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Abstract

The scientific literature on stigma has been confused because there are multiple components of stigma with different correlates. In order to make sense of this confusion, the present review focuses on research on the most commonly measured component: social distance. The review examines measurement of social distance; characteristics of people who desire greater social distance; experiences that affect social distance; characteristics of people that elicit social distance; the effects of psychiatric labelling; the effects of causal explanations for mental disorders; and interventions to reduce social distance. It is concluded that future research on social distance needs to focus on better evaluation of interventions and examine discriminatory and supportive behaviours in real life rather than in hypothetical situations.

Keywords

attitudes discrimination social distance stigma

People who have experienced mental disorders and their families nominate stigma as a central concern to them [1, 2]. Although stigma is an important area, the scientific literature on the topic is confusing. A major reason for this confusion is that stigma is a multi-faceted concept and these facets can be measured in a variety of ways. Factor analytic studies show that there are multiple dimensions of stigma, which means that various measures may weakly intercorrelate and have different predictors associated with them [3–6]. The various facets of stigma that have been distinguished include personal stigma, stigma perceived in others, internalized self-stigma, perception of mental disorders as due to weakness, reluctance to disclose to others, perceived dangerousness, desire for social control, goodwill, and desire for social distance.

A way through this complexity is to focus on specific aspects of stigma that have been measured in fairly consistent ways. One of the more common measures is the social distance scale. Social distance involves the desire to avoid contact with a particular group of people. It is a core component of stigma that is seen, for example, in the definition of stigma adopted in the 2001 World Health Report: ‘a mark of shame, disgrace or disapproval which results in an individual being rejected, discriminated against, and excluded from participating in a number of different areas of society’ [7].

The purpose of the present review was to advance the study of stigma by focusing on research that has measured this important component of stigma using a social distance scale. Social distance scales derive from the work of Emory Bogardus, who developed them in the 1920s to study attitudes to racial and ethnic minorities in the USA [8]. The first report of use of a social distance scale to measure attitudes toward people with mental disorders was by Cumming and Cumming [9], who were influenced by earlier unpublished work by Shirley Star. They developed several versions, ranging in length from five to eight items. The items reflected a hierarchy of desired distance ranging from ‘We should strongly discourage our children from marrying anyone who has been mentally ill’ to ‘I would be willing to sponsor a person who had been mentally ill for membership in my favourite club or society’. These items were selected to form a Guttman scale, on which agreement with any item implies agreement with any preceding item. The score was the number of responses indicating social acceptance. Since this initial work, many variant scales have been developed. Most contemporary social distance scales ask for responses to a vignette, rather than the undefined term ‘mental illness’, and use a Likert rating scale rather than a dichotomous response. Despite the variety of social distance scales that have been used, all use a similar approach to measuring attitudes, making synthesis of the evidence possible.

Method

The academic literature was systematically searched through PsycINFO and PubMed to include publications that met the following criteria: (i) described a study that involved the measurement of social distance towards mentally ill people; and (ii) focused on mental illnesses that included any psychiatric disorder with the exception of ‘mental retardation’.

Both PsycINFO and PubMed searches covered all studies between 1970 up to 31 August 2008 and were limited to English-language publications. A key word search in PsycINFO used: social distance AND mental illness OR schizophrenia OR depression OR eating disorder OR substance-related disorder OR psychopathology OR personality disorder OR anxiety disorder OR post-traumatic stress disorder. Using an autoexplode strategy, a search on PubMed was carried out using medical subject headings: social distance [Title/Abstract] and mental disorder. Additional papers were found by searching the reference lists of already retrieved studies, dating back to 1957, and altogether 145 articles were identified. During the selection of papers it was decided that dissertations would be excluded. Findings from the remaining studies were grouped into major themes and conclusions drawn. The studies were reviewed by one author and subsequently checked for accuracy by the other. The studies were reviewed in a bottom-up manner to arrive at specific conclusions. To increase readability, however, the results are presented in a top-down manner under each of these conclusions.

Results

The results of this review can be summarized as the set of conclusions in Table 1. The literature justifying each of these conclusions is reviewed in detail in the following sections.

Table 1.

Conclusions about social distance from people with mental disorders

Measurement of social distance

Social distance can be reliably measured as a unidimensional component of stigma towards people with mental disorders.

Social distance is associated with reported contact, indicating validity of the measure.

Characteristics of people who desire greater social distance

Social distance is higher in older than in younger adults.

Social distance declines during adolescence.

There is no reliable gender difference in social distance

Social distance has a weak association with low education.

There are some major cross-national differences in social distance.

Experiences associated with social distance

Contact with people who have had mental disorders is associated with less social distance.

An exception is mental health professionals, who do not report less social distance despite extensive contact.

Personal experience of mental disorders is associated with less social distance.

Exposure to negative events in the media, such as violent crimes committed by people with mental disorders, can increase social distance.

Knowledge of mental disorders is associated with less social distance, but whether this is causal is unknown.

Characteristics of people that elicit greater social distance

Greater social distance is desired from people with mental disorders than from normal people, those with minor troubles and those with physical illnesses.

Greater social distance is desired from people with substance use disorders, followed by schizophrenia and then depression/anxiety disorders.

Greater social distance is desired from male individuals with mental disorders than from female individuals.

Psychiatric labelling and social distance

Labelling a person as mentally ill or having a specific mental disorder can increase social distance. The effect varies, however, depending on the label used and the familiarity of the labeller with mental disorders.

Among the general public, greater social distance is generally desired from people if they are known to have sought professional help.

Among people with more knowledge of mental disorders (family members, professionals), greater social distance is sometimes desired if the person has not sought professional help.

