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Mental health literacy and attitude towards people with mental illness: A trend analysis based on population surveys in the eastern part of Germany
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www.sciencedirect.com European Psychiatry 24 (2009) 225e232
Original article
Mental health literacy and attitude towards people with mental illness: A trend analysis based on population surveys in the eastern part of Germany M.C. Angermeyer a,*, A. Holzinger b, H. Matschinger c a
Center for Public Mental Health, Untere Zeile 13, A-3482 Go¨sing a.W., Austria b Department of Psychiatry, Medical University Vienna, Austria c Department of Psychiatry, Leipzig University, Germany
Received 30 March 2008; received in revised form 11 June 2008; accepted 21 June 2008 Available online 10 April 2009
Abstract Background e There is growing evidence that mental health literacy has improved in western countries in recent years. The question arises as to whether this trend is paralleled by an improvement of attitudes towards people with mental illness. Aim e To examine the development of mental health literacy and the desire for social distance towards people with schizophrenia and major depressive disorder in Eastern Germany over a time period of eight years. Method e A trend analysis was carried out using data from two population surveys conducted in the eastern part of Germany in 1993 and 2001. By means of a fully structured interview psychiatric labelling, causal beliefs, help-seeking and treatment recommendations as well as the desire for social distance was assessed. Results e While there was an increase in the mental health literacy of the public, the desire for social distance from people with major depression and schizophrenia remained unchanged or even increased. Conclusions e The assumption underlying a number of anti-stigma campaigns, namely that educating people about mental disorders may automatically lead to the improvement of their attitudes towards the mentally ill, appears questionable. Ó 2008 Elsevier Masson SAS. All rights reserved. Keywords: Public beliefs; Social distance; Time trends; Major depressive disorder; Schizophrenia
1. Introduction There is growing evidence that mental health literacy has increased in western countries in recent years. Studies from the US, Australia and Germany have shown that the public has become more able to recognize mental disorders as such [15,19], that the gap between the public’s and mental health professionals’ beliefs about the causes and the treatment of mental disorders has become smaller [5,6,15,18,19], and that the willingness to seek help from mental health professionals has increased [6,15,19,24].
* Corresponding author. Tel.: þ43 2738 20036. E-mail address: [email protected] (M.C. Angermeyer). 0924-9338/$ - see front matter Ó 2008 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.eurpsy.2008.06.010
The question arises as to whether the increase of mental health literacy has also been accompanied by an improvement of attitudes towards people with mental illness. That better knowledge leads to more favourable attitudes seems commonplace, and in fact a number of anti-stigma campaigns are based on this assumption [11,29]. However, this notion has been challenged by findings from recently conducted population studies indicating that the public’s knowledge about mental disorders and its attitudes towards people suffering from these disorders may be unrelated or even inversely related [12,13,20,23,32]. Aim of this study is to examine whether what has been observed in cross-sectional studies can be replicated using a longitudinal study design. Based on data from two representative surveys conducted in the eastern part of Germany we
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will compare the development of psychiatric labelling, causal beliefs, help-seeking recommendations, and beliefs about treatment in case of schizophrenia and major depressive disorder with that of the desire for social distance towards people suffering from both disorders over a time period of eight years.
with the vignette depicting schizophrenia, 501 respondents with the vignette depicting major depressive disorder, and 530 with the vignette depicting borderline personality disorder. In 2001, respondents were shown only vignettes with schizophrenia (n ¼ 481) or major depressive disorder (n ¼ 522). Therefore, the trend analysis presented in this paper refers only to these two disorders.
2. Method 2.1. Sample In 1993 a representative survey was conducted in the eastern part of Germany among German citizens aged 18 years and older, living in non-institutional settings. The sample was drawn using a three-stage sampling procedure, with sample points (electoral wards) at the first stage, households at the second stage, and individuals within the target households at the third stage. Target households within the sample point were determined according to the random route procedure: that is, a street was selected randomly as starting point from where the interviewer followed a set route through the area [14]. Within the target households, the interviewees were selected by means of random digits. A total of 2094 interviews were conducted, reflecting a response rate of 71.2%. In 2001 a second representative survey was conducted. This time the sampling frame differed, with the sample being drawn from the whole of Germany, the number of interviews conducted in the West and East reflecting the proportions of the population living in the two parts of the country. Apart from this, the same three-stage sampling procedure was used as in the previous survey. In total, 5025 interviews were conducted (reflecting a response rate of 65.1%). 1001 interviews that were obtained in the eastern states of Germany have been included in our analysis. 2.2. Interview In both surveys a largely identical personal, fully structured interview was conducted. At the beginning of the interview respondents were presented with a vignette of a diagnostically unlabelled psychiatric case history. Then, respondents were asked a series of questions to assess their recognition of the disorder in the vignette, their causal attributions, their recommendations for help-seeking and treatment as well as their desire for social distance. 2.2.1. Vignettes In 1993, vignettes depicting a case of either schizophrenia or major depressive disorder or borderline personality disorder have been used. The symptoms described in the vignettes fulfilled the criteria of DSM-III-R [1] for the respective disorder. Before the vignettes were used in the survey, each was independently rated by five experts on psychopathology (psychiatrists or psychologists) masked to actual diagnosis, providing confirmation of the correct diagnosis for each case history. The respondents were randomly allocated to receive one of the three vignettes. 1063 respondents were presented
2.2.2. Labelling Following the presentation of the vignette, respondents were asked, using an open-ended question, to indicate how they would label the problem. The responses were noted down by the interviewers. These notes were then analysed by means of inductively derived categories, aiming at establishing a typology of problem definitions. Altogether, this typology comprised of 134 distinct categories which then were combined to four main categories (correct psychiatric diagnosis, other psychiatric illness or psychiatric illness unspecified, life crisis or personal problem, other definitions). Interrater reliability was checked by having two people code 200 interviews independently of one another. Cohens’s kappa reached 0.85. For our analysis, only the first category (correct diagnosis, i.e., labelling schizophrenic symptoms as expression of schizophrenia/psychosis and depressive symptoms as expression of depression) was used. 2.2.3. Causal attributions Following the question exploring labelling of the problem in the vignette, respondents were asked about their causal attributions. Although the lists of potential causes used in both surveys were not identical, there are four causes used in both surveys: two referencing psychosocial stress (partnership/ family problems, stress at work) and two referencing biological causes (brain disease, heredity). Using a five-point Likert scale ranging from ‘‘definitely a cause’’ to ‘‘definitely no cause’’, respondents were asked to indicate how relevant they considered each potential cause to be. In addition to the Likert scale also the response category ‘‘don’t know’’ was provided (the same applies to the questions assessing help-seeking and treatment recommendations). For statistical analysis, respondents who endorsed either of the two points on the scale on the side of the mid-point with the anchor ‘‘definitely a cause’’ were grouped together to the category ‘‘a cause’’. 2.2.4. Help-seeking recommendations After the assessment of their causal attributions respondents were asked to indicate from whom help should be sought. A catalogue of six sources of help was offered: psychiatrist, psychotherapist, general practitioner, priest, self-help group, confidant. The respondents were asked to indicate endorsement or rejection of each source of help using a five-point Likert scale ranging from ‘‘would strongly recommend’’ to ‘‘would not recommend at all’’. Similarly to causal attributions, respondents who endorsed either of the two points on the scale on the side of the mid-point with the anchor ‘‘strongly recommend’’ were grouped together to the category ‘‘recommend’’.
