Georg Schomerus

The stigma of psychiatric treatment and help-seeking intentions for depression

AimsThe stigma of mental illness has often been considered a potential cause for reluctant willingness to seek help for mental problems, but there is little evidence on this issue. We examine two aspects of stigma related to seeing a psychiatrist and their association with help-seeking intentions for depression: anticipated discrimination by others when seeking help and desire for social distance from those seeking help.MethodsRepresentative population survey in Germany 2007 (nxa0=xa02,303), containing a depression vignette with a question on readiness to seek psychiatric care for this problem, a focus group developed scale anticipated discrimination when seeing a psychiatrist (ADSP), and a scale on desire for social distance from someone seeing a psychiatrist (SDSP). We further elicited previous contact to psychiatric treatment, depressive symptoms, and socio-demographic data.ResultsBoth scales had good internal consistency (Cronbach’s alpha ADSP 0.87, SDSP 0.81). Exploratory factor analysis of all items revealed a distinct factor representing the social distance scale and three factors “anticipated discrimination”, “anticipated job problems” and “anticipated shame” derived from the ADSP scale. In both the general population and in those with current depressive syndrome, personal desire for social distance significantly decreased willingness to seek psychiatric help, but anticipated discrimination by others did not. Other factors related to likely help-seeking were female gender and previous contact to psychiatric treatment or to psychotherapy.ConclusionContrary to expectations, anticipated discrimination from others was unrelated to help-seeking intentions, while personal discriminatory attitudes seem to hinder help-seeking. Our findings point to self-stigmatization as an important mechanism decreasing the willingness to seek psychiatric help.

Stigma and its impact on help-seeking for mental disorders: what do we know?

AIMSnMany people suffering from serious mental illness do not seek appropriate medical help. The stigma of mental illness has often been considered a potential cause for reluctance in seeking help. We review recent evidence on this topic.nnnMETHODSnNarrative review of the recent literature on stigma and help-seeking for psychiatric disorders.nnnRESULTSnThere is proof of a particular stigma attached to seeking help for a mental problem. Anticipated individual discrimination and discrimination qua self-stigmatisation are associated with a reduced readiness to seek professional help for mental disorders. Intervention studies show that destigmatisation may lead to increased readiness to seek professional help, but other aspects like knowledge about mental diseases seem to be at least as important. The belief that seeking help for a mental health problem is actually helpful has been shown to be at the core of help-seeking intentions and thus offers a promising target for information programmes. Population based time-trend studies show that public attitudes towards help-seeking have improved over the last decade.nnnDISCUSSIONnThe relationship between help-seeking intentions and actual help-seeking needs further exploration. While many studies have been able to relate attitudes to intentions, predicting actual help-seeking has proved more difficult.

A prospective study of Quality of life in schizophrenia in three European countries.

Only a small number of studies have tried to identify factors influencing the subjective QoL of patients suffering from schizophrenia in a longitudinal design. These studies suffer from small clinical samples or compare baseline data only with a single follow-up. The European Schizophrenia Cohort Study overcomes these shortcomings by providing data from five time points on 1208 patients in psychiatric treatment in three European countries over a period of 2 years. QoL was measured with the brief version of Lehmans Quality of Life Interview. Random effects, between-effects and within-effects regression models were computed in order to measure the influence on subjective QoL of patients socio-demographic and clinical characteristics and objective QoL. Objective QoL scores were generally found to be related to the equivalent subjective QoL scores. Peoples financial situation, and depressive and positive symptoms had a general effect on almost all subjective domains. The significant effects of objective finances on subjective domains like health and social relations raise interesting possibilities for intervention. Sufficient financial resources appear to be a necessary condition for achieving satisfactory QoL in schizophrenia patients. However, changes in individuals characteristics and circumstances did not relate as strongly as expected to changes in QoL, suggesting effective intervention may be difficult.

Preferences of the public regarding cutbacks in expenditure for patient care : Are there indications of discrimination against those with mental disorders?

BackgroundIncreasing costs for patient care may necessitate financial cuts in the health-care budget. Our aim is to examine whether the public prefers cuts for psychiatric rather than medical conditions and how resource allocation preferences are related to illness beliefs and attitudes.MethodA telephone survey involving German adult population was conducted in 2004 (n = 1012). Participants were presented with a list of nine medical and mental diseases including alcoholism, depression, schizophrenia, Alzheimer’s disease, cancer, diabetes, rheumatism and AIDS, and were asked to name three conditions where they would prefer to see health-care resources cut. For all conditions we asked about personal attitudes and illness beliefs.ResultsPeople were more willing to have financial resources cut for psychiatric than for medical conditions, with resources for alcoholism having the least public backing. Alzheimer’s disease was rated more favourably compared to other mental disorders. Generally, the perception of the severity of a disease was associated with resource allocation decisions, favouring those conditions that were considered to be severe. Mental diseases evoked a far greater desire for social distance than most medical diseases which had considerable influence on resource allocation preferences. The perception of personal responsibility had, in contrast, only limited effect on resource allocation decisions. It varied considerably in the case of psychiatric conditions but was not fundamentally different among medical and mental diseases. Personal susceptibility, treatment effectiveness and the perceived life-threat posed by a disease also had limited effects.ConclusionAccording to public resource allocation preferences psychiatric patients are at risk of being structurally discriminated within the health-care system.

Public beliefs about the causes of mental disorders revisited

When the lay public is asked to prioritize their causal beliefs for a vignette depicting either schizophrenia or depression, psychosocial causes are most popular for depression, but a large proportion of respondents prefers biological causes for schizophrenia. Recognition of the vignette as mental illness enhances the likelihood to endorse brain disease as a cause and reduces choices of certain psychosocial causes.

