Adolescence is a critical developmental stage characterized by emotional, psychological, and social changes. In India, adolescents constitute a large proportion of the population, making their mental health a priority concern. Studies indicate that a substantial number of adolescents experience mental health problems, yet very few seek professional help. One of the major reasons for this gap is the lack of adequate knowledge, negative societal attitudes, and stigma surrounding mental illness. These factors create barriers to early identification and treatment, thereby worsening outcomes. Mental disorders constitute a major global public health concern and are among the leading causes of disability worldwide. They contribute substantially to reduced quality of life, impaired social and occupational functioning, and increased socioeconomic burden [1]. Although effective treatments are available for most mental health conditions, a large proportion of affected individuals either delay seeking care or do not seek professional help at all. This persistent treatment gap significantly exacerbates individual suffering and societal costs, making early identification and timely intervention a public health priority [2–4]. Help-seeking behaviour for mental health problems is influenced by a complex interplay of individual, social, cultural, and systemic factors. Low mental health literacy, preference for self-reliance, limited perceived need for care, financial constraints, and inadequate access to services have all been shown to reduce utilization of mental health care [5–7]. Among these factors, stigma associated with mental illness has consistently emerged as one of the most powerful barriers to help-seeking [8–11]. Stigma toward mental illness is a multifaceted construct encompassing negative stereotypes, prejudicial attitudes, and discriminatory behaviours directed toward individuals with mental health conditions. It operates at multiple levels, including public stigma, self-stigma, and structural stigma. Public stigma refers to widely held societal beliefs that portray individuals with mental illness as weak, unpredictable, or dangerous [12,13]. Self-stigma occurs when affected individuals internalize these negative societal views, leading to diminished self-esteem, reduced self-efficacy, and feelings of shame [14–16]. Structural stigma manifests through institutional policies and practices that limit access to education, employment, and healthcare services. Together, these forms of stigma can profoundly discourage individuals from acknowledging psychological distress and seeking professional care [11,17]. Help-seeking for mental health concerns is not a single event but a process involving symptom recognition, disclosure to others, and engagement with healthcare services. Stigma negatively influences each stage of this process. Fear of being labeled, socially rejected, or discriminated against often leads individuals to conceal symptoms, rely on maladaptive coping strategies, or avoid treatment altogether [8,10]. Such avoidance or delay in care is associated with worsening of symptoms, increased chronicity, impaired interpersonal relationships, and higher morbidity and mortality [2,18]. In low- and middle-income countries such as India, the impact of stigma on mental health care utilization may be particularly pronounced. Limited awareness of mental health issues, strong sociocultural beliefs, and persistent misconceptions surrounding mental illness often reinforce stigmatizing attitudes. Concerns related to family reputation, marriage prospects, and employment further discourage individuals from seeking professional help [11,19]. Understanding stigma within this sociocultural context is therefore essential for developing effective mental health interventions and policies. Although numerous studies have examined stigma and mental health service utilization, many have focused on attitudes, intentions, or hypothetical recommendations to seek help rather than actual help-seeking behaviour. While intentions are known to correlate with behaviour, a substantial gap exists between expressed willingness to seek help and real-world service use [20,21]. Importantly, only active help-seeking can meaningfully reduce the burden of mental disorders [2]. A case–control study design provides a robust methodological approach to examine differences in stigma levels and related factors between help-seekers and non-help-seekers. By allowing direct comparison between these groups, such a design facilitates identification of stigma components most strongly associated with failure to seek professional care.In this context, the present study was undertaken to assess stigma toward mental illness and to evaluate its impact on help-seeking behaviour using a case–control approach. By comparing individuals with mental health problems who have sought professional help with those who have not, this study aims to generate evidence that can inform stigma-reduction strategies, mental health awareness programs, and policies aimed at improving early, equitable, and effective access to mental health care.

