Beijing Hui Long Guan Hospital, Beijing, China and Department of Social Medicine, Harvard Medical School, Cambridge, MA, USA
Guangji Hospital, Suzhou, China
Department of Psychiatry, University of North Carolina at Chapel Hill, NC, USA
Jilin Provincial Neuropsychiatric Hospital, Siping, China.
Correspondence: Dr R. Phillips, Research Center of Clinical Epidemiology, Beijing Hui Long Guan Hospital, Beijing 100096, People's Republic of China
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ABSTRACT |
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Aims To develop a quantitative measure suitable for assessing the relationship of causal beliefs to expressed emotion, stigma, care-seeking and adherence.
Method The Causal Models Questionnaire for Schizophrenia, which includes 45 causes identified during indepth interviews with family members, was administered to 245 family members of 135 patients with DSM-III-R schizophrenia in Suzhou and Siping, China at the time of admission to hospital.
Results Respondents, who identified a mean of 2.5 causes (range 1-10, mode 2), attributed 84% of the cause of schizophrenia to social, interpersonal and psychological problems. Hence, their beliefs do not concur with Chinese professionals' ideas about the biomedical causes of schizophrenia. Multivariate analyses identified the socio-economic factors that influence family members' causal beliefs.
Conclusions Despite the complexity of causal models, measures can be developed that will help improve clinicians' communication with patients and understanding of help-seeking behaviours.
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INTRODUCTION |
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It has, however, proven difficult to develop a satisfactory method of assessing causal models because individuals commonly consider multiple causal explanations at the same time and because beliefs about an illness may change over time. This paper describes the development of the Causal Models Questionnaire for Schizophrenia (CMQS) in China and reports preliminary results of administering this instrument to family members of persons admitted to hospital with schizophrenia.
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METHOD |
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The final version of the CMQS, which takes 15-20 minutes to administer, includes four steps : (a) respondents, who are interviewed individually, are asked in an openended manner about their current and past beliefs about the causes of the first occurrence of the problem that led to admission to hospital ; (b) the 45 causes (excluding causes spontaneously reported) are read one at a time and respondents are asked whether they ever thought that the stated reason was a cause of the problem - if so, they classify the strength of its relationship to the problem as definite, definite but secondary or possible ; (c) respondents then rank all endorsed causes according to the time they first thought of them and according to their perceived importance at the time of the interview ; (d) respondents identify the person(s) who first mentioned each endorsed cause and indicate whether the perceived importance of each cause changed after the respondent made contact with psychiatrists.
Relative importance of different causes
A simple measure of the importance of a specific causal explanation for
schizophrenia (or any other illness) is the proportion of respondents who
identify the cause or, if there is more than one respondent for a particular
patient, the proportion of patients for whom at least one respondent
identifies the cause. The problem with these proportional measures is that
they do not take into consideration the relative importance of causes
attributed by respondents (Matschinger
& Angermeyer, 1996), the number of causes identified by each
respondent or the number of respondents per patient.
To overcome this problem, we developed the following weighting algorithm to assess the relative importance of each endorsed cause : the weighted importance of a specific cause for a single respondent equals 200 x (number of causes reported by respondent minus reported rank of cause+0.5) divided by the square of the number of causes reported by the respondent.
This algorithm generates weighted importance measures (range 0-100) for each endorsed cause ; the total weighted importance for all causes for a single respondent equals 100. If there are multiple respondents per patient, the weighted importance is the sum of the weighted importance of the cause for all respondents divided by the number of respondents. The weighted importance for a class of causes is the simple sum of the weighted importance of all specific causes included in the class. This weighted importance measure is more sensitive than proportional measures to differences between groups of respondents (or patients) and to changes in respondents' causal models over time. The test-retest and interrater reliabilities of the weighted importance measures are satisfactory : reevaluation of 29 CMQS family member respondents by a different interviewer (who was blind to the original result) an average of 33 days (range 21-45) after a first evaluation resulted in a mean intraclass correlation coefficient of the weighted importance measure for the six classes of causes of 0.67 (range 0.30-1.00).
Sample characteristics
The CMQS was administered to 245 family members (who gave written consent)
who were the principal caregivers of 135 consecutively admitted patients with
DSM-III-R schizophrenia (American
Psychiatric Association, 1987) at the time of admission to Guangji
Hospital in Suzhou and Jilin Provincial Neuropsychiatric Hospital in Siping.
The interviewers (Y.L. and L.X.) were attending psychiatrists who received 10
hours of training with the instrument.
