What is the impact of mental health-related stigma on help-seeking? A
systematic review of quantitative and qualitative studies
Clement S#*1, Schauman O*1, Graham T1, Maggioni F1, Evans-Lacko S1, Bezborodovs
N1, Morgan C1, Rüsch N2, Brown J.S.L.3 & Thornicroft G1
# Author for correspondence1
* These authors have contributed equally to the work
1. Health Service and Population Research Department, King’s College London, Institute of
Psychiatry
2. Department of Psychiatry II, University of Ulm, Germany
3. Psychology Department, King’s College London, Institute of Psychiatry
Target journal: Psychological Medicine
Financial support for the work: This publication presents independent research funded by
the National Institute for Health Research (NIHR) under its Programme Grants for Applied
Research scheme (Improving Mental Health Outcomes by Reducing Stigma and
Discrimination: RP-PG-0606-1053). The views expressed in this publication are those of the
author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. SC,
OS, TG, CM and GT are funded from this source. SEL is funded by a grant from Comic
Relief, the UK Government Department of Health and the European Commission. NB is
funded by an Erasmus grant from the European Commission. GT and JB are supported by the
Biomedical Research Centre for Mental Health at the South London and Maudsley NHS
Foundation Trust and Institute of Psychiatry, King's College London.
Abstract
1
Corresponding author
Dr Sarah Clement , Section of Community Mental Health,
PO29, Health Service and Population Research Department, King's College London, Institute
of Psychiatry, De Crespigny Park, London SE5 8AF, UK. Email [email protected].
Tel. +44(0)20 7848 0739. Fax +44 (0)20 7848 1462.
1
Background
Individuals often avoid or delay seeking professional help for mental health problems. Stigma
may be a key deterrent to help-seeking but this has not been reviewed systematically. Our
systematic review addressed the overarching question: What is the impact of mental healthrelated stigma on help-seeking for mental health problems? Sub-questions were (a) what is
the size and direction of any association between stigma and help-seeking? (b) to what extent
is stigma identified as a barrier to help-seeking? (c) what processes underlie the relationship
between stigma and help-seeking? and (d) are there population groups for which stigma
disproportionately deters help-seeking?
Method
Five electronic databases were searched from 1980 - 2011 and references of reviews checked.
A meta-synthesis of quantitative and qualitative studies, comprising three parallel narrative
syntheses and subgroup analyses, was conducted.
Results
The review identified 144 studies with 90,189 participants meeting inclusion criteria. The
median association between stigma and help-seeking was d = -0.27, with internalised and
treatment stigma being most often associated with reduced help-seeking. Stigma was the
fourth highest ranked barrier to help-seeking, with disclosure concerns the most commonly
reported stigma barrier. A detailed conceptual model was derived which describes the
processes contributing to, and counteracting, the deterrent effect of stigma on help-seeking.
Ethnic minorities, youth, men, and those in military and health professions were
disproportionately deterred by stigma.
Conclusions
Stigma has a small to moderate sized negative effect on help-seeking. Review findings can be
used to help inform the design of interventions to increase help-seeking.
Key words
Stigma, discrimination, access, help-seeking, barriers to care, service use
2
Introduction
In Europe and the USA 52% - 74% of people with mental disorders do not receive treatment
(Alonso et al., 2004; Kessler et al., 2005; Wittchen and Jacobi, 2005; Thornicroft, 2007). In
low- and middle-income settings, where provision is lower, even more go untreated. (Wang
et al., 2007). Although mental health problems may be self-limiting or respond to self- or layhelp (Oliver et al., 2005a), when individuals delay or avoid formal care this can have
problematic consequences. For psychosis, delays may contribute to adverse pathways to care
(Morgan et al., 2004), and the duration of untreated illness is associated with worse outcomes
in psychosis, bipolar disorder, and major depressive and anxiety disorders (Boonstra et al.,
2012; Dell'Osso et al., 2013). After initiation of mental health care, non-adherence to
treatment programmes and early withdrawal from services are common and may result in
adverse outcomes (Nose et al., 2003; Barrett et al., 2008).
The stigma associated with mental illness may be an important factor reducing help-seeking.
Stigma may be defined as a process involving labelling, separation, stereotype awareness,
stereotype endorsement, prejudice, and discrimination in a context in which social, economic,
or political power is exercised to the detriment of members of a social group (Link and
Phelan 2001). A number of different types of stigma have been identified and are used in this
review. These are: anticipated stigma (anticipation of personally being perceived or treated
unfairly); experienced stigma (the personal experience of being perceived or treated unfairly);
internalised stigma (holding stigmatising views about oneself); perceived stigma (participants
views about the extent to which people in general have stigmatising attitudes/behaviour
towards people with mental illness); stigma endorsement (participants’ own stigmatising
attitudes/behaviour towards other people with mental illness); and treatment stigma (the
stigma associated with seeking or receiving treatment for mental ill health).
To date, six non-systematic reviews on mental health-related stigma and help-seeking have
been published (Kushner and Sher, 1991; Corrigan and Rüsch, 2002; Corrigan, 2004; Gary,
2005; Schomerus and Angermeyer, 2008; Thornicroft, 2008). Each reported that there was
some evidence that stigma impedes help-seeking, a number of potential mechanisms were
proposed, and these reviews concluded that the field is currently poorly understood. To our
knowledge, no systematic review has been conducted.
3
The present review is concerned with help-seeking from formal services, specifically health
care (primary care or secondary / tertiary mental health services) or talking therapy services.
The term ‘help-seeking’ is used to denote all stages of the process, encompassing both
initiation of, and engagement with, care (Kovandžić et al., 2011). Through identifying and
synthesising relevant quantitative and qualitative studies, this systematic review sought to
address the overall research question: what is the impact of mental health-related stigma on
help-seeking for mental health problems? We aimed to investigate the following subquestions: (a) what is the size and direction of any association between stigma and helpseeking? (b) to what extent is stigma identified as a barrier to help-seeking? (c) what
processes underlie the relationship between stigma and help-seeking? and (d) are there
population groups for which stigma disproportionately deters help-seeking?
Method
The review methodology is a modification of the Evidence for Policy and Practice
Information (EPPI) Centre’s method (Oliver et al., 2005b) which was designed for broad
research questions for which there is both quantitative and qualitative evidence. It involves an
initial scoping and mapping to prioritise and specify sub-questions and relevant study types.
This revealed three main sets of literature: 1) quantitative ‘association studies’, which present
statistical data on the possible relationship between scores on a scale measuring stigma and a
measure relating to any aspect of help-seeking; 2) quantitative ‘barriers studies’, which
present data on the proportion of participants who report experiencing one or more stigmarelated barriers to help-seeking; and 3) ‘qualitative process studies’ which present analyses of
text-based data from interviews, focus groups or ethnographic observational studies about
stigma and help-seeking and say something about the processes which may underlie the
relationship between stigma and help-seeking. Following the next stage of the EPPI Centre
method, parallel systematic reviews were conducted, one for each sub-question (a) to (c),
with sub-question (d) addressed via subgroup analyses. In the final stage of the EPPI Centre
method, findings from the parallel syntheses are juxtaposed in a meta-synthesis to produce an
overall picture of the evidence (Pope et al., 2007). A protocol for this review was registered
with the PROSPERO systematic review protocol registry
(http://www.crd.york.ac.uk/prospero/; ID: CRD42011001647). Additional methodological
details are given in Supplement 1.
4
Search strategy and selection of studies
Five electronic databases (Medline, EMBASE, Sociological Abstracts, PsycInfo and
CINAHL) were searched from January1980 to December 2011, with no language restrictions.
The following subject heading and keywords were used: (stigma-related terms AND helpseeking-related terms AND mental health-related terms) OR (stigma-related terms AND
mental health service-related terms) (full database search strategies in Supplement 2). In
addition, reference lists of included studies and reviews were checked for further possible
studies.
Inclusion criteria were data-based studies on the relationship between mental health-related
stigma and help-seeking for mental ill health which addressed one or more of sub-questions
(a) – (c) (i.e. quantitative association or barriers studies or qualitative process studies) (see
Table 1). Titles and abstracts were screened and full reports of potentially relevant studies
were obtained. Two authors independently assessed the reports for eligibility with
discrepancies resolved by discussion.
-
Table 1 around here -
Data extraction, analysis and synthesis
Data on study design, sample characteristics, findings and methodological quality was
independently extracted by two authors. Narrative synthesis was undertaken due to
substantial methodological and clinical heterogeneity between studies (Popay et al., 2006).
For association studies, the statistic for the association between stigma and help-seeking was
extracted and converted to a standardised effect size (Cohen’s d), where possible. The median
effect size across studies was calculated and presented alongside the number of associations
in each direction together with statistically significant effects obtained (Grimshaw et al.,
2003).
Stigma-related barriers were grouped into shame/embarrassment, negative social judgement,
disclosure concerns/confidentiality, employment-related discrimination and general
stigma/other stigma barriers. For studies with five or more barriers of any type, the rank of
the most highly reported stigma barrier and the total number of barriers examined were used
to calculate a “standardised rank” by dividing the rank of the stigma barrier by a total number
of barriers in that study and multiplying that number by ten. This indicates the importance of
5
stigma in relation to other possible barriers, with all studies thereby standardised to having a
notional ten barriers of any type. To synthesise the barriers studies, the median and range of
the percentage of participants reporting the different types of stigma barriers, as well as the
median and range of the standardised rank were presented. The median is used as this gives a
better indication of the average, given that effect sizes and rankings are unlikely to be
normally distributed.
A thematic analysis was undertaken to synthesise the qualitative process studies (Thomas and
Harden, 2008). An initial coding frame was developed following preliminary inductive open
coding of a subset of the qualitative studies (n = 39) using QDA-MAX software by TG and
by discussion and data examination (SC, TG, CM). The relevant data were all of the
participant quotations and study author interpretations / summarising statements relating to
the processes by which stigma may relate to help-seeking reported in the results section of the
papers. Using data from the full set of qualitative process studies (n = 51), SC copied these
data verbatim into a spreadsheet containing the preliminary coding frame, grouping and regrouping the data into a revised set of inter-related themes and subthemes to form a final
coding framework and draft synthesising conceptual model. The relationships between the
themes were based on finding at least one quotation or author interpretation in the data
supporting the relationship and its direction. A second author (OS/NB) then independently
repeated the data extraction process using the final coding frame. TG and CM examined the
draft model, exemplar quotations and theme / sub-theme names to corroborate and finalise
model.
For the association and barriers studies, methodological quality was rated using a crosssectional survey checklist (Crombie, 1996) with minor adaptations for the different contexts
(eight criteria for association studies and six for barriers studies). The methodological quality
of the process studies was assessed using the seven-item Critical Appraisal Skills programme
(CASP) tool for qualitative research (Public Health Resource, 2006). Two authors
independently assessed the studies against these criteria and resolved discrepancies through
discussion.
