mental health and substance use 101

What are we talking about when we talk about mental health and substance use? 

Mental health encompasses emotional and psychological health, and it affects how people think, feel, and behave. It can impact people’s ability to deal with stress, maintain relationships with others, and make rational decisions. Mental illnesses are very common; over 20% of adults in the U.S. have a diagnosable mental illness [1]. 

Substance use refers to the intake of substances like alcohol, tobacco products, or illicit drugs that can cause harm or dependence [2]. Substance use disorders (SUDs) occur when someone continues compulsive substance use even though it causes them significant harm [3]. It is estimated that over 21 million people from the U.S. have a diagnosable SUD [4].

A stigma is a negative association that arises when people link a label to someone and then apply a stereotype to that label [4]. People may experience self-stigma (feelings of shame or fear of negative reactions from others); social stigma (stigma in interpersonal interactions); or structural stigma (stigma embedded in social institutions) [5]. Stigma can lead to social distance, discrimination, or harm toward the stigmatized person, and people with mental illnesses or SUDs are often stigmatized [4]. 

Why do mental health and substance use matter in healthcare?

People with mental illness or SUDs often experience barriers to accessing care they need. These populations face stark health care disparities including inferior care, an increased risk of conditions unrelated to their mental illness or SUD, and a life expectancy of 10-25 years lower than the general population. The health care system contributes to these disparities; for instance, people with mental illness or SUDs are less likely to get important services like vaccinations, cancer screenings, and treatment following diagnosis with a physical health issue [5]. 

One way that the health care system creates disparities is through social stigma. A study of people with SUDs found that 28% of those who needed treatment and did not get it reported stigma as the reason they did not access or engage in care. Moreover, physicians tend not to adequately screen for SUDs or refer patients with SUDs to treatment [6]. Even when people who face stigma do access care, stigma can decrease the quality of care medical professionals provide them [4]. Structural stigma also contributes to health care disparities. Care for mental illness and SUDs is deprioritized, causing services for these conditions to be under-resourced. Moreover, the common separation between the treatment of mental and physical illness can lead to the neglect of physical health in these groups [5]. 

What do we know about mental health and substance use in medical and health professions education?

Because of the widespread stigma surrounding mental illness and SUDs, medical and health professions education has the potential to influence students’ attitudes toward these conditions. However, some studies have raised concerns that medical education can actually promote stigma toward mental illness and SUDs [7, 8]. For example, one study found that as students progressed through medical school and residency, their negative beliefs toward patients with SUDs increased [8]. Another aspect of mental health in medical and health professions education is that medical students have significantly worse mental health than their peers of the same age, and resources for addressing student mental health are lacking [9]. 

To better equip students to treat patients with mental illness and SUDs, one study found that curricular reform designed to reduce stigma and teach students about treating SUDs effectively improved students’ attitudes toward patients with SUDs [11]. Other authors have noted success with strategies to increase interpersonal contact between people with mental illness and students, including teaching students about lived experiences of mental illness [7]. Similar curricular reform can prepare students to fill the health care gap that occurs when providers fail to notice or treat SUDs, with one training course making participants feel more prepared to help patients with SUDs and more excited about working with them [6].

How does the Bias Checklist address disability and ableism in health professions education content?

The Bias Checklist first asks: 

  • “Does the content include any mention of mental health and substance use?”

If you answer no, you will be prompted to consider whether your content should mention mental health and substance use. 

Below are some examples of common ways in which bias, shame, stereotype and stigma toward mental health and substance use can manifest in health professions education content:

  • Implying that patients with mental health concerns are violent/dangerous

  • Undermining the dignity of people with mental health concerns by not recognizing how some might value neurodiversity as well as wishing treatment for symptoms that cause suffering

  • Using language of personal responsibility and self-control to discuss addiction, rather than acknowledging that it is a disease

  • Referring to patients as “crazy”, “insane”, “addicts”, “junkies”, “drunks”, etc.

  • Using “us” and “them” language when talking about patients with disabilities (failing to recognize that many learners and colleagues may experience mental health concerns or substance use)

  • Any comment about this subject that is meant to elicit laughter 

Last, the Checklist asks: 

  • “Could the content be perceived as promoting stereotypes, bias, shame or stigma?”

What can we do to address this problem?

