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Original article
Changes in the perception of mental illness stigma in Germany over the last two decades Matthias C. Angermeyer a,*,b, Herbert Matschinger c,d, Mauro G. Carta b, Georg Schomerus e,f a
Center for Public Mental Health, Untere Zeile 13, A-3482 Go¨sing am Wagram, Austria Department of Public Health and Clinical and Molecular Medicine, University of Cagliari, Italy Institute of Social Medicine, Occupational Health and Public Health, University of Leipzig, Germany d Department of Health Economics and Health Services Research, University of Hamburg, Germany e Department of Psychiatry, Ernst Moritz Arndt University Greifswald, Germany f HELIOS Hanseklinikum Stralsund, Germany b c
A R T I C L E I N F O
A B S T R A C T
Article history: Received 22 February 2013 Received in revised form 22 September 2013 Accepted 12 October 2013 Available online xxx
Purpose: To examine the evolution of the perception of the stigma attached to mental illness in Germany since 1990 up to the present. Subjects and methods: Population surveys were conducted in the old German States (former Federal Republic of Germany) in 1990, 2001, and 2011. The perception of stigma attached to people with mental illness was assessed with the help of Link’s perceived discrimination and devaluation scale. Results: In the 2011 survey, less mental illness stigma was perceived by respondents than in the previous surveys. In the eyes of the German public, the devaluation and rejection of people with mental illness has substantially decreased since 1990. Discussion: The perception of a decline of the stigmatization is in contrast to the development of the German public’s attitudes towards persons with mental disorders, which remained unchanged or even worsened. Conclusion: Perceived and personal attitudes towards persons with mental illness have developed differently, and it remains to be seen whether perceptions of less public stigma will ultimately be followed by improved personal attitudes. ß 2013 Elsevier Masson SAS. All rights reserved.
Keywords: Perceived stigma Mental illness Time trend Population survey
1. Introduction Studies on the development of public attitudes towards people with mental illness indicate that they have not changed for the better over the last decades. In a systematic review and metaanalysis of population studies conducted since 1990 we found that, although there were insignificant trends towards reduced blame in schizophrenia and depression, notions of dangerousness did not change. Most strikingly, social acceptance of mentally ill persons did not increase since 1990, instead, acceptance of persons with schizophrenia in various social relationships diminished [28]. While the evolution of public attitudes towards people with mental illness has been studied in various western countries (e.g., Austria [13], Germany [3,4], Netherlands [16], Poland [37], U.K. [22], U.S. [23]) hardly anything is known about how the public’s
* Corresponding author. Tel.: +43 664 43 53 199. E-mail address: [email protected] (M.C. Angermeyer).
perception of the stigma surrounding mental illness has developed in recent years. So far, only two studies have dealt with this question, coming up with inconsistent results. In Germany, we had found that former mental patients were perceived by the public in 2001 as being slightly less devalued and discriminated against than 11 years before [5]. In a more recent study in Australia, covering the time period between 2002/2003 and 2011, no changes were observed as regards depression with and without suicidal thoughts and early schizophrenia; only in case of chronic schizophrenia there was an increase in the perception that others believe in the dangerousness of such a person [25]. As the perception of the stigma surrounding mental disorders may influence how the public reacts to people suffering from these illnesses as well as how individuals deal with their illness it is important to learn more about how public views on mental illness stigma have developed over time. The empathy-altruism theory [7] posits that the perception of someone being in need elicits empathic concern, which in turn produces altruistic motivation; with the possible behavioral consequence that one might help or
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may have someone other help this person. In a series of socialpsychological experiments, it has been shown that inducing empathetic concern for a member of a stigmatized group improved attitudes towards the group as a whole [8]. According to this theory, the more the public perceives people with mental disorders as being devalued and discriminated against, and therefore in need, the more it may develop empathetic concern and be ready to engage in or support efforts to reduce stigma and discrimination because of mental illness. Vice versa, the perception of decreasing stigmatization may let people become less enthusiastic about antistigma initiatives. Moreover, following attribution theory [38], the perception of reduced stigma may have an ironic effect by actually increasing stigmatizing attitudes as psychosocial impairments of mental illness seem more self-caused rather than societally imposed. Apart from influencing the public’s reaction to people with mental illness, the perception of the stigma prevalent in society may also have an impact on those suffering from mental illness. According to the modified labeling theory [18], expectations as to what extent most people in a given culture stigmatize and discriminate against persons with mental illness are particularly relevant for those who themselves develop a mental disorder. If one believes that others will reject people with mental disorders one must fear that this rejection applies personally. This anticipated discrimination may have serious personal consequences for the afflicted person such as demoralization [18], loss of self-esteem [40] and reduced quality of life [21]. In view of the importance of this issue and the scarcity of empirical findings, we set out to examine the evolution of the perception of the stigma attached to mental illness in Germany over the last two decades.
2. Subjects and methods 2.1. Surveys The study is based on data from three population surveys among German citizens aged 18 years and over. The first survey was carried out in 1990 in the former Federal Republic of Germany before reunification (3067 participants, response rate 70.0%) while the surveys in 2001 and 2011 were carried out in the whole of Germany (2001: 5025 participants, response rate 65.1%; 2011: 3642 participants, response rate 64.0%). To make comparison possible, from the latter two surveys only interviews conducted in
the ‘‘old’’ German States (= former Federal Republic) were included into the analysis. In all three surveys, the samples were drawn using a random sampling procedure with three stages: (1) sample points, (2) households, and (3) individuals within the target households. Target households within the sample points were determined according to the random route procedure, that is, a street was selected randomly as the starting point from where the interviewers followed a set route through the area. Target persons were selected using random digits. Fieldwork was done in 1990 by GETAS (Hamburg), in 2001 and 2011 by USUMA (Berlin), both companies specialized in market and social research. Informed consent was considered to have been given when individuals agreed to complete the interview. The study has been approved by the ethics committee of the Universities of Heidelberg, Leipzig and Greifswald. Due to time constraints, randomly drawn sub-samples were presented with different sets of questions. In 1990, a sub-sample of 2044 individuals, in 2001 of 1943 individuals, and in 2011 of 965 individuals, all originating from the former Federal Republic or the ‘‘old’’ German States, respectively, were asked about their views on mental illness stigma. Socio-demographic characteristics of the study samples are reported in Table 1. 2.2. Interview In all three surveys, face-to-face interviews were conducted by trained interviewers who registered the answers of the interviewees using pencil and paper. On all three occasions, the interview was identical as concerns wording and sequence of questions and consisted of two parts. In the first part, respondents were presented an unlabeled case-vignette depicting a person displaying symptoms of either schizophrenia or major depression. They were then asked about their beliefs and attitudes concerning the person described in the vignette. In the second part of the interview, respondents answered questions of a more general nature, not referring to the vignette. Among other things, respondents’ perception of stigma attached to persons with mental illness was assessed with the help of the German version of Link’s perceived discrimination and devaluation scale [18]. This self-administered questionnaire has been used in population surveys [18,27] as well as in studies involving patients suffering from mental illness [11,19]. As the original, the authorized German version demonstrated adequate reliability [20]. The instrument asks about the extent of agreement with statements indicating that most people devalue former psychiatric patients by perceiving
Table 1 Socio-demographic characteristics of study samples. 2001
1990
Gender Male Female Age, years 18–25 26–45 46–60 61+ Educational attainment Still student No schooling completed 8/9 years of schooling 10 years of schooling 12/13 years of schooling a
2011
Survey (n = 2,044) %
Total Populationa %
Survey (n = 1,943) %
Total Populationa %
Survey (n = 965) %
Total Populationa %
44.1 55.9
48.5 51.5
43.3 56.7
48.3 51.7
44.7 55.3
48.6 51.4
10.1 35.6 26.6 27.6
12.3 38.0 24.2 25.5
11.4 40.9 23.7 23.9
9.8 37.8 23.8 29.1
8.5 33.9 25.4 32.1
11.3 31.9 26.9 29.9
1.9 3.6 53.9 24.0 16.5
0.4 2.5 55.8 25.8 15.5
3.2 2.1 47.5 29.3 17.9
0.2 2.1 49.1 27.5 21.1
0.8 2.6 44.7 33.3 18.7
1.0 4.0 38.5 29.3 27.1
Data from the Federal Statistical Office of Germany.
