Avances en Salud Mental Relacional / Advances in relational mental health
Vol.3, núm. 3 - Noviembre 2004
Órgano Oficial de expresión de la Fundación OMIE
Revista Internacional On-line / An International On-line Journal
REPRESENTATIONS OF PSYCHIATRIC TREATMENTS
D. Goerg1, E. Zbinden1, W. Fischer1, J. Guimón2
Department of Psychiatry
University Hospital of Geneva
Geneva, Switzerland
1
Sociologists, Department of psychiatry, University Hospital of Geneva
2
Honorary
Professor,
University
of
Geneva,
Professor of psychiatry, University of the Basque Country
Address for correspondence :
D. Goerg, Département de psychiatrie
2, Chemin du Petit-Bel-Air
CH-1225 Chêne-Bourg
Geneva, Switzerland
tel. +4122/305.57.50 / fax +4122/305.57.99
E-mail : Danielle.Goerg@hcuge.ch
ASMR Revista Internacional On-line - Dep. Leg. BI-2824-01 - ISSN 1579-3516
CORE Academic, Instituto de Psicoterapia, Manuel Allende 19, 48010 Bilbao (España)
Copyright © 2004
Geneva
Avances en Salud Mental Relacional / Advances in relational mental health
Vol.3, núm. 3 - Noviembre 2004
Órgano Oficial de expresión de la Fundación OMIE
Revista Internacional On-line / An International On-line Journal
SUMMARY
Objectives : The goal of this study is to determine whether the public differentiates between
the various mental disorders and their treatments, since social representations of mental
illness and its treatment play an important role in its detection and in orienting patients
towards certain therapies.
Methods : The public's representations are examined in a survey carried out among a stratified
sample of the Swiss population, through the use of clinical vignettes, for three mental
illnesses in terms of definition as an illness, etiology, treatments foreseen and prognosis.
Results : A clear differentiation exists between schizophrenia, on the one hand, and
depression and panic disorder on the other. Schizophrenia is more frequently considered as a
real illness, with a multifactorial etiology, a more pessimistic prognosis and for which
psychotherapy and family therapy are the prescribed treatments. There is, however, a lack of
differentiation in regards several etiological factors of psychiatric disorders, in particular
psychosocial factors which are given very considerable weight, and certain treatments,
especially those involving medication, which is only recommended for all three psychiatric
disorders by a quarter of subjects interviewed.
Conclusions : The public's representations appear to be nuanced. Even if a majority of the
population has some experience of psychiatry or psychology (acquaintance with people
working in the field, psychological difficulties experienced either personally or within the
subject's entourage), its representations often show a lack of awareness of the current
scientific debate.
KEY WORDS
Representations, psychosocial factors.
ASMR Revista Internacional On-line - Dep. Leg. BI-2824-01 - ISSN 1579-3516
CORE Academic, Instituto de Psicoterapia, Manuel Allende 19, 48010 Bilbao (España)
Copyright © 2004
Avances en Salud Mental Relacional / Advances in relational mental health
Vol.3, núm. 3 - Noviembre 2004
Órgano Oficial de expresión de la Fundación OMIE
Revista Internacional On-line / An International On-line Journal
RESUMEN
Las conclusiones del estudio que presento determinan que las representaciones
sociales aparecen matizadas. No obstante, una mayoría de la población tiene alguna
experiencia en psiquiatría o psicología. Las representaciones sociales muchas veces muestran
invitan a pensar en que la población posee una falta de conciencia sobre el debate científico
común.
PALABRAS CLAVE
Representaciones, factores psicosociales.
ASMR Revista Internacional On-line - Dep. Leg. BI-2824-01 - ISSN 1579-3516
CORE Academic, Instituto de Psicoterapia, Manuel Allende 19, 48010 Bilbao (España)
Copyright © 2004
Avances en Salud Mental Relacional / Advances in relational mental health
Vol.3, núm. 3 - Noviembre 2004
Órgano Oficial de expresión de la Fundación OMIE
Revista Internacional On-line / An International On-line Journal
PUBLIC REPRESENTATIONS OF MENTAL DISORDERS AND PSYCHIATRIC
TREATMENTS : DIFFERENTIATION OR LACK OF DIFFERENTIATION ?
INTRODUCTION
The public representations of, and attitudes towards, mental disorders and their
treatment play an important role both in the detection and in the treatment of the mentally ill.
These social representations condition the way in which therapists, patients and their families
perceive each other. They are also determining factors of how compliant patients will be with
the treatments proposed.
Certain studies on the attitudes of the general population towards psychiatric treatment
and particularly towards psychotropic medication have shown that the public very seldom
differentiates between the various mental disorders and the different categories of
psychotropic drugs and their indications. Thus the studies of Angermeyer et al. in Germany
[1-4] showed that the public makes practically no distinction between schizophrenia, major
depression and panic disorder insofar as treatment is concerned. The public gives much
greater preference to psychotherapy than to medication. The proportion of those opposed to
psychotropic drugs is twice as high as those favoring them for the treatment of schizophrenia
or panic disorder, and this opposition to psychotropic medication is stronger still for
depression. In Australia, Jorm et al. [5] also observed that the same system of beliefs
concerning the appropriate treatments was applied to diverse mental disorders. For Benkert et
al. [6], in another study on public attitudes towards psychotropic medication in Germany, the
majority of the population disregards recourse to psychotropic medication in cases of mental
disorder. The spectrum of mental illness seems reduced, for the public, to two extremes :
madness and malaise in which the public also classifies severe disorders such as depression.
