Department of Psychiatry, University of Leipzig, Germany
Correspondence: Professor Dr M.C. Angermeyer, University of Leipzig, Department of Psychiatry, Johannisallee 20, D-04317 Leipzig, Germany.Tel: +49 341 9724530; fax: +49 341 9724539 24539; e-mail: krausem{at}medizin.uni-leipzig.de
Declaration of interest None. Funding detailed in Acknowledgement.
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ABSTRACT |
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Aims To examine how the German publics causal attributions of schizophrenia and their desire for social distance from people with schizophrenia developed over the 1990s.
Method A trend analysis was carried out using data from two representative population surveys conducted in the Länder constituting the former Federal Republic of Germany in 1990 and 2001.
Results Parallel to an increase in the publics tendency to endorse biological causes, an increase in the desire for social distance from people with schizophrenia was found.
Conclusions The assumption underlying current anti-stigma programmes that there is a positive relationship between endorsing biological causes and the acceptance of people with mental illness appears to be problematic.
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INTRODUCTION |
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METHOD |
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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 the 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%), 4020 of which were obtained in the States (Länder) representing the former Federal Republic of Germany. The socio-demographic characteristics of both samples are shown in Table 1. For comparison, data from the Official Registry for the total population are also provided; no major difference is apparent.
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Interview
In both surveys a largely identical personal, fully structured interview
was conducted. Therefore, no pre-testing was necessary for the second survey.
In both surveys, the same vignettes and the same instruments were applied and
used for analyses.
Vignettes
At the beginning of the interview respondents were presented with a
vignette of a diagnostically unlabelled psychiatric case history, depicting a
case of either schizophrenia or major depressive disorder. The symptoms
described in the vignettes fulfilled the criteria of DSMIIIR
(American Psychiatric Association,
1987) 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 the actual diagnosis, providing
confirmation of the correct diagnosis for each case history. The respondents
were randomly allocated to receive one of the two vignettes. In this analysis
only data from interviews containing the vignette depicting schizophrenia have
been used (1990 survey, n=511; 2001 survey, n=1987).
Causal attributions
Respondents attributions of the cause of the schizophrenic disorder
depicted in the vignette were assessed by responses to eight items, with two
items each referencing psychosocial stress (life event, stress at work),
biological causes (brain disease, heredity), conditions of socialisation
(broken home, lack of parental affection) or causes that individuals could
influence themselves (lack of willpower, immoral lifestyle). 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.
Social distance
For the assessment of respondents desire for social distance we used
a scale developed by Link et al
(1987), a modified version of
the Bogardus Social Distance Scale
(Bogardus, 1925). It includes
seven items representing the following social relationships: tenant,
co-worker, neighbour, member of the same social circle, person one would
recommend for a job, 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.
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 peoples causal attributions and their
desire for social distance. The year 2001 served as the 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
(Stata, 2003), using the 510
sample points as primary sampling units. Owing to the large sample sizes, the
power of statistical tests was quite high; effect sizes therefore were also
calculated.
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RESULTS |
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Change in beliefs during the 1990s
During the 1990s the most pronounced changes occurred with regard to
biological causes. The percentage of those who endorsed brain disease and
hereditary factors as a cause increased substantially, from 55% to 70% and
from 45% to 60%, respectively. With values of 0.39, effect sizes indicated a
small to medium effect. The attribution to psychosocial stress remained
practically unchanged. However, the readiness to blame the individual for the
illness decreased considerably. In 2001 the respondents attributed the cause
less frequently to a lack of will power than 11 years before, and the same
applies to the conditions under which the individual grew up, with a broken
home being less frequently assumed to be a cause. In conclusion, one can state
that during the 1990s the gap between mental health professionals views
on the origin of schizophrenia and public beliefs became narrower. There is a
stronger tendency towards adopting the causal explanations approved of by
psychiatry, whereas those that are disapproved of are more frequently rejected
(Table 2).
Changes in desire for social distance during the 1990s
In sharp contrast to the changes observed with regard to the publics
causal attributions was the development of the publics desire for
social distance from people with schizophrenia. Rather than having decreased,
as one might expect, the desire for social distance in all social
relationships studied increased markedly
(Table 3). For example, whereas
19% of the respondents rejected an individual with schizophrenia as a
neighbour in 1990, this number had risen to 35% in 2001; in 1990 about 44%
would not rent a room to someone with schizophrenia but in 2001 this
proportion amounted to 63%.
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DISCUSSION |
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Time trends in major depression
The question arises as to whether our findings are specific for
schizophrenia or apply to other mental disorders as well. Comparison with data
for major depression derived from the same survey reveals that the changes
concerning the endorsement of biological factors were here far less
pronounced: in 2001, brain disease was assumed to be a cause as frequently as
in 1990, and the tendency to attribute the cause to hereditary factors
increased only slightly (effect size 0.15 as compared with 0.39 for
schizophrenia). The desire for social distance remained virtually unchanged
across all social relationships over the study period. Thus, the time trends
of causal attributions and the desire for social distance with regard to major
depression differed markedly from those found with schizophrenia. However, the
observation that there was hardly any change of causal attributions and social
distance is not inconsistent with the notion of a positive association between
the two that has been observed with schizophrenia.
Relationship between causal attributions and desire for social distance
The results of our trend analysis correspond with those of cross-sectional
analyses of the data from 1990 and 2001. In both surveys, an assumption that
biological factors were a cause of schizophrenia was positively associated
with a greater preference for social distance. Moreover, in 2001 this
association was significantly stronger than in 1990. A more detailed analysis
revealed that the more respondents endorsed biological factors (particularly
brain disease) as a cause, the more lacking in self-control, unpredictable and
dangerous they believed individuals with schizophrenia to be. This, in turn,
was associated with a higher degree of fear, which resulted in a stronger
desire for social distance (Dietrich et
al, 2005).
Societal changes and their influences on social distance
Apart from public beliefs, other factors might have influenced
peoples attitudes towards those with mental illness. During the 1990s,
mainly due to reunification, major societal changes took place in Germany; for
example, the unemployment rate increased substantially. However, this should
not have affected the publics attitudes to people with schizophrenia,
since in our samples no significant association between the respondents
employment status and their desire for social distance could be found.
Cutbacks in health services and other aspects of the welfare state, which
might also have an effect on public attitudes to people with mental illness,
became effective only after our second survey had been completed. In the early
1990s a number of violent acts against prominent figures had been committed in
Germany by individuals who were mentally ill. Although following these
incidents negative attitudes of the public to people with schizophrenia
increased, they did not persist at the same level during the subsequent years.
Thus, it seems unlikely that this could be responsible for the stronger desire
for social distance expressed by the respondents in 2001
(Angermeyer & Matschinger,
1996; Angermeyer & Schulze,
2001).
Implications for anti-stigma interventions
In conclusion, one has to say that we are facing a dilemma. On the one
hand, there are good reasons for improving the publics mental health
literacy by informing them about the views shared by mental health
professionals on the aetiology of schizophrenia, as they may have a positive
effect on peoples readiness to seek professional help
(Angermeyer et al,
1999); on the other, promulgating biological factors as a cause of
the disorder may lead to more instead of less rejection. Against the backdrop
of our findings, the idea underlying some current anti-stigma programmes
namely that by educating people about biological causes of
schizophrenia their attitudes will automatically improve appears
rather problematic. Our concern is that, in the end, the opposite of what was
originally intended may occur.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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REFERENCES |
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Received for publication May 18, 2004. Revision received September 23, 2004. Accepted for publication September 30, 2004.