Indian Journal of Social Psychiatry

: 2016  |  Volume : 32  |  Issue : 2  |  Page : 128--133

Stigma in dual diagnosis: A narrative review

Yatan Pal Singh Balhara1, Arpit Parmar1, Siddharth Sarkar1, Rohit Verma2,  
1 Department of Psychiatry, National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi, India
2 Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India

Correspondence Address:
Dr. Yatan Pal Singh Balhara
Department of Psychiatry, National Drug Dependence Treatment Centre, WHO Collaborating Centre on Substance Abuse, All India Institute of Medical Sciences, New Delhi


Stigma has been described as a mark of disgrace associated with a particular person, quality, or a circumstance. Persons with either psychiatric illness or substance use disorders, their family members, caregivers, as well as health professionals engaged in the management of these persons are subject to stigma. Interestingly, there is a high prevalence of substance use disorders among persons with psychiatric disorders and vice versa. However, only a limited literature has focused on stigma in the context of co-occurrence of psychiatric disorders and substance use disorders. The current review is aimed at the presentation of various aspects of stigma in the context of dual diagnosis of psychiatric disorders and substance use disorders. Findings on the published literature on stigma in the context of psychiatric disorders and substance use disorders have been examined separately to develop an understanding into the relevance and implication of addressing stigma in the context of dual diagnosis.

How to cite this article:
Balhara YP, Parmar A, Sarkar S, Verma R. Stigma in dual diagnosis: A narrative review.Indian J Soc Psychiatry 2016;32:128-133

How to cite this URL:
Balhara YP, Parmar A, Sarkar S, Verma R. Stigma in dual diagnosis: A narrative review. Indian J Soc Psychiatry [serial online] 2016 [cited 2022 Jun 28 ];32:128-133
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Stigma has been described as “a mark of disgrace associated with a particular person, quality, or a circumstance.”[1] This modern concept of stigma has gained increasing attention from researchers over the past few decades. Three levels of stigma have been identified in the literature-public, structural, and internalized stigma.[1] Public stigma is a stigma in which large social groups endorse stereotypes and discrimination about mental illness and act against individuals who are mentally ill. Structural stigma signifies institutional practices and policies that create an environment of inequality and restrict opportunities for persons with mental illness. Internalized stigma (commonly known as self-stigma) is characterized by negative feelings about self and is accompanied by identity transformation, stereotype endorsement, and maladaptive behavior. It results from persons' past experiences and perceptions, or anticipation of negative social reactions on the basis of their mental illness. Public stigma has been studied extensively and is the most prominent form which is observed among the general population.[1] It reflects the prejudice general population has toward those with mental illnesses.

Stigma has been studied in the context of various medical disorders (like leprosy, tuberculosis, and AIDS), physical disabilities, economic constraints, and persons with homoerotic preferences.[2],[3] A considerable number of studies related to stigma have also been conducted for mental illnesses. Persons with either psychiatric illness or substance use disorders, their family members, caregivers, as well as health professionals engaged in the management of these persons are subjected to stigma.[4] Interestingly, there is a high prevalence of substance use disorders among persons with psychiatric disorders and vice versa.[5] However, only a limited literature has focused on stigma in the context of co-occurrence of psychiatric disorders and substance use disorders. The current review is aimed at presentation of various aspects of stigma in the context of dual diagnosis of psychiatric disorders and substance use disorders. Findings on the published literature on stigma in the context of psychiatric disorders and substance use disorders have been examined separately to develop an understanding into the relevance and implication of addressing stigma in the context of dual diagnosis.

 Stigma and Psychiatric Disorders

Stigma has been studied extensively in the context of the psychiatric disorders. It is necessary to understand the various facets of stigma in psychiatric disorders, as it is an important determinant of the help-seeking, treatment outcome, as well as quality of life of persons with psychiatric disorders.

Self-stigma (internalized stigma)

Self-stigma is defined as a subjective process that is embedded within a social context and is characterized by negative feelings about oneself, maladaptive behaviors, and stereotype endorsement.[6] It results because of an individual's past experiences, perceptions, and anticipation of negative social reactions to the individual's psychiatric illness. Negative stereotypes (e.g. people with psychiatric illness are not productive) are prevalent in the society. People agreeing to these stereotypes develop prejudice which ultimately leads to discrimination. Because of this, people with psychiatric illness are also vulnerable to endorse such stereotypical attitudes toward themselves. Self-stigma proceeds through stages of awareness (person knows about prevalent stereotypes), agreement (persons starts believing those stereotypes to be true), and finally application (person starts endorsing the same stereotype about him/herself).[7] These leads the negative emotional reactions such as poor self-efficacy and decreased self-esteem.[8] This may further cause self-stigmatization and self-isolation leading to adverse consequences like decreased health care use, poor disease outcome, poor quality of life, and interference with the achievement of life goals.[9],[10]

