The Impacts of Mental Health Stigma

According to a recent definition, “stigma exists when elements of labelling, stereotyping, separation, status loss, and discrimination occur together in a power situation that allows them” (Link 2001) (Buechter, Pieper, Ueffing, & Zschorlich, 2013)

According to Corrigan and Watson (121), public stigma denotes the reaction of the general public to a certain group of individuals based on the stigma that is attached to this group. It comprises three components: stereotype, prejudice and discrimination. Stereotypes are collectively shared beliefs about a group of individuals. Most of the people are familiar with these stereotypes, however, not everybody adopts them. If they are adopted, prejudices develop, which result in negative emotional reactions and from these, in turn, discriminatory behaviour may develop. (Angermeyer & Dietrich, 2006, p. 171)

According to a widely cited model, stigma involves elements of stereotyping, prejudice and discrimination (Corrigan 2005). A stereotype is a simplified or over-generalised belief about a group of people, based on characteristics such as ethnic origin, sexual orientation, socioeconomic status, gender, health status or religion. Stereotypes are not harmful per se since people can be aware of them without agreeing with them. Prejudice, on the other hand, involves pre-judgement (Hinshaw 2007). It occurs when someone endorses a stereotype, particularly if the stereotype involves unfounded, unjustifiable and negative attitudes towards others based on their group membership. Discrimination occurs when prejudice results in an unfair treatment of people because of their group membership. An alternative stigma model introduces the concept of ignorance along with prejudice and discrimination, which is defined as a lack o fknowledge or mental health literacy (Thornicroft 2007). (Buechter et al., 2013)

From a societal perspective, stigma can be differentiated into public stigma, self-stigma and structural stigma (Corrigan 2005). Public stigma is defined as the negative reaction of the general population towards the stigmatised group based on stereotypes such as the beliefthat all people with mental illnesses are dangerous or incompetent. Self-stigma - sometimes called internalised stigma - occurs when people who are stigmatised share these stereotypes and turn them again themselves (e.g. “people with mental illnesses are incompetent, so I must be incompetent too”). Structural stigma involves practices of public institutions that restrict the rights of the stigmatised groups, either intentionally or unintentionally, for example when people’s right to vote, marry or serve on a jury is undermined. (Buechter et al., 2013)

According to Link and Phelan (120), the stigma process sets off by recognizing and labelling a difference between a person and other people. The next step involves the linking of the labelled person with the negative stereotypes that predominate in society about this group of people. This way, the person now belongs to a distinct category of people from whom the beholder dissociates. The stigma process culminates in that the person concerned is exposed to different forms of discrimination and the negative social consequences resulting from this. The authors differentiate between individual and structural discrimination as well as self-stigmatization. The first refers to the behaviour of individuals that is directed straight against the members of a stigmatized group. The most frequently applied measure of individual discrimination is the desire for social distance (122). Structural discrimination describes the negative consequences that result from the imbalances and injustice inherent in social structures, political decisions and legal regulations for the members of a stigmatized group. The third form of discrimination (self-stigmatization) comes from within the mentally ill persons themselves in that they adopt the stereotypes prevailing in society about people with mental illness. (Angermeyer & Dietrich, 2006, p. 170)

Outcomes of public stigma change have been assessed in several ways, with self-reported social-cognitive measures dominating (21–23). These are sometimes understood in terms of a simple path model: attitudes, affect, and behavior (9). Attitudes reflect the stereotypes about mental illness and include ideas about blame, dangerousness, and incompetence. Affect concerns the emotional reaction to attitudes: dangerousness begets fear, and blame yields to anger. Discriminatory behavior results from stereotypic attitudes and affect; for example, the public is hesitant to employ (24– 28) or to rent property (28–31) to people with mental illness. Behavior per se is a difficult construct to assess because most studies do not have resources to observe actual responses after stigmatizing attitudes and affect. This kind of assessment requires some form of independent observation in an overwhelming number of settings and times. (Morris, 2012, p. 2)

The link between the two components of the stigma process, stereotype and discrimination, has been investigated in the meantime, with the interest lying on the impact of the different aspects of the stereotype of the mentally ill on individual discrimination and on the acceptance of structural discrimination of people with schizophrenia. Of the different stereotype components, the idea of unpredictability and dangerousness had the strongest impact on the social distance desired towards a person with schizophrenia: the more this view was adopted, the higher was the desire for social distance. The converse applies to the idea that people with schizophrenia were particularly intelligent and gifted. The acceptance of structural discrimination, on the contrary, was mainly influenced by the belief that those affected are to blame for their own illness: the more distinct the inclination to blame the ill, the higher the tendency towards approving of structural discriminations (35). Of particular interest for the structural discrimination of mentally ill persons is the result of a survey in Germany, which investigated the public’s preferences when it comes to the allocation of financial resources to health care and medical research. While somatic illnesses like cancer or cardiovascular diseases ranked first, depression, schizophrenia and alcoholism were the taillights (38, 39). Findings similar to what has been found in Germany are reported from the US: respondents who labelled persons with mental disorders as suffering from mental illness expressed a preference for greater social distance; and the degree of dangerousness that the public ascribed to these persons appeared to mediate the influence of the labelling effect (66). (Angermeyer & Dietrich, 2006, p. 171)

Despite increasing public awareness about schizophrenia, stigma towards people with this disorder has actually increased (Link et al., 1999; Hinshaw, 2006; Pescosolido et al., 2010). The effects ofstigma are devastating, including reduced employment opportunities (Hinshaw, 2005), social support availability (Sartorius, 1999), quality of life (Link and Phelan, 2001), and community acceptance (Hinshaw, 2006; Hinshaw and Stier, 2008). Indeed, stigma is one ofthe greatest barriers in achieving functional recovery (Berge and Ranney, 2005). (Heenan et al., 2014, p. 238)

In 1950, Shirley Star and colleagues from the National Opinion Research Center (NORC) conducted face-to-face interviews with a representative sample of 3,529 American adults (cf. Phelan, Link et al., 2000). Of the many goals of the survey, Star (1952, 1955) examined public impressions of people with mental illness. Most important to the point here was whether research participants viewed people with serious mental illness as violent. In 1996, NORC repeated items from the Star survey as part of a snapshot of NORC’s annual snapshot of contemporary life. In the 1996 sample, about two and a halftimes more likely to view individuals with serious mental illness as dangerous compared to 1950. Researchers in the 1996 study conducted a second interview in 2006 and had similar sobering findings (Martin et al., 2009, personal communication). Comparisons of 2006 with 1996 data are not totally completed at the time of publishing this book. However, the investigators did report no significant reduction in attitudes between 1996 and 2006. Things have not really improved. (Tsang et al., p. 25)

The study covering the longest period of time was undertaken in the US. Phelan et al. (68) compared the data of a survey dating from 1996 and those taken from a study conducted by Star back in 1950. They found that while today, the image of mental disorders is somewhat more differentiated among the American public, mentally ill individuals are nowadays more frequently considered to be dangerous as compared to the 1950s. (Angermeyer & Dietrich, 2006, p. 171)

The general public seems to infer mental illness from four cues: psychiatric symptoms, social-skills deficits, physical appearance, and labels (Corrigan, 2000; Penn & Martin, 1998). Many of the symptoms of severe mental illnesses like psychoses—for example, inappropriate affect and bizarre behavior—are manifest indicators of psychiatric illness that produce stigmatizing reactions (Link, Cullen, Frank, & Wozniak, 1987; Penn et al., 1994; Socall & Holtgraves, 1992). Moreover, poor social skills (Bellack, Mueser, Morrison, Tierney, & Podell, 1990; Mueser, Bellack, Douglas, & Morrison, 1991) that result from some psychiatric illnesses also lead to stigmatizing responses from others. (Corrigan, P., 2004, p. 615)

A survey in the US yielded that people from the South of the US tended to endorse more frequently that the person’s bad character or stresses in life are responsible for the occurrence of mental disorders (70). Their preferences for social distance from persons with mental disorders were the same as in the rest of the US (66). Asian and Hispanic respondents perceived mental patients as significantly more dangerous than did white respondents (71). African Americans were more likely than whites to reject the idea that mental illnesses are caused by either genetics or an unhealthy family upbringing. They also tended to have more negative attitudes than whites towards professional mental health treatment (70). (Angermeyer & Dietrich, 2006, p. 172)

