research mental health stigma

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• > Journals
• > European Psychiatry
• > Volume 20 Issue 8
• > Mental illness stigma: Concepts, consequences, and...

Article contents

• What is stigma?
• Public and self-stigma
• Different conceptualizations of stigma
• The consequences of stigma
• Ways to reduce the stigma towards mental illness
• Conclusions

Mental illness stigma: Concepts, consequences, and initiatives to reduce stigma

Published online by Cambridge University Press:  16 April 2020

Persons with mental illness frequently encounter public stigma and may suffer from self-stigma. This review aims to clarify the concept of mental illness stigma and discuss consequences for individuals with mental illness. After a conceptual overview of stigma we discuss two leading concepts of mental illness stigma and consequences of stigma, focussing on self-stigma/empowerment and fear of stigma as a barrier to using health services. Finally, we discuss three main strategies to reduce stigma - protest, education, and contact – and give examples of current anti-stigma campaigns. Well-designed anti-stigma initiatives will help to diminish negative consequences of mental illness stigma.

Persons with mental illness often have to struggle with a double problem. First, they have to cope with the symptoms of the disease itself; depending on the particular mental disorder they may have problems such as recurrent hallucinations, delusions, anxiety, or mood swings. These symptoms can make it difficult for someone with a mental illness to work, live independently or achieve a satisfactory quality of life. Second, the misunderstandings of society about the various mental disorders result in stigma. Some persons who manage their mental illness well enough to work still have tremendous difficulties finding a job because employers discriminate against them. Thus, mental illness results not only in the difficulties arising from the symptoms of the disease but also in disadvantages through society's reactions. As a further complication, some people with mental illness may accept the common prejudices about mental illness, turn them against themselves, and lose self-confidence. The latter is referred to as ‘self-stigma’ and will be discussed further below.

In this paper we want to give a conceptual background of public and self-stigma, discuss how stigma of mental illness interferes with empowerment of persons with mental illness and with service use, review strategies to reduce stigmatization of persons with mental illness and give examples of current initiatives. We believe that it is important to review conceptually relevant work in the field of mental illness stigma to provide a framework for a better interpretation of various empirical findings. Therefore, in this review we wish to summarize conceptually driven work and research on mental illness stigma from different countries. We focussed on two concepts that have been most relevant in research on mental illness stigma: Stigma as conceptualised by Link and Phelan Reference Link and Phelan [63] and the concept of Corrigan and coworkers Reference Corrigan [28] . In this paper, we will first conceptualise stigma using an integrative conceptualisation, combining the two mentioned concepts. We will then discuss differences between these two concepts and their consequences for research and interpretation of results.

This review may be of help to readers from different backgrounds: It may be useful for researchers as a framework to generate and test hypotheses; for clinicians who work with people with mental illness to recognise public stigma and self-stigma more easily and help people with mental illness to cope with the consequences; for mental health professionals to question their own possibly stigmatising attitudes towards people with mental illness; for teachers and students to establish educational and other anti-stigma initiatives in their schools or universities; last not least for people with mental illness to better understand stigma and self-stigma and to actively fight stigma and its consequences in their environment.

1. What is stigma?

Stigmatizing attitudes contain some core assumptions. Media analyses of film and print have identified three common misconceptions about people with mental illness: they are homicidal maniacs who should be feared; they are rebellious, free spirits; or they have childlike perceptions of the world that should be marveled [40,50,103] . Independent factor analyses from Canada, England and Germany confirm these findings by identifying the following factors: First, fear and exclusion: persons with severe mental illness are to be feared and, therefore, kept out of communities; second, authoritarianism: persons with severe mental illness are irresponsible, so life decisions should be made by others; and third, benevolence: persons with severe mental illness are childlike and need to be cared for [7,11,101] . Although stigmatizing attitudes are not confined to mental illness, the general public seems to disapprove of persons with psychiatric disabilities more than of persons with physical illness [83,97,105] . Persons with mental illness are more likely to be seen as responsible for causing their illness [22,105] . This assumption of responsibility is less pronounced for schizophrenia than for substance addiction and eating disorders Reference Angermeyer and Matschinger [4] . These attitudes lead to corresponding discriminatory behavior. Citizens are less likely to hire persons with mental illness Reference Bordieri and Drehmer [9] , less likely to rent them apartments Reference Page [79] , and more likely to falsely press charges for violent crimes [98,99] .

As an example of a person suffering from stigma, consider what happened to Anne. Anne is 25years old and has been hospitalised several times with acute symptoms of schizophrenia. For two years, she had been symptom-free, living on her own, working in a local tourist information office and enjoying an active social life. Recently though, she had a relapse of her mental illness. She again was hospitalised and it took her two months to recover and to get ready to go back to work again. However, after recovery she realised that getting over the symptoms of her disease did not suffice: Her employer discharged her because he believed she could have a dangerous outburst in the office due to her mental illness. In addition, her family convinced her that it was too risky to live on her own and made her move back to her parents’ home. Since her family lived in another town, that made her lose her friends. In summary, despite a good recovery from the symptoms of her mental illness, within a month after discharge from the mental hospital Anne had lost her job, appartment and friends. Imagine in comparison a person with a chronic somatic illness like diabetes. Similar to schizophrenia, diabetes can lead to severe relapses and hospitalisations. However, unlike a person with schizophrenia, a person with diabetes is unlikely to encounter comparably consequential public stigma related to her illness.

2. Public and self-stigma

2.1. a social cognitive model of public stigma.

Public stigma comprises reactions of the general public towards a group based on stigma about that group. Although we are used to distinguishing between groups in society and to label these groups with different attributes, this is not a self-evident process. Most human differences are mainly ignored and socially irrelevant in Western societies of our time. For example, the color of one's car or the size of one's shoes do not matter for most people under most circumstances. However, other personal features like skin-color, sexual orientation or income are often relevant to one's social appearance. There is obviously a social selection of which human qualities matter socially and which do not.

It is often taken for granted to distinguish between different groups in society and to label human differences accordingly. However, every demarcation of groups requires an oversimplification. Even with obvious attributes like skin-color, there is no clear demarcation line between, for example, 'black' and 'white'. Even more so, there is no sharp line between mental health and mental illness Reference Link and Phelan [63] .

That cultural attitudes to behavior and (mental) illness change substantially over time is another aspect of the social selection of human differences in creating groups Reference Conrad and Schneider [13] . Whether patterns of behavior, thinking and feeling are being noticed at all and if so, whether they are described in moral, psychosocial or medical terms is influenced by societal discourse and usually varies over time. Attention deficit hyperactivity disorder is an example of a label that was unknown a few decades ago and is likely to change again Reference Seidler [95] .

It is further important to note that labeling often implies a separation of 'us' from 'them'. This separation easily leads to the belief that 'they' are fundamentally different from 'us' and that 'they' even are the thing they are labelled. 'They' become fundamentally different from those who do not share a negative label, so that 'they' appear to be a completely different sort of people Reference Link and Phelan [63] . Our use of language is revealing regarding the use of labels to distinguish 'us' from 'them'. For example, it is common to call someone a 'schizophrenic' instead to call her or him a person with schizophrenia. For physical illness, things are often handled differently and people usually say, a person has cancer. The person afflicted with cancer remains one of 'us' and has an attribute, while the 'schizophrenic' becomes one of 'them' and is the label we affix to the person Reference Link and Phelan [63] . In this way, language can be a powerful source and sign of stigmatization.

Given this background of distinguishing between groups, labeling and separating 'us' from 'them', social psychology has identified different cognitive, emotional and behavioral aspects of public stigma: stereotypes, prejudice, and discrimination (see Table 1 ). It is important for both theoretical research and practical initiatives to understand these components. Stereotypes are knowledge structures known to most members of a social group [48,53] . Stereotypes are an efficient way to categorize information about different social groups because they contain collective opinions about groups of persons. They are efficient in the sense that they quickly generate impressions and expectations of persons who belong to a stereotyped group Reference Hamilton, Sherman, Wyer, RS and Srull [45] .

Table 1 Components of Public and Self-Stigma

People do not necessarily agree with the stereotypes they are aware of Reference Jussim, Nelson, Manis and Soffin [54] . Many persons may, for example, be aware of stereotypes of different ethnic groups but do not think these stereotypes are valid. Prejudiced persons, on the other hand, endorse these negative stereotypes (“That's right! All persons with mental illness are violent“) and have negative emotional reactions as a consequence (“They all scare me“) [35,36,48] . Prejudice leads to discrimination as a behavioral reaction Reference Crocker, Major, Steele, Gilbert and Fiske [32] . Prejudice that yields anger can lead to hostile behavior. In the case of mental illness, angry prejudice may lead to withholding help or replacing health care with the criminal justice system Reference Corrigan [28] . Fear leads to avoidant behavior. For example, employers do not want persons with mental illness around them so they do not hire them. This association between perceived dangerousness of persons with mental illness, fear, and increased social distance has been validated for different countries, including Germany Reference Angermeyer and Matschinger [3] , Russia Reference Angermeyer, Buyantugs, Kenzine and Matschinger [1] and the United States Reference Corrigan [15] .

Stereotypes and prejudice alone are not sufficient for stigma. In addition, social, economic and political power is necessary to stigmatize. For example, if individuals with mental illness form stereotypes and prejudices against staff in a mental health service, this staff is unlikely to become a stigmatized group because the persons with mental illness simply do not have the social power to put serious discriminatory consequences against the staff into practice Reference Link and Phelan [63] .

In summary, public stigma consists of these three elements - stereotypes, prejudice and discrimination - in the context of power differences and leads to reactions of the general public towards the stigmatised group as a result of stigma.

2.2. A social cognitive model of self-stigma

Self-stigma refers to the reactions of individuals who belong to a stigmatized group and turn the stigmatizing attitudes against themselves Reference Corrigan and Watson [25] . Like public stigma, self-stigma comprises of stereotyping, prejudice and discrimination ( Table 1 ). First, persons who turn prejudice against themselves agree with the stereotype: “That's right; I am weak and unable to care for myself!” Second, self-prejudice leads to negative emotional reactions, especially low self-esteem and self-efficacy Reference Wright, Gronfein and Owens [106] . Also self-prejudice leads to behavior responses. Because of their self-prejudices, persons with mental illness may fail to pursue work or independent living opportunities. If they fail to reach this goal this is often not due to their mental illness itself but due to their self-discriminating behavior Reference Link, Cullen, Struening and Shrout [66] . How can self-stigma arise? Many persons with mental illness know the stereotypes about their group such as the belief that people with mental illness are incompetent Reference Hayward and Bright [47] . But, as in public stigma, knowledge alone does not necessarily lead to stigma, if persons are aware of the stereotypes but do not agree with them Reference Crocker and Major [33] . Thus, fortunately for many persons with mental illness, awareness of stereotypes alone does not lead to self-stigma.

3. Different conceptualizations of stigma

The conceptualization of mental illness stigma given above combines two leading current concepts, i.e. the one of Corrigan and coworkers Reference Corrigan [28] and the concept of Link and colleagues Reference Link and Phelan [63] .

Corrigan and colleagues focus on the cognitive and behavioral core features of mental illness stigma: Stereotypes (cognitive knowledge structures), prejudice (cognitive and emotional consequence of stereotypes) and discrimination (behavioral consequence of prejudice). Focussing on these core components, their model allows one to examine different elements of stigmatizing attitudes and behaviors and their modifiability by anti-stigma initiatives. It is a merit of this model that it makes it feasible to disentangle different phenomena underlying stigma and to make them accessible to empirical research.

In the definition of Link and Phelan, “stigma exists when elements of labeling, stereotyping, separation, status loss, and discrimination co-occur in a power situation that allows these processes to unfold” Reference Link and Phelan [63] . In their concept, stereotypes, separation, and status loss/discrimination parallel Corrigan's stereotypes, prejudice and discrimination. Since Link and colleagues deal with various stigmata, although focussing on mental illness stigma, they stress that no definition of stigma can be universally applicable. Therefore, Link and colleagues emphasize that definitions of stigma should always be made transparent by the respective researchers, and dictionary definitions alone such as “a mark of disgrace” are by no means sufficient. Writing from a sociological perspective, in comparison to the model of Corrigan and colleagues, Link and Phelan put more stress on two societal aspects: First, as a precondition of stigma differences between persons have to be noticed, to be regarded as relevant and to be labeled accordingly. This labeling process is at the core of Link's modified labeling theory Reference Link, Cullen, Struening and Shrout [66] . Second, for stigma to unfold its deleterious consequences, the stigmatizing group has to be in a more powerful position than the stigmatized group. Therefore, for instance, jokes about powerful groups such as politicians may be stereotyping but do not normally lead to discrimination and therefore are not ‘stigmatizing’ in a strict sense of the word. This sociological perspective does not contradict the model of Corrigan and colleagues, but helps to connect it with societal aspects. A further focus of the approach of Link and Phelan is the subjective expectation and experience of being labeled and discriminated because of one's mental illness.

Although the two models are well compatible, they still seem to show slightly different consequences in methodology, results and interpretation of studies. Link and colleagues in their research focussed on the expectations and experiences of being labeled and stigmatized, which was usually measured by Link's Perceived Devaluation and Discrimination Scale, and on the consequences of stigma on self-esteem (e.g. [62,64,67] ). Thus the emphasis here is on what we call self-stigma including recent work that operationalises their concept how stigma affects individuals Reference Ritsher and Phelan [86] . In the field of anti-stigma initiatives, the sociological focus on the complexities of discriminating mechanisms in a society seems to lead to a more sceptical approach towards anti-stigma initiatives because effects at an individual level may be outweighed by other paths of discrimination (see our discussion below).

The research of Corrigan and colleagues focussed on the central features of Corrigan's model: Stereotypes, prejudice and (discriminating) behavior of the public towards people with mental illness. Several studies examined these elements and their interrelationship, especially perceptions of dangerousness, fear and social distance Reference Corrigan, Green, Lundin, Kubiak and Penn [18] ; authoritarianism, benevolence and social distance Reference Corrigan, Edwards, Green, Diwan and Penn [17] ; controllability, responsibility and stability Reference Corrigan, River, Lundin, Wasowski, Campion and Mathisen [22] . As an extension of these studies, the effect of anti-stigma initiatives using the strategies of education and contact (see below) was examined in several studies [21,23] . Thus, the research focuses, slightly different from the research of Link and colleagues, on public stigma. Recently though, Corrigan and colleagues have been bridging the gap to the work of Link and coworkers and have extended their research to include conceptual work on self-stigma Reference Corrigan and Watson [25] , to the perception of discrimination by people with mental illness Reference Corrigan, Thompson, Lambert, Sangster, Noel and Campbell [27] and are currently developing a measure of self-stigma in mental illness that operationalises their concept of self-stigma.

4. The consequences of stigma

As far as mental illness is concerned, stigmas seem to be widely supported by the general public. This is true for the United States [61,81] and for other Western nations including Norway Reference Hamre, Dahl and Malt [46] , Greece Reference Madianos, Madianou, Vlachonikolis and Stefanis [71] or Germany [2,52] while levels of stigmatisation may differ between nations. Unfortunately, research suggests that public attitudes toward people with mental illness seem to have become more stigmatizing over the last decades: Survey research suggests that a representative 1996 population sample in the US was 2.5 times more likely to endorse dangerousness stigma than a comparable 1950 group, i.e. perceptions that mentally ill people are violent or frightening substantially increased Reference Phelan, Link, Stueve and Pescosolido [81] . A recent German study also found increasing stigmatizing attitudes towards people with schizophrenia Reference Angermeyer and Matschinger [5] . On the other hand, the use of outpatient psychotherapy in the US increased between 1987 to 1997, at least among people about 60years old, among the unemployed and persons with mood disorders Reference Olfson, Marcus, Druss and Pincus [78] . It has been speculated that the increased use of psychotherapy in these groups may be due to decreased stigmatisation especially of mood disorders. However, the link between stigma and use of psychotherapy was not assessed in this study, psychotherapy was very broadly defined including treatments of only one or two sessions, and the overall use of psychotherapy did not change in this period. In addition, being in psychotherapy may not necessarily mean to consider oneself having a ‘mental illness’ or to be considered ‘mentally ill’ by one's environment, so different stigmata may apply and change independently over time. Another sobering fact is that mental health professionals equally support stigmatizing views [44,58,80,92] .

Two deleterious consequences of stigma can only briefly be mentioned here. First, public stigma results in everyday-life discriminations encountered by persons with mental illness in interpersonal interactions as well as in stereotyping and negative images of mental illness in the media Reference Wahl [103] . Second, structural discrimination includes private and public institutions that intentionally or unintentionally restrict opportunities of persons with mental illness Reference Corrigan, Markowitz and Watson [19] . Examples of structural discrimination are discriminatory legislation or allocation of comparatively fewer financial resources into the mental health system than into the somatic medical system [26,73] . It is important to note that for example a person with schizophrenia may experience structural discrimination whether or not someone treats her or him in a discriminatory way because of some stereotype about schizophrenia Reference Link and Phelan [63] .

In this paper we want to focus on two other negative consequences of stigma that are both related to the way a person with mental illness reacts to the experience of being stigmatized in the society: Self-stigma/empowerment and fear of stigma as a reason to avoid treatment. We focus on these two aspects because both are highly relevant for clinicians working in the mental health field. By this we do not imply that stigma is only an individual problem. In contrast we believe stigma to be primarily a social problem that should be addressed by public approaches Reference Mills [76] . Still, until stigma has been reduced in society, the clinician should be aware of the meaning and consequences of stigma for individuals with mental illness.

4.1. Self-stigma and empowerment

Research has shown that empowerment and self-stigma are opposite poles on a continuum Reference Corrigan [14] . At one end of the continuum are persons who are heavily influenced by the pessimistic expectations about mental illness, leading to their having low self-esteem. These are the self-stigmatized. On the other end are persons with psychiatric disability who, despite this disability, have positive self-esteem and are not significantly encumbered.

Many persons who are discriminated against and suffer from public stigma do not experience self-stigma while others do. Correspondingly, the evidence is equivocal on this point: Some studies suggest that people with mental illness, who are generally well aware of the prejudices against them, show diminished self-esteem [65,66,72,87,102,106] . On the other hand, other surveys did not find that awareness of common stereotypes leads to diminished self-esteem in persons with mental illness Reference Hayward and Bright [47] . Even more amazingly, some stigmatized minority groups show increased self-esteem, including persons of color Reference Hoelter [49] and people with physical disabilities Reference Llewellyn [68] . Being stigmatized may stimulate psychological reactance Reference Brehm [10] so that instead of applying the common prejudices to themselves persons oppose the negative evaluation which results in positive self-perceptions. This fact that some react with righteous anger to stigma, while others are indifferent to stigma and yet another group self-stigmatizes has been called the paradox of self-stigma and mental illness Reference Corrigan and Watson [25] . Why do people react so differently to public stigma? Corrigan and colleagues developed a model of the personal response to mental illness stigma ( Fig. 1 ).

Fig. 1 Model of personal response to mental illness stigma (adapted from Reference Corrigan and Watson [25] ).

Persons with a stigmatizing condition like serious mental illness perceive and interpret their condition and the negative responses of others. The collective representations in the form of common stereotypes influence both the responses of others and the interpretation of the stigmatized. Persons with a stigmatizing condition who do not identify with the stigmatized group are likely to remain indifferent to stigma because they do not feel that prejudices and discrimination actually refer to them ( Fig. 1 ). However, those who identify with the group of the mentally ill apply the stigma to themselves Reference Jetten, Spears and Manstead [51] . Their reaction is moderated by perceived legitimacy. If they consider the stigmatizing attitudes to be legitimate, their self-esteem and self-efficacy are likely to be low [91,93] . If, on the other hand, they regard public stigma to be illegitimate and unfair, they will probably react with righteous anger Reference Frable, Wortman and Joseph [41] ( Fig. 1 ). People who are righteously angry are often active in empowerment efforts, targeting the quality of services.

Related to empowerment and self-stigma is the issue of stigma and disclosure. To disclose one's mental illness may have both significant benefits, e.g. possibly increased self-esteem and decreased distress of keeping one's illness a secret, and costs, e.g. social disapproval. Whether or not individuals decide to disclose will depend on context and their sense of identity Reference Corrigan and Matthews [29] . For instance, if a woman with mental illness does not consider her illness a relevant part of her identity, she will be unlikely to tell her relatives about her mental illness, especially if those have repeatedly made stigmatising remarks about mental illness. If, on the other hand, a man with mental illness who is active in self-help groups and regards his mental illness as an important part of his life has trustworthy colleagues that have not shown discriminating behavior against people with mental illness, he is more likely to disclose his mental illness at work.

While the model of self-stigma, originating in social psychological research on other stigmatized groups (e.g. people of color, people with physical diseases), is useful to understand the different ways people react to stigma, three aspects have to be included to take into account the special case of mental illness. First, self-stigma resulting in decreased self-esteem and self-efficacy must be distinguished from decreased self-esteem during depressive syndromes that are common not only in affective disorders. Second, reaction to stigmatizing conditions depends on the awareness of having a mental illness, which may be impaired during episodes of, for instance, a psychotic condition Reference Rüsch and Corrigan [90] . Third, the reaction to a stigmatizing environment is dependent on one's perception of the subtle stigmatizing messages from other people. This social cognition may be impaired in serious mental illness such as schizophrenia Reference Corrigan and Penn [20] .

4.2. Fear of stigma as a barrier to use health services

Psychiatric symptoms and life disabilities of many persons living with mental illness can be significantly improved by various psychiatric and psychosocial treatments. Unfortunately, many persons who are likely to benefit from that kind of treatment either choose to never start treatment or opt to end it prematurely. This low rate of participation is not only the case in minor mental illness such as adjustment disorders; less than two thirds of persons with schizophrenia take part in treatment Reference Regier, Narrow, Rae and Manderscheid [85] and generally people with serious mental illness do not participate in treatment more often than those with minor disorders Reference Narrow, Regier, Norquist, Rae, Kennedy and Arons [77] . While many persons do not start treatment, even more do not fully adhere to prescribed interventions once they are begun. On average, almost half of persons on anti-psychotic medication fail to comply with the prescribed medication fully Reference Cramer and Rosenheck [31] . This is a major reason for the high rate of relapse that causes almost a billion dollar increase in hospital costs per year world wide Reference Weiden and Olfson [104] .

Health belief models explain why persons choose not to take part in treatments. These models assume that humans act rationally in ways that diminish perceived threats (disease symptoms) and enhance perceived benefits (improved health following treatment) Reference Rosenstock [88] . Key elements in the equation that produce health related behavior are negative effects of treatment, such as side-effects of medication. But of major importance is also the effect on the social environment; i.e. being labeled and stigmatized as a person with a mental illness after treatment.

Persons with mental illness who try to avoid stigma by not pursuing psychiatric services are called “potential consumers”. They consider themselves part of the public, are aware of the common prejudices against persons with mental illness and do not want to be seen as part of the “mentally ill” minority and thus avoid public stigma. They also avoid decreased self-esteem resulting from being mentally ill, i.e. self-stigma. Unlike other stigmatized groups, like those of color, persons with mental illness do not share a readily visible condition. Therefore the greatest single cue that produces public stigma is the label Reference Link [61] ; this label usually stems from participating in psychiatric services. Potential consumers may opt not to access care as a way to avoid this label.

There are some data to support our assertion that stigma limits service use. Persons in a large epidemiologic study were less likely to use services if they expected negative reactions of family members Reference Leaf, Bruce and Tischler [59] . In addition, there are other variables that interact with stigma and service use. Demographics may play a major role; in a study of outpatients with depression, only older persons showed a significant association between perceived stigma and disruption of treatment Reference Sirey, Bruce, Alexopoulos, Perlick, Raue and Friedman [96] . Also social status appears to influence service use because less educated and poorer people express more concern about family reactions Reference Leaf, Bruce, Tischler and Holzer [60] . The vocational background of potential consumers is also relevant. Contrary to what one might expect, those who should know better do avoid treatment due to fear of stigma: Only a third of medical students with clinical levels of distress sought help because they were concerned about stigma [12,39] .

Further research needs to confirm the link between stigma and service use. But the data available so far are sufficient to suggest that the reduction of public and self-stigma will be an important means to increase treatment participation (for an overview see Reference Corrigan and Rüsch [24] ).

5. Ways to reduce the stigma towards mental illness

In Germany, the US and many other countries, consumer groups have actively targeted stigma in an attempt to improve the lives of persons with mental illness. Due to the large number of successful programmes, the following examples are by no means meant to be comprehensive. As a particularly successful example in the US, the National Alliance of the Mentally Ill, a group of family members and persons with mental illness, has been educating the public in order to diminish stigmatizing conditions; e.g. by pressing for better legal protection for persons with mental illness in the areas of housing and work. Called ‘stigmabusters’, the NAMI-programme has been successfully used to protest against media representations of stigma in all 50 states of the US. In Germany, there are various anti-stigma campaigns, two of which should be mentioned here: BASTA – The alliance for mentally ill people (previously called ‘Bavarian Anti-Stigma Action’; ‘basta’ also meaning ‘stop’ in Italian and German), based in Munich, is active in various fields, including protest campaigns using email alerts, extensive education programmes in schools and police academies with active participation of mental health consumers, education of the media, and exhibitions of art by people with mental illness and other cultural activities ( www.openthedoors.de ). Another major German initiative is Irrsinnig Menschlich (engl. ‘Madly Human’), based in Leipzig. Here, too, various educational anti-stigma activities are undertaken, both locally and nationwide: These include the school project “Crazy? So what!” which raises students' awareness of mental health, and the international film workshop “Against the images in our heads”, a practical programme to reduce stigma and improve the lives of persons with mental illness ( www.irrsinnig-menschlich.de ). Other successful examples include the Like Minds, Like Mine Campaign in New Zealand ( www.likeminds.govt.nz ) that involves a vast number of local, regional and national initiatives, including active participation of persons with mental illness at all levels, and Sane Australia ( www.sane.org ), a nationwide anti-stigma campaign active for 20years and particularly successful in educating journalists and fighting stigmatising media messages.

In 1996, the World Psychiatric Association (WPA) started an international programme to fight the stigma and discrimination related to schizophrenia ( www.openthedoors.com ). Schizophrenia was chosen as the focus of this programme because it is a serious condition with symptoms that the public typically associates with mental illness, often of long duration. Rehabilitation of persons with schizophrenia is often hampered by stigma-associated difficulties Reference Sartorius [92] . The WPA-initiative tries to increase the awareness and knowledge of the nature of schizophrenia and treatment options, to improve public attitudes about individuals with schizophrenia and their families and to generate action to eliminate discrimination and prejudice.

Three main strategies have been used to fight stigma: protest, education, and contact Reference Corrigan and Penn [30] .

