Presenter:
Ezra Golberstein
Dept of Health Care Policy
Harvard University
Stigma and Help-seeking for
Mental Health Problems
among College Students
Academy Health Annual Research Meeting
June 30, 2009
Acknowledgments
• Lead author: Daniel Eisenberg (Michigan)
• Co-authors: Marilyn Downs (Tufts), Kara Zivin
(U-M and Ann Arbor VA)
• Funding
2
 Blue Cross Blue Shield of Michigan Foundation
 University of Michigan (Depression Center, OVPR,
School of Public Health, Dept of Health Mgt and
Policy, Rackham Graduate School)
 Participating institutions (see later slide)
 Children, Youth, and Families Consortium (Penn St.)
Background
3
Mental Disorders and Young Adults
4
• Among adolescents and young adults, mental
disorders account for larger burden of disease than
any other class of health condition (Michaud et al,
2006 Population Health Metrics)
• Three-quarters of lifetime mental disorders have
first onset by age 24 (Kessler et al, 2005 Arch Gen
Psych)
• Most people in the U.S. with mental disorders do not
receive treatment, or only after extensive delays
• ~50% of American youths attend post-secondary
school
National Focus on Stigma
5
• “The most formidable obstacle to future
progress in the arena of mental illness and
health … deters the public from seeking, and
wanting to pay for, care.” (Surgeon General’s
Report on Mental Health, 1999)
• Stigmatizing attitudes are substantial for a
range of disorders (including depression), and
does not appear to have diminished much since
1950 (Phelan et al, 2000 J Health & Social
Behavior)
• Evidence that stigma impedes help-seeking is
not on par with the amount of policy attention
Dimensions of Stigma
• Perceived Public Stigma: the extent to which
individuals believe that the public attaches
negative stereotypes and discriminates against
people with mental disorders
• Personal Stigma: the extent to which
individuals apply negative stereotypes and
potentially discriminate against people with
mental disorders
6
Studies of Stigma and Help-seeking
• Our previous work with college student
samples suggests that perceived public stigma
may not be a major barrier to help-seeking
(Golberstein et al, Psych Services 2008 and In
Press)
7
• No previous studies, to our knowledge, assess
how both types of stigma relate to helpseeking behavior in a random non-clinical
sample
Research Questions
• RQ1: What are the levels of perceived public
and personal stigma among college students?
 How do perceived public and personal stigma compare?
 Which types of students have higher stigma?
• RQ2: How do perceived public and personal
stigma correlate with help-seeking for mental
health?
8
 Hypothesis: Both are independently associated with
lower help-seeking.
Methods
9
Sample: 2007 Healthy Minds Study
• Each of 13 schools: random sample of 1,000
from database of currently enrolled students
• Recruitment for confidential web survey
 Introductory letter with $1 bill
 Email reminders
 Entry into cash sweepstakes
• Length of survey: 18 minutes on average
• Participation rates:
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 Overall, 5,689 students (44%) completed survey
 Range across schools: 33-61%
Methods: Non-response Analysis
• Non-response weights
 Based on administrative data for all students (e.g.,
race/ethnicity, gender, academic level, GPA)
• Non-response survey
 Random sample of non-respondents were recruited
(after main survey is completed) for an abbreviated
(1-2 minute) “non-response survey” with small
number of key measures (e.g., PHQ-2)
11
Stigma Measures
• Perceived public stigma: adaptation of
Discrimination-Devaluation scale (Link et al,
1987 Am. Sociological Review)
 12 items
 Six point Likert scale for agreement with
statements beginning w/: “Most people think…” or
“Most people believe…” or “Most people would…”
 Scale is scored 0-5 (5 is most perceived stigma)
12
• Personal stigma: adaptation of three items
from our perceived stigma scale
 Substituted “I” in place of “Most people”
Help-seeking Measures (Past Year)
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• Perceived need for help with mental health
(item from Healthcare for Communities study)
• Psychotropic medication (HCC)
• Counseling or therapy for mental health (HCC)
• Counseling or support from non-clinical
sources (friends, family, religious contact,
support group, or other)
• Willingness to talk with academic personnel, if
mental health problem affects performance
(hypothetical – not necessarily past year)
Statistical Analysis
• Simple descriptive statistics
• Multivariable regressions
 Linear for continuous outcomes (stigma measures)
 Logistic for dichotomous outcomes (help-seeking)
 Models adjust for mental health status,
sociodemographics, religiosity
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• All analyses included survey response
propensity weights
Results
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Sample Description
• N=5555 with complete stigma scales
• 54.2% female, 45.8% male
• 73.7% undergraduate, 23.4% graduate (2.9%
undetermined)
• 10.3% Asian, 6.1% black, 6.3% Hispanic, 4.7%
multiple categories, 66.7% white, 5.9% other
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Average Levels of Stigma
3435
2116
2.41
2.46
Overall
5555 2.43 (0.75)
Asian
Black
Hispanic
Multi
Other
White
579
266
302
240
290
3870
Female
Male
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N
Perceived
stigma (0-5)
2.50
2.77
2.50
2.48
2.54
2.38
Personal
stigma (0-5)
(ref)
***
***
***
***
**
*
(ref)
1.01 (0.84)
0.91
1.13
1.45
0.93
1.05
0.91
1.10
0.95
(ref)
***
***
*
***
(ref)
Stigma and Help-seeking
Dep. Variable
(below)
Perceived need
for help
Perceived stigma Personal stigma
OR (95% CI)
OR (95% CI)
1.18 (1.05, 1.32) 0.67 (0.61, 0.74)
Therapy/
counseling
1.02 (0.90, 1.14)
Medication use
Informal support
18
Would talk to
acad. personnel
1.17 (0.99, 1.38)
0.57 (0.49, 0.67)
1.08 (0.98, 1.19)
0.77 (0.72, 0.83)
0.88 (0.76, 1.03)
0.57 (0.51, 0.64)
0.90 (0.80, 1.01)
Summary of Results
• Perceived public stigma was higher than
personal stigma.
• Stigma was higher among certain types of
students.
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• Personal stigma was significantly associated
with help-seeking, perceived public stigma was
not.
Limitations
• Cannot make definitive causal interpretations
(particularly because data are cross-sectional)
• Reports of low personal stigma may partly
reflect desire (conscious or not) to give socially
acceptable response
20
Policy Implications
• Stigma reduction efforts may be tailored
towards specific subpopulations
• But, this still presents a major challenge:
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 May be more policy options available to reduce
perceived public stigma or mitigate its effects
 Limited evidence that stigmatizing attitudes are
easily changed
 If improving access is the goal, other policy
approaches may prove more effective than personal
stigma reduction
More information
• Web: www.healthymindsstudy.net
• email: daneis@umich.edu
Or
• email: golberstein@hcp.med.harvard.edu
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Participating Schools
(Fall 2007 Healthy Minds Study)
Tufts
U-Michigan
UI-Chicago
CSU-Chico
Penn St.
Miami
UI-Springfield
UNC-G
UI-UC
UNC-CH
NM State
Emory
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Yeshiva
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0
1
Personal Stigma
2
3
4
5
Perceived Public vs Personal Stigma
0
24
1
3
2
Perceived Public Stigma
4
5