research questions about mental health stigma

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Published: 18 October 2021

Types of stigma experienced by patients with mental illness and mental health nurses in Indonesia: a qualitative content analysis

Muhammad Arsyad Subu 1 , 2 ,
Del Fatma Wati 3 ,
Netrida Netrida 4 ,
Vetty Priscilla 4 ,
Jacqueline Maria Dias 1 ,
Mini Sarah Abraham 1 ,
Shameran Slewa-Younan 5 &
Nabeel Al-Yateem ORCID: orcid.org/0000-0001-5355-8639 1 , 6

International Journal of Mental Health Systems volume 15 , Article number: 77 ( 2021 ) Cite this article

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Stigma refers to the discrediting, devaluing, and shaming of a person because of characteristics or attributes that they possess. Generally, stigma leads to negative social experiences such as isolation, rejection, marginalization, and discrimination. If related to a health condition such as mental illness, stigma may affect a person’s illness and treatment course, including access to appropriate and professional medical treatment. Stigma has also been reported to affect patients’ families or relatives, along with professionals who work in mental healthcare settings. Stigma is strongly influenced by cultural and contextual value systems that differ over time and across contexts. However, limited information is available on how types of stigma are experienced by patients with mental illness and mental health nurses in Indonesia.

We explored the stigma-related experiences of 15 nurses and 15 patients in Indonesia. The study design and analysis of interview data were guided by deductive (directed) content analysis.

Five themes emerged. Four themes were patient-related: personal/patients’ stigma, public/social stigma, family stigma, and employment stigma. The fifth theme related to stigma toward healthcare professionals working with patients with mental illnesses, which we categorized as professional stigma.

Conclusions

This study has achieved a deep understanding of the concept of stigma in the Indonesian context. This understanding is a prerequisite for developing appropriate interventions that address this phenomenon and thereby for the development of mental health services in Indonesia. This study may also be transferable to other countries that share similar cultural backgrounds and adhere to traditional and religious value systems.

Stigma was initially described by Erving Goffman in 1963. He identified stigma as any characteristic or attribute by which a person was devalued, tainted, or considered shameful or discredited. Subsequent work in this area was influenced by the work of Goffman, and the concept of stigma has been explored in many contexts and cultures. Stigma is strongly influenced by cultural and contextual value systems that differ over time and across contexts. However, most authors agree with Goffman’s basic definition, which identified the main elements of stigma such as labeling, stereotyping, social isolation, prejudice, rejection, ignorance, status loss, low self-esteem, low self-efficacy, marginalization, and discrimination [ 1 , 2 , 3 ].

Mental health stigma is defined as the disgrace, social disapproval, or social discrediting of individuals with a mental health problem [ 4 , 5 ]. Literature identifies multiple dimensions or types of mental health-related stigma, including self-stigma, public stigma, professional stigma, and institutional stigma. Self-stigma refers to negative attitudes of an individual to his/her own mental illness and is also referred to as internalized stigma [ 1 , 6 ]. Self-stigma has been related to poor outcomes, such as failure to access treatment, disempowerment, reduced self-efficacy, and decreased quality of life [ 7 , 8 ]. Public stigma refers to negative attitudes towards those with mental illness by held by the general public [ 1 , 6 ], often based on misconceptions, fear, and prejudice. Related to public stigma is perceived stigma which is defined as individual’s beliefs about the attitudes of others towards mental illness. Research has demonstrated the significant impact of public stigma such as discrimination in workplaces and public agencies [ 8 ]. Professional stigma occurs when healthcare professionals hold stigmatizing attitudes toward their patients, which are often based on fear or misunderstandings of the causes and symptoms of mental illness, or when professionals themselves experience stigma from the public or other healthcare professionals because of their work and connection with stigmatized individuals [ 1 ]. Professional stigma is of particular concern as it may affect the care and treatment a person with mental illness receives [ 1 ], including treatment for physical illnesses [ 8 ], thereby impacting their well-being and recovery. Finally, institutional stigma refers to an organization’s policies or culture of negative attitudes and beliefs toward stigmatized individuals, such as those with mental health problems [ 1 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 ]. Such stigma can also be reinforced by legal frameworks, public policy, and professional practices, thereby becoming deeply embedded in society [ 8 ].

In the context of mental healthcare, stigma has been identified as a major issue for patients and families. Stigma hinders access to appropriate and professional medical and psychological treatment, and can result in a person’s condition worsening or multiple readmissions [ 3 , 6 , 7 , 15 ]. Furthermore, the impact of stigma is so great that patients describe the stigma and prejudice they encounter as almost as bad as the symptoms of their disorder [ 16 ], and as a burden on their private and public lives [ 17 ]. Stigma also affects patients’ families or relatives and the professionals who work in mental healthcare settings. Therefore, to reduce stigma in mental healthcare and facilitate the development of appropriate services in Indonesia and similar countries or contexts, it is important that the different types of stigma are clarified and understood within the unique value system and culture.

The Republic of Indonesia has the fourth largest population in the world and the third largest in the Asian continent. As estimated in 2020, the Indonesian population comprises 267 million people; approximately 151 million people (around 56.6% of the Indonesian population) live in urban areas and the remainder lives in rural areas [ 18 , 19 ]. In general, Indonesians follow a traditional way of life that is strongly affected by traditional and religious beliefs. The prevalence of severe mental illness in Indonesia is estimated at 1.7/1000 population, and that of mild mental illness is around 60/1000 population [ 18 ]. Stigma is known to be common in such traditional contexts [ 19 , 20 ]. Therefore, understanding how stigma manifests in this context will help reduce stigma and contribute to developing mental healthcare services in Indonesia and potentially in other similar Asian contexts.

Treatment for mental illness in Indonesia is currently inadequate. The country has the lowest ratio of psychiatrists per capita in the world, and mental healthcare facilities are limited in availability and underdeveloped in terms of quality, human resources, and infrastructure [ 20 , 21 , 22 ]. This situation, along with low public awareness of mental illness, persisting stigmatizing and traditional beliefs about mental health, and the lack of local professional knowledge in the area, seriously impact the care of patients with mental illness in terms of access to and quality of services. In addition, stigma about mental illness is rarely discussed openly, which results in misunderstanding, prejudice, confusion, and fear. In this context, families often hide or ostracize family members with mental illness because they are reluctant to bring them to public attention or seek help [ 18 , 21 , 23 ].

A recent study found that the experience of stigma among patients with mental illness in Indonesia was pervasive and negatively impacted use of mental health services[ 24 ]. The stigmatization of mental illness is manifested by families, community members, mental health professionals and staff, governmental institutions, and the media. Stigmatization is characterized by violence, fear, exclusion, isolation, rejection, blame, discrimination, and devaluation, primarily as a result of general (mis)understandings about mental illness. Until the stigma associated with mental illness is addressed at the national level, Indonesians with mental illness will continue to suffer and face barriers to accessing mental health services [ 24 ]. Given Indonesia’s predominantly rural population and traditional way of life, it is particularly important to examine stigma in this context. For example, persisting stigma means that families in traditional societies such as Indonesia and other Asian countries hide those with mental illness because of embarrassment and shame, and are unwilling to access public mental health services [ 25 ]. Stigma may also prevent a family from socializing with other community members. In addition, others may blame family members for the person’s illness, meaning patients experience further feelings of shame and guilt [ 24 , 25 , 26 , 27 , 28 ]. It has also been reported that stigma means that health professionals in psychiatric hospitals often do not treat patients with dignity or respect, and do not provide optimal protection for patients who are hospitalized [ 29 ].

Despite the prevalence of mental illness and the high levels of stigma toward patients with mental illness, little research has been conducted to clarify the elements, attributes, and features of different types of stigma in the Indonesian culture and value system. A literature review on mental health in Indonesia conducted in PubMed returned 161 studies published between 1949 and 2020. However, only 15 of these studies discussed stigma either directly or in the context of Indonesian mental health services [ 18 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 ]. Among these 15 studies, six discussed stigma in general, consequences of stigma (i.e., “pasung” or confinement), attitudes toward mental health, and perceptions of mental health [ 18 , 30 , 31 , 41 , 42 , 43 ]. Previous investigations of stigma in Indonesia mainly examined personal stigma, with a focus on the perceptions of those with mental illness and their families, how they respond to stigmatization in their lives, and the impact of stigma on access to mental health facilities or treatment [ 18 , 20 , 21 , 22 , 23 , 44 ]. The present study offers a unique perspective given its comprehensive approach to understanding the different types of stigma that exist in Indonesian culture.

Question guiding this inquiry

This qualitative study explored different types of stigma that affect individuals with mental health conditions in Indonesia, as described by patients and nursing staff. Specifically, we aimed to clarify the elements, attributes, and features of different types of stigma experienced by patients and nursing staff in Indonesia. Exploring these diverse perspectives allowed us to achieve an in-depth understanding of stigma in this context. The results of this study therefore build on existing literature and may inform specific and effective interventions targeting different types of stigma. Finally, given Indonesia’s size and the similarity of its cultural context to other Asian countries, the results of this study may improve our understanding of types of stigma experienced in the wider Asian context.

Study design

This study used a qualitative design based on deductive (directed) content analysis. Content analysis is considered a research method or technique as well as a data analysis tool [ 45 , 46 ]. Research using deductive (directed) content analysis usually has prior theoretical knowledge as the starting point [ 47 ], and this study was informed by previous research findings and theories focused on mental health stigma. Bengtsson (2016) outlined the different stages of qualitative content analysis (e.g., identifying the study problem, planning data collection methods, and data analysis) and described both “manifest” and “latent” analysis techniques. The present study used a latent analysis technique, whereby we attempted to understand underlying meanings reflected in the data in the context of extant knowledge and theories relevant to the topic under study. This aided in developing a deeper understanding of individual meanings and experiences of stigma in this context. Using deductive (directed) content analysis allowed us to explore meanings related to mental illness stigma constructed by patients with mental illness and nurses, and describe and interpret those meanings. In addition, this study design allowed us to go deep into the data to reveal participants’ thoughts and experiences that were close to their realities at that particular place and time.