Urban residence, victimhood and the appraisal of personal safety in people with schizophrenia: results from the European Schizophrenia Cohort (EuroSC)

BACKGROUNDnPatients with schizophrenia are at increased risk of being victims of violent and non-violent crimes. We have determined how the experience of crime and subjective feelings of safety differ between urban and rural residential areas.nnnMETHODnWe analysed data from the European Schizophrenia Cohort (EuroSC), a 2-year follow-up study of 1208 patients in the UK, France and Germany. Subjective safety and a history of victimhood were elicited with Lehmans Quality of Life Inventory. Regression models adjusted the effects of living environment for country, education, employment, financial situation, drug and alcohol abuse, criminal arrests and the level of schizophrenic symptoms.nnnRESULTSnTen per cent of patients were victims of violent and 19% of non-violent crimes. There was no significant relationship between victim status and residential area. However, subjective safety was clearly worse in cities than in rural areas. Aspects of objective and subjective safety were related to different factors: being the victim of violence was most strongly associated with alcohol and drug abuse and with criminal arrests of the patients themselves, whereas impaired subjective safety was most strongly associated with poverty and victimhood experience.nnnCONCLUSIONSnAlthough urban living was not associated with increased objective threats to their security, patients did feel more threatened. Such stress and anxiety can be related to concepts of social capital, and may contribute unfavourably to the course of the illness, reflecting the putative role of appraisal in cognitive models of psychosis. Securing patients material needs may provide a way to improve subjective safety.

Residential area and social contacts in schizophrenia. Results from the European Schizophrenia Cohort (EuroSC).

BackgroundSocial isolation is associated with poor prognosis in schizophrenia. We aim to determine the effect of rural or urban residence on frequency of social and family contacts.MethodWe analysed data from the European Schizophrenia Cohort, a two-year follow-up study of 1,208 patients in Britain, France and Germany. Frequency of contact was elicited with Lehman’s Quality of Life Inventory. Between-effect error component regression models adjusted the effects of living environment for country, age, gender, education, schizophrenia symptoms and global functioning.ResultsAcross all living conditions, contact with family occurred more frequently than contact with others. Family visits, social visits and planned social activities were less common in urban compared to rural settings, whereas no significant differences were found for social and family telephone calls and time spent with a spouse. Patients living with a partner had more family, but fewer social contacts, while women had more contact by phone. Family and social contacts across all categories decreased with age. Employment increased social contacts, but did not affect visits or phone calls within the family. Schizophrenia symptoms, particularly negative symptoms, and impaired global functioning decreased all aspects of social and family contacts.DiscussionContrasting with results of previous studies, we found rural living was associated with greater frequency of social contacts in patients suffering from schizophrenia. Beyond living environment, our findings stress the importance both of an adequate control of negative symptoms and of employment opportunities for schizophrenia patients in order to enhance their social networks.

The association of schizophrenia with split personality is not an ubiquitous phenomenon

A widely prevalent stereotype connected with schizophrenia is its misperception as split personality. We examine whether the popular meaning of the term schizophrenia differs in countries of different cultural imprint by conducting an international cross-cultural comparison of public associations with the word schizophrenia in a Western and a Non-Western industrialized country. We analyze data from two representative population surveys in Novosibirsk, Russia (nxa0=xa0745), and large German cities (nxa0=xa0952) that used identical questions and sampling procedures. Unprompted associations with schizophrenia are compared by assigning them to a differentiated categorical system. 31.6% of respondents in Germany associated split personality with schizophrenia, compared to 2.0% in Novosibirsk. Logistic regression analysis controlling for age, gender and educational achievement demonstrated that country differences were independent of socio-demographic variables. Mention of split personality increased significantly with higher education. In Novosibirsk, associations with abnormality and unpredictability prevailed. We hypothesize on those cultural particularities in both countries that have shaped the different public understanding of the term and discuss implications for anti-stigma interventions.

Traces of Freud – The Unconscious Conflict as a Cause of Mental Disorders in the Eyes of the General Public

Background: We aim to elicit how far the public has incorporated Freudian theory in its understanding of mental illness in different countries, focussing on the unconscious conflict as a possible cause of mental disorders. Sampling and Methods: We conducted representative population surveys with identical sampling procedures and face-to-face interviews in Germany (1990, n = 3,078; 2001, n = 5,025), Novosibirsk (Russia, 2002, n = 745), and Bratislava (Slovakia, 2003, n = 1,000) and a representative telephone survey in Germany in 2006. Results: Two thirds of respondents in Germany endorsed an unconscious conflict as a cause of mental disorder. Endorsement was stronger for depression than for schizophrenia, increased with duration of schooling, and was less prevalent in Bratislava and Novosibirsk and in East compared to West Germany. Endorsement in Germany increased between 1990 and 2001. However, only 5% of respondents could offer a definition of unconscious conflict that resembled Freud’s initial theory. Discussion: The observed West-East gradient is likely to mirror the past political undesirability of psychoanalysis in former communist countries. The popularity of psychoanalytical concepts seems to lag behind their actually declining influence within psychiatry in Germany. Public conception of unconscious conflict however hardly resembles Freud’s original ideas. Conclusions: Although psychoanalytical concepts warrant consideration when exploring patients’ causal beliefs about mental illness, psychiatrists should focus on the subjective meaning of seemingly psychoanalytic phrases.