Public Stigma and Self-Stigma: Differential Association With Attitudes Toward Formal and Informal Help Seeking
Abstract
Objective
Individuals in need of psychiatric treatment often avoid seeking help because of stigma. This study examined the impact of two stigma dimensions on help-seeking attitudes. Perceived public stigma refers to discrimination and devaluation by others, and anticipated self-stigma refers to internalization of negative stereotypes about people who seek help.
Methods
Data were from the 2009 Stigma in a Global Context–Belgian Mental Health Study, in which face-to-face interviews were conducted with a representative sample of the general Belgian population. The study reported here included 728 respondents who received a vignette depicting major depression or schizophrenia. Perceived public stigma and anticipated self-stigma were measured with validated instruments. Respondents’ attitudes toward help seeking were measured by the importance they assigned to care from formal and informal providers: general practitioners, psychiatrists, psychologists, family members, or friends. Multiple linear regression models were estimated.
Results
Respondents with higher levels of anticipated self-stigma attached less importance to care provided by general practitioners or psychiatrists, and those with higher levels of perceived public stigma rated informal help seeking as less important. The gender and the ethnicity of the person and respondents’ sociodemographic characteristics had relatively little effect on help-seeking attitudes.
Conclusions
Anticipated self-stigma and perceived public stigma appeared to have a differential impact on attitudes toward formal and informal help seeking. Internalization of negative stereotypes was negatively associated with the perceived importance of care from medical providers (general practitioners and psychiatrists). Awareness of stereotypes held by others deterred respondents from acknowledging the importance of informal care.
There is a high level of unmet need among individuals with mental illness (1,2). Unmet need refers to a situation in which an individual who is in need of psychiatric treatment does not seek care. Because mental illness is not readily visible, entering psychiatric treatment is generally the primary means by which a person is labeled as mentally ill. This label is associated with a range of culturally agreed-upon beliefs or stereotypes transmitted through socialization (3). Thus the threat of being associated with those stereotypes (4) and the fear of stigmatization are reasons for not seeking help (5–7).
Stigma is a multidimensional phenomenon. Corrigan and Watson (8) underlined the theoretical difference between perceived public stigma and anticipated self-stigma. Perceived public stigma refers to the awareness of stereotypes held by the general public about service users (9), and anticipated self-stigma refers to the application of such stereotypes to oneself, leading to internalized devaluation and disempowerment (10). However, a person can be aware of stereotypes without concurring with them (8,11). Therefore, unlike Vogel and colleagues (12), we consider perceived public stigma and anticipated self-stigma as two different stigma dimensions.
Perceived public stigma may lead individuals to avoid seeking help, if they expect that others discriminate against and devalue service users (7). Before people perform a behavior, they adopt the perspective of the generalized other through the process of role taking (13). Thus, out of fear of negative reactions of others, they adapt their behavior and might not seek help. Empirical studies have shown that perceived stigma is related to a more negative attitude toward help seeking (14) and to less willingness to seek formal care (15).
Anticipated self-stigma may also lead people to avoid seeking help because self-stigma affects feelings of self-esteem and self-efficacy (16–18). For example, endorsing the stereotype of blame (that individuals with mental illness are responsible for their condition) may trigger feelings of guilt and shame (19). To avoid these feelings, people choose coping strategies such as secrecy or social withdrawal instead of seeking help (11). There is empirical evidence that people with a higher level of anticipated self-stigma are more reluctant to seek help (15,20,21).
Research on help seeking examines both formal and informal sources of care. First, it is important to distinguish between types of formal care providers because the impact of stigma depends on the source of care that is considered (15,22). The negative association between stigma and formal help seeking is generally stronger for specialist care than for general care. Second, it is crucial to take informal care into account. Obtaining informal support might facilitate entering the formal care sector (23) and also might encourage treatment adherence. Furthermore, informal support can help prevent relapse after treatment (24,25). The benefits of informal support have been acknowledged by Jorm and colleagues (26) in their model of overlapping waves of action, by Pescosolido (27,28) in the network-episode model, and by Milstein and colleagues (29) in their COPE continuum. For this study, we hypothesized that the negative association between stigma and informal help seeking would be more pronounced for help from friends than from family members. Stigma has less effect on close ties because family members feel obliged to help, following the hierarchy of responsibility (30).
In addition, research on help seeking should control for certain potential confounders. Women are more predisposed to seek help (31–33), whereas men are more inclined to manage emotional problems on their own (34). Young people are more likely to turn to nonprofessional sources of care (35), and older people are more likely to choose general care (36). Furthermore, people with a higher level of education are more likely to seek specialist care (37). Those who are divorced or separated are more likely than those who are married or cohabiting to rely on professional care (38). Employment status is also correlated with formal help seeking (39). Finally, it is important to consider whether respondents report mental health complaints themselves and whether they are familiar with mental health services (40,41).
