Stigma and the Acceptability of Depression Treatments
Among African Americans and Whites
Jane L. Givens, MD, MSCE1,6, Ira R. Katz, MD, PhD2, Scarlett Bellamy, ScD5, and William C.
Holmes, MD, MSCE3,4,5
1Boston University Medical Center, Geriatrics Section, Boston, MA 02118-2393, USA;2Section of Geriatric Psychiatry, Department of Psychiatry,
University of Pennsylvania, Philadelphia, PA, USA;3Center for Health Equity Research and Promotion, Philadelphia Veterans Administration
Medical Center, Philadelphia, PA, USA;4Division of General Internal Medicine, University of Pennsylvania, Philadelphia, PA, USA;5Center for
Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA;688 East Newton Street, Robinson 2, room 2702,
Boston, MA 02118-2393, USA.
BACKGROUND: Stigma is associated with depression
treatment, however, whether stigma differs between
depression treatment modalities is not known, nor have
racial differences in depression treatment stigma been
OBJECTIVE: To measure stigma for four depression
treatments and estimate its association with treatment
acceptability for African Americans and whites.
DESIGN: Cross-sectional, anonymous mailed survey.
PARTICIPANTS: Four hundred and ninety African-
American and white primary care patients.
MEASUREMENTS: The acceptability of four depression
treatments (prescription medication, mental health
counseling, herbal remedy, and spiritual counseling) was
assessed using a vignette. Treatment-specific stigma was
evaluated by asking whether participants would: (1) feel
ashamed; (2) feel comfortable telling friends andfamily; (3)
feel okay if people in their community knew; and (4) not
want people at work to know about each depression
treatment. Sociodemographics, depression history, and
current depressive symptoms were measured.
RESULTS: Treatment-specific stigma was lower for
herbal remedy than prescription medication or mental
health counseling (p<.01). Whites had higher stigma
than African Americans for all treatment modalities. In
adjusted analyses, stigma relating to self [AOR 0.43
(0.20–0.95)] and friends and family [AOR 0.42 (0.21–
0.88)] was associated with lower acceptability of mental
health counseling. Stigma did not account for the lower
acceptability of prescription medication among African
CONCLUSIONS: Treatment associated stigma signifi-
but not prescription medication. Efforts to improve de-
pression treatment utilization might benefit from addres-
sing concerns about stigma of mental health counseling.
KEY WORDS: stigma; depression treatment; patient preferences;
© 2007 Society of General Internal Medicine 2007;22:1292–1297
Depression is the most common mental health disorder,
affecting nearly 14 million U.S. adults annually.1Despite the
availability of effective depression treatments, utilization rates
are low.2–4One reason may be the stigma associated with
receiving treatment. Stigma, defined by sociologist Goffman5
as “spoiled identity” and characterized as the perception of
difference associated with undesirable traits,6is recognized as
a barrier to mental health care.7Stigma has been cited by the
1999 Surgeon General’s Mental Health Report,8the Depart-
ment of Health and Human Service’s Healthy People 2010,9
and the 2003 President’s New Freedom Commission on Mental
Health10as an important reason for low receipt of treatment.
These reports have identified reducing stigma as a major goal
in improving mental health care delivery.
Prior research reports that depressed patients with higher
stigma are less likely to adhere to pharmacologic treatment,11,12
and that stigma may be a barrier to initiating other forms of
treatment.13However, whether the level and effect of stigma
differs between depression treatment modalities remains
understudied. We sought to measure the stigma of four
depression treatment modalities and to estimate the association
between treatment stigma and treatment acceptability.
Differences in depression treatment acceptability between
African Americans and whites have been documented, with
African-Americans expressing lower acceptability of antide-
pressant medication,14greater preference for counseling,15
and more interest in counseling from clergy.16In addition,
concern has been raised that mental health stigma may be
higher among African Americans than whites.17,18For these
reasons, in our exploration of depression treatment stigma, we
sought to investigate differences between African Americans
and whites and to assess whether stigma could explain racial
differences in treatment acceptability.