For madness there is a tendency for medication to be accepted; for malaise, medication is in
general refused as it is not perceived as an illness.
Other works aimed mainly on the recognition of psychiatric disorders, their causes and
prognosis, as well as attitudes towards those who suffer from such disorders, have sometimes
shown more differentiated results in the general public [7-11] and in specific population
samples [12-14]. If little difference seems to be made between diverse psychiatric disorders,
ASMR Revista Internacional On-line - Dep. Leg. BI-2824-01 - ISSN 1579-3516
CORE Academic, Instituto de Psicoterapia, Manuel Allende 19, 48010 Bilbao (España)
Copyright © 2004
Avances en Salud Mental Relacional / Advances in relational mental health
Vol.3, núm. 3 - Noviembre 2004
Órgano Oficial de expresión de la Fundación OMIE
Revista Internacional On-line / An International On-line Journal
part of these works tend to show that schizophrenia is more readily perceived as an illness, is
considered to have darker outcome and provokes a greater social distance than other
disorders.
The hypothesis examined in our study is that the population in Switzerland does not
differentiate between various psychiatric disorders nor between the different treatments which
might be chosen for these disorders. More specifically, the question of lack of differentiation
between three serious psychiatric disorders (schizophrenia, depression, panic disorder) will be
dealt with under the following different aspects: their definition as an illness, their etiology,
treatments deemed to be adequate, and finally their prognosis. If differences nevertheless
appear, their determining social factors and the elements which may be linked to them will be
investigated.
METHODS
The results presented are part of a study carried out with a representative sample of the
population resident in Switzerland, aged between 20 and 75. The stratified sample was based
on gender, age and professional activity. The 1016 subjects thus selected answered a
standardized questionnaire principally covering the representations of psychiatric disorders
and their treatment, attitudes towards psychotropic medication, attitudes towards medication
in general and attitudes towards psychiatric patients. The socio-demographic, professional,
cultural and familial characteristics of the subjects were also examined.
In order to depict the public's representations of psychiatric disorders and psychiatric
treatments, three clinical vignettes were elaborated. The vignettes presented the following
three cases: major depression, schizophrenia and panic disorder. They were created on the
basis of DSM-III criteria with the assistance of a psychiatrist. Each of them was presented to a
third of the sample. Interviewers selected vignettes in a set order (schizophrenia, major
depression, panic disorder). The vignette portraying a case of schizophrenia was thus given to
353 subjects, that for major depression to 333 subjects and that for panic disorder to 330
subjects. The three sub-samples had no differences in the principal socio-demographic,
professional, cultural and family background characteristics of those interviewed. Neither
were they differentiated according to their proximity to psychiatry, contacts with persons
having undergone psychological difficulties or their own experience with such problems.
ASMR Revista Internacional On-line - Dep. Leg. BI-2824-01 - ISSN 1579-3516
CORE Academic, Instituto de Psicoterapia, Manuel Allende 19, 48010 Bilbao (España)
Copyright © 2004
Avances en Salud Mental Relacional / Advances in relational mental health
Vol.3, núm. 3 - Noviembre 2004
Órgano Oficial de expresión de la Fundación OMIE
Revista Internacional On-line / An International On-line Journal
Following the presentation of each vignette, we asked those interviewed what would,
in their opinion, be the most useful treatments for the person described (with a choice of a
maximum of three treatments) out of a list of six possibilities, with other forms of therapy left
open to suggestion. For those subjects who did not select medication, an open-ended question
with 18 pre-coded answers was asked pertaining to the reasons they did not mention it. These
items were regrouped into six variables, of the presence/absence kind. The social
representations of the etiology of illness were first addressed through a list of 18 items,
borrowed from Angermeyer [15]. Six weighted indices were created, regrouping three items
each referring to the same dimension; the answer "yes" was worth 2 points, "maybe", 1 point.
An index totaling positive replies to the 18 items was also drawn up. The two items on
definition of illness and prognosis were closed questions.
Other indices on societal factors were also established. These principally concerned
cultural differentiation (foreigners, persons having moved here from other regions, a mother
tongue which is not that of the region in which the person lives, spouse with a different
mother tongue), a weighted index of proximity to psychiatry (a psychiatric institution located
nearby, knowledge of the workings of a psychiatric institution, types of links to an institution)
and a weighted index of contacts with persons suffering from mental disorders.
Answers on the vignettes were compared with diverse usual tests - 2 and variance analysis (+
Scheffe test) - according to the type of variable concerned. Logistic regression analyses have
been used to distinguish societal factors associated with the definition of the different
disorders in terms of illness.
RESULTS
Definition of mental illness
Assessment of the public's perception of the persons described in the different clinical
vignettes as suffering from psychiatric disorder was indicated in their opinion as:
certainly ill, probably ill, probably not ill or certainly not ill.
