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Clinicians, advocates, and policy makers have presented mental illnesses as medical diseases in efforts to overcome low service use, poor adherence rates, and stigma. The authors examined the impact of this approach with a 10-year comparison of public endorsement of treatment and prejudice. The authors analyzed responses to vignettes in the mental health modules of the 1996 and 2006 General Social Survey describing individuals meeting DSM-IV criteria for schizophrenia, major depression, and alcohol dependence to explore whether more of the public 1) embraces neurobiological understandings of mental illness; 2) endorses treatment from providers, including psychiatrists; and 3) reports community acceptance or rejection of people with these disorders. Multivariate analyses examined whether acceptance of neurobiological causes increased treatment support and lessened stigma. In 2006, 67% of the public attributed major depression to neurobiological causes, compared with 54% in 1996. High proportions of respondents endorsed treatment, with general increases in the proportion endorsing treatment from doctors and specific increases in the proportions endorsing psychiatrists for treatment of alcohol dependence (from 61% in 1996 to 79% in 2006) and major depression (from 75% in 1996 to 85% in 2006). Social distance and perceived danger associated with people with these disorders did not decrease significantly. Holding a neurobiological conception of these disorders increased the likelihood of support for treatment but was generally unrelated to stigma. Where associated, the effect was to increase, not decrease, community rejection. More of the public embraces a neurobiological understanding of mental illness. This view translates into support for services but not into a decrease in stigma. Reconfiguring stigma reduction strategies may require providers and advocates to shift to an emphasis on competence and inclusion.
Am J Psychiatry 167:11, November 2010 1321
which people should be blamed and punished. Many
prominent reports emphasized scientifi c understand-
ing as a way to reduce stigma. For example, the Surgeon
General’s report identifi ed scientifi c research as “a potent
weapon against stigma, one that forces skeptics to let go
of misconceptions and stereotypes” (1, p. 454). Stigma
reduction, based in part on disseminating information on
neurobiological causes, became a primary policy recom-
mendation of the President’s New Freedom Commission
on Mental Health (3) as well as of international efforts (4).
Finally, while not intended specifi cally as an antistigma
effort, commercial advertisements provided information
on psychiatric symptoms, brain-based etiologies, and
specifi c psychopharmacological solutions. In fact, direct-
to-consumer advertising involved more U.S. resources
than all those dedicated to educational campaigns (e.g.,
over $92 million on Paxil in 2000 [5]).
Deeply embedded in social and cultural norms, stigma
includes prejudicial attitudes that discredit individuals,
The past 20 years have witnessed a resurgence in clini-
cal, policy, and research efforts to reduce stigma attached
to mental illness. The White House Conference on Mental
Illness and the Surgeon General’s fi rst-ever report on men-
tal health (1), both in 1999, coalesced knowledge and fos-
tered renewed action. These comprehensive assessments
applauded the range and effi cacy of existing treatments
for mental illness brought by advances across the medical
and social-behavioral sciences, particularly neuroscience.
However, they also documented a “staggeringly low” rate
of service use among those in need, a shortage of provid-
ers and resources, and continued alarming levels of preju-
dice and discrimination (1, p. viii; 2).
After reviewing the scientifi c evidence, the Surgeon Gen-
eral concluded that the stigma attached to mental illness
constituted the “primary barrier” to treatment and recov-
ery (1, p. viii). Stigma could be reduced, many believed,
if people could be convinced that mental illnesses were
“real” brain disorders and not volitional behaviors for
(Am J Psychiatry 2010; 167:1321–1330)
Bernice A. Pescosolido, Ph.D.
Jack K. Martin, Ph.D.
J. Scott Long, Ph.D.
Tait R. Medina, M.A.
Jo C. Phelan, Ph.D.
Bruce G. Link, Ph.D.
Objective: Clinicians, advocates, and
policy makers have presented mental ill-
nesses as medical diseases in efforts to
overcome low service use, poor adher-
ence rates, and stigma. The authors ex-
amined the impact of this approach with
a 10-year comparison of public endorse-
ment of treatment and prejudice.
Method: The authors analyzed responses
to vignettes in the mental health modules
of the 1996 and 2006 General Social Sur-
vey describing individuals meeting DSM-IV
criteria for schizophrenia, major depres-
sion, and alcohol dependence to explore
whether more of the public 1) embraces
neurobiological understandings of mental
illness; 2) endorses treatment from provid-
ers, including psychiatrists; and 3) reports
community acceptance or rejection of
people with these disorders. Multivariate
analyses examined whether acceptance
of neurobiological causes increased treat-
ment support and lessened stigma.
Results: In 2006, 67% of the public attrib-
uted major depression to neurobiological
causes, compared with 54% in 1996. High
proportions of respondents endorsed treat-
ment, with general increases in the propor-
tion endorsing treatment from doctors and
specifi c increases in the proportions en-
dorsing psychiatrists for treatment of alco-
hol dependence (from 61% in 1996 to 79%
in 2006) and major depression (from 75%
in 1996 to 85% in 2006). Social distance
and perceived danger associated with peo-
ple with these disorders did not decrease
signifi cantly. Holding a neurobiological
conception of these disorders increased
the likelihood of support for treatment but
was generally unrelated to stigma. Where
associated, the effect was to increase, not
decrease, community rejection.
Conclusions: More of the public em-
braces a neurobiological understanding
of mental illness. This view translates
into support for services but not into a
decrease in stigma. Reconfi guring stigma
reduction strategies may require provid-
ers and advocates to shift to an emphasis
on competence and inclusion.
A Disease Like Any Other”? A Decade of Change
in Public Reactions to Schizophrenia, Depression,
and Alcohol Dependence
This article is featured in this month’s AJP Audio and is discussed in an editorial by Dr. Goldman (p. 1289).
1322 Am J Psychiatry 167:11, November 2010
elded as modules in the General Social Survey (GSS). The GSS is
a biennial stratifi ed multistage area probability sample survey of
household clusters in the United States representing noninstitu-
tionalized adults (age 18 and over). Face-to-face interviews were
conducted by trained interviewers using pencil and paper in the
1996 survey and a computer-assisted format in the 2006 survey.
Mode effects were minimal and were unrelated to the data used
here (19). GSS response rates were 76.1% in 1996 and 71.2% in 2006.
The 1996 and 2006 GSS modules utilized a vignette strategy
to collect data on public knowledge of and response to mental
illness. This strategy helps circumvent social desirability bias
and allows assessment of public recognition by providing a case
description meeting psychiatric diagnostic criteria but no diag-
nostic label. Respondents were randomly assigned to a single
vignette describing a psychiatric disorder meeting DSM-IV cri-
teria for schizophrenia (N=650), major depression (N=676), or
alcohol dependence (N=630). The gender, race (white, black, His-
panic), and education (<high school, high school, >high school)
of vignette characters were randomly varied.
Because of the adoption in 2004 of a subsampling design to
capture nonrespondents, weighting that adjusts for the selection
of one adult per household is required for cross-year compari-
sons (sampling error=±3%). All analyses were conducted in Stata,
release 11 (20). Institutional review board approval for the GSS
was obtained at the University of Chicago, as well as at Indiana
University for secondary data analysis.
Respondents were read the randomly selected vignette, given a
card with the vignette printed on it, and asked questions in three
broad areas.
Attributions/causation. Respondents were asked how likely it
is that the person in the vignette is experiencing “a mental illness”
and/or “the normal ups and downs of life,” as well as how likely
the situation might be caused by “a genetic or inherited problem,”
“a chemical imbalance in the brain,” “his or her own bad charac-
ter,” and/or “the way he or she was raised.” Questions were not
mutually exclusive, and respondents could endorse multiple at-
tributions. Responses of “very likely” and “somewhat likely” were
coded 1; “not very likely,” “not at all likely,” and “do not know”
were coded 0. Analyses were run again with responses of “do not
know” coded as missing as well as including controls for the vi-
gnette character’s race, gender, and education, and substantively
similar results were obtained (data available on request from the
rst author). A neurobiological conception measure was coded 1
if the respondent labeled the problem as mental illness and at-
tributed cause to either a chemical imbalance or a genetic prob-
lem; it was coded 0 otherwise.
Treatment endorsement. Respondents were asked whether
the person in the vignette should seek consultation with or treat-
ment by “a general medical doctor,” “a psychiatrist,” “a mental
hospital,” and/or “prescription medications.” Responses were
coded 1 if “yes” and 0 if “no” or “do not know.”