Causal explanations for mental disorders and social distance

Belief that mental disorders are due to diseases of the brain is associated with greater social distance; but belief that mental disorders are due to a biochemical imbalance does not appear to be associated.

There is no consistent evidence that belief in genetic causes increases social distance or that belief in psychosocial causes reduces it.

Belief that mental disorders are due to character weakness is associated with greater social distance

Interventions to reduce social distance

Social distance can be reduced by planned interventions and these effects persist for at least some months.

Social distance has changed over time in some countries, but not in a consistent direction.

Measurement of social distance

Social distance can be reliably measured as a unidimensional component of stigma towards people with mental disorders

Early psychometric work applying social distance scales to mental disorders showed that they satisfied the requirements of a unidimensional Guttman scale [9–12]. More recent research has applied various methods of factor analysis or principal component analysis to investigate the dimensionality of social distance items. Some of these studies have found evidence of a single factor [4, 13–16], while others have found evidence for two factors representing closer and more distant types of relationship [17–19]. The application of factor analysis methods to social distance items, however, is not straightforward. As Angermeyer and Matschinger have pointed out, when these methods are applied to items with very different rates of endorsement, artefactual factors of highly endorsed and lowly endorsed items can result [20]. When more appropriate methods are applied, such as non-linear principal components analysis, a single factor emerges [20].

Social distance is associated with reported contact, indicating validity of the measure

If social distance scales are valid, then responses should predict behaviour towards people with mental disorders, including discrimination. Consistent with the validity of the scales, there is evidence (reviewed below) that people with lower social distance also report more contact with people with mental disorders. It is surprising, however, that there have been no studies testing whether these scales predict discriminatory behaviour.

Characteristics of people who desire greater social distance

Social distance is higher in older than in younger adults

Many surveys of adult community samples have investigated age differences. The results have been reported in different ways and adjusted for a range of covariates, making it impossible to summarize effect sizes. Studies from a range of countries, however, have found that desire for social distance is greater at older ages [12, 14, 21–32], although there are some studies showing no association [33–36]. Despite this relative consistency, an increase in social distance with age may not be culturally universal. A study of Inuit people, for example, found that social distance was higher in younger people [18].

Despite the common observation of an age difference, it is not known whether this is an ageing or cohort effect. In communities in which a historical reduction in social distance has occurred, then a cohort effect seems a plausible interpretation.

Social distance declines during adolescence

Most of the research on age differences relates to the adult age range. Much less has been done on age differences in adolescents. Within the adolescent age range, any differences are more likely to reflect developmental trends than cohort effects. Dietrich et al. found a decrease in social distance between 13 and 18 years of age [37], while Jorm and Wright found a decrease between 12 and 25 years of age [4]. In contrast, Walker et al. found no difference by grade level for a sample aged between 8 and 18 years [38], but because that study used an Internet-recruited sample the age groups may be atypical.

There is no reliable gender difference in social distance

As with age differences, gender differences have been reported in various ways and adjusting for a varying range of covariates, making it impossible to summarize effect sizes. When examining the direction of gender differences, however, there is little consistency. In community samples most show no significant gender difference [12, 23–25, 32, 36, 39, 40], but some show greater social distance in female subjects [17, 18, 27, 29], and others in male subjects [4, 32, 35, 41]. Surveys of student samples show a similar lack of consistency, showing either no difference [42–45], greater social distance in female subjects [46, 47], or greater in male subjects [37, 48].

Social distance has a weak association with low education

Most general population surveys have found that education is associated with reduced social distance [12, 22, 24, 25, 29, 31, 34, 35, 39], but the size of the association is small and not all studies show it [32, 33, 49, 50]. In one study of Canadian Inuit there was even an association of education with increased social distance [18].

Major cross-national differences in social distance

There have been two studies examining cross-national comparisons using a common methodology. Dietrich et al. found that social distance was greater in Russia and Mongolia than in Germany [51], while Griffiths et al. found that it was greater in Japan than in Australia [52]. The differences in the Australia–Japan comparison were very large. For example, 82% of Japanese people reported that they would be unwilling to live next door to a person with depression, compared to only 12% of Australian people. Although there can be subtleties of language and culture that make direct comparisons of survey data difficult across countries, these differences are consistent with the patterns of mental health care in the two countries, with community care emphasized more in Australia and hospital care more in Japan.

Experiences associated with social distance

Contact with people who have had mental disorders is associated with less social distance

One of the most researched correlates of social distance is contact with people who have experienced mental disorders, often referred to as ‘familiarity’. Most of this research has focused on social distance from people with schizophrenia or depression, but a number of other mental disorders have been investigated as well. Contact has been found to be associated with reduced social distance across a broad range of populations and cultures [13, 18, 21, 30–33, 35, 39, 41, 46, 47, 53–61], although there are some negative results [62–65]. Some researchers have proposed that the quality of the contact is important [21, 35], but comparatively little work has been done on this issue. Martin et al. found that contact was associated with reduced social distance only when the relationship became stronger, not when it was unchanged, became worse or ended [35].

While it is well established that contact is associated with reduced social distance, the interpretation of this association is unclear. Most researchers have assumed that the association reflects a causal effect of contact on social distance. Some researchers, however, have considered the possibility of reverse causality, whereby attitudes lead to greater willingness to have contact. Angermeyer and Matschinger attempted to test the reverse causality hypothesis by distinguishing types of contact that are voluntary (contact with friends) from those that are involuntary (neighbourhood or work contact) [54]. If contact leads to reduced social distance, rather than the reverse, then involuntary contact should be associated with lower social distance. For schizophrenia they found that social distance was lower for involuntary than for voluntary contact, but this did not apply to depression, for which social distance was similar for the two types of contact.

The only sure way to test whether contact can cause lower social distance is to have an experimental intervention. Only one randomized trial has been carried out looking at the effects of contact alone (without other components to the intervention), but that study supported that it can have a causal effect [66].

