Changes in causal explanations of mental disorders

There has been an increase in the German public's endorsement of biological causes for schizophrenia, however, for both depression and alcohol dependence there was a trend in the opposite direction. Whereas the first result is in line with findings from previous studies, this is not the case for the other two disorders, where other studies have also reported an increasing adoption of biogenetic causal attributions for these conditions. ^{Reference Schomerus, Schwahn, Holzinger, Corrigan, Grabe and Carta12-Reference Angermeyer, Holzinger and Matschinger14} One reason for this discrepancy may be that previous studies covered the time period up to 2006, whereas our study ended more recently in 2011. A trend analysis in Western Germany between 1990 and 2001, based on a subsample that had been presented with the male version of the depression vignette, also showed a slight increase in the endorsement of brain disease as a potential cause for this disorder. ^{Reference Angermeyer, Holzinger and Matschinger14} This suggests that the decrease in the public endorsing biogenetic explanations for depression observed in the current study is likely to have occurred between 2001 and 2011. We hypothesise that this new trend is the result of social developments that have taken place during this time frame, namely profound changes in working conditions in the wake of the process of globalisation and the economic crisis that began in 2008. Although Germany seems to be faring better than other Member States of the European Union, the German public are concerned by the crisis, as reflected by the results of a national survey conducted in 2010 according to which over half of respondents felt threatened as a result of the economic situation. ^{Reference Heitmeyer and Heitmeyer15} This may have resulted in a growing awareness of the importance of social forces in people's emotional well-being. This interpretation is supported by our finding that significantly more people in 2011 endorsed work-related problems, including unemployment, as a cause of depression. Also of note, over the past 10 years there has been a rise in the labelling of depressive episodes as burnout. ^{Reference Bahlmann, Angermeyer and Schomerus16}

Changes in help-seeking and treatment recommendations

Across all three disorders, the German public's readiness to recommend help-seeking from mental health professionals has increased since 1990. Similar trends have also been reported from the USA, Australia and some European countries. ^{Reference Schomerus, Schwahn, Holzinger, Corrigan, Grabe and Carta12-Reference Angermeyer, Holzinger and Matschinger14,Reference Reavley and Jorm17} It is evident that consulting a psychiatrist or a psychotherapist has become a less unusual and a more accepted way to deal with mental health problems than it used to be in the past. The trend towards greater acceptance of mental health services has also been observed with regard to psychiatric hospitals; here too, public attitudes have become more favourable over the past two decades. ^{Reference Angermeyer, Matschinger and Schomerus18} However, it currently is not possible to establish what accounts more for this trend - the improvements in treatments offered by mental health professionals or the improvements in the organisation of mental health services. It is apparent that the German public has taken note of the reforms in mental healthcare as in the 2011 survey we found that the majority of respondents shared the view that the number of office-based psychotherapists had increased over the past 20 years as well as the proportion of people with mental illness being treated in out-patient services instead of hospitals. ^{Reference Schomerus and Angermeyer19} The reforms may have resulted in lower barriers to help-seeking from mental health services, objectively in terms of a greater availability of such services as well as subjectively in terms of lower stigma attached to using them. This change in attitude was paralleled by a growing number of people turning to mental health professionals for help. ^{Reference Gaebel and Zielasek20} However, the increasing acceptance of mental health professionals does not seem to be closely related to time trends about causal beliefs as, regardless of whether biological causes were more or less frequently endorsed in 2011, the public was more ready to recommend seeking help from psychiatrists as well as from psychotherapists.

Across all three disorders, the two best-established psychiatric treatment modalities, psychotherapy and psychotropic medication, showed the most pronounced increase in public acceptance. In the case of schizophrenia the readiness to recommend psychotropic medication grew significantly more than for the other two disorders. It was also only for schizophrenia that the increase in endorsement of medication was significantly greater than that for alternative methods, whereas with the other two disorders there was some overlap between the evolution of attitudes towards both treatments. Schizophrenia was the only condition for which the willingness to recommend relaxation techniques decreased significantly. This perhaps should be considered in relation to the increasing endorsement of a biological causation that we found, although it remains unclear whether there is a causal link between both trends or whether this is a coincidence. In support of the first view are the results of cross-sectional analyses of the data from both 1990 ^{Reference Angermeyer and Matschinger21} and 2011 (unpublished results, details available from the authors on request), showing a positive association between the endorsement of biological causes and the propensity to recommend medication. On the other hand, the finding that psychotherapy has gained ground across all three disorders independently of how causal beliefs have developed argues against a close relationship between causal beliefs and treatment recommendations. This trend is more remarkable given that over the past decades the public has been increasingly exposed in the media to information on biological research about mental disorders and the pharmacological treatment of these illnesses, whereas reports about psychological interventions have been rather rare. ^{Reference Lewison, Roe, Wentworth and Szmukler22,Reference Clarke and Gawley23}

