 .28
Ever treated differently in keeping a job 0.18 522 < .01
Ever treated differently when using public transport 0.04 644 .3
Ever treated differently when getting or keeping a driving licence 0 328 .94
Ever treated differently getting travel visas 0.18 214 .01
Ever treated differently getting welfare benefits or disability pensions 0.15 543 < .01
Ever treated differently opening a bank account 0.16 509 < .01
Ever treated differently with voting in elections 0.16 608 < .01
Ever treated differently getting any type of insurance 0.05 351 .34
Ever treated differently borrowing money or taking out a loan 0.03 295 .66
Ever treated differently in religious practices 0.18 539 < .01
Ever treated differently in social life 0.12 612 < .01
Ever treated differently by the police 0.15 538 < .01
Ever treated differently arranging payment for medical care 0.13 508 < .01
Ever treated differently for dental problems 0.24 664 < .01
Ever treated differently in personal privacy 0.08 688 .04
Ever treated differently in personal safety or security 0.08 649 .04
Ever treated differently when wanting to start a family 0.06 371 .28
Ever treated differently during pregnancy and childbirth 0.08  61 .53
Ever treated differently in being able to act as a parent 0.12 215 .07
Ever treated differently in any other important ways 0.09 518 .05
How much an advantage to have schizophrenia diagnosis 0.06 652 .12
How much stopped yourself from applying for work/training/education 0.01 684 .7
How much stopped yourself from looking for close relationship –0.04 683 .3
How much stopped yourself from doing something important –0.06 646 .15
How much felt disrespected etc. by mental health staff –0.16 706 < .01
How much been avoided etc. by those who know about diagnosis –0.06 703 .12
How much feel need to conceal diagnosis –0.06 707 .1
How often been able to take vacation –0.09 682 .02
How much been denied social or welfare benefits –0.05 561 .2
How much have you made friends outside mental health services 0.01 684 .85

account, voting in elections, religious practices, social life, nor was there an association with the experience of being
treatment by the police, arranging payment for medical avoided by others or with the need of concealing the diag-
care, dental treatment, disrespectful treatment by mental nosis. Associations between discrimination related to phys-
health staff and a significant association (p < .05) in being ical health and discrimination related to other life fields are
treated differently in personal safety, security and personal shown in Table 2.
privacy. There was no association with disadvantages to
family and intimate/sexual relationships, dating, neigh-
bours, finding a job, housing and homeless services.
Comparison of different forms of health
Interestingly, there was no association with self-stigma
when people stop doing something important because of A large proportion (42%) of the patients using home care
how others might respond to their mental health problem; services felt more discrimination related to personal safety
Harangozo et al. 363

Table 3.  Some differences between post-communist and other European countries in level of discrimination and self-stigma
(N = 777).

Question Post-communist n (%)a Other countries n (%)a

Ever treated differently when wanting to start a family Fisher’s exact test, p = .02
Missing 73 316
Strong disadvantage 22 (23.4%) 40 (13.6%)
Moderate disadvantage 8 (8.5%) 39 (13.3%)
Slight disadvantage 16 (17.0%) 28 (9.5%)
No different treatment 44 (46.8%) 172 (58.5%)
Slight advantage 0 (0%) 5 (1.7%)
Moderate advantage 4 (4.3%) 5 (1.7%)
Strong advantage 0 (0%) 5 (1.7%)
Ever treated differently in personal privacy χ2 = 6, p = .42
Missing 4 35
Strong disadvantage 17 (10.4%) 59 (10.3%)
Moderate disadvantage 16 (9.8%) 35 (6.1%)
Slight disadvantage 8 (4.9%) 48 (8.3%)
No different treatment 119 (73.0%) 414 (72.0%)
Slight advantage 2 (1.2%) 9 (1.6%)
Moderate advantage 2 (1.2%) 4 (0.7%)
Strong advantage 1 (0.6%) 6 (1.0%)
How much felt disrespected by mental health staff χ2 = 6.2, p = .05
Missing 4 10
Not at all 97 (59.5%) 368 (61.3%)
A little 30 (18.4%) 144 (24.0%)
A lot 36 (22.1%) 88 (14.7%)
How much been avoided by those who know about diagnosis χ2 = 5.1, p = .08
Missing 4 14
Not at all 84 (51.5%) 249 (41.8%)
A little 53 (32.5%) 223 (37.4%)
A lot 26 (16.0%) 124 (20.8%)
a100% = those who answered the given question.