An exception is mental health professionals, who do not report less social distance despite extensive contact

If involuntary contact does lead to reduced social distance, then it would be expected that mental health professionals would have low social distance, because contact is required by their work. Contrary to this hypothesis, however, studies of mental health and general health professionals show that they do not differ from the general public in social distance [27, 30, 53, 67, 68]. But in a general population survey in which participants were asked whether they ever had a job providing treatment or services to a person like the one portrayed in a vignette, professional contact was associated with lower social distance [32]. In that study most of the professional contact would not have been through specialist mental health services.

Studies of university students training to be health professionals are also relevant in this regard. It has been found that students in mental health-related professions have lower social distance than students in other areas [47, 48, 69], but this may reflect selection of the area of study or greater knowledge rather than the effects of contact. One study found that final year medical students who had had psychiatric training had lower social distance than first-year students [70], and another found that social distance was lower in later-year psychology students [69]. Another study, however, found no difference between first-year and senior occupational therapy students [48]. Again, it is unclear whether any change is due to greater knowledge or to contact. The quality of the contact may be an important factor with mental health professionals. Contact may not reduce social distance in mental health professionals because they are seeing people when they are most disabled rather than when they are well.

Personal experience of mental disorders is associated with less social distance

A number of surveys have looked at personal experience of mental disorders or psychiatric treatment and its association with social distance. Surveys of community and student samples in a range of countries show that personal experience is associated with lower social distance [4, 32, 39, 54, 58, 64]. There are a few studies, however, that did not find this association [63, 68].

Exposure to negative events in the media, such as violent crimes committed by people with mental disorders, can increase social distance

Exposure to people with mental disorders through the media is very common [57]. Some of this exposure may be through planned campaigns to reduce stigma, but there is often unplanned exposure to sensationalized negative messages as well. Dietrich et al. examined the effect of media exposure in an experimental intervention with German students [37]. They randomly assigned students to read a newspaper article linking mentally ill persons with violent crime or an informative article correcting misconceptions about mental illness. Although the negative article increased perceptions of dangerousness, there was no effect on social distance. But while a single exposure to a negative article might not affect social distance, there is evidence that more intensive exposure can. Angermeyer and Matschinger tracked social distance in Germany in the early 1990s at a time when there were two well-publicized cases of people with schizophrenia violently attacking politicians [71]. They found a marked increase in social distance from people with schizophrenia immediately following the attacks, but no effect on social distance from people with depression. Repeated low-level exposure may also have an impact. Angermeyer et al. found that watching a lot of TV and reading tabloid and regional newspapers rather than broadsheets was associated with social distance from people with schizophrenia [72]. They attributed this association to the more emotive messages found on TV and in tabloids.

Knowledge of mental disorders is associated with less social distance, but whether this is causal is unknown

Knowledge of mental disorders is a complex variable that can be influenced by many factors such as contact, personal experience, and exposure to campaigns and training courses. There are few studies examining knowledge specifically. A Canadian community survey found that knowledge of schizophrenia was associated with lower social distance [30], whereas a US community survey (with a much smaller sample) found no association [63]. An uncontrolled intervention study of a Web-based programme for reducing depression stigma found that knowledge increased while social distance reduced [73]. Similarly, a comparison of first-year and final-year medical students found both greater knowledge and lower social distance in the final year students [70]. But for both of these interventions, it is not known whether the increase in knowledge mediated the reduction in social distance.

Characteristics of people that elicit greater social distance

Greater social distance is desired from people with mental disorders than from normal people, those with minor troubles and those with physical illnesses

Social distance scales were originally interpreted against an ideal standard by which 100% acceptance was expected, but this approach was questioned by Siassi et al., who pointed out that even an idealized ‘normal’ individual would not necessarily receive perfect acceptance [74]. Since then a number of studies have used case vignettes to compare social distance of a person with a mental illness with some sort of control person. Invariably, in community or student samples, social distance is greater from people with mental illnesses, whether compared to someone with normal behaviour [10, 16, 28, 59, 75–77], someone with minor troubles [35, 78] or physical diseases such as asthma, skin cancer or ruptured disk [35, 42, 79]. When effect sizes can be calculated, they are large, generally >1 SD for schizophrenia, substance dependence or undefined mental illness, and >0.75 SD for depression and attention-deficit–hyperactivity disorder (ADHD).

Greater social distance is desired from people with substance use disorders, followed by schizophrenia and then depression/anxiety disorders

When there have been direct comparisons of vignettes portraying different disorders, most studies have found that social distance is greater for schizophrenia than for depressive and anxiety disorders, and is greater again for substance use disorders [10, 28, 32, 33, 41, 42, 45, 49, 67, 75, 77–81]. Personality disorders have not received much research, but in one study narcissistic personality disorder was found to elicit similar social distance to schizophrenia [49]. There is also little evidence on childhood disorders, but adults have been found to report greater social distance from children with ADHD than depression [35], while children themselves show similar social distance from peers with ADHD and depression [38]. In professional samples there is a similar hierarchy of social distance, with schizophrenia more distant than depressive and anxiety disorders [11, 19, 67], and borderline personality disorder more distant again [19]. Other studies of the public have simply used disorder labels rather than vignettes, but have found a similar hierarchy, with substance disorders more distant than schizophrenia, which is more distant than depression [48, 82]. There is also variation within diagnostic categories, depending on the type of behaviour portrayed in vignettes. For example, paranoid schizophrenia elicits greater social distance than simple schizophrenia [10, 33, 75, 77], and chronic schizophrenia more than early schizophrenia [52].