In sum, we expected to find a negative association between stigma and help seeking. However, we hypothesized that perceived public stigma and anticipated self-stigma would have a differential impact on help seeking from various sources of formal and informal care. Furthermore, we hypothesized that the strength of the association would be more pronounced for specialist care than for general care and for help from friends than from family members.
Methods
Sample
This study is based on data from the 2009 survey Stigma in a Global Context–Belgian Mental Health Study, which examined the attitudes of the general public toward mental health care services and people with mental illness. Fully structured, face-to-face, computer-assisted interviews were conducted with a representative sample of the noninstitutionalized adult Belgian population. The interview included questions referring to a person in a randomly chosen hypothetical vignette; the vignettes included unlabeled psychiatric case histories describing symptoms that met DSM-IV criteria. This vignette technique is often applied in general population research about mental illness (42–48). The vignettes were taken from the 1996 U.S. General Social Survey (49) and were rewritten during a meeting with representatives from teams from all the countries participating in the Stigma in a Global Context survey and a cross-cultural psychiatrist who had been involved in World Health Organization studies (50).
To define the target population, a multistage cluster sampling design was used based on data from the Belgian National Register. In stage 1, municipalities were weighted according to number of inhabitants. Subsequently, 140 municipalities were randomly selected; selection included the possibility of being selected more than once. In stage 2, a total of 15 respondents were randomly selected in each municipality, resulting in a target sample of 2,100 people. After complete description of the study to potential participants, written informed consent was obtained from 1,166. The response rate was 55.5%, and the cooperation rate, excluding those who were incapable because of such factors as language barriers, illness, or not being at home for the interview, was 66.9% (51).
For this study, we included only respondents who received the vignettes depicting major depression or schizophrenia. [The two vignettes are available in an online supplement to this article.] Therefore, one-third of respondents—those who received the asthma vignette—were excluded from the research sample, resulting in a sample of 755 respondents. Furthermore, a poststratification weighting procedure was applied to approximate the cross-classification of the census population count within gender, age, and education. Accordingly, our weighted sample consisted of 728 cases.
Variables
Dependent variables.
To assess help-seeking attitudes, respondents were presented with a list of potential care providers whom the person in the vignette could consult to cope with the situation: general practitioner, psychiatrist, psychologist, family member, and friend. Respondents were asked to rate how important it was for the person in the vignette to consult each type of care provider to deal with the problem. Importance was rated from 1, not important at all, to 10, very important. This measure is comparable to the rating of helpfulness of diverse treatment options, which is often used in vignette studies (22,43–46).
Independent variables.
Perceived public stigma was measured with Link's Perceived Devaluation and Discrimination Scale (9). Responses are made on a 4-point Likert scale, from totally agree to absolutely disagree. Some items are reverse-scored, so higher values represent more anticipated discrimination and devaluation. In this study, we referred to former service users in general, instead of to someone who has been in a psychiatric hospital. Construct validity has been demonstrated in other studies (52). In this study, Cronbach’s alpha was .82.
Anticipated self-stigma was derived from the social isolation subscale of Fife and Wright (53), which has been used in other studies (15,54). It consists of five items that assess negative reactions toward oneself if one were to enter psychiatric treatment. Examples are “I would feel ashamed if I had received psychiatric care,” and “Receiving psychiatric care would make me feel useless.” Responses are scored on a 5-point Likert scale, ranging from totally agree to totally disagree. The scores were reversed so that the mean score would represent a higher level of anticipated self-stigma. The internal consistency of the scale is very good (Cronbach’s alpha=.90).
Control variables.
Education was measured as number of years of education (55). To assess mental health status, the shortened General Health Questionnaire was used (56). The response categories were coded on a 4-point Likert scale: not at all, not more than usual, a little more than usual, and a lot more than usual. Scores of positive items were first reversed, and all items were summed so that possible scores ranged from 0 to 36. Cronbach’s alpha was .79. To assess contact with mental health services, respondents were asked whether they ever received psychiatric treatment and whether a family member, friend, or acquaintance had received psychiatric treatment. They were assigned to the category representing the most direct form of contact.
Finally, analyses controlled for characteristics of the person in the vignette—gender, type of disorder, and in-group versus out-group status. Belgian nationality was considered in-group status, and Turkish nationality was considered out-group status, because the Turkish community is one of the largest ethnic minority groups in Belgium.
Analysis
This study focused on the association between perceived public stigma and anticipated self-stigma and attitudes toward formal and informal help seeking. Analyses were performed with SPSS Statistics, version 19. Multiple linear regression models were estimated because a separate model was estimated for each type of care provider. The dependent variables had a skewed distribution; we performed a logarithmic transformation to approach a normal distribution and to render the estimations of the ordinary least-squares regression analyses more accurate (57). Subsequently, all independent variables were entered as a block. We also checked for problems of multicollinearity for the two stigma variables, but variance inflation factor scores showed that this was not the case. Unstandardized coefficients are reported, accompanied by their standard errors and the test statistic values.