and security compared to those using inpatient (36%), out- Discussion

patient (27%) or day care services (34%) (χ2 = 27.4, p <
.01). Similarly, patients using home care services felt more More than 17% of patients experienced discrimination
discrimination in personal privacy (44%) than subjects when treated with physical problems, which can contrib-
using other forms of health care (inpatient: 26%; outpa- ute to inappropriate results when treating the physical
tient: 27%; day care services; 27%; χ2 =27.9, p < .01). symptoms of people with schizophrenia and also to
patients avoiding medical services (Harangozó et al.,
2005; Leucht et al., 2007; Mitchell & Mallone, 2006;
Differences between post-communist and Salokangas, 2007). Professionals in mental health ser-
other countries vices often believe that they do a lot to reduce stigma.
Slightly more than half (53%) of the 94 patients from the Our data do not support this. More than 38% of partici-
post-communist countries versus 41.5% of the 294 partici- pants felt disrespected by mental health staff, with higher
pants from other countries, felt discrimination when want- ratings in the post-communist sample. This can contrib-
ing to start a family. Severe discrimination was detected by ute to the frequent avoidance of mental health services
23% versus 14% of the participants in the post-communist by people who need them (Corrigan, 2004). Overall, par-
and other countries, respectively (Fisher’s exact test, p = .02) ticipants reported better experiences with dental treat-
(Table 3). Perceived disrespect was higher in the sample ment. According to these results, mental health services
from the post-communist countries compared to the other cause more stigma and discrimination than other medical
countries (χ2 = 6.2, p = .05) (Table 3). Avoidance was mar- services, which is in contradiction with some results in
ginally significantly lower in the post-communist countries the literature that show less respectful attitudes of non-
(χ2 = 5.1, p = .08) (Table 3). psychiatric staff (Björkman et al., 2008).
364 International Journal of Social Psychiatry 60(4)

