Experienced and anticipated discrimination among people with major depressive disorder in Serbia

Abstract

Background:

Experiences of discrimination have significant impact on the lives of people with mental illness.

Aim:

This study investigates the nature and severity of experienced and anticipated discrimination reported by persons with a depressive disorder in Serbia.

Methods:

Patients were recruited from two psychiatric day hospitals and a primary mental health service with a diagnosis of major depressive disorder. Interviews were conducted using a socio-demographic questionnaire and the Discrimination and Stigma Scale.

Results:

The respondents experienced discrimination mostly in the field of family relationships, making and keeping friends and keeping a job. In domains of making close personal relationships or applying for education, anticipated discrimination was higher than experienced. The need to conceal mental health problems was stronger than experiences of being avoided. The need to hide mental health problems was higher than the overall score for experienced discrimination. Participants who were hospitalized in some period of life reported higher experienced discrimination. Compared to younger participants, older participants experienced more negative as well as positive discrimination. Married participants experienced more negative discrimination than unmarried.

Conclusion:

It is important to design interventions to overcome discrimination toward persons with depression at all levels.

Keywords

Stigma discrimination depression INDIGO project

Introduction

Discrimination and stigmatization occur when people belonging to certain groups (minorities in particular) are treated unfairly because they are seen as being different from others. Stigmatization and discrimination of people with mental illness are a global issue. Stigma is a mark of disgrace associated with a particular circumstance, quality or person, and discrimination is an unjust distinction in the treatment of different categories of people (Thornicroft, 2006). Stigma and discrimination can affect many aspects of people’s lives and can be barriers to seeking early treatment, causing relapses and hindering recovery (Kadri & Sartorius, 2005). These effects can be the consequences of experienced or anticipated discrimination (Thornicroft, Van Bortel, Brohan, & Leese, 2009). Several investigations dealt with stigma and depression (Alonso et al., 2009; Aromaa, Tolvanen, Tuulari, & Wahlbeck, 2011; Brohan, Gauci, Sartorius, & Thornicroft, 2011; Hayward, Wong, Bright, & Lam, 2002). These studies were based on data about stigma reported by persons with mental illness but did not explore discrimination in various areas of life. Similar studies in Serbia are rare. One study (Milačić Vidojević, Čolić, & Dragojević, 2013) explored the valence and the structure of stigmatization toward persons with depressive disorder. A more comprehensive picture of how discrimination affects the various life domains in people with depression worldwide is explored in Anti Stigma Programme European Network (ASPEN) and the International Study of Discrimination and Stigma Out-comes (INDIGO) Depression study, a part of which is this study. The general objective of the INDIGO Depression study was to provide an important contribution to the reduction in stigma and discrimination against people with depression. The study was undertaken in 35 countries worldwide at 39 sites with 19 sites in 18 European countries and 20 sites in 17 countries in the wider INDIGO Research group. The key outcomes were the availability of a high-quality assessment tool providing insights into the nature and severity of discrimination experienced and anticipated by people with depression, the implementation of ‘best practices’ and the influence of legal regulations.

The findings of the INDIGO depression study about the nature, direction and severity of and correlation between experienced and anticipated discrimination based on self-reported answers of persons with depression are presented in the Lasalvia et al. (2013). In this article, we present the results of experienced and anticipated discrimination reported by persons with a depressive disorder in Serbia.

Methods

Sample

Socio-demographic and clinical characteristics of participants included age, gender, marital and living status, level of education, employment status, years since first contact with mental health services, ever being admitted for psychiatric care, ever undergoing compulsory treatment, number of depressive episodes, type of actual treatment, knowledge of their diagnosis and attitude about their diagnosis. The sample characteristics are presented in Table 1. Inclusion criteria were age of 18 years or older and a clinical diagnosis of a Major Depressive Disorder according to the Diagnostic and Statistical Manual of Mental Disorders (4th ed.) during the past 12 months. Service users from daily hospitals and outpatients were included in the study.

Table 1.

Socio-demographic and clinical characteristics of sample (n = 52).