Public stigma. Two sets of measures, for social distance and for
perceptions of dangerousness, were used. The fi rst asked respon-
dents how willing they would be to have the person described in
the vignette 1) work closely with them on a job; 2) live next door;
3) spend an evening socializing; 4) marry into the family; and 5) as
a friend. Responses of “defi nitely unwilling” and “probably unwill-
ing” were coded 1 (i.e., stigmatizing) and responses of “probably
willing,” “defi nitely willing,” and “do not know” were coded 0. The
second measure asked respondents how likely is it that the person
in the vignette would “do something violent toward other people
and/or “do something violent toward him/herself.” Responses of
“very likely” and “somewhat likely” were coded 1; responses of “not
very likely,” “not at all likely,” and “do not know” were coded 0.
marking them as tainted and devalued (6). For individuals,
stigma produces discrimination in employment, housing,
medical care, and social relationships (7–9). Individuals
with mental illness may be subjected to prejudice and dis-
crimination from others (i.e., received stigma), and they
may internalize feelings of devaluation (i.e., self-stigma
[10]). On a societal level, stigma has been implicated in low
service use, inadequate funding for mental health research
and treatment (i.e., institutional stigma), and the “courtesy”
stigma attached to families, providers, and mental health
treatment systems and research (11–13). Public stigma
refl ects a larger social and cultural context of negative com-
munity-based attitudes, beliefs, and predispositions that
shape informal, professional, and institutional responses.
Antistigma efforts in recent years have often been
predicated on the assumption that neuroscience offers
the most effective tool to reduce prejudice and discrimi-
nation. Thus, NAMI’s Campaign to End Discrimination
sought to improve public understanding of neurobiologi-
cal bases of mental illness, facilitating treatment-seeking
and lessening stigma. Over the past decade, the American
public has been exposed to symptoms, biochemical etio-
logical theories, and the basic argument that mental ill-
nesses are diseases, no different from others amenable to
effective medical treatment, control, and recovery (14, 15).
Given projections of the place of mental illness in the
global burden of disease in the coming years (for example,
depression alone is expected to rank third by 2020 [16]),
the unprecedented amount of resources being directed to
science-based antistigma campaigns, and the frustration
of clinicians, policy makers, and consumers in closing the
need-treatment gap, it is crucial that the effi cacy and impli-
cations of current efforts be evaluated. However, despite
reported successes in launching campaigns and dissemi-
nating information, few studies have undertaken system-
atic evaluation of stigma reduction efforts (see references
17 and 18 for exceptions). The critical unanswered ques-
tion is whether these efforts have changed public under-
standing and acceptance of persons with mental illness.
In this study, we assessed whether the cumulative impact
of efforts over the past decade have produced change in
expected directions. Using the mental health modules of
nationally representative surveys 10 years apart, we exam-
ined whether the public changed during that interval in
its embrace of neurobiological understandings of mental
illness; its treatment endorsements for a variety of provid-
ers, including psychiatrists and general medical doctors;
and its reports of community acceptance or rejection of
persons described as meeting DSM-IV criteria for schizo-
phrenia, major depression, or alcohol dependence.
The 2006 National Stigma Study–Replication reproduces the
1996 MacArthur Mental Health Study; both data collections were
Am J Psychiatry 167:11, November 2010 1323
Covariates. Respondents’ age (in years), sex (coded 1 for female,
0 for male), education (coded 1 for at least a high school degree,
and 0 otherwise), and race (code 1 for white, 0 for other) were in-
cluded as controls. In 1996, the mean age of respondents was 43
years (SD=16); 51% were female, 31% completed more than a high
school degree, and 81% were white. In 2006, the mean age was
45 years (SD=17); 54% were female, 39% completed more than a
high school degree, and 75% were white. Profi les are consistent
with Census Bureau data. Differences between samples refl ect
changes in the U.S. population (e.g., signifi cant but small changes
in education and race).
Statistical Analysis
We evaluated changes across years in public attributions,
endorsement of treatment, and public stigma by comparing 1996
and 2006 unadjusted percentages. Because the data were weighted,
a design-based F-statistic (20) that utilized the second-order Rao
and Scott (21) correction was used to test the equality of the 1996
and 2006 percentages. To adjust for possible demographic shifts
between survey years, we estimated logistic regression models for
each outcome and for each vignette condition with controls for
respondents’ age, sex, education, and race. We then computed the
difference in the predicted probabilities for a given outcome (e.g.,
mental illness) between 1996 and 2006 holding the control vari-
ables at their means for the combined sample; these are referred
to as discrete change coeffi cients and are presented graphically.
Ninety-fi ve percent confi dence intervals were computed with the
delta method and are shown graphically with tic marks.
We used logistic regression to examine the association of neu-
robiological conception with treatment endorsement and stigma.
Models included controls for age, sex, education, and race and
were run separately by year and vignette condition. Odds ratios
are presented. To evaluate changes in the effect of neurobiologi-
cal conception on treatment endorsement and stigma over time,
discrete change coeffi cients were computed from logit models
that included interactions between neurobiological conception
and year and controls and year. Traditional tests of the equality of
coeffi cients across groups (in this case the equality of the effect of
neurobiological conception across survey year) cannot be used
because the estimated logit coeffi cients confound the magnitude
of the effect of a predictor with the degree of unobserved hetero-
geneity in the model (22). Predicted probabilities are not affected
by this issue of identifi cation (J.S. Long, unpublished manuscript,
2009). Accordingly, we computed the discrete change in the pre-
dicted probability for a given outcome (e.g., treatment endorse-
ment) between those who held a neurobiological conception
and those who did not and then compared these discrete change
coeffi cients across survey years. While these coeffi cients are not
affected by the identifi cation issue that makes it inappropriate to
compare regression coeffi cients between times, the magnitude of
the discrete change depends on the level at which the control vari-
ables are held. To control for differences in demographic variables
between the survey years, we computed discrete change coeffi -
cients for each year with controls held at their means for the com-
bined sample. To maintain metric consistency with the unadjusted
percentages, predicted probabilities and discrete change coeffi -
cients were multiplied by 100 (e.g., 0.43 becomes 43%).
More of the public embraced a neurobiological under-
standing of mental illness in 2006 than in 1996 (Table 1). A
large and statistically signifi cant increase (6 to 13 percent-
age points) was evident across nearly all indicators and all
vignette conditions. Neurobiological conception showed
an increase of 10 percentage points for schizophrenia (from
76% to 86%; F=8.00, p=0.01), 13 points for depression (from
54% to 67%; F=9.94, p=0.002) and nine points for alcohol
dependence (from 38% to 47%; F=4.06, p=0.04). Social or
moral conceptions of mental illness decreased across most
indicators, and a signifi cant decrease in labeling the con-
dition as “ups and downs” was observed for depression
(from 78% to 67%; F=7.63, p=0.01). However, sociomoral
conceptions of alcohol dependence were either largely
unchanged or, for attributions of “bad character,” sig-
nifi cantly increased (from 49% to 65%; F=13.50, p<0.001).
Findings were largely unaffected by the addition of controls
for respondents’ age, sex, education, and race (Figure 1). A
slight attenuation of the year effect for chemical imbalance
for alcohol dependence reduced the effect to nonsignifi -
cance. Further analyses (not reported) suggested that this
was not due to the addition of any one covariate but to the
addition of all covariates simultaneously.
Treatment Endorsement
An across-the-board increase in public endorsement of
medical treatment was reported (Table 1). In 2006, a large
majority supported both general and specialty care for
individuals with mental illness. Over 85% indicated that
the major depression vignette character should go to a
psychiatrist (from 75% in 1996; F=9.27, p=0.002), and 79%
recommended psychiatric treatment for alcohol depen-
dence (from 61% in 1996; F=17.78, p<0.001). A signifi cant
increase in endorsement of prescription medicine was
reported across all vignette conditions. Only treatment at
a mental hospital remained unsupported by a majority of
respondents for depression or alcohol dependence (27%
and 26%, respectively). However, for schizophrenia, not
only was hospitalization endorsed by a majority, but sup-
port for hospitalization signifi cantly increased (from 53%
to 66%; F=8.97, p=0.003). Findings were largely unaffected
by the addition of controls for respondents’ age, sex, edu-
cation, and race (Figure 2). The slight attenuation of the
year effect in the endorsement of prescription medication
for depression reduced the effect to nonsignifi cance.
