Perspectives - Vol. 2, No. 2 - Slackers, Stigma and Depression

While scientists are still studying whether exposure to toxic chemicals has damaged the health of Gulf War veterans, it is not disputed that those who fought in the war with Iraq suffer disproportionately from clinical, or major, depression, and a special White House panel report concludes that battlefield stress was almost certainly a contributing factor to the constellation of symptoms known as Gulf War Syndrome.

This should come as no surprise. Soldiers returning from war have often suffered stress-induced depression, which has gone by different names over the years, including "shell shock" during World War I.

Yet Sen. Rockefeller does not want to accept stress as a possible cause for even some of the veterans' symptoms. Like most Americans, he distrusts the psychological, viewing illnesses "of the mind" as imaginary. Implicit in the above quotation is the notion that someone who suffers a "psychological" illness cannot truly be "very, very sick" or, alternatively, is somehow weak and blameworthy. Either way, society is not eager to lavish medical benefits on such cases. The continuing problems of bias facing the mentally ill are once again in todays news, this time in connection with new government rules requiring employers to take reasonable steps to accommodate employees with mental illnesses.

This article argues that the stigma surrounding the mentally ill constitutes a serious problem, and that we need to pay more attention to how the names we use to label disorders such as depression promote stigmas.

Clinical depression affects some 17.6 million Americans each year, according to the National Institute of Mental Health. Even in the 1990s, after repeated attempts to explain that clinical depression is as real an illness as any other, one can still find major American newspapers running op-ed articles that condescendingly -- and, worse, perniciously -- advise the depressed to "get a haircut," "get over yourself," "throw away your anti-depressants," and "go away and sulk until you're ready to be sociable." (This comes from a perfectly serious Washington Post article of October 1994.) Such stigmatizing attitudes lead many who are in pain to avoid treatment, whether it be psychotherapy, drug therapy or both. Were the list of suicides resulting from untreated depression not so long and distinguished, the ignorance displayed in the quoted op-ed piece would be laughable.

Though sophisticated journalists ought to know better, it is less surprising that the public widely shares this dismissive view. In the words of one psychiatrist I interviewed, insurance companies and others often act as though depressed people were slackers complaining about a bad hair day." (This fits perfectly with the op-ed writer's exhortation to the depressed to "get a haircut.") The psychiatrist's anecdotal view, based on his years of practice, is supported by empirical evidence. According to a recent survey, 64 percent of those polled did not know that many mental illnesses have a physiological basis, and nearly a quarter view mental illness as a personal shortcoming.

New York Times columnist Frank Rich correctly notes in his recent article about Mets pitcher Frank Harnisch that it takes great courage for depressed persons to be open about their illness. Hence, employers the Wall Street Journal quoted as worried that employees will fake mental illnesses in order to claim special accommodations have little to fear. The stigma is so great that the healthy are unlikely to claim mental illness in order to get, say, additional flex-time.

Stigmas attending different diseases vary in important ways. While people afflicted with "physical" illnesses such as AIDS face stigma because of the fear of contagion and, in many instances, anti-gay sentiment, no one seriously thinks that AIDS patients should "just snap out of it." Psychotic persons are stigmatized because what is commonly called madness is generally feared -- and has been since at least medieval times, when it was equated with demonic possession and sin.

By contrast, depression is known not to be communicable (though a pre-disposition to depression appears to be hereditary), and persons suffering from depression are not feared as psychotics are. Rather, the stigma associated with depression is largely that of the malingerer or a person of weak (and therefore blameworthy) character.

Mental health professionals and organizations have been working for years now to erase the stigma associated with mental illnesses. These efforts have largely centered on educating the public about the true nature of various disorders. This is critically important work, but alone it has not yet succeeded. Nor should it be our sole approach. Scant attention has been paid, by either mental health professionals or social scientists, to how the names we use for diseases such as depression affect our thinking about them.

While the literature is replete with studies discussing what effect labeling someone as "mentally ill" or "retarded" has on attitudes towards that person, there has been surprisingly little examination of the effects of substituting a new label for a particular disorder.

A notable exception appears in Paul J. Fink and Allan Tasman (eds.), Stigma and Mental Illness (American Psychiatric Press, 1992). In their contribution to the book, University of Wisconsin psychiatrists Herzl Spiro and Donald P. Hay highlight the importance of semantic issues.

Dr. Hay writes, "Depression is a generic term that has many different meanings in our culture. It is important to distinguish, therefore, between the situational sadness that is understood by most individuals [as depression] and the medical disease 'depression' that is so effectively treated. . . ."

A simple way to distinguish between the situational sadness people commonly mean when they say, Im depressed, and clinical depression is to employ different words to denote the two.

Would re-naming depression as something like "unipolar disorder" (in contrast to "bipolar disorder," another name for manic-depression) lessen the associated stigma? It might. Unlike depression, unipolar disorder is not used in common parlance and lacks everyday associations that can mislead.

While psychiatrists and other professionals in the field are generally and understandably more interested in improving their diagnostic methods and treatments, they should no longer ignore a potentially easy way to reduce the stigma associated with depression.

Our semantic confusion regarding depression extends to its psychiatric classification, and also needs to be examined. Depression is termed an "affective" or mood disorder, connoting a transient state, yet it can be characterized by many chronic symptoms not necessarily at all related to mood: fatigue, diminished ability to concentrate, early morning awakening/insomnia, loss of appetite and sex drive.

Millions of Americans who, like the Mets Mr. Harnisch, are struggling with these and other symptoms should not also have to contend with a stigma that is exacerbated by what, after all, may be nothing more than a poorly chosen name. At the very least, it is a topic deserving further professional study.

Martin Kimel, a lawyer with an undergraduate degree in psychology, has published articles in the Washington Post, the Wall Street Journal, the Baltimore Sun, the Forward, the American Bar Association Journal, the American Lawyer and elsewhere.

Reference
Kimel, Martin (1997). Slackers, stigma, and depression: Americans' disdain for the "psychological". [Online]. Perspectives. [1997, May 15].

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