Internalized stigma may influence a greater perception of barriers to seeking and receiving treatment for depression, according to a study published in the Journal of Mental Health. Untreated depression, a major risk factor for suicide, and persistent stigma surrounding mental health conditions make determining barriers to treatment an important public health goal.

James Marcus Arnaez, PhD, from the West Virginia Department of Health and Human Services, Bureau of Public Health-Health Statistics Center, Charleston, and colleagues performed multivariable-adjusted linear regressions to explore barrier outcomes based on internalized and perceived stigma. Participants were recruited from an introductory university psychology course and received partial course credit for the survey.

Internalized stigma was gauged using the Internalized Stigma of Mental Illness scale, depression stigma with the Perceived Devaluation and Discrimination Scale, barriers to seeking care with the Barriers to Care checklist, and depression severity with the Patient Health Questionnaire-9. Alongside linear regressions, the study authors evaluated outcomes by depression severity, using likelihood-ratio tests.

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Complete data (N=2551) were collected from 1298 subjects in 2014 and 1153 in 2016. The authors examined 3 hypotheses: that internalized stigma would be a stronger predictor of barriers to seeking mental health care than perceived stigma, that alienation would be a stronger predictor of barriers than other components of internalized stigma, and that depression severity would modify the relationship of depression stigma and barriers to care.

After factor analysis, the results of the investigation bore out the first hypothesis: the association for internalized stigma was stronger than it was for perceived stigma for a number of barrier types, including low perceived need, negative treatment expectations, and structural barriers.

The results also demonstrated that alienation was a stronger predictor of overall barrier endorsement than the stereotype endorsement or stigma resistance factors of the Internalized Stigma of Mental Illness scale (the second hypothesis). For the third hypothesis, no significance was found for interaction between stigma and depression severity.

Among the limitations of the study was the inability to investigate how stigma and barriers interact to hinder treatment-seeking. The investigators were also unable to control for socioeconomic status, and results may not be applicable to the general public, given the study’s reliance on a sample of college students from an introductory psychology course.

The study authors argued that the issue of internalized stigma must be addressed in individuals expressing barrier concerns, in addition to addressing the more obvious barriers to treatment-seeking and stigma in the general public.


Arnaez JM, Krendl AC, McCormick BP, Chen Z, Chomistek AK. The association of depression stigma with barriers to seeking mental health care: a cross-sectional analysis [published online August 2, 2019]. J Mental Health. doi:10.1080/09638237.2019.1644494

This article originally appeared on Psychiatry Advisor