Abstract presented at the Society of General Internal Medicine annual
meeting, Los Angeles, CA, 2006
Funding source: University Research Foundation of the University of
Received November 3, 2006
Revised April 5, 2007
Accepted June 19, 2007
Published online July 4, 2007
The conceptual framework for this study was drawn from the
Theory of Reasoned Action.19In our adaptation of this model,
the outcome was the intention to accept a depression treat-
ment. We tested the effect of stigmatizing beliefs about depres-
sion treatment(treatment stigma) andsocial pressures to accept
treatment (social norms) on treatment acceptability, adjusting
for other beliefs about depression treatments, sociodemo-
graphics, depression history, and current depressive symptoms.
MATERIALS AND METHODS
Potential participants were selected from patients seen in the
University of Pennsylvania Health System Network of Affiliated
Practices, which includes over 200 primary care practices. We
included patients from internal medicine, family medicine, and
women’s health practices. Patients were eligible if they: (1)
were seen in their practice within the last 12 months; (2) were
18 years or older; and (3) were identified in the network
database as either African American or white. From the
100,602 patients who met eligibility criteria, we assembled a
stratified random sample of 755 patients with approximately
equal numbers of African American and white patients to
maximize our ability to make comparisons between the racial
The study questionnaire was mailed to all potential partici-
pants; nonresponders got up to two repeat mailings. Those who
completed the questionnaire were asked to also return, sepa-
rately, a postcard with a unique identifier. This identifier
provided investigators knowledge about who had and had not
responded, whereas assuring participants that their responses,
in the separately mailed questionnaire, remained anonymous.
Treatment Acceptability. Acceptability of the four treatment
modalities was assessed using the following vignette:
For the past 2 months, you have been feeling down and
have lost interest in many of your normal activities. You
no longer want to go out with friends and feel a loss of
energy. Lately you have had difficulty sleeping and have
been worried about a change in your weight. Your doctor
has examined and tested you thoroughly and has made
a diagnosis of depression.
Participants were asked whether they would accept each of
four possible depression treatments (prescription medication,
mental health counseling, herbal remedy, or spiritual counsel-
ing). All treatments were described as low cost. Response
options were: “Definitely yes,” “probably yes,” “probably no,”
and “definitely no.”
Treatment Stigma. Current published measures of mental
illness stigma are not specific to depression, but rather,
evaluate stigma associated with a wide range of mental
illnesses including schizophrenia. In addition, they do not
assess the stigma associated with accepting treatment.20,21In
this study, we focused on two aspects of stigma, namely, the
feelings of personal shame and fear of disclosure that a person
considering depression treatment might be concerned with.
These important components of stigma22have been linked to
avoidance of mental health treatment.12Because the wish to
avoid disclosure may be one of the most fundamental
components of stigma,23it is likely to be a sensitive measure.
For these reasons, we developed the following items to assess
If I were taking a prescribed medication for depression,
I would feel ashamed
I would feel comfortable telling my friends or family
I would feel okay if people in my community (church,
school, etc) knew
I would not want to tell people at my job 4.
These questions were repeated, once for each of the other
treatments (with text changed only to indicate treatment
modality). Possible response options were “yes” and “no” for
Social Norms. To measure social norms associated with
depression treatment, we assessed anticipated support from
others using a 5-point Likert scale from strongly agree to
strongly disagree. (i.e., “If I were taking a prescription
medication for depression, people close to me would support
me”). Responses of strongly agree and agree were combined
and compared to the other responses in dichotomous analysis.
Other Beliefs. We included several items assessing beliefs about
depression and depression treatment, the majority adapted
from the Patient Attitudes Toward and Ratings of Care for
Depression (PARC-D) questionnaire.24Items addressed the
perceived effectiveness or harmfulness of each treatment, the
importance of treating depression, the etiology of depression,
side effects of antidepressants, and the power of prayer to treat
depression. Response options were on a 5-point Likert scale
from −2 (disagree) to +2 (agree). Responses of +1 and +2 were
combined and compared to the other responses in dichotomous
Demographics, Medical History, and Depressive Symptoms.
