Depression stigma in
Australian high school
students
To identify predictors of depression stigma in a group of Australian school
students, participants (1,804 students aged 12–15 years) completed a
questionnaire covering sociodemographic information, recognition of depression
in a vignette, stigma towards a depressed peer, help-seeking intentions,
information from teachers, and student mental health. Results suggested that
depression stigma is a multidimensional construct with different factors predicting
different aspects of stigma. Increased recognition of depression was associated
with an increased belief in depression as a sickness rather than a weakness,
but also with an increased belief that those with depression are dangerous and
unpredictable. It is likely that multifaceted stigma-reduction interventions are
needed, with emphasis on reducing the associations between depression and
danger and targeting those of non-English-speaking backgrounds.
by Nicola Reavley
& Anthony Jorm
tigmatising attitudes towards people with mental disorders are common in adolescents
and are of major concern to those with these disorders (Hinshaw 2005; Walker et al.
2008). Such attitudes may act as barriers to help-seeking, can interfere with treatment
and adversely affect quality of life as they may cause a young person to feel abnormal, socially
disconnected and dependent on others (Sirey et al. 2001; Corrigan 2004; Meredith et al. 2009).
The help-seeking gap is of particular importance in young people, as evidence suggests that
only about one-third of adolescents with symptoms of anxiety and depression seek appropriate
help (Zachrisson, Rodje & Mykletun 2006; Rickwood, Deane & Wilson 2007).
A number of studies have attempted to understand the factors involved in the formation of
stigmatising attitudes in the hope that improved understanding can help to focus attempts to
reduce the negative impact of stigma (Angermeyer & Matschinger 2004; Wolkenstein & Meyer
2008). Evidence suggests that stigmatising attitudes vary according to type of mental illness,
and that there is a need to explore attitudes to different illnesses separately (Jorm & Wright 2008;
Wolkenstein & Meyer 2008).
In Australian adults, personal stigma associated with depression has been linked to male
gender, lower levels of education, being born overseas, lower depression literacy and greater
psychological distress (Griffiths, Christensen & Jorm 2008). However, there has been relatively
S
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VOLUME 30 NUMBER 2 2011
33
little research on the factors predicting
stigmatising attitudes in adolescents. There
is some evidence that male gender is linked
to greater stigmatising attitudes, although
results across studies are not consistent
(Calear, Griffiths & Christensen 2011;
Chandra & Minkovitz 2006; Jorm & Wright
2008; Walker et al. 2008; Moses 2009). The
relationship between age and stigma appears
to be complex and may be linked to increases
in some stigmatising attitudes but not others
(Jorm & Wright 2008; Walker et al. 2008;
Moses 2009). Having a non-English-speaking
background is generally linked to higher
stigmatising attitudes, as is poor mental
health (Calear, Griffiths & Christensen 2011;
Fogel & Ford 2005; Rapee et al. 2006; Moses
2009). There is some evidence that receiving
mental health information at school can
result in reductions in stigmatising attitudes
(Pinfold et al. 2003; Naylor et al. 2009).
Overall, findings are not consistent across
studies and interpretation is complicated by
different ways of measuring stigma. There is
general agreement that the factors predicting
stigma in adolescents are not well understood
and that there is a need for further research
(Wahl 2002; Hinshaw 2005; Hennessy, Swords
& Heary 2008).
Adolescence is a period of peak onset
of some mental disorders and is also a time
when relationships with peers assume great
significance (Sawyer et al. 2001; Kessler et
al. 2007). An improved understanding of
factors predicting stigma at this critical time
may help in the development of interventions to reduce stigma from peers and
improve help-seeking for those developing
mental disorders. The aim of this study was
to identify the predictors of stigmatising
attitudes towards depression in a group of
adolescent high school students in Australia.
Method
Participants
Eligible participants were students in the
middle years of school (i.e. Years 8–10, ages
12–15 years) recruited as part of a trial of
Mental Health First Aid for teachers (Jorm
et al. 2010). The project was approved by the
34
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VOLUME 30 NUMBER 2 2011
Human Research Ethics Committee of the
University of Adelaide. Questionnaires were
only provided to students whose parents gave
consent. This paper reports on baseline data
collected from 1,804 students, 53% of whom
were female and 47% male. The mean (SD)
age of participants was 13.7 (0.9) years and the
median age was 14. The majority (90.5%) spoke
English at home, 1.8% spoke another language
and 7.6% spoke English and another language.
