Years ago, I was the only physician serving a small country town and its surroundings. While the local people were kind, I was new to the area and felt very much alone. I also had depression, so life was difficult. At least I recognized that I needed help and regularly left the town for treatment. Rather than go to the nearest city, I drove to one twice as far away, out of fear that the town would learn about my mental illness.
Now, I look back on my younger self and feel sympathy for him: isolated, depressed, and fearful. I also wish he had made a different choice. Why did I not seek treatment closer by, treatment I could access more often that would have made me happier and a better physician? A substantial minority of the town’s population must have had their own mental health issues — how many of them, if they knew that their own doctor understood their struggle in a very direct way, would have been more willing to present themselves for treatment? As it was, I had very few discussions about my patients’ mental health.
I often think about that experience. By internalizing the prevailing stigma against mental illness, I was discriminating against myself. This is a universal experience: Globally we know of no culture that does not severely stigmatize mental illness.
In recent years, there has been a movement in the West to counter the stigma around mental illness. This has been a tremendous good, as it encourages people to seek help and feel more comfortable going out in the world. But both the public and some advocates are missing something important: There are different kinds of stigma at work here, and we cannot effectively push back against them without recognizing that distinction. Two stigmas are most common and therefore most important to address directly.
The first type of stigma is particular to schizophrenia and other psychotic disorders in which the affected person has sensory experiences (hallucinations or delusions) that do not reflect reality. This stigma manifests as fear and mistrust — fear that the person may be violent or otherwise a threat, and mistrust that the person will follow the normal rules of society and act in expected ways. Seeing people as unpredictable may lead people to think that they are capable of anything. Perception that they are not seeing the world as it really is makes all their interpretations, reactions, and suggestions (even about their own wellbeing) suspect and discountable. It’s what most people think of when they say someone is “crazy” or when they label a school shooter or other violent person as mentally ill.
A second type of stigma, while different, is no less severe and affects many more people. This refers to people with the nonpsychotic but much more common mental disorders such as depression or anxiety. Here, the challenge is that these same terms also cover typical reactions to the ups and downs of life we all experience. We have all felt depressed or anxious due to life events and, having made it through (as most of us do), may consider those with ongoing depression or anxiety as weak and inadequate. The conflation of feeling depressed or anxious with illnesses that carry the same names makes it difficult to realize that temporary responses to life events and having these disorders have as much in common as a bruised arm has with a broken one.
This conflation underlies how we treat people with these common mental disorders: We don’t fear or mistrust them and so we are less avoidant than with those with psychotic disorders. But we do look down on them as weak, inadequate. In thinking we understand them, we criticize them for not being more resilient like us, perhaps even too lazy to address their problems, and so less worthy of assistance. I’ve heard this from everyone ranging from my neighbors to members of Congress.
Each type of stigma presents different challenges. The stigma associated with psychoses elicits sympathy, but this reaction manifests as a need to isolate the mentally ill and shield them from responsibilities in the name of “protecting” them, much like we treat children. A subtext is that we also want to be protected from them. One study found that more than 60% of Americans saw people with schizophrenia as dangerous, a number that is rising. Most of us will never knowingly meet a person with psychosis, partly because many are living functional and healthy lives and are reluctant to share their experiences, but also because psychoses are rarely manifest: Of the 3% of people who will experience a psychotic episode in their lifetime, 25% will never have another episode, and 50% may have another but will live normal lives with proper treatment. Even during an active episode, they are unlikely to be a threat. In fact, they are less likely to be violent than the average person but more likely to be a victim of violence.
A national survey in Singapore reported that “50.8% of respondents saw mental illness, particularly depression, as a sign of personal weakness”. In the U.S., a survey found 40% of respondents associated depression with “bad character” or the way a person is raised, but fewer than 30% saw them as dangerous. While we are not afraid of those with depression or anxiety, we don’t much value them and we even blame them for their situation, seeing them as people who won’t help themselves. This makes more resources for mental health services a hard sell. It’s why, even in the face of overwhelming data on the prevalence and impact of these disorders on the welfare of society, we don’t act. Meanwhile, physical disorders that don’t approach the impact of mental illness attract much more attention and funding. Half the global population will have a mental illness in their lifetime, and mental illnesses cause one-third of all disability. In 2023 suicide killed 740,000 people while HIV killed 630,000 and malaria 597,000.
Those numbers show that stigma reduction is not only a mental health issue but a global public health priority. Both types of stigma hold us back from addressing mental health as a major global health and social issue.
Anti-stigma campaigns among the general population can be helpful for both types of stigma. Common elements include emphasizing the success of existing treatments, to counter widespread beliefs that recovery is not typical. Descriptions of recovery need to emphasize ability to perform the roles that society values, such as career and income-earning and family relationships. Three target groups are particularly important: the young, employers who hold the key to economic well-being, and governments behind the laws that in many countries curtail the rights of people living with mental illness.
Any campaign also needs to link content to the drivers of stigma. This requires a different approach for each type of stigma. For the psychoses, the public is already aware of this as a medical disorder, but misperceptions about perpetrating violence make it increasingly important to address myths about violence and unpredictability and the success of treatment.
Battling stigma against people with common mental disorders like depression needs to emphasize that these are not personal failings. And we need to reach out not only to the public but to caretakers and the affected themselves who are more likely to see their disorder as a personal weakness and lack of willpower.
Social exposure to persons with mental illness is an effective approach as it challenges misperceptions about what to expect of people who are living with mental disorders, but this also requires different approaches. For people with psychoses, social contact demonstrates that they are not violent or unpredictable.
Since the common mental disorders carry a different perception — more of weakness than danger — interactions need to emphasize that people are “successful” in terms of navigating responsible positions in society and in their relationships. Celebrity revelations of mental illness can also be helpful by taking advantage of the parasocial relationships of intimacy and connection experienced by followers of the famous. They are also particularly effective in countering the misperception that those with common mental disorders are weak by contrasting their fame and success with their disorder. A good example is Michael Phelps, the most successful athlete in Olympics history, who has spoken of his depression.
In pursuing these approaches, we need to refer back to the two stigmas. We need awareness campaigns and social exposures that refer not only to stigma based in fear and mistrust, but stigma rooted in inferiority and weakness. We cannot focus on just one type.
Paul Bolton is a senior scientist in the Department of Mental Health at Johns Hopkins University Bloomberg School of Public Health. He was worked in more than 25 countries in all global regions, assessing local mental health perceptions and needs and designing and implementing service programs. He thanks Sarah Murray, associate professor in the Department of Mental Health, Johns Hopkins University Bloomberg School of Public Health, for her contributions to this essay.
