suicide (Barraclough, 1971; Miller, 1976). However, suicide victims are three times more likely to have difficulties accessing health care than people who died from other causes (Miller and Druss, 2001).

These findings underscore the importance of sifting through reasons why people escape detection or fail to receive adequate diagnosis and treatment for risk factors and suicidality. They also underscore the importance of taking a broad view of barriers—focusing on suicidality, as well as on risk factors—because their treatment is so intertwined.

The barriers discussed in this chapter collectively weigh against treatment. Each barrier is unlikely to act in isolation, but likely interacts with and reinforces the others. The complex relationship of various precipitative, exacerbative, and maintenance effects of barriers is unique in each clinical case. Deeper and more nuanced understanding of the multiple barriers to treatment is essential for design, development, and implementation of preventive interventions. Prospective longitudinal studies can help to elucidate relationships among barriers as they change across the life-span and across the development of suicidality.

The chapter works its way from general to more specific barriers. It first looks broadly at barriers to treatment—such as stigma, cost, and the fragmented organization of mental health services. It then covers barriers raised within a range of therapeutic settings—by both clinician and patient. Finally, the chapter focuses on barriers for groups at greatest risk for suicide: older people, adolescents, certain ethnic populations, and incarcerated persons.

GENERAL BARRIERS TO TREATMENT

Stigma and Discrimination

The stigma of mental illness is one of the foremost barriers deterring people who need treatment from seeking it (US DHHS, 1999). About two-thirds of people with diagnosable mental disorders do not receive treatment (Kessler et al., 1996; Regier et al., 1993; US DHHS, 1999). Stigma toward mental illness is pervasive in the United States and many other nations (Bhugra, 1989; Brockington et al., 1993; Corrigan and Penn, 1998).

Stigma refers to stereotypes and prejudicial attitudes held by the public. These pejorative attitudes induce them to fear, reject, and distance themselves from people with mental illness (Corrigan and Penn, 1998; Hinshaw and Cicchetti, 2000; Penn and Martin, 1998). The stigma of mental illness is distinct from the stigma surrounding the act of suicide itself. The stigma of mental illness deters people from seeking treatment for mental illness, and thereby creates greater risk for suicide. The stigma surrounding suicide is thought to act in the opposite direction—to deter



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