Among the negative attributes attached to people with mental disorders the most prevalent one appears to be that they are unpredictable. This holds true more for people with schizophrenia (54–85%) or alcoholism (71%) than for people with depression (28–56%) or anxiety disorders (50%) (13, 34, 35, 41, 59, 104). Less frequently, persons with mental disorders are considered as violent and dangerous. Here, a similar picture emerges as with unpredictability. In particular, people with schizophrenia (18–71%) and alcoholism (65–71%) are seen as dangerous. To a lesser extent, this also applies to people with depression (14–33%) and anxiety disorders (26%) (13, 34, 35, 59, 62, 65, 66, 85, 101). The majority of the public show pro-social reactions, i.e. they feel sorry for persons with mental illnesses and they also feel the need to help them. This is particularly true for depression. Next come feelings of uneasiness, uncertainty and fear, reactions which are mostly set off by persons with schizophrenia. Infrequently, aggressive reactions occur (20, 34). There is an observable tendency towards distancing from persons with mental illness. With increasing intimacy of social relationships increases the desire for social distance. Rejection is most pronounced towards persons with drug abuse and alcoholism, followed by those with schizophrenia and is less pronounced towards people with depression and anxiety disorders (10, 15, 34, 51, 65, 67, 104, 111). All vignette studies examining the effect of subject-generated mental illness labels on public attitudes show that labelling leads to more rejection and other adverse reactions (20, 33, 41, 51, 66, 98, 109). (Angermeyer & Dietrich, 2006, p. 170)

In a survey in the US, most respondents agreed that psychiatric medications are effective, and fewer than half had concerns regarding potential problems. However, the majority of the respondents would not be willing to take them (72). (Angermeyer & Dietrich, 2006, p. 169)

Acute stress in the form of life events is the most frequently endorsed cause (schizophrenia: 72.5–87%, depression: 81–85.5%), followed by (chronic) stress in partnership and family (schizophrenia: 59–64%, depression: 70–74%), brain disease (schizophrenia: 48.5–71%, depression: 19– 59%) and heredity (schizophrenia: 39–67.5%, depression: 21–58%). (Angermeyer & Dietrich, 2006, p. 165)

Public responses to short descriptions (vignettes) of people with mental illnesses in several surveys show that mental illness is often associated with stigma. For example, in the mental health module of the US General Social Survey, between 35% and 69% of participants responded that they were unwilling to make friends with, have as a neighbour, socialise with, work closely with or have marry into their family a person with schizophrenia. For major depression, responses ranged from 20% to 53% for each of the items. Furthermore, 60% of the respondents reported that the character with schizophrenia described in the vignette would likely be violent towards others (Pescosolido 2010). This was also reported by 32% of the respondents in response to the vignette character with major depression. (Buechter et al., 2013)

Corrigan (2000) argued that mental health stigma in particular is sustained by the majority's fear of the disparaged group, leading to avoidance of stigmatized individuals. For instance, Link et al. (1999) found that people who read about individuals labelled as having schizophrenia were significantly more frightened, and more likely to believe that people with schizophrenia should be institutionalized to keep the public safe. (Heenan et al., 2014, p. 239)

Much of our current knowledge about public stigma toward persons with mental illness and substance abuse comes from the General Social Survey (GSS), which in 1996 and 2006 asked respondents to report their attitudes toward persons e portrayed in vignette format e with untreated and symptomatic schizophrenia, major depression, alcohol dependence, and cocaine dependence (Link et al., 1999; Pescosolido et al., 2010). These four mental illness/substance abuse vignettes engendered different levels of negative response from the American public, with substance abuse eliciting higher levels of stigma than mental illness. For example, one-third of Americans thought that persons with untreated and symptomatic major depression were likely to commit violence toward others, compared to much larger proportions of respondents who believed that persons with untreated and symptomatic schizophrenia (60%), alcohol dependence (65%), and cocaine dependence (87%) were likely to be violent (Link et al., 1999; Pescosolido et al., 2010). The GSS vignette methodology has also been used to measure stigma toward persons with mental illness e but not substance abuse e outside the US. A consistent finding across countries is that the public holds higher levels of stigma toward persons with schizophrenia than toward persons with depression (Pescosolido et al., 2013).The GSS has also provided critical information about how Americans perceive the causes of mental illness and substance abuse. A study comparing the results of the 1996 and 2006 surveys showed that in 2006, Americans increasingly identified biomedical and neurobiological factors e opposed to family upbringing or character defects e as important causes of mental illness and substance abuse (Pescosolido et al., 2010). Significantly, the same study found that increased endorsement of the biological basis of mental illness was not associated with corresponding decreases in stigma (Pescosolido et al., 2010). This finding failed to support the central tenet of the anti-stigma efforts of the 1990s and early 2000s, which focused on increasing public perceptions of mental illness and substance abuse as biologically based e and therefore on par with conditions like heart disease or cancer e as the pathway to reducing stigma (Pescosolido et al., 2010). (McGinty, Goldman, Pescosolido, & Barry, 2015, p. 74)

An important question throughout this article is whether the problem ofstigma and adherence applies to the generic concept of mental illness or differs by diagnosis and/or level of disability. Research evidence on this issue is mixed. On one hand, research suggests there is a nonspecific label effect, implying that people labeled mentally ill, regardless of the specific psychiatric diagnosis or level of disability, are stigmatized more severely than those with other health conditions (Corrigan et al., 2000; Weiner, Magnusson, & Perry, 1988). On the other hand, studies suggest the public discriminates among psychiatric groups in terms of stigma; for example, people with psychotic disorders are judged more harshly than people with depression or anxiety disorders (Pescosolido, Monahan, Link, Stueve, & Kikuzawa, 1999). (Corrigan, P., 2004, p. 614)

A principal components factor analysis identified that stigma attitudes have the same three factors structure across all diagnoses; negative stereotypes, patient blame and inability to recover. Schizophrenia was significantly associated with the most negative stereotypes, least blamed and viewed as least likely to recover compared to anxiety and depression. (Wood, Birtel, Alsawy, Pyle, & Morrison, 2014, p. 604)

There has been a growing awareness among mental health professionals that mental illness is still surrounded by stigma. According to Sartorius it is the most important obstacle to the provision of mental health care for people with mental disorders (4). Moreover, as Jorm (5) was able to show, the public’s mental health literacy is still unsatisfactory and needs to be improved. Otherwise, this may hinder public acceptance of evidence-based mental health care. (Angermeyer & Dietrich, 2006, p. 164)

By educating the public about mental illnesses, prevailing stereotypes and prejudices may be contradicted and replaced with more realistic and positive images, that could decrease desire for social distance and ultimately reduce discrimination. For example, there is an association between the belief that mental illnesses are caused by character weaknesses and greater social distance, suggesting that education may reduce this aspect of stigma (Jorm 2009). (Buechter et al., 2013)

Society is undergoing a process of medicalization. Suffering and deviance are increasingly defined as disease-like entities with biological and genetic (biogenetic) causes. This process can be discerned in the growing media coverage of psychiatric neuroscience (Racine, Waldman, Rosenberg, & Illes, 2010), in the proliferation and expansion ofdiagnostic categories (Conrad & Potter, 2000; Scott, 1990), in the efforts to align public understanding of mental disorders with medical professionals (Jorm, 2000; Watson et al., 2004), and in the rising public acceptance of biogenetic explanations for mental disorders (Schomerus et al., 2012). From the viewpoint of reducing the stigma of mental disorders, medicalization has often been considered a positive process, prompting anti-stigma initiatives to describe schizophrenia as an ‘illness’ that ‘affects the normal functioning of the brain’ (SANE Australia, 2012), and depression as ‘a biological, medical illness’ (National Alliance on Mental Illness, 2012). (Kvaale, Gottdiener, & Haslam, 2013, p. 95)