Survey
The questionnaires covered the following:
Sociodemographic information
Sociodemographic information included age,
school grade, gender and language spoken
at home, with options for English, another
language and English and another language.
Recognition of depression in a vignette
The survey was based on the following,
previously validated vignette of a young
person with depression (Lubman et al. 2007):
Jenny is a 15-year-old who has been feeling
unusually sad and miserable for the last
few weeks. She is tired all the time and has
trouble sleeping at night. Jenny doesn’t feel
like eating and has lost weight. She can’t
keep her mind on her studies and her marks
have dropped. She puts off making any
decisions and even day-to-day tasks seem too
much for her. Her parents and friends are
very concerned about her.
After being presented with the vignette,
respondents were asked what they thought
was wrong with Jenny. Responses mentioning
depression were coded as ‘yes’ to recognition
while incorrect or missing responses were
coded as ‘no’.
Stigma towards a depressed peer
Students were asked questions to assess
personal and perceived stigma (Griffiths et al.
2004; Jorm & Wright 2008). Personal stigma
statements were preceded by the following:
The next few questions contain statements
about Jenny’s problem. Please indicate how
strongly you personally agree or disagree
with each statement.
TABLE 1 Predictors of stigmatising attitudes
Independent variables
Stigma ‘dangerous
/unpredictable’
OR (95% CI)
Stigma ‘weak not
sick’
OR (95% CI)
Perceived stigma
OR (95% CI)
Stigma ‘reluctance
to disclose’
OR (95% CI)
Male vs. female
1.39 (1.12-1.71)*
1.65 (1.32-2.05)***
1.15 (0.93-1.42)
1.20 (0.96-1.50)
Younger vs. older age
1.06 (0.94-1.18)
0.79 (0.70-0.89)***
1.06 (0.95-1.19)
1.14 (1.01-1.28)*
Language spoken at home Another language vs.
English
1.36 (0.56-2.81)
4.75 (1.97-11.46)**
0.53 (0.25-1.15)
1.08 (0.51-2.30)
English and another
language vs. English
1.73 (1.19-2.52)*
1.87 (1.27-2.75)**
1.35 (0.93-1.96)*
1.01 (0.69-1.49)
Yes vs. no
1.31 (1.07-1.61)*
0.47 (0.38-0.58)***
1.19 (0.97-1.46)
1.04 (0.84-1.29)
Received information
about mental health
problems from teachers
1.13(0.91-1.41)
0.92 (0.73-1.17)
0.99 (0.79-1.24)
1.11 (0.89-1.40)
Borderline vs. normal
0.99 (0.63-1.55)
0.99 (0.63-1.55)
1.50 (0.98-2.29)
1.65 (1.07-2.53)*
Abnormal vs. normal
1.12 (0.77-1.62)
0.58 (0.38-0.89)*
1.23 (0.85-1.78)
1.69 (1.16-2.47)**
Borderline vs. normal
1.17 (0.80-1.71)
1.56 (1.05-2.32)*
1.40 (0.93-1.99)
1.61 (1.10-2.36)*
Abnormal vs. normal
0.90 (0.62-1.30)
1.66 (1.12-2.44)*
0.84 (0.58-1.21)
1.54 (1.06-2.24)*
Borderline vs. normal
1.27 (0.92-1.76)
1.42 (1.01-1.99)*
0.97 (0.70-1.35)
1.18 (0.85-1.65)
Abnormal vs. normal
1.46 (1.08-1.96)*
1.30 (0.95-1.78)
1.10 (0.82-1.47)
1.01 (0.74-1.37)
Borderline vs. normal
1.013(0.75-1.41)
1.11 (0.80-1.55)
1.15 (0.84-1.58)
1.49 (1.08-2.04)*
Abnormal vs. normal
0.78 (0.47-1.31)
0.80 (0.47-1.37)
1.50 (0.90-2.49)
1.74 (1.05-2.91)*
Borderline vs. normal
0.98 (0.71-1.34)
1.12 (0.81-1.56)
0.69 (0.50-0.95)*
1.73 (1.25-2.38)*
Abnormal vs. normal
0.77 (0.55-1.08)
1.59 (1.12-2.26)*
0.89 (0.64-1.25)
1.42 (1.01-1.99)*
Recognition of depression
Emotional symptoms Conduct problems Hyperactivity Peer problems Prosocial problems Legend: *p<0.05; **p<0.01; ***p<0.001
Examples included: ‘Jenny could snap out
of it if she wanted’; ‘Jenny’s problem is not a
real medical illness’; and ‘Jenny is dangerous’.
