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Public attitudes to people with depression: have there been any changes over the last decade?
Journal of Affective Disorders 83 (2004) 177 – 182 www.elsevier.com/locate/jad
Research report
Public attitudes to people with depression: have there been any changes over the last decade? Matthias C. Angermeyer*, Herbert Matschinger Department of Psychiatry, University of Leipzig, Johannisstr.20, 04317 Leipzig, Germany Received 3 March 2004; received in revised form 11 August 2004; accepted 12 August 2004
Abstract Background: A consistent finding of representative surveys that were conducted in Germany in the early 1990s was that people with depression encountered a substantial amount of stigma and discrimination. The aim of this study was to examine whether public attitudes have improved over the last decade or not. Methods: In 2001, a representative survey was carried out among the adult population of the boldQ Federal Republic of Germany using the same methodology as in a previous survey in 1990. Results: Regarding emotional reactions of the respondents towards people with depression, our findings are inconsistent. While there has been an increase in the readiness to feel pity and also a slight increase in the tendency to react aggressively, the expression of fear remained unchanged. The public’s desire for social distance from people with depression was as strong in 2001 as it had been in 1990. Conclusion: The hypothesis of a change for the better regarding public attitudes towards depressed people is not supported by our findings. Further efforts are needed to reach this goal. D 2004 Elsevier B.V. All rights reserved. Keywords: Public attitudes; Major depression; Time trend
1. Introduction In the early 1990s, several surveys investigated attitudes of the German public towards people with mental disorders. A consistent finding across all these * Corresponding author. Tel.: +49 341 9724530; fax: +49 341 97245. E-mail address: [email protected] (M.C. Angermeyer). 0165-0327/$ - see front matter D 2004 Elsevier B.V. All rights reserved. doi:10.1016/j.jad.2004.08.001
surveys was that—while people with alcohol dependence or schizophrenia were mostly rejected—people with depression also encountered a substantial amount of stigma and discrimination. For example, 35% of the general population would not rent a room to someone with major depression, and 42% refused to recommend him for a job (Angermeyer and Matschinger, 1997). Only 20% wanted to talk with neighbours, colleagues, or acquaintances about a close relative suffering from depression. This number compares
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M.C. Angermeyer, H. Matschinger / Journal of Affective Disorders 83 (2004) 177–182
with 64% in the case of hypertension, or 55% in the case of diabetes (Hillert et al., 1999). The question arises as to whether today, a decade later, the stigma attached to depression is still the same or whether there have been any changes. Some observations suggest that public attitudes might have improved in recent years. There has been an increase in media coverage including voluntary disclosures of affective disorders by public figures which may reflect a more accepting attitude and may itself have had a destigmatizing effect. Moreover, a number of best-selling first-person accounts of people with affective disorders have been published (e.g., Wurtzel, 1994; Jamison, 1995; Manning, 1995). In fact, the authors of a report on a survey that was conducted in 2001 in two German cities come to the conclusion that bin recent years, knowledge and attitudes of the public about depression appear to have improved as compared with previous surveysQ (Althaus et al., 2001). Unfortunately, all the studies mentioned have used different methods, thus precluding a direct comparison of the data. Therefore, the authors’ conclusion remains somewhat tentative. A nationwide survey that was conducted in spring 2001 provided the first opportunity to test the hypothesis that public attitudes have improved in Germany over the past 10 years, since, in this study, the same methodology regarding sampling, interview type and assessment instruments was used as in a previous survey conducted in 1990. Based on the data from these two surveys, the following questions will be addressed: !
!
Does the German public show more positive and less negative emotional reactions towards people with major depression in 2001 than in 1990? Is the desire of the German public for social distance from people with major depression less pronounced in 2001 than it was in 1990?
2. Method 2.1. Surveys In 1990, a representative survey was conducted in the boldQ Federal Republic of Germany, involving German citizens aged 18 years or over who were
living in private households. The sample was drawn using a three-stage random sampling procedure with electoral wards at the first stage, households at the second, and individuals within the target households at the third stage. Target households within the sample points were determined according to the random route procedure (i.e., a household was selected randomly as a starting point from where a set route through the area was followed). Target individuals were selected according to random digits. In total, 2118 interviews were completed, the response rate being 65.5%. In 2001, another representative survey was conducted in Germany. This time, the sampling frame differed, with the sample being drawn from the whole of Germany, and the number of interviews conducted in the East and the West reflecting the proportion of the population living in both parts of the country. Apart from this, the same sampling procedure was used as in the 1990 survey. In total, 5025 interviews were conducted, which reflects a response rate of 65.1%; 4005 interviews resulted from the boldQ laender (equivalent of the boldQ Federal Republic of Germany). In both surveys, informed consent was considered to have been given when individuals agreed to complete the interview. Regarding gender and age, in 1990 and 2001, the samples were comparable to the whole of the German population aged 18 years and over in the two respective years (Official Registry Report 1992/2002). 2.2. Interview A personal, fully structured interview was conducted that was largely identical in both surveys. The vignette as well as all the measures needed for this analysis were the same. Therefore, no pretesting was necessary. 2.2.1. Vignette The interview began with the presentation of a vignette containing a diagnostically unlabelled psychiatric case history. De facto, the case histories either depicted a case of schizophrenia or major depressive disorder. The symptoms described in the vignettes fulfilled the criteria of DSM-III-R for the respective disorder. Before being used in the surveys, the vignettes had been submitted to five psychiatrists or psychologists (all proven experts on psychopathol-
M.C. Angermeyer, H. Matschinger / Journal of Affective Disorders 83 (2004) 177–182
ogy) for blind diagnostic allocation. All experts were able to provide the correct diagnoses for both case histories. Random subsamples were presented with only one vignette. In this paper, only interviews with the vignette depicting someone suffering from major depression will be used. 2.2.2. Emotional reactions Respondents were asked to indicate their emotional reactions to the person described in the vignette by means of twelve five-point Likert-scaled (1=definitely the case, 5=definitely not the case) items. Factor analysis with varimax rotation yielded the following three dimensions which are virtually identical with those identified in a previous study (Angermeyer and Matschinger, 1997): !
