Depression and discrimination: the ASPEN/INDIGO study


A large multinational study has found that a majority of individuals with major depressive disorder have experienced some form of discrimination (Lasalvia et al. Lancet 2013; 381: 55–62). The study was a collaborative effort by 18 countries participating in the Anti Stigma Programme European Network (ASPEN), and 17 countries involved in the International Study of Discrimination and Stigma for Depression (INDIGO).

A total of 1,082 participants were assessed using the 32-item Discrimination and Stigma Scale (DISC-12), which obtains subscores for experienced discrimination, and anticipated discrimination. (DISC-12 available at Mean age was 44.9 years; 66% were female; 50% were married/cohabiting; and 39% were working full- or part-time.

Overall, 79% reported experiencing discrimination in at least one aspect of their lives. The most common area was discrimination by family members (40%). Other domains affected were avoidance/shunning by other people (34%), making/keeping friends (33%), and marriage/divorce (23%). The areas least commonly affected involved public transport (6%), dealings with the police (6%) and religious practices (5%).

Experienced discrimination resulted in 37% not initiating a close personal relationship, 25% not applying for a job, and 20% not signing up for further education or training.

Discrimination was most commonly experienced by individuals with at least one psychiatric admission or multiple depressive episodes, which may be indicators of illness severity. Discrimination was also more common if the individual was divorced/separated/widowed, unemployed/looking for a job, or had greater anticipated discrimination. However, anticipated discrimination was not necessarily the result of experienced discrimination: 47% of people who expected discrimination in finding/keeping a job and 45% who expected discrimination in their intimate relationships had not experienced discrimination.

The researchers noted that people with higher levels of anticipated discrimination were more likely not to disclose a diagnosis of depression, suggesting that people may avoid treatment if they expect to be judged by others. Thus, expected discrimination would appear to be an important aspect of the treatment gap – with a majority of patients with major depression (56.3%), dysthymia (56%) and bipolar disorder (50.2%) in the community remaining untreated (Kohn et al. Bull World Health Organ 2004; 82: 858-866; free full text at


Drs. Arun Ravindran and Nisha Ravindran: The last three decades have seen significant growth in the literature on psychiatric stigma.  This recent publication, the result of a large collaborative European study focusing on patients with major depression, reports findings that are notable but not unexpected.  It confirms that experiencing stigma as well as its anticipation have significant adverse impact on individuals suffering with depression, and contribute to treatment refusal, thus adding further to the disease burden. It should also be noted that it is likely that stigma has an adverse effect in other forms of mental illnesses including post-traumatic stress disorder. As Peter Byrne notes in an excellent editorial, the definition of stigma and the perception of what constitutes stigma varies widely; and despite advances in the treatment of mental illnesses, the detrimental effect of stigma persists (Byrne P. Br J Psychiatry 2001;178:281-284).  Public and media opinion about stigma is often coloured by emotion in ways that are complex to interpret.  Interestingly, interventions used previously for stigma reduction are now thought paradoxically to worsen it.  For example, it has been observed that celebrity disclosure of depression, and linking creativity with mental illness may not contribute to stigma reduction and in fact may be counterproductive (McKeon P. Lancet 1998;352:1942).

While there is consensus that stigma has significant adverse effect on those who suffer from mental illness, there is less agreement on what type of interventions are effective in stigma reduction.  It has been suggested that public education and protesting discriminating practices are often effective in stigma reduction. However, there may be a rebound effect as suppression of prejudice, protest and blame, can lead to backlash (Byrne 2001).  Focused and carefully planned education for specific groups, with added emphasis on the need for good quality of life for individuals with mental illness, are now thought to be the best strategies for anti-stigma efforts.

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