Study setting and participants

This study was conducted at the largest of Indonesia’s 33 psychiatric hospitals. The hospital is located in West Java, which is one of the 34 provinces in Indonesia, and receives patients referred from across the province (urban and rural areas). West Java is an ethnically diverse province with a range of inhabitants from various ethnicities. Study participants were 15 patients (seven males, eight females) and 15 psychiatric nurses (10 males, five females) recruited purposefully from the hospital. Although all participants were recruited in the same site, they originated from both urban and rural areas. The majority of participants were Sundanese, and some were Javanese. Patient participants were aged 21–52 years with mild/moderate symptoms (as noted in their medical records). Nurse participants were psychiatric nurses who had graduated from nursing schools with a specialty in mental health nursing. These nurses were aged 22–43 years and had 5–15 years of clinical experience in mental health settings. We based our sample size (N = 30) on a previous study [ 48 ], which indicated that 30 participants was sufficient to ensure data saturation.

Our initial contact with participating nurses was made through a meeting and a presentation about this study at the study hospital. This initial meeting was followed by data collection at a mutually agreed time. We made contact with patient participants after discussion with the hospital healthcare team. We excluded patients with severe psychosis or severe symptoms of their mental illness. All participants were required to be able to read and write. Data were collected at the hospital through interviews held in environments that were private and quiet to facilitate participants’ comfort and confidence to speak. All participants signed an informed consent form before their interview and were assured of the anonymity and confidentiality of their data. All data were coded for analysis, and all data (including field notes and memos) were kept securely by the primary investigator.

Data collection

The primary method of data collection was semi-structured interviews. Interview questions were developed based on themes identified during a literature review. Interview questions were not prescriptive, but were used as a guide to explore aspects that were considered vital to understand the elements of the different types of mental health-related stigma and stigmatization experienced by participants in traditional Indonesian culture and reality. Interviews took from 30 to 45 min for both nurses and patients’ participants. Interview questions were phrased to suit participants (i.e. nurses and patients). Sample of interview questions is below:

For patients:

In your opinion how does Indonesian society see or deal with mentally ill persons?

How is it to live in Indonesia when you have a mental health issue?

For nurses:

How is it to live in Indonesia for someone who have a mental health issues?

Could you give me an idea about your work in a mental health hospital?

Additional data were collected via memos, field notes, and a document review. These additional data collection methods enabled data triangulation, which improved the credibility of the interpretations of the data. The interviewer also used memos to record their thoughts and interpretations of the interviews, the research process (including questions and gaps), and the analytic progress of the research. Field notes were used to record observations and reflections on the data. We also conducted a document review to collect hard copy and electronic data that were available in the hospital. This mute evidence was important in guiding our interpretation of participants’ experiences, attitudes, and beliefs.

In total, we conducted 30 semi-structured interviews in the Indonesian language (Bahasa Indonesia). To ensure the interviews were consistent, all interviews were conducted by two experienced interviewers (MAS and DFW), who were local members of the research team. At the beginning of the interview with each participant, the interviewers introduced themselves and explained the purpose of the study and the confidential nature of the data collected. This gave participants opportunity to ask any questions and helped to establish a comfort level before the interview began. The appropriateness of the interview location and timing was verified with participants; the interviewers tried not to take up too much of their time, and were prepared to provide emotional support to participants when necessary. Before their interview started, each participant confirmed that they had read the participant information sheet and were fully informed about the study. The informed consent process was completed before the start of the interview (in Bahasa Indonesia).

All 30 participants attended on the scheduled day of their interview. The interviews were conducted in hospital meeting rooms or nurses’ offices. The questions were asked in the order they were presented in the interview protocol. During the interviews, participants were given time to reflect on and consider their responses to ensure they did not feel pressured to respond before they were ready. Participants were given opportunity to ask more questions at the end of the interview. Finally, the interviewers expressed gratitude for participants’ time and willingness to participate in this study. Immediately after the interview, the information was summarized, and field notes and memos were checked.

Data analysis

We analyzed data using deductive (directed) content analysis. This method was suitable for this study as we aimed to gain a deep understanding of the experiences of Indonesian patients with mental illness and mental health nurses in relation to the different types and categories of mental health stigma reported in the literature. The interviews were analyzed by the Indonesian members of the research team, who then translated important quotations into English for reporting. Linguistic equivalence was an important consideration during the translation process to ensure the integrity of our findings. The first author (MAS) has English as his first language. During this translation process, this author (MAS) was assisted by an Indonesian professional English nursing translator to ensure linguistic equivalence. The translation process focused on verifying that the translation from Indonesian to English was correct in terms of words, terms, concepts, and overall meaning. This ensured that the English translations were comprehensible, but faithful to the interview data obtained from participants.

During the analysis process, we read the interview transcripts several times to become familiar with the text. Next, we merged and coded the words, sentences, and paragraphs line-by-line, as relevant to each other in terms of both the content and context of stigma. Then, parts related to the experiences of the participating patients and nurses regarding types of stigma were extracted and placed in a separate text file. Codes and units of meaning were interpreted in the context of the study and compared in terms of similarities and differences. Finally, abstract themes were developed reflecting types of stigma consistent with the literature.

Study participants were 15 patients with mental illness (seven men, eight women) who were hospitalized in the participating psychiatric hospital, and 15 nurses (five women, 10 men) who worked in the same hospital. Our analysis revealed five main themes. Four themes were related to patients with mental illnesses and loosely classified under the categories of either public or perceived stigma. These themes were ‘perceived stigma from a patient perspective’, ‘public stigma’, family ‘attitudes’, and ‘employment discrimination’. The fifth theme, professional stigma, described stigma experienced (or held) by healthcare professionals who worked with patients with mental illnesses. Although these themes reflected the stigma experienced by participants in our study, they were consistent with the types of stigma described in the literature. This was because we used deductive (directed) content analysis, which draws on existing knowledge and theories as the starting point for the analysis.

Theme 1: perceived stigma from a patient perspective

The theme of personal/patients’ stigma was strongly represented in the narratives of all participating patients, but received little attention from participating nurses. Therefore, only findings related to patients’ perspectives are presented. Participants described feelings of shame and isolation from the community, and indicated that they were viewed as different from other “normal” people. They also believed that others thought they were inadequate, and reported suffering insults. A patient described being insulted as making them ashamed:

Within society, there is insult, discredit…They insult me. I am called “crazy,” or “former crazy people.” Yes, I have been insulted. It is from friends and the community too. I cannot do anything. I am sad and ashamed, my heart cries without tears. I hope that God helps me... (Participant 4)

Participants also indicated that they were labeled as a “mentally ill person.” One patient reported that this labeling was part of their suffering.

If in the community, people see me [they say], “whew a professor’s patient.” People say “wuhh wuhh” (see lowly), “the patient of doctor R, wuhhh (low).” Yes, they do look down. If I visit my professor, my label is not for recovery. Moreover, they make a label for me as the professor’s patient; it means that I am a mentally ill person. They consider me like that… (Participant 7)

Participating patients also believed that they were rejected, avoided, and discriminated against because they had a mental illness. Further, they reported that community members rejected them because society held wrong assumptions about mental illness. One participant reported:

Yes, they (patients) are rejected, like that. They actually can be accepted again by their community, but they (the community) don’t accept. I also need to change. So, we are “crazy” depend on us. There are still wrong assumptions in the community about mentally ill people. Yes...probably, only few of them, I see, who can be accepting. (Participant 2)

Another participant described how they had been discriminated against by others.

…All the problems are because the problem cannot be solved by our family members. I experience that there is discrimination…Other people treat us as unequal with people who have physical illness. Yes, they [general people] do discriminate… (Participant 5)

Theme 2: public stigma

Public/social stigma was an issue highlighted by both groups of participants. Therefore, this theme is discussed from both patients’ and nurses’ perspectives.

Patients’ perspectives

Support from community members or other social support is essential for improving outcomes for people with mental illness. However, most patients felt they lacked this social support.

…I do not have support…I don’t have support at all. I do not know why it is like that sir. My community, my sister and other people do not provide support, no [support]. They only care [about] themselves. No, I do not have support from other people when in this hospital. They just want me to go to witchcraft, go to a shaman. (Participant 11)

Of particular concern, some participants reported forms of community violence towards those with mental illness. Participating patients described experiencing violence from people in the community. One patient shared their experience of being hit and tied by other people in their community.

…Yes, I was tied and hit. Therefore, I was really angry and I don’t want to meet the people in my community. However, if they come to my home and apologize to me, then, I will come to apologize at their homes. Therefore, I still feel [the need for] revenge because I was tied and hit. (Participant 1)

Additionally, participants perceived that many people in the community believed that mental illness is a communicable illness, similar to some physical illnesses.

...They stay away from sufferers. Sometimes, they are afraid that mental illness is a contagious illness. People are afraid because of this. Actually, sufferer isn’t harmful. If they are embraced, they will be OK. (Participant 5)

Nurses’ perspectives

Some nurse participants noted that the general public/wider society lacked consideration and empathy toward those who suffered from mental illness. This lack of consideration and corresponding lack of appropriate policies often resulted in homelessness and isolation among people with mental illness.

Our societies still lack care...less attention for people with mental illness. Because communities lack care, communities do not care. They just ignore…I am sure, if 10 people [met a person] with mental illness, only one or two people will still want to say hello or interact with them. (Nurse 7)

A lack of social acceptance was reported by participants as resulting in people with mental illness being rejected. A nurse described the impact of patients not being accepted in their community.

Because they (patients) could not be accepted in society…society cannot accept them. Other people reject them. In addition, their families cannot be accepted by society. Patients cannot be productive anymore; minimal in fulfilling their basic needs. (Nurse 1)

In general, participants reported that community members feared dangers posed by those with mental illness. Participants indicated that people were afraid of patients with mental illness because of a perceived tendency for violent behavior or fear of being attacked by a patient. A nurse described how people were often scared and ran away.

They (community members) are afraid, sir…afraid…scared…anxious. The society is scared. Yes, it is really, true [people] are scared, run away, they are like that. They (patients) are ignored, they are left, finally [laughs]. Because they (society) are scared, the patients are ignored. (Nurse 1)

Theme 3: family attitudes towards mentally ill patients

Similar to public/social stigma, both participant groups shared their views and experiences of family stigma. Therefore, findings reflecting both patients’ and nurses’ perspectives are presented.

Family support plays an important role in the recovery of a person with mental illness. However, our participants indicated that their family members provided minimal support because of stigma and shame.

