Stigma towards individuals with mental health conditions such as depression is well documented (Wood et al., 2014) and highly common (see Pattie’s Mental Elf blog on the prevalence of self-stigma in depression). However, the nature and direction of the relationship between stigma and depression has been relatively unexplored despite it potentially impacting approaches to treatment.

Simply put, stigma refers to the negative appraisal of a person or group of people based on a characteristic or part of their identity that is frowned upon by mainstream society. Complicating matters, there are also different types of stigma, including:

• Anticipated stigma (i.e., one’s expectation of how others will treat them based upon the identity in question)
• Enacted stigma (i.e., experiencing discrimination based upon the identity or trait in question)
• Internalised or self-stigma (i.e., how one comes to see oneself through the perspective of others; Fox et al., 2018).

Furthermore, stigmatised identities may be visible, such as ethnicity, or concealable, such as mental health conditions (Quinn et al., 2020). That said, some mental health conditions such as body-focused repetitive behaviors (BFRBs) also have visible elements. For example, those with BFRBs often have evident hair-loss or skin lesions (Mathew et al., 2021).

To better understand the relationship between anticipated and internalised stigma and depression, O’Donnell and Foran (2024) undertook a systematic review to:

1. Establish whether anticipated and/or internalised stigma could predict levels of depression
2. Assess the quality of evidence for a causal relationship between stigma and depression.

Methods

Following PRISMA guidelines, the authors searched four online databases (including a grey literature database) to identify studies that:

• Collected quantitative data
• Utilised valid and reliable stigma and depression measures
• Involved participants aged 18+ with a stigmatised identity other than depression
• Included depression as an outcome measure
• Were available in English

The authors focused on studies with stigma as a predictor and depression as an outcome. Their interest was on the direct link between stigma and depression, not mediating effects. Consequently, they excluded studies that only reported correlational analyses or showed a mediation diagram instead of a regression table.

The initial search resulted in 2000+ possible studies, and screening proceeded in stages. The researchers piloted the first 100 results with two independent screeners, and then each researcher independently screened all titles and abstracts, resolving discrepancies through discussion. They utilized the National Institutes of Health (NIH) quality assessment tool for observational cohort and cross-sectional studies, independently rating studies as “good,” “satisfactory,” or “poor” and resolving inconsistencies through discussion.

Results

Study characteristics

Eighty-three studies were included in the systematic review. The majority of studies were cross-sectional (n = 73) with the second most common type of study being longitudinal (n = 10). Across the studies, there was a total of 34,705 participants. Most studies included in the review were conducted in the United States (n = 39), with some representation from Asia (n = 22), Africa (n = 9), and Europe (n = 6).

Five of the studies focused exclusively on anticipated stigma. Sixty-one studies measured internalised stigma, with a further nine studies measuring this construct under ‘self-stigma’. Eight of the included studies measured both anticipated and internalised stigma.

The 83 studies analysed 21 different stigmatised identities, which the authors organised under the following five subcategories:

• Sexual and gender minorities
• HIV/AIDS
• Illness or disability-related (non-HIV)
• Weight
• Other

Main findings

Sixty studies showed direct evidence for a positive link between internalised stigma and/or anticipated stigma and depression. Another 13 showed evidence for the positive link with some qualifications (i.e., did not show a significant relationship when other variables were considered), nine studies contradicted the predicted link, and one study found that internalized stigma predicted lower depression. In total, 12% of studies did not support the predicted link.

Results by stigmatised identity category

• 33.7% of the studies focused on the link between stigma related to sexual or gender minority status and depression, with approximately half (53.6%) supporting a positive relationship between anticipated and/or internalised stigma with levels of/likelihood of depression.
• 32.5% of the studies examined the link between HIV/AIDS stigma and depression. 23 of the 27 studies (85.2%) found a significant positive link between anticipated and/or internalised stigma and depression.
• 9.6% of the studies focused on the link between weight stigma and depression. All of the studies in this category found a significant positive link between anticipated and/or internalised stigma and depression.
• 15.7% of the studies explored the relationship between illness or disability-related stigma and depression, with the most commonly studied illnesses being COVID-19 and cancer. Given the range of conditions, this category lacked sufficient cohesion for meaningful quantitative analysis and comparison.
• Similar to the above, although 8.9% of included studies were categorised as “other”, there was not enough similarity among them to draw conclusions.

