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Targeting “help-seeking” for mental disorders in
empirical research is a difficult undertaking, since help-
seeking does not constitute a singular decision or act (like
“seeing a psychiatrist” or “taking antidepressants”), but
an individual pathway, shaped by a sequence of interac-
tions between available resources and personal beliefs
and attitudes (Rogler & Cortes, 1993). Help-seeking
pathways may meander between resources of lay- and
professional spheres. They may, quickly or with delays,
lead to appropriate help, but may also constitute failed or
insufficient treatment. The need to understand the hin-
drances of the public’s help-seeking is pressing: although
highly prevalent, mental disorders frequently remain
untreated. Population based studies in several countries
have examined the unmet need for healthcare and have
found an annual incidence between 3% and 15% of
severe untreated mental illness (Alonso et al., 2007;
Demyttenaere et al., 2004; Grabe et al., 2005; Regier et
al., 1993; Wittchen & Jacobi. 2001). A large European
survey using a conservative estimate of need found half
of those needing treatment for mental disorders not get-
ting any medical help for their problem (Alonso et al.,
2007). Use of services is generally lower in developing
than in developed countries (Wang et al., 2007). Help-
seeking behaviour differs for different mental disorders:
people with substance abuse disorders more frequently
fail to seek help than those with anxiety or mood disor-
ders (Wang et al., 2005; Wittchen & Jacobi, 2001). Those
seeking help often do so after a considerable delay of
many years (Wang et al., 2005).
This “service use problem” (Corrigan & Rüsch, 2003)
has frequently been attributed to the stigma of mental ill-
ness. The potential exposure to stigma is referred to as a
cause of the reluctance of those with mental disorders to
seek help (Gaebel et al., 2004; Sartorius, 2007). It seems
to be a truism that stigma inhibits optimal treatment for
mental disorders – although, a closer look reveals that
very few studies have in fact examined the impact of stig-
Epidemiologia e Psichiatria Sociale, 17, 1, 2008
31
Special Articles
Stigma and its impact on help-seeking for mental disorders:
what do we know?
GEORG SCHOMERUS and MATTHIAS C. ANGERMEYER
Department of Psychiatry, Leipzig University, Leipzig (Germany)
SUMMARY. Aims – Many people suffering from serious mental illness do not seek appropriate medical help. The stigma of
mental illness has often been considered a potential cause for reluctance in seeking help. We review recent evidence on this topic.
Methods – Narrative review of the recent literature on stigma and help-seeking for psychiatric disorders. Results – There is proof
of a particular stigma attached to seeking help for a mental problem. Anticipated individual discrimination and discrimination qua
self-stigmatisation are associated with a reduced readiness to seek professional help for mental disorders. Intervention studies show
that destigmatisation may lead to increased readiness to seek professional help, but other aspects like knowledge about mental dis-
eases seem to be at least as important. The belief that seeking help for a mental health problem is actually helpful has been shown
to be at the core of help-seeking intentions and thus offers a promising target for information programmes. Population based time-
trend studies show that public attitudes towards help-seeking have improved over the last decade. Discussion – The relationship
between help-seeking intentions and actual help-seeking needs further exploration. While many studies have been able to relate
attitudes to intentions, predicting actual help-seeking has proved more difficult.
Declaration of Interest: None.
Address for correspondence: Dr. G. Schomerus, Department of
Psychiatry, Leipzig University, Johannisallee 20, 04317 Leipzig
(Germany).
Fax: +49-341-972.4539
E-mail: Georg.Schomerus@medizin.uni-leipzig.de
ma on help-seeking. In this article, we review recent evi-
dence on this topic, thereby sketching a theoretical frame-
work of how stigma could affect help-seeking. We aim to
put this evidence in context with additional research on
other beliefs and attitudes that might influence help-seek-
ing for mental disorders.
