Today, people in the United States know far more about mental illness than did previous generations. They might know what it looks like: changes in emotions, thinking, or behavior that make function in daily life difficult, if not impossible. They’re much more likely to understand that most of us will experience some form of mental illness in our lifetimes, like depression or anxiety. And they know that smaller numbers of people will experience more severe conditions like bipolar disorder, schizophrenia, or PTSD.

Despite this progress, for decades attitudes toward people with mental disorders have hardly budged. How do we know this? One of the crucial ways we measure prejudice is to ask about “social distance.” In this case, that involves asking: How close would you be willing live to someone with a mental illness? Would you live in the same state? Be in the same classroom or workplace? Participate together on a project? Ride next to them on public transportation? Go out with them? Let your offspring marry them? 

When friends, family, and society shame people for their illness, and shun them, that’s stigma. This shaming can take many forms, from stereotypes (“they’re dangerous”) to moral judgments (“you’re just a coward”) to dismissive labeling (“you’re crazy”). There can be real consequences of stigma, such as lost job opportunities and social 

marginalization, as well as giving up on seeking treatment. Overt discrimination is a big part of stigma, too: People with mental disorders, in many states, cannot run for office, serve on a jury, keep a driver’s license, or retain child custody. Most perniciously, the stigma of mental illness can lead people to hide their troubles and refuse to get help—which is likely to worsen their condition and create a vicious cycle.

Until very recently, studies consistently showed that the desire for social distance from people with mental illness had not improved over the past 50 to 60 years. In fact, in some ways it had actually worsened, as more people than before automatically linked mental illness with aggression and violence.

At the same time, studies also showed that people had greater knowledge of ADHD, depression, bipolar disorder, PTSD, and more—but just “knowing” more facts about mental illness can actually make things worse. For example, if you learn that people with schizophrenia may hear voices and become paranoid, you might consider that to be quite frightening, even threatening. Similarly, understanding that people with severe depression may come to feel that their lives are not worth living—and may therefore consider suicide—can trigger the belief that such individuals are utterly self-centered. What might not be understood is that severe depression can foster the belief, in people affected, that everyone else would be better off without them.

In other words, factual knowledge about mental disorders, alone, can actually fuel stereotypes. In addressing stigma, the missing piece isn’t knowledge—it’s contact, empathy, and humanization.

A recent study published in December by the JAMA Network Open suggests that things may finally be starting to change. But the picture is complicated: Some kinds of illness are becoming less stigmatized, true, but people still want to keep distance from other 

forms. The good news is that young people are much less likely to stigmatize mental illness than older generations—and that there are specific steps we can take, as individuals and society, to keep making progress.

Generational shifts driving acceptance

In surveying a representative group of U.S. adults during a period of over two decades, sociologist Bernice A. Pescosolido and her colleagues found a significant and important decrease in desire for social distance related to depression over the past few years.

That is unprecedented, and of real importance. However, in the same paper, the researchers found that attitudes related to conditions like schizophrenia and substance-use disorders did not show signs of improvement—and had actually worsened.

Even though the participants in this study were many—over 4,000 adults—it would take even larger groups to understand how socioeconomic, ethnic, or racial characteristics affected changing attitudes toward mental illness. Still, from this study and a number of others, it does appear that improvements are driven mainly by younger people.

In fact, research hints at a massive generational shift in how mental illness is perceived and socially experienced. Multiple other surveys and studies besides the one by Pescosolido and her colleagues suggest that both millennials (those born from the early ’80s to the mid-’90s) and Generation Z (who were mostly born in the 21st century) are much more accepting and knowledgeable about mental illness than previous generations.

Why? Rates of diagnosed mental illness have been rising among young people. For example, one 2019 study found almost half experience depression, peaking at 60% for teens aged 14–17—considerably more than previous generations. More recent work conducted during the COVID-19 pandemic hints at a profound mental health crisis.