5.1. Protest

Protest is often applied against stigmatizing public statements, media reports and advertisments. Many of these protest interventions have successfully changed such public statements. A German example is the above mentioned ‘BASTA – the alliance for mentally ill people’ that uses email to quickly alert members about stigmatizing advertisements or media messages. About 80% of the discriminating cases that BASTA took action against were successfully stopped and the respective companies or media institutions apologised. Usually, these campaigns were most effective if several actions coincided: if many people wrote to the public relations department and to the managing director or owner of the respective company or media institution; if BASTA turned to a national surveillance commission, e.g. one that was responsible for supervising advertising messages, and this commission supported BASTA's campaign; and if all these simultaneous activities and the responses of the respective company or media institution were documented on BASTA's website (Kerstin Wundsam, personal communication). There is evidence also from the US that these initiatives are effective in diminishing negative public images of mental illness Reference Wahl [103] . However, little is known about the effect of protest against people's prejudices. Social psychological research has found that protest leads to suppression of stereotypic thoughts and discriminating behavior. Unfortunately, there are two major problems with suppression. First, suppression is an effortful, resource-demanding process that reduces attentional resources, so that people are less likely to learn new information that would disconfirm the old stigmatizing stereotype Reference MacRae, Bodenhausen, Milne and Wheeler [70] . Second, there seems to be a rebound effect to suppressing minority group stereotypes. Subjects, asked to suppress thinking in a stereotypic way, after a while actually had more stigmatizing thoughts than before Reference MacRae, Bodenhausen, Milne and Jetten [69] . Thus, protest seems to be a useful way to reduce stigmatizing public images of mental illness. It may be less apt to change people's prejudices. As a reactive strategy, it may help to reduce stigmatizing public behavior, but it is likely to be less effective in promoting positive, new attitudes. However, effects of repeated protests on behavior should be further investigated. Furthermore, by reducing stigmatising public behaviour protest improves the quality of life for people with mental illness.

5.2. Education

Education tries to diminish stigma by providing contradictory information. Different forms like books, videos, and structured teaching programmes have been used to convey this kind of information. Brief educational courses on mental illness have proved to reduce stigmatizing attitudes among a wide variety of participants (police officers Reference Pinfold, Toulmin, Thornicroft, Huxley, Farmer and Graham [84] ; industrial workers and government employees Reference Tanaka, Ogawa, Inadomi, Kikuchi and Ohta [100] ; high school students Reference Esters, Cooker and Ittenbach [38] ). However, research on educational campaigns suggests changes of behavior are often not assessed, effect sizes are limited, and programmes are more effective for participants who have a better knowledge of mental illness before the education or had contact with persons with mental illness beforehand. Thus, educational programmes tend to reach those that already agree with the message Reference Devine and Tesser [35] . Since stigmatising behaviors and attitudes are common among mental health care professionals Reference Gray [44] , effective anti-stigma interventions for this group are important, but are, to our knowledge, rarely available so far and have not yet been evaluated.

It is further important to note that the content of education programmes seems to matter. Nowadays neurobiological models of mental illness are predominant in Western psychiatry. Therefore biological causes of schizophrenia, for example, are a main part of the message in educational programmes. The hope underlying this approach is that to view mental illness as a biochemical, mainly inherited problem will reduce shame and blame associated with it. On the other hand, the focus on neurobiology could, in the eyes of the public, turn people with mental illness into 'almost a different species' Reference Mehta and Farina [74] . The sense of separation between 'us' and 'them' could be increased by pointing out a genetic, unchangeable aetiology and the hope for recovery could be reduced. Mehta and Farina Reference Mehta and Farina [74] found describing mental illness in medical instead of psychosocial terms actually led to harsher behavior towards people with mental illness. A recent international study of public beliefs on causality of mental illness had similar results. Among over 7000 subjects interviewed in Germany, Russia and Mongolia, the view of schizophrenia as being of biological origin led to greater desire for social distance from persons with schizophrenia Reference Dietrich, Beck, Bujantugs, Kenzine, Matschinger and Angermeyer [37] . Given these findings and the complexities of interactions between genes and environment, the message of mental illness as being 'genetic' or 'neurological' may not only be overly simplistic but also of little use to reduce stigma Reference Phelan [82] .

5.3. Contact

Contact with persons with mental illness may help to augment the effects of education on reducing stigma. Research has shown that members of the majority who have met minority group members are less likely to stigmatize against members of this minority [6,43] . Hence, contact may be an important strategy to decrease stereotypes and mental health stigma. Research shows that contact both during undergraduate training Reference Kolodziej and Johnson [55] and in an experimental situation Reference Desforges, Lord, Ramsey and Mason [34] reduced stigma and improved positive attitudes. In a number of interventions with secondary school students education and contact have been combined [8,84,94] . Results suggest that contact may be the more efficacious part of the intervention. Particularly interesting in this respect is an Austrian study that compared education without contact with a combination of both education and contact. A positive change of students’ attitudes was observed only when a consumer was involved in the intervention (contact and education Reference Meise, Sulzenbacher, Kemmler, Schmid, Rössler and Guenther [75] ).

There are a number of factors that create an advantageous environment for interpersonal contact and stigma reduction. This includes equal status among participants, a cooperative interaction as well as institutional support for the contact initiative. For example, a school programme will be more successful if its efforts find support from the principal and if it allows for informal discussions between consumer and students instead of a consumer lecturing in front of a silent audience of students. Cooperation during work also offers a good opportunity to achieve equal status of consumers and members of the majority if both participate in the same task.

Also of importance are minority members who mildly disconfirm the stereotype towards this minority. Contact seems to be effective by changing stigmatizing knowledge structures. After contact, a person's natural stereotype of a minority group may be replaced by another, more positive image of that group Reference Rothbart and John [89] . For instance, after working with a person of equal status and with mental illness at one's new job, one may discard stereotypes about this person being dangerous or incompetent. The strength of the effect of change in stereotypes depends on the level of disconfirmation by the contacted minority group member. Contact experiences with persons who do not at all resemble stereotypes about the minority group are unlikely to have a major effect on those stereotypes Reference Kunda and Oleson [56] . For example, contact during work with a woman with mental illness who is also highly attractive and successful in her professional and personal life may not only fail to diminish stigma but even lead to a boomerang effect Reference Kunda and Oleson [57] . The information about this woman may not be used to disconfirm the stereotype about the minority of people with mental illness, but the woman will likely be subtyped as unusual. She may even be reclassified as belonging to 'us' instead of 'them' Reference Gaertner, Mann, Dovidio and Murrell [42] . This kind of subtyping can in fact corroborate stigma according to the saying that the exception proves the rule.

To sum up our overview of different methods to reduce stigma, contact combined with education seems to be the most promising avenue. To end on a more cautious note, though, one has to bear in mind a limitation of every anti-stigma initiative that focuses on a specific behavior of a certain group, e.g. local employers and their not offering jobs to persons with mental illness. On the one hand, prejudices and behavior of one group are an appealing target, because it reduces the complexity of the stigma-phenomenon and focuses on a target that matters Reference Corrigan [16] . On the other hand, the areas of individual discrimination, structural discrimination and self-stigma lead to innumerable mechanisms of stigmatization. If one discriminating mechanism is blocked, a powerful stigmatizing group can always create new ways to discriminate Reference Link and Phelan [63] . If for example persons with mental illness are protected by new work-legislation, employers can find new, informal ways not to employ or to fire them. Therefore, to substantially reduce discriminating behavior, stigma-related attitudes of power groups have to be fundamentally changed.

6. Conclusions

In this review we gave a conceptual overview of stigma, its main components - stereotypes, prejudice and discrimination - , and its consequences, focussing on self-stigma and empowerment and on fear of stigma as a barrier to use health services. We then discussed different avenues to reduce stigma and gave examples of anti-stigma initiatives. Since stigma is a complex phenomenon, much more research is needed on public stigma, self-stigma, the impact of stigma on families of persons with mental illness and on structural discrimination of persons with mental illness, especially inside the health care system. We also lack information on the different effects stigma has on persons with different mental disorders. It is unlikely that people with various disorders face the same stigmatizing attitudes and react to discrimination in the same way. While current anti-stigma initiatives certainly have a good intention, further empirical work is necessary to find out what strategy and content is best to reduce stigmatizing attitudes and behavior in what target group. We also still need to find out whether, in addition to public approaches, psychotherapeutic approaches might support people with mental illness to better cope with stigma until public stigma has been substantially diminished. In this context we also need more information on the relationship between stigma, emotions such as shame, and self-esteem.

Public stigma has a major impact on many people with mental illness, especially if it leads to self-stigma, and may interfere with various aspects of life, including work, housing, health care, social life and self-esteem. In order to support people with mental illness, successful long-term anti-stigma campaigns are necessary to reduce public stigma in society.

Acknowledgements

The authors are grateful to Christoph Nissen and Roland Zahn for their comments on an earlier draft of this paper.

Fig. 1 Model of personal response to mental illness stigma (adapted from [25]).

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• Perspective
• Published: 10 June 2024

An integrated understanding of the mechanisms linking social stigma to mental health among marginalized populations

• David M. Frost   ORCID: orcid.org/0000-0001-9284-5219 1 &
• Diego Castro   ORCID: orcid.org/0009-0005-3908-0006 1  

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This Perspective presents a model that integrates mechanisms that explain the association between stigma and mental health that are shared across multiple stigmatized populations. By distinguishing among mediating, protective and intensifying factors, the model can be used to achieve two broad aims: to understand the similarities and differences in common and/or comparable mechanisms that explain the effect of stigma on mental health; and to understand how mechanisms linking stigma to mental health are experienced by individuals at the intersection of multiple stigmatized statuses. Applications and opportunities for new research within and across a variety of stigmatized populations are discussed in relation to these aims.

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Link, B. G., Phelan, J. C. & Hatzenbuehler, M. L. in The Oxford Handbook of Stigma, Discrimination, and Health (eds. Major, B. et al.) 53–68 (Oxford Univ. Press, 2017); https://doi.org/10.1093/oxfordhb/9780190243470.013.4

Frost, D. M. & Meyer, I. H. Minority stress theory: application, critique, and continued relevance. Curr. Opin. Psychol. 51 , 101579 (2023).

Article   PubMed   PubMed Central   Google Scholar  

Williams, D. R. Stress and the mental health of populations of color: advancing our understanding of race-related stressors. J. Health Soc. Behav. 59 , 466–485 (2018).

Frost, D. M. Social stigma and its consequences for the socially stigmatized. Soc. Personal Psychol. Compass 5 , 824–839 (2011).

Article   Google Scholar  

Major, B., Dovidio, J. F., Link, B. G. & Calabrese, S. K. in The Oxford Handbook of Stigma, Discrimination, and Health (eds. Major, B. et al.) 3–28 (Oxford Univ. Press, 2017); https://doi.org/10.1093/oxfordhb/9780190243470.013.1

Promoting Mental Health: Concepts, Emerging Evidence, Practice: Summary Report (World Health Organization, 2004).

Goffman, E. Stigma: Notes on the Management of Spoiled Identity (Prentice Hall, 1963).

Herek, G. M. in Contemporary Perspectives on Lesbian, Gay, and Bisexual Identities (ed. Hope, D. A.) 65–111 (Springer, 2009); https://doi.org/10.1007/978-0-387-09556-1_4

Link, B. G. & Phelan, J. C. Conceptualizing stigma. Annu. Rev. Sociol. 27 , 363–385 (2001).

Earnshaw, V. A. et al. Integrating time into stigma and health research. Nat. Rev. Psychol. 1 , 236–247 (2022).

Hatzenbuehler, M. L. & Link, B. G. Introduction to the special issue on structural stigma and health. Soc. Sci. Med. 103 , 1–6 (2014).

Article   PubMed   Google Scholar  

Allport, G. W. The Nature of Prejudice (Addison-Wesley, 1954).

Devine, P. G. Stereotypes and prejudice: their automatic and controlled components. J. Pers. Soc. Psychol. 56 , 5–18 (1989).

Major, B. & O’Brien, L. T. The social psychology of stigma. Annu. Rev. Psychol. 56 , 393–421 (2005).

Fiske, S. T. in The Handbook of Social Psychology (eds. Gilbert, D. T. et al.) 357–411 (McGraw-Hill, 1998).

Sue, D. W. Microaggressions in Everyday Life: Race, Gender, and Sexual Orientation (John Wiley & Sons, 2010).

Schwartz, S. & Meyer, I. H. Mental health disparities research: the impact of within and between group analyses on tests of social stress hypotheses. Soc. Sci. Med. 70 , 1111–1118 (2010).

Carter, R. T. et al. A meta-analytic review of racial discrimination: relationships to health and culture. Race Soc. Probl. 11 , 15–32 (2019).

de Lange, J., Baams, L., van Bergen, D. D., Bos, H. M. W. & Bosker, R. J. Minority stress and suicidal ideation and suicide attempts among LGBT adolescents and young adults: a meta-analysis. LGBT Health 9 , 222–237 (2022).

Frost, D. M. Hostile and harmful: structural stigma and minority stress explain increased anxiety among migrants living in the United Kingdom after the Brexit referendum. J. Consult. Clin. Psychol. 88 , 75–81 (2020).

Oh, H., Waldman, K., Koyanagi, A., Anderson, R. & DeVylder, J. Major discriminatory events and suicidal thoughts and behaviors amongst Black Americans: findings from the National Survey of American Life. J. Affect. Disord. 263 , 47–53 (2020).

Vargas, S. M., Huey, S. J. & Miranda, J. A critical review of current evidence on multiple types of discrimination and mental health. Am. J. Orthopsychiatry 90 , 374–390 (2020).

Frost, D. M. et al. Social change and the health of sexual minority individuals: do the effects of minority stress and community connectedness vary by age cohort? Arch. Sex. Behav. 51 , 2299–2316 (2022).

Quinn, D. M., Camacho, G., Pan-Weisz, B. & Williams, M. K. Visible and concealable stigmatized identities and mental health: experiences of racial discrimination and anticipated stigma. Stigma Health 5 , 488–491 (2020).

Gómez, F., Cumsille, P. & Barrientos, J. Mental health and life satisfaction on Chilean gay men and lesbian women: the role of perceived sexual stigma, internalized homophobia, and community connectedness. J. Homosex. 69 , 1777–1799 (2022).

James, D. Self- and group-focused internalized racism, anxiety, and depression symptoms among African American adults: a core self-evaluation mediated pathway. Group Process. Intergroup Relat. 24 , 1335–1354 (2021).

Lee, H. et al. Internalized transphobia and mental health among transgender adults: a nationwide cross-sectional survey in South Korea. Int. J. Transgend. Health 21 , 182–193 (2020).

Roberson, K. & Pieterse, A. L. Internalized racism and self-esteem: do depressive symptoms matter? Cultur. Divers. Ethnic Minor. Psychol. 27 , 531–536 (2021).

Major, B. & Schmader, T. in The Oxford Handbook of Stigma, Discrimination, and Health (eds. Major, B. et al.) 85–104 (Oxford Univ. Press, 2017); https://doi.org/10.1093/oxfordhb/9780190243470.013.3

Hatzenbuehler, M. L., Nolen-Hoeksema, S. & Dovidio, J. How does stigma ‘get under the skin’? Psychol. Sci. 20 , 1282–1289 (2009).

Hatzenbuehler, M. L. How does sexual minority stigma ‘get under the skin’? A psychological mediation framework. Psychol. Bull. 135 , 707–730 (2009).

Burton, C. L., Wang, K. & Pachankis, J. E. Does getting stigma under the skin make it thinner? Emotion regulation as a stress-contingent mediator of stigma and mental health. Clin. Psychol. Sci. 6 , 590–600 (2018).

Kaya, Z. & Oskay, U. Stigma, hopelessness and coping experiences of Turkish women with infertility. J. Reprod. Infant Psychol. 38 , 485–496 (2020).

Brooks, B. D. et al. Anticipated sexual minority stress and mental health after the 2016 presidential election: examining a psychological mediation framework. J. Homosex. https://doi.org/10.1080/00918369.2022.2087481 (2022).

Hollinsaid, N. L., Pachankis, J. E., Bränström, R. & Hatzenbuehler, M. L. Hypervigilance: an understudied mediator of the longitudinal relationship between stigma and internalizing psychopathology among sexual-minority young adults. Clin. Psychol. Sci. https://doi.org/10.1177/21677026231159050 (2023).

Perlson, J., Scholl, J., Mayer, K. H., O’Cleirigh, C. & Batchelder, A. W. To disclose, not disclose, or conceal: a qualitative study of HIV-positive men with multiple concealable stigmatized identities. AIDS Patient Care STDS 35 , 47–55 (2021).

Han, S. et al. Perceived discrimination and mental health symptoms among persons living with HIV in China: the mediating role of social isolation and loneliness. AIDS Care 33 , 575–584 (2021).

Himmelstein, M. S., Puhl, R. M. & Quinn, D. M. Weight stigma and health: the mediating role of coping responses. Health Psychol. 37 , 139–147 (2018).

Ngamake, S. T., Walch, S. E. & Raveepatarakul, J. Discrimination and sexual minority mental health: mediation and moderation effects of coping. Psychol. Sex Orientat. Gend. Divers. 3 , 213–226 (2016).

Chaiton, M. O., Cohen, J. E., O’Loughlin, J. & Rehm, J. A systematic review of longitudinal studies on the association between depression and smoking in adolescents. BMC Public Health 9 , 356 (2009).

Follins, L. D., Garrett-Walker, J. J. & Lewis, M. K. Resilience in Black lesbian, gay, bisexual, and transgender individuals: a critical review of the literature. J. Gay Lesbian Ment. Health 18 , 190–212 (2014).

Kwon, P. Resilience in lesbian, gay, and bisexual individuals. Pers. Soc. Psychol. Rev. 17 , 371–383 (2013).

Meyer, I. H. Identity, stress, and resilience in lesbians, gay men, and bisexuals of color. Couns. Psychol. 38 , 442–454 (2010).

Hutcheon, E. & Lashewicz, B. Theorizing resilience: critiquing and unbounding a marginalizing concept. Disabil. Soc. 29 , 1383–1397 (2014).

Neblett, E. W. Racial, ethnic, and cultural resilience factors in african american youth mental health. Annu. Rev. Clin. Psychol. 19 , 361–379 (2023).

Raeifar, E., Halkett, A., Lohman, M. C. & Sirey, J. A. The relation between mastery, anticipated stigma and depression among older adults in a primary care setting. J. Nerv. Ment. Dis. 205 , 801–804 (2017).

Rueda, S. et al. Mastery moderates the negative effect of stigma on depressive symptoms in people living with HIV. AIDS Behav. 16 , 690–699 (2012).

Miller, C. T. & Kaiser, C. R. A theoretical perspective on coping with stigma. J. Soc. Issues 57 , 73–92 (2001).

McIntosh, R. C. & Rosselli, M. Stress and coping in women living with HIV: a meta-analytic review. AIDS Behav. 16 , 2144–2159 (2012).

Kadianaki, I. The transformative effects of stigma: coping strategies as meaning-making efforts for immigrants living in Greece. J. Community Appl. Soc. Psychol. 24 , 125–138 (2014).

Conn, B. M., de Figueiredo, S., Sherer, S., Mankerian, M. & Iverson, E. ‘Our lives aren’t over’: a strengths‐based perspective on stigma, discrimination, and coping among young parents. J. Adolesc. 66 , 91–100 (2018).

Seawell, A. H., Cutrona, C. E. & Russell, D. W. The effects of general social support and social support for racial discrimination on african american women’s well-being. J. Black Psychol. 40 , 3–26 (2014).

Trujillo, M. A., Perrin, P. B., Sutter, M., Tabaac, A. & Benotsch, E. G. The buffering role of social support on the associations among discrimination, mental health, and suicidality in a transgender sample. Int. J. Transgend. 18 , 39–52 (2017).

Chae, D. H., Lee, S., Lincoln, K. D. & Ihara, E. S. Discrimination, family relationships, and major depression among Asian Americans. J. Immigr. Minor. Health 14 , 361–370 (2012).

Fuller, K. A. & Riggs, D. W. Family support and discrimination and their relationship to psychological distress and resilience amongst transgender people. Int. J. Transgend. 19 , 379–388 (2018).

Reynolds, J. E. & Gonzales-Backen, M. A. Ethnic-racial socialization and the mental health of African Americans: a critical review. J. Fam. Theory Rev. 9 , 182–200 (2017).

Ikram, U. Z. et al. Perceived ethnic discrimination and depressive symptoms: the buffering effects of ethnic identity, religion and ethnic social network. Soc. Psychiatry Psychiatr. Epidemiol. 51 , 679–688 (2016).

Marciano, A. & Antebi-Gruszka, N. Offline and online discrimination and mental distress among lesbian, gay, and bisexual individuals: the moderating effect of LGBTQ facebook use. Media Psychol. 25 , 27–50 (2022).

Chang, C. et al. The mediating role of perceived social support in the relationship between perceived stigma and depression among individuals diagnosed with substance use disorders. J. Psychiatr. Ment. Health Nurs. 29 , 307–316 (2022).

Kalb, N., Brodkin, S., Goldstein, A. L. & Gillis, J. R. We’re in this together: LGBQ social identity buffers the homonegative microaggressions–alcohol relationship. J. LGBT Youth 19 , 379–395 (2022).

Craney, R. S., Watson, L. B., Brownfield, J. & Flores, M. J. Bisexual women’s discriminatory experiences and psychological distress: exploring the roles of coping and LGBTQ community connectedness. Psychol. Sex. Orientat. Gend. Divers. 5 , 324–337 (2018).

Ünsal, B. C., Demetrovics, Z. & Reinhardt, M. Stronger together: community participation, structural stigma, and depression among sexual and gender minority adults in 28 European countries. Soc. Psychiatry Psychiatr. Epidemiol. 58 , 657–669 (2023).

Velez, B. L. & Moradi, B. A moderated mediation test of minority stress. Couns. Psychol. 44 , 1132–1157 (2016).

Watson-Singleton, N. N., Mekawi, Y., Wilkins, K. V. & Jatta, I. F. Racism’s effect on depressive symptoms: examining perseverative cognition and Black Lives Matter activism as moderators. J. Couns. Psychol. 68 , 27–37 (2021).

Hope, E. C., Velez, G., Offidani-Bertrand, C., Keels, M. & Durkee, M. I. Political activism and mental health among Black and Latinx college students. Cultur. Divers. Ethnic Minor. Psychol. 24 , 26–39 (2018).

Frost, D. M., Fine, M., Torre, M. E. & Cabana, A. Minority stress, activism, and health in the context of economic precarity: results from a national participatory action survey of lesbian, gay, bisexual, transgender, queer, and gender non‐conforming youth. Am. J. Community Psychol. 63 , 511–526 (2019).

Major, B., McCoy, S., Kaiser, C. & Quinton, W. Prejudice and self-esteem: a transactional model. Eur. Rev. Soc. Psychol. 14 , 77–104 (2003).

Eliezer, D., Major, B. & Mendes, W. B. The costs of caring: gender identification increases threat following exposure to sexism. J. Exp. Soc. Psychol. 46 , 159–165 (2010).

McCoy, S. K. & Major, B. Group identification moderates emotional responses to perceived prejudice. Pers. Soc. Psychol. Bull. 29 , 1005–1017 (2003).

Chae, D. H., Lincoln, K. D. & Jackson, J. S. Discrimination, attribution, and racial group identification: implications for psychological distress among Black Americans in the National Survey of American Life (2001–2003). Am. J. Orthopsychiatry 81 , 498–506 (2011).

Curll, S. L. & Brown, P. M. Weight stigma and psychological distress: a moderated mediation model of social identification and internalised bias. Body Image 35 , 207–216 (2020).

Quinn, D. M. & Crocker, J. When ideology hurts: effects of belief in the Protestant ethic and feeling overweight on the psychological well-being of women. J. Pers. Soc. Psychol. 77 , 402–414 (1999).

Napier, J. L., Suppes, A. & Bettinsoli, M. L. Denial of gender discrimination is associated with better subjective well‐being among women: a system justification account. Eur. J. Soc. Psychol. 50 , 1191–1209 (2020).

Suppes, A., Napier, J. L. & van der Toorn, J. The palliative effects of system justification on the health and happiness of lesbian, gay, bisexual, and transgender individuals. Pers. Soc. Psychol. Bull. 45 , 372–388 (2019).

Platow, M. J., Byrne, L. & Ryan, M. K. Experimentally manipulated high in-group status can buffer personal self-esteem against discrimination. Eur. J. Soc. Psychol. 35 , 599–608 (2005).

Schmitt, M. T., Branscombe, N. R., Kobrynowicz, D. & Owen, S. Perceiving discrimination against one’s gender group has different implications for well-being in women and men. Pers. Soc. Psychol. Bull. 28 , 197–210 (2002).

Pachankis, J. E. et al. The burden of stigma on health and well-being: a taxonomy of concealment, course, disruptiveness, aesthetics, origin, and peril across 93 stigmas. Pers. Soc. Psychol. Bull. 44 , 451–474 (2018).

Turan, J. M. et al. Challenges and opportunities in examining and addressing intersectional stigma and health. BMC Med. 17 , 7 (2019).

Williamson, T. J., Mahmood, Z., Kuhn, T. P. & Thames, A. D. Differential relationships between social adversity and depressive symptoms by HIV status and racial/ethnic identity. Health Psychol. 36 , 133–142 (2017).

Hatzenbuehler, M. L. in The Oxford Handbook of Stigma, Discrimination, and Health (eds. Major, B. et al.) 105–122 (Oxford Univ. Press, 2017); https://doi.org/10.1093/oxfordhb/9780190243470.013.13

Hatzenbuehler, M. L. Structural stigma: research evidence and implications for psychological science. Am. Psychol. 71 , 742–751 (2016).

Reid, A. E., Dovidio, J. F., Ballester, E. & Johnson, B. T. HIV prevention interventions to reduce sexual risk for African Americans: the influence of community-level stigma and psychological processes. Soc. Sci. Med. 103 , 118–125 (2014).

Stangl, A. L. et al. The Health Stigma and Discrimination Framework: a global, crosscutting framework to inform research, intervention development, and policy on health-related stigmas. BMC Med. 17 , 31 (2019).

Ryan, C., Russell, S. T., Huebner, D., Diaz, R. & Sanchez, J. Family acceptance in adolescence and the health of LGBT young adults. J. Child Adolesc. Psychiatr. Nurs. 23 , 205–213 (2010).

Earnshaw, V. A. et al. Intersectional internalized stigma among Black gay and bisexual men: a longitudinal analysis spanning HIV/sexually transmitted infection diagnosis. J. Health Psychol. 26 , 465–476 (2021).

Balsam, K. F., Molina, Y., Beadnell, B., Simoni, J. & Walters, K. Measuring multiple minority stress: the LGBT people of color microaggressions scale. Cultur. Divers. Ethnic Minor. Psychol. 17 , 163–174 (2011).

Kalichman, S. C., Shkembi, B. & Eaton, L. A. A novel psychometric approach to assessing intersectional HIV stigma: the geometric intersectional stigma scales. J. Behav. Med. 45 , 804–811 (2022).

Bauer, G. R. et al. Intersectionality in quantitative research: a systematic review of its emergence and applications of theory and methods. SSM Popul. Health 14 , 100798 (2021).

Bauer, G. R. & Scheim, A. I. Methods for analytic intercategorical intersectionality in quantitative research: discrimination as a mediator of health inequalities. Soc. Sci. Med. 226 , 236–245 (2019).

Berger, M. & Sarnyai, Z. ‘More than skin deep’: stress neurobiology and mental health consequences of racial discrimination. Stress 18 , 1–10 (2015).

Nolen-Hoeksema, S., Wisco, B. E. & Lyubomirsky, S. Rethinking rumination. Perspect. Psychol. Sci. 3 , 400–424 (2008).

Timmins, L., Rimes, K. A. & Rahman, Q. Minority stressors, rumination, and psychological distress in lesbian, gay, and bisexual individuals. Arch. Sex. Behav. 49 , 661–680 (2020).

Gross, J. J. & Jazaieri, H. Emotion, emotion regulation, and psychopathology. Clin. Psychol. Sci. 2 , 387–401 (2014).

Mata-Greve, F. & Torres, L. Ethnic discrimination, sexism, and depression among Latinx women: the roles of anxiety sensitivity and expressive suppression. J. Latinx Psychol. 8 , 317–331 (2020).