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2.2.5. Treatment recommendations Using a five-point scale ranging from ‘‘would strongly recommend’’ to ‘‘would not recommend at all’’ respondents were asked to provide their assessment of four different treatment methods offered by us, two representing established forms of psychiatric treatment (drug treatment, psychotherapy) and two representing ‘‘alternative’’ treatment modalities (natural remedies, meditation/yoga). The response categories were combined in the same way as described for help-seeking recommendations. 2.2.6. Social distance For the assessment of respondents’ desire for social distance we used a scale developed by Link et al. [22], a modified version of the Bogardus Social Distance Scale [10]. The translation of the American original into German was carried out following the guidelines developed by WHO [30]. The scale includes seven items representing the following social relationships: tenant, co-worker, neighbour, person one would recommend for a job, person of the same social circle, in-law and child carer. Using a five-point Likert scale ranging from ‘‘in any case’’ to ‘‘in no case at all’’, the respondents could indicate to what extent they would, in the situation presented, accept the person described in the vignette. Respondents who endorsed either of the two points on the scale on the side of the mid-point with the anchor ‘‘in no case at all’’ were grouped together to the category ‘‘social rejection’’.
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Table 1 Socio-demographic characteristics of population samples. 1993 (n ¼ 1564) %
2001 (n ¼ 1003) %
Gender Male Female
47.2 52.8
43.3 56.7
Age, years 18e25 26e45 46e60 61þ
11.6 39.0 26.8 22.6
11.2 30.0 27.0 31.8
2.5 28.9
0.7 33.0
48.3
50.9
20.3
15.4
61.5 14.4 7.3 19.1
54.4 11.2 14.4 20.0
Educational attainment No school completed Hauptschule (9 years of school completed) Realschule/Polytechnische Oberschule (10 years of school completed) Fachhochschulreife/Abitur (technical college of higher education/A-levels) Marital status Married Divorced Widowed Single
during the same time period from 26.9% to 37.5% (OR 0.539; 95% CI 0.407e0.768; p ¼ 0.000).
2.3. Statistical analysis To test the effect of time on the two combined response categories, indicating either agreement or disagreement, logit models were estimated with each of the items, assessing people’s labelling, causal beliefs, help-seeking and treatment recommendations as well as their desire for social distance. The year 2001 served as reference category. All effects were controlled for the effect of gender, age and educational attainment. In order to take into account the multistage sampling procedure, the analyses were carried out with SVYLOGIT of STATA version 8 SE [31], using the sample points as primary sampling units. 3. Results
3.3. Changes in causal attributions Biological etiologies were more highly endorsed as cause of schizophrenia in 2001 than in 1993. By contrast, the endorsement of psychosocial stress remained unchanged, resulting in both brain disease and family/partnership problems to be considered equally frequently as a cause of schizophrenia. As concerns major depression, the proportion of respondents endorsing a brain disease as cause increased also substantially while the endorsement of hereditary factors remained unchanged. The same holds true for work stress while family/partnership problems tended to be more frequently seen as a cause (Table 2).
3.1. Samples
3.4. Changes in help-seeking recommendations
As shown in Table 1, the socio-demographic characteristics of both samples differed only slightly.
As shown in Table 3, the percentage of the public recommending that a person with schizophrenia should see a psychotherapist increased significantly. By contrast, the percentage of those recommending to turn to a confidant or to a priest for help decreased. The willingness to recommend to see a GP or a psychiatrist or to join a self-help group remained unchanged. A somewhat similar development was also to be observed in case of major depression. However, while in 2001 mental health professionals had become the most frequently endorsed helping source in case of schizophrenia, in case of
3.2. Changes in labelling symptoms While in 1993 17.1% of those questioned labelled the individual with schizophrenic symptoms as suffering from schizophrenia/psychosis, in 2001 22.4% applied this label (OR 0.653, 95% CI 0.511e0.834, p ¼ 0.000). The percentage of respondents identifying depression correctly increased
M.C. Angermeyer et al. / European Psychiatry 24 (2009) 225e232
228 Table 2 Causal attributionsa.
1993 %c
2001 %c
Odds ratioa (95% CI) P
(n ¼ 1058e1059)b 49.3
(n ¼ 477e481)b 67.4
1.974 (1.417e2.750)
44.5
56.9
1.538 (1.136e2.082)
63.9
67.5
1.225 (0.902e1.664)
63.8
64.0
0.994 (0.711e1.391)
(n ¼ 498e499)b 24.7
(n ¼ 516e522)b 37.6
1.714 (1.158e2.536)
37.3
40.3
1.052 (0.724e1.529)
73.1
80.8
1.605 (1.053e2.445)
75.0
80.3
1.322 (0.899e1.945)
Schizophrenia Brain disease 0.000 Heredity 0.005 Family/partnership problems 0.193 Work stress 0.974 Major depression Brain disease 0.007 Heredity 0.790 Family/partnership problems 0.028 Work stress 0.156 a b c
Logit analysis controlling for gender, age, and educational attainment; reference category 2001; primary sampling units. Variation of number of cases due to missing data. Scores on points 1 and 2 on the five-point Likert scale ranging from ‘‘definitely a cause’’ (1) to ‘‘definitely not a cause’’ (5) have been combined.
