Objective: To review literature on the impact of stigmatisation and perceived social support on the treatment of substance use disorder patients.
Methods: The systematic review was conducted from March 2020 to June 2021, and comprised literature search through key words on PubMed, Scopus, PsycINFO, Science Direct, Full Free PDF, and Google Scholar databases of studies about stigma, social support and treatment of substance use disorders published in English language between 2010 and 2021.
Results: Of the 52 studies found, 8(15.3%) qualified for detailed review. The outcome suggested that the impact of stigma had negative consequences on the treatment of substance use disorders, and negative comments from close relatives was a major cause of relapse. In contrast, perceived social support had a constructive impact on the treatment of substance use disorders.
Conclusion: Further research is required to understand the phenomenon of stigmatisation in the Pakistani population through validated tools.
Keywords: Stigmatisation, Perceived social support, Treatment, Relapse, SUD. (JPMA 73: 848; 2023)
Submission completion date: 25-04-2022 -Acceptance date: 29-09-2022
Substance use disorders (SUDs) are known as the most stigmatised disorder among all mental health disorders.1 Because SUD patients experience more rejection in society and people perceive them mostly as weird, harmful, irresponsible and an economic and social burden.2 Moreover, SUDs are also considered social taboos3 and in the 1980s, SUDs were recognised as a psychiatric problem that can be treated just as any other psychological disorder.4 According to the United Nations Office on Drug and Crime (UNODC), this social evil has been increasing by 40,000 per year in Pakistan which makes the country one of the most alarming and drug-affected worldwide.5 Moreover, 4.25 million Pakistanis are diagnosed with SUDs needing long-term treatment.6 But very few patients reach out to get the complete treatment, and even a number of recovered patients experience repetitive relapse due to stigmatisation and lack of validation from their loved ones.7 Even non-treatment-seekers experience the problem of stigma.8 The reason behind it is lack of validation and social acceptance by the caregivers, family members and loved ones, and sometimes it could be the main barrier between SUD patients’ recovery and relapse. In addition, percieved stigma and discrimination on the part of the family and society increases hinderances in the way of SUD treatment.9,10
Stigma is known as a combination of labelling, discrimination and stereotypical attitude or behaviour towards someone that has several negative consequences for the stigmatised person, especially those suffereing from stigma-related disorders, such as SUD.11
Similarly, stigmatisation is the most challenging obstacle in the treatment progress of SUD, and, therefore, mental health professionals rejected and avoid the term ‘mentally ill or sick’ that is mainly associated with stigmatisation.12 Moreover, SUD patients commonly suffer from public and internalised stigma which is very challenging for them when it comes to managing the primary symptoms of SUD.13 In contrast, social support plays a vital role in the reduction of stigma related to substamce use, and in improving other mental health problems, but, unfortunately, very few people accept the strength of social support and fail to provide it to the sufferers.
Social support is considered a crucial coping mechanism to maintain homeostasis between physical and mental illness.14 Negative attitudes, beliefs and stigma towards SUD patients lead to a wide range of other mental problems, such as depression, anxiety and mixed symptoms.15 In spite of knowing the issues, regrettably, it prevails commonly in Pakistani society. Moreover, the negative attitude towards SUD patients increases negative consequences on their mental health and they create reluctance in the treatment-seeking behaviour.16
Literature reports that stigma can be the hurdle in SUD treatment, but social support can overcome the impact of stigma.17 Another study supported that social support mediates the relationship between perceived stigma and psychological wellbeing.18 Likewise, internalised stigma could be the bridge between social support and depression.19,20 Furthermore, a poor social network increases internalised stigma in schizophrenic patients,21 while social support predicts an adequate prognosis of SUD. For instance, if patients think their family and friends are supportive towards them, it minimises the risk of internalised stigma in them.22 Additionally, perceived support is a good predictor of all mental health issues.23
The current systemtic review was planned to examine the effect of stigmatisation and perceived social support (PSS) on SUD treatment.
