A systematic review of offender mental health stigma: commonality, psychometric measures and differential diagnosis

Figures & data

Figure 1. PRISMA study selection flowchart.

Figure 2. Flowchart describing the selection of comparative research studies.

Table 1. Overview of the final studies selected for the current review.

Study ID	Authors of study	Sample size gender split and mean age (SD)	Participant type/job role	Study location	Research aims/questions	Summarise main findings in regard to stigma	Quality of study AXIS criteria /20
1.	Nee and Witt (2013)	243 (total) 70% female 30% male 35 (13.18) yrs	General Public	UK	This study predicted: ‘(i) those with mental health problems would be seen as more likely to commit crime; (ii) participants’ own familiarity with mental health problems and/or criminal behaviour would result in a less negative, stereotypical response towards individuals with mental health problems. (iii) increased participant age will result in a less negative, stereotypical response to individuals with mental health problems.’	‘The sample were significantly more likely to think that a character would ‘possibly’ commit future crime if he had mental illness in comparison to the control, but crimes were expected to be minor’	20
2.	Garcia et al. (2020)	290 (total) 53% female 47% male <1% prefer not to say 37.31(11.52)yrs	General public	United states	‘To understand public perceptions of the relationship between mental illness, perceived criminality and race. Increase understanding of stigmatization of mentally ill. Hypothesis: Vignettes depicting mental illness would be associated with higher levels of criminality; familiarity with mental illness or criminality would be associated with lower levels of stereotypical beliefs.’	‘The presence of a mental health diagnostic label elicited higher levels of risk of criminality. The public appear to view individuals with mental illness as being more dangerous, it was not specific to mental health diagnosis.’	19
3.	Rao et al. (2009)	108 (total) 86% female 14% male 43.2 (1.2) yrs	Health professionals 58% qualified nurses 13% healthcare assistants 9% did not state profession 20% doctors	South East, England, UK	‘Aimed to assess stigmatized attitudes among health professionals. Research Questions: 1. Do health professionals have more stigmatizing attitudes towards schizophrenia than brief psychotic episodes? 2. Do health professionals have more stigmatizing attitudes towards patients admitted to a secure hospital than somebody who has been diagnosed with schizophrenia alone?’	‘Participants had highly stigmatized attitudes towards patients from a forensic hospital. This suggested that health professionals have stigmatized attitudes towards an illness such as schizophrenia and this is worse towards patients from a secure hospital.’	19
4.	Sowislo et al. (2017)	2207 (total) 61.5% female 38.5% male 43.4 (13.4) yrs	General Public	Basel-Stadt, Switzerland	Compared stigma in relation to psychiatric symptoms, to that related to the type of psychiatric service use. ‘Compared stigma around BPD with schizophrenia and alcohol dependence. Understood differences in stigma between different psychiatric inpatient services such as forensic settings.’	‘Desired social distance was significantly lower in relation to psychiatric service use than to psychiatric symptoms. Overall, symptoms of alcohol dependency, behaviour endangering others, and the fictitious character's being male tend to increase stigmatization. The character being hospitalized in a psychiatric unit at a general hospital and also respondent and familiarity with psychiatric services tend to decrease stigmatization’	18
5.	Adjorlolo et al. (2018)	113 65% female 35% male 75% <30 yrs 35% >30 yrs	Qualified Mental Health Nurses	Ghana	‘This study investigated mental health nurses’ attitudes toward mental illness, as well as punishment-oriented attitudes (i.e. conviction proneness and punitiveness) as predictors of their attitudes toward offenders with mental illness. Second, the study examines whether mental health nurses’ demographic backgrounds, namely, gender, age, and years of practice, have significant influence on their attitudes toward offenders with mental illness.’	‘The nurses’ scores in conviction proneness and criminal blameworthiness significantly predict negative attitudes toward the offenders even after controlling for their attitudes toward mental illness.’	18
6.	Lammie et al. (2010)	58 50% 29 female 41.4% 24 male 8.6% 5 prefer not to say <21 yrs = 0 21–30 yrs = 19 31–40 yrs = 16 41–50 yrs = 15 51+yrs = 4 Unknown = 4	Nursing disciplines in forensic wards	UK	‘To examine practitioner attitudes towards patients within forensic mental health care; to identify whether qualitative and quantitative approaches provide different insights. that participants who work within the medium secure unit would rate the fictitious patient less favourably than those who work within the low secure unit, due to their contact with patients who are considered to require a higher level of security. Stigma hypotheses: That male nurses, across both sites, would rate the fictitious patient higher on all factors, with the exception of fear and danger, than female nurses. That older participants would be less fearful of the fictitious patient and rate him lower on the factor of dangerousness than younger participants.’	