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them as failures, as less intelligent than other persons, or as individuals whose opinions need not to be taken seriously. It also asks to what extent the respondent agrees with statements indicating that most people distance themselves from psychiatric patients in various social relationships, like having a patient as a close friend or letting him teach young children in school. The scale is balanced such that a high level of perceived stigma is indicated by agreement with six of the items and by disagreement with six others. Answers to the items are recorded using 5-point Likert scales with the anchors ‘‘totally agree’’ (1) and ‘‘totally disagree’’ (5). Our measure of familiarity with mental illness comprises four hierarchical categories representing the intensity of personal experience with mental illness: the respondent has been/is in psychiatric treatment; a family member has been/is undergoing psychiatric treatment; the respondent either knows someone within his/her circle of friends, among his/her colleagues at work, or in his/her neighbourhood who has been/is undergoing psychiatric treatment, or s/he himself/herself or another member of the family, one of his/her friends etc. has been/is active as either a professional or voluntary helper in the field of mental health care; none of the listed possibilities applies to the respondent, i.e. he/ she has no personal experience with mental illness.
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In addition socio-demographic characteristics (gender, age, educational attainment) were assessed. 2.3. Statistical analysis In order to examine the change of perceived stigma over time, we performed a linear regression analysis, using STATA, release 12.1 [31]. Usually, the sum score of the twelve items is used based on the assumption of equal weights of the items with respect to the latent trait to be measured. However, a principal component analysis showed that this assumption is not fulfilled. The principal component analysis yielded two factors with an eigen value greater than one. The first factor comprises the six items representing the opposite of devaluation and discrimination (eigen value 4.84, explained variance 40.3%): item 1 (see Table 2 for wording of statements; factor loading 0.695), item 2 (0.680), item 3 (0.765), item 4 (0.700), item 8 (0.621), item 10 (0.729). The second factor comprises the six reversed items representing devaluation and discrimination (eigen value 1.42, explained variance 11.8%): item 5 (factor loading 0.472), item 6 (0.499), item 7 (0.683), item 9 (0.589), item 11 (0.480), item 12 (0.622). These factors, however, do not represent different dimensions of perceived stigma but rather an artefact related to item direction [14,15]. All twelve items load positively on the second factor, which represents nothing but the quadratic form of the first factor, also called a ‘‘horse shoe’’ [29,36]. Therefore,
Table 2 The German public’s perception of the stigma attached to former mental patients in 1990, 2001, and 2011. Item
Response category
1990 (n = 2,044) %
2001 (n = 1,943) %
2011 (n = 965) %
1
Most people would willingly accept a former mental patient as a close friend
2
Most people believe that a person who has been in a mental hospital is just as intelligent as the average person
3
Most people believe that a former mental patient is just as trustworthy as the average citizen
4
Most people would accept a fully recovered former mental patient as a teacher of young children in a public school
5
Most people feel that entering a mental hospital is a sign of personal failure (R)
6
Most people would not hire a former mental patient to take care of their children, even if he or she had been well for some time (R)
7
Most people think less of a person who has been in a mental hospital (R)
8
Most employers will hire a former mental patient if he or she is qualified for the job
9
Most employers will pass over the application of a former mental patient in favor of another applicant (R)
10
Most people in my community would treat a former mental patient just as they would treat anyone
11
Most young women would be reluctant to date a man who has been hospitalized for a serious mental disorder (R)
12
Once they know a person was in a mental hospital, most people will take his opinion less seriously (R)
Agree Undecided Disagree Agree Undecided Disagree Agree Undecided Disagree Agree Undecided Disagree Agree Undecided Disagree Agree Undecided Disagree Agree Undecided Disagree Agree Undecided Disagree Agree Undecided Disagree Agree Undecided Disagree Agree Undecided Disagree Agree Undecided Disagree
29.7 29.5 49.8 30.8 28.0 41.2 21.7 26.9 51.4 14.9 21.7 63.4 45.8 25.9 28.3 59.6 20.3 20.1 64.6 22.6 12.8 22.1 30.4 47.5 64.7 21.9 13.4 18.3 26.8 54.9 57.7 24.8 17.5 48.6 32.3 19.1
30.8 30.8 38.4 39.0 30.8 30.2 29.7 29.2 41.1 19.7 26.2 54.1 38.6 24.8 36.6 61.9 20.4 17.7 56.2 28.1 15.7 25.0 33.4 41.6 63.2 23.7 13.1 23.2 34.0 42.8 61.0 27.0 11.9 40.2 37.2 22.5
43.4 32.6 23.9 53.7 26.8 19.5 42.8 29.6 27.6 27.6 27.5 45.0 37.5 30.5 32.0 47.6 31.2 21.2 47.6 30.7 21.8 29.0 34.9 36.1 59.4 26.6 14.0 32.5 33.4 35.1 57.3 28.3 14.4 27.3 43.3 29.4
Note: Respondents who endorsed the two points on either side of the mid-point of the five-point scales (values 1 + 2 and 4 + 5) were grouped together to the categories ‘‘agree’’ and ‘‘disagree’’. R reversed item.
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3. Results Looking at the proportions of respondents agreeing or disagreeing with each statement (Table 2), it appears that the perception that mentally ill people are devalued decreased substantially in Germany between 1990 and 2011. For instance, while in 1990 more respondents disagreed than agreed with statements that former mental patients will be seen by most people as intelligent or as trustworthy, 21 years later the opposite was true. In 1990, over half of respondents had disagreed that former mental patients would be treated by most people as anyone; in 2011, one third each agreed and disagreed with that or was undecided. Had almost half of those questioned shared the view that once a person was in a psychiatric hospital most people would not take his or her opinion seriously, 21 years later the percentage has dropped by almost half. Concerning the perception of rejection experienced by former patients with mental illness, similar changes were observed. While, for instance, in 1990 the percentage of those agreeing that most people would not accept a former mental patient as a close friend exceeded by far the percentage of those who did not share this view, in 2011 the opposite was found. The same held true for the notion that most people would accept such a person as teacher of young children. However, no change at all occurred as concerns the belief that most young women would be reluctant to date a man who had been hospitalized for a serious mental disorder. Table 3 shows results of a multiple regression analysis with the component score of all 12 items. This analysis corroborated the Table 3 Perception of stigma attached to former mental patients regressed on time, familiarity with mental illness, gender, age, and educational attainment (n = 4,952).
Survey 2001a Survey 2001 age Survey 1990a Survey 1990 age Age Genderb Educational attainment Familiarity with mental illnessc
B
s.e.
t
P > jtj
0.2368 0.0004 0.7661 0.0042 0.0004 0.0303 0.0184 0.1004
0.0890 0.0018 0.1128 0.0021 0.0012 0.0278 0.0162 0.0302
2.66 0.21 6.79 1.96 0.29 1.09 1.14 3.32
0.008 0.831 0.000 0.050 0.769 0.275 0.256 0.001
F(8,4943) = 30.34, P > jFj = 0.000; Adj. R2 = 0.045. a Reference category: 2011. b Reference category: male. c Reference category: unfamiliar with mental illness.
