The Forsaken Specialty

PhotoCredit: guardian.co.uk

Abstract and Introduction
Introduction

As a medical student I found that most other students thought that psychiatry was not a true profession—the consultants sit and sip tea, talk nonsense, and nobody ever seems to gets better. No blood test confirms what is wrong. No imaging shows the diagnosis. Simply put, ward rounds that consist of sitting in a room and chatting just didn't seem like "real medicine" to most of my peers. Psychiatric patients were people to be mocked, feared ("you were left alone with them?"), or ignored. Revision for objective structured clinical exams and written papers was left to the last minute because it was "only psych."

I don't know why I thought this would be different when I qualified. Perhaps the "doctor" title would equate to being surrounded by those who understand, appreciate, and respect psychiatry? Goes to show that a label does not define how you act.

Throughout medical school I was taught to be impartial and non-judgmental, and I swore to uphold the Hippocratic oath and "do no harm or injustice" to patients, either verbally or physically. I am sure the doctor who rolled his eyes, saying "nutter" under his breath when a patient who had overdosed on paracetamol came in had taken the same oath as me. I've heard qualified doctors share a joke about a "schizo" patient, giggling and clutching their sides laughing.

Needless to say I have never sat and shared a joke about a patient receiving palliative care, so why the difference?

Anyone who has experienced similar scenarios must realise that stigma, fear, and discrimination stand between us and our duty of care. Why the view that psychiatry is the bottom of the pile? A career only fit for the students who just scraped through medical school? Odd, when you consider that one in four British adults will have at least one diagnosable mental health problem in any one year and that suicide remains the most common cause of death in men under the age of 35. The stigma surrounding mental health and those who work within the specialty seems to be cemented in many minds.

Perhaps I am too sensitive and defensive. I have lived with mental health issues since I was a child, and have experienced them both first hand and in my daily environment. I am not unique or alone in having these experiences and am by no means a martyr, but there is nothing quite like seeing a parent lying intubated on the intensive care unit after they have hanged themselves to get you to take mental health seriously.

Stigmatised Within Their Own Profession

So why is mental health and psychiatry viewed the way it is?

A recent press release by the Royal College of Psychiatrists showed that only a quarter of medical students thought that a career in psychiatry was appealing, with most believing it was not seen as a prestigious career by either the public or by other doctors. Surgery was viewed as the most well respected profession.

A separate piece of research showed the effect of this stigma on doctors' career choices. Researchers asked 51 psychiatrists and 50 non-psychiatrists about their opinions of different medical specialties; 57% of the psychiatrists felt their own specialty was the least respected. Many said they felt stigmatised within their own profession. Forty one per cent thought their advice was not valued by non-psychiatric colleagues, and 55% felt there was a stigma attached to being associated with mental illness.

An article in the Journal of Psychosocial Nursing and Mental Health Services describes three types of stigma: public stigma (what people with mental health problems believe the public think of them), self-stigma (how these people view themselves), and label avoidance (which ultimately suggests that people with mental health disorders avoid accepting their diagnosis for fear of others discriminating against them). Although self-stigma and label avoidance are more directed towards people with mental illness, public stigma is a phenomenon that we as doctors and students are clearly affected and shaped by. The article stresses that challenging public stigma is "essential in helping individuals accomplish recovery-related goals" and that stigma can be addressed through protest and education.

Laugh at Someone Who is Suffering

Cinematic stereotypes of mental health workers have probably deepened public stigma. Robin Williams is the all hugging, loving, overly involved therapist in Good Will Hunting; Dr Frasier Crane is the comical, hopeless radio psychiatrist; and the infamous, evil Dr Hannibal Lecter simply ate his patients. Rarely portrayed as using scientific methods and drugs, these versions do not mirror professionals that I have met. Depictions of people with mental illness are no better in cinema. Jim Carrey in Me, Myself and Irene encourages us to laugh at someone with "advanced delusionary schizophrenia with narcissistic rage," and the recent film Shutter Island sees traumatised and paranoid Leonardo DiCaprio violently murder his wife. Even the television drama Crash, a series about newly qualified junior doctors, shows a man with schizophrenia murder the leading character in an unprovoked attack. No wonder 36% of us think people with mental health problems are prone to violence.

David Healy, consultant psychiatrist and professor of psychiatry at Cardiff University, suggests that it may not be that stigma is attached to the mental health issue itself, but that mental health disorders are so challenging to treat. "Surgeons win, we lose," he told me, "the stigma is not because it is mental health, but that we are not overly good at treating it." This clearly has weight; surgeons can successfully remove a lump or resect a bowel and give a reasonable guarantee of a cure. Psychiatrists cannot do the same.

Some steps have been made toward public education and destigmatisation of mental health. The Royal College of Psychiatrists' Changing Minds campaign produced a two minute film called 1 in 4 that emphasises that anyone can have mental illness. It says, "1 in 4 could be your brother, your sister. Could be your wife, your girlfriend … 1 in 4 could be your daughter … 1 in 4 could be me … it could be YOU."

Campaign group Time to Change works in the United Kingdom to challenge the misconception that people with schizophrenia are often violent. In April they launched a film called Schizo. It begins like a horror film, with grainy images and flashing lights, and words such as "terrifying," "chilling," and "he is among us" fill the screen. Then it cuts to a middle aged man called Stuart, who is making a cup of tea in his kitchen with his wife. He describes his struggle with the stigma attached to his diagnosis of schizophrenia. It is a powerful video and hopefully one that will help challenge public opinion and work towards alleviating the fear that surrounds mental illnesses such as schizophrenia.

Exposed to Public Stigma

I am not suggesting that all students and doctors behave badly towards patients with mental health issues, or that all medics dismiss psychiatry as a specialty. They don't. But we are all exposed to the stigma of mental health, and affected by it. Many people believe that more needs to be done to improve psychiatry's reputation. Professor Healy is concerned that medical placements are so focused on passing exams that much of the mystery and finesse of psychiatry is lost. "The fun is taken out," he says.

He calls on medical schools to expose their students to neuroscience, to teach about the theories on the difference between the brain and the mind, and to show how fascinating it is to never have two patients who are the same.

It might not require quite as much investment from already overstretched education budgets, however. A Scottish study, presented at the International Congress of the Royal College of Psychiatrists in Edinburgh, showed that students who completed a short placement in psychiatry ended up viewing the specialty far more positively. Before their placement, just 25% of students believed that psychiatry was an appealing career, but after a four week placement in the specialty, this number jumped from 25% to 70%. Perhaps, as James Strain writes in the New England Journal of Medicine, "destigmatisation requires demystification," and simply allowing students to have short yet broad placements in psychiatry will go a long way to improving the situation.

Stigma has reduced throughout time—thankfully we no longer think that psychotic traits are supernatural in their origin—but there is still a long way to go. When people with mental illness are asked to name the greatest obstacle to recovery, by far the most common answer is discrimination and stigma. Stigma is a prejudice, based on stereotypes, leading to discrimination. As medical students and doctors we have sworn to treat without prejudice, judgment, or bias. We need to stop stigma before stigma stops us, be it in our job or even accepting that we may end up being the "1 in 4." Challenging attitudes is going to be difficult, but if we keep an open mind and appreciate the intricacies and mystery surrounding mental illness, and acknowledge that a condition that has no cure is not one to be feared, then maybe we can make a change.

"Assent and you're sane; demur, you're straightway dangerous, and handled with a chain."

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