Journal of Affective Disorders 164 (2014) 28–32
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Journal of Affective Disorders journal homepage: www.elsevier.com/locate/jad
Research report
Beliefs about depression—Do affliction and treatment experience matter? Results of a population survey from Germany Eva Mnich a,n, Anna Christin Makowski a, Martin Lambert b, Matthias C. Angermeyer c, Olaf von dem Knesebeck a a
Department of Medical Sociology, University Medical Centre Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany Psychosis Centre, Department for Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Germany c Center for Public Mental Health, Untere Zeile 13, 3482 Gö sing am Wagram, Austria b
art ic l e i nf o
a b s t r a c t
Article history: Received 25 February 2014 Received in revised form 2 April 2014 Accepted 2 April 2014 Available online 12 April 2014
Background: There is not much known about the associations of beliefs about depression (depression literacy) with a history of depression and treatment experience. Methods: Analyses were based on a telephone survey in two large German cities (Hamburg and Munich). Written vignettes with typical signs and symptoms suggestive of a depression were presented to 1293 respondents. Respondents were then asked about beliefs about causes, symptoms, prevalence, and treatment using a standardized questionnaire. For the analysis respondents were divided into three groups: (1) people who never had a depression, (2) people who had a depression but were not treated and (3) people with treatment experience. Results: Respondents with experience in treatment for depression were more likely to correctly recognize the disorder, to positively evaluate treatability and to favor external factors (adverse conditions in childhood and psychosocial stress) as potential causes of depression compared to those who never were afflicted. There were no significant differences between these two groups regarding beliefs about the effectiveness of treatment options. There were only few significant differences in depression literacy between respondents who have a history of depression but have not sought help and those who never were afflicted. Limitations: The three groups were constituted on the basis of respondents' self-reports, not medical diagnoses. Conclusions: Our findings only partly support the general assumption that being afflicted and having sought help is associated with beliefs closer to those of professionals. & 2014 Elsevier B.V. All rights reserved.
Keywords: Beliefs about depression Depression literacy History of depression Treatment experience
1. Introduction Public knowledge and beliefs about mental disorders can be conceptualized as ‘mental health literacy’. According to Jorm (2000) mental health literacy consists of several components, including the ability to recognize specific disorders, knowledge and beliefs about risk factors and causes, about self-help interventions and about professional help. Although there is a general trend of increasing mental health literacy (Schomerus et al., 2012), there are still deficiencies in the public knowledge about depression (‘depression literacy’) (Gabriel, 2010; Jorm, 2012). As a consequence, many members of the public do not know what they can do for prevention, people often delay or avoid seeking treatment, view recommended treatments with suspicion or they
n
Corresponding author. Tel.: þ 49 40 7410 54514; fax: þ49 40 7410 54934. E-mail address: [email protected] (E. Mnich).
http://dx.doi.org/10.1016/j.jad.2014.04.001 0165-0327/& 2014 Elsevier B.V. All rights reserved.
are unsure how to assist people afflicted by depression (Jorm, 2012). In terms of factors associated with depression literacy, results concerning gender and age are inconsistent (Angermeyer and Dietrich, 2006; Holzinger et al., 2012). Knesebeck et al. (2013a) found that education is positively associated with illness recognition and a realistic estimation of the lifetime prevalence. Moreover, people with high education were more likely to believe that medication is effective in treating depression and less likely to agree with the statement that a weak will is a potential cause. Furthermore, previous contact to mentally ill had a positive influence on the correct recognition of a depression vignette (Lauber et al., 2003). Only a few studies examined the effect that experiencing depression and receiving treatment might have on depression literacy. Comparing individuals with major depression with people with other depressions and those who were not depressed, Goldney et al. (2001) found few significant differences between the groups in terms of mental health literacy. In a study from
E. Mnich et al. / Journal of Affective Disorders 164 (2014) 28–32
Austria, respondents familiar with the treatment of depression tended to be more ready to recommend to seek help from mental health professionals and to endorse various treatment options, particularly medication. In this study, being familiar with depression meant either respondents who had been in treatment for depression themselves or who had such a person among their family or friends (Holzinger et al., 2011). Other studies found that people with exposure to depression were less likely to believe that antidepressants are harmful (Jorm et al., 2005; Reavley and Jorm, 2012). Beliefs about the helpfulness of diverse medical, psychological and lifestyle interventions were studied by Jorm et al. (2000). They found few significant associations with history of depression and help-seeking beliefs. In sum, results seem scarce and partially inconsistent and most studies did not cover different components of mental health literacy. Against this background associations of beliefs about depression with history of depression and treatment experience were analyzed. To this end, we examined several aspects of depression literacy among three groups: people who never had a depression, people who had or have a depression but never were in treatment and, individuals who reported to be or have been in treatment for depression.
