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Attitudes towards psychiatric treatment and people with mental illness: changes over two decades

  • Matthias C. Angermeyer (a1), Herbert Matschinger (a2) and Georg Schomerus (a3)



Over the past decades, psychiatry, as a science and a clinical discipline, has witnessed profound changes.


To examine whether these changes are reflected in changes in the public's conceptualisation of mental disorders, the acceptance of mental health treatment and attitudes towards people with mental illness.


In 1990 and 2011, population surveys were conducted in Germany on public attitudes about schizophrenia, depression and alcohol dependence.


Although the public has become more inclined to endorse a biological causation of schizophrenia, the opposite trend was observed with the other two disorders. The public's readiness to recommend help-seeking from mental health professionals and using psychotherapy and psychotropic medication has increased considerably. Attitudes towards people with schizophrenia worsened, whereas for depression and alcohol dependence no or inconsistent changes were found.


The growing divide between attitudes towards schizophrenia and other mental disorders should be of particular concern to future anti-stigma campaigns.

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Corresponding author

Matthias C. Angermeyer, Center for Public Mental Health, Untere Zeile 13, A-3482 Gösing am Wagram, Austria. Email:


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Attitudes towards psychiatric treatment and people with mental illness: changes over two decades

  • Matthias C. Angermeyer (a1), Herbert Matschinger (a2) and Georg Schomerus (a3)
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Attitudes towards psychiatric treatment and people with mental illness changes over two decades

Aniruddha Basu, Senior Resident
07 October 2013

To The Editor,

We read with interest the study by Angermeyer et al. and appreciate the painstaking efforts undertaken for performing this longitudinal survey at an interval of 21 years(1). This is a longitudinal vignette based survey. In the field of stigma or related social science research, vignettes are very popular because they allow the researcher to present amore elaborate stimulus to respondents than simply asking about "mental illness" or a "psychiatric hospital/ patient". Furthermore, vignettes can be administered to randomly selected general population samples. At the same time, it is important to recognize that vignettes are hypothetical and abstracted from "real life" experience. Since, vignettes have drawbacks, it is expected that the best approach to develop future knowledge in this area will be built on information derived from multiple methodological approaches with different strengths and weaknesses. On suchapproach may be qualitative study design which has been shown to be successful in social science research notwithstanding its own limitations.

One of the goals of this study was to study whether public attitudes towards people with mental illness has changed or not. For this purpose the authors have only assessed 'emotional reactions' and 'desire for social distance'. However, as per Link and Phelan these are two aspects of'stigma' which is a holistic concept having several interrelated components like labeling, stereotyping, cognitive separating, emotional reactions, status loss/discrimination, structural discrimination, and behavioural responses (2). A reductionist view-point in this respect can give rise to undue controversy. For this reason a comprehensive instrument dealing with all the components of stigma should be used and only this can gauge the important social construct of 'stigma' in a rapidly changing socio-cultural and economic milieu. Another issue in thiscontext is that whether the instrument would retain similar validity across a time span of two decades or whether it would require a fresh validation.

In the 'Desire for social distance scale' there is a limitations of social desirability bias (3). Over the years, public education and anti-stigma campaigns have made it clear to the public that rejecting a person simply because he or she has a mental illness or is seen by a psychiatristor been treated in a mental hospital is unjust and wrong. Not wanting to appear heartless or ignorant, people might deny social distancing responses in order to appear enlightened and caring. Under that circumstances, assessments of reported social distance underestimate the extent of true social distancing sentiments. Such bias can be lessened by judicious use and random allocation of the vignettes, details of which have not been mentioned. Inspite, of such limitations the study is unique in terms of its effort to understand the trajectory of change in knowledge attitude practices and belief systems for mental illnesses in a representative sample. References:1. Angermeyer MC, Matschinger H, Schomerus G. Attitudes towards psychiatric treatment and people with mental illness: changes over two decades. Br J Psychiatry J Ment Sci. 2013 Aug;203:146-51. 2. Link BG, Phelan JC. Conceptualizing Stigma. Annu Rev Sociol. 2001;27(1):363-85. 3. Link BG, Yang LH, Phelan JC, Collins PY. Measuring mental illness stigma. Schizophr Bull. 2004;30(3):511-41.

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'Desire for social distance' for Schizophrenia: Pre- or post-treatment?

The recently published study by Angermeyer et al 1 is, indeed, a commendable exercise undertaken on a large population - based random sample. The study deals with an important issue of public acceptance of treatment and public attitudes towards mental disorders. It is encouraging to know that perception of psychiatric treatments has become more favorable in the past two decades.Contrary to author's expectations, in spite of a greater public acceptance of treatment services and a higher endorsement of biological causation for schizophrenia, the 'desire for social distance' has apparently increased. We wish to raise a methodological query in relation to this, as it is not clear from the paper and appears to be unaddressed.

The 'desire for social distance' was measured by means of seven- items asking the respondents to rate on a likert scale if they were willing to have the concerned person (from a case vignette) 'as a neighbour' , willing to 'rent a room' , 'marry into family' or entrust'care of your children' to him or her . The schizophrenia case vignette( not appended in the article) is likely to have described a person with delusion/s, hallucination/s, disorganized speech or behavior and some degree of dysfunction (in accordance with standard diagnostic criteria). We are curious to know if the question on 'desire for social distance' took into account the treatment effects, and if respondents were told that the person is under treatment before assessing their behavioral intentions in a variety of social/personal situations.

We wish to emphasize the fact that a different, and perhaps more favorable, response may have been evoked if the concerned person (from case vignette) was reported to have received treatment. If authors were expecting improved public attitudes over past 20 years, one of the crucial reasons for such expectation would be 'availabilityof treatments' and 'enhanced coverage of mental health care services.' (among some other factors). Even in anti-stigma campaigns, the recovery-oriented messages are employed most commonly and proven to be most effective. Therefore, the effects of treatment of mental disorders are important to take into account in order to accurately measure the extentof public (mis)perception.

The article by Link et al 2 has also discussed stigma in the context of formerly treated patients with mental illness, and have presented vignette for 'treated' patients with varying degree of persistent dysfunction. Having said that, we acknowledge that the responses have been measured at two distinct time intervals and the finding of a 5-15% increase in 'desire for social distance' in various hypothetical social situations is not being debated by us. Few other points to add to discussion: The 2011 survey have a relative proximity in time to the 2009 tragic school shoot out in Germany, which may have affected the public attitudes. There have been few other incidents over recent decade (and extensively covered by international media) where a person with mental illness has been involved in violence and multiple casualties in public settings. With advent of social networking, widespread information dissemination and an increasingly deeper penetration of media in the households across the world, the public attitudes (especially concerning safety and maintaining social distance) may have been colored by such incidents. A technical issue with most surveys assessing stigmatizing attitudes for mental illness isthe lack of a control group of another chronic disabling illness, giving no reference point. However, the present survey had two distinct time-points of reference and provides some interesting insights about the relative change in public attitudes towards psychiatric disorders.

Reference:1.Angermeyer MC, Matschinger H, Schomerus G.Attitudes towards psychiatrictreatment and people with mental illness: changes over two decades. The British Journal of Psychiatry 2013; 203, 146-1512.Link BG, Cullen FT, Frank J, Wozniak JF. The social rejection of formermental patients: understanding why labels matter. Am J Sociol 1987; 92: 1461-500.

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Conflict of interest: None declared

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