A Systematic Literature Review to Highlight the Causes and Destructive Impact of Stigmatization on Health Status of Mentally Challenged Clients in Developing Countries

Introduction: Mental illness is a major obstacle of the health care system throughout the world. The solutions and knowledge about mental health issues have increased many folds over time. However, in many parts of the world, the stigma is still attached to the mental illness. It is felt that it will bring a bad name to the family if any of the family members are mentally unstable. Purpose: This paper aims to highlight major causes, probable consequences and suggest recommendations to demark stigmatized mentally ill patients in the developing world. Method: A systemic review of 25 pieces of literature from recent scholar articles (20082014) was conducted to study the impact of stigmatization on mentally ill patients. Result: The findings suggest that the most significant causes of the stigma in the socio-cultural domain are society’s pre-conceived ideas, lack of knowledge, and myths that authenticate this stigma surrounding the mental illness. Moreover, the vicious cycle of stigmatization on patients’ lives and the attitude of health care providers are also among the very important aspects highlighted in some studies. The impact manifested was even more devastating including under or over diagnosed mental illness, delay in health seeking behavior and poor prognosis in community as well as hospital setting. Recommendation: It is essential to address these issues and arrange awareness sessions in order to improve the quality of life.


Introduction
Humans are social animals and their tendency to accept and reject other beings has a huge impact. Being liked and disliked as a human is one of the greatest battles ever fought in time. Human nature clinches the labels over time for almost all of us and then pushes us in the direction our perception guides us in. Struggling with this perception, many create a difference in this world of opportunities while others underestimate themselves and settle unanimously. Those with better prospects have greater acceptability and are well received among social circles. In contrast, under achievers, to whom life has hit hard in the face, feel difficulty in adapting to daily life situations. Society stigmatizes such individuals and this gradually results in discrimination and social seclusion. "Stigma as stereotype or negative views attributed to a person or groups of people when their characteristics or behaviors are viewed as different from or inferior to societal norms". In a mental health clinic, we encountered a 28-year-old patient diagnosed with bipolar disorder. She is a student at NED University and lives with her aunt. Subjective data revealed that the patient was not willing to get treatment for her mental illness. She verbalized that her family forced her to get admitted to Karwan-e-Hayat. On probing, the patient expressed her feelings regarding a fear of getting stigmatized due to her mental illness. She used to avoid social gatherings and was afraid of making close friends due to the fear that she may have to disclose something about her diagnoses. Moreover, this fear leads her to limit the utilization of her support system that ultimately results in the further progression of her disease. She was not able to cope with the situation at hand and withdrew herself even from those activities that she used to enjoy before admission to the hospital. Stigmatization related to the mental disorder is relatively high, which results in discrimination and a distinguished impact on the patients' life and perception.

Methodology
A systemic review of 25 pieces of literature from recent scholar articles (2008)(2009)(2010)(2011)(2012)(2013)(2014) was conducted to study the impact of stigmatization on mentally ill patients. The authentic databases include Science Direct, Google Scholar and Pubmed. Prevalence Mental illness is considered one of the major obstacles worldwide. According to Ahmedani (2011), mental health problems persist throughout 12% of the world, and will increase to 15% by 2020. In addition to this, World Health Report (2001, as cited in Shrivastava, Johnston, & Bureau; identified that "one of the identified reasons for low support for mental health is the stigma attached to mentally ill individuals". Furthermore, Afridi (2008) suggests that the prevalence of people in developed countries who remain untreated for mental disorders due to a stigma is 44-70%; in developing countries, it is 90%. This suggests that stigmatization exists in every part of the world and the rate of labeling mentally challenged clients is profoundly higher in developing countries.

Discussion
There are various causes and consequences of stigmatization but this paper mainly focuses on socio-cultural effects, delays in healthcare-seeking behavior, and the attitude of health care professionals towards mental illnesses.

Eastern and Western World Perspectives:
In Asian countries, mental disorders are associated with evil spells and witch crafts. For this reason, Asians prefer to get treated privately with spiritual healers or pir-babas, commonly known as Sufis and Shamans respectively (Gadit, 2008). Moreover, eastern societies value norms such as emotional impulse control, communism, and upholding their family's dignity via achievements and services. As a victim of mental disorder fails to accomplish these norms, they become the target of stigmatization. On the other hand, western culture supports independence, acquisitiveness and materialism. Due to mental illness, individuals need assistance in accomplishing materialistic goals. Furthermore, their potentials are rated lower when compared to a normal successful person. This leads to the feeling of low self-esteem and discrimination (Abdullah & Brown, 2011). Hence, stigmas related to psychiatric illness are found in both eastern and western culture. However, the eastern world is facing unenviable consequences due to this, as compared to the western world.