Structural stigma

Structural stigma is defined as the stigma created by the structures (institutional policies and practices) that surround a person with psychiatric illness. Psychiatric illnesses are reported in a more pejorative way in newspapers as compared to the medical journals.[11] Such media provide distorted view of psychiatric illnesses and also equate it with dangerousness, unpredictability, and criminality. The terms used to describe persons with psychiatric illness in everyday life are also pejorative which leads to profound effects on lives of persons suffering from psychiatric illness.[12] Police also consider persons with psychiatric illness as less responsible and with violence potential.[13] Even among health care (including psychiatric health care) such discrimination has been reported.[14],[15] Medical students have also been reported to have negative attitude toward people with psychiatric illness.[16]

Public stigma

Public stigma is defined as a set of negative attitudes/beliefs about persons with psychiatric illness that turns individuals against them and leads them to avoid, fear, or discriminate against those with psychiatric illness.[17] Studies suggest that most people consider persons with psychiatric illness to be dangerous.[18],[19],[20],[21],[22] Patients with psychiatric illnesses such as schizophrenia and depression are more likely to be considered violent as compared to individuals without these conditions.[10] Similar finding have also been reported for children with attention deficit hyperactivity disorder (ADHD) as compared to children with illness like asthma.[20] People also feel threatened by persons with psychiatric illness and such threat varies across different illness.[21],[23],[24] Persons with schizophrenia are more likely to be considered as dangerous to others as compared to patients with depression, while patients with depression are seen more dangerous to themselves.[24],[25] Sociodemographics also contribute to such threat perception. For example, girls are considered more dangerous as compared to boys, while younger children (<8 years) are considered more dangerous as compared to older children (>14 years).[26] Stigmatizing beliefs related to criminality have also been consistently reported in association with psychiatric illnesses such as schizophrenia, depression, and ADHD.[27] Adults with psychiatric illness are considered as less competent about taking decisions on treatment-related as well as financial issues.[28] Children with psychiatric illness are considered to be lazy as compared to children with an illness like asthma. Moreover, children consider illness like ADHD to be more shameful as compared to asthma and other medical illnesses.[27]

 Stigma and Substance Use Disorders

Persons with substance use disorders also face stigma in its various forms, including perceived, public, and self-stigma.[29] Previous studies consistently report that persons with substance use disorders experience stigma which leads to multiple negative outcomes including delay in treatment seeking.[30] Due to associated stigma, such persons are considered to be dangerous, threat to others, and incompetent to take responsibility. Previous studies suggest that persons with substance disorders are more likely to be viewed as dangerous as compared to “normal” persons.[10],[21] Patients with drug dependence problems are considered to be more dangerous as compared to other mental illnesses.[10],[21],[24] Similarly, persons with alcohol use disorders are also considered to be more dangerous to themselves.[25] Studies also suggest that persons with substance use disorder are considered less competent to take their treatment decisions as well as financial decisions as compared to persons with depression and other mental illnesses by overwhelming majority of respondents.[28] Social distance from persons with substance use disorder is also widespread. Persons with alcohol use elicited a significantly higher desire for social distance among adults.[21],[24] For adults with mental illness, the desire for social distance is maximum for substance users followed by other mental illnesses such as schizophrenia and depression.[10],[21],[24]

 Stigma in Dual Diagnosis Patients

As already discussed, stigma in mental disorders including substance use disorders is probably the highest among those diagnosed with any illness. However, studies focusing on stigma among persons with dual diagnosis (persons with co-occurring psychiatric illness and substance use disorders) are scarce. Whether such patients experience stigma differently or at a higher level is largely unknown.[31] Measuring stigma and discrimination through single domains may underestimate the effects for persons experiencing multiple types of stigmas (in this case stigma of substance abuse along with psychiatric illness) or ignore the potential interactions. However, patients with dual diagnosis are known to suffer from various kinds of stigma which leads to treatment noncompliance, reduced self-esteem, social exclusion, discrimination, and relapse.[32] It is also important to consider where and with whom such persons identify themselves. One hypothesis suggests that persons with both psychiatric illness and substance use disorders prefer to be aligned with the substance users as they perceive it to be more acceptable.[33],[34] The lack of meaning among patients with certain psychiatric disorders triggers use of the substance and once substance use is initiated, it creates a meaning and identity and the person feels part of a group or network.[35]