!
!
Fear (eigenvalue 3.9; explained variance 32.5%)— uneasiness (factor loading 0.85), fear (0.81), feelings of insecurity (0.77), and embarrassment (0.52). Pity (eigenvalue 1.9; explained variance 16.1%)— desire to help (factor loading 0.79), empathy (0.78), and pity (0.66). Anger (eigenvalue 1.3; explained variance 10.6%)—ridicule (factor loading 0.77), anger (0.74), irritation (0.74), and lack of understanding (0.63).
2.2.3. Social distance For the assessment of respondents’ desire for social distance, we made use of a scale developed by Link et al. (1987)—a modified version of the Bogardus Social Distance Scale (Bogardus, 1925). It includes the following seven items representing various social relationships to the respondent: – – – – – –
Would you rent out a room to somebody with these problems? Would you accept a person like this as your coworker? Would you accept a person like this as your neighbour? Would you hire this person for taking care of your kids for a few hours? Would you accept a person like this as an in-law? Would you introduce someone like this to your friends?
–
179
If a friend of yours was looking for an employee, would you recommend a person like this?
Using a five-point Likert scale ranging from bin any caseQ (1) to bin no case at allQ (5), the respondents could indicate to what extent they would, in the situation presented, accept the person described in the vignette. With the seven items, a homogeneity analysis (Gifi, 1990) was carried out that provides both optimal quantifications for the categories of the items and scores for the observations maximizing the internal consistency (Greenacre and Blasius, 1994; Lebart et al., 1984; Matschinger, 1996). Reliability (Cronbach’s alpha) was 0.86. The object scores of the first axis were used for further analysis. High scores indicate a strong desire for social distance. 2.2.4. Problem definition Using an open-ended question, respondents were asked to indicate how they would label the problem described in the vignette. The responses were noted down by the interviewers, to be coded later using a coding system that had already proved to be useful in previous surveys. Four main categories were distinguished: correct psychiatric diagnosis, other psychiatric illness or unspecified psychiatric illness, personal problem (i.e., the subject described in the vignette is facing an acute life crisis or some chronic difficulty), and other definitions of the problem depicted in the vignette. If multiple labels were suggested by the respondent, only the label coming closest to the correct psychiatric diagnosis was registered. Interrater reliability was checked by having two people code 200 interviews independently of one another. Cohen’s kappa reached 0.85. For our analyses, the first two response categories were combined in the category bperceives problem as mental illnessQ, and the latter two in the category bperceives problem not as mental illnessQ.
3. Results As shown in Table 1, in both years (1990 and 2001), respondents reacted to the individual with major depression most frequently with pity or other related feelings, such as empathy and the desire to
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Table 1 Emotional reactions of the German public towards people with major depression: comparison between 1990 and 2001 Dimension Fear
Pity
Anger
Emotional reactions
1990 (n=501, %)a
2001 (n=2012, %)a
Uneasiness Feelings of insecurity Fear Desire to help Pity Empathy Lack of understanding Irritation Anger Ridicule
34.8 25.3 24.8 60.0 59.7 24.6 14.1 9.5 6.8 4.4
33.9 25.1 20.9 65.8 64.0 33.3 13.6 12.9 7.8 4.2
a
Respondents who endorsed either of the two points on the five-point Likert scale on the side of the midpoint with the anchor a˜ strongly agreea˜ were grouped together.
help. After pity, respondents most frequently reacted with fear, uneasiness, and feelings of insecurity. Least frequently, the individual depicted in the vignette elicited anger and other aggressive reactions, such as lack of understanding, irritation, and ridicule. In order to examine whether emotional reactions have changed over the study period, a multiple regression analysis was calculated, with time as independent and the three emotional dimensions (pity, fear, and anger) as dependent variables, controlling for the effect of gender, age, and educational attainment as well as whether respondents labelled the individual depicted in the vignette as suffering from depression or another mental illness or not (Table 2). Regarding pity, there was a significant change between the two surveys, with more respondents reacting this way in 2001 than in 1990. However, there was also a slight increase in the tendency to react with anger. There was no change with regard to fear, except for a significant interaction effect (B= 0.185, S.E.= 0.093, p=0.048) indicating that the preexisting gender difference, i.e., women reacting more frequently with fear, has decreased. Apart from this, there were no significant interaction effects between sociodemographic characteristics of the respondents or labelling as mental illness on the one hand and time on the other. Over the 11 years, the public’s desire for social distance from the individual with major depression has remained unchanged (Tables 3 and 4). While in
Table 2 Regression of emotional reactions on time, labeling, gender, age and education attainment B
S.E.