depression it was still the confidant who was most frequently recommended to turn to. 3.5. Changes in treatment recommendations As shown in Table 4, the percentage of respondents recommending psychotropic medication and psychotherapy for the treatment of schizophrenia increased significantly. As concerns major depression, there was a less pronounced trend in the same direction. While natural remedies were less frequently endorsed for the treatment of schizophrenia in 2001 there was no change as concerns major depression. Meditation/yoga enjoyed growing acceptance with both disorders. 3.6. Changes in desire for social distance In contrast to the changes observed with regard to the public’s causal attributions and its recommendations for help-seeking and treatment was the development of the public’s desire for social distance from people with both mental disorders. Rather than having decreased, as one might have expected, the desire for social distance remained unchanged in all social relationships except for the recommendation for a job and acceptance as member of the same social circle where respondents distanced themselves even more (Table 5). 3.7. Effect of labelling on illness beliefs and attitudes In order to examine whether the effect of psychiatric labelling on illness beliefs and attitudes towards people with mental illness remained the same or whether there occurred some changes we estimated logit models for the total sample
including labelling of the symptoms depicted in the vignette, type of disorder, and time point as independent variables, plus socio-demographic characteristics (gender, age, educational attainment) as control variables. Across both surveys and both disorders, the definition of the symptoms depicted in the vignettes as indication of either schizophrenia/psychosis or depression was associated with a greater tendency to endorse brain disease as a cause (OR 2.130, 95% CI 1.142e3.971, p ¼ 0.018) while family/partnership problems were less frequently considered as etiologically relevant (OR 0.492, 95% CI 0.294e0.824, p ¼ 0.007). There was also a greater readiness to recommend to turn to a psychiatrist for help (OR 3.111, 95% CI 1.260e7.681, p ¼ 0.000) as well as to use psychotropic medication (OR 2.222, 95% CI 1.262e3.910, p ¼ 0.006) and psychotherapy (OR 3.641, 95% CI 1.513e 8.758, p ¼ 0.004). There were also a few interaction effects between problem definition and type of disorder: If the symptoms depicted in the vignette were identified as expression of the respective disorder, family/partnership problems as well as work stress were more frequently endorsed as a cause of depression (OR 2.794, 95% CI 1.391e5.612, p ¼ 0.004; OR 3.111, 95% CI 1.458e6.639, p ¼ 0.003) while psychotropic medication was more frequently recommended for the treatment of schizophrenia (OR 0.458, 95% CI 0.233e0.901, p ¼ 0.024). Three interaction effects between labelling and time point of survey are of particular interest, indicating that labelling as schizophrenia/psychosis or as depression, respectively, had different effects in 1993 and 2003. In 2001, recognition of the mental disorder was strongly associated with the endorsement of brain disease as a cause (OR 0.467, 95% CI 0.232e0.938, p ¼ 0.033) as well as with the recommendation of psychotropic medication for treatment
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229
Table 3 Help-seeking recommendations. 1993 %c
2001 %c
Odds ratioa (95% CI) P
(n ¼ 1056e1058)b 76.9
(n ¼ 478e480)b 81.5
1.166 (0.797e1.708)
71.6
80.6
1.659 (1.195e2.302)
67.1
67.7
0.934 (0.671e1.301)
62.9
62.0
0.998 (0.731e1.361)
18.5
11.9
0.558 (0.362e0.859)
79.3
70.8
0.646 (0.453e0.922)
(n ¼ 498)b 61.4
(n ¼ 519e522)b 69.9
1.394 (0.960e2.026)
62.8
71.8
1.450 (1.028e2.046)
63.7
69.1
1.145 (0.817e1.606)
60.4
66.9
1.296 (0.914e1.840)
19.1
14.8
0.680 (0.434e1.065)
85.9
78.3
0.601 (0.381e0.977)
Schizophrenia Psychiatrist 0.428 Psychotherapist 0.003 GP 0.687 Self-help group 0.987 Priest 0.008 Confidant Major depression Psychiatrist 0.081 Psychotherapist 0.034 GP 0.430 Self-help group 0.145 Priest 0.092 Confidant 0.040 a b c
Logit analysis controlling for gender, age, and educational attainment; reference category 2001; primary sampling units. Variation of number of cases due to missing data. Scores on points 1 and 2 on the five-point Likert scale ranging from ‘‘definitely recommended’’ (1) to ‘‘definitely not recommended’’ (5) have been combined.
Table 4 Treatment recommendations. 1993 %c
2001 %c
Odds ratioa (95% CI) P
(n ¼ 1057e1059)b 36.3
(n ¼ 477e480)b 50.6
1.678 (1.218e2.312)
71.7
81.5
1.746 (1.226e2.487)
38.5
30.4
0.705 (0.515e0.964)
25.3
35.4
1.723 (1.246e2.384)
(n ¼ 497e498)b 29.5
(n ¼ 521e522)b 38.7
1.427 (0.951e2.142)
63.2
72.7
1.505 (1.046e2.163)
37.7
35.9
0.904 (0.644e1.269)
24.9
39.7
2.141 (1.486e3.084)
Schizophrenia Psychotropic drugs 0.002 Psychotherapy 0.002 Natural remedies 0.029 Meditation/yoga 0.001 Major depression Psychotropic drugs 0.086 Psychotherapy 0.028 Natural remedies 0.559 Meditation/yoga 0.000 a b c
Logit analysis controlling for gender, age, and educational attainment; reference category 2001; primary sampling units. Variation of number of cases due to missing data. Scores on points 1 and 2 on the five-point Likert scale ranging from ‘‘definitely recommended’’ (1) to ‘‘definitely not recommended’’ (5) have been combined.
230
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Table 5 Social distance desired by the public. 1993 %c
2001 %c
Odds ratioa (95% CI) P
(n ¼ 1047e1057)b 57.5
(n ¼ 476e480)b 65.3
1.274 (0.940e1.727)
23.9
26.0
1.083 (0.763e1.539)
27.1
27.0
0.955 (0.658e1.388)
79.2
82.3
1.234 (0.759e1.664)
65.9
67.4
0.977 (0.707e1.348)
36.1
60.6
2.625 (1.907e3.614)
49.3
60.2
1.475 (1.081e2.011)
(n ¼ 488e497)b 41.8
(n ¼ 519e522)b 42.4
0.959 (0.685e1.343)
14.1
13.2
0.890 (0.527e1.503)
16.2
13.5
0.781 (0.466e1.311)
66.1
71.4
1.203 (0.814e1.779)
50.1
46.1
0.775 (0.539e1.114)
23.4
43.9
2.451 (1.640e3.661
34.9
46.4
1.536 (1.059e2.227)
Schizophrenia Tenant 0.118 Co-worker 0.654 Neighbour 0.811 Child care 0.559 In-law 0.885 Member of the same social circle 0.000 Person one would recommend for a job 0.014 Major depression Tenant 0.807 Co-worker 0.662 Neighbour 0.348 Child care 0.353 In-law 0.168 Member of the same social circle 0.000 Person one would recommend for a job 0.024 a
Logit analysis controlling for gender, age, and educational attainment; reference category 2001; primary sampling units. Variation of number of cases due to missing data. c Percentage of individuals who would not accept the individual in the case vignette in the specified role. Scores on points 4 and 5 on the five-point Likert scale ranging from ‘‘in any case’’ (1) to ‘‘in no case’’ (5) have been combined. b
(OR 0.508, 95% CI 0.259e0.998, p ¼ 0.049). While in 1993 respondents who identified the symptoms depicted in the vignette as expression of either one of the two mental disorders were more prepared to recommend to turn to a GP, in 2001 recognition of the two mental disorders did not make any difference (OR 0.503, 95% CI 0.257e0.987, p ¼ 0.046). All other items referring to mental health literacy did not show any statistically significant main effect or interaction effect. Among the seven social distance items there were only two which showed an interaction effect between labelling and type of disorder: If schizophrenic symptoms were identified as expression of schizophrenia/psychosis the individual depicted in the vignette was more likely to be rejected as tenant (OR 0.389, 95% CI 0.198e0.765, p ¼ 0.006) and less likely to be recommended for a job (OR 0.358, 95% CI 0.191e0.669, p ¼ 0.001). In addition, there was a threefold interaction effect indicating that in 2001 individuals with depressive symptoms were more frequently rejected as child carer if they were considered as suffering from depression (OR 0.247, 95% CI 0.091e0.674, p ¼ 0.006).