All the aforementioned research has examined social distance in relation to the behaviour portrayed in vignettes, rather than in response to real-life behaviour. One study, however, has looked at the social distance scores of relatives of former mental patients in relation to the person's level of impairment [15]. That study found that social distance scores were more associated with anxiety, depression and somatic complaints than with symptoms of psychosis.

Greater social distance is desired from male individuals with mental disorders than from female individuals

It is not only the behaviour of the person that is associated with social distance. When male and female vignettes are presented describing the same behaviours, social distance is typically greater to the male version [32, 33, 35, 40, 65, 74, 83, 84], but not always so [45]. This difference might be due to greater perceived dangerousness of male individuals.

Psychiatric labelling and social distance

Labelling a person as mentally ill or having a specific mental disorder can increase social distance, but the effect varies depending on the label used and the familiarity of the labeller with mental disorders

Thomas Scheff proposed that labelling of people as being mentally ill led to expectations from society that they would behave in certain ways, and that these people changed their behaviour to fulfil society's expectations [85]. According to this view, use of labels would be a major contributor to social distance. Scheff's theory led to a major debate about the relative importance of behaviour versus labels [86]. As far as social distance is concerned, the evidence reviewed earlier clearly shows that the behaviour portrayed in a vignette is a major determinant. The issue is what additional effect labelling may have.

The effects of labelling have been investigated using either experimental studies, in which participants are provided with various labels for a person in a vignette or video, and correlational studies in which participants are asked about what they think is wrong with the person or whether they think the person is mentally ill. The labels investigated have generally been broad ones such as ‘mentally ill’, but sometimes specific diagnostic labels or more positive alternative labels have been examined. Some studies have labelled the person by whether or not they received professional help or the type of help received.

A number of experimental studies have been carried out in which a person's behaviour is presented in a vignette or video and the behaviour is labelled in various ways (e.g. the person has a history of mental illness vs no label). These studies have involved either students or members of the public. One of these studies found that labelling increased social distance [87], but other studies have found no effect [16, 76] or an effect only under limited conditions, namely, that labelling increased social distance from a normal person but not one with an anxiety neurosis [88], or if the labeller perceived the person as potentially dangerous [86].

A larger number of studies have looked at the effects of labelling correlationally. These studies have more consistently found that labelling of a wide variety of disorders is associated with social distance [24, 27, 35, 36, 50, 75, 89], but there have been a few studies that found the association only under some circumstances: for labelling of depression in 1990, but not in 2001 [22], and for labelling of a common stress vignette, but not for depression or alcohol dependence vignettes [65].

Other studies have looked at use of more specific labels. In experimental studies, labels such as ‘paranoid’, ‘schizophrenic’ and ‘neurotic’ are generally found to increase social distance [28, 55, 90, 91].

A complicating factor with psychiatric labels is that they are often misunderstood by the public, which may add to any effects on social distance; for example, in some countries ‘schizophrenia’ is commonly thought to indicate ‘split personality’ [26, 30, 82]. As familiarity with mental disorders increases, the effects of labelling may change. For example, the psychiatric label of depression does not appear to increase social distance in present-day Australia or Germany [22, 32].

There have also been studies examining the effects of alternative labels with more positive connotations. Penn and Nowlin-Drummond in the USA found that use of the politically correct term ‘consumer of mental health services’ to label a vignette led to less social distance than conventional labels such as ‘person with severe mental illness’, ‘person with schizophrenia’ and ‘schizophrenic’ [92]. Although ‘person with schizophrenia’ was rated as more politically correct that ‘schizophrenic’, these labels did not differ in effect on social distance. In Hong Kong Chung, and Chan investigated whether use of a less pejorative Chinese translation for schizophrenia (‘dysregulation of thought and perception’ versus the conventional ‘mind-split disease’) affected social distance in secondary students, but found no effect [56].

Among the general public, greater social distance is generally desired from people if they are known to have sought professional help

Other studies have investigated the effects of labelling a person in a vignette by the type of help that they have received. The typical experiment has involved presenting a range of vignettes and pairing these with information about a range of help-seeking from none to mental hospital admission. In the first study of this type, members of the US public desired the lowest social distance when the person sought no help, followed by help from a clergyman, physician and psychiatrist, through to treatment in a mental hospital as the highest [77]. Later, a study of US college students using the same method found that labelling the person as a help-seeker increased social distance only if the person in the vignette showed normal behaviour or had a mild problem.

Among people with more knowledge of mental disorders (family members, professionals), greater social distance is sometimes desired if the person has not sought professional help

More recent research has indicated that, for people with more knowledge of mental disorders, not seeking appropriate help is seen more negatively than seeking it. A study of Hong Kong university students found that previous contact with people with mental disorders was an important moderator of the effect [47]. For students with no previous contact, social distance was increased by knowledge that the person had sought help. For students with previous contact, however, help-seeking was associated with lower social distance. A study of psychiatric nurses in the USA found a similar effect, in which social distance was reduced when the help-seeking was appropriate compared to when there was no help-seeking [11]. In a study of Spanish university students, social distance was reduced when a vignette described a person with paranoid schizophrenia as receiving treatment and showing improvement [69].

Causal explanations for mental disorders and social distance

Perhaps the most controversial area of research on social distance has concerned the effects of biological versus psychosocial causal explanations. On the one hand, there are researchers who argue that biological causal explanations could increase social distance because the person with a mental illness is seen as having a fundamental immutable flaw [42, 93, 94]. John, Read, in particular, has argued that promoting ‘biogenetic’ explanations to the public may increase stigma and that psychosocial explanations should be promoted instead [93]. On the other hand suggest that attributing a cause that is outside of the individual's control, such as genetic factors, will reduce social distance [35].