2. Methods 2.1. Study design and sample Analyses were based on a representative telephone survey (computer assisted telephone interviewing, CATI), which was conducted in autumn 2011 in two large German cities (Hamburg and Munich). This survey was part of a large project on mental health in the metropolitan region of Hamburg, called “psychenet – Hamburg network mental health”. A major component of this project is an awareness and education campaign on mental health including mental disorders. One purpose of the survey is to evaluate the effects of the information campaign with Munich as the control region. The present survey served as a baseline (before the start of the campaign); a follow-up is intended in 2014. The sample consisted of persons aged 18 years and older living in private households with conventional telephone connection in one of the two metropolises. The sample was randomly drawn from all registered private telephone numbers. Additionally, numbers were computer-generated to allow for extra-directory households as well. Repeat calls on different occasions were made until a number dropped out. 2014 men and women agreed to do the interview and participated in the study, which reflected a response rate of about 51%. Informed consent was given when the respondents agreed to complete the interview. The ethics commission of the medical association in Hamburg approved this study. A comparison with official statistics in the two cities showed that the distribution of gender, age, level of education, and family status were similar to those in the general population (Knesebeck, 2013b). Vignettes with typical signs and symptoms suggestive of depression, schizophrenia and eating disorders were presented to the respondents at the beginning of the interview. To reduce the length of the questionnaire and to avoid excessive demands for the interviewee only two randomly permuted vignettes were included at a time. This leads to a sub-sample of about two thirds (N ¼1293) of the total sample that was presented a depression vignette. Gender of the ‘patient’ was systematically varied, i.e. in 50% of the cases the patient was female. The vignette was developed with the input of experienced clinicians and is congruent with ICD-10 and DSM-IV criteria for depression. In order to increase reliability and to ‘neutralize’ possible interviewer-associated effects, all vignettes
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were recorded with a trained speaker and these audio files were presented to the respondents. 2.2. Measures After the interviewers presented the depression vignette (see Appendix), the respondents were asked about the patient's diagnosis. They were informed about the mental illness in question in case they did not identify the disorder correctly. Furthermore, the interviewee was asked to estimate the lifetime prevalence of depression in an open-ended question (‘What do you think, how many persons out of 100 will have such an illness at some point in their lives?’). We compared the answers with epidemiological data on life time prevalence in Germany. Lifetime prevalence of 10–25% is considered correct for depression as prevalence estimates in the literature show this range (Bromet et al., 2011; Robert-KochInstitute, 2010). Afterwards, the respondents were asked whether the depression is treatable (1 ¼‘not at all’ to 4¼ ‘very well’). This was followed by the question how effective medication, psychotherapy, alternative therapy (e.g. acupuncture), participation in a self-help group and own activities like sport or relaxation are for the treatment of depression. The scale was ranging from 1 (‘not at all effective’) to 4 (‘very effective’) for each of the therapeutic measures. Furthermore, respondents' causal attributions for depression were assessed by a slightly modified list of causes described by Angermeyer and Matschinger (2003) as well as Schomerus et al. (2014). It contained ten items, which suggested potential causes of depression. The items were coded from 1 (‘not true at all’) to 4 (‘completely true’). A factor analysis (principal component analysis with varimax rotation) yielded four independent factors. Items loading on the first factor were ‘broken home’, ‘lack of parental affection’, and ‘sexual abuse in childhood’. This factor was named ‘conditions of socialization’ (Cronbach's Alpha 0.72). The second factor consisted of the items ‘job stress’, ‘family strain’, ‘critical life event’ and was termed ‘psychosocial stress’ (Cronbach's Alpha 0.70). The third factor named ‘intrapsychic causes’ (Cronbach's Alpha 