Self-labeling as having a mental or physical illness: the effects of stigma and implications for help-seeking

Abstract

Purpose

Personal and perceived stigma can hinder persons in appraising their symptoms as constituting part of a mental illness (self-labeling), an important early step in the help-seeking process. This study examines the impact of personal and perceived stigma on self-labeling and provides prospective data on the possible connections between self-labeling and help-seeking behavior.

Methods

Personal stigmatizing attitudes, perceived stigma and self-labeling behavior as well as their statistical connections were cross-sectionally investigated in a community sample of 207 participants with a present untreated mental health problem. We further conducted prospective analyses to investigate possible associations between self-labeling and help-seeking behavior at 3 and 6 month follow-ups. Socio-demographics, previous treatment and depression symptoms were also measured as potential confounders.

Results

Personal stigmatizing attitudes were significantly more pronounced in respondents who self-labeled as physically compared to mentally ill, while group differences in levels of perceived stigma were not. Self-labeling as physically or mentally ill increased the likelihood of seeking help from the health service provider deemed most suitable for that label (physical: GP, p <0.05; mental: MHP, p < 0.1) compared to persons who applied no self-label.

Conclusions

The findings suggest that personal stigmatizing attitudes—rather than perceived stigma—impact on self-labeling, and highlight the need for interventions that assist persons with mental illness in overcoming those attitudes. They also underscore the possible impact of self-labeling in the help-seeking process and underline the important role of GPs in mental health care. Further, preferably epidemiological research into the matter would be desirable.

This is a preview of subscription content, access via your institution.

Fig. 1

References

  1. 1.

    Thornicroft G, Chatterji S, Evans-Lacko S, Gruber M, Sampson N, Aguilar-Gaxiola S, Al-Hamzawi A, Alonso J, Andrade L, Borges G, Bruffaerts R, Bunting B, de Almeida JM, Florescu S, de Girolamo G, Gureje O, Haro JM, He Y, Hinkov H, Karam E, Kawakami N, Lee S, Navarro-Mateu F, Piazza M, Posada-Villa J, de Galvis YT, Kessler RC (2017) Undertreatment of people with major depressive disorder in 21 countries. Br J Psychiatry 210:119–124

    PubMed  PubMed Central  Article  Google Scholar 

  2. 2.

    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(9590):841–850

    PubMed  PubMed Central  Article  Google Scholar 

  3. 3.

    Kohn R, Saxena S, Levav I, Saraceno B (2004) The treatment gap in mental health care. Bull World Health Organ 82(11):858–866

    PubMed  PubMed Central  Google Scholar 

  4. 4.

    Thornicroft G (1991) Social deprivation and rates of treated mental disorder. Developing statistical models to predict psychiatric service utilization. Br J Psychiatry 158(4):475–484

    CAS  PubMed  Article  Google Scholar 

  5. 5.

    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. https://doi.org/10.1186/1471-244X-10-113

    Article  PubMed  PubMed Central  Google Scholar 

  6. 6.

    Tomczyk S, Muehlan H, Freitag S, Stolzenburg S, Schomerus G, Schmidt S (2018) Is knowledge “half the battle”? The role of depression literacy in helpseeking among a non-clinical sample of adults with currently untreated mental health problems. J Affect Disord 238:286–296

    Article  Google Scholar 

  7. 7.

    Green AC, Hunt C, Stain HJ (2012) The delay between symptom onset and seeking professional treatment for anxiety and depressive disorders in a rural Australian sample. Soc Psychiatry Psychiatr Epidemiol 47(9):1475–1487

    PubMed  Article  Google Scholar 

  8. 8.

    Evans-Lacko S, Knapp M (2016) Global patterns of workplace productivity for people with depression: absenteeism and presenteeism costs across eight diverse countries. Soc Psychiatry Psychiatr Epidemiol 51(11):1525–1537

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  9. 9.

    Newheiser AK, Barreto M (2014) Hidden costs of hiding stigma: ironic interpersonal consequences of concealing a stigmatized identity in social interactions. J Exp Soc Psychol 52:58–70

    Article  Google Scholar 

  10. 10.

    Saunders S, Bowersox N (2007) The process of seeking treatment for mental health problems. Mental Health Learn Disabil Res Pract 4(2):99–123

    Article  Google Scholar 

  11. 11.

    Rickwood D, Thomas K (2012) Conceptual measurement framework for help-seeking for mental health problems. Psychol Res Behav Manag 5:173–183

    PubMed  PubMed Central  Article  Google Scholar 

  12. 12.