The patients - 57 men (42%) and 78 women (58%) - had a mean age of 28.1 years (s.d.=6.5, range 16-42), a mean of 10.1 (s.d.=3.2) years of schooling (range 0-17), a mean duration of illness of 2.4 years (s.d.=1.6, range 0.5-6.3) and a mean of 1.6 (s.d.=0.8) admissions (range 1-5). This was the first admission for 81 (60%) of the patients.
Two family members were interviewed (independently) from 110 patients' families, and one family member was interviewed from 25 patients' families. The 245 respondents - 120 men (49%) and 125 women (51%) - had a mean age of 48.2 years (s.d.=12.4, range 20-75) and a mean of 7.4 (s.d.=4.0) years of schooling (range 0-17). Respondents included 94 mothers, 68 fathers, 54 spouses, 17 siblings and 12 other relatives. Of the respondents, 193 (78.8%) lived with the patient.
The following factors potentially relating to family members' causal models were also assessed.
Statistical methods
Several of the patient and respondent characteristics are related to each
other, so multivariate analyses were employed in order to identify factors
independently related to respondents' causal beliefs. Logistic regression was
used to determine the predictors of the dichotomous outcomes (i.e. whether or
not at least one family member reported a cause in each class of causes), and
multiple linear regression was used to determine the predictors of the
continuous outcomes (i.e. the weighted importance of each causal class). The
following variables were considered : patients' gender, age, years of
schooling, location of residence (rural v. urban), marital status
(currently married v. not currently married), employment status
(currently working v. not currently working), duration of illness,
number of admissions to hospital (single v. multiple), health
insurance status (insured v. uninsured), BPRS total score at index
admission, SANS-CV total score at admission, effect of the illness on the
family over the previous three months, mean family per capita income, and the
mean age and years of schooling of the family member(s) who completed the
CMQS. All variables were present for all cases (i.e. n=135 for all
analyses).
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RESULTS |
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Respondents attributed more than 84% of the cause of schizophrenia (i.e. the proportion of the combined importance of all causes) to social, interpersonal and psychological problems ; biological and spiritual causes accounted for less than 12% of the overall cause. The most important individual folk causes reported are stress, personality problems and conflicts in nonfamily relationships. None of the respondents endorsed brain disease as a cause of their relative's illness, and alcohol or drug misuse was identified as a cause for only two of the 135 patients.
Respondents identified 275 most important causes ; in 69% (189/275) of cases this was also the first cause considered at the onset of the illness. The relative ranking of the most important causes and of the first causes considered is similar to the ranking by weighted importance presented in Table 1. In 92% of cases (567/614), respondents identified themselves as the first person to consider the endorsed cause. Only four respondents reported changing their beliefs about the cause of schizophrenia after contact with psychiatrists.
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Independence of the classes of causes
There were no significant positive correlations between the weighted
importance of the six classes of causes ; this indicates that the classes of
causes are independent constructs. There were, however, several significant
negative correlations : respondents who endorsed social environmental causes
were unlikely to concurrently endorse interpersonal relationship causes
(Spearman's ranked correlation coefficient rs=-0.44,
n=135, two-tailed P<0.001), personal characteristic
causes (rs=-0.41, P<0.001),
physical-biological causes (rs=-0.27, P=0.002) or
miscellaneous causes (rs=-0.23, P=0.008) ; and
respondents who endorsed personal characteristic causes were unlikely
concurrently to endorse spiritual-mystical causes
(rs=-0.27, P=0.001).
Predictors of the use of different types of causal model
Table 2 presents the results
of multivariate analyses of the relationship between patient and respondent
characteristics and family members' causal beliefs. Logistic regression
analyses and multiple regression analyses identified identical predictor
analyses for the endorsement of social environment causal models (lack of
health insurance), of causal models involving patients' personal
characteristics (urban residence and a high level of education in the patient)
and of spiritual or mystical causal models (rural residence). Both analyses
identified a relatively low level of symptoms on admission as an independent
predictor for belief in causal models involving a patient's interpersonal
relationships, but the multiple regression analysis also identified another
independent predictor : a relatively mild effect of the patient's illness on
the family (as reported by respondents). The multiple regression analysis
identifies a single important predictor of the use of physical and biological
causal models (a short duration of illness), while the logistic regression
analysis identified three independent predictors (few admissions to hospital,
current marriage and current unemployment).
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DISCUSSION |
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Methodological issues in the assessment of causal models
Given large cultural differences in causal beliefs about mental illness
(Patel, 1995), clinical
application of the explanatory model approach requires the development of
culture-sensitive measures of causal beliefs. The method of developing
measures of causal beliefs and of coding and weighting the results can be the
same cross-culturally, but the specific causes identified and the grouping of
these causes into classes will be different in different settings.
