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Identifying depression and schizophrenia using vignettes: A methodological note
Psychiatry Research 210 (2013) 357–362
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Identifying depression and schizophrenia using vignettes: A methodological note Gertrude Sai, Adrian Furnham n Research Department of Clinical, Educational and Health Psychology, University College London, United Kingdom
art ic l e i nf o
a b s t r a c t
Article history: Received 15 March 2012 Received in revised form 29 April 2013 Accepted 4 May 2013
The aim of this study was to assess lay people's ability to identify depression and schizophrenia from well established vignettes using hypothetical patients of both sexes. In all 122 participants answered a questionnaire, consisting of six vignette case studies describing psychological symptoms; three each associated with depression and schizophrenia. They answered three questions: what is the person's main problem; how could they be best helped; what would you do to help? Overall, depression was more often correctly identified compared to schizophrenia. The gender of the participant and the individual presented in the vignette did have an effect on the vignette identification task. Limitations and implications of these results and the use of vignette methodology were discussed. & 2013 Elsevier Ireland Ltd. All rights reserved.
Keywords: Mental health literacy Vignette Schizophrenia Depression
1. Introduction Jorm et al. (1997b) defined mental health literacy (MHL) as public knowledge and beliefs about mental disorders which aid their recognition, management or prevention. A number of studies have investigated the mental health literacy with respect to various disorders such as: personality disorders (Furnham et al., 2011; Furnham and Winceslaus, 2012), schizophrenia (Furnham and Murao, 1999; Furnham and Wong, 2007), anxiety disorders (Coles and Coleman, 2010) and conduct disorders (Furnham and Carter Leno, 2012) to name a few. It has been suggested that up to 70% of individuals suffering from a mental health disorder do not seek professional help or recognise common disorders in others (Farrer et al., 2008; Jorm et al., 1997b; Burns and Rapee, 2006; Jorm, 2000). Evidence suggests that previous experience with mental illness aids recognition in a vignette identification task (Furnham et al., 2011). Lay people tend to view people with schizophrenia as more dangerous compared to those with depression (Angermeyer and Matschinger, 1999; Jorm et al., 1997b, 2000; Pescosolido et al., 1999). However it has been shown that direct contact with people with schizophrenia does increase their knowledge and shape their attitudes (Furnham and Blythe, 2012). Jorm (2012) has argued that MHL can be improved by community campaigns and interventions in educational settings.
n
Corresponding author. E-mail address: [email protected] (A. Furnham).
0165-1781/$ - see front matter & 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.psychres.2013.05.004
There have been a number of studies which have investigated the differences in recognition and labelling between depression and schizophrenia (Caldwell and Jorm, 2000; Dietrich et al., 2004; Won Pat-Borja et al., 2010). The results have been inconsistent and may reflect the methodological differences. For instance, in Jorm et al.'s (1997b) study, participants, in the vignette-identification component, were presented with an open ended question while Lauber et al. (2005) and Link et al. (1999) presented participants with a closed-ended question which inferred that there was something wrong with the individuals in the vignette, i.e. they were suffering from a ‘mental illness’. They also used different vignettes which may not have been equivalent. Evidence suggests that depression is twice as likely in women compared to men and that around 10% of people around the world experience some depressive episode during their lives (Andrade and Caraveo, 2003). Latest WHO figures suggest that depression is the most common mental disorder in the world with 350 million people suffering from it and that it is on the rise. The WHO factsheet notes that depression is caused by a complex interaction of biological, psychological and social factors, that there are effective treatments but that fewer than half those suffering from it get any form of treatment (WHO, 2012). It has also been found that males are less likely to recognise symptoms due to the emphasis on externalisation of mental health problems (Cotton et al., 2006). A study on young Australians found that males demonstrated poorer knowledge, with respect to depression, compared to females (Burns and Rapee, 2006). Also, it has been found that depression induces less stigma amongst lay people and more social acceptance if symptoms typically associated with depression are exhibited by a female compared to a
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male (Farina, 1981). Also males are less likely to seek advice from a doctor/counsellor/psychologist but often resort to substance abuse such as alcohol to deal with mental health problems (Cotton et al., 2006). There is a greater incidence of males being diagnosed with schizophrenia compared to females, with between 0.30% and 0.66% of people diagnosed in the population (Van Os and Kapur, 2009). Few studies that have been conducted report that positive symptoms are more likely to be apparent in females and negative symptoms more apparent in males (Addington et al., 1996; Rector and Seeman, 1992; Ring et al., 1991). Despite prevalence rates for women and men being the same for schizophrenia, studies have shown that the incidence for men aged 18–25 is double the amount for women, which shows an earlier onset in men (Warner, 1994). The influence of gender has also been investigated using the vignette technique to identify whether the gender of the vignette has an influence on vignette identification (Jorm et al., 1997a,b). Overall results are mixed with a number of studies showing no effect of vignette gender on MHL. However there is some evidence that the gender of the respondent does have an effect on things like what recommendations for help and assistance are made (Jorm, 2012). Using the vignette method, similar to the one used by Furnham and Carter Leno (2012), we will compare individuals' ability to correctly recognise depression and schizophrenia. The study will also investigate whether the gender of the vignette will influence recognition (Jorm, 1987). The proposed hypothesis states that depression will be “correctly” identified more as opposed to schizophrenia using vignette case studies (H1). Secondly, it is predicted that the gender of the participant and the character depicted in the vignette will have an effect on correct recognition (H2). 2. Method 2.1. Participants There were a total of 122 participants: 27.9% male and 72.1% female with a mean age of 26.3 years (S.D. ¼10.17). There were European Caucasian (41.8%), Black/ Black British (24.6%), Asian British (21.3%) and the remainder of participants fell into the ‘other’ category (12.3%). The majority of participant's highest educational qualification was A levels (12th grade) or equivalent (54.9%), followed by BSc/BA or equivalent (26.2%), GCSE (10th grade) or equivalent (8.2%), MSc or equivalent (6.6%), PhD (0.8%) and other (3.3%). A third had studied some psychology (37.7%). In all 12% of participants reported that they had been diagnosed with a mental illness but a larger proportion of participants reported knowing someone that had been diagnosed with a mental disorder (37.7%). The highest prevalence of mental disorders for both questions being reported were depression (24.6%) and schizophrenia (4.9%), respectively, as well as a range of other mental disorders. 2.2. Materials Vignette identification: Participants were presented with six vignette case studies each ranging between 50 and 150 words long and written to be easily comprehensible. The case vignettes were all based upon fictional characters illustrating symptoms which are in line with the DSM-IV (APA, 1994) diagnosis of depression and schizophrenia. Case 1 was taken from a textbook entitled ‘Abnormal Psychology’ by Seligman et al. (2001); Case 2 was obtained from Jorm et al. (1997a); Case 3 was obtained from Eastern Illinois University (2008); Case 4 was adapted from Link et al. (1999); Case 5 was also taken from Jorm et al. (1997a) and Case 6 was adapted from Jorm et al. (2006). The depression vignettes were represented by Cases 1, 2 and 5. The schizophrenia vignettes were represented in Cases 3, 4 and 6. The gender across all the vignettes was alternated (See Appendix). Participants were asked to propose a diagnosis when asked ‘What would you say is X's main problem?’ Participants were asked to propose what method of treatment would be useful; ‘How do you think X could best be helped?’ and also what they would suggest if they personally knew the individual; ‘Imagine X is someone you have known for a long time and care about. You want to help him. What would you do?’ There were two versions of each vignette case study i.e. each vignette had a male and female version. Similar to the technique used by Furnham and Carter Leno (2012), a content analysis was conducted on open ended questions, e.g. ‘What
would you say is X's main problem?’ This was completed using the Q sort technique (Bracken and Fischel, 2006) with 10% of responses given to another researcher which was to ensure reliability. In few instances (around 8%) where participants gave multiple responses, the first response was analysed as it was assumed to be the most important.
