In both Western (Crisp, Gelder, Rix, Meltzer, & Rowlands, 2000) and Eastern societies (Chou & Mak, 1998; Tsang, Tam, Chan, & Cheung, 2003), individuals with serious mental illness, such as schizophrenia and other psychotic disorders, are stigmatized by society (Farina, 1998). The extent of this phenomenon may be increasing (Phelan, Link, Stueve, & Pescosolido, 2000). Stigmatizing attitudes toward persons with SMI have a number of recurring themes: persons with SMI are viewed as dangerous, unpredictable, irresponsible, and childlike (Brockington, Hall, Levings, & Murphy, 1993; Levey & Howells, 1995), and unable to manage their own treatment needs (Pescosolido, Monahan, Link, Stueve, & Kikuzawa, 1999). These attitudes are not only held by those in the community but also may be present among mental health professionals and trainees. Specifically, there is evidence that some mental health professionals, including psychiatrists (Chaplin, 2000; Miller, Shepard, & Magen, 2001), social workers (Dudley, 2000; Minkoff, 1987), general mental health providers (Ryan, Robinson, & Hausmann, 2001; Sartorius, 2002), and medical and mental health graduate students (Hasui, Sakamoto, Sugiura, & Kitamua, 2000; Mukherjee, Fialho, Wijetunge, Checinski, & Surgenor, 2002; Werrbach & DePoy, 1993) may hold stigmatizing beliefs about those with mental disorders. The effects include “discrimination in housing, education and employment, and increased feelings of hopelessness in people with schizophrenia” (Hocking, 2003, p. S47). These findings suggest that efforts to destigmatize mental illness should not be limited to community members, but also should include mental health and medical training professionals.

The tendency to stigmatize individuals with mental illness is not a byproduct of adult experiences but has its roots in childhood. In a recent

review of the literature, Wahl (2002) concluded that negative attitudes toward persons with mental illness are evident as early as in third grade. In general, those with mental illness are viewed more negatively and with more fear than are individuals with physical disabilities (Wahl, 2002). Wahl reported that there is evidence that these negative attitudes increase over time, suggesting a longitudinal process in which negative stereotypes become increasingly ingrained, culminating in potentially discriminating behaviors in adulthood.

Direct evidence for the presence of stigmatizing beliefs about peers with mental illness was obtained from a recent national survey of young people (ages 14–22) conducted by the Adolescent Risk Communication Institute of The University of Pennyslvania's Annenberg Public Policy Center (APPC). The National Annenberg Risk Survey of Youth (NARSY) was conducted by telephone in the spring of 2002 with 900 respondents who were selected by means of random digit dialing procedures. The response rate for the survey (52.7%), taking into account those who could not be reached as well as those who refused, was comparable to the rates achieved by the Centers for Disease Control and Prevention (CDC; about 49%) in its national surveys of risk behavior (CDC, 2003; see Romer, 2003, for a description of the survey methods and sample).

Respondents were asked if they were aware of four mental disorders: major depression, bipolar disorder, schizophrenia, and eating disorders. Awareness was highest for eating disorders (89%) and depression (86%), but high levels of awareness were registered for the other disorders as well (81% for schizophrenia and 73% for bipolar disorder). Respondents who were aware of at least one disorder were asked a series of questions concerning two disorders selected at random from among those with which they reported familiarity. In particular, they were asked to imagine someone their age who had the disorder and to indicate whether they thought this person was “more likely, less likely, or about as likely as other people to be” (a) “violent,” (b) “prone to committing suicide,” and (c) “good in school.” The order of the traits was randomized across respondents.

Responses to the three items for each of the disorders indicate (Table 27.1) that large proportions of young people believe that persons with these disorders are different from other people. Over half thought that persons with major depression are more likely to be violent, whereas over 90% said that such persons are more prone to suicide, and about three quarters said they are less likely to be good in school than other people. Although all of the disorders displayed the same pattern, violence was most associated with schizophrenia, and doing badly in school was linked the most with major depression. Eating disorders were somewhat of an exception in that they were less associated with violence than the other disorders.

There were few differences in these stereotypes by age, gender, or education. African-American and Latino youth were more likely than others to think that the persons with the disorders were not different from others (data not shown).

Correlational analyses using gamma coefficients (to compensate for the skewed distributions) indicated that the three items were highly intercorrelated for each disorder (with “good in school” reverse scored). Coefficient alphas based on the gamma correlation coefficients were .64 for depression, .61 for bipolar disorder, .68 for schizophrenia, and .53 for eating disorders. These findings suggest that each disorder had an underlying stereotype that could guide respondents' reactions to persons with mental disorders. In addition, the stereotypes were correlated across disorders, from a low of .35 to a high of .52. It appears, therefore, that young people hold a general stereotype of mental disorder that includes a heightened risk for suicide and violence as well as the inability to function in an adaptive manner.

The survey also included questions to identify youth with potential symptoms of depression. In particular, respondents were asked if (a) “during the past 12 months have you ever felt so sad or hopeless for 2 weeks or more in a row that you stopped doing your usual activities,” and if (b) “during the past 12 months have you ever seriously considered attempting suicide.” Nearly a quarter of the sample (N = 221) responded affirmatively to one of these questions. However,

youth who had experienced these conditions were as likely to report the stereotypes as those who had not.

Stigmatization also plays a role in whether an individual initiates and adheres to treatment. Interestingly, failure to initiate treatment may not only be due to having a mental illness but also result from the stigma attached to seeking help. For example, Ben-Porath (2002) found that a case vignette describing someone with depression was rated most negatively when the target individual sought help for the disorder. This suggests that individuals with a mental illness have to wrestle with the fear of both being stigmatized for having a disorder and for seeking help for it.

There is growing evidence that stigma affects individuals with mental disorders in ways that minimize the likelihood that they will be successfully treated. For example, concerns that others will learn that their child is receiving mental health treatment is a common worry for parents of children between the ages of 5 and 19 (Richardson, 2001). In addition, higher levels of stigma are associated with greater treatment delay among individuals with SMI (Okazaki, 2000), parents of rural children with emotional disorders (Starr, Campbell, & Herrick, 2002), athletes (Ferraro & Rush, 2000), individuals with HIV (or concerns of having HIV) (Chesney & Smith, 1999; Fortenberry et al., 2002), general community participants unselected for presence of mental illness (Cooper, Corrigan, & Watson, 2003), and women with alcohol or drug addictions (Copeland, 1997).

Once in treatment, perceived stigma may be a barrier to medication compliance and treatment continuation (Buck, Baker, Chadwick, & Jacoby, 1997; Pugatch, Bennett, & Patterson, 2002; Sirey et al., 2001a, 2001b). Buck et al. (1997) reported that feelings of being stigmatized were associated with lower adherence to antiepileptic drug treatment. Pugatch et al. (2002) reported similar findings; fears of being stigmatized were associated with poorer adherence to drug regimens among