The "backbone" of stigma: identifying the global core of public prejudice associated with mental illness

Abstract

Objectives: We used the Stigma in Global Context-Mental Health Study to assess the core sentiments that represent consistent, salient public health intervention targets.

Methods: Data from 16 countries employed a nationally representative sampling strategy, international collaboration for instrument development, and case vignettes with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition depression and schizophrenia criteria. We measured knowledge and prejudice with existing questions and scales, and employed exploratory data analysis to examine the public response to 43 items.

Results: Across countries, levels of recognition, acceptance of neurobiological attributions, and treatment endorsement were high. However, a core of 5 prejudice items was consistently high, even in countries with low overall stigma levels. The levels were generally lower for depression than schizophrenia, and exclusionary sentiments for more intimate venues and in authority-based roles showed the greatest stigma. Negative responses to schizophrenia and depression were highly correlated across countries.

Conclusions: These results challenge researchers to reconfigure measurement strategies and policymakers to reconsider efforts to improve population mental health. Efforts should prioritize inclusion, integration, and competences for the reduction of cultural barriers to recognition, response, and recovery.

FIGURE 1—

Public response on mental health knowledge, beliefs, and treatment endorsements for (a) schizophrenia and (b) depression: Stigma in Global Context–Mental Health Study, 2004–2012. Note. AR = Argentina (South America; n = 1420); BD = Bangladesh (Asia; n = 1501); BE = Belgium (Europe; n = 1166); BG = Bulgaria (Europe n = 1121); BR = Brazil (South America; n = 1522); CY = Cyprus (Europe; n = 804); DE = Germany (Europe; n = 1255); ES = Spain (Europe; n = 1206); GB = Great Britain (Europe; n = 1030); HU = Hungary (Europe; n = 1252); IS = Iceland (Europe; n = 1033); KO = South Korea (Asia; n = 1003); NZ = New Zealand (Australia; n = 1020); PH = Philippines (Asia; n = 1200); US = United States (North America; n = 1425); ZA = South Africa (Africa; n = 1550). Area of circle corresponds to percentage agreeing on each item in each country. Items are ordered from low to high according to across-country mean percentage agreeing (second-to-last column) and countries are ordered from low to high according to across-item mean percentage stigmatizing. The sample sizes were n = 6542 for schizophrenia and n = 6539 for depression.

FIGURE 2—

Public response to stigma items for (a) schizophrenia and (b) depression: Stigma in Global Context–Mental Health Study, 2004–2012. Note. AR = Argentina (South America; n = 1420); BD = Bangladesh (Asia; n = 1501); BE = Belgium (Europe; n = 1166); BG = Bulgaria (Europe n = 1121); BR = Brazil (South America; n = 1522); CY = Cyprus (Europe; n = 804); DE = Germany (Europe; n = 1255); ES = Spain (Europe; n = 1206); GB = Great Britain (Europe; n = 1030); HU = Hungary (Europe; n = 1252); IS = Iceland (Europe; n = 1033); KO = South Korea (Asia; n = 1003); NZ = New Zealand (Australia; n = 1020); PH = Philippines (Asia; n = 1200); US = United States (North America; n = 1425); ZA = South Africa (Africa; n = 1550). Area of circle corresponds to percentage stigmatizing on each item in each country. The sample sizes were n = 6542 for schizophrenia and n = 6539 for depression.

FIGURE 3—

Correlation of schizophrenia and depression across country item means for (a) knowledge, beliefs, and treatment endorsement items and (b) stigma items: Stigma in Global Context–Mental Health Study, 2004–2012. Note. The sample sizes were n = 16 for knowledge, beliefs, and treatment endorsement items and n = 27 for stigma items.