Public Stigma
No signifi cant decrease was reported in any indicator of
stigma, and levels remained high (Table 1). A majority of
the public continued to express an unwillingness to work
closely with the person in the vignette (62% for schizophre-
nia, 74% for alcohol dependence), socialize with the per-
son (52% for schizophrenia, 54% for alcohol dependence),
or have the person marry into their family (69% for schizo-
phrenia, 79% for alcohol dependence). In fact, signifi -
cantly more respondents in the 2006 survey than the 1996
survey reported an unwillingness to have someone with
schizophrenia as a neighbor (from 34% to 45%; F=6.31,
p=0.01) or to have someone with alcohol dependence
marry into their family (from 70% to 79%; F=4.01, p=0.05).
Furthermore, a majority again reported that the vignette
character with schizophrenia or alcohol dependence
1324 Am J Psychiatry 167:11, November 2010
TABLE 1. Unadjusted Survey Year Differences in Attributions of Mental Illness, Treatment Endorsement, and Stigma, by
Vignette Condition, 1996 and 2006a
SchizophreniabMajor Depressionc
Outcome Measure 1996 (%) 2006 (%) Differ-
enceeFfp 1996 (%) 2006 (%) Differ-
Neurobiological attributions
Mental illness 85 91 6 4.42 0.04 65 72 8 3.68 0.06
Chemical imbalance 78 87 9 6.77 0.01 67 80 13 11.23 0.001
Genetic problem 61 71 11 6.12 0.01 51 64 12 8.38 0.004
Neurobiological conceptiong76 86 10 8.00 0.01 54 67 13 9.94 0.002
Sociomoral attributions
Ups and downs 40 37 –3 0.48 0.49 78 67 –11 7.63 0.01
Bad character 31 31 0 0.01 0.91 38 32 –6 1.83 0.18
Way raised 40 33 –7 2.75 0.10 45 41 –5 1.14 0.29
Treatment endorsement
Physician 72 87 15 14.86 <0.001 78 91 13 20.25 <0.001
Psychiatrist 90 92 2 0.50 0.48 75 85 10 9.27 0.002
Mental hospital 53 66 13 8.97 0.003 25 27 2 0.31 0.58
Prescription medicine 76 86 11 7.59 0.01 71 79 9 5.14 0.02
Social distance: unwilling to
Work closely with 56 62 6 1.97 0.16 46 47 0 0.01 0.95
Have as a neighbor 34 45 11 6.31 0.01 23 20 –4 1.00 0.32
Socialize with 46 52 6 1.74 0.19 35 30 –5 1.35 0.25
Make friends with 30 35 5 1.27 0.26 23 21 –2 0.36 0.55
Have marry into family 65 69 4 0.88 0.35 57 53 –5 1.19 0.28
Violent toward self 81 84 4 1.14 0.29 73 70 –4 0.82 0.37
Violent toward others 54 60 6 1.74 0.19 33 32 –2 0.17 0.68
a Data are from the 1996 and 2006 mental health modules of the General Social Survey and are weighted.
b Sample size ranges from 633 to 639 because of missing data.
c Sample size ranges from 666 to 671 because of missing data.
d Sample size ranges from 617 to 623 because of missing data.
e Because of rounding, the year difference does not always equal the 2006 percentage minus the 1996 percentage.
f A design-based F test for weighted data tests the equality of the 1996 and 2006 percentages.
g Coded 1 if the respondent labeled the problem as mental illness and attributed cause to a chemical imbalance or a genetic problem,
coded 0 otherwise.
would likely be violent toward others. While stigmatizing
reactions did not signifi cantly decrease for the depression
vignette, levels remained comparatively lower. Findings
were unaffected by controls (Figure 3).
Association of Neurobiological Conception With
Treatment Endorsement and Stigma
In both survey years and across all conditions, holding
a neurobiological conception of mental illness tended to
increase the odds of endorsing treatment (e.g., for schizo-
phrenia, from 1996 to 2006, the odds of endorsing a psy-
chiatrist increased by a factor of 7.61; 95% CI=2.43–23.77,
p<0.001; see Table 2). However, in both years and across all
conditions, holding a neurobiological conception of men-
tal illness either was unrelated to stigma or increased the
odds of a stigmatizing reaction. In 2006, holding a neuro-
biological conception of schizophrenia increased the odds
of preferring social distance at work by a factor of 2.20 (95%
CI=1.02–4.76, p=0.05), and for depression it increased the
odds of perceiving dangerousness to others by a factor of
2.70 (95% CI=1.53–4.78, p<0.001). In no instance was a neu-
robiological conception associated with signifi cantly lower
odds of stigma. Furthermore, for all but three indicators, the
difference in the predicted probability between those who
held a neurobiological conception and those who did not
was larger in 2006 than 1996. For the depression vignette,
a neurobiological attribution increased the predicted prob-
ability of perceived dangerousness to self by 20 points in
1996 and by 35 points in 2006, for a difference of 15 points
(marginally signifi cant, 95% CI=1 to 31, p=0.07).
Public attitudes matter. They fuel “the myth that men-
tal illness is lifelong, hopeless, and deserving of revulsion
(14, p. xiv). Public attitudes set the context in which indi-
viduals in the community respond to the onset of mental
health problems, clinicians respond to individuals who
come for treatment, and public policy is crafted. Attitudes
can translate directly into fear or understanding, rejection
or acceptance, delayed service use or early medical atten-
tion. Discrimination in treatment, low funding resources for
mental health research, treatment, and practice, and lim-
ited rights of citizenship also arise from misinformation and
stereotyping. Attitudes help shape legislative and scientifi c
leaders’ responses to issues such as parity, better treatment
Am J Psychiatry 167:11, November 2010 1325
Alcohol Dependenced
1996 (%) 2006 (%) DifferenceeFfp
44 50 6 1.82 0.18
59 68 9 3.91 0.05
58 68 10 5.14 0.02
38 47 9 4.06 0.04
60 61 1 0.09 0.76
49 65 16 13.50 <0.001
64 69 5 1.56 0.21
74 89 15 19.55 <0.001
61 79 18 17.78 <0.001
25 26 1 0.10 0.75
40 53 13 7.78 0.01
72 74 2 0.15 0.69
44 39 –5 1.30 0.25
56 54 –1 0.05 0.82
35 36 2 0.13 0.72
70 79 8 4.01 0.05
78 79 1 0.16 0.69
65 67 1 0.11 0.74
systems, and dedicated mental illness research funds (23).
Assumptions about these attitudes and beliefs have defi ned
most messages of stigma reduction efforts (14, 15).
With House Joint Resolution 174, the U.S. Congress des-
ignated the 1990s as the “Decade of the Brain,” premised on
the assumption that the advancement of neuroscience was
the key to continued progress on debilitating neural diseases
and conditions, including mental illness. An explicit goal of
the bipartisan measure was to enhance public awareness of
the benefi ts to be derived from brain research. One of these
benefi ts was to come in the area of stigma, and the Decade
of the Brain “helped to reduce the stigma attached” to condi-
tions, including “mind disorders” (24). With a neurobiologi-
cal understanding of mental illness, people would see that
symptoms denote real illness and not volitionally driven
deviant behaviors. As a consequence, people with men-
tal disorders would be understood and treated rather than
blamed and punished. This view found resonance in the Sur-
geon General’s optimism for the stigma-reducing potential
of neurobiological and molecular genetic discoveries (15,
25). Similar optimistic statements have been common in
medical journals (26–28).
From a scientifi c perspective, claims that stigma was dis-
sipating were optimistic and speculative, based on narrow,
anecdotal, or unsystematic observation. Whether or not
there has been a decrease in stigma is subject to empirical
social science evaluation. Mental illness occurs in communi-
ties where “the public” is defi ned beyond political represen-
tatives, advocacy groups, and scientifi c organizations (29).
Our analyses of data from the GSS, the premier, longest-
running monitor of American public opinion, reveal that
intensive efforts through the 1990s to 2006, mounted on
the promise of neuroscience, have been rewarded with
signifi cant and widespread increases in public acceptance
of neurobiological theories and public support for treat-
ment, including psychiatry, but no reduction in public
stigma. Furthermore, in surveys from both 1996 and 2006
and across all vignette conditions, holding a neurobio-
logical conception of mental illness either was unrelated
to stigma or tended to increase the odds of a stigmatizing
reaction. Our most striking fi nding is that stigma among
the American public appears to be surprisingly fi xed, even
in the face of anticipated advances in public knowledge.
