MHGCJ – 2020
Mental Health: Global Challenges Journal
https://mhgcj.org ISSN 2612-2138
Stigma and mental health: The curious case of
COVID-19
Connie J. Snider
1
Maureen P. Flaherty
2
Alzheimer Society of Saskatchewan, Saskatoon Resource Centre, Saskatoon, Saskatchewan, Canada
1
University of Manitoba,
Winnipeg, Canada
2
Abstract
Introduction: This article considers the impact of COVID-19 on stigma and mental health across
the life spectrum and the ways that people access services.
Purpose: To explore the ways that a pandemic (COVID-19) has changed/shifted the relationship
between mental illness or mental ill health and stigma across the life spectrum and call to re-
focus resources on sustainable healthy societies, building cultures of peace.
Methodology: A literature search was employed, combined with informal interviews and
observation.
Results and Discussion: On the one hand, the pandemic has opened public discussion of
mental health challenges such as anxiety and depression, reducing some of the stigma
attached as the experience is more common amongst people who have not previously
declared mental health challenges. On the other hand, people previously experiencing mental
ill health have mostly had that health challenge exacerbated by the pandemic. With fewer
resources available, and changes in service delivery to largely on-line resources, the reduction
in stigma has not meant better mental health care and services, but rather further marginalized
some of the population. Cultures of peace are inclusive and provide space for full growth of all
citizens, in contrast to reactive approaches now more readily applied. Mental health services
are a basic right for all people and should be considered as such in all planned health
strategies.
Limitations: The article focuses on literature review, anecdotal and observation and is focused
over a short term, in North America. It is a preliminary study.
Strengths: As a preliminary study, the article highlights an emergent and present dilemma. It
also highlights the need for a much more holistic, global approach to mental health and
wellbeing across the lifespan.
Conclusion: While there are calls for national strategies for mental health services and services
for people with dementia, in particular, there is still a need to take a more holistic approach to
mental health as part of a whole health strategy to support human dignity and inclusion across
the lifespan
Keywords
mental health, mental illness, dementia, stigma, COVID-19, peacebuilding
Address for correspondence:
Connie J. Snider, First Link Coordinator, Alzheimer Society of Saskatchewan, Saskatoon
Resource Centre, Saskatoon, Saskatchewan, Canada e-mail: csnider@alzheimer.sk.ca
This work is licensed under a Creative Commons Attribution-
NonCommercial 4.0 International License (CC BY-NC 4.0).
©Copyright: Snider, Flaherty, 2020
Licensee NDSAN (MFC- Coordinator of the NDSAN), Italy
DOI:: http://doi.org/10.32437/mhgcj.v3i1.89
Submitted for publication: 14
June 2020
Received: 14 June 2020
Accepted for publication: 5
October 2020
MHGCJ – 2020
Mental Health: Global Challenges Journal
https://mhgcj.org ISSN 2612-2138
Introduction
COVID-19 continues to greatly impact the
ways ordinary citizens lead our lives. With the
shutdown of businesses, educational
establishments of all kinds, services, and almost
any kind of direct human contact outside of
family ‘bubbles’, there has been an increase in
the reported incidence of anxiety and depression
in particular. There has also been a change in the
ways that anxiety and depression are talked
about. Mental ill health in general, has become
a more acceptable topic of discussion on the
interpersonal, community and even the
international level. This article shares a preliminary
exploration of the ways that the pandemic
(COVID-19) has changed/shifted the relationship
between mental illness or mental ill health and
stigma for some and the various ramifications of
same. The article begins with an introduction to
COVID-19, the pandemic that has changed lives
and caused many deaths around the world. We
move to a discussion of mental health and the
stigma that often accompanies it. We then
explore the change in the relationship between
mental health and stigma in the first six months of
COVID-19 and consider the shifts to accessing
services for those living with mental health
challenges during these times. We conclude by
considering ways that the challenges of this
pandemic may be utilized for improvement in
approaches to mental health and wellbeing
(health promotion, services, service access,
service promotion and attitudinal change). This
article is further to an introductory article on
mental health and peacebuilding in Canada
and Ukraine (Flaherty, Sikorski, Hayduk, Klos, & Vus,
2020).