4. Discussion 4.1. Limitations Before discussing our findings, some limitations of the present study have to be acknowledged. First, not being a panel study it is not possible to study changes of beliefs and attitudes and the associations between the two on an individual level. Second, only causes tapping into ideas about how stress and biology lead to mental illness could be assessed, both of which correspond to our current understanding of the development of mental illness. It would be also interesting to know how beliefs in more esoteric causes have developed over time. Third, only one stigma component, namely the desire for social distance, has been assessed. It is quite conceivable that other components such as the stereotypes of dangerousness or unpredictability as well as the tendency to blame people with mental illness as responsible for their own plight have developed differently during the study period. Fourth, our findings refer to the situation in
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eastern Germany. It would be of interest whether they can be replicated in other countries. 4.2. Development of mental health literacy Our results indicate that the mental health literacy of the public in the eastern part of Germany has somewhat increased over an eight-year period. This holds true particularly for the beliefs about the causes and the treatment of schizophrenia. These changes involve the public becoming more similar to mental health professionals in their beliefs. There was also a slight increase of the percentage of people who were able to identify the symptoms depicted in the vignettes as indication of the respective mental disorders. In 2001, recognition of the two mental disorders had an even stronger positive impact on the readiness of the public to endorse a brain disease as a cause and to recommend psychotropic medication for treatment than eight years before. Thus, the psychiatric diagnoses were more closely associated with biological conceptualisations of the respective disorders. The public’s willingness to seek help from a mental health professional in case of the two disorders in question also increased while the other helping sources were recommended as frequently or even less frequently as before. We can only speculate about the reasons for these changes. One reason for the shift towards biological etiologies may be that in 1990 the American Congress declared the 90s as the ‘‘Decade of the Brain’’ which, as a consequence, may have led to a greater emphasis on biological research in psychiatry. Another reason may be that first results of the Human Genome Project were presented at that time. Both received broad coverage by the media which may have had some impact on public conceptualisations of mental disorders. During the 1990s, important advances were made in the treatment of mental disorders. Here, most notable is the introduction of the second generation of psychotropic drugs. Progress was also made in the field of psychotherapy, particularly as concerns the development of evidence-based interventions. This may have resulted in a greater acceptance of treatment offered by mental health services. During the 1990s, mental health care in the eastern part of Germany underwent tremendous changes, particularly a change from custodial care provided by large institutions to community-focused services [9], which may have led to a lower reluctance of those in need for treatment to seek help from mental health services. It seems particularly noteworthy that during the time period covered by our study no campaign aimed at enhancing public awareness of mental disorders was carried out. However, despite these changes, there are still some major discrepancies between public and professional beliefs, particularly in relation to treatment options, with psychotherapy being more frequently recommended than psychotropic medication and, in case of depression, alternative treatment modalities as frequently as psychotropic drug treatment. In 2001, meditation and yoga had become even more popular than eight years before. An explanation for this rather unexpected trend may be that while in the former FRG techniques aimed more at the enhancement of personal growth
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than the treatment of psychological distress had become increasingly popular since the early 1970s [3], in the former GDR they had remained rather unfamiliar. It was only after reunification that meditation and yoga enjoyed growing popularity also in the eastern part of Germany. 4.3. Development of the desire for social distance In contrast to the increase in mental health literacy, only a small change could be observed in the desire for social distance towards persons suffering from major depressive disorder or schizophrenia. The effect of labelling on social distance remained also virtually unchanged. Thus, the trend in public beliefs was mainly unparalleled as regards public attitudes. To our knowledge, there is only one single study also comparing time trends in beliefs and attitudes [5]. In this study that has been conducted in the western part of Germany the development of causal beliefs and the desire for social distance towards people with schizophrenia was examined. While the endorsement of biological causes increased substantially over a 11-year period, the public’s rejection of people with schizophrenia also increased considerably in all social relationships. Thus, our study does not fully replicate the findings of the previous study. Our findings are in line with a number of crosssectional population studies where also no relationship between the endorsement of biogenetic causes and the desire for social distance has been observed [16,23]. We also know from targeted interventions aimed at reducing the stigma surrounding mental illness that improving knowledge may not necessarily be accompanied by a decrease of social distance [21,25,26]. 5. Conclusion Although our findings do not lend full support to the notion that promoting biomedical conceptualisations of mental disorders in general, and schizophrenia in particular [27,28], may increase prejudice rather than decrease it, they also do not support the idea underlying a number of anti-stigma programs that by increasing people’s mental health literacy their attitudes towards people with mental illness will also improve. To facilitate contact with people with mental illness and making the public more familiar with mentally ill people may prove more promising [7,17]. 6. Conflict of interest The authors have no conflict of interest. Acknowledgment The study was funded by the German Research Association (grant AN 101/5-1) and the Federal Ministry of Health. References [1] American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-III-R). Washington DC: APA; 1987.
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[3] Angermeyer MC, Ku¨hn L. Der Psychoboom auf dem deutschen ¨ sterr Z Soziol 1985;10:250e9. Buchmarkt. O [5] Angermeyer MC, Matschinger H. Causal beliefs and attitudes to people with schizophrenia. Br J Psychiatry 2005;186:331e4. [6] Angermeyer MC, Matschinger H. Have there been any changes in the public’s attitudes towards psychiatric treatment? Results from representative populations surveys in Germany in the years 1990 and 2001. Acta Psychiatr Scand 2005;111:68e73. [7] Angermeyer MC, Matschinger H, Corrigan PW. Familiarity with mental illness and social distance from people with schizophrenia and major depression: testing a model using data from a representative population survey. Schizophr Res 2004;69:175e82. [9] Arbeitsgemeinschaft Psychiatrie der obersten Landesgesundheitsbeho¨rden: Bestandsaufnahme zu den Entwicklungen der Psychiatrie in den letzten 25 Jahren. Chemnitz; 2003. [10] Bogardus ES. Measuring social distances. J Appl Sociol 1925;9: 299e308. [11] Crisp A, Cowan L, Hart D. The college’s anti-stigma campaign, 1998e2003. Psychiatry Bull 2004;28:133e6. [12] Dietrich S, Beck M, Bujantugs B, Kenzine D, Matschinger H, Angermeyer MC. The relationship between public causal beliefs and social distance to mentally ill people. Aust N Z J Psychiatry 2004;38:348e54. [13] Dietrich S, Matschinger H, Angermeyer MC. The relationship between biogenetic causal explanations and social distance toward people with mental disorders. Results from a population survey in Germany. Int J Soc Psychiatry 2006;52:166e74. [14] Gabler S, Hoffmeyer-Zlotnik JHP. Stichproben in der Umfragenpraxis. Opladen: Westdeutscher Verlag; 1997. [15] Goldney RD, Fisher LJ, Dal Grande E, Taylor AW. Changes in mental health literacy about depression: South Australia, 1998 to 2004. Med J Aust 2005;183:134e7. [16] Grausgruber A, Meise U, Katschnig H, Scho¨ny W, Fleischhacker WW. Patterns of social distance towards people suffering from schizophrenia in Austria: a comparison between the general public, relatives and mental health staff. Acta Psychiatr Scand 2007;115:310e9. [17] Holzinger A, Dietrich S, Heitmann S, Angermeyer MC. Evaluation zielgruppenorientierter Antistigma-Interventionen. Eine systematische ¨ bersicht. Psychiatr Prax 2008 [Epub ahead of print]. U [18] Jorm AF, Christensen H, Griffiths KM. Public beliefs about causes and risk factors for mental disorders. Changes in Australia over 8 years. Soc Psychiatry Psychiatr Epidemiol 2005;40:764e7.