Mean age	45.9 years
Male sex	19 (36.5%)
Highest completed education
Primary	5 (9.6%)
Secondary	34 (65.4%)
Diploma, degree or post-graduate qualification	11 (21.1%)
Vocational	2 (3.8%)
Living status
Alone	8 (15.4%)
With partner or partner and children	16 (30.8%)
With children but no partner	7 (13.5%)
With other relatives, unrelated people or individuals providing assistance	21 (40.4%)
Marital status
Married or cohabiting	16 (30.8%)
Single or non-cohabiting partner	22 (42.3%)
Widowed, separated or divorced	14 (26.9%)
Employment
Full-time or part-time	16 (30.8%)
Volunteer or working in a sheltered accommodation or at home, student	9 (17.3%)
Looking for a job, unemployed	14 (26.9%)
Retired	13 (25%)
Years since first contact with mental health services	36.4
Outpatient mental health care, day care	44 (84.6%)
Ever admitted for psychiatric care	24 (46.1%)
Compulsory treatment ever	12 (23.1%)
No advantage to have diagnosis of major depressive disorder as an explanation of mental health problems	16 (30.8%)
Does not know the diagnosis	13 (25%)
Agrees with diagnosis
Yes	37 (71.1%)
No	5 (9.6%)
Unsure or does not know	10 (19.2%)

Instruments and procedure

Patients were recruited from two psychiatric daily hospitals in Belgrade, the psychiatric hospital ‘Dr Laza Lazarević’ and KBC Medical center (Kliničko-bolnički centar) ‘Dr Dragiša Mišović-Dedinje’, and from the Primary Mental Health Service Stari Grad in Belgrade.

The study consisted of interviews administered to gather direct self-reports of discrimination that was actually experienced and anticipated by people with depression. Interviews were conducted by two experienced and trained psychologists, one specialist in clinical psychology. Interviewers were situated in a private room with the participant. The interviewers were not involved in the treatment of the participants. The participants were informed they could stop the interview at any moment and their responses would be kept confidential and will have no implications for treatment or care received. The testing procedure lasted 30–45 minutes. Local requirements for ethical approval of the study were met. The participants provided full written consent for taking part at the study. Interviewing was conducted during 2010–2011.

In the study, the revised 32-item Discrimination and Stigma Scale (DISC 12), interview-based instrument, was applied. DISC 12 was translated in Serbian language, back-translated and approved by general team of the INDIGO Depression study. Participants were asked to comment on the extent to which they had experienced stigma and discrimination as a result of their mental disorder. The instrument addresses key areas of everyday life and social participation, including work, marriage, parenting, housing, leisure and religious activities. This instrument also considers the extent to which participants limit their involvement in areas of everyday life due to anticipated discrimination or self-stigma. DISC 12 considers experiences of positive as well as negative discrimination while also focusing on these events from a service user perspective.

In the first part (questions 1–21), the experienced discrimination was explored. Service users were asked about situations when they have been treated unfairly because of their depression (e.g. ‘I would like to ask about times when you have been treated unfairly because of mental health problem?’ or ‘Have you been treated unfairly in making or keeping friends?’) In the second part (questions 22–25), the anticipated discrimination was explored. Participants were asked how often they have stopped themselves from doing things because of anticipated social responses. In the third part, the possibility of overcoming stigma and discrimination (questions 26 and 27) was explored. In the last part, the frequency of more positive treatments because of mental health problems (questions 28–32) was explored. The service users were asked to give examples of each experience of stigmatization.

In each part of the interview, participants had to answer whether they encountered these situations within the last 12 months: not at all (score 0), a little (score 1), moderately (score 2) or a lot (score 3). If the question was not applicable for a particular participant, a score of 9 was applied. (e.g. The question ‘Have you been treated unfairly in your role as a parent to your children?’ was not applicable if the participants had no children.) Other than quantitative data, qualitative answers to DISC 12 questions were collected. We shall not analyze qualitative answers in this study.