They (family members) do not talk to me. They do not support me. Sometimes, my parents are ashamed…My father is not proud of me in front of other people. For example, “my son is like this.” “See! My son has been like this.” What can he tell others? Other parents will say “my child goes to the college in Jayabaya (a university) takes informatics engineering field.” My parents do not mention about me like that. My father and mother do not do that…They are ashamed. (Participant 10)

Participating nursing staff described how many families had moved to another location or changed their address because of feelings of shame. They indicated that some families also denied they had relatives who were treated in the hospital.

Their families disappear because of shame? The first, their domicile (address) changes. Then, although we go there and we find the address, they say “I have no family relationship with him, all his family members have died.” Some patients have been here since they were young. Probably, they are the patient’s family. People who were at home are his family members, but they don’t acknowledge him. “We don’t recognize that patient” [the] family said. (Nurse 8)

Participants also indicated that the extended families often reject relatives that suffered from mental illness. This rejection was reported to happen even after a patient’s hospitalization.

Especially for long-time patients, for example, [those who have spent] many years here, it is difficult to get them (families) to take their relatives home. Because they assume that at home, the patient will annoy them. They will annoy their family’s activities. Then, [the] patient is rejected. Mostly they are rejected… (Nurse 6)

Theme 4: Employment discrimination

Both nurses and patients commented on the stigma that people with mental illness experience in the context of their employment. The perspectives of both nurses and patients are presented below. Overall, most participants indicated there was a great deal of stigma related to mental illness in workplaces.

Returning to work after treatment was reported as difficult. Many patients were rejected from returning to their former workplace, including a patient that was previously employed in a government role.

…Yes, it is, very often. Other people do not want to accept a patient to work again in his job…“You are an ex-crazy individual.” They will say that. I was a government employee…The government officers will not allow me to work again. (Participant 2)

A nurse described how patients found it difficult to find a job because of having a mental illness label.

…If they have mental hospital label or have stigma from society, then looking for a job, it is difficult for them. I have had a house assistant who has been violent. Then, she worked at my parents-in-law; I was worried to leave her at home alone. I asked: “did you hear voices?” She said “yes.” I was scared too. Fortunately, she asked to resign. (Nurse 2)

Theme 5: professional stigma

The fifth theme that emerged from the interviews was professional stigma. Two forms of professional stigma emerged in this study: stigma directed toward mental health nurses, and stigma from healthcare professionals toward their patients with mental illness. Although this type of stigma was mostly present in nurses’ narratives, some patients reported experiencing stigma from healthcare professionals; therefore, both nurses’ and patients’ perspectives are discussed.

Participating nurses described how mental health nurses were labeled as “crazy nurses,” which captured the stigma directed to nurses working with patients with mental illness. Some nurses shared examples of how non-mental health nurse colleagues and the general public used terms that insulted them.

…People say “ohhhhh [it is] because you are psychiatric nurse”...“Uhhhhh...yeah, since he works to care for the gelo (crazy) people.” They say “whew psychiatric nurse.” Sometimes this stigma sticks to the nurses from people in our society. Yes…also, we are labeled by our friends (nurses). They are either joking or serious, I do not know. In addition, my friends say: “ihhhhh...whew, psychiatric nurse.” Yes, similar, as crazy as his patients. (Nurses 6)

It was also noted that as well as the general public, some healthcare professionals also believed that mental illness was contagious, similar to many physical illnesses.

….Yesterday, there was a student who feared to be contaminated by this illness. She is a student from Palangkaraya, Kalimantan who fears of contamination too. Besides fearing being contaminated, they [are] disgusted [by] mentally ill patients. Their disgust with mentally ill people is similar to leprous, dirty, disgusting. In reality, mental illness does not spread, right? Then, there is an image (label)...“Don’t have relation[ships] with the patients.” (Nurse 4)

Participating patients also reported that some healthcare professionals held stigma toward patients with mental illness. They noted this stigma was frequently manifested in the use of restraint or seclusion. Some nurses and other hospital staff were reported to physically abuse their patients.

Yes, I was tied. True, it was true. I have to tell you. My jaws are tied, by Mr. A (a nurse). I was injected, it was pain, right? I don’t understand, probably his education wasn’t high enough so that he didn’t understand. My need isn’t food, but, they just don’t care… (Patient 9)

Stigma has significant impacts on patients with mental illness, family members, communities, and healthcare professionals. To date, little research has investigated the types of stigma and corresponding impact in the Indonesian context. Stigma is a worldwide concern that influences people’s illness trajectory, treatment process, available opportunities, quality of life, and recovery outcomes. Our study sought to investigate the types of stigma experienced by people with mental illness and mental health professionals in the Indonesian context. Using a deductive approach (directed content analysis), our findings on the examples of stigma reported were loosely centred around public and perceived stigma, consistent with the types of stigma previously reported in the literature [ 1 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 ]. However, we identified features of these types of stigma in the Indonesian context, and our study therefore makes a direct contribution to the literature. As described in previous studies [ 7 , 8 ], stigma is a burden for patients with mental illness that can be intrapersonal (self-stigma), interpersonal or in relationships with other people, and structural or discriminatory stigma relating to exclusionary policies and other aspects of life or systems. Our participants shared their experiences of different types of stigma, along with the corresponding elements, attributes, and features within the unique Indonesian culture and value system.

Perceived stigma from a patient perspective

Many participants described feelings of shame and being rejected and isolated from society, which resulted in feelings of powerlessness. A plausible explanation for this is that patients had internalized stigma (self-stigma) because of negative attitudes and beliefs toward them. Other studies reported that around 40% of people with severe mental illness had high levels of self-stigma [ 11 , 13 ]. Self-stigma exists when an individual believes negative stereotypes about mental illness and people with mental illness, and feels that these stereotypes apply to them [ 14 ]. In addition, almost 70% of patients reported moderate to high levels of perceived discrimination, which has been significantly associated with high self-stigma [ 11 ]. Implicit self-stigma appears to be associated with negative outcomes. It has been noted that patients who internalize stigma do not respond as well to evidence-based interventions as those that do not internalize stigma [ 14 ]. Self-stigma has been associated with poor self-esteem, hopelessness, reduced self-efficacy, and disempowerment [ 9 ].

Furthermore, our participants’ descriptions of these negative feelings indicated they were implicit processes. This means that they were activated automatically and occurred whether or not the individual deliberately endorsed the proposition that mental illness is shameful. For example, a patient with mental illness or healthcare professionals working with that patient may explicitly disapprove of such stigmatization, but implicitly, they may still experience the shame associated with this stigmatization. Attempts to reduce self-stigma should therefore consider these implicit processes [ 49 ]. In addition, our findings indicated that many patients were labeled by others as mentally ill. Participating patients expressed feelings of shame, and spoke about how the label of being a “crazy” person made them feel useless and powerless. For patients, hospitalization in a psychiatric hospital can be experienced as disempowering and stigmatizing [ 15 ]. Because self-stigma can have negative effects on an individual’s life and treatment outcomes, it is important for clinicians to be aware of the existence of self-stigma, so they can recognize patients’ internalized stigma and address this effectively in treatment.

Public stigma

Public stigma has negative effects on the lives of people with mental illness, and creates barriers to the individual’s pursuit of vocational, housing, and healthcare goals [ 50 ]. In addition, public stigma affects living, working, and socializing for people with a mental illness [ 51 ]. A similar study found that nine out of 10 patients with mental illness had experienced discrimination [ 52 ]. Our study also found that both nurse and patient participants reported that people in the community enacted violence toward people with mental illness. For example, because community members were ashamed and afraid of those with mental illness, they commonly subjected people with mental illness to confinement or “pasung” and seclusion or “seklusi” [ 19 ]. Confinement/pasung and seclusion/seklusi have a negative impact on patients with mental illness, and their use has potential to cause physical harm and further psychological trauma [ 29 ]. In addition, many Indonesians adhere to traditional causal beliefs of mental illness, and these beliefs may drive mental health stigma [ 21 , 22 , 26 , 34 , 37 ]. Given that Indonesia is a developing country, it is likely that these traditional beliefs underling mental health stigma are common across rural and urban communities.

Family attitudes

Our findings indicated that stigma related to mental illness also impacted patients’ families. This was consistent with Nurjannah et al. [ 46 ], who noted that mental health stigma has negative implications on the health and wellbeing of patients and their families. Various impacts on the families of people with mental illness have been documented, including sleep disorders, alterations in interpersonal relationships, worsening of wellbeing, and reduced quality of life [ 53 , 54 ]. Further, it has been reported that some families with a relative suffering from mental illness experience shame because other people blame them for being responsible for the illness [ 24 ]. A family can also feel ashamed if people in their community know that they have relative with mental illness. Three stereotypes associated with family stigma have been described: shame, blame, and contamination [ 28 ]. Our study showed that parents were blamed for their offspring having a mental illness, leading to feelings of shame. It was also noted that family members stayed away from patients when they were in hospital and would not visit them. If nurses conducted home visits, family members denied that they had hospitalized relatives. In addition, we found that family members sometimes perpetrated violence towards relatives who had mental illness. For example, participating patients indicated that families subjected them to pasung/confinement or isolated them in a room (seclusion) because community members ordered them to do so, or because they were ashamed or afraid that the patient would be violent [ 19 , 20 ].

Professional stigma

Another significant finding that emerged from participants’ narratives was the presence of professional stigma. This type of stigma included stigma that nurses held toward patients with mental illness, as well as their experiences of being stigmatized by others because of their job. Our participants reported that some nurses and hospital staff held stigmatized attitudes towards patients, which was consistent with existing literature. This type of stigma is a major concern for healthcare professionals, especially nurses, as it may result in disparities in healthcare access and treatment, and affect outcomes [ 55 ]. A previous study indicated that despite healthcare professionals’ attitudes towards mental illness being more positive than those of the general public, paternalistic or negative attitudes were also common, especially around prognosis and the (supposed) limited possibilities for recovery of people with mental illness [ 56 ]. It may also be that nurses and other healthcare professionals continue to misunderstand the causes and symptoms of mental illness, despite considerable experience in this setting. Nurses may also fear mental illness, especially if they believe that mental illness is contagious and can be transmitted like a contagious physical illness [ 24 ]. We speculated that such fear and misunderstanding may be a particular challenge in strongly traditional societies such as Indonesia. Our results also showed that nurses felt that they were discriminated against by other (non-mental health) nurses because they worked in a mental hospital. They also felt humiliated when other people called them as “crazy” as their patients. In addition, our findings indicated that nurses and hospital staff used restraint and seclusion because of fear. This was consistent with a previous study that reported staff may use restraint and seclusion when patients are perceived as dangerous [ 57 ].

