"Julie*" managed to keep her chronic depression at bay for two years, despite the stress of attending a prestigious law school. But when she got into a car accident during her third year, she experienced a brutal resurgence of anxiety, sadness and insomnia. In search of sleeping pills, Julie went to a doctor. He recommended she see a therapist, but she refused.
"I was afraid that I might have to disclose my medical records for bar admission," she says.
Julie's worries were warranted: All 50 states' bar associations ask about applicants' mental health histories, and there are several cases of people being denied admittance on the basis of mental health problems—even if they've been successfully treated.
Now a successful lawyer, Julie still keeps her depression from her co-workers for fear of how they'd react.
That's an all-too-common situation, says Bernice Pescosolido, PhD, a stigma researcher at Indiana University.
"She had a good reason to worry," says Pescosolido, principal investigator for several major National Institutes of Health-funded stigma studies. "The two areas where Americans are most stigmatizing are marriage into the family and work."
Despite decades of public information campaigns costing tens of millions of dollars, Americans may be as suspicious of people with mental illness as ever. New research by Pescosolido, published in the Journal of Health and Social Behavior (Vol. 41, No. 2), finds that 68 percent of Americans do not want someone with a mental illness marrying into their family and 58 percent do not want people with mental illness in their workplaces.
Some attitudes have gotten worse over time: For instance, people are twice as likely today than they were in 1950 to believe that mentally ill people tend to be violent.
Of course, the vast majority of people with mental illness are not violent—though they are 2.5 times more likely to be victims of violence than members of the general population, according to a study published in 2001 in the International Journal of Law and Psychiatry (Vol. 24, No. 6). And a new study, published in February in the Archives of General Psychiatry (Vol. 66, No. 2) finds that mental illness alone does not increase the chances that a person will become violent.
Since that fear of violence is not based in fact, it may stem from media portrayals of mental illness—particularly in the news, says Patrick Corrigan, PsyD, a psychology professor at the Illinois Institute of Technology and head of the Chicago Consortium for Stigma Research.
"Every time something really bad happens, people think it must be because of mental illness," says Corrigan. "If a woman drowns her children, people speculate—the news media speculates—that she must be off her medication."
In addition to being inaccurate and unfair, such beliefs come at a major cost to society, Pescosolido notes. An estimated one in four adults has a diagnosable mental illness, according to the National Institute of Mental Health. That's about 76 million Americans who live with the fear that others may find out about their disorder and think less of them or even keep them from getting jobs or promotions, she says. And people like Julie often avoid treatment due to the all-too-reasonable worry they'll be found out and discriminated against, Pescosolido says.
The good news: After decades of well-meaning but largely ineffective efforts to change public opinion, researchers are now working to understand the underpinnings of stigma and are even beginning to turn the tide of public opinion in American and abroad.
An insidious effect
The toxic effects of stigma are well-documented, says Corrigan. People with mental illness often internalize society's beliefs about them—that they are incompetent, irrational and untrustworthy—and that can lead to distress that's sometimes worse than the mental illness itself, he says.
About half of people with schizophrenia believe that former psychiatric patients are less trustworthy than others, finds a study by psychologist Birgit Kleim, PhD, of Kings College in London, Corrigan, and colleagues. The patients who believed this tended to isolate themselves from social support, a course of action that can increase the severity of psychotic symptoms, according to the study published in the Journal of Mental Health, (Vol. 17, No. 5).
"We know that social support of people with psychosis, for instance by friends or family, is crucial for their recovery," says Kleim.
Stigma can also keep people from taking their medications, finds a study by Hector Tsang, PhD, a psychology professor at Hong Kong Polytechnic University, published in the Journal of Behavior Therapy and Experimental Psychiatry, (Vol. 40, No. 1). That's in part because antipsychotic medication often has visible side-effects, such as tongue smacking and grimacing, which can mark one as mentally ill.
"Medication-induced stigma is regarded as one of the principal barriers to compliance," Tsang notes.
Even high-functioning college students fall prey to the effects of stigma, according to a study by Diane Quinn, PhD, a psychology professor at the University of Connecticut. In the study, published in Personality and Social Psychology Bulletin (Vol. 30, No. 7), Quinn and her colleagues asked college students to take a portion of the GRE Analytic Test, a difficult test of logic and reasoning. At the top of the test were several demographic questions, and, for half of the participants, a question about whether they had any history of mental illness.
Simply answering "yes" to that question caused some students' performance to plummet. Of the students who had a history of mental illness, those who had to disclose it before taking the test did about half as well as those who were allowed to keep quiet.
"It's really surprising that something as subtle as answering a question can effect people's performance," says Quinn.
The result, she notes, is similar to one that's found when students are asked to identify their race or gender before a test. Identifying oneself as part of a stigmatized group activates a fear of being stereotyped, and students must devote brainpower to pushing that out of their minds, which results in poorer test performance.