‘Significant minority of negative attitudes in relation to desire for social distance. Quantitative results showed high stigma scores for avoidance and segregation. There were no significant differences in attitudes between medium and low secure settings. However overall, males reported more negative attitudes in relation to blame and avoidance and younger participants demonstrated more negative attitudes than older participants in relation to fear and danger. While fear and blame were low overall, males reported more blame and younger practitioners reported more fear. This may indicate that experience (contact) reduces stigma in forensic settings although we cannot assume this from the study.’	20
7.	Frailing and Slate (2016)	196 (total) 55% female 45% male 119 Florida 60% female 40% male 82% 18–25 yrs	Students	Southern Texas & Florida	‘This research reported on the measurement of criminal justice and criminology students’ attitudes towards people with mental illness, before and after a class on criminalisation of mental health in offenders.’	The ‘results indicate that criminal justice and criminology students’ attitudes toward people with mental illness, offenders with mental illness, and community-based mental health services were significantly more positive at the conclusion of our classes than they were at the beginning. These outcomes were unaffected by choice of instrument or research location.’	18
8.	Perkins et al. (2009)	404 (total) 67% female 33% male 52.18 (16.08) yrs	General public	Indiana	‘1.An adult male with schizophrenia who is actively engaged in competitive, wage-based community employment will elicit less social distance than one who is unemployed. 2. An adult male with schizophrenia who has a past history of misdemeanor criminal conduct will elicit less social distance than one with a past history of felony criminal conduct.’	‘The individual who was gainfully employed (vs. unemployed), or who had a prior misdemeanour (versus felony) criminal offense, elicited significantly less stigma. Employment may destigmatize a person coping with both psychiatric disability and a criminal record.’	19
9.	Batastini et al. (2014)	465 (total) 66.7% female 33.3% male Not reported 18–24 yrs – 84% 25–34 yrs – 12.1% 35–44 yrs – 2.2% 45–54 yrs – 1.8%	University psychology students	West Texas	Hypothesised that regardless of education or experience, the job applicant with a history of both mental illness and criminal involvement will be rated the least desirable candidate for the job. They hypothesized that ‘prior experience with a mentally ill or criminal justice involved person would be associated with less stigmatized attitudes toward the respective job applicant.’	‘Applicants with a history of both mental illness and criminal behaviour were perceived as the least acceptable candidates for employment. However, this finding did not hold true when participants (i.e. the hypothetical employers) were exposed to a brief explanation about the benefits of employment.’	18
10.	Durand et al. (2017)	116 50.9% female 49.1% male 26.8 (10.77) yrs	General public	International but most common Europe, North America & Asia	The study ‘hypothesized a negative relationship between high expression of psychopathic traits and stigmatization towards psychopaths, and also hypothesized that this negative relationship would be strongest within interpersonal-affective features due to their association with fearlessness.’	‘The presence of psychopathic traits, particularly those related to boldness, was negatively correlated with the degree of stigmatizing behaviours towards psychopaths.’	18
11.	Weaver et al. (2019)	358 77% female 23% male 28.49 (9.02) yrs	College students majoring in social work (35%) or criminal justice (65%)	University of Southern Mississippi, US	‘This study investigates attitudes toward offenders living with mental illness among a cross-section of college students.’	‘Results indicated that Social Work students were less likely to have negative stereotypes (than criminal justice students) toward offenders with mental illness and tended to be more supportive of their potential for rehabilitation. The two groups of students appeared to share ambivalence regarding the dangerousness and culpability of offenders living with mental illness.’	19
12	Batastini et al. (2017)	138 29.7% female 70.3% male 49.43 (12.84) yrs	23.1% Judges, 24.3% Prosecutors, 52.7% Public Defendants	Mississippi	The ‘primary purpose of this study was to identify the prevalence of stigmatizing beliefs among judges, prosecutors, and public defenders. It was hypothesized that defence attorneys would self-report significantly less biased and stigmatizing attitudes about mental illness in general and seriously mentally ill defendants than both judges and prosecutors.’	‘Public defenders, relative to both judges and prosecutors, endorsed more compassionate attitudes about defendants with mental illnesses. While judges and prosecutors endorsed more negative stereotypes about mental illness and perceived mentally ill defendants as a greater risk to the community, mean scores across groups suggested moderately positive attitudes overall.’	19