Despite the complexity of causal beliefs, this study demonstrates that a quantitative measure of causal models of schizophrenia can be developed after preliminary qualitative research (using in-depth interviews) has identified the causal explanations employed by members of the target community. The weighting algorithm employed by the CMQS makes it possible to adjust for a variety of common situations not addressed by other instruments, such as different numbers of causes reported by respondents, different levels of importance ascribed to reported causes by respondents and different numbers of respondents per patient.
The weighted importance measure of the different classes of cause provides a better reflection of the complexity of causal beliefs than dichotomous proportional measures. It is, therefore, a suitable parameter for comparisons across different groups of respondents, for comparison within a group of respondents over time, for identifying important predictors of different causal beliefs, and for assessing the relationship of causal beliefs to the level of expressed emotion, stigma, care-seeking behaviour and adherence.
Interpretation of the findings in China
These CMQS results indicate that Chinese family members' beliefs do not
concur with Chinese professionals' ideas about the biomedical causes of
schizophrenia (Kleinman,
1986). The predominance seen in our respondents of psychosocial
causal models of schizophrenia over physiological models has also been
reported in the general public and among caregivers in both developed and
developing countries (Furnham & Bower,
1992 ; Karanci,
1995 ; Jorm et al,
1997). The infrequent identification of alcohol or drug misuse as
a cause of schizophrenia is related to the low (though increasing) prevalence
of these conditions in mainland China
(Cooper & Sartorius,
1996).
The use of physical and biological causal models is predicted by a short duration of illness and a single admission to hospital. Early in the course of the illness, Chinese families of patients with schizophrenia often seek out multiple forms of treatment for the patient before coming to psychiatry (Phillips, 1993) because they hope to find a biological cause that can be cured. These somatic causal models are reluctantly discarded as the illness progresses, but they are not replaced by the professional's biomedical model which considers schizophrenia a biological disease of the brain.
Despite the apparent similarity of social environment and interpersonal relationships, the strong negative correlation of the weighted importance of these two classes of cause (rs=-0.44) indicates that they are independent classes of cause for Chinese caregivers. The different predictive factors identified in the multivariate analyses confirms this finding : lack of health insurance predicts belief in social environment causal models (e.g. stress, work pressure, financial difficulties, etc.), whereas a low severity of symptoms and a relatively mild effect of the illness on family members predict belief in causal models related to the patient's interpersonal relationships. In China the lack of health insurance (seen in 37% of our sample) is a marker for persons who do not have a stable job or access to social support services and are therefore susceptible to a variety of social stressors ; it is understandable that family members would identify these stressors as the causes of a mental illness. We hypothesise that the association of social relationship causal models with mild forms of the illness occurs because the illness of patients with less florid psychotic symptoms who create less social disruption is more likely to be interpreted by family members as an exacerbation of normal interpersonal conflicts than is the illness of patients with more bizarre symptoms and disruptive behaviour.
Family members of well-educated urban patients are more likely to employ internal attributions which tend to blame the illnes on some defect in the patient (such as personality problems). Rural respondents are more likely to employ external attributions which attribute the illness to factors outside the patient's control (such as spiritual and mystical forces). The relatively low importance ascribed to spiritual and mystical causes is probably related to the low proportion of respondents from rural areas (58 of 245), where such belief systems are still prevalent (Li & Phillips, 1990).
Changing family members' causal models
An important practical issue is the extent to which caregivers' beliefs and
attributions are alterable. Our respondents reported that their ideas about
the causes of illness changed little after contact with psychiatrists. This
may be partly due to the high proportion of first-admission patients in the
study (81 of 135) who had little prior contact with psychiatrists, and to the
disinclination of Chinese psychiatrists to educate family members about the
illness (Phillips, 1993).
Interventions focused on changing family members' beliefs about the causes of schizophrenia (attributional retraining) may result in beneficial decreases in the level of expressed emotion (particularly hostility) towards the patient (Brewin, 1994), but there is as yet no conclusive evidence to support this hypothesis. If true, the hypothesis would be of particular importance in China and in other developing countries where more than 90% of patients with schizophrenia live with family members, and where the family makes most of the health care decisions for the patient (Phillips, 1998).
Future work
There are a variety of uses for semi-quantitative causal model
questionnaires such as the CMQS. Improved methods of assessing patients' and
family members' causal models will increase understanding of poor adherence
and could be used to help improve health care services. Comparison of beliefs
about the causes of an illness for different types of patients (e.g. male
v. female, young v. old) helps to clarify the role that
sociocultural factors play in the understanding and management of illness
episodes. Comparison of causal models between different subgroups of
respondents (e.g. spouses v. patients, fathers v. mothers)
identifies discordant views within families that should be a focus for family
interventions. Changes in the relative importance of attributed causes over
time could measure the effectiveness of psycho-educational interventions.