Employment discrimination

Having a secure job provides an individual with status in society. For a patient with mental illness, employment is an important part of recovery. Our findings indicated that patients had experienced stigma in their workplaces, which was consistent with the concept of institutional stigma previously reported. The reports of participants in this study suggested that many employers in Indonesia still have negative attitudes and discriminate against people with a mental illness. Many participants reported being refused work because they had a mental illness. In addition, some were not accepted back to their previous place of employment. A previous study found that employment rates for people with severe mental illness were as low as 4% [ 10 ]. Discrimination and stigmatizing beliefs and attitudes make it difficult for people with mental illness to find employment [ 58 ]. A study involving people living with schizophrenia found that over one-third anticipated discrimination in job-seeking [ 11 ]. Stigma can result in difficulties for people with mental illness entering the competitive workforce. Some employers explicitly express negative attitudes regarding workers with mental illness and may be hesitant to hire them [ 59 ]. Having a mental illness may also limit a person’s career advancement, as employers are less likely to offer promotion to this group [ 60 ]. In addition, people with mental illness reported being passed over for jobs for which they were qualified or fired because of their illness [ 60 ]. Our findings showed that although these studies were conducted some time ago, similar issues continue to be experienced by people with mental illness.

Linking them all together

The result of the study confirms that stigmatization of mental illness within the Indonesian context, similar to other countries is a complex and multiple dimensional phenomenon impacting individuals, families, organizations and within the whole society. The outcomes of different types of stigma include social disgrace at personal and family level, separation and loss of social integration amongst families, friends and relatives, status loss and discrimination, homelessness, unemployment, and treatment avoidance. Professional stigma held by nurse professionals toward mental patients develops very much in the same way as public stigma. Nurses themselves are also the recipients of stigma because their work and their workplace are seen as dangerous or even contagious.

Study limitations

Stigma may limit patients’ ability to fully disclose their feelings and stigmatization experiences. Therefore, a major limitation of this study was that despite assuring all participants of the anonymity and confidentiality of their data, some participants might not have felt comfortable in expressing or discussing difficult experiences, and might not have been fully open and honest in sharing their perceptions or experiences. Therefore, during the interviews, participants might not have completely disclosed their situation in their responses or withheld information. The small sample size used in this study (N = 30) may also be considered a limitation. However, after our analysis of the interviews transcripts, the research team believed that saturation had been reached and no further data collection was necessary. Another major limitation was that this study relied on the researchers’ interpretation of the meaning implied in the interview data, which means that some bias persists. To minimize this bias, triangulation was performed using several methods of data collection (interviews, field notes, and writing memos). In addition, bias might have been introduced in our sample as all participants were recruited from a single large referral hospital. This limits the generalizability of our findings as participants cannot be considered representative of the entire spectrum of mental health settings in Indonesia. Finally, verification of data analysis and interpretation with participants could have been a useful step to further deepen understanding and increase credibility, this step was not feasible and could not be performed within this study.

Despite these limitations, we believe that our findings are particularly relevant for mental health professionals, as well as for professionals in other fields where patients and families may be exposed to different kinds of stigmatization. The results of this study may be used to inform research activity in similar settings elsewhere, and contribute to improving practice, education, and research in mental health in Indonesia and similar areas. Although generalization is not the intent of qualitative studies per se, it is possible for our results to be considered in the context of other communities or countries with similar cultural and religious backgrounds. The replication of this study in other mental health settings with different groups of participants may produce different important data.

In Indonesia and other countries with similar cultural contexts, people adhere to traditional and religious value systems that affect (positively or negatively) various aspects of life, including psychosocial aspects and health. Some of these values have strong roots, and therefore have more effects on vulnerable people, which is of particular importance. Traditional beliefs about causes of and treatments for mental illness are prominent in Indonesian culture and traditions, and have seeded the persistent existing taboos or stigma that affect the lives and health of patients, families, and relatives. This study achieved a deep understanding of the concept of stigma in the context of mental healthcare in Indonesia; this understanding is a prerequisite for developing appropriate interventions and the development of mental healthcare services in the country.

Availability of data and materials

The datasets used and/or analysed in the present study are available from author MS on reasonable request.

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Muhammad Arsyad Subu, Jacqueline Maria Dias, Mini Sarah Abraham & Nabeel Al-Yateem

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Subu, M.A., Wati, D.F., Netrida, N. et al. Types of stigma experienced by patients with mental illness and mental health nurses in Indonesia: a qualitative content analysis. Int J Ment Health Syst 15 , 77 (2021). https://doi.org/10.1186/s13033-021-00502-x

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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.

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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

	Public	Self	Structural
Stereotypes & Prejudices	People with mental illness are dangerous, incompetent, to blame for their disorder, unpredictable	I am dangerous, incompetent, to blame	Stereotypes are embodied in laws and other institutions
Discrimination	Therefore, employers may not hire them, landlords may not rent to them, the health care system may offer a lower standard of care	These thoughts may lead to lowered self-esteem and self-efficacy: "Why try? Someone like me is not worthy, or unable to work, live independently, or have good health."	Leads to intended and unintended loss of opportunity

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

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

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Research article
Open access
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.

Peer Review reports

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

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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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Graduate School of Health Sciences, Kobe University, 701, 2-6-2, Yamamoto-dori, Chuo-ku, Kobe, Hyogo, 650-0003, Japan

Chika Tanaka & Hiroya Matsuo

City Health Office, City Government of Muntinlupa, Muntinlupa, Philippines

Maria Teresa Reyes Tuliao

Hyogo Institute for Traumatic Stress, Kobe, Japan

Eizaburo Tanaka

Kobe City College of Nursing, Kobe, Japan

Tadashi Yamashita

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Contributions

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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Correspondence to Chika Tanaka .

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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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Participants were informed that the information they shared in the interviews would be published in anonymised form. Written informed consent for publication was obtained.

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The authors declare that they have no competing interest.

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Additional files

Additional file 1:.

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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55 research questions about mental health

Last updated

11 March 2024

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Brittany Ferri, PhD, OTR/L

Short on time? Get an AI generated summary of this article instead

Research in the mental health space helps fill knowledge gaps and create a fuller picture for patients, healthcare professionals, and policymakers. Over time, these efforts result in better quality care and more accessible treatment options for those who need them.

Use this list of mental health research questions to kickstart your next project or assignment and give yourself the best chance of producing successful and fulfilling research.

Why does mental health research matter?

Mental health research is an essential area of study. It includes any research that focuses on topics related to people’s mental and emotional well-being.

As a complex health topic that, despite the prevalence of mental health conditions, still has an unending number of unanswered questions, the need for thorough research into causes, triggers, and treatment options is clear.

Research into this heavily stigmatized and often misunderstood topic is needed to find better ways to support people struggling with mental health conditions. Understanding what causes them is another crucial area of study, as it enables individuals, companies, and policymakers to make well-informed choices that can help prevent illnesses like anxiety and depression.

How to choose a strong mental health research topic

As one of the most important parts of beginning a new research project, picking a topic that is intriguing, unique, and in demand is a great way to get the best results from your efforts.

Mental health is a blanket term with many niches and specific areas to explore. But, no matter which direction you choose, follow the tips below to ensure you pick the right topic.

Prioritize your interests and skills

While a big part of research is exploring a new and exciting topic, this exploration is best done within a topic or niche in which you are interested and experienced.

Research is tough, even at the best of times. To combat fatigue and increase your chances of pushing through to the finish line, we recommend choosing a topic that aligns with your personal interests, training, or skill set.

Consider emerging trends

Topical and current research questions are hot commodities because they offer solutions and insights into culturally and socially relevant problems.

Depending on the scope and level of freedom you have with your upcoming research project, choosing a topic that’s trending in your area of study is one way to get support and funding (if you need it).

Not every study can be based on a cutting-edge topic, but this can be a great way to explore a new space and create baseline research data for future studies.

Assess your resources and timeline

Before choosing a super ambitious and exciting research topic, consider your project restrictions.

You’ll need to think about things like your research timeline, access to resources and funding, and expected project scope when deciding how broad your research topic will be. In most cases, it’s better to start small and focus on a specific area of study.

Broad research projects are expensive and labor and resource-intensive. They can take years or even decades to complete. Before biting off more than you can chew, consider your scope and find a research question that fits within it.

Read up on the latest research

Finally, once you have narrowed in on a specific topic, you need to read up on the latest studies and published research. A thorough research assessment is a great way to gain some background context on your chosen topic and stops you from repeating a study design. Using the existing work as your guide, you can explore more specific and niche questions to provide highly beneficial answers and insights.

Trending research questions for post-secondary students

As a post-secondary student, finding interesting research questions that fit within the scope of your classes or resources can be challenging. But, with a little bit of effort and pre-planning, you can find unique mental health research topics that will meet your class or project requirements.

Examples of research topics for post-secondary students include the following:

How does school-related stress impact a person’s mental health?

To what extent does burnout impact mental health in medical students?

How does chronic school stress impact a student’s physical health?

How does exam season affect the severity of mental health symptoms?

Is mental health counseling effective for students in an acute mental crisis?

Research questions about anxiety and depression

Anxiety and depression are two of the most commonly spoken about mental health conditions. You might assume that research about these conditions has already been exhausted or that it’s no longer in demand. That’s not the case at all.

According to a 2022 survey by Centers for Disease Control and Prevention (CDC), 12.5% of American adults struggle with regular feelings of worry, nervousness, and anxiety, and 5% struggle with regular feelings of depression. These percentages amount to millions of lives affected, meaning new research into these conditions is essential.

If either of these topics interests you, here are a few trending research questions you could consider:

Does gender play a role in the early diagnosis of anxiety?

How does untreated anxiety impact quality of life?

What are the most common symptoms of anxiety in working professionals aged 20–29?

To what extent do treatment delays impact quality of life in patients with undiagnosed anxiety?

To what extent does stigma affect the quality of care received by people with anxiety?

Here are some examples of research questions about depression:

Does diet play a role in the severity of depression symptoms?

Can people have a genetic predisposition to developing depression?

How common is depression in work-from-home employees?

Does mood journaling help manage depression symptoms?

What role does exercise play in the management of depression symptoms?