There is, however, little evidence that medicalization has reduced stigma. A recent review of population trends concluded that the rising popularity of biogenetic explanations has not translated into greater public acceptance of people with mental disorders (Schomerus et al., 2012). Critics have also cautioned that popularizing biogenetic explanations may have unintended side effects that could exacerbate stigma (Haslam, 2000; Phelan, 2002; Read, Haslam, Sayce, & Davies, 2006). Stigma is a multifaceted phenomenon that comprises not only blame, but also negative stereotypes, a tendency to separate ‘us’ from ‘them’, and various forms of social exclusion and discrimination (Hinshaw, 2007; Link & Phelan, 2001; Link, Yang, Phelan, & Collins, 2004). Biogenetic understandings of mental disorders may reduce the public’s tendency to blame at the cost of aggravating negative stereotypes, pessimism about recovery, and desire for distance and separation (Haslam, 2011) are concerns sometimes voiced by people with mental disorders themselves (Easter, 2012; Laegsgaard, Stamp, Hall, & Mors, 2010; Schreiber & Hartrick, 2002). (Kvaale et al., 2013, p. 96)

There is a substantial, growing body of research on the associations between biogenetic explanations and components of stigma, which has generated mixed findings and led previous qualitative reviews to reach diverging conclusions. One review defined stigma broadly as negative attitudes and concluded that biogenetic explanations were positively related to stigma (Read et al., 2006). A second review defined stigma as social distance and highlighted the heterogeneity in findings, suggesting that different types of biogenetic explanations relate differently to stigma (Jorm & Oh, 2009). A third review defined stigma as social distance and concluded that biogenetic explanations were positively associated with stigma toward people with schizophrenia, but not necessarily other disorders (Angermeyer, Holzinger, Carta, & Schomerus, 2011). A fourth review focused on perceptions of dangerousness and suggested that biogenetic explanations increase this component of stigma (Jorm, Reavley, & Ross, 2012). Together, these reviews suggest that (1) stigma is a multifaceted construct that must be analyzed in its specific components, (2) biogenetic explanations form a heterogeneous albeit related group of explanation types comprising hereditary mechanisms, neurochemical mechanisms and other forms of biological mechanisms, which may relate differently to the various facets of stigma, and (3) biogenetic explanations may influence stigmatizing attitudes differently depending on the type of mental disorder they are provided for. (Kvaale et al., 2013, p. 96)

In the framework of attribution theory, biogenetic explanations reduce perceptions of the controlability of behavior, which might help to prevent a blaming response toward people experiencing mental disorders (Corrigan et al., 2000; Weiner et al., 1988). Our findings lend some support to this claim, at least for genetic explanations, in student samples, and in the context of schizophrenia. On the other hand, the favorable effects of biogenetic explanations on blame do not appear to generalize to greater acceptance of people with mental disorders. On the contrary, biogenetic explanations were related to stereotyping people with mental disorders as dangerous, as well as increased desire for distance from individuals with schizophrenia. These discouraging findings are understandable within the theoretical framework of essentialism (Haslam, 2000; Phelan, 2002; Read et al., 2006). Essentialist thinking involves defining a group of individuals with reference to a deep-seated, unchangeable essence that makes them fundamentally different from others (Haslam & Ernst, 2002; Haslam, Rothschild, & Ernst, 2000), and has been found to be associated with stereotyping and prejudice toward a variety of social groups (Bastian & Haslam, 2006; Haslam, Rothschild, & Ernst, 2002; Jayaratne et al., 2006; Keller, 2006), including people with mental disorders (Howell, Weikum, & Dyck, 2011). Biogenetic explanations induce essentialist thinking (Boysen, 2011) and may therefore reinforce and legitimize stereotypes about mental disorders. When the stereotypes are particularly disturbing, as is the case for schizophrenia (Angermeyer et al., 2011; Crisp, Gelder, Rix, Meltzer, & Rowlands, 2000; Magliano, De Rosa, Fiorillo, Malangone, & Maj, 2004), it is not surprising to find a greater desire for distance amongst people subscribing to essentialist explanations. (Kvaale et al., 2013, p. 99)

A continuum model corresponds to findings of epidemiological studies on the prevalence and severity of symptoms of mental illness among the general population. Continua from a few mild symptoms to many severe symptoms have been found for psychiatric disorders, like schizophrenia [7], depression [8], or alcohol dependence [9]. Stressing the continuous nature of mental distress has already been discussed as a potentially useful anti-stigma strategy [10]. The idea of replacing a perceived fundamental, qualitative difference between those with and those without mental disorder with a more quantitative difference on a symptom continuum is in line with current models of the stigma process: The widely used model proposed by Link and Phelan [11,12] posits the separation between ‘us’ and ‘them’ as central to the stigma process. Stressing the normality of mental illness symptoms could reduce separation: ‘‘if we are all affected – who are ‘the mentally ill’?’’ ([9], p. 442). (Schomerus et al., 2016, p. 21)

Surveys among large samples of the general population in Germany [13] and France [14] showed that endorsement of a mental health-mental illness continuum was associated with less fear, more empathy and less desire for social distance from a person with schizophrenia, depression, or alcohol dependence as described in a case vignette with no diagnostic label. An online-study of a convenience sample of 120 adults found continuum beliefs regarding schizophrenia associated with less negative stereotypes [15]. However, there have also been warnings of possible side effects of a continuity approach. Potentially, ‘likeness-based’ messages could increase notions of blame and foster the false belief that persons with mental illness only ‘have to pull themselves together’, thereby worsening stigma instead of reducing it [16,17]. (Schomerus et al., 2016, p. 22)

There seems to be a natural tension between a continuous model of mental health and a medical approach aiming at a firm diagnosis of mental illness. After all, establishing a diagnosis and discerning healthy from ill persons is among the public’s core expectations from psychiatrists [29]. Integrating a mental health-mental illness continuum into a useful concept of mental disorder is thus an ongoing challenge to academic psychiatry. Current diagnostic systems, such as ICD-10 reflect the continuous nature of mental health by linking psychiatric diagnoses to the number and severity of present symptoms, thus establishing thresholds on a continuum [30]. By stressing these thresholds, however, diagnostic systems seem to downplay rather than emphasize the continuum. Debates on ‘at risk’ stages or ‘subclinical phenotypes’ [31] further explore the continuum of mental distress, frequently defining new and lower thresholds to identify persons at risk of developing a mental disorder [32]. The new DSM-5 has started to incorporate dimensional approaches within selected diagnostic groups, such as personality disorders or autism spectrum disorder [33], and the controversial Research Domain Criteria (RDoC) proposed by the National Institute of Health are conceptualized as continuous functional domains [34]. (Schomerus et al., 2016, p. 25)

The effects of continuum messages on social acceptance and perceived differentness regarding a person with mental illness found in this study indicate that such messages are potentially useful in anti-stigma campaigns. Moreover, fears that continuum messages could increase blame [16,17] were not corroborated by our study. So far however, continuum messages have not played a prominent role in anti-stigma work. In a qualitative consensus development study evaluating different messages for their usefulness in population wide anti-stigma campaigns [26], Clement et al. found continuum messages ranking only 6th among 10 proposed messages. In that study, a panel of stigma researchers, clinicians, persons with lived experience and relatives rated different anti-stigma messages. While persons with experience of mental disorders seemed to support continuity messages, psychiatrists were critical: They gave continuum messages a usefulness-rating of only 2.5 out of 10, compared to an overall rating of continuum messages of 7 out of 10 by the entire panel. (Schomerus et al., 2016, p. 25)