    Schomerus G, Stolzenburg S, Freitag S, Speerforck S, Janowitz D, Evans-Lacko S, Muehlan H, Schmidt S (2018) Stigma as a barrier to recognizing personal mental illness and seeking help: a prospective study among untreated persons with mental illness. Eur Arch Psychiatry Clin Neurosci. https://doi.org/10.1007/s00406-018-0896-0

    Article  PubMed  Google Scholar 

  13. 13.

    Stolzenburg S, Freitag S, Evans-Lacko S, Muehlan H, Schmidt S, Schomerus G (2017) The stigma of mental illness as a barrier to self-labeling as having a mental illness. J Nervous Mental Dis 205:903–909

    Article  Google Scholar 

  14. 14.

    Thoits PA (1985) Self-Labeling processes in mental illness: the role of emotional deviance. Am J Sociol 91:221–249

    Article  Google Scholar 

  15. 15.

    Leventhal H, Leventhal EA, Contrada RJ (1998) Self-regulation, health, and behavior: a perceptual-cognitive approach. Psychol Health 13:717–733

    Article  Google Scholar 

  16. 16.

    Ali K, Farrer L, Fassnacht DB, Gulliver A, Bauer S, Griffiths KM (2017) Perceived barriers and facilitators towards help-seeking for eating disorders: a systematic review. Int J Eat Disord 50(1):9–21

    PubMed  Article  Google Scholar 

  17. 17.

    Clement S, Schauman O, Graham T, Maggioni F, Evans-Lacko S, Bezborodovs N, Morgan C, Rusch N, Brown JS, Thornicroft G (2015) What is the impact of mental health-related stigma on help-seeking? A systematic review of quantitative and qualitative studies. Psychol Med 45(1):11–27

    CAS  PubMed  Article  Google Scholar 

  18. 18.

    Coleman SJ, Stevelink SAM, Hatch SL, Denny JA, Greenberg N (2017) Stigma-related barriers and facilitators to help seeking for mental health issues in the armed forces: a systematic review and thematic synthesis of qualitative literature. Psychol Med 47(11):1880–1892

    CAS  PubMed  Article  Google Scholar 

  19. 19.

    Gronholm PC, Thornicroft G, Laurens KR, Evans-Lacko S (2017) Mental health-related stigma and pathways to care for people at risk of psychotic disorders or experiencing first-episode psychosis: a systematic review. Psychol Med 47:1–13

    Article  Google Scholar 

  20. 20.

    Eisenberg D, Downs MF, Golberstein E, Zivin K (2009) Stigma and help seeking for mental health among college students. Med Care Res Rev 66(5):522–541

    PubMed  Article  Google Scholar 

  21. 21.

    Corrigan P (2004) How stigma interferes with mental health care. Am Psychol 59:614–625

    PubMed  Article  Google Scholar 

  22. 22.

    Corrigan PW, Druss BG, Perlick DA (2014) The impact of mental illness stigma on seeking and participating in mental health care. Psychol Sci Public Interest 15:37–70

    PubMed  Article  Google Scholar 

  23. 23.

    Savage H, Murray J, Hatch SL, Hotopf M, Evans-Lacko S, Brown JS (2016) Exploring professional help-seeking for mental disorders. Qual Health Res 26:1662–1673

    PubMed  Article  Google Scholar 

  24. 24.

    Komiti A, Judd F, Jackson H (2006) The influence of stigma and attitudes on seeking help from a GP for mental health problems. Soc Psychiatry Psychiatr Epidemiol 41:738–745

    PubMed  Article  Google Scholar 

  25. 25.

    Golberstein E, Eisenberg D, Gollust SE (2008) Perceived stigma and mental health care seeking. Psychiatr Serv 59:392–399

    PubMed  Article  Google Scholar 

  26. 26.

    Schmidt S, Thyen U, Chaplin J, Mueller-Godeffroy E, and the DISABKIDS group (2007) Cross-cultural development of a child health care questionnaire on satisfaction, utilization and needs (CHC-SUN). Ambul Pediatrics 132:374–382 (now Academic Pediatrics)

    Article  Google Scholar 

  27. 27.

    Schomerus G, Matschinger H, Angermeyer MC (2009) Attitudes that determine willingness to seek psychiatric help for depression: a representative population survey applying the theory of planned behaviour. Psychol Med 39(11):1855–1865

    CAS  PubMed  Article  Google Scholar 

  28. 28.

    Schomerus G, Matschinger H, Angermeyer MC (2009) The stigma of psychiatric treatment and help-seeking intentions for depression. Eur Arch Psychiatry Clin Neurosci 259:298–306

    PubMed  Article  Google Scholar 

  29. 29.

    Schnyder N, Panczak R, Groth N, Schultze-Lutter F (2017) Association between mental health-related stigma and active help-seeking: systematic review and meta-analysis. Br J Psychiatry J Mental Sci 210(4):261–268

    Article  Google Scholar 

  30. 30.