2.3. Procedure Once ethical approval was obtained, participants were recruited using an opportunistic sample from three sources: public places in central London; using social network sites available to the authors and mailing lists of people on a participant panel. Around a third were approached at London railway stations but because of time constraints the response rate was around 40% of people who completed the whole questionnaire. Both authors sent the questionnaire to around 60 contacts and here the response rate was around 80%. The department also has a panel of people who volunteer to take part in various studies. A small number (around 20) were approached to increase the sample. The questionnaire was thus presented using both paper and electronic form. Where possible, participants were fully debriefed. All individuals participated on a purely voluntary basis and were not remunerated for their partaking.
3. Results 3.1. Diagnosis/classification The percent “correct” response on the vignette-identification component differed between the two disorders. “Correct” included for depression, depressive disorder, affective disorder and malignant sadness, while for schizophrenia psychotic or psychosis was accepted as correct. A response of “mental illness” or “psychological problem” was not classed as correct. Overall, the depression vignettes (72.7%) were more correctly identified compared to the schizophrenia vignettes (46.4%). Four factors emerged from the content analysis. The first category ‘Psychology/Psychiatric’ used known psychological or psychiatric labels. The second category entitled ‘Social factors’ was related to responses that geared toward external causes such as ‘stress at work’. The third category entitled ‘Emotional factors’ was concerned with inner feelings of conflict such as ‘she is heartbroken’. The fourth category entitled ‘Lifestyle problems’ refers to the overall style of the individuals that has caused the problems described in the vignette. An example of a response that would be classified in this category would be ‘substance abuse’. Table 1 shows the differential diagnosis between cases of depression and schizophrenia respectively. Over 75% of respondents saw the depression vignettes as evidence of psychiatric illness. The schizophrenia vignettes tended to cumulatively have more lifestyle issues proposed compared to depression with a considerable proportion in Case 3, although there were a number of participants that seemed to propose that there was in fact nothing wrong with the individual, particularly in schizophrenia Cases 1 and 3. 3.2. Treatment A content analysis of answers to the question ‘How do you think X could best be helped?’ was conducted using the same method as above. Table 1 Percentages (%) of diagnostic labels used in all six vignettes. Psychological/ Social Emotional Lifestyle Nothing Psychiatric Depression case 1 Depression case 2 Depression case 3 Schizophrenia case 1 Schizophrenia case 2 Schizophrenia case 3
76.2 80.3 85.2 47.5 92.6 82.8
21.3 2.5 1.6 2.5 1.6 0.8
0.0 9.8 8.2 9.8 2.5 1.6
2.5 9.0 4.1 32.8 3.3 9.0
0.0 0.0 0.8 7.4 0.0 5.7
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Various categories that emerged from the content analysis were: Medical, with responses such as ‘anti-depressants’, ‘anti-psychotics’ and ‘sleeping pills’. Professional Help, refer to more humanistic methods such as ‘ going to see the GP/doctors’, ‘therapy’, ‘CBT’. The third category was entitled Medication and Professional Help, and referred to a combination of both medication and a therapy e.g. ‘anti-depressant and CBT’. The fourth was classified as ‘Social Activities’ which included more suggestions of hobbies or informal chats e.g. ‘get more sleep’, ‘advise that she goes on holiday’. The next was entitled Emotional which was characterised by having responses such as ‘I would talk to him,’ ‘be there for them’ and so, lending the individual emotional support. The next was entitled Other which referred to responses that could not be categorised using the aforementioned criteria such as ‘tell him that's life’ or ‘inform the FBI’. Nothing refers to participants claiming that the individual did not need any help. The next part of the vignette component asked ‘Imagine X is someone you have known for a long time and care about. You want to help him. What would you do?’ The same aforementioned categories were used for the treatment questions. Pairwise comparisons were conducted to establish whether there was a difference between the treatment the individual believes they would benefit from and how they would help if they knew the individual in the vignette. All were found to be statistically significant except for the female version of Case 6. There was not a significant difference of gender between the two questions. Table 2 shows comparative percentages between depression and schizophrenia respectively when asked “How do you think X could best be helped”. Overall, participants favoured therapy as most effective but there were marked differences between depression and schizophrenia. The most apparent differences were in regards to therapy and medication. 50.5% rated therapy as more effective with depression compared to 42.4% in schizophrenia. Also, medication was proposed twice as often in reference to schizophrenia (16.93%) than depression (8.47%). Emotional support was considered more in depression (6.3%) compared to schizophrenia (3.57%). Table 3 shows the comparative percentages of differing treatments recommended to individuals with depression (top) and schizophrenia (bottom) when asked ‘Imagine X is someone you have known for a long time and care about. You want to help him. What would you do?’ For both depression and schizophrenia, medication was proposed less compared to the prior question. There is a statistically significant increase of emotional support proposed for both disorders: over four
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times the amount in depression (28.12%) and 3 the amount in schizophrenia (13.9%) (po0.05). 3.3. Effect of gender Table 4 shows there was no difference in “correct” recognition in Cases 1, 4 and 5 regardless of whether the individual in the vignette was male or female. However, Cases 3 and 6 were significantly correctly identified more when the individual in the vignette was male. Chi square statistics showed that male participants were less likely to recognise the symptoms of schizophrenia when the individual in the vignette was a female in Case 4, χ2 (1)¼11.32, p¼ 0.001. With regards to Case 5, females were more likely to accurately recognise symptoms for depression compared to males when the individual in the vignette was male χ2 (1) ¼8.92, p ¼0.01 With regards to Case 6, males were more likely to accurately recognise symptoms compared to females when the individual in the vignette was a female exhibiting schizophrenia, χ2 (1) ¼6.05, p¼ 0.01. No other analyses examining gender difference in participant or vignette showed significance.
4. Discussion As predicted, the recognition rate for the depression cases was higher overall compared to schizophrenia (H1). These results are consistent with previous findings (Jorm et al., 1997b; Lauber et al., 2005) and contradictory to some other findings who found schizophrenia was more correctly identified compared to depression (Angermeyer and Matschinger, 1999, 2003; Link et al., 1999). There was a considerable amount of variation present in the first question of the vignette component “What would you say is X's Table 4 Accuracy of correct recognition on the effect of gender of the vignette. The figure illustrates variation in accuracy in vignette diagnosis of depression and schizophrenia when the vignette was described male or female.
Female Male
1
2
3
4
5
6
72 72
64 59
11 18
66 64
84 85
57 62
Table 2 Comparative percentages of differing treatments recommended to individuals with depression and schizophrenia when asked ‘How do you think X could best be helped?
Depression case 1 Depression case 2 Depression case 3 Schizophrenia case 1 Schizophrenia case 2 Schizophrenia case 3
Medication
Therapy
Combined
Social
Emotional
Other
Nothing
4.1 13.1 8.2 13.9 18.0 18.9
57.4 50.8 43.4 23.8 52.5 50.8
8.2 9.8 23.0 3.3 13.9 16.4
22.1 22.1 18.9 46.7 13.1 9.8
8.2 4.1 6.6 5.7 2.5 2.5
0.0 0.0 0.0 5.7 0.0 1.6
0.0 0.0 0.0 0.8 0.0 0.0
Table 3 Comparative percentages of differing treatments recommended to individuals with depression and schizophrenia when as ‘Imagine X is someone you have known for a long time and care about. You want to help him. What would you do?