A number of experimental studies have been carried out to investigate this issue (Table 2). In these studies the participants were randomized to receive different causal explanations of the same mental disorder. The findings are consistent: varying causal explanation has no effect on social distance from a mentally ill person. The only exception was one study that found an effect on social distance from siblings of a mentally ill person (although not on the mentally ill person). While these experimental studies are a strong methodology for establishing cause–effect relationships, the interventions involved are minor (e.g. varying a few sentences in a vignette). It is possible that they are not sufficient to overcome pre-existing beliefs.

Table 2.

Summary of experimental studies on causal explanations and social distance

Study	Stigmatized group	Participants in study	Intervention	Findings
Bennett et al. (2008) [95]	People with schizophrenia	Welsh university students n=268	Vignette explained as due to either genetic or environmental factors	No significant effect (p>0.05)
Breheny (2007) [79]	People with schizophrenia and depression	New Zealand public n=232	Vignette explained as either genetic or definitely not genetic	No significant effect (p>0.05)
Eker (1985) [44]	People with paranoid schizophrenia	Turkish university students n=137	Vignette explained as due to either psychological, social, genetic or accident factor	No significant effect (p>0.05)
Jackson & Hetherington (2006) [87]	People with mental illness	Jamaican high school students n=1223	Videotaped job interview gave information that applicant had spent time in mental hospital resulting from either ‘a dysfunctional family environment’ or ‘a chemical imbalance’	No significant effect (p>0.05)
Lincoln et al. (2008) [96]	People with schizophrenia	German university students n=121	Information presented via brochures and video promoting either biogenetic or psychosocial explanations	Both interventions led to reduction in social distance No significant difference between interventions (p>0.05)
Phelan (2005) [42]	People with schizophrenia and depression	US public n=1241	Vignette explained as either genetic, partly genetic or not genetic	No significant effect on social distance towards mentally ill person (p>0.05) Increased social distance to sibling of mentally ill person (p<0.05)

Most of the evidence on causal explanations has come from correlational studies (Table 3) in which participants are presented with a case vignette and asked about the likely causes, either using an open-ended question or by rating a range of causal items. In studies involving ratings of a range of potential causes, multiple regression models are typically used to investigate the independent contribution of each causal explanation. The evidence from these studies is complex and is reviewed in the following sections under the main categories of causal explanations that have been investigated.

Table 3.

Summary of correlational studies on causal explanations and social distance

Study	Stigmatized group	Participants in study	Association with genetic explanation	Association with brain disease explanation	Association with biochemical imbalance explanation	Association with childhood adversity explanation	Association with social stressor explanation	Association with character weakness explanation
Bag et al. (2005) [24]	People with schizophrenia and depression	Turkish public n=856	Positive (β=0.099, p<0.05)	Positive (β=0.169, p<0.01)		NS	NS
Coker (2005) [81]	People with psychosis, alcohol abuse or possession	Egyptian workers n=208					Negative χ² significant p<0.001
Dietrich et al. (2004) [51]	People with schizophrenia and depression	West German public n=1987 East German public n=494 Russian public n=375 Mongolian public n=474	Positive Schizophrenia: (B=0.059, p<0.01) Depression: (B=0.045, p<0.01) Positive (schizophrenia only) (B=0.089, p<0.05) Positive (schizophrenia only) (B=0.073, p<0.05) Positive Schizophrenia: (B=0.079, p<0.01) Depression: (B=0.160, p<0.001)	Positive Schizophrenia: (B=0.171, p<0.001) Depression: (B=0.096, p<0.001) Positive (schizophrenia only) Positive (depression only) (B=0.106, p<0.001) Positive (schizophrenia only) (B=0.074, p<0.01)		Negative (depression only) (B=−0.054, p<0.01) NS NS Negative Schizophrenia (B=0.097, p<0.001) Depression: (B=−0.075, p<0.01)	Negative (depression only) (B=−0.090, p<0.001) NS NS Negative Schizophrenia: (B=−0.097, p<0.001) Depression: (β=−0.108, p<0.01)	Positive Schizophrenia: (B=0.040, p<0.05) Depression: (β=0.123, p<0.001) Positive (depression only) (B=0.094, p<0.01) Positive (schizophrenia only) (B=0.068, p<0.05) NS
Grausgruber et al. (2007) [34]	People with schizophrenia	Austrian public n=1042 Relatives n=137 Staff=460	NS NS NS				Negative (β=0.103, p=0.003) NS NS	Positive (β=−0.089, p=0.008) NS NS
Jorm & Griffiths (2008) [32]	People with schizophrenia and depression	Australian public n=3998	NS			NS	NS	Positive Schizophrenia: (B=−0.58, p<0.001) Depression: (B=0.71, p<0.001)
Lincoln et al. (2008) [96]	People with schizophrenia	German university students n=121	NS			NS	NS
Martin et al. (2000) [36]	People with depression, schizophrenia, alcohol dependence, drug dependence	US public n=1444	Negative (B=−0.505, p<0.05)		NS	NS	Negative (B=−0.719, p<0.05)	Positive (B=0.645, p<0.05)
Martin et al. (2007) [35]	Children and adolescents with ADHD and depression	US public n=1393	NS		NS	NS	NS	Positive (B=0.105, p<0.001)
Ozmen et al. (2004) [97]	People with depression	Turkish public n=719					Positive (B=−0.886, p<0.05)	Positive (B=−0.493, p<0.05)
van't Veer et al. (2006) [31]	People with mental illness	Dutch public n=812	Negative (β=−0.086, p<0.05)	NS		Negative (β=−0.082, p<0.001)	Negative (β=−0.172, p<0.001)	NS

ADHD, attention-deficit–hyperactivity disorder; B, unstandardized coefficient; β, standardized coefficient; NS, no significant association; Positive, causal explanation significantly associated with increased social distance; Negative, causal explanation significantly associated with decreased social distance.

