International Journal of Social Psychiatry http://isp.sagepub.

com/

The Stigma of Mental Illness: Patients' Anticipations and Experiences

Matthias C. Angermeyer, Michael Beck, Sandra Dietrich and Anita Holzinger Int J Soc Psychiatry 2004 50: 153 DOI: 10.1177/0020764004043115 The online version of this article can be found at: http://isp.sagepub.com/content/50/2/153

Published by:
http://www.sagepublications.com

Additional services and information for International Journal of Social Psychiatry can be found at: Email Alerts: http://isp.sagepub.com/cgi/alerts Subscriptions: http://isp.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav Citations: http://isp.sagepub.com/content/50/2/153.refs.html

Downloaded from isp.sagepub.com at UNIVERSITE DE MONTREAL on February 5, 2011

THE STIGMA OF MENTAL ILLNESS: PATIENTS ANTICIPATIONS AND EXPERIENCES

MATTHIAS C. ANGERMEYER, MICHAEL BECK, SANDRA DIETRICH & ANITA HOLZINGER

ABSTRACT Background: There are studies that either deal with the stigmatization patients anticipate or with patients concrete stigmatization experiences. Up until now, however, research is short of studies that investigate both aspects of subjective stigmatization simultaneously. Aims: This study aims at investigating to what extent patients with schizophrenia or depression anticipate and experience stigmatization and how this is inuenced by the type of mental disorder and the social environment. Method: A total of 210 patients with schizophrenia or a depressive episode were interviewed, one half living in a city and the other in a small town. Results: Most of the patients expect negative reactions from the environment, particularly as concerns the access to work. Concrete stigmatization experiences were most frequently reported in the domain of interpersonal interaction. Even though schizophrenia patients and patients with depression anticipated stigmatization similarly frequently, the former reported concrete stigmatization experiences more frequently than the latter. Conversely, patients living in a small town anticipated stigmatization more frequently than patients from the city, even though both had actually experienced stigmatization at a similar rate. Conclusion: The results underline the necessity to differentiate between anticipated and experienced stigmatization. This is highly relevant for planning interventions aimed at reducing the stigma of mental disorder.

INTRODUCTION
Ever since Gomans (1963) pioneering work Stigma: notes on the management of spoiled identity psychiatric stigma research has been primarily interested in the negative reactions of the environment to mentally ill people. Attitudinal surveys among the general public (e.g. Angermeyer & Matschinger, 1997), key gures and opinion leaders (e.g. Grausgruber et al., 1989) as well as analog behavioral experiments (e.g. Farina & Ring, 1965) were used to investigate the stereotypes that prevail in society about mentally ill people and the kind of discrimination mentally ill people face in society. The subjective stigma experiences of the people aected, however, have only played a minor role in stigma research. Only recently, this question has aroused more interest. Here, two aspects can be distinguished: patients perceptions of stigmatization and their concrete stigmatization experiences.
International Journal of Social Psychiatry. Copyright & 2004 Sage Publications (London, Thousand Oaks and New Delhi) www.sagepublications.com Vol 50(2): 153162. DOI: 10.1177/0020764004043115

Downloaded from isp.sagepub.com at UNIVERSITE DE MONTREAL on February 5, 2011

154

INTERNATIONAL JOURNAL

OF

SOCIAL PSYCHIATRY 50(2)