- Insert Figure 1 about here Taking into account positive answers and those with a positive tendency, we noted
that more than 7 subjects out of 10 considered the persons presented in the vignette to be
mentally ill. The vignette presenting a case of schizophrenia provoked more positive answers
ASMR Revista Internacional On-line - Dep. Leg. BI-2824-01 - ISSN 1579-3516
CORE Academic, Instituto de Psicoterapia, Manuel Allende 19, 48010 Bilbao (España)
Copyright © 2004
Avances en Salud Mental Relacional / Advances in relational mental health
Vol.3, núm. 3 - Noviembre 2004
Órgano Oficial de expresión de la Fundación OMIE
Revista Internacional On-line / An International On-line Journal
(more than 8 subjects out of 10) than those concerning either depression or panic disorder
(approximately two-thirds of the cases), with statistically significant differences (Figure 1).
The distinction between schizophrenia on the one hand, and depression and panic
disorder on the other, was more marked for the unequivocally positive response (38.5% for
schizophrenia and, respectively, 21.3% for depression, p < .001, 18.8% for panic disorder, p <
.001).
ETIOLOGY OF PSYCHIATRIC DISORDERS
Questioned about the factors which could be at the origin of the situation presented in
the clinical vignettes, the public, overall, favored psychosocial stress factors (important lifedisturbing events, work problems, family or couple difficulties) and psychological factors
(personal psychological problems, lack of willpower, too demanding of oneself) in
interpreting the causes of psychiatric illness (Table 1). These were followed by biological
factors (diseases of the brain, weak or fragile constitution, heredity), those linked to early
socialization (lack of parental affection, separation of parents during childhood,
overprotective parents), societal factors (a perceived estrangement of today's world from
nature, loss of tradition, social inequalities and exploitation). Supernatural factors (divine
intervention, astrology, witchcraft) were very rarely mentioned.
- Insert Table 1 about here The public did not differentiate between the clinical vignettes for two types of
etiological factors: psychosocial stress and societal factors. Clinical cases inspired, however,
contrasted representations of their etiology for the three other factor types - psychological,
biological and those linked to early socialization. Thus the social representations of the
etiology of schizophrenia were particularly differentiated, as much from those of depression
as from those of panic disorder, by the greater weight granted to factors linked to
socialization. Biological factors were evoked more frequently for schizophrenia and panic
disorder; psychological factors for schizophrenia and depression. Among psychological
factors, the public much more often considered a lack of willpower to be the cause of
schizophrenia than of depression (30.9% as against 19.6%, p < .001) and even more so for
panic disorder (10.2%, p < .001). In contrast, schizophrenia was less closely linked than the
other two diagnoses to self-exacting behavior (15.2% in the case of schizophrenia, as against
ASMR Revista Internacional On-line - Dep. Leg. BI-2824-01 - ISSN 1579-3516
CORE Academic, Instituto de Psicoterapia, Manuel Allende 19, 48010 Bilbao (España)
Copyright © 2004
Avances en Salud Mental Relacional / Advances in relational mental health
Vol.3, núm. 3 - Noviembre 2004
Órgano Oficial de expresión de la Fundación OMIE
Revista Internacional On-line / An International On-line Journal
26.7% for depression, p < .001, and 22.7% for panic disorder, p < .05). A greater number of
causes were mentioned for schizophrenia than for the other two illnesses: subjects gave an
average of 3.9 affirmative answers for items concerning the etiology of schizophrenia, 3.2 for
depression and 3.0 for panic disorder (p < .001). This indicated a still more pronounced
endorsement of a multifactored explanation for schizophrenia than for the other two
diagnoses.
Very few differences appeared in the representations of the etiology of depression and
panic disorder. However, the weight of psychological factors, and most specifically a lack of
willpower, was greater in the first case, and that of biological factors in the second.
Considered treatments
Subjects had to choose three treatments thought most beneficial for the person described in
each of the clinical vignettes from a list comprising six types of therapy. In addition to
psychiatric-type solutions, this list mentioned possible recourse to natural or alternative
means. We also gave the possibility of evoking other forms of treatment. The selection of
treatments gave indications on the social representations subjects made of the different
treatments and on their representations of the various psychiatric disorders.
- Insert Table 2 about here Psychiatric approaches were most clearly preferred and individual psychotherapy
appeared as the most appropriate treatment for mental disorders since it was selected by
almost six out of ten subjects (Table 2). More than one-third of the subjects considered
relaxation therapy useful, one-fourth chose psychotropic medication and approximately onefifth, family therapy. Natural products or means as well as meditation and yoga were also
mentioned by one-fifth of the subjects interviewed. Other possibilities were only rarely
suggested, and subjects who said that the person described was not in need of any form of
treatment were exceptional.
Very significant variations were found between treatments chosen for schizophrenia
on the one hand, and depression or panic disorder on the other. The exception was medication
which was mentioned with the same frequency for the three types of psychiatric disorders.
Two-thirds of the subjects considered that psychotherapy was the most important treatment
for schizophrenia, while half suggested it for the other disorders. For schizophrenia, the
subjects considered family therapy in second place, then to a lesser degree, medication. The
other treatments proposed - relaxation, natural means, meditation and yoga were very
ASMR Revista Internacional On-line - Dep. Leg. BI-2824-01 - ISSN 1579-3516
CORE Academic, Instituto de Psicoterapia, Manuel Allende 19, 48010 Bilbao (España)
Copyright © 2004
Avances en Salud Mental Relacional / Advances in relational mental health
Vol.3, núm. 3 - Noviembre 2004
Órgano Oficial de expresión de la Fundación OMIE
Revista Internacional On-line / An International On-line Journal
seldom chosen, whereas they were mentioned more often in the two other clinical cases; this
was particularly true for relaxation. The public thus mentioned a significantly lower number
of treatments for schizophrenia, whereas the range was more diversified for depression and
panic disorder (1.8 on an average for schizophrenia, 2 for the two other diagnoses, p < .01).