The size of the association, the reported barriers and qualitative processes were examined in
subgroups relating to: age, ethnicity, gender, rural setting, occupational group, mental health
of participants, and whether participants were currently receiving care. For association
6
studies we also undertook subgroup analyses on type of stigma and methodology. In a
sensitivity analysis to investigate the effect of methodological quality on the results, one third
of the studies within each of the three parallel syntheses, which had the lowest quality rating,
were excluded from the analyses.
Lastly we conducted a two-stage meta-synthesis. In the first stage we extended the
conceptual model derived from the qualitative process studies to produce an overarching
conceptual framework. We did this by (i) checking back in the barriers papers to see which
subthemes identified in the qualitative process studies were also reported as barriers to helpseeking in this set of papers; (ii) ascertaining whether any barriers in the quantitative studies
were not identified in the subthemes from the qualitative process data; (iii) three authors
meeting to consider if any concepts were missing from the model and adding these to the
model (clearly marked as not derived from the data). In the second stage we presented the
findings from the three parallel syntheses in juxtaposition to produce a tabular view of the
evidence on the impact of mental health-related stigma on help-seeking.
Results
Database searching yielded 5810 non-duplicate items, 354 papers were identified as
potentially relevant and full papers were assessed against eligibility criteria, which resulted in
the exclusion of 211 papers. A quarter of these (n = 54) were data-based studies on helpseeking and stigma in mental health but did not address at least one of the specific research
questions (e.g. intervention studies with both stigma and help-seeking as outcomes,
qualitative studies reporting that stigma deterred help-seeking but not elucidating any
processes). These studies are listed in Supplement 3. Overall 144 studies, including data
from 90189 participants, were included in the review, including 56 on the association
between stigma and help-seeking, 44 on stigma-related barriers and 51 qualitative studies on
processes underlying the stigma – help-seeking relationship (see PRISMA diagram, Figure
1). The majority of the studies (69%, 99/143) were conducted in the United States or Canada;
20 were undertaken in Europe; 10 in Australia and New Zealand; 8 in Asia; and 1 in South
America. In addition, five of the studies were conducted across more than one continent.
Thirty studies (21%) were on students in higher education, and 14 (10%) on school students.
In 56 studies (39%) all participants had experience of mental health problems/being in
treatment. Of the 62 studies which focused on a specific condition, 28 investigated
7
depression; 8 severe mental illness / psychosis; 7 perinatal depression; 7 self-harm; 4 anxiety
disorders; 4 eating disorders; and 4 other conditions. Full details of study and sample
characteristics are in Supplement 4.
-
Figure 1 around here -
Association studies
56 studies reported an association between stigma and help-seeking and included data from
27572 participants with 26313 contributing effect size data. Five studies reported longitudinal
data and 26 (46%) of the studies were conducted on university students.
The median effect size in the association studies was -0.27 and ranged from -2.73 to 0.36 for
individual studies, the negative association indicating stigma reduces help-seeking. The
median size of this association could be interpreted as small (Cohen, 1992). The majority of
the association studies reported a negative association with the majority being statistically
significant (see Table 2).
- Insert Table 2 around here -
Subgroup analyses for association studies
When we investigated associations by type of stigma, the two types of stigma that exhibited a
small and consistent negative association with help-seeking were internalised stigma and
treatment stigma (see Table 2). Although a few studies showed significant negative
associations with stigma endorsement and with perceived stigma, the median effect sizes
were negligible at -0.05 and -0.02 respectively.
When study methodology was taken into account, cross-sectional studies with
attitudinal/intentional help-seeking measures reported moderate median effect size of -0.52 (0.273 to 0.34) with the majority (25/33) reporting a statistically significant negative
association between stigma and help-seeking. Cross-sectional studies using behavioural
indicators of help-seeking exhibited more mixed results with nine studies reporting a negative
association (three statistically significant) and the same number a positive association (two
statistically significant). Four out of the five prospective studies reported a negative
association (two were statistically significant). Both behavioural indicators and prospective
8
studies groups reported a median association that was very close to zero (<-0.01 and -0.07
respectively, see Table 2).
Finally, the population subgroup analyses indicated that there was a median large negative
association in samples of Asian Americans (-1.20) and in Arabic students (-0.21). There was
a small negative median association in the samples of African Americans (-0.25) and mixed
samples (-0.23) (see Table 2). For all other subgroup comparisons (age group, gender,
psychosis/non-psychosis, currently receiving mental health care or not, occupational group,
rural/non-rural), the number of studies within each subgroup was small (<5) rendering
findings inconclusive, or no differences were found.
Quality assessment and sensitivity analyses for association studies
The quality criteria ratings indicate that the quality of the association studies was moderate as
six of the eight criteria were met by the majority (55-100%) of studies. The main problems
identified by the quality rating tools were: no sample size justification; lack of evidence for
the reliability and validity of help-seeking measures; and selection bias. The sensitivity
analyses indicated that, when the studies in the bottom third for quality (3+ criteria unmet)
were excluded from the analyses, the median effect size for the overall association between
stigma and help-seeking was reduced from -0.27 to -0.18.
Barriers Studies
Forty-four studies reported data on stigma barriers and included 60036 participants. In
contrast to the association studies, only two of the barriers studies were conducted in a
university student population, undertaken with the majority of the studies undertaken in
general population (36%, 16/44) or clinical (32%, 14/44) samples.
Overall, the analyses indicated that stigma ranks as the fourth highest barrier to help-seeking
when the total number of barriers investigated is standardised to ten. Given that there is no
rule of thumb for interpreting this ranking, we suggest this may be interpreted as indicating
that stigma has a moderate negative effect on help-seeking compared to other types of barrier.
The barriers data also show that stigma is typically reported as a barrier to care seeking by
21% to 23% of participants across the studies for shame/embarrassment, negative social
judgement and employment-related discrimination. Disclosure concerns/confidentiality had
the highest median endorsement with 32% reporting this as a barrier. However, there was
9
wide variation (4 – 73%) in reported stigma-related barriers to help-seeking across studies
(see Table 3).
- Insert Table 3 around here -
Subgroup analyses for barriers studies
Subgroup analyses for the barriers studies indicated that stigma is generally ranked much
higher among individuals in the military compared to other population groups, especially
when considering employment-related discrimination. For health professionals,
disclosure/confidentiality concerns as well as negative social judgement were more
frequently reported than in the other groups although the standardised rank was not different
(see Table 3).
When comparing gender groups, stigma was ranked lower among studies that only included
women. The types of stigma-related barriers reported most frequently in mixed gender
samples were shame/embarrassment and negative social judgement.
The third subgroup analysis categorised study samples as psychosis/serious mental illness
(SMI), non-psychosis, and samples of the general population (which will include people with
and without mental illness of either type). Findings indicated that the two former categories
reported more shame and embarrassment barriers than studies with general population
samples. The relative rank of stigma as a barrier was however greatest in the general
population samples group (see Table 3). Results for subgroups with three or fewer studies in
all subgroups (age group, ethnicity, rural/non-rural, currently receiving mental health care or
not) were inconclusive.
Quality assessment and sensitivity analyses for barriers studies
Overall the quality of the barriers studies was considered moderate as for four of the six
quality criteria the majority of studies (73-100%) met the criterion. The main problems
identified were no sample size justification and lack of evidence for the reliability and
validity of barriers measures. A sensitivity analysis revealed that the results were not affected
by the exclusion of studies in the bottom third for quality (3+ criteria unmet) as the median
standardised rank remained at 4.3.
10
Qualitative process studies
Fifty-one qualitative studies with a total of 5540 participants were included. Participants were
mainly from clinical (51%, 26/51) and population (37%, 19/51) samples. Five themes and 43
subthemes were identified describing processes which underlie the relationship between
stigma and help-seeking. The five themes were: Dissonance between preferred self / social
identity and mental illness stereotypes / beliefs; Anticipation / experience of stigma /
discrimination; Need / preference for non-disclosure; Stigma-related strategies used by
individual; and Stigma-related aspects of care. The themes, subthemes, their frequencies and
relationship to help-seeking are represented by the solid-lined boxes and linking arrows in a
conceptual model (see Figure 2). Dissonance between a person’s preferred self or social
identity and common stereotypes about mental illness (e.g. that it denotes weakness or being
crazy) resulted in individuals anticipating or experiencing negative consequences (e.g.
labelling and unwanted disclosure; public stigma such as social judgement and rejection,
employment discrimination, shame/embarrassment and family stigma). To avoid these
consequences, individuals did not tell others about their mental health problems and masked
the symptoms, and this, together with the anticipated or experienced negative consequences,
deterred them from help-seeking. We also identified stigma-related enabling factors that
facilitated help-seeking. These were strategies used by individuals (such as selective
disclosure and non-disclosure and normalising mental health problems) as well as service
factors such as less stigmatising forms of care and confidential services. What constituted
non-stigmatising forms of care included non-clinical approaches, talk-based care, help in
community centres and generic medical settings, care that is welcoming and preserves dignity
and practitioners who use terms that reflect clients’ understandings of their problems.
Exemplar quotations from participants in the primary studies are presented in Supplement 5
to illustrate the subthemes.
- Insert Figure 2 around here -
Subgroup analyses for qualitative process studies
The subgroup data can be seen in Supplement 6. Studies with African American samples
were more likely to include the subthemes ‘weak’, ‘keeping it within the family’, and ‘nondisclosure’, and those with samples from any ethnic minority were more likely to include the
subthemes ‘stigma for family’. Studies with samples of young people (aged less than 18)
were more likely to include the subtheme ‘not normal’. The subtheme ‘difficulty talking to
11
professionals’ was more common in the studies with male samples and the subthemes
‘selective/controlled disclosure’ and ‘non-disclosure’ were more common in mixed gender
groups. Studies with community samples were more likely to include the subthemes ‘weak’,
‘social rejection’, ‘difficulty talking to professionals’ and ‘confidential/anonymous services’.
Studies with samples who were currently receiving mental health care were more likely to
include the subthemes ‘crazy’ and ‘non-disclosure’, but less likely to include the subtheme
‘difficulty talking to professionals’.
Quality assessment and sensitivity analysis for qualitative process studies
The overall quality of the qualitative process studies was considered good as the majority
(75-96%) of the studies met six of the seven quality criteria. The main methodological
limitation was failure to provide a reflexive account of the researchers’ influence. The
sensitivity analysis revealed that when the bottom third of studies were removed all
subthemes were retained.
Meta-synthesis
We found that 16 of the 43 subthemes identified in the qualitative process studies data were
also apparent in the quantitative barriers studies. One stigma-related barrier in the
quantitative studies was found which had not appeared in the qualitative data, namely fear of
psychiatric patients. The authors considered that five types of structural stigma also interfered
with help-seeking, two via increasing or maintaining stereotypes and three via a direct effect
on help-seeking (see Figure 2). A meta-synthesis table juxtaposing the findings for the
research questions about association, barriers and processes, and placing these in a matrix
with the subgroup and methodological quality findings can be found in Table 4.