The rst aspect addresses the anticipation of stigma and not the discrimination mentally ill people have actually experienced. Numerous studies have used Link et al.s (1989) Perceived Devaluation and Discrimination Scale to demonstrate the negative eects of anticipated stigmatization on the ill in the sense of a reduced self-esteem (Markowitz, 1998; Wright et al., 2000; Link et al., 2001), increased demoralization (Link, 1987; Link et al., 1991) and depressiveness (Link et al., 1997) as well as reduced social relationships (Angermeyer et al., 1985a; Link et al., 1989; Perlick et al., 2001), increased unemployment (Link, 1987) and a reduced quality of life (Mechanic et al., 1994; Roseneld, 1997; Markowitz, 1998; Yanos et al., 2001). In contrast, actual stigmatization experiences have rarely been investigated. Up until now, the largest study in this eld has been carried out by Wahl (1999). The questionnaire developed by the author (Consumer Experiences of Stigma Questionnaire) has been used in a further study with people with schizophrenia (Dickerson et al., 2002). Furthermore, a focus group study with patients suering from schizophrenia is worth mentioning (Schulze & Angermeyer, 2003). This study yielded four domains of subjective stigmatization. Participants most frequently reported stigmatization in the domain of interpersonal interaction. The image of mentally ill people that dominates public opinion is experienced as discriminating and comes second, followed by the barriers to the access to social roles (partnership, work). Participants only rarely mentioned so-called structural discrimination, i.e. injustices and imbalances inherent in political decisions and legal regulations which lead to a discrimination of mentally ill people, for instance in health care. A few studies have reported data for both aspects of subjective stigmatization (Link et al., 1997; Markowitz, 1998; Stengler-Wenzke et al., 2000; Yanos et al., 2001), a systematic comparison between the two aspects, however, has not been the subject of any study up until now. The aim of this study is to contrast anticipated and concrete stigmatization experiences of patients with schizophrenia or major depression. The focus will be on the following questions: 1. 2. 3. Which forms of subjective stigmatization are reported most frequently by the patients? Are there any dierences regarding anticipated and actually experienced stigmatizations? How strong is the correlation between anticipated and experienced stigmatization? How does the type of illness inuence subjective stigmatization? From representative surveys on desired social distance among the general public it can be expected that the degree of subjective stigmatization will be higher among people with schizophrenia as compared to people with major depression (Angermeyer & Matschinger, 1997; Link et al., 1999). Is this true for both anticipated and experienced stigmatization, or are there any dierences? In what way does the social environment inuence subjective stigmatization? This will be investigated by comparing patients living in a city and patients living in a small town. The results from population surveys that have investigated correlations between social environment and desired social distance are inconsistent. In one study, community size and desired social distance were positively correlated (Martin et al., 2000), in another study, both were negatively correlated (Kemali et al., 1989). Two studies reported no statistically signicant correlations at all (Angermeyer et al., 1985b; Stuart & Arboleda Florez, 2001). We are interested in whether there are any dierences with regard to anticipation of stigmatization and stigmatization experiences.

4.

Downloaded from isp.sagepub.com at UNIVERSITE DE MONTREAL on February 5, 2011

ANGERMEYER ET AL.: THE STIGMA OF MENTAL ILLNESS

155

METHODS Sample
The study was carried out in Spring 2002 in Leipzig, a city with 493,000 inhabitants, and Plauen, a small town with less than 71,000 inhabitants, both of which are in Saxony (Germany). In all three psychiatric facilities in Leipzig providing their services to the city, a key-date survey was carried out with patients who had been diagnosed with schizophrenia (ICD-10 F 21) or a depressive episode (ICD-10 F 32). Of the 118 patients who were included in the survey, 11% refused to participate. Fifty of the 105 subjects who participated in the study had schizophrenia and 55 had experienced a depressive episode. In Plauen, all patients with both diagnoses who had been treated in the psychiatric facility providing its services to the town, were consecutively included in the survey until a sample of at least 50 patients per diagnostic group was reached. Of the 121 patients who were recruited for the study, 13% refused to participate. Fifty-one of the 105 patients who participated in the study suered from schizophrenia and 53 from a depressive episode. Participants were asked to sign a written consent before they were included in the study. The study was approved by the ethical committee of the Faculty of Medicine of the University of Leipzig. Table 1 summarizes the most important socio-demographic and clinical characteristics of the sample, broken down by diagnosis and place of residence. As expected, the percentage of women and the average age was higher for the depressive patients as was the percentage of married people or people living with a partner as well as that of employed people. Conversely, the illness had, on average, lasted for a longer period of time with schizophrenia patients compared to patients with depression. There were no statistically signicant dierences between inhabitants of the city and the small town, apart from the fact that the level of educational attainment of the depressive patients was higher among those living in the city.
Table 1 Socio-demographic and clinical characteristics of the sample Schizophrenia (n 101) Small town City (n 51) (n 50) Gender Female (%) Age (years, mean) Level of educational attainment Low (max. compulsory school) (%) Middle (secondary school) (%) High (at least A-Levels) (%) Marital status Married/living with a partner (%) Occupational status Employed (%) Treatment status Inpatient (%) Duration of illness (years, mean) 54.0 42.9 27.5 49.0 23.5 47.1 80.4 80.0 14.1 56.0 38.6 22.9 52.1 25.0 24.0 86.0 86.0 10.3 Depression (n 108) Small town City (n 53) (n 55) 79.2 50.8 41.5 43.4 15.1 49.1 67.9 82.4 8.5 77.4 46.6 13.0 48.1 38.9 41.8 72.7 70.9 8.2

