The present study investigated whether attitudes towards PMI across four factors (social distancing, tolerance/support for community care, social restrictiveness, and prejudice and misconception) differed between 2015 and 2023 and examined the sociodemographic correlates associated with these attitudes in 2023. The findings of the study reflect a positive shift in attitudes, aligning with evidence from mental health professionals [30, 31]. These improved attitudes are important as there is evidence that people’s intention to seek help is positively associated with better public support [4, 34]. However, it is important to note that whilst overall attitudes have improved, scores for tolerance/support for community care remain relatively low, indicating that the public remains apprehensive about community care. Other studies have postulated that this may be attributed to the “not in my backyard” phenomenon, where individuals oppose the inclusion of mental health services in their neighbourhood, even if they support the need for such services elsewhere [35,36,37]. This reluctance could stem from various concerns, such as physical safety or perceiving a more critical need for services for other groups in the community [35,38]. This lack of support and tolerance for community care can lead to lower quality, accessibility, and availability of services that PMI might need, highlighting the importance of fostering support among the public [38].

The sociodemographic characteristics associated with attitudes did not differ much in 2023 compared to 2015. Consistent with Mind Matters 2015, the 2023 study revealed that older individuals, males, and individuals with lower educational levels had poorer attitudes towards PMI. One possible explanation for younger adults having better attitudes is their greater exposure to mental health information through social media platforms leveraged by many local campaigns. A 2020 study found that social distancing tendencies increase with age, possibly explained by the ‘impressionable years model’, which proposes that attitudes formed in younger years remain stable through adulthood [39]. This could explain why older adults are still associated with worse attitudes [39]. Corroborating this notion, a meta-analysis conducted to explore changes in public stigma among respondents from 14 different countries revealed that current mental health educational interventions are generally more effective with adolescents as compared to their older counterparts [40].

Furthermore, consistent with present findings, other studies have also reported that females tend to hold more positive attitudes toward PMI than males across different measures [41, 42]. Cultural and gender norms strongly influence perceptions of what topics are appropriate for discussion and the types of support that are considered acceptable [43]. Cross-cultural perspectives suggest that mental health-related shame in many Asian societies stems from enduring cultural and religious beliefs that prioritise family honour and view mental illness as a personal or moral failing [44,45,46]. When these beliefs intersect with traditional masculine norms that emphasise strength, emotional restraint, and responsibility as the family provider, mental health difficulties are often trivialised as personal weakness, leading to greater negative attitudes and reduced empathy towards PMI [44,47,48,49]. Previous studies have also indicated that females are more likely to seek support for mental health conditions despite similar prevalence rates among both genders, possibly due to sociocultural expectations that portray men as strong and self-reliant [43,50]. Collectively, these differences might help explain why females have better attitudes towards PMI than males.

The findings also indicated that while Indian and Malay respondents exhibited higher levels of prejudice and misconceptions, Indian respondents demonstrated lower social distancing and restrictiveness, as well as greater tolerance/support for community care compared to Chinese respondents, patterns consistent with those observed in 2015. Cultural frameworks appear to shape the expression and sources of negative attitudes differently across ethnic groups. Tan and colleagues (2020) noted that etiological beliefs surrounding mental illness vary between different cultures in Singapore, which may contribute to distinct forms of stigma [3]. In Indian and Malay communities, explanations such as religion, retribution, and supernatural elements are often associated with stigma [51,52,53]. In contrast, within Chinese societies, stigma is closely tied to the cultural construct of “loss of face”, a reflection of social status and moral reputation [54]. Another local study has shown that although PMI are frequently perceived as dangerous and unpredictable by Indian respondents, they tend to be more accepting and willing to engage with them compared to their Chinese counterparts [25]. Similar findings from India suggest that despite persistence of stigma, PMI often receive support from their families and communities [55,56]. However, more research is needed to clarify how these etiological beliefs translate into specific manifestations of attitudes.