The patterns reported here are bolstered by a grow-
ing body of similar international studies reporting mixed
ndings (30–32). In a trend analysis in eastern Germany,
Angermeyer and Matschinger (30) documented an identi-
cal pattern of increases over time in public mental health
literacy and the endorsement of neurobiological causa-
tion coupled with either no change or an increase in public
stigma of mental illness. In Turkey (33), Germany, Russia,
and Mongolia (34), the endorsement of neurobiological
attributions was also associated with a desire for social
distance, although it had no effect on social distance in
Australia (35) and in Austria (36).
Our effort is not without limitations. First, vignette
approaches can be sensitive to large and small changes
in core descriptions (10, 37). How the public would react
to individuals at different places along the diagnostic
spectrum remains unanswered. Our “cases” met DSM-IV
diagnostic criteria and simulated what individuals in the
community encounter—a person with “problem” behav-
iors but no medical labels or history. This vignette strategy
allowed us to explore the association of a neurobiological
understanding of current or active “problem” behaviors
with stigmatizing responses. However, the assumption
underlying many antistigma interventions is that embrac-
ing a neurobiological understanding of mental illness
will increase support for help-seeking behavior and sub-
sequently lead to treatment that can mitigate symptoms.
This in turn would reduce others’ stigmatizing responses.
Testing this idea of recovery and stigma reduction would
require a different set of vignette circumstances than ours. It
stands as an important hypothesis for future research. Sec-
ond, attitudes are not behaviors, and predispositions may
or may not closely track discrimination (38). Both classic
and recent studies suggest that attitudes reveal more nega-
tive tendencies than individuals are willing to act upon in
1326 Am J Psychiatry 167:11, November 2010
TABLE 2. Neurobiological Conception of Mental Illness as Predictor of Treatment Endorsement and Stigma in 1996 and
2006, by Vignette Conditiona
1996 2006
Outcome Odds Ratiob95% CI p N Odds Ratiob95% CI p N
Treatment endorsement
Physician 1.12 0.58 to 2.17 0.73 290 2.73 0.93 to 7.97 0.07 341
Psychiatrist 2.17 1.03 to 4.59 0.04 291 7.61 2.43 to 23.77 <0.001 341
Mental hospital 3.01 1.57 to 5.78 0.001 288 1.84 0.77 to 4.35 0.16 341
Prescription medicine 5.19 2.66 to 10.14 <0.001 289 9.61 3.65 to 25.30 <0.001 341
Social distance: unwilling to
Work closely with 1.73 0.95 to 3.15 0.07 292 2.20 1.02 to 4.76 0.05 341
Have as a neighbor 1.71 0.87 to 3.36 0.12 292 2.39 1.07 to 5.37 0.03 341
Socialize with 1.23 0.67 to 2.26 0.50 292 1.83 0.85 to 3.94 0.12 341
Make friends with 1.31 0.68 to 2.52 0.43 292 1.79 0.77 to 4.17 0.17 341
Have marry into family 2.39 1.27 to 4.48 0.01 291 2.09 0.93 to 4.70 0.08 340
Violent toward self 2.51 1.23 to 5.14 0.01 293 4.62 1.99 to 10.73 <0.001 341
Violent toward others 2.23 1.20 to 4.13 0.01 292 2.41 1.13 to 5.16 0.02 341
Major depression
Treatment endorsement
Physician 0.84 0.46 to 1.53 0.57 293 2.48 1.13 to 5.41 0.02 374
Psychiatrist 2.17 1.21 to 3.89 0.01 290 5.77 2.92 to 11.43 <0.001 374
Mental hospital 1.87 1.01 to 3.46 0.05 291 3.52 1.82 to 6.84 <0.001 374
Prescription medicine 2.08 1.20 to 3.61 0.01 290 5.62 2.95 to 10.72 <0.001 374
Social distance: unwilling to
Work closely with 1.01 0.61 to 1.67 0.97 294 1.52 0.90 to 2.59 0.12 374
Have as a neighbor 1.03 0.56 to 1.90 0.91 293 1.99 0.98 to 4.05 0.06 374
Socialize with 0.76 0.45 to 1.28 0.30 294 0.89 0.50 to 1.58 0.67 374
Make friends with 0.90 0.47 to 1.70 0.74 293 1.05 0.53 to 2.10 0.88 374
Have marry into family 1.03 0.62 to 1.70 0.91 294 1.20 0.72 to 2.01 0.48 374
Violent toward self 2.85 1.61 to 5.04 <0.001 295 5.04 2.84 to 8.95 <0.001 374
Violent toward others 1.38 0.79 to 2.41 0.25 294 2.70 1.53 to 4.78 <0.001 374
Alcohol dependence
Treatment endorsement
Physician 1.40 0.76 to 2.58 0.29 274 1.65 0.77 to 3.53 0.20 346
Psychiatrist 3.04 1.69 to 5.50 <0.001 270 2.99 1.53 to 5.84 0.001 346
Mental hospital 3.18 1.74 to 5.82 <0.001 273 2.04 1.15 to 3.64 0.02 346
Prescription medicine 2.25 1.29 to 3.92 0.004 274 1.64 0.97 to 2.80 0.07 346
Social distance: unwilling to
Work closely with 0.76 0.42 to 1.36 0.36 273 1.30 0.72 to 2.34 0.38 346
Have as a neighbor 1.80 1.05 to 3.09 0.03 273 1.23 0.73 to 2.08 0.43 346
Socialize with 1.09 0.64 to 1.86 0.74 273 0.75 0.45 to 1.26 0.28 346
Make friends with 0.91 0.52 to 1.58 0.74 273 0.70 0.42 to 1.18 0.18 345
Have marry into family 1.06 0.57 to 1.95 0.86 270 0.97 0.53 to 1.77 0.93 346
Violent toward self 2.19 1.11 to 4.30 0.02 275 1.17 0.62 to 2.21 0.62 346
Violent toward others 1.62 0.90 to 2.89 0.11 272 1.01 0.59 to 1.73 0.96 346
a Logistic regression predicting treatment endorsement and stigma. Data are from the 1996 and 2006 mental health modules of the General
Social Survey and are weighted.
b Reports the factor change in the odds of treatment endorsement or stigma associated with holding a neurobiological conception, adjusted
for respondent’s age, sex, education, and race. Odds ratios >1 indicate that holding a neurobiological conception increases the odds of
treatment endorsement or stigma.
c Reports the discrete change in the predicted probability for a given outcome with respect to neurobiological conception, multiplied by
100, calculated with controls held at their means for the combined sample.
d Reports the year difference in the discrete change multiplied by 100. Because of rounding, this column will not always equal the 2006
discrete change minus the 1996 discrete change.
Am J Psychiatry 167:11, November 2010 1327
Discrete Change With
Respect to Neurobiologi-
cal Conceptionc
1996 2006 Differenced95% CI p
2 14 11 –11 to 34 0.33
7 22 15 –5 to 35 0.13
27 14 –12 –38 to 13 0.34
34 37 3 –22 to 27 0.84
14 19 6 –18 to 30 0.65
12 20 8 –13 to 30 0.45
5 15 10 –14 to 33 0.42
6 12 7 –14 to 27 0.53
21 17 –4 –28 to 21 0.76
16 26 11 –12 to 33 0.36
20 22 2 –22 to 25 0.88
–3 8 11 –2 to 23 0.09
14 23 9 –6 to 23 0.23
11 21 10 –4 to 24 0.17
15 30 15 –1 to 31 0.06
0 10 10 –8 to 28 0.27
1 10 9 –5 to 23 0.21
–6 –3 4 –13 to 21 0.67
–2 1 3 –13 to 19 0.73
1 5 4 –14 to 22 0.67
20 35 15 –1 to 31 0.07
7 19 12 –3 to 28 0.12
6 5 –2 –15 to 11 0.80
25 17 –8 –24 to 7 0.29
22 14 –9 –24 to 7 0.28
19 12 –7 –26 to 11 0.46
–5 5 10 –6 to 26 0.20
15 5 –10 –28 to 8 0.29
2–7–927 to 90.32
–2 –8 –6 –23 to 11 0.50
1 0 –2 –17 to 14 0.85
12 2 –10 –24 to 4 0.16
11 0 –10 –27 to 7 0.24
real situations (39, 40). While important, these limitations
are unlikely to have affected our observed results.