Abramson, L. Y., Metalsky, G. I. & Alloy, L. B. Hopelessness depression: a theory-based subtype of depression. Psychol. Rev. 96 , 358–372 (1989).

Salentine, C. M., Hilt, L. M., Muehlenkamp, J. J. & Ehlinger, P. P. The link between discrimination and worst point suicidal ideation among sexual and gender minority adults. Suicide Life Threat. Behav. 50 , 19–28 (2020).

Mata-Greve, F. & Torres, L. Examining hopelessness as a link between discrimination and depression among Latinx women: a brief report. Stigma Health 8 , 262–265 (2023).

Alang, S., VanHook, C., Judson, J., Ikiroma, A. & Adkins-Jackson, P. B. Police brutality, heightened vigilance, and the mental health of Black adults. Psychol. Violence 12 , 211–220 (2022).

Zavaleta, D., Samuel, K. & Mills, C. Measures of social isolation. Soc. Indic. Res. 131 , 367–391 (2017).

Pachankis, J. E. et al. Structural stigma and sexual minority men’s depression and suicidality: a multilevel examination of mechanisms and mobility across 48 countries. J. Abnorm. Psychol 130 , 713–726 (2021).

Hu, T., Zhang, D. & Wang, J. A meta-analysis of the trait resilience and mental health. Pers. Individ. Dif. 76 , 18–27 (2015).

Dunn, T. L., Gonzalez, C. A., Costa, A. B., Nardi, H. C. & Iantaffi, A. Does the minority stress model generalize to a non-U.S. sample? An examination of minority stress and resilience on depressive symptomatology among sexual minority men in two urban areas of Brazil. Psychol. Sex. Orientat. Gend. Divers. 1 , 117–131 (2014).

Scandurra, C., Amodeo, A. L., Valerio, P., Bochicchio, V. & Frost, D. M. Minority stress, resilience, and mental health: a study of Italian transgender people. J. Soc. Issues 73 , 563–585 (2017).

Folkman, S. & Moskowitz, J. T. Coping: pitfalls and promise. Annu. Rev. Psychol. 55 , 745–774 (2004).

West, L. M., Donovan, R. A. & Roemer, L. Coping with racism: what works and doesn’t work for black women? J. Black Psychol. 36 , 331–349 (2010).

Chaudoir, S. R. et al. Coping with HIV stigma: do proactive coping and spiritual peace buffer the effect of stigma on depression? AIDS Behav. 16 , 2382–2391 (2012).

Pearlin, L. I. & Schooler, C. The structure of coping. J. Health Soc. Behav. 19 , 2 (1978).

Louie, P. & Upenieks, L. Vicarious discrimination, psychosocial resources, and mental health among Black Americans. Soc. Psychol. Q. 85 , 187–209 (2022).

Mosley, A. J. & Branscombe, N. R. Benefit-finding improves well-being among women who have experienced gender discrimination. Sex Roles 84 , 404–417 (2021).

Botha, M., Dibb, B. & Frost, D. M. ‘Autism is me’: an investigation of how autistic individuals make sense of autism and stigma. Disabil. Soc. 37 , 427–453 (2022).

House, J. S., Umberson, D. & Landis, K. R. Structures and processes of social support. Annu. Rev. Sociol 14 , 293–318 (1988).

Molero, F., Silván-Ferrero, P., Fuster-Ruiz de Apodaca, M. J., Nouvilas-Pallejá, E. & Pérez-Garín, D. Subtle and blatant perceived discrimination and well-being in lesbians and gay men in Spain: the role of social support. Psichotema 29 , 475–481 (2017).

Google Scholar  

Frable, D. E. S., Platt, L. & Hoey, S. Concealable stigmas and positive self-perceptions: feeling better around similar others. J. Pers. Soc. Psychol. 74 , 909–922 (1998).

Frost, D. M. & Meyer, I. H. Measuring community connectedness among diverse sexual minority populations. J. Sex. Res. 49 , 36–49 (2012).

García-Cid, A., Gómez-Jacinto, L., Hombrados-Mendieta, I., Millán-Franco, M. & Moscato, G. Discrimination and psychosocial well-being of migrants in Spain: the moderating role of sense of community. Front. Psychol. 11 , 2235 (2020).

Ramirez-Valles, J., Fergus, S., Reisen, C. A., Poppen, P. J. & Zea, M. C. Confronting stigma: community involvement and psychological well-being among HIV-positive Latino gay men. Hisp. J. Behav. Sci. 27 , 101–119 (2005).

van Zomeren, M. & Iyer, A. Introduction to the social and psychological dynamics of collective action. J. Soc. Issues 65 , 645–660 (2009).

Jost, J. T. & Brenda, M. in The Psychology of Legitimacy: Emerging Perspectives on Ideology, Justice, and Intergroup Relations (eds. Jost, J. T. & Major, B.) 3–30 (Cambridge Univ. Press, 2001).

Hansen, N. & Sassenberg, K. Exploring the self-directed anger of the stigmatized. Group Process. Intergroup Relat. 14 , 807–818 (2011).

Jones, E. et al. Social Stigma. The Psychology of Marked Relationships (Freeman, 1984).

Major, B. et al. Perceiving personal discrimination: the role of group status and legitimizing ideology. J. Pers. Soc. Psychol. 82 , 269–282 (2002).

Kerbo, H. R. Social Stratification and Inequality: Class Conflict in Historical and Global Perspective (McGraw-Hill, 2003).

Jiang, S. & Dong, L. The effects of teacher discrimination on depression among migrant adolescents: mediated by school engagement and moderated by poverty status. J. Affect. Disord. 275 , 260–267 (2020).

Goldberg, A. E. & Smith, J. Z. Stigma, social context, and mental health: lesbian and gay couples across the transition to adoptive parenthood. J. Couns. Psychol. 58 , 139–150 (2011).

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Frost, D.M., Castro, D. An integrated understanding of the mechanisms linking social stigma to mental health among marginalized populations. Nat. Mental Health 2 , 645–654 (2024). https://doi.org/10.1038/s44220-024-00264-8

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Stigma and Discrimination Research Toolkit

The Stigma and Discrimination Research toolkit is a collection of evidence and resources related to stigma and discrimination research. Health-related stigma and discrimination research has produced theories, models, frameworks, measures, methods, and interventions that can be applied across conditions and populations to help reduce the impact of stigma and discrimination.

This toolkit may be helpful for researchers, government officials looking to incorporate research into policy, community agencies, and various other stakeholders across disciplines and sectors. This toolkit includes a special emphasis for those looking to address stigma and discrimination issues related to the coronavirus (COVID-19)  pandemic.

This toolkit was developed by NIMH, in partnership with the Fogarty International Center (FIC), the National Institute on Drug Abuse (NIDA), and the NIH Stigma Scientific Interest Group.

Note: These resources are provided for informational purposes only. These are not comprehensive lists and do not constitute an endorsement by NIMH, FIC, NIDA, the National Institutes of Health, the U.S. Department of Health and Human Services, or the U.S. government.

About Stigma

Stigma is a social phenomenon that involves negative attitudes (prejudices) or beliefs (stereotypes) about others typically (but not always) based on defining characteristics such as sexuality or health conditions (e.g., HIV, mental illness, or substance use) that are perceived to be contagious, dangerous, or incurable. It is relational in nature as occurring in the context of power. Goffman defined stigma as “an attribute that is deeply discrediting” that reduces the individual “from a whole and usual person to a tainted, discounted one.” [1]    Stigma and the process of stigmatization consists of identifying and labeling a “difference,” linking a labeled person to undesirable characteristics, and separating “them” from “us”; thus, the stigmatized group (“them”) subsequently experiences discrimination and loss of status in the context of social, economic and political power. For example:

• Health-related stigma happens when people have or are associated with a specific health condition perceived as undesirable. As a result of this stigma, they may avoid seeking screening or treatment or are treated differently or poorly by others because of it.
• Health-related discrimination is discrimination based on a health condition, disease, or another health-related issue. It may occur in the workplace, health care, education, housing, and other settings.

There are multiple types of health-related stigma, including:  

• Internalized stigma: The individual believes they are bad or at fault for having a health condition
• Enacted stigma: The individual experiences discrimination from others because they are known or believed to have a health condition
• Anticipated stigma: The individual expects or fears future discrimination due to the health condition
• Associated stigma: Others, such as family members or healthcare workers, experience discrimination because of their proximity to those with a health condition.
• Perceived stigma: An individual’s perceptions about how stigmatized groups are treated due to a health condition.

Stigma exists at multiple levels:

• Individual level: A person’s cognitive, affective, and behavioral responses to facing or experiencing stigma, including concealment and disclosure, internalization, and stigma consciousness
• Interpersonal level: Discrimination as expressed by one person toward another, manifesting in ways such as lack of respect, devaluation, and dehumanization
• Structural level: Societal-level conditions, cultural norms, and institutional policies that constrain the opportunities, resources, and well-being of the stigmatized [ 2   ]

Stigma’s Impact on Health

Research shows that health-related stigma for any condition is not just a social problem. It can have detrimental impacts on how health care is sought, accessed, and delivered, and slow scientific progress. Stigma is also associated with poor health outcomes and reduced service utilization. For example, stigma related to conditions like HIV, tuberculosis, epilepsy, and substance use, increases the likelihood that the individual will develop a related mental disorder like depression or anxiety. In addition, research shows that stigma reduces quality of life and makes individuals less likely to seek out needed care.

Language and Stigma

The language we use to talk about health plays a crucial role in shaping opinions and beliefs about a disease or condition, and the people affected. Scientific and medical terminology typically used by the research community may inadvertently create or perpetuate stereotypes about diseases or drive fear and “othering.”

Proactively using language that empowers individuals and communities, and takes patient experience into account, can help individuals communicate about health in a non-stigmatizing way. The below language guides offer examples.

• National Institute of Allergy and Infectious Diseases (NIAID) HIV Language Guide   : When scientists and administrators write or speak about HIV, the words they choose have the power to passively perpetuate ignorance and bias. Conversely, they have the power to represent people and ideas respectfully and accurately. This guide was designed to help those at NIAID communicate about their work using empowering rather than stigmatizing language, especially as it relates to HIV. This guide includes information on conditions and populations related to and affected by HIV, including tuberculosis, disability, older adults, and race, ethnic, and cultural identities.
• National Institute on Drug Abuse (NIDA) Preferred Language for Talking About Addiction   : Addiction is a chronic but treatable health condition. Often unintentionally, many people still talk about addiction in ways that are stigmatizing—meaning they use words that can portray someone with a substance use disorder (SUD) in a shameful or negative way that may prevent individuals from seeking treatment for SUDs. With simple changes in language, stigma and negativity around SUDs can be reduced or avoided. This resource discusses what stigma is, how it affects people with SUD, and how to change language usage.

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A qualitative study: experiences of stigma by people with mental health problems

Affiliations.

• 1 Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, UK.
• 2 Stockport and District Mind, UK.
• 3 Department of Psychology, Social Work and Counselling, University of Greenwich, London, UK.
• PMID: 29345416
• DOI: 10.1111/papt.12167

Objectives: Prior research has examined various components involved in the impact of public and internalized stigma on people with mental health problems. However, studies have not previously investigated the subjective experiences of mental health stigma by those affected in a non-statutory treatment-seeking population.

Design: An in-depth qualitative study was conducted using thematic analysis to investigate the experiences of stigma in people with mental health problems.

Methods: Eligible participants were recruited through a local mental health charity in the North West of England. The topic of stigma was examined using two focus groups of thirteen people with experience of mental health problems and stigma.

Results: Two main themes and five subthemes were identified. Participants believed that (1) the 'hierarchy of labels' has a profound cyclical impact on several levels of society: people who experience mental health problems, their friends and family, and institutional stigma. Furthermore, participants suggested (2) ways in which they have developed psychological resilience towards mental health stigma.

Conclusions: It is essential to utilize the views and experiences gained in this study to aid understanding and, therefore, develop ways to reduce the negative impact of public and internal stigma.

Practitioner points: People referred to their mental health diagnosis as a label and associated that label with stigmatizing views. Promote awareness and develop improved strategies (e.g., training) to tackle the cyclical impact of the 'hierarchy of labels' on people with mental health problems, their friends and family, and institutional stigma. Ensure the implementation of clinical guidelines in providing peer support to help people to combat feeling stigmatized. Talking about mental health in psychological therapy or health care professional training helped people to take control and develop psychological resilience.

Keywords: charity; community; institutional stigma; internalised stigma; labels; mental health; non-statutory; public stigma; qualitative; resilience.

© 2018 The British Psychological Society.

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Fighting stigma by mental health providers toward patients

Using person-first, nonstigmatizing language is crucial to overcoming biases and providing better treatment

Vol. 55 No. 5 Print version: page 32

• Psychotherapy
• Racism, Bias, and Discrimination

Throughout her undergraduate and graduate training in psychology, Maya Nauphal was surprised that her professors and colleagues sometimes perpetuated unhelpful stereotypes about people with mental illness. In an introductory course on psychopathology, for example, she remembers a professor “showing pictures of [police] mug shots as an example of what happens to folks who use drugs,” said Nauphal, now an intern at Montefiore Medical Center in the Bronx.

“People in our field sometimes use judgmental language when talking about patients,” Nauphal added. “We don’t always notice that we’re doing it, but it has a big impact on the way we think about and interact with our patients.”

While stigma by mental health providers toward mental health patients remains understudied, the existing research suggests it is common. Psychologists, other mental health professionals, and health care workers in general all exhibit this kind of discrimination. A review by sociologist Stephanie Knaak, PhD, of the University of Calgary, and colleagues, for instance, cites several studies showing that people with lived experience of mental illness commonly report feeling “devalued, dismissed, and dehumanized” by many providers they encounter ( Healthcare Management Forum , Vol. 30, No. 2, 2017 ). Similarly, a Swedish study found that both mental health staff and patients held negative attitudes about patients, particularly when it came to accepting a patient’s work applications, dating a person who had been hospitalized, or hiring a patient to take care of children ( Hansson, L., et al., International Journal of Social Psychiatry , Vol. 59, No. 1, 2011 ).

Knack’s review also found that a number of factors appear to underlie such stigma. These include societal stereotypes about mental illness that can lead to negative and sometimes unconscious attitudes and behaviors; therapeutic pessimism—the idea that people with mental illness cannot get better; and stigma in the workplace culture, which can lead people with lived experience of mental health difficulties to remain silent. In addition, inexperienced providers may be more prone to stigmatizing patients than others, said John F. Kelly, PhD, ABPP, a professor of psychiatry at Harvard Medical School who treats people with substance use disorders and studies ways to reduce stigma related to this population.

“We all have implicit biases that we suffer from—stereotypes and prejudices toward those who are different from us,” he said. “Those tendencies can be amplified in clinicians, particularly when they don’t have much experience with certain types of disorders.”

Why it happens

In some respects this phenomenon is understandable: Providing good mental health care can be challenging, and dealing with difficult patient symptoms and high levels of need can fuel provider stress. That stress is compounded when psychologists work in settings with high caseloads and low institutional support. To underscore the point, APA’s 2023  Practitioner Pulse Survey  found that during and since the COVID-19 pandemic, many psychologists said that patients are entering treatment with more severe symptoms and staying longer, and 36% of those surveyed said they felt burned out as a result.

But holding these negative views, whether overtly or covertly, is not good for patients, providers, families, or the public. Studies show that patients pick up on provider stigma and it can lead to feelings of marginalization, treatment dropout, and failure to enter treatment in the first place. In a survey of 350 mental health service users, those who felt that providers held negative attitudes toward them were more likely than others to feel disempowered, a perception linked to internalized stigma ( Wang, K., et al.,  Psychiatry Research , Vol. 259, 2018 ). Meanwhile, a literature review headed by Claire Henderson, PhD, of King’s College London points to specific provider behaviors that patients perceive as barriers to recovery. These include being overly controlling about the kinds of treatment patients receive, having low expectations for treatment success, and displaying “protective benevolence”—treating patients like children, for example by withholding important treatment information because the provider thinks it may hurt their feelings. Conversely, providers who are seen as understanding, dependable, reliable, open, and honest help facilitate recovery, according to patient reports ( The Lancet Psychiatry , Vol. 1, No. 6, 2014 ).

Perhaps not surprisingly, mental health providers stigmatize some disorders more than others, research also finds. Conditions with the highest associated bias include schizophrenia ( Valery, K.-M., & Prouteau, A.,  Psychiatry Research , Vol. 290, 2020 ), borderline personality disorder ( Knaak, S., et al.,  Borderline Personality Disorder and Emotion Dysregulation , Vol. 2, No. 9, 2015 ), and substance use disorders ( Earnshaw, V.,  American Psychologist , Vol. 75, No. 9, 2020 ). This bias often appears in the language used to describe people with these conditions, Nauphal commented.

“Calling someone with borderline personality disorder ‘manipulative’ or ‘attention seeking,’ or using terms like ‘an addict’ or ‘a schizophrenic,’ are all ways we use dehumanizing language that also makes assumptions about people’s character and motives,” she said.

Tackling the problem

There are many ways psychologists can help reduce patient-related stigma, whether internally, within their professional settings, or in the community at large, according to psychologists who study these forms of stigma. Here are some suggestions:

Take a personal inventory

Improving your awareness of the problem is a good start, these psychologists said. Consider your own internalized and sometimes unconscious biases about mental illness, how the need to fit in with your colleagues may lead you to talk in certain ways about patients, and most importantly, how stigma affects patients. For some, there may also be the lurking issue of self-stigma: If you have a lived experience of mental illness yourself, it can be difficult to bring it up for social and professional reasons, which in turn can affect your mental health and that of your patients (see  June 2024  Monitor ). In fact, many of us struggle with emotional and psychological issues, and it is unhelpful to treat patients as if they are the only ones who experience such difficulties, said Andrew Devendorf, a graduate student at the University of South Florida who is doing his internship at the Veterans Affairs Puget Sound Health Care System in Seattle.

“Instead of having the attitude that, ‘I’m a psychologist; therefore, I don’t experience these things,’ I think we should share with patients that we’re human beings who also experience these things, and we know it can be difficult,” said Devendorf, who studies mental health stigma within the profession. “Patients are better able to identify with that kind of attitude than with the traditional power dynamic that’s gone on.”

A potent way to combat stigma on an individual level is simply to change the way you talk about patients with colleagues and otherwise, Kelly added. In a randomized study he led, the team found that in vignettes where a person was labeled a “substance abuser,” participants viewed that person as a greater social threat, more likely to act out in negative ways, and more deserving of punishment than a person labeled as “having a substance use disorder” ( International Journal of Drug Policy , Vol. 21, No. 3, 2010 ). In general, Kelly recommended using person-first, nonstigmatizing language such as “a person with a substance use disorder” rather than “a substance abuser,” as well as language that describes a person’s behavior rather than their overall character.

“There is something about language that can evoke these implicit biases towards individuals,” he said, “so it’s important to be careful about how we talk about our patients.”

Learn new care methods

If you have not done so already, consider getting training in care models that are person centered, strength based, and recovery oriented. Such approaches—which help patients set and pursue their own goals and work collaboratively with providers to develop skills to live, learn, and work in the community—view patients as autonomous human beings rather than as illnesses to be treated. That is to say not that medical approaches should be eliminated, but that the two can complement one another (see, for example,  Duckworth, K.,  National Alliance on Mental Illness Blog , Apr. 10, 2015 ).

This newer philosophy also recognizes that while recovery is a journey that is not always linear, it is possible for people with mental illness to gain greater health and even recover entirely, said Patrick Corrigan, PsyD, Distinguished Professor of Psychology at the Illinois Institute of Technology in Chicago and a seminal researcher on stigma. “Everything is not automatically a failure, a downhill course, and gloom and doom,” as he put it. Indeed, research is starting to show that these approaches can promote optimism, empowerment, and recovery ( Warner, R.,  The Psychiatrist , Vol. 34, No. 1, 2010 ).

Getting trained in relevant skills can also help reduce stigma by increasing provider confidence, comfort, and understanding of specific conditions, research finds ( Knaak, S., et al.,  Canadian Journal of Psychiatry , Vol. 59, No. 1, 2014 ). In addition, “understanding the true nature of a particular condition can help to increase compassion,” Kelly noted.

Educate others

Another way to make a positive difference is to train and educate others, said Cassie Boness, PhD, a research assistant professor at the University of New Mexico who studies stigma related to substance use disorders.

For example, she serves as medical codirector of an online tele-mentoring program called Project ECHO (Extension for Community Healthcare Outcomes), where she talks with psychologists, physicians, and other health care providers about the latest research and best practices for working with people who use substances as well as how to avoid stigmatizing them.

In those discussions, she debunks the prevalent myth that people with substance use disorder rarely recover and that true recovery can only occur with complete abstinence. “Actually, a lot of research tells us that people do get better and achieve recovery, and that most people achieve recovery without formal treatment,” she tells participants. She also suggests how providers might apply these findings to their clinical work: If they are aware that recovery is possible and take a more optimistic approach to treatment, patients will feel it and have more hope themselves. In turn, these attitudes can help support treatment success and lead to less provider burnout, she said.

In a similar vein, Stephen P. Lewis, PhD, a professor of psychology at the University of Guelph in Ontario, Canada, employs various outreach activities related to non-suicidal self-injury (NSSI), his area of study. These include TED Talks where he shares his own lived experience with self-injury, depression, and trauma. 

“I really try and break down some of the barriers and challenge canonical discourses around NSSI and what people think about when this topic comes up,” Lewis said. 

Psychologists can also get involved in anti-stigma advocacy activities—a potent way to tackle the problem, Nauphal said. Within the field, that may include developing and disseminating stigma-specific trainings, uplifting the voices of psychologists with lived experience of mental illness, and committing to a lifelong practice of becoming aware of and unlearning internalized biases, for example. In the policy arena, it may involve advocating for system-level changes aimed at addressing the sources of bias.

“A lot of mental health problems are not individual problems; they’re system-level problems,” she said. “We can’t understand and treat mental health if we don’t also work to dismantle systems that perpetuate mental health difficulties.”

Design and test interventions

In a general sense, research finds that anti-stigma interventions that incorporate education, involve interactions with people who have lived experience with mental illness, and take a long-term approach to intervention have the greatest chances of success ( Carrara, B. S., et al.,  International Journal of Social Psychiatry , Vol. 67, No. 7, 2021 ).

Psychologists, thanks to their expertise in research design, are in a prime position to craft such efforts, Kelly said. “When you educate people about the nature of a condition, when you teach them to talk and think about it differently, and when you expose them to individuals who have the disorder, it starts to improve patient engagement and retention,” he said.

An example is a project underway at the University of Bordeaux in France, where psychologists Kévin-Marc Valery, PhD, and Antoinette Prouteau, PhD, are developing an anti-stigma intervention for mental health providers, part of a larger research program called STIGMApro.

To design the project, the team convened a committee of mental health professionals, patients, relatives, public funders, field experts, and researchers in psychology and public health, who developed a range of studies to identify practices associated with reduced stigma toward patients in mental health workplaces. Those practices included using recovery-oriented principles, implementing institutional cultures that highlighted the similarities between professionals and patients, and supporting group-designed projects involving professionals, patients, and families ( International Journal of Psychiatry in Clinical Practice , Vol. 27, No. 2, 2023 ). The committee then incorporated those elements into the intervention, which included 6 sessions attended by 8 to 12 mental health professionals along with professional peer helpers, patients, and family members. It is now being tested in a multisite randomized controlled trial comparing the intervention with stigma training as usual.

Full patient participation was an essential part of the effort, Valery underscored.

“Stigmatizing practices have harmful consequences for patients, including worsening of symptoms, lower self-esteem, less hope, poorer functioning, and less adherence to care,” he said. “None of us entered the field to do that. So it is vitally important that we combat this tendency in the service of our patients’ mental health and well-being.”

Further reading

From the medical model to the recovery model: Psychologists engaging in advocacy and social justice action agendas in public mental health Carr, E. R., et al., American Journal of Orthopsychiatry , 2023

Developing effective anti-stigma interventions Ponte, K., National Alliance on Mental Illness Blog , Apr. 15, 2022

Mental illness stigma as a quality-of-care problem Knaak, S., et al., The Lancet Psychiatry , 2015

A US national randomized study to guide how best to reduce stigma when describing drug-related impairment in practice and policy Kelly, J. F., et al., Addiction , 2021

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Related and recent.

• Stigma, Prejudice and Discrimination Against People with Mental Illness

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More than half of people with mental illness don't receive help for their disorders. Often, people avoid or delay seeking treatment due to concerns about being treated differently or fears of losing their jobs and livelihood. That's because stigma, prejudice and discrimination against people with mental illness are still very much a problem.

Stigma, prejudice and discrimination against people with mental illness can be subtle or obvious—but no matter the magnitude, they can lead to harm. People with mental illness are marginalized and discriminated against in various ways, but understanding what that looks like and how to address and eradicate it can help.

The Facts on Stigma, Prejudice and Discrimination

Stigma often comes from lack of understanding or fear. Inaccurate or misleading media representations of mental illness contribute to both those factors. A review of studies on stigma shows that while the public may accept the medical or genetic nature of a mental health disorder and the need for treatment, many people still have a negative view of those with mental illness.

Researchers identify different types of stigma: (See chart below.)

• Public stigma involves the negative or discriminatory attitudes that others may have about mental illness.
• Self-stigma refers to the negative attitudes, including internalized shame, that people with mental illness may have about their own condition.
• Structural stigma  is more systemic, involving policies of government and private organizations that intentionally or unintentionally limit opportunities for people with mental illness. Examples include lower funding for mental illness research or fewer mental health services relative to other health care.

Stigma not only directly affects individuals with mental illness but also the loved ones who support them, often including their family members.

Stigma around mental illness especially an issue in some diverse racial and ethnic communities and it can be a major barrier to people from those cultures accessing mental health services. For example, in some Asian cultures, seeking professional help for mental illness may be counter to cultural values of strong family, emotional restraint and avoiding shame. Among some groups, including the African American community's, distrust of the mental healthcare system can also be a barrier to seeking help. (See more on mental health in Diverse Populations .)

Types of Stigma

Source: Adapted from Corrigan, et al., 2014.

Media representations of people with mental illness can influence perceptions and stigma, and they have often been negative, inaccurate or violent representations. A study published by Scarf, et. al. in 2020 looked at a recent example, the popular film Joker (2019), which portrays the lead character as a person with mental illness who becomes extremely violent. The study found that viewing the film "was associated with higher levels of prejudice toward those with mental illness." Additionally, the authors suggest, " Joker may exacerbate self-stigma for those with a mental illness, leading to delays in help seeking."

The stigma of mental illness is universal. A 2016 report on stigma concluded "there is no country, society or culture where people with mental illness have the same societal value as people without mental illness."

Harmful Effects of Stigma and Discrimination

Stigma and discrimination can contribute to worsening symptoms and reduced likelihood of getting treatment. A recent extensive review of research found that self-stigma leads to negative effects on recovery among people diagnosed with severe mental illnesses. Effects can include:

• reduced hope
• lower self-esteem
• increased psychiatric symptoms
• difficulties with social relationships
• reduced likelihood of staying with treatment
• more difficulties at work

A 2017 study by Oexle et al  involving more than 200 individuals with mental illness over a period of two years found that greater self-stigma was associated with poorer recovery from mental illness after one and two years.

An editorial in the Lancet notes that the impacts of stigma are pervasive, affecting political enthusiasm, charitable fundraising and availability, support for local services and underfunding of research for mental health relative to other health conditions.

