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Public Beliefs About and Attitudes Towards People with Mental Illness: A
Review of Population Studies

Article in Acta Psychiatrica Scandinavica · April 2006

DOI: 10.1111/j.1600-0447.2005.00699.x · Source: PubMed

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Acta Psychiatr Scand 2006: 113: 163–179 Copyright
2005 Blackwell Munksgaard
All rights reserved ACTA PSYCHIATRICA
DOI: 10.1111/j.1600-0447.2005.00699.x
SCANDINAVICA

Review article
Public beliefs about and attitudes towards
people with mental illness: a review of
population studies
Angermeyer MC, Dietrich S. Public beliefs about and attitudes M. C. Angermeyer, S. Dietrich
towards people with mental illness: a review of population studies. Department of Psychiatry, University of Leipzig, Leipzig,
Acta Psychiatr Scand 2006: 113: 163–179.
2005 Blackwell Munksgaard. Germany

Objective: To provide a review of population-based attitude research

in psychiatry during the past 15 years.
Method: An electronic search using PubMed, Medline, and Academic
Search Premier plus a hand search of the literature was carried out for
studies on public beliefs about mental illness and attitudes towards the
mentally ill published between 1990 and 2004.
Results: Thirty-three national studies and 29 local and regional studies
were identified, mostly from Europe. Although the majority are of
descriptive nature, more recent publications include studies testing
theory-based models of the stigmatization of mentally ill people,
analyses of time trends and cross-cultural comparisons, and Key words: attitudes; population; mental disorders
evaluations of antistigma interventions. Matthias C Angermeyer, Department of Psychiatry,
Conclusion: Attitude research in psychiatry made considerable University of Leipzig, Johannisallee 20, D-04317 Leipzig,
progress over the past 15 years. However, there is still much to be done Germany.
to provide an empirical basis for evidence-based interventions to E-mail: [email protected]
reduce misconceptions about mental illness and improve attitudes
towards persons with mental illness. Accepted for publication September 28, 2005

Summations
• In the time period since 1990, misconceptions about mental disorders still prevailed among the
general public.
• There are indications of inter-cultural variations of beliefs and attitudes as well as of changes over
time.
• There are marked differences between the various mental disorders with regard to beliefs and
attitudes.

Considerations
• Up until now, population-based attitude research in psychiatry has mainly been descriptive in
nature. Other approaches, e.g. the testing of theory-based models, are still under-represented.
• So far, attitude research was mainly focused on schizophrenia and depression, other mental disorders
have been neglected.
• There is only little known about the relation between attitudes towards people with mental disorders
and the actual behaviour towards them.

163
Angermeyer and Dietrich

The answers to these questions may give an

Introduction
impression of the magnitude of the problem, give
In 1989, a review article was published in this some insights into how stigma operates and pro-
journal by Dinesh Bhugra on ÔAttitudes towards vide some clues as to what strategies may be best
mental illnessÕ focusing on studies of public atti- suited to modify existing misconceptions about
tudes towards mental illness, mentally ill people mental disorders.
and their treatment environs (1). Ever since then, in
many countries reforms of mental health care have
Material and methods
been initiated or have made further progress (2, 3).
One aim of these reforms was to better integrate We electronically searched PubMed, Medline and
mentally ill people into society. However, in recent Academic Search Premier for studies covering the
years there has been a growing awareness among time period from January 1990 to December 2004.
mental health professionals that mental illness is The search was conducted by entering each of the
still surrounded by stigma. According to Sartorius following keywords (attitudes*), (public attitudes*),
it is the most important obstacle to the provision of (general public*), (beliefs*), (lay beliefs*),
mental health care for people with mental disorders (stigma*), and (social distance*) in combination
(4). Moreover, as Jorm (5) was able to show, the with (mental illness*), (mental disorder*), (schizo-
public’s Ômental health literacyÕ is still unsatisfac- phrenia*), (depression*), (Alzheimer’s disease*),
tory and needs to be improved. Otherwise, this may (anxiety disorder*), (OCD*), (alcoholism*), (drug
hinder public acceptance of evidence-based mental addiction*), (dementia*), (eating disorder*) and
health care. In the 1990s, several programs have (bipolar disorder*) into each of these databases.
been launched around the globe, aimed at either Following the electronic search, hand searches of
improving public knowledge about mental disor- the literature identified were undertaken in the form
ders or reducing the stigmatization and discrimin- of citation chasing. From these primary and secon-
ation of those suffering from these disorders (e.g. dary references, those reports were included in our
6–9). In view of these developments we thought that review that met the following criteria: first, the paper
it is time to carry out a new literature review on was written in English. Second, the focus of the
public beliefs and attitudes, covering the time study was on the general public. Studies investi-
period between 1990 and 2004. gating attitudes and beliefs of particular subgroups
(e.g. consumers, carers, health professionals, uni-
versity students, etc.) were excluded. Third, studies
Aims of the Study
were based on random or quota samples drawn
In particular, the following questions are from the general population or from primary care
addressed: services. Studies using convenience samples were
not taken into consideration. Searches for articles in
i) To what extent are mental disorders recog-
October, November and December issues (2004) of
nized as such and what beliefs about the
the main journals publishing relevant articles were
origin, treatment and course of mental disor-
performed to identify any research that had not yet
ders prevail among the general public?
been entered into any of the above databases. The
ii) What attitudes towards mentally ill people are
following journals were searched: Social Psychiatry
prevalent among the general public?
and Psychiatric Epidemiology, Acta Psychiatrica
iii) How are beliefs and attitudes related to
Scandinavica, British Journal of Psychiatry, Psy-
people’s socio-demographic characteristics
chological Medicine, European Psychiatry, Inter-
and how are they influenced by familiarity
national Journal of Social Psychiatry, American
with mental illness?
Journal of Public Health, Social Science and Medi-
iv) What are the results of studies testing hypo-
cine, European Archives of Psychiatry and Clinical
theses derived from modern stigma theory?
Neurosciences, Canadian Journal of Psychiatry,
v) Have there been any changes in attitudes and
and Schizophrenia Bulletin. All articles included
beliefs over the years?
into our review were systematically screened by both
vi) Which results yield cross-cultural comparisons
authors for information relevant to the questions
of beliefs about mental disorders and attitudes
posed in the Introduction.
towards people with mental disorder?
vii) What are the results of studies evaluating the
effect of interventions aimed at improving the Results
public’s knowledge and at reducing the stigma
The above search strategy yielded an output of 3651
attached to mental disorders?
articles. However, this output constitutes a gross

