people from completing suicide.2 A prominent nationally representative survey conducted in the early 1990s found that 44 percent of Americans are opposed to suicide under any circumstances; most of the remainder are opposed to suicide except in the case of terminal illness (Agnew, 1998). In some situations, however, the stigma of suicide acts to increase suicide risk because it may prevent people from disclosing to clinicians their suicidal thoughts or plans. Studies cited later in this chapter clearly indicate that patients often do not discuss their suicidal plans with their clinician. This, in turn, leads to their under-treatment and thus increases their likelihood of suicide.
The existence of stigma surrounding mental illness is best supported by nationally representative studies of public attitudes. Studies find that about 45–60 percent of Americans want to distance themselves from people with depression and schizophrenia. The figures are even greater for substance use disorders (Link et al., 1999). Stigma leads the public to discriminate against people with mental illness in housing and employment (Corrigan and Penn, 1998). It also discourages the public from paying for treatment through health insurance premiums (Hanson, 1998). Public attitudes toward mental health treatment are somewhat contradictory: while nationally representative surveys find that Americans generally support mental health treatment for people with disorders, the public is less willing to use formal services if they anticipate a mental health problem for themselves (Pescosolido et al., 2000; Swindle et al., 2000).
For people with mental illness, the consequences of societal stigma can be severe: diminished opportunities, lowered self-esteem, shame and concealment of symptoms, and lower help-seeking behavior (Hornblow et al., 1990; Link et al., 1997; Sussman et al., 1987; Wahl, 1999). The National Comorbidity Survey, one of the only nationally representative studies to investigate why individuals with mental illnesses do not seek treatment, found that almost 1 in 4 males and 1 in 5 females with Posttraumatic Stress Disorder cite stigma as their reason (Kessler, 2000). While the majority with mental illness do not seek treatment, there is wide demographic variability: women and younger adults (ages 18-44) are more likely to reach some kind of care, whereas ethnic minorities and older people are less likely (Bland et al., 1997; Gallo et al., 1995; Narrow et al., 2000; US DHHS, 1999; US DHHS, 2001). If they make contact with primary care providers, stigma inhibits them from bringing up their mental health concern. Patients may instead report more somatic symptoms of