Results by study design

Of the 73 cross-sectional studies included, the majority (n = 56; 76.7%) supported a significant positive relationship between internalised and/or anticipated stigma and depression.

In comparison, of the 10 longitudinal studies reviewed, only four (40%) found a positive effect of internalised stigma on increased depressive symptoms over time.

Conclusions

This systematic review by O’Donnell and Foran (2024) concluded that anticipated and/or internalised stigma is a predictor of depression. Evidence across samples showed internalised and/or anticipated stigma to be significantly and positively linked to levels of depression, independent of factors such as age, gender identity, education, sexual orientation, and enacted stigma, although the strength of the relationship varied by type of stigmatised identity. Given that results varied considerably by study design, with cross-sectional studies demonstrating a more consistent relationship than longitudinal studies, the authors suggest further examination of the impact of stigma over time.

Strengths and limitations

Strengths

• Prior research has focused on internalised and enacted stigma towards people with depression. This review makes a new contribution by highlighting how pre-existing stigma can impact one’s depression, furthering our understanding of how marginalised populations experience this mental health condition in unique ways.
• The methodological strengths of this article include the authors’ adherence to the NIH quality assessment tool for observation cohort and cross-sectional studies, which was used to conduct a quality assessment of each included study. Studies were of “good” or “fair” quality, indicating the relative reliability of the findings.
• The majority of studies included in the review used well-validated measures of internalised stigma, anticipated stigma, and depression, which have been used across a wide variety of contexts and consistently provide reliable results measuring the intended construct.

Limitations

• Methodological limitations include the use of a systematic review rather than a meta-analysis, which would allow for a more precise estimate of effect sizes and provide more quantitative evaluation and synthesis of the data. It is also not entirely clear why the authors decided against a meta-analysis.
• The authors did not include kappa values to indicate inter-rater reliability between the two screeners. It is therefore unknown if there was good reliability between the screeners, which would increase confidence in the findings.
• The authors did not elaborate on how they retrieved the identified records, and 19 reports were unavailable due to the authors’ requests for access not being returned; however, they do not make it clear how they went about trying to obtain these reports. These reports could potentially hold important information in relation to the systematic review, which could impact its validity and reliability.
• The majority of studies included in the review were cross-sectional, meaning that the authors cannot make claims about how stigma impacts depression over time. However, understanding the relationship over time is critical to establishing a causal relationship, which can subsequently help us to understand what needs to be targeted in interventions.
• Findings from longitudinal studies were different from the results of the cross-sectional studies included, indicating a weaker link between stigma and depression. However, given that the number of longitudinal studies included was much lower than the number of cross-sectional studies, it is difficult to draw conclusions about the significance of this difference. Further research would benefit from a more balanced sample.

Implications for practice

The results of this review are important in the context of mental health conditions beyond major depressive disorder. As reported by Thornicroft et al. (2016) in their Lancet Commission, mental health conditions bring a double jeopardy to those who experience the symptoms of their disorder and are subject to stigma, with the latter often reported as feeling worse than the former. Many therapeutic approaches still focus on the primary symptoms of the disorder without considering the impact of chronic stigma and shame. This is particularly the case for lesser-known disorders, where lack of awareness and understanding drive higher levels of stigma.

A case in point is body-focused repetitive behaviors (BFRBs) such as trichotillomania (hair pulling) and dermatillomania, or excoriation disorder (skin-picking). These disorders are associated with significant stigma and depressive symptoms (Mathew et al., 2021), but are so stigmatized that many people with BFRBs who approach health professionals for support find that the ‘experts’ know little to nothing about their condition (Tucker et al., 2011; Woods et al., 2006).