164
 Public beliefs about and attitudes towards mentally ill

total since a number of studies appeared more than (23, 40, 42, 44, 46, 47, 49, 51, 53, 54, 66, 70, 71, 83,
once after the different keyword combinations were 105, 111) and the evaluation of interventions aimed
entered into each of the databases. Of the articles at improving knowledge of mental disorders and
identified, 110 met the inclusion criteria. While reducing stigmatization of mentally ill people (56,
between 1990 and 1992 only two relevant articles 57, 83, 87, 96, 97, 114–116). In the following, the
had been published in the following years, a steep major findings of these various approaches of
linear increase can be observed (1993–1995: 11 attitude research are presented.
articles, 1996–1998: 23 articles, 1999–2001: 32
articles), resulting in a maximum of 41 articles
Descriptive studies on public beliefs about mental disorders
between 2002 and 2004. The articles referred to 62
studies. Differentiating between surveys on a Studies on beliefs about mental disorders take an
national level and those on a regional or local interest in the question as to what extent they are
level, the characteristics of the studies included are recognized as such and what beliefs about the
reported in Tables 1 and 2. The tables show that a causes, the course and the treatment of these
total of 33 national surveys have been conducted in illnesses are prevalent among the public. Several
14 different countries, with 23 of these having been studies using case vignettes agree that many
carried out in Europe, six in America, and two each members of the lay public cannot correctly recog-
in Asia and Oceania. An additional stock of 29 local nize mental disorders. Schizophrenic symptoms are
or regional surveys can be added to the collection, more often seen as an expression of a mental illness
with 14 of them having been conducted in Europe, (range 69–88%) than are depressive symptoms (26–
five each in America and in Asia, four in Oceania 69%) or symptoms of alcoholism (16–49%) (23,
and one in Africa. The majority of the surveys (44) 24, 34, 41, 50, 65, 66, 74, 80, 109).
are based on random samples of the general All studies using vignettes conclude that lay
population. The number one interview technique beliefs about the causes of mental disorders clearly
used was personal interviewing (38), followed by differ from the results of psychiatric research in that
telephone interviews (13). Only five of the surveys psychosocial factors, particularly psychosocial
were conducted by mail. Response rates for the stress, are predominating in comparison with bio-
personal interview surveys varied between 64.0 and logical factors. This holds even truer for depression
98.3%, between 44.0 and 75.4% for the telephone than for schizophrenia (22, 23, 32, 34, 40, 41, 47, 65,
surveys and between 34.5 and 60.0% for the mail 81, 93). If one concentrates on the studies using the
surveys. Sample sizes ranged from a minimum of 90 same instrument for the assessment of causal beliefs
to a maximum of 7278 individuals. While depression (22, 23, 32, 34, 40) the following picture emerges:
(31 surveys) and schizophrenia (29 surveys) were in acute stress in the form of life events is the
the lead of the illnesses addressed in these studies, most frequently endorsed cause (schizophrenia:
alcoholism (8), anxiety disorders (7), dementia (6) 72.5–87%, depression: 81–85.5%), followed by
and drug addiction (4) were studied comparatively (chronic) stress in partnership and family (schizo-
rarely. One survey each paid attention to mania, phrenia: 59–64%, depression: 70–74%), brain
obsessive–compulisive disorder, prescription drug disease (schizophrenia: 48.5–71%, depression: 19–
dependency, eating disorders, mental retardation 59%) and heredity (schizophrenia: 39–67.5%,
and childhood hyperactivity. Twenty-six studies depression: 21–58%). Studies using diagnostic
dealt with mental illness in general. Thirty surveys labels as stimulus come up with somewhat mixed
used vignettes as a stimulus. The majority of surveys results: while in the case of depression, psychosocial
were focused on public beliefs about mental illnesses stress is again favoured over biological causes as
(51 surveys) and attitudes towards persons with explanation (57, 60, 87), in the case of schizophre-
mental illnesses (45 surveys). Only 11 surveys nia the situation is different, with biological factors
investigated attitudes towards psychiatric facilities. being as frequently endorsed as a cause (86) or even
Articles reporting descriptive data on public more frequently than psychosocial stress (22,
beliefs about mental illness and attitudes towards 101–103). The results of studies assessing causal
people with mental illness made up the lion’s share beliefs about mental illness in general are rather
(10–19, 21, 22, 26–32, 34, 36, 40–45, 47–55, 58–65, inconsistent in this regard (46, 62, 91, 95, 107, 119).
67, 69, 73–86, 89–95, 98–109, 111–113). In contrast, As far as help-seeking beliefs are concerned, the
articles devoted to testing of theory-based models results are inconsistent. This may, in part, have to
of the stigmatization of mentally ill people (33, 35, do with the diversity of the care systems in the
37–39, 72, 109) were rare. The same applies to various countries. However, some general tenden-
the analysis of time trends (20, 24, 25, 58, 68, 87), cies emerge. In the case of depression, the general
cross-cultural comparisons of beliefs and attitudes practitioner is most frequently recommended as a