-
Insert Table 4 around here -
Discussion
This is the first systematic review to examine the relationship between stigma and mental
health help-seeking. It provides a comprehensive overview of the large body of existing
literature, combining evidence from both quantitative and qualitative studies to clearly map
out what is known about this complex relationship. Our syntheses of quantitative studies
provide evidence that mental health-related stigma has a small to moderate detrimental
12
impact on help-seeking for mental ill health. The conceptual model, initially derived from our
synthesis of qualitative process studies, details the multiple factors that contribute to this
detrimental effect, as well as some that help to ameliorate it. This model was partially
validated by our finding that over a third (37%, 16/43) of the subthemes had also been
endorsed as barriers in the quantitative studies, and the latter studies only yielded one barrier
not identified in the qualitative data (‘fear of psychiatric patients’). The subthemes not
replicated in the quantitative data may be an indicator of the value of qualitative data for
providing a nuanced, detailed picture of multifaceted processes. The conceptual model was
further extended by the addition of our findings on population group moderators and our
propositions about the potential impact of structural stigma on help-seeking. This model will
be an important foundation for future research and the development of interventions to
increase help-seeking.
Quantitative studies
The findings from the association studies indicate that the majority of studies report a
negative association, and that the size of the association can be interpreted as small.
However, a large proportion of these studies identified in this review were cross-sectional.
Most help-seeking outcomes were attitudinal or intentional, although there is evidence that
help-seeking attitudes are associated with actual service use (ten Have et al., 2010). Crosssectional association studies which use behavioural measures of help-seeking behaviour
exhibit much more mixed results, which could be partly accounted for by ‘reverse causation’
(the probability of the presumed outcome being causally related to the presumed exposure) ,
that is seeking of help / receipt of mental health care increasing stigma.
When comparing effect sizes for different types of stigma, the key types are treatment stigma
(the stigma associated with seeking or receiving treatment for mental ill health) and
internalised stigma as only they show a small consistent negative association with helpseeking. Internalised stigma (shame / embarrassment) also features in the findings from the
barriers and qualitative process studies as a help-seeking deterrent. Vogel and colleagues
have found that internalised stigma is a mediator in a pathway from public stigma to health
care avoidance (Vogel et al., 2007). It is possible that treatment stigma may also be on this
pathway, and this may explain the strength of their association with reduced help-seeking.
Endorsed stigma and perceived stigma are only weakly negatively associated with helpseeking. While there is some support for the importance of anticipated stigma, only two of
13
the 56 association studies examined the effects of this type of stigma, indicating this is
understudied.
The studies that investigated stigma barriers indicate that stigma is a moderately important
barrier, ranking fourth out of ten barriers and was generally reported as a barrier by
approximately a quarter to one third of the participants. Disclosure and confidentiality
concerns appear to be the most prominent type of stigma barrier. This finding was echoed in
the qualitative process studies synthesis where there was one theme and four subthemes
relating to disclosure concerns. A major national population study concluded that by far the
largest treatment barriers was wanting to handle the problem on one’s own, followed by low
perceived need for care (Mojtabai et al., 2011). Although not considered to be stigma-related
barriers these factors may be influenced by stigma (Clement et al., 2012a). A systematic
review of barriers and facilitators to mental health help-seeking in young people, showed the
key barriers to be stigma, confidentiality issues, lack of accessibility, self-reliance, low
knowledge about mental health services and fear / stress about the act of help-seeking or the
source of help itself (Gulliver et al., 2010). Consequently it is important to see stigma as part
of a larger network of beliefs and other constraints deterring help-seeking (Schomerus and
Angermeyer, 2008).
Qualitative studies
The synthesis of the qualitative studies produced a detailed conceptual model of the processes
underlying the relationship between stigma and help-seeking, with five major themes: 1)
Dissonance between a person’s preferred self or social identity and common stereotypes
about mental health; 2) Anticipation/experience of negative consequences; 3)
Need/preference for non-disclosure; 4) Stigma-related strategies used by individuals to enable
help-seeking; and 5) Stigma-related aspects of care that facilitate help-seeking.
These themes, and the subthemes within them, extend existing models about how stigma
reduces help-seeking. For example, Corrigan (Corrigan, 2004) hypothesised that stigma may
deter help-seeking via two routes: by people wishing to avoid the label that receiving formal
care often brings, in order to escape public stigma, and via the wish to avoid experiencing
internalised stigma such as shame and embarrassment. Others (Schomerus and Angermeyer,
2008) have proposed that help-seeking may be impeded via the stigma attached to helpseeking (treatment stigma), anticipated discrimination, and internalised stigma. The model
14
produced in the present review includes these elements, but also includes disclosure issues
which were found to play a key role, as well as stigma-related facilitators, such as ignoring
what other’s think or forms of care being named in less stigmatising ways. It therefore
provides a considerably more comprehensive and detailed account of processes as well as
being systematically grounded in the extant literature.
Population group moderators
The subgroup analyses identified certain population groups for whom stigma had a
disproportionate effect on help-seeking: those from Asian, Arabic, African American, and
other minority ethnic groups; young people; males; and those in military and health
occupations (barriers studies). Studies of individuals with experience of mental ill health
were more likely to report shame or embarrassment and less likely to include the themes
‘weak’, ‘social rejection’, ‘difficulty talking to professionals’ and ‘confidential/anonymous
services’. The former may reflect that fact that shame is inherent in many disorders (Rüsch et
al., 2007), and the latter may indicate that need is overcoming concerns; care changing
perceptions; or those who feel less stigma are more able to access services. These findings
are in line with individual studies which have investigated whether sociodemographic
characteristics interact with stigma to reduce help-seeking. However such studies are small in
number and have used disparate methods. Consequently our review has made a significant
addition to the literature of population group moderators in the relationship between stigma
and help-seeking.
Gary (Gary, 2005) has proposed that people from ethnic minority groups experience double
stigma whereby racism outside and within mental health services is added to the public and
internalised stigma of mental illness to deter help-seeking. For males, gender stereotypes (e.g.
being strong and stoical) may be interacting with mental illness stereotypes (mental illness
indicates weakness) to exacerbate the effect of stigma on help-seeking (Judd et al., 2008). As
identity and peer group issues are both highly salient in adolescence (Kroger, 2004) young
people may feel the dissonance between their preferred self- and social-identity and mental
illness stereotypes more acutely than others and this may increase the effects of stigma of
help-seeking for this group. The ethos of invincibility in medicine (Henderson et al., 2012)
and of machismo (Held and Owens, 2012) in the military may contribute to explaining why
these groups are particularly likely to be deterred from help-seeking by stigma.
15
Limitations
The individual studies were limited by a number of methodological issues, with the
association and barriers studies judged as having moderate methodological quality. For the
association synthesis, excluding lower quality studies lessened the effect size of the overall
findings. The vast majority of the studies were undertaken in high income countries and so
the findings are limited in their generalisability to other settings.
The review has a number of strengths such as its breadth of research questions and inclusion
of both quantitative and qualitative studies, its comprehensive multi-database search strategy
and dual-author data extraction. However, some relevant studies may have been missed due
to the exclusion of grey literature, or due to publication bias. As we adopted the EPPI
method of pre-specifying the main study types, some pertinent areas were not included. We
did not include quantitative studies on processes, for example through path analysis (Vogel et
al., 2007), nor anti-stigma intervention studies with help-seeking outcomes (except where
such studies provided data of relevance to the association research question). A systematic
review of randomised controlled trials (RCTs) of interventions aiming to increase helpseeking reported that of two out of three anti-stigma interventions improved help-seeking
attitudes (Gulliver et al., 2012). However two anti-stigma intervention RCTs not included
Gulliver and colleagues’ review reported no change in help-seeking intentions (Clement et
al., 2012b; Han et al., 2006). Furthermore, we did not include mental health literacy
interventions (Kitchener and Jorm, 2006) which may directly, or indirectly via stigmareduction, increase help-seeking attitudes (Gulliver et al., 2012; Jorm et al., 2000). Also we
did not gather data on studies on the impact of structural stigma (e.g. underfunding of mental
health services, insufficient health insurance coverage for mental ill health, media
stereotypes) on access to mental healthcare (Schomerus and Angermeyer, 2008; Vogel et al.,
2008), although we have delineated the potential role of structural stigma in our conceptual
model. While the use of subgroup analysis was informative, and for qualitative studies
innovative, this was limited by the small number of studies in some subgroups per study type
(e.g. populations in rural settings or in later life).
Future research
Our review highlights a number of key evidence gaps. There are particular needs for further
research (i) set in low- and middle-income countries; (ii) on help-seeking for underrepresented conditions such as bipolar, personality and anxiety disorders (substance misuse
16
disorders were excluded from this review but may also be under-represented in the literature);
(iii) studies on stigma and help-seeking by school age youth; and (iv) studies with prospective
study designs; (v) studies on stigma-related factors that facilitate help-seeking. Furthermore,
as most research has focused on initial access to care we need to know more about how
stigma contributes to disengagement and discontinuation by those already in contact with
services. The impact of anti-stigma interventions on help-seeking is warrants further research.
Disclosure issues were found to be a particular concern, and whilst other reviews have
mapped out the benefits and harms of disclosure in employment contexts (Brohan et al.,
2012), we need to understand more about disclosure in relation to help-seeking. It would also
be useful to investigate how different types of stigma may relate to other help-seeking
barriers, such as wanting to deal with problems oneself, and low perceived need. Further
research is also needed to establish what constitutes a minimally-stigmatising service and on
the effectiveness of the strategies individuals use to overcome treatment stigma and access
services. Future studies are needed to add to the literature about groups particularly likely to
be deterred from help-seeking by stigma, especially for under-researched groups such as
older people and those in rural settings.
Implications for practice
Stigma has a clear, but small to moderate, deterrent effect on help-seeking for mental health
problems, and this review can help towards the development of interventions to increase
access to care. The data we reviewed demonstrates that multiple different types and aspects
of stigma contribute to this effect, consequently multi-faceted approaches are likely to be
most productive.