Some of the other harmful effects of stigma can include:

• Reluctance to seek help or treatment and reduced likelihood of staying with treatment.
• Social isolation.
• Lack of understanding by family, friends, coworkers, or others.
• Fewer opportunities for work, school or social activities or trouble finding housing.
• Bullying, physical violence or harassment.
• Health insurance that doesn't adequately cover your mental illness treatment.
• The belief that you'll never succeed at certain challenges or that you can't improve your situation.

Source: Adapted from Mayo Clinic 2017

Stigma Can Also Impact Family and Friends

Family members and friends, who often provide essential help and support for people with mental illness, can also experience stigma. They may internalize stigma and blame themselves, or they may fear that people will blame them for causing a loved one’s illness or reject the family socially. This stigma can lead to reduced emotional support, social isolation, and reluctance to seek care for their relative. (Yanos, 2023; Mclean, 2023)

Stigma in Diverse Communities

Stigma around mental illness is especially an issue in some diverse racial and ethnic communities, and it can be a major barrier to people from those cultures accessing mental health services. For more information, please see Mental Health Disparities: Diverse Populations.

Stigma in the Workplace

A 2022 national poll from the American Psychiatric Association (APA) found that mental health stigma is still a major challenge in the workplace. About half (48%) of workers say they can discuss mental health openly and honestly with their supervisor, down from 56% in 2021 and 62% in 2020. Half (52%) also say they feel comfortable using mental health services with their current employer, compared to 64% in 2021 and 67% in 2020. In a more positive trend, fewer adults are worried about retaliation if they take time off or seek care for their mental health. About one in three (36%) worried about retaliation if they took time off, compared to 48% in 2021 and 52% in 2020. Less than one-third (31%) were worried about retaliation for seeking care, compared to 43% in 2021 and 2020. (APA, 2022)

Reducing Stigma

Public health approaches.

Many years of research on anti-stigma interventions has found that successful interventions (Yanos, 2023):

• Include contact (in person, but video can also be a feature if done right).
• Focus on a range of disorders, not just depression or mental illness broadly.
• Involve participation of people with “lived experience.”
• Target groups that have the most interaction or where lack of help-seeking is most problematic (e.g., young people, undocumented communities, military communities).
• Are tailored to be credible to specific language and cultural signifiers of the target group.
• Last several years in order to be effective.

Substantial research shows that knowing or having contact with someone with mental illness is one of the best ways to reduce stigma. Individuals speaking out and sharing their stories can have a positive impact. When we know someone with mental illness, it becomes less scary and more real and relatable.

Teens are searching for health information online and mental health issues are among the top searches, according to a national survey from Hope Lab (Hope Lab, 2021). About four in 10 teens said they have looked for people with similar health concerns. Many celebrities, such as Demi Lovato, Dwayne "The Rock" Johnson, Michael Phelps, Taraji P. Henson and Lady Gaga have publicly shared their stories of mental health challenges and brought the discussion much more into the general media and everyday conversation. Young people are looking for information and for these personal stories online.

Recent studies have also shown the effectiveness of brief videos in reducing stigma. One study tracked more than 700 students across two years in a randomized controlled trial and found that watching videos of people sharing their personal experiences and videos with information on mental health improved students' mental health care access (da Conceição, et al 2023). The researchers found that the intervention was particularly effective for those in need, enabling them to recognize their need for care and behave accordingly. Another study found that a video featuring an actor sharing a story was as effective as a person with lived experience. (Amsalem, et al 2023).

Social marketing campaigns can also be effective. For example, a research study looked at the effectiveness of an anti-stigma social marketing campaign in California and found that the campaign increased service use by helping people better understand symptoms of distress and increasing awareness that help is available. (Collins, et al 2019). The researchers suggest that widespread exposure to the mental health campaign could significantly increase access to treatment.

Individual Actions to Reduce Stigma

The National Alliance on Mental Illness (NAMI) offers some suggestions about what we can do as individuals to help reduce the stigma of mental illness:

• Talk openly about mental health, such as sharing on social media.
• Educate yourself and others – respond to misperceptions or negative comments by sharing facts and experiences.
• Be conscious of language – remind people that words matter.
• Encourage equality between physical and mental illness – draw comparisons to how they would treat someone with cancer or diabetes.
• Show compassion for those with mental illness.
• Be honest about treatment – normalize mental health treatment, just like other health care treatment.
• Let the media know when they are using stigmatizing language presenting stories of mental illness in a stigmatizing way.
• Choose empowerment over shame – "I fight stigma by choosing to live an empowered life. To me, that means owning my life and my story and refusing to allow others to dictate how I view myself or how I feel about myself." – Val Fletcher.

Employers who are leading efforts to address stigma offer some suggestions (CWMH):

• Tailor programs/approaches to your company culture and existing strengths.
• Mention your commitment to leading a behaviorally healthy workplace every time you mention the company's commitment to its overall culture of health, attracting and retaining the best talent, and valuing its employees, etc.
• Train leaders to identify emotional distress and make referrals and to responding promptly and constructively to behavioral performance issues.
• Be welcoming of the need for accommodations. Train managers to respond appropriately

Organizations and Campaigns

Across the country numerous organizations and campaigns focus on addressing the issue of mental health stigma and discrimination. A few examples are highlighted below:

How So We Stop Stigma? Conversation

Try these simple tips for talking.

• "Thanks for opening up to me."
• "Is there anything I can do to help?"
• "I'm sorry to hear that. It must be tough."
• "I'm here for you when you need me."
• "I can't imagine what you're going through."
• "People do get better."
• "Oh man, that sucks."
• "Can I drive you to an appointment?"
• "How are you feeling today?"
• "I love you."

Don't Say

• "It could be worse."
• "Just deal with it."
• "Snap out of it."
• "Everyone feels that way sometimes."
• "You may have brought this on yourself."
• "We've all been there."
• "You've got to pull yourself together."
• "Maybe try thinking happier thoughts."

Source: MakeItOK.org

  References

• Amsalem, D. et al. 2023. Stigma Reduction Via Brief Video Interventions: Comparing Presentations by an Actor Versus a Person With Lived Experience. Psychiatric Services. https://doi.org/10.1176/appi.ps.20230215
• APA News Release: Employees Say Workplaces Are Offering Fewer Mental Health Services in 2022, According to APA Poll. May 22, 2022.
• Barnett, D. 2023. ‘Tis the Season: Opportune Time to Help Reduce Stigma of Substance Use Disorders Psychiatric News. Nov. 27, 2023. https://doi.org/10.1176/appi.pn.2023.12.12.35
• Center for Workplace Mental Health. Working Well Toolkit . 2016.
• Collins, R.L., et al. Social Marketing of Mental Health Treatment: California's Mental Illness Stigma Reduction Campaign . Am J Public Health . 2019 June; 109(Suppl 3): S228–S235.
• Corrigan, Pw, Druss, BG, Perlick, DA. The Impact of Mental Illness Stigma on Seeking and Participating in Mental Health Care . Psychological Science in The Public Interest . 2014, 15(2);37-70.
• da Conceição, V., Mesquita, E., & Gusmão, R. (2023). Effects of a stigma reduction intervention on help-seeking behaviors in university students: A 2019-2021 randomized controlled trial . Psychiatry research, 331, 115673. Advance online publication. https://doi.org/10.1016/j.psychres.2023.115673
• Forde, K. 2020. By Sharing Their Own Struggles, Celebs Help Teens Tear Down Mental Health Stigma .
• Greenstein, L. 9 Ways To Fight Mental Health Stigma . NAMI blog, Oct. 11, 2017.
• Hope Lab, Common Sense, and California HealthCare Foundation. 2021. Coping With Covid-19: How Young People Use Digital Media To Manage Their Mental Health.
• Mayo Clinic. Mental health: Overcoming the stigma of mental illness . 2017.
• McLean/Mass General Brigham, 2023. Let’s Face It, No One Wants To Talk About Mental Health
• Oexle N, Müller M, Kawohl W, et al. Self-stigma as a barrier to recovery: a longitudinal study . European Archives of Psychiatry and Clinical Neuroscience . October 2017. doi: 10.1007/s00406-017-0773-2.
• Pescosolido, BA. The public stigma of mental illness: what do we think; what do we know; what can we prove? J Health Soc Behav . 2013 Mar;54(1):1-21. doi: 10.1177/0022146512471197.
• Scarf, D., et al. Association of Viewing the Films Joker or Terminator: Dark Fate With Prejudice Toward Individuals With Mental Illness . JAMA Network Open . April 24, 2020.
• Yanos, P., Amsalem, D., Dixon, L. 2023. Brief video interventions to reduce self-, public, and affiliate stigma among/toward young individuals with psychosis. Presentation at APA 2023 Mental Health Services Conference

Physician Review

Nikhita Singhal, M.D. University of Toronto, Psychiatry Resident

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Mental Health Stigma

Reviewed by Psychology Today Staff

Mental health stigma refers to negative beliefs people may hold about those with mental illness, which can lead to stereotypes, prejudice, and discrimination . Public awareness and literacy have increased substantially over the years, yet some entrenched stigmas persist today.

• What Does Mental Health Stigma Mean?
• How to Combat Mental Health Stigma

Mental health stigma involves marking and discrediting people due to their differences, which can instill feelings of shame or worthlessness. Those with mental health conditions may be labeled, stereotyped, or discriminated against as a result. For example, someone with a mental health condition may be called “crazy” or “dangerous”. Another may be denied a job due to their diagnosis.

Different models of stigma propose different structures for the construct. One views stigma as a combination of three components: cognitive (ignorant beliefs), emotional (negative feelings of dislike or fear ), and behavior (ostracization and oppression). Another defines stigma by the process through which it arises. This involves distinguishing and labeling differences, linking labels to negative stereotypes, placing labeled people in distinct categories, decreasing their status, and limiting access to social, economic, and political power, which perpetuates rejection and discrimination .

Mental health stigma has been categorized into three types. Public stigma refers to the negative attitudes society has toward people with mental illness. Self-stigma or internalized stigma is when an individual with mental illness internalizes these negative attitudes. Institutional stigma is systemic and includes laws or policies from the government or other organizations that, intentionally or not, discriminate against those with mental illness. An example of institutional stigma is the insurance coverage disparities between psychiatric treatment and medical treatment.

Personally accepting and agreeing with stereotypes and prejudices held against oneself is called internalized stigma or self-stigma. Some believe that it results in part from the stress of experiencing stigma. Internalized stigma is linked to emotional distress, feelings of low self-worth, and loss of self-efficacy . There can be practical ramifications as well; for example, internalized stigma may stop someone from applying for a job because they don’t believe they are capable.

What people stigmatize varies from culture to culture; culture informs how people perceive and explain differences. America tends to value individualism and independence, which some argue perpetuates stigma by placing responsibility or “blame” solely on the individual. People in many other parts of the world don’t blame individuals for their differences or their struggles. They may blame God, the family, a malevolent spirit, karma, or the stress of war, poverty, and other sociopolitical forces. 

Stigma forces people to not only struggle with their disorder but to cope with prejudice and rejection. This can lead people to develop feelings of self-blame and low self-esteem, and prevent them from seeking treatment or social and professional opportunities. A systematic review demonstrates these repercussions, finding that mental health stigma negatively affects employment, income, and public views about resource allocation and healthcare costs. 

People with mental disorders have been blamed, vilified, and ostracized throughout human history. While attitudes about mental illness, and treatment for those conditions, have improved dramatically over the last century, stigma has not disappeared. Yet individuals, organizations, and societies are continuing to address mental health stigma and its consequences.

The evolution of stigma over time is complex. Today there is greater awareness, information, and literacy than in years prior. Yet that doesn’t always translate into attitudes and beliefs. For example, a recent study that assessed trends in the stigma of mental illness in the U.S. between 1996 and 2018 found a substantial decrease in stigma for major depression but not for schizophrenia or alcohol dependence. The study also reported a substantial increase in acceptance of biomedical causes of mental illness, but that acceptance didn’t lead to less social rejection. While there has been progress, it’s far from uniform or all-encompassing.

Research suggests that awareness and literacy, though important, are not always effective at reducing stigma. One experience that does seem to reduce stigma is interacting with people with mental health conditions. Proximity to and relationships with people with mental illness, and being open about those relationships with others, can shift attitudes. In the absence of live interactions, depictions in television and movies can be helpful substitutes. Similarly, celebrity disclosures can be beneficial as well. 

There are several actions individuals can take to fight stigma in their lives and their communities. They can educate themselves by reading about mental health, stereotypes, and myths. They can research the factors that contribute to stigma such as culture, stress, and poverty. They can explore any self-stigma and if so practice self-compassion and empowerment. And they can help others by volunteering or advocating on behalf of those with mental health conditions. 

People with mental health conditions can respond to stigma by continuing to seek treatment, even when it feels difficult. They can join a support group, share their story, and reframe experiences of stigma. Speaking to a mental health professional can also help people process painful experiences, develop coping skills, and build resilience . 

Yes. A systematic review found that self-stigma interventions are generally effective in reducing internalized stigma, and they take the form of group-based programs that involve psychoeducation, cognitive behavioral theory, and disclosure-focused exercises. Two examples of treatments that target internalized stigma are narrative enhancement and cognitive therapy and coming out proud. 

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At any moment, someone’s aggravating behavior or our own bad luck can set us off on an emotional spiral that could derail our entire day. Here’s how we can face triggers with less reactivity and get on with our lives.

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• Published: 05 October 2018

A qualitative study on the stigma experienced by people with mental health problems and epilepsy in the Philippines

• Chika Tanaka   ORCID: orcid.org/0000-0002-6288-5532 1 ,
• Maria Teresa Reyes Tuliao 2 ,
• Eizaburo Tanaka 3 ,
• Tadashi Yamashita 4 &
• Hiroya Matsuo 1  

BMC Psychiatry volume  18 , Article number:  325 ( 2018 ) Cite this article

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Stigma towards people with mental health problems (PMHP) is known to have substantial negative impacts on their lives. More in-depth exploration of the stigma and discrimination experienced by PMHP in low- and middle-income countries is needed. Previous research suggests that negative attitudes towards PMHP are widespread among the Filipino general public. However, no study has investigated PMHP’s own experiences of being stigmatised in the Philippines.

A qualitative study was conducted on the stigma experienced by PMHP (including people with epilepsy) and its related factors in the Philippines, employing the constructivist grounded theory approach. We analysed data on 39 PMHP collected through interviews with PMHP, their carers, and community health volunteers who know them well.

The findings highlight the culturally and socio-economically specific contexts, consequences, and impact modifiers of experiences of stigma. Participants emphasised that PMHP face stigma because of the cultural traits such as the perception of mental health problem as a disease of the family and the tendency to be overly optimistic about the severity of the mental health problem and its impact on their life. Further, stigma was experienced under conditions where mental health care was not readily available and people in the local community could not resolve the PMHP’s mental health crisis. Stigma experiences reduced social networks and opportunities for PMHP, threatened the economic survival of their entire family, and exacerbated their mental health problems. An individual’s reaction to negative experiences can be fatalistic in nature (e.g. believing in it is God’s will). This fatalism can help PMHP to remain hopeful. In addition, traditional communal unity alleviated some of the social exclusion associated with stigma.

Conclusions

The study indicates that existing stigma-reduction strategies might have limitations in their effectiveness across cultural settings. Therefore, we propose context-specific practical implications (e.g. emphasis on environmental factors as a cause of mental health problems, messages to increase understanding not only of the possibility of recovery but also of challenges PMHP face) for the Philippines.

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Stigma and discrimination against people with mental health problems (PMHP) are a global public health issue [ 1 , 2 , 3 ] and can have substantial negative impacts on all aspects of a person’s life, from employment and housing to social and family life [ 4 , 5 , 6 , 7 ]. Public stigma, the general public’s reaction towards a stigmatised group, can be conceptualised as having three distinct elements [ 8 ]. First, a negative belief about a stigmatised group is seen as stereotype. Second, an emotional reaction to the stereotype is seen as prejudice. Third, a behavioural manifestation of the prejudice is discrimination. Historically, research on stigma related to mental health has been conducted mainly on stereotypes, prejudices, and intentions to discriminate that are held by the general public with regard to PMHP. Such research revealed that the general public frequently label PMHP as dangerous, blameworthy, incompetent and weak, which is often accompanied with emotions of fear and anger and can lead to behavioural intention of avoidance, punishment, and coercion [ 9 , 10 , 11 , 12 ]. Further, the literature shows that internalisation of public stigma or self-stigma is also frequent among PMHP, which reduces self-esteem, causes social isolation, and inhibits help-seeking behaviour [ 6 , 13 , 14 , 15 ].

Recent research has more often investigated levels of discrimination using direct reports from PMHP. The results of such research suggest that discrimination against PMHP is a universal phenomenon around the world [ 2 , 3 , 16 ]; however, PMHP’s experiences of discrimination and its related factors might differ in high-income countries (HICs) versus low- and middle- income countries (LMICs). Some studies suggest that PMHP experience a lower level of stigma in LMICs [ 17 ], such as India [ 18 ], China [ 19 ], and Nigeria [ 20 ], compared with HICs. The reasons for the more positive acceptance of PMHP in those settings have been considered to be a more supportive environment with social cohesion as well as more social role options that PMHP are able to fulfil [ 21 , 22 ]. At the same time, there is also accumulating evidence revealing that in LMICs, experiences of stigma, discrimination and human rights abuses related to mental health problems are common and severe [ 23 , 24 , 25 , 26 , 27 ]. The stigmatisation in LMICs has been attributed to the combined effects of socioeconomic and ethno-cultural characteristics of the setting [ 28 ]. For example, the economic situation of widespread poverty may contribute to further marginalisation of PMHP who are not able to financially contribute to society [ 29 ]. Moreover, the cultural value of collectivism may results in discrimination towards PMHP especially with regarding to marriage and childrearing, since a person’s mental health problem is often seen as the family’s mental health problem [ 30 ]. Overall, practices and outcomes of stigma differ across cultures and socioeconomic backgrounds [ 29 , 31 , 32 ], and meaningful comparison across cultural settings may not be achievable with cross-cultural measures [ 33 ]. In consideration of this, researchers have called for an in-depth qualitative exploration of the experiences of stigma among PMHP in LMICs settings, where about 85% of the world’s population live [ 21 ].

PMHP in the Philippines, a lower-middle income country in Asia, might experience a significant level of stigma and discrimination. Filipino immigrants believed that personal characteristics (i.e. self-centeredness and “soul weakness”) resulted in mental health problems [ 34 , 35 ], which have been shown to be related to blaming PMHP and discriminatory behaviour in other settings [ 36 ]. Also, a multi-country survey revealed that, among 16 countries surveyed, the Philippines had the second highest proportion of citizens who agreed that PMHP should not be hired for a job even if they are qualified [ 37 ]. Further, some studies that involved interviews with Filipino immigrants living in Australia and the United States and that sampled from the general population revealed that a fear of being labelled as ‘crazy’ and spoiling their family’s reputation made Filipinos hesitate to seek help from mental health professionals [ 35 , 38 , 39 ]. Although these previous studies provide some knowledge regarding public stigma in the Filipino context, all of them looked at stereotypes, prejudices and intentions to discriminate held by the general public towards PMHP. To our knowledge, there is no study investigating PMHP’s own experiences of being stigmatised and discriminated against and the related factors in the Philippines.

To fill the gaps in the literature, we conducted a qualitative study on the factors related to experiences of stigma as well as the experiences itself of PMHP in the Philippines, using interviews with PMHP and people who know them well. Revealing the existence, types, and sources of stigma experienced by PMHP in the Philippines can contribute to the stigma research in Asian LMIC settings. Further, exploring the experiences of stigma and its related factors can provide fundamental knowledge for the design of an effective stigma reduction program in the Filipino setting.

The current research utilised the principles of constructivist grounded theory, which is deemed suitable for revealing the social phenomenon of PMHP’s experiences of stigma [ 40 ] in the Filipino context. The constructivist grounded theory assumes a relativist ontology (accepting that multiple realities exist) and a subjectivist epistemology (involving a co-construction of meaning through interaction between the researcher and participant) [ 41 ]. It provides a means of studying power, inequality, and marginality [ 42 ].

Our study was conducted in Muntinlupa, the southernmost city in the Philippines’ National Capital Region. The city has a population of 481,461 as of 2016. The majority comprises Tagalog ethnic groups and professes Christian, primarily Roman Catholic, faith. Households below the food threshold, the minimum income required to meet basic food needs, account for 21.5% of the total in the city [ 43 ]. The majority of citizens cannot afford private medical services, which cost five times more than the public medical services [ 44 ]. With respect to public psychiatric service, the city has one outpatient and no in-patient facility. The nearest public in-patient psychiatric facility is located about 23 km away.

Main data collection

Participants.

We collected data on PMHP from three different sources of information: PMHP themselves, their carers, and community health volunteers who knew them well. The eligibility criteria for PMHP were 1) having a mental health problem, listed in the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5), or epilepsy, and 2) currently not using residential care. Epilepsy was included for several reasons. First, people with epilepsy are known to suffer stigma and discrimination [ 45 , 46 ]. Second, the condition has a long history of being classified as a psychiatric problem [ 47 ]. Third, even with the present-day efforts promoting mental health in LMICs, epilepsy is often treated together with mental health issues [ 48 ]. Last, pilot interviews revealed that local lay people do not clearly differentiate epilepsy from mental health problems.

For the recruitment, we approached 42 PMHP in person; one of them declined to participate owing to time constraints. Thus, we obtained informed consent from 41 PMHP. Among them, two PMHP were excluded because they were confirmed to have only physical health problems and no mental health problems as listed in DSM-5. Consequently, we used data of 39 PMHP for our analysis. The profiles of the final sample are shown in Table  1 . In 20 of the PMHP, we interviewed the PMHP and their main carer, usually a parent or sibling. In the remaining 19 PMHP, only a main carer was interviewed, as the 19 PMHP had communication difficulties that hindered them from answering interview questions. Additionally, in 11 PMHP, we conducted interviews with a community health volunteer who was in charge of the district in which the PMHP lived.

Recruitment

We aimed to include a wide variation in the characteristics of the PMHP, namely, gender, age, marital status, educational attainment, employment status, religion, type of mental health problem, and history of using health and welfare services. To achieve this, the participants were recruited by purposive sampling in cooperation with two different collaborating stakeholders. First, as stigma was considered to inhibit Filipino people from seeking professional help for their mental condition [ 35 , 49 ], we recruited the majority of PMHP ( n  = 36) in cooperation with community health volunteers, which enabled us to recruit PMHP regardless of their history of receiving health care. The community health volunteers had good knowledge of the profiles of the residents of the district under their charge and covered all the areas of the city. Second, we recruited a small number of PMHP ( n  = 3) with common mental health problems (e.g. anxiety and depressive problems) from the outpatient clinical practice of a psychiatrist, as the community health volunteers did not identify any people with these types of problems.

To check the eligibility of those who had never been diagnosed by a specialist as having a mental health problem, a research member, ET, carefully reviewed the data of the individual participants, including interview recordings, transcriptions, and field notes, and then provided informed presumption if the participants had a mental health problem or not. ET also assessed which chapter, the broadest classification in DSM-5, the participant most fitted. ET has clinical experience as a psychiatrist in Japan for over 15 years.

Interview procedures

Data on the PMHP were collected through semi-structured in-depth interviews. Prior to the beginning of data collection, an interview guide was developed, referring to previous research [ 18 , 50 ], and then modified based on six pilot interviews in the setting. The interview guide had a series of open questions on three major topics: onset of mental health problems and coping behaviours, experiences of being treated negatively owing to the problem and its consequences, and activities PMHP gave up because of how others might respond to their health problem. The interview guides for interviews with PMHP and for interviews with carers and community health volunteers can be accessed in Additional files  1 and 2 , respectively. Consistent with the grounded theory methods, we used the interview guide as a flexible tool that could be revised as the analysis progressed. The carers and community health volunteers were not asked about their own experiences of stigma as a carer or person working in mental health. Instead, we asked them about the PMHP’s experiences regarding the same topics, based on their observations. Demographic data of the PMHP were also obtained at the beginning of the interview.

The first author, CT (female, a Japanese public health nurse), conducted all of the data collection between January and March 2017. During the interview, Tagalog or English was used as preferred by the participants. When Tagalog was chosen, the interviews were interpreted by one of two health workers who had lived in the city for more than 30 years and were fluent in both Tagalog and English. After explaining the study and gaining informed consent, the interviews were conducted in their home, a health centre, or the city hospital, depending on the participants’ preference. Wherever possible, we conducted interviews in a space where there was no one but the interviewee, interviewer, and interpreter around. However, five PMHP were not willing to be interviewed alone. In which case, a family member was in the same place and assisted the interview. All the interviews were digitally recorded with interviewees’ permission and lasted between 19 and 53 min; the median length was 29 min. The participants received 100 Philippine pesos (1.9 US dollars) as acknowledgement for their participation.

Supplementary data collection

We included data of interviews with seven health workers into our analysis to gain a wider perspective on the stigma experienced by PMHP. CT conducted the interviews during her one-month participant observation at health services provided by the city government. During the observation, CT discussed the role of stigma and its impact on PMHP with more than 85 health and welfare workers. We analysed seven interviews with those who shared episodes on PMHP with whom they were in direct contact as a part of their duty at work. The interviewees were three community health volunteers, two nurses, one doctor, and one rehabilitation program officer. Notes were taken during the interviews and six out of seven interviews were audiotaped with their permission.

All of the recordings were transcribed verbatim by two trained transcribers. Tagalog recordings were simultaneously translated into English by the transcribers fluent in English and Tagalog. An independent research assistant randomly selected 10% of the English transcripts and checked their accuracy by matching them with the Tagalog and English recordings. During this checking process, no significant errors were found thus the transcripts were quality assured.

Data analysis started as soon as the initial data were collected. We set aside theoretical ideas from the existing literature; instead, we remained open to exploring the theoretical possibilities we could discern from the data. After reading each of the transcripts at least twice, CT and ET independently conducted the initial coding. Simple codes were created to describe the phenomenon in each segment of data, using the qualitative data analysis software, Nvivo Version 11.4.1 (QSR International, 2016). The initial codes with identical meanings were merged through discussion, whereas those with different meanings were left unchanged to increase the variety in the interpretation of the data. We used data from interviews with cares, health volunteers, health and welfare workers to increase variety of data on stigma experienced by PMHP and gain comprehensive understanding of its context. Thus, when accounts showed some discrepancy between a person with mental health problem and his/her carer or a person who knew him/her well, we used the data from both accounts for our analysis.

The authors gradually moved on to the focus coding, in which the initial codes were concentrated on or collapsed into categories that make analytical sense, and then tested these against extensive data. The interpersonal interaction between people with and without mental health problems was treated as the central phenomenon of our interest. To explore comprehensively PMHP’s experiences of stigma, we decided to treat any “uncomfortable treatments from others” reported as stigma experience, regardless of the actors’ motivation. We constantly compared data on similarities and differences within a participant as well as across participants to examine the categories and develop links among them. CT led the preliminary focus coding. Subsequently, discussions were held between CT, ET, and HM, in which we reviewed the developed categories and links to determine if they were grounded in data and sufficiently explained the phenomenon.

After analysing the data of the 35 PMHP, a tentative model that explains the relations between categories was developed. We then collected and analysed data on four additional PMHP. Through discussion, the full research team determined that the categories and themes were sufficiently relevant and that the model held true for these additional PMHP. We then concluded that the model was theoretically saturated.

Analyses revealed four interrelated themes surrounding stigma experienced by PMHP: (1) the context affecting stigma experience, (2) stigma experience, (3) impact modifier of the stigma experience, and (4) consequence of the stigma experience. Figure  1 shows the relationship among the themes.