    Schomerus G, Auer C, Rhode D, Luppa M, Freyberger HJ, Schmidt S (2012) Personal stigma, problem appraisal and perceived need for professional help in currently untreated depressed persons. J Affect Disord 139(1):94–97

    PubMed  Article  Google Scholar 

  31. 31.

    Biddle L, Donovan J, Sharp D, Gunnell D (2007) Explaining non-help-seeking amongst young adults with mental distress: a dynamic interpretive model of illness behaviour. Sociol Health Illn 29(7):983–1002

    PubMed  Article  Google Scholar 

  32. 32.

    Barney LJ, Griffiths KM, Jorm AF, Christensen H (2006) Stigma about depression and its impact on help-seeking intentions. Aust N Z J Psychiatry 40:51–54

    PubMed  Article  Google Scholar 

  33. 33.

    Alonso J, Angermeyer MC, Bernert S, Bruffaerts R, Brugha TS, Bryson H, de Girolamo G, Graaf R, Demyttenaere K, Gasquet I, Haro JM, Katz SJ, Kessler RC, Kovess V, Lepine JP, Ormel J, Polidori G, Russo LJ, Vilagut G, Almansa J, Arbabzadeh-Bouchez S, Autonell J, Bernal M, Buist-Bouwman MA, Codony M, Domingo-Salvany A, Ferrer M, Joo SS, Martinez-Alonso M, Matschinger H, Mazzi F, Morgan Z, Morosini P, Palacin C, Romera B, Taub N, Vollebergh WA, Investigators EM (2004) Prevalence of mental disorders in Europe: results from the European study of the epidemiology of mental disorders (ESEMeD) project. Acta Psychiatr Scand Suppl 420:21–27

    Google Scholar 

  34. 34.

    Gräfe K, Zipfel S, Herzog W, Löwe B (2004) Screening psychischer Störungen mit dem “Gesundheitsfragebogen für Patienten (PHQ-D)”. Diagnostica 50:171–181

    Article  Google Scholar 

  35. 35.

    Kroenke K, Spitzer RL, Williams JB, Löwe B (2010) The patient health questionnaire somatic, anxiety, and depressive symptom scales: a systematic review. Gen Hosp Psychiatry 32:345–359

    PubMed  Article  Google Scholar 

  36. 36.

    Ackenheil M, Stotz-Ingenlath G, Dietz-Bauer R, Vossen A (1999) MINI mini international neuropsychiatric interview, German Version 5.0. 0 DSM IV. Germany: Psychiatrische Universitätsklinik München

  37. 37.

    Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, Hergueta T, Baker R, Dunbar GC (1998) The mini-international neuropsychiatric interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry 59:22–33

    PubMed  PubMed Central  Google Scholar 

  38. 38.

    Corrigan PW, Watson AC, Barr L (2006) The self-stigma of mental illness: implications for self-esteem and self-efficacy. J Soc Clin Psychol 25(9):875–884

    Article  Google Scholar 

  39. 39.

    Mojtabai R (2010) Mental illness stigma and willingness to seek mental health care in the European union. Soc Psychiatry Psychiatr Epidemiol 45:705–712

    PubMed  Article  Google Scholar 

  40. 40.

    Angermeyer MC, Heiß S, Kirschenhofer S, Ladinser E, Löffler W, Schulze B, Swiridoff M (2003) The German version of the community-attitudes-toward-the-mentally-Ill (CAMI) Inventory. Psychiatr Prax 30(4):202–206

    PubMed  Article  Google Scholar 

  41. 41.

    Link BG, Cullen FT, Frank J, Wozniak JF (1987) The social rejection of former mental patients—understanding why labels matter. Am J Sociol 92:1461–1500

    Article  Google Scholar 

  42. 42.

    Downey RG, King C (1998) Missing data in Likert ratings: a comparison of replacement methods. J Gen Psychol 125:175–191

    CAS  PubMed  Article  Google Scholar 

  43. 43.

    Roth PL, Switzer FS, Switzer DM (1999) Missing data in multiple item scales: a Monte Carlo analysis of missing data techniques. Organ Res Meth 2:211–232

    Article  Google Scholar 

  44. 44.

    Statistical Office Germany (2015) https://www.destatis.de/DE/ZahlenFakten/GesellschaftStaat/BildungForschungKultur/Bildungsstand/Tabellen/Bildungsabschluss.html. Accessed April 2, 2019

  45. 45.

    Wrigley S, Jackson H, Judd F, Komiti A (2005) Role of stigma and attitudes toward help-seeking from a general practitioner for mental health problems in a rural town. Aust N Z J Psychiatry 39:514–521

    PubMed  Article  Google Scholar 

  46. 46.