Depression case 1 Depression case 2 Depression case 3 Schizophrenia case 1 Schizophrenia case 2 Schizophrenia case 3
Medication
Therapy
Combined
Social
Emotional
Other
Nothing
0.8 2.5 1.6 1.6 6.6 6.6
30.3 43.4 41.8 27.0 47.5 60.7
2.5 4.9 3.3 2.5 7.4 3.3
23.0 31.1 30.3 45.9 24.6 18.0
43.4 18.0 23.0 18.9 13.1 9.8
0.0 0.0 0.0 3.3 0.8 0.8
0.0 0.0 0.0 0.8 0.0 0.8
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main problem?” Overall, the majority of participants were aware of a mental health problem. There were also some differences of the effect of gender of the vignette between half the cases (therefore only partly confirming H2). The most apparent being Cases 3 and 6 which yielded higher recognition when the individual in the vignette was male. Although Case 3 (schizophrenia Case 1) yielded the lowest recognition results regardless of gender; the reasons for the low recognition result of this case could be down to level of description offered. Despite the symptoms depicted in Case 3 being associated for schizophrenia, the description was not as long or therefore detailed compared to the others. Over 25% of participants stated that they knew someone who had been diagnosed with depression compared with 4.8% stating the same for schizophrenia. This may explain why depression was correctly identified in the vignette identification tasks since it has been shown that individuals tend to gain knowledge about mental disorders through contact with a person who has been diagnosed with a mental disorder (Wolff et al., 1996). The difference in prevalence rates could also be a contributing factor into why depression was recognised more compared to schizophrenia. The Office for National Statistics (ONS) placed schizophrenia at 0.5% compared to depression affecting 10% of the population in Britain (ONS, 2000; Hale, 1997). Interestingly, the influence of gender was only statistically apparent overall in Cases 3 and 6 which depicted schizophrenia. But there were statistical differences in regards to a number of individual cases with regards to gender of the participant. There were statistical differences in Cases 4 and 6, when the individual in the vignette was female and exhibiting symptoms associated with schizophrenia, with males less likely to accurately recognise symptoms associated with schizophrenia. These are contradictory to previous findings that found gender of the character to have no effect on the psychosis vignette (Cotton et al., 2006) but consistent with findings which illustrated an effect (Jorm et al., 1997a,b). Also, in regards to Case 5, females were more likely than males to recognise the symptoms relating to depression when the individual in the vignette was male. It could be that males may be more likely to have a ‘female’ stereotype of depression and so are less likely to recognise symptoms when the individual is atypical of the disorder. This is related to the higher incidence of depression in women compared to males and so the low prevalence of the disorder in males limits the identification in others (Cotton et al., 2006; Jones and Cochrane, 1981). This suggests that lay people are more prone to associate schizophrenia with males compared to females (Iacono and Beiser, 1992). There was little difference in correct recognition with regard to the depression vignettes, which is contradictory to previous findings (Jorm et al., 1997a,b). However, it is unclear whether these findings could be replicated if participants were directly faced with the person exhibiting such symptoms. Nevertheless, the results do show that individuals are able to correctly identify the presence of a mental disorder in an individual at a fairly high accurate level, thus reflecting a growth in knowledge within society. There were instances where participants proposed that there was nothing wrong with the individual depicted in the vignette (Case 3: 7.4%; Case 6: 5.7%). This inability to recognise symptoms could be potentially more damaging, resulting in help less likely to be administered; directly or indirectly (Farrer et al., 2008; Jorm et al., 1997b). Overall, individuals were more likely to propose counselling help such as therapy compared to the administration of medication such as anti-depressants or anti-psychotics. The distinction between the ‘How do you think X could best be helped’ and the more personal ‘Imagine X is someone you have known for a long time and care about. You want to help him. What would you do?’ illustrated
even more marked differences. In regards to interventions, individuals were more likely to support the effectiveness of therapy as opposed to medication as found by the results of the vignetteidentification tasks and previous studies (Addis and Jacobson, 1996; Jorm et al., 1997a). The results also show that individuals were more inclined to propose medication as an effective method of treatment for schizophrenia (16.93%) compared to depression (8.47%). Despite the vast number of individuals preferring therapy, respondents still recognised the difference in severity of the two disorders thus; schizophrenia may be able to benefit from medication more compared to depression. However, research in this area shows that lay people's views about medicines in mental health have changed over the years (Jorm, 2012). There seems to be the view that new drugs have less harmful effects and greater benefits than in the past. This study had various limitations. Perhaps most importantly it had a small and unrepresentative sample who may be expected to know more about mental illness. This was clearly not a representative population being younger and better educated in general and in mental health issues in particular compared to the general population. It would have been better to have a much larger and more representative sample to ensure the generalisability of these results. Next we required only three responses to each vignette and it may have been very interesting to ask participants other questions about the vignette such as their ideas about aetiology and prognosis. Third, the results showed that Case 3 (Schizophrenia Case 1) showed very different results to the other cases partly as a function of its short length and therefore the smaller number of details provided. Indeed it was half the length of Cases 4 and 5. This study has shown that people recognise depression more easily than schizophrenia. However perhaps the most important conclusion of the paper is for vignette methodology used in psychiatric studies of MHL. Many studies in this area have used vignette methodology sometimes presenting cases with the same disorder (e.g, schizophrenia) but subtly different symptoms (Kurihara et al., 2000) while others have used just the one long and detailed vignette (Tanaka et al., 2005). There is now a considerable critical literature on vignette methodology from many different perspectives (O’Dell et al., 2012). This study has shown how supposedly equivalent vignettes illustrating the same disorder yield important different responses in part because of the sex of the person in the vignette but also the number and type of symptoms described. The choice of vignette for research may have an important impact of research. Thus using multiple vignettes for the same disorder is recommended to ensure the generalisability of the findings. Appendix This was the order in which the cases were presented: Case 1. Nancy (Joseph) is 24 years old. Recently, she (he) has been having trouble getting out of bed, she (he) randomly burst into tears at the dinner table a couple of days ago and had to be excused from the table. That did not really matter to her (him) because she/he was not hungry anyway. She (He) saw her future as very bleak and believed she (he) would never be accepted by any clinical psychology graduate school and that she (he) would never again find anyone she (he) would love as much. (Depression 1). Case 2. John (Bernadette) is 30 years old. He (She) has been feeling unusually sad and miserable for the last few weeks. Even though he (she) is tired all the time, he (she) has trouble sleeping nearly every night. John (Bernadette) does not feel like eating and has lost weight. He (She) cannot keep his (her) mind on his (her)
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work and puts off making decisions. Even day-to-day tasks seem too much for him (her). This has come to the attention of his (her) boss, who is concerned about John's (Bernadette's) lowered productivity. (Depression 2). Case 3. Jane (Michael) is a 34 year old middle class white Female/ Male bank executive so has over the last couple of weeks been staying up later at night. She (He) typically wakes up her (his) husband (wife) to talk about the “revolutionary” news ideas she (he) had about creating an international bank cartel. She (He) is “full of energy” and talked rapidly about the many ideas that she (he) has. (Schizophrenia 1). Case 4. Greg (Gina) is 24 and lives at home with his (her) parents. He (She) has had a few temporary jobs since finishing school but is now unemployed. Over the last 6 months he (she) has stopped seeing his (her) friends and has begun locking himself (herself) in his (her) bedroom and refusing to eat with the family or to have a bath. His (Her) parents also hear him (her) walking about his/her bedroom at night while they are in bed. Even though they know he (she) is alone, they have heard him (her) shouting and arguing as if someone else is there. When they try to encourage him (her) to do more things, he (she) whispers that he (she) would not leave home because he (she) is being spied upon by the neighbour. They realise he (she) is not taking drugs because he (she) never sees anyone or goes anywhere. (Schizophrenia 2). Case 5. Elaine (Ian) is 26 years old. For the past 2 weeks Elaine (Ian) has been feeling really down. She (He) wakes up in the morning with a flat heavy feeling that sticks with her (him) all day long. She (He) is not enjoying things the way she normally would. In fact nothing gives her (him) pleasure. Even when good things happen, they do not seem to make Elaine (Ian) happy. She (He) pushes on through her/his days, but it is really hard. The smallest tasks are difficult to accomplish. She (He) finds it hard to concentrate on anything. She (He) feels out of energy and out of steam. And even though Elaine/Ian feels tired, when night comes she (he) cannot go to sleep. Elaine (Ian) feels pretty worthless and very discouraged. Elaine's (Ian's) family has noticed that she (he) has not been herself (himself) for about the last month and that she (he) has pulled away from them. Elaine (Ian) just does not feel like talking. (Depression 3).
Case 6. Peter (Penny), who is 20 years old, spends lots of time alone. He (She) does not react correctly when he (her) family try to talk to him (her), for example laughing at bad news. He (She) sometimes gets his (her) words mixed up, and his (her) family have heard him (her) talking even when he' (she's) alone in his (her) room. Sometimes he (she) will go for hours without moving, even though he's (she's) not asleep. He (she) also sometimes experiences auditory hallucinations and delusions. (Schizophrenia 3).