STIGMA AND HELP-SEEKING
FOR MENTAL DISORDERS
Stigmatisation of those with mental illness has been
conceptualised as a process ultimately resulting in status
loss and discrimination (Link et al., 2001). When consid-
ering the impact of stigma on help-seeking, it is helpful to
contemplate how discrimination may affect those seeking
help for mental disorders on their help-seeking pathway
and to distinguish three levels of discrimination: individ-
ual, structural, and discrimination qua self-stigmatisation.
Individual discrimination refers to the behaviour of indi-
viduals that is intended to have a differential or harmful
effect on the members of a stigmatised group (Pincus,
1996), whereas structural discrimination describes the
negative consequences for the members of such a group
that result from the imbalances and injustice inherent in
social structures, political decisions and legal regulations
(Link & Phelan, 2001). Self-stigmatisation occurs when
members of a minority group internalise the stigmatising
ideas of their social environment and start to believe that
they are of less value and will be rejected by most people.
Structural discrimination of those seeking help for
mental illness would include a lack of available mental
health services, difficult access to services, or insufficient
coverage of mental health care by health insurances
(Kluge et al., 2007). Whereas at first glance this does not
seem to be a major problem in Western European coun-
tries with well established public mental health services,
it certainly is at issue in many, if not most other countries
(Becker & Vazquez-Barquero, 2001; Saxena et al.,
2007). But even in rich industrialized countries, private
health insurance plans often provide insufficient cover-
age for mental health problems (Hanson, 1998). Attitudes
among the public favouring structural discrimination of
psychiatric patients have been found in population-based
surveys in Germany. When asked to prioritise funding for
selected medical and mental diseases during a period of
financial restraint, respondents showed a clear preference
for medical diseases (Beck et al., 2003; Schomerus et al.,
2006), thus potentially putting mentally ill patients at a
disadvantage. However, whether increasing the availabil-
ity of services will result in better service use is under
debate. In an Australian survey, 65% of those who did
not receive treatment for a serious mental disorder stated
that they had no need for treatment (Andrews et al.,
2001), pointing to the importance of intra-personal atti-
tudes and considerations for under-utilization of mental
health care.
Discrimination at the individual level has been
researched extensively for mental diseases. There is evi-
dence of stigmatisation of mentally ill patients by those
entrusted with helping them. Family doctors and psychi-
atrists have more pessimistic views about the outcomes
for mental illnesses than the general public (Jorm et al.,
1999), and mental health professionals hold more nega-
tive stereotypes about mentally ill patients, but, reassur-
ingly, they are less accepting of restrictions towards them
(Nordt et al., 2006). So far, studies on discrimination
have focused predominantly on persons that have been
hospitalised or have a longstanding history of mental ill-
ness – as in Link’s classic Perceived Discrimination and
Devaluation Scale, that refers to “a former mental
patient” or to “a person that has been in a mental hospi-
tal” (Link, 1987). With help-seeking, the focus is on pre-
treatment cases, a population which may be less severely
affected. While it is well established that the stigma of
mental illness varies according to diagnosis (Crisp et al.,
2000), a person considering seeing a psychiatrist often
does not yet have a diagnosis. Discrimination of those
seeking help could thus be the result of the stigma
attached to help-seeking, i.e. the stigma of seeing a psy-
chiatrist, visiting a mental health centre, or talking to a GP
about a mental health problem. An experimental study
targeting stigma of help-seeking examined how college
students judged a person described in a case vignette. In
fact, a depressed person seeking help was judged as more
emotionally unstable than an identical person that did not
seek help for the disease (Ben-Porath, 2002).