Research questions about personality disorders

Personality disorders are complex mental health conditions tied to a person’s behaviors, sense of self, and how they interact with the world around them. Without a diagnosis and treatment, people with personality disorders are more likely to develop negative coping strategies during periods of stress and adversity, which can impact their quality of life and relationships.

There’s no shortage of specific research questions in this category. Here are some examples of research questions about personality disorders that you could explore:

What environments are more likely to trigger the development of a personality disorder?

What barriers impact access to care for people with personality disorders?

To what extent does undiagnosed borderline personality disorder impact a person’s ability to build relationships?

How does group therapy impact symptom severity in people with schizotypal personality disorder?

What is the treatment compliance rate of people with paranoid personality disorder?

Research questions about substance use disorders

“Substance use disorders” is a blanket term for treatable behaviors and patterns within a person’s brain that lead them to become dependent on illicit drugs, alcohol, or prescription medications. It’s one of the most stigmatized mental health categories.

The severity of a person’s symptoms and how they impact their ability to participate in their regular daily life can vary significantly from person to person. But, even in less severe cases, people with a substance use disorder display some level of loss of control due to their need to use the substance they are dependent on.

This is an ever-evolving topic where research is in hot demand. Here are some example research questions:

To what extent do meditation practices help with craving management?

How effective are detox centers in treating acute substance use disorder?

Are there genetic factors that increase a person’s chances of developing a substance use disorder?

How prevalent are substance use disorders in immigrant populations?

To what extent do prescription medications play a role in developing substance use disorders?

Research questions about mental health treatments

Treatments for mental health, pharmaceutical therapies in particular, are a common topic for research and exploration in this space.

Besides the clinical trials required for a drug to receive FDA approval, studies into the efficacy, risks, and patient experiences are essential to better understand mental health therapies.

These types of studies can easily become large in scope, but it’s possible to conduct small cohort research on mental health therapies that can provide helpful insights into the actual experiences of the people receiving these treatments.

Here are some questions you might consider:

What are the long-term effects of electroconvulsive therapy (ECT) for patients with severe depression?

How common is insomnia as a side effect of oral mental health medications?

What are the most common causes of non-compliance for mental health treatments?

How long does it take for patients to report noticeable changes in symptom severity after starting injectable mental health medications?

What issues are most common when weaning a patient off of an anxiety medication?

Controversial mental health research questions

If you’re interested in exploring more cutting-edge research topics, you might consider one that’s “controversial.”

Depending on your own personal values, you might not think many of these topics are controversial. In the context of the research environment, this depends on the perspectives of your project lead and the desires of your sponsors. These topics may not align with the preferred subject matter.

That being said, that doesn’t make them any less worth exploring. In many cases, it makes them more worthwhile, as they encourage people to ask questions and think critically.

Here are just a few examples of “controversial” mental health research questions:

To what extent do financial crises impact mental health in young adults?

How have climate concerns impacted anxiety levels in young adults?

To what extent do psychotropic drugs help patients struggling with anxiety and depression?

To what extent does political reform impact the mental health of LGBTQ+ people?

What mental health supports should be available for the families of people who opt for medically assisted dying?

Research questions about socioeconomic factors & mental health

Socioeconomic factors—like where a person grew up, their annual income, the communities they are exposed to, and the amount, type, and quality of mental health resources they have access to—significantly impact overall health.

This is a complex and multifaceted issue. Choosing a research question that addresses these topics can help researchers, experts, and policymakers provide more equitable and accessible care over time.

Examples of questions that tackle socioeconomic factors and mental health include the following:

How does sliding scale pricing for therapy increase retention rates?

What is the average cost to access acute mental health crisis care in [a specific region]?

To what extent does a person’s environment impact their risk of developing a mental health condition?

How does mental health stigma impact early detection of mental health conditions?

To what extent does discrimination affect the mental health of LGBTQ+ people?

Research questions about the benefits of therapy

Therapy, whether that’s in groups or one-to-one sessions, is one of the most commonly utilized resources for managing mental health conditions. It can help support long-term healing and the development of coping mechanisms.

Yet, despite its popularity, more research is needed to properly understand its benefits and limitations.

Here are some therapy-based questions you could consider to inspire your own research:

In what instances does group therapy benefit people more than solo sessions?

How effective is cognitive behavioral therapy for patients with severe anxiety?

After how many therapy sessions do people report feeling a better sense of self?

Does including meditation reminders during therapy improve patient outcomes?

To what extent has virtual therapy improved access to mental health resources in rural areas?

Research questions about mental health trends in teens

Adolescents are a particularly interesting group for mental health research due to the prevalence of early-onset mental health symptoms in this age group.

As a time of self-discovery and change, puberty brings plenty of stress, anxiety, and hardships, all of which can contribute to worsening mental health symptoms.

If you’re looking to learn more about how to support this age group with mental health, here are some examples of questions you could explore:

Does parenting style impact anxiety rates in teens?

How early should teenagers receive mental health treatment?

To what extent does cyberbullying impact adolescent mental health?

What are the most common harmful coping mechanisms explored by teens?

How have smartphones affected teenagers’ self-worth and sense of self?

Research questions about social media and mental health

Social media platforms like TikTok, Instagram, YouTube, Facebook, and X (formerly Twitter) have significantly impacted day-to-day communication. However, despite their numerous benefits and uses, they have also become a significant source of stress, anxiety, and self-worth issues for those who use them.

These platforms have been around for a while now, but research on their impact is still in its infancy. Are you interested in building knowledge about this ever-changing topic? Here are some examples of social media research questions you could consider:

To what extent does TikTok’s mental health content impact people’s perception of their health?

How much non-professional mental health content is created on social media platforms?

How has social media content increased the likelihood of a teen self-identifying themselves with ADHD or autism?

To what extent do social media photoshopped images impact body image and self-worth?

Has social media access increased feelings of anxiety and dread in young adults?

Mental health research is incredibly important

As you have seen, there are so many unique mental health research questions worth exploring. Which options are piquing your interest?

Whether you are a university student considering your next paper topic or a professional looking to explore a new area of study, mental health is an exciting and ever-changing area of research to get involved with.

Your research will be valuable, no matter how big or small. As a niche area of healthcare still shrouded in stigma, any insights you gain into new ways to support, treat, or identify mental health triggers and trends are a net positive for millions of people worldwide.

Should you be using a customer insights hub?

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Office for Disparities Research and Workforce Diversity Webinar Series: Understanding Stigma and Discrimination as Drivers of Mental Health Disparities for Diverse, Rural, LGBTQ+ Communities

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This webinar will present the goals and procedures of the Rural Engagement and Approaches For LGBTQ+ Mental Health (REALM) study, which is developing a longitudinal cohort of diverse LGBTQ+ adults residing in rural and small metropolitan communities across the United States.

Employing a minority stress framework, REALM aims to determine the following: whether types of stigma, discrimination, and traumatic experiences vary across LGBTQ+ groups; how these exposures are associated with increased prevalence and incidence of depression, suicidal ideation, and suicide attempts; and if and how proximal minority stress-related factors mediate and/or moderate these associations. Further, building on these findings, REALM will compare the relative acceptability of various technology-delivered intervention components for depression and suicide prevention for diverse rural LGBTQ+ communities.

Challenges with online recruitment and enrollment and creative solutions will be shared, in addition to lessons learned in how to ensure participant safety. The webinar will end with a description of the cohort to date and share preliminary baseline findings related to study aims.

About the speakers

Sarah m. murray, ph.d., m.s.p.h..

Assistant Professor Johns Hopkins Bloomberg School of Public Health Department of Mental Health

Sarah M. Murray (she/her) is a psychiatric epidemiologist and assistant professor at the Bloomberg School of Public Health at John Hopkins University. Her primary research interest is using mixed methods to understand the multifaceted relationship between violence, stigma, and common mental disorders to inform the development of effective strategies to promote the mental health and psychosocial well-being of individuals experiencing marginalization and/or living in situations of complex adversity in high-, middle- and low-income countries. Much of her research focuses on better understanding and measuring experiences of stigma among sexual and gender minority adults. As principal investigator of the REALM study, Dr, Murray seeks to better understand how these experiences may drive mental health disparities and what strengths-based and protective factors may contribute to positive mental health outcomes to inform intervention development.

Kirsten Siebach, M.S.W.

NIMH Global Mental Health T32 Doctoral Fellow Johns Hopkins Bloomberg School of Public Health Department of International Health

Kirsten Siebach (she/they) is a third year doctoral student in the International Health Department at the Bloomberg School of Public Health at Johns Hopkins University. Kirsten’s research interests lie in the impact of the structural environment, including policies, laws, social attitudes, and norms, on mental health and psychosocial well-being, specifically among the LGBTQ+ community. Kirsten’s dissertation work will examine how structural stigma impacts LGBTQ+ adults living in the rural United States. Kirsten has a master’s degree in social work from the Boston College School of Social Work. She works with Mariah Valentine and clinician Gina Baily Herring to implement the mental health safety protocol for the REALM study.

Mariah Valentine-Graves, M.P.H.

Public Health Program Associate Emory University Rollins School of Public Health Program, Research, Innovation in Sexual Minority Health (PRISM)

Mariah Valentine-Graves (she/her) received her bachelor’s degree in history and political science from the University of California, San Diego (UCSD) in 2013, followed by her Master of Public Health in behavioral science and health education from the Rollins School of Public Health at Emory University in 2016. During her time at UCSD, she was involved in social justice work as an intern with both the UCSD LGBT Resource Center and the UCSD Women’s Center. During her time at Emory University, Mariah worked for two years as a graduate research assistant for the Women’s Interagency HIV Study at the Grady Infectious Disease Program. She has worked with PRISM Health as a public health program associate since 2016, coordinating the Engage[men]t Study, a cohort study of men living with HIV in Atlanta. She leads participant-facing activities in the REALM study including recruitment and retention of participants.

About the Office for Disparities Research and Workforce Diversity Webinar Series

The Office for Disparities Research and Workforce Diversity Webinar Series is designed for investigators conducting or interested in conducting research on mental health disparities, women’s mental health, minority mental health, and rural mental health.

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Kids’ mental health is in crisis. Here’s what psychologists are doing to help

Research is focused on child and teen mental health, exploring why they are struggling and what can be done to help them

Vol. 54 No. 1 Print version: page 63

Mental Health

[ This article is part of the 2023 Trends Report ]

The Covid -19 pandemic era ushered in a new set of challenges for youth in the United States, leading to a mental health crisis as declared by the United States surgeon general just over a year ago. But U.S. children and teens have been suffering for far longer.

