Elsevier

General Hospital Psychiatry

Volume 25, Issue 5, September–October 2003, Pages 311-315
General Hospital Psychiatry

Psychiatry and primary care
Stigma and depression among primary care patients

https://doi.org/10.1016/S0163-8343(03)00066-5Get rights and content

Abstract

We assessed stigma affecting employment, health insurance, and friendships in 1,187 depressed patients from 46 U.S. primary care clinics. We compared stigma associated with depression, HIV, diabetes, and hypertension. Finally, we examined the association of depression-related stigma with health services use and unmet need for mental health care during a 6-month follow-up. We found that 67% of depressed primary care patients expected depression related stigma to have a negative effect on employment, 59% on health insurance, and 24% on friendships. Stigma associated with depression was greater than for hypertension or diabetes but not HIV. Younger men reported less stigma affecting employment. Women had more employment-related stigma but this was somewhat mitigated by social support. Other factors associated with stigma included ethnicity (associated with health insurance stigma) and number of chronic medical conditions (associated with health insurance and friendship related stigma). Stigma was not associated with service use, but individuals with stigma concerns related to friendships reported greater unmet mental health care needs. In summary, stigma was common in depressed primary care patients and related to age, gender, ethnicity, social support and chronic medical conditions. The relationship between stigma and service use deserves further study in diverse settings and populations.

Introduction

High rates of psychiatric disorders and significant unmet needs for care for individuals with these disorders are pressing public health issues. There has been growing concern that stigma among individuals with mental illnesses can be a significant barrier to care and contribute to poor quality care particularly among vulnerable groups such as ethnic minorities [1]. Research suggests that stigma associated with psychiatric disorders and use of mental health services prevents people from seeking care [2], contributes to treatment discontinuation [3], lowers their quality of life and self-esteem [4], [5], and worsens health outcomes [6].

Stigma is negative stereotyping of individuals with specific characteristics that set them apart, such as a disabling medical condition, or a mental illness. Labeling theory says that a psychiatric label activates negative images about mental illness that are applied to the individual by others or himself/herself. The resulting discrimination and internalized stigma interferes with several life areas including employment, relationships with family and friends, and general well being, including self-esteem and self-efficacy [7].

One study assessed stigma among patients with depression [3]; most studies have surveyed unaffected individuals in the community or individuals with severe and chronic mental illnesses. In this exploratory study, we describe the extent to which depressed patients report that disclosure of a depression history would have negative consequences in significant areas of their lives, specifically: gaining employment, obtaining health insurance, and maintaining friendships. We compare stigma about depression to stigma associated with other medical conditions, identify characteristics of individuals with stigma, and explore the impact of stigma on use of medical and mental health services.

Section snippets

Study design and sample

We used data from a survey of 46 clinics associated with six managed care organizations in Maryland, Minnesota, California, Texas, and Colorado. These organizations were part of a study to improve quality of care for depression in managed primary care settings and included public, private, staff, and network practice models in urban, suburban, and rural areas [8]. More information about this quality of care intervention study has been published previously [8].

Eligible patients were 18 years or

Results

The characteristics of the enrolled sample are given in Table 1.The age range was from 18 to 90 years with a mean of 44. Those enrolled did not differ significantly from the eligible population in health measures, but were more likely to be female, older, and better educated.

Sixty-seven percent of patients (Table 2) expected negative consequences due to disclosure of depression on gaining employment, 59% for obtaining health insurance, and 24% on friendships. Stigma associated with depression

Discussion and conclusions

We found that stigma was widespread among depressed primary care patients. As we anticipated, stigma concerns about depression were more common than for medical conditions, but less than for HIV, a very highly stigmatized condition [11]. Mental health stigma has previously been found to be greater than stigma associated with medical conditions, and as much as stigma associated with criminal activity [12].

Stigma was related to reported unmet need but not to actual service use. Stigma was more

Acknowledgements

Financial support was provided by the National Institute of Mental Health through grants MH54623 and MH0090 and the Agency for Health Care Policy and Research (HS08349). The authors gratefully acknowledge Diana Liao, M.P.H. for statistical assistance, and the clinicians and patients who contributed to this study.

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