Examination of the major associations, barriers and themes indicates that anti-stigma
programmes, services and practitioners should focus on both countering stereotypes
(particularly weakness and ‘craziness’); social judgement and rejection of people with mental
health problems; employment discrimination; and shame/embarrassment. Disclosure issues
were found to be a particular concern, and interventions to aid decision-making around
disclosure may be warranted (Henderson et al., 2013). Our syntheses also have implications
for interventions directed at individuals already in receipt of care. Services and practitioners
could, for example, support service users to develop additional strategies to cope with, and
counter, treatment stigma and to address internalised stigma. One approach to countering
treatment stigma would be to discuss with service users the facilitative strategies individuals
17
were found to have used is the studies in this review , such as non-disclosure, selective and
open disclosure, rejecting stigma, ignoring what others think, and normalising mental health
problems. Mittal and colleagues (2012) have identified a number of interventions with
preliminary evidence of effectiveness in reducing internalised stigma, including
psychoeducation (with or without CBT), acceptance and behaviour therapy, and multimodal
interventions. There is a need to configure services to minimise their stigmatising effect. Our
syntheses indicate that this is likely to be one which avoids unnecessary labelling (Brown et
al., 2006; Marshall et al., 2004); respects confidentiality; and is community-based (Brown et
al., 2004; Johnson et al., 2004; Mishra et al., 2009). In light of our finding that certain groups
are particularly vulnerable to stigma compromising help-seeking, interventions that provide
destigmatising care for such groups are warranted, such as universal post-deployment
programmes incorporating psychoeducation for military personnel (Adler et al., 2009) and
mental health programmes based in ‘Black churches’ (Blank et al., 2002). Lastly, given that
stigma is not the only or main factor compromising help-seeking, future interventions should
embed stigma-reducing strategies within broader approaches so that both stigma-related and
other key treatment barriers are addressed, for example combining anti-stigma programmes
with those addressing mental health literacy (Wright et al, 2006).
Acknowledgements
This study presents independent research funded by the National Institute for Health
Research (NIHR) under its Programme Grants for Applied Research scheme (Improving
Mental Health Outcomes by Reducing Stigma and Discrimination: RP-PG-0606-1053). The
views expressed in this publication are those of the author(s) and not necessarily those of the
NHS, the NIHR or the Department of Health. SC, OS, TG, CM and GT are funded from this
source. SEL is funded by a grant from Comic Relief, the UK Government Department of
Health and the European Commission. NB is funded by an Erasmus grant from the European
Commission. GT and JB are supported by the Biomedical Research Centre for Mental Health
at the South London and Maudsley NHS Foundation Trust and Institute of Psychiatry, King's
College London.
Declaration of Interest
None
18
19
Legend for Figure 1
Figure 1 PRISMA flow diagram
20
Legend for Figure 2
Figure 2 Synthesising conceptual model representing the processes underlying the
relationship between stigma and help-seeking for mental health problems
Footnote for Figure 2
1. Boxes with solid lines represent themes identified in the synthesis of the qualitative
process data. Figures in parentheses denote the number of qualitative process studies (of n
= 51 studies) containing each subtheme.
2. Underlined subthemes are those which also appeared in the quantitative barriers studies
3. Boxes with dashed lines denote groups found to be disproportionately deterred by stigma
4. Boxes with dotted lines represent the processes by which structural stigma (not assessed
in this review) may theoretically affect help-seeking
21
References
Main text
Adler AB, Bliese PD, McGurk D, Hoge CW, Castro CA (2009). Battlemind debriefing and
battlemind training as early interventions with soldiers returning from Iraq: Randomization
by platoon. Journal of Consulting & Clinical Psychology 77, 928-40.
Alonso J, Angermeyer MC, Bernert S, Bruffaerts R, Brugha TS, Bryson H, (2004). Use
of mental health services in Europe: results from the European Study of the Epidemiology of
Mental Disorders (ESEMeD) project. Acta Psychiatrica Scandinavica 420, 47-54.
Barrett MS, Chua W, Crits-Christoph P, Gibbons MB, Casiano D, Thompson D (2008).
Early withdrawal from mental health treatment: implications for psychotherapy practice.
Psychotherapy: Theory, Research, Practice, Training 46, 247-267.
Blank MB, Mahmood M, Fox JC, Guterbock T (2002). Alternative mental health services:
The role of the black church in the South. American Journal of Public Health 92, 1668-1672.
Boonstra N, Klaassen R, Sytema S, Marshall M, De Haan L, Wunderink L, Wiersma D
(2012). Duration of untreated psychosis and negative symptoms: a systematic review and
meta-analysis of individual patient data. Schizophrenia Research 142, 12-19.
Brohan E, Henderson C, Wheat K, Malcolm E, Clement S, Barley EA, Slade M,
Thornicroft G (2012). Systematic review of beliefs, behaviours and influencing factors
associated with disclosure of a mental health problem in the workplace. BMC Psychiatry 12,
11. http://www.biomedcentral.com/1471-244X/12/11 (accessed 20/12/12)
Brown JSL, Elliott SA, Boardman J, Ferns J, Morrison J (2004). Meeting the unmet need
for depression services with psycho-educational self-confidence workshops: preliminary
report. The British Journal of Psychiatry 185, 511-515.
Brown JSL, Elliott SA, Butler C (2006). Can large-scale self-referral psycho-educational
stress workshops help improve the psychological health of the population? Behavioural and
Cognitive Psychotherapy 34, 165-177.
Clement S, Brohan E, Jeffery D, Henderson C, Hatch SL, Thornicroft G. (2012)
Development and psychometric properties the Barriers to Access to Care Evaluation scale
(BACE) related to people with mental ill health. BMC Psychiatry, 12.
http://www.biomedcentral.com/1471-244X/12/36 (accessed 20/12/12)
Clement, S., van Nieuwenhuizen A, Kassam A, Flach C, Lazarus A, de Castro M,
McCrone P, Norman I, Thornicroft G (2012b). Filmed v. live social contact interventions
to reduce stigma: randomised controlled trial. British Journal of Psychiatry 201, 57-64.
22
Cohen, J. (1992). A power primer. Psychological Bulletin 112 (1), 155-159.
Corrigan PW (2004). How stigma interferes with mental health care. American Psychologist
59, 614-625.
Corrigan P, Rüsch N (2002). Mental illness stereotypes and clinical care: do people avoid
treatment because of stigma? Psychiatric Rehabilitation Skills 6(3), 312-334.
Crombie I (1996). The pocket guide to critical appraisal: a handbook for healthcare
professionals. BMJ Books: London.
Dell'Osso B, Glick ID, Baldwin DS, Altamura AC (2013). Can long-term outcomes be
improved by shortening the duration of untreated illness in psychiatric disorders: A
conceptual framework. Psychopathology 14, 14-21.
Gary F (2005). Stigma: barrier to mental health care among ethnic minorities. Issues in
Mental Health Nursing 26, 979-999.
Grimshaw J, McAuley LM, Bero LA, Grilli R, Oxman AD, Ramsay C, Vale L,
Zwarenstein M (2003). Systematic reviews of the effectiveness of quality improvement
strategies and programmes. Quality and Safety in Health Care 12, 298-303.
Gulliver A, Griffiths KM, Christensen H (2010). Perceived barriers and facilitators to
mental health help-seeking in young people: a systematic review. BMC Psychiatry 10, 113.
Gulliver A, Griffiths KM, Christensen H, Brewer JL (2012). A systematic review of helpseeking interventions for depression, anxiety and general psychological distress. BMC
Psychiatry 12, 12-81.
Hackler AH, Vogel DL, Wade NG (2010). Attitudes toward seeking professional help for
an eating disorder: the role of stigma and anticipated outcomes. Journal of Counseling &
Development 88, 424-431.
Halter MJ (2004). The stigma of seeking care and depression. Archives of Psychiatric
Nursing 18, 178-84.
Hammer JH, Vogel DL (2010). Men's help seeking for depression: The efficacy of a malesensitive brochure about counseling. The Counseling Psychologist 38, 296-313.
Han D-Y, Chen S-H, Hwang K-K, Wei H-L (2006). Effects of psychoeducation for
depression on help-seeking willingness: biological attribution versus destigmatization.
Psychiatry and Clinical Neurosciences 60, 662-668.
Held P, Owens GP (2012). Stigmas and attitudes toward seeking mental health treatment in
a sample of veterans and active duty service members. Traumatology.
http://tmt.sagepub.com/content/early/2012/08/16/1534765612455227.abstract (accessed
20/12/12)
23
Henderson M, Brooks SK, del Busso L, Chalder T, Harvey SB, Hotopf M, Madan I,
Hatch S (2012). Shame! Self-stigmatisation as an obstacle to sick doctors returning to work:
a qualitative study. In BMJ Open 2 http://bmjopen.bmj.com/content/2/5/e001776.full
(accessed 20/12/12)
Henderson C, Brohan E, Clement S, Williams P, Lassman F, Schauman O, Dockery L,
Farrelly S, Murray J, Murphy C, Slade M, Thornicroft G (2013). Randomised controlled
trial of a decision aid on disclosure of mental health status to an employer: feasibility and
outcomes. British Journal of Psychiatry 203, 350-357.
Johnson S, Bingham C, Billings J, Pilling S, Morant N, Bebbington P, McNicholas S,
Dalton J (2004). Women's experiences of admission to a crisis house and to acute hospital
wards: a qualitative study. Journal of Mental Health 13, 247-262.
Jorm AF, Medway J, Christensen H, Korten AE, Jacomb PA, Rodgers B (2000). Public
beliefs about the helpfulness of interventions for depression: effects on actions taken when
experiencing anxiety and depression symptoms. Australian and New Zealand Journal of
Psychiatry 34, 619-626.
Judd F, Komiti A, Jackson H (2008). How does being female assist help-seeking for mental
health problems? Australian and New Zealand Journal of Psychiatry 42, 24-29.
Kessler R, Demler O, Frank R, Olfson M, Pincus H, Walters E, Wang P, Wells K,
Zaslavsky A (2005). Prevalence and treatment of mental disorders, 1990 to 2003. New
England Journal of Medicine 352, 2515-2523.
Kitchener BA, Jorm AF (2006). Mental health first aid training: review of evaluation
studies. Australian and New Zealand Journal of Psychiatry 40, 6-8.
Kovandžić M, Chew-Graham C, Reeve J, Edwards S, Peters S, Edge D, Aseem S, Gask
L, Dowrick D (2011) Access to primary mental health care for hard-to-reach groups: From
‘silent suffering’ to ‘making it work’ Social Science & Medicine, 72, 763-772.
Kroger J (2004). Identity in adolescence: the balance between self and other. Routledge:
New York.
Kushner M, Sher K (1991). The relation of treatment fearfulness and psychological service
utilization: an overview. Professional Psychology - Research & Practice 22, 196-203.
Link B, Phelan JC (2001). Conceptualizing stigma. American Review of Sociology 27, 36385.
Marshall M, Lockwood A, Lewis S, Fiander M (2004). Essential elements of an early
intervention service for psychosis: the opinions of expert clinicians. BMC Psychiatry 4, 17.
24
Mishra S, Lucksted A, Gioia D, Barnet B, Baquet C (2009). Needs and preferences for
receiving mental health information in an African American focus group sample. Community
Mental Health Journal 45, 117-126.
Mittal D, Sullivan G, Chekuri L, Alllee E, Corrigan P (2012). Empirical studies of selfstigma reduction strategies: A critical review of the literature. Psychiatric Services 63
http://ps.psychiatryonline.org/mobile/article.aspx?articleid=1305548 (accessed 20/12/12)
Mojtabai R, Olfson M, Sampson N, Jin R, Druss B, Wang P, Wells K, Pincus H, Kessler
R (2011). Barriers to mental health treatment: results from the National Comorbidity Survey
Replication. Psychological Medicine 41, 1754-1761.