Stigma experienced by people with mental health problems and its related factors in the Philippines

Context affecting stigma experience

We identified two contextual categories that changed how others treated PMHP in a negative way.

Public belief about mental health problems

Public beliefs surrounding mental health issues are a contextual category of stigma experienced by PMHP in the Philippines. It consists of three themes: familial problems, unrealistic pessimism and optimism about severity, and oversimplified chronic course.

Familial problems

Community health volunteers and health workers observed that families of PMHP and people in the local community do not provide appropriate support for PMHP because they perceive mental affliction as a family problem and indicative of so-called “bad blood”. The belief that mental health problems can be transmitted among relatives pushed families of PMHP to deny the existence of mental health issues and people in the community to distance themselves from PMHP. A nurse shared an episode of a male patient with depression:

His family could not accept the idea that one of their relatives is actually depressed. (…) It’s because in our culture, when it comes to mental illness, it tends to be a family affair. People think if one of you has a history of mental illness, there is a chance that almost all of you already have that as well. We care about how others think about our family more than anything else. And other people feel that it is not their place to intervene in some family matters. (Interview 48, Nurse, Female)

In particular, marrying age PMHP faced stigma because of the belief in heredity. People in the community often believe that PMHP have mental health problems in their family’s blood and are afraid of developing those problems in their kinship via marriage.

I had one neighbour that I reported to the barangay [district government] because she mocked me. She was saying that I had mental illness in our blood and no one dare marry me and get in trouble. (Interview 51, PMHP, Male)

Unrealistic pessimism and optimism about severity

PMHP experienced stigma when others were overly pessimistic about the severity of a mental health problem. Participants often criticised those who believe that mental health problems generally cause severe functional impairments. This belief has resulted in unfair treatment towards PMHP in the Philippines.

[Researcher: What is the biggest challenge for the [social inclusion] program?] Finding a job. It’s very difficult. The community people don’t believe they [PMHP] are functional and don’t hire them. (…) So now some barangays [district governments] have started to hire them. We hope people see them working hard and start to trust them. (Interview 27, Rehabilitation program officer, Male)

Meanwhile, unrealistic optimism about its severity also caused stigma. The commonly held belief is that individuals are able to overcome any psychological suffering by themselves, and as a result, it will not become a serious problem. It was common for PMHP to be doubted or withheld empathy in such a culture that emphasises resilience and humour under stressful situations.

Filipinos are proud of being resilient. We find something funny in any difficult situation. But when you have this illness, that kind of thinking gives you a huge pressure. (…) One day, I opened up about my mental illness to my friends, but they all had the same reaction. They laughed at me and didn’t take it seriously. (Interview 71, PMHP, Female)

Oversimplified chronic course

The oversimplified chronic course of mental health problems emerged as one of the causes of stigma. People without any experience of a mental health problem often misunderstand the repetitive relapse and remission in the course of a mental health problem. They tend to apply an acute illness model and expect a complete cure in the short term. However, as the symptoms are prolonged, they begin to mistrust the PMHP’s account.

After one month of no work, I was able to work and sleep. But in February, it came back. I couldn’t sleep for several days. (...) My supervisors were thinking that I should be working a night shift duty, but I told them that I would have to take sick leave. But because it was the same reason for my previous absent, they are already thinking that I am making up stories. (Interview 30, PMHP, Male)

Interpersonal condition

Interpersonal condition was identified as a direct trigger of stigma experience. It consists of two themes: unresolved threat and unmet expectation.

Unresolved threat

Unresolved threat is a condition where PMHP are at risk of hurting themselves or others owing to their mental health problems, with the people in contact with the PMHP failing to manage such risks. Under such conditions, PMHP often experience physical violence, being avoided, and being restricted by others. Although the PMHP, their families, and community health volunteers attributed the threats to PMHP’s personal factors, such as personality and outwardly noticeable symptoms, they also emphasised the culpability of people in the local community for their lack of understanding and skills in interacting with PMHP. When others became familiar with PMHP, they successfully managed those threats and prevented PMHP from experiencing stigma. The mother of a boy with a neurodevelopmental problem told us:

My son easily becomes violent. For example, when someone takes and plays with his toy. The neighbours don’t understand why he is angry and they bully him. But there are also some playmates who fully understand him. When they know that my son is about to be angry, they immediately keep distance from him. And after a while, my son calms down and they start playing around together. (Interview 4, Mother of a boy with a mental health problem)

Unmet expectation

Unmet expectation was another context of stigma. In this context, there is a gap between PMHP’s abilities and other people’s expectations of them. Some PMHP reported suffering from stigma when others’ expectations were too high for their situation. People in this cultural setting tend to value strong bonds and reciprocity among families and neighbours. PMHP sometimes were unable to perform in accordance with this value owing to their mental health conditions. Violation of this value was judged as morally wrong.

They [the neighbours] say I should help my mum by doing washing, cleaning, and taking care of my brother, even when I say I feel weak or don’t know how to. (Interview 5, PMHP, Female) She is big but still doesn’t help her mother. That’s why the neighbours don’t like her. They say she is not a good daughter. (Interview 18, Community health volunteer, Female)

Meanwhile, some other PMHP experienced stigma when others underestimated PMHP’s abilities. Families often criticised other people that looked only at PMHP’s disabilities but not at their abilities.

When someone in our neighbourhood was trying to talk to my sister and she did not respond back, they started bullying her and calling her crazy. [Researcher: How do you think we can change such situation?] I think proper communication towards her would be the best since she’s really a good listener. The problem is that other people don’t know she actually understands things really well. (Interview 8, Sister of a woman with a mental health problem)

Stigma experience

Although we frequently found that PMHP were positively treated by others because of their mental health problems, we also discovered that almost all the PMHP participants were faced with negative treatment from others. PMHP experienced psychological abuse (e.g. being verbally insulted, laughed at, stared at, gossiped about, doubted), physical violence (e.g. being hit, stones being thrown at them), being restricted (e.g. being told not to go outside alone, tied with a rope to a pillar), not being supported (e.g. lack of understanding and sympathy), being taken advantage of (e.g. being cheated out of money and belongings), being neglected (e.g. privacy not being protected, medical care not being provided), and being rejected (e.g. not being associated with, not being hired). Families were an important source of stigma in terms of prominence as stigma from families was often repetitive (e.g. frequently being slapped) and prolonged (e.g. being locked up in a room for several months). PMHP also experienced stigma frequently from their neighbours, and sometimes from school friends, co-workers and employers. People who were involved with PMHP as a part of their duty at work (i.e. health workers and public safety officers) were a source of stigma as well. For complete information on the stigma experience by source, please see Table  2 .

Impact modifier of stigma experience

Even if the nature of stigma experiences were similar, the extent and degree of its influence on PMHP’s life varied depending on impact modifier of stigma experience . PMHP had three impact modifiers consisting of internal (i.e. fatalistic appraisal) and external (i.e. peer bonds, community unity) factors.

Fatalistic appraisal of stigma experience

Fatalistic appraisal of stigma experience offered PMHP and their families a strategy to cope with the emotional pain caused by stigma experience. People in the setting generally believed that God predetermined life events in the past, present and future. Some PMHP and their family accepted unfair treatments from others as “fate.” They were able to remain hopeful because they believed that God would help them if they had faith in God.

Sometimes people say he is crazy. [Researcher: What do you do in response to that?] Nothing. People say what they want to say. We just say “God is good.” As long as we believe in Him, it will be alright. (Interview 23, Sister of a man with a mental health problem)

Peer bonds , the emotional bonds with other people with similar mental health problems, empowered PMHP to change their stigmatised situation in a positive way. Stigma experience could marginalise them in the community, but when they were together with peers who understood not only their health condition but also their lowered social status, they were empowered and motivated to change the situation for themselves and their peers.

[Researcher: What are the barriers to your recovery?] The different perceptions of people towards us [she and other people with mental health problems]. It is so discouraging for us. And we are the only ones who can understand each other very well. We are like brothers and sisters already. Nevertheless, we make sure that the reason we join the [rehabilitation] program is not only for ourselves but to show them that we can change ourselves for the better. If we will be given a chance to work again, we will make 100 percent effort to get things done accordingly. (Interview 34, PMHP, Female)

Support based on Bayanihan spirit

Support based on Bayanihan spirit , a traditional concept of community unity, relieved the negative impacts of stigma on PMHP. It was not rare that community people gave food or rented a house free to PMHP and their family who had little income. Helping one another in a time of need was inherent in their lives, called Bayanihan in Tagalog. For example, a homeless woman with schizophrenia told us that she had felt hopeless because she had been bullied at school and was in a materially deprived circumstance. However, she was now enjoying her life and managing to make a living because some of her neighbours treated her as a valued community member (e.g. regularly invited her to a local dancing event) and occasionally gave her food. A community health volunteer explained why she had good relationships with the community as follows:

That is natural here. When your family member is sick, neighbours and friends are there to pay for medicines, bring food, help with housework, and take care of small kids. We call it Bayanihan. (Interview 3, Community health volunteer, Female)

Consequence of stigma experience

Stigma experience was found to bring about a substantial negative impact on PMHP’s social networks, roles, opportunities, and mental health.

Reduction of social networks

Stigma experience reduced PMHP’s social networks, which led to them spending their days isolated at home without any interaction with people outside of their immediate family. This was due not only to the direct influence of experiences of stigma (i.e. being physically restrained , being avoided by others ) but also the indirect influence of changes in three aspects: PMHP’s behaviour, restriction by families, and relationships with others. First, after being negatively treated, PMHP tended to “close off to everybody” and distanced themselves from others.

Going out is sometimes like an obstacle. (…) After that [hearing my friends gossiping about me], I have been afraid of people’s judgments. (Interview 62, PMHP, Female)

Second, families started to restrict PMHP’s behaviour to protect them from further stigma experiences.

We do not allow him to go out. We are afraid that something like that [neighbours calling him crazy] might happen to him again or someone might abduct him. (Interview 9, Sister of a man with a mental health problem)

Third, stigma experiences provoked conflicts, from a quarrel to a physical fight, and worsened the relationship between PMHP and others. The conflicting relationships produced a further stigmatising attitude towards PMHP.

He got into a fight with his playmates because they said bad words to him. (…) Many of our neighbours told me that he should be in a cell. They told me that they knew a policeman who could put him in jail. (Interview 1, Mother of a man with metal health problem)

Lost social roles and opportunities

As a result of stigma experience, PMHP lost social roles and opportunities , such as being employed, going to school, having a romantic partner, getting married, parenting, helping with household chores and the family business, taking care of younger siblings and joining religious activities.

She was a member of the choir in church. She likes singing and has a good voice. And plenty of friends visited her in the past and they went to church together. But no more. Nobody visits her, and she quit attending it. (Interview 10, Mother of a woman with a mental health problem)

Increased financial strain

Lost social roles and opportunities increased financial strain, which negatively affected the families as well as PMHP themselves. In this setting, PMHP and their families lived in communities where many people find it difficult to make a living. The cost of transportation to medical facilities and treatment fees put them in a further difficult situation economically. In such conditions, entire families often suffered from the financial strain that was due to stigma to the degree that they could not afford basic items including food and clothing.

If only I could find a good job like when I was well. Even though we do not have enough money to buy things, my family really makes an effort to find ways that we can buy those medicines. (Interview 20, PMHP, Male)

Aggravated mental health

The participants reported that the stigma experiences aggravated mental health in PMHP. The memory of negative treatment from others often stuck in their mind and its influence lasted for a long time. A 32-year-old woman with anxiety problem explained how the experience of being bullied when she was a teenager influenced her current condition:

It triggers my anxiety. When I remember their facial expressions, even now, I feel overwhelmed and breathless (Interview 39, PMHP, Female).

The experience of stigma also affected the mental health condition of PMHP by preventing them from seeking help. Some PMHP and their families choose to keep their mental health status a secret. However, families have limited capacities to take care of a person with a mental health problem, especially in the case of someone with severe symptoms. In the worst case in terms of the influence of stigma on PMHP’s mental health, a community health volunteer reported that the parents of a daughter with a mental health problem locked her up in her room and took care of her without seeking professional help. However, her condition kept deteriorating and eventually she committed suicide inside her room.

To our knowledge, this is the first study to document the stigma experienced by PMHP in the Philippines. This study adds to the understanding of discrimination in LMIC settings and its related contextual factors in the Philippines.

First, our results showed that PMHP in the Philippines experienced stigma, which brought about negative impacts on PMHP’s social networks, roles and opportunities, financial burden, and mental health. Although stigma types, sources, and areas of impact were generally consistent with the existing literature in this field [ 4 , 6 , 51 ], we found that experiences of stigma threatened the economic survival of the entire family of PMHP and increased the mental health crisis in the LMIC context, given the minimal welfare and mental health care provisions. Several studies with participants recruited from clinical settings have shown that PMHP in LMICs suffered less from stigma [ 2 , 18 , 19 , 20 ]. In this study, we involved PMHP without psychiatric service use, which prevented us from overlooking the stigma experienced by the poorest and most marginalised PMHP. Our findings might better reflect the reality in LMIC settings, where it is estimated that more than 70% of PMHP receive no treatment for their mental health conditions [ 52 ].

Second, we found that pessimistic and over-optimistic reactions to a mental health problem are among the important contexts of experiences of stigma in the Philippines. Historically, stigma research has mainly focused on the pessimistic view on the prognosis and its negative effects [ 10 , 53 , 54 , 55 , 56 ]. Meanwhile, when the over-optimistic view on the outcome of mental health problems has been documented among Filipino immigrants, it was only recognised as a barrier to help-seeking [ 35 , 39 ]. Our qualitative exploration’s original finding is that the over-optimistic belief among the community regarding the severity of mental health problems results in PMHP’s receiving inappropriate or negative treatment. This is an important finding for the Philippines, because resilience and optimism under difficult situations are among the well-known cultural traits of Filipinos [ 57 , 58 ]. Stigma resulting from optimism might be prevalent in the Philippines; a prior study showed that among the 16 countries, the Philippines posted the highest proportion of respondents who agreed that mental illness would improve on its own [ 59 ].

Third, the results indicated that mental health problems were perceived as problems of the family and discouraged people from accepting mental health problems. The finding is consistent with psychiatrists’ clinical experiences with Filipino patients [ 60 , 61 ]. We also found that a belief in transmissibility among relatives led to PMHP experiencing reduced marriage opportunities. Previous studies conducted on Chinese descent groups [ 62 , 63 , 64 ] showed that the threat of genetic contamination was related to endorsement of reproductive restriction. We propose that it might hold true in the Filipino context, meaning that the threat to family lineage through genetic contamination via marriage accounts for some of the discrimination experienced by PMHP.

Fourth, we revealed a context-specific impact modifier of stigma experiences, namely, fatalistic appraisal of stigma experience . Existing studies have discussed that Filipinos typically attribute illness to “the will of God” [ 39 , 49 , 65 ]. A new finding of this study is that negative treatments from others were also attributed to fate. Globally, it is known that fatalistic appraisal of negative events inhibits active coping and worsens health [ 66 , 67 ]. However, we found that fatalism offered a spiritual coping strategy and shielded PMHP from the adverse effects of stigma in the Catholic dominant setting of the Philippines. These findings are consistent with the literature that have showed that fatalism facilitates adjustment to negative life events [ 49 , 68 , 69 ]. Moreover, support based on Bayanihan spirit was another culturally relevant impact modifier. The origin of the Bayanihan spirit is traced back to the country’s tradition wherein towns’ people cooperate to carry a family’s entire house on their shoulders to a new location. It is considered a core essence of the Filipino culture. Our finding supports the arguments by Lasalvia [ 21 ] and Mascayano et al. [ 29 ] that communal network, which tends to be better maintained in LMICs, is among the existing strengths to reduce the negative effects of stigma.

Lastly, the research method of obtaining perspectives from multiple participants who witnessed and experienced stigma allowed us to reveal that the interpersonal conditions (i.e. unresolved threat and unmet expectations ) preceded stigma experiences. Consistent with previous research from India [ 24 ] and Indonesia [ 70 ], in the setting where mental health care is not readily available at a local level, people in the community needed to cope with the possible danger of PMHP to self or others and can violate PMHP’s human rights. Similar to the results of prior qualitative analyses of interviews with PMHP and their families [ 18 , 71 ], the expectations of others in contrast to PMHP’s actual capabilities caused negative reactions from others. Those interpersonal conditions might be a more important determinant of stigma experiences than PMHP’s personal factors, considering the previous studies showing individual variables (e.g. employment status, symptom, and treatment experiences) accounted for only less than 30% of total variance of experienced stigma [ 2 , 3 ].

Practical implications

Our results suggest that mental health care must have the objective of the reduction of stigma towards PMHP. The Department of Health and Local Government Units are required by the Mental Health Act [ 72 ], established in 2018 as the first law of its kind in the Philippines, to initiate and sustain nationwide campaigns to raise the level of awareness on the protection and promotion of mental health and rights. In conducting stigma reduction campaigns, they should: 1) target families of PMHP, community people, health workers, and public safety officers; 2) avoid genetic explanations for mental health problems and emphasise the role of environmental and social factors as its cause; 3) increase public understanding of not only the possibility of recovery but also the challenges that PMHP face; and 4) improve families’ and community members’ skills in assessing and coping with possible danger posed by PMHP to self or others [ 73 , 74 , 75 , 76 ]. These interventions might be more effective when they utilise the existing communal network and increase social contact between PMHP and others [ 77 , 78 ] We also propose that mental health and welfare services for PMHP should: 1) be community-based and support PMHP in meeting expectations that are meaningful for themselves and others; 2) provide opportunities for PMHP to share their experiences with peers to empower them [ 79 , 80 , 81 ]; and 3) prevent PMHP from internalising experiences of stigma with acknowledgement of fatalistic appraisal of them as a coping strategy. Lastly, to mitigate the adverse influences of stigma, it is necessary to change the structure of health care and welfare service provision for PMHP (e.g. inclusive education, welfare benefits, and job schemes). It is also essential to provide effective and accessible mental health care.

Study limitations

We were unable to recruit people with common mental health problems who were not using psychiatric services. In fact, community health volunteers do not recognise any people having common mental health problems. This may reflect stigma-related situations where local people do not recognise the manifestation of symptoms of those problems as a health issue, or where people with those problems hide their conditions. Additionally, cultural and language barriers may have played a part in data collection and interpretation. However, we also encountered a number of situations where the interviewee provided the data collector, who was from another cultural background, with further explanations, especially on their culture. Further, some interviews were too short to be considered an in-depth interview. Also, we needed to rely in part on data from narratives of people who know PMHP well, instead of from PMHP themselves. These were because the interviewer had difficulty encouraging some participants, especially PMHP, to talk about sensitive topics. Thus, there might be experiences and related themes that we could not explore. Lastly, we conducted the study in one city; thus, the results may not be generalisable to another part of the Philippines (e.g. rural and Muslim-dominant areas).

Our findings highlight that PMHP in the Philippines experience substantial discrimination and its adverse effects are severe to the degree that it threatens the financial survival of the entire family. Culture-bound beliefs and social structure (e.g. perceiving mental health problems as a familial problems, traditional communal unity) played important roles in shaping and modifying stigma experiences. More research is needed to develop stigma reduction interventions utilising these findings and to evaluate their effectiveness.

Abbreviations

The Diagnostic and Statistical Manual of Mental Disorders

High-income countries

Low- and middle-income countries

People with mental health problems

Seeman N, Tang S, Brown AD, Ing A. World survey of mental illness stigma. J Affect Disord. 2016;190:115–121. Available from: https://doi.org/10.1016/j.jad.2015.10.011 Elsevier.

Article   Google Scholar  

Lasalvia A, Zoppei S, Van Bortel T, Bonetto C, Cristofalo D, Wahlbeck K, et al. Global pattern of experienced and anticipated discrimination reported by people with major depressive disorder: a cross-sectional survey. Lancet. 2013;381:55–62. Available from: https://doi.org/10.1016/S0140-6736(12)61379-8 Elsevier Ltd

Thornicroft G, Brohan E, Rose D, Sartorius N, Leese M. Global pattern of experienced and anticipated discrimination against people with schizophrenia: a cross-sectional survey. Lancet; 2009;373:408–415. Available from: https://doi.org/10.1016/S0140-6736(08)61817-6 . Elsevier Ltd

Sharac J, McCrone P, Clement S, Thornicroft G. The economic impact of mental health stigma and discrimination: a systematic review. Epidemiol Psichiatr Soc. 2010;19:223. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21261218 .

Clement S, Schauman O, Graham T, Maggioni F, Evans-Lacko S, Bezborodovs N, et al. What is the impact of mental health-related stigma on help-seeking? A systematic review of quantitative and qualitative studies. Psychol Med. 2015;45:11–27 Available from: http://www.ncbi.nlm.nih.gov/pubmed/24569086 .

Article   CAS   Google Scholar  

Livingston JD, Boyd JE. Correlates and consequences of internalized stigma for people living with mental illness: a systematic review and meta-analysis. Soc Sci Med. 2010;71:2150–2161. Available from: https://doi.org/10.1016/j.socscimed.2010.09.030 Elsevier Ltd

Link BG, Phelan JC. Conceptualising stigma. Annu Rev Sociol. 2001 [cited 2018 Jul 3];27:363–385. Available from: https://www.annualreviews.org/doi/pdf/10.1146/annurev.soc.27.1.363

Corrigan PW. Mental health stigma as social attribution: implications for research methods and attitude change. Clin Psychol Sci Pract. 2006;7:48–67 Available from: http://doi.wiley.com/10.1093/clipsy.7.1.48 .

Mannarini S, Boffo M. Anxiety, bulimia, drug and alcohol addiction, depression, and schizophrenia: what do you think about their aetiology, dangerousness, social distance, and treatment? A latent class analysis approach. Soc Psychiatry Psychiatr Epidemiol. 2015;50:27–37.

McGinty EE, Goldman HH, Pescosolido B, Barry CL. Portraying mental illness and drug addiction as treatable health conditions: effects of a randomized experiment on stigma and discrimination. Soc Sci Med; 2015;126:73–85. Available from: https://doi.org/10.1016/j.socscimed.2014.12.010 . Elsevier Ltd

Angermeyer MC, Dietrich S. Public beliefs about and attitudes towards people with mental illness: a review of population studies. Acta Psychiatr Scand. 2006;113:163–79.

Corrigan PW, Markowitz FE, Watson A, Rowan D, Kubiak MA. An attribution model of public discrimination towards persons with mental illness. J Health Soc Behav. 2003;44:162–79.

Corrigan P, Watson A. The paradox of self-stigma and mental illness. Clin Psychol Sci Pract. 2002;9:35–53 Available from: https://onlinelibrary.wiley.com/doi/10.1093/clipsy.9.1.35 .

Google Scholar  

Evans-Lacko S, Brohan E, Mojtabai R, Thornicroft G. Association between public views of mental illness and self-stigma among individuals with mental illness in 14 European countries. Psychol Med. 2012;42:1741–52.

Mccann TV, Renzaho A, Mugavin J, Lubman DI. Stigma of mental illness and substance misuse in sub-Saharan African migrants: a qualitative study. Int J Ment Health Nurs. 2017;27:956–65.

Camden Schizoph E, Corker EA, Beldie A, Brain C, Jakovljevic M, Jarema M, et al. Experience of stigma and discrimination reported by people experiencing the first episode of schizophrenia and those with a first episode of depression: The FEDORA project Anamaria Vasilache 2 , Margda Waern 3,4 , Norman Sartorius 10 , Graham Thornicroft 1 and the FEDORA study group. Int J Soc Psychiatry. 2015 [cited 2018 Jul 3];61:438–445. Available from: http://journals.sagepub.com/doi/pdf/10.1177/0020764014551941

Lasalvia A, Van Bortel T, Bonetto C, Jayaram G, Van Weeghel J, Zoppei S, et al. Cross-national variations in reported discrimination among people treated for major depression worldwide : the ASPEN / INDIGO international study. Br J Psychiatry. 2015;207:507–14.

Koschorke M, Padmavati R, Kumar S, Cohen A, Weiss HA, Chatterjee S, et al. Experiences of stigma and discrimination of people with schizophrenia in India. Soc Sci Med; 2014;123:149–159. Available from: https://doi.org/10.1016/j.socscimed.2014.10.035 . Elsevier Ltd

Lv Y, Wolf A, Wang X. Experienced stigma and self-stigma in Chinese patients with schizophrenia. Gen Hosp Psychiatry. 2013;35:83–8. Available from: https://doi.org/10.1016/j.genhosppsych.2012.07.007 Elsevier Inc.

Oshodi YO, Abdulmalik J, Ola B, James BO, Bonetto C, Cristofalo D, et al. Pattern of experienced and anticipated discrimination among people with depression in Nigeria: a cross-sectional study. Soc Psychiatry Psychiatr Epidemiol. 2014;49:259–66.

Lasalvia A. Tackling the mental illness stigma in low- and middle-income countries: lessons learned from high-income countries and mistakes to avoid. Epidemiol Psychiatr Sci. 2015;24:395–8 Available from: https://www.cambridge.org/core/journals/epidemiology-and-psychiatric-sciences/article/tackling-the-mental-illness-stigma-in-low-and-middleincome-countries-lessonslearned-from-highincome-countries-and-mistakes-to-avoid/83D63EA7FD15A3A3F2F9085E7E1700A2 .

Rosen A. Destigmatizing day-to-day practices: what developed countries can learn from developing countries. World Psychiatry. 2006;5:21–24. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1472257/ .

Alonso J, Buron A, Bruffaerts R, He Y, Posada-Villa J, Lepine JP, et al. Association of perceived stigma and mood and anxiety disorders: results from the world mental health surveys. Acta Psychiatr Scand. 2008;118:305–14.

Mathias K, Kermode M, San Sebastian M, Koschorke M, Goicolea I. Under the banyan tree--exclusion and inclusion of people with mental disorders in rural North India. BMC Public Health. 2015;15:–446 Available from: https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-015-1778-2 .

Maramis A, Van Tuan N, Minas H. Mental health in Southeast Asia. Lancet. 2011;377:700–2.

Minas H, Diatri H. Pasung: Physical restraint and confinement of the mentally ill in the community. Int J Ment Health Syst. 2008;2 Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2442049/ .

Tawiah PE, Adongo PB, Aikins M. Mental Health-Related Stigma and Discrimination in Ghana: Experience of Patients and Their Caregivers. Ghana Med J. 2015 [cited 2018 Jul 3];49:30–6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26339082 .

Lauber C, Rössler W. Stigma towards people with mental illness in developing countries in Asia. Int Rev Psychiatry [Internet]. 2007;19:157–78 Available from: https://www.ncbi.nlm.nih.gov/pubmed/17464793 .

Mascayano F, Armijo JE, Yang LH. Addressing stigma relating to mental illness in low- and middle-income countries. Front Psychiatry. 2015;6:1–4.

Abdullah T, Brown TL. Mental illness stigma and ethnocultural beliefs, values, and norms. Clin Psychol Rev. 2011;31:934–48.

Semrau M, Evans-Lacko S, Koschorke M, Ashenafi L, Thornicroft G. stugma and discrimination related to mental illness in low- and middle-income countries. Epidemiol. Psychiatr. Sci. [Internet]. 2015;24:382–94. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25937022 .

Yang LH, Kleinman A, Link BG, Phelan JC, Lee S, Good B. Culture and stigma: adding moral experience to stigma theory. Soc Sci Med. 2007;64:1524–35.