Downloaded from isp.sagepub.com at UNIVERSITE DE MONTREAL on February 5, 2011

156

INTERNATIONAL JOURNAL

OF

SOCIAL PSYCHIATRY 50(2)

Instrument A self-administered questionnaire was developed. Based on the results of the aforementioned focus group study (Schulze & Angermeyer, 2003), for each of the four domains of subjective stigmatization (interpersonal interaction, public image of mentally ill people, access to social roles and structural discrimination), two items were formulated that represented the stigmatization experiences that had been mentioned most frequently during the group discussions. Participants were questioned about the stigmatization they anticipate (e.g. I believe that most people would not enter into a partnership with somebody who is mentally ill) and their concrete stigmatization experiences (e.g. Has it ever happened to you that you were rejected by somebody you wanted to start a relationship with after it became known that you are mentally ill?). Statements involving anticipated stigmatization were answered using ve-point Likert-scales with the extreme categories absolutely agree (1) and absolutely disagree (5). To answer the questions regarding stigmatization experiences, dichotomous (yes/no) or trichotomous (yes/no/dont know) response categories were provided. The rst draft of the questionnaire was discussed in two focus groups by patients with dierent disorders. According to their suggestions for improvement, the original draft was modied, pre-tested with a further 20 patients and then revised accordingly.

RESULTS
Table 2 reports, broken down by diagnosis and place of residence, how many of the patients anticipated the dierent forms of stigmatization. Patients most frequently anticipated a negative impact on their access to social roles (job, partnership). This was followed by the negative public image of mental illness that emerges from a one-sided media coverage and the distorted depiction of mentally ill people in feature lms. About two-thirds of the patients stated that mentally ill people would usually only appear in media reports when they had committed a violent act; feature lms mostly depict mentally ill people as murderers or violent criminals. Just as frequently, the subjects anticipated discrimination in the context of interpersonal interaction, either because they are rejected by other people or that others avoid contact with them. Structural discriminations, in such a way that they are turned down because of their mental illness when wanting to take out an insurance or to participate in a rehabilitation measure, were anticipated less frequently. In order to investigate the impact of the diagnosis and the place of residence on the eight stigma facets, multiple regressions were calculated with gender, age, level of educational attainment, marital status, occupational status, treatment status and duration of the illness as control variables. Table 2 only shows the unstandardized regression coecients for diagnosis and place of residence. At a glance it can be noticed that schizophrenia and depressive patients do not dier in their rating of the risk of stigmatization. However, dierences can be found between the patients living in a city and those living in a small town. The patients who live in a small town anticipate signicantly more frequently that they are avoided by others. In addition, they assess the public image of mental illness as it is mediated by the media more negative than patients who live in the city.