pN|t|
0.033 0.028 0.167 0.001 0.153 0.282
0.046 0.038 0.037 0.001 0.021 0.106
0.476 0.466 0.000 0.208 0.000 0.008
Pity Time (2001=1) Labeling (mental illness =1) Gender (female=1) Age Educational attainment Constant
0.127 0.004 0.214 0.004 0.012 0.037
0.047 0.039 0.038 0.001 0.022 0.109
0.007 0.913 0.000 0.718 0.586 0.734
Anger Time (2001=1) Labeling (mental illness=1) Gender (female=1) Age Educational attainment Constant
0.117 0.154 0.215 a˜ 0.002 0.060 a˜ 0.225
0.049 0.040 0.039 0.001 0.022 0.112
0.017 0.000 0.000 0.114 0.007 0.044
Fear Time (2001=1) Labeling (mental illness=1) Gender (female=1) Age Educational attainment Constant
1990, labelling had a significant effect, with respondents who considered the individual as suffering from depression or another mental illness expressing a stronger desire for social distance, this difference has disappeared in 2001 (interaction labelingtime: B= 0.185, S.E.= 0.093, p=0.048). There were no significant interaction effects between sociodemographic characteristics and time.
Table 3 Desire of the German public for social distance from people with major depression: comparison between 1990 and 2001 Work together Neighbor Rent a room Introduce to friends Recommend for job Marry into family Child care a
1990 (n=501, %)a
2001 (n=1983, %)a
16.5 18.0 35.4 38.8 41.6 53.3 56.7
15.9 17.7 38.4 39.4 41.5 48.4 66.6
Respondents who endorsed either of the two points on the five-point Likert scale on the side of the midpoint with the anchor bstrongly agreeQ were grouped together.
M.C. Angermeyer, H. Matschinger / Journal of Affective Disorders 83 (2004) 177–182 Table 4 Regression of social distance on time, labeling, gender, age and educational attainment B Time (2001=1) Labeling (mental illness =1) Gender (female=1) Age Educational attainment Constant
0.037 0.030 0.048 0.008 0.068 0.326
S.E.
pN|t|
0.048 0.040 0.039 0.001 0.022 0.110
0.432 0.454 0.209 0.000 0.002 0.003
Across both surveys, female respondents tended to react more frequently with pity as well as with fear, and less frequently with anger. There was no gender difference with regard to the desire for social distance. The three emotional reactions were not related to age. The desire for social distance increased with increasing age. Respondents with higher educational attainment expressed less fear and anger; their desire for social distance was less strong than that of respondents with lower educational attainment. Labelling the individual depicted in the vignette as suffering from depression or another mental illness was associated with less anger. However, in all analyses, the sociodemographic variables together with labelling and time of survey explained only a very small percentage of variance, with an adjusted R 2 not exceeding 0.03.
4. Discussion The optimistic view expressed by other authors (Althaus et al., 2001) that attitudes to people with depression have improved in recent years is not supported by our findings. Only with regard to prosocial reactions—the tendency to feel pity for or to empathize with people suffering from the disorder, or to feel the need to help them—can a slight change for the better be observed. It is not unlikely that this results from the increase in media coverage including voluntary disclosures of depression by public figures as well as the publication of first-person accounts of people with the disorder, both of which may have helped the public to empathize with those suffering from the illness. However, the tendency to react aggressively, i.e., with anger, irritation, or lack of understanding, has also increased slightly. In 2001, depressive behavior elicited as much fear as it did in
181
1990. The desire to distance oneself from someone with depression was also as strong in 2001 as it had been in 1990. Overall, one has to conclude that the attitudes of the public in Western Germany have remained more or less unchanged, regardless of gender (with the exception of fear), age, and educational attainment. The stigma concept proposed by Corrigan and Watson (2002) allows us to connect both attitudinal components, emotional reactions and desire for social distance, with each other. According to these authors, people who endorse negative stereotypes, i.e., notions of the mentally ill, which have collectively been agreed upon, generate emotional reactions, which, in turn, lead to social discrimination as expressed by the desire for social distance. As the increase of positive reactions (pity) has been paralleled by an increase of negative reactions (anger), i.e., the time trends for both have more or less neutralized each other, it is not surprising that the desire for social distance remained unchanged over the study period. We are unable to say whether our findings are specific to Germany, or whether they can be generalized. There is only one other study—from Great Britain—on time trends of public attitudes towards depression (Paykel et al., 1998). However, this study— which was carried out in the context of the Defeat Depression Campaign launched by the Royal College of Psychiatrists—was mainly focused on public beliefs about the causes and treatment of depression plus views about general practitioners rather than on how the public reacts to depressed people. In contrast to schizophrenia (Angermeyer and Matschinger, 2003), labelling of people with depression as mentally ill appears to have no substantial effect on public attitudes, and if so, it is a positive rather than a negative one. This may in part be because the term bdepressionQ is somewhat enigmatic, denoting a wide range of mental health problems and not necessarily a serious mental disorder (as is most likely the case with schizophrenia). The fact that respondents who identified the person depicted in the vignette as suffering from a mental illness tended to express less anger may result from a greater readiness to grant the privileges of the patient role (Parsons, 1958) and not to hold the patient responsible for the illness. Because our findings challenge the notion that the stigma of depression has been declining in recent years
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and provide convincing evidence that people with this disorder are still being exposed to negative reactions of the public, further efforts are needed to improve public acceptance of people with depression. Currently, an intervention program is under way in a large German city (bNuremberg Alliance against DepressionQ). It is aimed at informing the public about depressive illness and preventing suicide (Althaus et al., 2001). This and similar programs may help to reduce the stigma attached to those suffering from the illness. Finally, some limitations of our study should be addressed. First, this is a comparison of two crosssectional studies and not a panel study which would allow an examination of the development over time of attitudes on an individual level. Second, the relationship between attitudes and social distance was examined. Other forms of discrimination such as structural discrimination were not considered. Third, the use of the vignette methodology limits our conclusions to the responses given in the case presented, which may not be identical to the responses that would be given in actual situations.
