The starting point for this discussion is the idea of stigma. This term (plural stigmata) was originally used to refer to an indelible dot left on the skin after stinging with a sharp instrument, sometimes used to identify vagabonds or slaves.^{(1, 2, 3 and 4)} In modern times stigma has come to mean ‘any attribute, trait or disorder that marks an individual as being unacceptably different from the ‘normal’ people with whom he or she routinely interacts, and that elicits some form of community sanction.’^{(5, 6 and 7)}

There is now a voluminous literature on stigma.^{(5,8)(9, 10, 11, 12 and 13,13, 14, 15, 16, 17, 18 and 19)} The most complete model of the component processes of stigmatization has four key components:⁽²⁰⁾

Five key features have limited the usefulness of stigma theories. First, while these processes are undoubtedly complex, academic writings on stigma (which in the field of mental health have almost entirely focused upon schizophrenia) have made relatively few connections with legislation concerning disability rights policy⁽²³⁾ or clinical practice. Second, most work on mental illness and stigma has been descriptive, overwhelmingly describing attitude surveys or the portrayal of mental illness by the media. Very little is known about effective interventions to reduce stigma. Third, there have been notably few direct contributions to this literature by service users.⁽²⁴⁾ Fourth, there has been an underlying pessimism that stigma is deeply historically rooted and difficult to change. This has been one of the reasons for the reluctance to use the results of research in designing and implementing action plans. Fifth, stigma theories have de-emphasized cultural factors and paid little attention to the issues related to human rights and social structures.

Recently there have been early signs of a developing focus upon discrimination. This can be seen as the behavioural consequences of stigma, which act to the disadvantage of people who are stigmatized.^{(23,25, 26 and 27)} The importance of discriminatory behaviour has been clear for many years in terms of the personal experiences of service users, in terms of devastating effects upon personal relationships, parenting and childcare, education, training, work, and housing.⁽²⁸⁾ Indeed, these voices have said that the rejecting behaviour of others may bring greater disadvantage than the primary condition itself.

Stigma can therefore be seen as an overarching term that contains three important elements: ⁽²⁹⁾

Do we know if discrimination varies between countries and cultures? The evidence here is stronger, but still frustratingly patchy.⁽³⁶⁾ Although studies on stigma and mental illness have been carried out in many countries, few have been comparison of two or more places, or have included non-Western nations.⁽³⁷⁾

In Africa one study described attitudes to mentally ill people in rural sites in Ethiopia. Among almost 200 relatives of people with diagnoses of schizophrenia or mood disorders, 75 per cent said that they had experienced stigma due to the presence of mental illness in the family, and a third (37 per cent) wanted to conceal the fact that a relative was ill. Most family members (65 per cent) said that praying was their preferred of treating the condition.⁽³⁸⁾ Among the general population in Ethiopia schizophrenia was judged to be the most severe problem, and talkativeness, aggression, and strange behaviour were rated as the most common symptoms of mental illness.⁽³⁹⁾ The authors concluded that it was important to work closely with traditional healers.

In South Africa,^(40,41) a survey was conducted of over 600 members of the public on their knowledge and attitudes towards people with mental illness.⁽⁴²⁾ Different vignettes, portraying depression, schizophrenia, panic disorder, or substance misuse were presented to each person. Most thought that these conditions were either related to stress or to a lack of willpower, rather than seeing them as medical disorders.⁽⁴³⁾ Similar work in Turkey,⁽⁴⁴⁾ and in Siberia and Mongolia⁽⁴⁵⁾ suggests that people in such countries may be more ready to make the individual responsible for his or her mental illness and less willing to grant the benefits of the sick role.

Most of the published work on stigma is by authors in the USA and Canada,^{(11,27,46,47)} but there are also a few reports from elsewhere in the Americas and in the Caribbean.⁽⁴⁸⁾ In a review of studies from Argentina, Brazil, Dominica, Mexico, and Nicaragua, mainly from urban sites, a number of common themes emerged. The conditions most often rated as ‘mental illnesses’ were the psychotic disorders, especially schizophrenia. People with higher levels of education tended to have more favourable attitudes to people with mental illness. Alcoholism was considered to be the most common type of mental disorder. Most people thought that a health professional needs to be consulted by people with mental illnesses.⁽⁴⁹⁾