Since the late 1990s, the dual burden of mental illness and mental illness-related stigma has become globally more aware. This may largely be contributed to the efforts of international organizations such as the World Health Organization (WHO), the World Psychiatric Association (WPA), the World Association for Social Psychiatry and several nongovernmental organizations (1). Educational programs on schizophrenia (i.e., the Open-the-Doors program) were WPAs first step in what would become a major international effort to combat stigmatization of people with schizophrenia (2, 3). A short time later, the WHO systematically addressed the stigma related to mental illness and its consequences through awareness raising and advocacy efforts. The recognition of stigma as an important barrier to appropriate treatment (i.e., recognized as such for the first time in the World Health Report, 2001) and the implementation of global anti-stigma awareness campaigns (i.e., implemented as such for the first time by the World Health Day, 2001) were important milestones on this path (4–6). Stimulated by these developments, numerous programs and campaigns aimed at reducing stigmatization have been undertaken across the world (7–9). But fighting stigma has turned out as a multifaceted, difficult, and yet unresolved task on different societal levels.

Large-scale anti-stigma programs (i.e. England’s Time to Change programme) are found to have small to moderate long-term effects (10). Furthermore, time-trend studies on changes of stigma in the U.S. and Germany (8, 11) equally found that stigmatizing attitudes are specific to different mental health conditions by providing evidence of significant decreases in public stigma toward depression, but not for schizophrenia or alcohol dependence.

These findings have provoked ideas on rethinking the stigma concept and on retooling reduction strategies. There are calls for addressing more intensively structural aspects of the mental illness stigma (11) by recognizing societal-level conditions that legitimize and perpetuate stigmatization (12). Stigma is a social phenomenon rooted in social structures (13). The decision to stigmatize an individual is not an individual decision; rather, it is embedded in social structures in which people live.

Consequently, there is a need to focus on both discriminatory social structures (e.g., laws and policies) and on existing cultural norms that make it justifiable to devalue certain identities/statuses (12, 14). Aside from cultural variations in the mental illness stigma (15), we argue that there is a need to analyze differences within societies more intensively. Due to growing migration worldwide, western societies have become more ethnically and culturally diverse (16). And in the light of increasing and polarizing social conflicts, tendencies of social division (i.e., the experience of living in different worlds or bubbles) are often discussed. German society is far away from being divided into ‘separate bubbles’ (17). However, societies are made up of different social groups that may, of course, represent different social, cultural, and political values.

Values are intertwined with attitudes and behavior and might therefore be reflected in both attitudes and behavior of people. (18). A closer look at certain social groups might show differences between these groups in the way they think and behave towards mental illnesses. Traditional analyses are largely limited to the question of how certain attitudes or discriminatory behavior are distributed in the population as a whole, but not across individual social groups.

And, beyond that, existing subgroup analyses on sociodemographic characteristics provide limited insight into stigma in general, as well as the differences in stigma between depression and schizophrenia (11). In the present study, we therefore use a milieu approach to shed light on broader social strata. In addition to the objective social situation, measured by income or education, attitudes and basic orientations, the mentalities of people are considered (19). Looking at stigmatization through a ‘milieu lens’ offers an opportunity for studying how social, cultural, and political realities are related to mental-illness stigma. It recognizes value orientations and expectations about society as lenses on what is important for people (e.g., liberalism, traditionalism, achievement-orientation). In this study, we apply this framework to the sociological understanding of the stigma associated with mental illness, aiming at providing a better understanding of societal-level conditions beyond stigmatization.

We analyzed the interrelation of stigmatization of people with mental illness and the value-world in which people live, think, and act. At this broader, milieu level, our results indicate differences between perceptions and attitudes towards people with depression and schizophrenia among nine milieu groups. Attributions of ‘weakness of will’ and ‘dangerousness’ were common, especially within milieu groups that are leaning more towards the authoritarian pole. We identified at least three out of nine milieu groups with nearly or more than one third of the respondents’ perceiving people with a depression as weak-willed, respectively people with a schizophrenia as dangerous.