Furthermore, while mental health conditions are often considered a concealable stigma, it may be that people with BFRBs experience self-stigma in ways that align more with those who experience visible stigmas such as weight stigma. Self-stigma can delay treatment-seeking, and those with visible stigmas may have a higher likelihood of experiencing internalised and anticipated stigma, leading to chronic shame, which may then lead to depression. These insights can inform destigmatisation efforts for clinicians and researchers to improve clinical outcomes for people with BFRBs and other mental health conditions that are more visible.

For clinicians, it is important to:

• Address stigma at the outset of treatment. Self-stigma can deter treatment-seeking, as well as interfere with treatment adherence (Kamaradova et al., 2016). Therefore, it is important to ask clients during assessment about aspects of their identity that feel stigmatised in order to proactively identify and find ways of addressing this potential barrier.
• Build clients’ awareness of the psychological effects associated with holding a stigmatised identity, alongside identifying factors that may protect against these effects.

For researchers, it is important to:

• Explore the relationship between internalised and anticipated stigma in under-researched areas like BFRBs. For BRFBs, this research could include excoriation disorder and trichotillomania as the outcome measures.
• Utilise both quantitative and qualitative methods to explore the development, maintenance and impact of self-stigma in individuals with BFRBs.
• Develop destigmatisation interventions tailored to those with visible stigmas such as BFRBs.

Statement of interests

None.

Links

Primary paper

O’Donnell, A. T., & Foran, A.-M. (2024). The link between anticipated and internalized stigma and depression: A systematic review. Social Science & Medicine, 349, 116869–116869.

Other references

Fox, A. B., Earnshaw, V. A., Taverna, E. C., & Vogt, D. (2018). Conceptualizing and measuring  mental illness stigma: The mental illness stigma framework and critical review of measures. Stigma and Health, 3(4), 348–376.

Gonsalves, P. (2023). Self-stigma for people with depression: systematic review presents global prevalence data, risk factors and protective factors. The Mental Elf.

Kamaradova, D., Latalova, K., Prasko, J., Kubinek, R., Vrbova, K., Mainerova, B., … & Tichackova, A. (2016). Connection between self-stigma, adherence to treatment, and discontinuation of medication. Patient Preference and Adherence, 1289-1298.

Mathew, A. S., Harvey, A. M., & Lee, H.-J. (2021). Development of the social concerns in individuals with body-focused repetitive behaviors (SCIB) scale. Journal of Psychiatric Research, 135, 218–229.

Quinn, D. M., Camacho, G., Pan-Weisz, B., & Williams, M. K. (2019). Visible and concealable stigmatized identities and mental health: Experiences of racial discrimination and anticipated stigma. Stigma and Health.

Thornicroft, G., Mehta, N., Clement, S., Evans-Lacko, S., Doherty, M., Rose, D., … & Henderson, C. (2016). Evidence for effective interventions to reduce mental-health-related stigma and discrimination. The Lancet, 387(10023), 1123-1132.

Tucker, B. T., Woods, D. W., Flessner, C. A., Franklin, S. A., & Franklin, M. E. (2011). The Skin Picking Impact Project: phenomenology, interference, and treatment utilization of pathological skin picking in a population-based sample. Journal of Anxiety Disorders, 25(1), 88-95.

Wood, L., Birtel, M., Alsawy, S., Pyle, M., & Morrison, A. (2014). Public perceptions of stigma towards people with schizophrenia, depression, and anxiety. Psychiatry Research, 220(1-2), 604–608.

Woods, D. W., Flessner, C. A., Franklin, M. E., Keuthen, N. J., Goodwin, R. D., Stein, D. J., & Walther, M. R. (2006). The Trichotillomania Impact Project (TIP): exploring phenomenology, functional impairment, and treatment utilization. Journal of Clinical Psychiatry, 67(12), 1877.

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