Yang LH, Thornicroft G, Alvarado R, Vega E, Link BG. Recent advances in cross-cultural measurement in psychiatric epidemiology: utilizing “what matters most” to identify culture-specific aspects of stigma. Int. J. Epidemiol. [internet]. 2014;43:494–510. Available from. https://www.ncbi.nlm.nih.gov/pubmed/24639447 .

Edman JL, Johnson RC. Filipino American and Caucasian American beliefs about the causes and treatment of mental problems. Cultur Divers Ethnic Minor Psychol. 1999;5:380–6.

Thompson S, Hartel G, Manderson L, Woelz-Stirling N, Kelaher M. The mental health status of Filipinas in Queensland. Aust N Z J Psychiatry. 2002;36:674–80.

Corrigan PW, Rowan D, Green A, Lundin R, River P, Uphoff-Wasowski K, et al. Challenging two mental illness Stigmas : personal responsibility and dangerousness. Schizophr Bull. 2002;28:293–310.

Pescosolido BA, Medina TR, Martin JK, Long JS. The “Backbone” of Stigma: Identifying the Global Core of Public Prejudice Associated With Mental Illness. Am. J. Public Health [Internet]. 2013;103:853–60. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23488508 .

Gong F, Gage SJL, Tacata LA. Helpseeking behavior among Filipino Americans: a cultural analysis of face and language. J Community Psychol. 2003;31:469–88.

Javier JR, Supan J, Lansang A, Beyer W, Kubicek K, Palinkas LA. Preventing Filipino mental health disparities: perspectives from adolescents, caregivers, providers, and advocates. Asian Am J Psychol [Internet]. 2014;5:316–24 Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4319658/ .

Charmaz K. Constructing Grounded Theory. 2nd ed. SAGE Publications Ltd; 2014.

Charmaz K. Grounded theory methods in social justice research. In: Denzin NK, Lincoln YS, editors. SAGE Handb. Qual. Res. SAGE; 2011. p. 359–380.

Charmaz K. The Power of Constructivist Grounded Theory for Critical Inquiry. Qual. Inq. [Internet]. 2017;23:34–45. Available from: http://journals.sagepub.com/doi/10.1177/1077800416657105

City Government of Muntinlupa. POVERTY AND EMPLOYMENT STATISTICS [Internet]. 2017 [cited 2017 Jun 30].

Philippine Statistics Authority. Philippines National Demographic and Health Survey 2013. 2013 [cited 2017 Jun 30]. Available from: https://dhsprogram.com/pubs/pdf/FR294/FR294.pdf .

Boling W, Means M, Fletcher A. Quality of Life and Stigma in Epilepsy, Perspectives from Selected Regions of Asia and Sub-Saharan Africa. Brain Sci. [Internet]. Multidisciplinary Digital Publishing Institute (MDPI); 2018 [cited 2018 Jun 27];8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/29614761 .

Herrmann LK, Welter E, Berg AT, Perzynski AT, Van Doren JR, Sajatovic M. Epilepsy misconceptions and stigma reduction: Current status in Western countries. Epilepsy Behav. [Internet]. 2016 [cited 2018 Jun 27];60:165–73. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27208826 .

Koch-Stoecker S. Neuropsychiatric issues in epilepsy. In: Matsuura M, Inoue Y, editors. Neuropsychiatr. issues epilepsy [Internet]. John Libbey Eurotext; 2010 [cited 2018 Jun 27]. p. 233. Available from: https://books.google.co.jp/books?id=FQXhAAAAQBAJ&pg=PA174&lpg=PA174&dq=epilepsy+Emil+Kraepelin&source=bl&ots=r35Oh0rwjA&sig=IZa-67-5hrTVkzSl4HEIoGkaobQ&hl=en&sa=X&ved=0ahUKEwjd26SwkvPbAhWEnZQKHUvrDZsQ6AEIsAEwEw#v=onepage&q=epilepsyAQ28EmilKraepelin&f=false .

World Health Organization. mhGAP Training Manuals - for the mhGAP Intervention Guide for mental, neurological and substance use disorders in non-specialized health settings, version 2.0 [Internet]. WHO. World Health Organization; 2017 [cited 2018 Jun 27]. Available from: http://www.who.int/mental_health/mhgap/training_manuals/en/

Tuliao AP. Mental health help seeking among Filipinos: a review of the literature. Asia Pacific J Couns Psychother [Internet]. 2014;5:124–36 Available from: http://www.tandfonline.com/doi/abs/10.1080/21507686.2014.913641 .

Yang LH, Valencia E, Alvarado R, Link B, Huynh N, Nguyen K, et al. A theoretical and empirical framework for constructing culture-specific stigma instruments for Chile. Cad. saude coletiva [Internet]. 2013;21:71–9. Available from: /pmc/articles/PMC3753780/?report=abstract.

Hamilton S, Pinfold V, Cotney J, Couperthwaite L, Matthews J, Barret K, et al. Qualitative analysis of mental health service users’ reported experiences of discrimination. Acta Psychiatr Scand. 2016;134:14–22.

Demyttenaere K, Bruffaerts R, Posada-Villa J, Gasquet I, Kovess V, Lepine JP, et al. Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization world mental health surveys. JAMA [internet]. 2004;291:2581–90. Available from. http://www.ncbi.nlm.nih.gov/pubmed/15173149 .

Wig NN, Suleiman MA, Routledge R, Murthy RS, Ladrido-Ignacio L, Ibrahim HH, et al. Community reactions to mental disorders. A key informant study in three developing countries. Acta Psychiatr. Scand. [Internet]. 1980;61:111–26. Available from: https://www.ncbi.nlm.nih.gov/pubmed/7361584 .

Ando S, Yamaguchi S, Aoki Y, Thornicroft G. Review of mental-health-related stigma in Japan. Psychiatry Clin Neurosci. 2013;67:471–82.

van Boekel LC, Brouwers EP, van Weeghel J, Garretsen HF. Comparing stigmatising attitudes towards people with substance use disorders between the general public, GPs, mental health and addiction specialists and clients. Int J Soc Psychiatry [Internet]. 2014;61:539–49 Available from: http://isp.sagepub.com/cgi/doi/10.1177/0020764014562051 .

Clement S, Jarrett M, Henderson C, Thornicroft G. Messages to use in population-level campaigns to reduce mental health-related stigma: consensus development study. Epidemiol Psichiatr Soc. 2010;19:72–9.

Dy MB. Values in Philippine culture and education. Washington, DC: CRVP; 1994.

Social Weather Stations. Social Weather Station Survey. [Internet]. 2017 [cited 2017 Nov 9]. Available from: https://www.sws.org.ph/swsmain/artcldisppage/?artcsyscode=ART-20170816103037

Pescosolido BA, Martin JK, Olafsdottir S, Long JS, Medina TR, Martin JK. The theory of industrial society and cultural schemata: does the “cultural myth of stigma” underlie the WHO schizophrenia paradox? Am J Sociol. 2015;121:783–825.

Araneta EG. Psychiatric Care of Pilipino Americans. In: Gaw AC, editor. Cult. Ethn. Ment. Illn. Washington, DC: American Psychiatric Press; 1993. p. 377–412.

Sanchez F, Gaw A. Mental health Care of Filipino Americans. Psychiatr Serv [Internet] 2007;58:810–815. Available from: https://www.ncbi.nlm.nih.gov/pubmed/17535941

Wonpat-Borja AJ, Yang LH, Link BG, Phelan JC. Eugenics, genetics, and mental illness stigma in Chinese Americans. Soc Psychiatry Psychiatr Epidemiol. 2012;47:145–56.

Yang LH, Purdie-Vaughns V, Kotabe H, Link BG, Saw A, Wong G, et al. Culture, threat, and mental illness stigma: identifying culture-specific threat among Chinese-American groups. Soc. Sci. Med. [internet]. Elsevier Ltd. 2013;88:56–67 Available from: https://doi.org/10.1016/j.socscimed.2013.03.036 .

Yang LH, Kleinman A. “Face” and the embodiment of stigma in China: the cases of schizophrenia and AIDS. Soc Sci Med. 2008;67:398–408.

Abad PJB, Tan ML, Baluyot MMP, Villa AQ, Talapian GL, Reyes ME, et al. Cultural beliefs on disease causation in the Philippines: challenge and implications in genetic counseling. J Community Genet. 2014;5:399–407.

De Los Monteros KE, Gallo LC. The relevance of fatalism in the study of Latinas’ cancer screening behavior: a systematic review of the literature. Int J Behav Med. 2011;18:310–8.

Roberts RE, Roberts CR, Chen IG. Fatalism and risk of adolescent depression. Psychiatry [internet]. 2000;63:239–52. Available from. http://www.ncbi.nlm.nih.gov/pubmed/11125670 .

Cheng H, Sit JWH, Twinn SF, Cheng KKF, Thorne S. Coping with breast Cancer survivorship in Chinese women the role of fatalism or fatalistic voluntarism. Cancer Nurs. 2013;36:236–44.

Gonzalez P, Nuñez A, Wang-Letzkus M, Lim J-W, Flores KF, Nápoles AM. Coping with breast cancer: reflections from Chinese American, Korean American, and Mexican American women. Heal Psychol [Internet] 2016;35:19–28. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26389720 .

Nurjannah I ,Mills J PT& UK. Human rights of the mentally ill in Indonesia. Int Nurs Rev. 2015;62:153–61.

Habtamu K, Alem A, Hanlon C. Conceptualizing and contextualizing functioning in people with severe mental disorders in rural Ethiopia: a qualitative study. BMC psychiatry [internet]. 2015;15:34. Available from: https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-015-0418-9 .

An act establishing a national mental health policy for the purpose of enhancing the delivery of integrated mental health services, promoting and protecting the rights of persons utilizing psychiatric, neurologic and psychosocial health services, APPROPRI [Internet]. Republic of the Philippines; 2018. Available from: http://www.officialgazette.gov.ph/2018/06/20/republic-act-no-11036/

Kitchener B, Jorm A. Mental health first aid training for the public: evaluation of effects on knowledge, attitudes and helping behavior. BMC Psychiatry [Internet]. 2002;2:10. Available from: http://www.biomedcentral.com/1471-244X/2/10

Morgan AJ, Ross A, Reavley NJ. Systematic review and meta-analysis of Mental Health First Aid training: Effects on knowledge, stigma, and helping behaviour. Doran CM, editor. PLoS One [Internet]. 2018 [cited 2018 Jun 28];13:e0197102. Available from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0197102 .

Bond KS, Jorm AF, Kitchener BA, Reavley NJ. Mental health first aid training for Australian medical and nursing students: an evaluation study. BMC Psychol. [Internet]. 2015 [cited 2018 Jun 28];3:11. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25914827 .

Jorm AF, Kitchener BA, Fischer J-A, Cvetkovski S. Mental Health First Aid Training by e-Learning: A Randomized Controlled Trial. Aust. New Zeal. J. Psychiatry [Internet]. 2010 [cited 2018 Jun 28];44:1072–81. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21070103 .

Corrigan PW, Morris SB, Michaels PJ, Rafacz JDRN. Challenging the public stigma of mental illness: a meta-analysis of outcome studies. Psychiatr. Serv. [Internet]. 2012;63:963–73 Available from: https://www.ncbi.nlm.nih.gov/pubmed/23032675 .

Corrigan PW, Michaels PJ, Vega E, Gause M, Larson J, Krzyzanowski R, et al. Key ingredients to contact-based stigma change: A cross-validation. Psychiatr. Rehabil. J. [Internet]. 2014 [cited 2018 Jun 28];37:62–4. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24417232 .

Corrigan PW, Larson JE, Michaels PJ, Buchholz BA, Del Rossi R, Fontecchio MJ, et al. Diminishing the self-stigma of mental illness by coming out proud. Psychiatry Res. 2015;229:148–54.

Rüsch N, Abbruzzese E, Hagedorn E, Hartenhauer D, Kaufmann I, Curschellas J, et al. Efficacy of Coming Out Proud to reduce stigma’s impact among people with mental illness: pilot randomised controlled trial. Br. J. Psychiatry [Internet]. 2014 [cited 2018 Jun 28];204:391–7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24434073 .

Corrigan PW, Rüsch N, Scior K. Adapting disclosure programs to reduce the stigma of mental illness. Psychiatr. Serv. [internet]. 2018 [cited 2018 Jun 28];appi.Ps.2017004. Available from: http://www.ncbi.nlm.nih.gov/pubmed/29606076 .

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Acknowledgments

We are grateful to the interviewees for their participation. We would like to thank Dr. Magdalena C. Meana, Dr. Ma. Luisa Babaran-Echavez, and barangay health workers for their assistance with data collection.

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CT had a major role in the conception of the study, undertook the data collection, carried out the data analysis, and had a major role in writing the manuscript. MT contributed to the design of the study, assisted the data collection and interpretation, and supervised writing the manuscript. ET assisted data collection, conducted data analysis, and revised the manuscript. YT assisted data collection and revised the manuscript. HM supervised the design of the study, had a role in data analysis, and revised the manuscript. All authors read and approved the final manuscript.

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Ethical approval was obtained from the ethical committee of the Graduate School of Health Sciences, Kobe University, Japan (reference number 561). The study was conducted in accordance with the ethical guidelines set forth by the Declaration of Helsinki and the Ethical Guidelines for Medical and Health Research Involving Human Subjects provided by the Ministry of Health, Labour, and Welfare of Japan. The City Health Office of the local government approved a head of time our study protocol, especially ethical aspects for potentially participating citizens. Potential participants received written and oral information about the study. It was emphasized that participation was voluntary. During the data collection, we obtained written consent from all the interviewees and verbal assent from PMHP whose carers participated in the interviews. In the case where the interviewee was under 18 years old, we gained verbal assent from them and written consent from their parents.

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Interview guide for interviews with people with mental health problems. A set of questions we referred while interviewing PMHP. (DOCX 88 kb)

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Interview guide for interviews with carers and community health volunteers. A set of questions we referred while interviewing carers and community health volunteers. (DOCX 90 kb)

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Tanaka, C., Tuliao, M.T.R., Tanaka, E. et al. A qualitative study on the stigma experienced by people with mental health problems and epilepsy in the Philippines. BMC Psychiatry 18 , 325 (2018). https://doi.org/10.1186/s12888-018-1902-9

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The overwhelming case for ending stigma and discrimination in mental health

Living with a mental health condition like schizophrenia or depression is difficult, but for many people living with mental health conditions, the negative perceptions and behaviours that arise in others and yourself are even worse.

 “I live with schizophrenia. It is amazing how people react the moment they just hear the word – they immediately take a step backwards,” says Charlene Sunkel, founder of the Global Mental Health Peer Network and co-chair of the Lancet Commission on Ending Stigma and Discrimination in Mental Health. “They are afraid of you because of this whole false perception that we are dangerous, we are unable to think, unable to work – that we are basically useless.”

Stigma is far from just negative attitudes – discriminatory behaviours are equally important to consider – which is why many prefer to use “stigma and discrimination” together.

Sir Graham Thornicroft, Professor of Community Psychiatry at King’s College London and other co-chair of the Lancet Commission, helpfully illustrates this through a phenomenon known as “diagnostic overshadowing”.

“Let’s imagine that a person who has depression develops severe pain in their stomach. They go into an emergency department. The doctor looks at the patient’s case records, sees that they have depression, and says, ‘It’s all in your mind’. On this occasion, it’s actually an appendix that’s about to burst, which could be a fatal complication.”

He admits this is a dramatic example, but it helps define the stakes – stigma can be an issue of life or death.

Stigma is the biggest barrier to thriving

Charlene and Graham entered the world of stigma reduction from different perspectives – Graham as care provider, Charlene as care user.

Graham entered through his work as a psychiatrist and researcher, recognizing that what separated psychiatry from other areas of medicine was the problem of stigma. A diagnosis could follow a person well beyond their interactions with health services, both in the form of negative attitudes or prejudice (“I don’t want to be around this person, they are dangerous”) and misinformation (“You can’t recover from depression”).

Prejudice and misinformation can in turn lead to discrimination, both at the interpersonal level (public stigma) and in laws and policies (structural stigma). Stigma has also been cited as a reason that mental health services receive less funding and are considered less prestigious than other health services in many countries.

People may also internalize stigmatizing beliefs (self-stigma), which can lead to poor self-esteem and “why-try syndrome” – not engaging in activities that are important to their livelihood, such as applying to university, because they believe they will fail.

Charlene entered the field through her experience of living with schizophrenia. “I was told that I’d never be able to work. I was also constantly in hospitals experiencing the abuse within the system in South Africa. It was when I started speaking to fellow peers that I began to realize that stigma is probably the biggest barrier for us to really gain our life back and thrive.”

What does the evidence say?

Graham and Charlene worked with 42 other researchers and people with the lived experience of mental health conditions to produce, in 2022, the Lancet Commission on Ending Stigma and Discrimination in Mental Health. This umbrella review of 216 systematic reviews, interspersed with poems from people living with mental health conditions, summarizes the best available evidence on what it takes to reduce stigma and discrimination.

Stigma is often framed in terms of mental health literacy. By correcting misinformation about mental health conditions, the theory goes, you reduce prejudice and make it less likely for someone to discriminate.

The problem is that correcting knowledge does not necessarily reduce prejudice; “The evidence is extremely weak,” Graham says.

“Awareness-raising activities are not enough to tackle the problem,” he continues.

According to the Lancet Commission, the best way to reduce stigma is through social contact – prejudice-reducing interactions between people living with mental health conditions and people without a condition.

While social contact may involve correcting misinformation, the focus is on changing attitudes and improving behaviour. Often, this involves having someone share their experiences of living with a mental health condition, balancing frank descriptions of past suffering with clear demonstrations of recovery and resilience.

It does not even need to be in person – there is increasing evidence that virtual contact can be just as effective, including positive and accurate portrayals of people with mental health conditions in film.

“Social contact can allow the target group to attach more agency to the person with a mental condition and show more empathy towards them,” says Graham.

People living with mental health conditions who are trained in social contact are often called “experts by experience”. It is important that these experts also lead anti-stigma initiatives, as it can make such initiatives more tailored to the context and ultimately more effective. Social contact tends to have greater impact in reducing prejudice when the person sharing is of relatively equal status to the audience.

“We have so much value to add because of our experiences,” says Charlene. “It’s not something you can study. We bring that value of practical solutions.”

So, what is being done?

The Lancet Commission provides 8 recommendations for various stakeholders, including WHO, on what to do to reduce stigma and discrimination. Both Graham and Charlene have been working to implement these recommendations.

Charlene, along with the advocacy organization she founded in 2018 called the Global Mental Health Peer Network, has taken ownership of recommendation 8 – developing funded programmes for people with lived experience. The Global Mental Health Peer Network aims to empower people living with mental health conditions to break down stigma in their communities and countries by providing them with a peer community and training opportunities.

Charlene says, “If there’s one solution to resolving stigma, it’s inclusion of people with mental health conditions in everything – in employment, education, communities. By including people, others can see it’s another human being, deserving of dignity and human rights”.

Graham and other researchers in King’s College London have partnered with WHO/Europe and members of the Global Mental Health Peer Network to fulfil recommendation 2 – developing a toolkit to reduce stigma and discrimination in mental health.

The toolkit, called the “WHO MOSAIC toolkit to end stigma and discrimination in mental health”, provides practical, step-by-step guidance on how to set up anti-stigma initiatives based on principles of social contact, co-leadership by people with lived experience and meaningful collaboration. It aims to be useful for individuals as well as groups and organizations.

The toolkit is undergoing expert consultation, being most recently presented to participants of the “Workshop on leadership and service transformation in mental health” in Brussels, Belgium on 22–23 May 2024.

The toolkit will be launched on 10 October 2024, World Mental Health Day.

Global Mental Health Peer Network

King’s College London

Lancet Commission on ending stigma and discrimination in mental health

Pan-European Mental Health Coalition

• Introduction
• Conclusions
• Article Information

Changes shown on attributions (A), preferences for social distance (B), and perceptions of dangerousness (C), by condition. Significant changes ( P  < .05) from one wave to the next (eg, 1996 to 2006) are indicated with heavy lines. Changes that were significant across the full time period (ie, 1996-2018), but not across successive waves, are indicated with a dashed line. All estimates are weighted. Data collected from the US National Stigma Studies. 12

The solid line provides the estimated trend across age groups (A), over time (B), and across cohorts (C). The shaded areas around the lines represent CIs, from light (95%) to dark (75%). Estimated cohort trends, which represent cohort-specific deviations from age and period trends, were obtained by averaging over all of the age-by-period combinations for a given cohort. For convenience, cohorts are indexed according to the first birth year in the birth cohort. The 1907 and 1917 cohorts were pooled to increase cell sizes. In all cases, higher values indicate a preference for greater social distance; lower values indicate the reverse. All estimates are weighted and adjust for respondents’ educational level, sex, and race and ethnicity, as well as the education, sex, and race and ethnicity of the person described in the vignette. Data collected from the US National Stigma Studies.

eMethods. Materials and Methods

eTable 1. Unadjusted Survey Year Differences

eTable 2. Adjusted Survey Year Differences

eTable 3. Model Fit of Candidate Models in APC Analyses

eTable 4. Deviation Magnitude Tests

eTable 5. Average Cohort Deviation Across Periods

eTable 6. Age and Period Main Effects

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Pescosolido BA , Halpern-Manners A , Luo L , Perry B. Trends in Public Stigma of Mental Illness in the US, 1996-2018. JAMA Netw Open. 2021;4(12):e2140202. doi:10.1001/jamanetworkopen.2021.40202

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Trends in Public Stigma of Mental Illness in the US, 1996-2018

• 1 Department of Sociology, Indiana University, Bloomington
• 2 Department of Sociology, Pennsylvania State University, University Park

Question   What changes in the prejudice and discrimination attached to mental illness have occurred in the past 2 decades?

Findings   In this survey study of 4129 adults in the US, survey data from 1996 to 2006 showed improvements in public beliefs about the causes of schizophrenia and alcohol dependence, and data from a 2018 survey noted decreased rejection for depression. Changes in mental illness stigma appeared to be largely associated with age and generational shifts.

Meaning   Results of this study suggest a decrease in the stigma regarding depression; however, increases and stabilized attributions regarding the other disorders may need to be addressed.

Importance   Stigma, the prejudice and discrimination attached to mental illness, has been persistent, interfering with help-seeking, recovery, treatment resources, workforce development, and societal productivity in individuals with mental illness. However, studies assessing changes in public perceptions of mental illness have been limited.

Objective   To evaluate the nature, direction, and magnitude of population-based changes in US mental illness stigma over 22 years.

Design, Setting, and Participants   This survey study used data collected from the US National Stigma Studies, face-to-face interviews conducted as 1996, 2006, and 2018 General Social Survey modules of community-dwelling adults, based on nationally representative, multistage sampling techniques. Individuals aged 18 years or older, including Spanish-speaking respondents, living in noninstitutionalized settings were interviewed in 1996 (n = 1438), 2006 (n = 1520), and 2018 (n = 1171). The present study was conducted from July 2019 to January 2021.

Main Outcomes and Measures   Respondents reacted to 1 of 3 vignettes (schizophrenia, depression, alcohol dependence) meeting Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition , criteria or a control case (daily troubles). Measures included beliefs about underlying causes (attributions), perceptions of likely violence (danger to others), and rejection (desire for social distance).

Results   Of the 4129 individuals interviewed in the surveys, 2255 were women (54.6%); mean (SD) age was 44.6 (16.9) years. In the earlier period (1996-2006), respondents endorsing scientific attributions (eg, genetics) for schizophrenia (11.8%), depression (13.0%), and alcohol dependence (10.9%) increased. In the later period (2006-2018), the desire for social distance decreased for depression in work (18.1%), socializing (16.7%), friendship (9.7%), family marriage (14.3%), and group home (10.4%). Inconsistent, sometimes regressive change was observed, particularly regarding dangerousness for schizophrenia (1996-2018: 15.7% increase, P  = .001) and bad character for alcohol dependence (1996-2018: 18.2% increase, P  = .001). Subgroup differences, defined by race and ethnicity, sex, and educational level, were few and inconsistent. Change appeared to be consistent with age and generational shifts among 2 birth cohorts (1937-1946 and 1987-2000).

Conclusions and Relevance   To date, this survey study found the first evidence of significant decreases in public stigma toward depression. The findings of this study suggest that individuals’ age was a conservatizing factor whereas being in the pre–World War II or millennial birth cohorts was a progressive factor. However, stagnant stigma levels for other disorders and increasing public perceptions of likely violence among persons with schizophrenia call for rethinking stigma and retooling reduction strategies to increase service use, improve treatment resources, and advance population health.

Stigma, the prejudice and discrimination attached to devalued conditions, has been consistently cited as a major obstacle to recovery and quality of life among people with psychiatric disorders. 1 - 3 Stigma has been implicated in worsening outcomes for people with serious mental illness, 4 , 5 with nearly 40% of this population reporting unmet treatment needs despite available effective treatments. 6 , 7 Although some psychiatrists claim that stigma has decreased 8 or is irrelevant, 9 stigma remains concerning to health care professionals, patients, advocacy groups, and policy makers. Research has not supported claims of a decrease in stigma. 3 Moreover, national levels of public stigma have been associated with treatment-seeking intentions and experiences of discrimination reported by people with mental illness. 10 , 11 Findings on antistigma interventions also reflect the persistence of stigma 3 , 12 , 13 ; the unclear, limited, or short-term effectiveness of both large-scale messaging and small-scale interventions 12 - 16 ; and the lack of scalability of many such programs. Herein, we examine US public stigma over a 22-year period to provide a detailed assessment of changes in the nature and magnitude of public stigma over 2 decades for major mental health disorders.

The US National Stigma Studies (US-NSSs) use the General Social Survey (GSS), a biannual, household-based, multistage, cluster-sampled interview project providing nationwide, representative data on adults (age ≥18 years) living in noninstitutionalized settings in the continental US. 12 Face-to-face interviews for the US-NSSs were conducted by trained interviewers using the pencil/paper mode in 1996 (n = 1444; response rate, 76.1%) and computer-assisted personal interview format in 2006 (n = 1522; response rate, 71.2%) and 2018 (n = 1173; response rate, 59.5%). The GSS follows the American Association for Public Opinion Research ( AAPOR ) reporting guideline, which the present study followed. Mode effects, tested between 1996 and 2006, were minimal 17 and analyses to identify potential biases resulting from changing response rates did not identify problems. 18 Weights are provided and used where appropriate. Respondents receive an information page in English/Spanish and are asked for their consent to begin the interview. Institutional review board approval for the GSS and this study is held at NORC and at Indiana University. The present study was conducted from July 2019 to January 2021.

The US-NSSs used a survey experimental design using vignettes describing a fictitious person with behaviors meeting Diagnostic & Statistical Manual of Mental Disorders, Fourth Edition 19 criteria for schizophrenia, major depression, alcohol dependence, and a daily troubles control (eMethods in the Supplement ). 20 , 21 This vignette strategy avoids identifying the nature of the problem, allowing for data collection on knowledge, recognition, and labeling by respondents. 20 , 21 The vignette character’s psychiatric condition as well as their self-reported sex (man or woman), race (African American, Hispanic, or White), and educational level (eighth grade, high school, or college) were randomly varied and assigned as experimental characteristics in the stimulus. These data were not reported or collected in the interview. One vignette per respondent was read aloud by the interviewer and printed on a card given to the respondent who was then asked a series of questions.