Acknowledgement The study was supported by the German Research Association (grant AN 101/5-1).
Appendix A. Vignette of major depressive disorder Imagine that you hear the following about an acquaintance with whom you occasionally spend your leisure time: Within the past two months, your acquaintance’s nature has changed. In contrast to previously, he is down and sad without being able to make out a concrete reason for his feeling low. He appears serious and worried. There is no longer anything that will make him laugh. He hardly ever talks, and if he says something, he speaks in a low tone of voice about the worries he has with regard to his future. Your acquaintance feels useless and has the impression of doing everything wrong. All attempts to cheer him up have failed. He has lost all interest in things and is not motivated to do anything. He complains of often waking up in the middle of the night and not being
able to get back to sleep. Even in the morning, he feels exhausted and without energy. He says that he encounters difficulty in concentrating on his job. Unlike before, everything takes him a very long time. He hardly manages his workload. As a consequence, he has already been summoned by his boss. References Althaus, D., Stefanek, J., Hasford, J., Hegerl, U., 2001. Wissensstand und Einstellungen der Allgemeinbevo¨lkerung zu Symptomen, Ursachen und Behandlungsmo¨glichkeiten depressiver Erkrankungen. Nervenarzt 73, 6559 – 6664. Angermeyer, M.C., Matschinger, H., 1997. Social distance towards the mentally ill: results of representative surveys in the Federal Republic of Germany. Psychol. Med. 27, 131 – 141. Angermeyer, M.C., Matschinger, H., 2003. The stigma of mental illness: effects of labelling on public attitudes towards people with mental disorder. Acta Psychiatr. Scand. 108, 304 – 309. Bogardus, E.S., 1925. Measuring social distances. J. Appl. Sociol. 1–2, 216 – 226. Corrigan, P.W., Watson, A.C., 2002. Understanding the impact of stigma on people with mental illness. World Psychiatry 1, 6 – 20. Gifi, A., 1990. Nonlinear Multivariate Analysis. Wiley, Chichester, New York. Greenacre, M.J., Blasius, J., 1994. Correspondence Analysis in the Social Sciences. Recent Developments and Applications. Academic Press, London. Hillert, A., Sandmann, J., Ehmig, S.C., Weisbecker, H., Kepplinger, H.M., Benkert, O., 1999. The general public’s cognitive and emotional perception of mental illnesses: an alternative to attitude-research. In: Guimo´n, J., Fischer, W., Sartorius, N. (Eds.), The Image of Madness. The Public Facing Mental Illness and Psychiatry. Karger, Basel, pp. 56 – 71. Jamison, K.R., 1995. An Unquiet Mind. Knopf, New York. Lebart, L., Morineau, A., Warwick, K.M., 1984. Multivariate Descriptive Statistical Analysis. Wiley, New York. Link, B.G., Cullen, F.T., Frank, J., Wozniak, J.F., 1987. The social rejection of former mental patients: understanding why labels matter. Am. J. Sociol. 92, 1461 – 1500. Manning, M.M., 1995. Undercurrents. A Life Beneath the Surface. HarperCollins, New York. Matschinger, H., 1996. Analysis of bdon’t knowQ answers by cluster analysis with optimal scaling features. In: Ferligoij, A., Kramberger, A. (Eds.), Developments in Data Analysis. Faculty of Social Sciences, University of Ljubljana, Ljubljana, pp. 167 – 184. Parsons, T., 1958. Definitions of health and illness in the light of American values and social structure. In: Jaco, E.g. (Ed.), Patients, Physicians and Illness. Free Press, New York. Paykel, E.S., Hart, D., Priest, R.G., 1998. Changes in public attitudes to depression during the defeat depression campaign. Br. J. Psychiatry 173, 519 – 522. Wurtzel, E., 1994. Prozac Nation. Young and Depressed in America. Houghton Mifflin, Boston.
