Stigma and the Acceptability of Depression Treatments
Among African Americans and Whites
Jane L. Givens, MD, MSCE1,6, Ira R. Katz, MD, PhD2, Scarlett Bellamy, ScD5, and William C.
Holmes, MD, MSCE3,4,5
1Boston University Medical Center, Geriatrics Section, Boston, MA 02118-2393, USA;2Section of Geriatric Psychiatry, Department of Psychiatry,
University of Pennsylvania, Philadelphia, PA, USA;3Center for Health Equity Research and Promotion, Philadelphia Veterans Administration
Medical Center, Philadelphia, PA, USA;4Division of General Internal Medicine, University of Pennsylvania, Philadelphia, PA, USA;5Center for
Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA;688 East Newton Street, Robinson 2, room 2702,
Boston, MA 02118-2393, USA.
BACKGROUND: Stigma is associated with depression
treatment, however, whether stigma differs between
depression treatment modalities is not known, nor have
racial differences in depression treatment stigma been
OBJECTIVE: To measure stigma for four depression
treatments and estimate its association with treatment
acceptability for African Americans and whites.
DESIGN: Cross-sectional, anonymous mailed survey.
PARTICIPANTS: Four hundred and ninety African-
American and white primary care patients.
MEASUREMENTS: The acceptability of four depression
treatments (prescription medication, mental health
counseling, herbal remedy, and spiritual counseling) was
assessed using a vignette. Treatment-specific stigma was
evaluated by asking whether participants would: (1) feel
ashamed; (2) feel comfortable telling friends andfamily; (3)
feel okay if people in their community knew; and (4) not
want people at work to know about each depression
treatment. Sociodemographics, depression history, and
current depressive symptoms were measured.
RESULTS: Treatment-specific stigma was lower for
herbal remedy than prescription medication or mental
health counseling (p<.01). Whites had higher stigma
than African Americans for all treatment modalities. In
adjusted analyses, stigma relating to self [AOR 0.43
(0.20–0.95)] and friends and family [AOR 0.42 (0.21–
0.88)] was associated with lower acceptability of mental
health counseling. Stigma did not account for the lower
acceptability of prescription medication among African
CONCLUSIONS: Treatment associated stigma signifi-
but not prescription medication. Efforts to improve de-
pression treatment utilization might benefit from addres-
sing concerns about stigma of mental health counseling.
KEY WORDS: stigma; depression treatment; patient preferences;
© 2007 Society of General Internal Medicine 2007;22:1292–1297
Depression is the most common mental health disorder,
affecting nearly 14 million U.S. adults annually.1Despite the
availability of effective depression treatments, utilization rates
are low.2–4One reason may be the stigma associated with
receiving treatment. Stigma, defined by sociologist Goffman5
as “spoiled identity” and characterized as the perception of
difference associated with undesirable traits,6is recognized as
a barrier to mental health care.7Stigma has been cited by the
1999 Surgeon General’s Mental Health Report,8the Depart-
ment of Health and Human Service’s Healthy People 2010,9
and the 2003 President’s New Freedom Commission on Mental
Health10as an important reason for low receipt of treatment.
These reports have identified reducing stigma as a major goal
in improving mental health care delivery.
Prior research reports that depressed patients with higher
stigma are less likely to adhere to pharmacologic treatment,11,12
and that stigma may be a barrier to initiating other forms of
treatment.13However, whether the level and effect of stigma
differs between depression treatment modalities remains
understudied. We sought to measure the stigma of four
depression treatment modalities and to estimate the association
between treatment stigma and treatment acceptability.
Differences in depression treatment acceptability between
African Americans and whites have been documented, with
African-Americans expressing lower acceptability of antide-
pressant medication,14greater preference for counseling,15
and more interest in counseling from clergy.16In addition,
concern has been raised that mental health stigma may be
higher among African Americans than whites.17,18For these
reasons, in our exploration of depression treatment stigma, we
sought to investigate differences between African Americans
and whites and to assess whether stigma could explain racial
differences in treatment acceptability.
Abstract presented at the Society of General Internal Medicine annual
meeting, Los Angeles, CA, 2006
Funding source: University Research Foundation of the University of
Received November 3, 2006
Revised April 5, 2007
Accepted June 19, 2007
Published online July 4, 2007
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Givens et al.: Stigma of Depression Treatments