In addition to test performance, stigma can harm the physical health of people with mental illness, finds a study by Quinn, in press in the Journal of Personality and Social Psychology. In it, she surveyed 235 people who kept some parts of their identities secret to avoid stigma, including people with mental illness, rape victims and people with criminal histories. The more stigmatized their secret identities, the more likely people were to report symptoms of physical illness, Quinn found.
"Stigma is a day-to-day stressor, she says. "Little things happen every day to make people feel devalued, and that can add up and affect people's health."
When information leads to fear
Such findings underscore the importance of changing society's views of the mentally ill—especially those beliefs that the mentally ill are incompetent. However, most anti-stigma campaigns convey the message that mental illness is a disease like any other, says Pescosolido. Specifically, they explain the biological causes of depression and other disorders, emphasizing that people can't just "snap out of it," she says.
That was the case for the National Institute of Mental Health campaign, "Real Men, Real Depression," which focused on how common depression is, and gave men information to help them recognize it in themselves. Such information may encourage people to seek treatment, but the campaign's emphasis on how many people have a mental disorder may have reinforced fear in the general population, says Corrigan.
"Mental illness's impact is huge and omnipresent," he says. "Everyone's family in America has a person with serious mental illness, and that spooks us."
Canadian anti-stigma campaigns also tend to focus on the prevalence and symptoms of mental illness, says University of Calgary stigma-researcher JianLi Wang, PhD.
In one sense, these efforts work: In a study by Wang, published in the Canadian Journal of Psychiatry (Vol. 52, No. 7), 75 percent of Canadians correctly diagnosed a depressed person as described in a story, and they agreed with statements about the biochemical underpinnings the disorder. However, more than 45 percent of people Wang surveyed in a follow-up study said they believed that depressed people are unpredictable, and 20 percent said that depressed people tend to be dangerous.
"You can hold the belief that mental illness is a real disease and still be afraid of people with it," Wang says.
Such campaigns may even increase stigma, says Pescosolido. In particular, the idea that mental illness has genetic causes may make disorders seem incurable, she says.
"The 'disease-like-any-other' message was not an effective strategy, and it's what we used in the vast majority of anti-stigma campaigns," Pescosolido says.
A recent campaign in Scotland called "See Me" tried a different strategy. It educated reporters and editors about the harmfulness and inaccuracy of the stereotype that people with schizophrenia are prone to violence.
The campaign succeeded in reducing the number of news stories linking violence and mental illness, but had some unintended consequences, according to research published in February in the International Journal of Health Promotion (Vol. 10, No. 1). An analysis of five years of newspaper articles showed that, over the life of the anti-stigma campaign, coverage of people with mental illness became more negative—with stories frequently depicting people with mental illness as objects of pity, for example.
Perhaps even more concerning was that newspaper coverage of mental illness decreased overall, says study author Neil Quinn, PhD, a lecturer at the Glasgow School of Social Work.
"One of our conclusions was that journalists became afraid to report about schizophrenia full stop, because reporting did go down significantly," Quinn says.
A new tack
A lesson of the Scotland campaign, says study co-author Lee Knifton, is that anti-stigma campaigns can't just focus on eradicating negative depictions of people with mental illness. They need to tell positive stories as well, he says.
To that end, Knifton launched the Scottish Mental Health Arts and Film Festival, which highlights the contributions that people with mental illness make to society by showcasing music, film, comedy, literature and theater by people with mental illness. The festival, which began in 2007, also sponsors a contest for films that depict people with mental illness in realistic, holistic ways, says Knifton.
Last October, the festival drew 12,000 attendees and sparked 120 newspaper articles that emphasized the fact that people with mental illness are generally active, useful members of society, he says.
Such anti-stigma campaigns are more likely to work than the "disease like any other" campaigns of the past, says Pescosolido.
"If you focus on the competence of people with mental illness, that tends to lead to greater tolerance," she says.
That's also the goal of a new Canadian anti-stigma campaign, which tells the stories of people with mental illness—stories like that of Candace Watson, who was diagnosed as bipolar after an unsettling manic episode. She's since been successfully treated and now works as a nurse.
"I know I'm a competent person and I have things to offer," she says in a video that the campaign has disseminated through public service announcements and a Web site.
The Canadian campaign is based on research by Corrigan showing that contact with people who have mental illness tends to decrease stigma. For instance, one study by Corrigan, published in 2002 in Psychiatric Rehabilitation Skills (Vol. 6, No. 2), found that meeting people who have mental illness weakens people's tendency to link mental illness and violence.
It's also important to stress the normalcy of many people who have mental illness, he says.
"When the population gets a better sense of how many people with mental illness are actually successful—if more people come out of the closet—perhaps the stigma of mental illness will finally decline," he says.
*Editor's note: Julie is a pseudonym.
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Corrigan, P.W. (2005). On the stigma of mental illness: Practical strategies for research and social change. Washington, D.C.: APA.
Pescosolido, B.A., Jensen, P.S., Martin, J.K., Perry, B.L., Olafsdottir, S., & Fettes, D. (2008). Public knowledge and assessment of child mental health problems: Findings from the National Stigma Study—Children. Journal of the American Academy of Child & Adolescent Psychiatry, 47, 339–349.