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Stigma alone does not explain non-disclosure of psychological symptoms in general practice
  1. Jim Bolton, MRCPsych, BSc (Hons)
  1. Liaison Psychiatrist
 South West London & St George’s Mental Health
 NHS Trust; Honorary Senior Lecturer,
 St George’s Hospital Medical School
 London, UK

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 QUESTION: Do people fail to disclose psychological symptoms to general practitioners for fear of stigma, or for other reasons?

    Design

    Qualitative focus group study.

    Setting

    Primary care practices, Wales.

    Participants

    127 people aged 18–70 from rural, urban and valley practices. Participants were selected from 3 age groups (15 women, 17 men aged 18–25; 18 women, 16 men aged 35–45 and 32 women, 29 men aged 50–70).

    Data collection and analysis

    Data were generated from 4 focus group exercises: discussion of fictional situations and emotional states; ranking of importance of physical and emotional symptoms; ranking of importance of sources of help for common mental disorders and finally, suitability of different questionnaires for ascertaining cases in primary care.

    Main Results

    Concerns about stigma were not the only reasons given for non-disclosure. Other reasons for non-disclosure may include a perception that psychological symptoms are less worrisome than physical symptoms; that psychological symptoms should be dealt with by the individual, rather than a health professional, or that psychological symptoms are not a “health problem” but a “part of life”.

    Conclusions

    Health professionals need to be aware that, as well as fear of stigma, psychological symptoms may not be reported due to differences in importance lay people and professionals ascribe to these symptoms when describing illness.

    Commentary

    Stigma is alleged to be the biggest single obstacle to improving the quality of life of patients with mental illness.1 It is also commonly given as a reason why patients fail to disclose potentially treatable psychiatric problems to health professionals. However, the focus on stigma in recent mental health campaigns may have obscured the influence of other important factors.

    This study identifies another significant factor in non-disclosure. Patients may understand and interpret the symptoms of mental illness in different ways to health professionals. In contrast to physical symptoms, symptoms of mild to moderate psychiatric disorder were often considered to be part of everyday life and beyond medical help.

    When considering the implications of the findings, the study’s limitations should be borne in mind. The response rate to an invitation to participate in the study was low, and subjects with a history of mental health problems may have been over-represented. Also, focus groups draw on group rather than individual responses, and different factors may operate in one-to-one consultations. Finally, the focus of the study was on “mild to moderate” psychiatric disorders, not on “severe” mental illnesses. It might be expected that psychotic symptoms, for example, would be unlikely to be considered part of normal human experience and more likely to be stigmatised.

    Getting people to disclose the presence of emotional symptoms is a challenge for health services, and this study has implications for both individual practitioners and mental health campaigns. When enquiring after emotional symptoms, health professionals should seek to understand how their patients construe mental illness, as well as being alert to the effects of stigma. Public education campaigns should also consider these factors. Not only are common mental health problems stigmatised, but also, many people do not consider them to be illnesses at all.

    References

    View Abstract

    Footnotes

    • Sources of funding: The National Assembly for Wales (1998–2000) under the auspices of the Wales Office of Research and Development (Grant no. R 98/1/023).

    • Correspondence to: Lindsay Prior, tel: +44 2920875428 email: priorl{at}cardiff.ac.uk

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