To our knowledge, this is the first direct comparison between the patterns of predictors for perceived and personal stigma. It is also the first study to systematically investigate the predictors of personal stigma (including depression literacy) among people with a high level of depressive symptoms.
Notably, the pattern of findings for personal stigma was very similar for the national, community and depressed samples (see Table ). For each of these samples, personal stigma was higher among men, and those with less education, greater psychological distress, and lower depression literacy. In addition, a lower level of self-reported prior contact with depression was associated with higher stigma in both the national and community samples. These findings differed from those for perceived stigma in a number of important ways. First, the percentage of variance in perceived stigma that was explained by predictors was very small, particularly for the national survey. Secondly, the pattern of findings for perceived stigma showed somewhat greater inconsistency across and within the three samples. Thirdly, some of the associations were reversed in comparison with the pattern noted for personal stigma. Thus, with some exceptions, self-reported contact tended to be associated with higher perceived stigma, whereas it was associated with consistently lower personal stigma. Similarly, in contrast to the pattern for personal stigma, depression literacy did not affect level of perceived stigma and perceived stigma was not higher among men, being either less (community sample) or equal to that for women. Findings for age also differed for the two types of stigma. The only consistently similar finding for personal and perceived stigma was that current psychological distress was a predictor for both stigma types.
Summary of variables that predict depression stigma and attitudinal social distance for each of the three surveys.
The finding that the pattern of predictors differed for personal/public and perceived stigma demonstrates the importance of treating these concepts separately, not only in designing measures of stigma (some researchers combine perceived and personal stigma items in one scale) and in interpreting the pattern of findings in studies of the predictors of stigma, but also in designing, interpreting the impact of and disseminating interventions for stigma.
On the other hand, the evidence that the pattern of findings for personal stigma in people with depression is similar to that for people in the broader community, demonstrates for the first time that similar risk factors for personal stigma apply whether the person is depressed or not. Thus the current findings suggest public destigmatisation programs targeted at those who are less educated, male, or born overseas or who have higher current psychological distress and lower depression literacy may also be effective in targeting those people with depression who are most at risk of holding stigmatising (personal) views. However, since personal stigma may be associated with a number of negative clinical outcomes including reduced adherence to appropriate treatments, such programs should not be restricted to public health campaigns but should also be applied at an individual level by health practitioners when providing treatment to people with depression.
As has been reported in previous studies [2
], self reported contact with depression was associated with lower personal stigma and lower social distance. However, family members (Sample 1) and members of the general community with higher levels of contact with depression (Sample 2) reported higher levels of perceived stigma. It is not clear whether this effect results from a greater exposure by those in closer contact to instances of stigma and discrimination directed at people with depression or a greater sensitivity to such events or both. By contrast, people self-reporting a history of depression in the national sample showed both lower personal stigma/social distance and lower perceived stigma. If exposure to stigma were critical in yielding higher levels of perceived stigma, it might have been expected that, like family members, this group would show higher perceived stigma. It may be that participants in the face-to-face survey who were willing to report a history of depression were those who perceived less stigma in the community and hence less reason to conceal their history of illness. Equally, it is possible that the association between personal
stigma/social distance and self-reported depression was affected by the respondents' willingness to self-disclose the presence of depression, particularly given that one of the personal stigma items was "If I had a problem like John's I would not tell anyone". Finally, the finding that providers of mental health services show less personal stigma in both the national and community samples is of interest given the often cited claim that stigma is high among providers. In fact, health providers ranked lowest on personal stigma of all levels of contact for Sample 2 (see Figure ).
Relationship between Personal stigma and level of contact (based on modified Level of Contact Report ).
We found that depression literacy was associated with lower personal stigma in the depressed group and that correctly recognising depression was associated with less personal stigma and lower social distance in the national sample as was knowledge of beyondblue
, Australia's national depression initiative. These findings are contrary to those of Lauber et al.[2
], who reported higher levels of social distance among participants who recognised a depression vignette as depicting a 'mental illness' in a national Swiss survey. They also differ from Angermeyer and Matschinger's findings from a representative survey in Germany, which found that labelling a depression vignette as either depression or another mental illness was unrelated to social distance [31
]. It is unclear if the discrepancies between these findings and our own arise as a result of cultural differences or some other factor such as the use of different tasks of recognition and literacy. It is encouraging that in our Australian sample, those who recalled the national depression initiative, and those with better depression knowledge held less stigmatising attitudes. However, it is not possible to determine if this knowledge leads to lower personal stigma or if lower personal stigma leads to improved knowledge.
We have previously reported substantially higher levels of perceived compared to personal stigma in surveys 1 and 3 [15
]. Griffiths et al. [18
] suggested that this pattern might be attributable to an over-estimation of the prevalence of stigmatising beliefs in the community due to improved awareness of depression resulting from initiatives such as beyondblue
. However, the current analysis yielded no evidence that awareness of beyondblue
was associated with greater perceived stigma (p = 0.66). It is still possible that general media exposure about depression, some of which may have been triggered or promoted by public health initiatives such as beyondblue
has led to an overall increase in perceived stigma. Indeed, we have previously reported that there has been an increase over a 7 year period in the belief that a person with depression would be discriminated against, particularly in those Australian States with greatest exposure to beyondblue
We found that level of current psychological distress was associated both with higher personal stigma and higher perceived stigma in each of the samples. This is consistent with findings from two other studies of a relationship between level of depressive symptomatology and stigma where the latter was evaluated with a measure comprising mixed personal and perceived items in one case [9
] and primarily perceived items in the other [16
]. Two other studies found no effect of depression severity on measures comprising perceived [12
] and primarily perceived stigma items respectively [7
]. In the current study, when CES-D scores were substituted for K10 scores in the hierarchical regression, higher CES-D depressive symptoms were associated with higher perceived stigma (p = 0.001) but not higher personal stigma (p = 0.21). This raises the possibility that the K10 is tapping a factor other than level of depressive symptoms that is important in personal stigma. Substitution for the K10 by the ATQ, a measure of dysfunctional thoughts, produced a similar pattern to the CES-D suggesting that cognitive distortions may be particularly important in the perceptions of others' attitudes. Further investigation of these factors is required.
The finding that the level of personal and perceived stigma among rural residents is the same as that among their city counterparts challenges the common belief that level of stigma associated with depression is higher among rural residents than those in the city [32
]. Significantly, this was true both controlling for and not controlling for demographic and other variables. Apart from the current study, there is little empirical evidence concerning the relative prevalence of stigma in rural and city residents. One previous US study did investigate perceived stigma among local convenience samples of city and rural residents with and without depressive symptoms in two adjacent counties [33
]. In that study there were no rural-urban differences in perceived stigma associated with the condition of depression itself or with treatment for the overall sample. Rural residents with depressive symptoms did show a non-significant trend towards greater perceived treatment stigma, but this effect disappeared after controlling for education.