Materials and Methods
The systematic review was conducted from March 2020 to June 2021, and comprised literature search through key words on PubMed, Scopus, PsycINFO, Science Direct, Full Free PDF, and Google Scholar databases of studies related stigma, social support and treatment of SUD published in English language between 2010 and 2021. Only high-impact studies were included with no restrictions on methodological design. For inclusion, the studies had to explicitly target and evaluate measures of provider stigma; evaluate evidence-based interventions to reduce provider stigma; or provide evidence-based recommendations for reducing provider stigma for SUDs. Any study that fulfilled at least two of the selection criteria, or that warranted further inquiry, was included if the full text was available. Conference abstracts, case reports, editorials as well as study having sample without a primary SUD, and peripherally-related research as determined by the dissertation committees were excluded.
Done in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses” (PRISMA) guidelines, the systematic review used key wrds stigma, substance abuse, negative attitude about substance abusers, and treatment of substance abuse, SUD (smoking, drug, alcohol and tobacco). The search terms were used in combination.24
Data collected included the names of the authors, the date of study publication, the sample size and relevant sample demographics, like provider’s occupation, the study design, including measures of stigma and PSS, as well as key findings, recommendations and summaries.
After the initial search, duplicates and irrelevant studies not meeting the inclusion criteria were excluded. The included studies were analysed in detail.
Of the 52 studies initially found, 8(15.3%)7,8,19,20,22,29,30,31 were selected. Quantitative and qualitative studies included had been conducted in China, Australia, Hong Kong, Canada, Turkey, Taiwan, United States, and United Kingdom. No indigenous study was found on the specific subject.
The studies analysed demonstrated that SUD patients experienced a huge social and internalised stigma. The studies provided evidence that stigma was directly associated with poor mental health and hindrance of treatment.24,25 Previous findings showed that stigma was negatively correlated with SUD treatment.26 Moreover, the impact of internalised stigma had negative effects on perceived stigma, and PSS had positive effects on mental health and wellbeing.27 Majority of drug addicts avoided being treated because of the stigma associated with diagnosis. In contrast, social support was beneficial to motivating SUD patients to seek professional help and also to cope with the negative consequences of stigma.28,29 Additionally, social support could also help reduce perceived and internalised stigma in SUD patients. The review strongly supports the notion that PSS from caregivers is directly associated in lowering internalised stigma and shame.30,31
Limitations: The findings of the current systamtic review should be considered in the context of several limitations because very few studies met the inclusion criteria, and, so, a systematic review is more appropriate than a quantitative meta-analysis. It is possible that the search terms were too specific and limited the adequate capture of existing research on SUD stigma given by primary caregivers, due to variability in language and key words. While substantial and valuable qualitative research has been discussed in the current review, these articles were not subjected to quality assessment or formally included in the review due to a lack of sufficient inclusion criteria. While the studies included were of relatively high quality, many did not report randomisation procedures, blinding, or addressed within-study bias. Due to limited research on SUD stigma, only general guidelines for primary caregivers could be outlined.
The current systematic review highlighted the urgent need for healthcare providers to receive education on stigma. They should use appropriate language when referring to patients, and, most importantly, they should engage with SUD patients and understand their problems. In addition, to provide advocacy for the rights and worthiness of clients, curiosity and thoughtful examination of individual biases towards patients may facilitate a shift in the culture of addiction treatment. Structural changes must be made to foster improved provider-client interactions, enhance treatment engagement, and decrease provider burnout. Given the paucity of quantitative research targetting providers, more research is needed to examine the efficacy of provider stigma interventions, tailor professional education by occupational needs, and incentivise institutions to support their healthcare providers and the clients they treat. Government backing and social media campaigns are suggested as powerful tools for future anti-stigma efforts. As SUDs are highly treatable conditions, more effort needs to be made at both social and structural levels to better serve the patients whose healthcare needs are unmet, and who bear an undue burden of stigma from themselves, their peers and their providers.
Conflict of Interest: None.
Source of Funding: None.
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