Is Mental Health Stigma Decreasing? It’s Complicated

The Merriam-Webster dictionary defines stigma as “a set of negative and often unfair beliefs that a society or group of people have about something… a mark of shame or discredit.” Borrowed from Latin, it ultimately comes from the Greek "stizein" meaning, "to tattoo," and refers to marks used on slaves and criminals in Ancient Greece.

Throughout history, people with mental and behavioral disorders were routinely blamed, ostracized, isolated, imprisoned, tortured, or killed. And while our treatment of—and attitudes about—mental illness have improved dramatically in the 20th and 21st centuries, mental health stigma has not disappeared. A 2016 review of the research by Zurich University psychologist Wulf Rössler concluded: “There is no country, society or culture where people with mental illness have the same societal value as people without a mental illness.”

When mental health problems are stigmatized, those who cope with them are consigned to wrestle not just with the disorder, but also with the attendant social prejudice and rejection. The effects of stigma are profound both personally and socially, as they may compel people to hide or deny their issues, refrain from seeking help, and engage in self-blame (AKA self-stigma).

A 2010 systematic review of the literature by Jessica Sharac of King’s College London and colleagues looked at 27 studies of stigma and its effects, concluding, “Mental illness stigma/discrimination was found to impact negatively on employment, income, public views about resource allocation and healthcare costs.”

Columbia University stigma researchers Bruce Link and Jo Phelan concur: “Stigmatization probably has a dramatic bearing on the distribution of life chances in such areas as earnings, housing, criminal involvement, health, and life itself.”

Laypersons may intuit that stigma is one thing—a negative, prejudiced attitude about something. Yet research suggests that stigma, like most everything else in life, is a complex construct.

Contemporary research has tended to divide the construct of stigma into three separate elements. As Graham Thornicroft of King’s College London and colleagues explain, those are “a lack of knowledge (ignorance), negative attitudes (prejudice) and people behaving in ways that disadvantage the stigmatised person (discrimination)”

In other words, stigma involves a cognitive component (ignorant beliefs), an emotional component (negative feelings of dislike, loathing, fear), and a behavioral component (acting to ostracize and oppress the stigmatized person or group).

Bruce Link and Jo Phelan (2001) proposed a model in which a stigma is defined by the process of convergence among five distinctive components:

The first component involves distinguishing and labeling human differences. The second involves the process by which “dominant cultural beliefs link labeled persons to undesirable characteristics-to negative stereotypes.” The third component occurs when “labeled persons are placed in distinct categories so as to accomplish some degree of separation of "us" from "them." The fourth component has labeled persons “experience status loss and discrimination that lead to unequal outcomes.”

Finally, the fifth component is access to social, economic, and political power, which allows “the separation of labeled persons into distinct categories, and the full execution of disapproval, rejection, exclusion, and discrimination.” In other words, “when people have an interest in keeping other people down, in or away, stigma is a resource that allows them to obtain ends they desire.”

The multi-dimensional structure of stigma makes plausible the prediction that different aspects of stigma may operate quite independently of one another. For example, we may come to fear depressed people less, but still believe ignorantly that their depression is their fault. Likewise, a stigmatized group may simultaneously gain in social status and incur increased prejudice and hostility. If this is so, then addressing one component of stigma successfully may prove insufficient in reducing its overall ill-effects.

A recent (2021) study by sociologist Bernice Pescosolido of Indiana University and colleagues provides an illustration of this complexity. The authors used data from face-to-face interviews conducted three times between 1996 and 2018 with a representative sample of over 4,000 U.S. adults.

Participants were asked to respond to one of three vignettes showing people who met DSM diagnostic criteria for schizophrenia, depression, and alcohol dependence or a control case (showing a person dealing with mere daily troubles). Participants then answered questions about the underlying causes (attributions) as well as the likelihood of violence (danger to others), and rejection (desire for social distance) regarding the person in the vignette.

Results showed a mixed pattern. The period between 1996-2006 saw an increase in the endorsement of genetic attributions for schizophrenia, depression, and alcohol dependence. In the later period (2006-2018), the desire for social distance decreased for depression across domains such as work, socializing, friendship, and marriage. At the same time, regressive changes were also observed. In 2018, participants saw people with schizophrenia as more dangerous and were more likely to attribute alcoholism to bad character than did 1996 participants.

The researchers found that demographic factors such as race and ethnicity, sex, and educational attainment failed to predict significant differences in the overall time trends. The one demographic factor that appears to have the most influence on stigma is age. “Older individuals in each period were significantly more unwilling to have the vignette person marry into the family.”

The researchers identified five robust patterns in the data:

First, they concluded that the turn of the century (1996-2006) “saw a substantial increase in the public acceptance of biomedical causes of mental illness.” This shift toward a greater acceptance of scientific data did not, however, translate into a reduction in social rejection (desire for distance).

Second, they concluded that the recent survey period (2006-2018) documented the first significant, substantial decrease in stigma for major depression, although like decreases were not found for schizophrenia or alcohol dependence.

Third, the researchers found that participants’ demographic characteristics “offered little insight into stigma, generally, or into observed decreases for depression.” Thinking and attitudes about depression appear to have changed across the board.

Fourth, age matters to stigma in a predictable way. The authors note: “change over time may be associated with age as a conservatizing factor, a cohort process in which older, more conservative individuals are replaced by younger, more liberal US residents.”

Fifth, while findings for depression were encouraging, other results disappointed. “For schizophrenia, there has been a slow shift toward greater belief of dangerousness… the increase was substantial and relatively large over the entire period (approximately 13 percent).” With regard to alcohol dependence, the results came up 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.”

The authors conclude on an optimistic note, observing that their results suggest that stigma can change, and that scientific literacy has increased among U.S. citizens. And yet, they note: “what the public believes and knows often aligns with science… but may fail to influence their attitudes and behavior (ie, desire for social distance from individuals with mental illness, except depression).”

With stigma as with other complex psychosocial issues, the sobering truth remains that knowledge of the facts, while necessary, is insufficient for producing significant changes in attitudes or behavior.