Dr. Annie Fox will use a National Institute of Mental Health grant to better understand how stigma and mental health in people aged 18-25 changes over time and determine times for optimal treatment improvements.

The stigma surrounding mental health is well documented. Despite the progress around the acceptance of mental health challenges and those seeking treatment, stigma still prevents people from seeking treatment, or even acknowledging they may be experiencing a problem. But does stigma change over time? And if we know how stigma changes, can specific times be identified to intervene to encourage people to seek treatment?

Those are some of the questions Dr. Annie Fox wants to answer through a new National Institute of Mental Health research grant. Fox, an Associate Professor of Quantitative Methods at the IHP, is co-principal investigator on the 5-year, $2,608,875 grant titled: “Pathways to mental health care: Examining the longitudinal impact of stigma mechanisms on treatment engagement in emerging adults.” Valerie Earnshaw of the University of Delaware is the other co-principal investigator. 

“There are a lot of goals with this study,” said Fox, whose research focuses on the conceptualization, measurement, and consequences of mental illness stigma. “We're trying to understand how stigma and mental health change over time, how it impacts treatment, and when the best points might be to intervene."

“This kind of research has not been done before.” 

Fox and Earnshaw will be following 4,000 emerging adults (age 18-25) for three years and surveying them every three months so the researchers can better understand the following: 1) how stigma changes over time; 2) how it impacts their mental health symptoms; and 3) how it impacts their decision to seek (or not seek) treatment.  

The chosen age group is particularly vulnerable to mental health stigma because this is when significant life changes occur; this population also has the highest rates of mental health problems and the lowest rates of seeking treatment. “We're hoping to get a sense for how their attitudes are changing, how their mental health is changing, how those things are interacting,” explained Fox. “We want to better understand where points of intervention might be. Do we need to be focusing on people's attitudes right before they develop a mental health issue? Do we have a window after they start developing symptoms that we could target specific stigma mechanisms? What about people who are already in treatment—how is stigma affecting them over time?”

Seven Types of Stigma to be Tracked

Fox and Earnshaw will examine seven different types of stigma, which are also referred to as “stigma mechanisms”: 

  • Stereotypes: Negative beliefs one holds about a particular group
  • Prejudice: Emotional reaction one has
  • Discrimination: Overt behaviors directed toward a stigmatized group
  • Anticipated: Worried about being target of discrimination
  • Experienced:  Actually experiencing discrimination
  • Internalized: Applying the negative stereotypes of mental illness to oneself (e.g., feeling that you’re mentally weak, due to mental illness)
  • Perceived: What do you think other people think about people with mental illness 

“One of big weaknesses in previous research is that researchers don’t always treat the different types of stigma as unique, instead measuring them altogether without trying to disentangle their effects. But when you measure everything together, you can’t really tease them apart,” said Fox. “By measuring each of these mechanisms separately, we’ll have a better sense of which types of stigma are most important, and this is key to developing effective interventions.”

“This is going to be the first study that has looked at all of these different stigma mechanisms, over time, in this particular age group,” she continued. “By looking at all of these and how they're changing over time in accordance with mental health, hopefully we're really going to have a sense for which stigma mechanisms emerged as the most important to target for improving the mental health and treatment seeking rates.” 

The consequences of COVID-19 will be a linchpin to the research.  “The statistics on mental health in young adults are striking right now,” she said. “I’ve seen some estimates that as many as 65% of 18-to-21-year-olds might be dealing with a mood or anxiety disorder. It's a lot and so we're going to have a nice snapshot of their mental health over a three-year period coming out of the pandemic."

This NIMH research grant dovetails with a recent paper in Nature Reviews Psychology that Fox was co-author on, which called for the importance of considering time in research on stigma and health inequities. Fox and Earnshaw, who was lead author on the paper, say they are putting their call for time-based research in the Nature paper into action in this grant by studying mental illness stigma during a vulnerable period of development - emerging adulthood.   

“Emerging adults have the highest rates of mental illness, and the lowest treatment seeking rates, across all age groups,” said Fox. “And unfortunately, with COVID, the rates of mental illness in young adults have only continued to rise. “