Downloaded from isp.sagepub.com at UNIVERSITE DE MONTREAL on February 5, 2011

Table 2 Anticipated stigmatization Schizophrenia %a Interpersonal interaction Rejection by others Avoidance of contact Public image of mentally ill people Media coverage Representation in feature lms Access to social roles Job/occupation Partnership Structural discrimination Taking out an insurance Rehabilitation measures
a b c

ANGERMEYER ET AL.: THE STIGMA OF MENTAL ILLNESS

Depression %a 61.1 55.6 70.4 72.2 81.5 49.1 28.0 38.3 (53.2)c

bb 0.101 0.204 0.02 0.106 0.216 0.014 0.108 0.217

p(F ) NS NS NS NS NS NS NS NS

Small town %a 66.7 67.6 75.0 76.0 76.2 44.8 38.1 42.9 (62.5)c

City %a 59.0 54.3 61.9 62.9 75.0 49.5 24.0 38.5 (49.4)c

bb 0.310 0.539 0.462 0.577 0.112 0.129 0.433 0.286

Downloaded from isp.sagepub.com at UNIVERSITE DE MONTREAL on February 5, 2011

p(F ) NS 0.003 0.017 0.003 NS NS NS NS

64.4 66.3 66.0 66.0 69.0 44.6 33.7 42.6 (57.3)c

Response categories 1 and 2 (agreement) of the ve-point Likert scale combined Multiple regression with control of gender, age, level of educational attainment, marital status, occupational status, treatment status and duration of illness (schizophrenia 1, depression 0/city 1, small town 0) Without response category dont know

157

158

Table 3 Experienced stigmatization

Downloaded from isp.sagepub.com at UNIVERSITE DE MONTREAL on February 5, 2011

INTERNATIONAL JOURNAL

Schizophrenia %a Interpersonal interaction Rejection by others Avoidance of contact Public image of mentally ill people Media coverage Representation in feature lms Access to social roles Job/occupation Partnership Structural discrimination Taking out an insurance Rehabilitation measures
a b c

Depression %a 45.3 26.4 37.4 37.0 1.9 10.3 3.8 (4.5)c 5.7 c (12.2)c
c

bb 1.497 0.493 0.772 1.044

p(F ) NS <0.001< NS NS

Small town %a 49.5 39.4 31.4 36.2 11.5 14.4 12.4 (16.7)c 9.5 c (19.2)c
c

City %a 55.9 38.2 43.7 41.0 8.7 17.8 7.8 (16.2)c 9.7 c (22.2)c
c

bb 1.043 1.797 1.443 1.057

p(F ) NS NS NS NS

60.0 51.5 38.0 40.6 19.0 21.6 15.8 (27.5)c 13.9 c (29.8)c
c

OF

SOCIAL PSYCHIATRY 50(2)

12.439

0.001

0.686

NS

5.775

0.034

0.679

NS

Response categories 1 and 2 (agreement) of the ve-point Likert scale combined Logistic regression with control of gender, age, level of educational attainment, marital status, occupational status, treatment status and duration of illness (schizophrenia 1, depression 0/city 1, small town 0) Without response category doesnt apply