This study was conducted to assess knowledge, attitude, and stigma toward mental illness and its impact on help-seeking behaviour. The study was carried out in a tertiary care healthcare setting over a defined study period after obtaining approval from the Institutional Ethics Committee. A total of 110 participants were included in the study. Participants were divided into two groups: • Individuals with mental health problems who had sought professional help from mental health services. • Individuals with mental health problems who had not sought any professional mental health care despite experiencing symptoms. The sample size of 110 was considered adequate to detect meaningful differences in stigma-related variables between the two groups. Inclusion Criteria • Adults aged 18 years and above • Individuals experiencing symptoms suggestive of a mental health problem • Ability to understand and respond to the study questionnaire • Willingness to provide informed consent Exclusion Criteria • Individuals with severe cognitive impairment or active psychotic symptoms impairing comprehension • Patients with acute medical or neurological illnesses affecting participation • Individuals unwilling to provide informed consent Data Collection Tools Data were collected using a structured questionnaire, which consisted of the following sections: 1. Sociodemographic profile: age, gender, education, occupation, marital status, and socioeconomic status. 2. Clinical characteristics: duration of symptoms, perceived severity, and prior exposure to mental health information. 3. Stigma assessment: stigma toward mental illness was assessed using a validated stigma assessment scale measuring components such as public stigma, self-stigma, and attitudes toward mental illness. 4. Help-seeking behaviour: information regarding past or present utilization of mental health services, reasons for seeking or not seeking help, and perceived barriers to care. The questionnaire was administered through face-to-face interviews to ensure completeness and accuracy of responses. Statistical Analysis Data were entered into Microsoft Excel and analyzed using SPSS version 25statistical software. Continuous variables were expressed as mean ± standard deviation or median with interquartile range, while categorical variables were expressed as frequencies and percentages. Comparisons between cases and controls were performed using the Chi-square test or Fisher’s exact test for categorical variables and the independent t-test or Mann–Whitney U test for continuous variables, as appropriate.A p-value of <0.05 was considered statistically significant.

The mean age of the overall study population was 34.8 ± 9.6 years, with a median age of 34 years (IQR: 28–41). The mean age among cases was 35.6 ± 9.1 years, while that among controls was 34.1 ± 10.0 years. The difference in mean age between the two groups was not statistically significant (p = 0.48, independent samples t-test). Of the 110 participants, 62 (56.4%) were males and 48 (43.6%) were females. Among cases, 30 (54.5%) were males and 25 (45.5%) were females, whereas among controls, 32 (58.2%) were males and 23 (41.8%) were females. There was no statistically significant difference in sex distribution between the two groups (p = 0.69, Chi-square test). Most participants had completed secondary or higher education. Graduate-level education was observed in 38.2% of cases and 34.5% of controls. The association between educational status and help-seeking behaviour was not statistically significant (p = 0.74, Chi-square test).The mean overall stigma score in the study population was 52.3 ± 9.8, with a median score of 53 (IQR: 46–59).Cases had a significantly lower mean stigma score (47.6 ± 8.1; median 48, IQR: 42–54) compared to controls (57.1 ± 9.4; median 58, IQR: 51–63).This difference was statistically significant (p < 0.001, independent samples t-test), indicating higher stigma levels among individuals who had not sought professional help.Self-stigma scores were significantly higher in the control group. The mean self-stigma score among controls was 29.4 ± 5.6, compared to 23.8 ± 5.1 among cases. The difference was statistically significant (p < 0.001, Mann–Whitney U test), demonstrating a strong association between higher self-stigma and non-help-seeking behaviour.Negative attitudes toward help-seeking were observed in 60.0% of controls compared to 29.1% of cases. This association between negative help-seeking attitudes and non-utilization of mental health services was statistically significant (p = 0.002, Chi-square test). Table 1. Sociodemographic Characteristics of the Study Population (n = 110) Variable Cases (n = 55) Controls (n = 55) Test applied p-value Age (years) 35.6 ± 9.1 34.1 ± 10.0 Independent t-test 0.48 Median age (IQR) 35 (29–41) 34 (27–42) Mann–Whitney U test 0.52 Sex Chi-square test 0.69 • Male 30 (54.5%) 32 (58.2%) • Female 25 (45.5%) 23 (41.8%) Educational status Chi-square test 0.74 • Up to secondary 18 (32.7%) 20 (36.4%) • Higher secondary 16 (29.1%) 16 (29.1%) • Graduate & above 21 (38.2%) 19 (34.5%) Table 2. Comparison of Stigma Scores Between Cases and Controls Stigma variable Cases (n = 55) Controls (n = 55) Test applied p-value Overall stigma score 47.6 ± 8.1 57.1 ± 9.4 Independent t-test <0.001 Median (IQR) 48 (42–54) 58 (51–63) Mann–Whitney U test <0.001 Self-stigma score 23.8 ± 5.1 29.4 ± 5.6 Mann–Whitney U test <0.001 Table 3. Attitudes Toward Help-Seeking in Cases and Controls Attitude toward help-seeking Cases (n = 55) Controls (n = 55) Test applied p-value Positive attitude 39 (70.9%) 22 (40.0%) Chi-square test 0.002 Negative attitude 16 (29.1%) 33 (60.0%)