0.50) comprised the items ‘lack of willpower’ and ‘immoral lifestyle’. Finally, items loading on the fourth factor were ‘brain disease’ and ‘heredity’. This factor was termed as ‘biological causes’ (Cronbach's Alpha 0.50). Together, the four factors accounted for a cumulative variance of 66%. The rotated factor scores were used for analysis. Additionally, the respondents were asked whether they have ever been afflicted by depression themselves at some point in their life and if so, whether they are or were under treatment. For the analysis the respondents were divided into three groups: one group with no depression, a second group of individuals who stated to have suffered from depression but have not sought treatment and a third group who reported to be or have been in treatment for depression. Age, gender, and education were introduced as control variables. Education was measured by the highest school qualification achieved. Respondents were divided into three educational groups (lower secondary education, secondary education and upper secondary or higher education). 2.3. Statistical analysis Descriptive analyses gave a first overview on the three groups and beliefs about depression under study. To test for betweengroups difference Chi square-tests were performed. In order to explore associations between affliction, treatment and beliefs, binary logistic regression analyses were carried out. Odds ratios, 95% confidence intervals and significances are displayed. Regarding attitudes toward different treatment options, response categories were dichotomized, combining ‘very effective’ and ‘rather effective’ in one category and ‘rather not effective’ and
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E. Mnich et al. / Journal of Affective Disorders 164 (2014) 28–32
‘not effective at all’ in another. In terms of the four subscales of causal attributions (conditions of socialization, psychosocial stress, intra-psychic causes and biological causes) the upper tertile was compared with the lower tertiles. All p-values were two-tailed with an excepted significance level of 0.05. All analyses were conducted with the statistical program package SPSS 20.
3. Results About 30% of the respondents (n ¼385) reported that they were or had been suffering from depression in their life. About 55% of them (n ¼216) had been in treatment. Socio-demographic characteristics of the groups under study can be seen in Table 1. Women and respondents with a low education were overrepresented among those who had sought help. When testing for differences between the two depressed groups and the nondepressed group, similar p-values for gender, age and education were obtained (results not displayed). Table 2 shows the distribution of beliefs about depression according to socio-demographic factors (age, gender and education). Some beliefs significantly vary according to age and gender but there are more significant educational differences in depression literacy. Results of the regression analyses are displayed in Table 3. Persons who had been in treatment for depression were
significantly more likely to recognize the vignette presented compared to the group of respondents who never had a depression. Respondents afflicted but not in treatment were significantly less likely to correctly estimate the lifetime prevalence. Regarding beliefs about the general treatability of depression, respondents in treatment were more likely to believe that depression is treatable. With one exception, no significant associations were attained for beliefs about the effectiveness of different forms of treatment. Respondents with depression experiences without treatment were significantly less likely to believe that medication is effective. Concerning psychotherapy, participation in self-help groups and own activities the treatment-group tended to be more likely to positively evaluate these measures. In terms of causal attributions, respondents who had been in treatment were significantly more likely to accept conditions of socialization and psychosocial stress as potential causes for depression while they were less likely to endorse biological causes. Finally, compared to respondents who never had a depression, those who had a history of depression but had not sought help were more likely to think that psychosocial stress is a potential cause of depression.
4. Discussion Based on a population survey in Germany, we examined depression literacy among three groups: people who never had a
Table 1 Socio-demographic characteristics of the sample according to affliction and treatment.