165
 Table 1. Overview of national surveys published since 1990

166
Beliefs Attitudes Attitudes
about towards towards
Response Sample mental mentally psychiatric
Country Year Sampling procedure Age Interview rate (%) size Disorder Stimulus illness ill people services References

Austria 1991 Quota sample 15+ Personal interview – 1443 Schizophrenia Vignette X X (10)
Depression
Anxiety/Panic disorder
Psychosis
1998 Quota sample 14+ Personal interview – 1042 Dementia Vignette X X (11)
Schizophrenia
Angermeyer and Dietrich

Mental illness – X
Germany 1990 Random sample 18+ Personal interview 68.9* 2045* Schizophrenia Vignette X X X (12–17)
Depression
Mental illness –
1990 Random sample 18+ Personal interview 71.9* 2118* Schizophrenia Vignette X X (12–15, 18–20)
Depression
Panic disorder with agoraphobia
1990 Random sample 18+ Personal interview 72.3*/67.4à 1022*/980à Schizophrenia Vignette X X (12–15, 17–19, 21–27)
Depression
Alcoholism
1991 Random sample 18+ Personal interview 70.9* 1912* Schizophrenia Vignette X (12–15)
1991 Random sample 18+ Personal interview 67.8* 2030* Schizophrenia Vignette X (12–15)
Depression
1992 Random sample 18+ Personal interview 70.1* à 5125* à Schizophrenia Vignette X (12–15)
1992 Quota sample 16+ Personal interview – 2176* à Paranoia Vignette X (28, 29)
Depression
Drug addiction
Alcoholism
Addiction to prescribed drugs
Mania
Social phobia
Alzheimer's disease
1993 Random sample 18+ Personal interview 73.0*/71.2à 2143*/2094à Schizophrenia Vignette X X X (12, 14–16, 26, 30, 32)
Depression
Mental illness –
1993 Random sample 18+ Personal interview 70.3* 2024* Schizophrenia Vignette X (12, 14, 15)
2001 Random sample 18+ Personal interview 65.1* à 5025* à Schizophrenia Vignette X X (20, 24, 25, 33, 40)
Depression
Schizophrenia Label
Depression
Alcoholism
Alzheimer's disease
Drug abuse
Mental illness
Italy 2000/2001 Cluster sample§ 18–70 Self-report 98.5 714 Schizophrenia Vignette– X X (41, 42)
questionnaire
Luxembourg Quota sample 15+ Telephone interview – 501 X (43, 83)
Norway 1992 Stratified random sample 15+ Telephone interview – 1063 Mental illness – X X (45)
Switzerland 1994 ? 18–84 Personal interview ? 697** Mental illness – X (46)
1998/1999 Random sample 16–76 Telephone interview 63 1737 Schizophrenia Vignette X X X (47–55)
Depression
 Table 1. (Continued)

Beliefs Attitudes Attitudes

about towards towards
Response Sample mental mentally psychiatric
Country Year Sampling procedure Age Interview rate (%) size Disorder Stimulus illness ill people services References

Mental illness –
UK 1991 Quota sample 15+ Personal interview – 2009 Depression Label X (56, 57)
1995 Quota sample 15+ Personal interview – 2050 Depression Label X (57)
1997 Quota sample 15+ Personal interview – 1946 Depression Label X (57)
1997 Quota sample 15+ Personal review – 1804 Schizophrenia Label X X (58)
1998 Random sample 16+ Personal interview 67 1737 Schizophrenia Label X (59)
Severe depression
Alcohol addiction
Drug addiction
Panic disorder
Eating disorder
Dementia
Ireland 1989 Quota sample 16+ Personal interview – 1403 Depression Label X X (60)
Canada 2002 Random sample ? ? 1000 Dementia Label X (61)
US 1989 Stratified random sample 21+ Telephone interview 44 1326 Mental illness X X X (62)
1990 Random sample 18+ Telephone interview 63 1507 Mental illness – X (63, 64)
1996 Random sample 21+ Personal interview 76.1 1444 Schizophrenia Vignette X X (65–72)
Depression
Alcohol dependence
Drug dependence
Mental illness –
1998 Random sample ? Personal interview 76.4 1387 Mental illness – X (73)
Dominica 1995 Stratified random sampleàà ? Personal interview 64 135 Psychosis Vignette X (74)
Depression
Alcoholism
Childhood
Hyperactivity
Hong Kong 1994 Random sample ? Telephone interview 59.6 1043 Mental illness – X X X (75)
1996 Random sample 18–80 Telephone interview 65 1273 Mental illness – X X X (76)
Australia 1995 Random sample 18–74 Personal interview 85 2031 Schizophrenia Vignette– X X (77–82)
Depression
New Zealand ? Random sample 15–44 Telephone interview 65 1017 Mental illness – X X (83)
Schizophrenia Label X

*Old Laender.
DSM III-R.
àNew Laender.
§In 30 randomly selected geographical areas 25 persons were consecutively recruited in a randomly selected GP unit.
–ICD-10.
**Swiss–German and Swiss–French population only.
DSM IV.
ààParticipants were drawn from the records of community health centres in each of the country's seven health regions. The various communities in the regions were selected to represent both urban and rural areas and to be geographically representative of the
country's population.