.2 Linear Prediction -.2 0 -.4 -.6
for our analysis factor scores of the first factor of the un-rotated solution were used. Higher scores indicate greater perceived devaluation and discrimination. The scale showed sufficient internal consistency (Cronbach’s alpha 0.859). The overall mean is zero and its standard deviation is 1. We regressed the component score of the devaluationdiscrimination scale as dependent variable on year of survey (using the 2011 survey as reference category). To adjust the year effect for demographic changes across samples, the regression analysis controlled for respondents’ gender (male = 0, female = 1), age (years), and educational attainment (unknown = 0, no school completed = 1, 8 + 9 years of schooling = 2, 10 years of schooling = 3, 12 + 13 years of schooling = 4). Since in previous studies, the perception of stigma has shown an association with familiarity with mental illness [5] this has also been included into the regression equation as a dichotomous variable (any form of familiarity = 1, no familiarity = 0). To examine whether time trends are similar across different age groups interaction terms between age and time of survey were included. All variables plus the interaction terms were simultaneously introduced into the regression equation.
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18
28
38
48 1990
58 age
68 2001
78
88
98
2011
Fig. 1. Predictive margins of the first component of the perceived discrimination and devaluation scale with 95% CI. The ordinate represents the dependent variable, e.g. the first component. Each point in the graph shows the means of this component with respect to the two dummies representing 2001 and 2011 and the two linear interactions with age. All the other variables in the model are held at their means. Confidence intervals are estimated in 10-year intervals for the range of 18 to 98 years.
observations on item-level, yielding a significant decrease in perceived stigma over the last decade. Thus, the trend that has already been observed in the 1990s [5] continued during the following years. Over the whole study period, the amount of stigma perceived by respondents has substantially decreased. There was also an interaction with age in the sense that the decrease in stigma perception was particularly pronounced among young respondents (see also Fig. 1 showing the predicted margins of the component score). Respondents familiar with mental illness perceived less stigma than those who were unfamiliar with it. Stigma perception was not associated with socio-demographic characteristics of respondents.
4. Discussion In summary, our findings indicate that the perception of the stigma attached to mental illness has improved in the ‘‘old’’ States of Germany since 1990. In the eyes of the public, the devaluation and discrimination of persons with mental illness has considerably decreased in recent years. As indicated by the interaction effect, improvement between 1990 and 2011 was particularly pronounced among the young. People grown up in recent years tend to judge the situation of persons with mental illness less pessimistically than their counterparts two decades before. However, despite these positive developments, in 2011 a substantial proportion of respondents still believed that former psychiatric patients are devalued and rejected by the public. For instance, over half thought that most employers would pass over the application of a former mental patient in favor of another applicant. And almost half believed that people think less of a person who has been in a psychiatric hospital. The positive trend in the perception of mental illness stigma is in contrast to the development of the German public’s personal attitudes towards persons with mental illness. Over the same time period emotional reactions to people with schizophrenia and alcohol dependence have worsened while those to people with depression have only slightly improved. The public’s desire for social distance from people with schizophrenia increased while with the other two disorders there were no significant or inconsistent changes [6]. Thus, discrimination against persons with mental illness and the perception of the discrimination they are exposed to have not developed in parallel. Interestingly, a
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similar finding has also been reported from Australia: while between 2003/2004 and 2011 beliefs in dangerousness increased across all four different forms of mental disorder under study (depression with and without suicidal thoughts, early and chronic schizophrenia), the perception that others believe in dangerousness remained unchanged except for chronic schizophrenia [25]. What could be the reason for this divided development of public attitudes? One reason might be that the numerous antistigma programs that have been implemented in Germany in recent years [12] had a soothing effect on the public’s consciousness of the stigma surrounding mental illness. People may be aware of these efforts and expect that they have effectively reduced mental illness stigma. The example of some prominent persons who gave personal accounts of their mental illness (mostly depression, for example in ‘‘Stern’’ No.45, 4.11.2010) might have added to this picture. A similar effect may have had political initiatives that have been taken in recent years to improve the protection of human rights and dignity of people suffering from mental disorders and to implement the necessary legislation in order to empower them to participate fully and equally in society [9]. In the first place, the UN Convention on the Rights of Disabled People [35] has to be mentioned here, which has been ratified by the German parliament in 2009. In 2005, the WHO European Ministerial Conference on Mental Health issued the ‘‘Mental Health Declaration for Europe’’ [39], which provides basic rules and guidelines for promoting citizenship and fighting the violation of rights of persons with mental health problems. These initiatives and programs may have had stronger effects on stigma perception than on actual stigma. Another explanation for this disconnect may be that, fuelled by the proclamation of the 1990s as ‘‘Decade of the Brain’’ by the American Congress, during the study period the conceptualization of mental disorders has increasingly shifted towards a biomedical model [23]. This change is also reflected in a study of the media portrayal of depression in high circulating magazines in Canada and the U.S., that found that depression moved from a problem explained in a variety of ways in the 1980s to a primarily biomedical phenomenon in the 1990s and 2000s [10]. A study on reporting of mental health research in British media between 1999 and 2010 observed an emphasis on biological research while stories on psychological interventions were rare [17]. Similarly, in a recent review mental health websites were found to overemphasize biogenetic causal explanations and medication [24]. An analysis of five large German newspapers between 1999 and 2009 similarly found an increase of reports on biological causes and biomedical treatments compared to psychosocial causes and psychotherapy (Schomerus et al., unpublished results). The conventional wisdom has been that the shift towards a biomedical model would be accompanied by a decrease of mental illness stigma – although empirical evidence does not support this notion and points rather into the opposite direction [2,26]. In consequence, people endorsing biogenetic conceptualizations may nowadays tend to distance themselves from people with mental illness as much as in the past, or even more, while at the same time they may be persuaded that stigma has declined. As a consequence of the decrease of perceived stigma, people with mental illness may anticipate to be less exposed to discrimination. In a previous study, we had found that persons with schizophrenia, depression and obsessive-compulsive disorder anticipate discrimination far more frequently than they have actually experienced discrimination. The discrepancy between both forms of discrimination was particularly marked as concerns the access to social roles (partnership, occupation) [1,32]. Similar findings have also been reported from the INDIGO study for people with schizophrenia [33,34]. The expectation of less discrimination may help increase confidence and self-esteem of people with
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mental illness which, in turn, may have a positive effect on their socio-economic opportunities [33]. Thus, from the patients’ point of view the situation may have improved even though attitudes towards people with mental disorders (and, in consequence, discrimination enacted against them) have not changed for the better. Our findings have to be considered in the context of our study’s limitations. First, a limitation may be that attitudes towards mental illness in general and not attitudes towards specific mental disorders had been assessed. Therefore, we do not know which particular illnesses were associated with this term by our respondents. In the 1990 and 2011 interviews, before administering the scale measuring perceived stigma, one half each of respondents had been presented with vignettes depicting symptoms of either schizophrenia or major depression while in the 2001 interview only the vignette with major depression had preceded the perceived stigma scale. In order to examine to what extent the vignettes may have framed the perception of the stimulus ‘‘former mental patient’’ we repeated the regression analysis with the data from the 1990 and 2011 surveys including the type of vignette as control variable. Neither in 1990 nor in 2011, the predicted margins differed significantly between both vignettes (1990: schizophrenia 0.185, 95% C.I. 0.125–0.245, major depression 0.253, 95% C.I. 0.342–0.164; 2011: schizophrenia 0.280, 95% C.I. 0.218 0.342, major depression 0.422, 95% C.I. 0.512–0.333). Thus, the observed trend in the perception of devaluation and discrimination cannot be explained by an effect of preceding vignettes and does not represent an artifact. Second, another limitation may be that the scale used in our study does not cover all aspects of stigma but rather focuses on the stereotype of incompetence and on the desire for social distance. For instance, the perception of how violent most people think mentally ill patients are has not been assessed. Third, since no weights have been available for the first survey, and for the second and third survey only weights for the whole of Germany but not for the ‘‘old’’ States, weighting of our data was not possible. Although the sociodemographic characteristics of the three samples correspond well with those of the general population, except for an underrepresentation of better-educated persons in 2011, the representativity of our results remains, therefore, an open question. Finally, a limitation may also be seen in the fact that we compared three cross-sectional assessments at different points in time and did not follow up a panel drawn from the general population. However, since we were primarily interested in monitoring changes of people’s attitudes on a collective rather than on an individual level, the study design chosen appears appropriate, nothing to say of problems inherent to panel studies such as the lack of representativity of the follow-up assessment due to the huge attrition rate to be expected over a time period of 21 years.