Table 2. Mean stigma scores of identified studies and comparison groups.

Authors of study	Name and reference of measure	Direction of score	Brief description of what measure operationalises	Mean score	Comparison/control group mean score	T test	Is offender mental health stigma significantly higher than control?
Nee and Witt (2013)	No name (5 questions)	10-point Likert Higher scores = less stigma for trust and sympathy and rehab potential. Higher scores = more stigma for likelihood and severity of future crime	Vignettes included an offender with a mental health condition of either depression/schizophrenia	Mean response % categorised by depression or schizophrenia	Control group (no mental illness no criminal background)
			Subscales:
			Trustworthiness	Depression: 65.00 (SD = 17.85, n = 44) Schizophrenia: 69.46(SD = 15.47, n = 37)	72.79 (SD = 16.52, n = 43)	Depression: t (85) = 2.11, p = 0.04* Schizophrenia: t (78) = 0.93, p = 0.36	Yes for depression
			Sympathy	Depression: 72.27 (SD = 16.82, n = 44) Schizophrenia: 74.59(SD = 23.99, n = 37)	53.02 (SD = 22.20, n = 43)	Depression: t (85) = 4.58, p < .001* Schizophrenia: t (78) = 5.17, p < .001*	Yes for depression & schizophrenia
			Likelihood future crime (scores reported are possibility to definitely commit crime)	Depression: 5.02 (SD = 2.61, n = 44) Schizophrenia: 4.81(SD = 2.95, n = 37)	2.65 (SD = 2.70, n = 43)	Depression: t (85) = 4.16, p < .001* Schizophrenia: t (78) = 3.42, p < .001*	Yes for depression & schizophrenia
			Severity of future crime (minor crime category)	Depression: 4.21 (SD = 1.86, n = 32) Schizophrenia: 4.12(SD = 1.91, n = 24)	3.38 (SD = 1.54, n = 16)	Depression: t (46) = 1.54, p = 0.13 Schizophrenia: t (38) = 1.29, p = 0.20	No
			Rehab potential	Depression: 67.8 (SD = 19.13, n = 32) Schizophrenia: 75.00(SD = 16.55, n = 26)	75.29 (SD = 20.65, n = 17)	Depression: t (47) = 1.27, p = 0.21 Schizophrenia: t (41) = 0.05, p = 0.96	No
Garcia et al. (2020)	No name (5 questions as used in Nee & Witt, 2013)	10-point Likert (1 = lower stigma/positive, 10 = higher/negative)	Perceptions: sympathy, trustworthy, future crime likelihood and severity, rehab potential. Means reported for only one subscale:	Schizophrenia condition only one reported. Other categories are grouped as ‘mental illness’
		Higher stigma for both mental illness and schizophrenia for future crime	Likelihood of future crime	Mental Illness grouped: 5.11 (SD = 2.09, estimated n = 217) Schizophrenia: 5.23 (SD = 1.97, estimated n = 72)	Control Group from Nee and Witt (2013) 2.65 (SD = 2.70, n = 43)	Mental Illness grouped: t (258) = 6.69, p < .001* Schizophrenia: t (113) = 5.90, p < .001*	Yes for mental illness grouped and for schizophrenia specifically
Rao et al. (2009)	Attitude to Mental Illness Questionnaire (AMIQ) Luty et al. (2006)	5-point Likert (max +2 min −2, neutral/don't know 0) Total score between −10 and +10 Lower scores indicate negative attitudes, higher = positive	Stigmatised attitudes	Admitted to forensic hospital – Broadmoor No subscales reported Forensic hospital: −1.2 (SD = 3.12, n = 108)	Control group- general public from Luty et al. (2006) validation study 5.86 (SD = 2.40, n = 879)	Forensic hospital: t (985) = 27.83, p < .001*	Yes