Belief that mental disorders are due to diseases of the brain is associated with greater social distance, but belief that mental disorders are due to a biochemical imbalance does not appear to be associated

There are a number of correlational studies on brain disease as a causal explanation and these mostly show a positive association with social distance. This evidence has led to cautions about promoting biological explanations of mental disorder, lest they increase stigma [51, 93, 94]. Griffiths and Christensen, however, have questioned whether ‘brain disease’ reflects the term used in most health promotion programmes [98]. Unlike the alternative biological term ‘biochemical imbalance’, it suggests less ability of the individual to exercise control over their behaviour and lower treatability. There is more limited evidence on biochemical imbalance as a causal explanation. What evidence there is, however, from one experimental study and two correlational studies (Tables 2 and 3), suggests no association with social distance.

There is no consistent evidence that belief in genetic causes increases social distance or that belief in psychosocial causes reduces it

The interest in the effect of genetic explanations is increased by the fact that the human genome project has become increasingly prominent in the public arena, potentially leading to a dominance of genetic accounts of human behaviour [42]. In fact, repeat surveys of the public in both Germany and Australia have found an increased belief in genetic causes of mental illnesses [99, 100].

As summarized in Table 2, experimental studies in a number of countries consistently find that providing genetic explanations has no effect on social distance towards a mentally ill person, although one study did find that it increased social distance towards a sibling of a mentally ill person. Table 3 summarizes the correlational studies. These show little consistency, finding positive, negative and non-significant associations.

Explanations of mental disorders in terms of childhood adversity have been investigated, including coming from a broken home, lack of parental affection, death of mother, lack of discipline in the home, sexual abuse, or the way the person was raised in general. The evidence from correlational studies again is inconsistent. Some have found that this type of explanation is associated with reduced social distance, but the majority of studies have found no association.

A range of social stressors have been examined as causal explanations, including stress at work, bad living conditions, financial problems, dysfunctional family environment, and adverse life events in general. Experimental studies show no effect. Correlational studies have had mixed results, with most showing either a negative association or no association, and one study finding a positive association.

In conclusion, the findings in this area are not always consistent. A possible reason for the discrepancies may be the use of multiple regression models with varying sets of predictors. Griffiths and Christensen have pointed out that surveys of the public show a high degree of overlap in endorsement of various causal explanations [98]. Respondents do not face a dichotomous choice between biological and psychosocial explanations. Indeed, the scientifically correct answer is that typically both are involved. Griffiths and Christensen have also argued for caution in interpreting multiple regression models in which highly correlated causal explanations are predictors. It may be that these yield results that are more relevant to the minority, who adhere to simple biological-only or psychosocial-only explanations. Another reason for the inconsistencies may be that there are true differences between populations. The connotations of terms such as ‘hereditary’ may differ between various languages and cultures and have differing implications for social distance.

Belief that mental disorders are due to character weakness is associated with greater social distance

A number of correlational studies have examined associations with explanations such as ‘lack of will’ [51], ‘weak character’ [34], ‘weakness of character’ [32], ‘weakness of personality’ [97], ‘one's own character’ [31] and ‘bad character’ [35, 36]. Most of these studies have found a positive association with social distance.

Interventions to reduce social distance

Social distance can be reduced by planned interventions and these effects persist for at least some months

There are 16 studies that have evaluated interventions for reducing social distance. These are summarized in Table 4. Most of these studies have been aimed at reducing social distance from people with severe mental disorders, particularly schizophrenia, but some have been aimed at people with depression, and one at parents of people with chronic mental illness. The participants in these studies have included community members, students, police officers, and employees. The interventions were wide ranging. Some involved complex training packages (such as Mental Health First Aid and Crisis Intervention Team Training), two involved population-wide campaigns, while most involved more specific interventions (such as personal contact, lecture, video, brochure or website). Most of the studies did not have high-quality research designs, with only three of the 16 studies involving randomized controlled trials. Despite the diversity of the interventions and research methods, all but three of the studies showed significant reductions in social distance. Whether these interventions led to lasting changes is less clear, because most studies used only pre-test and post-test measures. In the five studies, however, that had follow ups ranging from 1 to 6 months, all but one found persisting effects. Another limitation of these studies was the lack of measures of actual contact, and the quality of that contact, to complement self-reports of preferred social distance. The only measures of this sort were self-reports of contacts, which were included in studies of Mental Health First Aid training. These studies showed no change in the amount of contact, but improvements in quality of the contacts, namely, providing help to the person or advising the person to get professional help [105, 107].

Table 4.