Results

Scores were calculated in two ways (see Table 2). Scores labeled as DISC-count refer to a number of questions on which a participant marked any answer except 0, that is answers 1, 2 and 3 (a little, moderate and a lot, respectively). Frequencies of a little, moderate and a lot answers were not considered, but just the information if there was, or was not, any discrimination, for every question. Scores labeled as DISC-mean were calculated as a mean of all questions, for experienced discrimination (DISC-exp) and for anticipated discrimination (DISC-antic). DISC-mean scores include frequency of different answers (not at all, a little, moderate and a lot), not just the information if there was, or was not, any discrimination, for every question. The two ways of calculating scores appeared to be different because the Pearson correlation between DISC-mean and DISC-count scores for experienced discrimination was negative (−.322) and significant (.023), while the correlation between DISC-mean and DISC-count scores for anticipated discrimination was insignificant.

Table 2.

Differences between DISC-count and DISC-mean scores.

	N	Minimum	Maximum	Mean	Standard deviation
DISC_exp_count	52	.00	18.00	11.8077	3.66241
DISC_antic_count	52	.00	4.00	2.3846	1.17413
DISC_exp_mean	50	1.00	2.20	1.2158	0.27934
DISC_antic_mean	48	1.00	3.00	1.8420	0.69599

DISC: Discrimination and Stigma Scale.

The global result of being discriminated in any degree (a little, moderate and a lot answers) shows that the great majority of participants reported some degree of experienced (96.2%) and anticipated (92.3%) discrimination in different life realms. In the present sample, experienced discrimination was reported in family relations, in contacts with friends, in keeping the job and in social contacts (see Table 3). As for social contacts, 36% of participants reported being avoided by persons who were acquainted with their mental health problems. The majority of participants reported no discrimination in medical treatment, in contact with staff in institutions for mental and physical health, in realms of personal safety and security, levels of privacy, social life, public transport and police.

Table 3.

Responses for experienced discriminatiozn by combined category (n (%)).

Item	Disadvantage		No different treatment		Not applicable/missing
	n	%	n	%	n	%
Family	18	36	31	62	1	2
Avoided or shunned by people	18	36	25	50	7	14
Making or keeping friends	17	34	27	54	6	12
Keeping job	15	30	11	22	24	48
Privacy	9	18	36	72	5	10
Physical health	8	16	41	83	1	2
Personal safety and security	7	14	41	82	2	4
Marriage/divorce	6	12	19	38	25	50
Neighborhoods	5	10	31	62	14	28
Role as a parent	5	10	19	38	26	52
Dating and intimate relationships	4	8	16	32	30	60
Finding job	4	8	11	22	35	70
Public transport	4	8	43	84	3	6
Police	4	8	40	80	6	12
Mental health stuff	4	8	46	92	0	0
Social life	3	6	38	76	9	18
Education	2	4	11	22	37	74
Welfare benefits or disability pensions	2	4	7	14	41	82
Housing	1	2	15	30	34	68
Religious practice	1	2	15	30	34	68
Starting a family or having children	0	0	7	14	43	86

The score for anticipated discrimination was based on answers to questions, whether participants had stopped themselves from applying for work, for education or training courses and from having close relationships, and whether they had concealed or hidden their mental health problems (see Table 4).

Table 4.

Responses for anticipated discrimination by category (n (%)).

Item	Anticipated	Not at all	Not applicable
Stopped self from applying for work (DISC 22)	14 (26.9%)	14 (26.9%)	24 (46.2%)
Stopped self from applying for education or training (DISC 23)	21 (40.4%)	17 (32.7%)	14 (26.9%)
Stopped self from looking for a close relationship (DISC 24)	31 (59.6%)	19 (36.5%)	2 (3.8%)
Felt the need to conceal diagnosis (DISC 25)	35 (67.3%)	15 (28.8%)	2 (3.8%)

DISC: Discrimination and Stigma Scale.