Clinical, Research, and Policy Implications
What appears to have been mistaken is the assumption
that global change in neuroscientifi c beliefs would translate
into global reductions in stigma. Our analyses suggest that
even if the embrace of neuroscience had been more pro-
nounced, a signifi cant and widespread reduction in stigma
would not have followed. We are not the fi rst to suggest
that there may be unintended consequences or a backlash
effect of genetic explanations of mental illness (41). Even in
1999, the Surgeon General’s report cautioned against a sim-
plistic approach, noting that most recent studies suggested
that increased knowledge among the public did not appear
to translate into lower levels of stigma.
The critical question centers on future directions. As
an alternative to our focus on neuroscience, we also con-
sidered another approach that pervades public debates.
Given the efforts of the Treatment Advocacy Center to
link violence in mental illness to policy changes neces-
sary to improve the mental health system, we did a post
hoc analysis that looked at the associations among pub-
lic perceptions of dangerousness, social distance, and
public support for increased funding. As Torrey (42) has
argued, people who recognize the potential dangerous-
ness of untreated mental illness will support the infusion
of more resources to the mental health system. Americans
assessments of dangerousness are high and, as in previ-
ous research, signifi cantly related to social distance (43).
However, a measure of public support for federally funded
services is not signifi cantly associated with public percep-
tions of danger. Far from providing the public support
needed to improve the mental health system, such fear
only appears to have a detrimental effect on community
We stand at a critical juncture. Neuroscientifi c advances
are fundamentally transforming the landscape of men-
tal illness and psychiatry. Given expectations surround-
ing the Decade of the Brain and the blame that pervaded
earlier etiological theories of individual moral weakness
and family defi cits, it is hardly surprising that antistigma
efforts relied on neuroscience. The “disease like any other”
tagline has taken clinical and policy efforts far but is not
without problems. It is our contention that future stigma
reduction efforts need to be reconfi gured or at least sup-
plemented. An overreliance on the neurobiological causes
of mental illness and substance use disorders is at best
ineffective and at worst potentially stigmatizing.
Historians, looking to instances in the past where stigma
decreased, suggest that continued advances in neurosci-
ence that will prevent, cure, or control mental illnesses are
critical to developing treatments that will render them less
disabling (44). In fact, the past decade has witnessed major
policy and clinical progress, including the passage of the
Mental Health Parity and Addiction Equity Act in 2008 and
1328 Am J Psychiatry 167:11, November 2010
FIGURE 1. Adjusted Survey Year Differences in Attributions of Mental Illness, by Vignette Condition, 1996 and 2006a
Genetics Neurobiological Ups and
Change From 1996 to 2006
Major depression
Alcohol dependence
a Graphs indicate the discrete change in the predicted probability for a given outcome with respect to year (multiplied by 100), calculated
with controls held at their means for the combined sample. Data are from the mental health modules of the 1996 and 2006 General Social
Surveys and are weighted. Tic marks indicate 95% confi dence intervals.
FIGURE 2. Adjusted Survey Year Differences in Treatment Endorsement, by Vignette Condition, 1996 and 2006a
a Graphs indicate the discrete change in the predicted probability for a given outcome with respect to year (multiplied by 100), calculated
with controls held at their means for the combined sample. Data are from the mental health modules of the 1996 and 2006 General Social
Surveys and are weighted. Tic marks indicate 95% confi dence intervals.
Change From 1996 to 2006
Major depression
Alcohol dependence
FIGURE 3. Adjusted Survey Year Differences in Stigma, by Vignette Condition, 1996 and 2006a
a Graphs indicate the discrete change in the predicted probability for a given outcome with respect to year (multiplied by 100), calculated
with controls held at their means for the combined sample. Data are from the mental health modules of the 1996 and 2006 General Social
Surveys and are weighted. Tic marks indicate 95% confi dence intervals.
Work Neighbor Socialize Friend Marry Violent to
Violent to
Change From 1996 to 2006
Major depression
Alcohol dependence
Am J Psychiatry 167:11, November 2010 1329
12. Markowitz FE: Modeling processes in recovery from mental ill-
ness: relationships between symptoms, life satisfaction, and
self-concept. J Health Soc Behav 2001; 42:64–79
13. Wahl OF: Mental health consumers’ experience of stigma.
Schizophr Bull 1999; 25:467–478
14. Hinshaw SP: The Mark of Shame: Stigma of Mental Illness and
an Agenda for Change. Oxford, UK, Oxford University Press, 2006
15. Shostak S, Conrad P, Horwitz AV: Sequencing and its conse-
quences: path dependence and the relationships between
genetics and medicalization. Am J Sociol 2008; 114(suppl):
16. Murray CJL, Lopez AD: Global Burden of Disease: A Compre-
hensive Assessment of Mortality and Disability From Diseases,
Injuries, and Risk Factors in 1990 and Projected to 2020 Cam-
bridge, Mass, Harvard School of Public Health, 1996
17. Dumesnil H, Verger P: Public awareness campaigns about de-
pression and suicide: a review. Psychiatr Serv 2009; 60:1203–
18. Pilgrim D, Rogers AE: Psychiatrists as social engineers: a study
of an anti-stigma campaign. Soc Sci Med 2005; 61:2546–2556
19. Smith TW, Kim S: A Review of CAPI Effects on the 2002 General
Social Survey. GSS Methodological No. 98. Chicago, National
Opinion Research Center, 2003
20. StataCorp: Survey Data Reference Manual. College Station, Tex,
Stata Press, 2009
21. Rao JNK, Scott AJ: On chi-squared tests for multi-way tables
with cell proportions estimated from survey data. Ann Stat
1984; 12:46–60
22. Allison PD: Comparing logit and probit coeffi cients across
groups. Sociol Methods Res 1999; 28:186–208
23. Burstein P: Should sociologists consider the impact of public
opinion on public policy? Soc Forces 1998; 77:27–62
24. Jones EG, Mendell LM: Assessing the decade of the brain. Sci-
ence 1999; 284:739
25. Blazer DG: The Age of Melancholy: Major Depression and Its
Social Origins. New York, Routledge, 2005
26. Baxter WE: American psychiatry celebrates 150 years of caring.
Psychiatr Clin North Am 1994; 17:683–693
27. Editorial: Reducing the stigma of mental illness. Lancet 2001;
28. Goin MK: Presidential address. Am J Psychiatry 2004;
29. Pescosolido BA, Martin JK, Lang A, Olafsdottir S: Rethinking
theoretical approaches to stigma: a framework integrating
normative infl uences on stigma (FINIS). Soc Sci Med 2008;
30. Angermeyer MC, Matschinger H: Causal beliefs and attitudes
to people with schizophrenia: trend analysis based on data
from two population surveys in Germany. Br J Psychiatry 2005;
31. Blumner KH, Marcus SC: Changing perceptions of depression:
ten-year trends from the General Social Survey. Psychiatr Serv
2009; 60:306–312
32. Mehta N, Kassam A, Leese M, Butler G, Thornicroft G: Public
attitudes towards people with mental illness in England and
Scotland, 1994–2003. Br J Psychiatry 2009; 194:278–284
33. Bag B, Yilmaz S, Kirpinar I: Factors infl uencing social distance
from people with schizophrenia. Int J Clin Pract 2006; 60:289–294
34. Dietrich S, Beck M, Bujantugs B, Kenzine D, Matschinger H, An-
germeyer M: The relationship between public causal beliefs
and social distance toward mentally ill people. Aust NZ J Psy-
chiatry 2004; 38:348–354
35. Jorm AF, Griffi ths KM: The public’s stigmatizing attitudes to-
wards people with mental disorders: how important are
biomedical conceptualizations? Acta Psychiatr Scand 2008;
inroads into the genetics of schizophrenia (45). However,
clinicians need to be aware that focusing on genetics or
brain dysfunction in order to decrease feelings of blame in
the clinical encounter may have the unintended effect of
increasing client and family feelings of hopelessness and
Antistigma campaigns will require new visions, new
directions for change, and a rethinking of what motivates
stigma and what may reduce it, a conclusion reached at a
2009 meeting of stigma experts at the Carter Center. While
new research will be needed, current stigma research
suggests that a focus on the abilities, competencies, and
community integration of persons with mental illness and
substance use disorders may offer a promising direction
to address public stigma (46).