Female (%) Age (mean) Education (%) Low Middle High a b
Total Sample (N ¼ 1293)
No depression (n¼ 908)
Depression, no treatment (n ¼169)
Depression and treatment (n¼ 216)
p
51.6 48.0
49.1 47.5
54.2 47.5
61.6 51.2
0.004a 0.006b
31.5 23.5 45.0
28.7 23.7 47.6
35.2 22.2 42.6
41.1 23.8 35.0
0.004a
Significance of Chi square-test. Kruskal–Wallis.
Table 2 Beliefs about depression according to socio-demographic characteristics of the sample (%). Total
Age groups
N ¼1293 18–40 (n¼ 492) Recognition of depression 71.9 Realistic estimation of 28.2 prevalence Depression is 79.9 treatable (well/very well) Treatments (rather/very effective) Medication 76.2 Psychotherapy 92.9 Self-help groups 91.0 Alternative therapy 44.8 Own activities 91.7 Possible causes (upper tertile) Conditions of 33.3 socialization Psychosocial stress 33.6 Intra-psychic causes 33.3 Biological causes 33.3 a
Significance of Chi-square.
Gender pa
Female (n¼6590
Education Male (n ¼634)
pa
High (n¼ 590)
o 0.001 60.5 o 0.001 25.7
70.4 18.3
80.4 34.7
o 0.001 o 0.001
0.445 79.1
79.4
80.3
0.899
67.0 89.3 93.7 39.6 91.6
76.5 92.7 93.2 54.7 94.0
82.3 95.1 88.4 43.1 90.8
o 0.001 0.003 0.006 o 0.001 0.257
30.8
0.076 35.1
34.4
31.7
0.542
32.6 36.1 29.1
0.487 27.7 0.057 46.2 0.003 29.8
38.2 36.0 31.1
35.9 22.9 37.5
0.011 o 0.001 0.043
61þ (n¼ 358)
74.7 27.5
79.0 25.3
59.6 32.6
o 0.001 76.8 0.058 22.6
66.5 34.2
80.0
84.4
74.3
0.002 80.8
78.9
74.1 94.2 89.4 45.2 90.9
78.8 94.9 91.5 46.4 90.5
76.0 88.7 92.5 42.3 94.1
0.257 0.001 0.265 0.520 0.113
78.8 93.1 90.4 50.4 91.0
73.6 92.7 91.6 38.8 92.3
37.4
31.6
29.2
0.051 35.8
32.8 40.6 33.1
36.9 24.7 31.7
30.5 33.4 35.8
0.183 34.6 o 0.001 30.6 0.541 37.6
0.035 0.746 0.438 o 0.001 0.423
Low (n¼ 402)
pa
Middle (n¼ 301)
41–60 (n¼ 443)
E. Mnich et al. / Journal of Affective Disorders 164 (2014) 28–32
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Table 3 Affliction, treatment and beliefs about depression: odds ratios, significances and 95% CI (reference group: no depression).a Outcomes
Depression, no treatment
Depression and treatment
Recognition of depression Realistic estimation of prevalence Depression is treatable (well/very well)
0.76 (0.53–1.10) 0.38nnn (0.24–0.61) 1.18 (0.76–1.83)
1.51n (1.05–2.18) 0.75 (0.53–1.08) 1.67n (1.10–2.53)
Treatments (rather/very effective) Medication Psychotherapy Own activities Alternative therapy Self-help groups
0.60n 0.77 0.85 1.29 0.94
(0.41–0.87) (0.42–1.40) (0.48–1.50) (0.89–1.85) (0.53–1.68)
Possible causes (upper tertile) Conditions of socialization Psychosocial stress Intra-psychic causes Biological causes
1.44 1.46n 1.10 0.82
(0.99–2.11) (1.01–2.12) (0.75–1.62) (0.55–1.20)
0.89 1.44 1.62 0.89 1.41
(0.62–1.30) (0.75–2.74) (0.84–3.10) (0.65–1.23) (0.77–2.60)
2.11nnn(1.51–2.94) 1.62nn(1.16–2.27) 0.73 (0.51–1.05) 0.62n (0.43–0.89)
a
Adjusted for gender, age and education. p o 0.05. nn po 0.01. nnn p o0.001. n
depression, people who had or have a depression but never were in treatment and, individuals who reported to be or have been in treatment for depression. About 30% of the respondents in our sample stated to have experienced depression at some point in life. Epidemiological studies in Germany yielded lifetime prevalence rates for depression between 10% and 25% (Robert-KochInstitute, 2010; Bromet et al. 2011; Busch et al., 2013). However, it needs to be considered that the survey was conducted in Hamburg and Munich. The prevalence of depression has been found to be higher in metropolitan areas (Busch et al., 2013). Results of multivariate logistic regression analyses showed that respondents with experience in treatment for depression significantly differed from those who were never afflicted by depression in that they were more likely to correctly recognize the disorder, to positively evaluate treatability and to favor external factors (conditions of socialization and psychosocial stress) as potential causes of depression. However, we did not find significant differences between these two groups regarding beliefs about the effectiveness of five different treatment options (medication, psychotherapy, alternative therapy, self-help groups, own activities). Studies from other countries (Austria and Australia), also examining associations of treatment beliefs with treatment experience found a significantly more positive view of antidepressants among respondents who were afflicted and sought help (Holzinger et al., 2011; Reavley and Jorm, 2012). Inconsistency of the results may be due to methodological aspects (e.g. use of different measures of treatment beliefs) or different countries under study. Overall, our findings only partly support