In the 10 years leading up to the pandemic, feelings of persistent sadness and hopelessness—as well as suicidal thoughts and behaviors—increased by about 40% among young people, according to the Centers for Disease Control and Prevention’s (CDC) Youth Risk Behavior Surveillance System .

“We’re seeing really high rates of suicide and depression, and this has been going on for a while,” said psychologist Kimberly Hoagwood, PhD, a professor of child and adolescent psychiatry at New York University’s Grossman School of Medicine. “It certainly got worse during the pandemic.”

In addition to the social isolation and academic disruption nearly all children and teens faced, many also lost caregivers to Covid -19, had a parent lose their job, or were victims of physical or emotional abuse at home.

All these difficulties, on top of growing concerns about social media, mass violence, natural disasters, climate change, and political polarization—not to mention the normal ups and downs of childhood and adolescence—can feel insurmountable for those who work with kids.

“The idea of a ‘mental health crisis’ is really broad. For providers and parents, the term can be anxiety-provoking,” said Melissa Brymer, PhD, who directs terrorism and disaster programs at the UCLA–Duke University National Center for Child Traumatic Stress. “Part of our role is to highlight specific areas that are critical in this discussion.”

Across the field, psychologists are doing just that. In addition to studying the biological, social, and structural contributors to the current situation, they are developing and disseminating solutions to families, in schools, and at the state level. They’re exploring ways to improve clinical training and capacity and working to restructure policies to support the most vulnerable children and teens.

Psychologists were also behind new mental health recommendations from the U.S. Preventive Services Task Force, a group of volunteer health professionals who evaluate evidence on various preventive health services. The task force now recommends regular anxiety screenings for youth ages 8 to 18 and regular depression screenings for adolescents ages 12 to 18.

“I see these trends in children’s mental health problems as being critical, but there are solutions,” Hoagwood said. “If we refocus our efforts toward those solutions, we could see some of these tides turn.”

Sources of stress

Across the United States, more than 200,000 children lost a parent or primary caregiver to Covid -19 (“ Covid -19 Orphanhood,” Imperial College London, 2022). In the face of those losses, families had to curtail mourning rituals and goodbye traditions because of social distancing requirements and other public health measures, Brymer said. Many children are still grieving, sometimes while facing added challenges such as moving to a different home or transferring to a new school with unfamiliar peers.

The CDC also reports that during the pandemic, 29% of U.S. high school students had a parent or caregiver who lost their job, 55% were emotionally abused by a parent or caregiver, and 11% were physically abused ( Adolescent Behaviors and Experiences Survey—United States, January–June 2021 , CDC ).

“Schools are crucial for keeping kids safe and connecting them with services, but the pandemic completely disrupted those kinds of supports,” Brymer said.

Those extreme disruptions didn’t affect all young people equally. Echoing pre- Covid -19 trends, the CDC also found that girls, LGBTQ+ youth, and those who have experienced racism were more likely to have poor mental health during the pandemic, said social psychologist Kathleen Ethier, PhD, director of the CDC’s Division of Adolescent and School Health.

Contributing factors likely include stigma, discrimination, and online bullying, Ethier said. Female students also report much higher levels of sexual violence than their male peers, which can further harm mental health.

As much hardship as Covid -19 wrought, it’s far from the only factor contributing to the current crisis. Biology also appears to play a role. The age of puberty has been dropping for decades, especially in girls, likely leading to difficulty processing complex feelings and knowing what to do about them ( Eckert-Lind, C., et al., JAMA Pediatrics , Vol. 174, No. 4, 2020 ). In early puberty, regions of the brain linked to emotions and social behavior are developing more quickly than regions responsible for the cognitive control of behavior, such as the prefrontal cortex, Ethier said.

Those developmental changes drive young people to seek attention and approval from their peers . For some, using social media fulfills that need in a healthy way, providing opportunities for connection and validation to youth who may be isolated from peers, geographically or otherwise.

For others, negative messages—including online bullying and unrealistic standards around physical appearance—appear to have a detrimental effect, but more research is needed to understand who is most at risk.

“There is clearly some aspect of young people’s online life that’s contributing [to the mental health crisis], we just don’t know exactly what that is,” said Ethier.

Finally, structural factors that affect millions of U.S. children, including poverty, food insecurity, homelessness, and lack of access to health care and educational opportunities, can lead to stress-response patterns that are known to underlie mental health challenges.

“Even in very young children, prolonged stress can trigger a cycle of emotion-regulation problems, which can in turn lead to anxiety, depression, and behavioral difficulties,” Hoagwood said. “These things are well established, but we’re not doing enough as a field to address them.”

Building capacity in schools

The biggest challenge facing mental health care providers right now, experts say, is a shortage of providers trained to meet the mounting needs of children and adolescents.

“There’s a growing recognition that mental health is just as important as physical health in young people’s development, but that’s happening just as mental health services are under extreme strain,” said clinical psychologist Robin Gurwitch, PhD, a professor in the Department of Psychiatry and Behavioral Sciences at Duke University Medical Center.

Schools, for example, are a key way to reach and help children—but a 2022 Pew Research Center survey found that only about half of U.S. public schools offer mental health assessments and even fewer offer treatment services. Psychologists are now ramping up efforts to better equip schools to support student well-being onsite.

Much of that work involves changing policies at the school or district level to provide more support for all students. For example, school connectedness—the degree to which young people feel that adults and peers at school care about them and are invested in their success—is a key contributor to mental health. Youth who felt connected during middle and high school have fewer problems with substance use, mental health, suicidality, and risky sexual behavior as adults ( Steiner, R. J., et al., Pediatrics , Vol. 144, No. 1, 2019 ).

Through its What Works in Schools program , the CDC funds school districts to make changes that research shows foster school connectedness. Those include improving classroom management, implementing service-learning programs for students in their communities, bringing mentors from the community into schools, and making schools safer and more supportive for LGBTQ+ students.

Psychologists are also building training programs to help teachers and other school staff create supportive classrooms and aid students who are in distress. Classroom Wise (Well-Being Information and Strategies for Educators), developed by the Mental Health Technology Transfer Center Network and the University of Maryland’s National Center for School Mental Health (NCSMH), is a free, flexible online course and resource library that draws on psychological research on social-emotional learning, behavioral regulation, mental health literacy, trauma, and more ( Evidence-Based Components of Classroom Wise (PDF, 205KB), NCSMH, 2021 ).

“We’re using evidence-based practices from child and adolescent mental health but making these strategies readily available for teachers to apply in the classroom,” said clinical psychologist Nancy Lever, PhD, codirector of NCSMH, who helped develop Classroom Wise .

The course incorporates the voices of students and educators and teaches actionable strategies such as how to create rules and routines that make classrooms feel safe and how to model emotional self-regulation. The strategies can be used by anyone who interacts with students, from teachers and administrators to school nurses, coaches, and bus drivers.

“What we need is to build capacity through all of the systems that are part of children’s lives—in families, in schools, in the education of everybody who interacts with children,” said psychologist Ann Masten, PhD, a professor of child development at the University of Minnesota.

Other training efforts focus on the students themselves. Given that preteens and teenagers tend to seek support from their peers before turning to adults, the National Child Traumatic Stress Network (NCTSN) created conversation cards to equip kids with basic skills for talking about suicide. The advice, available in English and Spanish, includes how to ask about suicidal thoughts, how to listen without judgment, and when to seek guidance from an adult ( Talking About Suicide With Friends and Peers, NCTSN, 2021 ).

While training people across the school population to spot and address mental health concerns can help reduce the strain on mental health professionals, there will always be a subset of students who need more specialized support.

Telehealth, nearly ubiquitous these days, is one of the best ways to do that. In South Carolina, psychologist Regan Stewart, PhD, and her colleagues colaunched the Telehealth Outreach Program at the Medical University of South Carolina in 2015. Today, nearly every school in the state has telehealth equipment (Wi-Fi and tablets or laptops that kids can use at school or take home) and access to providers (psychology and social work graduate students and clinicians trained in trauma-focused cognitive behavioral therapy). Students who need services, which are free thanks to grant funding or covered by Medicaid, meet one-on-one with their clinician during the school day or after hours ( American Psychologist , Vol. 75, No. 8, 2020 ).

“We learned a lot about the use of technology during the pandemic,” Ethier said. “At this point, it’s very much a matter of having sufficient resources so more school districts can access those sources of care.”

Expanding the workforce

Limited resources are leaving families low on options, with some young people making multiple trips to the emergency room for mental health-related concerns or spending more than six months on a waiting list for mental health support. That points to a need for more trained emergency responders and psychiatric beds, psychologists say, but also for better upstream screening and prevention to reduce the need for intensive care.

“Just as we need more capacity for psychiatric emergencies in kids, we also need an infusion of knowledge and ordinary strategies to support mental health on the positive side,” Masten said.

In New York, Hoagwood helped launch the state-funded Evidence Based Treatment Dissemination Center in 2006, which offers free training on evidence-based practices for trauma, behavioral and attention problems, anxiety, depression, and more to all mental health professionals who work with children in state-licensed programs, which include foster care, juvenile justice, and school settings, among others. The center provides training on a core set of tools known as PracticeWise ( Chorpita, B. F., & Daleiden E. L., Journal of Consulting and Clinical Psychology , Vol. 77, No. 3, 2009 ). It also offers tailored training based on requests from community agency leaders and clinicians who provide services to children and their families.

Hoagwood, in collaboration with a consortium of family advocates, state officials, and researchers, also helped build and test a state-approved training model and credentialing program for family and youth peer advocates. The peer advocate programs help expand the mental health workforce while giving families access to peers who have similar lived experience ( Psychiatric Services , Vol. 71, No. 5, 2020).

Youth peer advocates are young adults who have personal experience with systems such as foster care, juvenile justice, or state psychiatric care. They work within care teams to provide basic education and emotional support to other youth, such as giving advice on what questions to ask a new mental health practitioner and explaining the differences between psychologists, psychiatrists, and social workers. Youth peer advocates in New York can now receive college credit for their training in peer specialist work.

“Making community health work into a viable career can also increase diversity among mental health workers and help us address structural racism,” Hoagwood said.