In this case–control study, we examined the association between mental illness–related stigma and help-seeking behaviour among individuals with mental health problems. A total of 110 participants (55 cases and 55 controls) were analysed to compare stigma scores, self-stigma, and attitudes toward seeking professional help. Our results showed no statistically significant differences between cases and controls in terms of age (mean age cases: 35.6 ± 9.1 years; controls: 34.1 ± 10.0 years; p = 0.48) and sex distribution (p = 0.69), suggesting that these basic sociodemographic factors did not independently influence help-seeking in our sample. This aligns with findings from larger population studies where, after controlling for stigma, sociodemographic variables often show limited direct impact on actual service use when stigma is high[22]. In the present study, individuals who had not sought professional help (controls) demonstrated significantly higher overall stigma scores (57.1 ± 9.4) compared with help-seekers (47.6 ± 8.1), with the difference highly significant (p< 0.001). This supports a large body of evidence indicating that higher stigma is associated with lower utilisation of mental health services. A systematic review by Clement et al. found that greater stigma was strongly associated with reduced help-seeking behaviour across diverse populations, highlighting stigma as one of the most consistent barriers to help seeking[22]. Published work further suggests that stigma-related barriers extend across cultural and healthcare settings. For example, Henderson and colleagues reported that stigma significantly suppressed help-seeking attitudes even in regions with established mental health awareness campaigns, indicating the deep-rooted nature of stigma in influencing access to care[23]. Our results indicated that self-stigma scores were significantly higher in controls (29.4 ± 5.6) compared with cases (23.8 ± 5.1; p< 0.001). This pattern is well supported by the literature: self-stigma, which refers to internalised negative beliefs about one’s own mental health condition, is consistently linked with reduced help-seeking intentions and behaviours[24]. Empirical evidence shows that individuals with higher self-stigma are more likely to expect rejection, anticipation of negative social outcomes, and fear of discrimination—factors that discourage service utilization [24]. This is consistent with our finding that those who never sought help exhibited higher self-stigma, indicating that internalised stigma may be a robust deterrent to converting help-seeking intentions into action. In our study, negative attitudes toward help-seeking were more prevalent among controls (60%) than cases (29.1%), and this difference was statistically significant (p = 0.002). Attitudes toward help-seeking are shaped by both public perceptions and personal beliefs about treatment efficacy, confidentiality, and social acceptance. Numerous studies have demonstrated that negative or avoidant attitudes strongly correlate with lower mental health service uptake. The Theory of Planned Behaviour suggests that attitudes, subjective norms, and perceived control influence behavioural intentions, which then predict actual behaviour. Although intentions frequently correlate with help-seeking actions, stigma may weaken this link—people can express willingness to seek help yet refrain from doing so due to fear of judgement or shame .Findings from research examining the nuanced roles of stigma subtypes (public, personal, self-stigma) suggest that self-stigma and attitudinal stigma are particularly influential in actual help-seeking behaviours. A meta-analysis reported that internalised stigma and negative attitudes toward help-seeking were more strongly associated with reduced help-seeking than general public stigma[25]. The findings underscore the importance of targeted interventions to reduce self-stigma and promote more positive help-seeking attitudes to improve mental health service utilization. Evidence from intervention studies suggests that anti-stigma campaigns, especially those providing education and contact with people with lived experience, are effective in improving help-seeking attitudes and reducing discrimination[26]. Since our study highlights internalised stigma as a key barrier, tailored programmes aimed at reducing self-stigma—such as cognitive-behavioural strategies, peer support groups, and media literacy—may be particularly beneficial in facilitating help-seeking behaviour.