However, the decision to seek help for a mental prob-
lem often occurs prior to overt discrimination: a person
considering seeking help for a mental health problem for
the first time has not yet been labelled as mentally ill,
hence the person does not yet belong to the discriminated
group of “those” with mental illness. However, when
considering seeing a psychiatrist, the person might antic-
ipate being diagnosed as mentally ill and, as a result, fear
potential discrimination. Factual discrimination is thus
preceded by anticipated discrimination. Admitting a psy-
chological problem was anticipated as much more stig-
matising than admitting a physical health problem among
soldiers returning from Bosnia (Britt, 2000). Barney and
her colleagues examined the influence of anticipated stig-
matisation on help-seeking preferences. They used a
G. Schomerus, M. C. Angermeyer
Epidemiologia e Psichiatria Sociale, 17, 1, 2008
32
labelled depression vignette to ask a population sample of
1,312 Australians how likely they were to seek help from
a list of different professional helpers if they were
depressed like the person described (Barney et al., 2006).
They found a significant minority of people expected
professionals to respond negatively to them, and this atti-
tude was associated with a decreased readiness to seek
help. In a smaller study of 142 Australians from a rural
town, higher anticipated stigmatisation was equally asso-
ciated with more negative attitudes towards seeking pro-
fessional psychological help but not with past help-seek-
ing behaviour (Wrigley et al., 2005). Other studies also
failed to demonstrate a relationship between anticipated
stigmatisation and real help-seeking. A study examining
300 Australians from rural areas also did not find an asso-
ciation between perceived stigmatisation and past help-
seeking from a GP for mental health problems (Komiti et
al., 2006). Employing a quite sophisticated design, Jorm
and his group examined how attitudes towards people
with depression translated into future help-seeking
behaviour in a small population based sample of
depressed persons. In an initial survey, they asked 3,109
adults whether they thought a depressed person was like-
ly to experience discrimination. Additionally, they
recorded beliefs about long-term outcomes, drawing on a
list stereotypes of mentally ill people like “to be violent”,
“to have poor friendship” or, positively, “to be under-
standing of other people’s feelings” and “to be a caring
parent”. After six months, they re-interviewed a sub-sam-
ple of 422 people that were found to be depressed at base-
line about their actions to relieve their symptoms. Neither
negative nor positive beliefs about outcomes and antici-
pated discrimination predicted help-seeking actions. This
held true for both actions that involved someone else hav-
ing to know that the person had psychiatric symptoms
and for actions which did not (Jorm et al., 2000b). In a
study of 92 depressed persons seeking treatment from a
psychiatric outpatient clinic for the first time, however,
anticipated individual discrimination did predict treat-
ment discontinuation in older but not in younger patients
(Sirey et al., 2001).
Similar to anticipated discrimination, the third level of
discrimination again lies within the help-seeking person
himself/herself. Corrigan & Rüsch (2003) have pointed
to the particular importance of self-stigma on help-seek-
ing. The negative attitudes someone entertains towards
those with mental illness turn against himself when he is
forced to consider himself as a member of the stigmatised
group, possibly resulting in lowered self esteem or low-
ered self-efficacy. Negative attitudes towards those seek-
ing help for a mental health problem could thus translate
into reluctance to seek help in order to avoid identifica-
tion with the disliked group. Discrimination qua self-stig-
matisation is the least researched part of stigma and help-
seeking. Barney and colleagues have subsumed self-stig-
ma to “feeling embarrassed” when seeking help and
found this feeling to be significantly associated with
decreased readiness to consult professional helpers
(Barney et al., 2006). In an examination of beliefs asso-
ciated with potential help-seeking, Cooper and her col-
leagues found a reduced readiness to seek help for psy-
chological problems in those respondents who attributed
high responsibility to those affected and had feelings of
anger towards them (Cooper et al., 2003).
So far, we have seen that there is evidence for a par-
ticular stigma attached to help-seeking for mental disor-
ders and that anticipated individual discrimination and
discrimination qua self-stigmatisation are associated with
a reduced readiness to seek professional help for mental
disorders. Most studies have failed, however, to demon-
strate variations in actual help-seeking behaviour corre-
sponding to these attitudes. The translation of attitudes
and intentions into actual help-seeking thus seems not to
be as straight forward as expected – either because the
time frame of the studies was too short to depict signifi-
cant decisions on the help-seeking pathway, or because
other attitudes and beliefs besides stigma shape the inten-
tion whether or not to seek professional help for mental
problems.