the general assumption that having sought help is associated with beliefs closer to those of professionals (Jorm, 2000), which are for example characterized by a positive evaluation of the effectiveness of medication (Jorm et al., 1997). In terms of respondents who have a history of depression but have not sought help, there were only few significant differences in depression literacy compared to those who were never afflicted. This is in line with results of a study from Australia (Goldney et al., 2001). In our study, people with a depression history were less likely to realistically estimate lifetime prevalence and to think that medication is an effective way to treat depression and were more likely to endorse psychosocial stress as a possible cause. Especially the lower probability of realistic prevalence estimation is striking. When looking at the direction of this ‘misestimation’ those afflicted overestimate the lifetime prevalence of depression (results not shown). This holds true for those who have received treatment. Respondents in both afflicted
groups stated that approximately every other person is suffering from depression at some point in life. Thus, the public overestimation of depression prevalence shown in some population studies (Comas and Alvarez, 2004; Knesebeck et al., 2013b) seems at least in part is due to the responses given by those who are personally affected. In general, the majority of respondents in our study overestimated the lifetime prevalence of depression. This trend was stronger pronounced among females, the younger age groups and among respondents with lower education (results not shown). Regarding causal attributions, our results indicate a gradient, i.e. a linear trend in beliefs beginning with individuals who were never afflicted, followed by those who were afflicted but not in treatment and those who have sought help. This gradient is observable when it comes to the endorsement of external causes (conditions of socialization and psychosocial stress) and to the reluctant evaluation of biological causes (hereditary factors, brain disease). Affliction and treatment experience seems to alter causal beliefs which are known to be associated with stigmatizing attitudes towards people with depression and often are addressed in population-level information campaigns to reduce stigma and increase willingness to seek help (Angermeyer et al., 2011; Clement et al., 2010; Schomerus et al., 2009, 2014). 4.1. Limitations Several methodological limitations should be considered when interpreting our findings. First, about half of the selected eligible persons refused to participate or were not available. Although a response rate of 51% is quite good compared to other telephone surveys in Germany (Schlinzig and Schneiderat, 2009), we cannot rule out a selection bias due to non-response. On the other hand, a comparison with official statistics in the two cities supports the external validity of our study (Knesebeck 2013b). Moreover, rate of respondents in our sample who stated to have experienced depression at some point in life (about 30%) corresponds with results of epidemiological studies in German metropolitan areas (Busch et al., 2013). Given that the numbers of cases in the depressed groups are relatively small (depression, no treatment n¼169; depression and treatment n¼ 216) statistical power to detect differences was limited. While we consider it a strength of our study that we used vignettes that were developed with the input of clinicians based on the ICD-10 criteria, it is possible that the respondents have a notion of depression that differs from the scientific conception. This has to be kept in mind
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E. Mnich et al. / Journal of Affective Disorders 164 (2014) 28–32
when interpreting their beliefs about prevalence, the causes and treatment options. Furthermore, in terms of mental health literacy, in some cases it is difficult to evaluate which beliefs about the effectiveness of treatment options or causes of the disorders are ‘correct’. Furthermore, the three comparison groups (no depression, depression not treated, treated depression) were constituted on the basis of respondents' self-reports, and not medical diagnoses. Finally, as we dichotomized the variables for the logistic regression analyses, results on associations to some extent are crude. We decided to dichotomize the variables and use logistic regression models for the sake of clearness and comprehensibility. However, in no instance did this dichotomization affect the direction or significance of an association reported.