5. Conclusions In conclusion, we can state that perceived and personal attitudes towards persons with mental illness have developed differently in the ‘‘old’’ States of Germany since 1990. It remains to be seen whether perceptions of less public stigma will ultimately be followed by improved personal stigmatizing attitudes. One should hope that continuing anti-stigma-efforts will work in this direction, although there is no evidence yet for a transition of lower stigma perceptions to lower stigma. As suggested by the interaction effect between the 1990 survey and age of respondents, the improvement of personal stigmatizing attitudes might happen first among the young generation, which should further encourage the implementation of school based anti-stigma and mental health literacy programs [30].
Please cite this article in press as: Angermeyer MC, et al. Changes in the perception of mental illness stigma in Germany over the last two decades. European Psychiatry (2013), http://dx.doi.org/10.1016/j.eurpsy.2013.10.004
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Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. Acknowledgement We would like to thank the two anonymous reviewers for their very helpful comments on an earlier version of this paper. The study was funded by the Fritz-Thyssen-Stiftung (Az. 10.11.2.175) References [1] Angermeyer MC, Beck M, Dietrich S, Holzinger A. The stigma of mental illness: patients’ anticipations and experiences. Int J Soc Psychiatry 2004;50:153–62. [2] Angermeyer MC, Holzinger A, Carta MG, Schomerus G. Biogenetic explanations and public acceptance of mental illness. A systematic review of population studies. Br J Psychiatry 2011;199:367–72. [3] Angermeyer MC, Holzinger A, Matschinger H. Mental health literacy and attitude towards people with mental illness: a trend analysis based on population surveys in the eastern part of Germany. Eur Psychiatry 2009;24:225–32. [4] Angermeyer MC, Matschinger H. Causal beliefs and attitudes to people with schizophrenia – trend analysis based on data from two population surveys in Germany. Br J Psychiatry 2005;186:331–4. [5] Angermeyer MC, Matschinger H. The stigma of mental illness in Germany: a trend analysis. Int J Soc Psychiatry 2005;51:276–84. [6] Angermeyer MC, Matschinger H, Schomerus G. Attitudes towards psychiatric treatment and people with mental illness: Changes over two decades. Br J Psychiatry 2013;203:146–51. [7] Bateson CD. Altruism in humans. Oxford New York: Oxford University Press; 2011. [8] Bateson CD, Polycarpou MP, Harmon-Jones E, Imhoff HJ, Mitchener EC, Bednar LL, et al. Empathy and attitudes: Can feeling of a member of a stigmatized group improve feelings towards the group? J Person Soc Psychol 1997;72:105– 18. [9] Callard F, Sartorius N, Arboleda-Flo´rez J, Bartlett P, Helmchen H, Stuart H, et al. Mental illness, discrimination and the law. Fighting for social justice. New York: John Wiley & Sons; 2012. [10] Clarke J, Gawley A. The triumph of pharmaceuticals: the portrayal of depression from 1980 to 2005. Adm Policy Ment Health 2009;36:91–101. [11] Freidl M, Piralic-Spitzl S, Grohe N, Aigner M. Association between fear of stigma, depressive and anxiety symptoms in patients with somatoform pain disorder. Psychiat Prax 2012;39:263–6. [12] Gaebel W, Ahrens W, Schlamann P. Konzeption und Umsetzung von Interventionen zur Entstigmatisierung seelischer Erkrankungen: Empfehlungen und Ergebnisse aus Forschung und Praxis. Berlin: Aktionsbu¨ndnis Seelische Gesundheit; 2010. [13] Grausgruber A, Scho¨ny W, Grausgruber-Berner R, Koren G, Apor BF, Wancata J, et al. Schizophrenie hat viele Gesichter‘‘–Evaluierung der o¨sterreichischen Anti-Stigma-Kampagne 2000-2002. Psychiat Prax 2009;36:327–33. [14] Heiser WJ. Undesired nonlinearities in nonlinear multivariate analysis. Leiden: University of Leiden; 1985. [15] Heiser WJ, Meulmann JJ. Homogeneity analysis: exploring the distribution of variables and their nonlinear relationships. In: Greenacre M, Blasius J, editors. Correspondence analysis in the social sciences: recent developments and applications. London San Diego: Academic Press; 1994. p. 179–209. [16] Kwekkeboom MH. Social draagvlak voor de vermaatschappelijking in de geestelijke Gesondheitdswetenschappen. Ontwikkelingen tussen 1976 en 1997. Tijdschr Gezondheitswetenschappen 2000;78:165–71. [17] Lewison G, Roe P, Wentworth A, Szmukler G. The reporting of mental disorders research in British media. Psychol Med 2012;42:435–41.
[18] Link BG, Cullen FT, Struening E, Shrout P, Dohrenwend BP. A modified labeling theory approach in the area of mental disorders. An empirical assessment. Am Sociol Rev 1989;54:100–23. [19] Lundberg B, Hansson L, Wentz E, Bjo¨rkman T. Sociodemographic and clinical factors related to devaluation/discrimination and rejection experiences among users of mental health services. Soc Psychiatry Psychiatr Epidemiol 2007;42:295–300. [20] Matschinger H, Angermeyer MC, Link BG. Variationen der Antwortstrukturen in Abha¨ngigkeit vom Grad perso¨nlicher Betroffenheit. Eine Methodenstudie am Beispiel der ‘‘Discriminatioin-Devaluation-Scale’’. Psychother Psychosom Med Psychol 1991;41:278–83. [21] Mechanic D, McAlpine D, Rosenfield S, Davis D. Effects of illness attribution and depression on the quality of life among persons with serious mental illness. Soc Sci Med 1994;39:155–64. [22] Mehta N, Kassam A, Leese M, Butler G, Thornicroft G. Public attitudes towards people with mental illness in England and Scotland, 1994-2003. Br J Psychiatry 2009;194:278–84. [23] Pescosolido BA, Martin JK, Long JS, Medina TR, Phelan JC, Link BG. ‘‘A disease like any other?’’ A decade of change in public reactions to schizophrenia, depression and alcohol dependence. Am J Psychiatry 2010;167:1321–30. [24] Read J, Cain A. A literature review and metaanalysis of drug company-funded mental health websites. Acta Psychiat Scand 2013 [Epub ahead of print]. [25] Reavley NJ, Jorm AF. Stigmatising attitudes towards people with mental disorders: changes in Australia over 8 years. Psychiatr Res 2012;197:302–6. [26] Schomerus G, Matschinger H, Angermeyer MC. Causal attributions and social distance towards persons with mental illness: a comparative analysis of schizophrenia, depression and alcoholism. Psychol Med 2013 [Epub ahead of print]. [27] Schomerus G, Matschinger H, Kenzin D, Breier P, Angermeyer MC. Public attitudes towards mental patients: a comparison between Novosibirsk, Bratislava and German cities. Eur Psychiatry 2006;21:436–41. [28] Schomerus G, Schwahn C, Holzinger A, Corrigan PW, Grabe HJ, Carta MG, et al. Evolution of public attitudes about mental illness. A systematic review and meta-analysis. Acta Psychiatr Scand 2012;125:440–52. [29] Schriever BF. Order dependence. Amsterdam: Free University of Amsterdam; 1985. [30] Schulze B, Richter-Werling M, Matschinger H, Angermeyer MC. Crazy? So what! Project weeks on mental health and illness. Their effect on secondary school students’ attitudes towards people with schizophrenia. Acta Psychiatr Scand 2003;107:142–50. [31] Statacorp. Stata Statistical Software. Release 12. College Station. TX: Stat Press; 2011. [32] Stengler-Wenzke, Beck M, Holzinger A, Angermeyer MC. Stigmatisierungserfahrungen von Patienten mit Zwangserkrankungen. Fortschr Neurol Psychiatr 2004;72:7–13. [33] Thornicroft G, Brohan E, Rose D, Sartorius N, Leese M, for the INDIGO Study Group. Global pattern of experienced and anticipated discrimination against people with schizophrenia: a cross-sectional survey. Lancet 2009;373:408– 15. [34] Uc¸ok A, Brohan E, Rose D, Sartorius N, Leese M, Yoon CK, et al. Anticipated discrimination among people with schizophrenia. Acta Psychiatr Scand 2012;125:77–83. [35] United Nations. Convention on the rights of persons with disabilities and optional protocol. New York: The United Nations; 2006. [36] Van Rijckevorsel JLA. The application of fuzzy coding and horseshoes in multiple correspondence analysis. Leiden: DSWO Press; 1987. [37] Wcio´rka B, Wcio´rka J. Stereotyp i dystans-choroby psychiczne i chorzy psychicznie w opinii spo ecze stwa polskiego (1996 i 1999). Poszepy Psychiatr Neurol 2000;9:353–82. [38] Weiner B. On sin versus sickness. A theory of perceived responsibility and social motivation. Am Psychologist 1993;48:957–65. [39] WHO European Ministerial Conference on Mental Health. Mental Health Declaration for Europe. Helsinki: WHO Europe; 2005. [40] Yanos PT, Roe D, Markus K, Lysaker PH. Pathways between internalized stigma and outcomes related to recovery in schizophrenia spectrum disorders. Psychiatr Serv 2008;59:1437–42.