Batastini et al. (2014)	Attribution Questionnaire (AQ-27) Corrigan (2003)/ Brown (2008) subscales	9-point Likert Higher score = higher stigma (Some subscales reverse scored)	Stigma/stereotypes using Brown’s (2008) subscales (Fear/dangerousness, help/interact, responsibility, forcing treatment, empathy).	Non psychoeducation group Bipolar I disorder and theft jail sentence	Control group
			Fear/Danger	Bipolar I disorder: 22.23 (SD = 11.59, n = 56)	16.16 (SD = 9.32, n = 55)	Bipolar I disorder: t (109) = 3.04, p = .003*	Yes
			Responsibility	Bipolar I disorder: 13.25(SD = 4.80, n = 56)	16.60 (SD = 4.11, n = 55)	Bipolar I disorder: t (109) = 3.95, p < .001*	Yes
			Help/interact	Bipolar I disorder: 22.55 (SD = 9.14, n = 56)	21.16 (SD = 8.18, n = 55)	Bipolar I disorder: t (109) = 0.84, p = .40	No
	Social Distance Scale Link et al. (1987), Martin et al. (2000)	4-point Likert Higher scores = more desired social distance	Social distance	Bipolar I disorder: 13.92 (SD = 4.29, n = 56)	12.71 (SD = 3.42)	Bipolar I disorder: t (109) = 1.64, p = .10	No
Durand et al. (2017)	Attribution Questionnaire (AQ-20) Corrigan et al. (2003) / Brown (2008) Subscales	9-point Likert Higher scores = higher stigma	Stigma, originally developed to measure schizophrenia but was replaced psychopathy Split into Brown’s (2008) subscales:	Psychopathy with conviction of theft	Control Batastini et al. (2014)
			Fear/dangerousness	Psychopathy: 22.48 (SD = 12.00, n = 116)	16.16 (SD = 9.32, n = 55)	Psychopathy: t (169) = 3.44, p < .001*	Yes
			Help/interact	Psychopathy: 37.21 (SD = 8.70, n = 116)	21.16 (SD = 8.18, n = 55)	Psychopathy: t (109) = 10.01, p < .001*	Yes

Note: Asterisk denotes a significant difference (p < .05) between groups.

Table 3. Quick reference list of stigma measures.

Measure	ADJORLOLO 2018	BATASTINI 2014	BATASTINI 2017	DURAND 2017	FRAILING 2016	GARCIA 2020	LAMMIE 2010	NEE 2013	PERKINS 2009	RAO 2009	SOWISLO 2017	WEAVER 2019
Attitudes toward mentally ill offenders (ATIMO, Brannen et al., 2004) Adapted versions of: ATMIO (Church et al., 2009)
Attitude to mental illness questionnaire (AMIQ) Luty et al. (2006)
Attitudes and beliefs about psychopathy (ABP) Smith et al. (2014)
Attribution questionnaire (AQ-27; Corrigan et al., 2003) Attribution questionnaire (Brown, 2008)
Community attitudes toward mental illness (CAMI) (Taylor & Dear, 1981; Swedish version) CAMI adapted 20 item version (Högberg et al., 2008)
Bogardus social distance scale (Bogardus, 1925)
Modification of Self-stigma of mental illness scale (Corrigan et al., 2006) Stereotype subscale only
Social distance scale (Link et al., 1987)
Survey of attitudes (Steadman & Cocozza, 1977)
5 questions by Nee and Witt (2013)

Table 4. Psychometrics for each measure included in the review.