Purpose
This article explores the ways that a pandemic
(COVID-19) has changed/shifted the relationship
between mental illness or mental ill health and
stigma and the various ramifications, considering
mental health and illness in general and
dementia in particular as these are the areas of
our special interest. We note that this is a
preliminary discussion in the midst of a pandemic
that has been experienced for six months for
those of us who live in North America, but several
more months in different areas of the globe.
Methodology
A literature search was employed, combined
with informal interviews and observation.
Results and Discussion
COVID – 19
COVID-19 is the name attributed to the novel-
corona virus first reported to officials in Wuhan
City, China in December in 2019. The virus or
infections disease, first identified as connected to
a food market in Wuhan City spread very quickly
to other countries. Officially known as SARS-CoV-2,
the disease was identified as such in early
January 2020 and this disease has now been
found in all corners of the world (World Health
Organization, 2020). At the time of writing,
autumn 2020, there have been almost 929
thousand deaths out of almost 29.3 million cases
worldwide (BBC News, 2020). In response to the
speed the disease has spread, many countries
shut down work from offices, and closed all in-
person business by mid-March of this year. While
this is a global phenomenon which stopped
international travel for months and halted much
in-person communication for that same time
period and longer, many businesses have not re-
opened in Canada at the time of writing. When
they do open, it is with strict protocols about
wearing masks, sanitizing areas, and restricting
access (Government of Ontario, 2020) .
Both the responses to and the impact of
the virus have varied across sectors, often related
to a number of the social determinants of health,
including Indigeneity, food security and insecurity
and socio-economic resources in general
(Statistics Canada, 2020).
Mental Health
The Canadian Association of Social Workers’
(n.d.) provides a helpful definition of mental
health:
Mental health is the capacity of the individual,
the group and the environment to interact with
one another in ways that promote subjective well-
being, the optimal development and use of
mental abilities (cognitive, affective and
relational), the achievement of individual and
collective goals with justice and the attainment
and preservation of conditions of fundamental
equality.
Indeed, Helen Verdeli (2016) reflects on the
WHO’s 2001 statistics related to the challenges to
mental health and wellness, noting that one in
four people around the world will “experience at
some point in their lives a mental or neurological
condition” (Verdeli, 2016, p. 761). Verdeli is clear
that “cultural norms, beliefs and attitudes can
either exacerbate stigma and instill shame or
serve as protective factors by establishing clear
social roles and community structure” (p. 765) to
MHGCJ – 2020
Mental Health: Global Challenges Journal
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support good mental health and assist both
individuals and communities to reach their full
potentials.
Indeed, while sometimes seen as controversial
and stigmatizing (DeFehr, 2020), the diagnosing
of mental ill health, often known as a “disorder”
has become critical in today’s medical
approach to health for individuals to access
many of the services that can help them live well,
particularly when dealing with what are
considered to be “major mental illnesses”, or
serious mental illness (SMI) – “mental, behavioral
or emotional disorder[s] resulting in serious
functional impairment, which substantially
interferes with or limits one’s major life activities”
(National Institute of Mental Health, 2019, para 4).
Even when symptoms are accurately reported to
medical practitioners, many people experiencing
mental ill health receive inadequate care. In
Canada for example, family doctors are often
overworked and overwhelmed with patients, and
as a result, many people are left without a family
doctor (Canadian News Facts, 2001; Dinshaw,
2016). This is troubling because the majority of
individuals who seek professional help for their
mental health turn to someone they know and
trust, their family doctor (Statistics Canada, 2017)
and it is often there a referral is made to more
specialized services, if they are available and
deemed necessary. We remember that these
are not preventative services, but rather
responding often to health challenges that will
have already impaired an individual’s ability to
function in society.
If one is fortunate enough to access a suitable
mental health care individual or service, there are
still challenges to accessing appropriate
treatment. A study with users of mental health
services and psychiatrists (Gunasekara, Patterson,
& James, 2017) revealed that it was not
uncommon for patients to feel as if they were
being judged in the process of accessing
treatment, and that their humanity was reduced
to a diagnosis.
In Canada, out of a population of just over 35
million people (Statistics Canada, 2017) over the
course of a year an estimated 4.9 million
Canadians over the age of 15 required
professional help for their mental health (Statistics
Canada, 2017). Many of those people were
unsatisfied with the quality of care they received
more than a third felt that they received only
adequate assistance (Statistics Canada, 2017).