Three sets of dependent variables operationalized stigma. First, attributions targeted respondents’ evaluation of likely scientific causes (chemical imbalance and genetics) as well as their recognition of the situation as a mental illness. Other potential moral/social explanations (bad character, God’s will, ups and downs of life, and way raised [all coded 1 if very/somewhat likely; 0 otherwise]) were also included. Second, dangerousness asked about the likelihood that the vignette person would do something violent toward others (coded 1 if very/somewhat likely; 0 otherwise). Third, social distance, the most common measure of stigma, measured respondents’ unwillingness to work closely with the vignette person on a job, live next door to them, spend an evening socializing with them, marry into their family, make friends with them, or live near a group home (categories collapsed into not willing/do not know [1] or willing [0]); details are reported in eTable 1 in the Supplement . Additional analyses used an overall social distance, factor-analytic scale for depression (1-factor solution, factor loadings ranging between 0.47 and 0.80, Cronbach α = .85).

Statistical analyses evaluated changes across years. Because data were weighted, a design-based F statistic that used the second-order Rao and Scott 22 correction was used to test the equality of raw percentages. To adjust for possible sociodemographic shifts between survey years and examine disparities, logistic regression models were fit. Differences in the estimated probabilities for outcomes were calculated, holding control variables at sample-specific means. The delta method was used to determined 95% CIs. To explore subgroup differences in trends, we fit a series of regression models that included interactions between time periods and respondents’ sociodemographic characteristics. Model estimates were used to calculate estimated probabilities of preferring social distance at each time point (1996, 2006, and 2018) and for each group (eg, men vs women), as well as group-specific changes over time and group differences in trends. Owing to the population representation of racial and ethnic groups in the US population, African American and Hispanic groups were collapsed into a non-White category in the subgroup analysis to avoid estimation problems within the vignette-specific analyses. Variance estimates were again obtained via the delta method. In addition, an exploratory age, period, and cohort analysis applied the age-period cohort (APC)–I method of Luo and Hodges 23 to assess the unique contribution of birth cohorts to overall trends in the preferences of US residents for social distance. Aligned with Ryder’s view that a cohort’s meaning is “implanted in the age-time specification,” 24 [p861] this approach quantifies cohort associations as the differential outcomes of time periods depending on age groups (eMethods in the Supplement ). Different from conventional APC models that assume cohort associations occur independently of period and age, the APC-I approach acknowledges the association of age, period, and cohort, as originally proposed by Ryder, which makes the approach useful for identifying factors that might be attributed to cohort membership. The total sample size of the individual-level APC analysis is 4134, with the number of participants per age-period combination ranging between 126 and 345. Hypothesis tests were all 2 sided. The APC analysis was carried out using R, version 3.6.2 (R Foundation for Statistical Analysis). The rest of the analysis—including data cleaning and variable transformations—was performed using Stata, version 16 (StataCorp LLC). Findings at P  < .05 were considered significant.

Table 1 provides the sociodemographic profile of US NSS respondents across the 3 survey periods: 1996 (n = 1438), 2006 (n = 1520), and 2018 (n = 1171). Representation of age, sex, race and ethnicity, and educational level were roughly in line with US Census Bureau data (1996: men, 642 [44.6%]; women, 796 [55.4%]; mean [SD] age, 44.7 [17.0] years; 2006: men, 666 [43.8%]; women, 854 [56.2%]; mean [SD] age, 46.7 [17.0] years; men, 566 [48.3%]; women, 605 [51.7%]; mean [SD] age, 49.0 [17.4] years). The slight overrepresentation of women across time has been commonly seen in interview studies. The GSS did not collect specific ethnicity data until 2000; from then, race and ethnicity categories comprised non-White (2006: 425 [28.0%]; 2018: 322 [27.5%]) and White (2006: 1095 [72.0%]; 2018: 849 [72.5%]) individuals. Overall mean (SD) age was 44.6 (16.9) years.

Figure 1 depicts unadjusted changes across survey waves. Adjusted changes reveal few differences compared with unadjusted results and are reported here (eTable 2 in the Supplement ). Scientific attributions (chemical imbalance, genetics) were high and selected by increasing percentages of US residents, with the major increase occurring in the first period (1996-2006). Overall, in the earlier period (1996-2006), scientific attributions (eg, genetics) for schizophrenia (11.8%), depression (13.0%), and alcohol dependence (10.9%) increased. The only case in which public endorsement was lower than 50%, but still substantial, was for the control situation: daily troubles ( Figure 1 A; eTable 1 in the Supplement ). These results may suggest a medicalization of life problems. However, this early significant increase in the category of chemical imbalance was followed by a decrease later.

Although problem recognition increased only for schizophrenia in the first period and for alcohol dependence only in the second period, the levels were high for all mental illnesses. No change was documented for depression, with recognition already high, or for the control, in which depression was considered not warranted, signaling a distinct difference in the public response to nonclinical problems ( Figure 1 A).

Social and moral attributions were endorsed by relatively few respondents with little change over time ( Figure 1 A). Significantly fewer respondents cited ups and downs as a cause of depression or selected God’s will. The latter choice decreased significantly in the first period for daily troubles, even as the way an individual was raised increased significantly later. Alcohol dependence, however, was increasingly stigmatized, marked by significant change in respondents simultaneously citing bad character (18.2%) and ups and downs of life (11.3%) (eTable 2 in the Supplement ). Overall, trends suggest increasing mental health literacy, including distinguishing between daily problems and mental illness.

Social distance showed little change over time, except for depression ( Figure 1 B). In the later period (2006-2018), the desire for social distance decreased for depression in work (18.1%), socializing (16.7%), friendship (9.7%), family marriage (14.3%), and group home (10.4%) (eTable 2 in the Supplement ). For depression, the decreases were statistically significant and substantial. Reductions occurred in the later period, spanning all domains except neighbor, which was already low. Other minor changes in a direction indicating a higher stigma were in evidence early. This change included an increase in social distance for schizophrenia as neighbor and having the vignette person marry into the family ( Figure 1 B; eTable 2B in the Supplement ).

Inconsistent, sometimes regressive change, was observed, particularly regarding dangerousness for schizophrenia ( Figure 1 C) (1996-2018: 15.7% increase, P  ≤ .001) and bad character for alcohol dependence (1996-2018: 18.2% increase, P  ≤ .001).

The similarity between unadjusted and adjusted results suggests that sociodemographic characteristics offer little power in explaining stigma. Table 2 reports the results of analyses of subgroup factors for race and ethnicity, sex, age, and educational attainment (vignette person characteristics controlled). There were no significant differences in the overall time trends for sociodemographic groups, but a few associations were observed within periods. More men endorsed stigma (ie, in the most recent period for socializing, in the middle period for neighbor, and in the earliest period for friendship and group home support) compared with women. More respondents who self-reported race as non-White desired social distance from individuals with depression as neighbors in the most recent period.

The most consistent sociodemographic association was noted with age. Older individuals in each period were significantly more unwilling to have the vignette person marry into the family. This response did not change over time. In addition, more individuals with lower levels of education endorsed stigma in the most recent period (neighbor) and the middle period (marriage into the family).

In Figure 2 , a composite social distance scale depicts possible explanations of the stigma decrease for depression (eTables 3-6 in the Supplement ). Age and social distance appeared to be conservatizing factors ( Figure 2 A). Distinct period responses were noted, especially from 2006 to 2018, when stigma toward depression decreased significantly (Figure 2B). Two cohorts were more likely than expected to report lower stigma—the Silent Generation (part of the 1937-1946 birth cohort, after the Greatest Generation but before the Baby Boomers) and Millennials (1987-2000 birth cohort) ( Figure 2 C). The average deviation for the 1937-1946 birth cohort was −0.12 (SE, 0.05) ( P  = .02), and the average deviation for the 1987-2000 birth cohort was−0.21 (SE, 0.08) ( P  = .01) (eTable 5 in the Supplement ).

Our analyses identified both stability and change in stigma over the 22-year period from 1996 to 2018. Five robust and clear patterns emerged. First, the period around the turn of the century (1996-2006) saw a substantial increase in the public acceptance of biomedical causes of mental illness. Survey participants were more likely to recognize problems as mental illness and draw a line between daily troubles and diagnosable conditions. These changes mark greater scientific beliefs and a decrease in stigmatizing attributions, but no reduction in social rejection. Overall, trends suggest increasing mental health literacy, including distinguishing between daily living problems and mental illness, aligning with earlier research. 25 , 26 Second, the more recent period (2006-2018) documented, to our knowledge, the first significant, substantial decrease in stigma, albeit for one mental illness diagnosis: major depression. Fewer survey respondents expressed a desire for social distance from people with depression across nearly all domains, including work and family. Considered in the context of previous research, these decreases are statistically significant, substantively large, and persist in the presence of controls. Other disorders did not see reductions in social distance, and public perceptions of dangerousness for schizophrenia and moral attributions for alcohol dependence increased.

Third, respondents’ sociodemographic characteristics offered little insight into stigma, generally, or into observed decreases for depression. What is unusual about these findings is the absence of subgroup differences, suggesting a broad shift in the respondents’ thinking about depression. This absence of sociodemographic differences may be unexpected, but it supports findings from earlier NSSs. 10 , 27

Fourth, change over time may be associated with age as a conservatizing factor, 28 , 29 a cohort process in which older, more conservative individuals are replaced by younger, more liberal US residents, 29 , 30 and/or a period outcome stemming from broad shifts that are uniformly seen regarding social distance discriminatory predispositions across age and cohort. Although prior research tended to assume the observed trends primarily reflect a period-based process, we used the APC-I method to explore unique cohort patterns in public stigma of mental illness. Disaggregating the effects of age, period, and cohort revealed age as a conservatizing factor also seen in a parallel German study, 12 and a liberalizing tendency among both pre-WWII birth cohorts (referred to by demographers as the Silent Generation) and the most recent birth cohorts (Millennials), and a recent period outcome.

Fifth, although findings for depression are notable, other results may raise concerns. For schizophrenia, there has been a slow shift toward greater belief of dangerousness. Although not statistically significant in either of the time periods, the increase was substantial and relatively large over the entire period (approximately 13%), a finding analyzed in detail elsewhere. 31 The results for alcohol dependence are similarly mixed. Although there was an increase in the selection of alcohol dependence as a mental illness with chemical and genetic roots, the problem was also trivialized as ups and downs. Moreover, we observed a return to a moral attribution of bad character in the first period that remain stable into the second period.

This study has limitations. Responses to survey vignettes reflect attitudes, beliefs, and predispositions—not behavior. The lack of importance of sociodemographic characteristics may signal insensitivity in a vignette approach or in stigma measurement. 32 - 34 Although subgroup differences are widely believed to exist, such research is rare and often not generalizable. Yet, although our estimates of sociodemographic outcomes are somewhat inefficient owing to sample size constraints, power analyses indicate that they are adequately powered to detect very small effects overall (Cohen h = 0.12), and small to moderate associations within vignette condition (Cohen h = 0.25) (eMethods in the Supplement ). In addition, our vignettes are designed to capture public perceptions of behavior changes that typically occur with the onset of mental illness. Public response might differ if the vignettes included information about help-seeking and eventual recovery. Research that specifically targeted this limitation revealed a small but statistically significant lowering of public stigma when vignette persons were described as being in treatment or recovery. 35

Other limitations must also be considered. Decreasing response rates present a challenge to researchers who seek to model trends over time in attitudes or behaviors. As noted, GSS response rates decreased approximately 16% over the 22-year period in question. If GSS respondents were somehow increasingly selected on tolerance for individuals with mental illness, finding stigma change would be likely even in the absence of actual change. This explanation seems unlikely given our results. We found respondents’ attitudes toward mental illness were more accepting in some cases (eg, depression), but less accepting in others (eg, schizophrenia). Even for depression, in which change was found across social venues, the degree to which that happens varied greatly. If findings were an artifact of a simple sample selection process, we would not expect to observe this level of complexity. Trends over time would be more consistent across conditions, and differences between social domains would be less pronounced.

Equally important, although it may be tempting to associate the changes in mental health literacy in the earlier period with the stigma reduction for depression in the latter period, doing so would be premature. These data cannot support claims about lag effects owing to the GSS’s cross-sectional design. In addition, previous work, which examined this issue in detail in the earlier period alone, could document neither individual nor aggregate associations between accepting scientific attributions for mental illness and stigma levels. 10

Despite limitations, these findings have important implications for research and treatment as well as antistigma program and policy efforts. First and foremost, the results of this study suggest that public stigma can change. To our knowledge, this study is one of the first indications that revise the larger cultural climate of prejudice and discrimination without the coordinated, translational, and research-monitored program of stigma reduction used in other Western nations. 3 , 12 , 13 Research and antistigma efforts require content retooling to make use of what is known and address the most problematic and unique aspects of stigma. In the US, controversial and structural aspects of mental illness stigma have rarely been addressed. Not only are perceptions of violence increasing for schizophrenia, individuals with schizophrenia likely face the greatest resistance in dismantling public, legal, policy, treatment, and resource barriers. Furthermore, calls for tailoring efforts to diverse or specialized populations may be limited by a thin, unrepresentative, and contradictory scientific base. 36 , 37 Data gaps in our analysis signal the need for novel stigma targets in research, whether new measures or populations widely believed to hold distinct ideas about mental illness and stigma. Our results also raise questions on how the progress reported herein can be accelerated and regressive shifts reversed. These results suggest that we must be realistic because societies change slowly and change efforts must be persistent and sustainable. Randomized clinical trial–based antistigma research often reports positive findings in typical inoculation-style programs but confronts effects that are extinguished over time. 3 , 38

The NSSs have served as the de facto primary data source about public stigma in the US for the past 2 decades. In this analysis of 22 years of survey data, we found a significant decrease in public stigma toward major depression and increased scientific attribution for schizophrenia, major depression, and alcohol dependence. Our findings are consistent with the claims of Braslow et al 5 that what the public believes and knows often aligns with science (ie, increasing agreement with scientific attributions) but may fail to influence their attitudes and behavior (ie, desire for social distance from individuals with mental illness, except depression). The societal and individual effects of stigma are broad and pervasive. Stigma translates into individual reluctance to seek care, mental health professional shortages, and societal unwillingness to invest resources into the mental health sector. Yet, the research, teaching, and programming resources targeted to redress prejudice and discrimination remain a low priority, small in scale, and individually focused. 39 With indications that the level of stigma may be reducing, strategies to identify factors associated with the decrease in stigma for depression, to address stagnation or regression in other disorders, and to reach beyond current scientific limits are essential to confront mental illness’s contribution to the global burden of disease and improve population health.

Accepted for Publication: October 27, 2021.

Published: December 21, 2021. doi:10.1001/jamanetworkopen.2021.40202

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2021 Pescosolido BA et al. JAMA Network Open .

Corresponding Author: Bernice A. Pescosolido, PhD, Department of Sociology, Indiana University, 1022 E Third St, Bloomington, IN 47401 ( [email protected] ).

Author Contributions: Drs Pescosolido and Halpern-Manners had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Pescosolido, Halpern-Manners, Luo.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Pescosolido, Halpern-Manners.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Halpern-Manners, Luo.

Obtained funding: Pescosolido, Perry.

Administrative, technical, or material support: Pescosolido, Perry.

Supervision: Pescosolido.

Conflict of Interest Disclosures: Dr Luo reported receiving grants from the National Institutes of Health outside the submitted work. No other disclosures were reported.

Funding/Support: Support for the study was provided by the Brain & Behavior Research Foundation (formerly National Alliance for Research on Schizophrenia & Depression) Distinguished Investigator Award and from Indiana University Network Science Institute (Dr Pescosolido), and base support and supplement from the National Science Foundation to the National Opinion Research Center (NORC) for the General Social Survey (GSS) and the National Stigma Studies.

Role of the Funder/Sponsor: The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Information: All GSS data are available from NORC ( https://gss.norc.org ) and the GSS data explorer ( https://gssdataexlporer.norc.org ).

Additional Contributions: We thank Alejandra Laszlo Capshew, MS (Indiana Consortium for Mental Health Services Research), who assisted with project management; the College of Arts and Sciences and the Sociomedical Sciences Research Institute at Indiana University provided infrastructural support; and Tom W. Smith, PhD, and Jaesok Son, PhD (NORC at the University of Chicago), provided project assistance as key members of the NORC GSS Team. No financial compensation was provided.

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How Politicizing Migration Harms Health

Politicians around the world are increasingly mobilizing anti-immigrant sentiment to garner support and votes—a trend that is especially evident as the US presidential election approaches.

While political rhetoric that stereotypes and scapegoats immigrants is well-documented, less attention has been given to the impact of these sentiments on immigrants themselves. In an article published today in the Journal of the American Medical Association ( JAMA ) and in a recently published book, Migration Stigma (MIT Press), scholars identify “migration stigma” as a pervasive and destructive force that links responses to immigration—such as prejudice and politics—to the health of immigrants.

“This concept of ‘migration stigma’ for the first time pulls together phenomena like the politicization of immigration and goes beyond how the native born think of immigrants to consider how it influences physical and mental health,” said Lawrence Yang , professor and chair of the Department of Social and Behavioral Sciences at NYU School of Global Public Health, first author of the JAMA article, and lead editor of Migration Stigma.

The human cost

In the JAMA article, the authors write that being labeled as a migrant can set off a cascade of negative consequences: stereotyping, separation or “othering,” discrimination, and loss of social status. In the context of power dynamics, these factors together result in stigma.

Stigma can take different forms, but all risk harming the health and mental health of immigrants. One form, structural stigma, occurs when groups are treated differently by laws or policies based on their status. For immigrants, this may mean worse access to education, housing, health care, and jobs—all of which are powerful social determinants of health, or social and structural factors that influence health outcomes. 

Other forms of stigma may be less obvious. For instance, immigrants and their descendants who are attuned to the negative political environment and stereotypes people hold about immigrants may feel shame and internalize these negative beliefs. 

Internalized stigma can increase stress, which may lead to a host of mental health issues, including anxiety, depression, and sleep disorders, and can even exacerbate post-traumatic stress disorder (PTSD) among migrants who endured traumatic journeys across borders. Moreover, internalized stigma—coupled with the fear of deportation—may deter immigrants from seeking medical attention and other services that ultimately improve their health and life opportunities, including jobs and education. 

“New immigrants who are aware that the US is not the most hospitable place right now may respond to this negative environment by inadvertently avoiding opportunities to maintain their health,” said Yang, who is also the founding director of the Global Mental Health and Stigma Program at the NYU School of Global Public Health.

Addressing migration stigma

“A new focus on the intersection of migration and stigma creates an opportunity to break the cycle of harmful policies and rhetoric that fuel stigma and hurt the health of immigrants and others,” Yang said. And because stigma involves many factors—labeling, stereotyping, “othering,” and loss of status—interventions to reduce stigma can work to address any of these linkages. 

“For instance, we can introduce new narratives to change a label or address stereotyping, or can encourage policymakers to enact anti-discrimination laws to preserve access to health care and education,” said Yang.

The authors also write in JAMA that to avoid stigmatizing migrant patients, health professionals can recognize that health and illness stem from social, political, and economic structures. 

A new field of research

The concept of migration stigma grew out of an international forum, convened by the Ernst Stüngmann Foundation, that brought together scholars in the fields of stigma and migration to explore connections between the two. 

“Although both fields examine the causes and consequences of prejudice and discrimination, until recently there was little formal collaboration between stigma and migration scholars,” said Yang. 

Through this process, the scholars coined the concept of migration stigma and launched this new field of research. Future areas of study include the impact of the migrant label on different life domains, whether the label extends beyond migrants themselves to other generations or associated racial or ethnic groups, and whether stigma has long-term health consequences.

“By examining how the seemingly disparate phenomena of anti-immigrant politics and individuals’ health are related, we enhance the possibilities for researchers and clinicians to understand, and ideally, intervene to promote public health,” the authors write in JAMA . 

The JAMA article was co-authored by Bruce Link of UC Riverside and the Columbia Mailman School of Public Health and Maureen Eger of Umeå University and the Center for Right-Wing Studies at UC Berkeley. Eger and Link are also the co-editors of the book. 

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Study finds high unmet need for mental health care among adolescents in Asia and Europe

by University of Turku

A large international study conducted at the University of Turku in Finland found that most adolescents do not seek professional help even when they have a high level of mental health problems. This unmet need was prevalent across all eight Asian and European countries involved in this study but especially in lower-income countries.

The study , published in European Child & Adolescent Psychiatry , revealed that even though many adolescents consider getting help or seek help from informal sources for their mental health problems , very few seek help from formal sources.

Doctoral Researcher Yuko Mori from the Research Center for Child Psychiatry at the University of Turku, Finland, and the lead author of the study, tells that when adolescents attempt to get external help to deal with their mental health problems, there are two main types of help-seeking sources: informal and formal sources of help.

"Adolescents may get help from informal sources such as friends, teachers, and family members and/or formal sources such as school nurses, psychologists, and counselors for professional assistance. Where they seek help from depends, for example, on the availability of services, cultural background , and stigma associated with mental illness ," Mori says.

Less than 1% of adolescents in middle-income countries seek professional help

The study included 13,184 adolescents aged 13 to 15 who completed self-administered surveys between 2011 and 2017 across eight Asian and European countries: China, Finland, Greece, India, Israel, Japan, Norway, and Vietnam. The study was conducted as part of the Eurasian Child Mental Health Study (EACMHS), a school-based cross-national study into the well-being and mental health of adolescents.

In middle-income countries, less than 1% sought help from professional sources while in high-income countries, this rate is slightly higher, between 2% and 7%. Girls are generally more likely to seek help for mental health problems than boys.

Only 1%–2% of adolescents with a high level of emotional and behavioral problems in middle-income countries (India, Vietnam, China) sought formal help. In other words, 98%–99% of those who suffer from a high level of problems do not seek formal help. In high-income countries, the rate was significantly higher but still limited, 6%–7% in Greece, Israel, and Japan and 21%–25% in Norway and Finland.

"Interestingly, significant difference between girls and boys on the unmet need were found only in Norway and Finland where girls were more likely to seek formal help than boys," Mori notes.

Global need for mental health awareness and literacy programs

The study also revealed that informal sources of help are widely used among adolescents and are the key sources of help in many countries, particularly in lower-income countries.

The leader of the EACMHS, Professor Andre Sourander, MD says that the widely used informal sources of help especially in lower-income countries highlight a global need for mental health awareness and literacy programs.

"Cross-cultural studies on adolescent mental health such as the present study are important because almost all mental health research comes from high-income Western countries. There is a huge knowledge gap because most research represents less than 10% of adolescent population.

"Maybe the most striking result was how important informal sources of help such as teachers, friends and parents were. This indicates worldwide importance of promoting culturally sensitive mental health awareness and literacy programs," says Professor Sourander.

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More From Forbes

How leaders can address mental health and well-being in the workplace.

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Michael Timmes is an HR consultant with Insperity . He specializes in team building, employee engagement and performance improvement.

Last month was National Mental Health Awareness Month , but these days, discussions of mental health and well-being have been front and center in the workplace year-round. In fact, the American Psychological Association (APA) reports that 92% of people want to work for a company that provides mental health support , underlining the importance of mental health and well-being in the workplace to recruitment and retention.

Mental Health Versus Mental Well-Being

Employers may not know there is a difference between mental health and well-being. Mental health refers to the current state of our mental functioning, including our emotional, social and psychological states. Addressing mental health often means seeking support from medical professionals for a diagnosed psychological condition. This is important to know in the workplace since over one in five U.S. adults live with mental illness.

Mental wellness, or well-being, on the other hand, refers to an overall positive state of mind and is discussed in terms of prevention. Tied closely to self-care, mental wellness is defined by the Global Wellness Institute as an "internal resource that helps us think, feel, connect and function." More than just the absence of mental illness, mental wellness allows us to be emotionally resilient when faced with challenges, be aware of our strengths and weaknesses, develop healthy relationships and produce results in the workplace.

Fundamentally, mental health and well-being are interrelated, and a healthy workforce fuels successful organizations. Successful leaders take care of their people; the following outlines a few ways employers can better support employees for a more mentally healthy workforce.

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Even though conversations about mental health and well-being are becoming more common, they still carry stigma for some. Long days at work can take their toll, but many do not want to talk about stress and its impact on their mental health, concerned they may be seen as weak. Even though mental health topics may be front and center, the APA survey points out that more than half of employees feel their employer thinks their workplace is more mentally healthy than it is.

Long-held perceptions like these can change when you as a leader approach mental health honestly and regularly. An employee assistance program (EAP) is an important tool to support your employees in times of struggle, whether dealing with relationship problems, financial stressors, legal issues or other challenges. By connecting employees with necessary resources, an EAP can be one of the first lines of defense for people.

Managers can also serve as a model of mental health by openly discussing wellness and self-care. To set an example for their direct reports, managers can let their team know when they take a mental health day and share how they regularly practice self-care. Taking mental health and wellness seriously in the workplace starts with open conversations to break down any barriers.

That said, managers are not trained mental health professionals. It is understandable for managers to feel overwhelmed if their team comes to depend on them as their main source of mental health support. Encourage managers to connect with HR for guidance on helping connect employees with the mental health resources they need and setting appropriate boundaries—which will support the well-being of everyone involved.

In any workplace setup, whether remote, hybrid or in-person, one-on-one check-ins are another key tool to monitor changes. A decrease in the quality or quantity of work produced can also be a tell-tale sign of a bigger problem. Whenever you suspect an employee’s mental health or wellness is declining, you should approach them with compassion and caution, and tap your people and culture experts for support if needed.

Stay Flexible

Conversations are critical, but you also need to offer flexibility and time off for people to take care of their mental health and wellness. Some jobs are not flexible, but for those that are, flex-time options can allow employees to attend therapy sessions in the afternoon or spend time with loved ones.

Hybrid and remote work can also help with mental well-being by allowing employees to take breaks throughout the day and work in a familiar environment. Of course, in-office work has mental health benefits as well, like greater collaboration and an increased sense of community, which can reduce isolation.

Supporting the use of PTO is another tactic to further mental wellness in the workplace. Pew Research Center found that 46% of U.S. workers with PTO take less time than offered . Even with unlimited PTO, employees may feel guilty about taking "too much" time off, and while no PTO plan is truly unlimited, your team also needs to rest and recharge regularly. As a leader or manager, you should take your own PTO and set work-life boundaries to model self-care for your employees.

Any policies or procedures around these practices should be detailed in the employee handbook so your entire organization has clarity on where you stand.

Train Your Team

Supporting mental health and well-being can seem like a daunting task. However, there can be dire consequences if issues go unaddressed. Managers often are the first to notice when employees are not themselves. That said, mental health conversations may not come naturally. Ongoing mental health and well-being training for everyone within the organization will reduce the stigma and prepare colleagues to approach mental health and wellness helpfully.

It is also important to equip managers with education and training on how to manage mental health and wellness at work. This could involve teaching how to openly communicate with employees without crossing any lines into uncomfortable territory. Encourage your managers to keep an eye on their direct reports and elevate serious mental health concerns to HR so your employees feel valued and get the help they need.

By creating a supportive culture where mental health and well-being are seen as valuable parts of the workplace, you can improve the health of employees and the organization. Implement these strategies consistently and with the utmost care, and you will position your company as an employer of choice while doing right by your conscience.

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How to address health inequities affecting the LGBTQ community

The thesis is simple and intuitive: stress caused by experiencing bias, rejection, hostility, and marginalization takes a toll on the body and mind. the data bear that out..

Pride Month is a welcome opportunity to celebrate the LGBTQ community’s diversity and unyielding spirit. But the community needs more than parades and rainbow flags.

Ongoing discrimination and an unprecedented wave of legal, political, and societal threats are inflicting damage on the mental and physical health of LGBTQ people. The public needs need more research funding to document the resulting health inequities, more training for health professionals to recognize and address the unique needs of the LGBTQ community, and more policies to support the equality, dignity, and humanity of every human being.