There were several differences between the treatments selected for depression (natural
means, meditation, yoga, and family therapy) and for panic disorder, where other possibilities,
principally recourse to somatic medicine, were called into play.
REASONS FOR NOT CHOOSING MEDICATION
Choosing medication as a form of treatment for psychiatric disorders was relatively
infrequent, as already noted, since it was only mentioned in a quarter of cases, whatever the
psychiatric disorder described. What reasons could explain this fact ? Doubts about the
effectiveness of medication (45.6% of those who did not choose medication) and fear of sideeffects (43.4%) were frequently evoked. Other reasons linked either to the characteristics of
the persons presented in the vignettes, who supposedly did not need medication (30.5%) or
were not ill (24.0%), or to negative attitudes towards medication in general (18.9%), were less
cited. Very few subjects stated that they were unfamiliar with psychiatric medication (4.6%).
Grounds alluded to were the same for the three clinical cases under consideration, with the
sole exception of fear of side-effects, slighter for schizophrenia than for depression and panic
disorder combined. These results reinforced the observation previously noted that the public
lacks specific awareness of psychotropic medication and its connection to distinct psychiatric
disorders.
PROGNOSIS OF PSYCHIATRIC DISORDERS
The answer to a question on the outcome the vignette subject would have, should
he or she follow the treatment suggested by the person interviewed, gave further
information on the representations that the public had of psychiatric disorders.
- Insert Figure 2 about here A relatively favorable prognosis on outcome was given (Figure 2). More than nine
subjects out of ten (94.4%) thought that the person could be cured or improve, even if only
ASMR Revista Internacional On-line - Dep. Leg. BI-2824-01 - ISSN 1579-3516
CORE Academic, Instituto de Psicoterapia, Manuel Allende 19, 48010 Bilbao (España)
Copyright © 2004
Avances en Salud Mental Relacional / Advances in relational mental health
Vol.3, núm. 3 - Noviembre 2004
Órgano Oficial de expresión de la Fundación OMIE
Revista Internacional On-line / An International On-line Journal
partially, whatever the diagnosis in question. However, if we confined ourselves to the
"possibility of a cure", schizophrenia again appeared more serious than the other two
disorders, since only one-quarter of the subjects interviewed (24.7%) considered it likely;
34.4% for depression (p < .05) and 44.9% for panic disorder (p < .001). The prognosis for
depression was less favorable than that of panic disorder (p < .05).
There was a relationship between the definition of the psychiatric disorder and
prognosis: subjects who defined the disorder as an illness more rarely considered that it could
be cured. Nevertheless, this relationship was statistically significant only with regard to
depression. For schizophrenia and panic disorder, relationships were much more vague
indicating undoubtedly a certain ambiguity in the public's representations of these disorders.
What could explain the lack of recognition of mental disorders?
A majority of those interviewed considered the cases presented in the vignettes as
showing some kind of mental disorder, especially for schizophrenia. We felt it was important
to investigate which factors were linked to an absence of recognition of the disorder as a
psychiatric illness and into what other set of social representations did this lack of recognition
fall.
We made a logistic regression, for each of the clinical vignettes, to relate the nonrecognition of illness with socio-demographic characteristics (gender, age), socio-cultural
(professional level, cultural distance) and variables of proximity to psychiatry and contacts
with people suffering from psychiatric disorders. The probability of not defining
schizophrenia as an illness was different for men and women. For men there was no relation
to any other variables, but for women, non recognition was linked to a younger age and lower
socio-professional level (Table 3).
- Insert Table 3 about here Furthermore, an absence of definition for schizophrenia as an illness corresponded to
differing representations of its etiology and treatment. Female subjects who did not identify a
psychiatric disorder in the vignette less frequently suggested an etiology of a biological or
psychological nature. Insofar as treatment was concerned, the use of psychotherapy (51.9%
for 77.6%, p < .01) and medication (11.1% for 36.0%, p < .05) were considered much less
pertinent.
None of the factors retained in logistic regression appeared to intervene in the
assessment of depression and panic disorder. We found however several differences with
ASMR Revista Internacional On-line - Dep. Leg. BI-2824-01 - ISSN 1579-3516
CORE Academic, Instituto de Psicoterapia, Manuel Allende 19, 48010 Bilbao (España)
Copyright © 2004
Avances en Salud Mental Relacional / Advances in relational mental health
Vol.3, núm. 3 - Noviembre 2004
Órgano Oficial de expresión de la Fundación OMIE
Revista Internacional On-line / An International On-line Journal
regard to representations on their etiology and treatment. When depression was not perceived
as an illness, societal factors were less frequently mentioned in its etiology, and
psychotherapy as well as medication more rarely suggested as a treatment. For panic disorder,
factors linked to early socialization were less frequently cited and, if psychotherapy was less
often suggested, other treatments (mostly of a somatic nature) were, on the contrary, chosen
more often.
DISCUSSION
There are several similarities as well as differences in the social representations the
public has of the definition, etiology, treatment and outcome of psychiatric disorders.
1. Investigating the aspects of differentiation, it would appear that the principal difference is
found in the contrasting representations that the public has of schizophrenia as compared to
depression and panic disorder.
