378 Psychiatria Danubina, 2021; Vol. 33, No. 3, pp 378-385 https://doi.org/10.24869/psyd.2021.378 Review © Medicinska naklada - Zagreb, Croatia COVID-19 Forum: Transformation of Our World and Mental Health ONE FLEW OVER THE CUCKOO'S NEST: THE CHRONICLES OF STIGMA AND A PROPOSED SOCIO-COGNITIVE-EMOTIONAL-BEHAVIORAL MODEL FOR UNDERSTANDING ITS GENESIS IN COVID-19 Kumari Rina 1 , Vikas Menon 2 & Susanta Kumar Padhy 1 1 Department of Psychiatry, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, Odisha, India 2 Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, India received: 5.1.2021; revised: 14.3.2021; accepted: 7.4.2021 SUMMARY Stigma is a convoluted interaction between history, sociology, psychology, medicine, anthropology, and politics. Often, stigma is inter-twined at cognitive-emotional-behavioral level with a socio-cultural-economic-political milieu and hence distinct from prejudice, discrimination or, stereotypy. Stigma against diseases as a concept has evolved and has differed among various illnesses. At this time of humanitarian crisis, it is prudent to understand the concept, elements and models of stigma to tackle stigma against COVID-19 instrumentally. Stigma against COVID-19 can be partially extrapolated from various models described in psychiatry for mental illness. We propose an integrated socio-cognitive-emotional-behavioral model of stigma to conceptualize and understand the stigma against COVID-19, a matter of immense public health significance. Key words: stigma – stigmatized - models of stigma - COVID-19 – pandemic - stigma in COVID-19 * * * * * INTRODUCTION From 1720-2020, COVID-19 is among the four hardest-hitting pandemics in history of mankind (Gupta 2020). Infectious diseases are the most stigmatized illnesses (Earnshaw & Quinn 2013). Stigma, prejudice, and discrimination associated with infectious diseases have ravaged humanity. The word stigma comes from Greek ‘steizen’ referred originally to a mark or brand on slaves or traitors (Goffman 1963). At an individual level, the negative con- sequences of stigma spawn into social ostracism, diminished self-esteem, self-confidence and, self- efficacy; feeling of shame, guilt and embarrassment, precipitating or worsening of mental illness (like anxiety, depression, post-traumatic stress disorder, substance abuse, suicide rate), reduced quality of life, influence healthcare-seeking decisions and behaviors; participation and treatment adherence (Türközer & Öngür 2020, Corrigan et al. 2014). They also govern outcomes in terms of the availability of healthcare services. It undermines the government’s efforts on policies, legislation, jurisprudence and implementation on a large scale and may prolong infection trans- mission (Corrigan et al. 2014, Stangl et al. 2019). Although stigma is overweighed by criticism, it might have a beneficial and adaptive evolutionary role in disease avoidance. The universal ‘unitary theory’ of stigma is lacking (Smith 2002). Stigma, its various elements, and models have been proposed in the literature in the past. CONCEPTUALIZING STIGMA AND ITS ELEMENTS The pioneering work of Erving Goffman, 1963 and Allport, 1958, sprang research in stigma. Prejudice is defined as “an aversive or hostile attitude toward a person who belongs to a group, simply because he belongs to that group, and is therefore presumed to have the objectionable qualities ascribed to the group” (Allport 1958). Their work portrayed negative atti- tudes, discrimination, and biased treatment towards disadvantaged groups. Crocker et al. 1998 emphasized the ‘devaluation of the stigmatized individuals’ posses- sing (or believed to possess) some attribute, or charac- teristic conveying a social identity in a particular ‘so- cial context’. Experts have cited three main compo- nents of stigma. These are authoritarianism, fear and exclusion, and benevolence (Corrigan & Miller 2004, Brockington et al. 1993, Farina 1998). Thornicraft et al. 2007, advocated three elements of stigma, as igno- rance (problem of knowledge), prejudice (problem of attitudes), and discrimination (problems of behavior). Figure 1 conceptualizes stigma and its elements (Goff- man 1963, LeBel 2008, Watson & River 2006, Ritscher et al. 2003, Mak et al. 2008, Rössler et al. 2016).