[19] Jorm AF, Christensen H, Griffiths KM. The public’s ability to recognize mental disorders and their beliefs about treatment: changes in Australia over 8 years. Aust N Z J Psychiatry 2006;40:36e41. [20] Lauber C, Nordt C, Falcato L, Ro¨ssler W. Factors influencing social distance toward people with mental illness. Community Ment Health J 2004;40:265e74. [21] Lauria-Horner BA, Kutcher S, Brooks S. The feasibility of a mental health curriculum in elementary school. Can J Psychiatry 2004;49:208e11. [22] Link BG, Cullen FT, Frank J, Wozniak JF. The social rejection of former mental patients: understanding why labels matter. Am J Sociol 1987;92:1461e500. [23] Martin JK, Pescosolido BA, Olafsdottir S, McLeod JD. The construction of fear: Americans’ preferences for social distance from children and adolescents with mental health problems. J Health Soc Behav 2007; 48:50e67. [24] Mojtabai R. Americans’ attitudes toward mental health treatment seeking: 1990-2003. Psychiatr Serv 2007;58:642e51. [25] Pinfold V, Huxley P, Thornicroft G, Farmer P, Toulmin H, Graham T. Reducing psychiatric stigma and discrimination. Evaluating an educational intervention with the police force in England. Soc Psychiatry Psychiatr Epidemiol 2003;38:337e44. [26] Pinfold V, Toulmin H, Thornicroft G, Huxley P, Farmer P, Graham T. Reducing psychiatric stigma and discrimination: evaluation of educational interventions in UK secondary schools. Br J Psychiatry 2003;182: 342e6. [27] Read J. Why promoting biological ideology increases prejudice against people labeled schizophrenic. Aust Psychol 2007;42:118e28. [28] Read J, Haslam N, Sayce L, Davies E. Prejudice and schizophrenia: a review of the ‘mental illness is an illness like any other’ approach. Acta Psychiatr Scand 2006;114:303e18. [29] Sartorius N. Stigma and discrimination because of schizophrenia: a summary of the WPA global programme against stigma and discrimination because of schizophrenia. World Psychiatry 2005;4:11e5. [30] Sartorius N, Kuyken W. Translation of health status instruments. In: Orley J, Kuyken W, editors. Quality of life assessment: international perspectives. Berlin: Springer; 1994. [31] Stata. Stata statistical software: release 8.0. College Station TX: Stata Corporation; 2003. [32] Wang J, Lai D. The relationship between mental health literacy, personal contacts and personal stigma against depression. J Affect Disord 2008 [Epub ahead of print].
www.sciencedirect.com European Psychiatry 24 (2009) 225e232
Original article
Mental health literacy and attitude towards people with mental illness: A trend analysis based on population surveys in the eastern part of Germany M.C. Angermeyer a,*, A. Holzinger b, H. Matschinger c a
Center for Public Mental Health, Untere Zeile 13, A-3482 Go¨sing a.W., Austria b Department of Psychiatry, Medical University Vienna, Austria c Department of Psychiatry, Leipzig University, Germany
Received 30 March 2008; received in revised form 11 June 2008; accepted 21 June 2008 Available online 10 April 2009
Abstract Background e There is growing evidence that mental health literacy has improved in western countries in recent years. The question arises as to whether this trend is paralleled by an improvement of attitudes towards people with mental illness. Aim e To examine the development of mental health literacy and the desire for social distance towards people with schizophrenia and major depressive disorder in Eastern Germany over a time period of eight years. Method e A trend analysis was carried out using data from two population surveys conducted in the eastern part of Germany in 1993 and 2001. By means of a fully structured interview psychiatric labelling, causal beliefs, help-seeking and treatment recommendations as well as the desire for social distance was assessed. Results e While there was an increase in the mental health literacy of the public, the desire for social distance from people with major depression and schizophrenia remained unchanged or even increased. Conclusions e The assumption underlying a number of anti-stigma campaigns, namely that educating people about mental disorders may automatically lead to the improvement of their attitudes towards the mentally ill, appears questionable. Ó 2008 Elsevier Masson SAS. All rights reserved. Keywords: Public beliefs; Social distance; Time trends; Major depressive disorder; Schizophrenia
1. Introduction There is growing evidence that mental health literacy has increased in western countries in recent years. Studies from the US, Australia and Germany have shown that the public has become more able to recognize mental disorders as such [15,19], that the gap between the public’s and mental health professionals’ beliefs about the causes and the treatment of mental disorders has become smaller [5,6,15,18,19], and that the willingness to seek help from mental health professionals has increased [6,15,19,24].
* Corresponding author. Tel.: þ43 2738 20036. E-mail address: [email protected] (M.C. Angermeyer). 0924-9338/$ - see front matter Ó 2008 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.eurpsy.2008.06.010
The question arises as to whether the increase of mental health literacy has also been accompanied by an improvement of attitudes towards people with mental illness. That better knowledge leads to more favourable attitudes seems commonplace, and in fact a number of anti-stigma campaigns are based on this assumption [11,29]. However, this notion has been challenged by findings from recently conducted population studies indicating that the public’s knowledge about mental disorders and its attitudes towards people suffering from these disorders may be unrelated or even inversely related [12,13,20,23,32]. Aim of this study is to examine whether what has been observed in cross-sectional studies can be replicated using a longitudinal study design. Based on data from two representative surveys conducted in the eastern part of Germany we
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will compare the development of psychiatric labelling, causal beliefs, help-seeking recommendations, and beliefs about treatment in case of schizophrenia and major depressive disorder with that of the desire for social distance towards people suffering from both disorders over a time period of eight years.
with the vignette depicting schizophrenia, 501 respondents with the vignette depicting major depressive disorder, and 530 with the vignette depicting borderline personality disorder. In 2001, respondents were shown only vignettes with schizophrenia (n ¼ 481) or major depressive disorder (n ¼ 522). Therefore, the trend analysis presented in this paper refers only to these two disorders.
