A Double Stigma: combined physical - mental illness & inequalities in health care

1. A Double Stigma: combined physical - mental illness & inequalities in health care Chris Platania-Phung Prof Brenda Happell Dr David Scott Institute for Health & Social Science Research Central Queensland University June 2, 2011 Rockhampton

2. Introduction People with serious mental illness have much lower physical wellbeing than the general population There are inequalities in physical care for people classified as having serious mental illness Inequalities in access and quality of care may be partly due to mental (illness) stigma and physical (illness) stigma Research directly on multiple stigmas and health care is urgently required

3. Overview Physical ill-health & mental ill-health Health care inequalities Stigma A Double-Stigma: • Mental • Physical Obesity stigma Research on stigma Research steps on multiple stigmas

4. INEQUALITIES: MENTAL/PHYSICAL HEALTH & HEALTH CARE

5. The physical health of people with serious mental illness Co-morbidities Longevity Saha et al. (2007, p. 1128):

6. Reasons for link between mental & physical illness? Socio-Economic conditions (e.g. Wilton, 2004) Medication side-effects Lifestyle Health care systems • Inequality in access and quality of care • Fragmentation in care services & philosophies of care

7. Inequalities in physical care for people with SMI Duty to Care Report (Lawrence, Holman & Jablensky, 2001) Recent literature reviews (e.g. Scott, Happell, Platania-Phung, in press) Most common reason? • Mental illness stigma • Also physical stigma?

8. STIGMA

9. Stigma “A stigma is a culturally recognised attribute that is used to differentiate and discredit a person. The stigma may be physical (a bodily deformity), behavioral (for example, a sexual preference), or social (in the sense of membership of a group). The identification of the stigma is used to reduce the person form a complex whole, to a single, tainted and discounted trait, upon which all social interaction with the person will be based.” (Edgar & Sedgwick, 1999, p. 381)

10. Labels, categories, classifications

11. Stigma is toxic Individual Individual associates (Hebel & Mannix, 2003) Places (Keenem & Padilla, 2010) Groups (McGorry) Societies >> Health, wellbeing

12. Stigma reduction Contact (Alexander & Link, 2003; Happell) Education (Happell; Sartorius, 2007) Empathy (Teachman et al., 2008) Social consensus perceptions (Puhl, Schwartz & Brownell, 2005)

13. Health care gap debates Why mental stigma? • Coming from mental health service point of view • Fragmentation in research literature also a problem (not only care models & services) What about physical stigma?

14. STIGMA OF OBESITY

15. Beliefs/assumptions Belief sets and assumptions (e.g. see Rothblum & Solovay, 2009): • “Fat is bad” • Body weight can be changed through willpower & self- control, behaviour change • ‘Happiness’ and ‘better life’ follows major weight loss • Physical appearance reflects qualities of the inner self (Inner ‘thin’ self underneath) • ‘Just World’ Beliefs

16. Stigma of obesity: disgust Vartanian 2010, p. 1304

17. Obesity stigma Everyday events (Puhl & Heuer, 2009) Schools (Puhl & Heuer, 2009) Job selection, pay, employment (Judge & Cable, 2010; Puhl & Brownell, 2001; Swami et al. 2008; Rudolph, 2009) Health care (Teixeira & Budd, 2010; Schwartz et al., 2003)

18. Obesity & mental illness Obesity & mental illness co-occurrence (Gariepy, Nitka, Schmitz, 2010; Shafer & Ferraro, 2011; Morris et al., 2010) Experienced stigma, distress & mental illness

19. Challenging anti-fat bias & prejudice A fat-hating society asks fearfully, “Do I look fat?” I respond, “I am fatacus!”….Fat functions as a floating signifier, attached to individuals based on power relationships, not a physical measurement. People all along the weight spectrum may experience fat oppression…I welcome thin people not as allies but as colleagues. Instead, the conflict is between all of us against a system that would weigh our value as people. If we cannot feel at home in our own skins, where else are we supposed to go?” (Wann, 2009)

20. A turn in Nutritional Sciences? Questioning the ‘weight paradigm’ (Bacon & Aphramor, 2011): • Efficacy of weight reduction programs • ‘Good’ outcomes from large weight loss • Stigma as a motivator Instead: • Health-At-Every-Size-Programs • Clinical efficacy & ethics

