Personal Stigma and Use of Mental Health Services Among People with Depression in a General Population in Finland

Esa Aromaa; Asko Tolvanen; Jyrki Tuulari; Kristian Wahlbeck


BMC Psychiatry. 2011;11 

In This Article


To our knowledge this is the first large population study in Europe that investigates the connection between stigmatizing attitudes and actual use of mental health services among those with depression.

Some limitations of our study need to be considered. First, the survey response rate was 51.6%. It is however increasingly difficult to reach higher response rates in mail surveys of the general population, and it has been claimed that percentages over 50 are acceptable and even in some cases good.[28] In our data the risk of non-response bias is highest among the young, with the response rate was below 40% for those aged 16–23 and also among men, whose overall response rate was 43%. Second, because we chose to customize the attitude and discrimination scales for our population we must be careful when comparing our results with earlier studies. However, many individual scale items were identical with items used in previous stigma studies. The internal consistency of our depression stigma- and discrimination-scales is acceptable if we take into the consideration the shortness of our scales.[29] Third, in some attitude items we use such vague expressions as "mental health problem" or "mental illness" which can be perceived in different ways by respondents. It is possible that a person with depression does not think that he or she has a "mental health problem". We also know that stereotypes connected with different mental conditions can vary a lot.[30] Fourth, this study is a cross-sectional study and cannot be taken as providing evidence of causal relationship between the attitude items and scales and professional help-seeking. People's experiences of health care services probably have an effect on their attitudes as has been shown in previous studies.[31,32] Finally, social desirability may always have an effect on attitude questionnaires. People are likely to underreport their stigmatizing stereotypes compared with their real-life behavior. In our social distance scale we measure people's intentions, not their actual behavior.

When inspecting the actual self-reported professional service use among those with depression, more active use of services is connected with realistic views on the effects of antidepressants and fewer discriminative social intentions. Interaction between the severity of depression and stigma may also have an important role in mental health service use.

Occurrence of depression and personal beliefs about one's own responsibility for depression did not correlate. One might expect people with depression to be aware that they are not responsible for their problems, but our results suggest that many of them also share the stereotypes prevailing in society and maybe stigmatize themselves. An alternative explanation for this result is depression itself. Self-accusation is one of the typical symptoms in depression and it may counteract the personal knowledge about the nature of origins of depression.

On the social discrimination scale, people with depression showed more social tolerance towards people with mental problems. This replicates results from previous studies.[33,34] The greater the knowledge of or experience with mental illness, the less frequently people express the desire to keep social distance from people with mental conditions. Perhaps experiencing the burden of depression helps one empathize with the suffering of other people.

Those with depression seem to know more about the non-addictive nature of antidepressants, possibly because of their own experiences of those medicines.

Almost 40% of persons with questionnaire scores indicating major depressive disorder had had contact with health care professionals during the last year. Internationally this is a rather positive result but far from optimal. Another result was also alarming: the prevalence of depression was higher among younger people, but older people used services more actively.

In our data, respondents with more serious depression had used mental health services more actively. This connection has been found in previous studies too.[35,36]

It can be assumed that if a person believes that he is responsible for his depression, he bears more feelings of guilt and shame and hesitates to seek professional help. In our data this hypothesis was not confirmed. "Depression is a matter of will" - scale was not connected to service use.

If respondents with depression say they are willing to have close social contact with people with mental problems, their probability of using mental health services was higher. This connection has been found at least in one earlier study.[17] Perhaps people with depression are not worried about the perceived public stigma associated with seeking professional services if they have had contact with someone who has experienced mental problems. Attitudes toward antidepressant drugs seem to be an important differentiating factor between those who use mental health services for their depression and those who do not. Knowledge or belief about the adverse effects of antidepressants is relevant but even more so is the worry about addiction. This worry may connect with the idea of "self management" and that many people are afraid of all kinds of dependence - also in therapeutic relationships. On a primary health care level, the role of attitudes towards antidepressants is especially important because psychotherapy is often unavailable.