2. Method 2.1. Sample In 1993 a representative survey was conducted in the eastern part of Germany among German citizens aged 18 years and older, living in non-institutional settings. The sample was drawn using a three-stage sampling procedure, with sample points (electoral wards) at the first stage, households at the second stage, and individuals within the target households at the third stage. Target households within the sample point were determined according to the random route procedure: that is, a street was selected randomly as starting point from where the interviewer followed a set route through the area [14]. Within the target households, the interviewees were selected by means of random digits. A total of 2094 interviews were conducted, reflecting a response rate of 71.2%. In 2001 a second representative survey was conducted. This time the sampling frame differed, with the sample being drawn from the whole of Germany, the number of interviews conducted in the West and East reflecting the proportions of the population living in the two parts of the country. Apart from this, the same three-stage sampling procedure was used as in the previous survey. In total, 5025 interviews were conducted (reflecting a response rate of 65.1%). 1001 interviews that were obtained in the eastern states of Germany have been included in our analysis. 2.2. Interview In both surveys a largely identical personal, fully structured interview was conducted. At the beginning of the interview respondents were presented with a vignette of a diagnostically unlabelled psychiatric case history. Then, respondents were asked a series of questions to assess their recognition of the disorder in the vignette, their causal attributions, their recommendations for help-seeking and treatment as well as their desire for social distance. 2.2.1. Vignettes In 1993, vignettes depicting a case of either schizophrenia or major depressive disorder or borderline personality disorder have been used. The symptoms described in the vignettes fulfilled the criteria of DSM-III-R [1] for the respective disorder. Before the vignettes were used in the survey, each was independently rated by five experts on psychopathology (psychiatrists or psychologists) masked to actual diagnosis, providing confirmation of the correct diagnosis for each case history. The respondents were randomly allocated to receive one of the three vignettes. 1063 respondents were presented
2.2.2. Labelling Following the presentation of the vignette, respondents were asked, using an open-ended question, to indicate how they would label the problem. The responses were noted down by the interviewers. These notes were then analysed by means of inductively derived categories, aiming at establishing a typology of problem definitions. Altogether, this typology comprised of 134 distinct categories which then were combined to four main categories (correct psychiatric diagnosis, other psychiatric illness or psychiatric illness unspecified, life crisis or personal problem, other definitions). Interrater reliability was checked by having two people code 200 interviews independently of one another. Cohens’s kappa reached 0.85. For our analysis, only the first category (correct diagnosis, i.e., labelling schizophrenic symptoms as expression of schizophrenia/psychosis and depressive symptoms as expression of depression) was used. 2.2.3. Causal attributions Following the question exploring labelling of the problem in the vignette, respondents were asked about their causal attributions. Although the lists of potential causes used in both surveys were not identical, there are four causes used in both surveys: two referencing psychosocial stress (partnership/ family problems, stress at work) and two referencing biological causes (brain disease, heredity). Using a five-point Likert scale ranging from ‘‘definitely a cause’’ to ‘‘definitely no cause’’, respondents were asked to indicate how relevant they considered each potential cause to be. In addition to the Likert scale also the response category ‘‘don’t know’’ was provided (the same applies to the questions assessing help-seeking and treatment recommendations). For statistical analysis, respondents who endorsed either of the two points on the scale on the side of the mid-point with the anchor ‘‘definitely a cause’’ were grouped together to the category ‘‘a cause’’. 2.2.4. Help-seeking recommendations After the assessment of their causal attributions respondents were asked to indicate from whom help should be sought. A catalogue of six sources of help was offered: psychiatrist, psychotherapist, general practitioner, priest, self-help group, confidant. The respondents were asked to indicate endorsement or rejection of each source of help using a five-point Likert scale ranging from ‘‘would strongly recommend’’ to ‘‘would not recommend at all’’. Similarly to causal attributions, respondents who endorsed either of the two points on the scale on the side of the mid-point with the anchor ‘‘strongly recommend’’ were grouped together to the category ‘‘recommend’’.
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2.2.5. Treatment recommendations Using a five-point scale ranging from ‘‘would strongly recommend’’ to ‘‘would not recommend at all’’ respondents were asked to provide their assessment of four different treatment methods offered by us, two representing established forms of psychiatric treatment (drug treatment, psychotherapy) and two representing ‘‘alternative’’ treatment modalities (natural remedies, meditation/yoga). The response categories were combined in the same way as described for help-seeking recommendations. 2.2.6. Social distance For the assessment of respondents’ desire for social distance we used a scale developed by Link et al. [22], a modified version of the Bogardus Social Distance Scale [10]. The translation of the American original into German was carried out following the guidelines developed by WHO [30]. The scale includes seven items representing the following social relationships: tenant, co-worker, neighbour, person one would recommend for a job, person of the same social circle, in-law and child carer. Using a five-point Likert scale ranging from ‘‘in any case’’ to ‘‘in no case at all’’, the respondents could indicate to what extent they would, in the situation presented, accept the person described in the vignette. Respondents who endorsed either of the two points on the scale on the side of the mid-point with the anchor ‘‘in no case at all’’ were grouped together to the category ‘‘social rejection’’.
227
Table 1 Socio-demographic characteristics of population samples. 1993 (n ¼ 1564) %
2001 (n ¼ 1003) %
Gender Male Female
47.2 52.8
43.3 56.7
Age, years 18e25 26e45 46e60 61þ
11.6 39.0 26.8 22.6
11.2 30.0 27.0 31.8
2.5 28.9
0.7 33.0
48.3
50.9
20.3
15.4
61.5 14.4 7.3 19.1
54.4 11.2 14.4 20.0
Educational attainment No school completed Hauptschule (9 years of school completed) Realschule/Polytechnische Oberschule (10 years of school completed) Fachhochschulreife/Abitur (technical college of higher education/A-levels) Marital status Married Divorced Widowed Single
during the same time period from 26.9% to 37.5% (OR 0.539; 95% CI 0.407e0.768; p ¼ 0.000).
2.3. Statistical analysis To test the effect of time on the two combined response categories, indicating either agreement or disagreement, logit models were estimated with each of the items, assessing people’s labelling, causal beliefs, help-seeking and treatment recommendations as well as their desire for social distance. The year 2001 served as reference category. All effects were controlled for the effect of gender, age and educational attainment. In order to take into account the multistage sampling procedure, the analyses were carried out with SVYLOGIT of STATA version 8 SE [31], using the sample points as primary sampling units. 3. Results
3.3. Changes in causal attributions Biological etiologies were more highly endorsed as cause of schizophrenia in 2001 than in 1993. By contrast, the endorsement of psychosocial stress remained unchanged, resulting in both brain disease and family/partnership problems to be considered equally frequently as a cause of schizophrenia. As concerns major depression, the proportion of respondents endorsing a brain disease as cause increased also substantially while the endorsement of hereditary factors remained unchanged. The same holds true for work stress while family/partnership problems tended to be more frequently seen as a cause (Table 2).
3.1. Samples
3.4. Changes in help-seeking recommendations
As shown in Table 1, the socio-demographic characteristics of both samples differed only slightly.
As shown in Table 3, the percentage of the public recommending that a person with schizophrenia should see a psychotherapist increased significantly. By contrast, the percentage of those recommending to turn to a confidant or to a priest for help decreased. The willingness to recommend to see a GP or a psychiatrist or to join a self-help group remained unchanged. A somewhat similar development was also to be observed in case of major depression. However, while in 2001 mental health professionals had become the most frequently endorsed helping source in case of schizophrenia, in case of
3.2. Changes in labelling symptoms While in 1993 17.1% of those questioned labelled the individual with schizophrenic symptoms as suffering from schizophrenia/psychosis, in 2001 22.4% applied this label (OR 0.653, 95% CI 0.511e0.834, p ¼ 0.000). The percentage of respondents identifying depression correctly increased
M.C. Angermeyer et al. / European Psychiatry 24 (2009) 225e232
228 Table 2 Causal attributionsa.
1993 %c
2001 %c
Odds ratioa (95% CI) P
(n ¼ 1058e1059)b 49.3
(n ¼ 477e481)b 67.4
1.974 (1.417e2.750)
44.5
56.9
1.538 (1.136e2.082)
63.9
67.5
1.225 (0.902e1.664)
63.8
64.0
0.994 (0.711e1.391)
(n ¼ 498e499)b 24.7
(n ¼ 516e522)b 37.6
1.714 (1.158e2.536)
37.3
40.3
1.052 (0.724e1.529)
73.1
80.8
1.605 (1.053e2.445)
75.0
80.3
1.322 (0.899e1.945)
Schizophrenia Brain disease 0.000 Heredity 0.005 Family/partnership problems 0.193 Work stress 0.974 Major depression Brain disease 0.007 Heredity 0.790 Family/partnership problems 0.028 Work stress 0.156 a b c
Logit analysis controlling for gender, age, and educational attainment; reference category 2001; primary sampling units. Variation of number of cases due to missing data. Scores on points 1 and 2 on the five-point Likert scale ranging from ‘‘definitely a cause’’ (1) to ‘‘definitely not a cause’’ (5) have been combined.