5. Conclusions There were only few significant differences in depression literacy between respondents who have a history of depression but have not sought help and those who never were afflicted. Although there were more differences between respondents with experience in treatment for depression and those who were never afflicted, beliefs about treatment options were similar. Thus, having sought help does not seem to influence important aspects of depression literacy. Putting more effort into the empowerment of patients by improving their knowledge about depression and treatment is one important implication of our findings. In terms of people who have not been afflicted by depression so far and those who were affected but did not seek help, community information campaigns can improve depression literacy by increasing knowledge about symptoms, causes and treatment options. This is important because people often do not know what they can do for prevention, they delay or avoid seeking treatment and view recommended treatments with suspicion (Jorm, 2012).
Role of funding source The study is supported by the Federal Ministry of Education and Research (01KQ1002B) in the frame of “psychenet – Hamburg network mental health” (2011– 2014). In no instance did the Ministry interfere with undertaking and evaluating the study.
Conflict of interest All authors declare that they have no conflicts of interest.
Acknowledgments The study is supported by the Federal Ministry of Education and Research (01KQ1002B) in the frame of “psychenet – Hamburg network mental health” (2011– 2014). The aim of the project is to promote mental health today and in the future, and to achieve an early diagnosis and effective treatment of mental illnesses. Further information and a list of all project partners can be found at www.psychenet.de. We would like to thank all respondents for taking part in the study and USUMA (Berlin) for conducting the telephone survey.
Appendix. Vignette Depression1: 46-year-old Dagmar D. has been constantly depressed and unhappy for the last few months. She worries about the future. Mrs. D. feels useless, has the impression everything she does is wrong and has lost all interest in everyday activities. Besides, she complains about insomnia and feels nerveless and weak, already in the mornings. Mrs. D's capability to work turns out to be declining.
1
Gender of the ‘patient’ in the depression vignette was systematically varied.
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Journal of Affective Disorders journal homepage: www.elsevier.com/locate/jad
Research report
Beliefs about depression—Do affliction and treatment experience matter? Results of a population survey from Germany Eva Mnich a,n, Anna Christin Makowski a, Martin Lambert b, Matthias C. Angermeyer c, Olaf von dem Knesebeck a a
Department of Medical Sociology, University Medical Centre Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany Psychosis Centre, Department for Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Germany c Center for Public Mental Health, Untere Zeile 13, 3482 Gö sing am Wagram, Austria b
art ic l e i nf o
a b s t r a c t
Article history: Received 25 February 2014 Received in revised form 2 April 2014 Accepted 2 April 2014 Available online 12 April 2014
Background: There is not much known about the associations of beliefs about depression (depression literacy) with a history of depression and treatment experience. Methods: Analyses were based on a telephone survey in two large German cities (Hamburg and Munich). Written vignettes with typical signs and symptoms suggestive of a depression were presented to 1293 respondents. Respondents were then asked about beliefs about causes, symptoms, prevalence, and treatment using a standardized questionnaire. For the analysis respondents were divided into three groups: (1) people who never had a depression, (2) people who had a depression but were not treated and (3) people with treatment experience. Results: Respondents with experience in treatment for depression were more likely to correctly recognize the disorder, to positively evaluate treatability and to favor external factors (adverse conditions in childhood and psychosocial stress) as potential causes of depression compared to those who never were afflicted. There were no significant differences between these two groups regarding beliefs about the effectiveness of treatment options. There were only few significant differences in depression literacy between respondents who have a history of depression but have not sought help and those who never were afflicted. Limitations: The three groups were constituted on the basis of respondents' self-reports, not medical diagnoses. Conclusions: Our findings only partly support the general assumption that being afflicted and having sought help is associated with beliefs closer to those of professionals. & 2014 Elsevier B.V. All rights reserved.