The perceived stigma questions involved
the same items, but concerned what the
respondent thought others would believe.
All started with ‘Most other people believe
that …’. Each scale had seven statements
that were rated on a scale of: ‘strongly agree’,
‘agree’, ‘neither agree nor disagree’, ‘disagree’
or ‘strongly disagree’.
Beliefs about help-seeking
Students were given a list of 14 people or
services and asked if they would seek help
for these if they felt the same way as Jenny.
Response categories were ‘yes’, ‘no’ and ‘not
sure’. People and services were divided into
four categories:
• information sources: internet, posters/
pamphlets;
• informal personal sources: close family
member, close friend, community member;
Youth Studies Australia
VOLUME 30 NUMBER 2 2011
35
• p
rofessional sources: teacher, pastoral
care worker, community-based religious
leader, GP/family doctor, youth health
service; and
• mental health professionals: school/
student counsellor, telephone helpline,
Child and Adolescent Mental Health
Service (CAMHS), other mental health
professionals (MHPs).
Help/information received from teachers
Students were asked: ‘Over the past month,
have you received any information about
mental health problems from your teachers?’
(‘yes’, ‘no’).
Campaigns by
beyondblue,
the Australian
national
depression
initiative, have
been shown
to affect
knowledge of
depression,
but not social
distance.
Student mental health
Behavioural, emotional and relationship
strengths and difficulties were measured
by the self-rated Strengths and Difficulties
Questionnaire (SDQ) with five subscales of
five items each, rated ‘not true’, ‘somewhat
true’ or ‘certainly true’:
• hyperactivity (e.g. ‘I am constantly fidgety
or squirming’);
• emotional symptoms (e.g. ‘I am often
unhappy, depressed or tearful’);
• conduct problems (e.g. ‘I fight a lot. I can
make other people do what I want’);
• peer problems (e.g. ‘I have one good
friend or more’); and
• prosocial behaviour (e.g. ‘I am kind to
younger children’ (Goodman 1997).
An ‘abnormal’ score on a scale may be used
to identify participants who are likely to have
mental health issues or behavioural disorders.
Statistical methods
In order to identify components of stigma,
the stigma items were subjected to principal
components analysis with varimax rotation.1
Results
Principal components analysis
of stigma items
The scree plot indicated that four components
should be retained. The eigenvalues for the
first four components were 2.80, 1.91, 1.44,
1.10. Inspection of the rotated component
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Youth Studies Australia
VOLUME 30 NUMBER 2 2011
matrix revealed that one item: ‘If I had a
problem like Jenny’s, I would not tell anyone’
did not load with other items and it was
decided to force a three-factor solution using
the other items. In the resulting rotated
component matrix, the first component had
high loadings on perceived stigma items and
was labelled ‘perceived stigma’. The second
component was labelled ‘weak not sick’,
following the precedent of Jorm and Wright
(2008), as it had the highest loadings on the
items, ‘Jenny’s problem is not a real medical
illness’ and, ‘Jenny’s problem is a sign of
personal weakness’. The third component
had high loadings on items concerned with
danger and unpredictability (both personal
and perceived): (‘Jenny is dangerous’ and
‘Jenny’s problem makes her unpredictable’)
and was termed ‘stigma – dangerous/unpredictable’.
Scales were constructed by summing
the items with loadings greater than 0.5.
Cronbach’s alphas for the scales were: Stigma
‘dangerous/unpredictable: 0.60; stigma ‘weak
not sick’: 0.62; and perceived stigma: 0.61. For
the previous study (Jorm & Wright 2008) the
values were 0.68, 0.68 and 0.67 respectively.
Coefficients of congruence comparing the
loadings to those previously reported gave
values >0.99, which shows replication.
Factors associated with stigma
Sociodemographic factors were associated
with different stigma scales in different ways
(see Table 1). Higher ‘dangerous/unpredictable’ stigma scores were associated with male
gender, speaking both English and another
language at home, recognising depression in
the vignette and having abnormal levels of
hyperactivity–inattention on the SDQ. Higher
‘weak not sick’ stigma scores were predicted
by male gender, younger age, lack of
recognition of depression, speaking another
language or speaking both English and
another language at home, having borderline
and abnormal levels of conduct problems,
having abnormal hyperactivity–inattention,
having abnormal levels of prosocial problems
and normal levels of emotional symptoms.