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Original article
Changes in the perception of mental illness stigma in Germany over the last two decades Matthias C. Angermeyer a,*,b, Herbert Matschinger c,d, Mauro G. Carta b, Georg Schomerus e,f a
Center for Public Mental Health, Untere Zeile 13, A-3482 Go¨sing am Wagram, Austria Department of Public Health and Clinical and Molecular Medicine, University of Cagliari, Italy Institute of Social Medicine, Occupational Health and Public Health, University of Leipzig, Germany d Department of Health Economics and Health Services Research, University of Hamburg, Germany e Department of Psychiatry, Ernst Moritz Arndt University Greifswald, Germany f HELIOS Hanseklinikum Stralsund, Germany b c
A R T I C L E I N F O
A B S T R A C T
Article history: Received 22 February 2013 Received in revised form 22 September 2013 Accepted 12 October 2013 Available online xxx
Purpose: To examine the evolution of the perception of the stigma attached to mental illness in Germany since 1990 up to the present. Subjects and methods: Population surveys were conducted in the old German States (former Federal Republic of Germany) in 1990, 2001, and 2011. The perception of stigma attached to people with mental illness was assessed with the help of Link’s perceived discrimination and devaluation scale. Results: In the 2011 survey, less mental illness stigma was perceived by respondents than in the previous surveys. In the eyes of the German public, the devaluation and rejection of people with mental illness has substantially decreased since 1990. Discussion: The perception of a decline of the stigmatization is in contrast to the development of the German public’s attitudes towards persons with mental disorders, which remained unchanged or even worsened. Conclusion: Perceived and personal attitudes towards persons with mental illness have developed differently, and it remains to be seen whether perceptions of less public stigma will ultimately be followed by improved personal attitudes. ß 2013 Elsevier Masson SAS. All rights reserved.
Keywords: Perceived stigma Mental illness Time trend Population survey
1. Introduction Studies on the development of public attitudes towards people with mental illness indicate that they have not changed for the better over the last decades. In a systematic review and metaanalysis of population studies conducted since 1990 we found that, although there were insignificant trends towards reduced blame in schizophrenia and depression, notions of dangerousness did not change. Most strikingly, social acceptance of mentally ill persons did not increase since 1990, instead, acceptance of persons with schizophrenia in various social relationships diminished [28]. While the evolution of public attitudes towards people with mental illness has been studied in various western countries (e.g., Austria [13], Germany [3,4], Netherlands [16], Poland [37], U.K. [22], U.S. [23]) hardly anything is known about how the public’s
* Corresponding author. Tel.: +43 664 43 53 199. E-mail address: [email protected] (M.C. Angermeyer).
perception of the stigma surrounding mental illness has developed in recent years. So far, only two studies have dealt with this question, coming up with inconsistent results. In Germany, we had found that former mental patients were perceived by the public in 2001 as being slightly less devalued and discriminated against than 11 years before [5]. In a more recent study in Australia, covering the time period between 2002/2003 and 2011, no changes were observed as regards depression with and without suicidal thoughts and early schizophrenia; only in case of chronic schizophrenia there was an increase in the perception that others believe in the dangerousness of such a person [25]. As the perception of the stigma surrounding mental disorders may influence how the public reacts to people suffering from these illnesses as well as how individuals deal with their illness it is important to learn more about how public views on mental illness stigma have developed over time. The empathy-altruism theory [7] posits that the perception of someone being in need elicits empathic concern, which in turn produces altruistic motivation; with the possible behavioral consequence that one might help or
0924-9338/$ – see front matter ß 2013 Elsevier Masson SAS. All rights reserved. http://dx.doi.org/10.1016/j.eurpsy.2013.10.004
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may have someone other help this person. In a series of socialpsychological experiments, it has been shown that inducing empathetic concern for a member of a stigmatized group improved attitudes towards the group as a whole [8]. According to this theory, the more the public perceives people with mental disorders as being devalued and discriminated against, and therefore in need, the more it may develop empathetic concern and be ready to engage in or support efforts to reduce stigma and discrimination because of mental illness. Vice versa, the perception of decreasing stigmatization may let people become less enthusiastic about antistigma initiatives. Moreover, following attribution theory [38], the perception of reduced stigma may have an ironic effect by actually increasing stigmatizing attitudes as psychosocial impairments of mental illness seem more self-caused rather than societally imposed. Apart from influencing the public’s reaction to people with mental illness, the perception of the stigma prevalent in society may also have an impact on those suffering from mental illness. According to the modified labeling theory [18], expectations as to what extent most people in a given culture stigmatize and discriminate against persons with mental illness are particularly relevant for those who themselves develop a mental disorder. If one believes that others will reject people with mental disorders one must fear that this rejection applies personally. This anticipated discrimination may have serious personal consequences for the afflicted person such as demoralization [18], loss of self-esteem [40] and reduced quality of life [21]. In view of the importance of this issue and the scarcity of empirical findings, we set out to examine the evolution of the perception of the stigma attached to mental illness in Germany over the last two decades.