This is in accordance with previous studies showing a high agreement with these statements. A review article conducted by Jorm et al. (21), for example, reported prevalence rates of the belief in dangerousness for early and chronic schizophrenia from 20.4% to 60%. While attitudes about depression have improved in the past decades (8, 11), research shows that attributions of personal weakness are still present in the public mind with approval rates of approximately 43% (22, 30)]. Moreover, we identified one milieu group that stands out particularly negatively (i.e., the participation-oriented milieu group) with high levels of agreement for both statements and potential preferences in creating or encouraging ‘us-versus-them’ relations. Regarding political and social attitudes, respondents of the participation-oriented milieu group expressed strong demands in general welfare principles towards their own nation whilst refusing policies related to European solidarity. The tendency to favor the ingroup over the outgroup and to think of the world in ‘us versus them’ terms is known to affect several political and social attitudes (31). Using Link and Phelan (32) conceptualization of stigma, the ‘us versus them’ thinking (i.e., the cognitive separating component) is also associated with negative attributions to the outgroup and social distancing. People with a mental illness are perceived as distinct and separate from those without mental illness. This ‘us versus them’ mentality fosters the belief that people with mental illnesses are fundamentally different, thereby increasing social distance (32, 33).

Regarding the desire for social distance from people with depression or schizophrenia, we found significant milieu differences, whereby the desire for social distance from people with schizophrenia was generally more pronounced than the desire for social distance from people with depression. This finding is in line with previous research (8, 11, 34) arguing that firstly, the acceptance of biological explanations for serious mental illnesses increases stigmatizing attitudes and social distance, secondly, buffering factors such as familiarity with the disorder due to own clinical history or of that of a close other are more strongly related to depression than in schizophrenia, and thirdly, depression is more likely viewed in a dimensional versus a categorical conceptualization (8).

On milieu level, our findings suggest that milieu groups with a more liberal attitude on the socio-cultural dimension expressed a lower desire for social distancing towards depression and there was also a certain tendency to express a lower desire for social distancing towards schizophrenia. Regarding depression, distinctiveness (i.e., based on the number of statistically significant mean differences between the more liberal and the more authoritarian milieu groups) was high. Significant mean differences were detected between liberal – and all authoritarian milieu groups (i.e., the cosmopolitan intellectuals) or at least four out of six authoritarian milieu groups (i.e., the committed citizenship, the social market optimists). Those who speak out in favor of social liberalization, but also endorse economic conservatism (the cosmopolitan intellectuals, the committed citizenship) desired less social distance from the people depicted in the vignettes as well as those who speak out of in favor of both, social liberalization, and market liberalization (the social market optimists). Social conservatism or authoritarianism and intolerance of deviance or outgroups are often viewed as intertwined, as well as tolerance and liberalism (35). Tolerance is usually regarded as an integral part of the liberal identity and probably both are consequences of personal traits like openness.

Several studies have shown that openness may influence prejudices and tolerance (36) and beyond that, several other studies have already shown that openness to experiences is positively correlated with liberalism (37). It is therefore quite possible that milieu groups with a more liberal attitude on the socio-cultural dimension (i.e., the cosmopolitan intellectuals, the committed citizenship, and the social market optimists) are more open to mental health issues and therefore express a lower desire for social distance towards people with mental illnesses.

Research further reveals that liberals want to feel more empathy and experience more empathy than conservatives do (38). They might more often talk and listen to stories of lived experiences, which in turn can break down the stigma surrounding mental illnesses. Further, consensus within the two poles with more liberal – or authoritarian values was high. For example, we identified only one significant pairwise comparison within all authoritarian milieu groups with the disappointed having the highest mean scores on the SDS and the market sceptics having the lowest mean scores. Those who voice doubts and disappointment about a lack of fairness, societal diversity, and European solidarity (i.e., the disappointed) are more negative towards people with depression depicted in the unlabeled vignettes. The doubts and uncertainties regarding the (unpredictable) dynamics of the world seem to be a basic characteristic of this milieu group and the desire for social distance might be a further consequence of increased uncertainty regarding the deviation from ideal or normal mental health. The unpredictability – not only regarding the individual with depression in the case vignettes but also regarding political, social, or economic changes across the world – potentially raises several doubts and uncertainties which in turn might lead to people withdrawing or wanting more distance.