Research report
Public attitudes to people with depression: have there been any changes over the last decade? Matthias C. Angermeyer*, Herbert Matschinger Department of Psychiatry, University of Leipzig, Johannisstr.20, 04317 Leipzig, Germany Received 3 March 2004; received in revised form 11 August 2004; accepted 12 August 2004
Abstract Background: A consistent finding of representative surveys that were conducted in Germany in the early 1990s was that people with depression encountered a substantial amount of stigma and discrimination. The aim of this study was to examine whether public attitudes have improved over the last decade or not. Methods: In 2001, a representative survey was carried out among the adult population of the boldQ Federal Republic of Germany using the same methodology as in a previous survey in 1990. Results: Regarding emotional reactions of the respondents towards people with depression, our findings are inconsistent. While there has been an increase in the readiness to feel pity and also a slight increase in the tendency to react aggressively, the expression of fear remained unchanged. The public’s desire for social distance from people with depression was as strong in 2001 as it had been in 1990. Conclusion: The hypothesis of a change for the better regarding public attitudes towards depressed people is not supported by our findings. Further efforts are needed to reach this goal. D 2004 Elsevier B.V. All rights reserved. Keywords: Public attitudes; Major depression; Time trend
1. Introduction In the early 1990s, several surveys investigated attitudes of the German public towards people with mental disorders. A consistent finding across all these * Corresponding author. Tel.: +49 341 9724530; fax: +49 341 97245. E-mail address: [email protected] (M.C. Angermeyer). 0165-0327/$ - see front matter D 2004 Elsevier B.V. All rights reserved. doi:10.1016/j.jad.2004.08.001
surveys was that—while people with alcohol dependence or schizophrenia were mostly rejected—people with depression also encountered a substantial amount of stigma and discrimination. For example, 35% of the general population would not rent a room to someone with major depression, and 42% refused to recommend him for a job (Angermeyer and Matschinger, 1997). Only 20% wanted to talk with neighbours, colleagues, or acquaintances about a close relative suffering from depression. This number compares
178
M.C. Angermeyer, H. Matschinger / Journal of Affective Disorders 83 (2004) 177–182
with 64% in the case of hypertension, or 55% in the case of diabetes (Hillert et al., 1999). The question arises as to whether today, a decade later, the stigma attached to depression is still the same or whether there have been any changes. Some observations suggest that public attitudes might have improved in recent years. There has been an increase in media coverage including voluntary disclosures of affective disorders by public figures which may reflect a more accepting attitude and may itself have had a destigmatizing effect. Moreover, a number of best-selling first-person accounts of people with affective disorders have been published (e.g., Wurtzel, 1994; Jamison, 1995; Manning, 1995). In fact, the authors of a report on a survey that was conducted in 2001 in two German cities come to the conclusion that bin recent years, knowledge and attitudes of the public about depression appear to have improved as compared with previous surveysQ (Althaus et al., 2001). Unfortunately, all the studies mentioned have used different methods, thus precluding a direct comparison of the data. Therefore, the authors’ conclusion remains somewhat tentative. A nationwide survey that was conducted in spring 2001 provided the first opportunity to test the hypothesis that public attitudes have improved in Germany over the past 10 years, since, in this study, the same methodology regarding sampling, interview type and assessment instruments was used as in a previous survey conducted in 1990. Based on the data from these two surveys, the following questions will be addressed: !
!
Does the German public show more positive and less negative emotional reactions towards people with major depression in 2001 than in 1990? Is the desire of the German public for social distance from people with major depression less pronounced in 2001 than it was in 1990?
2. Method 2.1. Surveys In 1990, a representative survey was conducted in the boldQ Federal Republic of Germany, involving German citizens aged 18 years or over who were
living in private households. The sample was drawn using a three-stage random sampling procedure with electoral wards at the first stage, households at the second, and individuals within the target households at the third stage. Target households within the sample points were determined according to the random route procedure (i.e., a household was selected randomly as a starting point from where a set route through the area was followed). Target individuals were selected according to random digits. In total, 2118 interviews were completed, the response rate being 65.5%. In 2001, another representative survey was conducted in Germany. This time, the sampling frame differed, with the sample being drawn from the whole of Germany, and the number of interviews conducted in the East and the West reflecting the proportion of the population living in both parts of the country. Apart from this, the same sampling procedure was used as in the 1990 survey. In total, 5025 interviews were conducted, which reflects a response rate of 65.1%; 4005 interviews resulted from the boldQ laender (equivalent of the boldQ Federal Republic of Germany). In both surveys, informed consent was considered to have been given when individuals agreed to complete the interview. Regarding gender and age, in 1990 and 2001, the samples were comparable to the whole of the German population aged 18 years and over in the two respective years (Official Registry Report 1992/2002). 2.2. Interview A personal, fully structured interview was conducted that was largely identical in both surveys. The vignette as well as all the measures needed for this analysis were the same. Therefore, no pretesting was necessary. 2.2.1. Vignette The interview began with the presentation of a vignette containing a diagnostically unlabelled psychiatric case history. De facto, the case histories either depicted a case of schizophrenia or major depressive disorder. The symptoms described in the vignettes fulfilled the criteria of DSM-III-R for the respective disorder. Before being used in the surveys, the vignettes had been submitted to five psychiatrists or psychologists (all proven experts on psychopathol-
M.C. Angermeyer, H. Matschinger / Journal of Affective Disorders 83 (2004) 177–182
ogy) for blind diagnostic allocation. All experts were able to provide the correct diagnoses for both case histories. Random subsamples were presented with only one vignette. In this paper, only interviews with the vignette depicting someone suffering from major depression will be used. 2.2.2. Emotional reactions Respondents were asked to indicate their emotional reactions to the person described in the vignette by means of twelve five-point Likert-scaled (1=definitely the case, 5=definitely not the case) items. Factor analysis with varimax rotation yielded the following three dimensions which are virtually identical with those identified in a previous study (Angermeyer and Matschinger, 1997): !