References Addington, D., Addington, J., Patten, S., 1996. Gender and affect in schizophrenia. Canadian Journal of Psychiatry 41, 265–268. Addis, M.E., Jacobson, N.S., 1996. Reasons for depression and the process and outcome of cognitive-behavioural psychotherapies. Journal of Consulting and Clinical Psychology 64, 1417–1424. American Psychiatric Association, 1994. Diagnostic and Statistical Manual of Mental Disorders DSM-IV, 4th edn APA, Washington, DC. Andrade, L., Caraveo, A., 2003. Epidemiology of major depressive episodes. International Journal of Methods in Psychiatric Research 12, 3–21. Angermeyer, M.C., Matschinger, H., 1999. Social representations of mental illness among the public. In: Guimon, J., Fischer, W., Sartorius, N. (Eds.), The Image of Madness: the Public Facing Mental Illness and Psychiatric Treatment. Karger, Basel. (pp. 20–28).
361
Angermeyer, M.C., Matschinger, H., 2003. Public beliefs about schizophrenia and depression: similarities and differences. Social Psychiatry and Psychiatric Epidemiology 38, 526–534. Bracken, S.S., Fischel, J.E., 2006. Assessment of preschool classroom practices: application of Q-sort methology. Early Childhood Research Quarterly 21, 417–430. Burns, J.R., Rapee, R.M., 2006. Adolescent mental health literacy: young people's knowledge of depression and help seeking. Journal of Adolescence 29, 225–239. Caldwell, T.M., Jorm, A.F., 2000. Mental health nurses' beliefs about inventions for schizophrenia and depression: a comparison with psychiatrists and the public. Australian and New Zealand Journal of Psychiatry 34, 602–611. Coles, M.E., Coleman, S.L., 2010. Barriers to treatment seeking for anxiety disorders: initial data on the role of mental health. Depression and Anxiety 27, 63–71. Cotton, S.M., Wright, A., Harris, M.G., Jorm, A.F., McGorry, P.D., 2006. Influence of gender on mental literacy in young Australians. Australian and New Zealand Journal of Psychiatry 40, 790–796. Dietrich, S., Beck, M., Bujantugs, B., Kenzine, D., Matschinger, H., Angermeyer, M., 2004. The relationship between public causal beliefs and social distance toward mentally ill people. Australian and New Zealand Journal of Psychiatry 38, 348–354. Eastern Illinois University, 2008. DSM Case Vignettes. Retrieved October 5, 2011 from Eastern Illinois University. Web site: 〈http://www.eiu.edu/csd/files/ leitschuh/leitschuhdsmvignettes.pdf〉. Farrer, L., Leach, L., Griffiths, K.M., Christensen, H., Jorm, A.F., 2008. Age differences in mental health literacy. BMC Public Health 8, 125. Farina, A., 1981. Are women nicer people than men? Sex and the stigma of mental disorders. Clinical Psychology Review 1, 223–243. Furnham, A., Blythe, C., 2012. Schizophrenia literacy: the effect of direct experience with the illness. Psychiatry Research 198, 18–23. Furnham, A., Carter Leno, V., 2012. Psychiatric literacy and the conduct disorders. Research in Developmental Disabilities 33, 24–31. Furnham, A., Kirkby, V., McClelland, A., 2011. Non-expert's theories of three major personality disorders. Personality and Mental Health 5, 43–56. Furnham, A., Murao, M., 1999. A cross-cultural comparison of British and Japanese lay theories of schizophrenia. International Journal of Social Psychiatry 46, 4–20. Furnham, A., Winceslaus, J., 2012. Psychiatric literacy and the personality disorders. Psychopathology 45, 29–41. Furnham, A., Wong, L., 2007. A cross-cultural comparison of British and Chinese beliefs about the causes, behaviour manifestation and treatment of schizophrenia. Psychiatry Research 151, 123–138. Hale, A.S., 1997. ABC of mental health. British Medical Journal 315, 43–46. Iacono, W.G., Beiser, M., 1992. Are males more likely than females to develop schizophrenia? American Journal of Psychiatry 149, 1070–1074. Jones, L., Cochrane, R., 1981. Stereotypes of mental illness. A test of the labelling hypothesis. International Journal of Social Psychiatry 27, 99–107. Jorm, A.F., 1987. Sex and age differences in depression: a quantitative synthesis of published research. Australian and New Zealand Journal of Psychiatry 21, 46–53. Jorm, A.F., 2000. Mental health literacy: public's knowledge and beliefs about mental disorders. British Journal of Psychiatry 177, 396–401. Jorm, A.F., 2012. Mental health literacy. American Psychologist 67, 231–243. Jorm, A.F., Angermeyer, M., Katschnig, H., 2000. Public knowledge of and attitudes to mental disorders: a limiting factor in the optimal use of treatment services. In: Andrews, G., Henderson, A.S. (Eds.), Unmet Need in Psychiatry. Cambridge University Press, Cambridge, pp. 399–413. Jorm, A.F., Christensen, H., Griffiths, K.M., 2006. Changes in depression awareness and attitudes in Australia: the impact of beyondblue: the national depression initiative. Australian and New Zealand Journal of Psychiatry 40, 42–44. Jorm, A.F., Korten, A.E., Jacomb, P.A., Christensen, H., Rodgers, B., Pollitt, P., 1997a. “Mental health literacy”: a survey of the public's ability to recognise mental disorders and their beliefs about the effectiveness of treatment. Medical Journal of Australia 166, 182–186. Jorm, A.F., Korten, A.E., Jacomb, P.A., Christensen, H., Rodgers, B., Pollitt, P., 1997b. Public beliefs about causes and risk factors for depression and schizophrenia. Social Psychology and Psychiatric Epidemiology 32, 143–148. Kurihara, T., Kato, M., Sakamoto, S., Reverger, R., Kitamura, T., 2000. Public attitudes towards the mentally ill. Psychiatry and Clinical Neurosciences 54, 547–552. Lauber, C., Ajdacic-Goss, V., Fritschi, N., Stulz, N., Rössler, W., 2005. Mental health literacy in an education elite—an online survey among university students. BMC Public Health 5, 44. Link, B.G., Phelan, J.C., Bresnahan, M., Stueve, A., Pescosolido, B.A., 1999. Public conceptions of mental illness: labels, causes, dangerousness, and social distance. American Journal of Public Health 89, 1328–1333. O'Dell, L., Crafter, S., de Abreu, G., Cline, T., 2012. The problem of interpretation in vignette methology in research with young people. Qualitative Research 12, 702–714. ONS, 2000. Psychiatric Morbidity Among Adults Living in Private Households in Great Britain. Pescosolido, B.A., Monahan, J., Link, B.G., Stueve, A., Kikuzawa, S., 1999. The public's view of the competence, dangerousness, and need for legal coercion of persons with mental health problems. American Journal of Public Health 89, 1339–1345. Rector, N.A., Seeman, M.V., 1992. Auditory hallucinations in women and men. Schizophrenia Bulletin (7), 233–236. Ring, N., Tantum, D., Montague, L., Newby, D., Balack, D., Morris, J., 1991. Gender differences in incidence of definite schizophrenia and atypical psychosis: focus on negative symptoms in schizophrenia. Acta Psychiatrica Scandinavia 84, 489–496.
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Seligman, M.E.P., Walker, E., Rosenhan, D.L., 2001. Abnormal Psychology, 4th ed. W. W. Norton, New York. Tanaka, G., Inadomi, H., Kikuchi, Y., Ohta, Y., 2005. Evaluating community attitudes to people with schizophrenia and mental disorders using a case vignette method. Psychiatry and Clinical Neuroscience 59, 96–101. Van Os, J., Kapur, S., 2009. Schizophrenia. Lancet 374, 635–645. Warner, R., 1994. Recovery From Schizophrenia—Psychiatry and Political Economy. Routledge, London.
Wolff, G., Pathare, S., Craig, T., Leff, J., 1996. Community knowledge of mental illness and reaction to mentally ill people. British Journal of Psychiatry 168, 191–198. Won Pat-Borja, A., Yang, L., Link, B., Phelan, J., 2010. Eugenics, genetics and mental illness stigma in Chinese Americans. Social Psychiatry and Psychiatric Epidemiology 47, 145–156. WHO, 2012. World Health Organisation fact sheet no 369. Depression.