ANGERMEYER ET AL.: THE STIGMA OF MENTAL ILLNESS

159

Table 3 provides information on how many patients have actually experienced the dierent forms of stigmatization themselves. Patients most frequently answered with yes to questions about discrimination in the domain of interpersonal interaction, i.e. whether they had met rejection by others or whether others had broken o contact because of the illness. Second comes the confrontation with media reports or depictions of mentally ill people in feature lms that are experienced as hurtful. Compared with the fear the patients have voiced, reports of being turned down for a job because of the mental illness were comparatively rare; the same applies to instances where the patient was rejected by somebody whom he/she wanted to start a relationship with after his/her mental illness became known. Patients only occasionally stated that their application for taking out an insurance was turned down or their participation in a rehabilitation program rejected because of their mental disorder. The impact of the diagnosis and the place of residence on the risk of concrete stigmatization experiences was investigated with logistic regression analyses, with gender, age, level of educational attainment, marital status, occupational status, treatment status and duration of illness being included into analysis as control variables. As shown in Table 3, schizophrenia patients report stigmatization experiences more frequently than patients with depression; twice as often they stated to be avoided by others. In addition, they complained signicantly more frequently that their access to social roles is more dicult and that they are faced with structural discrimination. However, it is irrelevant whether patients live in the city or in a small town. A direct comparison between the extent of the patients anticipated and concretely experienced stigmatizations is only possible to a limited extent since the scales used (interval scales vs. dichotomous categories) are of dierent qualities. Nevertheless, from the data presented in Table 2 and Table 3 it can be concluded that patients anticipate stigmatizations more frequently than they actually experience stigmatizations. This discrepancy is clearly noticeable for the complicated access to social roles, particularly with regard to access to work. As shown in Table 4, the two aspects of subjective stigmatization are only loosely connected with each other. The tightest connection can be found in the domain of interpersonal interaction, especially as concerns rejection by others. No connection at all exists between the assessment of the public image of mentally ill people and concrete relevant experiences. Statistically signicant correlations are more frequently observable for schizophrenia patients than they are for patients with a depressive episode. A statistically signicant connection between experienced and anticipated avoidance by others can only be found for the patients from the small town.

DISCUSSION
Our results indicate that patients anticipate stigmatizations more frequently than they actually experience stigmatizations. This discrepancy is particularly developed for the barriers to access social roles. Furthermore, there is only a loose correlation between anticipated and actually experienced stigmatization. According to Link et al.s (1989) modied labeling approach, everybody irrespective of whether he/she becomes mentally ill or not learns in the course of their socialization how society behaves toward people with mental

Downloaded from isp.sagepub.com at UNIVERSITE DE MONTREAL on February 5, 2011

160

INTERNATIONAL JOURNAL

OF

SOCIAL PSYCHIATRY 50(2)

Table 4 Correlations between anticipated and experienced stigmatization Schizophrenia ra Interpersonal interaction Rejection by others Avoidance of contact Public image of mentally ill people Media coverage Representation in feature lms Access to social roles Job/occupation Partnership Structural discrimination Taking out an insurance Rehabilitation measures
a

Depression ra 0.229* 0.101 0.007 0.080 0.060 0.221* 0.070 0.253

City ra 0.313*** 0.095 0.129 0.161 0.040 0.167 0.211 0.450**

Small town ra 0.302** 0.265** 0.027 0.119 0.260 0.171 0.386* 0.155

0.374*** 0.209* 0.101 0.191 0.281* 0.124 0.317* 0.289

Point-biserial correlations * p < 0:05; ** p < :01; *** p < :001

disorders. This shapes patients expectations. Real, actual experiences are only of subordinate signicance. Guided by these ideas or because of their concrete experiences, patients avoid situations that hold a high risk of stigmatization. For instance, they simply do not apply for a job and, therefore, do not experience what it means to be rejected. A similar situation arises when patients are not eligible for a job because of the severity of their disability. The risk of stigmatization in this situation is extremely low because of lack of occasion. As we had expected from the results of attitudinal surveys, schizophrenia patients report stigmatization experiences more frequently than patients with depression. On the one hand, this can be due to the fact that people with schizophrenia face more rejection and are also more frequently denied access to social roles because of the stereotypes linked with this illness (Crisp et al., 2000). On the other hand, it might be due to the severity of their symptoms that people suering from schizophrenia experience negative reactions from their environment more frequently. Which of the two explanations is the most applicable one cannot be decided upon at the moment. In spite of their dierent experiences, both patients with schizophrenia and depression anticipated the same extent of stigmatizations. One reason might be that the respondents did not distinguish between dierent groups of mentally ill people but thought of mentally ill people in general. Another reason might be that due to cognitive biases that are typical of depression, depressive patients anticipated more negative reactions from their environment than they have actually experienced. A reverse situation shows when inhabitants of the city and those of the small town are compared with each other. They do not dier with regard to the extent of the stigmatization they have actually experienced. However, patients from the small town tended to anticipate stigmatization more frequently than those living in the city. Obviously, the patients shared

