Background: Throughout history people with mental illnesses have been stigmatized. There is a wide range of literature on stigmatization and discrimination of people with mental illness. Purpose: To examine the relationships between stigma, mental illness and help-seeking. Method and Material: A review of this body of literature was carried out. Evidence was collected through Medline database. Results: The role of supernatural, religious and magical approaches to mental illness was prevailing in the past. Individuals with mental illness are still being stigmatized despite modern medicine and more humane treatment. People with mental illness are considered as dangerous and aggressive which in turn increases the social distance. The pathway to care is often shaped by scepticism towards mental health services and the treatments offered. Stigma experienced from family members is pervasive. Moreover, social disapproval and devaluation of families with mentally ill individuals are an important concern. Conclusions: This review revealed that the stigmatization of people with mental illness is widespread. Because of the importance of this subject, future research should be conducted to look at why mental illness is stigmatized by the general public and mainly orientate towards finding a way for individuals with mental illness to live in a world without stigma.
Mental illness, stigmatization, discrimination, help-seeking
Researchers commonly suggest that the stigma attached to mental illness is one of the major confounding factors in help seeking from mental health professionals.
Mental illnesses are medical conditions that disrupt a person's thinking, feeling, mood, ability to relate to others, and daily functioning . Stigma has been defined as the negative effect of a label  and a product of disgrace that sets a person apart from others . There are a number of distinct constructs that comprise stigma. These include stereotype, prejudice, and discrimination. A stereotype is a belief held about a certain group of people. For example, believing that all people with a diagnosed mental illness are dangerous is a stereotype. Prejudice is an agreement with the said stereotype that results in a negative emotional reaction . Further, prejudice has also been defined as an unfavorable opinion formed without just grounds or before sufficient knowledge . An example of prejudice might be agreeing that persons with mental illness are indeed dangerous, causing an emotional reaction such as fear or anger. Discrimination is the behavioral response to prejudice, which might include, for example, avoiding a person with mental illness because of the fear from the prejudice and the belief that the person is dangerous .
Authors have reported negative attitudes from the general population regarding social distance and adults with mental illness . People with mental illness were believed to be mentally retarded, a public nuisance, and dangerous. Less than half of the participants believed that such people could be treated outside of a hospital and only 25% believed that they could work regular jobs. Poor knowledge about mental illness also was prevalent among the participants. Participants were unwilling to have social interactions with those with a mental illness - 83% reported that they would be afraid to have a conversation, 78% said that they would be upset or disturbed about working on the same job, 81% reported that they would not share a room, and 83% responded that they would feel ashamed if people knew that someone in their family had been diagnosed with a mental illness. Only 17% reported that they could maintain a friendship with a person with a mental illness. The authors concluded that there is poor knowledge about the cause and nature of mental illness and that education is needed so that stigma towards those with a mental illness can decrease .
Stigma is defined as a combination of perceived dangerousness and social distance. People with mental illness suffer from societal stigma everyday. Wherever they go, whatever they do, the pressures of conforming to a society that neither accepts nor understands them can be overwhelming. The impact of stigma must seem to be as difficult to overcome as the direct effects of the disease itself . Only by thoroughly understanding the origins of stigma can society’s views towards individuals with mental illness be changed.
Stigma affects people with mental illness in all aspects of their lives including employment and housing difficulties, social issues, and a decreased quality of life and self esteem. These individuals are also thought to be very dangerous by others in society .
During the primitive era, mental illness was directly tied to religion. Hinshaw and Cicchetti 9 mentioned that dating back 500,000 years people put circular holes in the skulls of individuals thought to have a mental illness in order to let the evil spirits out. Views changed dramatically in the Greco-Roman era. In the early Greek times the supernatural beliefs regarded as causes for mental illness continued .
In ancient Greece “Hippocrates believed that abnormal behavior originated from internal bodily causes, particularly imbalances of the four basic fluids (yellow bile, black bile, phlegm, and blood) ”. Hippocrates also believed that the brain was responsible for mental and emotional purposes. The Middle Ages witnessed a shift back to belief in the supernatural model. Society used exorcisms, torture, death by fire, and starvation to rid the person of evil.
Hospitals for the insane began to develop in the 16th century. The treatment in these asylums was cruel and inhumane . The fear of individuals with mental illnesses in other places made the number of asylums increase. During the time of the French Revolution Philippe Pinel (1745-1826) advocated for a humanitarian approach to the treatment of people with mental illnesses. Pinel demanded the removal of chains on inmates in asylums. He believed that doctors should treat people with mental illnesses .