Regarding schizophrenia, distinctiveness between the more liberal – and the more authoritarian milieu groups was less pronounced. Notably, a smaller number of significant mean differences was observed. Particularly for the social market optimists, we observed only two significant mean differences and that was between milieu groups with the highest (i.e., the conservatives) and the second highest (i.e., the participation-oriented) preferences for social distance. Compared to the depression vignette, consensus within the more authoritarian milieu groups was comparable. We identified two significant pairwise comparisons within all authoritarian milieu groups, located all within the fourth quadrant of the two-axis chart (i.e., representing authoritarian values and economically liberal positions). Those, who emphasize individual performance, performance-related compensation, and gratification by opposing social assistance transfers as well as preferring a profit-oriented economy (i.e., the conservatives) more intensively wanted to distance themselves from people with schizophrenia than milieu groups who emphasize even more the benefits of market liberalization and competition (i.e., the performance-oriented) or adopt even more authoritarian values (i.e., the individualists). In contrast to the third quadrant of the two-axis chart (i.e., representing authoritarian values and economically conservative positions), the fourth quadrant appears to be more inhomogeneous and predominantly more tolerant towards people with schizophrenia. The preferences of the performance-oriented were similar to the preferences of all three milieu groups with a more liberal attitude. An almost similar pattern was observed for the individualists. Only the conservative’s milieu group, with a larger proportion of older men with higher incomes, does not seem to fit the pattern here. These ‘successful’ high performers diverge from predominantly female and more liberal milieu groups as well as lower-income milieu groups within the fourth quadrant (i.e., the performance-oriented and the individualists). For the conservatives, having a serious mental illness such as schizophrenia might be more associated with failure and poor performance and therefore incompatible with their own self-conception.

This would also fit into the picture that the conservatives themselves are less likely to seek psychotherapeutic help due to mental health problems. Their understanding of mental illnesses might diverge from prevailing ideas of masculinity and performance expectations (26) which in turn could also be evident in their dealing with people with schizophrenia (39).

Overall, our findings suggest that milieu-specific differences are more visible regarding depression than schizophrenia. We discussed a higher liberal-authoritarian distinctiveness regarding the desire for social distance towards people with depression than towards people with schizophrenia. Explaining this pattern is actually somewhat difficult; however, we argue that the manner in which mental health awareness campaigns are designed and delivered could be used as an explanation. Awareness campaigns primarily refer to depression and less to schizophrenia. Consequently, primarily attitudes towards people with depression are changing (40). At the same time, research (41) finds that there are demographic groups with higher campaign awareness (e.g., women, younger people). We argue that people with more liberal attitudes may also be more receptive to destigmatizing messages about depression but not about schizophrenia. Schizophrenia is usually not visible in awareness campaigns. Across all milieu groups, there is a general level of unfamiliarity. Milieu-specific differences are therefore less visible.

The year 2024 marks more than 30 years since the WHO systematically addressed the stigma related to mental illness and its consequences through awareness raising and advocacy efforts. In contrast to the 1990s, awareness of (certain) mental illnesses is on the rise, and much has been done to achieve the goal of ending stigmatization.

Stigmatization has been seen through the lenses of different perspectives and countries (for an overview see 42). However, there is still much to be done. According to this, a Lancet commission on ending stigma and discrimination in mental health has summarized interventions for stigma reduction. In this umbrella review of 216 systematic reviews, interventions based on the principle of social contact that have been appropriately adapted to different contexts and cultures are highlighted as particularly effective to reduce stigmatization worldwide (for an overview see 43). Milieu research typically provides insights into the context of individuals’ lives and therefore recognizes the social embeddedness of stigmatization.