Several questions in the survey are indirectly related to an integration of medical and psychosocial care and the estab-
medical services. Nearly 25% of participants with schizo- lishment of standards for recovery-based routine medical
phrenia suffer from significant disadvantages in the field of practices in which anti-stigma strategies are planned, imple-
privacy and nearly 30% had disadvantages related to per- mented and monitored. Psychiatrists (and other health profes-
sonal safety and security, many of those being patients who sionals) should always remember that while providing
use home care. Disadvantages in privacy also vary with dif- treatment, they can either increase stigmatization or de-stig-
ferent types of service. The results show that home care matize their patients (Schlosberg, 1993). Recovery-based ser-
services often do not support social recovery and are felt to vices are needed, where patients’ needs drive the efforts for
be intrusive by the patients. treatment and rehabilitation, and assertive communication
About half of the respondents had no experience of with staff and regular monitoring of staff behaviour may help
wanting to start a family, and only 64 participants had any to avoid stigmatization and discrimination that contributes to
experience with pregnancy and childbirth, showing that poor prognosis of mental disorder, loss of self-esteem and
many of the respondents had no chance of having their own poor chances for recovery. Medical service providers who
family. Over a third (39%) of respondents experienced dis- often focus on evidence-based interventions should recall that
advantages when wanting to start a family, and about a values and contexts are also important parts of effective treat-
quarter at pregnancy and childbirth. Discrimination when ment. Information obtained by qualitative research with the
wanting to start a family was higher in the post-communist involvement of service users can be of great value in building
sample. Stigma and discrimination might increase difficul- mental health services.
ties when wanting to start a family.
Only 44% did not experience avoidance by those who Acknowledgements
knew about their diagnosis and only 27% did not conceal The authors would like to thank the INDIGO study principal
the diagnosis, showing a high level of experienced stigma, investigators Professor Graham Thornicroft, Dr Diana Rose and
discrimination and self-stigmatization. Professor Norman Sartorius. They would also like to thank the
Differences in the ratings of the post-communist sample INDIGO study group: Austria: Professor Heinz Katschnig, Dr
show more control over patients’ family plans and more Marion Freidl. Belgium: Professor Dr Chantal Van Audenhove,
disrespect by mental health staff, indicating higher social Gert Scheerder and Alison Hwong. Brazil: Cecilia Villares,
control over the lives of patients. Fernanda de Almeida Pimentel, Valeska Janas Murier, Renata
Tosta and Professor Miguel R. Jorge. Bulgaria: Mrs Galina
Veshova, Dr Galina Petrova, Dr Vladimir Sotirov, Dr Svetlozar
Conclusions Vassilev and Dimitar Germanov. Canada: Dr Roumen Milev and
Liane Tackaberry. Cyprus: Dr Yiannis Kalakoutas, Dr Maria
Stigma and discrimination are major risk factors for mental Tziongourou. England: Professor Graham Thornicroft, Dr Diana
ill health, eroding empowerment and contributing to the Rose, Professor Norman Sartorius, Elaine Brohan, Dr Ann Law,
poor prognosis of mental disorders (Vauth, Kleim, Wirtz & Dr Richard Church, James Fisher, Dr Morven Leese, Rosalind
Corrigan, 2007). Some data and opinions support the idea Willis, Dr Anil Kumar, Aliya Kassam and Gabriele Schmid.
that western psychiatry often provides treatment in a dehu- Finland: Professor Kristian Wahlbeck, Joel Lillqvist and Dr Carita
manizing context lacking a holistic approach, which Tuohimäki. France: Dr Jean Luc Roelandt, Dr Jean Yves Giordana
and Nicolas Daumerie. Germany: Dr Anja Esther Baumann,
increases stigma, self-stigma and discrimination and also
Harald Zäske, Julia Weber, Petra Decker, Professor Wolfgang
decreases empowerment and the possibility for patients to Gaebel and Professor Hans-Juergen Möller. Greece: Dr Marina
think about themselves as individual and unique human Economou, Christina Gramandani, Eleni Louki, Dimitrios
beings with unique human experiences (Rosen, 2006; Kolostoumpis, Dimitri Spiliotis and Dr Lambros Yotis. Hungary:
Wetters, 2010). In the current study, stigma and discrimina- Dr Judit Harangozo. India: Dr R. Thara. Italy (Verona): Alessia
tion were frequently experienced by people with mental ill- Cicolini, Antonio Lasalvia, Davide Maggiolo, Alessandro Ricci
ness when using health services, particularly mental health and Professor Michele Tansella. Italy (Brescia): Dr Giuseppe
services. In this way, our data support the notion that ser- Rossi, Dr Michela Vittorielli and Dr Chiara Buizza. Lithuania: Dr
vices often increase the burden of mental health problems Arunas Germanavicius, Natalja Markovskaja and Vida Pazikaite.
on patients and their families. Malaysia: Dr Chee Kok Yoon and Dr Nor Hayati Ali. Netherlands:
Mental health service providers could do much to pre- Dr Jaap van Weeghel and Annette Plooy. Norway: Dr Jan Olav
Johannessen and Sveinung Dybvig. Poland: Dr Anna Bielañska,
vent or reduce stigma by improving the practices of acute
Dr Andrzej Cechnicki and Hubert Kaszynski. Portugal: Dr Maria
treatment and rehabilitation and by doing more to reduce Vargas-Moniz and Liliana Filipe. Romania: Dr Radu Teodorescu.
stigmatizing and discriminating practices at the therapeutic Slovakia: Marcela Barova. Slovenia: Dr Vesna Švab and Dr
and organizational level, following international guidelines Mateja Strbad. Spain: Dr Blanca Reneses, Dr José Luis Carrasco
(WHO, 2008). and Professor Juan J. Lopez-Ibor. Switzerland: Professor Wulf
From an ethical and social perspective, people with schiz- Rössler and Dr Christoph Lauber. Tajikistan: Alisher Latypov.
ophrenia should not receive lower-quality health care than Turkey: Professor Alp Uçok and Dr Banu Aslantas. USA: Dr
other citizens (Maj, 2009). Therefore, the authors recommend Richard Warner.
Harangozo et al. 365