2. Subjects and methods 2.1. Surveys The study is based on data from three population surveys among German citizens aged 18 years and over. The first survey was carried out in 1990 in the former Federal Republic of Germany before reunification (3067 participants, response rate 70.0%) while the surveys in 2001 and 2011 were carried out in the whole of Germany (2001: 5025 participants, response rate 65.1%; 2011: 3642 participants, response rate 64.0%). To make comparison possible, from the latter two surveys only interviews conducted in
the ‘‘old’’ German States (= former Federal Republic) were included into the analysis. In all three surveys, the samples were drawn using a random sampling procedure with three stages: (1) sample points, (2) households, and (3) individuals within the target households. Target households within the sample points were determined according to the random route procedure, that is, a street was selected randomly as the starting point from where the interviewers followed a set route through the area. Target persons were selected using random digits. Fieldwork was done in 1990 by GETAS (Hamburg), in 2001 and 2011 by USUMA (Berlin), both companies specialized in market and social research. Informed consent was considered to have been given when individuals agreed to complete the interview. The study has been approved by the ethics committee of the Universities of Heidelberg, Leipzig and Greifswald. Due to time constraints, randomly drawn sub-samples were presented with different sets of questions. In 1990, a sub-sample of 2044 individuals, in 2001 of 1943 individuals, and in 2011 of 965 individuals, all originating from the former Federal Republic or the ‘‘old’’ German States, respectively, were asked about their views on mental illness stigma. Socio-demographic characteristics of the study samples are reported in Table 1. 2.2. Interview In all three surveys, face-to-face interviews were conducted by trained interviewers who registered the answers of the interviewees using pencil and paper. On all three occasions, the interview was identical as concerns wording and sequence of questions and consisted of two parts. In the first part, respondents were presented an unlabeled case-vignette depicting a person displaying symptoms of either schizophrenia or major depression. They were then asked about their beliefs and attitudes concerning the person described in the vignette. In the second part of the interview, respondents answered questions of a more general nature, not referring to the vignette. Among other things, respondents’ perception of stigma attached to persons with mental illness was assessed with the help of the German version of Link’s perceived discrimination and devaluation scale [18]. This self-administered questionnaire has been used in population surveys [18,27] as well as in studies involving patients suffering from mental illness [11,19]. As the original, the authorized German version demonstrated adequate reliability [20]. The instrument asks about the extent of agreement with statements indicating that most people devalue former psychiatric patients by perceiving
Table 1 Socio-demographic characteristics of study samples. 2001
1990
Gender Male Female Age, years 18–25 26–45 46–60 61+ Educational attainment Still student No schooling completed 8/9 years of schooling 10 years of schooling 12/13 years of schooling a
2011
Survey (n = 2,044) %
Total Populationa %
Survey (n = 1,943) %
Total Populationa %
Survey (n = 965) %
Total Populationa %
44.1 55.9
48.5 51.5
43.3 56.7
48.3 51.7
44.7 55.3
48.6 51.4
10.1 35.6 26.6 27.6
12.3 38.0 24.2 25.5
11.4 40.9 23.7 23.9
9.8 37.8 23.8 29.1
8.5 33.9 25.4 32.1
11.3 31.9 26.9 29.9
1.9 3.6 53.9 24.0 16.5
0.4 2.5 55.8 25.8 15.5
3.2 2.1 47.5 29.3 17.9
0.2 2.1 49.1 27.5 21.1
0.8 2.6 44.7 33.3 18.7
1.0 4.0 38.5 29.3 27.1
Data from the Federal Statistical Office of Germany.
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them as failures, as less intelligent than other persons, or as individuals whose opinions need not to be taken seriously. It also asks to what extent the respondent agrees with statements indicating that most people distance themselves from psychiatric patients in various social relationships, like having a patient as a close friend or letting him teach young children in school. The scale is balanced such that a high level of perceived stigma is indicated by agreement with six of the items and by disagreement with six others. Answers to the items are recorded using 5-point Likert scales with the anchors ‘‘totally agree’’ (1) and ‘‘totally disagree’’ (5). Our measure of familiarity with mental illness comprises four hierarchical categories representing the intensity of personal experience with mental illness: the respondent has been/is in psychiatric treatment; a family member has been/is undergoing psychiatric treatment; the respondent either knows someone within his/her circle of friends, among his/her colleagues at work, or in his/her neighbourhood who has been/is undergoing psychiatric treatment, or s/he himself/herself or another member of the family, one of his/her friends etc. has been/is active as either a professional or voluntary helper in the field of mental health care; none of the listed possibilities applies to the respondent, i.e. he/ she has no personal experience with mental illness.
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In addition socio-demographic characteristics (gender, age, educational attainment) were assessed. 2.3. Statistical analysis In order to examine the change of perceived stigma over time, we performed a linear regression analysis, using STATA, release 12.1 [31]. Usually, the sum score of the twelve items is used based on the assumption of equal weights of the items with respect to the latent trait to be measured. However, a principal component analysis showed that this assumption is not fulfilled. The principal component analysis yielded two factors with an eigen value greater than one. The first factor comprises the six items representing the opposite of devaluation and discrimination (eigen value 4.84, explained variance 40.3%): item 1 (see Table 2 for wording of statements; factor loading 0.695), item 2 (0.680), item 3 (0.765), item 4 (0.700), item 8 (0.621), item 10 (0.729). The second factor comprises the six reversed items representing devaluation and discrimination (eigen value 1.42, explained variance 11.8%): item 5 (factor loading 0.472), item 6 (0.499), item 7 (0.683), item 9 (0.589), item 11 (0.480), item 12 (0.622). These factors, however, do not represent different dimensions of perceived stigma but rather an artefact related to item direction [14,15]. All twelve items load positively on the second factor, which represents nothing but the quadratic form of the first factor, also called a ‘‘horse shoe’’ [29,36]. Therefore,
Table 2 The German public’s perception of the stigma attached to former mental patients in 1990, 2001, and 2011. Item
Response category
1990 (n = 2,044) %
2001 (n = 1,943) %
2011 (n = 965) %
1
Most people would willingly accept a former mental patient as a close friend
2
Most people believe that a person who has been in a mental hospital is just as intelligent as the average person
3
Most people believe that a former mental patient is just as trustworthy as the average citizen
4
Most people would accept a fully recovered former mental patient as a teacher of young children in a public school
5
Most people feel that entering a mental hospital is a sign of personal failure (R)
6
Most people would not hire a former mental patient to take care of their children, even if he or she had been well for some time (R)
7
Most people think less of a person who has been in a mental hospital (R)
8
Most employers will hire a former mental patient if he or she is qualified for the job
9
Most employers will pass over the application of a former mental patient in favor of another applicant (R)
10
Most people in my community would treat a former mental patient just as they would treat anyone
11
Most young women would be reluctant to date a man who has been hospitalized for a serious mental disorder (R)
12
Once they know a person was in a mental hospital, most people will take his opinion less seriously (R)
Agree Undecided Disagree Agree Undecided Disagree Agree Undecided Disagree Agree Undecided Disagree Agree Undecided Disagree Agree Undecided Disagree Agree Undecided Disagree Agree Undecided Disagree Agree Undecided Disagree Agree Undecided Disagree Agree Undecided Disagree Agree Undecided Disagree
29.7 29.5 49.8 30.8 28.0 41.2 21.7 26.9 51.4 14.9 21.7 63.4 45.8 25.9 28.3 59.6 20.3 20.1 64.6 22.6 12.8 22.1 30.4 47.5 64.7 21.9 13.4 18.3 26.8 54.9 57.7 24.8 17.5 48.6 32.3 19.1
30.8 30.8 38.4 39.0 30.8 30.2 29.7 29.2 41.1 19.7 26.2 54.1 38.6 24.8 36.6 61.9 20.4 17.7 56.2 28.1 15.7 25.0 33.4 41.6 63.2 23.7 13.1 23.2 34.0 42.8 61.0 27.0 11.9 40.2 37.2 22.5
43.4 32.6 23.9 53.7 26.8 19.5 42.8 29.6 27.6 27.6 27.5 45.0 37.5 30.5 32.0 47.6 31.2 21.2 47.6 30.7 21.8 29.0 34.9 36.1 59.4 26.6 14.0 32.5 33.4 35.1 57.3 28.3 14.4 27.3 43.3 29.4
Note: Respondents who endorsed the two points on either side of the mid-point of the five-point scales (values 1 + 2 and 4 + 5) were grouped together to the categories ‘‘agree’’ and ‘‘disagree’’. R reversed item.