Schizophrenia is more often perceived as an illness than depression and panic disorder
(84% versus 62% and 69% respectively). Link et al. [9], comparing five vignettes in the USA,
and Jorm et al. [7], examining the recognition of schizophrenia and depression in the
Australian population, also found that the former was more often defined as an illness than
the latter (respectively 88% versus 69% for depression in the first case and 84% versus 72%
in the second). Its prognosis also appears more pessimistic, thus corroborating the results of
other studies [7,14]: only one-fourth predicts a cure against one-third for depression and 45%
for panic disorder. In regards to etiology, schizophrenia is more often perceived than the other
two diagnoses as being linked to early socialization, and biological factors weigh more
heavily than for depression. This coincides with other studies, such as the Australian survey
showing that the public gives more importance to childhood events and to genetic factors in
the case of schizophrenia than in that of depression [8]. In Germany, biological factors are
considered more important for schizophrenia than for both depression and panic disorder [16].
Finally, in our study, psychological factors are cited more often for schizophrenia than for
panic disorder. Among the psychological factors, lack of willpower and low self-exacting
behaviour seem to indicate the existence of a kind moral judgment, which also appeared in
the Australian study, but in the same proportion for both diagnoses studied. With regard to
treatment, the population massively favors two psychiatric-type treatments : individual
ASMR Revista Internacional On-line - Dep. Leg. BI-2824-01 - ISSN 1579-3516
CORE Academic, Instituto de Psicoterapia, Manuel Allende 19, 48010 Bilbao (España)
Copyright © 2004
Avances en Salud Mental Relacional / Advances in relational mental health
Vol.3, núm. 3 - Noviembre 2004
Órgano Oficial de expresión de la Fundación OMIE
Revista Internacional On-line / An International On-line Journal
psychotherapy and family therapy. This could be linked to the type of etiological
representation made of this disorder. Other forms of treatment - relaxation techniques or
alternative methods, often selected for depression or panic disorder - are only exceptionally
mentioned. Jorm et al. [5] also observed that lifestyle interventions (naturopath, vitamins,
physical activity, family, friends, etc.) received more positive rankings for the depression
vignette than for schizophrenia. For all the treatments proposed, with the exception of
medication which we shall discuss later, important differences exist in public representations
between schizophrenia and depression or panic disorder.
In contrast, social representations of depression and panic disorder are very little
differentiated. These disorders are less clearly perceived as illnesses than schizophrenia. Only
one subject out of five considers them to obviously be illnesses, even if for an important
portion of those interviewed (41%, respectively 50%) the possibility is not excluded. For a
non-differentiated portion of the population, depression does not seem to appear as an illness,
but rather as a fairly ordinary condition. Representation of panic disorder is undoubtedly more
vague and at times could be linked to somatic problems. In fact, the public is more favorable
to the somatic causality of panic disorder and the psychological causality of depression which
is more often thought to be a result of a lack of willpower. The treatments proposed are quite
often the same, even though the public gives a slightly higher preference to relaxation
techniques and recourse to natural means, meditation or yoga for depression. Other methods,
frequently of a somatic nature, are mentioned for panic disorder. Finally, the prognosis for
this disorder is slightly more favorable than for that of depression.
The chasm between schizophrenia on the one hand, and depression and panic disorder
on the other, thus appears evident. This divergence undoubtedly arises from the elements of
bizarre behavior and social nonconformity which schizophrenic disorder presents more
obviously than do other clinical tableaux. Different studies dealing with social distance
towards the mentally ill tend to confirm this hypothesis. It appears that the desired social
distance varies according to the type of psychiatric disorder. Angermeyer and Matschinger
[10] observed that the greatest social distance is found towards alcohol dependents, then
towards schizophrenic patients. Individuals suffering from narcissistic personality disorders
are better accepted, whereas individuals suffering from panic disorder with agoraphobia or
from major depression meet with the greatest social acceptance. Link et al. [9] found very
similar results. Respondents desired the most social distance from cocaine and alcohol
ASMR Revista Internacional On-line - Dep. Leg. BI-2824-01 - ISSN 1579-3516
CORE Academic, Instituto de Psicoterapia, Manuel Allende 19, 48010 Bilbao (España)
Copyright © 2004
Avances en Salud Mental Relacional / Advances in relational mental health
Vol.3, núm. 3 - Noviembre 2004
Órgano Oficial de expresión de la Fundación OMIE
Revista Internacional On-line / An International On-line Journal
dependents, then from the person depicted as having schizophrenia. The major depression and
the troubled person vignettes were much better accepted. But these authors go one step further
and show that social distance is directly related to the perception of dangerousness.
2. It is true that beyond the differences examined to this point, other aspects of social
representations tend more towards a lack of differentiation. This principally concerns the
etiology of psychiatric disorders and treatments.
In social representations of the etiology of disorders, very considerable weight is given
to psychosocial factors whatever the diagnosis under consideration. Societal factors, though
much weaker, do not vary either. The very great importance given to psychosocial factors
appears in different countries. In the United States, stressful circumstances are considered as
the first cause of various psychiatric disorders [9]. In Australia, the factors most often cited as
causes both for schizophrenia and depression are to be found in the immediate social
environment [8]. Angermeyer and Matschinger [11] also underlined the emphasis placed by
the public on psychosocial factors, for schizophrenia in particular, an accent which bears
witness to the extent to which notions of stress have been disseminated in the general public.