The evidence of high anticipated discrimination in persons with depression can be seen with 67.3% of participants feeling the need to conceal mental health problems from others. Analysis of variance for repeated measurements indicated that there were no differences in anticipating discrimination in different life realms. Statistical significance of the difference between experienced and anticipated discrimination was calculated by t-test for dependent samples (see Table 5). The mean of anticipated discrimination in life realms of having close personal relationships and applying for education was significantly higher than the mean of experienced discrimination in these domains. The need to conceal mental health problems from others is significantly stronger than experiences of being avoided. It was also established that the need to hide mental health problems is significantly higher than the overall score for experienced discrimination. The only insignificant difference was between experienced and anticipated discrimination in applying for work.

Table 5.

Statistical significance of difference between experienced and anticipated discrimination.

		t	df	Significance
Pair 1	DISC 03–DISC24 (close relationships)	−3.000	11	.012
Pair 2	DISC 05–DISC23 (education)	−4.500	6	.004
Pair 3	DISC 08–DISC 22 (applying for work)	.000	7	1.000
Pair 4	DISC 21–DISC 25 (hiding mental health problems)	−2.664	27	.013
Pair 5	DISC 2–DISC_exp_mean (hiding–experienced discrimination)	4.538	30	.000

DISC: Discrimination and Stigma Scale; df: degrees of freedom.

Table 6. Multiple regression analysis shows that experienced discrimination is a predictor of anticipated discrimination with a success rate of 17.4% calculated with DISC-count scores or with a success rate of 10.7% calculated with DISC-mean scores (see Table 6).

Table 6.

Multiple regression analysis.

R ²	df	F	Significance
Disc-count.417^a	.174	1; 50	10.547	.002^a
Disc-mean.327^a	.107	1; 48	5.742	.021^a

DISC: Discrimination and Stigma Scale; df: degrees of freedom.

Correlations with clinical variables

A correlation between discrimination and familiarity with the diagnosis, as well as between discrimination and coercive hospitalization, was not established. According to DISC-count scores for experienced discrimination and DISC-mean scores for overcoming stigma, participants who were hospitalized in some period of life reported significantly higher experienced discrimination (t: −2.087, degrees of freedom (df): 50, significance: 042) and lower overcoming (t: 1.999, df: 47, significance: 051).

Correlations with socio-demographic variable

As for socio-demographic data, splitting the sample into two age groups (under and over the age of 40 years) and using the independent-samples t-test, it was established that, for DISC-count scores, older participants felt having significantly more experienced (t: −2.066, df: 48, significance: 044) and positive discrimination (t: −3.367, df: 48, significance: 002). The independent-samples t-test for married participants showed that for DISC-count scores, married participants felt having more experienced discrimination (t: 3.329, df: 50, significance: 002).

Discussion

The study conducted was the first systematic study in Serbia in which participants with major depression reported their stigmatizing and discriminating experiences in different areas of life.

The two ways of calculating scores with the DISC instrument differed significantly. The Pearson correlation between DISC-mean and DISC-count scores for experienced discrimination was negative (−.322) and significant (.023), while the correlation between DISC-mean and DISC-count scores for anticipated discrimination was insignificant. So, the calculation of scores for DISC should be evaluated further.

Participants reported having experienced discrimination mostly in the areas of family life, making or keeping friends, social contacts and keeping a job. These results agree with the results of other studies in which family relationships appear to be potentially powerful supportive factor but also a source of everyday stigmatizing experiences. In the study aimed to explore experience of discrimination described by service users in England (Hamilton et al., 2014), the great majority of participants reported discrimination from their family because of their diagnosis. Family was almost the only relationship in which dismissiveness was reported. Participants also reported it had taken time for their families to become supportive. Thornicroft (2006) wrote that reactions by family members depend mostly on their understanding of the causes of mental illness and whether they expect the person to recover. If relatives, for example, believe a mental illness is contagious, they may keep their distance, or if they believe a cure is impossible, then they are more likely to abandon their relatives. Intensive emotional exchanges in the family, as well as other family member’s experiences of being stigmatized by courtesy stigma (Goffman, 1963), can strengthen experiences of stigmatization.