Furthermore, the specific causal explanations could be re-classified into
different categories in order to address different theoretical issues, such as
the relationship between internal v. external attribution of illness
and outcome.
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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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Brewin, C. R. (1994) Changes in attribution and expressed emotion among the relatives of patients with schizophrenia. Psychological Medicine, 24, 905 -911.[Medline]
Cooper, J. E. & Sartorius, N. (eds) (1996) Mental Disorders in China : Results of the National Epidemiological Survey in 12 Areas. London : Gaskell.
Eisenbruch, M. (1990) Classification of natural and supernatural causes of mental distress : development of a Mental Distress Explanatory Model Questionnaire. Journal of Nervous and Mental Disease, 178, 712 -719.[Medline]
Fosu, G. B. (1981) Disease classification in rural Ghana : framework and implications for health behavior. Social Science and Medicine, 158, 471 -482.
Furnham, A. & Bower, P. (1992) A comparison of academic and lay theories of schizophrenia. British Journal of Psychiatry, 161, 201 -210.[Abstract]
Harrison, C. A., Dadds, M. R. & Smith, G.
(1998) Family caregivers' criticism of patients with
schizophrenia. Psychiatric Services,
49, 918
-924.
Jorm, A. F., Korten, A. E., Jacomb, P. A., et al (1997) Public beliefs about causes and risk factors for depression and schizophrenia. Social Psychiatry and Psychiatric Epidemiology, 32, 143 -148.[Medline]
Karanci, A. N. (1995) Caregivers of Turkish schizophrenic patients : causal attributions, burdens and attitudes to help from the health professionals. Social Psychiatry and Psychiatric Epidemiology, 30, 261 -268.[Medline]
Kelly, G. R., Mamon, J. A. & Scott, J. E. (1990) Utility of the health belief model in examining medication compliance among psychiatric outpatients. Social Science and Medicine, 25, 1205 -1211.
Kleinman, A. (1980) Patients and Healers in the Context of Culture. Berkeley, CA : University of California Press.
Kleinman, A. (1986) Social Orgins of Distress and Disease. New Haven, CT : Yale University Press.
Li, S. X. & Phillips, M. R. (1990) Witchdoctors and mentall illness in mainland China : a preliminary study. American Journal of Psychiatry, 147, 221 -224.[Abstract]
Lloyd, K. R., Jacob, K. S., Patel, V., et al (1998) The development of the Short Explanatory Model Interview (SEMI) and its use among primary-care attenders with common mental disorders. Psychological Medicine, 28, 1231 -1237.[CrossRef][Medline]
Matschinger, H & Angermeyers, M. C. (1996) Lay beliefs about the causes of mental disorders : a new methodological approach. Social Psychiatry and Psychiatric Epidemiology. 31, 309 -315.[Medline]
Overall, J. E. & Gorham, D. R. (1962) The brief psychiatric rating scale. Psychological Reports, 10, 799 -812.
Patel, V. (1995) Explanatory models of mental illness in sub-Saharan Africa. Social Science and Medicine, 40, 1291 -1298.[CrossRef][Medline]
Phillips, M. R. (1993) Strategies used by Chinese familes coping with schizophrenia. In Chinese Families in the Post-Mao Era (eds D. Davis & S. Harrell), pp. 277 -306. Berkeley, CA : University of California Press.
Phillips, M. R. (1998) The transformation of China's mental health sevices. The China Journal, 39, 1-36.
Phillips, M. R., Zhao, Z., Xiong, X., et al (1991) Changes in positive and negative symptoms of schizophrenic inpatients in China. British Journal of Psychiatry, 159, 226 -231.[Abstract]
Phillips, M. R. & Xiong, W. (1995) Expressed emotion in mainland China : Chinese families with schizophrenic patients. International Journal of Mental Health, 24, 54-75.
Weisman, A. G., Nuechterlein, K. H., Goldstein, M. J., et al (1998) Expressed emotion, attributions, and schizophrenia symptom dimensions. Journal of Abnormal Psychology, 107, 355 -359.[CrossRef][Medline]
Weiss, M. (1997) Explanatory Model Interview Catalogue (EMIC) : framework for comparative study of illness. Transcultural Psychiatry, 34, 235 -263.
Received for publication August 31, 1999. Revision received January 18, 2000. Accepted for publication January 19, 2000.