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3. Results Looking at the proportions of respondents agreeing or disagreeing with each statement (Table 2), it appears that the perception that mentally ill people are devalued decreased substantially in Germany between 1990 and 2011. For instance, while in 1990 more respondents disagreed than agreed with statements that former mental patients will be seen by most people as intelligent or as trustworthy, 21 years later the opposite was true. In 1990, over half of respondents had disagreed that former mental patients would be treated by most people as anyone; in 2011, one third each agreed and disagreed with that or was undecided. Had almost half of those questioned shared the view that once a person was in a psychiatric hospital most people would not take his or her opinion seriously, 21 years later the percentage has dropped by almost half. Concerning the perception of rejection experienced by former patients with mental illness, similar changes were observed. While, for instance, in 1990 the percentage of those agreeing that most people would not accept a former mental patient as a close friend exceeded by far the percentage of those who did not share this view, in 2011 the opposite was found. The same held true for the notion that most people would accept such a person as teacher of young children. However, no change at all occurred as concerns the belief that most young women would be reluctant to date a man who had been hospitalized for a serious mental disorder. Table 3 shows results of a multiple regression analysis with the component score of all 12 items. This analysis corroborated the Table 3 Perception of stigma attached to former mental patients regressed on time, familiarity with mental illness, gender, age, and educational attainment (n = 4,952).
Survey 2001a Survey 2001 age Survey 1990a Survey 1990 age Age Genderb Educational attainment Familiarity with mental illnessc
B
s.e.
t
P > jtj
0.2368 0.0004 0.7661 0.0042 0.0004 0.0303 0.0184 0.1004
0.0890 0.0018 0.1128 0.0021 0.0012 0.0278 0.0162 0.0302
2.66 0.21 6.79 1.96 0.29 1.09 1.14 3.32
0.008 0.831 0.000 0.050 0.769 0.275 0.256 0.001
F(8,4943) = 30.34, P > jFj = 0.000; Adj. R2 = 0.045. a Reference category: 2011. b Reference category: male. c Reference category: unfamiliar with mental illness.
.2 Linear Prediction -.2 0 -.4 -.6
for our analysis factor scores of the first factor of the un-rotated solution were used. Higher scores indicate greater perceived devaluation and discrimination. The scale showed sufficient internal consistency (Cronbach’s alpha 0.859). The overall mean is zero and its standard deviation is 1. We regressed the component score of the devaluationdiscrimination scale as dependent variable on year of survey (using the 2011 survey as reference category). To adjust the year effect for demographic changes across samples, the regression analysis controlled for respondents’ gender (male = 0, female = 1), age (years), and educational attainment (unknown = 0, no school completed = 1, 8 + 9 years of schooling = 2, 10 years of schooling = 3, 12 + 13 years of schooling = 4). Since in previous studies, the perception of stigma has shown an association with familiarity with mental illness [5] this has also been included into the regression equation as a dichotomous variable (any form of familiarity = 1, no familiarity = 0). To examine whether time trends are similar across different age groups interaction terms between age and time of survey were included. All variables plus the interaction terms were simultaneously introduced into the regression equation.
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4
18
28
38
48 1990
58 age
68 2001
78
88
98
2011
Fig. 1. Predictive margins of the first component of the perceived discrimination and devaluation scale with 95% CI. The ordinate represents the dependent variable, e.g. the first component. Each point in the graph shows the means of this component with respect to the two dummies representing 2001 and 2011 and the two linear interactions with age. All the other variables in the model are held at their means. Confidence intervals are estimated in 10-year intervals for the range of 18 to 98 years.
observations on item-level, yielding a significant decrease in perceived stigma over the last decade. Thus, the trend that has already been observed in the 1990s [5] continued during the following years. Over the whole study period, the amount of stigma perceived by respondents has substantially decreased. There was also an interaction with age in the sense that the decrease in stigma perception was particularly pronounced among young respondents (see also Fig. 1 showing the predicted margins of the component score). Respondents familiar with mental illness perceived less stigma than those who were unfamiliar with it. Stigma perception was not associated with socio-demographic characteristics of respondents.
4. Discussion In summary, our findings indicate that the perception of the stigma attached to mental illness has improved in the ‘‘old’’ States of Germany since 1990. In the eyes of the public, the devaluation and discrimination of persons with mental illness has considerably decreased in recent years. As indicated by the interaction effect, improvement between 1990 and 2011 was particularly pronounced among the young. People grown up in recent years tend to judge the situation of persons with mental illness less pessimistically than their counterparts two decades before. However, despite these positive developments, in 2011 a substantial proportion of respondents still believed that former psychiatric patients are devalued and rejected by the public. For instance, over half thought that most employers would pass over the application of a former mental patient in favor of another applicant. And almost half believed that people think less of a person who has been in a psychiatric hospital. The positive trend in the perception of mental illness stigma is in contrast to the development of the German public’s personal attitudes towards persons with mental illness. Over the same time period emotional reactions to people with schizophrenia and alcohol dependence have worsened while those to people with depression have only slightly improved. The public’s desire for social distance from people with schizophrenia increased while with the other two disorders there were no significant or inconsistent changes [6]. Thus, discrimination against persons with mental illness and the perception of the discrimination they are exposed to have not developed in parallel. Interestingly, a
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similar finding has also been reported from Australia: while between 2003/2004 and 2011 beliefs in dangerousness increased across all four different forms of mental disorder under study (depression with and without suicidal thoughts, early and chronic schizophrenia), the perception that others believe in dangerousness remained unchanged except for chronic schizophrenia [25]. What could be the reason for this divided development of public attitudes? One reason might be that the numerous antistigma programs that have been implemented in Germany in recent years [12] had a soothing effect on the public’s consciousness of the stigma surrounding mental illness. People may be aware of these efforts and expect that they have effectively reduced mental illness stigma. The example of some prominent persons who gave personal accounts of their mental illness (mostly depression, for example in ‘‘Stern’’ No.45, 4.11.2010) might have added to this picture. A similar effect may have had political initiatives that have been taken in recent years to improve the protection of human rights and dignity of people suffering from mental disorders and to implement the necessary legislation in order to empower them to participate fully and equally in society [9]. In the first place, the UN Convention on the Rights of Disabled People [35] has to be mentioned here, which has been ratified by the German parliament in 2009. In 2005, the WHO European Ministerial Conference on Mental Health issued the ‘‘Mental Health Declaration for Europe’’ [39], which provides basic rules and guidelines for promoting citizenship and fighting the violation of rights of persons with mental health problems. These initiatives and programs may have had stronger effects on stigma perception than on actual stigma. Another explanation for this disconnect may be that, fuelled by the proclamation of the 1990s as ‘‘Decade of the Brain’’ by the American Congress, during the study period the conceptualization of mental disorders has increasingly shifted towards a biomedical model [23]. This change is also reflected in a study of the media portrayal of depression in high circulating magazines in Canada and the U.S., that found that depression moved from a problem explained in a variety of ways in the 1980s to a primarily biomedical phenomenon in the 1990s and 2000s [10]. A study on reporting of mental health research in British media between 1999 and 2010 observed an emphasis on biological research while stories on psychological interventions