    Altweck L, Marshall TC, Ferenczi N, Lefringhausen K (2015) Mental health literacy: a cross-cultural approach to knowledge and beliefs about depression, schizophrenia and generalized anxiety disorder. Front Psych. https://doi.org/10.3389/fpsyg.2015.01272

    Article  Google Scholar 

  47. 47.

    Wang PS, Angermeyer M, Borges G, Bruffaerts R, Tat Chiu WAI, De Girolamo G, Fayyad J, Gureje OYE, Haro JM, Huang Y, Kessler RC, Kovess V, Levinson D, Nakane Y, Oakley Brown MA, Ormel JH, Posada-Villa J, Aguilar-Gaxiola S, Alonso J, Lee S, Heeringa S, Pennell BE, Chatterji S, Üstün TB, Committee for The WHO World Mental Health Survey (2007) Delay and failure in treatment seeking after first onset of mental disorders in the world health organization’s world mental health survey initiative. World Psychiatry 6:177–185

    PubMed  PubMed Central  Google Scholar 

  48. 48.

    Brandstetter S, Dodoo-Schittko F, Speerforck S, Apfelbacher C, Grabe H-J, Jacobi F, Hapke U, Schomerus G, Baumeister SE (2017) Trends in non-help-seeking for mental disorders in Germany between 1997–1999 and 2009–2012: a repeated crosssectional study. Soc Psychiatry Psychiatr Epidemiol 52:1–9

    Article  Google Scholar 

  49. 49.

    Evans-Lacko S, Brohan E, Mojtabai R, Thornicroft G (2012) Association between public views of mental illness and self-stigma among individuals with mental illness in 14 European countries. Psychol Med 42:1741–1752

    CAS  PubMed  Article  Google Scholar 

  50. 50.

    Makowski AC, Mnich EE, von dem Knesebeck O (2018) Self-stigma of depression scale SSDS—Evaluation der deutschen skalenversion [Self-stigma of depression scale SSDS—evaluation of the German Version]. Psychiat Prax 45:314–320

    Article  Google Scholar 

  51. 51.

    Schenner M, Kohlbauer D, Meise U, Haller C, Pixner-Huber M, Stürz K, Günther V (2018) „StigMa“—evaluation eines psychologischen Therapieprogramms zu Stigma-Management [“StigMa”—evaluation of a psychological therapy program for stigma-management]. Psychiat Prax 45:16–22

    Article  Google Scholar 

  52. 52.

    Corrigan P, Morris SB, Michaels P, Rafacz J, Rüsch N (2012) Challenging the public stigma of mental illness: a meta-analysis of outcome studies. Psychiatr Serv 63:963–973

    PubMed  Article  Google Scholar 

  53. 53.

    Thornicroft G, Mehta N, Clement S, Evans-Lacko S, Doherty M, Rose D, Koschorke M, Shidhaye R, O’Reilly C, Henderson C (2016) Evidence for effective interventions to reduce mental-health-related stigma and discrimination. Lancet 387:1123–1132

    PubMed  Article  Google Scholar 

  54. 54.

    Corrigan PW, Schmidt A, Bink AB, Nieweglowski K, Al-Khouja MA, Qin S, Discont S (2016) Changing public stigma with continuum beliefs. J Ment Health 26:1–8

    Google Scholar 

  55. 55.

    Schomerus G, Angermeyer MC, Baumeister SE, Stolzenburg S, Link BG, Phelan JC (2016) An online intervention using information on the mental health-mental illness continuum to reduce stigma. Eur Psychiatry 32:21–27

    CAS  PubMed  Article  Google Scholar 

  56. 56.

    Schomerus G, Matschinger H, Angermeyer MC (2013) Continuum beliefs and stigmatizing attitudes towards persons with schizophrenia, depression and alcohol dependence. Psychiatry Res 209:665–669

    PubMed  Article  Google Scholar 

Download references

Acknowledgements

This work was funded by the Deutsche Forschungsgemeinschaft (DFG) (grant IDs SCHO 1337/4-1 and SCHM 2683/4-1). The authors declare no conflict of interest.

Author information

Affiliations

Authors

Corresponding author

Correspondence to Philip Horsfield.

Ethics declarations

Ethical standards

The study was approved by the local ethics committee of University Medicine Greifswald. The manuscript does not contain clinical studies or patient data.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Horsfield, P., Stolzenburg, S., Hahm, S. et al. Self-labeling as having a mental or physical illness: the effects of stigma and implications for help-seeking. Soc Psychiatry Psychiatr Epidemiol 55, 907–916 (2020). https://doi.org/10.1007/s00127-019-01787-7

Download citation

Keywords

  • Stigma
  • Self-labeling
  • Help-seeking
  • Personal stigmatizing attitudes
  • Mental health