!
!
Fear (eigenvalue 3.9; explained variance 32.5%)— uneasiness (factor loading 0.85), fear (0.81), feelings of insecurity (0.77), and embarrassment (0.52). Pity (eigenvalue 1.9; explained variance 16.1%)— desire to help (factor loading 0.79), empathy (0.78), and pity (0.66). Anger (eigenvalue 1.3; explained variance 10.6%)—ridicule (factor loading 0.77), anger (0.74), irritation (0.74), and lack of understanding (0.63).
2.2.3. Social distance For the assessment of respondents’ desire for social distance, we made use of a scale developed by Link et al. (1987)—a modified version of the Bogardus Social Distance Scale (Bogardus, 1925). It includes the following seven items representing various social relationships to the respondent: – – – – – –
Would you rent out a room to somebody with these problems? Would you accept a person like this as your coworker? Would you accept a person like this as your neighbour? Would you hire this person for taking care of your kids for a few hours? Would you accept a person like this as an in-law? Would you introduce someone like this to your friends?
–
179
If a friend of yours was looking for an employee, would you recommend a person like this?
Using a five-point Likert scale ranging from bin any caseQ (1) to bin no case at allQ (5), the respondents could indicate to what extent they would, in the situation presented, accept the person described in the vignette. With the seven items, a homogeneity analysis (Gifi, 1990) was carried out that provides both optimal quantifications for the categories of the items and scores for the observations maximizing the internal consistency (Greenacre and Blasius, 1994; Lebart et al., 1984; Matschinger, 1996). Reliability (Cronbach’s alpha) was 0.86. The object scores of the first axis were used for further analysis. High scores indicate a strong desire for social distance. 2.2.4. Problem definition Using an open-ended question, respondents were asked to indicate how they would label the problem described in the vignette. The responses were noted down by the interviewers, to be coded later using a coding system that had already proved to be useful in previous surveys. Four main categories were distinguished: correct psychiatric diagnosis, other psychiatric illness or unspecified psychiatric illness, personal problem (i.e., the subject described in the vignette is facing an acute life crisis or some chronic difficulty), and other definitions of the problem depicted in the vignette. If multiple labels were suggested by the respondent, only the label coming closest to the correct psychiatric diagnosis was registered. Interrater reliability was checked by having two people code 200 interviews independently of one another. Cohen’s kappa reached 0.85. For our analyses, the first two response categories were combined in the category bperceives problem as mental illnessQ, and the latter two in the category bperceives problem not as mental illnessQ.
3. Results As shown in Table 1, in both years (1990 and 2001), respondents reacted to the individual with major depression most frequently with pity or other related feelings, such as empathy and the desire to
180
M.C. Angermeyer, H. Matschinger / Journal of Affective Disorders 83 (2004) 177–182
Table 1 Emotional reactions of the German public towards people with major depression: comparison between 1990 and 2001 Dimension Fear
Pity
Anger
Emotional reactions
1990 (n=501, %)a
2001 (n=2012, %)a
Uneasiness Feelings of insecurity Fear Desire to help Pity Empathy Lack of understanding Irritation Anger Ridicule
34.8 25.3 24.8 60.0 59.7 24.6 14.1 9.5 6.8 4.4
33.9 25.1 20.9 65.8 64.0 33.3 13.6 12.9 7.8 4.2
a
Respondents who endorsed either of the two points on the five-point Likert scale on the side of the midpoint with the anchor a˜ strongly agreea˜ were grouped together.
help. After pity, respondents most frequently reacted with fear, uneasiness, and feelings of insecurity. Least frequently, the individual depicted in the vignette elicited anger and other aggressive reactions, such as lack of understanding, irritation, and ridicule. In order to examine whether emotional reactions have changed over the study period, a multiple regression analysis was calculated, with time as independent and the three emotional dimensions (pity, fear, and anger) as dependent variables, controlling for the effect of gender, age, and educational attainment as well as whether respondents labelled the individual depicted in the vignette as suffering from depression or another mental illness or not (Table 2). Regarding pity, there was a significant change between the two surveys, with more respondents reacting this way in 2001 than in 1990. However, there was also a slight increase in the tendency to react with anger. There was no change with regard to fear, except for a significant interaction effect (B= 0.185, S.E.= 0.093, p=0.048) indicating that the preexisting gender difference, i.e., women reacting more frequently with fear, has decreased. Apart from this, there were no significant interaction effects between sociodemographic characteristics of the respondents or labelling as mental illness on the one hand and time on the other. Over the 11 years, the public’s desire for social distance from the individual with major depression has remained unchanged (Tables 3 and 4). While in
Table 2 Regression of emotional reactions on time, labeling, gender, age and education attainment B
S.E.
