Stigma

OBJECTIVE(S): Specific Aim 1. To estimate the level of concerns that insured US adults have about experiencing adverse consequences from stigma related to receiving treatment for mental health or substance abuse problems; and to examine individual factors, including sociodemographic and cultural factors, need and social supports, and prior services use, that are associated with these stigma concerns. Specific Aim 2. Among the insured, to determine the impact of stigma concerns on access to mental health services (*primary care and specialty care services), controlling for need, predisposing (i.e., knowledge, attitudes) and enabling (i.e., insurance status, social support) factors known to affect access to care in the literature. Specific Aim 3. To examine whether interventions to increase the use of guideline concordant primary care treatments for depression are effective at improving the quality of care for both persons with high and low levels of concern about depression-related stigma. Specific Aim 4. To examine whether use of guideline-concordant treatments for depression (as opposed to quality improvement programs that promote access to those treatments) improve outcomes for both persons with high and low concerns about depression-related stigma.

METHODS: This study analyzes secondary data sets from three unique and complementary studies. The first data set is Healthcare for Communities (HCC), part of The Robert Wood Johnson Foundation Community Tracking Studies (Sturm et al., 1999). The study was designed to provide detailed information about need, unmet need, and access to general and mental health care using a sample that is representative of the US civilian non-institutionalized population. The two other data sets are from intervention studies concerning depression. Partners in Care (PIC) is a multi-site, group-level randomized trial of the implementation of chronic disease management or quality improvement programs for depression versus care as usual, in community-based, managed primary care (Wells, 1999). We Care is a randomized trial at the individual level, looking at the clinical outcomes and cost-effectiveness of providing opportunities for effective depression treatments for poor young women with depression. Each intervention study has longitudinal data on use of services, quality of care, and health outcomes, and included the same measures at baseline of individuals' concerns about depression-related stigma.

FINDINGS: Distribution of concerns regarding friends, employers, and insurers, were considered separately for White, Black and Latino participants. Concern regarding friends was moderate among all ethnic groups across all three samples. Concerns regarding the impact of seeking treatment on employment and insurance were high among all ethnic groups in all three samples. About three-quarters of each group reported concerns about the impact of mental health or substance abuse treatment on their employment, and close of half of these respondents reported a lot of concern in these areas. Although insurance concerns were slightly less than those regarding employment, they remained quite high. There were no differences between those with a mental disorder diagnosis regarding stigma concerns from those without such a diagnosis. There were no differences between Black and White participants in stigma concerns. Latinos differed from white participants in stigma associated with friends and insurers. Latinos are somewhat more concerned about friends and less concerned about insurers than are their white counterparts. The rural and urban participants did not differ in stigma concerning friends or employers, but did show a trend toward the rural participants reporting more stigma regarding employment. Preliminary findings indicate little relationship between stigma concerns and accessing primary care mental health treatment or specialty mental health treatment at six months.

STATUS: Data analysis is ongoing.

IMPACT: We find that depressed individuals and individuals in the general public are more concerned about insurers and employers learning about depression treatment than about friends learning about depression treatment. Thus it appears that policies directed at reducing such discrimination are needed. Preliminary findings indicate that stigma concerns do not necessarily keep individuals with depression from accessing care.