Keywords: Beliefs about depression Depression literacy History of depression Treatment experience
1. Introduction Public knowledge and beliefs about mental disorders can be conceptualized as ‘mental health literacy’. According to Jorm (2000) mental health literacy consists of several components, including the ability to recognize specific disorders, knowledge and beliefs about risk factors and causes, about self-help interventions and about professional help. Although there is a general trend of increasing mental health literacy (Schomerus et al., 2012), there are still deficiencies in the public knowledge about depression (‘depression literacy’) (Gabriel, 2010; Jorm, 2012). As a consequence, many members of the public do not know what they can do for prevention, people often delay or avoid seeking treatment, view recommended treatments with suspicion or they
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Corresponding author. Tel.: þ 49 40 7410 54514; fax: þ49 40 7410 54934. E-mail address: [email protected] (E. Mnich).
http://dx.doi.org/10.1016/j.jad.2014.04.001 0165-0327/& 2014 Elsevier B.V. All rights reserved.
are unsure how to assist people afflicted by depression (Jorm, 2012). In terms of factors associated with depression literacy, results concerning gender and age are inconsistent (Angermeyer and Dietrich, 2006; Holzinger et al., 2012). Knesebeck et al. (2013a) found that education is positively associated with illness recognition and a realistic estimation of the lifetime prevalence. Moreover, people with high education were more likely to believe that medication is effective in treating depression and less likely to agree with the statement that a weak will is a potential cause. Furthermore, previous contact to mentally ill had a positive influence on the correct recognition of a depression vignette (Lauber et al., 2003). Only a few studies examined the effect that experiencing depression and receiving treatment might have on depression literacy. Comparing individuals with major depression with people with other depressions and those who were not depressed, Goldney et al. (2001) found few significant differences between the groups in terms of mental health literacy. In a study from
E. Mnich et al. / Journal of Affective Disorders 164 (2014) 28–32
Austria, respondents familiar with the treatment of depression tended to be more ready to recommend to seek help from mental health professionals and to endorse various treatment options, particularly medication. In this study, being familiar with depression meant either respondents who had been in treatment for depression themselves or who had such a person among their family or friends (Holzinger et al., 2011). Other studies found that people with exposure to depression were less likely to believe that antidepressants are harmful (Jorm et al., 2005; Reavley and Jorm, 2012). Beliefs about the helpfulness of diverse medical, psychological and lifestyle interventions were studied by Jorm et al. (2000). They found few significant associations with history of depression and help-seeking beliefs. In sum, results seem scarce and partially inconsistent and most studies did not cover different components of mental health literacy. Against this background associations of beliefs about depression with history of depression and treatment experience were analyzed. To this end, we examined several aspects of depression literacy among three groups: people who never had a depression, people who had or have a depression but never were in treatment and, individuals who reported to be or have been in treatment for depression.