Authors’ Note discrimination reported by people with major depressive dis-

order: A cross-sectional survey. The Lancet, 381, 55–62.
Two authors have been supported by the National Institute for
Lauber, C., Nordt, C., Braunschweig, C., & Rössler, W.
Health Research (NIHR) under its Programme Grants for Applied
(2006). Do mental health professionals stigmatize their
Research scheme (RP-PG-0606-1053). The views expressed in
patients? Acta Psychiatrica Scandinavica Supplement,
this publication are those of the author(s) and not necessarily
429, 51–59.
those of the National Health Service (NHS), the NIHR or the
Lawrie, S., Martin, K., McNeil, G., Drife, J., Chrystie, P., Reid,
Department of Health. One of the authors is also funded through
A., … Ball, J. (1998). General practitioners’ attitudes to psy-
an NIHR Specialist Mental Health Biomedical Research Centre at
chiatric and medical illness. Psychological Medicine, 28,
the Institute of Psychiatry, King’s College London and the South 1463–1467.
London and Maudsley NHS Foundation Trust. Leucht, S., Burkard, T., Henderson, J., Maj, M., & Sartorius, N.
(2007). Physical illness and schizophrenia: A review of the
References literature. Acta Psychiatrica Scandinavica, 116, 317–333.
Liggins, J., & Hatcher, S. (2005). Stigma toward mentally ill in
Arvaniti, A., Samakouri, M., Kalamara, E., Bochtsou, V., Bikos, general hospital. General Hospital Psychiatry, 27, 359–364.
C., & Livaditis, M. (2009). Health service staff’s attitudes Loch, A. A., Hengartner, M. P., Guarniero, F. B., Lawson, F. L.,
towards patients with mental illness. Social Psychiatry and Wang, Y. P., Gattaz, W. F., & Rössler, W. (2012). The more
Psychiatric Epidemiology, 44, 658–665. information, the more negative stigma towards schizophrenia:
Björkman, T., Angelman, T., & Jönson, M. (2008). Attitudes Brazilian general population and psychiatrists compared. Psy-
towards people with mental illness: A cross-sectional study chiatry Research, 205, 185–191.
among nursing staff in psychiatric and somatic care. Scandi- Maj, M. (2009). Physical health care in persons with severe men-
navian Journal of Caring Science, 22, 170–177. tal illness: A public health and ethical priority. World Psy-
Brown, S. (1997). Excess of mortality of schizophrenia: A meta- chiatry, 8, 1–2.
analysis. British Journal of Psychiatry, 171, 502–508. Major, B., & O’Brien, L. T. (2005). The social psychology of
Capasso, R., Lineberry, T., Bostwick, J., Decker, P. A., & St Sau- stigma. Annual Review of Psychology, 56, 393–421.
ver, J. (2008). Mortality in schizophrenia and schizoaffective Mitchell, A. J., & Mallone, D. (2006). Physical health and schizo-
disorder: An Olmsted County Minessota cohort 1950–2005. phrenia. Current Opinion on Psychiatry, 19, 432–437.
Schizophrenia Research, 98, 287–294. Nordt, C., Rössler, W., & Lauber, C. (2006). Attitudes of mental
Corrigan, P. (2004). How stigma interferes with mental health health professionals toward people with schizophrenia and
care. American Psychologist, 59, 614–625. major depression. Schizophrenia Bulletin, 32, 709–714.
De Hert, M., Schreurs, V., Vancampfort, D., & van Winkel, R. Prince, M., Patel, V., Saxena, S., Maj, M., Maselko, J., Phil-
(2009). Metabolic syndrome in people with schizophrenia. lips, M. R., & Rahman, A. (2007). No health without mental
World Psychiatry, 8, 15–21. health. The Lancet, 370, 859–877.
Des Courtis, N., Lauber, C., Costa, C. T., & Cattapan-Ludewig, Rosen, A. (2006). Destigmatizing day-to-day practices: What