Results
Table 1 presents descriptive data for the study population. It should be noted that two-thirds of respondents (N=488, 67%) stated that other people look down on former service users, and almost half of respondents (N=357, 49%) agreed that other people think that receiving psychiatric treatment is a sign of personal failure (perceived public stigma). In regard to anticipated self-stigma, one-quarter of respondents (N=182, 25%) agreed that they would feel ashamed of being in psychiatric treatment; 313 (43%) stated that they would start to doubt themselves after psychiatric treatment.
| Characteristic | N | % |
|---|---|---|
| Gender | ||
| Men | 354 | 48.6 |
| Women | 374 | 51.4 |
| Marital status | ||
| Married or cohabiting | 464 | 63.8 |
| Divorced | 65 | 8.9 |
| Widowed | 59 | 8.1 |
| Single | 140 | 19.2 |
| Employment status | ||
| Employed | 392 | 53.9 |
| Unemployed | 46 | 6.3 |
| Retired | 171 | 23.5 |
| Other (student or homemaker) | 119 | 16.3 |
| Residence | ||
| Urban | 544 | 74.8 |
| Rural | 184 | 25.2 |
| Previous contact with mental health care | ||
| None | 261 | 36.0 |
| Personal experience | 113 | 15.5 |
| Knows someone with contact | 354 | 48.5 |
| Age (M±SD)b | 48.11±17.82 | |
| Education (M±SD years)c | 11.94±3.69 | |
| Mental health status (M±SD)d | 14.34±4.80 | |
| Stigma (M±SD score) | ||
| Perceived public stigmae | 2.68±.40 | |
| Anticipated self-stigmaf | 2.62±1.09 | |
| Importance rating (M±SD)g | ||
| General practitioner | 8.80±1.54 | |
| Psychiatrist | 8.30±2.12 | |
| Psychologist | 8.51±5.45 | |
| Family | 8.11±2.01 | |
| Friends | 7.69±2.04 |
a
Data (weighted) were from the 2009 Stigma in a Global Context–Belgian Mental Health Study.
b
Range 18 to 94
c
Range 0 to 24
d
Possible scores range from 0 to 34, with higher scores representing worse mental health status with more complaints.
e
Possible scores range from 1 to 4, with higher scores representing greater perceived public stigma.
f
Possible scores range from 1 to 5, with higher scores representing greater anticipated self-stigma.
g
Rated on a scale from 1 to 10, with higher scores indicating greater importance
As shown in Table 2, perceived public stigma was negatively associated with the rating of importance of informal care providers (family and friends). Respondents who reported a higher level of perceived public stigma were less likely to rate as important help from family (B=–.111, p<.01) and friends (B=–.113, p<.01). Perceived public stigma did not appear to have a significant impact on formal help-seeking options.
| Variable | General practitioner | Psychiatrist | Psychologist | Family | Friends | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| B | SE | tb | B | SE | tb | B | SE | tb | B | SE | tb | B | SE | tb | |
| Perceived public stigma | .017 | .023 | .71 | .013 | .041 | .32 | .034 | .037 | .91 | –.111 | .036 | –3.08** | –.113 | .037 | –3.00** |
| Anticipated self-stigma | –.022 | .009 | –2.56* | –.032 | .015 | –2.21* | –.022 | .014 | –1.61 | .008 | .014 | .59 | –.010 | .014 | –.73 |
| Female (reference: male) | .027 | .019 | 1.42 | .013 | .033 | .39 | .009 | .030 | .29 | .016 | .029 | .53 | –.034 | .030 | –1.12 |
| Age | .001 | .001 | .76 | .000 | .002 | –.26 | –.003 | .001 | –2.33* | –.003 | .001 | –2.25* | –.004 | .001 | –2.63** |
| Education | .005 | .003 | 1.72 | .007 | .005 | 1.56 | .014 | .004 | 3.25** | –.001 | .004 | –.34 | .007 | .004 | 1.58 |
| Marital status(reference: married or cohabiting) | |||||||||||||||
| Divorced | .055 | .032 | 1.72 | –.045 | .057 | –.79 | .019 | .052 | .38 | –.035 | .050 | –.69 | .011 | .052 | .22 |
| Widowed | .023 | .036 | .62 | .057 | .065 | .88 | .132 | .059 | 2.25* | .040 | .057 | .70 | .012 | .059 | .20 |
| Single | .012 | .028 | .42 | .052 | .049 | 1.06 | –.023 | .044 | –.51 | .008 | .043 | .19 | .016 | .045 | .37 |
| Employment status(reference: employed) | |||||||||||||||
| Unemployed | .003 | .039 | .08 | .041 | .069 | .59 | .129 | .062 | 2.06* | –.004 | .061 | –.06 | .030 | .063 | .47 |
| Retired | .005 | .034 | .14 | –.007 | .060 | –.12 | .061 | .054 | 1.14 | –.028 | .052 | –.54 | .000 | .054 | .01 |
| Other (student or homemaker) | –.018 | .028 | –.64 | .054 | .049 | 1.11 | .083 | .044 | 1.88 | –.044 | .043 | –1.02 | –.011 | .044 | −.24 |
| Urban residence (reference: rural) | –.024 | –.006 | .036 | –.006 | .036 | –.17 | .003 | .033 | .107 | –.020 | .032 | –.62 | .011 | .033 | .33 |
| Mental health status | .000 | .002 | –.13 | .002 | .004 | .55 | .004 | .003 | 1.22 | –.003 | .003 | –.91 | –.002 | .003 | −.64 |
