Stigma in Context: How Racialized Identity, Diagnosis, and Etiology Shape Mental Health Treatment Recommendations

Background: Persistent racial disparities in mental health care utilization highlight the need to examine not only structural barriers but also how stigma operates differently across racialized groups. While stigma is often treated as a static or linear process, it is shaped by context, identity, and varied narratives about mental illness. Research frequently overlooks how situational cues—such as diagnosis and etiology—interact with racialized identity to shape perceptions of treatment need. Grounded in modified labeling theory, informed by intersectionality, and aligned with anti-oppressive perspectives, this study investigates how mental health diagnosis (depression vs. schizophrenia), illness etiology (biogenetic vs. psychosocial), and the racialized identity of a vignette character (Black vs. White) influence public and personal stigma, help-seeking attitudes, and mental health treatment recommendations. We examine whether these effects are mediated by stigma and whether they differ by the racialized identity of the respondents.

Methods: We conducted a national cross-sectional survey in May 2024 using an experimental vignette design. A total of 1,246 U.S. adults (50% identifying as Black, Indigenous, or People of Color [BIPOC]) were randomly assigned to one of eight vignette conditions varying by diagnosis, illness etiology, and vignette racialized identity. Each vignette described a 30-year-old man experiencing symptoms consistent with either depression or schizophrenia, attributed to either biogenetic or psychosocial causes. Racialized identity was signaled through the name and description (Jamal for Black; Jake for White).

After vignette exposure, participants completed validated measures assessing attitudes and beliefs toward mental health and mental health care, including public stigma (Perceived Devaluation and Discrimination Scale), personal stigma (SAMHSA Mental Illness Attitudes Scale), help-seeking attitudes (Attitudes Toward Seeking Professional Psychological Help Scale), and a single-item asking about mental health treatment recommendations (1–10 scale). Multivariate regression assessed main effects, and mediation/moderation analyses examined indirect pathways through stigma and help-seeking attitudes by participant racialized identity.

Results: Among White participants, diagnosis and illness etiology significantly predicted treatment recommendations. These effects were not observed among Black participants. Vignette racialized identity did not directly affect treatment recommendations for either group. Among Black participants, vignette identity significantly predicted personal stigma and help-seeking attitudes, which in turn mediated its influence on treatment recommendations, indicating a significant indirect effect. Public stigma was not a significant predictor of treatment recommendations in either group. Gender differences also emerged in stigma pathways, highlighting the importance of intersectional analysis.

Conclusions: These findings demonstrate that stigma operates through racialized and relational mechanisms, with distinct pathways to care shaped by diagnostic framing and social identity. Interventions that rely on static or universal assumptions may overlook how individuals interpret and respond to mental illness through racialized lenses. This study highlights the need for culturally responsive, contextually grounded approaches to stigma reduction. By identifying indirect effects of racialized cues on treatment recommendations, the results can inform future research and policy efforts, particularly regarding measurement and population-based messaging campaigns, aimed at advancing mental health equity in ways that are attentive to social context and structural dynamics.