Morgan C, Mallett R, Hutchinson G, Leff J (2004). Negative pathways to psychiatric care
and ethnicity: the bridge between social science and psychiatry. Social Science & Medicine
58, 739-752.
Nose M, Barbui C, Tansella M (2003). How often do patients with psychosis fail to adhere
to treatment programmes? a systematic review. Psychological Medicine 33 (7), 1149-1160.
Oliver MI, Pearson N, Coe N, Gunnell D (2005a). Help-seeking behaviour in men and
women with common mental health problems: cross-sectional study. The British Journal of
Psychiatry 186, 297-301.
Oliver S, Harden A, Rees R, Shepherd J, Brunton G, Garcia J, Oakley A (2005b). An
emerging framework for including different types of evidence in systematic reviews for
public policy. Evaluation 11, 428-446.
Popay J, Roberts H, Sowden A, Petticrew M, Arai L, Rodgers M, Britten N, Roen K,
Duffy S (2006). Guidance on the conduct of narrative synthesis in systematic reviews. ESRC
Methods Programme: University of Lancaster, UK.
Pope C, Mays NJP (2007). Synthesising qualitative and quantitative health evidence: A
guide to methods. Open University Press: Maidenhead.
Public Health Resource Unit (2006). Critical Skills Appraisal Programme (CASP):
Qualitative research.
http://www.pillole.org/public/aspnuke/downloads/documenti/strumentiappraisal.pdf
(accessed 20/12/12)
Rüsch N, Lieb K, Göttler I, Hermann C, Schramm E, Richter H, Jacob GA, Corrigan
PW, Bohus M (2007). Shame and implicit self-concept in women with borderline personality
disorder. American Journal of Psychiatry 164, 500-508.
Schomerus G, Angermeyer M (2008). Stigma and its impact on help-seeking for mental
disorders: what do we know? Epidemiologia e Psichiatria Sociale 17, 31-37.
25
ten Have M, de Graaf R, Ormel J, Vilagut G, Kovess V, Alonso J (2010). Are attitudes
towards mental health help-seeking associated with service use? Results from the European
Study of Epidemiology of Mental Disorders. Social Psychiatry & Psychiatric Epidemiology
45, 153-163.
Thomas J, Harden A (2008). Methods for the thematic synthesis of qualitative research in
systematic reviews. BMC Medical Research Methodology 8, 45.
Thornicroft G (2007). Most people with mental illness are not treated. The Lancet 370, 807808.
Thornicroft G (2008). Stigma and discrimination limit access to mental health care.
Epidemiologia e Psichiatria Sociale 17, 14-19.
Vogel DL, Gentile DA, Kaplan SA (2008). The influence of television on willingness to
seek therapy. Journal of Clinical Psychology 64, 276-295.
Vogel DL, Wade NG, Hackler AH (2007). Perceived public stigma and the willingness to
seek counseling: the mediating roles of self-stigma and attitudes toward counseling. Journal
of Counseling Psychology 54, 40-50.
Wang PS, Aguilar-Gaxiola S, Alonso J, Angermeyer MC, Borges G, Bromet EJ,
Bruffaerts R, de Girolamo G, de Graaf R, Gureje O, Haro JM, Karam EG, Kessler RC,
Kovess V, Lane MC, Lee S, Levinson D, Ono Y, Petukhova M, Posada-Villa J, Seedat S,
Wells JE (2007). Use of mental health services for anxiety, mood, and substance disorders in
17 countries in the WHO world mental health surveys. Lancet 370, 841-850.
Wittchen H, Jacobi F (2005). Size and burden of mental disorders in Europe: A critical
review and appraisal of 27 studies. European Neuropsychopharmacology 15, 357-376.
Wright A, McGorry PD, Harris MG, Jorm AF, Pennell K (2006). Development and
evaluation of a youth mental health community awareness campaign: the Compass Strategy.
BMC Public Health 6, 215.
Included studies
Abrams LS, Dornig K, Curran L (2009). Barriers to service use for postpartum depression
symptoms among low-income ethnic minority mothers in the United States. Qualitative
Health Research 19, 535-551.
Adams EFM, Lee AJ, Pritchard CW, White RJE (2010). What stops us from healing the
healers: a survey of help-seeking behaviour, stigmatisation and depression within the medical
profession. International Journal of Social Psychiatry 56, 359-70.
26
Ahmed A, Stewart DE, Teng L, Wahoush O, Gagnon AJ (2008). Experiences of
immigrant new mothers with symptoms of depression 240. Archives of Women's Mental
Health 11, 295-303.
Aisbett DL, Boyd CP, Francis KJ, Newnham K (2007). Understanding barriers to mental
health service utilization for adolescents in rural Australia. Rural & Remote Health 7, 624.
Al-Krenawi A, Graham JR (2011). Mental health help-seeking among Arab university
students in Israel, differentiated by religion. Mental Health, Religion & Culture 14, 157-167.
Alvidrez J, Azocar F (1999). Distressed women's clinic patients: preferences for mental
health treatments and perceived obstacles. General Hospital Psychiatry 21, 340-7.
Alvidrez J, Snowden LR, Kaiser DM (2008). The experience of stigma among Black
mental health consumers. Journal of Health Care for the Poor & Underserved 19, 874-893.
Alvidrez J, Snowden LR, Patel SG (2010). The relationship between stigma and other
treatment concerns and subsequent treatment engagement among Black mental health clients.
Issues in Mental Health Nursing 31, 257-264.
Aromaa E, Tolvanen A, Tuulari J, Wahlbeck K (2011). Personal stigma and use of mental
health services among people with depression in a general population in Finland. BMC
Psychiatry 11, 52.
Ayalon L, Alvidrez J (2007). The experience of Black consumers in the mental health
system--identifying barriers to and facilitators of mental health treatment using the
consumers' perspective. Issues in Mental Health Nursing 28, 1323-1340.
Bambauer KZ, Prigerson HG (2006). The Stigma Receptivity Scale and its association with
mental health service use among bereaved older adults. Journal of Nervous & Mental Disease
194, 139-41.
Barney LJ, Griffiths KM, Christensen H, Jorm AF (2009). Exploring the nature of
stigmatising beliefs about depression and help-seeking: implications for reducing stigma 126.
BMC Public Health 9, 61.
Becker AE, Hadley AA, Perloe A, Fay K, Striegel-Moore RH (2010). A qualitative study
of perceived social barriers to care for eating disorders: perspectives from ethnically diverse
health care consumers. International Journal of Eating Disorders 43, 633-647.
Belloch A, Del Valle G, Morillo C, Carrio C, Cabedo E (2009). To seek advice or not to
seek advice about the problem: the help-seeking dilemma for obsessive-compulsive disorder.
Social Psychiatry & Psychiatric Epidemiology 44, 257-64.
27
Biddle L, Donovan JL, Gunnell D, Sharp D (2006). Young adults' perceptions of GPs as a
help source for mental distress: a qualitative study. British Journal of General Practice 56,
924-931.
Bilszta J, Ericksen J, Buist A, Milgrom J (2010). Women's experience of postnatal
depression - beliefs and attitudes as barriers to care. Australian Journal of Advanced Nursing
27, 44-54.
Boey KW (1998a). Psychosocial factors associated with seeking psychiatric treatment: a
study on adolescents in Shanghai. International Medical Journal 5, 293-298.
Boey KW (1998b). Help-seeking pattern of psychiatric outpatients in urban China.
International Journal of Psychiatric Nursing Research 4, 433-43.
Boey KW (1999). Help-seeking preference of college students in urban China after the
implementation of the "open-door" policy. International Journal of Social Psychiatry 45,
104-16.
Boyd C, Francis K, Aisbett D, Newnham K, Sewell J, Dawes G, Nurse S (2007).
Australian rural adolescents' experiences of accessing psychological help for a mental health
problem. Australian Journal of Rural Health 15, 196-200.
Brown JSL, Casey SJ, Bishop AJ, Prytys M, Whittinger N, Weinman J (2011). How
Black African and White British women perceive depression and help-seeking: a pilot
vignette study. International Journal of Social Psychiatry 57, 362-374.
Bruffaerts R, Demyttenaere K, Hwang I, Chiu WT, Sampson N, Kessler RC, Alonso J,
Borges G, de Girolamo G, de Graaf R, Florescu S, Gureje O, Hu C, Karam EG,
Kawakami N, Kostyuchenko S, Kovess-Masfety V, Lee S, Levinson D, Matschinger H,
Posada-Villa J, Sagar R, Scott KM, Stein DJ, Tomov T, Viana MC, Nock MK (2011).
Treatment of suicidal people around the world. British Journal of Psychiatry 199, 64-70.
Burke S, Kerr R, McKeon P (2008). Male secondary school student's attitudes towards
using mental health services. Irish Journal of Psychological Medicine 25, 52.
Carpenter-Song E, Chu E, Drake RE, Ritsema M, Smith B, Alverson H (2010). Ethnocultural variations in the experience and meaning of mental illness and treatment:
Implications for access and utilization. Transcultural Psychiatry 47, 224-251.
Chandra A, Minkovitz CS (2006). Stigma starts early: gender differences in teen
willingness to use mental health services. Journal of Adolescent Health 38, 754.e1-8.
Chandra A, Minkovitz CS (2007). Factors that influence mental health stigma among 8th
grade adolescents. Journal of Youth and Adolescence 36, 763-774.
28
Chew-Graham CA, Rogers A, Yassin N (2003). 'I wouldn't want it on my CV or their
records': medical students' experiences of help-seeking for mental health problems 50.
Medical Education 37, 873-880.
Chung I (2010). Changes in the sociocultural reality of Chinese immigrants: challenges and
opportunities in help-seeking behaviour. International Journal of Social Psychiatry 56, 43647.
Conner KO, Koeske G, Brown C (2009). Racial differences in attitudes toward professional
mental health treatment: the mediating effect of stigma. Journal of Gerontological Social
Work 52, 695-712.
Conner KO, Copeland VC, Grote NK, Koeske G, Rosen D, Reynolds CFIII, Brown C
(2010a). Mental health treatment seeking among older adults with depression: the impact of
stigma and race. The American Journal of Geriatric Psychiatry 18, 531-543.
Conner KO, Copeland VC, Grote NK, Rosen D, Albert S, McMurray ML, Reynolds
CF, Brown C, Koeske G (2010b). Barriers to treatment and culturally endorsed coping
strategies among depressed African-American older adults. Aging & Mental Health 14, 97183.
Conner KO, Lee B, Mayers V, Robinson D, Reynolds IiiCF, Albert S, Brown C (2010c).
Attitudes and beliefs about mental health among African American older adults suffering
from depression. Journal of Aging Studies 24, 266-277.