The present case–control study demonstrated that stigma toward mental illness plays a significant role in influencing help-seeking behaviour among individuals with mental health problems. While cases and controls were comparable with respect to sociodemographic characteristics such as age, sex, and educational status, marked differences were observed in stigma-related domains. Individuals who had not sought professional help exhibited significantly higher overall stigma and self-stigma scores, along with more negative attitudes toward help-seeking, compared to those who had accessed mental health services. These findings highlight that stigma—particularly internalized stigma and unfavorable perceptions of mental health care—acts as a major barrier to the utilization of professional mental health services. The study underscores that help-seeking behaviour is not determined solely by symptom presence or demographic factors, but is strongly shaped by psychosocial attitudes and beliefs surrounding mental illness. The results emphasize the need for comprehensive stigma-reduction strategies that focus on enhancing mental health literacy, reducing self-stigma, and promoting positive attitudes toward seeking professional care. Public health interventions, community-based awareness programs, and policy initiatives should prioritize addressing stigma to facilitate early help-seeking and reduce the treatment gap in mental health care. LIMITATIONS OF THE STUDY Despite providing valuable insights into the relationship between stigma and help-seeking behaviour, the present study had certain limitations that should be acknowledged. First, the case–control design and cross-sectional nature of the study limited the ability to establish a causal relationship between stigma and help-seeking behaviour. The associations observed could not determine whether stigma preceded non-help-seeking or developed as a consequence of it. Second, the study relied on self-reported data, which may have been subject to recall bias and social desirability bias. Participants might have underreported stigmatizing attitudes or overreported socially acceptable responses, potentially affecting the accuracy of stigma and help-seeking measures. Third, the study was conducted in a single-center setting with a relatively small sample size (n = 110), which may limit the generalizability of the findings to broader populations or different sociocultural contexts. Regional and cultural variations in stigma and help-seeking behaviour may not have been fully captured. Fourth, although validated instruments were used to assess stigma, the study did not comprehensively evaluate other important determinants of help-seeking behaviour such as severity of illness, mental health literacy, social support, accessibility of services, and economic factors, which could have acted as confounding variables. Finally, the study focused on current or past help-seeking behaviour and did not assess longitudinal changes in stigma or attitudes over time. Future longitudinal studies are needed to better understand how stigma evolves and how changes in stigma influence help-seeking behaviour across different stages of mental illness.

