An urgent call for change: tackling the discrimination faced by people with severe mental illness

To improve outcomes for people with severe mental illness, we must champion their right to acceptance, good clinical care and support.

The problem

While stigmatising views towards common mental health conditions like depression and anxiety may have changed, the same cannot be said for severe mental illness. A 2022 paper published in the British Journal of Psychiatry revealed that among those with mental illnesses, people living with schizophrenia are the most likely to face discrimination due to their condition, and people with depression are the least likely¹.

These discriminatory attitudes arise from the belief that severe mental illness is somehow a negative character flaw, intrinsic to who people are, that can never be changed – rather than an illness that can be treated.

As psychiatrists, we witness the impact of this discrimination every day. Many of our patients face outdated and old-fashioned stereotypes and tropes, which are simply wrong. This can affect every aspect of their lives – their mental health, physical health, housing and job security, and family life and relationships.

The reality is that people with severe mental illness are some of the most marginalised and vulnerable in our society. Too often they are treated as pariahs – shunned and excluded – in their daily lives and in the media. Internalising this discrimination makes it much harder for people to accept their condition and believe they can be helped. They may delay seeking treatment, increasing their risk of going into crisis. It also makes it harder to find employment, have meaningful relationships, and secure somewhere safe and comfortable to live.

Recent research shows the fear of being labelled, ostracised, or misunderstood due to their condition often deters individuals with severe mental illness from seeking help promptly – for both their physical and mental health². They are significantly more likely to die by suicide, and their life expectancy is 15-20 years lower on average because of avoidable physical health conditions.

This is a travesty.

The impact

Recent NHS data recorded 572,556 people in England with a severe mental illness, although the actual figure is likely higher³.

People with bipolar illness, schizophrenia or other psychotic conditions are classed as having a severe mental illness. More than 1 million people (2% of the population) live with bipolar in the UK, and over 5 million friends and family are significantly affected by a loved one’s bipolar condition⁴. It takes an average of 9.5 years to get a diagnosis after first disclosing symptoms to a healthcare professional, and more than half of people with bipolar have been hospitalised due to their condition. Tragically, someone with bipolar illness takes their own life every day.

Schizophrenia affects around 1% of the population (669,700 people)⁵. Not enough people with schizophrenia get all the treatment they need. The delay in initiating clozapine, the gold standard treatment for psychosis, is up to 4 years⁶. Only 1 in 10 of those who could benefit get access to cognitive behavioural and cognitive remediation therapy despite these being recommended by NICE. Access to psychoeducation, family intervention, social skills training and assertive community treatment are all limited – despite being effective and important aspects of the treatment package. And, among those accessing services for their psychotic condition, eighty seven percent report experiences of stigma and discrimination. Only 8% of people with schizophrenia are in employment, yet more could and would like to work⁷. Families who are carers for people with schizophrenia save the public purse £1.24 billion per year, but they are not receiving support and are not treated as partners in care.

Graham Morgan, 61, works to improve the lives of people with mental illness, having been diagnosed with schizophrenia aged 28. Sharing his story, he said:

“In my heart and at my core, I fundamentally believe that I am actually a bad person, contaminated, and contributing to the destruction of the world. I believe that my family, the people around me, and society, would be better off without me here…

“When you think so terribly of yourself it’s hard to also think about how others view you too. It’s horrible to think that some people would avoid being around me because of my condition.

“I have a very idealistic vision of love, kindness and belonging. I think if people like me felt fully part of society and accepted, not tolerated, life would be very different.”

People with severe mental illness and their loved ones are constantly expected to overcome barriers that society has put in their way. This isn’t fair. A concerted effort is needed to eliminate the widespread discrimination they face. More must be done to help them achieve their potential and lead fulfilling, happy lives – just like everybody else.

Those who do not believe in mental illness or treating mental illness, some even within our own ranks, only serve to compound the discrimination by shaming those like Graham who seek treatment for their disorder. I’d like to think that their views arise from ignorance of the intense suffering that people with severe mental illness often have to endure when they are ill, and that they simply have not met people in the throes of a psychotic relapse. I cannot believe that those critical of psychiatric care would condemn people like Graham to such horrendous suffering if they had truly seen how devastating it can be.

The solution

We have a duty to spread awareness of this discrimination and ensure it receives the attention it deserves, both in our work and day-to-day lives.

We have a duty to continue to inform ourselves, through education and training, about the specific hardships our patients face and how to make life better for them.

And, of course, we have a duty to support our patients with severe mental illness and deliver the best care we can for them.

We know there are highly effective treatments that can help the majority of people with severe mental illness get well. With holistic care – psychological support, lifestyle support, and treatment for any associated substance use issues – they are also more likely to stay well.

High-quality treatment that is safe, timely and therapeutic can reduce the duration of episodes and minimise relapses. Treating people early is key to preventing lives being cut short. It reduces the risk of crisis, improves long term outcomes, and enables people to build strong relationships and live fulfilling lives. As psychiatrists we must all surely want this for our patients? We are doctors. It is our duty to spend our time and energy researching and delivering good quality, evidence-based care so that we can alleviate the suffering of people like Graham. 

But, for us to do this, Government must also do its part to achieve parity of esteem and address the treatment and mortality gap for people with mental illness. That is why the College is calling for funded, properly resourced mental health services, and for the expansion and widened scope of regular health checks, with increased provision for people with diagnosed mental illness. Bipolar illness costs the UK economy £20 billion a year⁸, and schizophrenia and psychosis cost £11.8 billion a year⁷ – but this could be significantly reduced if we invested in prevention and effective care.

Urgent change is needed to tackle the discrimination faced by people with severe mental illness. All of us can – and must – do better.

Resources

To hear more from people affected by severe mental illness, you can listen to our full interview with Graham where he talks about his condition and how it has impacted him over the past 35 years.

You can also read Kate Northcott Spall’s blog about her late brother William’s experiences of living with schizophrenia. Kate is an award-winning campaigner who is advocating for greater awareness and safety around the use of antipsychotic medication.

And you can read Angela McCrimmon’s poem Stand Up, which advocates for people with severe mental illness. Angela was first diagnosed when she was 19 years old.

All of these resources and more are accessible for free via the College’s Mental Health Awareness Hub.

References

1. Creating a hierarchy of mental health stigma: testing the effect of psychiatric diagnosis on stigma, British Journal of Psychiatry (2022): Creating a hierarchy of mental health stigma: testing the effect of psychiatric diagnosis on stigma - PMC (nih.gov)
2. Understanding and Addressing Mental Health Stigma Across Cultures for Improving Psychiatric Care: A Narrative Review, Open Access Review (2023):  cureus-0015-00000039549.pdf (nih.gov)
3. Severe Mental Illness - OHID (phe.org.uk)
4. The Findings of the Bipolar Commission (2023)
5. Rethink Schizophrenia Factsheet (2020)
6. Howes O, Vergunst F, Gee S, McGuire P, Kapur S, Taylor D. Adherence to treatment guidelines in clinical practice: study of antipsychotic treatment prior to clozapine initiation. Br J Psychiatry 2012; 201(6): 481-5. Adherence to treatment guidelines in clinical practice: study of antipsychotic treatment prior to clozapine initiation - PubMed (nih.gov)
7. Findings of the Schizophrenia Commission (2012)
8. The Findings of the Bipolar Commission (2023)