Sociodemographic variables included age, sex, ethnicity, race,
education, marital status, household income, and religious
service attendance. We also assessed personal and family
history of depression and prior depression treatment. We
used the Patient Health Questionnaire (PHQ-9) to measure
current depressive symptoms.25Scores range from 0 to 27,
with a score of 10 or greater having a sensitivity of 88% and
specificity of 88% for major depression. PHQ-9 scores of 5, 10,
15, and 20 represent mild, moderate, moderately severe, and
severe depression, respectively.25
Pilot Testing. The entire questionnaire was pilot tested on a
convenience sample of 20 patients in an adult primary care
practice of the University of Pennsylvania. Pilot study
Givens et al.: Stigma of Depression Treatments
participants were 65% African American, 30% white, and 80%
female. The purpose of the pilot testing was to assess the face
and content validity of the vignette and the stigma items. In
addition, to ensure that items were understood, we asked
participants to discuss the wording of items and to suggest
alternative wording if appropriate. Changes were incorporated
iteratively into the questionnaire during the pilot study with
particular attention focused on ensuring that questions were
meaningful and intelligible to all participants.
Analytic Strategy. We assessed the internal consistency of the
treatment stigma items, within each treatment modality, to
determine whether they could be combined. Cronbach’s
alphas were too low to allow items to be combined (range
0.54–0.59); thus, simple frequencies were used to describe
treatment stigma items for each modality as well as treatment
acceptability. We used McNemar’s test26to make pairwise
comparisons of treatment stigma item responses for different
modalities (i.e., medication vs counseling).
The association between treatment-specific stigma and
treatment acceptability was first tested with unadjusted
logistic regression and then with multivariable logistic regres-
sion models. The purpose of this analysis was to assess
whether stigma items significant in unadjusted analysis
remained significant after adjusting for other covariates and
to assess the adjusted effect of race on treatment acceptability.
We focused on the acceptability of prescription medication and
mental health counseling because of their relevance to depres-
sion treatment in primary care settings. In each adjusted
model we included only treatment-specific stigma items and
other belief items that were significant in unadjusted analysis
at the p<.10 level. Models were adjusted for all sociodemo-
graphic variables, depression history, PHQ-9 scores, and social
norms. All covariates were assessed for collinearity. For those
variables with a correlation coefficient equal to or greater than
0.4, the covariate with a higher predictive value in unadjusted
analysis was retained in the model. In the case of two
correlated sociodemographic variables where neither was
predictive in unadjusted analysis, the variable with the
stronger association in the adjusted model was retained. All
analyses were performed using STATA SE version 8.2 (STATA
Corporation, College Station, TX). This study was approved by
the University of Pennsylvania institutional review board.
Of the 755 patients to whom questionnaires were mailed, six
were ineligible because of death or visual problems, and 46
had their questionnaires returned because of an incorrect
address. Of the remaining 703 potential participants, 528
(75%) returned the anonymous questionnaires, and 447 also
returned the tracking postcards. Postcard responders were
more likely to be female (67 vs 58%, P=.02) and older (mean
age 54 vs 47 years, p<.001) than nonresponders. There was no
racial difference between responders and nonresponders.
From the 528 questionnaires, 38 were excluded because
participants did not confirm their race was either African
American or white (25 with missing race data, eight “other,”
three “unknown,” one American Indian, one Asian). This left
490 questionnaires for subsequent analysis. As seen in Table 1,
the analytic sample was 43% African American, the majority
were female (68%) and had a high school education (90%).
Approximately one third of participants reported a history of
depression, and of these, over 90% reported prior treatment
with either prescription medication or counseling. Most parti-
cipants (68%) had no depressive symptoms, 18% had mild
symptom levels, and 14% had clinically significant levels with
PHQ-9 scores of 10 or greater.
Treatment Stigma and Treatment Acceptability
Table 2 displays treatment stigma items for each of the four
depression treatments. Stigma for all treatments increased
with expansion of the social circle, being the lowest for feeling
ashamed and increasing sequentially for disclosure to friends
and family, community, and then to the workplace. Herbal
remedy stigma for self, community, and workplace was
significantly lower than the corresponding stigma items for
prescription medication and mental health counseling (p<.01
for each comparison). Treatment stigma was not related to
history of depression or to prior use of depression treatments
(data not shown).
Whites had higher treatment stigma than African Amer-
icans related to the workplace (all treatments), the community
(prescription medication, mental health counseling and spiri-
tual counseling), and friends and family (spiritual counseling).