Cooper AE, Corrigan PW, Watson AC (2003). Mental illness stigma and care seeking.
Journal of Nervous & Mental Disease 191, 339-41.
Corrigan PW, Swantek S, Watson AC, Kleinlein P (2003). When do older adults seek
primary care services for depression? Journal of Nervous & Mental Disease 191, 619-22.
Cruz M, Pincus HA, Harman JS, Reynolds CF, Post EP (2008). Barriers to care-seeking
for depressed African Americans. International Journal of Psychiatry in Medicine 38, 71-80.
David E (2010). Cultural mistrust and mental health help-seeking attitudes among Filipino
Americans. Asian American Journal of Psychology 1, 57-66.
Deane FP, Chamberlain K (1994). Treatment fearfulness and distress as predictors of
professional psychological help-seeking. British Journal of Guidance & Counselling 22, 207217.
Dinos S, Stevens S, Serfaty M, Weich S, King M (2004). Stigma: the feelings and
experiences of 46 people with mental illness: Qualitative study. British Journal of Psychiatry
184, 176-181.
29
Donnelly TT, Hwang JJ, Este D, Ewashen C, Adair C, Clinton M (2011). If I was going
to kill myself, I wouldn't be calling you. I am asking for help: challenges influencing
immigrant and refugee women's mental health. Issues in Mental Health Nursing 32, 279-290.
Eaton KM, Hoge CW, Messer SC, Whitt AA, Cabrera OA, McGurk D, Cox A, Castro
CA (2008). Prevalence of mental health problems, treatment need, and barriers to care among
primary care-seeking spouses of military service members involved in Iraq and Afghanistan
deployments. Military Medicine 173, 1051-6.
Eisenberg D, Downs MF, Golberstein E, Zivin K (2009). Stigma and help seeking for
mental health among college students. Medical Care Research & Review 66, 522-41.
Elhai JD, Schweinle W, Anderson SM (2008). Reliability and validity of the Attitudes
Toward Seeking Professional Psychological Help Scale-Short Form. Psychiatry Research
159, 320-9.
Ey S, Henning KR, Shaw DL (2000). Attitudes and factors related to seeking mental health
treatment among medical and dental students. Journal of College Student Psychotherapy 14,
23-39.
Fikretoglu D, Guay S, Pedlar D, Brunet A (2008). Twelve month use of mental health
services in a nationally representative, active military sample. Medical Care 46, 217-23.
Flynn HA, Henshaw E, O'Mahen H, Forman J (2010). Patient perspectives on improving
the depression referral processes in obstetrics settings: a qualitative study. General Hospital
Psychiatry 32, 9-16.
Fortune S, Sinclair J, Hawton K (2008). Adolescents' views on preventing self-harm. A
large community study 372. Social Psychiatry & Psychiatric Epidemiology 43, 96-104.
Gibbs DA, Rae Olmsted KL, Brown JM, Clinton-Sherrod AM (2011). Dynamics of
stigma for alcohol and mental health treatment among army soldiers. Military Psychology 23,
36-51.
Givens JL, Katz IR, Bellamy S, Holmes WC (2007). Stigma and the acceptability of
depression treatments among african americans and whites. Journal of General Internal
Medicine 22, 1292-7.
Golberstein E, Eisenberg D, Gollust SE (2008). Perceived stigma and mental health care
seeking. Psychiatric services (Washington, D.C.) 59 (4), 392-399.
Golberstein E, Eisenberg D, Gollust SE (2009). Perceived stigma and help-seeking
behavior: longitudinal evidence from the healthy minds study. Psychiatric Services 60, 12546.
30
Goodman JH (2009). Women's attitudes, preferences, and perceived barriers to treatment for
perinatal depression. Birth 36, 60-9.
Gorman LA, Blow AJ, Ames BD, Reed PL (2011). National Guard families after combat:
mental health, use of mental health services, and perceived treatment barriers. Psychiatric
Services 62, 28-34.
Gould M, Adler A, Zamorski M, Castro C, Hanily N, Steele N, Kearney S, Greenberg N
(2010). Do stigma and other perceived barriers to mental health care differ across Armed
Forces? Journal of the Royal Society of Medicine 103, 148-56.
Gum AM, Iser L, Petkus A (2010). Behavioral health service utilization and preferences of
older adults receiving home-based aging services. American Journal of Geriatric Psychiatry
18, 491-501.
Hackler AH, Vogel DL, Wade NG (2010). Attitudes toward seeking professional help for
an eating disorder: the role of stigma and anticipated outcomes. Journal of Counseling &
Development 88, 424-431.
Halter MJ (2004). The stigma of seeking care and depression. Archives of Psychiatric
Nursing 18, 178-84.
Hammer JH, Vogel DL (2010). Men's help seeking for depression: The efficacy of a malesensitive brochure about counseling. The Counseling Psychologist 38, 296-313.
Hepworth N, Paxton SJ (2007). Pathways to help-seeking in bulimia nervosa and binge
eating problems: a concept mapping approach. International Journal of Eating Disorders.40,
493-504.
Hines-Martin V, Malone M, Kim S, Brown-Piper A (2003). Barriers to mental health care
access in an African American population. Issues in Mental Health Nursing 24, 237-256.
Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL (2004). Combat
duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England
Journal of Medicine 351, 13-22.
Howerton A, Byng R, Campbell J, Hess D, Owens C, Aitken P (2007). Understanding
help seeking behaviour among male offenders: qualitative interview study. BMJ 334, 303.
Interian A, Ang A, Gara MA, Link BG, Rodriguez MA, Vega WA (2010). Stigma and
depression treatment utilization among Latinos: utility of four stigma measures. Psychiatric
Services 61, 373-9.
Iversen AC, van Staden L, Hughes JH, Greenberg N, Hotopf M, Rona RJ, Thornicroft
G, Wessely S, Fear NT (2011). The stigma of mental health problems and other barriers to
care in the UK Armed Forces. BMC Health Services Research 11, 31.
31
Jesse DE, Dolbier CL, Blanchard A (2008). Barriers to seeking help and treatment
suggestions for prenatal depressive symptoms: focus groups with rural low-income women.
Issues in Mental Health Nursing 29, 3-19.
Kadir NBA, Bifulco A (2010). Malaysian Moslem mothers' experience of depression and
service use. Culture, Medicine and Psychiatry 34, 443-467.
Kanter JW, Rusch LC, Brondino MJ (2008). Depression self-stigma: a new measure and
preliminary findings. Journal of Nervous & Mental Disease 196, 663-70.
Kessler RC, Berglund PA, Bruce ML, Koch JR, Laska EM, Leaf PJ, Manderscheid
RW, Rosenheck RA, Walters EE, Wang PS (2001). The prevalence and correlates of
untreated serious mental illness. Health Services Research 36, 987-1007.
Kim PY, Britt TW, Klocko RP, Riviere LA, Adler AB (2011). Stigma, negative attitudes
about treatment, and utilization of mental health care among soldiers. Military Psychology
23, 65-81.
Kim PY, Thomas JL, Wilk JE, Castro CA, Hoge CW (2010). Stigma, barriers to care, and
use of mental health services among active duty and National Guard soldiers after combat.
Psychiatric Services 61, 572-588.
Komiti A, Judd F, Jackson H (2006). The influence of stigma and attitudes on seeking help
from a GP for mental health problems: a rural context. Social Psychiatry & Psychiatric
Epidemiology 41, 738-45.
Komiya N, Good GE, Sherrod NB (2000). Emotional openness as a predictor of college
students' attitudes toward seeking psychological help. Journal of Counseling Psychology 47,
138-143.
Kovandžić M, Chew-Graham C, Reeve J, Edwards S, Peters S, Edge D, Aseem S, Gask
L, Dowrick D (2011) Access to primary mental health care for hard-to-reach groups: From
‘silent suffering’ to ‘making it work’ Social Science & Medicine, 72, 763-772.
Langston V, Greenberg N, Fear N, Iversen A, French C, Wessely S (2010). Stigma and
mental health in the Royal Navy: a mixed methods paper. Journal of Mental Health 19, 8-16.
Lazear KJ, Pires SA, Isaacs MR, Chaulk P, Huang L (2008). Depression among lowincome women of color: qualitative findings from cross-cultural focus groups 362. Journal of
Immigrant & Minority Health 10, 127-133.
Lee AMR, Simeon D, Cohen LJ, Samuel J, Steele A, Galynker II (2011). Predictors of
patient and caregiver distress in an adult sample with bipolar disorder seeking family
treatment. Journal of Nervous & Mental Disease 199, 18-24.
32
Lee S, Juon H, Martinez G, Hsu CE, Robinson ES, Bawa J, Ma GX (2009). Model
minority at risk: expressed needs of mental health by Asian American young adults 740.
Journal of Community Health 34, 144-152.
Leong FT, Zachar P (1999). Gender and opinions about mental illness as predictors of
attitudes toward seeking professional psychological help. British Journal of Guidance &
Counselling 27, 123-132.
Lindsey MA, Joe S, Nebbitt V (2010). Family matters: the role of mental health stigma and
social support on depressive symptoms and subsequent help seeking among African
American boys. Journal of Black Psychology 36, 458-482.
Loya F, Reddy R, Hinshaw SP (2010). Mental illness stigma as a mediator of differences in
Caucasian and South Asian college students' attitudes toward psychological counseling.
Journal of Counseling Psychology 57, 484-490.
Marques L, LeBlanc NJ, Weingarden HM, Timpano KR, Jenike M, Wilhelm S (2010).
Barriers to treatment and service utilization in an internet sample of individuals with
obsessive-compulsive symptoms. Depression & Anxiety 27, 470-5.
Marques L, Weingarden HM, Leblanc NJ, Wilhelm S (2011). Treatment utilization and
barriers to treatment engagement among people with body dysmorphic symptoms. Journal of
Psychosomatic Research 70, 286-93.
Masuda A, Suzumura K, Beauchamp KL, Howells GN, Clay C (2005). United States and
Japanese college students' attitudes toward seeking professional psychological help.
International Journal of Psychology 40, 303-313.
McCarthy M, McMahon C (2008). Acceptance and experience of treatment for postnatal
depression in a community mental health setting. Health Care for Women International 29,
618-637.
Meltzer H, Bebbington P, Brugha T, Farrell M, Jenkins R, Lewis G (2003). The
reluctance to seek treatment for neurotic disorders. International Review of Psychiatry 15 (12), 123-128.
Menke R, Flynn H (2009). Relationships between stigma, depression, and treatment in white
and African American primary care patients. Journal of Nervous & Mental Disease 197, 40711.
Meredith LS, Stein BD, Paddock SM, Jaycox LH, Quinn VP, Chandra A, Burnam A
(2009). Perceived barriers to treatment for adolescent depression. Medical Care 47, 677-85.
Meyer DF (2001). Help-seeking for eating disorders in female adolescents. Journal of
College Student Psychotherapy 15, 23-36.