| Previous contact with mental health care (reference: none) | |||||||||||||||
| Personal experience | .053 | .029 | 1.83 | .050 | .052 | .96 | .045 | .047 | .96 | .028 | .046 | .61 | .007 | .047 | .16 |
| Knows someone with contact | .002 | .020 | .11 | –.015 | .035 | –.43 | –.036 | .032 | –1.13 | .008 | .031 | .25 | –.038 | .032 | –1.18 |
| Schizophrenia vignette (reference: depression vignette) | –.017 | .018 | –.95 | .100 | .032 | 3.16** | .073 | .029 | 2.53* | .008 | .028 | .28 | –.020 | .029 | .63 |
| Female vignette (reference: male vignette) | .024 | .018 | 1.35 | .056 | .032 | 1.76 | .062 | .028 | 2.16* | .028 | .028 | 1.02 | .018 | .029 | .63 |
| Out-group status vignette (reference: in-group status) | –.022 | .018 | –1.23 | .013 | .032 | .42 | –.003 | .028 | –.09 | –.014 | .028 | –.50 | .005 | .029 | .16 |
a
Data (weighted) were from the 2009 Stigma in a Global Context–Belgian Mental Health Study.
b
df=18
* p<.05, **p<.01
Anticipated self-stigma was associated with rating as less important help provided by a general practitioner (B=–.022, p<.05) or a psychiatrist (B=–.032, p<.05). Anticipated self-stigma was not significantly associated with ratings of help provided by a psychologist or ratings of informal help.
Discussion
This study found that two stigma dimensions—anticipated self-stigma and perceived public stigma—had a differential impact on survey respondents’ perceived importance of formal and informal care. Anticipated self-stigma was associated with rating help from medical care providers (general practitioners and psychiatrists) as less important. Perceived public stigma was associated with rating informal help (from family and friends) as less important.
The finding that respondents who had higher levels of anticipated self-stigma had negative attitudes toward help seeking from general practitioners and psychiatrists but not from nonmedical specialists (psychologists) is striking. A comparison of respondents’ attitudes toward general practitioners and psychiatrists showed that the effect of anticipated self-stigma was strongest in regard to help provided by psychiatrists, which is in accordance with findings of Barney and colleagues (15). This finding is not surprising, because many people have doubts about the quality and effectiveness of specialized psychiatric treatment (58–63).
It is remarkable that fear of anticipated discrimination and devaluation by others (perceived public stigma) appeared to prevent respondents from viewing informal care as an important coping strategy. Our finding is in line with results of the few research studies that have found links between stigma and informal help seeking; these studies found that informal help seeking was impaired when study participants feared devaluation (in the sense of being perceived as inferior or incompetent) (64) and when young participants feared social discrimination (22). Respondents with higher levels of perceived public stigma were equally likely to give lower importance ratings to help from friends and from family members in our study. These findings and our results call into question Perry’s (30) argument that stigma is more pronounced with regard to peripheral network ties, compared with core network ties.
Another interesting finding is that the gender and the ethnicity of the person in the vignette had almost no impact on help-seeking attitudes, which strengthens the main effects. Moreover, respondents’ sociodemographic characteristics had a limited effect on help-seeking attitudes, which is a common finding (65,66).
The policy implications of these findings are fourfold. First, structural stigma related to the mental health care sector and psychiatrists in particular should be addressed. Second, it is worrying that stigma was associated with consulting a general practitioner. If patients experience barriers to disclosing mental health problems to such a familiar and accessible source of care, then general practitioners should take the initiative and screen patients for psychiatric symptoms, referring them to specialist care if necessary. Thus a gatekeeper system is recommended (67). Third, it is interesting that anticipated self-stigma did not prevent respondents from acknowledging the importance of psychologists. The role of nonmedical specialist care in the mental health care sector should be better acknowledged. Fourth, some people seemed to fear devaluation and discrimination by their significant others. Therefore, psychoeducation of families and friends of people with mental illness should be encouraged, which would enhance the provision of lay support.