Another area of reported experienced discrimination in this study was making or keeping friends. In the study by Hamilton et al. (2014) in which they describe experienced discrimination from the perspective of service users, the most common type of discrimination reported in relation to friends is social distance. Participants reported incidents of avoidance or comments as the impact of disclosing mental health problems to others. Participants talked about losing friends, lack of understanding from friends or in some cases no longer having any kind of social life. Kirsner, Figueredo, and Jacobs (2003) reported that people who develop depression express a reduced desire for people with whom they could make friends. Also, they show a balance between the needs for friendship and to be alone (Boydell, Gladstone, & Craford, 2002). Becker, Albert, Angermeyer, and Thornicroft (1997) point that while mental illness can have negative effect on the size and quality of social networks, people with larger social networks are less likely to be admitted to a hospital for mental health reasons. This could pose questions about the shares which the subtle discrimination or the behavior of the mentally ill each might have in causing changes of relations within family or friendship.

Another area of life in which respondents experienced discrimination was keeping a job. People with anxiety or depression were more likely to be employed, but fewer than 60% were employed full-time or part-time (Thornicroft, 2006). In the Hamilton et al. (2014) study, the most frequently described behavior among employers was stereotyping, for example, through considering the participant to be incompetent or unsuitable for a job. For those who have not disclosed their diagnosis, there can be a continuing fear that someone will find out. Lasalvia et al. (2013) suggested that non-disclosure of mental health problems is also a crucial issue in employment because in some countries accommodations in the workplace for people with mental illness can only be made if the employer has knowledge of the employee’s mental health status. Returning to work after a period of absence because of mental illness is a difficult period of confronting with the reactions of colleagues. There is often a sense that a person has now become unpredictable (Glozier, 2004). If an employer offers a less stressful work position, users may interpret this as a humiliation which only increases the stress, slows down the recovery and precipitates the next onset of illness. Nevertheless, it is clear that some mental illnesses can compromise the skills needed at work, such as attention, memory and interpersonal skills (Thornicroft, 2006).

A review of anticipated discrimination shows that 59.6% of respondents stopped themselves from looking for a close relationship, 40.4% from applying for education and 26.9% from applying for work. The comparison of results for experienced and anticipated discrimination in our study shows that the mean for anticipated discrimination is significantly higher than the mean for experienced discrimination in realms of close relationships and education. Participants in this study stopped themselves from looking for a close relationship and applying for education. Persons with mental illnesses in the situation of starting close relationships anticipate that they will be discriminated against, and to protect themselves they limit their social interactions. Another area of anticipated high discrimination is the field of education. Persons with mental illness might fail to pursue education opportunities because they find it hard to balance undertaking a course while dealing with the effects of mental illness. There is evidence that stigma experiences make people with mental disorders less likely to apply for educational opportunities (Wahl, 1999).

In this study, experienced discrimination is associated with older age, being married and being hospitalized in some period of life. Participants older than 40 years felt having had significantly more experienced as well positive discrimination. Older persons could have more episodes of depression followed by hospital admission. Lasalvia et al. (2013) suggested that people with depression might perceive specific mental health-care facilities as more (e.g. psychiatric hospitals) or less (e.g. outpatient settings) stigmatizing. Older people are also eligible for social welfare benefits (pension, paid medication), so they experience a higher degree of positive discrimination. Results showed that married participants experienced more discrimination in comparison with participants who were single, divorced or widowed. Marriage is associated with stressful events like child birth, residence change, job change and conflicts with relatives, which already vulnerable persons who cannot cope with these high demands might experience their partner’s behavior as stigmatizing. Although marriage is a good support system which alleviates stress events, with some persons it could be the source of stigmatizing experiences.

Limitations

The limitations of the study include a small sample size, lack of measures to evaluate clinical severity of depression symptoms and the possibility that participants with depression might have emphasized their subjective assessment of stigma experiences.