21. Obesity stigma: implications for combined care Obesity stigma (and other ‘physical’ stigmas) are not considered in research/policy on inequalities in physical care for people with SMI

22. RESEARCH ON STIGMA

23. Evidence for stigma: consumer viewpoints Qualitative studies of consumer experiences while in health care (e.g. van den Tillaart et al., 2009)

24. Evidence for stigma/bias: attitudes Explicit • Self-report (e.g. Schwartz et al., 2006) • Behaviours observed (e.g. Hebl & Mannix, 2003) Implicit • Implicit Association Test (Teachman et al., 2003) • Brain imaging (Schupp & Renner, 2011)

25. Miller & Lundgren p.714 Experimental paradigm

26. Experimental paradigm McFerran et al., (2010)

27. IMPLICATIONS: MULTIPLE STIGMAS & HEALTH CARE

28. Stigma (physical/mental) & Quality of Care Lower standard of care due to mental illness stigma Lower standard of care due to physical stigma (also interventions, see Wott & Carels, 2010) Need to look at both and as potential sources of inequality in care between general population and people with SMI

29. Researching double stigma’ Views of consumers with SMI Views/conduct of health care staff Evidence for a double stigma effect Reduction of multiple stigmas

30. Further progressing the research Duality of ‘mental’ & ‘physical’ Intersectionality Anti-stigmatization may be stigmatizing

31. People with serious mental illness have much lower physical wellbeing than the general population There are inequalities in physical care for people classified as having serious mental illness Inequalities in access and quality of care may be partly due to mental (illness) stigma and physical (illness) stigma Research directly on multiple stigmas and health care is urgently required

32. Social relationships Holt-Lunstad, Smith & Layton, 2010 (p. 14)

33. References (I) Alexander, L.A., & Link, B.G. (2003). The impact of contact on stigmatizing attitudes toward people with mental illness. Journal of Mental Health, 12(3), 271-89. Bacon, L., & Aphramor, L., (2011). Weight science: evaluating the evidence for a paradigm shift. Nutrition Journal, 10. Compton, M.T. et al. (2006). Cigarette smoking and overweight/obesity among individuals with serious mental illnesses: a preventive perspective. Harvard Review of Psychiatry, 14, 212-22. Corrigan, P.W. (2007). How clinical diagnosis might exacerbate the stigma of mental illness. Social Work, 52(1), 31-9, Corrigan, P.W., Markowitz, F.E., & Watson, A.C. (2004). Structural levels of mental illness stigma and discrimination. Schizophrenia Bulletin, 30(3), 481-491. Corrigan, P.W., & O’Shaughnessy, J.R. (2007). Changing mental illness stigma as it exists in the real world. Australian Psychologist, 42(2), 90-97. DeHert, M., Schreurs, V., Vancampfort, D., & van Winkel, R. (2009). Metabolic syndrome in people with schizophrenia: a review. World psychiatry, 8, 15-22. Daumit, G.L. et al. (2003). Prevalence and correlates of obesity in a community sample of individuals with severe and persistent mental illness. The Journal of Nervous and Mental Disease, 191(12), 799-805. Dickerson, F.B. et al., (2006). Obesity among individuals with serious mental illness. Acta Psychiatr Scandinavia, 113, 306-13.

34. References (II) Gariepy, G., Nitka, D., Schmitz, N. (2010). The association between obesity and anxiety disorders in the population: a systematic review and meta-analysis. International Journal of Obesity, 34, 407-419. Hebl, M.R., & Mannix, L.M. (2003). The weight of obesity in evaluating others: a mere proximity effect. Personality and Social Psychology Bulletin, 29(1), 28-38. Hendersenj, C., & Thornicroft, G. (2009). Stigma and discrimination in mental illness: time to change. Lancet, 373, 1928-1929. Hocking, B. (2003). Reducing mental illness stigma and discrimination - everybody’s business. Medical Journal of Australia, 178, S47-8. Holt-Lunstad, J., Smith, T.B., & Layton, J.B. (2010). Social relationships and mortality risk: a meta-analytic review. PLos Medicine, 7(7), 1-20. Keenem D.E., & Padilla, M.B. (2010). Race, class and stigma of place: moving to “opportunity” in Eastern Iowa. Health and Place, 16, 1216-1223. Kirk, S.F.L., Penney, T.L. (2010). Managing obesity in healthcare settings. Obesity and Weight Management, 21-24. Lawrence, S.A., Hazlett, R., & Abel, E.M. (2011). Obesity related stigma as a form of oppression: implications for a social work education. Social Work Education, 1-12. McFerran et al. (2010). Might an overweight waitress make you eat more? How the body type of others is sufficient to alter our food consumption. Journal of Consumer Psychology, 20, 146-151. Maj, M. (2009). Physical health care in persons with severe mental illness: a public health and ethical priority. World Psychiatry, 8(1).