Using Wald tests, we examined whether effects of the two oppositely framed interventions differed significantly. This was confirmed for effects on perceived difference (P < 0.001). For social acceptance, effects of the continuum and dichotomy intervention differed just below the 0.05 level of significance (P = 0.07). When restricting our analysis to those respondents who received one of the two intervention texts and who did recall the intervention correctly at the end of the interview (n = 663 out of 1068 from both intervention groups), social acceptance was significantly greater in those who had received the continuum vignette compared to the dichotomy vignette (0.16 SD, P = 0.044, see online Table S5). Coefficients did not differ significantly for blame (P = 0.81), suggesting that the observed reduction of blame was a non-specific intervention effect. Table 3 also shows that the schizophrenia vignette provoked stronger perceptions of fundamental difference, less social acceptance, less blame and more perceived unpredictability and dangerousness compared to the depression vignette. Interaction analyses revealed that treatment effects were not modified by the type of vignette condition the respondents received (online Table S4).So far, our analyses show that the continuum intervention increased belief in a symptom continuum of mental disorder, increased social acceptance, and reduced perceived fundamental difference. Next, we wanted to find out whether these intervention effects were in fact mediated by stronger continuity beliefs. Structural equation models adjusted for age, sex, education and type of vignette showed that 24.9% (95% confidence interval, CI: 6.3–43.4) of the total effect of the continuum intervention on perceived difference and 26.4% (CI 5.9–46.8) of its total effect on social acceptance were mediated by continuity beliefs. Values for the dichotomy intervention were slightly lower: 21.9% (CI 1.7– 42.0) of the total effect on perceived differentness and 23.2% (CI 0.9–45.5) of the (not significant) total effect on social acceptance were mediated by continuity beliefs. Our analyses are thus consistent with a partial mediation of the continuum intervention effect on stigma by increasing continuity beliefs. (Schomerus et al., 2016, p. 25)

The Surgeon General of the United States has identified stigma as a significant impediment to the treatment of mental disorders (US Department of Health and Human Services, 1999). (Couture & Penn, 2003, p. 291)

The U.S. Surgeon General eloquently summed up the concern in his 1999 report: Stigmatization of people with mental disorders has persisted throughout history. It is manifested by bias, distrust, stereotyping, fear, embarrassment, anger, and/or avoidance. Stigma leads others to avoid living, socializing or working with, renting to, or employing people with mental disorders, especially severe disorders such as schizophrenia (Satcher, 1999, Chapter 1).Advocacy groups like the National Alliance for the Mentally Ill, the National Mental Health Association, and the World Health Organization have echoed concerns about the harm caused by stigma and have called for programs that challenge the prejudice and discrimination that result. (Corrigan, P. W., 2004, p. 113)

The United States first systematically pursued antistigma campaigns after the 1999 White House Conference on Mental Health. American efforts against stigma have soared given the energy and resources of professional groups (the American Psychiatric Association and American Psychological Association), advocacy groups (such as the National Alliance on Mental Illness [NAMI] and Mental Health America), pharmaceutical companies (Eli Lilly), and government bodies (the Substance Abuse and Mental Health Services Administration and the National Institute of Mental Health). (Morris, 2012, p. 1)

Major advocacy groups in the United States such as the National Alliance for the Mentally Ill and the National Mental Health Association have prioritized stigma as an important concern. Additional groups have made the stigma of mental illness a prime focus, including the National Stigma Clearinghouse and the Resource Center to Address Discrimination and Stigma Associated with Mental Illnesses. Both federal and state governments have joined the fray. In the past few years, the U.S. Substance Abuse and Mental Health Services Administration (SAMH-SA) and the National Institute of Mental Health have supported nationwide conferences on stigma. SAMHSA produced and disseminated an anti-stigma kit that included posters and brochures challenging common stereotypes. Tipper Gore and Alma Powell joined with other national leaders to form the National Mental Health Awareness Campaign that developed a multi-level effort to challenge stigma. Similar efforts are evident elsewhere in the world. The World Psychiatric Association has launched “Schizophrenia: Open the Doors.” The program is currently active on three continents: Asia, Europe, and South America. Prominent among these efforts is “Changing Minds” by the British Royal College of Psychiatrists. (Corrigan, P. W., 2004, p. 116)

There are also several examples of state governments using contact to diminish stigma and enhance consumer empowerment. New York (Blanch, Fisher, Tucker, Walsh & Chassman, 1993; Knight & Blanch, 1993a, 1993b), Florida (Loder & Glover, 1992), and Illinois (Corrigan, Lickey, Schmook, Virgil & Juricek, 1999) have arranged formal dialogues between persons with mental illness and mental health care professionals as a way to change insidious attitudes in the mental health system that undermine empowerment. These dialogues provided a forum for consumers and health care professionals to exchange perspectives about mental illness and challenge latent stigmatizing attitudes. Moreover, the U.S. Center for Mental Health Services has an intramural office on consumer empowerment and funds consumer based, extramural projects that attempt to discount stigma. Many state departments of mental health hire consumer advocates whose job, in part, includes vigilance to misrepresentations of mental health issues. (Corrigan, P. W., 2004, p. 116)

Any population-level intervention will need to contain - explicitly or implicitly - messages about what mental health problems are and what a world without discrimination against people with mental health problems would look like (Sayce, 2000), and these must be carefully chosen (Lauber, 2008). However, there is little research evidence to inform decisions about this key aspect of anti-stigma initiatives, as is evident from the evidence overview produced for this study (described in the methods section below). Furthermore, there is wide variation in the types of message used, and considerable disagreement about which types of message are best (Callard et al., 2008). Consensus development methods seek to synthesise judgments so that policy decisions can be made when uncertainty exists (Murphy et al., 1998). (Clement et al., 2010, p. 72)

Reduced service use could be seen as representing a saving to the economy, which may be good or bad. However, we here assume that reduced use as a result ofstigma or discrimination represents a ‘welfare loss’ (i.e. this is negative) to the individual which can be valued using the cost incurred were this service to be provided. As such, we are assuming that the service use that would otherwise have taken place would have been appropriate (this also means that in the longer term any apparent savings would likely be lost because reduced service use may be reflected in poorer health outcomes). Similarly, foregone leisure/recreational activities can be valued using the price that would have been paid to engage in them. This would again represent a welfare loss to the individual, although not an overall economic loss if we assume that the funds that would have been spent on these activities will be spent in other ways. Costs/values for each service that was used less or more often in the previous 6 months as a consequence of discrimination or stigma were calculated from recognised national sources [9, 10]. (Wright et al., 2015, p. 788)

The total costs for each session were DVD UK £100; live £675; and lecture £199. The DVD had costs that were £575 lower than the costs for the live session. It also had better outcomes in terms of stigmatising attitudes and was therefore dominant (superior). The DVD had costs that were £99 lower than for the lecture, and with better outcomes was again dominant. Finally, the live session had higher costs (by £476) and better outcomes (adjusted difference of 1.77 on the MICA) compared with the lecture and therefore the incremental cost-effectiveness ratio indicates that it costs £269 per extra unit decrease in stigmatising attitudes for the live session compared with the lecture. (Clement et al., 2012)

General attitudes to serious mental illness, as measured by the Attitudes Toward Serious Mental Illness Scale - Adolescent Version (Watson etal,2005), a 21-item validated measure of general attitudes in young people where higher scores indicate more negative attitudes. Perceived dangerousness, measured by the Dangerousness Scale (Link & Cullen,1986), a 5-item questionnaire with good internal consistency where ratings are made on a 5-point Likert scale, with higher scores indicating greater perceived dangerousness. Social distance, measured by the Social Distance Scale (Penn etal,1994), a 6-item questionnaire with good internal consistency where higher scores are indicative of a tendency to maintain a greater social distance from people diagnosed with a serious mental illness. Attitudes to psychiatry, measured by the Attitudes to Psychiatry Scale (Burra etal,1982), a well-validated 30-item questionnaire where higher scores indicate a more positive attitude towards psychiatry. (Kerby et al., 2008, p. 346)

Link’s social distance scale [50] was used in four studies (slightly modified version of the same scale was used in other two studies). The following scales were used twice: the affect scale [51], the attitudes towards seeking professional psychological help scale [52], the Positive and Negative Affect Scale [53], the Community attitudes towards mental illness scale [54], the dangerousness scale [55], and the implicit attitudes test [56]. (Janoušková et al., 2017, p. 3)

This self-report his self-report questionnaire, which can be completed in questionnaire, which can be completed in 5 to 10 min, may help us understand more about the role of stigma of psychiatric illness in research and clinical settings. (King et al., 2007) 