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Psychiatry Research journal homepage: www.elsevier.com/locate/psychres
Identifying depression and schizophrenia using vignettes: A methodological note Gertrude Sai, Adrian Furnham n Research Department of Clinical, Educational and Health Psychology, University College London, United Kingdom
art ic l e i nf o
a b s t r a c t
Article history: Received 15 March 2012 Received in revised form 29 April 2013 Accepted 4 May 2013
The aim of this study was to assess lay people's ability to identify depression and schizophrenia from well established vignettes using hypothetical patients of both sexes. In all 122 participants answered a questionnaire, consisting of six vignette case studies describing psychological symptoms; three each associated with depression and schizophrenia. They answered three questions: what is the person's main problem; how could they be best helped; what would you do to help? Overall, depression was more often correctly identified compared to schizophrenia. The gender of the participant and the individual presented in the vignette did have an effect on the vignette identification task. Limitations and implications of these results and the use of vignette methodology were discussed. & 2013 Elsevier Ireland Ltd. All rights reserved.
Keywords: Mental health literacy Vignette Schizophrenia Depression
1. Introduction Jorm et al. (1997b) defined mental health literacy (MHL) as public knowledge and beliefs about mental disorders which aid their recognition, management or prevention. A number of studies have investigated the mental health literacy with respect to various disorders such as: personality disorders (Furnham et al., 2011; Furnham and Winceslaus, 2012), schizophrenia (Furnham and Murao, 1999; Furnham and Wong, 2007), anxiety disorders (Coles and Coleman, 2010) and conduct disorders (Furnham and Carter Leno, 2012) to name a few. It has been suggested that up to 70% of individuals suffering from a mental health disorder do not seek professional help or recognise common disorders in others (Farrer et al., 2008; Jorm et al., 1997b; Burns and Rapee, 2006; Jorm, 2000). Evidence suggests that previous experience with mental illness aids recognition in a vignette identification task (Furnham et al., 2011). Lay people tend to view people with schizophrenia as more dangerous compared to those with depression (Angermeyer and Matschinger, 1999; Jorm et al., 1997b, 2000; Pescosolido et al., 1999). However it has been shown that direct contact with people with schizophrenia does increase their knowledge and shape their attitudes (Furnham and Blythe, 2012). Jorm (2012) has argued that MHL can be improved by community campaigns and interventions in educational settings.
n
Corresponding author. E-mail address: [email protected] (A. Furnham).
0165-1781/$ - see front matter & 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.psychres.2013.05.004
There have been a number of studies which have investigated the differences in recognition and labelling between depression and schizophrenia (Caldwell and Jorm, 2000; Dietrich et al., 2004; Won Pat-Borja et al., 2010). The results have been inconsistent and may reflect the methodological differences. For instance, in Jorm et al.'s (1997b) study, participants, in the vignette-identification component, were presented with an open ended question while Lauber et al. (2005) and Link et al. (1999) presented participants with a closed-ended question which inferred that there was something wrong with the individuals in the vignette, i.e. they were suffering from a ‘mental illness’. They also used different vignettes which may not have been equivalent. Evidence suggests that depression is twice as likely in women compared to men and that around 10% of people around the world experience some depressive episode during their lives (Andrade and Caraveo, 2003). Latest WHO figures suggest that depression is the most common mental disorder in the world with 350 million people suffering from it and that it is on the rise. The WHO factsheet notes that depression is caused by a complex interaction of biological, psychological and social factors, that there are effective treatments but that fewer than half those suffering from it get any form of treatment (WHO, 2012). It has also been found that males are less likely to recognise symptoms due to the emphasis on externalisation of mental health problems (Cotton et al., 2006). A study on young Australians found that males demonstrated poorer knowledge, with respect to depression, compared to females (Burns and Rapee, 2006). Also, it has been found that depression induces less stigma amongst lay people and more social acceptance if symptoms typically associated with depression are exhibited by a female compared to a
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male (Farina, 1981). Also males are less likely to seek advice from a doctor/counsellor/psychologist but often resort to substance abuse such as alcohol to deal with mental health problems (Cotton et al., 2006). There is a greater incidence of males being diagnosed with schizophrenia compared to females, with between 0.30% and 0.66% of people diagnosed in the population (Van Os and Kapur, 2009). Few studies that have been conducted report that positive symptoms are more likely to be apparent in females and negative symptoms more apparent in males (Addington et al., 1996; Rector and Seeman, 1992; Ring et al., 1991). Despite prevalence rates for women and men being the same for schizophrenia, studies have shown that the incidence for men aged 18–25 is double the amount for women, which shows an earlier onset in men (Warner, 1994). The influence of gender has also been investigated using the vignette technique to identify whether the gender of the vignette has an influence on vignette identification (Jorm et al., 1997a,b). Overall results are mixed with a number of studies showing no effect of vignette gender on MHL. However there is some evidence that the gender of the respondent does have an effect on things like what recommendations for help and assistance are made (Jorm, 2012). Using the vignette method, similar to the one used by Furnham and Carter Leno (2012), we will compare individuals' ability to correctly recognise depression and schizophrenia. The study will also investigate whether the gender of the vignette will influence recognition (Jorm, 1987). The proposed hypothesis states that depression will be “correctly” identified more as opposed to schizophrenia using vignette case studies (H1). Secondly, it is predicted that the gender of the participant and the character depicted in the vignette will have an effect on correct recognition (H2). 2. Method 2.1. Participants There were a total of 122 participants: 27.9% male and 72.1% female with a mean age of 26.3 years (S.D. ¼10.17). There were European Caucasian (41.8%), Black/ Black British (24.6%), Asian British (21.3%) and the remainder of participants fell into the ‘other’ category (12.3%). The majority of participant's highest educational qualification was A levels (12th grade) or equivalent (54.9%), followed by BSc/BA or equivalent (26.2%), GCSE (10th grade) or equivalent (8.2%), MSc or equivalent (6.6%), PhD (0.8%) and other (3.3%). A third had studied some psychology (37.7%). In all 12% of participants reported that they had been diagnosed with a mental illness but a larger proportion of participants reported knowing someone that had been diagnosed with a mental disorder (37.7%). The highest prevalence of mental disorders for both questions being reported were depression (24.6%) and schizophrenia (4.9%), respectively, as well as a range of other mental disorders. 2.2. Materials Vignette identification: Participants were presented with six vignette case studies each ranging between 50 and 150 words long and written to be easily comprehensible. The case vignettes were all based upon fictional characters illustrating symptoms which are in line with the DSM-IV (APA, 1994) diagnosis of depression and schizophrenia. Case 1 was taken from a textbook entitled ‘Abnormal Psychology’ by Seligman et al. (2001); Case 2 was obtained from Jorm et al. (1997a); Case 3 was obtained from Eastern Illinois University (2008); Case 4 was adapted from Link et al. (1999); Case 5 was also taken from Jorm et al. (1997a) and Case 6 was adapted from Jorm et al. (2006). The depression vignettes were represented by Cases 1, 2 and 5. The schizophrenia vignettes were represented in Cases 3, 4 and 6. The gender across all the vignettes was alternated (See Appendix). Participants were asked to propose a diagnosis when asked ‘What would you say is X's main problem?’ Participants were asked to propose what method of treatment would be useful; ‘How do you think X could best be helped?’ and also what they would suggest if they personally knew the individual; ‘Imagine X is someone you have known for a long time and care about. You want to help him. What would you do?’ There were two versions of each vignette case study i.e. each vignette had a male and female version. Similar to the technique used by Furnham and Carter Leno (2012), a content analysis was conducted on open ended questions, e.g. ‘What
would you say is X's main problem?’ This was completed using the Q sort technique (Bracken and Fischel, 2006) with 10% of responses given to another researcher which was to ensure reliability. In few instances (around 8%) where participants gave multiple responses, the first response was analysed as it was assumed to be the most important.
2.3. Procedure Once ethical approval was obtained, participants were recruited using an opportunistic sample from three sources: public places in central London; using social network sites available to the authors and mailing lists of people on a participant panel. Around a third were approached at London railway stations but because of time constraints the response rate was around 40% of people who completed the whole questionnaire. Both authors sent the questionnaire to around 60 contacts and here the response rate was around 80%. The department also has a panel of people who volunteer to take part in various studies. A small number (around 20) were approached to increase the sample. The questionnaire was thus presented using both paper and electronic form. Where possible, participants were fully debriefed. All individuals participated on a purely voluntary basis and were not remunerated for their partaking.