The Socio-Cultural Domain:
Socio-cultural aspects that influence an individual may have a heavy impact on stigmatization, which ultimately results in social isolation. Society usually perceives mentally ill clients as inferior, due to which the patient's basic needs and rights get compromised.
According to Hinshaw (2005, as cited in Foltz & Logsdon, 2009), stronger members of society usually blame the mentally ill patient for their disease and thus hold their basic resources. In addition to this, it creates a sense of fear, shame, and guilt because people believe that mental illnesses occur due to evil spells or brutal punishments from God (Ganesh, 2011). Thus the social stigma can lead to self-stigmatization in which the patient will experience low self-esteem, which can negatively affect their mental status. According to Ahmedani (2011), self-stigmatization can occur when society continuously stigmatizes the person to the point that it results in alteration of one's behavior and leads to negative selfconcept. All of these consequences result in social isolation of the mentally ill clients.

Delays in Healthcare-Seeking Behavior:
Stigmatization results in a delay in healthcare-seeking behavior. It causes people to perceive mental illnesses to be incurable and leads them to not seek medical treatment. Consequently, the family isolates the individual with the mental disorder, in order to conceal their diagnoses from society. On the other hand, Heflinger and Hinshaw (2010) report that stigmatization carries a strong feeling of shame, due to the victim and their family ignoring to seek proper treatment even if they are aware about the severity of the condition. As a result, the sufferer avoids hospitalization or even visits to the clinic, due to the fear of being discriminated by society. "The fear of stigma by association in families of adults with mental illness has also linked to a lack of acknowledgement of mental illness and a consequent avoidance of help seeking" (Heflinger&Hinshaw, 2010). Consequently, due to stigma and lack of awareness, the client and the family ignore the mental issues and therefore it causes a delay in seeking healthcare.

Attitude of Health Care Professional:
Lastly, the specific attitudes of health care professionals also reveal stigmatization in mentally ill clients. It is observed that the heath care personals (including the physician, nurses, paramedical staff, coworker etc.) stigmatize the patient with their diagnosis and label them, causing the patient's respect and dignity to become compromised. "It may seem unlikely that social workers and other healthcare professionals would carry stigmatized beliefs towards clients; especially those whom they know are affected by a variety of barriers to treatment engagement" (Ahmedani, 2011). This also indicates that patient autonomy, their feelings, and their pain are not considered as important due to stigmatization, which results in poor quality care. Besides that, Heflinger and Hinshaw (2010) reveal that the health care providers become frustrated sometimes in dealing with severe mental cases, due to their prejudiced thoughts, increased workload and stressful environment. Hence, this affects the client's care and prognosis. Furthermore, Ganesh (2011) points out that the health care workers' negative attitude and lack of knowledge about the mental illness are the important factors that hinder the decision to provide holistic care.

Law and Ordinance in Pakistan
Stigmatization and discrimination are not only the acts of an individual or a social group; it is also widespread in health care settings. Ahmedani (2011) explains that health professionals label psychiatric patients and are biased in delivering care to these patients. Mental health ordinance for Pakistan (2001), in its chapter of offences and indemnity (chapter VIII), states that "any person employed in a psychiatric facility, who strikes, ill-treats, maltreat or willfully neglects any patient confined in such psychiatric facility shall be guilty of an offence" (p.31). Furthermore it states that: Any person who carries out any form of inhumane treatment, on a mentally disordered person which includes: trepanning, branding, scalding, beating, exorcising, chaining to a tree etc……. or subjecting any such person to physical, emotional or sexual abuse, shall be guilty of an offence, punishable with rigorous imprisonment which may extend to five years or with fine extending up to Rs.50,000 or with both. (p.31) Unfortunately, "despite the fact that the new Mental Health Ordinance was promulgated on 20th February, 2001 with an intention to come into force immediately in all Pakistan but is yet to be implemented" (Afridi, 2008, p.226). This indicates that the execution of policy made by the government of Pakistan for the protection of mentally ill clients is still lacking. Gadit (2008) makes it crystal clear that patients in psychiatric hospitals of Pakistan are discriminated in brutal ways. They are beaten, sexually abused, and chained to the trees by the staff. Moreover, in some hospitals, electroconvulsive therapy is conducted without anesthesia. Even the prisoner's psychiatric units are called "mad wards".

Conclusion
In conclusion, the promotion of mental health is still neglected amongst all domains of health. One of the root causes behind this is the stigma attached to it. Socio cultural norms, delays in treatment, and the perception of health care personals are the critical aspects which need to be managed to separate the stigma from the mental health. Therefore, it is necessary to raise awareness regarding de-stigmatization in order to promote prosperity in the arena of mental health.

Recommendation
Analyzing all these causes and consequences, it is necessary to be vocal in order to detach stigmatization from mental illness. According to Foltz and Logsdon (2009), nurses can play a vital role in eliminating stigmas from society, as they possess the ability to create a positive impact on the society. As nurses already carry trust amongst the general public, their teachings are considered most relevant and inspiring. Furthermore, governmental agencies should make sure that equivalent care should be provided to psychiatric clients, and strict penalties should be given to the health care providers who discriminate the mentally ill clients with the general patients. As a student health nurse, it's my duty to provide accurate care to the mentally ill patient and conduct awareness sessions for the community regarding de-stigmatization. This will help the staff in treating their clientele within the boundaries of ethical principles in which the client's rights are protected. Moreover, it will also enhance therapeutic communication skills in which empathizing attitudes are followed so that client is treated holistically in all dimensions.

Conflict of Interest
The authors assert no conflict of interest.