Stigmatization can have a negative effect on seeking and using mental health care [7–9]. Particularly among young people, the stigma and embarrassment are the most often perceived barriers to help seeking [10]. According to the US National Comorbidity Survey, only one third of adolescents with mental disorders received any mental health care [11]. Stigmatization may also contribute to other problems, such as lower self-esteem, or reduced hope for recovery [12,13], decreased quality of life [14], difficulties in social relationships, and embarrassment of close relatives [15] and subsequent suicidal behaviour [16]. (Janoušková et al., 2017, p. 1)

The first episode or prodromal symptoms of schizophrenia typically occur in adolescence [1,2]. However, stigma towards schizophrenia is one of the most important factors related to the obstruction of its early detection and treatment [3,4]. Therefore, it is vital to decrease stigma among parents of adolescents to contribute to the removal of this barrier [5]. (Ling, Watanabe, Yoshii, & Akazawa, 2014, p. 1)

Economic theory suggests that individuals engage in specific activities to maximise their ‘utility’ (which may alternatively be described as ‘wellbeing’). Failure to engage in desired activities would, therefore, result in a ‘cost’ to the individual in the form of non-realised utility or welfare. For example, avoidance of visits to cafes or restaurants because of perceived discrimination will lead to a loss to the individual, although the value of this is hard to determine. This can also extend to engagement with activities where the benefit may be in the future. Some effects are more tangible—for example discrimination in terms of employment. Discrimination in relation to mental health problems, therefore, is likely to come with a cost. (Wright, Henderson, Thornicroft, Sharac, & McCrone, 2015, p. 787)

Many people who would benefit from mental health services opt not to pursue them or fail to fully participate once they have begun. One of the reasons for this disconnect is stigma; namely, to avoid the label of mental illness and the harm it brings, people decide not to seek or fully participate in care. Stigma yields 2 kinds of harm that may impede treatment participation: It diminishes self-esteem and robs people of social opportunities. (Corrigan, P., 2004, p. 2)

Many young people report low levels of mental health literacy and moderate levels of mental illness stigma [4,5]. These negative attitudes towards people with mental illness, which may form early on during childhood [6], may play a role in the treatment gap. (Janoušková et al., 2017, p. 1)

Two specific manifestations that dissuade people from treatment: the threats of diminished self-esteem and of public identification when labeled “mentally ill.” (Corrigan, P., 2004, p. 614)

Research from the Epidemiologic Catchment Area (ECA) Study showed that less than 30% of people with psychiatric disorders seek treatment (Regier et al., 1993). A subsequent large-scale study, the National Comorbidity Survey, showed similar results (Kessler et al., 2001). Less than 40% of respondents with mental illness in the past year received stable treatment.  About 40% of people with such serious disorders as schizophrenia failed to obtain treatment (Regier et al., 1993), and people with serious mental illness were no more likely to participate in treatment than those with relatively minor disorders (Narrow et al., 2000). A national survey conducted by the Substance Abuse and Mental Health Services Administration found similar sobering results (Willis, Willis, Male, Henderson, & Manderscheid, 1998); fewer than 10% of people with psychiatric disabilities receive such diagnostically indicated services as vocational rehabilitation, case management, or day treatment. Findings from a national survey conducted by the Schizophrenia Patient Outcome Research Team are also alarming (Lehman et al., 1998). Although more than 90% of individuals in the survey received maintenance neuroleptic treatment, participation in evidence-based psychosocial treatments was far lower. Less than half of survey participants reported participation in appropriate psychotherapies, less than a quarter were involved in family therapy, and only about 10% received intensive case management. A recent review of 34 studies of compliance with psychiatric medication found, on average, that more than 40% of persons receiving antipsychotic medication failed to fully comply with prescribed regimens (Cramer & Rosenbeck, 1998). Failure to adhere to antipsychotic regimens increased rehospitalization by three-fold, accounting for an $800 million increase in hospital costs world wide (Weiden & Olfson, 1995). In addition, many persons drop out of psychosocial interventions before finishing the complete regimen (Falloon, Lindley, McDonald, & Marks, 1977; Tarrier et al., 1998). (Corrigan, P., 2004, p. 615)

Individuals with mental illness may opt to avoid the stigma all together by denying their group status and by not seeking the institutions that mark them (i.e., mental health care). This kind of label avoidance is perhaps the most significant way in which stigma impedes care seeking. Controlled social laboratory studies have demonstrated an inverse association between public stigma and care seeking. Results of one survey showed members of the general public who blamed individuals for their mental illness and withheld help to them were less likely to seek care for themselves (Cooper, Corrigan, & Watson, 2003). A second study showed an inverse relationship between stigmatizing attitudes and treatment adherence (Sirey, Bruce, Alexopoulos, Perlick, Raue, et al., 2001). In this study, stigma was measured using the Scale of Perceived Stigma (Link, Cullen, Struening, Shrout, & Dohrenwend, 1989). Scores on the Scale of Perceived Stigma were associated with whether 134 adults were compliant with their antidepressant medication regimen three months later. Findings on these small samples have been supported by additional population-based studies that frequently incorporated probability samples. One study on about 3,000 community residents is an example. Endorsing negative attitudes about mental illness inhibits personal service utilization in those at risk for psychiatric disorder (Leaf, Bruce, Tischler, & Holzer, 1987). Results from the National Comorbidity Survey identified several specific beliefs that might sway people from treatment (Kessler et al., 2001). These include concerns about what others might think and wanting to solve problems on one’s own. These two studies were completed on adults. A third study using a national probability sample examined the influence of stigma on care seeking in adolescents (Penn et al., in press). The National Annenberg Risk Survey of Youth was conducted by telephone in the spring of 2002 with 900 respondents selected via random-digit dialing procedures. Results showed that adolescents who were more likely to endorse the stigma of mental illness were less likely to obtain care when needed. An additional interesting finding was that the connection between stigma and treatment seeking was mediated by perceptions about treatment success. Views about stigma were less relevant to care seeking when the adolescent believed treatment was likely to be successful. This result parallels another study done on adults with neurotic disorders; people in this group were less likely to seek treatment when they believed no one could help them (Meltzer et al., 2003). (Corrigan, P., 2004, p. 616)

Worldwide, more than 70% of young people and adults with mental illness do not receive any mental health treatment from health care staff.1 The difference between true prevalence and treated prevalence can be called the treatment gap.2 The relationship between stigma and discrimination and access to care is multifaceted; stigma and discrimination can impede access at institutional (legislation, funding, and availability of services),6,7,8 community (public attitudes and behaviors),9 and individual levels.10a Descriptive studies and epidemiological surveys suggest potent factors that increase the likelihood of treatment avoidance, delays to care, and discontinuation of service use include (1) lack of knowledge to identify features of mental illnesses, (2) ignorance about how to access treatment, (3) prejudice against people who have mental illness, and (4) expectation of discrimination against people diagnosed with mental illness. (Henderson, Evans-Lacko, & Thornicroft, 2013, p. 777)

Stigma can be a barrier to help-seeking (Barney, Griffiths, Jorm, & Christensen, 2006; Christiana et al., 2000; Corrigan & Rüsch, 2002; Mojtabai, 2010), makes employment and accommodation harder to find (Alisky & Iczkowski, 1990; Bordieri & Drehmer, 1986; Brohan et al., 2012; Page, 1977, 1995; Thornicroft, Brohan, Rose, Sartorius, & Leese, 2009), is associated with loss of interpersonal contacts and roles (Cechnicki, Angermeyer, & Bielanska, 2011; Schulze & Angermeyer, 2003; Thornicroft et al., 2009), and can lead to hopelessness about recovery and symptom exaggeration (Livingston & Boyd, 2010). Stigma represents a chronic challenge to emotional well-being and self-esteem (Livingston & Boyd, 2010; Richman & Leary, 2009; Wright, Gronfein, & Owens, 2000) that is perhaps as detrimental to the individual as the mental disorder itself (Corrigan & Penn, 1999). (Kvaale et al., 2013, p. 95)