35. References (III) Mitchell, A.J., & Lord, O. (2010). Do deficits in cardiac care influence high mortality rates in schizophrenia? A systematic review and pooled analysis. Journal of Psychopharmacology, 24(11), 69-80. Morris, J. et al. (2010). Implications of excess weight on mental wellbeing. Australian Health Review, 34, 368-74. Peris, T.S., Teachman, B.A., & Nosek, B.A. (2008). Implicit and explicit stigma of mental illness: links to clinical care. The Journal of Nervous and Mental Disease, 196(10), 752-60. Puhl, R.M., & Heuer, C.A. (2009). The stigma of obesity: a review and update. Obesity, 17(5), 941-64. Roberts, S.H. & Bailey, J.E. (2011). Incentives and barriers to lifestyle interventions for people with severe mental illness: a narrative synthesis of quantitative, qualitative and mixed method studies. Journal of Advanced Nursing, 67(4), 690-708. Rudolph, C.W., et al. (2009). A meta-analysis of empirical studies of weight-based bias in the workplace. Journal of Vocational Behavior, 74, 1-10. Saha, S., Chant, D., & McGrath, J. (2007). A systematic review of mortality in schizophrenia: is the differential mortality gap worsening over time? Archives of General Psychiatry, 64(10), 1123-31. Sartorius, N. (2007). Stigma and mental health. Lancet, 370, 810-1. Schupp, H.T., & Renner, B. (2011). The implicit nature of the anti-fat bias. Frontiers in Human Neuroscience, 5, 1-11. Shafer, M.H., Ferraro, K.F. (2011). The stigma of obesity: does perceived weight discrimination affect identity and physical health? Social Psychology Quarterly, 74(1), 76-97. Schwartz, M.B., Chambliss, H.O., Brownell, K.D., Blair, S.N., Billington, C. (2003). Weight bias among health professionals specializing in obesity. Obesity Research, 11(9), 1033-9. Scott, D., Happelll, B., & Platania-Phung, C. (in press). Quality of care for cardiovascular disease and diabetes among individuals with serious mental illness and those using anti-psychotic medications. Journal of Quality in HealthCare. Swami, V., Chan, F., Wong, V., Furnham, A., & Tovee, M.J. (2008). Weight-based discrimination in occupational hiring and helping behaviour. Journal of Applied Social Psychology, 38(4), 968-81.

36. References (IV) Teachman, B.A., Wilson, J.G., & Komarovskava, I. (2006). Implicit and explicit stigma of mental illness in diagnosed and healthy samples. Journal of Social and Clinical Psychology, 25(1), 75-95. Teachman, B.A., Gapinski, K.D., Brownell, K.D., Rawlings, M., & Jeyaram, S. (2003). Demonstrations of implicit anti-fat bias: the impact of providing causal information and evoking empathy. Health Psychology, 22(1), 68-78. Teixeira, M.E., Budd, G.M. (2010). Obesity stigma: a new recognized barrier to comprehensive and effective type 2 diabetes management. Journal of the American Academy of Nurse Practitioners, 22, 527-33. Vartanian, L.R. (2010). Disgust and perceived control in attitudes toward obese people. Internatiional Journal of Obesity, 34, 1302-7. Wang, S.S., Brownell, K.D., & Wadden, T.A. (2004). The influence of the stigma of obesity on overweight individuals. International Journal of Obesity, 28, 1333-7. Welthagen, E., Talbot, S., Harrison, O., & Phelan, M. (2004) Providing a primary care service for psychiatric in-patients. The Psychiatrist, 28, 167-70. Wilton, R. (2004). Putting policy into practice? Poverty and people with serious mental illness. Social Science and Medicine, 58, 25-39. Wott, C.B., & Carels, R.A. (2010). Overt weight stigma, psychological distress and weight loss treatment outcomes. Journal of Health Psychology, 15(4), 608-14.