In the first half of this year alone, more than 500 discriminatory anti-LGBTQ bills have been introduced in state legislatures. Among many other goals, these bills would ban access to life-saving health care for transgender individuals and criminalize teachers for discussing the existence of LGBTQ people. (Seven out of 10 LGBTQ youth surveyed report the existence of these bills adversely impacted their mental health , even when the bills do not become law.) On top of this, there has been an unparalleled, coordinated attack on clinicians providing gender-affirming care as well as LGBTQ researchers, legislators, and many others.

I’m an epidemiologist who focuses on health inequities affecting LGBTQ communities. Colleagues and I have spent decades documenting how discrimination impacts LGBTQ people through a process we call “minority stress.” The thesis is simple and intuitive: Stress caused by experiencing bias, rejection, hostility, and marginalization takes a toll on the body and mind. The data bear that out.

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Health care providers don’t routinely collect information on patients’ sexual orientation or gender identity, so data on health inequities is incomplete. But we do have evidence that LGBTQ people are burdened with disproportionate rates of mental health conditions, such as depression and suicide among adolescents , as well as physical health conditions like cancer . LGBTQ people are more likely to develop hypertension during their pregnancies and have their babies born preterm . Notably, they are more likely to die prematurely. Colleagues and I recently published a landmark study in JAMA based on 40 years of data with more than 90,000 participants. We found that lesbian and bisexual women die 26 percent earlier than their heterosexual peers.

The National Institutes of Health has designated LGBTQ individuals as a health disparities population, thereby opening new avenues for research funding. As recently as the 1990s, just a handful of peer-reviewed studies were published on LGBTQ health each year. Now it’s several thousand each year. Even so, LGBTQ communities remain dramatically understudied and underfunded. Just 1 percent of NIH-funded research focuses on LGBTQ health, even though almost 1 in 10 people in the United States are LGBTQ, and that number is twice as high among young people, who may feel less stigma in self-identifying as LGBTQ.

Public health and medical professionals have critical roles in addressing the health crises facing LGBTQ communities. Yet even elite institutions aren’t giving future leaders the skills and understanding they need to do their part.

For example, medical school students are not routinely trained to take a social history that’s inclusive of LGBTQ experiences. Public health students are not trained on how, or even why, they should collect sexual orientation and gender identity data along with other demographic data like age, race, ethnicity, and income. These gaps hamper our ability to document inequities, develop policies to address those inequities, and appropriately screen and treat patients who may be more vulnerable to certain health conditions due to minority stress.

This is undoubtedly a moment of adversity for LGBTQ communities. Yet it’s also an opportunity to demand and drive change. This month, colleagues and I are launching the LGBTQ Health Center of Excellence, a joint venture between the Harvard T.H. Chan School of Public Health and Harvard Pilgrim Health Care Institute. Our mission is to advance health equity for LGBTQ communities with a focus on training to prepare the next generation of LGBTQ health leaders; research to expand the evidence base of LGBTQ health; and dissemination to inform policy makers, health care providers, and the larger public about how to improve LGBTQ health most effectively. I’m hopeful that our center can serve as a model for change, but we need other institutions to follow suit.

Leaders in public health and medicine must raise our voices loudly and clearly to demand increased support and protections for the LGBTQ community. Our call to action cannot wait — we must secure dedicated research funding from NIH and philanthropists, train the next generation of leaders, conduct empirically grounded research, and translate our work into change.

Through solidarity and science, we can ensure that everyone — regardless of their sexual orientation or gender identity — has the chance to live a long and healthy life.

Dr. Brittany Charlton is the founding director of the LGBTQ Health Center of Excellence at the Harvard T.H. Chan School of Public Health and Harvard Pilgrim Health Care Institute.

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Mental illness-related stigma in healthcare

Stephanie knaak.

1 Opening Minds, Mental Health Commission of Canada, Ottawa, Ontario, Canada.

2 Department of Psychiatry, University of Calgary, Calgary, Alberta, Canada.

3 Programs and Priorities, Mental Health Commission of Canada, Ottawa, Ontario, Canada.

Andrew Szeto

4 Department of Psychology and Office of the Provost, University of Calgary, Calgary, Alberta, Canada.

Mental illness-related stigma, including that which exists in the healthcare system and among healthcare providers, creates serious barriers to access and quality care. It is also a major concern for healthcare practitioners themselves, both as a workplace culture issue and as a barrier for help seeking. This article provides an overview of the main barriers to access and quality care created by stigmatization in healthcare, a consideration of contributing factors, and a summary of Canadian-based research into promising practices and approaches to combatting stigma in healthcare environments.

Introduction

Mental illness-related stigma, including that which exists in the healthcare system and among healthcare providers, has been identified as a major barrier to access treatment and recovery, as well as poorer quality physical care for persons with mental illnesses. 1 – 5 Stigma also impacts help-seeking behaviours of health providers themselves and negatively mediates their work environment. 6 – 9 What follows is a consideration of the literature on the main sources of personal and interpersonal stigma in healthcare, impacts for both patients and providers, and evidence-based solutions that can be implemented to improve patient-provider interactions and quality of care.

What are the main sources of stigma in healthcare?

Developed from Goffman’s pioneering work, 10 stigma is conceptualized as a complex social process of labeling, othering, devaluation, and discrimination involving an interconnection of cognitive, emotional, and behavioural components. 11 , 12 Stigmatization occurs on multiple levels simultaneously—intrapersonal (eg, self-stigma), interpersonal (eg, relations with others), and structural (eg, discriminatory and/or exclusionary policies, laws, and systems). 11 – 13 It is also keenly recognized that only powerful social groups can stigmatize. 11 Such an understanding is helpful for appreciating how stigmatization occurs on multiple levels throughout the healthcare sector, including structural (eg, investment of resources, quality of care standards, organizational culture), interpersonal (eg, patient–provider interactions, discriminatory behaviours, negative attitudes), and intraindividual (eg self-stigma, patient reluctance to seek care, provider reluctance to disclose a mental illness and/or seek care). 12 , 13

Research has identified a number of issues contributing to stigmatization in healthcare, which have direct and indirect impacts on access and quality of care for persons living with mental illnesses. These have been described as “key learning needs,” 14 acknowledging that they are specific concerns that can be changed through targeted initiatives.

Negative attitudes and behaviours

People with lived experience of a mental illness commonly report feeling devalued, dismissed, and dehumanized by many of the health professionals with whom they come into contact. 15 – 21 Key themes include feeling excluded from decisions, receiving subtle or overt threats of coercive treatment, being made to wait excessively long when seeking help, being given insufficient information about one’s condition or treatment options, being treated in a paternalistic or demeaning manner, being told they would never get well, and being spoken to or about using stigmatizing language. 15 – 21 While research also highlights many positive patient experiences (eg, Clark et al. 19 Barney et al. 20 and Connor et al. 21 ), the pervasiveness with which negative interactions are reported suggests the problem is not isolated to a few insensitive providers but is more systemic in nature—that it is a problem with how healthcare culture prioritizes and perceives persons with mental illnesses. 1 , 4 – 7

Research with healthcare providers is consistent with this idea, finding that stigmatizing attitudes and behaviours towards persons with mental illnesses exist across the spectrum of healthcare. 2 , 5 – 7 Also, patients with certain disorders, such as personality disorders, tend to be particularly rejected by healthcare staff and are often felt to be difficult, manipulative, and less deserving of care. 6 , 22 – 24 A Canadian qualitative study 14 articulated stigmatization among health providers to be, at least in part, related to a tendency “see the illness ahead of the person,” which can contribute to a failure to use person-first language and/or a tendency to engage in behaviours that may be experienced as dismissive or demeaning. Burnout and compassion fatigue have been identified as exacerbating concerns. 2 , 14

Lack of awareness

Another issue is a lack of awareness and unconscious biases, which acknowledge the power of hidden beliefs and attitudes that can underlie stigma-related behaviour. 14 , 25 – 28 Qualitative research has found that for many healthcare providers, it is only through the experience of receiving anti-stigma training that they become aware of the subtle and unintended ways certain beliefs and behaviours may have been contributing to stigmatizing experiences among their patients (Knaak et al. 14 see also Sukhera et al. 25 and Horsfall et al. 28 )

Therapeutic pessimism

Research consistently demonstrates that healthcare providers tend to hold pessimistic views about the reality and likelihood of recovery, which is experienced as a source of stigma and a barrier to recovery for people seeking help for mental illnesses. 2 , 6 , 7 , 12 , 29 Research also suggests that pessimism about recovery for some providers is associated with a sense of helplessness, leading them to believe that “what they do doesn’t matter.” 14

Lack of skills

Inadequate skills and training seem to be associated with stigmatization in two ways. First, it is believed to lead to feelings of anxiety or fear and a desire for avoidance and social/clinical distance among practitioners, which can negatively impact patient–provider interactions and quality of care. 6 , 29 – 31 Second, it can lead to less effective treatment and poorer outcomes. 2 , 6 , 32

Stigma in workplace culture

Importantly, the problem is not just outward facing—mental illness-related stigma also permeates the healthcare sector as a workplace. It has been described as a problem of culture, where staff are often discouraged to talk openly or seek help for psychological problems. 1 , 6 , 8 , 9 Research with healthcare providers in Canada indicates that the level of stigma regarding their own willingness to disclose and/or seek help for a mental illness is consistently higher than their level of stigma for other dimensions such as negative attitudes and preference for social distance. 33 Also, within the workplace context, people with mental illnesses are perceived as less competent, dangerous, and unpredictable and that work itself is not good for people with mental illnesses. 34

Consequences of stigma for access and quality care

These issues create barriers through such pathways as delays in help-seeking, discontinuation of treatment, suboptimal therapeutic relationships, patient safety concerns, and poorer quality mental and physical care. 1 – 2 , 12 , 35 – 37 For example, anticipated stigma from healthcare providers has been identified as a factor in people’s reluctance to seek help for a mental illness. 12 , 15 , 19 Compromised patient–provider relationships and early termination of treatment are also consequences. 2 , 5 , 15 , 16 , 38 , 39 A survey conducted by the Canadian Psychiatric Association found that 79% reported first-hand experiences of discrimination towards a patient and 53% observed other medical providers, discriminating against a patient from psychiatry. 1 Stigma also has consequences for patient safety. 16 , 40 A recent Canadian study identified stigma as a barrier to patient safety through factors such as staff attitudes and institutional culture and the accepted marginalization of mental health patients that occurs through stigmatization. 40

Poorer physical care for persons with mental illnesses is another consequence of stigmatization. Persons with lived experience of a mental illness commonly report barriers to having their physical care needs met, including not having their symptoms taken seriously when seeking care for non-mental health concerns. 5 , 15 – 16 , 19 Studies also demonstrate that persons with mental illness histories receive poorer quality care for their physical health problems. 29 , 35 , 37 , 41 , 42 This is believed to occur largely through a process of diagnostic and treatment overshadowing, whereby physical symptoms are misattributed to a patient’s mental illness, creating delays in diagnoses and treatment options. 29

Stigmatization also has inward-facing impacts for health professionals’ own willingness to seek help or disclose a mental health problem, which can result in an over-reliance on self-treatment, low peer support—including ostracization and judgment from co-workers if disclosure does occur—and increased risk of suicide. 1 , 6 , 8 , 9 , 43 Given that mental illnesses are related to presenteeism and productivity losses in the workplace (eg, Dewa et al. 44 ), it’s even more important to consider the impact of stigma in this context. For example, initial reluctance to seek help may result in decreased productivity, which may lead to confirmation of stereotypes and additional stigma by co-workers resulting in further reluctance to seek help.

Removing barriers to access and care through stigma reduction

The deleterious impacts of stigma in healthcare have promoted increased calls to action for health organizations to take leadership roles in tackling the problem. 1 , 18 , 26 , 27 , 45 – 47 A growing body of Canadian research has identified promising strategies for stigma reduction in healthcare settings. For example, qualitative and theoretical models emphasize the importance of approaching stigma reduction with the goal of culture change, a dedication to taking a sustained, integrated approach to target stigma from both outward- and inward-facing perspectives (avoiding the temptation to employ one-off programming), and committing to strong leadership support. 14 , 27 Implementation models also emphasize mandatory and/or incentivized participation, as well as the incorporation of stigma reduction metrics into hospital and other accreditation processes as a key measure for quality of care. 3 , 14

Key ingredients for effective stigma reduction in healthcare contexts have also been identified. 48 It is believed the effectiveness of these ingredients lies in the extent to which they are able to address the sources of stigma describe above. 14 These include teaching skills that help healthcare providers know “what to say” and “what to do,” ensuring program facilitators are modelling person-first behaviours and making ample use of social contact. 48 Social contact generally refers to hearing first-voice testimonies from people with lived experience of a mental illness who are trained to speak about their experiences of illness and recovery, as well as their experiences within the healthcare system, and is a key strategy for interprofessional educational approaches to stigma reduction in healthcare. 48 – 50 It is a qualitatively different kind of contact from typical provider-patient interactions. In social contact approaches, people with lived experience of a mental illness are seen not as patients but as educators. 45 , 50 – 52 Social contact has been shown to disconfirm stereotypes, diminish anxiety, heighten empathy, make personal connections, and improve understanding of recovery. 50 – 52

Two other key ingredients have also been identified. The first is providing interventions that include myth busting or a transformative learning focus to target unconscious biases and correct false beliefs that may be negatively impacting care. 25 , 27 , 48 The second is demonstrating/emphasizing recovery from a mental illness and showing ways in which healthcare providers play an impactful role in that process. 48 More fulsome implementation of person-centred recovery-oriented models of care is also believed to be important. 53 – 55

There is also a growing body of program-based Canadian evaluation research with healthcare providers. 25 , 31 , 45 , 52 , 56 – 64 Effective models include workshop-based interventions, skills-based interventions, and intensive social contact interventions. One workshop program showing promising results is a 2-hour face-to-face delivered program called Understanding Stigma developed by the Ontario Central Local Health Integration Network. 56 , 57 This program includes educational elements designed to increase knowledge, skills, and awareness, “action-oriented” elements aimed at behaviour change, and one or more social contact elements. It has been evaluated in numerous settings with different healthcare audiences using a pre-post follow-up design and the 15-item Opening Minds Scale for Health Care Providers (OMS-HC) scale, developed specifically to measure attitudes and behavioural intentions of healthcare providers towards persons with mental illnesses. 33 Evaluation results show significant pre-post improvements in all 3 factors of the OMS-HC, with changes being sustained at 3- and 6-month follow-up with the implementation of a booster session. 56 , 57

Another program demonstrating encouraging evaluation results using the OMS-HC is a web-based accredited on-line continuing medical education program called “Combating Stigma,” 58 , 59 freely available at www.mdcme.ca . Participant observation, human factors, and design thinking were primary methods informing the curriculum design, as the key objective was to address the challenge that stigma is a largely unperceived learning need for many health providers with denied limitations in quality of care. 59 While designed primarily for physicians, evaluation data show that over half of the program’s participants are nurses and allied health professionals. 59 A similar program for nurses titled “De-Stigmatizing Practices and Mental Illness” is now available on the www.mdcme.ca site.

The Working Mind (TWM) is a promising inward-facing program being used in healthcare settings. 64 Developed from the Department of National Defence’s Road to Mental Readiness Program, 65 the primary objectives of TWM are to reduce the stigma of mental illnesses, increase resiliency, and promote early help seeking in program participants. 47 , 64 , 65 Preliminary evaluation results indicate the program is effective at improving attitudes, encouraging people to seek help, and increasing readiness to deal with stress and challenging events, 64 and is currently being adapted for resident doctors and physicians.

Skills-based training also holds promise as a model for reducing stigma. Skills-based interventions focus on behaviour change by aiming to improve confidence, comfort, and understanding of mental illnesses as being inherently treatable and manageable. 14 , 48 One example is the Adult Mental Health Practice Support Program developed in British Columbia. 30 , 31 , 60 , 64 The program teaches self-management cognitive behavioural tools to family physicians and other frontline healthcare providers for patients with mild to moderate depression and anxiety. It aims to reduce stigma through improved patient-provider interactions and improved confidence and competence in working with patients with mental illnesses. 30

An evaluation of this program in British Columbia found that physicians reported decreased reliance on prescribing antidepressant medications, felt their patients were better able to stay or return to work, and reported improved patient care. 30 A randomized control study of this same program in Nova Scotia found robust improvements in confidence and skills compared to treatment-as-usual (TAU) and also a significant reduction in social distance. 31 , 64 Researchers also found significantly lower Patient Health Questionnaire (PHQ)-9 depressive ratings among patients at 6-month follow-up and significantly lower levels of anti-depressant prescribing compared to TAU. 64

Another important model is that of intensive social contact, where health providers meet at multiple time points with a person with lived experience of a mental illness living in recovery in order to learn about that person’s life and experiences. 45 , 52 , 63 Evaluations using the OMS-HC have shown this model to be effective at improving attitudes and behavioural intentions and sustaining those improvements over time, and qualitative research suggests the personal and cooperative nature of the social contact can provide a powerful and positively transformative learning experience for both providers and client educators. 45 , 63

The primary focus of this article was to identify barriers to access and quality care created by stigmatization processes at the level of personal and interpersonal stigma and to identify solutions that can be implemented within existing structures. A key limitation of the evidence described in this article is that many anti-stigma interventions are evaluated using provider-based outcomes—typically attitudes and behavioural intentions of health providers. There is a need for more research that targets the impacts of stigma reduction initiatives on patient experiences and specific care practices. As well, many programs are implemented and evaluated as “one-off” interventions. Longitudinal research using mixed-method designs that track the implementation of more sustained stigma reduction efforts within healthcare organizations and setting would be of benefit.

An organizational culture that promotes staff health and well-being and is committed to combating stigma in patient care is likely to have a positive impact on staff and patient safety as well as the financial bottom line. Approaching the problem of stigmatization from an organizational culture perspective and a quality of care perspective—and developing and implementing relevant stigma reduction metrics and targets into health and safety (eg, Canadian Standards Association 66 ) and accreditation standards—would likely be an effective way to target the personal and interpersonal components of stigma described above and would also begin to address the structural aspects of stigma embedded in the health system.

Acknowledgments

The authors would like to thank Romie Christie, Dr. Scott Patten, Dr. Heather Stuart, Dr. Rob Whitley, and the 2 anonymous reviewers for reviewing and providing input on earlier drafts of this article.

Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was made possible through funding from Opening Minds, the anti-stigma initiative of the Mental Health Commission of Canada. The work of the Mental Health Commission of Canada is supported by a grant from Health Canada.

40 Facts About Elektrostal

Written by Lanette Mayes

Modified & Updated: 01 Jun 2024

Reviewed by Jessica Corbett

Elektrostal is a vibrant city located in the Moscow Oblast region of Russia. With a rich history, stunning architecture, and a thriving community, Elektrostal is a city that has much to offer. Whether you are a history buff, nature enthusiast, or simply curious about different cultures, Elektrostal is sure to captivate you.

This article will provide you with 40 fascinating facts about Elektrostal, giving you a better understanding of why this city is worth exploring. From its origins as an industrial hub to its modern-day charm, we will delve into the various aspects that make Elektrostal a unique and must-visit destination.

So, join us as we uncover the hidden treasures of Elektrostal and discover what makes this city a true gem in the heart of Russia.

Key Takeaways:

• Elektrostal, known as the “Motor City of Russia,” is a vibrant and growing city with a rich industrial history, offering diverse cultural experiences and a strong commitment to environmental sustainability.
• With its convenient location near Moscow, Elektrostal provides a picturesque landscape, vibrant nightlife, and a range of recreational activities, making it an ideal destination for residents and visitors alike.

Known as the “Motor City of Russia.”

Elektrostal, a city located in the Moscow Oblast region of Russia, earned the nickname “Motor City” due to its significant involvement in the automotive industry.

Home to the Elektrostal Metallurgical Plant.

Elektrostal is renowned for its metallurgical plant, which has been producing high-quality steel and alloys since its establishment in 1916.

Boasts a rich industrial heritage.

Elektrostal has a long history of industrial development, contributing to the growth and progress of the region.

Founded in 1916.

The city of Elektrostal was founded in 1916 as a result of the construction of the Elektrostal Metallurgical Plant.

Located approximately 50 kilometers east of Moscow.

Elektrostal is situated in close proximity to the Russian capital, making it easily accessible for both residents and visitors.

Known for its vibrant cultural scene.

Elektrostal is home to several cultural institutions, including museums, theaters, and art galleries that showcase the city’s rich artistic heritage.

A popular destination for nature lovers.

Surrounded by picturesque landscapes and forests, Elektrostal offers ample opportunities for outdoor activities such as hiking, camping, and birdwatching.

Hosts the annual Elektrostal City Day celebrations.

Every year, Elektrostal organizes festive events and activities to celebrate its founding, bringing together residents and visitors in a spirit of unity and joy.

Has a population of approximately 160,000 people.

Elektrostal is home to a diverse and vibrant community of around 160,000 residents, contributing to its dynamic atmosphere.

Boasts excellent education facilities.

The city is known for its well-established educational institutions, providing quality education to students of all ages.

A center for scientific research and innovation.

Elektrostal serves as an important hub for scientific research, particularly in the fields of metallurgy , materials science, and engineering.

Surrounded by picturesque lakes.

The city is blessed with numerous beautiful lakes , offering scenic views and recreational opportunities for locals and visitors alike.

Well-connected transportation system.

Elektrostal benefits from an efficient transportation network, including highways, railways, and public transportation options, ensuring convenient travel within and beyond the city.

Famous for its traditional Russian cuisine.

Food enthusiasts can indulge in authentic Russian dishes at numerous restaurants and cafes scattered throughout Elektrostal.

Home to notable architectural landmarks.

Elektrostal boasts impressive architecture, including the Church of the Transfiguration of the Lord and the Elektrostal Palace of Culture.

Offers a wide range of recreational facilities.

Residents and visitors can enjoy various recreational activities, such as sports complexes, swimming pools, and fitness centers, enhancing the overall quality of life.

Provides a high standard of healthcare.

Elektrostal is equipped with modern medical facilities, ensuring residents have access to quality healthcare services.

Home to the Elektrostal History Museum.

The Elektrostal History Museum showcases the city’s fascinating past through exhibitions and displays.

A hub for sports enthusiasts.

Elektrostal is passionate about sports, with numerous stadiums, arenas, and sports clubs offering opportunities for athletes and spectators.

Celebrates diverse cultural festivals.

Throughout the year, Elektrostal hosts a variety of cultural festivals, celebrating different ethnicities, traditions, and art forms.

Electric power played a significant role in its early development.

Elektrostal owes its name and initial growth to the establishment of electric power stations and the utilization of electricity in the industrial sector.

Boasts a thriving economy.

The city’s strong industrial base, coupled with its strategic location near Moscow, has contributed to Elektrostal’s prosperous economic status.

Houses the Elektrostal Drama Theater.

The Elektrostal Drama Theater is a cultural centerpiece, attracting theater enthusiasts from far and wide.

Popular destination for winter sports.

Elektrostal’s proximity to ski resorts and winter sport facilities makes it a favorite destination for skiing, snowboarding, and other winter activities.

Promotes environmental sustainability.

Elektrostal prioritizes environmental protection and sustainability, implementing initiatives to reduce pollution and preserve natural resources.

Home to renowned educational institutions.

Elektrostal is known for its prestigious schools and universities, offering a wide range of academic programs to students.

Committed to cultural preservation.

The city values its cultural heritage and takes active steps to preserve and promote traditional customs, crafts, and arts.

Hosts an annual International Film Festival.

The Elektrostal International Film Festival attracts filmmakers and cinema enthusiasts from around the world, showcasing a diverse range of films.

Encourages entrepreneurship and innovation.

Elektrostal supports aspiring entrepreneurs and fosters a culture of innovation, providing opportunities for startups and business development .

Offers a range of housing options.

Elektrostal provides diverse housing options, including apartments, houses, and residential complexes, catering to different lifestyles and budgets.

Home to notable sports teams.

Elektrostal is proud of its sports legacy , with several successful sports teams competing at regional and national levels.

Boasts a vibrant nightlife scene.

Residents and visitors can enjoy a lively nightlife in Elektrostal, with numerous bars, clubs, and entertainment venues.

Promotes cultural exchange and international relations.

Elektrostal actively engages in international partnerships, cultural exchanges, and diplomatic collaborations to foster global connections.

Surrounded by beautiful nature reserves.

Nearby nature reserves, such as the Barybino Forest and Luchinskoye Lake, offer opportunities for nature enthusiasts to explore and appreciate the region’s biodiversity.

Commemorates historical events.

The city pays tribute to significant historical events through memorials, monuments, and exhibitions, ensuring the preservation of collective memory.

Promotes sports and youth development.

Elektrostal invests in sports infrastructure and programs to encourage youth participation, health, and physical fitness.

Hosts annual cultural and artistic festivals.

Throughout the year, Elektrostal celebrates its cultural diversity through festivals dedicated to music, dance, art, and theater.

Provides a picturesque landscape for photography enthusiasts.

The city’s scenic beauty, architectural landmarks, and natural surroundings make it a paradise for photographers.

Connects to Moscow via a direct train line.

The convenient train connection between Elektrostal and Moscow makes commuting between the two cities effortless.

A city with a bright future.

Elektrostal continues to grow and develop, aiming to become a model city in terms of infrastructure, sustainability, and quality of life for its residents.

In conclusion, Elektrostal is a fascinating city with a rich history and a vibrant present. From its origins as a center of steel production to its modern-day status as a hub for education and industry, Elektrostal has plenty to offer both residents and visitors. With its beautiful parks, cultural attractions, and proximity to Moscow, there is no shortage of things to see and do in this dynamic city. Whether you’re interested in exploring its historical landmarks, enjoying outdoor activities, or immersing yourself in the local culture, Elektrostal has something for everyone. So, next time you find yourself in the Moscow region, don’t miss the opportunity to discover the hidden gems of Elektrostal.

Q: What is the population of Elektrostal?

A: As of the latest data, the population of Elektrostal is approximately XXXX.

Q: How far is Elektrostal from Moscow?

A: Elektrostal is located approximately XX kilometers away from Moscow.

Q: Are there any famous landmarks in Elektrostal?

A: Yes, Elektrostal is home to several notable landmarks, including XXXX and XXXX.

Q: What industries are prominent in Elektrostal?

A: Elektrostal is known for its steel production industry and is also a center for engineering and manufacturing.

Q: Are there any universities or educational institutions in Elektrostal?

A: Yes, Elektrostal is home to XXXX University and several other educational institutions.

Q: What are some popular outdoor activities in Elektrostal?

A: Elektrostal offers several outdoor activities, such as hiking, cycling, and picnicking in its beautiful parks.

Q: Is Elektrostal well-connected in terms of transportation?

A: Yes, Elektrostal has good transportation links, including trains and buses, making it easily accessible from nearby cities.

Q: Are there any annual events or festivals in Elektrostal?

A: Yes, Elektrostal hosts various events and festivals throughout the year, including XXXX and XXXX.

Elektrostal's fascinating history, vibrant culture, and promising future make it a city worth exploring. For more captivating facts about cities around the world, discover the unique characteristics that define each city . Uncover the hidden gems of Moscow Oblast through our in-depth look at Kolomna. Lastly, dive into the rich industrial heritage of Teesside, a thriving industrial center with its own story to tell.

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State Housing Inspectorate of the Moscow Region

Phone 8 (496) 575-02-20 8 (496) 575-02-20

Phone 8 (496) 511-20-80 8 (496) 511-20-80

Public administration near State Housing Inspectorate of the Moscow Region