One of the initial studies conducted on 84 men with dual diagnosis reported enduring effects of stigma on the well-being of patients despite improvement in their symptoms of psychiatric illness as well as substance use disorder.[36] Most persons reported a feeling of being stigmatized and rejected because of their substance use and mental health problems. They also agreed on the fact that the dually diagnosed individuals are devalued and discriminated against. Most participants suggested that they would be rejected, had experienced rejection by others, and had taken steps to avoid such rejection. Authors reported that such stigma continued to complicate the lives of stigmatized individuals despite symptomatic and functional improvement in all domains after a year and concluded about the need to address the associated stigma in order to maximize the improvement and well-being of these persons. However, due to unavailability of the control arm (patients with only mental illness or substance use disorder), details on the qualitative and quantitative differences in the stigma experienced between these two populations are unavailable.

A more recent pilot study among 49 subjects with co-occurring schizophrenia and substance use disorders reported an association between self-stigma and decreased self-esteem.[37] Alcohol use severity along with dysphoria was also negatively associated with self-esteem. Stereotype concurrence in these subjects mediated the relationship between autistic preoccupation and self-esteem.

Similarly, a qualitative study on stigma about substance use among persons with co-occurring disorders identified five themes: “addict,” “self-esteem,” “family and friends,” “health care workers,” and “work.” All of them reported stigma coming from aspects of being labeled as “addict” which affected their self-esteem. Other major sources of stigma included family and friends as well as health care workers which affected their career. Similarly, “labeled” and “self-esteem” themes were related to the mental health question related to stigma.[38]

 Implications of Stigma

The implications of stigma are varied, diverse, and affect almost all life areas of the affected individual. Results of two independent surveys (done on more than 2000 English and American citizens) suggested three themes of stigmatizing attitudes - fear and exclusion which means that such persons should be feared and kept out of the communities; authoritarianism which means that such persons are irresponsible, and so their life decisions should be taken by others and benevolence which means that such persons need to be cared for.[39],[40]

Not only stigma causes reduced autonomy and self-efficacy, but it is also associated with less treatment seeking, and worse treatment retention and adherence.[41],[42] However, a more recent study from the USA reported that there was an improvement in treatment seeking by people with mental illness between the years of 1999 and 2003, with more persons with mental illness who are willing, comfortable, and less embarrassed for seeking treatment for their mental health problems.[43] Importantly, there was no change in the perception regarding the treatment effectiveness or chances of recovering from illness without treatment. Most recent studies suggest that people have become more receptive toward the treatment for their mental health problems.[44],[45] Preference for treatment seeking also depends on the nature of the psychiatric illness. However, coercive treatments are considered more acceptable for illnesses like schizophrenia and substance use disorders as compared to depression.[28]

The patients with any type of psychiatric illness are more likely to face discrimination while searching for housing and employment.[42],[46] Since these persons are considered less competent to take their own decisions, they are forced to received coercive treatment and have reduced independence.[44] The perception of incompetence also varies with the type of illness with persons with substance use disorder considered to be most incompetent to make their financial decisions.[28] Other consequences of such discriminatory behavior include fewer opportunities in housing, employment, school admission, as well as discrimination at workplaces making reintegration into the community harder even after improvement of psychiatric symptoms.[47]

Implications for dual diagnosis

Although impact of stigma have been widely studied in psychiatric illness and substance use disorders in isolation, the same has not been the case for persons with dual diagnosis. It is important to note that substance abuse and psychiatric illness are common comorbid conditions. This comorbid relationship is likely to be more prevalent over time as the incidence of substance abuse tends to increase after the onset of psychiatric illness and vice versa.[48] This high prevalence is associated with the high level of need. More importantly, in persons with dual diagnosis, there is an even larger unmet need as compared to those with only psychiatric illness.[49] Most such persons do not receive any kind of formal treatment.[50],[51] A survey from USA reported that 72% of persons with co-occurring disorders did not receive any formal psychiatric or substance use treatment in the past year.[52] Only 8% of them received both specialty substance use and psychiatric treatment as recommended to them. This might be the result of higher stigma and more barriers to formal treatment.[31] Moreover, even among those receiving formal treatment for one of the two conditions, the other might get undetected and consequently remain untreated. A study done at substance abuse treatment center in New Jersey reported that only 22% of persons meeting criteria for dual diagnosis were recognized as having co-occurring mental illness by their treating doctors. Despite recognition of mental illness, only 58% were referred for further management of mental illness.[53] This has been attributed to the structural discrimination which is influenced by vague institutional boundaries, and lack of role clarity in the health care system.[54]