pN|t|
0.033 0.028 0.167 0.001 0.153 0.282
0.046 0.038 0.037 0.001 0.021 0.106
0.476 0.466 0.000 0.208 0.000 0.008
Pity Time (2001=1) Labeling (mental illness =1) Gender (female=1) Age Educational attainment Constant
0.127 0.004 0.214 0.004 0.012 0.037
0.047 0.039 0.038 0.001 0.022 0.109
0.007 0.913 0.000 0.718 0.586 0.734
Anger Time (2001=1) Labeling (mental illness=1) Gender (female=1) Age Educational attainment Constant
0.117 0.154 0.215 a˜ 0.002 0.060 a˜ 0.225
0.049 0.040 0.039 0.001 0.022 0.112
0.017 0.000 0.000 0.114 0.007 0.044
Fear Time (2001=1) Labeling (mental illness=1) Gender (female=1) Age Educational attainment Constant
1990, labelling had a significant effect, with respondents who considered the individual as suffering from depression or another mental illness expressing a stronger desire for social distance, this difference has disappeared in 2001 (interaction labelingtime: B= 0.185, S.E.= 0.093, p=0.048). There were no significant interaction effects between sociodemographic characteristics and time.
Table 3 Desire of the German public for social distance from people with major depression: comparison between 1990 and 2001 Work together Neighbor Rent a room Introduce to friends Recommend for job Marry into family Child care a
1990 (n=501, %)a
2001 (n=1983, %)a
16.5 18.0 35.4 38.8 41.6 53.3 56.7
15.9 17.7 38.4 39.4 41.5 48.4 66.6
Respondents who endorsed either of the two points on the five-point Likert scale on the side of the midpoint with the anchor bstrongly agreeQ were grouped together.
M.C. Angermeyer, H. Matschinger / Journal of Affective Disorders 83 (2004) 177–182 Table 4 Regression of social distance on time, labeling, gender, age and educational attainment B Time (2001=1) Labeling (mental illness =1) Gender (female=1) Age Educational attainment Constant
0.037 0.030 0.048 0.008 0.068 0.326
S.E.
pN|t|
0.048 0.040 0.039 0.001 0.022 0.110
0.432 0.454 0.209 0.000 0.002 0.003
Across both surveys, female respondents tended to react more frequently with pity as well as with fear, and less frequently with anger. There was no gender difference with regard to the desire for social distance. The three emotional reactions were not related to age. The desire for social distance increased with increasing age. Respondents with higher educational attainment expressed less fear and anger; their desire for social distance was less strong than that of respondents with lower educational attainment. Labelling the individual depicted in the vignette as suffering from depression or another mental illness was associated with less anger. However, in all analyses, the sociodemographic variables together with labelling and time of survey explained only a very small percentage of variance, with an adjusted R 2 not exceeding 0.03.
4. Discussion The optimistic view expressed by other authors (Althaus et al., 2001) that attitudes to people with depression have improved in recent years is not supported by our findings. Only with regard to prosocial reactions—the tendency to feel pity for or to empathize with people suffering from the disorder, or to feel the need to help them—can a slight change for the better be observed. It is not unlikely that this results from the increase in media coverage including voluntary disclosures of depression by public figures as well as the publication of first-person accounts of people with the disorder, both of which may have helped the public to empathize with those suffering from the illness. However, the tendency to react aggressively, i.e., with anger, irritation, or lack of understanding, has also increased slightly. In 2001, depressive behavior elicited as much fear as it did in
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1990. The desire to distance oneself from someone with depression was also as strong in 2001 as it had been in 1990. Overall, one has to conclude that the attitudes of the public in Western Germany have remained more or less unchanged, regardless of gender (with the exception of fear), age, and educational attainment. The stigma concept proposed by Corrigan and Watson (2002) allows us to connect both attitudinal components, emotional reactions and desire for social distance, with each other. According to these authors, people who endorse negative stereotypes, i.e., notions of the mentally ill, which have collectively been agreed upon, generate emotional reactions, which, in turn, lead to social discrimination as expressed by the desire for social distance. As the increase of positive reactions (pity) has been paralleled by an increase of negative reactions (anger), i.e., the time trends for both have more or less neutralized each other, it is not surprising that the desire for social distance remained unchanged over the study period. We are unable to say whether our findings are specific to Germany, or whether they can be generalized. There is only one other study—from Great Britain—on time trends of public attitudes towards depression (Paykel et al., 1998). However, this study— which was carried out in the context of the Defeat Depression Campaign launched by the Royal College of Psychiatrists—was mainly focused on public beliefs about the causes and treatment of depression plus views about general practitioners rather than on how the public reacts to depressed people. In contrast to schizophrenia (Angermeyer and Matschinger, 2003), labelling of people with depression as mentally ill appears to have no substantial effect on public attitudes, and if so, it is a positive rather than a negative one. This may in part be because the term bdepressionQ is somewhat enigmatic, denoting a wide range of mental health problems and not necessarily a serious mental disorder (as is most likely the case with schizophrenia). The fact that respondents who identified the person depicted in the vignette as suffering from a mental illness tended to express less anger may result from a greater readiness to grant the privileges of the patient role (Parsons, 1958) and not to hold the patient responsible for the illness. Because our findings challenge the notion that the stigma of depression has been declining in recent years
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and provide convincing evidence that people with this disorder are still being exposed to negative reactions of the public, further efforts are needed to improve public acceptance of people with depression. Currently, an intervention program is under way in a large German city (bNuremberg Alliance against DepressionQ). It is aimed at informing the public about depressive illness and preventing suicide (Althaus et al., 2001). This and similar programs may help to reduce the stigma attached to those suffering from the illness. Finally, some limitations of our study should be addressed. First, this is a comparison of two crosssectional studies and not a panel study which would allow an examination of the development over time of attitudes on an individual level. Second, the relationship between attitudes and social distance was examined. Other forms of discrimination such as structural discrimination were not considered. Third, the use of the vignette methodology limits our conclusions to the responses given in the case presented, which may not be identical to the responses that would be given in actual situations.