Treatment acceptability rates were 76% for prescription
medication, 72% for mental health counseling, 75% for herbal
remedy, and 53% for spiritual counseling. African Americans
reported significantly lower acceptability of prescription medi-
of acceptability of spiritual counseling (69 vs 53%, p<.001).
Association between Treatment-specific Stigma
and Treatment Acceptability
Table 3 displays the results of multivariable logistic regression
models for the outcomes of prescription medication and
mental health counseling acceptability. For the outcome of
Table 1. Participant Characteristics (N=490)
Age (year), mean (SD)
African American (vs white)
High school education or greater
History of depression
Family history of Depression
Prior antidepressant use
Prior counseling for depression
Prior use of herbal remedy for depression
Prior use of spiritual counseling for depression
Patient Health Questionnaire-9
Minimal depression (score 1–4)
Mild depression (score 5–9)
Moderate depression (score 10–14)
Moderately severe depression (score 15–19)
Severe depression (score 20–27)
Givens et al.: Stigma of Depression Treatments
prescription medication acceptability, no stigma items were
included in the adjusted analysis because of a lack of
association in unadjusted analysis. The only sociodemo-
graphic characteristics associated with decreased prescription
medication acceptability were being African American and
having higher income.
For mental health counseling, two stigma items, those
relating to self and friends/family, remained significant in the
adjusted model, associated with lower odds of treatment
acceptability. Being married was also associated with de-
creased mental health counseling acceptability.
Perceiving that others would support the use of treatment
treatments; whereas age, sex, education, religious service atten-
dance, prior depression treatment, and family history of depres-
sion were not associated with acceptability of either treatment.
Because the variables for history of depression and depres-
sion treatment history were highly correlated, we included
treatment history variables in the adjusted models because
they were stronger predictors of treatment acceptability.
Similarly, because income and marriage were correlated, the
variable with a stronger association to the outcome was
retained in the adjusted models (income for the prescription
medication model and marriage for the mental health counsel-
ing model). Stigma items were not correlated with other belief
items or social norms. There were no interactions between
stigma and race or stigma and prior depression treatment on
the outcomes of treatment acceptability.
In this study of stigma associated with depression treatment,
we found that for all four depression treatments, stigma
increased as the focus moved from the individual to the wider
community; a minority of individuals reported feelings of
personal shame and over half reported fear of their community
and workplace knowing of any depression treatment. These
results mirror prior findings from depressed patients where
24% reported expecting depression-related stigma to have a
negative impact on friends and 67% a negative impact on
employment.27Our results indicate, then that despite our
study being vignette-based with participants being asked to
project themselves into a hypothetical depressed state, partic-
ipants appeared to perceive similar negative societal views
about depression and were concerned with revealing a diag-
Table 3. Adjusted Odds Ratios (AOR) From Multivariable Logistic Regression Models Predicting Acceptability of Prescription Medication and
Mental Health Counseling
Variable Prescription medication AOR (95%CI)
P valueMental health counseling AOR (95%CI)
African American (vs white)
High School education
Religious service attendanceb
Prior depression treatments
Mental health counseling
Family history of depression
Prescription medications are effective
Depression is a medical illness
Mental health counseling is effective
Antidepressants cover up depression
Models also adjusted for other belief items significant in unadjusted analysis. Only belief items found to be significant in either the prescription medication
or mental health counseling models are displayed in the table.
aVariable not included in analysis because of collinearity
bReligious service attendance of at least twice a month
cItems not included in model because of lack of significance in unadjusted analysis
Table 2. Stigma Item Endorsement for Each of Four Depression
84 (18)117 (25)303 (65)315 (68)
89 (19)124 (27)310 (66)318 (68)
65 (14)115 (25)287 (62) 303 (65)
73 (16)128 (28)294 (63)306 (67)
Givens et al.: Stigma of Depression Treatments
nosis of depression in the same way as has been shown in
actual depressed patients.