Higher perceived stigma was predicted by
speaking both English and another language
at home, while borderline levels of prosocial
problems predicted reduced perceived
stigma. Higher ‘reluctance to disclose’ stigma
scores were predicted by older age, abnormal
levels of conduct problems, borderline
and abnormal levels of peer problems and
borderline and abnormal levels of prosocial
problems. Thus, SDQ psychopathology was
linked to a reluctance to disclose (other than
for hyperactivity–inattention). Externalising
problems (hyperactivity–inattention and
conduct problems), were largely linked to a
belief in weakness rather than sickness and
internalising problems (emotional problems
and peer problems) were linked to a belief in
sickness.
Discussion
The results support the growing number
of studies which suggest that depression
stigma is a multidimensional construct,
and that different factors predict different
aspects of stigma (Griffiths et al. 2008; Jorm
& Oh 2009). In the current study, those who
recognised depression in the vignette were
half as likely to believe that the person was
weak rather than sick, but were more likely
to believe that the person was dangerous or
unpredictable. Male gender was associated
with an increased belief in danger/unpredictability and weakness rather than sickness.
Older age was associated with a decreased
belief in weakness rather than sickness and
an increased reluctance to disclose. Speaking
a language other than English at home was
associated with an almost fivefold increase in
belief in weakness rather than sickness, and
speaking both English and another language
predicted increased belief in danger/unpredictability, weakness rather than sickness and
perceived stigma.
These results are somewhat similar to
other findings, particularly those indicating
that male gender and non-English-speaking
backgrounds tend to be associated with
higher stigmatising attitudes (Fan 1999;
Sheikh & Furnham 2000; Angermeyer &
Dietrich 2006). However, comparisons with
other studies are complicated by the limited
research involving adolescents, by differences
in the questionnaire items and descriptions of
disorders, and also by the lack of a generally
agreed set of components of stigma.
Two previous studies of attitudes
towards depression have used items similar
or identical to those used in the current
study (Griffiths, Christensen & Jorm 2008;
Jorm & Wright 2008). Griffiths, Christensen
and Jorm were interested in exploring two
types of stigma – personal and perceived
(using the same scale repeated, with one
referencing personal beliefs and the other
scale referencing other people’s beliefs),
while Jorm and Wright preferred a threecomponent interpretation, with ‘stigma
dangerous/unpredictable’, ‘stigma weak
not sick’ and ‘stigma perceived in others’ as
distinct constructs. Our results support the
latter interpretation and reinforce the need
to approach stigma as a multidimensional
construct, particularly when considering
interventions to reduce it. Evidence
suggests that no single effort reduces all
aspects of stigma, for example campaigns
by beyondblue, the Australian national
depression initiative, have been shown to
affect knowledge of depression, but not social
distance (Morgan & Jorm 2007).
In the current study, recognition of
depression was associated with the belief
that the person is sick rather than weak,
but also with the perception of danger and
unpredictability. In a study of US children
and adolescents aged 8–18, Walker et al.
(2008) found that, in comparison with
asthma and ADHD, depression was more
stigmatised and was particularly associated
with the perception of violence and antisocial
behaviour. Thus, evidence suggests that
efforts should be aimed at reducing the link
between recognition of depression and the
view that those with the disorder are unpredictable and dangerous. While the underlying
reasons for these views cannot be assessed
using our data, it is possible that media
portrayals of mental illness, which tend to be
biased toward depictions of danger, may be
a contributory factor (Wahl 2002; Morgan &
Jorm 2009).
The results also suggest that those who
speak languages other than English are an
Youth Studies Australia
VOLUME 30 NUMBER 2 2011
37
important target for stigma reduction. The
association between non-English-speaking
backgrounds and the perception of weakness
rather than sickness is particularly notable.
This may underlie the lower levels of helpseeking reported in those from different ethnic
backgrounds, as there is some evidence that
lack of recognition of depression contributes
to lower levels of help-seeking in ethnic
populations (Klimidis, Hsiao & Minas 2007).
It is likely that interventions need to target
the whole family and be adapted to particular
cultural contexts, as illness labels vary between
cultural groups and from society to society (Yeh
et al. 2003; Minas, Klimidis & Tuncer 2007).