With regards to the treatments recommended for the different psychiatric disorders, we must
first of all point out the very great importance conferred on psychotherapy. Despite the
differences according to the diagnoses evidence of which was previously given, it appears as
the preferred treatment of mental disorders, which corresponds to the results of the different
studies realized in Germany [1,4,6], with slightly different methods. The predominance of
psychotherapy among treatments, as well as the weight of psychological factors in the
etiology of disorders, seem to show the wide spread dissemination of psychological notions in
the public.
In contrast, the public gives minor importance to medication, and this whatever the
disorder, even if it ranks third among treatments proposed. Only a quarter of subjects suggest
recourse to medication for schizophrenia as well as for depression and panic disorder. Jorm et
al. [5] show that the Australian public has a negative vision of medical treatments (which
mainly include different types of medication, but also electroshock therapy and psychiatric
hospitalization), while it is favorable to psychological intervention or intervention linked to
lifestyle. Benkert et al. [6,17] obtained more favorable results with pharmacotherapy for
schizophrenia than for the six other disorders examined, while Angermeyer et al. [2], as with
our study, reported the same absence of discrimination. However, the place attributed to
ASMR Revista Internacional On-line - Dep. Leg. BI-2824-01 - ISSN 1579-3516
CORE Academic, Instituto de Psicoterapia, Manuel Allende 19, 48010 Bilbao (España)
Copyright © 2004
Avances en Salud Mental Relacional / Advances in relational mental health
Vol.3, núm. 3 - Noviembre 2004
Órgano Oficial de expresión de la Fundación OMIE
Revista Internacional On-line / An International On-line Journal
pharmacotherapy is still weaker than in our results, since only 14% of the population is
favorable. We cannot, however, know if this difference is linked to the method used (three
recommended treatments in our study, appreciation of each form of treatment for
Angermeyer), to differences between the German and Swiss populations, or finally to an
evolution in judgements over time, as Angermeyer's surveys were carried out in 1990 and
ours in 1997.
Among the reasons listed for not choosing medication, the public especially expresses
doubts about their effectiveness and a fear of side effects. These reasons appeared in the
studies of Angermeyer et al. [1-3]. They do not vary according to the clinical case foreseen,
with the exception of slightly improved tolerance to their side effects for schizophrenia.
Studying arguments for and against pharmacotherapy, Angermeyer et al. underline the degree
to which sedative qualities are generally attributed to medication. For these authors, the
public does not discriminate between the different categories of psychotropics, and
extrapolates the properties of tranquilizers to psychotropics in general.
CONCLUSION
In summary, the contrasted public views of mental disorder emerge, showing a clear
differentiation between schizophrenia, on the one hand, and depression and panic disorder on
the other; a lack of differentiation for several etiological factors, and the utilization of
medication. Some results suggest a certain ambiguity in representations, particularly in the
perception of disorders as illnesses, and their prognoses. Results also demonstrate what Jorm
[18] called a poor "mental health literacy". The public shows an obvious unawareness of the
current state of knowledge, or more specifically, of the opinion of experts currently dominant
in this domain. It seems however that certain arguments springing from current scientific
debate (or sometimes from some earlier debates) have been incorporated into a "commonsense viewpoint". We can thus explain the importance accorded to psychosocial factors in the
etiology of the different mental disorders under examination or the weight of individual
psychotherapy in the treatment of these same illnesses. Pop psychology has permeated a large
proportion of the public and certain elements are used to describe disorders which sometimes
do not appear to be serious. This is particularly true for depression and, to a certain degree,
panic disorder.
ASMR Revista Internacional On-line - Dep. Leg. BI-2824-01 - ISSN 1579-3516
CORE Academic, Instituto de Psicoterapia, Manuel Allende 19, 48010 Bilbao (España)
Copyright © 2004
Avances en Salud Mental Relacional / Advances in relational mental health
Vol.3, núm. 3 - Noviembre 2004
Órgano Oficial de expresión de la Fundación OMIE
Revista Internacional On-line / An International On-line Journal
Faced with the clinical vignette presenting a case of schizophrenia, other features may
play a leading role: those which refer to bizarre behavior, the signs of madness. However, for
a segment of the population this disorder is not perceived as an illness. For them, the
"otherness" of deviancy is not burdened by psychiatric connotations. For men, this absence of
recognition is not tied to social characteristics nor to their psychiatric experience. It is as if the
disorder can only be understood as a function of some unknown logic which our data does not
reveal. On the other hand, older women and those with higher professional qualifications
seem to better identify the illness. By analogy with that shown by Boltanski [19] perceptiom
fo morbid sensations varies between social classes, and women pay greater attention to their
bodies than do men we can suppose that the same logic could apply to the perception of
mental illness in others. Women, who are generally responsible for the health care of others
(children, family), could acquire through life experience a greater capacity to perceive
pathological signs.
One last point must be underlined. These representations are those of a population
which, in its majority, may have had a certain experience in the domain of psychiatry or
psychology. More than half (53%) know people who work in psychiatry or psychology; more
than two-thirds (69%) indicate that members of their family, their friends or acquaintances
have suffered from psychological difficulties; 60% that members of their entourage have been
treated by a psychologist or psychiatrist; 45% that persons in their entourage have been
admitted to a psychiatric hospital; finally 28% of the subjects interviewed say that they have
had psychological difficulties themselves, even if those who sought counseling for this reason
are fewer. It would therefore seem that if personal experience with mental illness may modify
attitudes towards psychiatric patients [20 and in the results of our study to be published], such
experiences have little effect on the representations and knowledge of the public.