When the CDC surveyed almost 8,000 high school students in the first six months of 2021, researchers found that depression, anxiety, and other disorders permeated the lives of adolescents during the pandemic. All groups reported more persistent sadness since spring 2020, though the rate rose faster among white teens than others. Nearly half of lesbian, gay, bisexual, and transgender teens reported seriously thinking about suicide, compared with 14% of heterosexual peers. One in four girls did so, twice the rate of boys.

Did that translate into higher suicide rates? Yes, and decidedly so, especially for girls. Some emergency departments have reported a significant increase in teens coming in for suicide attempts. (Note that these numbers are only provisional and could go up with time.)

What’s responsible for these negative trends? That’s a topic hotly debated by scholars, with most suggesting some combination of factors like the pandemic, climate change, political and economic instability, increased educational competition, and technological changes like phones and social media. Even more, for teenage girls in particular, a toxic “triple bind” of impossible expectations (be supportive and nurturing, be super competitive, and do both of the above effortlessly while looking “hot”) plays a key role.

However, as depression and anxiety spread among young people, it does seem as though these conditions are becoming normalized—and that youth are becoming more open and compassionate with one another. And high school clubs, as well as college programs, that focus on reducing stigma with respect to mental disorders have been shown to create real benefits.

All evidence to date suggests that many kinds of mental illness carry less stigma for younger generations. As these young people attain full maturity, the tide could eventually turn even for disorders like schizophrenia—the way it has, convincingly, for issues like same-sex marriage over the past 20 years. There are steps we can take to keep pushing this process forward.

What can create more positive change?

First, from a “top-down” perspective, enforcement of anti-discrimination policies, including the Americans with Disabilities Act, can help to drive acceptance. Title I of the ADA blocks employers from discriminating against people with disabilities, including mental illness, and requires them to make reasonable accommodations. Last week, a man in Kentucky won a half-a-million-dollar judgment against the employer who fired him for having a panic attack at work, which will surely discourage other companies from doing the same.

Beyond employment protection, we need enforcement of laws mandating “parity” for coverage of mental and physical disorders, and there’s much work to do with police and the courts to make a distinction between criminal activity and mental health crises.

Such steps can limit the consequences of stigma, but they can’t erase its existence. Though we’ve learned that information all by itself doesn’t reduce stigma, that doesn’t mean we should stop educating people from early ages about diagnosis and treatment—and there is evidence to suggest public health campaigns can reduce stigma if properly funded and executed.

For example, surveys conducted two years after Scotland’s multiyear, multiplatform “See Me” campaign—which aimed to normalize mental illness—showed a 17% drop in fear of people with serious mental illness, among other good outcomes. A much briefer social media campaign in Canada called “In One Voice” resulted in a “small but significant” decrease in a desire for social distance one year after it ended—though the same study also found that people didn’t feel more motivated to actually help someone in a mental health crisis.

The contrasting results of these two campaigns suggest that size and scope matter when it comes to changing attitudes. Scotland’s much more comprehensive approach made more of an impact than “In One Voice.” And it emphasized personal contact, not just factual knowledge, asking us to “see” real people in all their complexity.

The California Mental Health Services Act is a statewide prevention and early intervention program directly addressing stigma and discrimination, including “a major social marketing campaign; creation of websites, toolkits, and other informational resources; an effort to improve media portrayals of mental illness; and thousands of in-person educational trainings and presentations occurring in all regions of the state.” An independent evaluation found that it succeeded in reducing stigma in California, “with more people reporting a willingness to socialize with, live next door to, and work with people experiencing mental illness.” Participants also reported “providing greater social support to those with mental illness.”

Policies and education do work to reduce stigma, but they alone cannot change human hearts.

***

Join a circle this Saturday with Chris Shaw-- a stand-up comedian, musician, and mental health advocate. "Suicide Prevention: A Journey from the Edge". More details and RSVP info here.