were rare [17]. Similarly, in a recent review mental health websites were found to overemphasize biogenetic causal explanations and medication [24]. An analysis of five large German newspapers between 1999 and 2009 similarly found an increase of reports on biological causes and biomedical treatments compared to psychosocial causes and psychotherapy (Schomerus et al., unpublished results). The conventional wisdom has been that the shift towards a biomedical model would be accompanied by a decrease of mental illness stigma – although empirical evidence does not support this notion and points rather into the opposite direction [2,26]. In consequence, people endorsing biogenetic conceptualizations may nowadays tend to distance themselves from people with mental illness as much as in the past, or even more, while at the same time they may be persuaded that stigma has declined. As a consequence of the decrease of perceived stigma, people with mental illness may anticipate to be less exposed to discrimination. In a previous study, we had found that persons with schizophrenia, depression and obsessive-compulsive disorder anticipate discrimination far more frequently than they have actually experienced discrimination. The discrepancy between both forms of discrimination was particularly marked as concerns the access to social roles (partnership, occupation) [1,32]. Similar findings have also been reported from the INDIGO study for people with schizophrenia [33,34]. The expectation of less discrimination may help increase confidence and self-esteem of people with
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mental illness which, in turn, may have a positive effect on their socio-economic opportunities [33]. Thus, from the patients’ point of view the situation may have improved even though attitudes towards people with mental disorders (and, in consequence, discrimination enacted against them) have not changed for the better. Our findings have to be considered in the context of our study’s limitations. First, a limitation may be that attitudes towards mental illness in general and not attitudes towards specific mental disorders had been assessed. Therefore, we do not know which particular illnesses were associated with this term by our respondents. In the 1990 and 2011 interviews, before administering the scale measuring perceived stigma, one half each of respondents had been presented with vignettes depicting symptoms of either schizophrenia or major depression while in the 2001 interview only the vignette with major depression had preceded the perceived stigma scale. In order to examine to what extent the vignettes may have framed the perception of the stimulus ‘‘former mental patient’’ we repeated the regression analysis with the data from the 1990 and 2011 surveys including the type of vignette as control variable. Neither in 1990 nor in 2011, the predicted margins differed significantly between both vignettes (1990: schizophrenia 0.185, 95% C.I. 0.125–0.245, major depression 0.253, 95% C.I. 0.342–0.164; 2011: schizophrenia 0.280, 95% C.I. 0.218 0.342, major depression 0.422, 95% C.I. 0.512–0.333). Thus, the observed trend in the perception of devaluation and discrimination cannot be explained by an effect of preceding vignettes and does not represent an artifact. Second, another limitation may be that the scale used in our study does not cover all aspects of stigma but rather focuses on the stereotype of incompetence and on the desire for social distance. For instance, the perception of how violent most people think mentally ill patients are has not been assessed. Third, since no weights have been available for the first survey, and for the second and third survey only weights for the whole of Germany but not for the ‘‘old’’ States, weighting of our data was not possible. Although the sociodemographic characteristics of the three samples correspond well with those of the general population, except for an underrepresentation of better-educated persons in 2011, the representativity of our results remains, therefore, an open question. Finally, a limitation may also be seen in the fact that we compared three cross-sectional assessments at different points in time and did not follow up a panel drawn from the general population. However, since we were primarily interested in monitoring changes of people’s attitudes on a collective rather than on an individual level, the study design chosen appears appropriate, nothing to say of problems inherent to panel studies such as the lack of representativity of the follow-up assessment due to the huge attrition rate to be expected over a time period of 21 years.
5. Conclusions In conclusion, we can state that perceived and personal attitudes towards persons with mental illness have developed differently in the ‘‘old’’ States of Germany since 1990. It remains to be seen whether perceptions of less public stigma will ultimately be followed by improved personal stigmatizing attitudes. One should hope that continuing anti-stigma-efforts will work in this direction, although there is no evidence yet for a transition of lower stigma perceptions to lower stigma. As suggested by the interaction effect between the 1990 survey and age of respondents, the improvement of personal stigmatizing attitudes might happen first among the young generation, which should further encourage the implementation of school based anti-stigma and mental health literacy programs [30].
Please cite this article in press as: Angermeyer MC, et al. Changes in the perception of mental illness stigma in Germany over the last two decades. European Psychiatry (2013), http://dx.doi.org/10.1016/j.eurpsy.2013.10.004
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Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. Acknowledgement We would like to thank the two anonymous reviewers for their very helpful comments on an earlier version of this paper. The study was funded by the Fritz-Thyssen-Stiftung (Az. 10.11.2.175) References [1] Angermeyer MC, Beck M, Dietrich S, Holzinger A. The stigma of mental illness: patients’ anticipations and experiences. Int J Soc Psychiatry 2004;50:153–62. [2] Angermeyer MC, Holzinger A, Carta MG, Schomerus G. Biogenetic explanations and public acceptance of mental illness. A systematic review of population studies. Br J Psychiatry 2011;199:367–72. [3] Angermeyer MC, Holzinger A, Matschinger H. Mental health literacy and attitude towards people with mental illness: a trend analysis based on population surveys in the eastern part of Germany. Eur Psychiatry 2009;24:225–32. [4] Angermeyer MC, Matschinger H. Causal beliefs and attitudes to people with schizophrenia – trend analysis based on data from two population surveys in Germany. Br J Psychiatry 2005;186:331–4. [5] Angermeyer MC, Matschinger H. The stigma of mental illness in Germany: a trend analysis. Int J Soc Psychiatry 2005;51:276–84. [6] Angermeyer MC, Matschinger H, Schomerus G. Attitudes towards psychiatric treatment and people with mental illness: Changes over two decades. Br J Psychiatry 2013;203:146–51. [7] Bateson CD. Altruism in humans. Oxford New York: Oxford University Press; 2011. [8] Bateson CD, Polycarpou MP, Harmon-Jones E, Imhoff HJ, Mitchener EC, Bednar LL, et al. Empathy and attitudes: Can feeling of a member of a stigmatized group improve feelings towards the group? J Person Soc Psychol 1997;72:105– 18. [9] Callard F, Sartorius N, Arboleda-Flo´rez J, Bartlett P, Helmchen H, Stuart H, et al. Mental illness, discrimination and the law. Fighting for social justice. New York: John Wiley & Sons; 2012. [10] Clarke J, Gawley A. The triumph of pharmaceuticals: the portrayal of depression from 1980 to 2005. Adm Policy Ment Health 2009;36:91–101. [11] Freidl M, Piralic-Spitzl S, Grohe N, Aigner M. Association between fear of stigma, depressive and anxiety symptoms in patients with somatoform pain disorder. Psychiat Prax 2012;39:263–6. [12] Gaebel W, Ahrens W, Schlamann P. Konzeption und Umsetzung von Interventionen zur Entstigmatisierung seelischer Erkrankungen: Empfehlungen und Ergebnisse aus Forschung und Praxis. Berlin: Aktionsbu¨ndnis Seelische Gesundheit; 2010. [13] Grausgruber A, Scho¨ny W, Grausgruber-Berner R, Koren G, Apor BF, Wancata J, et al. Schizophrenie hat viele Gesichter‘‘–Evaluierung der o¨sterreichischen Anti-Stigma-Kampagne 2000-2002. Psychiat Prax 2009;36:327–33. [14] Heiser WJ. Undesired nonlinearities in nonlinear multivariate analysis. Leiden: University of Leiden; 1985. [15] Heiser WJ, Meulmann JJ. Homogeneity analysis: exploring the distribution of variables and their nonlinear relationships. In: Greenacre M, Blasius J, editors. Correspondence analysis in the social sciences: recent developments and applications. London San Diego: Academic Press; 1994. p. 179–209. [16] Kwekkeboom MH. Social draagvlak voor de vermaatschappelijking in de geestelijke Gesondheitdswetenschappen. Ontwikkelingen tussen 1976 en 1997. Tijdschr Gezondheitswetenschappen 2000;78:165–71. [17] Lewison G, Roe P, Wentworth A, Szmukler G. The reporting of mental disorders research in British media. Psychol Med 2012;42:435–41.
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