3. Results 3.1. Diagnosis/classification The percent “correct” response on the vignette-identification component differed between the two disorders. “Correct” included for depression, depressive disorder, affective disorder and malignant sadness, while for schizophrenia psychotic or psychosis was accepted as correct. A response of “mental illness” or “psychological problem” was not classed as correct. Overall, the depression vignettes (72.7%) were more correctly identified compared to the schizophrenia vignettes (46.4%). Four factors emerged from the content analysis. The first category ‘Psychology/Psychiatric’ used known psychological or psychiatric labels. The second category entitled ‘Social factors’ was related to responses that geared toward external causes such as ‘stress at work’. The third category entitled ‘Emotional factors’ was concerned with inner feelings of conflict such as ‘she is heartbroken’. The fourth category entitled ‘Lifestyle problems’ refers to the overall style of the individuals that has caused the problems described in the vignette. An example of a response that would be classified in this category would be ‘substance abuse’. Table 1 shows the differential diagnosis between cases of depression and schizophrenia respectively. Over 75% of respondents saw the depression vignettes as evidence of psychiatric illness. The schizophrenia vignettes tended to cumulatively have more lifestyle issues proposed compared to depression with a considerable proportion in Case 3, although there were a number of participants that seemed to propose that there was in fact nothing wrong with the individual, particularly in schizophrenia Cases 1 and 3. 3.2. Treatment A content analysis of answers to the question ‘How do you think X could best be helped?’ was conducted using the same method as above. Table 1 Percentages (%) of diagnostic labels used in all six vignettes. Psychological/ Social Emotional Lifestyle Nothing Psychiatric Depression case 1 Depression case 2 Depression case 3 Schizophrenia case 1 Schizophrenia case 2 Schizophrenia case 3
76.2 80.3 85.2 47.5 92.6 82.8
21.3 2.5 1.6 2.5 1.6 0.8
0.0 9.8 8.2 9.8 2.5 1.6
2.5 9.0 4.1 32.8 3.3 9.0
0.0 0.0 0.8 7.4 0.0 5.7
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Various categories that emerged from the content analysis were: Medical, with responses such as ‘anti-depressants’, ‘anti-psychotics’ and ‘sleeping pills’. Professional Help, refer to more humanistic methods such as ‘ going to see the GP/doctors’, ‘therapy’, ‘CBT’. The third category was entitled Medication and Professional Help, and referred to a combination of both medication and a therapy e.g. ‘anti-depressant and CBT’. The fourth was classified as ‘Social Activities’ which included more suggestions of hobbies or informal chats e.g. ‘get more sleep’, ‘advise that she goes on holiday’. The next was entitled Emotional which was characterised by having responses such as ‘I would talk to him,’ ‘be there for them’ and so, lending the individual emotional support. The next was entitled Other which referred to responses that could not be categorised using the aforementioned criteria such as ‘tell him that's life’ or ‘inform the FBI’. Nothing refers to participants claiming that the individual did not need any help. The next part of the vignette component asked ‘Imagine X is someone you have known for a long time and care about. You want to help him. What would you do?’ The same aforementioned categories were used for the treatment questions. Pairwise comparisons were conducted to establish whether there was a difference between the treatment the individual believes they would benefit from and how they would help if they knew the individual in the vignette. All were found to be statistically significant except for the female version of Case 6. There was not a significant difference of gender between the two questions. Table 2 shows comparative percentages between depression and schizophrenia respectively when asked “How do you think X could best be helped”. Overall, participants favoured therapy as most effective but there were marked differences between depression and schizophrenia. The most apparent differences were in regards to therapy and medication. 50.5% rated therapy as more effective with depression compared to 42.4% in schizophrenia. Also, medication was proposed twice as often in reference to schizophrenia (16.93%) than depression (8.47%). Emotional support was considered more in depression (6.3%) compared to schizophrenia (3.57%). Table 3 shows the comparative percentages of differing treatments recommended to individuals with depression (top) and schizophrenia (bottom) when asked ‘Imagine X is someone you have known for a long time and care about. You want to help him. What would you do?’ For both depression and schizophrenia, medication was proposed less compared to the prior question. There is a statistically significant increase of emotional support proposed for both disorders: over four
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times the amount in depression (28.12%) and 3 the amount in schizophrenia (13.9%) (po0.05). 3.3. Effect of gender Table 4 shows there was no difference in “correct” recognition in Cases 1, 4 and 5 regardless of whether the individual in the vignette was male or female. However, Cases 3 and 6 were significantly correctly identified more when the individual in the vignette was male. Chi square statistics showed that male participants were less likely to recognise the symptoms of schizophrenia when the individual in the vignette was a female in Case 4, χ2 (1)¼11.32, p¼ 0.001. With regards to Case 5, females were more likely to accurately recognise symptoms for depression compared to males when the individual in the vignette was male χ2 (1) ¼8.92, p ¼0.01 With regards to Case 6, males were more likely to accurately recognise symptoms compared to females when the individual in the vignette was a female exhibiting schizophrenia, χ2 (1) ¼6.05, p¼ 0.01. No other analyses examining gender difference in participant or vignette showed significance.
4. Discussion As predicted, the recognition rate for the depression cases was higher overall compared to schizophrenia (H1). These results are consistent with previous findings (Jorm et al., 1997b; Lauber et al., 2005) and contradictory to some other findings who found schizophrenia was more correctly identified compared to depression (Angermeyer and Matschinger, 1999, 2003; Link et al., 1999). There was a considerable amount of variation present in the first question of the vignette component “What would you say is X's Table 4 Accuracy of correct recognition on the effect of gender of the vignette. The figure illustrates variation in accuracy in vignette diagnosis of depression and schizophrenia when the vignette was described male or female.
Female Male
1
2
3
4
5
6
72 72
64 59
11 18
66 64
84 85
57 62
Table 2 Comparative percentages of differing treatments recommended to individuals with depression and schizophrenia when asked ‘How do you think X could best be helped?
Depression case 1 Depression case 2 Depression case 3 Schizophrenia case 1 Schizophrenia case 2 Schizophrenia case 3
Medication
Therapy
Combined
Social
Emotional
Other
Nothing
4.1 13.1 8.2 13.9 18.0 18.9
57.4 50.8 43.4 23.8 52.5 50.8
8.2 9.8 23.0 3.3 13.9 16.4
22.1 22.1 18.9 46.7 13.1 9.8
8.2 4.1 6.6 5.7 2.5 2.5
0.0 0.0 0.0 5.7 0.0 1.6
0.0 0.0 0.0 0.8 0.0 0.0
Table 3 Comparative percentages of differing treatments recommended to individuals with depression and schizophrenia when as ‘Imagine X is someone you have known for a long time and care about. You want to help him. What would you do?