167
Public beliefs about and attitudes towards mentally ill
168
Table 2. Overview of regional and local surveys published since 1990

Beliefs Attitudes Attitudes

about towards towards
Response Sample mental mentally psychiatric
Region Year Sampling procedure Age Interview rate (%) size Disorder Stimulus illness ill people services References

Helsinki, Sein
joki, Joensun, 1985 Random sample ? Self-administered 69 514 Mental illness – X (84)
Pieks
m
ki, Tampere, Finland questionnaire
Mannheim/Germany ? Random sample Telephone interview ? 82 Mental illness X (44)
Angermeyer and Dietrich

Berlin, Bonn, Dsseldorf, Essen, 2001 Random sample 16+ Telephone interview 75.4 7278 Schizophrenia Label X X (85, 86)
Cologne, Munich/Germany
Nuremberg, Wrzburg/Germany 2000 Random sample 18+ Telephone interview 51.9 1426 Depression Label X (87)
2001 Random sample Telephone interview 68.5 1508 Depression Label X
Two boroughs in greater 1994 Random sample 19–64 Personal interview ? 360 Mental illness – X (88)
Athens/Greece
Vizcaya/Spain ? Stratified random sample 16–65 Personal interview ? 400 Depression Label X X (89)
Geneva/Switzerland 1996 Quota sample 20–75 ? – 324 Mental illness – X X (90)
Schizophrenia Vignette
Depression
Panic attack
Northtown/UK ? Quota sample ? Personal interview – 154 Schizophrenia Vignette X
ÔPuerperal illnessÕ
Mental illness X (91)
Malvern and Bromsgrove/UK 1989 Quota sample 15+ Personal interview – 1987 Mental illness – X (92, 93)
Schizophrenia Vignette X X
Depression
Herne Hilland and 1993 Random sample ? Personal interview 70 215 Mental illness – X X (94–97)
Streatham Hill/UK
Two urban areas/UK ? Random sample 18+ Postal survey 42.6 208 Mental illness Vignette X X (98)
Scotland/UK 2001 Random sample 16+ Personal interview ? 1061 Alcoholism X (99)
Co. Louth and Co. Meath/Ireland ? Random sample 17–86 Personal interview 77.5 155 Mental illness – X (100)
Calgary, Drumheller, 1998/1999 Random sample 15+ Telephone interview 71.9 1653 Schizophrenia Label X X (101, 102)
Edmonton/Canada
Qubec/Canada ? Stratified random sample 18+ ? 60.7 1001 Schizophrenia Label X X (103)
Delaware County/US 1988 Stratified random sample ? Postal survey 34.5 206 Schizophrenia Vignette* X X (104)
Depression
GAD
San Francisco/US ? Random sampleà 55+ Personal interview ? 209 Dementia Label X (105)
Mexico City/Mexico ? Quota sample 18-60 Personal interview – 800 Mental illness – X X X (106)
2 Kibbutzim/Israel ? A) Random sample 20+ Self-administered 96.4 108 Mental disorders – X X (107)
questionnaire
B) Total population 20+ Self-administered 97.8 90 Psychosis Vignette X
questionnaire Depression
Istanbul/Turkey ? Random sample 15+ Personal interview 98.3 707 Depression Vignette X X (108)
Sancakli/Turkey 2000 Total population 18+ Personal interview 84.9 208 Schizophrenia Vignette X X (109)
Novosibirsk/Russia 2002 Random sample 18+ Personal interview 74.5 745 Schizophrenia Vignette* X X (40, 110)
Depression
Ulaanbaatar/Mongolia 2002 Random sample 18+ Personal interview 95.2 952 Schizophrenia Vignette* X X (40, 110)
Depression
 Public beliefs about and attitudes towards mentally ill

References
helping source (28–30, 52, 74, 78, 89, 118). In the

(112, 113)

(117, 118)
(114–116)
case of schizophrenia, the public is more ready to

(111)

(119)
recommend seeking help from a psychiatrist than
in case of depression (28–30, 52, 58, 74). If mental
psychiatric

disorders are recognized as such, the willingness to

Attitudes
towards

services

address a psychiatrist increases (52).

All studies using case vignettes agree in that the
public’s beliefs about psychological interventions
ill people
Attitudes

mentally

(e.g. psychotherapy or counselling) are predomin-

towards

antly favourable, while very negative views prevail

X

X
about pharmacological treatments (10, 19, 23, 24,
27–29, 41, 52, 78, 80, 82, 118). Surprisingly, with one
mental
Beliefs

illness
about

exception (10), the particular liking of psychother-

X

X
X

apy is more developed for schizophrenia than for

depression (19, 27–29, 52, 78, 80, 82). For example,
Stimulus

Vignette

Vignette

Vignette

in a study from Australia (80) psychotherapy was

Label

considered by 55% of the respondents as being

–

helpful for the treatment of schizophrenia and by

34% as being helpful for the treatment of depression
Mental retardation
Anxiety disorder

while only 23% recommended antipsychotic medi-

Mental illness
Schizophrenia
Disorder

cation and 29% antidepressants. Similar findings

Depression

Depression

Depression

Depression
Alcoholism

have been reported from a study in Switzerland

using the same instrument (52). Similarly to causal
beliefs, the results are somewhat different when
explicit diagnostic labels are used. In the case of
Sample
size

3109

1094

3010
450

164

depression, again, psychosocial interventions are

favoured over medication (57, 87), while in the case
of schizophrenia, medication is more frequently
Response
rate (%)

considered as the appropriate form of treatment (58,

60

70.2
39

55

86, 101). In a survey in the US, most respondents

?

àParticipants were recruited from four public sector primary-care clinics and were randomly selected from clinic logs.

agreed that psychiatric medications are effective,

and fewer than half had concerns regarding poten-
Personal interview

Personal interview

tial problems. However, the majority of the

Interview

Postal survey

Postal survey

Postal survey

respondents would not be willing to take them (72).

In general, in the absence of a treatment, the
course of mental disorders is seen rather pessim-
istically. The deterioration of the mentally ill
17–70

20–59

18–52
Age

person’s state is expected to be severer for schizo-

15+
?

phrenia than for depression. Conversely, on con-

dition that an appropriate treatment is provided,
Sampling procedure

the prognosis for both disorders is assessed quite

Random sample

Random sample

Random sample

Random sample
Random sample

optimistically (10, 23, 34, 58, 67, 78).