depression it was still the confidant who was most frequently recommended to turn to. 3.5. Changes in treatment recommendations As shown in Table 4, the percentage of respondents recommending psychotropic medication and psychotherapy for the treatment of schizophrenia increased significantly. As concerns major depression, there was a less pronounced trend in the same direction. While natural remedies were less frequently endorsed for the treatment of schizophrenia in 2001 there was no change as concerns major depression. Meditation/yoga enjoyed growing acceptance with both disorders. 3.6. Changes in desire for social distance In contrast to the changes observed with regard to the public’s causal attributions and its recommendations for help-seeking and treatment was the development of the public’s desire for social distance from people with both mental disorders. Rather than having decreased, as one might have expected, the desire for social distance remained unchanged in all social relationships except for the recommendation for a job and acceptance as member of the same social circle where respondents distanced themselves even more (Table 5). 3.7. Effect of labelling on illness beliefs and attitudes In order to examine whether the effect of psychiatric labelling on illness beliefs and attitudes towards people with mental illness remained the same or whether there occurred some changes we estimated logit models for the total sample
including labelling of the symptoms depicted in the vignette, type of disorder, and time point as independent variables, plus socio-demographic characteristics (gender, age, educational attainment) as control variables. Across both surveys and both disorders, the definition of the symptoms depicted in the vignettes as indication of either schizophrenia/psychosis or depression was associated with a greater tendency to endorse brain disease as a cause (OR 2.130, 95% CI 1.142e3.971, p ¼ 0.018) while family/partnership problems were less frequently considered as etiologically relevant (OR 0.492, 95% CI 0.294e0.824, p ¼ 0.007). There was also a greater readiness to recommend to turn to a psychiatrist for help (OR 3.111, 95% CI 1.260e7.681, p ¼ 0.000) as well as to use psychotropic medication (OR 2.222, 95% CI 1.262e3.910, p ¼ 0.006) and psychotherapy (OR 3.641, 95% CI 1.513e 8.758, p ¼ 0.004). There were also a few interaction effects between problem definition and type of disorder: If the symptoms depicted in the vignette were identified as expression of the respective disorder, family/partnership problems as well as work stress were more frequently endorsed as a cause of depression (OR 2.794, 95% CI 1.391e5.612, p ¼ 0.004; OR 3.111, 95% CI 1.458e6.639, p ¼ 0.003) while psychotropic medication was more frequently recommended for the treatment of schizophrenia (OR 0.458, 95% CI 0.233e0.901, p ¼ 0.024). Three interaction effects between labelling and time point of survey are of particular interest, indicating that labelling as schizophrenia/psychosis or as depression, respectively, had different effects in 1993 and 2003. In 2001, recognition of the mental disorder was strongly associated with the endorsement of brain disease as a cause (OR 0.467, 95% CI 0.232e0.938, p ¼ 0.033) as well as with the recommendation of psychotropic medication for treatment
M.C. Angermeyer et al. / European Psychiatry 24 (2009) 225e232
229
Table 3 Help-seeking recommendations. 1993 %c
2001 %c
Odds ratioa (95% CI) P
(n ¼ 1056e1058)b 76.9
(n ¼ 478e480)b 81.5
1.166 (0.797e1.708)
71.6
80.6
1.659 (1.195e2.302)
67.1
67.7
0.934 (0.671e1.301)
62.9
62.0
0.998 (0.731e1.361)
18.5
11.9
0.558 (0.362e0.859)
79.3
70.8
0.646 (0.453e0.922)
(n ¼ 498)b 61.4
(n ¼ 519e522)b 69.9
1.394 (0.960e2.026)
62.8
71.8
1.450 (1.028e2.046)
63.7
69.1
1.145 (0.817e1.606)
60.4
66.9
1.296 (0.914e1.840)
19.1
14.8
0.680 (0.434e1.065)
85.9
78.3
0.601 (0.381e0.977)
Schizophrenia Psychiatrist 0.428 Psychotherapist 0.003 GP 0.687 Self-help group 0.987 Priest 0.008 Confidant Major depression Psychiatrist 0.081 Psychotherapist 0.034 GP 0.430 Self-help group 0.145 Priest 0.092 Confidant 0.040 a b c
Logit analysis controlling for gender, age, and educational attainment; reference category 2001; primary sampling units. Variation of number of cases due to missing data. Scores on points 1 and 2 on the five-point Likert scale ranging from ‘‘definitely recommended’’ (1) to ‘‘definitely not recommended’’ (5) have been combined.
Table 4 Treatment recommendations. 1993 %c
2001 %c
Odds ratioa (95% CI) P
(n ¼ 1057e1059)b 36.3
(n ¼ 477e480)b 50.6
1.678 (1.218e2.312)
71.7
81.5
1.746 (1.226e2.487)
38.5
30.4
0.705 (0.515e0.964)
25.3
35.4
1.723 (1.246e2.384)
(n ¼ 497e498)b 29.5
(n ¼ 521e522)b 38.7
1.427 (0.951e2.142)
63.2
72.7
1.505 (1.046e2.163)
37.7
35.9
0.904 (0.644e1.269)
24.9
39.7
2.141 (1.486e3.084)
Schizophrenia Psychotropic drugs 0.002 Psychotherapy 0.002 Natural remedies 0.029 Meditation/yoga 0.001 Major depression Psychotropic drugs 0.086 Psychotherapy 0.028 Natural remedies 0.559 Meditation/yoga 0.000 a b c
Logit analysis controlling for gender, age, and educational attainment; reference category 2001; primary sampling units. Variation of number of cases due to missing data. Scores on points 1 and 2 on the five-point Likert scale ranging from ‘‘definitely recommended’’ (1) to ‘‘definitely not recommended’’ (5) have been combined.