Summary of intervention studies

Study	Stigmatized group	Participants in study	Content of intervention and control condition	Design of evaluation	Level of evidence†	Findings
Altindag et al. (2006) [101]	People with schizophrenia	Turkish medical students: n=25 in intervention group; n=35 in control group	Intervention: 1 day programme involving: 2 h lecture describing common causes, myths, relationship of schizophrenia and violence/aggression and independence; discussion with affected peer; watching film about John Nash Control: lecture and film not about mental disorders	Comparative study with concurrent controls (non-randomized clustered experimental trial). Questionnaires given before, after and at 1 month follow up	III-2	Significant decreases in social distance to co-workers (p<0.001) and neighbours (p<0.001), but these were not maintained at 1 month follow up No change in attitudes to marriage or renting house
Bahora et al. (2008) [102]	People with mental disorders (depression, schizophrenia) and substance dependence (alcohol, cocaine)	US police officers: n=58 entered the study and n=40 underwent post-test assessment	Intervention: 40 h Crisis Intervention Team Training involving: structured lectures and discussions by health professionals and advocacy groups; site visits to local emergency facilities and inpatient psychiatric units; experiential de-escalation training using videos and role-plays Control: none	Case series with pre-test/post-test outcomes Questionnaires given before and after	IV	Significant decreases in social distance scale for all disorders Greater change found in those without a family history of psychiatric treatment (p<0.001)
Bell et al. (2006) [103]	People with schizophrenia and severe depression	Australian pharmacy students: n=117 in intervention group; n=94 in control group	Intervention: five tutorial classes that received pharmacist-led instruction plus additional input from mental health consumer–educators Control: four tutorial classes that received pharmacist-led instruction	Comparative study with concurrent controls (non-randomized clustered experimental trial) Questionnaires given before and after	III-2	Significant decrease in social distance scale in intervention compared to control (p=0.02)
Compton et al. (2006) [104]	People with schizophrenia	US police officers: n=159	Intervention: 40 h Crisis Intervention Team Training involving educational training by mental health professionals, family advocates and mental health consumer groups Control: none	Case series with pre-test/post-test outcomes Questionnaires given before and after	IV	Significant decrease in social distance scale (p<0.001) Same degree of change for those who knew or did not know someone with schizophrenia
Cumming & Cumming (1957) [9]	People with mental illness	Canadian community members: n=540 in intervention town; n=107 in control town	Intervention: 6 month-long mental health education programme involving talks, radio programme, newspaper articles, film festival Control: none	Comparative study with concurrent controls (non-randomized clustered experimental trial) Questionnaires given before and after	III-2	No change in social distance in either intervention or control town
Finkelstein & Lapshin (2007) [73]	People with depression	US university staff and graduate students: n=42	Intervention: Web-based depression stigma programme covering education on depression, personal stories of patients, and scenarios of behaviour towards people with depression Control: none	Case series with pre-test/post-test outcomes Questionnaires given before and after	IV	Significant decrease in social distance scale (p=0.005) Social distance to people with HIV (not a target of the intervention) also decreased, but not as much as to depression (p=0.003)
Gaebel et al. (2008) [17]	People with schizophrenia	German community members aged ≥16 years: n=1493 in two intervention cities; n=3129 in four control cities	Intervention: Open the Doors campaign in two cities. This involved 4 years of public events such as lectures, art exhibitions, cinema events, readings, theatre events and charity concerts Control: schizophrenia awareness programme aimed at GPs and teachers in two cities; no intervention in two other cities	Comparative study with concurrent controls (non-randomized clustered experimental trial) Questionnaires given before and after	III-2	Significant decreases in social distance scale in intervention cities compared to control cities (p=0.01) Social distance improved with ‘transient social relations’ but not ‘close social relations’
Jorm et al. (2004) [105]	People with schizophrenia or depression	Australian adult community members: n=416 in eight intervention communities; n=337 in eight control communities	Intervention: 9 h Mental Health First Aid training course Control: waiting list	Cluster randomized controlled trial Questionnaires given before and at 4 month follow up	II	Significant decreases in social distance compared to control group (β=−0.26, p=0.032)
Kitchener & Jorm (2002) [106]	People with schizophrenia or depression	Australian adult community members: n=210	Intervention: 9 h Mental Health First Aid training course Control: none	Case series with pre-test/post-test outcomes Questionnaires given before, after and at 6 month follow up	IV	Significant decrease in social distance scale (p<0.001)
Kitchener & Jorm (2004) [107]	People with schizophrenia or depression	Australian public servants: n=146 in intervention group; n=155 in control group	Intervention: 9 h Mental Health First Aid training course Control: waiting list	Randomized controlled trial Questionnaires given before and at 5 month follow up	II	Significant decreases in social distance for depression, but not schizophrenia, compared to control group (p=0.005)
Lewis & Frey (1988) [108]	Parents of the chronically mentally ill	US social work students: n=39 in intervention group; n=27 in control group	Intervention: 3 h class involving interactions with parents who had adult children with mental illnesses Control: students who received no intervention	Comparative study with concurrent controls (non-randomized experimental trial) Questionnaires given before and after	III-2	No change in social distance compared to control group
Lincoln et al. (2007) [96]	People with schizophrenia	German medical and psychology students: n=41 in biogenetic causal explanation group; n=40 in psychosocial causal explanation group; n=39 in control group	Intervention 1: information presented via brochures and video promoting biogenetic causal explanations Intervention 2: information presented via brochures and video promoting psychosocial causal explanations Control: information presented about ice and glaciers	Pseudo-randomized controlled trial Questionnaires given before and after	III-1	Significant decreases in social distance with both interventions for medical students. (p<0.001) No effect for psychology students.
Mann & Himelein (2008) [109]	People with schizophrenia and bipolar disorder	US psychology students: n=27 in intervention group; n=26 in control group	Intervention: 2 week ‘humanizing approach’ psychopathology course involving reading first-person narratives, watching video with personal experiences, and poetry assignment from perspective of person with mental illness Control: 2 week ‘diagnostic approach’ psychopathology course involving reading clinical descriptions, watching third-person video, and assignment requiring application of diagnostic criteria	Comparative study with concurrent controls (non-randomized experimental trial) Questionnaires given before and after	III-2	Significant decreases in social distance for intervention compared to control (p<0.01)
Mino et al. (2001) [110]	People with mental illness	Japanese medical students: n=95 in intervention group; n=94 in control group	Intervention: 1 h educational programme dealing with importance of community services Control: lecture on another topic to students at another university	Comparative study with concurrent controls (non-randomized experimental trial) Questionnaires given before and after	III-2	Significant decreases in social distance compared to control group in acceptance of marriage in family (p=0.005), rent a room (p=0.002) and co-worker (p=0.004). No change in acceptance as neighbour or community member
Reinke et al. (2004) [66]	People with severe mental illness	US community college students: n=164 assigned to 1 of 5 groups	Intervention 1: 15 min presentation and discussion with person who has experienced mental illness, yet lived a ‘normal’ life Intervention 2: 15 min video and discussion about the same person. Video content was randomized to provide either little, moderate or high disconfirmation of stereotypes Control: presentation on ‘Hobbies and Technology in the 90s’	Randomized controlled trial Questionnaires given before and after	II	Significant decreases in social distance for both in vivo (p<0.05) and video (p<0.05) contact compared to controlVideos moderately disconfirmed stereotypes produced greater decrease in social distance
Schulze et al. (2003) [111]	People with schizophrenia	German school students aged 14–18 years: n=90 in intervention group; n=60 in control group	Intervention: school project involving discussion of emotional well-being and mental health using artwork and games, and meeting with a young person with schizophrenia Control: school project unrelated to mental health	Comparative study with concurrent controls (non-randomized experimental trial) Questionnaires given before, after and at 1 month follow up	III-2	No change in social distance