No consistent relationships were found between
gender and age of respondents on the one hand,
and their illness beliefs on the other. Respondents
with a higher educational level less frequently
1998
1993
Year

tended to make the person afflicted responsible for

?

his or her illness and were more willing to

recommend psychosocial interventions for treat-
Albury and surrounding rural area
in New South Wales/Australia

ment (23, 47, 69, 81, 111).

New South Wales/Australia
Canberra and south-east

Dunedin/New Zealand
Table 2. (Continued)

Descriptive studies on attitudes towards people with mental

BahirDar/Ethiopia

South Australia

disorders
*DSM III-R.
DSM IV.

People with mental disorders are experienced by

Region

the majority of the public to be in need of help and

169
Angermeyer and Dietrich

dependent on others (20, 34, 36). Among the of 38 observations a positive relationship showed
negative attributes attached to people with mental between educational level and attitudes: persons
disorders the most prevalent one appears to be that with a higher educational level tended to distance
they are unpredictable. This holds true more for themselves less from the mentally ill and expressed
people with schizophrenia (54–85%) or alcoholism more liberal views (20, 34, 41, 53, 54, 67, 75, 76, 84,
(71%) than for people with depression (28–56%) 88, 92–94, 107, 111, 119). In 18 cases, no relation-
or anxiety disorders (50%) (13, 34, 35, 41, 59, 104). ship with education was reported (12, 15, 34, 40,
Less frequently, persons with mental disorders are 66, 88, 94, 100, 109, 119). The few studies dealing
considered as violent and dangerous. Here, a with urban–rural differences come up with quite
similar picture emerges as with unpredictability. contradictory results. While two studies found a
In particular, people with schizophrenia (18–71%) stronger desire for social distance among rural
and alcoholism (65–71%) are seen as dangerous. residents (101), another study found the opposite
To a lesser extent, this also applies to people with (66). While in one study the perception of mentally
depression (14–33%) and anxiety disorders (26%) ill people as being unpredictable was more pro-
(13, 34, 35, 59, 62, 65, 66, 85, 101). The majority of nounced among rural residents (42), in two other
the public show pro-social reactions, i.e. they feel studies no urban–rural differences were found with
sorry for persons with mental illnesses and they regard to perceived dangerousness (63, 67).
also feel the need to help them. This is particularly In 61 cases the relationship between familiarity
true for depression. Next come feelings of uneasi- with mental illness, i.e. having personally experi-
ness, uncertainty and fear, reactions which are enced a mental illness or having personal contact
mostly set off by persons with schizophrenia. with people suffering from mental illness, and
Infrequently, aggressive reactions occur (20, 34). attitudes was examined. Thirty times it was repor-
There is an observable tendency towards distan- ted that people had more positive attitudes if they
cing from persons with mental illness. With were familiar with mental illness (15, 51, 54, 58, 59,
increasing intimacy of social relationships increases 60, 64, 68, 71, 72, 76, 77, 84, 92, 93, 98, 119). The
the desire for social distance. Rejection is most opposite was found in only one instance (59). In 30
pronounced towards persons with drug abuse and cases no association between familiarity and atti-
alcoholism, followed by those with schizophrenia tudes was reported (16, 48, 54, 71, 77, 94, 98, 100,
and is less pronounced towards people with 101, 107, 119).
depression and anxiety disorders (10, 15, 34, 51,
65, 67, 104, 111). All vignette studies examining the
Studies testing theory-based models of the stigmatization of
effect of subject-generated mental illness labels on
mentally ill people
public attitudes show that labelling leads to more
rejection and other adverse reactions (20, 33, 41, Two recently developed conceptualizations of
51, 66, 98, 109). stigma served as the main theoretical framework
Attitudes towards people with mental illness for empirical studies, namely Link and Phelan’s
vary to a small extent only depending on socio- (120) sociological concept of the Ôstigma processÕ
demographic characteristics. For example, in a and Corrigan and Watson’s (121) social–psycho-
German study, gender, age, education and resi- logical concept of the Ôpublic stigmaÕ.
dency accounted for only 1.4% of the variance According to Link and Phelan (120), the stigma
(36). As concerns gender, the results are quite process sets off by recognizing and labelling a
inconsistent. In the majority of cases (18 times) difference between a person and other people. The
where the influence of gender on attitudes was next step involves the linking of the labelled person
examined no association between the two was with the negative stereotypes that predominate in
observed (12, 15, 20, 40, 53, 54, 60, 66, 69, 88, 107, society about this group of people. This way, the
109, 119). In 11 instances men expressed more person now belongs to a distinct category of people
negative attitudes than women (17, 34, 51, 54, 88, from whom the beholder dissociates. The stigma
119), in six instances the opposite was found (17, process culminates in that the person concerned
34, 75, 76, 86). In most instances (32 times), is exposed to different forms of discrimination
negative attitudes were positively associated with and the negative social consequences resulting
age (12, 15, 20, 40, 41, 51, 54, 60, 66, 67, 69, 84, 88, from this. The authors differentiate between
92, 93, 107, 109, 119), while the reverse relationship individual and structural discrimination as well as
was reported only once (53). To what extent this self-stigmatization. The first refers to the beha-
may be due to either ageing or cohort effects viour of individuals that is directed straight
remains an open question. In 10 instances, age did against the members of a stigmatized group. The
not matter (34, 66, 67, 88, 94, 100, 109, 119). In 20 most frequently applied measure of individual