Pediatricians are another group that can provide a first line of defense, drawing on their relationships with parents to destigmatize mental health care.

“Pediatricians are in many ways uniquely positioned to help address the mental health crisis in youth,” said Janine A. Rethy, MD, MPH, division chief of community pediatrics at MedStar Georgetown University Hospital and an associate professor of pediatrics at Georgetown University School of Medicine. “We have the privilege of building long-term relationships with children and their families over many years,” with at least 12 well-child checkups in just the first three years of a child’s life, followed by annual visits.

During these visits, they can watch for warning signs of social and behavioral problems and screen for maternal depression and other issues in parents, which is now recommended by the American Academy of Pediatrics (PDF, 660KB) . Several new resources provide guidance for integrating mental health care into pediatric practices, including the Behavioral Health Integration Compendium (PDF, 4.1MB) and the Healthy Steps program . But most pediatricians need more education on mental health issues in order to effectively respond, Rethy said—yet another area where psychologists may be able to help. Psychologists can provide direct consultations and training to pediatricians through the Pediatric Mental Health Care Access program.

“The more we can weave mental health knowledge, capacity, and checkpoints into places where parents feel comfortable—like the doctor’s office and at school—the better,” Masten said. “All professionals who work with young people really need the knowledge that’s being generated by psychologists.”

11 emerging trends for 2023

Scientists reach a wider audience

Psychologists take aim at misinformation

Psychological research becomes more inclusive

EDI roles expand

Worker well-being is in demand

Efforts to improve childrens’ mental health increase

Partnerships accelerate progress

Suicide prevention gets a new lifeline

Some faculty exit academia

Venture capitalists shift focus

Psychologists rebrand the field

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Understanding the impact of stigma on people with mental illness

Patrick w corrigan.

1 University of Chicago Center for Psychiatric Rehabilitation and Chicago Consortium for Stigma Research, 7230 Arbor Drive, Tinley Park, IL 60477, USA

AMY C WATSON

Many people with serious mental illness are challenged doubly. On one hand, they struggle with the symptoms and disabilities that result from the disease. On the other, they are challenged by the stereotypes and prejudice that result from misconceptions about mental illness. As a result of both, people with mental illness are robbed of the opportunities that define a quality life: good jobs, safe housing, satisfactory health care, and affiliation with a diverse group of people. Although research has gone far to understand the impact of the disease, it has only recently begun to explain stigma in mental illness. Much work yet needs to be done to fully understand the breadth and scope of prejudice against people with mental illness. Fortunately, social psychologists and sociologists have been studying phenomena related to stigma in other minority groups for several decades. In this paper, we integrate research specific to mental illness stigma with the more general body of research on stereotypes and prejudice to provide a brief overview of issues in the area.

The impact of stigma is twofold, as outlined in Table Table1. 1 . Public stigma is the reaction that the general population has to people with mental illness. Self-stigma is the prejudice which people with mental illness turn against themselves. Both public and self-stigma may be understood in terms of three components: stereotypes, prejudice, and discrimination. Social psychologists view stereotypes as especially efficient, social knowledge structures that are learned by most members of a social group ( 1 - 3 ). Stereotypes are considered "social" because they represent collectively agreed upon notions of groups of persons. They are "efficient" because people can quickly generate impressions and expectations of individuals who belong to a stereotyped group ( 4 ).

Comparing and contrasting the definitions of public stigma and self-stigma


	Negative belief about a group (e.g., dangerousness, incompetence, character weakness)
	Agreement with belief and/or negative emotional reaction (e.g., anger, fear)
	Behavior response to prejudice (e.g., avoidance, withhold employment and housing opportunities, withhold help)


	Negative belief about the self (e.g., character weakness, incompetence)
	Agreement with belief, negative emotional reaction (e.g., low self-esteem, low self-efficacy)
	Behavior response to prejudice (e.g., fails to pursue work and housing opportunities)

The fact that most people have knowledge of a set of stereotypes does not imply that they agree with them ( 5 ). For example, many persons can recall stereotypes about different racial groups but do not agree that the stereotypes are valid. People who are prejudiced, on the other hand, endorse these negative stereotypes ("That's right; all persons with mental illness are violent!") and generate negative emotional reactions as a result ("They all scare me!") ( 1 , 3 , 6 ). In contrast to stereotypes, which are beliefs, prejudicial attitudes involve an evaluative (generally negative) component ( 7 , 8 ). Prejudice also yields emotional responses (e.g., anger or fear) to stigmatized groups.

Prejudice, which is fundamentally a cognitive and affective response, leads to discrimination, the behavioral reaction ( 9 ). Prejudice that yields anger can lead to hostile behavior (e.g., physically harming a minority group) ( 10 ). In terms of mental illness, angry prejudice may lead to withholding help or replacing health care with services provided by the criminal justice system ( 11 ). Fear leads to avoidance; e.g., employers do not want persons with mental illness nearby so they do not hire them ( 12 ). Alternatively, prejudice turned inward leads to self-discrimination. Research suggests self-stigma and fear of rejection by others lead many persons to not pursuing life opportunities for themselves ( 13 , 14 ). The remainder of this paper further develops examples of public and self-stigma. In the process, we summarize research on ways of changing the impact of public and self-stigma.

PUBLIC STIGMA

Stigmas about mental illness seem to be widely endorsed by the general public in the Western world. Studies suggest that the majority of citizens in the United States ( 13 , 15 - 17 ) and many Western European nations ( 18 - 21 ) have stigmatizing attitudes about mental illness. Furthermore, stigmatizing views about mental illness are not limited to uninformed members of the general public; even well-trained professionals from most mental health disciplines subscribe to stereotypes about mental illness ( 22 - 25 ).

Stigma seems to be less evident in Asian and African countries ( 26 ), though it is unclear whether this finding represents a cultural sphere that does not promote stigma or a dearth of research in these societies. The available research indicates that, while attitudes toward mental illness vary among non-Western cultures ( 26 , 27 ), the stigma of mental illness may be less severe than in Western cultures. Fabrega ( 26 ) suggests that the lack of differentiation between psychiatric and non-psychiatric illness in the three great non-Western medical traditions is an important factor. While the potential for stigmatization of psychiatric illness certainly exists in non-Western cultures, it seems to primarily attach to the more chronic forms of illness that fail to respond to traditional treatments. Notably, stigma seems almost nonexistent in Islamic societies ( 26 - 28 ). Cross-cultural examinations of the concepts, experiences, and responses to mental illness are clearly needed.

Several themes describe misconceptions about mental illness and corresponding stigmatizing attitudes. Media analyses of film and print have identified three: people with mental illness are homicidal maniacs who need to be feared; they have childlike perceptions of the world that should be marveled; or they are responsible for their illness because they have weak character ( 29 - 32 ). Results of two independent factor analyses of the survey responses of more than 2000 English and American citizens parallel these findings ( 19 , 33 ):

fear and exclusion: persons with severe mental illness should be feared and, therefore, be kept out of most communities;
authoritarianism: persons with severe mental illness are irresponsible, so life decisions should be made by others;
benevolence: persons with severe mental illness are childlike and need to be cared for.

Although stigmatizing attitudes are not limited to mental illness, the public seems to disapprove persons with psychiatric disabilities significantly more than persons with related conditions such as physical illness ( 34 - 36 ). Severe mental illness has been likened to drug addiction, prostitution, and criminality ( 37 , 38 ). Unlike physical disabilities, persons with mental illness are perceived by the public to be in control of their disabilities and responsible for causing them ( 34 , 36 ). Furthermore, research respondents are less likely to pity persons with mental illness, instead reacting to psychiatric disability with anger and believing that help is not deserved ( 35 , 36 , 39 ).

The behavioral impact (or discrimination) that results from public stigma may take four forms: withholding help, avoidance, coercive treatment, and segregated institutions. Previous studies have shown that the public will withhold help to some minority groups because of corresponding stigma ( 36 , 40 ). A more extreme form of this behavior is social avoidance, where the public strives to not interact with people with mental illness altogether. The 1996 General Social Survey (GSS), in which the Mac Arthur Mental Health Module was administered to a probability sample of 1444 adults in the United States, found that more than a half of respondents are unwilling to: spend an evening socializing, work next to, or have a family member marry a person with mental illness ( 41 ). Social avoidance is not just self-report; it is also a reality. Research has shown that stigma has a deleterious impact on obtaining good jobs ( 13 , 42 - 44 ) and leasing safe housing ( 45 - 47 ).

Discrimination can also appear in public opinion about how to treat people with mental illness. For example, though recent studies have been unable to demonstrate the effectiveness of mandatory treatment ( 48 , 49 ), more than 40% of the 1996 GSS sample agreed that people with schizophrenia should be forced into treatment ( 50 ). Additionally, the public endorses segregation in institutions as the best service for people with serious psychiatric disorders ( 19 , 51 ).

STRATEGIES FOR CHANGING PUBLIC STIGMA

Change strategies for public stigma have been grouped into three approaches: protest, education, and contact ( 12 ). Groups protest inaccurate and hostile representations of mental illness as a way to challenge the stigmas they represent. These efforts send two messages. To the media: STOP reporting inaccurate representations of mental illness. To the public: STOP believing negative views about mental illness. Wahl ( 32 ) believes citizens are encountering far fewer sanctioned examples of stigma and stereotypes because of protest efforts. Anecdotal evidence suggests that protest campaigns have been effective in getting stigmatizing images of mental illness withdrawn. There is, however, little empirical research on the psychological impact of protest campaigns on stigma and discrimination, suggesting an important direction for future research.

Protest is a reactive strategy; it attempts to diminish negative attitudes about mental illness, but fails to promote more positive attitudes that are supported by facts. Education provides information so that the public can make more informed decisions about mental illness. This approach to changing stigma has been most thoroughly examined by investigators. Research, for example, has suggested that persons who evince a better understanding of mental illness are less likely to endorse stigma and discrimination ( 17 , 19 , 52 ). Hence, the strategic provision of information about mental illness seems to lessen negative stereotypes. Several studies have shown that participation in education programs on mental illness led to improved attitudes about persons with these problems ( 22 , 53 - 56 ). Education programs are effective for a wide variety of participants, including college undergraduates, graduate students, adolescents, community residents, and persons with mental illness.

