Facets of clinical stigma after attempted suicide in Mumbai, India

Abstract

Community stigma studies may neglect clinically relevant experience and views of stigma that are important features of mental health problems. After attempting suicide, patients in a hospital emergency ward in Mumbai, India, were assessed for stigma referring to underlying prior problems motivating their deliberate self-harm (DSH) event, the DSH event itself and serious mental illness generally based on both anticipated community views and distinctive personal views. In this cultural epidemiological study of 196 patients, assessment items and four corresponding indexes were analysed and compared on a four-point scale, 0 to 3, for prominence of indicated stigma. Narratives from patients with high, low and discordant levels of stigma for prior problems and DSH events were analysed and compared. Disclosure, critical opinions of others and problems to marry were greater concerns for DSH events than prior problems. Problem drinking, unemployment, and sexual or financial victimization were common features of prior problems. Impulsivity of the DSH event and externalizing blame were features of lower levels of stigma. Ideas about most people’s views of serious mental illness were regarded as more stigmatizing than patients’ prior problems and DSH event; patients’ personal views of serious mental illness were least stigmatizing. Findings suggest linking suicidality and stigmatized mental illness may discourage help seeking. Suicide prevention strategies should therefore emphasize available help needed for severe stress instead of equating suicidality and mental illness. Findings also indicate the relevance of assessing clinical stigma in a cultural formulation and the value of integrated qualitative and quantitative stigma research methods.

Keywords:

• Deliberate self-harm
• cultural psychiatry
• cultural epidemiology
• illness explanatory models
• mixed methods

Ethical approval

The ethics committee of KEM Hospital, Mumbai, approved the research protocol and associated instruments on which this article is based. Conduct of the study was consistent with the code of ethics of the American Anthropological Association, as approved in 1998 and revised in 2012. The sponsors had no role in the study design; collection, analysis and interpretation of data; writing; or decision to submit for publication.

Acknowledgments

Dr. Varsha Dawani and Dr. Fabian Almeida conducted the interviews and managed data, and Dr. Leticia Grize from the Swiss Tropical and Public Health Institute, Basel, assisted with statistical analysis. We appreciate these inputs and the willingness of patients to participate in the study.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

This study was supported by the Research Society of the KEM Hospital and Seth GS Medical College, Mumbai. Additional support from the Swiss National Science Foundation (Grant 3200-051068, Cultural Research for Mental Health; and Grant 32003B-105913, Social, Cultural and Clinical Dimensions of Suicide and Deliberate Self-Harm) is acknowledged.