170
 Public beliefs about and attitudes towards mentally ill

discrimination is the desire for social distance tional reactions and from these, in turn, discrim-
(122). Structural discrimination describes the neg- inatory behaviour may develop.
ative consequences that result from the imbalances Using data from a study conducted in Germany,
and injustice inherent in social structures, political this model was applied to investigate the effect of
decisions and legal regulations for the members of labelling of schizophrenia and depression as mental
a stigmatized group. The third form of discrimin- illnesses. In the case of schizophrenia, this kind of
ation (self-stigmatization) comes from within the labelling elicited the belief that those affected with
mentally ill persons themselves in that they adopt this illness are dangerous and unpredictable. Con-
the stereotypes prevailing in society about people sequences were negative emotional reactions, like
with mental illness. increasing fear and aggression. These resulted in an
The link between the two components of the increasing desire for social distance. No such
stigma process, stereotype and discrimination, has associations could be demonstrated for depressive
been investigated in the meantime, with the interest disorders (33). Furthermore, the model was used to
lying on the impact of the different aspects of the study the effect of familiarity with mental illness on
stereotype of the mentally ill on individual dis- the attitudes towards people with schizophrenia
crimination and on the acceptance of structural and depression. It could be shown that with
discrimination of people with schizophrenia. Of the growing familiarity, the tendency towards consid-
different stereotype components, the idea of ering the ill person to be dangerous and unpre-
unpredictability and dangerousness had the strong- dictable was decreasing, and people had less fear
est impact on the social distance desired towards a and social distance was desired less frequently (37).
person with schizophrenia: the more this view was
adopted, the higher was the desire for social
Analysis of time trends in beliefs about mental illnesses and
distance. The converse applies to the idea that
attitudes towards people with mental illness
people with schizophrenia were particularly intel-
ligent and gifted. The acceptance of structural For identifying developmental trends in patterns of
discrimination, on the contrary, was mainly influ- beliefs and attitudes over time, results of cross-
enced by the belief that those affected are to blame sectional surveys, which were conducted at differ-
for their own illness: the more distinct the inclina- ent points in time, were compared with each other.
tion to blame the ill, the higher the tendency Unfortunately, there are only a few of these studies
towards approving of structural discriminations and they came up with rather contradictory results.
(35). Of particular interest for the structural The study covering the longest period of time was
discrimination of mentally ill persons is the result undertaken in the US. Phelan et al. (68) compared
of a survey in Germany, which investigated the the data of a survey dating from 1996 and those
public’s preferences when it comes to the allocation taken from a study conducted by Star back in
of financial resources to health care and medical 1950. They found that while today, the image of
research. While somatic illnesses like cancer or mental disorders is somewhat more differentiated
cardiovascular diseases ranked first, depression, among the American public, mentally ill individu-
schizophrenia and alcoholism were the taillights als are nowadays more frequently considered to be
(38, 39). Findings similar to what has been found in dangerous as compared to the 1950s. Covering a
Germany are reported from the US: respondents much shorter time period (only 2 years), a study
who labelled persons with mental disorders as from Hong Kong came up with similar results:
suffering from mental illness expressed a preference while the public’s knowledge of mental illness had
for greater social distance; and the degree of slightly improved, their attitudes towards mental
dangerousness that the public ascribed to these patients had become slightly more negative (76). In
persons appeared to mediate the influence of the contrast, Madianos et al. (88) reported that the
labelling effect (66). residents of two boroughs in greater Athens
According to Corrigan and Watson (121), public expressed more positive attitudes towards the
stigma denotes the reaction of the general public to mentally ill in 1994 than back in 1979/1980.
a certain group of individuals based on the stigma According to the authors, the results could be
that is attached to this group. It comprises three explained in the context of a positive and tolerant
components: stereotype, prejudice and discrimin- social climate in the Athens area, strengthened by
ation. Stereotypes are collectively shared beliefs the implementation of local community mental
about a group of individuals. Most of the people health intervention programmes. Finally, a com-
are familiar with these stereotypes, however, not parison of data from two surveys conducted in
everybody adopts them. If they are adopted, West German states in 1990 and 2001 revealed that
prejudices develop, which result in negative emo- the public’s emotional reactions and their desire for