Our findings should be viewed within the limitations of the data and measures. First, our data do not allow a strict causal interpretation of the results. Nevertheless, we partially controlled for the selection hypothesis, which suggests that previous negative experiences in the mental health care sector might trigger stigmatizing attitudes, by considering whether respondents had direct or indirect contact with mental health services. Second, the study examined the association between stigma and help-seeking attitudes, more specifically the perceived importance of seeking help from various care providers. A disadvantage of this approach is that importance ratings might be confounded by the respondent’s level of mental health literacy (68). A better strategy would have been to study actual help-seeking behavior. However, this was not possible because an analysis of the small number of service users (15.5%) in the study sample would lack statistical power. Nevertheless, a better understanding of help-seeking attitudes of the general public is helpful because it sheds light on the lay referral system (69). The lay referral system serves as a reference system, reflecting social norms about stigma related to help seeking (70,71).
A third limitation is that the stigma measures referred to attitudes toward former service users, and no information was provided to respondents about severity of the psychiatric symptoms. However, it has been found that social rejection associated with having been in psychiatric treatment is independent of symptom severity (9). People with a relatively minor mental disorder are not more likely to participate in treatment than those with more severe disorders (72).
Within these limitations, this study extends the research in this area in several ways. First, our study examined the association between stigma and help-seeking attitudes in a sample representative of the general population. Other research has been limited to student samples (12,73–78) or samples in rural areas (14,79,80). Furthermore, structural barriers to seeking mental health care in Belgium are limited because of the high density of health professionals, including mental health professionals, and because access to specialist care is unrestricted and mental health visits to medically trained professionals are covered by public insurance (81). Second, the study focused attention on stigma dimensions related to being in psychiatric treatment rather than relying on a general scale about professional help seeking, such as the Attitudes Toward Seeking Professional Psychological Help (82). Third, the study distinguished between different sources of care, including informal care providers, because little is known about the impact of stigma on attitudes toward seeking informal help (22).
Conclusions
Anticipated self-stigma and perceived public stigma had a differential impact on the perceived importance of formal and informal care. Respondents’ agreement with stereotypes about psychiatric treatment was negatively related to their perceptions of the importance of seeking help from general practitioners and psychiatrists. Respondents’ awareness that other people hold stereotypes about service users deterred them from acknowledging the importance of seeking informal care.
Acknowledgments and disclosures
This project was supported by grant 3G028709N from the Research Foundation Flanders and by grants 01B03308W and O1J15611T from the Special Research Fund of Ghent University. The authors thank Bernice Pescosolido, Ph.D., for the opportunity to collaborate on this project.
The authors report no competing interests.
Supplementary Material
Supplementary Material (232_ds001.pdf)
- View/Download
- 31.07 KB
References
1.
Alonso J, Codony M, Kovess V, et al.: Population level of unmet need for mental healthcare in Europe. British Journal of Psychiatry 190:299–306, 2007
2.
Kessler RC, Berglund PA, Bruce ML, et al.: The prevalence and correlates of untreated serious mental illness. Health Services Research 36:987–1007, 2001
3.
Scheff TJ: Being Mentally Ill: A Sociological Theory. Chicago, Aldine, 1966
4.
Steele CM: A threat in the air: how stereotypes shape intellectual identity and performance. American Psychologist 52:613–629, 1997
5.
Sartorius N: Stigma and mental health. Lancet 370:810–811, 2007
6.
Corrigan P: How stigma interferes with mental health care. American Psychologist 59:614–625, 2004
7.
Corrigan PW, Rüsch N: Mental illness stereotypes and clinical care: do people avoid treatment because of stigma? Psychiatric Rehabilitation Skills 6:312–334, 2002
8.
Corrigan PW, Watson AC: The paradox of self-stigma and mental illness. Clinical Psychology: Science and Practice 9:35–53, 2002
9.
Link BG: Understanding labeling effects in the area of mental disorders: an assessment of the effects of expectations of rejection. American Sociological Review 52:96–112, 1987
10.
Corrigan PW: Empowerment and serious mental illness: treatment partnerships and community opportunities. Psychiatric Quarterly 73:217–228, 2002
11.
Hinshaw SP: The Mark of Shame: Stigma of Mental Illness and an Agenda for Change. New York, Oxford University Press, 2007
12.
Vogel DL, Wade NG, Hackler AH: Perceived public stigma and the willingness to seek counseling: the mediating roles of self-stigma and attitudes toward counseling. Journal of Counseling Psychology 51:40–50, 2007
13.