ASMR Revista Internacional On-line - Dep. Leg. BI-2824-01 - ISSN 1579-3516
CORE Academic, Instituto de Psicoterapia, Manuel Allende 19, 48010 Bilbao (España)
Copyright © 2004
Avances en Salud Mental Relacional / Advances in relational mental health
Vol.3, núm. 3 - Noviembre 2004
Órgano Oficial de expresión de la Fundación OMIE
Revista Internacional On-line / An International On-line Journal
REFERENCES
Angermeyer MC, Held T, Görtler D (1993) Pro und contra: Psychotherapie und
Psychopharmakotherapie im Urteil des Bevölkerung. Psychother. Psychosom. med Psychol.
43: 286-292
Angermeyer MC, Daümer R, Matschinger H. (1993) Benefits and Risks of Psychotropic
Medication in the Eyes of the General Public: Results of a Survey in the Federal Republic of
Germany. Pharmacopsychiat 26: 114-120
Angermeyer MC (1994) Einstellung der Bevölkerung zu Psychopharmaka, in Naber D,
Müller-Spahn F Clozapin. Pharmakologie und Klinik eines atypischen Neuroleptikums,
Springer, Berlin, Heidelberg New York
Angermeyer MC, Matschinger H. (1996) Public attitudes towards psychiatric treatment. Acta
Psychiatr Scand, 94: 326-336
Jorm AF, Korten AE, Rodgers B, Pollitt P, Jacomb PA, Christensen H, Jiao Z (1997) Belief
systems of the general public concerning the appropriate treatments for mental disorders. Soc
Psychiatry Psychiatr Epidemiol 32: 468-473
Benkert O, Kepplinger HM, Sobota K. (1995) Psychopharmaka im Widerstreit. Eine Studie
zur Akzeptanz von Psychopharmaka - Bevölkerungsumfrage und Medienanalyse, Springer,
Berlin Heidelberg New York
Jorm AF, Korten AE, Jacomb PA, Christensen H, Rodgers B, Pollitt P (1997) "Mental health
literacy": a survey of the public's ability to recognise mental disorders and their beliefs about
the effectiveness of treatment. Med J Aust 166:182-186.
Jorm AF, Korten AE, Jacomb PA, Christensen H, Rodgers B, Pollitt P (1997) Public beliefs
about causes and risk factors for depression and schizophrenia. Soc Psychiatry Psychiatr
Epidemiol 32: 143-148
Link BG, Phelan JC, Bresnahan M, Stueve A, Pescolido BA (1999) Public Conceptions of
Mental Illness: Labels, Causes, Dangerousness, and Social Distance. Am J Public Health,
vol. 89, No 9: 1328-1333.
Angermeyer MC, Matschinger H (1997) Social distance towards the mentally: results of
representative surveys in the Federal Republic of Germany. Psychol Med 27: 131-141.
ASMR Revista Internacional On-line - Dep. Leg. BI-2824-01 - ISSN 1579-3516
CORE Academic, Instituto de Psicoterapia, Manuel Allende 19, 48010 Bilbao (España)
Copyright © 2004
Avances en Salud Mental Relacional / Advances in relational mental health
Vol.3, núm. 3 - Noviembre 2004
Órgano Oficial de expresión de la Fundación OMIE
Revista Internacional On-line / An International On-line Journal
Angermeyer MC, Matschinger H (1999) Social representations of mental illness among the
public. In Guimón J, Fischer W, Sartorius N (eds): The Image of Madness. The Public Facing
mental Illness and Psychiatric Treatment. Basel, Karger.
Eker D (1989) Attitudes toward mental illness: recognition, desired social distance, expected
burden and negative influence on mental health among Turkish freshmen. Soc Psychiatry
Psychiatr Epidemiol 24: 146-150.
Eker D, Arkar H (1991) Experienced Turkish nurses' attitudes towards mental illness and the
predictor variables of their attitudes. Int J Soc Psychiatry 37,3: 212-222
Arkar H, Eker D (1992) Influence of having a hospitalized mentally ill member in the family
on attitudes toward mental patients in Turkey. Soc Psychiatry Psychiatr Epidemiol 27: 151155
Angermeyer MC, Matschinger H (1994) Lay beliefs about schizophrenic disorder: the results
of a population survey in Germany. Acta Psychiatr Scand 89 (suppl. 382): 39-45
Angermeyer MC, Matschinger H 1999. Social representations of mental illness among the
public. In Guimón J, Fischer W, Sartorius N (eds): The Image of Madness. The public facing
mental illness and psychiatric treatment. Basel, Karger.
Benkert O, Graf-Morgenstern M, Hillert A et al. (1997) Public Opinion on Psychotropic
Drugs: An Analysis of the Factors Influencing Acceptance or Rejection. J Nerv Ment Dis
185,3: 151-158
Jorm AF (2000) Mental health literacy. Public knowledge and beliefs about mental disorders.
Br J Psychiatry 177: 396-401.
Boltanski L (1971) Les usages sociaux du corps. Annales 26,1: 205-233.