171
Angermeyer and Dietrich

social distance towards persons with major depres- patientsÕ social competence and civil rights than
sion had by and large remained unchanged (20). those from other parts of the country (42).
Psychotropic drugs were assessed more favourably A survey in the US yielded that people from the
by the German public in 2001 than 11 years ago South of the US tended to endorse more frequently
(25). Based on a series of surveys conducted in the that the person’s bad character or stresses in life
years 1990–1992, it could be shown that there was are responsible for the occurrence of mental
a marked increase of the preference for social disorders (70). Their preferences for social distance
distance from people with schizophrenia immedi- from persons with mental disorders were the same
ately following violent attacks by two individuals as in the rest of the US (66). Asian and Hispanic
suffering from schizophrenia against prominent respondents perceived mental patients as signifi-
German politicians (12–14). cantly more dangerous than did white respondents
(71). African Americans were more likely than
whites to reject the idea that mental illnesses are
Cross-cultural comparisons of beliefs and attitudes
caused by either genetics or an unhealthy family
A distinction can be made here between surveys upbringing. They also tended to have more negat-
which investigate variations in the pattern of ive attitudes than whites towards professional
beliefs and attitudes within a single country and mental health treatment (70). The results of a
others, which investigate variations between differ- study among older adults recruited from primary-
ent countries. Differences in beliefs and attitudes care clinics in San Fransisco indicated that Anglo
have been studied in five countries. A comparison older adults are significantly more knowledgable
between the old West German states and the New about Alzheimer’s disease than African American,
Laender (former German Democratic Republic, Asian, and Latino older adults (105).
GDR) in 1990, i.e. shortly after the German In New Zealand, as compared to the general
reunification, showed that lay beliefs about schi- population the awareness of mental illnesses and
zophrenia were almost identical. However, the the number of mental illnesses recalled was lower
tendency to define depressive symptoms as an among Maori and much lower among pacific
illness and to recommend psychiatric treatment people. While among Maori the acceptance of
was less pronounced in the former GDR (23). people with mental illness in general or schizo-
Eleven years later these differences had diminished phrenia in particular was similar to the general
and the beliefs of the East German population had population it was lower among pacific people (83).
become similar to those of the West German International comparisons are made possible by
population (24). surveys conducted in different countries using the
Surveys from Switzerland show that, as com- same methodology. Unfortunately, up until now
pared with French-speaking Swiss, there was a results from only two representative studies among
marked reluctance of the German-speaking Swiss the general population addressing the question of
to resort to specialist help, particularly to mental inter-country differences with regard to beliefs and
health professionals, in case of mental illness (46). attitudes have been published. A comparison
Another comparison of the three language regions between Novosibirsk (Russia), Ulaanbaatar (Mon-
in Switzerland revealed that people living in the golia) and Germany revealed that people from the
Italian-speaking part expressed a stronger desire former two cities show a stronger tendency
for social distance than people living in the towards attributing the cause of mental illness to
German- and French-speaking parts (51). People the afflicted individual (40). The same tendency has
from the French- and Italian-speaking parts were been reported from another non-western culture
more willing to accept restrictive measures against (109). As already outlined earlier, there was a close
persons with mental illness than those from the association for schizophrenia between labelling as
German-speaking part of Switzerland (54). People mental illness and the stereotype of dangerousness
living in the French-speaking part were also more in Germany. This association was neither found in
in favour of compulsory admissions (53). Non- Novosibirsk nor in Ulaanbaatar (110).
Swiss residents held more positive attitudes In another study the attitudes towards the
towards volunteering in psychiatry, i.e. they were mentally ill among the residents of two Central
more willing to regularly visit a long-term patient European regions which were at considerably
in a psychiatric institution, to help in a club for different stages of development in moving towards
ex-patients, or to look after a mentally ill person community-based care were compared. People
not belonging to the household (49). living in the community care area (a district of
A study from Italy reported that people living in the city of Mannheim in Germany) showed slightly
southern Italy were less ready to acknowledge more rejection. However, they also took a more

172
 Public beliefs about and attitudes towards mentally ill

rational and sophisticated position towards the asking about attitudes to different health profes-
mentally ill. People living in the custodially orien- sionals and treatments. The consumer guide was
ted catchment area (Grand Duchy of Luxem- sent to half of a subsample that scored above a set
bourg), on the contrary, showed a more vague cut-off point on the depression scale and indicated
pattern in their attitudes (44). interest in participating in the study. The remaining
half of the sample received a brochure providing
basic information about depression. Six months
Evaluation of interventions aimed at improving knowledge of
later, a second postal survey was conducted. Those
mental illnesses and reducing stigmatization of mentally ill
who had received the consumer guide more often
people
rated cognitive-behaviour therapy to be helpful.
Six studies are available in which population The same was true for electroconvulsive therapy
surveys have been used to evaluate interventions and St John’s wort. However, respondentsÔ views
aimed at transferring knowledge or reducing on antidepressants or interpersonal psychotherapy
stigma. Four studies were focused on depression. remained unchanged.
Paykel et al. (57) evaluated the ÔDefeat Depres- In another study conducted in the same area, the
sion CampaignÕ, an activity of the Royal College of effect of two internet depression sites on stigma
Psychiatrists in association with the Royal College have been investigated. A total of 525 individuals
of General Practitioners between 1992 and 1996 in with elevated scores on the depression assessment
the UK (56). Surveys of public attitudes and scale were randomly allocated to a depression
knowledge were conducted in late 1991, early information website, a cognitive-behavioural skills
1995 and mid-1997. The share of those subjects training website or an attention control condition.
who saw depression as a medical illness increased Personal stigmatizing attitudes to depression and
significantly. In addition, the acceptance of anti- the perception of what most people believe about
depressants increased, with more respondents people with mental illness were assessed before and
regarding them as effective in 1997. In contrast, after the intervention. Relative to the control, the
the proportion of those regarding antidepressants internet sites significantly reduced personal stig-
as addictive remained almost unchanged: three- matizing attributes, although the effects were small.
fourth of respondents agreed to this view. While informing the individuals had no effect on
Hegerl et al. (87) evaluated the effect of the the perceptions of stigma; the cognitive-beha-
ÔNuremberg Alliance Against DepressionÕ, a cam- vioural component was associated with an increase
paign aimed at informing the public about the in perceived stigma relative to the control (115,
causes and treatment of depression. Prior to the 116).
beginning of the campaign and 1 year later, tele- In order to evaluate a national media campaign
phone surveys were conducted with a random to counter stigma and discrimination associated
sample in the cities of Nuremberg and Wurzburg, with mental illness that has been launched in New
the latter functioning as the control region. As Zealand, a series of four surveys had been con-
concerns illness beliefs, the result was rather ducted. It could be shown that advertizing has a
sobering. Although the share of respondents significant impact on the public’s attitudes and
making a lack of self-control responsible for the knowledge. There was a significant increase in
disorder had decreased in Nuremberg more clearly reported acceptance of people with experience of
than it had in Wurzburg, fewer respondents from mental illness while the attitude towards people
both cities agreed to the view that a dysfunction of with schizophrenia remained virtually unchanged.
the brain was the cause. RespondentsÕ opinion in As compared with the general population, Maori
terms of using antidepressants for the treatment and pacific people did not show the same level of
remained almost unchanged, the same applies to improvement in attitudes (83).
respondentsÕ opinion as to the negative effects of Prior to the opening of two staffed group homes
antidepressants. for severely mentally ill people, situated in the
Jorm et al. (114) evaluated the effect of a London borough of Lambeth, immediate neigh-
consumer guide called ÔHelp for Depression: What bours living on the same street as these facilities
Works (and What Doesn’t)Õ, containing evidence- were interviewed. In one area, an educational
based information about treatments for depression. campaign was conducted comprising a primarily
A pretest, which included a scale assessing depres- didactic component (an information pack contain-
sion, was mailed as a screening test for depression ing a video and information sheets), a primarily
to a random sample of Canberra citizens and social component (social events and social over-
citizens from the area of south-east New South tures from staff) and a mixed component (a formal
Wales. The mail package also contained questions reception and informal discussion sessions). One