MENTAL HEALTH LITERACY
AND HELP-SEEKING
Other beliefs or attitudes may be of potential relevance
in help-seeking individuals. Combining various beliefs,
attitudes and abilities that promote mental well-being and
aid appropriate use of mental health services, Jorm intro-
duced the concept of mental health literacy (Jorm et al.,
1997; Jorm, 2000). Some studies have examined the
impact of mental health literacy on help-seeking prefer-
ences. Examining a population based sample of 1,207
young people from Australia, Wright and her colleagues
demonstrated that, compared to socio-demographic vari-
ables and previous contact with the disease, recognition
and accurate labelling of a depression or psychosis
vignette was the variable associated most frequently with
recommendation of appropriate help and treatment for
both diseases (Wright et al., 2007). In the case of depres-
sion, for example, those who recognized the disease were
more likely to recommend seeking help quickly, taking
antidepressants, calling on a psychologist, seeing a social
Stigma and its impact on help-seeking for mental disorders: what do we know?
Epidemiologia e Psichiatria Sociale, 17, 1, 2008
33
worker, or using counselling. Recommending a particular
treatment for another person, however, is different from
considering the same measure for oneself. In their above
cited study, Jorm et al. (2000a) evaluated whether, in
their general population based sub-sample of 422
depressed persons, beliefs about treatment influenced
help-seeking behaviour after six months. They asked
respondents to rate various medicines, activities, and peo-
ple whether they considered them as helpful, harmful or
neither for a depressed person. Six months later, they
questioned respondents about actions they had actually
taken in order to relieve their own symptoms. It turned
out that the rankings of interventions according to their
perceived helpfulness was considerably different from
the rankings of actual use. While most respondents
thought counselling or seeing a counsellor were helpful,
the rank order of used interventions was headed by hav-
ing an occasional drink and taking pain relievers. Only
for a minority of actions did rating them as helpful pre-
dict their actual use, among them the use of antidepres-
sants, turning to close friends, and reading about the
problem. Other actions, like seeing a GP, were unrelated
to their prior rating. A limitation of that study was the
short time frame of six months, which could have con-
tributed to the fact that “helpful” interventions involving
mental health services were rarely used.
HELP-SEEKING INTENTIONS
AND THE THEORY OF REASONED ACTION
Another methodological approach to help-seeking is
employing an established theory of social psychology to
beliefs and attitudes on help-seeking intentions, for exam-
ple the Theory of Reasoned Action (Fishbein & Ajzen,
1975). This theory is based on the assumption that behav-
iour is most precisely predicted by the intention to per-
form the behaviour. Intention in turn is determined by two
factors: attitude towards the behaviour, which represents
an individual’s general positive or negative evaluation of
performing the behaviour, and subjective norm, which
represents an individual’s general belief about whether
important others would approve or disapprove of him or
her performing the behaviour. Bayer & Peay (1997) have
first employed this theory for help-seeking for mental
problems in a study with 142 patients in a community
based general practice. They asked them how likely they
would be to seek help from a mental health professional
if they were experiencing a persistent personal problem in
their life. Attitude towards the behaviour was a stronger
predictor than subjective norm, indicating that personal
attitudes are more important than the disapproval of oth-
ers in predicting intentions to seek help form mental
health professionals. Specifically, likely help-seekers
more often believed that they would receive help from a
mental health professional and that they would experi-
ence acceptance, understanding and confidentiality from
mental health professionals than did unlikely help-seek-
ers. Similarly, in a post-hoc adaptation to the Theory of
Reasoned Action, a survey among 10,962 internet users
who screened positively for depressive symptoms showed
that personal attitudes were more important determinants
both for the intention not to accept the diagnosis of
depression, and for low perceived need for treatment than
subjective social norms (Van Voorhees et al., 2005;
2006). The most influential personal belief about treat-
ment in this study was the notion that medication is effec-
tive. The cited studies did not explicitly refer to stigma,
but the limited influence of social norms could point to a
limited influence of anticipated discrimination by others.