Public stigma impacts on people with mental illnesses, their families and caregivers in many ways. It can decrease people’s chances to obtain employment and housing and lead to segregation and social distance (Corrigan 2002; Kai 2001). Furthermore, people with mental illnesses are more likely to be disadvantaged by the justice system than others. For example, police officers may be less willing to help them, when they are victims of a crime (Corrigan 2005), Or their testimonies may be regarded as less trustworthy by the judicial system. There is also evidence that people with mental illness receive a poorer standard ofmedical care (Hert 2011). If public stigma is internalised by people with mental illnesses, it can foster beliefs that can diminish people’s self-esteem and self-efficacy and negatively affect emotional well-being (Dinos, 2004; Livingston 2010; Watson 2005). Furthermore, stigma may have a negative impact on health seeking behaviour, treatment adherence and recovery (Barney 2006; Barney 2009; Corrigan 2004b; Gulliver 2010; Livingston 2010; Malpass 2009; Perlick 2001). (Buechter et al., 2013)

Stigma has a significant negative impact on the psychosocial functioning of people with mental illnesses through both experienced and anticipated discrimination. People who have been patients in psychiatric hospitals report a wide range of discriminatory experiences in both occupational and social settings, including being turned down for jobs for which they are qualified, being counseled to lower their expectations for a productive life, being denied insurance coverage, being turned down for housing, and being rejected frequently in social situations (Page, 1995; Wahl, 1999). In the workplace, researchers have found that people who have received the label ‘mentally ill’ are underemployed and earn less income than people with the same psychiatric difficulties who have not received the label (Link, 1987). Even in the absence of direct discrimination, people with mental illnesses may anticipate stigmatizing responses at work and in relationships and become preoccupied with concealing their status (Smart & Wegner, 1999; Wahl, 1999). Anticipation of negative responses can also lead people with mental illnesses to withdraw from or limit their social and occupational functioning (Link et al., 1987, 2001; Perlick et al., 2001). (Alexander & Link, 2003, p. 272)

Several studies have shown that public stereotypes and prejudice about mental illness have a deleterious impact on obtaining and keeping good jobs (Bordieri & Drehmer, 1986; Farina & Felner, 1973; Farina, Felner, & Bourdreau, 1973; Link, 1982, 1987; Olshansky, Grab, & Ekdhal, 1960; Wahl, 1999; Webber & Orcutt, 1984) and leasing safe housing (Aviram & Segal, 1973; Farina, Thaw, Lovern, &Mangone, 1974; R. Hogan, 1985a, 1985b; Page, 1977, 1983, 1995; Segal, Baumohl, &Moyles, 1980; Wahl, 1999). (Corrigan, P., 2004, p. 616)

Three general strategies have been identified to combat stigma: education, contact and protest (Corrigan 1999). Education about mental illnesses involves overcoming the myths ofmental illnesses and replacing them with facts. Examples of educational interventions that have been studied include short e-mails to inform mental health professionals about stigma, documentary films and seminars about myths surrounding mental illnesses (Bayar 2009; Corrigan 2001; Corrigan 2007). Contact involves introducing people with mental illnesses to the public or other people who may stigmatise, either in person or on video, for example. Examples of contact that have been investigated include presentations about living with mental illnesses and the associated stigma by people with a history of schizophrenia or depression, who shared their experiences with school children, medical students or other groups (Brown 2010a; Chung 2005).Protest is a finger-wagging approach that aims to challenge inaccurate and negative representations ofmental illness, in themedia, for example. There are many ways that protest can be delivered, for example through writing, campaigns, phone calls, public denunciations such as press releases, marches, sit-ins and boycotts (Watson 2001). (Buechter et al., 2013)

The logic of a target-specific approach is all the more compelling when compared to the alternative; a generic effort to change the attitudes of the population as a whole. Consider, for example, a video that promotes the idea that mental illness affects 20% of the citizenry and hence is neither rare nor bizarre. Although this effort is well intentioned and poignant, such mass appeals suffer because they are not particularly relevant to specific elements of the populace. It is unclear who exactly is supposed to take note of this message. Moreover, the expected products of these efforts are fuzzy; it is unclear exactly how the population should change given the highlighted stereotypes and prejudice. “Okay, so 20% of the population may be mentally ill in their lifetime. Now, what should I do about it?” (Corrigan, P. W., 2004, p. 117)

Alternatives to PSAs and social marketing may be understood in terms of targeted and local. Tip O’Neill, speaker of the US House of Representatives from 1977 to 1987, used to say “all politics are local.” He meant that successful election to government office is achieved only by pressing the flesh and meeting constituents in one’s district. Mr. O’Neill, now deceased for 15 years, might question the twenty-first century’s fascination with marketing and media to spread the message and get out support. He would say advocacy groups should also consider targeted and local approaches to change. Targeted means the program attempts to change stigmatizing attitudes and behaviors of key groups in the lives of people stigmatized for their mental illness; for example, employers, landlords, health care professionals, teachers, police officers, and legislators. (Tsang et al., xv)

The focus on target and locality leads to benefits not necessarily had by PSAs and social marketing. Targeted and local provide an avenue for advocates themselves to pursue stigma change rather than relying on more macro-, typically government-based, efforts.It would be nice if the whole world would stop their biases but I am not sure this can be done. At the end of the day, what I really want is for employers to hire me and landlords to rent to me, for them to stop stigma and say, ‘‘You can do it!’’Targeted approaches focus the critical lens from the seemingly massive focus of PSAs to the beliefs and behaviors of more immediate groups. (Tsang et al., p. 16)

(Clement, Jarrett, Henderson, & Thornicroft, 2010, p. 75)

Two message types met our criteria for recommendation (consensus ≥ 80% and median ≥ 8): see the person and recovery-oriented messages, and a further two met criteria for warranting consideration: (consensus ≥ 70% and median ≥ 7): social inclusion / human rights and high prevalence of mental disorders messages.Psychiatrists gave higher ratings to biomedical messages (medians 6 vs 2, U = 23.5, p = 0.001) and lower ratings to continuum messages (medians 2.5 vs 7, U = 28.5, p = 0.004) than non-psychiatrists. People with personal experience of mental ill health rated anti-dangerousness (medians 9 vs 3, U = 56, p = 0.036) and psychosocial messages (medians 9 vs 5, U = 60, p = 0.029) more highly than those without this experience. There was no evidence for an association between having someone close experience mental ill health and ratings of the message types.Four themes were identified in the qualitative data:i) benefits of messages countering the ‘otherness’ ofpeople with mental ill healthii) problematic nature of messages referring to aetiologyiii) message impact being dependent on particular audienceiv) need for specific packages of messages. (Clement et al., 2010, p. 75)

Social-psychological research has identified factors that seem to moderate contact effects (10,11), including one-to-one contact so that people who engage with one another can learn of similar interests and potentially cultivate a friendship (12,13), contact that includes a common goal (14), and interactions with a person who moderately disconfirms prevailing stereotypes (15,16). (Morris, 2012, p. 2)

Although contact and education both seem to significantly improve attitudes and behavioral intentions toward people with mental illness, contact seems to yield significantly better change, at least among adults. This is especially evident in studies that used more rigorous research designs, such as RCTs. Mean effect sizes for contact when assessing overall effects as well as effects on attitudes and behavioral intentions were significantly greater than those found for education. Meeting people with serious mental illness seems to do more to challenge stigma than educationally contrasting myths versus facts of mental illness. (Morris, 2012, p. 7)

Empirical evidence on inter-group contact theory suggests that intergroup contact is generally associated with less prejudice; furthermore, while the criteria that were originally proposed by Allport enhance effects, they are not a prerequisite for reducing prejudice (Pettigrew2005). This finding is in line with themere exposure effect or familiarity principle, a psychological phenomenon according to which exposure to a person in itself can make the person more likeable (Bornstein 1989). (Buechter et al., 2013)

Inter-group contact theory provides a theoretical foundation for contact interventions. It is based on Allport’s inter-group contact hypothesis, which states that inter-group contact is an effective way of reducing prejudice between majority and minority groups ifcertain criteria are met (Allport 1954). According to the original formulation of the contact hypothesis, positive effects are likely when (a) groups share an equal status within the contact situation, (b) have a common goal, which (c) is attained through cooperative efforts of the groups and (d) authorities, law or custom support inter-group contact. Several other enhancing factors have been suggested since the initial development of the inter-group contact hypothesis. However, these factors are not necessarily independent of each other and may relate to the same underlying processes (Pettigrew 1998). Four mediating variables have been suggested through which contact may lead to a change in attitudes towards another group: (1) learning about the other group, (2) changing behaviour towards members of the other group, (3) establishing positive experiences and emotions and reducing anxiety and (4) providing new insights about their own group resulting in an increase in tolerance towards other groups (Pettigrew 1998). (Buechter et al., 2013)