Downloaded from isp.sagepub.com at UNIVERSITE DE MONTREAL on February 5, 2011

ANGERMEYER ET AL.: THE STIGMA OF MENTAL ILLNESS

161

the widespread belief that the risk of stigmatization is higher in small towns and rural communities because of increased social control (Rost et al., 1993) and lower tolerance of deviant behavior (Planck & Ziche, 1979). In conclusion, one can state that anticipated stigmatization and concrete stigmatization experiences are not the same. Both dier in quantity and are only slightly correlated with each other, and both are inuenced in dierent ways by illness-related and environmental factors. From these ndings practical implications can be derived. Eorts that aim at reducing stigmatization experiences of mentally ill people do not necessarily lead to a reduction of the stigmatization the patients anticipate and vice versa. It is not necessarily a positive signal when patients report fewer stigmatizations. This could rather indicate that they avoid situations with a high risk of stigma.

REFERENCES ANGERMEYER, M.C. & MATSCHINGER, H. (1997) Social distance towards the mentally ill: results of representative surveys in the Federal Republic of Germany. Psychological Medicine, 27, 131141. ANGERMEYER, M.C., LAMMERS, R. & HOFFMANN, J. (1985a) Sozialer Ruckzug: Reaktion auf das Stigma Psychischer Krankheit? Medizin Mensch Gesellschaft, 10, 132136. ANGERMEYER, M.C., CLASSEN, D., MAJCHER-ANGERMEYER, A. & HOFMANN, J. (1985b) Stigmatisierung psychisch Kranker: Stadt versus Land. Psychotherapie Psychosomatik Medizinische Psychologie, 35, 99103. CRISP, A.H., GELDER, M.G., RIX, S., MELTZER, H.I. & ROWLANDS, O.J. (2000) Stigmatisation of people with mental illnesses. British Journal of Psychiatry, 177, 47. DICKERSON, F.B., SOMMERVILLE, J., ORIGONI, A.E., RINGEL. N.B. & PARENTE, F. (2002) Experiences of stigma among outpatients with schizophrenia. Schizophrenia Bulletin, 28, 143155. FARINA, A. & RING, K. (1965) The inuence of perceived mental illness on interpersonal relations. Journal of Abnormal Psychology, 70, 4551. GOFFMAN, I. (1963) Stigma: Notes on the Management of Spoiled Identity. Englewood Clis, NJ: Prentice Hall. GRAUSGRUBER, A., HOFMANN, G., SCHONY, W. & ZAPOTOCZKY, K. (1989) Einstellung zu psychisch Kranken und zur psychosozialen Versorgung. Stuttgart: Thieme. KEMALI, D., MAJ, M., VELTO, F., CREPET, P. & LOBRACE, S. (1989) Sondaggio sulle opinioni degli italiani nei riguardi dei malati di mente e della situazione dellassistenza psichiatrica. Revista Sperimentale di Freniatria, 113, 13011351. LINK, B.G. (1987) Understanding labeling eects in the area of mental disorders: an assessment of the eects of expectations of rejection. American Sociological Review, 52, 96112. LINK, B.G., CULLEN, F.T., STRUENING, E.L., SHROUT, P.E. & DOHRENWEND, B.P. (1989) A modied labelling theory approach to mental disorders: an empirical assessment. American Sociological Review, 54, 400423. LINK, B.G., MIROTZNIK, J. & CULLEN, F.T. (1991) The eectiveness of stigma coping orientations: can negative consequences of mental illness labelling be avoided? Journal of Health and Social Behavior, 32, 301320. LINK, B.G., PHELAN, J.C., BRESNAHAN, M., STUEVE, A. & PESCOSOLIDO, B.A. (1999) Public conceptions of mental illness: labels, causes, dangerousness, and social distance. American Journal of Public Health, 89, 13281333. LINK, B.G., STRUENING, E.L., NEESE-TODD, S., ASMUSSEN, S. & PHELAN, J.C. (2001) The consequences of stigma for the self-esteem of people with mental illnesses. Psychiatric Services, 52, 16211626. LINK, B.G., STRUENING, E.L., RAHAV, M., PHELAN, J.C. & NUTTBROCK, L. (1997) On stigma and its consequences: evidence from a longitudinal study of men with dual diagnoses of mental illness and substance abuse. Journal of Health and Social Behavior, 38, 177190. MARKOWITZ, F.E. (1998) The eects of stigma on the psychological well-being and life satisfaction of persons with mental illness. Journal of Health and Social Behavior, 39, 335347.