Acknowledgement The study was supported by the German Research Association (grant AN 101/5-1).
Appendix A. Vignette of major depressive disorder Imagine that you hear the following about an acquaintance with whom you occasionally spend your leisure time: Within the past two months, your acquaintance’s nature has changed. In contrast to previously, he is down and sad without being able to make out a concrete reason for his feeling low. He appears serious and worried. There is no longer anything that will make him laugh. He hardly ever talks, and if he says something, he speaks in a low tone of voice about the worries he has with regard to his future. Your acquaintance feels useless and has the impression of doing everything wrong. All attempts to cheer him up have failed. He has lost all interest in things and is not motivated to do anything. He complains of often waking up in the middle of the night and not being
able to get back to sleep. Even in the morning, he feels exhausted and without energy. He says that he encounters difficulty in concentrating on his job. Unlike before, everything takes him a very long time. He hardly manages his workload. As a consequence, he has already been summoned by his boss. References Althaus, D., Stefanek, J., Hasford, J., Hegerl, U., 2001. Wissensstand und Einstellungen der Allgemeinbevo¨lkerung zu Symptomen, Ursachen und Behandlungsmo¨glichkeiten depressiver Erkrankungen. Nervenarzt 73, 6559 – 6664. Angermeyer, M.C., Matschinger, H., 1997. Social distance towards the mentally ill: results of representative surveys in the Federal Republic of Germany. Psychol. Med. 27, 131 – 141. Angermeyer, M.C., Matschinger, H., 2003. The stigma of mental illness: effects of labelling on public attitudes towards people with mental disorder. Acta Psychiatr. Scand. 108, 304 – 309. Bogardus, E.S., 1925. Measuring social distances. J. Appl. Sociol. 1–2, 216 – 226. Corrigan, P.W., Watson, A.C., 2002. Understanding the impact of stigma on people with mental illness. World Psychiatry 1, 6 – 20. Gifi, A., 1990. Nonlinear Multivariate Analysis. Wiley, Chichester, New York. Greenacre, M.J., Blasius, J., 1994. Correspondence Analysis in the Social Sciences. Recent Developments and Applications. Academic Press, London. Hillert, A., Sandmann, J., Ehmig, S.C., Weisbecker, H., Kepplinger, H.M., Benkert, O., 1999. The general public’s cognitive and emotional perception of mental illnesses: an alternative to attitude-research. In: Guimo´n, J., Fischer, W., Sartorius, N. (Eds.), The Image of Madness. The Public Facing Mental Illness and Psychiatry. Karger, Basel, pp. 56 – 71. Jamison, K.R., 1995. An Unquiet Mind. Knopf, New York. Lebart, L., Morineau, A., Warwick, K.M., 1984. Multivariate Descriptive Statistical Analysis. Wiley, New York. Link, B.G., Cullen, F.T., Frank, J., Wozniak, J.F., 1987. The social rejection of former mental patients: understanding why labels matter. Am. J. Sociol. 92, 1461 – 1500. Manning, M.M., 1995. Undercurrents. A Life Beneath the Surface. HarperCollins, New York. Matschinger, H., 1996. Analysis of bdon’t knowQ answers by cluster analysis with optimal scaling features. In: Ferligoij, A., Kramberger, A. (Eds.), Developments in Data Analysis. Faculty of Social Sciences, University of Ljubljana, Ljubljana, pp. 167 – 184. Parsons, T., 1958. Definitions of health and illness in the light of American values and social structure. In: Jaco, E.g. (Ed.), Patients, Physicians and Illness. Free Press, New York. Paykel, E.S., Hart, D., Priest, R.G., 1998. Changes in public attitudes to depression during the defeat depression campaign. Br. J. Psychiatry 173, 519 – 522. Wurtzel, E., 1994. Prozac Nation. Young and Depressed in America. Houghton Mifflin, Boston.