Using data from a study conducted in Germany, this model was applied to investigate the effect of labelling of schizophrenia and depression as mental illnesses. In the case of schizophrenia, this kind of labelling elicited the belief that those affected with this illness are dangerous and unpredictable. Consequences were negative emotional reactions, like increasing fear and aggression. These resulted in an increasing desire for social distance. No such associations could be demonstrated for depressive disorders (33). Furthermore, the model was used to study the effect of familiarity with mental illness on the attitudes towards people with schizophrenia and depression. It could be shown that with growing familiarity, the tendency towards considering the ill person to be dangerous and unpredictable was decreasing, and people had less fear and social distance was desired less frequently (37). (Angermeyer & Dietrich, 2006, p. 171)

A growing body of research suggests that personal experience with people who have a mental illness can reduce these stigmatizing attitudes (Corrigan et al., 2001; Holmes et al., 1999; Link & Cullen, 1986; Penn et al., 1994; Roth et al., 2000). (Alexander & Link, 2003, p. 272)

Research has consistently linked contact with people with mental illnesses to less stigmatizing attitudes towards people with mental illnesses (e.g., Corrigan et al., 2001; Holmes et al., 1999; Link & Cullen, 1986; Penn et al., 1994; Roth et al., 2000). It seems likely that through these encounters, members of the public learn that people with mental illnesses are not the dangerous ‘others’ they had expected. (Alexander & Link, 2003, p. 273)

Several randomised controlled trials (RCTs) attest to the effectiveness of live social contact interventions in reducing stigma.9–12 Filmed social contact may have practical and cost advantages and is more easily scaled up for use at the population level. We have identified four RCTs comparing filmed social contact interventions with a control without any form of social contact13–16 and all but one15 reported the intervention improved at least one stigma outcome. (Clement et al., 2012)

Positive contact with members of a stigmatized group can reduce prejudice and discrimination, particularly if this contact is combined with active learning (13–14). Brief contact based educational interventions have shown improvements in students’ knowledge of mental illness, and in their socially rejecting attitudes toward individuals with mental disorders (15–20)—changes that have persisted over 1 and 6 months of follow-up (15,17). However, contact-based education is difficult to implement widely because it requires trained individuals with mental illnesses to deliver the intervention. Given the importance of reducing stigma and discrimination, alternate approaches are needed.This study evaluated the effectiveness of an educational program in 8 high schools across Canada. As an alternative to direct contact, the program used video depictions ofindividuals with serious mental illnesses. A review of the literature revealed only one other video-based antistigma program (21). This program taught adolescents about serious mental illness with portrayals of the beliefs, feelings, and personal experiences ofteenagers who had experienced mental illness in their families. Students who received the intervention had greater knowledge and more positive opinions about mental illness, and these improvements persisted over 12 weeks of follow-up. (Stuart, 2006, p. 648)

In Corrigan et al.’s 2001 study, research volunteers listened to a 10-min presentation by a high-functioning individual with severe mental illness and then engaged in a 5min discussion with the individual about living with mental illness. In comparison with respondents who did not receive this contact, respondents who were in the contact condition later endorsed more positive views of people with mental illnessIn Desforges et al., 1991 study of attitudes towards people with mental illnesses, in which undergraduates performed cooperative learning tasks with a confederate whom had been described as a former mental patient. Undergraduates who collaborated with the confederate endorsed more positive and accepting views of people with mental illnesses following the exercise (Desforges et al., 1991). (Alexander & Link, 2003, p. 273)

To examine whether the contact-stigma relationship is due to pre-existing positive attitudes toward mental illness (i.e., people who already have less stigmatizing attitudes seek out contact), Link & Cullen (1986) compared the impact of contact that was more likely to be voluntary (e.g., work with people with mental illnesses) with contact that was less likely to be voluntary (e.g., hospitalized family member) in a mail survey of two Midwestern samples. They reasoned that the impact of voluntary contact might be explained by pre-existing positive attitudes; however, any positive impact of involuntary contact must be due to the contact itself. They found no difference between the more voluntary and less voluntary contact groups, supporting the notion that contact itself has a causative role in the contact – stigma relationship. (Alexander & Link, 2003, p. 273)

A total of 208 community college students completed three written measures about familiarity, perception of dangerousness, fear, and social distance. Path analysis with manifest variable structural modeling techniques was used to test a version of a model in which familiarity influences the perception of dangerousness, which in turn influences fear, which influences social distance from persons with serious mental illness. Results: Most of the participants reported experience with mental illness. Scores on the three written measures largely supported the path model. Correlations between the perception of dangerousness and fear as well as between fear and social distance were particularly strong. (Corrigan, Green, Lundin, Kubiak, & Penn, 2001, p. 953)

Portrayals of untreated and symptomatic schizophrenia, depression, and heroin addiction heightened negative public attitudes toward persons with mental illness and drug addiction. In contrast, portrayals of successfully treated schizophrenia, prescription painkiller addiction, and heroin addiction led to less desire for social distance, greater belief in the effectiveness of treatment, and less willingness to discriminate against persons with these conditions. Portrayal of persons with successfully treated mental illness and drug addiction is a promising strategy for reducing stigma and discrimination toward persons with these conditions and improving public perceptions of treatment effectiveness. (McGinty et al., 2015, p. 73)

Given the labour-intensive nature of existing anti-stigma interventions (Pinfold et al, 2003) and the power of audiovisual media to influence societal constructions of mental illness (Wahl, 1995), researchers have postulated that documentary films depicting people diagnosed with mental health problems may offer a more efficient approach to reducing stigma and discrimination among student groups (Penn et al, 2003). Indeed, existing research suggests that antistigma films can garner small and temporary improvements in specific areas such as social distance (Chung, 2005; Altindag et al, 2006), though with little change in general attitudes (Penn et al, 2003). This latter finding was attributed to the lack of an unambiguous disconfirmation of the mental illness stereotype within the film deployed (Penn et al, 2003). (Kerby, Calton, Dimambro, Flood, & Glazebrook, 2008, p. 345)

The first film, A Human Experience (Smith, 2005), was made in collaboration with service users at Rethink Nottingham. It is 15min long and adopts a ‘talking head’ documentary style approach. Its content revolves around three mental health professionals (a teacher/researcher, a Mental Health Act Commissioner and a psychiatrist) discussing their experiences after being diagnosed with a serious mental illness (psychosis, schizophrenia and severe depression - all of which resulted in hospitalisation) and, in particular, their experiences of stigma and discrimination. The film challenges particular stereotyped beliefs, including dangerousness, inability to work and inability to maintain relationships, and mentions positive aspects of serious mental illness (such as the importance of the experience of mental distress in the forging of personal identity, a sense of overcoming adversity, the celebration of difference, and a formulation of mental distress as a deepening of lived experience). The second film, A Day in the Mind of. . . (Green, 2005), was made by service users at Framework Housing Association Nottingham (a non-statutory organisation providing practical and emotional support for people experiencing mental distress and living in the community). It is 12min long and adopts a first-person perspective throughout. Its narrative focuses on the subjective experience of psychosis over the course of a typical day. The film attempts to convey to the viewer the first-hand experience of being diagnosed with a serious mental illness, thereby challenging the stereotype of psychosis as a condition opaque to understanding. (Kerby et al., 2008, p. 346)

Film and video have a long tradition in medical and psychiatric education [17–19], especially for the education of medical students [20] and nurses [21]. They may be effective at creating an emotional response and enhance empathy [22,23] alongside provision of information. Their importance has been growing in the context of development in media and technology during the last decades [24]. Video is considered to be an effective low cost, easy to use tool which can provide educational benefits [25]. It is also a tool that may be easily scaled-up and reach a broad audience [26], especially through social media. (Janoušková et al., 2017, p. 1)