230
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Table 5 Social distance desired by the public. 1993 %c
2001 %c
Odds ratioa (95% CI) P
(n ¼ 1047e1057)b 57.5
(n ¼ 476e480)b 65.3
1.274 (0.940e1.727)
23.9
26.0
1.083 (0.763e1.539)
27.1
27.0
0.955 (0.658e1.388)
79.2
82.3
1.234 (0.759e1.664)
65.9
67.4
0.977 (0.707e1.348)
36.1
60.6
2.625 (1.907e3.614)
49.3
60.2
1.475 (1.081e2.011)
(n ¼ 488e497)b 41.8
(n ¼ 519e522)b 42.4
0.959 (0.685e1.343)
14.1
13.2
0.890 (0.527e1.503)
16.2
13.5
0.781 (0.466e1.311)
66.1
71.4
1.203 (0.814e1.779)
50.1
46.1
0.775 (0.539e1.114)
23.4
43.9
2.451 (1.640e3.661
34.9
46.4
1.536 (1.059e2.227)
Schizophrenia Tenant 0.118 Co-worker 0.654 Neighbour 0.811 Child care 0.559 In-law 0.885 Member of the same social circle 0.000 Person one would recommend for a job 0.014 Major depression Tenant 0.807 Co-worker 0.662 Neighbour 0.348 Child care 0.353 In-law 0.168 Member of the same social circle 0.000 Person one would recommend for a job 0.024 a
Logit analysis controlling for gender, age, and educational attainment; reference category 2001; primary sampling units. Variation of number of cases due to missing data. c Percentage of individuals who would not accept the individual in the case vignette in the specified role. Scores on points 4 and 5 on the five-point Likert scale ranging from ‘‘in any case’’ (1) to ‘‘in no case’’ (5) have been combined. b
(OR 0.508, 95% CI 0.259e0.998, p ¼ 0.049). While in 1993 respondents who identified the symptoms depicted in the vignette as expression of either one of the two mental disorders were more prepared to recommend to turn to a GP, in 2001 recognition of the two mental disorders did not make any difference (OR 0.503, 95% CI 0.257e0.987, p ¼ 0.046). All other items referring to mental health literacy did not show any statistically significant main effect or interaction effect. Among the seven social distance items there were only two which showed an interaction effect between labelling and type of disorder: If schizophrenic symptoms were identified as expression of schizophrenia/psychosis the individual depicted in the vignette was more likely to be rejected as tenant (OR 0.389, 95% CI 0.198e0.765, p ¼ 0.006) and less likely to be recommended for a job (OR 0.358, 95% CI 0.191e0.669, p ¼ 0.001). In addition, there was a threefold interaction effect indicating that in 2001 individuals with depressive symptoms were more frequently rejected as child carer if they were considered as suffering from depression (OR 0.247, 95% CI 0.091e0.674, p ¼ 0.006).
4. Discussion 4.1. Limitations Before discussing our findings, some limitations of the present study have to be acknowledged. First, not being a panel study it is not possible to study changes of beliefs and attitudes and the associations between the two on an individual level. Second, only causes tapping into ideas about how stress and biology lead to mental illness could be assessed, both of which correspond to our current understanding of the development of mental illness. It would be also interesting to know how beliefs in more esoteric causes have developed over time. Third, only one stigma component, namely the desire for social distance, has been assessed. It is quite conceivable that other components such as the stereotypes of dangerousness or unpredictability as well as the tendency to blame people with mental illness as responsible for their own plight have developed differently during the study period. Fourth, our findings refer to the situation in
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eastern Germany. It would be of interest whether they can be replicated in other countries. 4.2. Development of mental health literacy Our results indicate that the mental health literacy of the public in the eastern part of Germany has somewhat increased over an eight-year period. This holds true particularly for the beliefs about the causes and the treatment of schizophrenia. These changes involve the public becoming more similar to mental health professionals in their beliefs. There was also a slight increase of the percentage of people who were able to identify the symptoms depicted in the vignettes as indication of the respective mental disorders. In 2001, recognition of the two mental disorders had an even stronger positive impact on the readiness of the public to endorse a brain disease as a cause and to recommend psychotropic medication for treatment than eight years before. Thus, the psychiatric diagnoses were more closely associated with biological conceptualisations of the respective disorders. The public’s willingness to seek help from a mental health professional in case of the two disorders in question also increased while the other helping sources were recommended as frequently or even less frequently as before. We can only speculate about the reasons for these changes. One reason for the shift towards biological etiologies may be that in 1990 the American Congress declared the 90s as the ‘‘Decade of the Brain’’ which, as a consequence, may have led to a greater emphasis on biological research in psychiatry. Another reason may be that first results of the Human Genome Project were presented at that time. Both received broad coverage by the media which may have had some impact on public conceptualisations of mental disorders. During the 1990s, important advances were made in the treatment of mental disorders. Here, most notable is the introduction of the second generation of psychotropic drugs. Progress was also made in the field of psychotherapy, particularly as concerns the development of evidence-based interventions. This may have resulted in a greater acceptance of treatment offered by mental health services. During the 1990s, mental health care in the eastern part of Germany underwent tremendous changes, particularly a change from custodial care provided by large institutions to community-focused services [9], which may have led to a lower reluctance of those in need for treatment to seek help from mental health services. It seems particularly noteworthy that during the time period covered by our study no campaign aimed at enhancing public awareness of mental disorders was carried out. However, despite these changes, there are still some major discrepancies between public and professional beliefs, particularly in relation to treatment options, with psychotherapy being more frequently recommended than psychotropic medication and, in case of depression, alternative treatment modalities as frequently as psychotropic drug treatment. In 2001, meditation and yoga had become even more popular than eight years before. An explanation for this rather unexpected trend may be that while in the former FRG techniques aimed more at the enhancement of personal growth
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than the treatment of psychological distress had become increasingly popular since the early 1970s [3], in the former GDR they had remained rather unfamiliar. It was only after reunification that meditation and yoga enjoyed growing popularity also in the eastern part of Germany. 4.3. Development of the desire for social distance In contrast to the increase in mental health literacy, only a small change could be observed in the desire for social distance towards persons suffering from major depressive disorder or schizophrenia. The effect of labelling on social distance remained also virtually unchanged. Thus, the trend in public beliefs was mainly unparalleled as regards public attitudes. To our knowledge, there is only one single study also comparing time trends in beliefs and attitudes [5]. In this study that has been conducted in the western part of Germany the development of causal beliefs and the desire for social distance towards people with schizophrenia was examined. While the endorsement of biological causes increased substantially over a 11-year period, the public’s rejection of people with schizophrenia also increased considerably in all social relationships. Thus, our study does not fully replicate the findings of the previous study. Our findings are in line with a number of crosssectional population studies where also no relationship between the endorsement of biogenetic causes and the desire for social distance has been observed [16,23]. We also know from targeted interventions aimed at reducing the stigma surrounding mental illness that improving knowledge may not necessarily be accompanied by a decrease of social distance [21,25,26]. 5. Conclusion Although our findings do not lend full support to the notion that promoting biomedical conceptualisations of mental disorders in general, and schizophrenia in particular [27,28], may increase prejudice rather than decrease it, they also do not support the idea underlying a number of anti-stigma programs that by increasing people’s mental health literacy their attitudes towards people with mental illness will also improve. To facilitate contact with people with mental illness and making the public more familiar with mentally ill people may prove more promising [7,17]. 6. Conflict of interest The authors have no conflict of interest. Acknowledgment The study was funded by the German Research Association (grant AN 101/5-1) and the Federal Ministry of Health. References [1] American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-III-R). Washington DC: APA; 1987.
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