Downloaded from isp.sagepub.com at UNIVERSITE DE MONTREAL on February 5, 2011

162

INTERNATIONAL JOURNAL

OF

SOCIAL PSYCHIATRY 50(2)

MARTIN, J.K., PESCOSOLIDO, B.A. & TUCH, S.A. (2000) Of fear and loathing: the role of disturbing behavior, labels, and causal attributions in shaping public attitudes toward people with mental illness. Journal of Health and Social Behavior, 41, 208223. MECHANIC, D., McALPINE, D., ROSENFIELD, S. & DAVIS, D. (1994) Eects of illness attribution and depression on the quality of life among persons with serious mental illness. Social Science and Medicine, 39, 155164. PERLICK, D.A., ROSENHECK, R.A., CLARKIN, J.F., SIREY, J.A., SALAHI, J., STRUENING, E.L. & LINK, B.G. (2001) Adverse eects of perceived stigma on social adaptation of persons diagnosed with bipolar aective disorder. Psychiatric Services, 52, 15271632. PLANCK, U. & ZICHE, J. (1979) Land- und Agrarsoziologie. Stuttgart: Ulmer. ROSENFIELD, S. (1997) Labeling mental illness: the eects of received services and perceived stigma on life satisfaction. American Sociological Review, 62, 660672. ROST, K., SMITH, G.R. & TAYLOR, J.L. (1993) Ruralurban dierences in stigma and the use of care for depressive disorders. Journal of Rural Health, 9, 5762. SCHULZE, B. & ANGERMEYER, M.C. (2003) Subjective experiences of stigma: a focus group study of schizophrenia patients, their relatives and mental health professionals. Social Science and Medicine, 56, 299312. STENGLER-WENZKE, K., ANGERMEYER, M.C. & MATSCHINGER, H. (2000) Depression and stigma. Psychiatrische Praxis, 27, 330335. STUART, H. & ARBOLEDA-FLOREZ, J. (2001) Community attitudes toward people with schizophrenia. Canadian Journal of Psychiatry, 46, 245252. WAHL, O.F. (1999) Mental health consumers experience of stigma. Schizophrenia Bulletin, 25, 467478. WRIGHT, E.R., GRONFEIN, W.P. & OWENS, T.J. (2000) Deinstitutionalization, social rejection, and the self-esteem of former mental patients. Journal of Health and Social Behavior, 41, 6890. YANOS, P.T., ROSENFIELD, S. & HORWITZ, A.V. (2001) Negative and supportive social interactions and quality of life among persons diagnosed with severe mental illness. Community Mental Health Journal, 37, 405419.
Matthias C. Angermeyer, University of Leipzig, Germany. Michael Beck, Dipl.-Soz., University of Leipzig, Germany. Sandra Dietrich, MA, University of Leipzig, Germany. Anita Holzinger, Dr med., University of Leipzig, Germany. Correspondence to Prof. Dr Matthias C. Angermeyer, University of Leipzig, Department of Psychiatry, Johannisallee 20, 04317 Leipzig, Germany. Email: krausem@medizin.uni-leipzig.de

Downloaded from isp.sagepub.com at UNIVERSITE DE MONTREAL on February 5, 2011