The early 20th century included an increase in beliefs of a biological basis for mental illness, which Hinshaw and Cicchetti  explained. The Mental Hygiene movement, which encouraged the humane treatment of people diagnosed with mental illnesses, was founded in 1908 [11,12]. Psychotropic medications were invented in the 1950’s according to Hinshaw and Cicchetti  and Rosen and Gregory . The second half of the 20th century focused on improving psychotropic medications and fighting stigmas . These treatments all stem from the biological model that was predominant during this period of history.
Deinstitutionalization of the mentally ill
Deinstitutionalization, a time period when asylums and institutions were closed and patients were moved into the community, gained attention in the 1960’s . The Community Mental Health Centers Act, passed in 1963, encouraged the deinstitutionalization process . The use of medications to treat mental illnesses caused a drop in the number of patients in mental hospitals. Although there were many benefits to the deinstitutionalization process, a major problem with this movement is that many of the patients were not prepared to function independently in the community because they had lived in institutions for most of their lives.
Yet, without constant follow-up, the mentally ill were not supported back in normal society. They were shunned by the general population and often had to turn to crime in order to support themselves. At this time, the government mandated the use of community mental health centers. By creating centers of care for the mentally ill, it was thought that they would have a better chance of becoming acclimated into a normal role in society. By the 1980’s, however, the community-based clinics were vastly underfunded creating an increase in unemployment, homelessness, and premature deaths .
Formation of Stigma
In order to understand the relationship between stigma and mental illness, the origins of stigma must be defined. Corrigan and Penn , consider stigmas as “negative and erroneous attitudes about these persons”. Stigmas have their roots in many different areas, and are reinforced in several ways. Many facets of society must be examined in order to understand fully the impact of stigma on people diagnosed with mental illnesses .
The media has one of the largest impacts on society’s views of individuals with mental illness. Corrigan and Penn  stated that the media portrays people diagnosed with mental illnesses in one of three ways “homicidal maniacs who need to be feared, they have childlike perceptions of the world that should be marveled or they are rebellious, free spirits”. The media tends to portray individuals with mental illnesses as violent and law breakers. The stigma that individuals diagnosed with mental illnesses face can translate into prejudice and discrimination at a later time . These labels and stereotypes reduce their dignity and alienate them from other people [14,15].
Public perception also plays an integral role in the formation of stigma. Herrman  explained that there is a need for promoting community understanding of mental illness as well as the illness itself. Herrman suggested that understanding by the public would help those who suffer from mental illnesses to be able to get and maintain a job more easily, help in education, and their health as well as assist in making laws and policies that help people instead of hurting them
The perceptions can start in youth and continue for life. The mentally ill can often have as hard a time combating stigma as they do coping with the effects of their illness itself. Now, it is necessary to understand the effects of stigma. Without looking at the effects, the general public cannot begin to understand what the mentally ill go through on a daily basis. In general, according to Penn and Martin , the public perceives people with mental illnesses as dangerous. This may play a big part in why the public stigmatizes individuals with mental illnesses .
Effects of Stigma
The mentally ill face many challenges in adapting to life in a society that does not fully understand them. Often, the effects of the stigma that they face are overwhelming. The following section will discuss how stigmas affect people with mental illnesses.
The forms and definitions of mental health vary from person to person. The Commonwealth Department of Health and Aged Care & Australian Institute of Health and Welfare referred to mental illness in 199918 as a broad range of problems including cognitive, emotional, and behavioural that impact the daily lives of people in their jobs or home and affect their relationships with others. This shows that people who have a mental illness not only have difficulties at home or at work but also in all aspects of their lives. Having a mental illness causes a person to undergo much stress in their daily lives, many to the point of total disability. Self-stigma occurs when mental patients assimilate social stereotypes about themselves as persons with severe mental illness. This results in a loss of self-esteem, diminished self-efficacy and a hesitancy to participate in society.
The stigma of mental illness and discrimination against mental patients are believed to be a significant obstacle to development of mental health care and to ensuring quality of life of those suffering from mental illness .