Depression case 1 Depression case 2 Depression case 3 Schizophrenia case 1 Schizophrenia case 2 Schizophrenia case 3
Medication
Therapy
Combined
Social
Emotional
Other
Nothing
0.8 2.5 1.6 1.6 6.6 6.6
30.3 43.4 41.8 27.0 47.5 60.7
2.5 4.9 3.3 2.5 7.4 3.3
23.0 31.1 30.3 45.9 24.6 18.0
43.4 18.0 23.0 18.9 13.1 9.8
0.0 0.0 0.0 3.3 0.8 0.8
0.0 0.0 0.0 0.8 0.0 0.8
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main problem?” Overall, the majority of participants were aware of a mental health problem. There were also some differences of the effect of gender of the vignette between half the cases (therefore only partly confirming H2). The most apparent being Cases 3 and 6 which yielded higher recognition when the individual in the vignette was male. Although Case 3 (schizophrenia Case 1) yielded the lowest recognition results regardless of gender; the reasons for the low recognition result of this case could be down to level of description offered. Despite the symptoms depicted in Case 3 being associated for schizophrenia, the description was not as long or therefore detailed compared to the others. Over 25% of participants stated that they knew someone who had been diagnosed with depression compared with 4.8% stating the same for schizophrenia. This may explain why depression was correctly identified in the vignette identification tasks since it has been shown that individuals tend to gain knowledge about mental disorders through contact with a person who has been diagnosed with a mental disorder (Wolff et al., 1996). The difference in prevalence rates could also be a contributing factor into why depression was recognised more compared to schizophrenia. The Office for National Statistics (ONS) placed schizophrenia at 0.5% compared to depression affecting 10% of the population in Britain (ONS, 2000; Hale, 1997). Interestingly, the influence of gender was only statistically apparent overall in Cases 3 and 6 which depicted schizophrenia. But there were statistical differences in regards to a number of individual cases with regards to gender of the participant. There were statistical differences in Cases 4 and 6, when the individual in the vignette was female and exhibiting symptoms associated with schizophrenia, with males less likely to accurately recognise symptoms associated with schizophrenia. These are contradictory to previous findings that found gender of the character to have no effect on the psychosis vignette (Cotton et al., 2006) but consistent with findings which illustrated an effect (Jorm et al., 1997a,b). Also, in regards to Case 5, females were more likely than males to recognise the symptoms relating to depression when the individual in the vignette was male. It could be that males may be more likely to have a ‘female’ stereotype of depression and so are less likely to recognise symptoms when the individual is atypical of the disorder. This is related to the higher incidence of depression in women compared to males and so the low prevalence of the disorder in males limits the identification in others (Cotton et al., 2006; Jones and Cochrane, 1981). This suggests that lay people are more prone to associate schizophrenia with males compared to females (Iacono and Beiser, 1992). There was little difference in correct recognition with regard to the depression vignettes, which is contradictory to previous findings (Jorm et al., 1997a,b). However, it is unclear whether these findings could be replicated if participants were directly faced with the person exhibiting such symptoms. Nevertheless, the results do show that individuals are able to correctly identify the presence of a mental disorder in an individual at a fairly high accurate level, thus reflecting a growth in knowledge within society. There were instances where participants proposed that there was nothing wrong with the individual depicted in the vignette (Case 3: 7.4%; Case 6: 5.7%). This inability to recognise symptoms could be potentially more damaging, resulting in help less likely to be administered; directly or indirectly (Farrer et al., 2008; Jorm et al., 1997b). Overall, individuals were more likely to propose counselling help such as therapy compared to the administration of medication such as anti-depressants or anti-psychotics. The distinction between the ‘How do you think X could best be helped’ and the more personal ‘Imagine X is someone you have known for a long time and care about. You want to help him. What would you do?’ illustrated
even more marked differences. In regards to interventions, individuals were more likely to support the effectiveness of therapy as opposed to medication as found by the results of the vignetteidentification tasks and previous studies (Addis and Jacobson, 1996; Jorm et al., 1997a). The results also show that individuals were more inclined to propose medication as an effective method of treatment for schizophrenia (16.93%) compared to depression (8.47%). Despite the vast number of individuals preferring therapy, respondents still recognised the difference in severity of the two disorders thus; schizophrenia may be able to benefit from medication more compared to depression. However, research in this area shows that lay people's views about medicines in mental health have changed over the years (Jorm, 2012). There seems to be the view that new drugs have less harmful effects and greater benefits than in the past. This study had various limitations. Perhaps most importantly it had a small and unrepresentative sample who may be expected to know more about mental illness. This was clearly not a representative population being younger and better educated in general and in mental health issues in particular compared to the general population. It would have been better to have a much larger and more representative sample to ensure the generalisability of these results. Next we required only three responses to each vignette and it may have been very interesting to ask participants other questions about the vignette such as their ideas about aetiology and prognosis. Third, the results showed that Case 3 (Schizophrenia Case 1) showed very different results to the other cases partly as a function of its short length and therefore the smaller number of details provided. Indeed it was half the length of Cases 4 and 5. This study has shown that people recognise depression more easily than schizophrenia. However perhaps the most important conclusion of the paper is for vignette methodology used in psychiatric studies of MHL. Many studies in this area have used vignette methodology sometimes presenting cases with the same disorder (e.g, schizophrenia) but subtly different symptoms (Kurihara et al., 2000) while others have used just the one long and detailed vignette (Tanaka et al., 2005). There is now a considerable critical literature on vignette methodology from many different perspectives (O’Dell et al., 2012). This study has shown how supposedly equivalent vignettes illustrating the same disorder yield important different responses in part because of the sex of the person in the vignette but also the number and type of symptoms described. The choice of vignette for research may have an important impact of research. Thus using multiple vignettes for the same disorder is recommended to ensure the generalisability of the findings. Appendix This was the order in which the cases were presented: Case 1. Nancy (Joseph) is 24 years old. Recently, she (he) has been having trouble getting out of bed, she (he) randomly burst into tears at the dinner table a couple of days ago and had to be excused from the table. That did not really matter to her (him) because she/he was not hungry anyway. She (He) saw her future as very bleak and believed she (he) would never be accepted by any clinical psychology graduate school and that she (he) would never again find anyone she (he) would love as much. (Depression 1). Case 2. John (Bernadette) is 30 years old. He (She) has been feeling unusually sad and miserable for the last few weeks. Even though he (she) is tired all the time, he (she) has trouble sleeping nearly every night. John (Bernadette) does not feel like eating and has lost weight. He (She) cannot keep his (her) mind on his (her)
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work and puts off making decisions. Even day-to-day tasks seem too much for him (her). This has come to the attention of his (her) boss, who is concerned about John's (Bernadette's) lowered productivity. (Depression 2). Case 3. Jane (Michael) is a 34 year old middle class white Female/ Male bank executive so has over the last couple of weeks been staying up later at night. She (He) typically wakes up her (his) husband (wife) to talk about the “revolutionary” news ideas she (he) had about creating an international bank cartel. She (He) is “full of energy” and talked rapidly about the many ideas that she (he) has. (Schizophrenia 1). Case 4. Greg (Gina) is 24 and lives at home with his (her) parents. He (She) has had a few temporary jobs since finishing school but is now unemployed. Over the last 6 months he (she) has stopped seeing his (her) friends and has begun locking himself (herself) in his (her) bedroom and refusing to eat with the family or to have a bath. His (Her) parents also hear him (her) walking about his/her bedroom at night while they are in bed. Even though they know he (she) is alone, they have heard him (her) shouting and arguing as if someone else is there. When they try to encourage him (her) to do more things, he (she) whispers that he (she) would not leave home because he (she) is being spied upon by the neighbour. They realise he (she) is not taking drugs because he (she) never sees anyone or goes anywhere. (Schizophrenia 2). Case 5. Elaine (Ian) is 26 years old. For the past 2 weeks Elaine (Ian) has been feeling really down. She (He) wakes up in the morning with a flat heavy feeling that sticks with her (him) all day long. She (He) is not enjoying things the way she normally would. In fact nothing gives her (him) pleasure. Even when good things happen, they do not seem to make Elaine (Ian) happy. She (He) pushes on through her/his days, but it is really hard. The smallest tasks are difficult to accomplish. She (He) finds it hard to concentrate on anything. She (He) feels out of energy and out of steam. And even though Elaine/Ian feels tired, when night comes she (he) cannot go to sleep. Elaine (Ian) feels pretty worthless and very discouraged. Elaine's (Ian's) family has noticed that she (he) has not been herself (himself) for about the last month and that she (he) has pulled away from them. Elaine (Ian) just does not feel like talking. (Depression 3).
Case 6. Peter (Penny), who is 20 years old, spends lots of time alone. He (She) does not react correctly when he (her) family try to talk to him (her), for example laughing at bad news. He (She) sometimes gets his (her) words mixed up, and his (her) family have heard him (her) talking even when he' (she's) alone in his (her) room. Sometimes he (she) will go for hours without moving, even though he's (she's) not asleep. He (she) also sometimes experiences auditory hallucinations and delusions. (Schizophrenia 3).