However, whether stigmatising attitudes shape subjective
evaluation of the helpfulness of professional help for
mental problems could be worth further exploration. By
using the established framework of the Theory of
Reasoned Action, these studies are helpful in weighting
different influences on help-seeking intentions, and thus
suggest promising targets for future interventions. They
show that expectations about the helpfulness of seeing a
mental health professional or receiving medication are
particularly important to those considering seeking pro-
fessional help for an emotional problem. Ajzen’s succes-
sor theory, the Theory of Planned Behaviour (Ajzen,
1991), also includes perceived difficulty of performing a
behaviour (perceived behavioural control) as a predictor
of behavioural intention, which could be helpful to target
structural discrimination, as well as perceptions of self-
efficacy as potential hindrances to help-seeking
(Schomerus et al., 2008).
INTERVENTIONS TO IMPROVE
HELP-SEEKING ATTITUDES
In order to improve attitudes towards help-seeking for
mental disorders, interventions have been designed and
evaluated. Providing knowledge about mental disorders
and their treatment has been shown to be a promising
way to increase readiness to seek help (Esters et al.,
1998; Han et al., 2006; Jorm et al., 2003). An evidence
based consumer guide about depression and its treatment
produced changes in some beliefs about treatments.
Participants from a population based sample of depressed
G. Schomerus, M. C. Angermeyer
Epidemiologia e Psichiatria Sociale, 17, 1, 2008
34
persons who were provided a consumer guide rated effec-
tive treatments more frequently as helpful than a control
group who received a general brochure on depression. In
particular, ratings for cognitive behavioural therapy, elec-
tro-convulsive therapy and St. John’s Wort increased sig-
nificantly, while no changes could be observed for the
ratings of other interventions or health professionals
(Jorm et al., 2003). In a small controlled study of adoles-
cents, a unit of instructions informing about sources of
help for mental problems in the community and the real-
ity of stigma improved opinion about mental illness and
attitudes towards seeking professional help (Esters et al.,
1998). There seems to be a differential effect of informa-
tion about the biological causes of depression and infor-
mation focussing on destigmatisation of help-seeking. In
a sample of Taiwanese college-students, Han and col-
leagues demonstrated that biological attribution increased
students’ willingness to seek help, while destigmatising
information did not alter attitudes towards help-seeking
(Han et al., 2006). Beyond providing information, con-
tact with mental patients has consistently been shown to
be a powerful predictor of less stigmatising attitudes
(Angermeyer & Dietrich, 2006). A school-based inter-
vention delivered by people who had personally experi-
enced mental illness, either by having a mental illness
themselves or by having cared for someone with mental
illness, was evaluated by Rickwood et al. (2004). This
intervention combined information on mental illness and
help-seeking with contact with affected persons or care-
givers. It had strong impact on increasing knowledge and
a moderate impact on reducing stigma. The intervention
did change some help-seeking intentions: those partici-
pating in the intervention were slightly more inclined to
seek help from professional sources than those having
regular classes instead.