33
Mishra S, Lucksted A, Gioia D, Barnet B, Baquet C (2009). Needs and preferences for
receiving mental health information in an African American focus group sample. Community
Mental Health Journal 45, 117-126.
Nadeem E, Lange JM, Edge D, Fongwa M, Belin T, Miranda J (2007). Does stigma keep
poor young immigrant and U.S.-born Black and Latina women from seeking mental health
care? Psychiatric Services 58, 1547-54.
Nadeem E, Lange JM, Miranda J (2008). Mental health care preferences among lowincome and minority women. Archives of Women's Mental Health 11, 93-102.
Nguyen QCX, Anderson LP (2005). Vietnamese Americans' attitudes toward seeking
mental health services: relation to cultural variables. Journal of Community Psychology 33,
213-231.
Nicolaidis C, Timmons V, Thomas MJ, Waters AS, Wahab S, Mejia A, Mitchell SR
(2010). "You don't go tell White people nothing": African American women's perspectives on
the influence of violence and race on depression and depression care. American Journal of
Public Health 100, 1470-6.
Ojeda VD, Bergstresser SM (2008). Gender, race-ethnicity, and psychosocial barriers to
mental health care: an examination of perceptions and attitudes among adults reporting unmet
need. Journal of Health & Social Behavior 49, 317-34.
Okazaki S (2000). Treatment delay among Asian-American patients with severe mental
illness. American Journal of Orthopsychiatry 70, 58-64.
Olfson M, Guardino M, Struening E, Schneier FR, Hellman F, Klein DF (2000). Barriers
to the treatment of social anxiety. American Journal of Psychiatry 157, 521-7.
Olmsted KL, Brown JM, Vandermaas-Peeler JR, Tueller SJ, Johnson RE, Gibbs DA
(2011). Mental health and substance abuse treatment stigma among soldiers. Military
Psychology 23, 52-64.
Pederson EL, Vogel DL (2007). Male gender role conflict and willingness to seek
counseling: testing a mediation model on college-aged men. Journal of Counseling
Psychology 54, 373-384.
Polyakova SA, Pacquiao DF (2006). Psychological and mental illness among elder
immigrants from the former Soviet Union. Journal of Transcultural Nursing 17, 40-49.
Prior L, Wood F, Lewis G, Pill R (2003). Stigma revisited: Disclosure of emotional
problems in primary care consultation in Wales. Social Science & Medicine 56, 2191-2200.
34
Quinn N, Wilson A, MacIntyre G, Tinklin T (2009). 'People look at you differently':
students' experience of mental health support within higher education. British Journal of
Guidance & Counselling 37, 405-418.
Reiling DM (2002). Boundary maintenance as a barrier to mental health help-seeking for
depression among the Old Order Amish. Journal of Rural Health 18, 428-436.
Reitmanova S, Gustafson DL (2009). Primary mental health care information and services
for St. John's visible minority immigrants: gaps and opportunities 20 4411. Issues in Mental
Health Nursing 30, 615-623.
Rojas-Vilches AP, Negy C, Reig-Ferrer A (2011). Attitudes toward seeking therapy among
Puerto Rican and Cuban American young adults and their parents. International Journal of
Clinical and Health Psychology 11, 313-341.
Rusch LC, Kanter JW, Manos RC, Weeks CE (2008). Depression stigma in a
predominantly low income African American sample with elevated depressive symptoms.
Journal of Nervous & Mental Disease 196, 919-22.
Rusch N, Corrigan PW, Wassel A, Michaels P, Larson JE, Olschewski M, Wilkniss S,
Batia K (2009). Self-stigma, group identification, perceived legitimacy of discrimination and
mental health service use. British Journal of Psychiatry 195, 551-2.
Sadavoy J, Meier R, Ong AYM (2004). Barriers to access to mental health services for
ethnic seniors: the Toronto study. The Canadian Journal of Psychiatry / La Revue
Canadienne de Psychiatrie 49, 192-199.
Saldivia S, Vicente B, Kohn R, Rioseco P, Torres S (2004). Use of mental health services
in Chile. Psychiatric Services 55, 71-6.
Sareen J, Jagdeo A, Cox BJ, Clara I, ten Have M, Belik SL, de Graaf R, Stein MB
(2007). Perceived barriers to mental health service utilization in the United States, Ontario,
and the Netherlands. Psychiatric Services 58, 357-64.
Schomerus G, Matschinger H, Angermeyer MC.(2009). The stigma of psychiatric
treatment and help-seeking intentions for depression. European Archives of Psychiatry &
Clinical Neuroscience 259, 298-306.
Schwenk TL, Gorenflo DW, Leja LM (2008). A survey on the impact of being depressed
on the professional status and mental health care of physicians. Journal of Clinical Psychiatry
69, 617-20.
Shechtman Z, Vogel D, Maman N (2010). Seeking psychological help: a comparison of
individual and group treatment. Psychotherapy Research 20, 30-36.
35
Sheffield JK, Fiorenza E, Sofronoff K (2004). Adolescents' willingness to seek
psychological help: promoting and preventing Factors. Journal of Youth and Adolescence 33,
495-507.
Sirey JA, Bruce ML, Alexopoulos GS, Perlick DA, Raue P, Friedman SJ, Meyers BS
(2001). Perceived stigma as a predictor of treatment discontinuation in young and older
outpatients with depression. American Journal of Psychiatry 158, 479-81.
Soheilian SS, Inman AG (2009). Middle Eastern Americans: the effects of stigma on
attitudes toward counseling. Journal of Muslim Mental Health 4, 139-158.
Stecker T, Fortney JC, Hamilton F, Ajzen I (2007). An assessment of beliefs about mental
health care among veterans who served in Iraq. Psychiatric Services 58, 1358-1361.
Stefl ME, Prosperi DC (1985). Barriers to mental health service utilization. Community
Mental Health Journal 21, 167-78.
Strike C, Rhodes AE, Bergmans Y, Links P (2006). Fragmented pathways to care: the
experiences of suicidal men 60. Crisis: Journal of Crisis Intervention & Suicide 27, 31-38.
Takeuchi DT, Leaf PJ, Kuo HS (1988). Ethnic differences in the perception of barriers to
help-seeking. Social Psychiatry & Psychiatric Epidemiology 23, 273-80.
Tang Yl, Sevigny R, Mao PX, Jiang F, Cai Z (2007). Help-seeking behaviors of Chinese
patients with schizophrenia admitted to a psychiatric hospital. Administration & Policy in
Mental Health 34, 101-7.
Teasdale K (1987). Stigma and psychiatric day care. Journal of Advanced Nursing 12, 339346.
Thompson VLS, Bazile A, Akbar M (2004). African Americans' perceptions of
psychotherapy and psychotherapists. Professional Psychology - Research & Practice 35, 1926.
Timlin-Scalera RM, Ponterotto JG, Blumberg FC, Jackson MA (2003). A grounded
theory study of help-seeking behaviors among White male high school students. Journal of
Counseling Psychology 50, 339-350.
Ting JY, Hwang WC (2009). Cultural influences on help-seeking attitudes in Asian
American students. American Journal of Orthopsychiatry 79, 125-32.
Tsang HWH, Fung KMT, Chung RCK (2010). Self-stigma and stages of change as
predictors of treatment adherence of individuals with schizophrenia. Psychiatry Research
180, 10-5.
Van Hook MP (1996). Challenges to identifying and treating women with depression in rural
primary care. Social Work in Health Care 23, 73-92.
36
Van Hook MP(1999). Women's help-seeking patterns for depression. Social Work in Health
Care 29, 15-34.
Vetter G (1989). Etikettierungseffekte und Stigmamanagementstrategien im vorfeld
schulpsychologischer beratung [Labeling effects and strategies of stigma management
antecedent to school-psychological counseling. Praxis Psychologischer Beratung 36, 283293.
Visco R (2009). Postdeployment, self-reporting of mental health problems, and barriers to
care 752 4516. Perspectives in Psychiatric Care 45, 240-253.
Vogel DL, Gentile DA, Kaplan SA (2008). The influence of television on willingness to
seek therapy. Journal of Clinical Psychology 64, 276-295.
Vogel DL, Shechtman Z, Wade NG (2010). The role of public and self-stigma in predicting
attitudes toward group counseling. The Counseling Psychologist 38, 904-922.
Vogel DL, Wade NG, Haake S (2006). Measuring the self-stigma associated with seeking
psychological help. Journal of Counseling Psychology 53, 325-337.
Vogel DL, Wade NG, Hackler AH (2007). Perceived public stigma and the willingness to
seek counseling: the mediating roles of self-stigma and attitudes toward counseling. Journal
of Counseling Psychology 54, 40-50.
Vogel DL, Wester SR, Wei M, Boysen GA (2005). The role of outcome expectations and
attitudes on decisions to seek professional help. Journal of Counseling Psychology 52, 459470.
Wade NG, Post BC, Cornish MA, Vogel DL, Tucker JR (2011). Predictors of the change
in self-stigma following a single session of group counseling. Journal of Counseling
Psychology 58, 170-82.
Wallace BC, Constantine MG (2005). Africentric cultural values, psychological helpseeking attitudes, and self-concealment in African American College students. Journal of
Black Psychology 31, 369-385.
Walsh J, Scaife V, Notley C, Dodsworth J, Schofield G (2011). Perception of need and
barriers to access: the mental health needs of young people attending a Youth Offending
Team in the UK. Health & Social Care in the Community 19, 420-428.
Ward EC, Clark LO, Heidrich S (2009b). African American women's beliefs, coping
behaviors, and barriers to seeking mental health services. Qualitative Health Research.19,
1589-1601.
Ward EC, Heidrich SM (2009a). African American women's beliefs about mental illness,
stigma, and preferred coping behaviors. Research in nursing & health 32 (5), 480-492.
37
Warner CH, Appenzeller GN, Mullen K, Warner CM, Grieger T (2008). Soldier
attitudes toward mental health screening and seeking care upon return from combat. Military
Medicine 173, 563-9.
Weinberger MI, Nelson CJ, Roth AJ (2011). Self-reported barriers to mental health
treatment among men with prostate cancer. Psycho-Oncology, 20, 444-446.
Wells JE, Robins LN, Bushnell JA, Jarosz D, Oakley-Browne MA (1994). Perceived
barriers to care in St. Louis (USA) and Christchurch (NZ): reasons for not seeking
professional help for psychological distress. Social Psychiatry & Psychiatric Epidemiology
29, 155-64.
Wrigley S, Jackson H, Judd F, Komiti A (2005). Role of stigma and attitudes toward helpseeking from a general practitioner for mental health problems in a rural town. Australian &
New Zealand Journal of Psychiatry 39, 514-21.
Yakunina ES, Rogers JR, Waehler CA, Werth JLJr (2010). College students' intentions
to seek help for suicidal ideation: accounting for the help-negation effect. Suicide & LifeThreatening Behavior 40, 438-50.
