Disparities in mental health service utilization remain a persistent public health concern, with Black, Indigenous, and People of Color (BIPOC) populations experiencing lower access and higher stigma. Yet, limited research examines how situational factors – such as diagnosis and illness etiology – interact with racialized stigma to shape treatment attitudes. The objective of this study was to examine how mental illness etiology, diagnosis, and race affect mental health care recommendations, and whether stigma and help-seeking attitudes mediate these effects.

Methods

We conducted a cross-sectional online survey in May 2024 using an experimental vignette design. A national sample of 1,246 U.S. adults (50% BIPOC) was randomly assigned to vignettes varying by diagnosis (schizophrenia/depression), illness etiology (biogenetic/psychosocial), and vignette race (Black/White). After reading the assigned vignette, participants completed validated measures of 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 mental health utilization (MHU) recommendation item. Multivariate regression models tested direct effects, and mediation/moderation analyses assessed indirect effects of stigma and help-seeking attitudes on MHU across racial groups.

Results

Illness etiology significantly predicted greater MHU recommendations among White participants but had no effect among Black participants. Diagnosis also impacted MHU recommendation for White participants only. Vignette race influenced personal stigma and help-seeking attitudes among Black participants only. Among Black respondents, race showed a significant indirect effect on MHU recommendation via stigma and attitudes. Gender differences also emerged in stigma pathways, highlighting the value of intersectional analysis.

Conclusions

These findings highlight the importance of situational and racialized factors in shaping stigma and treatment attitudes. Public health efforts to reduce disparities in mental health care must account for the relational and intersectional nature of stigma, recognizing that diagnostic framing and racial cues activate distinct pathways across communities. To be effective, stigma reduction strategies must move beyond one-size-fits-all messaging and reflect the lived experiences of individuals navigating mental illness within racialized contexts. This study offers evidence to guide the development of culturally responsive interventions that advance population-level mental health equity through context-sensitive, community-informed approaches.