Stigma is further diminished when members of the general public meet persons with mental illness who are able to hold down jobs or live as good neighbors in the community. Research has shown an inverse relationship between having contact with a person with mental illness and endorsing psychiatric stigma ( 54 , 57 ). Hence, opportunities for the public to meet persons with severe mental illness may discount stigma. Interpersonal contact is further enhanced when the general public is able to regularly interact with people with mental illness as peers.

SELF-STIGMA

One might think that people with psychiatric disability, living in a society that widely endorses stigmatizing ideas, will internalize these ideas and believe that they are less valued because of their psychiatric disorder. Self-esteem suffers, as does confidence in one's future ( 7 , 58 , 59 ). Given this research, models of self-stigma need to account for the deleterious effects of prejudice on an individual's conception of him or herself. However, research also suggests that, instead of being diminished by the stigma, many persons become righteously angry because of the prejudice that they have experienced ( 60 - 62 ). This kind of reaction empowers people to change their roles in the mental health system, becoming more active participants in their treatment plan and often pushing for improvements in the quality of services ( 63 ).

Low self-esteem versus righteous anger describes a fundamental paradox in self-stigma ( 64 ). Models that explain the experience of self-stigma need to account for some persons whose sense of self is harmed by social stigma versus others who are energized by, and forcefully react to, the injustice. And there is yet a third group that needs to be considered in describing the impact of stigma on the self. The sense of self for many persons with mental illness is neither hurt, nor energized, by social stigma, instead showing a seeming indifference to it altogether.

We propose a situational model that explains this paradox, arguing that an individual with mental illness may experience diminished self-esteem/self-efficacy, righteous anger, or relative indifference depending on the parameters of the situation ( 64 ). Important factors that affect a situational response to stigma include collective representations that are primed in that situation, the person's perception of the legitimacy of stigma in the situation, and the person's identification with the larger group of individuals with mental illness. This model has eventual implications for ways in which persons with mental illness might cope with self-stigma as well as identification of policies that promote environments in which stigma festers.

CONCLUSIONS

Researchers are beginning to apply what social psychologists have learned about prejudice and stereotypes in general to the stigma related to mental illness. We have made progress in understanding the dimensions of mental illness stigma, and the processes by which public stereotypes are translated into discriminatory behavior. At the same time, we are beginning to develop models of self-stigma, which is a more complex phenomenon than originally assumed. The models developed thus far need to be tested on various sub-populations, including different ethnic groups and power-holders (legislators, judges, police officers, health care providers, employers, landlords). We are also learning about stigma change strategies. Contact in particular seems to be effective for changing individual attitudes. Researchers need to examine whether changes resulting from anti-stigma interventions are maintained over time.

All of the research discussed in this paper examines stigma at the individual psychological level. For the most part, these studies have ignored the fact that stigma is inherent in the social structures that make up society. Stigma is evident in the way laws, social services, and the justice system are structured as well as ways in which resources are allocated. Research that focuses on the social structures that maintain stigma and strategies for changing them is sorely needed.

IMAGES

(PDF) Mental Health Stigma Among Filipinos: Time For A Paradigm Shift
Types of mental health related stigma
(PDF) A qualitative study on the stigma experienced by people with
Stigma associated with mental illness; the adverse consequences, and
Mental Health Stigma Assignment.docx
Stigma in Mental Health: Understanding the Impact and Definition of

COMMENTS

Public Stigma of Mental Illness in the United States: A Systematic Literature Review
Public stigma is a pervasive barrier that prevents many individuals in the U.S. from engaging in mental health care. This systematic literature review aims to: (1) evaluate methods used to study the public's stigma toward mental disorders, (2) summarize stigma findings focused on the public's stigmatizing beliefs and actions and attitudes toward mental health treatment for children and ...
Strategies to Reduce Mental Illness Stigma: Perspectives of People with
1. Introduction. The stigma of living with a mental health condition has been described as being worse than the experience of the illness itself [].The aversive reactions that members of the general population have towards people with mental illness is known as public stigma and can be understood in terms of (i) stereotypes, (ii) prejudice, and (iii) discrimination [].
Conceptualizing and Measuring Mental Illness Stigma: The Mental Illness
Mental illness stigma is as a major obstacle to well-being among people with mental illness (PWMI). According to findings from the most recent nationally representative study of public attitudes toward mental illness in the U.S., only 42% of Americans aged 18-24 believe PWMI can be successful at work, 26% believe that others have a caring attitude toward PWMI, and 25% believe that PWMI can ...
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.
Exploring perspectives of stigma and discrimination among people with
We searched PubMed from database inception to January 29, 2024, for articles reflecting co-produced research exploring mental health related stigma and discrimination. We used the broad terms in titles and abstracts ("co-produc∗" OR "co-design∗" OR "participatory") AND (stigma) AND (mental health), without any language restrictions.
Males and Mental Health Stigma
Men (79% of 38,364) die by suicide at a rate four times higher than women ( Mental Health America [MHA], 2020 ). They also die due to alcohol-related causes at 62,000 in comparison to women at 26,000. Men are also two to three times more likely to misuse drugs than women ( Center for Behavioral Health Statistics and Quality, 2017 ).
Assessment of perceived mental health-related stigma: The Stigma-9
The STIG-9 is a new, theory-grounded, patient-oriented and psychometrically promising self-report measure of perceived mental health-related stigma. It is brief, comprehensive, and appears to be well accepted by patients with mental disorders. Keywords: Anxiety; Depression; Measure; Mental disorder; Psychometric evaluation; Stigma.
(PDF) Mental Health Stigma: Theory, Developmental Issues, and Research
Abstract. Mental health stigma is arguably the fundamental issue in the entire mental health field, including developmental psychopathology, given its impact on every participant in the enterprise ...
The Influence of Stigma and Views on Mental Health Treatment
In light of mixed results from previous comparative studies on the perceived public stigma and the paucity of comparative research on views on mental health service effectiveness among non-Hispanic White, non-Hispanic Black, and Hispanic groups of adults, this study attempts to address the following three main research questions, using a ...
Trends in Public Stigma of Mental Illness in the US, 1996-2018
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 ...
Types of stigma experienced by patients with mental illness and mental
Stigma refers to the discrediting, devaluing, and shaming of a person because of characteristics or attributes that they possess. Generally, stigma leads to negative social experiences such as isolation, rejection, marginalization, and discrimination. If related to a health condition such as mental illness, stigma may affect a person's illness and treatment course, including access to ...
A qualitative study: experiences of stigma by people with mental health
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.
Stigma, Prejudice and Discrimination Against People with Mental Illness
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.
A qualitative study on the stigma experienced by people with mental
Background 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 ...
PDF DISCUSSION STARTERS: Stigma and Mental Illness
DISCUSSION STARTERS: Stigma and Mental Illness . ... Symptoms may be a more useful way to address this question: has anyone suffered from intense sadness, feeling tired all the time, extreme nervousness, etc. ... iii UCLA Center for Health Policy Research. Adult Mental Health Needs in California, November 2011.
Understanding and Addressing Mental Health Stigma Across Cultures for
Accumulating research suggests that stigma toward mental illness is common in various cultures, which can affect mental illness diagnosis, treatment, and management . Furthermore, some studies reveal that mental health stigma manifests differently across cultures and can be influenced by cultural beliefs, attitudes, and values . The stigma ...
55 research questions about mental health
Research questions about anxiety and depression. Anxiety and depression are two of the most commonly spoken about mental health conditions. You might assume that research about these conditions has already been exhausted or that it's no longer in demand. That's not the case at all. According to a 2022 survey by Centers for Disease Control ...
Office for Disparities Research and Workforce Diversity Webinar ...
Her primary research interest is using mixed methods to understand the multifaceted relationship between violence, stigma, and common mental disorders to inform the development of effective strategies to promote the mental health and psychosocial well-being of individuals experiencing marginalization and/or living in situations of complex ...
Mental illness-related stigma in healthcare
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 ...
Mental Health Stigma in Iran: A Systematic Review
Background and Aim Mental disorders are among the most common diseases in the world. Not only the lack of social support and health services but also the social stigma surrounding individuals with ...
Kids' mental health is in crisis. Here's what psychologists are doing
The Covid-19 pandemic era ushered in a new set of challenges for youth in the United States, leading to a mental health crisis as declared by the United States surgeon general just over a year ago.But U.S. children and teens have been suffering for far longer. In the 10 years leading up to the pandemic, feelings of persistent sadness and hopelessness—as well as suicidal thoughts and ...
Understanding the impact of stigma on people with mental illness
In this paper, we integrate research specific to mental illness stigma with the more general body of research on stereotypes and prejudice to provide a brief overview of issues in the area. The impact of stigma is twofold, as outlined in Table. . 1. Public stigma is the reaction that the general population has to people with mental illness.

Types of stigma experienced by patients with mental illness and mental health nurses in Indonesia: a qualitative content analysis

Conclusions

Question guiding this inquiry

Study design

Study setting and participants

Data collection

Data analysis

Theme 1: perceived stigma from a patient perspective

Theme 2: public stigma

Patients’ perspectives

Nurses’ perspectives

Theme 3: family attitudes towards mentally ill patients

Theme 4: Employment discrimination

Theme 5: professional stigma

Perceived stigma from a patient perspective

Public stigma

Family attitudes

Professional stigma

Employment discrimination

Linking them all together

Study limitations

Availability of data and materials

Acknowledgements

Author information

Contributions

Corresponding author

Ethics declarations

Consent for publication

Competing interests

Additional information

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

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The Facts on Stigma, Prejudice and Discrimination

Types of Stigma

Harmful Effects of Stigma and Discrimination

Stigma Can Also Impact Family and Friends

Stigma in the Workplace

Reducing Stigma

Individual Actions to Reduce Stigma

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

Organizations and Campaigns

How So We Stop Stigma? Conversation

Don't Say

Physician Review

Medical leadership for mind, brain and body.

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

Conclusions

Main data collection

Recruitment

Interview procedures

Supplementary data collection

Context affecting stigma experience

Public belief about mental health problems

Familial problems

Unrealistic pessimism and optimism about severity

Oversimplified chronic course

Interpersonal condition

Unresolved threat

Unmet expectation

Stigma experience

Impact modifier of stigma experience

Fatalistic appraisal of stigma experience

Support based on Bayanihan spirit

Consequence of stigma experience

Reduction of social networks

Lost social roles and opportunities

Increased financial strain

Aggravated mental health

Practical implications

Study limitations