TIME TRENDS IN ATTITUDES TOWARDS
HELP-SEEKING
From a population perspective, efforts to enhance pub-
lic understanding of mental illness and improve their atti-
tudes towards help-seeking seem to have succeeded,
since public attitudes towards help-seeking have posi-
tively changed over the last decade. Interestingly, time-
trend analyses from the United States, Australia and
Germany, all covering about the last decade, found very
similar changes in all three countries. In Germany, a
comparison of data from two representative population
surveys found both seeing a psychiatrist and psychother-
apist more readily recommended in 2001 than in 1990 for
someone suffering from schizophrenia or depression
(Angermeyer & Matschinger, 2005). Psychotropic drugs
became more popular for both disorders having been rec-
ommended for schizophrenia by 57.3% of respondents in
2001, compared to 30.7% in 1990 (Angermeyer &
Matschinger, 2005). Health professionals were more
often ranked as first choice recommendation for both dis-
orders in eastern German states in 2001 compared to an
earlier survey in 1993 (Riedel-Heller et al., 2005).
Similar findings come from two Australian surveys in
1995 and 2003-2004, where considerably more positive
beliefs about a range of appropriate medical and psy-
chosocial interventions surfaced in the later survey. The
perception that a person should deal with a mental disor-
der alone decreased markedly (Jorm et al., 2006).
Participants of a large representative US survey 2003
were also more willing to seek professional help for an
emotional problem than respondents of a similar survey
in 1990. They felt more comfortable talking about per-
sonal problems with a professional and felt less embar-
rassed to talk with friends about it (Mojtabai, 2007). The
study also analysed changes in attitudes of different age
groups (“generations”). While younger adults generally
had the most critical attitudes about seeking professional
help, attitudes in this generation also increased most,
pointing towards positive effects of mental health educa-
tion and media coverage of mental illness.
CONCLUSION
The relationship between stigma and help-seeking for
mental disorders is complex. While stigma is intuitively
regarded as one of the main obstacles to effective help-
seeking, pinpointing its influence proves difficult, since
the individual may encounter many situations on the
help-seeking pathway where stigma becomes relevant.
We have related previous research on stigma and help-
seeking to three levels of potential discrimination of help-
seekers: individual, structural, and discrimination qua
self-stigmatisation. Self-stigmatisation and anticipated
individual discrimination have been identified as impor-
tant cognitive processes within the help-seeking subject
that need further exploration. Intervention studies show
that destigmatisation may lead to increased readiness to
seek professional help, but other aspects like knowledge
about mental diseases may be equally important. The
belief that seeking help for a mental health problem is
actually helpful has been shown to be at the core of help-
seeking intentions and thus offers a promising target for
information programmes. However, the relationship of
Epidemiologia e Psichiatria Sociale, 17, 1, 2008
35
Stigma and its impact on help-seeking for mental disorders: what do we know?
help-seeking intentions and actual help-seeking needs
further exploration – while many studies were able to
relate attitudes to intentions, predicting actual help-seek-
ing proved much more difficult.
The last decade has seen an improvement of attitudes
towards help-seeking, and this could result in an
increased demand for mental health services. Given the
well-established under-utilisation of mental health care,
this would be a welcome development, but the question
remains whether health services are prepared to meet an
increased demand for mental health care.
Most studies dealing with determinants of help-seek-
ing for mental diseases chose to investigate help-seeking
for depression. There are many good reasons to investi-
gate this disorder, not least is its high incidence and the
assumption that healthy study participants can reasonably
well relate to its common symptoms. However, since
help-seeking is evidently more problematic for other dis-
eases like substance abuse disorders, it is worth consider-
ing whether research on help-seeking itself may reflect
stigmatising attitudes by neglecting certain diseases.
Attitudes towards help-seeking for early schizophrenia
would be a particularly promising field of research, since
there is substantial international interest in early inter-
ventions for this disease (Marshall & Lockwood, 2004).
Finally, apart from help-seeking for mental disorders,
recent work on the possibilities of mental health preven-
tion gives relevance to attitudes of healthy people
towards prevention of mental diseases (Riedel-Heller,
2006; Schomerus et al., 2008). Help-seeking for mental
disorders is an area where huge improvements seem pos-
sible – but more research still seems necessary to outline
how reducing the stigma of mental illness may contribute
to this goal.
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Stigma and its impact on help-seeking for mental disorders: what do we know?