1. Whiteford HA, Degenhardt L, Rehm J, Baxter AJ, Ferrari AJ, Erskine HE, et al. Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010. Lancet. 2013;382:1575–86. 2. Wang PS, Angermeyer MC, Borges G, Bruffaerts R, Tat Chiu W, de Girolamo G, et al. Delay and failure in treatment seeking after first onset of mental disorders. World Psychiatry. 2007;6:177–85. 3. Wittchen HU, Jacobi F, Rehm J, Gustavsson A, Svensson M, Jonsson B, et al. The size and burden of mental disorders and other disorders of the brain in Europe 2010. EurNeuropsychopharmacol. 2011;21:655–79. 4. Gustavsson A, Svensson M, Jacobi F, Allgulander C, Alonso J, Beghi E, et al. Cost of disorders of the brain in Europe 2010. EurNeuropsychopharmacol. 2011;21:718–79. 5. Mojtabai R, Olfson M, Sampson NA, Jin R, Druss B, Wang PS, et al. Barriers to mental health treatment. Psychol Med. 2011;41:1751–61. 6. Andrade LH, Alonso J, Mneimneh Z, Wells JE, Al-Hamzawi A, Borges G, et al. Barriers to mental health treatment. Psychol Med. 2014;44:1303–17. 7. Gulliver A, Griffiths KM, Christensen H. Perceived barriers and facilitators to mental health help-seeking in young people. BMC Psychiatry. 2010;10:113. 8. Clement S, Schauman O, Graham T, Maggioni F, Evans-Lacko S, Bezborodovs N, et al. Impact of mental health-related stigma on help-seeking. Psychol Med. 2015;45:11–27. 9. Corrigan PW. How stigma interferes with mental health care. Am Psychol. 2004;59:614–25. 10. Thornicroft G. Stigma and discrimination limit access to mental health care. Epidemiol Psichiatr Soc. 2008;17:14–9. 11. Schomerus G, Angermeyer MC. Stigma and its impact on help-seeking for mental disorders. Epidemiol Psichiatr Soc. 2008;17:31–7. 12. Link BG, Yang LH, Phelan JC, Collins PY. Measuring mental illness stigma. Schizophr Bull. 2004;30:511–41. 13. Angermeyer MC, Holzinger A, Carta MG, Schomerus G. Biogenetic explanations and public acceptance of mental illness. Br J Psychiatry. 2011;199:367–72. 14. Corrigan PW, Watson AC. The paradox of self-stigma and mental illness. Clin Psychol Sci Pract. 2002;9:35–53. 15. Livingston JD, Boyd JE. Correlates and consequences of internalized stigma. Soc Sci Med. 2010;71:2150–61. 16. Ritsher JB, Phelan JC. Internalized stigma predicts erosion of morale. Psychiatry Res. 2004;129:257–65. 17. Corrigan PW, Druss BG, Perlick DA. The impact of mental illness stigma on care. Psychol Sci Public Interest. 2014;15:37–70. 18. Rugulies R. Depression as a predictor for coronary heart disease. Am J Prev Med. 2002;23:51–61. 19. Gary FA. Stigma as a barrier among ethnic minorities. Issues Ment Health Nurs. 2009;26:979–99. 20. Ajzen I. The theory of planned behaviour. Organ Behav Hum Decis Process. 1991;50:179–211. 21. Holzinger A, Matschinger H, Angermeyer MC. Help-seeking recommendations of the public. Epidemiol Psychiatr Sci. 2011;20:163–69. 22. Fox AB, Earnshaw VA, Taverna EC, Vogt D. Conceptualizing and measuring mental illness stigma: The Mental Illness Stigma Framework and critical review of measures. Stigma Health. 2018 Nov;3(4):348–376. 23. Henderson C, Evans-Lacko S, Thornicroft G. Mental illness stigma, help seeking, and public health programs. Am J Public Health. 2013 May;103(5):777–780. 24. Docksey AE, Gray NS, Davies HB, Simkiss N, Snowden RJ. The Stigma and Self-Stigma Scales for attitudes to mental health problems: Psychometric properties and its relationship to mental health problems and absenteeism. Health Psychol Res. 2022 Jun 28;10(2):35630. 25. Schnyder N, Panczak R, Groth N, Schultze-Lutter F. Association between mental health-related stigma and active help-seeking: Systematic review and meta-analysis. Br J Psychiatry. 2017;210(4):261–268. 26. Crockett MA, Núñez D, Martínez P, Borghero F, Campos S, Langer AI, et al. Interventions to reduce mental health stigma in young people: A systematic review and meta-analysis. JAMA Netw Open. 2023;8(1):e2454730.