In 2023, respondents who were never married scored better in three domains of attitudes as compared to one (prejudice and misconception) in 2015. Marital status is typically associated with age, as younger adults are more likely to fall under the ‘never married’ category [57]. In our sample, the majority of respondents in the “never married” category also fell within the “18–34” age category, further supporting the observed age-related differences in attitudes. Additionally, apart from the consistent finding that those earning less were more likely to hold more prejudice and misconceptions, the 2023 study revealed that those earning less also had higher social distancing and restrictiveness and lower tolerance/support for community care. These changes in trends could plausibly suggest that improvements in attitudes were mainly amongst those in higher income groups. These individuals are more likely to have better access to information regarding mental health and the importance of social inclusivity for PMI. A study conducted in the United States highlighted that individuals in higher income groups were more likely to perceive a more unsupportive environment for PMI [58]. If this holds for the present study, it could be speculated that positive attitudes towards community care among those in higher income groups reflect their support for creating a more inclusive and supportive environment for PMI.

The consistent pattern of poorer attitudes among older adults, males, and individuals with lower socioeconomic status suggests that recent destigmatisation efforts have not effectively reached or influenced certain vulnerable groups, and measures should be taken to increase accessibility. Multi-pronged strategies that combine education with personal contact and target specific community settings are needed. Culturally sensitive, community-level interventions are essential, and the persistent link between ethnicity and attitudes underscores the importance of engaging key religious and community leaders [12,59,60,61,62]. Additionally, interventions that incorporate contact with PMI alongside education serve as an effective strategy directed towards positive changes in attitudes and fostering empathy towards PMI [41, 63, 64]. Current public initiatives in Singapore typically focus on education, whereas opportunities for contact are lacking. Some beneficial contact-based interventions have been implemented for specific subgroups. For example, an anti-stigma intervention implemented for local university students that involved both education and contact revealed promising short-term improvements in community attitudes towards mental illness among respondents [65]. It would be beneficial to extend access to these interventions for other subgroups, tailoring them to specific needs (e.g., delivering them in different local languages). Beyond these, integrating mental health care into general or primary healthcare settings is advantageous as it helps reduce stigma on top of improving access to care, especially for older adults who may already often use these facilities for physical conditions [59,66]. When mental health care is accessible within familiar healthcare settings, it helps normalise it.

The results of this study should be viewed in light of the following limitations. Firstly, although the questionnaire was administered through an interviewer to ensure response quality, respondents might have provided socially desirable responses as the topic pertained to attitudes [67]. Secondly, the present study used the umbrella term ‘mental illness’ when investigating stigma, however, individuals may hold different attitudes towards different mental illnesses [68]. Thus, these responses might have been affected by how the respondent interpreted the term, suggesting some levels of inconsistency. Notwithstanding these, the present study holds several strengths, including a large sample size generalisable to the general population, the use of multiple local languages ensuring inclusivity and the consistent methodology between the 2015 and 2023 surveys, ensuring that valid comparisons and conclusions can be made regarding changes in attitudes in the general population.

The present study provides a nationally representative update regarding public attitudes towards PMI in Singapore, comparing data between 2015 and 2023. The findings indicate modest improvement in attitudes over time, but relatively poor attitude scores for tolerance/support for community care, and the persistence of subgroups associated with worse attitudes highlights the need for improving and strategizing on our current mental health initiatives. These results extend the empirical literature by confirming that, despite broader societal shifts and destigmatisation efforts, certain subgroups remain vulnerable to entrenched stigma. Compared to prior studies primarily conducted in Western contexts or smaller Asian samples, this study offers a comprehensive view of public perceptions within a multiethnic Asian society.

In future, it would be beneficial to delve deeper and investigate the underlying causes for poorer attitudes towards PMI among subgroups for the development of targeted initiatives. Bradbury (2020) suggested a longitudinal approach in investigating attitude changes over time within-subjects to have a deeper understanding of relevant life-course determinants [41]. Additionally, it is also recommended that future studies include the degree of previous contact with PMI, as prior evidence consistently shows that personal contact is one of the strongest predictors of reduced stigma [34,69,70]. Incorporating this variable would provide a more comprehensive understanding of the factors shaping public attitudes and help identify potential leverage points of interventions. Furthermore, future studies can also examine whether improved attitudes translate into tangible behavioural changes, such as an increase in support for mental health policies, reduced treatment gaps, or better support in workplaces. Continuous investigation of attitudes in the nation would be beneficial in understanding emerging trends and further strategizing and improving mental health initiatives.