Yakunina ES, Weigold IK (2011). Asian international students' intentions to seek
counseling: integrating cognitive and cultural predictors. Asian American Journal of
Psychology 2, 219-224.
38
Table 1 Inclusion and exclusion criteria
Participants
Include
 Any population group of any age.
Exclude
 Persons help-seeking on behalf of another individual (e.g. family members, informal
carers).
 Professional caregivers, unless providing data about seeking help for their own mental
health problems.
 If a study includes data from both people with mental health problems and informal or
professional caregivers, only the data from the former group will be extracted. Where
the two cannot be distinguished the study will be excluded.
Outcomes
Stigma
Include
 Any type of stigma including public stigma, perceived stigma, internalised stigma,
anticipated stigma / discrimination, experienced stigma / discrimination, stigma by
association / family stigma and treatment stigma.
 Mental health-related stigma.
 Stigma as measured on scale or a subscale that has been referenced or examined for
reliability and/or validity.
 Minor adaptations of the scales are acceptable as long as the objective was to measure
the same construct as the original scale.
Exclude
 Stigma relating to other social attributes e.g. racism, homophobia.
 Scale developed by the authors not assessed for any psychometric properties.
 Stigma measured using a single item.
 Stigma-related barriers which do not report dichotomous data (barrier reported or not)
or cannot be definitely transformed into this format.
Help-seeking
Include
 Help-seeking for a mental health problem, defined as any mental disorder listed in
DSM IV-TR or any self-defined psychological, emotional or behavioural problem.
 Measures of help-seeking-related attitudes, intentions and behaviours.
 Help-seeking from a health practitioner or service (including primary, secondary or
tertiary care) or talking therapy (psychotherapy / psychology/ counselling services or
practitioner)
 Measures relating to any stage of help-seeking from seeking initial formal help to
service use
Exclude
 Help-seeking for intellectual disabilities, substance abuse or dementia.
Study type
Include
 Studies which address at least one of the three specified sub-questions using the
methodology indicated: (1) what is the size and direction of association between stigma
39
and help-seeking? (quantitative studies); (2) to what extend is stigma identified as a
barrier to help-seeking? (quantitative studies); or (3) what processes underlie the
relationship between stigma and help-seeking? (qualitative studies).
 Any data-based journal article.
 Published in any language
 Published between 1980 to January 2012.
Exclude
 Association studies for which findings cannot be classified into a standardised effect
size, despite using conversion approaches and attempting to contact authors.
 Studies that only report an association or prevalence of barriers in socio-demographic
subgroup of the study sample, unless these data can be provided by the authors or
calculated.
40
Table 2 Synthesis of studies examining the association between stigma and help-seeking and associated main subgroup analyses
Cohen’s d
Direction of the association
(n of studies with p<0.05 association)
N participants
(studies)
Interpretationc
Negative
Positive
Median
Range
42(30)
14(3)
-0.27
-2.73 to 0.36
Small negative association
Overall sample
27572 (56)a
Subgroup
analysis 1
Stigma type b
Anticipated
stigma
2438 (2)
2 (0)
0
-0.15
-0.26 to 0.04
No association
Experienced
stigma
483 (2)
1 (0)
1 (0)
<-0.01
<-0.01 to <0.01
No association
Internalised
Stigma
1710 (7)
5(4)
2(0)
-0.23
-1.78 to 0.01
Small negative association
Perceived
stigma
10579 (19)
12 (3)
7 (0)
-0.02
-1.61 to 0.22
No association
Stigma
endorsement
9741(12)
8 (4)
4 (0)
-0.05
-0.87 to 0.28
No association
Treatment
stigma
14966 (33)
25 (21)
8 (3)
-0.41
-2.73 to 0.36
Small negative association
Other stigma
424 (3)
1 (1)
2 (0)
0.06
-0.02 to 0.14
No association
41
Table 2 (continued)
Subgroup analysis 2
Methodology
N
participants
(studies)
Cohen’s d
Direction of the association (n
of studies with p<0.05 association)
Negative
Positive
Median
Range
Interpretationb
Attitudes & intentions
11297 (33)
29 (25)
4 (1)
-0.52
-2.73 to 0.34
Medium negative association
Behavioural indicators
15368 (18)
9 (3)
9 (2)
<-0.01
-0.26 to 0.36
No association
Prospective behaviour
907 (5)
4 (2)
1 (0)
-0.07
-0.46 to 0.02
No association
African American
(USA)
570 (4)
3 (2)
1 (0)
-0.25
-0.50 to <0.01
Small negative association
Arabic students
(Israel/USA)
297 (2)
2 (2)
0 (0)
-1.21
-1.76 to -0.66
Large negative association
Asian American (USA)
898 (6)
4 (4)
2 (1)
-1.20
-2.73 to 0.34
Large negative association
Latino, Cuban and
Puerto Rican (USA)
328 (2)
2 (0)
0 (0)
-0.09
-0.16 to -0.02
No association
Other / Mixed
25479 (42)
31 (22)
11 (2)
-0.23
-2.45 to 0.36
Small negative association
Subgroup analysis 3
Ethnicity
a 26313
participants contributed to effect size (Cohen’s d) analysis
than one outcome was extracted per study for this analysis if the study reported results on different types of stigma measures. Anticipated stigma (anticipation of personally being
perceived or treated unfairly); Experienced stigma (the person experience of being perceived or treated unfairly); Internalised stigma (holding stigmatising views about oneself); Perceived
stigma (participants views about the extent to which people in general have stigmatising attitudes/behaviour towards people with mental illness); Stigma endorsement (participants’ own
stigmatising attitudes/behaviour towards other people with mental illness); and Treatment stigma (stigma associated with seeking or receiving treatment for mental ill health)
c Based on published guidance by Cohen (1992), Small>0.2, Medium>0.5, Large >0.8
bMore
42
Table 3 Synthesis of studies reporting stigma-related barriers and associated main subgroup analyses
N
participants
(studies)
Shame/
embarrassment
median (range) %
Negative
social
judgement
median
(range) %
Overall Sample
60036 (44)
21 (8-59)
22 (4-73)
32 (4-68)
23 (9-71)
9 (5-43)
4.3 (0.6-9.5)
Professional
groups
Military
Health Professionals
Other
17961 (10)
2834 (3)
39241 (31)
21 (13-54)
26.5 (8-59)
23 (15-73)
46
16 (4-46)
23 (14-31)
50 (21-50)
32 (4-52)
28 (19-71)
14 (9-35)
-
8 (5-11)
21
8 (7-24)
0.9 (0.6-2.0)
5.3 (1.7-4)
5.0 (0.6-8.2)
Gender
Men
Women
Mixed
35 (1)
18072 (11)
41929 (32)
18 (14-19)
24 (8-59)
9
17 (4-55)
23 (4-73)
11
36 (35-36)
31 (4-68)
23 (9-71)
25 (7-43)
9 (5-24)
9.5
6.9 (2.2-8.3)
4.2 (0.6-8.2)
Sample/subgroup
Disclosure
concerns /
confidentiality
median (range) %
Employmentrelated
discrimination
median (range) %
Stigma
generally
/other, median
(range) %
Standardised
rank, median
(range)a
Mental health of
participants
Psychosis/ SMI
120 (2)
38
15
8
Non-psychosis
13298 (12)
35 (13-58)
18 (4-46)
31 (4-68)
21 (7-43)
5.0 (0.6-8.2)
Population samples
46618 (30)
20 (8-59)
23 (7-73)
32 (4-54)
23
8 (5-24)
4.0 (0.6-9.5)
a
Where a study measured 5+ barriers of any type, the barriers were ranked by endorsement and the standardised stigma rank is the rank of the barrier
(or the highest ranked if 2 or more stigma barriers) standardised for number of barriers (1=highest endorsed barriers, 10= least endorsed barrier)
43
Table 4 What is the impact of mental health-related stigma on help-seeking? Meta-synthesis of main findings from
the association, barriers and process studies
144 studies
(90189 participants)
Research question
Overall finding
Association studies
(56 studies, n = 27572 )
What is the direction and extent of
the association between stigma and
help-seeking?
Small negative association
Barriers studies
(44 studies, n = 60036)
To what extent is stigma reported to
be a barriers to help-seeking?
Ranked 4/10th highest reported
barrier when all types of barriers are
considered and the number of
barriers investigated standardised to
10
Impact of different aspects
of stigma
Stereotypes
Labelling
Anticipated /experienced
No association (anticipated /
prejudice / negative social
experienced stigma)
judgment)
Anticipated / experienced
employment-related
discrimination
Anticipated / experienced
other types of discrimination
Disclosure concerns
Qualitative process studies
(51 studies, n = 5540)
What are the processes underlying
the relationship between stigma and
help-seeking?
Anticipated and experienced stigma
based on stereotypes deters helpseeking directly and via nondiclosure. Some stigma-related
personal and service factors
facilitate help-seeking
Barrier reported by 22% (median)
Theme, 13 subthemes (3 – 30
studies)
Subtheme (23 studies)
Two subthemes (15, 31 studies)
Barrier reported by 23% (median)
Subtheme (18 studies)
Barrier reported by 32% (median)
44
Three subthemes (3, 15 and 26
studies)
Theme, 9 subthemes (4 – 36
studies)
Anticipated / experienced
internalised stigma / shame /
embarrassment
Treatment stigma
Population groups
disproportionately
affected
Ethnic minorities
Small negative association
Barrier reported by 21% (median)
Small negative association
- Asian Americans:
large negative association
- Arabic minorities:
large negative association
Age
Gender
- Females: less reporting of stigmarelated barriers
Profession
- Military: more reporting of
stigma-related barriers (esp.
employment-related discrimination)
- Health professionals: more
reporting of shame/embarrassment
and negative social judgement
barriers
- Experience of mental ill health:
more shame/embarrassment
Experience of mental health
problems
- Subtheme identified in 29 studies
- Partial theme: dissonance between
self identity and stereotypes
45
- African Americans: more studies
with subthemes of weak, stigma for
family, keeping it in the family, and
non-disclosure
- Other ethnic minorities: more
studies with subtheme of stigma for
family
Youth (< 18 years): more studies
with subtheme of not normal
- Males: more studies with
subtheme of difficulty talking to
professionals
- Experience of mental health
problems: fewer studies with
themes of weak, social rejection,
Rural setting
Methodological quality
Overall quality
Main methodological
limitations
Insufficient data
Insufficient data
difficulty talking to professionals,
and confidential / anonymous
services
Insufficient data
Low
No association with behavioural
indicators, prospective studies, or
when low quality studies were
removed
- Sample size not justified
- Lack of evidence for reliability
and validity of help-seeking
measures
- Selection bias in samples (student
samples, low response rates)
- Predominance of attitudinal /
intentional data
- Lack of prospective studies
Moderate
Good
- Sample size not justified
- Lack of evidence for reliability
and validity of measures
- Lack of reflexive account of
researchers’ influence
46
47