We hypothesized that stigma would differ between treat-
ment modalities and found that herbal remedy was less
stigmatizing than prescription medication or mental health
counseling. We also found that stigma affected the accept-
ability of treatments differently. In adjusted analyses, treat-
ment stigma adversely affected the acceptability of mental
health counseling but not prescription medication. These
findings suggest that participants may perceive concealing a
depression diagnosis to be more difficult when seeing a mental
health specialist than when seeing a pharmacist for medica-
tion. If true, integrating specialty mental health care into the
primary care setting could help to address this concern. Unfor-
tunately, although integrated mental health care is associated
with better patient outcomes as well as higher patient and
provider satisfaction,28–30these arrangements are not always
feasible and often are not available to patients.
We sought to investigate whether treatment stigma differed
for African Americans and whites and whether such a
difference could explain racial differences in treatment accept-
ability. Contrary to prior findings from qualitative work,18but
consistent with other quantitative results,31we found stigma
to be higher among whites than African Americans. Thus,
although African Americans in our study reported lower
acceptability of prescription medication, a finding seen in prior
work,14this lower acceptability could not be explained by
concerns about stigma. These variations in ethnic differences
in stigma argue for further research into the particular aspects
of stigma which may be salient to particular populations, as
well as larger studies examining stigma across ethnic groups.
Our results should be interpreted in light of certain method-
ological limitations as well as the particular characteristics of
our sample. We utilized a vignette-based questionnaire to assess
intended rather than observed behavior. As noted, however, our
findings mirror those reported for actual patients with depres-
sion. Because we were specifically interested in isolating the
effect of stigma on treatment acceptability, we intentionally
stated in the vignette that all treatments were low cost to
eliminate cost concerns from influencing the relative accept-
ability of the treatments. This constraint may have had theeffect
of raising the overall acceptability of treatments. We developed
new treatment stigma items not tested in other populations.
These items, which were intended to capture specific compo-
nents of stigma associated with treatment, may have also
captured stigma associated with the diagnosis of depression,
thus limiting our ability to measure the intensity of stigma
associated with specific treatment modalities. In addition, our
focus on the aspects of shame and fear of disclosure as well as
our use of yes/no response options may have limited our ability
to capture both the breadth and subtlety of stigma concerns.
Our sample was purposefully limited to African Americans and
whites, andso, ourfindings cannot be generalized to other racial
groups. These constraints to generalizability were counterba-
lanced, somewhat, bythestrengths ofourstudy, whichincluded
the use of random sampling from a large population of primary
care patients and the inclusion of patients with a range of
depressive symptom levels.
In our sample population, the majority of respondents found
the proposed depression treatments acceptable. Other patients
less enthusiastic about depressiontreatment may display higher
levels ofstigma. Oursamplealsoreportedahigherthanexpected
(30%) prevalence of a history of depression. This self-reported
history likely includes those with prior major depression as well
as those with milder episodes of symptoms not meeting criteria
for major depression. Whereas screening measures such as the
PHQ-9 may overestimate true disease levels, participants had
levels of current depressive symptoms similar to those expected
in primary care, where the combined prevalence of major and
reported high rates of depression treatment. Because of the
general nature of this question, however, it is not clear that these
reported rates of treatment reflect a full treatment course of
either medication or counseling.
Our study demonstrates a significant relationship between
treatment stigma and treatment acceptability for mental
health counseling, an important treatment option in primary
care settings and one generally preferred by patients.15,33This
suggests that providers should be aware that stigma could
play a determinative role in whether this treatment will be
accepted. Because of the nature of stigma, it may be difficult
for patients to bring up the topic. Some argue that providers
should elicit patient’s concerns regarding self-image, social
support, and fears of discrimination regarding mental health
treatment.34Our findings support such inquiry as well as
future research into how clinicians might best approach
discussing treatment stigma with their patients. Such discus-
sions can be an important step in reducing treatment stigma
and may help to individualize treatment plans in a manner
congruent with the patient’s social pressures and preferences.
Acknowledgments: The authors would like to acknowledge Jason
Fu and Brian Shin for their assistance with survey distribution and
data entry. This project was supported by funding from the
University Research Foundation of the University of Pennsylvania.
Conflict of Interest: None disclosed.
Corresponding Author: Jane L. Givens, MD, MSCE; 88 East
Newton Street, Robinson 2, room 2702, Boston, MA 02118-2393,
USA (e-mail: firstname.lastname@example.org).
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