  • Example: Many submissions to the Bias Checklist identify bias in descriptions of people with mental illness or substance use disorders. For example, it is frequently reported that the term “disheveled” is used to describe the appearance of people with mental illness. This description, when used in a large number of vignettes that deal with mental illness, can be stigmatizing, as it implies that people with mental illness look different than people without mental illness. Other descriptors that can stigmatize people with mental illness or substance use disorders are terms like “smoker,” “IVDU” (intravenous drug user), or “alcoholic,” since they identify the person with their behaviors. 

  • Example: Submissions to the Bias Checklist describe how certain words that describe substance use can stigmatize people. One submission identified the sentence, “He admits to IV drug abuse and many episodes of unprotected sex over the past few years" in a slideshow. The phrase “admits” implies a moral judgment; using a more neutral term such as “reports” would be better. Another submission identifies the description of a patient as “denying” drug use as at risk of bias, since this description casts the patient as untrustworthy, even before a provider knows anything about them. This patient could be more neutrally described as “reporting no drug use.”

Where can I go to learn more? 

I learn best by…

Reading

  • No One Cares About Crazy People: The Chaos and Heartbreak of Mental Health in America by Ron Powers

  • Strangers to Ourselves: Unsettled Minds and the Stories That Make Us by Rachel Aviv

  • The Urge: Our History of Addiction by Carl Erik Fisher

  • Dopesick: Dealers, Doctors, and the Drug Company that Addicted America by Beth Macy

Watching

Listening

Need a consultation?

The following people have identified themselves as experts in mental health and substance use and are willing to be contacted with questions regarding your content.

  • Contact list coming soon!

Have something to add? 

  • Email us at biaschecklist@gmail.com with any of the following:

  • Recommendations for additional important content to include above, or suggested corrections or clarifications → use the subject header “Mental Health and Substance Use 101 - Correction”

  • Suggestions for additional questions to add to the Bias Checklist → use the subject header “Mental Health and Substance Use 101 - Checklist Question”

  • Suggestions for additional resources for learning more → use the subject header “Mental Health and Substance Use 101 - Learn More”

  • Examples of curricular bias, including before and after versions of content → use the subject header “Mental Health and Substance Use 101 - Example”

  • Your name, credentials, affiliation, area(s) of expertise, and brief biography or summary of qualifications if you are willing to serve as an expert consultant → use the subject header “Mental Health and Substance Use 101 - Consultant”

References

  1. Centers for Disease Control and Prevention. (April 25, 2023). About Mental Health. https://www.cdc.gov/mentalhealth/learn/index.htm

  2. National Center for Health Statistics. (June 26, 2023). Substance use. Centers for Disease Control and Prevention. https://www.cdc.gov/nchs/hus/sources-definitions/substance-use.htm

  3. American Psychiatric Association. (2020). What Is a Substance Use Disorder? https://www.psychiatry.org/patients-families/addiction-substance-use-disorders/what-is-a-substance-use-disorder

  4. Ashford, Robert D. (2018). Substance use, recovery, and linguistics. Drug and Alcohol Dependence, 189, 131-138. https://doi.org/10.1016%2Fj.drugalcdep.2018.05.005

  5. Livingston, James D. (2020). Structural Stigma in Health–Care Contexsts for People with Mental Health and Substance Use Issues.” Mental Health Commission of Canada. 10.13140/RG.2.2.21168.17929

  6. Barron, Rebecca, et al. (2012). Evaluation of an Experiential Curriculum for Addiction Education Among Medical Students. Journal of Addiction Medicine, 6(2), 131-136. 10.1097/ADM.0b013e3182548abd

  7. Papish, Andriyka, et al. (2013). Reducing the stigma of mental illness in undergraduate medical education. BMC Medical Education, 13(141), 10.1186/1472-6920-13-141.

  8. Lindberg, Michael, et al. (2006). Physicians-in-training Attitudes Toward Caring For and Working with Patients with Alcohol and Drug Abuse Diagnoses. Southern Medical Association, 99(1). 

  9. D’Eon, Marcel, et al. (2021). The alarming situation of medical student mental health. Canadian Medical Education Journal, 12(3), 176-178. https://doi.org/10.36834%2Fcmej.70693

  10. Kidd, Jeremy D., et al. (2022). Medical Student Attitudes Toward Substance Use Disorders Before and After a Skills-Based Screening, Brief Intervention, and Referral to Treatment (SBIRT) Curriculum. Advances in Medical Education and Practice, 11(2020), 455-461. https://doi.org/10.2147/AMEP.S251391

contributing writer(s)

Sophie Pollack-Milgate, BA

last updated January 29, 2024