Authors of study selected for review	Name and reference of measure	Psychometric of the measure α = Cronbach's alpha (Validation study)	Mental health condition referred to	Vignette
Nee and Witt (2013)	No name (5 questions)	Not reported	Depression schizophrenia	Yes
Garcia et al. (2020)	No Name (5 questions, as used in Nee & Witt, 2013)	Not reported	Grouped as ‘mental illness’ (referring to depression & schizophrenia)	Yes
Rao et al. (2009)	Attitude to Mental Illness Questionnaire (AMIQ) Luty et al. (2006)	α = 0.933 (Luty et al., 2006)	Admitted to forensic hospital (Broadmoor)	Yes
Sowislo et al. (2017)	Modification of the Bogardus social distance scale (Bogardus, 1925)	α = 0.92 (von dem Knesebeck et al., 2013)	Psychiatric hospital with forensic unit (borderline personality disorder and acute psychosis)	Yes
Adjorlolo et al. (2018)	Community attitude toward mental illness (CAMI) Högberg et al. (2008)	Open-mindedness α = 0.77 Fear/avoidance α = 0.81 Community mental health α = 0.67 Total α = 0.79	Schizophrenia	Yes
Lammie et al. (2010)	Attribution Questionnaire- (AQ-27) Corrigan et al. (2003)	α = .70–96 Corrigan et al. (2003)	Schizophrenia	Yes
Weaver et al. (2019)	ATMIO Brannen et al. (2004)	Negative Stereotypes α = .86 Rehabilitation/Compassion α = .70 Community Risk α = .61 Diminished Responsibility α = .56 (Church et al., 2009).	Mentally ill	No
Frailing and Slate (2016)	Survey of attitudes Steadman and Cocozza (1977)	α = .63 to .82 (Steadman & Cocozza, 1977)	Mental illness	No
	Community Attitudes towards Mentally Ill (CAMI) adapted version Taylor and Dear (1981)	α = .86 (Thompson et al., 2014).	Mental illness	No
Perkins et al. (2009)	Social Distance questions (Link et al., 1987)	α  = 0.87 (Perkins et al., 2009)	Schizophrenia	Yes
Batastini et al. (2014)	Attribution Questionnaire (AQ-27) (Brown, 2008) subscales	Fear/dangerousness α = 0.93 Help/interact α = 0.82 Responsibility α = 0.60 (Brown, 2008)	Bipolar I disorder	No
	Social Distance Scale Link et al. (1987); Martin et al. (2000)	α = 0.87 (for 6 item version, Martin et al., 2000)	Bipolar I disorder	No
Durand et al. (2017)	Attribution Questionnaire, (AQ-20) Corrigan et al. (2003) / Brown (2008) Subscales	α = 0.53–0.93 (Durand et al., 2017)	Psychopathy	Yes
	Attitudes and Beliefs about Psychopathy (ABP) Smith et al. (2014)	α = 0.50–0.86 (9 subscales, Durand et al., 2017)	Psychopathy	No
Batastini et al. (2017)	Adapted version of: Attitudes Toward Mentally Ill Offenders (ATMIO) Church et al. (2009); Brannen et al. (2004)	α = .73 to .88 (Church et al., 2009).	Mentally ill	No
	Community Attitudes towards Mentally Ill (CAMI) adapted version Taylor and Dear (1981)	α = .86 (Total score, Thompson et al., 2014).	Mentally ill	No

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