Articles www.thelancet.com Published online October 18, 2012 http://dx.doi.org/10.1016/S0140-6736(12)61379-8 1 Published Online October 18, 2012 http://dx.doi.org/10.1016/ S0140-6736(12)61379-8 See Online/Comment http://dx.doi.org/10.1016/ S0140-6736(12)61457-3 *Members listed at end of paper Department of Public Health and Community Medicine, Section of Psychiatry, University of Verona, Verona, Italy (A Lasalvia MD, S Zoppei PsyD, C Bonetto PhD, D Cristofalo DrSciEdu); King’s College London, Institute of Psychiatry, London, UK (T Van Bortel PhD, Prof G Thornicroft PhD, S Ando MD); National Institute for Health and Welfare, Helsinki, Vasa, Finland (Prof K Wahlbeck MD); Etablissement Public Santé Mentale Lille-Métropole, Armentières, France (S V Bacle); Katholieke Universiteit Leuven, Leuven, Belgium (C Van Audenhove PhD); Stichting Kenniscentrum Phrenos, Utrecht, Netherlands (J van Weeghel PhD); Instituto de Psiquiatria, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos, Centro para la Investigación Biomédica en Red en Salud Mental, Madrid, Spain (B Reneses PhD, Prof J J Lopez-Ibor PhD); Vilnius University, Vilnius, Lithuania (A Germanavicius PhD); University Mental Health Institute, Athens, Greece (M Economou PhD); Istituto di Ricovero e Cura a Carattere Scientifico Centro San Giovanni di Dio– Fatebenefratelli, Brescia, Italy (M Lanfredi PsyD); and Association for the Improvement of Mental Health Programmes, Geneva, Switzerland (N Sartorius MD) Global pattern of experienced and anticipated discrimination reported by people with major depressive disorder: a cross-sectional survey Antonio Lasalvia, Silvia Zoppei, Tine Van Bortel, Chiara Bonetto, Doriana Cristofalo, Kristian Wahlbeck, Simon Vasseur Bacle, Chantal Van Audenhove, Jaap van Weeghel, Blanca Reneses, Arunas Germanavicius, Marina Economou, Mariangela Lanfredi, Shuntaro Ando, Norman Sartorius, Juan J Lopez-Ibor, Graham Thornicroft, and the ASPEN/INDIGO Study Group* Summary Background Depression is the third leading contributor to the worldwide burden of disease. We assessed the nature and severity of experienced and anticipated discrimination reported by adults with major depressive disorder worldwide. Moreover, we investigated whether experienced discrimination is related to clinical history, provision of health care, and disclosure of diagnosis and whether anticipated discrimination is associated with disclosure and previous experiences of discrimination. Methods In a cross-sectional survey, people with a diagnosis of major depressive disorder were interviewed in 39 sites (35 countries) worldwide with the discrimination and stigma scale (version 12; DISC-12). Other inclusion criteria were ability to understand and speak the main local language and age 18 years or older. The DISC-12 subscores assessed were reported discrimination and anticipated discrimination. Multivariable regression was used to analyse the data. Findings 1082 people with depression completed the DISC-12. Of these, 855 (79%) reported experiencing discrimination in at least one life domain. 405 (37%) participants had stopped themselves from initiating a close personal relationship, 271 (25%) from applying for work, and 218 (20%) from applying for education or training. We noted that higher levels of experienced discrimination were associated with several lifetime depressive episodes (negative binomial regression coeicient 0·20 [95% CI 0·09–0·32], p=0·001); at least one lifetime psychiatric hospital admission (0·29 [0·15–0·42], p=0·001); poorer levels of social functioning (widowed, separated, or divorced 0·10 [0·01–0·19], p=0·032; unpaid employed 0·34 [0·09–0·60], p=0·007; looking for a job 0·26 [0·09–0·43], p=0·002; and unemployed 0·22 [0·03–0·41], p=0·022). Experienced discrimination was also associated with lower willingness to disclose a diagnosis of depression (mean discrimination score 4·18 [SD 3·68] for concealing depression vs 2·25 [2·65] for disclosing depression; p<0·0001). Anticipated discrimination is not necessarily associated with experienced discrimination because 147 (47%) of 316 participants who anticipated discrimination in inding or keeping a job and 160 (45%) of 353 in their intimate relationships had not experienced discrimination. Interpretation Discrimination related to depression acts as a barrier to social participation and successful vocational integration. Non-disclosure of depression is itself a further barrier to seeking help and to receiving efective treatment. This inding suggests that new and sustained approaches are needed to prevent stigmatisation of people with depression and reduce the efects of stigma when it is already established. Funding European Commission, Directorate General for Health and Consumers, Public Health Executive Agency. Background Depression is the third leading contributor to the global burden of disease and the irst in middle-income and high-income countries. 1 It can be reliably diagnosed in both primary care and specialised services. Antidepres- sant drugs and brief structured psychotherapy sessions are efective in 60–80% of individuals with depression. 2 However, fewer than half the people with depression are treated. 3 Barriers to efective care include inadequate policy, mental health services, community resources, human resources, and funding, 4 and stigma associated with having a mental disorder. 5 Stigma is a mark or sign of disgrace usually eliciting negative attitudes to its bearer and, from a conceptual point of view, can be seen as an overarching term including diiculties associated with knowledge (ignor- ance or misinformation), attitudes (prejudice—namely, afective distancing), and behaviour (discrimination—ie, exclusion from normal forms of social participation). 6 Until a few years ago, the focus of most research was on investigation of stigma in people with mental disorders (mainly schizophrenia) through surveys of the general public’s attitudes in speciied scenarios, rather than the experiences of people with mental health problems. Without direct assessment of real behaviour, the assumption was that statements (usually about knowledge, attitudes, or behavioural intentions) were linked with behaviour. 6