^†Level of evidence according to National Health and Medical Research Council evidence hierarchy [112].

Social distance has changed over time in some countries, but not in a consistent direction

Given that social distance can be changed by various experiences, it is possible that historical changes have occurred within particular countries. Only two studies, however, have looked at this issue. In 1974, Brockman and D'Arcy resurveyed a Canadian town that had been the subject of a failed intervention to change community attitudes in 1951 [9, 25]. They found that willingness to have social contact with ‘ex-mental patients’ had improved from 53% to 67% in those under 40 years old, and from 26% to 43% in those over 40. By contrast, in Germany Angermeyer and Matschinger found no change in social distance from a person with major depression between 1990 and 2001, while they found an increase in social distance from a person with schizophrenia [22, 99].

Future directions

This review summarizes what can be concluded from the literature after 50 years of research on social distance. While much has been achieved, there are some major gaps. In particular, the convenience of social distance scales as proxy measures for rejection and discrimination has led to a neglect of behavioural measures. It is remarkable that social distance scales have not been validated against discriminatory or supportive behaviours. The convenience of vignettes and videos for presenting various mental disorders has also led to a neglect of social distance in response to real-life interactions. Vignettes and videos are decontextualized to a degree that responses to them may not reflect what occurs in everyday life. For example, it is not known whether learning that a friend or colleague has received a psychiatric diagnosis has the same effect as reading about a mental illness label applied to a hypothetical vignette. A related gap is that there has been little attention paid to the effect of being socially distanced on the mental health of patients and carers, even though they have nominated stigma as a major concern.

One of the major claims made in the stigma literature is that personal contact reduces social distance. But it is clear that contact is not always positive, as illustrated by the findings with mental health professionals. There is a need for greater understanding of the specific types of interactions that increase or decrease social distance.

It is clear that social distance can be reduced by planned intervention, but the quality of much of the evidence is poor. There is a need for well-designed intervention studies, with long-term follow up of effects on behaviour towards people with mental disorders as well as self-reported social distance. Given that patients and family members see stigma as an important priority, social distance should be routinely monitored as an indicator of national progress. Social distance measures could be added to existing regular population health surveys at minimal cost.

Finally, this review has attempted to make sense of the complex scientific literature on stigma by focussing on one consistently measured component. The conclusions drawn may not apply to other components. For example, correlations of social distance with perceptions of dangerousness are in the range 0.2–0.6 [45, 57, 65, 78], indicating that different predictors may be involved. Further progress could be made by carrying out similar reviews of these other components of stigma.

Footnotes

Acknowledgements

This work was supported by funding from the National Health and Medical Research Council and the Colonial Foundation.

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Desire for Social Distance from People with Mental Disorders

Abstract

Keywords

Method

Results

Measurement of social distance

Social distance can be reliably measured as a unidimensional component of stigma towards people with mental disorders

Social distance is associated with reported contact, indicating validity of the measure

Characteristics of people who desire greater social distance

Social distance is higher in older than in younger adults

Social distance declines during adolescence

There is no reliable gender difference in social distance

Social distance has a weak association with low education

Major cross-national differences in social distance

Experiences associated with social distance

Contact with people who have had mental disorders is associated with less social distance

An exception is mental health professionals, who do not report less social distance despite extensive contact

Personal experience of mental disorders is associated with less social distance

Exposure to negative events in the media, such as violent crimes committed by people with mental disorders, can increase social distance

Knowledge of mental disorders is associated with less social distance, but whether this is causal is unknown

Characteristics of people that elicit greater social distance

Greater social distance is desired from people with mental disorders than from normal people, those with minor troubles and those with physical illnesses

Greater social distance is desired from people with substance use disorders, followed by schizophrenia and then depression/anxiety disorders

Greater social distance is desired from male individuals with mental disorders than from female individuals

Psychiatric labelling and social distance

Labelling a person as mentally ill or having a specific mental disorder can increase social distance, but the effect varies depending on the label used and the familiarity of the labeller with mental disorders

Among the general public, greater social distance is generally desired from people if they are known to have sought professional help

Among people with more knowledge of mental disorders (family members, professionals), greater social distance is sometimes desired if the person has not sought professional help

Causal explanations for mental disorders and social distance

Belief that mental disorders are due to diseases of the brain is associated with greater social distance, but belief that mental disorders are due to a biochemical imbalance does not appear to be associated

There is no consistent evidence that belief in genetic causes increases social distance or that belief in psychosocial causes reduces it

Belief that mental disorders are due to character weakness is associated with greater social distance

Interventions to reduce social distance

Social distance can be reduced by planned interventions and these effects persist for at least some months

Social distance has changed over time in some countries, but not in a consistent direction

Future directions

Footnotes

Acknowledgements

References