Importantly, these numbers record only those
who actually received service and not the many
suffering who have not yet sought or received
help. An estimated 564,000 Canadians live with
Alzheimer’s disease and other dementias, yet
people with the illness often feel excluded or
treated differently (Alzheimer Society, n.d.).
Mental health and stigma
One of the greatest challenges facing people
experiencing mental health issues is stigma,
described by Goffman (1963) as the social
exclusion and reduction of an individual based
on an undesirable trait such as is found in the
negative views associated with those who
dealing with mental illness (Vogel, Heimerdinger-
Edwards, Hammer, & Hubbar, 2011). Numerous
researchers have noted the harmful impacts of
social stigma on those with mental health
conditions (see Chronister, Chou, & Liao, 2013;
Clement, et al., 2015; Corrigan, 2000).
Stigma surrounding mental health is
reproduced daily, found often in the language
used when discussing mental health with people
displaying mental illness or seeking treatment
called “crazy,” or “not being all there”, as if
because of their mental health they are missing
something (Larson, 2008; Corrigan, 2000). This
kind of hurtful language is the projection of
attitudes about mental health and illness (Marion,
Whitty-Rogers, & Panagopoulos, 2013). The
attitudes and language are found not only in the
general population but also, at times, amongst
health care professionals themselves (Hankir &
Zaman, 2015; Marion, Whitty-Rogers, &
Panagopoulos, 2013). While we have long talked
about stigma related to variety of illnesses such
as schizophrenia and bi-polar disorder, less often
do we acknowledge that this stigma extends to
people living with dementia (Alzheimer Society,
n.d.) and even to the their caregivers and others
associated with them (Werner & Heinik, 2008) . It
can be argued that stigma is the greatest barrier
to accessing and using mental health services
(Sartorius, 2007) with many people not bothering
to seek help because they feel marginalized by
any kind of diagnosis (Gearing, et al., 2015;
Corrigan P. , 2000; Vogel, Heimerdinger-Edwards,
Hammer, & Hubbar, 2011).
In addition to exposure to stigma from others,
people experiencing mental illness may also
contribute to the stigma themselves. Internalized
stigma, or self-stigma (Vogel, Heimerdinger-
Edwards, Hammer, & Hubbard, 2011) may
diminish one’s self-esteem and confidence
(Corrigan, 2004), impacting how one behaves in
the world and whether and how one seeks help
when struggling. Despite the educational
campaigns to reduce prejudice and increase
understanding of the often-genetic aspects to
mental illness, stigma remains strong, often
based on people’s personal interactions with
MHGCJ – 2020
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mental health challenges and what they see
portrayed in the media, which often focuses on
tragic events (Committee on the Science of
Changing Behavioral Health Social Norms; Board
on Behavioral, Cognitive and Sensory Sciences;
Division of Behavioral and Social Sciences and
Education; National Academies of Science,
Engieering, and Medicine, 2016). Sigma is
fundamentally a social phenomenon rooted in
social relationships and shaped by the culture
and structure of society.
COVID and stigma
With the development of COVID -19 and the
increased challenges to people’s health and
wellbeing, there has been a noticeable shift in
the way people talk about mental health.
Anecdotally, and in our local media (Morton,
2020; Crawford, 2020) and health services
publications (e.g. CAMH, 2020), we can attest to
an increased discussion of mental health and
wellness as well as challenges to these since the
start of COVID-19. In other words, some of the
stigma has been reduced – at least for now.
Anxiety and depression, as part and parcel of life
in uncertain times, are now much more a part of
everyday discourse. This is reflected locally and
internationally. As early as the end of May, 2020
Statistics Canada (2020) reported the United
Nations’ concern about the adverse effects of
social isolation on the population’s mental health.
People speak about exacerbating causes: being
much more housebound, unable to access
regular activities used to maintain social
connection (family gatherings, clubs, concerts,
dining out) enrichment (theatre, cinema) and
deal with stress (physical activity, team sports,
attending fitness venues). However, while this new
isolation has become a much more “shared”
phenomenon, experienced by most of the world
to some extent, the impact of these shared
experiences has been mitigated or exacerbated
to some extent dependent upon economic
status, living conditions, access to resources and
even race, as these factors often become
intertwined.