K. (2008). Beliefs about the mentally ill: A comparative study developed countries can learn from developing countries.
between healthcare professionals in Brazil and in Switzerland. World Psychiatry, 5, 21–24.
International Review of Psychiatry, 20, 503–509. Saha, S., Chant, D., & McGrath, J. (2007). A systematic
Fleischhacker, W., Cetrovich-Bakmas, M., De Hert, M., Hennek- review of mortality in schizophrenia: Is the differential gap
ens, C., Lambert, M., Leucht, S., … Lieberman, J. A. (2008). worsening over time? Archives of General Psychiatry, 64,
Comorbid somatic illness in patients with severe mental dis- 1123–1131.
orders: Clinical, policy and research challenges. Journal of Salokangas, R. (2007). Medical problems in schizophrenia
Clinical Psychiatry, 69, 514–519. patients living in the community (alternative facilities). Cur-
Fleischhacker, W., Meise, U., Günter, V., & Kurz, M. (1994). rent Opinion in Psychiatry, 20, 402–405.
Compliance with antipsychotic drug treatment: Influence of Schlosberg, A. (1993). Psychiatric stigma and mental health pro-
side effects. Acta Psychiatrica Scandinavica, 89 (Suppl. 382), fessionals (stigmatizers and destigmatizers). Medical Law
11–15. Review, 12, 409–416.
Harangozó, J., Döme, P., & Kristóf, R. (2005). Service-related Thornicroft, G., Brohan, E., Rose, D., Sartorius, N., Leese, M.,
needs and opinions of people with schizophrenia in Hungary. for the INDIGO Study Group. (2009). Global pattern of expe-
Psychiatric Services, 56, 754–755. rienced and anticipated discrimination against people with
Harris, E., & Barraclough, B. (1998). Excess of mortality of men- schizophrenia: A cross-sectional survey. The Lancet, 373,
tal disorder. British Journal of Psychiatry, 173, 11–53. 408–415.
Hori, H., Richards, M., Kawamoto, Y., & Kunugi, H. (2011). Atti- Thornicroft, G., Rose, D., & Kassman, A. (2007). Discrimination
tudes toward schizophrenia in the general population, psychi- in health care against people with mental illness. International
atric staff, physicians, and psychiatrists: A web-based survey Review of Psychiatry, 19, 113–122.
in Japan. Psychiatry Research, 186, 183–189. Ucok, A. P., Sartorius, N., Erkoc, S., & Atakli, C. (2004). Atti-
Horsfall, J., Cleary, M., & Hunt, G. E. (2010). Stigma in men- tudes of psychiatrists toward patients with schizophrenia. Psy-
tal health: Clients and professionals. Issues in Mental Health chiatry & Clinical Neurosciences, 58, 89–91.
Nursing, 31, 450–455. Vauth, R., Kleim, B., Wirtz, M., & Corrigan, P. W. (2007). Self-
Lasalvia, A., Zoppei, S., Van Bortel, T., Bonetto, C., Cristo- efficacy and empowerment as outcomes of self-stigmatizing
falo, D., Wahlbeck, K., … the ASPEN/INDIGO Study and coping in schizophrenia. Psychiatry Research, 150,
Group. (2013). Global pattern of experienced and anticipated 71–80.
366 International Journal of Social Psychiatry 60(4)

Wahl, O. F. (1999). Mental health consumers’ experience of WHO (World Health Organization). (2008). Stigma: A guidebook
stigma. Schizophrenia Bulletin, 25, 467–478. for action. Tackling the discrimination, stigma and social
Wetters, E. (2010). The Americanization of mental illness. exclusion experienced by people with mental health problems
The New York Times, 8 January. Retrieved from: http:// and those close to them. Retrieved from: http://ec.europa.eu/
www.nytimes.com/2010/01/10/magazine/10psyche-t. health/mental_health/eu_compass/policy_recommendations_
html?pagewanted=1 declarations/stigma_guidebook.pdf