Even when such persons receive treatment, there are disparities in the care provided. Compared to the psychiatric illnesses, persons with dual diagnosis were least likely to receive recommended nutrition and exercise counseling.[55] Another study found that such persons are more likely to undergo surgery from “low-quality” cardiac surgeons.[56] This is attributed to various factors including poor therapeutic alliance, negative attitude of treatment provider, and diagnostic overshadowing (i.e., erroneously attributing physical symptoms to mental illness resulting in under-recognition of physical illness).[31] However, most studies did not investigate potential interaction of substance abuse and psychiatric illness on the health care provided to persons with dual diagnosis.[57]

Apart from the discrimination faced in treatment, the exclusion of persons with dual diagnosis from most substance abuse and psychiatric illness research studies is also an important issue. Research studies often include “pure” rather than “typical” patients seen in the communities.[58] Hence, it impedes the generalizability of the findings about treatment and services given to persons with dual diagnosis.[31]

 Interventions to Reduce Stigma

Approaches to reduce stigma associated with psychiatric illness

The target audience for stigma reduction includes general public, patients, and health care professionals. Three approaches have been suggested to reduce stigma - education, protest, and contact.[59] Education provides the information about the psychiatric illness and so it helps the public to make more informed decisions about psychiatric illness. This approach has been studied extensively in the past. Studies suggest that persons with better understanding of psychiatric illness are less likely to endorse stigma.[40],[60],[61] Similarly, studies also suggest that participation in educational programs on psychiatric illness also leads to improved attitude about psychiatric illness.[62],[63]

Protest includes protesting the hostile and inaccurate representations of persons with psychiatric illness as a way to challenge the stigma. This strategy includes media (to stop reporting the inaccurate representation of persons with psychiatric illness) and public (to stop believing such representations).[9] As it is a reactive strategy, it only attempts to diminish the negative attitudes of illness and does not focus on promoting positive attitudes that are supported by facts. Moreover, studies supporting such a strategy are scarce and so there is a need for future research in this direction.

Studies have also shown an inverse relationship between having a contact with a person with psychiatric illness and endorsing discrimination and stigma toward them.[63] Stigma is diminished when general public meet such persons who are able to live good lives despite an illness or live as good neighbors or are able to hold down jobs.

Approaches to reduce stigma associated with substance use disorders

Various approaches targeted at persons substance use disorders, general population, and medical professionals have been studied. A recent systematic review of 13 studies suggested a range of interventions to be effective to reduce such stigma.[64] Group-based acceptance and commitment therapy was found to be effective to reduce self-stigma. Motivational interviewing and communicating positive stories of persons with substance use disorders were found to be effective for addressing social stigma. Contact-based training and education programs targeted at medical students and professionals like police were effective in changing structural stigma. The evidence suggests that interventions do have an impact on the stigma with small to moderate effect sizes.

Published literature on addressing stigma among those with dual diagnosis is conspicuous by its absence. While it might seem alluring to extrapolate the findings from studies among those with either psychiatric illness or substance use disorders alone to the persons with dual diagnosis, it might be an oversimplification of the complex issue of stigma. As described earlier, the stigma experienced by persons with dual diagnosis is likely to differ from the stigma experienced by those with either psychiatric illness of substance use disorder both quantitatively as well as qualitatively. Hence, it is important to study the stigma specifically in the context of dual diagnosis. In addition, comparative studies on stigma should be planned for dual diagnosis vis-a-vis psychiatric illness and substance use disorders.

 Conclusions and Future Directions

Stigma plays an important role in lives of those with either psychiatric illness or substance use disorder patients. The same is true for those with dual diagnosis. The consequences of such stigma and discrimination are often pervasive and long-term. Despite this, the stigma and discrimination in dual diagnosis have not been studied systematically and very little is known about the impact of stigma among persons with dual diagnosis. Although it is known that stigma is an important barrier to treatment for people with psychiatric illness and substance use disorders, persons with dual diagnosis may experience stigma differently. Not only is there a possibly of higher levels of stigma among those with dual diagnosis, but it is also likely that this stigma could be qualitatively different from the stigma among those with psychiatric illness or substance use disorders. Developing an understanding into the stigma in the context of dual diagnosis will be important to help these persons, their family members, caregivers, and treatment providers.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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