Changes in attitudes towards people with mental disorder

The marked trend towards greater acceptance of mental health treatment was not accompanied by greater acceptance of people with mental illness. Studies that have recently been conducted in the USA, Australia and some European countries ^{Reference Schomerus, Schwahn, Holzinger, Corrigan, Grabe and Carta12-Reference Angermeyer, Holzinger and Matschinger14,Reference Reavley and Jorm24-Reference Grausgruber, Schöny, Grausgruber-Berner, Koren, Apor and Wancata26} have also found no substantial improvement in attitudes towards people with mental illness. In our study we found that although the desire for social distance from people with schizophrenia has increased, no consistent trend was observed for depression or alcohol dependence. There is an interesting parallel to the development of biological causal explanations, which have only increased for schizophrenia. Moreover, fear about people with schizophrenia, prosocial feelings towards people with depression and anger towards those with alcohol dependence have increased. This corresponds with the increase in the adoption of biological causes in the case of schizophrenia and the decrease in the cases of depression and alcohol dependence. A cross-sectional analysis of the 2011 data has revealed that biogenic causal beliefs are associated with increasing social distance in the cases of schizophrenia and depression but with a decrease in the case of alcohol dependence. ^{Reference Schomerus, Matschinger and Angermeyer27,Reference Angermeyer, Holzinger, Carta and Schomerus28} The increase in fear about people with schizophrenia is also documented in the public's growing approval of compulsory admission to a psychiatric hospital for individuals with persecutory delusion or in cases of public nuisance. ^{Reference Angermeyer, Matschinger and Schomerus29} This trend appears to be supported by the finding that a growing proportion of the public hold the view that psychiatric hospitals are necessary to protect society from mentally ill people. ^{Reference Angermeyer, Matschinger and Schomerus18} Our result is all the more sobering given that over the past 10 years great efforts have been made in Germany to fight against the stigma attached to mental disorders. ^{Reference Gaebel, Ahrens and Schlamann30} However, these campaigns have been mostly regional and probably therefore have less of an impact than a large nationwide campaign, such as the one recently launched in the UK. ^{Reference Henderson, Corker, Lewis-Holmes, Hamilton, Flach and Rose31}

Strengths and weaknesses

With a time span of 21 years, our study is the longest vignette-based trend analysis of public attitudes towards mental disorders. Another strength of our study is the large sample size (nearly 1000 respondents each being presented with one of the three case vignettes at each assessment point), allowing for complex statistical analyses. To achieve maximum comparability between both surveys we adhered to the recommendations of experts in survey research ^{Reference De Leeuw, Hox and Dillman32} as closely as possible, using the same sampling procedure, interview mode and instruments. However, the exclusive focus on attitudes may also be seen as a limitation since it allows predicting behaviour with only limited accuracy. However, rather than using them as a proxy for individual behaviours public attitudes can also be conceptualised at a collective level as a reflection of cultural conceptions of mental illness. Such conceptions provide a cultural context that influences the way we think about mental illness and the people who have them. As Link et al have pointed out ‘as a context this cultural conception becomes an external reality, something that individuals must take into account when they make decisions and enact behavior’. ^{Reference Link, Angermeyer, Phelan, Thornicroft, Szmukler, Mueser and Drake33} The aim of our study was to document the variations in these cultural conceptions of mental illness over time. For this purpose, the comparison between two cross-sectional assessments at different points in time appears to be the most appropriate study design. Although also providing insights into the changes in people's attitudes at an individual level, a panel study would struggle with the lack of representativeness of the follow-up assessment, due to the huge attrition rate that can be expected over a time period of 21 years, and, therefore, this type of study is less suitable for studying changes on a collective level.

Implications

In conclusion, public attitudes towards mental healthcare providers and the treatment offered by them has improved considerably in Germany over the past 20 years. However, attitudes towards those with mental illnesses have remained unchanged or worsened. Seemingly, the changes that have taken place in psychiatry over the past decades have benefited the image of psychiatry, but have failed to improve the image of its patients. Further efforts are necessary to combat the stigmatisation and discrimination of people with mental illness. In light of our findings it seems advisable to focus all available resources on this endeavour. In view of the growing divide between schizophrenia and other mental disorders, special efforts should be made to stop this disquieting trend.