Mead GH: Mind, Self, and Society. Chicago, University of Chicago, 1934
14.
Wrigley S, Jackson H, Judd F, et al.: Role of stigma and attitudes toward help-seeking from a general practitioner for mental health problems in a rural town. Australian and New Zealand Journal of Psychiatry 39:514–521, 2005
15.
Barney LJ, Griffiths KM, Jorm AF, et al.: Stigma about depression and its impact on help-seeking intentions. Australian and New Zealand Journal of Psychiatry 40:51–54, 2006
16.
Corrigan PW, Watson AC, Barr L: The self-stigma of mental illness: implications for self-esteem and self-efficacy. Journal of Social and Clinical Psychology 25:875–884, 2006
17.
Rüsch N, Angermeyer MC, Corrigan PW: Mental illness stigma: concepts, consequences, and initiatives to reduce stigma. European Psychiatry 20:529–539, 2005
18.
Link BG, Struening EL, Neese-Todd S, et al.: Stigma as a barrier to recovery: the consequences of stigma for the self-esteem of people with mental illnesses. Psychiatric Services 52:1621–1626, 2001
19.
Rüsch N, Todd AR, Bodenhausen GV, et al.: Do people with mental illness deserve what they get? Links between meritocratic worldviews and implicit versus explicit stigma. European Archives of Psychiatry and Clinical Neuroscience 260:617–625, 2010
20.
Schomerus G, Matschinger H, Angermeyer MC: The stigma of psychiatric treatment and help-seeking intentions for depression. European Archives of Psychiatry and Clinical Neuroscience 259:298–306, 2009
21.
Sirey JA, Bruce ML, Alexopoulos GS, et al.: Perceived stigma as a predictor of treatment discontinuation in young and older outpatients with depression. American Journal of Psychiatry 158:479–481, 2001
22.
Yap MBH, Wright A, Jorm AF: The influence of stigma on young people’s help-seeking intentions and beliefs about the helpfulness of various sources of help. Social Psychiatry and Psychiatric Epidemiology 46:1257–1265, 2011
23.
Depression: A Global Crisis. Occoquan, Va, World Federation for Mental Health, 2012. Available at www.wfmh.org/2012DOCS/WMHDay%202012%20SMALL%20FILE%20FINAL.pdf
24.
Pearlin LI, Lieberman MA, Menaghan EG, et al.: The stress process. Journal of Health and Social Behavior 22:337–356, 1981
25.
Breier A, Strauss JS: The role of social relationships in the recovery from psychotic disorders. American Journal of Psychiatry 141:949–955, 1984
26.
Jorm AF, Griffiths KM, Christensen H, et al.: Actions taken to cope with depression at different levels of severity: a community survey. Psychological Medicine 34:293–299, 2004
27.
Pescosolido BA: Illness careers and network ties: a conceptual model of utilization and compliance. Advances in Medical Sociology 2:164–184, 1991
28.
Pescosolido BA: Beyond rational choice: the social dynamics of how people seek help. American Journal of Sociology 97:1096–1138, 1992
29.
Milstein G, Manierre A, Yali AM: Psychological care for persons of diverse religions: a collaborative continuum. Professional Psychology, Research and Practice 41:371–381, 2010
30.
Perry BL: The labeling paradox: stigma, the sick role, and social networks in mental illness. Journal of Health and Social Behavior 52:460–477, 2011
31.
Oliver MI, Pearson N, Coe N, et al.: Help-seeking behaviour in men and women with common mental health problems: cross-sectional study. British Journal of Psychiatry 186:297–301, 2005
32.
Mackenzie CS, Gekoski WL, Knox VJ: Age, gender, and the underutilization of mental health services: the influence of help-seeking attitudes. Aging and Mental Health 10:574–582, 2006
33.
Bijl RV, Ravelli A: Psychiatric morbidity, service use, and need for care in the general population: results of the Netherlands Mental Health Survey and Incidence Study. American Journal of Public Health 90:602–607, 2000
34.
Good GE, Wood PK: Male gender role conflict, depression and help seeking: do college men face double jeopardy? Journal of Counseling and Development 74:70–75, 1995
35.
Rickwood DJ, Braithwaite VA: Social-psychological factors affecting help-seeking for emotional problems. Social Science and Medicine 39:563–572, 1994
36.
Cole MG, Yaffe MJ: Pathway to psychiatric care of the elderly with depression. International Journal of Geriatric Psychiatry 11:157–161, 1998
37.
ten Have M, Oldehinkel A, Vollebergh W, et al.: Does educational background explain inequalities in care service use for mental health problems in the Dutch general population? Acta Psychiatrica Scandinavica 107:178–187, 2003
38.