Received Dec. 9, 2009; revision received April 28, 2010; accept-
ed June 3, 2010 (doi: 10.1176/appi.ajp.2010.09121743). From the
Schuessler Institute for Social Research and the Department of Soci-
ology, Indiana University; and the Mailman School of Public Health,
Columbia University, New York. Address correspondence and reprint
requests to Dr. Pescosolido, Schuessler Institute for Social Research,
Indiana University, 1022 East Third St., Bloomington, IN 47405; (e-mail).
All authors report no fi nancial relationships with commercial in-
1. US Department of Health and Human Services: Mental Health:
A Report of the Surgeon General. Bethesda, Md, US Depart-
ment of Health and Human Services, 1999
2. US Department of Health and Human Services: Report of the
Surgeon General’s Conference on Children’s Mental Health: A
National Action Agenda. Washington, DC, US Department of
Health and Human Services, 2001
3. US Department of Health and Human Services: Achieving the
Promise: Transforming Mental Health Care in America: The
President’s New Freedom Commission on Mental Health Re-
port. Bethesda, Md, US Department of Health and Human Ser-
vices, 2003
4. Sartorius N: Fighting schizophrenia and its stigma: a new World
Psychiatric Association educational programme. Br J Psychiatry
1997; 170:297
5. Rosenthal MB, Berndt ER, Frank RG, Donohue JM, Epstein AM:
Promotion of prescription drugs to consumers. N Engl J Med
2002; 346:498–505
6. Goffman E: Stigma: Notes on the Management of Spoiled Iden-
tity. Englewood Cliffs, NJ, Prentice Hall, 1963
7. Link BG, Cullen FT, Struening EL, Shrout PE, Dohrenwend BP:
A modifi ed labeling theory approach to mental disorders: an
empirical assessment. Am Sociol Rev 1989; 54:400–423
8. Link BG, Phelan JC: Conceptualizing stigma. Annu Rev Sociol
2001; 27:363–385
9. Rosenfeld S, Wenzel S: Social networks and chronic men-
tal illness: a test of four perspectives. Social Problems 1997;
10. Link BG, Yang L, Phelan JC, Collins P: Measuring mental illness
stigma. Schizophr Bull 2004; 30:511–541
11. Estroff SE: Making It Crazy: An Ethnography of Psychiatric Cli-
ents in an American Community. Berkeley, University of Cali-
fornia Press, 1981
1330 Am J Psychiatry 167:11, November 2010
42. Torrey EF: The Insanity Offense: How America’s Failure to Treat
the Seriously Mentally Ill Endangers Its Citizens. New York, WW
Norton, 2008
43. Pescosolido BA, Monahan J, Link BG, Stueve A, Kikuzawa S: The
public’s view of the competence, dangerousness, and need for
legal coercion of persons with mental health problems. Am J
Public Health 1999; 89:1339–1345
44. Grob GN: From Asylum to Community: Mental Health Policy in
Modern America. Princeton, NJ, Princeton University Press, 1991
45. Torkamani A, Dean B, Schork NJ, Thomas EA: Coexpression
network analysis of neural tissue reveals perturbations in de-
velopmental processes in schizophrenia. Genome Res 2010;
46. Ware NC, Hopper K, Tugenbert T, Dickey B, Fisher D: Connect-
edness and citizenship: redefi ning social integration. Psychiatr
Serv 2007; 58:469–474
36. Grausgruber A, Meise U, Katsching H, Schony W, Fleischhacker
WW: Patterns of social distance towards people suffering from
schizophrenia in Austria: a comparison between the general
public, relatives, and mental health staff. Acta Psychiatr Scand
2006; 115:310–319
37. Finch J: The vignette technique in survey research. Sociology
1987; 21:105–114
38. Asch S: The Legacy of Solomon Asch: Essays in Cognition and
Social Psychology. Hillsdale, NJ, Laurence Erlbaum Associates,
39. LaPiere RT: Attitudes vs actions. Soc Forces 1934; 13:230–237
40. Smith ER, Mackie DM: Surprising emotions. Science 2009;
41. Phelan JC: Geneticization of deviant behavior and conse-
quences for stigma: the case of mental illness. J Health Soc
Behav 2005; 46:307–322
... Although it has been questioned more recently [5,6], the serotonin theory of depression remains influential, with principal English language textbooks still giving it qualified support [7,8], leading researchers endorsing it [9][10][11], and much empirical research based on it [11][12][13][14]. Surveys suggest that 80% or more of the general public now believe it is established that depression is caused by a 'chemical imbalance' [15,16]. Many general practitioners also subscribe to this view [17] and popular websites commonly cite the theory [18]. ...
... The chemical imbalance theory of depression is still put forward by professionals [17], and the serotonin theory, in particular, has formed the basis of a considerable research effort over the last few decades [14]. The general public widely believes that depression has been convincingly demonstrated to be the result of serotonin or other chemical abnormalities [15,16], and this belief shapes how people understand their moods, leading to a pessimistic outlook on the outcome of depression and negative expectancies about the possibility of self-regulation of mood [64][65][66]. The idea that depression is the result of a chemical imbalance also influences decisions about whether to take or continue antidepressant medication and may discourage people from discontinuing treatment, potentially leading to lifelong dependence on these drugs [67,68]. ...
Full-text available
The serotonin hypothesis of depression is still influential. We aimed to synthesise and evaluate evidence on whether depression is associated with lowered serotonin concentration or activity in a systematic umbrella review of the principal relevant areas of research. PubMed, EMBASE and PsycINFO were searched using terms appropriate to each area of research, from their inception until December 2020. Systematic reviews, meta-analyses and large data-set analyses in the following areas were identified: serotonin and serotonin metabolite, 5-HIAA, concentrations in body fluids; serotonin 5-HT1A receptor binding; serotonin transporter (SERT) levels measured by imaging or at post-mortem; tryptophan depletion studies; SERT gene associations and SERT gene-environment interactions. Studies of depression associated with physical conditions and specific subtypes of depression (e.g. bipolar depression) were excluded. Two independent reviewers extracted the data and assessed the quality of included studies using the AMSTAR-2, an adapted AMSTAR-2, or the STREGA for a large genetic study. The certainty of study results was assessed using a modified version of the GRADE. We did not synthesise results of individual meta-analyses because they included overlapping studies. The review was registered with PROSPERO (CRD42020207203). 17 studies were included: 12 systematic reviews and meta-analyses, 1 collaborative meta-analysis, 1 meta-analysis of large cohort studies, 1 systematic review and narrative synthesis, 1 genetic association study and 1 umbrella review. Quality of reviews was variable with some genetic studies of high quality. Two meta-analyses of overlapping studies examining the serotonin metabolite, 5-HIAA, showed no association with depression (largest n = 1002). One meta-analysis of cohort studies of plasma serotonin showed no relationship with depression, and evidence that lowered serotonin concentration was associated with antidepressant use (n = 1869). Two meta-analyses of overlapping studies examining the 5-HT1A receptor (largest n = 561), and three meta-analyses of overlapping studies examining SERT binding (largest n = 1845) showed weak and inconsistent evidence of reduced binding in some areas, which would be consistent with increased synaptic availability of serotonin in people with depression, if this was the original, causal abnormaly. However, effects of prior antidepressant use were not reliably excluded. One meta-analysis of tryptophan depletion studies found no effect in most healthy volunteers (n = 566), but weak evidence of an effect in those with a family history of depression (n = 75). Another systematic review (n = 342) and a sample of ten subsequent studies (n = 407) found no effect in volunteers. No systematic review of tryptophan depletion studies has been performed since 2007. The two largest and highest quality studies of the SERT gene, one genetic association study (n = 115,257) and one collaborative meta-analysis (n = 43,165), revealed no evidence of an association with depression, or of an interaction between genotype, stress and depression. The main areas of serotonin research provide no consistent evidence of there being an association between serotonin and depression, and no support for the hypothesis that depression is caused by lowered serotonin activity or concentrations. Some evidence was consistent with the possibility that long-term antidepressant use reduces serotonin concentration.
... A World Health Organization study with 14 countries found that SUD was among the most highly stigmatized of 18 conditions [2]. The stigma associated with SUD affects different population groups and is expressed at various social levels, including in the family, the community and health care institutions, and it is a problem in various parts of the world [3][4][5][6][7][8][9][10][11]. ...
... In Europe and Latin America, several studies have indicated that persons with substance use disorder (PWSUD) are highly stigmatized by the public and experience a higher stigma than those with psychiatric disorders. The PWSUD are considered "criminals", weak in character, alienated, lacking self-control and irresponsible, which generates emotional reactions of fear, anger, pity and rejection from the general public, family and health professionals [1,[3][4][5]9,10,12]. These responses can lead PWSUD to internalize beliefs and feelings of unworthiness that affect their self-image, functioning, self-sufficiency and mental health, blocking access to early treatment for those interested in reducing their substance use [13][14][15][16][17]. ...