Research has found that the factors underlying the stigma attached by the public to mental illness are fear, ignorance, and intolerance . The stigma that the public feels toward individuals with mental illnesses is manifested in several different ways . First, they fear and exclude them. Second, the public feels they cannot care for themselves or make a decision (which is known as authoritarianism). Third, the public assumes that they are child-like . The stigmas portrayed by the media are a constant battle for the mentally ill to fight. Perceived devaluation and discrimination as well as stigma play a big role in the reduction of self-esteem .
Those who reported more concerns of stigma had more problems with social functioning outside their family but no problems within the family. These patients tended to be secretive or withdraw from the outside world, outside their family, in order to minimize their discrimination . Many people are reluctant to seek professional help, they feel uneasy or ashamed speckled or believe that seeking help is a weakness or failure. As a result, it is no surprise that, according to many studies, people seek help from relatives and friends and last by professionals . They are reluctant to reveal their problems to others because of fear of social rejection, social isolation and hostility. In the early stages of psychosis, these individuals may attribute the symptoms to causes not related to mental illness. Others may try to manage their symptoms alone, without any external help for as long as they can .
Mental illness is not considered merely a personal failure but also disgrace the family. These beliefs can affect family members. Therefore, the family of psychiatric patients often conceal the fact from others [9,24].
Stigma and Help-Seeking Behaviour
Stigma is attached to seeking help with mental illness. For some, this stigma may be harder to face than the effects of the illness. Reluctance in seeking mental health treatment is still a large factor in getting rid of the stigma that accompanies mental illness .
The results of the Komiya et al.,  study found that a greater stigma is negatively correlated with a more favorable attitude toward seeking psychological help. Studies have shown that stigma is formed in several different ways. The perceptions can start in youth and continue for life [27,28]. Individuals diagnosed with mental illnesses can often have as hard a time combating stigma as they do coping with the effects of their illness itself. Now, it is necessary to understand the effects of stigma. Without looking at the effects, the general public cannot begin to understand what people with mental illnesses go through on a daily basis.
In light of the advances made in the counselling profession, a stigma is still experienced by individuals who need or use psychological and mental health services . This stigma appears to be associated with treatment , denial of the problem or lack of problem recognition , and a sense of self-reliance with regard to solving personal problems [30,32]. Schonrt-Reichl and Muller’s  research indicates that people who are in need of help often fail to use helping resources because it represents an open admission of inadequacy. Even in children, the stigma associated with mental health treatment is a major barrier for receiving professional help. Simmons  said that as high as 85% of children who need mental health treatment are not receiving any because of the perceived stigma associated with mental illness. Moreover, some parents are afraid they will be blamed for their child’s state of mental illness . Stigma is often singled out as the primary factor inhibiting psychological and mental health service utilization.
Social stigmatization and negative feedback from family and friends are potential inhibiting factors to seek professional psychological help. Leaf et al.,  found that those in need of services who had not used the specialized mental health sector, those in the service gap, perceived higher stigma barriers associated with utilizing such services than those who had utilized mental health services. The rate of perceived stigma is almost twice as high for non-users as it is for users. Therefore, stigma barriers were relatively more important for creating the phenomena of service gap. That is, when individuals need mental health services but they are not receiving them. Because of the stigma mentioned, the need continues for more public education to modify or alter misconceptions about mental and psychological services and even about mental and psychological disorders.
Mental illness, social distance, and familiarity
The results revealed that the subjects who were familiar with mental illness were less likely to believe the population is dangerous. These respondents also were found to be less afraid of the mentally ill. Therefore, the more information provided to the subjects, the greater their understanding of individuals diagnosed with mental illnesses, and thus a greater level of acceptance. This study shows that a key to reducing stigmas may be to offer the public more information and make them more familiar with mental illness .
Younger populations, the more educated, and those with previous exposure to people with mental illness tended to have more enlightened views and have more accepting attitudes about schizophrenia. Older individuals were less knowledgeable, wanted more social distance, and had more stereotypes about mental illness .
Stigma is a variable consisting of many smaller components. Social distance, familiarity with mental illness, knowledge of mental illness, and perceived dangerousness are a few of the components that form the framework for stigma.
Attempts to increase awareness of mental illness have shown to be effective in reducing stigma and perceived violence.
Younger people and people with higher educational level expressed more positive attitudes towards social contact with psychiatric patients . Public education and the direct social contact reduce the stigma of mental patients. The stigma affects the lives of mentally ill in various ways. Minimizing the effects of stigma is a priority for mental health policy, particularly regarding schizophrenia.