Bracke PF, Colman E, Symoens SAA, et al.: Divorce, divorce rates, and professional care seeking for mental health problems in Europe: a cross-sectional population-based study. BMC Public Health 10:224–235, 2010
39.
Gouwy A, Christiaens W, Bracke P: Mental health services use in the general Belgian population: estimating the impact of mental health and social determinants. Archives of Public Health 66:50–68, 2008
40.
Holzinger A, Matschinger H, Angermeyer MC: What to do about depression? Help-seeking and treatment recommendations of the public. Epidemiology and Psychiatric Sciences 20:163–169, 2011
41.
Lauber C, Carlos N, Wulf R: Lay beliefs about treatments for people with mental illness and their implications for antistigma strategies. Canadian Journal of Psychiatry 50:745–752, 2005
42.
Angermeyer MC, Matschinger H, Riedel-Heller SG: What to do about mental disorder: help-seeking recommendations of the lay public. Acta Psychiatrica Scandinavica 103:220–225, 2001
43.
Angermeyer MC, Matschinger H, Riedel-Heller SG: Whom to ask for help in case of a mental disorder? Preferences of the lay public. Social Psychiatry and Psychiatric Epidemiology 34:202–210, 1999
44.
Angermeyer MC, Matschinger H: Causal beliefs and attitudes to people with schizophrenia: trend analysis based on data from two population surveys in Germany. British Journal of Psychiatry 186:331–334, 2005
45.
Angermeyer MC, Breier P, Dietrich S, et al.: Public attitudes toward psychiatric treatment: an international comparison. Social Psychiatry and Psychiatric Epidemiology 40:855–864, 2005
46.
Lauber C, Nordt C, Falcato L, et al.: Lay recommendations on how to treat mental disorders. Social Psychiatry and Psychiatric Epidemiology 36:553–556, 2001
47.
Lauber C, Nordt C, Rössler W: Recommendations of mental health professionals and the general population on how to treat mental disorders. Social Psychiatry and Psychiatric Epidemiology 40:835–843, 2005
48.
Riedel-Heller SG, Matschinger H, Angermeyer MC: Mental disorders—who and what might help? Help-seeking and treatment preferences of the lay public. Social Psychiatry and Psychiatric Epidemiology 40:167–174, 2005
49.
Link BG, Phelan JC, Bresnahan M, et al.: Public conceptions of mental illness: labels, causes, dangerousness, and social distance. American Journal of Public Health 89:1328–1333, 1999
50.
Hopper K, Harrison G, Wanderling J: An overview of course and outcome in the ISoS; in Recovery From Schizophrenia: An International Perspective: A Report From the WHO Collaborative Project, the International Study of Schizophrenia. Edited by, Hopper K, Harrison G, Janca A, et al. New York, Oxford University Press, 2007
51.
Response Rate: An Overview. Deerfield, Ill, American Association for Public Opinion Research. Available at www.aapor.org/Response_Rates_An_Overview1.htm
52.
Brohan E, Slade M, Clement S, et al.: Experiences of mental illness stigma, prejudice and discrimination: a review of measures. BMC Health Services Research 10:80–90, 2010
53.
Fife BL, Wright ER: The dimensionality of stigma: a comparison of its impact on the self of persons with HIV/AIDS and cancer. Journal of Health and Social Behavior 41:50–67, 2000
54.
Vogel DL, Wade NG, Haake S: Measuring the self-stigma associated with seeking psychological help. Journal of Counseling Psychology 53:325–337, 2006
55.
Schneider SL: Measuring educational attainment in cross-national surveys: the case of the European Social Survey. Presented at the EDUC Research Group Workshop, EQUALSOC, Dijon, France, Nov 22–24, 2007. Available at www.nuffield.ox.ac.uk/users/Schneider/pdfs/schn07.pdf
56.
Goldberg DP, Gater R, Sartorius N, et al.: The validity of two versions of the GHQ in the WHO study of mental illness in general health care. Psychological Medicine 27:191–197, 1997
57.
Moore DS, McCabe GP: Statistics in Practice [in Dutch]. The Hague, Netherlands, Academic Service, 1999
58.
ten Have M, de Graaf R, Ormel J, et al.: Are attitudes towards mental health help-seeking associated with service use? Results from the European Study of Epidemiology of Mental Disorders. Social Psychiatry and Psychiatric Epidemiology 45:153–163, 2010
59.
Gharaibeh NM: The psychiatrist’s image in commercially available American movies. Acta Psychiatrica Scandinavica 111:316–319, 2005
60.
Rosen A, Walter G, Politis T, et al.: From shunned to shining: doctors, madness and psychiatry in Australian and New Zealand cinema. Medical Journal of Australia 167:640–644, 1997
61.
Schulze B: Stigma and mental health professionals: a review of the evidence on an intricate relationship. International Review of Psychiatry 19:137–155, 2007
62.