Video interventions led to improvements in stigmatising attitudes. Video was found to be more effective than other interventions, such as classical face-to-face educational sessions or simulation of hallucinations. According to results of two studies, social contact delivered via video achieved similar destigmatization effect to that delivered via a live intervention. The findings suggest that video is a promising destigmatization tool among young people. (Janoušková et al., 2017, p. 1)

With respect to comparison between video and direct contact, two studies found the same positive effect-size for both interventions. Reinke et al. [48] found the same effect at posttest measurement using a social distance scale. Clement et al. [25] also conducted a follow-up measurement and the effect measured by four different scales persisted at four months. Both video intervention and direct contact intervention in these two studies had the same structure and content, which was a narrative of a person with mental illness. This might suggest that the content of the intervention, rather than its form, is important. (Janoušková et al., 2017, p. 3)

Clement et al. [25] compared a video intervention to an educational session, which included both a short discussion presented by a mental health nurse, and traditional lecture covering topics of stigma and discrimination. No direct social contact elements were present in this educational session. Two out of four measures (focused on general attitudes and social distance) indicated comparatively superior effect of the video intervention, while the rest of the measures indicated no difference. (Janoušková et al., 2017, p. 4)

Five video interventions, which had a positive effect at post-test [39,48,62,63], shared several common features. All of them depicted somebody with mental illness, mentioned symptoms and the possibility of leading a normal life. (Janoušková et al., 2017, p. 6)

The contact-based video seemed to have broader impact on stigma change than the educational video, and the effect also lasted after one week. The educational video had limited effect, showing improvement only in items related to responsibility and blame. The contact video had positive effect on items related to pity, empowerment, coercion, and segregation [43]. (Janoušková et al., 2017, p. 6)

Reinke et al. [48] found that videos (based on a testimony of a person having mental illness) with moderate and high level of disconfirmation (the first included balanced information about both positive and negative aspects of having mental illness, the second focused only on life triumphs of the person having the illness) were more effective than video with low level of disconfirmation (included only information about symptoms and negative impact of schizoaffective disorder on person’s life). (Janoušková et al., 2017, p. 6)

Most of effective videos included a social contact element with a narrative of a person who experienced a mental illness and this was accompanied by expert information (e.g. provided by a psychiatrist). At the same time, the majority of effective video interventions emphasized potential for recovery and/or possibility to lead a good life despite mental illness. This is in line with the expert recommendations to use recovery-oriented and see-the-person messages [66] for anti-stigma interventions. It is recommended to supplement video with the information combining psychosocial and biological explanation of mental illnesses. A balanced picture of mental illness is useful when it comes to deconstruction of stereotypes. Both high and moderate levels of disconfirmation brought similar and more effective results than video with low-level disconfirmation [48]. (Janoušková et al., 2017, p. 7)

Video interventions represent rather low cost, engaging, and easily scalable tools and we believe this is the first review to focus specifically on the effectiveness of video interventions among young people. (Janoušková et al., 2017, p. 7)

Programs like NAMI’s StigmaBusters have targeted stigmatizing advertisements, news stories, and entertainment through strategic letter-writing campaigns. Anecdotally, these seem to have had some effects—for example, one campaign led the American Broadcasting Company to pull its television drama Wonderland in 2000 after two episodes. The show stoked stereotypic connections between mental illness and violence. (Morris, 2012, p. 8)

The social marketing campaigns that rely on videotaped contact diminish grassroots control of the effort. Social marketing campaigns are often managed by government and advertising consortia rather than by people with mental illness who are targeting key groups at the local level for meaningful stigma change. In-person contact leads to better effects, but both types of contact significantly diminish stigma. Those crafting an antistigma campaign need to balance relative effect sizes with population served and grassroots control issues. (Morris, 2012, p. 8)

For example, a video about schizophrenia was played for 571 students from eight high schools across Canada [9]. In another example, a video based education program was implemented among 255 students from three middle schools in Hong Kong [10]. (Ling et al., 2014, p. 1)

In the absence of real world experience with mental illnesses, people must rely on their community’s messages and the media for cues (Link & Cullen, 1986). The vast majority of Americans report receiving information about mental illness from the mass media (Wahl, 1992). In our society, these images are typically inaccurate and overwhelmingly negative, characterizing people with mental illnesses as violent, dangerous, unpredictable, incompetent, and unlikable (Wahl, 1992; Wilson et al., 1999). Through media exposure, the public learns that people with mental illnesses are dangerous and that they should be avoided. (Alexander & Link, 2003, p. 272)

The students in the live group were significantly more likely to strongly agree that the session was interesting (72% v. 50%, w2 = 7.51, P= 0.006) and useful (67% v. 42%, w2 = 9.12, P= 0.003) compared with those in the DVD group, but did not differ on the three other views items listed below. Those receiving interventions with social contact (DVD or live) had more positive views on all five views items compared with those in the lecture group; being more likely to strongly agree that the training was interesting (w2 = 12.62, P50.001), confidence generating (w2 = 12.24, P50.001) and useful (w2 = 9.86, P= 0.002), to believe their attitude to people with mental health problems had positively changed (w2 = 4.32, P= 0.038) and that their behaviour towards these individuals will be different (w2 = 10.95, P= 0.001).What those in both the DVD and live groups liked best was hearing service user and carer stories, particularly the former (online Table DS3). The DVD group also often valued hearing a diversity of views. Both groups felt the structure/quality of their intervention could be improved and wanted particular aspects of mental healthcare to be covered. (Clement et al., 2012)

Objective: To evaluate the impact on high school students of a video-based antistigma program portraying real life experiences of individuals with schizophrenia and lesson plans to guide classroom discussions and active learning.Method: We used a pre- and posttest design to measure the short-term impact of the program on student’s knowledge of schizophrenia and its treatment as well as students’ self-reported socially distancing behaviours. Participants (571 students) were from 8 high schools across Canada. Results: Following the Reaching Out antistigma program, high school students were significantly more knowledgeable and less socially distancing. Impact also varied by age group and sex. Conclusions: Video-based antistigma programs are comparable to programs that deliver educational messages through direct contact with individuals with mental illnesses. Video-based programs are more easily disseminated on a broad scale. (Stuart, 2006, p. 647)

The main goal of this study was to evaluate the effects that a documentary film about schizophrenia might have on cognitive, affective and behavioural aspects of stigmatisation concerning people diagnosed with schizophrenia.It was hypothesized that the documentary film would diminish negative stereotypes and desired social distance towards people diagnosed with schizophrenia. This was confirmed as, within the Film group, stereotypes of dangerousness and unpredictability significantly decreased after viewing the film. This decrease in these particular stereotypes is important as they are significantly linked to desired social distance. In this study, after viewing the documentary film, the willingness for social distance significantly declined in the Film group but not in the Control group. This confirms our hypothesis and previous studies that also used filmed contact to change attitudes towards schizophrenia (Brown et al., 2010; Corrigan et al., 2007). These findings are promising as they suggest that a documentary film promoting indirect contact with people diagnosed with schizophrenia does not only have an effect on increasing knowledge about that illness, but also on improving certain attitudes towards people diagnosed with schizophrenia. Further, discrimination originating from desired social distance has been associated with lower self-esteem in stigmatised people (Lysaker, Tsai, Yanos, & Roe, 2007), underlining the importance of diminishing or preventing this kind of prejudicial attitude. (Thonon, Pletinx, Grandjean, Billieux, & Larøi, 2016, p. 199)

The present study examined young people’s attitudes about schizophrenia and evaluated the effect of a documentary film (depicting the lives of people diagnosed with schizophrenia) on reducing stigmatization about schizophrenia. One hundred and fifteen undergraduate psychology students first provided information concerning their attitudes and knowledge about schizophrenia, in addition to filling out a questionnaire assessing their degree of acceptance of negative stereotypes and degree of social distance towards schizophrenia patients. One week later, participants viewed the documentary film and completed the same questionnaire. The film significantly and positively influenced participants’ negative attitudes concerning schizophrenia. In particular, after having watched the film, participants revealed less negative and derogatory stereotypical attitudes about schizophrenia and desired less social distance with schizophrenia patients. This change was not related to social desirability, age, sex or years of education. (Larøi & van der Linden, 2009)