Covid-19 and access to mental health
resources
Despite what appears to be an increased
focus on the need for better mental health
services and resources and more focus on
normalizing this need (CAMH, 2020) these
resources have actually become less accessible
during times of COVID-19, and we wonder about
the long term impact of the disappearance of
these resources. The availability of many
resources has drastically changed. Like many
other individual day and group services,
community based, subsidized programs are not
available for people with dementia due to COVID
restrictions – no Adult Day Programs, no in-facility
respite, less in home respite and less available
Home Care programs and services. This has put
an increased stress on the primary caregiver who
used to rely on these programs to provide respite
to the caregiver. People with dementia have
died at a disproportionately high rate during
Covid-19 (Livingston, et al., 2020), their physical
and mental health needs further challenged by
decrease in supports for themselves and their
caregivers. Further, with more people in need of
mental health services, fewer are accessing the
resources that are there (Canadian Mental Health
Association, 2020), with increased protocols such
as mask-wearing, reduced walk-in services, etc.,
some turning to drugs and alcohol to cope with
their challenges, increasing co-morbidity of
substance abuse and mental health challenges
(Chiappini, Guirguis, John, Corkery, & Schifano,
2020). This has a domino effect, increasing the
rate of homelessness in our locales as people are
not managing to pay rent.
Indeed, many in-person services are no longer
available, or if they are, only on a sporadic basis.
If not able to avail themselves of services in
person, individuals may be able to have a
medical or counselling appointment on line –
something not accessible to those who are not
familiar with computers, or don’t have one, and
perhaps do not even have a home. Someone
with dementia, in particular may have difficulty
accessing online services. With a lack of
understanding of how to connect, or use the
technology, services are not just a phone call
away! Organizations such as the Alzheimer
Societies across Canada have had to learn how
to deliver programs that were in person, to online
services assisting people to get connected. Far
fewer programs are available to people and
when they are, they may not be just what people
need. Anecdotally, one client shared her
experience of receiving a diagnosis of Alzheimer
disease from a neurologist over the phone with
no follow up provided. Her story joins many who
have identifiable illnesses and no available
resources.
Conclusions
COVID-19 has highlighted the need for a
different and expanded understanding of mental
health and mental health services. This is a multi-
faceted, complex issue. First, increased attention
is being paid to mental health and wellness
MHGCJ – 2020
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during Covid-19 as people who have not
commented previously talk about their anxiety
and depression, perhaps newly experienced,
and exacerbated for those with pre-existing
conditions. Second, with the anxious uncertainty
and fewer material resources that accompany
COVID for many, there is a greater need for
services that would assist people experiencing
mental health challenges. Third, despite the
reality that more services are needed, many of
the resources that once were available have
disappeared, at least temporarily. Fourth, people
have become more creative in the ways that
they offer and utilize resources, using zoom and
telemedicine to share services. However, these
resources are out of reach for many with
cognitive challenges or any kind of financial
and/or housing instability. In short, with fewer
resources available, and changes in service
delivery to largely on-line resources, the reduction
in stigma has not meant better mental health
care and services, but rather further marginalized
some of the population.
The Canadian Association for Mental
Health notes concerns about the impact of
COVID-19 on the mental health of citizens and
calls for a long- term national strategy to improve
mental health care related to the pandemic and
beyond (Canadian Association for Mental Health,
2020). This is not the first time such a strategy has
been solicited; however, with the increased
acknowledgement of the impact of the COVID-
19 associated stressors on mental health for the
general population, there has been much more
social discourse about mental health. Clearly, an
international strategy with a focus on prevention
and good mental health as a part of our daily
discourse is needed. It is beyond time to return as
a global village to focus on the social
determinants of mental health outlined by the
World Health Organization in 2014 (World Health
Organization, 2014). The WHO notes, “Mental
health is integral to this conceptualization of
wellbeing, because it enables people to do and
be the things they have reason to value.
Conversely, being and doing things one has
reason to value contributes to mental health.”
(WHO, 2014, p. 13). This is not a luxury; it is about
agency and empowerment of citizens – a
necessity for our world’s survival.
Conflict of interest
The authors declare that they have no conflict
of interest.
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