Wahl OF: Media Madness: Public Images of Mental Illness. New Brunswick, NJ, Rutgers University Press, 1995
63.
Hamre P, Dahl AA, Malt UF: Public attitudes to the quality of psychiatric treatment, psychiatric patients, and prevalence of mental disorders. Nordic Journal of Psychiatry 48:275–281, 1994
64.
Nadler A: Help-seeking behavior: Psychological costs and instrumental benefits; in Prosocial Behavior: Review of Personality and Social Psychology. Edited by, Clark MS. New York, Academic Press, 1991
65.
Pescosolido BA, Olafsdottir S: The cultural turn in sociology: can it help us resolve an age-old problem in understanding decision making for health care? Sociological Forum 25:655–676, 2010
66.
Olafsdottir S, Pescosolido BA: Drawing the line: the cultural cartography of utilization recommendations for mental health problems. Journal of Health and Social Behavior 50:228–244, 2009
67.
Verhaak PFM, van den Brink-Muinen A, Bensing JM, et al.: Demand and supply for psychological help in general practice in different European countries: access to primary mental health care in six European countries. European Journal of Public Health 14:134–140, 2004
68.
Jorm AF: Mental health literacy: public knowledge and beliefs about mental disorders. British Journal of Psychiatry 177:396–401, 2000
69.
Freidson E: Profession of Medicine. New York, Dodd, Mead, 1970
70.
McKinlay JB: Social networks, lay consultation and help-seeking behavior. Social Forces 51:275–279, 1973
71.
Birkel RC, Reppucci ND: Social networks, information-seeking, and the utilization of services. American Journal of Community Psychology 11:185–205, 1983
72.
Narrow WE, Regier DA, Norquist G, et al.: Mental health service use by Americans with severe mental illnesses. Social Psychiatry and Psychiatric Epidemiology 35:147–155, 2000
73.
Golberstein E, Eisenberg D, Gollust SE: Perceived stigma and mental health care seeking. Psychiatric Services 59:392–399, 2008
74.
Golberstein E, Eisenberg D, Gollust SE: Perceived stigma and help-seeking behavior: longitudinal evidence from the Healthy Minds Study. Psychiatric Services 60:1254–1256, 2009
75.
Eisenberg D, Downs MF, Golberstein E, et al.: Stigma and help seeking for mental health among college students. Medical Care Review 66:522–541, 2009
76.
Cooper AE, Corrigan PW, Watson AC: Mental illness stigma and care seeking. Journal of Nervous and Mental Disease 191:339–341, 2003
77.
Vogel DL, Wester SR, Wei M, et al.: The role of outcome expectations and attitudes on decisions to seek professional help. Journal of Counseling Psychology 52:459–470, 2005
78.
Komiya N, Good GE, Sherrod NB: Emotional openness as a predictor of college students’ attitudes toward seeking psychological help. Journal of Counseling Psychology 47:138–143, 2000
79.
Komiti A, Judd F, Jackson H: The influence of stigma and attitudes on seeking help from a GP for mental health problems: a rural context. Social Psychiatry and Psychiatric Epidemiology 41:738–745, 2006
80.
Hoyt DR, Conger RD, Valde JG, et al.: Psychological distress and help seeking in rural America. American Journal of Community Psychology 25:449–470, 1997
81.
Bruffaerts R, Bonnewyn A, Demyttenaere K: Delays in seeking treatment for mental disorders in the Belgian general population. Social Psychiatry and Psychiatric Epidemiology 42:937–944, 2007
82.
Fisher EH, Farina A: Attitudes Toward Seeking Professional Psychological Help: a shortened form and considerations for research. Journal of College Student Development 36:368–373, 1995
Information & Authors
Information
Published In
Cover: Snowbound, by N. C. Wyeth, 1928. © Copyright 2014 National Museum of American Illustration™, Newport, Rhode Island. Photo courtesy Archives of the American Illustrators Gallery™, New York.
History
Published in print: February 2014
Published online: 15 October 2014
Authors
Metrics & Citations
Metrics
Citations
Export Citations
If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download.
For more information or tips please see 'Downloading to a citation manager' in the Help menu.
View Options
View options
PDF/EPUB
View PDF/EPUBLogin options
Already a subscriber? Access your subscription through your login credentials or your institution for full access to this article.
Personal login Institutional Login Open Athens loginNot a subscriber?
PsychiatryOnline subscription options offer access to the DSM-5-TR® library, books, journals, CME, and patient resources. This all-in-one virtual library provides psychiatrists and mental health professionals with key resources for diagnosis, treatment, research, and professional development.
Need more help? PsychiatryOnline Customer Service may be reached by emailing [email protected] or by calling 800-368-5777 (in the U.S.) or 703-907-7322 (outside the U.S.).