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Background: Substance use disorders are among the most stigmatized conditions worldwide. People with substance use disorder (PWSUD) are often considered responsible for their use of drugs. The objectives are to analyze changes in Mexican attitudes toward PWSUD in the general population over the period 2011 to 2016 and to use the latest Mexican household survey to determine which segments of the population are most likely to have negative attitudes. Methods: Two representative national household surveys employing similar methodologies were conducted in Mexico in 2011 and 2016 with persons aged 12-65 years. Participants were asked about their attitudes toward PWSUD, and changes were compared across GLM. Results: The surveys found a decrease from 2011 to 2016 in the number of respondents who considered PWSUD "sick" or in "need of help" and an increase in the number who believed they were "selfish" or "criminal". The 2016 survey found that men, people 18 years of age or older, people who do not use drugs and people with lower educational levels were the groups with the most negative attitudes toward PWSUD. Conclusions: These results suggest that it may not be recognized that PWSUD may have a health problem and that this helps to increase stigmatization towards this population.
... Across the U.S. and Western European countries, there has been an increase in public acceptance of the BDMA, but without a subsequent reduction in stigmatizing beliefs (Pescosolido et al. 2010). Meurk et al. (2013) found that knowledge about the BDMA did not increase empathy toward those with SUDs, despite 58% of their sample believing that it would. ...
... This is likely due, in part, to the complex and multifaceted nature of stigma, indicating that solely targeting blame as a mechanism for reducing stigma would likely have small effects. For instance, stigma also encompasses desire for social distance, prognostic pessimism, and fear (Pescosolido et al. 2010;Kvaale et al. 2013). ...
The National Institute of Drug Addiction has promoted the Brain Disease Model of Addiction (BDMA) for several decades, believing it will have a positive impact on drug-related social policies. Per research, neither understanding nor accepting the BDMA positively influences social behavior and decision making related to decreased stigma or increased support for treatment and funding for substance use disorders. An alternative model, the Malleability Model, focuses on the changeability of psychopathology associated with psychiatric disorders, and is associated with decreased hopelessness and increased prognostic optimism. The Moral Weakness Model focuses on moral character as the reason for addiction and is associated with punitive responses to use disorders. The current study sought to identify whether Malleability values were more predictive of willingness to vote for harm reduction (HR) policies than BDMA and Moral values (H1); and if agreement with Malleability values were more predictive of willingness to fund such policies than agreement with BDMA and Moral values (H2). Contrary to hypotheses, results indicated the Malleability Model failed to predict votes and donations, while agreement with the Moral Weakness Model and conservative political affiliation was predictive of lower HR donations. Agreement with the BDMA did not reliably predict votes and donations to policies; the associations reflected were tenuous and should be interpreted with caution. Overall, results indicated the Malleability Model did not increase votes and donations to HR policies, while agreement with Moral Weakness Model and conservative affiliation consistently predicted votes and donations.
... Lastly, stigma and personal experience with mental illness can further impact support for parity laws (McGinty et al., 2015(McGinty et al., , 2018Pescosolido et al., 2010). Research has documented how gender (Corrigan & Watson, 2007), ethnicity (Corrigan & Watson, 2007;WonPat-Borja et al., 2012), education levels (Corrigan & Watson, 2007;Phelan & Link, 2004), and political ideology (DeLuca & Yanos, 2016;Vaccaro et al., 2018) are associated with the stigmatization of people with mental illness. ...
... Stigma can also vary based on the mental illness and accompanying diagnosis. For example, numerous studies have described the higher levels of stigmatization associated with mental illnesses such as schizophrenia or psychosis, compared to mental illnesses like major depression or substance use (Krendl & Freeman, 2019;McGinty et al., 2015;Pescosolido et al., 2010Pescosolido et al., , 2013. However, experience with mental illness-either personally or through a close connection-has been associated with greater political and financial support of mental illness (McSween, 2002). ...
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Mental health parity legislation can improve mental health outcomes. U.S. state legislators determine whether state parity laws are adopted, making it critical to assess factors affecting policy support. This study examines the prevalence and demographic correlates of legislators’ support for state parity laws for four mental illnesses— major depression disorder, post-traumatic stress disorder (PTSD), schizophrenia, and anorexia/bulimia. Using a 2017 cross-sectional survey of 475 U.S. legislators, we conducted bivariate analyses and multivariate logistic regression. Support for parity was highest for schizophrenia (57%), PTSD (55%), and major depression (53%) and lowest for anorexia/bulimia (40%). Support for parity was generally higher among females, more liberal legislators, legislators in the Northeast region of the country, and those who had previously sought treatment for mental illness. These findings highlight the importance of better disseminating evidence about anorexia/bulimia and can inform dissemination efforts about mental health parity laws to state legislators.
... While our findings offer key insights about where to target anti-stigma training, the question remains around the best overall framework for stigma training. Counterintuitively, learning about the biomedical model of OUDs may have no effect or increase stigmatizing attitudes (Pescosolido et al., 2010;Schnittker, 2008). Focusing on the strengths and abilities of people with SUDs and the value of community integration may be more productive (Ware et al., 2007). ...
This study aimed to understand contributing factors of stigma toward people with opioid use disorder (OUD). We conducted a randomized factorial survey with Masters in Social Work (MSW) students (n = 70). Students received four vignettes describing a person with OUD, yielding a total of 275 vignettes for analysis. We tested whether stigma differed according to the characteristics of people with OUD. We found significantly more stigmatizing attitudes toward people with OUD who 1) inject heroin versus use oxycodone and 2) do not always take buprenorphine as prescribed versus always takes buprenorphine as prescribed. These findings indicate the need for MSW training that destigmatizes heroin use and inconsistent medication usage.
... Third, vignettes allow for depersonalization, which enables respondents to analyze the scenario from a variety of perspectives rather than responding based on their own circumstances (Schoenberg & Ravdal, 2000). Finally, the use of vignettes can help reduce respondents' social desirability bias by having them respond to the behavior of a character rather than their own actions (Pescosolido et al., 2010). ...
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Cannabis is the second most commonly used substance among Canadians for those 18 to 24 years old with the most prominent associated risk of driving under the influence. Cannabis consumption impairs executive functions necessary for driving and increases the likelihood of fatal motor vehicle crashes. The purpose of this study was to explore participant perceptions about the dangerousness and social acceptability of driving under the influence of cannabis (DUIC) compared to alcohol or while tired. Utilizing an experimental vignette design, participants (N = 453) were randomly assigned to one of six vignettes that varied on the substance used by a 22-year-old (cannabis, alcohol, no substance) and driver sex (male, female). Participants responded to a series of questions about the dangerousness and social acceptability of the driving behaviors described. A series of ANOVAs revealed a significant main effect of substance use across all items and a main effect of sex on social acceptability. DUIC was perceived as less dangerous and more socially acceptable than driving under the influence of alcohol. Furthermore, impaired driving was viewed as more acceptable for females than males. Findings help provide further insights into public perceptions of DUIC and highlight the importance of public education on the risks of DUIC.
... Studies suggested that people were more likely to attribute psychological causes than biological ones to mental illnesses, and that these etiological beliefs would be associated with discriminative attitudes (Mannarini and Rossi, 2019). However, even though a biological explanation of the disorder was correlated to higher recommendation of treatment endorsement, a study reported that it did not affect social rejection and perceived danger from the peers (Pescosolido et al., 2010). Furthermore, campaigns asserting "mental illness is an illness like any other and should be treated with medical treatments" did not prevent stigmatizing attitudes, possibly because it did not target the very anchored stereotype of dangerousness, uncontrollability and antisocial features of people with psychiatric condition (Angermeyer et al., 2011). ...