Angermeyer MC, Matschinger H (1996) The effect of personal experience with mental illness
on the attitude towards individuals suffering from mental disorders. Soc. Psychiatry Psychiatr
Epidemiol 31: 321-326
ASMR Revista Internacional On-line - Dep. Leg. BI-2824-01 - ISSN 1579-3516
CORE Academic, Instituto de Psicoterapia, Manuel Allende 19, 48010 Bilbao (España)
Copyright © 2004
Avances en Salud Mental Relacional / Advances in relational mental health
Vol.3, núm. 3 - Noviembre 2004
Órgano Oficial de expresión de la Fundación OMIE
Revista Internacional On-line / An International On-line Journal
Table 1 Etiological factors of psychiatric disorders
Factors
(mean of the indices)
Tota Schizo-
Depressio Panic
Varianc S/D 2 S/PD D/P
l
n
e
phrenia
Disorder
D
analysis
Scheffe
(sign.
differ.)
Psychosocial
3.4
3.3
3.3
3.5
Psychological
3.1
3.2
3.1
2.8
*** 1
Biological
2.2
2.3
2.0
2.3
**
*
to 2.1
2.4
2.0
1.7
***
*
2.1
2.2
2.0
2.0
stress
Linked
*
*
*
*
socialization
Societal
Probability is indicated as follows: * p < .05, ** p < .01, *** p < .001.
Answers cover the comparison of one psychiatric illness to another (in this case schizophrenia
vs. depression).
ASMR Revista Internacional On-line - Dep. Leg. BI-2824-01 - ISSN 1579-3516
CORE Academic, Instituto de Psicoterapia, Manuel Allende 19, 48010 Bilbao (España)
Copyright © 2004
Avances en Salud Mental Relacional / Advances in relational mental health
Vol.3, núm. 3 - Noviembre 2004
Órgano Oficial de expresión de la Fundación OMIE
Revista Internacional On-line / An International On-line Journal
Table 2 Treatments proposed for psychiatric disorders:
Treatments
% of favorable mentions
Tota Schizophreni Depression
Panic
l
Disorder
a
S/D 1 S/PD D/P
2
D
Psychotherapy
56.6 67.7
50.5
50.9
***2 ***
Relaxation
36.4 15.6
45.6
49.4
***
***
Medication
25.7 26.9
22.8
27.3
Family therapy
22.1 38.5
16.5
10.3
***
***
*
Natural means
20.8 11.0
29.7
22.1
***
***
*
Meditation, yoga 20.3 14.4
27.6
19.1
***
Other treatments 12.5
10.5
19.7
therapy
7.6
*
***
**
Answers cover the comparison of one psychiatric illness to another.
Probability is indicated as follows: * p < .05, ** p < .01, *** p < .001 (in this case
schizophrenia vs. depression).
ASMR Revista Internacional On-line - Dep. Leg. BI-2824-01 - ISSN 1579-3516
CORE Academic, Instituto de Psicoterapia, Manuel Allende 19, 48010 Bilbao (España)
Copyright © 2004
Avances en Salud Mental Relacional / Advances in relational mental health
Vol.3, núm. 3 - Noviembre 2004
Órgano Oficial de expresión de la Fundación OMIE
Revista Internacional On-line / An International On-line Journal
Table 3
Logistic regression on the absence of definition of schizophrenia as an illness
(women)
Variables
Odds
Sig
Age
-.0600
.0074
Professional level
-.6317
.0168
Cultural differentiation
-.0734
.7368
Proximity to psychiatry
-.0962
.2985
Contacts with persons suffering from psychiatric -.0792
.5727
disorders
ASMR Revista Internacional On-line - Dep. Leg. BI-2824-01 - ISSN 1579-3516
CORE Academic, Instituto de Psicoterapia, Manuel Allende 19, 48010 Bilbao (España)
Copyright © 2004
Avances en Salud Mental Relacional / Advances in relational mental health
Vol.3, núm. 3 - Noviembre 2004
Órgano Oficial de expresión de la Fundación OMIE
Revista Internacional On-line / An International On-line Journal
Figure 1 Representation of psychiatric disorder in terms of illness (in %)
Schizophrenia
certainly ill
Depression
probably ill
Panic disorder
0
20
40
60
80
100
ASMR Revista Internacional On-line - Dep. Leg. BI-2824-01 - ISSN 1579-3516
CORE Academic, Instituto de Psicoterapia, Manuel Allende 19, 48010 Bilbao (España)
Copyright © 2004
Avances en Salud Mental Relacional / Advances in relational mental health
Vol.3, núm. 3 - Noviembre 2004
Órgano Oficial de expresión de la Fundación OMIE
Revista Internacional On-line / An International On-line Journal
Figure 2
Presumed evolution of psychiatric disorders: estimation of the possibility of
improvement /cure (in %)
Schizophrenia
cure
Depression
improvement
Panic disorder
0
20
40
60
80
100
ASMR Revista Internacional On-line - Dep. Leg. BI-2824-01 - ISSN 1579-3516
CORE Academic, Instituto de Psicoterapia, Manuel Allende 19, 48010 Bilbao (España)
Copyright © 2004
IMPORTANTE: Algunos textos de esta ficha pueden haber sido generados partir de PDf original, puede sufrir variaciones de maquetación/interlineado, y omitir imágenes/tablas.
