In this study of stigma associated with depression treatment, we found that for all four depression treatments, stigma increased as the focus moved from the individual to the wider community; a minority of individuals reported feelings of personal shame and over half reported fear of their community and workplace knowing of any depression treatment. These results mirror prior findings from depressed patients where 24% reported expecting depression-related stigma to have a negative impact on friends and 67% a negative impact on employment.27
Our results indicate, then that despite our study being vignette-based with participants being asked to project themselves into a hypothetical depressed state, participants appeared to perceive similar negative societal views about depression and were concerned with revealing a diagnosis of depression in the same way as has been shown in actual depressed patients.
We hypothesized that stigma would differ between treatment modalities and found that herbal remedy was less stigmatizing than prescription medication or mental health counseling. We also found that stigma affected the acceptability of treatments differently. In adjusted analyses, treatment stigma adversely affected the acceptability of mental health counseling but not prescription medication. These findings suggest that participants may perceive concealing a depression diagnosis to be more difficult when seeing a mental health specialist than when seeing a pharmacist for medication. If true, integrating specialty mental health care into the primary care setting could help to address this concern. Unfortunately, although integrated mental health care is associated with better patient outcomes as well as higher patient and provider satisfaction,28–30
these arrangements are not always feasible and often are not available to patients.
We sought to investigate whether treatment stigma differed for African Americans and whites and whether such a difference could explain racial differences in treatment acceptability. Contrary to prior findings from qualitative work,18
but consistent with other quantitative results,31
we found stigma to be higher among whites than African Americans. Thus, although African Americans in our study reported lower acceptability of prescription medication, a finding seen in prior work,14
this lower acceptability could not be explained by concerns about stigma. These variations in ethnic differences in stigma argue for further research into the particular aspects of stigma which may be salient to particular populations, as well as larger studies examining stigma across ethnic groups.
Our results should be interpreted in light of certain methodological limitations as well as the particular characteristics of our sample. We utilized a vignette-based questionnaire to assess intended rather than observed behavior. As noted, however, our findings mirror those reported for actual patients with depression. Because we were specifically interested in isolating the effect of stigma on treatment acceptability, we intentionally stated in the vignette that all treatments were low cost to eliminate cost concerns from influencing the relative acceptability of the treatments. This constraint may have had the effect of raising the overall acceptability of treatments. We developed new treatment stigma items not tested in other populations. These items, which were intended to capture specific components of stigma associated with treatment, may have also captured stigma associated with the diagnosis of depression, thus limiting our ability to measure the intensity of stigma associated with specific treatment modalities. In addition, our focus on the aspects of shame and fear of disclosure as well as our use of yes/no response options may have limited our ability to capture both the breadth and subtlety of stigma concerns. Our sample was purposefully limited to African Americans and whites, and so, our findings cannot be generalized to other racial groups. These constraints to generalizability were counterbalanced, somewhat, by the strengths of our study, which included the use of random sampling from a large population of primary care patients and the inclusion of patients with a range of depressive symptom levels.
In our sample population, the majority of respondents found the proposed depression treatments acceptable. Other patients less enthusiastic about depression treatment may display higher levels of stigma. Our sample also reported a higher than expected (30%) prevalence of a history of depression. This self-reported history likely includes those with prior major depression as well as those with milder episodes of symptoms not meeting criteria for major depression. Whereas screening measures such as the PHQ-9 may overestimate true disease levels, participants had levels of current depressive symptoms similar to those expected in primary care, where the combined prevalence of major and minor depression ranges from 13.2 to −18.3%.32
Our sample also reported high rates of depression treatment. Because of the general nature of this question, however, it is not clear that these reported rates of treatment reflect a full treatment course of either medication or counseling.
Our study demonstrates a significant relationship between treatment stigma and treatment acceptability for mental health counseling, an important treatment option in primary care settings and one generally preferred by patients.15,33
This suggests that providers should be aware that stigma could play a determinative role in whether this treatment will be accepted. Because of the nature of stigma, it may be difficult for patients to bring up the topic. Some argue that providers should elicit patient’s concerns regarding self-image, social support, and fears of discrimination regarding mental health treatment.34
Our findings support such inquiry as well as future research into how clinicians might best approach discussing treatment stigma with their patients. Such discussions can be an important step in reducing treatment stigma and may help to individualize treatment plans in a manner congruent with the patient’s social pressures and preferences.