Mood disorders, including major depressive disorder and bipolar disorders, are frequent and heterogeneous psychiatric diseases. In order to better understand their pathophysiology, a new research area based on dimensions has emerged. It consists of exploring domains derived from fundamental behavioral components to link them to neurobiological systems. Beyond mood, emotional biases differentiate mood states in patients. Mania episodes are associated with positive biases, i.e. emotional stimuli become more rewarding and less aversive, while the opposite characterizes depression. The objective of this thesis was to identify hedonic bias in mouse models of depression and mania, and to study the underlying neural mechanisms. Using the GBR 12909-induced mouse model of mania, we found apart from the classical mania-like phenotype characterized by hyperlocomotion, strong negative olfactory and gustatory hedonic biases, at the opposite of what we expected. On the contrary, we uncovered a negative olfactory hedonic bias in the corticosterone-induced mouse model of depression, as we predicted. This bias was accompanied by specific basolateral amygdala (BLA) circuits activity disturbances. Furthermore, manipulating some of these BLA circuits activity thanks to chemogenetics was sufficient to partially improve the negative olfactory hedonic bias induced by chronic corticosterone administration. Taken together, our results highlight the interest of olfactory hedonic evaluation in mouse models of depression and mania, and demonstrate the causal role of BLA circuits in hedonic biases associated with depressive-like states.
Objective: The term "serious mental illness" (SMI) is widely used across research, practice, and policy settings. However, there is no consistent operational definition, and its reliability has not been systematically evaluated. The purpose of this review was to provide a comprehensive qualitative content analysis of "SMI" empirical research, including study and sample characteristics and SMI operational definitions. These data can provide important considerations for how stakeholders conceptualize SMI. Methods: Systematic review of PsycInfo, PsycArticles, and PubMed databases from January 1, 2015, to December 31, 2019, identified 788 original empirical studies that characterized the sample as having "SMI." Results: Descriptive content analysis indicated that most studies (85%) provided no operational definition for SMI. Only 15% defined the term, and an additional 26% provided examples of SMI that included only psychiatric diagnostic categories (e.g., SMI, such as schizophrenia). Of the 327 studies that provided any description of SMI, variability was noted regarding whether criteria included any mental health diagnosis (N=31) or only specified diagnoses (N=289), functional impairment (N=73), or any specified duration of symptoms (N=39). Across all studies that characterized samples as having SMI, substantial variability was noted regarding included diagnostic classifications. Conclusions: Referencing "SMI" is second nature for many stakeholders. Findings suggest that evidence-based practice and policy efforts should weigh the level of research support indicating that the construct and the term "SMI" lacks generalizability. Researchers and stakeholders are encouraged to develop precise and agreed-upon diagnostic language in their efforts to support and advocate for people with mental illnesses.
Background: Prior work has suggested that first responders have mixed feelings about harm reduction strategies used to fight the opioid epidemic, such as the use of naloxone to reverse opioid overdose. Researchers have also noted that provider-based stigma of people who use opioids (PWUO) may influence perceptions of appropriate interventions for opioid use disorder (OUD). This study examined first responders' perceptions of naloxone and the relationship between stigma of OUD and perceptions of naloxone. Methods: A web-based survey assessing perceptions of PWUO and naloxone was administered to 282 police officers and students enrolled in EMT and paramedic training courses located in the Northeastern United States. Bivariate and multivariable analyses assessed the relationship between variants of stigma (e.g., perceived dangerousness, blame, social distance, and fatalism) and self-reported perceptions of naloxone. Results: Participants, in the aggregate, held slightly negative attitudes toward the use of naloxone. Findings from multivariable modeling suggest that stigma of OUD, living in a rural area, and prior experience administering naloxone, were significantly and inversely related to support for the use of naloxone. Support for the disease model of addiction and associating drug use with low socioeconomic status were positively related to support for the use of naloxone. Conclusion: Efforts to alleviate perceptions of PWUO as dangerous, blameworthy, or incapable of recovery may increase first responders' support for naloxone. To this end, first responder training programs should include instruction on the disease model of addiction, and more broadly, attempt to foster familiarity between PWUO and the professionals who serve them.
Introduction: Illness models, including illness recognition, perceived severity, and perceived nature can affect treatment-seeking behaviors. Vignettes are a leading approach to examine models of illness but are understudied for substance use disorders (SUDs). We created vignettes for multiple common DSM-5 SUDs and assessed SUD illness models among college students. Methods: Seven vignettes in which the protagonist meets DSM-5 diagnostic criteria for SUDs involving tobacco, alcohol, cannabis, Adderall, cocaine, Vicodin, and heroin were pilot tested and randomly assigned to 216 college students who completed measures related to illness recognition, perceived severity, and perceived nature. MANOVAs with Scheffe post-hoc tests were conducted to examine vignette group differences on models of illness. Results: Vignettes met acceptable levels of clarity and plausibility. Participants characterized the protagonist's substance use as a problem, a SUD, or an addiction most frequently with Vicodin, heroin, and cocaine and least frequently with tobacco and cannabis. Participants assigned to the Vicodin, heroin, and cocaine vignettes were the most likely to view the protagonist's situation as serious and life-threatening, whereas those assigned to the cannabis vignette were the least likely. Numerically more participants characterized the pattern of substance use as a problem (91%) or an addiction (90%) than a SUD (76%), while only 15% characterized it as a chronic medical condition. Conclusions: Illness recognition and perceived severity varied across substances and were lowest for cannabis. Few participants conceptualized SUDs as chronic medical conditions. College students may benefit from psychoeducation regarding cannabis use disorder and the chronic medical condition model of SUDs.
Depression has become the most frequently diagnosed chronic mental illness, and is a disability encountered almost daily by mental health professionals of all trades. 'Major Depression' is a medical disease, which some would argue has reached epidemic proportions in contemporary society, and it affects our bodies and brains just like any other disease. Why, this book asks, has the incidence of depression been on such an increase in the last 50 years, if our basic biology hasn't changed as rapidly? To find answers, Dr. Blazer looks at the social forces, cultural and environmental upheavals, and other external, group factors that have undergone significant change. In so doing, the author revives the tenets of social psychiatry, the process of looking at social trends, environmental factors, and correlations among groups in efforts to understand psychiatric disorders.
Social science research on stigma has grown dramatically over the past two decades, particularly in social psychology, where researchers have elucidated the ways in which people construct cognitive categories and link those categories to stereotyped beliefs. In the midst of this growth, the stigma concept has been criticized as being too vaguely defined and individually focused. In response to these criticisms, we define stigma as the co-occurrence of its components-labeling, stereotyping, separation, status loss, and discrimination-and further indicate that for stigmatization to occur, power must be exercised. The stigma concept we construct has implications for understanding several core issues in stigma research, ranging from the definition of the concept to the reasons stigma sometimes represents a very persistent predicament in the lives of persons affected by it. Finally, because there are so many stigmatized circumstances and because stigmatizing processes can affect multiple domains of people's lives, stigmatization probably has a dramatic bearing on the distribution of life chances in such areas as earnings, housing, criminal involvement, health, and life itself. It follows that social scientists who are interested in understanding the distribution of such life chances should also be interested in stigma.
Critics of labeling theory vigorously dispute Scheff's (1966) provocative etiological hypothesis and downplay the importance of factors such as stigma and stereotyping. We propose a modified labeling perspective which claims that even if labeling does not directly produce mental disorder, it can lead to negative outcomes. Our approach asserts that socialization leads individuals to develop a set of beliefs about how most people treat mental patients. When individuals enter treatment, these beliefs take on new meaning. The more patients believe that they will be devalued and discriminated against, the more they feel threatened by interacting with others. They may keep their treatment a secret, try to educate others about their situation, or withdraw from social contacts that they perceive as potentially rejecting. Such strategies can lead to negative consequences for social support networks, jobs, and self-esteem. We test this modified labeling perspective using samples of patients and untreated community residents, and find that both believe that "most people" will reject mental patients. Additionally, patients endorse strategies of secrecy, withdrawal, and education to cope with the threat they perceive. Finally, patients' social support networks are affected by the extent to which they fear rejection and by the coping responses they adopt to deal with their stigmatized status.
Although many studies describe the social networks of people with chronic mental illness, we know little about the effects of these networks on well-being. This research tests four perspectives an social relations and quality of life, all of which hold that dimensions of networks shape life satisfaction by affecting self-esteem. However, these perspectives disagree about which particular dimension is consequential: relationships with Insiders vs. Outsiders, the extent of supportive relationships, or the number of negative ties. We test these perspectives using longitudinal data an 137 individuals with chronic mental illness. Results show that the proportion of Insiders or Outsiders makes little difference for quality of life. However, increases in the number of supportive relationships improves life quality. Moreover, negative interactions have a strong detrimental effect on life satisfaction. Further analyses show that supportive and negative relationships affect life quality, respectively, by increasing or decreasing individuals' self-esteem.