References Addington, D., Addington, J., Patten, S., 1996. Gender and affect in schizophrenia. Canadian Journal of Psychiatry 41, 265–268. Addis, M.E., Jacobson, N.S., 1996. Reasons for depression and the process and outcome of cognitive-behavioural psychotherapies. Journal of Consulting and Clinical Psychology 64, 1417–1424. American Psychiatric Association, 1994. Diagnostic and Statistical Manual of Mental Disorders DSM-IV, 4th edn APA, Washington, DC. Andrade, L., Caraveo, A., 2003. Epidemiology of major depressive episodes. International Journal of Methods in Psychiatric Research 12, 3–21. Angermeyer, M.C., Matschinger, H., 1999. Social representations of mental illness among the public. In: Guimon, J., Fischer, W., Sartorius, N. (Eds.), The Image of Madness: the Public Facing Mental Illness and Psychiatric Treatment. Karger, Basel. (pp. 20–28).
361
Angermeyer, M.C., Matschinger, H., 2003. Public beliefs about schizophrenia and depression: similarities and differences. Social Psychiatry and Psychiatric Epidemiology 38, 526–534. Bracken, S.S., Fischel, J.E., 2006. Assessment of preschool classroom practices: application of Q-sort methology. Early Childhood Research Quarterly 21, 417–430. Burns, J.R., Rapee, R.M., 2006. Adolescent mental health literacy: young people's knowledge of depression and help seeking. Journal of Adolescence 29, 225–239. Caldwell, T.M., Jorm, A.F., 2000. Mental health nurses' beliefs about inventions for schizophrenia and depression: a comparison with psychiatrists and the public. Australian and New Zealand Journal of Psychiatry 34, 602–611. Coles, M.E., Coleman, S.L., 2010. Barriers to treatment seeking for anxiety disorders: initial data on the role of mental health. Depression and Anxiety 27, 63–71. Cotton, S.M., Wright, A., Harris, M.G., Jorm, A.F., McGorry, P.D., 2006. Influence of gender on mental literacy in young Australians. Australian and New Zealand Journal of Psychiatry 40, 790–796. Dietrich, S., Beck, M., Bujantugs, B., Kenzine, D., Matschinger, H., Angermeyer, M., 2004. The relationship between public causal beliefs and social distance toward mentally ill people. Australian and New Zealand Journal of Psychiatry 38, 348–354. Eastern Illinois University, 2008. DSM Case Vignettes. Retrieved October 5, 2011 from Eastern Illinois University. Web site: 〈http://www.eiu.edu/csd/files/ leitschuh/leitschuhdsmvignettes.pdf〉. Farrer, L., Leach, L., Griffiths, K.M., Christensen, H., Jorm, A.F., 2008. Age differences in mental health literacy. BMC Public Health 8, 125. Farina, A., 1981. Are women nicer people than men? Sex and the stigma of mental disorders. Clinical Psychology Review 1, 223–243. Furnham, A., Blythe, C., 2012. Schizophrenia literacy: the effect of direct experience with the illness. Psychiatry Research 198, 18–23. Furnham, A., Carter Leno, V., 2012. Psychiatric literacy and the conduct disorders. Research in Developmental Disabilities 33, 24–31. Furnham, A., Kirkby, V., McClelland, A., 2011. Non-expert's theories of three major personality disorders. Personality and Mental Health 5, 43–56. Furnham, A., Murao, M., 1999. A cross-cultural comparison of British and Japanese lay theories of schizophrenia. International Journal of Social Psychiatry 46, 4–20. Furnham, A., Winceslaus, J., 2012. Psychiatric literacy and the personality disorders. Psychopathology 45, 29–41. Furnham, A., Wong, L., 2007. A cross-cultural comparison of British and Chinese beliefs about the causes, behaviour manifestation and treatment of schizophrenia. Psychiatry Research 151, 123–138. Hale, A.S., 1997. ABC of mental health. British Medical Journal 315, 43–46. Iacono, W.G., Beiser, M., 1992. Are males more likely than females to develop schizophrenia? American Journal of Psychiatry 149, 1070–1074. Jones, L., Cochrane, R., 1981. Stereotypes of mental illness. A test of the labelling hypothesis. International Journal of Social Psychiatry 27, 99–107. Jorm, A.F., 1987. Sex and age differences in depression: a quantitative synthesis of published research. Australian and New Zealand Journal of Psychiatry 21, 46–53. Jorm, A.F., 2000. Mental health literacy: public's knowledge and beliefs about mental disorders. British Journal of Psychiatry 177, 396–401. Jorm, A.F., 2012. Mental health literacy. American Psychologist 67, 231–243. Jorm, A.F., Angermeyer, M., Katschnig, H., 2000. Public knowledge of and attitudes to mental disorders: a limiting factor in the optimal use of treatment services. In: Andrews, G., Henderson, A.S. (Eds.), Unmet Need in Psychiatry. Cambridge University Press, Cambridge, pp. 399–413. Jorm, A.F., Christensen, H., Griffiths, K.M., 2006. Changes in depression awareness and attitudes in Australia: the impact of beyondblue: the national depression initiative. Australian and New Zealand Journal of Psychiatry 40, 42–44. Jorm, A.F., Korten, A.E., Jacomb, P.A., Christensen, H., Rodgers, B., Pollitt, P., 1997a. “Mental health literacy”: a survey of the public's ability to recognise mental disorders and their beliefs about the effectiveness of treatment. Medical Journal of Australia 166, 182–186. Jorm, A.F., Korten, A.E., Jacomb, P.A., Christensen, H., Rodgers, B., Pollitt, P., 1997b. Public beliefs about causes and risk factors for depression and schizophrenia. Social Psychology and Psychiatric Epidemiology 32, 143–148. Kurihara, T., Kato, M., Sakamoto, S., Reverger, R., Kitamura, T., 2000. Public attitudes towards the mentally ill. Psychiatry and Clinical Neurosciences 54, 547–552. Lauber, C., Ajdacic-Goss, V., Fritschi, N., Stulz, N., Rössler, W., 2005. Mental health literacy in an education elite—an online survey among university students. BMC Public Health 5, 44. Link, B.G., Phelan, J.C., Bresnahan, M., Stueve, A., Pescosolido, B.A., 1999. Public conceptions of mental illness: labels, causes, dangerousness, and social distance. American Journal of Public Health 89, 1328–1333. O'Dell, L., Crafter, S., de Abreu, G., Cline, T., 2012. The problem of interpretation in vignette methology in research with young people. Qualitative Research 12, 702–714. ONS, 2000. Psychiatric Morbidity Among Adults Living in Private Households in Great Britain. Pescosolido, B.A., Monahan, J., Link, B.G., Stueve, A., Kikuzawa, S., 1999. The public's view of the competence, dangerousness, and need for legal coercion of persons with mental health problems. American Journal of Public Health 89, 1339–1345. Rector, N.A., Seeman, M.V., 1992. Auditory hallucinations in women and men. Schizophrenia Bulletin (7), 233–236. Ring, N., Tantum, D., Montague, L., Newby, D., Balack, D., Morris, J., 1991. Gender differences in incidence of definite schizophrenia and atypical psychosis: focus on negative symptoms in schizophrenia. Acta Psychiatrica Scandinavia 84, 489–496.
362
G. Sai, A. Furnham / Psychiatry Research 210 (2013) 357–362
Seligman, M.E.P., Walker, E., Rosenhan, D.L., 2001. Abnormal Psychology, 4th ed. W. W. Norton, New York. Tanaka, G., Inadomi, H., Kikuchi, Y., Ohta, Y., 2005. Evaluating community attitudes to people with schizophrenia and mental disorders using a case vignette method. Psychiatry and Clinical Neuroscience 59, 96–101. Van Os, J., Kapur, S., 2009. Schizophrenia. Lancet 374, 635–645. Warner, R., 1994. Recovery From Schizophrenia—Psychiatry and Political Economy. Routledge, London.
Wolff, G., Pathare, S., Craig, T., Leff, J., 1996. Community knowledge of mental illness and reaction to mentally ill people. British Journal of Psychiatry 168, 191–198. Won Pat-Borja, A., Yang, L., Link, B., Phelan, J., 2010. Eugenics, genetics and mental illness stigma in Chinese Americans. Social Psychiatry and Psychiatric Epidemiology 47, 145–156. WHO, 2012. World Health Organisation fact sheet no 369. Depression.