Conclusion

Overall, our findings suggest that reducing the stigmatization and discrimination of persons with mental illness and identifying effective strategies to reduce anticipated discrimination by people with depression continue to be an important goal for mental health professionals. As persons with mental illness experience stigmatizing attitudes mostly in close relationships, it is important that consumers of mental health services and family members together be engaged in all aspects of the anti-stigma campaign. Also, it is important to target influential groups such as employers to make ‘reasonable accommodation’ of work conditions to be suitable for persons with mental illness.

Footnotes

Acknowledgements

Staff at INDIGO partner centers: Australia: Nicholas Glozier, Nicole Cockayne (Brain and Mind Research Institute, Sydney Medical School, University of Sydney, Sydney, NSW, Australia); Brazil: Luis Fernando Tofoli, Maria Suely Alves Costa (Universidade Federal do Ceara, Campus Sobral, Brazil); Canada: Roumen Milev, Teresa Garrah, Liane Tackaberry, Heather Stuart (Department of Psychiatry, Queen’s University, and Providence Care, Mental Health Services, Kingston, ON, Canada); Croatia: Branka Aukst Margetic, Petra Folnegovic Grošić, Miro Jakovljević (Department of Psychiatry, University Hospital Centre Zagreb, Croatia); Czech Republic: Barbora Wenigova, Šelepova Pavla (Centre for Mental Health Care Development, Prague, Czech Republic); Egypt: Doaa Nader Radwan (Institute of Psychiatry, Ain Shams University, Cairo, Egypt); India: Pradeep Johnson, Ramakrishna Goud, Nandesh (St John’s Medical College Hospital, St John’s National Academy of Health Sciences, Bangalore, India) and Geetha Jayaram (Department of Psychiatry, Johns Hopkins University, USA); Japan: Shuntaro Ando (Department of Psychiatry and Behavioral Science, Tokyo Metropolitan Institute of Medical Science, Tokyo, Japan) and Yuriko Suzuki, Tsuyoshi Akiyama, Asami Matsunaga, Peter Bernick (NTT Kanto Hospital, Tokyo, Japan); Nigeria: Bawo James (Federal Neuropsychiatric Hospital, Uselu, Benin City, Nigeria); Nigeria: Bolanle Ola, Olugbenga Owoeye (Federal Neuropsychiatric Hospital Yaba, Lagos, Nigeria); Nigeria: Yewande Oshodi (Department of Psychiatry, College of Medicine University of Lagos and Lagos University Teaching Hospital, Lagos, Nigeria); Nigeria: Jibril Abdulmalik (Federal Neuropsychiatric Hospital, Maiduguri, Nigeria); Malaysia: Kok-Yoon Chee, Norhayati Ali (Kuala Lumpur Hospital and Selayang Hospital, Malaysia); Morocco: Nadia Kadri, Dounia Belghazi, Yassine Anwar (Ibn Rushd University Psychiatric Centre, Casablanca, Morocco); Pakistan: Nashi Khan, Rukhsana Kausar (University of the Punjab, Department of Applied Psychology and Centre for Clinical Psychology, Lahore, Pakistan); Serbia: Ivona Milačić Vidojević (Faculty of Special Education and Rehabilitation, Belgrade, Serbia); Sri Lanka: Athula Sumathipala, Chesmal Siriwardhana (Institute of Psychiatry, King’s College London and Institute for Research and Development, Sri Lanka); Switzerland: Norman Sartorius (Association for the Improvement of Mental Health Programmes, Geneva, Switzerland); Taiwan: Chih-Cheng Chang (Chi Mei Medical Centre, Department of Psychiatry, Tainan, Taiwan); Tunisia: Fethi Nacef, Uta Ouali, Hayet Ouertani, Rabaa Jomli, Abdelhafi dh Ouertani, Khadija Kaaniche (Razi Hospital Manouba, Department of Psychiatry, Tunis, Tunisia); Venezuela: Ricardo Bello, Manuel Ortega, Arturo Melone, Maria Andreina Marques, Francisco Marco, Arturo Rios, Ernesto Rodriguez, Arianna Laguado (Hospital Universitario de Caracas, Caracas, Venezuela).

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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