Analysis of SDQ subscale scores revealed
that psychopathology was generally linked
to a reluctance to disclose. It is possible
that those with peer, conduct and prosocial
problems would be less likely to disclose
mental health problems to those around them
as these relationships are less likely to be
supportive (Offer et al. 1991; Marcus 1996). It
is of concern that the students most in need of
support are the least likely to disclose, particularly in the case of those with emotional
problems, who would be most similar to the
person portrayed in the vignette. This is a
barrier to getting both professional help and
support from the person’s social network.
However, the cross-sectional nature of the
data makes it difficult to interpret these results
more fully and there is a need for studies
that allow for the separation of stigmatising
attitudes from mental disturbance.
Limitations
Interpretation of the study findings is limited
by the cross-sectional nature of the study.
There is a need for longitudinal studies to
explore causal relationships and changes in
stigmatising attitudes over time. A further
limitation is the use of self-report data, as the
stigma items may be open to social desirability bias. In addition, other aspects of stigma,
notably social distance, were not measured in
the current study. There is a general need for
a more systematic examination of the various
aspects of stigmatising attitudes towards
different mental disorders in adolescents. This
should include behavioural aspects and links
38
Youth Studies Australia
VOLUME 30 NUMBER 2 2011
between different aspects of stigma and helpseeking.
Conclusions
Study results support the view of depression
stigma as a multidimensional construct
with different dimensions predicted by
different factors. In this study, an increased
recognition of depression was associated
with an increased belief in depression as a
sickness rather than a weakness, but also with
an increased belief in danger and unpredictability. Male gender and speaking a language
other than English also predicted greater
stigma, as did SDQ psychopathology. It is
likely that multifaceted interventions are
needed to target different aspects of stigma,
with a particular emphasis on reducing the
associations between depression and danger,
and targeting those of non-English-speaking
backgrounds.
Notes
1. Inspection of eigenvalues and the scree
plot were used to determine the number of
components to retain. Using coefficients of
congruence, the resulting components were
compared with those from an analysis of the
items obtained in a national survey of young
Australians (Jorm & Wright 2008). Items were
summed into scales based on the components
on which they loaded most highly and the
reliability assessed using Cronbach’s alpha
coefficients. Following the method used in
a previous study (Jorm & Wright 2008), the
resulting scales were dichotomised at the
median and used as dependent variables in
binary logistic regression analyses examining
the following as predictors of stigmatising
attitudes: gender, age, language spoken at
home, recognition of depression, receipt of information about mental health problems from
teachers and SDQ subscales. All analyses were
performed using PASW Release 18.
Acknowledgements
The authors would like to thank Betty
Kitchener, Michael Sawyer and Helen Scales
for their role in the study from which the data
were taken. Funding was provided by the
Australian Research Council, the NHMRC
and the Colonial Foundation.
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Youth Studies Australia
There is some
evidence
that lack of
recognition
of depression
contributes to
lower levels of
help-seeking
in ethnic
populations.
VOLUME 30 NUMBER 2 2011
39
AUTHORS
Nicola Reavley is
a research fellow
at Orygen Youth
Health Research
Centre, University of
Melbourne. She is
a chief investigator
on the MindWise
project, which
aims to evaluate
the effects of a
multifaceted mental
health literacy
intervention in
further education
students.
Anthony Jorm is a
professorial fellow at
Orygen Youth Health
Research Centre at
the University of
Melbourne and an
NHMRC Australia
Fellow. His research
focuses on public
knowledge and
beliefs about
mental illnesses,
and particularly on
interventions to
improve the public’s
helpfulness towards
people developing
mental illnesses.
40
Minas, H., Klimidis, S. & Tuncer, C. 2007, ‘Illness
causal beliefs in Turkish immigrants’, BMC
Psychiatry, v.7, n.34.
Morgan, A.J. & Jorm, A.F. 2007, ‘Awareness of
beyondblue: The national depression initiative in
Australian young people’, Australasian Psychiatry,
v.15, n.4, pp.329-33.
—— 2009, ‘Recall of news stories about mental
illness by Australian youth: Associations with
help-seeking attitudes and stigma’, Australian
and New Zealand Journal of Psychiatry, v.43, n.9,
pp.866-72.
Moses, T. 2009, ‘Stigma and self-concept among
adolescents receiving mental health treatment’,
American Journal of Orthopsychiatry, v.79, n.2,
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