173
Angermeyer and Dietrich

year after the start of the educational campaign the illness and the acceptance of people with
survey was repeated in both areas. There was no mental disorders. Consequently, to facilitate
significant difference between increase in know- the contact with people with mental disorders
ledge in the two areas over time. However, there may prove effective in reducing negative
was an overall decrease in the fear and exclusion attitudes.
dimension of the CAMI in the experimental area at vi) Models derived from modern stigma theories
follow-up compared to the control area. The allow to systematically investigate the relations
acceptance of patients increased in the experimen- between the various stigma components as,
tal area (96, 97). for instance, the effect of labeling on attitudes
or that of the different aspects of the stereotype
of the mentally ill on social distance or on
Discussion
the acceptance of structural discrimination.
The main findings of the last 15 years of attitude vii) Up until now, too few trend analyses have
research in psychiatry may be summarized as been carried out to allow firm conclusions to
follows: be drawn as concerns the development of
beliefs and attitudes over time. While there are
i) A substantial part of the public cannot recog-
some indications that the gap between public
nize specific mental disorders. When confron-
beliefs and scientific evidence has become
ted with pathological behaviour, as depicted in
narrower, attitudes do not show a consistent
a vignette, people most frequently tend to
trend in one direction or the other.
adopt psychosocial stress as causal explan-
viii) Comparisons between various regions or
ation and to recommend psychological inter-
ethnic groups within countries as well as
ventions for treatment. If diagnostic labels are
comparisons between countries reveal consid-
being used in case of depression the same is
erable differences in beliefs about mental
found while in case of schizophrenia biological
disorders and in attitudes towards people
explanations are as frequently or even more
with mental illness. There are some indications
frequently endorsed and psychotropic medi-
that people from non-western ethnic groups
cation recommended.
are less aware of and knowledgeable about
ii) The majority of the public consider people
mental illness and tend to attribute the cause
with mental disorders as in need of help and
of the illness more frequently to the afflicted
show pro-social reactions. However, a sub-
individual.
stantial part perceives them as unpredictable
ix) The evaluation of interventions aimed at
and dangerous and reacts with fear. There is
improving the public’s knowledge of depres-
an observable tendency to distance oneself
sion, using population surveys, suggests that
from people with mental disorders.
this may be achieved in some areas while
iii) Although there are various similarities
others, particularly people’s views on medica-
between mental disorders as concerns public
tion, may prove more resistant to change.
beliefs and attitudes, there are also marked
Some findings suggest that informing people
differences. For instance, people with schizo-
may not necessarily affect their attitudes.
phrenia or alcoholism are more frequently
considered as unpredictable and violent than From our review the following conclusions for
people with depression and anxiety disorders. future research may be drawn:
Rejection is most pronounced towards people
i) In recent years, attitude research in psychiatry
with drug abuse and alcoholism, followed by
has made considerable progress. However, the
those with schizophrenia, and is less pro-
vast majority of studies are still dedicated to
nounced towards people with depression and
the descriptive recording of public beliefs
anxiety disorders.
about mental illness and public attitudes
iv) While the association between gender and
towards persons with mental illnesses. There
attitudes is inconsistent, there exists strong
is a pressing need for more studies using more
evidence that negative attitudes are positively
sophisticated approaches, like the testing of
associated with age and negatively with edu-
theory-based models, cross-cultural compari-
cational attainment. However, the explanatory
sons and trend analyses. They only may
power of socio-demographic characteristics is
provide us with insights into the mechanisms
only poor.
of and contextual influences on stigma that are
v) If there is any relationship there is a positive
needed for successful antistigma interventions.
association between familiarity with mental

174
 Public beliefs about and attitudes towards mentally ill

ii) The vast majority of surveys covered by this cational programmes having yielded some
review have been conducted in Western coun- useful suggestions for the planning of inter-
tries and only nine out of 61 originate from the ventions aimed at reducing the stigma
rest of the world. There is a need for more attached to mental illness, we are still far
transcultural studies using representative sam- from evidence-based antistigma programmes.
ples [instead of convenience samples as have This is not the least due to the fact that
been used in a number of previous studies (e.g. popular strategies for combating mental illness
123, 124)]. stigma have received contradictory evalua-
iii) Current attitude research mainly took an tions, resulting in deep disagreement as to
interest in schizophrenia and depression. their effectiveness in actually reducing stigma
Only a few studies have looked into alcohol- and discrimination (125). For instance, while
ism, drug abuse, anxiety disorders and demen- some studies (66, 101) are supportive of the
tia. Other disorders such as bipolar disorder mental illness is a brain disease strategy, other
have not been the focus of population studies studies (36, 40, 51) found evidence that pro-
yet. Strictly speaking, the titles of the majority mulgating biological concepts among the
of papers alluding to Ômental disordersÕ or public might not contribute to a desired
Ômental illnessÕ in general (e.g. 10, 15, 16, 23, reduction in social distance towards people
26) are somewhat misleading. with mental disorders.
iv) Moreover, population surveys have thus far
focused almost exclusively on attitudes
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