2. Methods 2.1. Study design and sample Analyses were based on a representative telephone survey (computer assisted telephone interviewing, CATI), which was conducted in autumn 2011 in two large German cities (Hamburg and Munich). This survey was part of a large project on mental health in the metropolitan region of Hamburg, called “psychenet – Hamburg network mental health”. A major component of this project is an awareness and education campaign on mental health including mental disorders. One purpose of the survey is to evaluate the effects of the information campaign with Munich as the control region. The present survey served as a baseline (before the start of the campaign); a follow-up is intended in 2014. The sample consisted of persons aged 18 years and older living in private households with conventional telephone connection in one of the two metropolises. The sample was randomly drawn from all registered private telephone numbers. Additionally, numbers were computer-generated to allow for extra-directory households as well. Repeat calls on different occasions were made until a number dropped out. 2014 men and women agreed to do the interview and participated in the study, which reflected a response rate of about 51%. Informed consent was given when the respondents agreed to complete the interview. The ethics commission of the medical association in Hamburg approved this study. A comparison with official statistics in the two cities showed that the distribution of gender, age, level of education, and family status were similar to those in the general population (Knesebeck, 2013b). Vignettes with typical signs and symptoms suggestive of depression, schizophrenia and eating disorders were presented to the respondents at the beginning of the interview. To reduce the length of the questionnaire and to avoid excessive demands for the interviewee only two randomly permuted vignettes were included at a time. This leads to a sub-sample of about two thirds (N ¼1293) of the total sample that was presented a depression vignette. Gender of the ‘patient’ was systematically varied, i.e. in 50% of the cases the patient was female. The vignette was developed with the input of experienced clinicians and is congruent with ICD-10 and DSM-IV criteria for depression. In order to increase reliability and to ‘neutralize’ possible interviewer-associated effects, all vignettes
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were recorded with a trained speaker and these audio files were presented to the respondents. 2.2. Measures After the interviewers presented the depression vignette (see Appendix), the respondents were asked about the patient's diagnosis. They were informed about the mental illness in question in case they did not identify the disorder correctly. Furthermore, the interviewee was asked to estimate the lifetime prevalence of depression in an open-ended question (‘What do you think, how many persons out of 100 will have such an illness at some point in their lives?’). We compared the answers with epidemiological data on life time prevalence in Germany. Lifetime prevalence of 10–25% is considered correct for depression as prevalence estimates in the literature show this range (Bromet et al., 2011; Robert-KochInstitute, 2010). Afterwards, the respondents were asked whether the depression is treatable (1 ¼‘not at all’ to 4¼ ‘very well’). This was followed by the question how effective medication, psychotherapy, alternative therapy (e.g. acupuncture), participation in a self-help group and own activities like sport or relaxation are for the treatment of depression. The scale was ranging from 1 (‘not at all effective’) to 4 (‘very effective’) for each of the therapeutic measures. Furthermore, respondents' causal attributions for depression were assessed by a slightly modified list of causes described by Angermeyer and Matschinger (2003) as well as Schomerus et al. (2014). It contained ten items, which suggested potential causes of depression. The items were coded from 1 (‘not true at all’) to 4 (‘completely true’). A factor analysis (principal component analysis with varimax rotation) yielded four independent factors. Items loading on the first factor were ‘broken home’, ‘lack of parental affection’, and ‘sexual abuse in childhood’. This factor was named ‘conditions of socialization’ (Cronbach's Alpha 0.72). The second factor consisted of the items ‘job stress’, ‘family strain’, ‘critical life event’ and was termed ‘psychosocial stress’ (Cronbach's Alpha 0.70). The third factor named ‘intrapsychic causes’ (Cronbach's Alpha 0.50) comprised the items ‘lack of willpower’ and ‘immoral lifestyle’. Finally, items loading on the fourth factor were ‘brain disease’ and ‘heredity’. This factor was termed as ‘biological causes’ (Cronbach's Alpha 0.50). Together, the four factors accounted for a cumulative variance of 66%. The rotated factor scores were used for analysis. Additionally, the respondents were asked whether they have ever been afflicted by depression themselves at some point in their life and if so, whether they are or were under treatment. For the analysis the respondents were divided into three groups: one group with no depression, a second group of individuals who stated to have suffered from depression but have not sought treatment and a third group who reported to be or have been in treatment for depression. Age, gender, and education were introduced as control variables. Education was measured by the highest school qualification achieved. Respondents were divided into three educational groups (lower secondary education, secondary education and upper secondary or higher education). 2.3. Statistical analysis Descriptive analyses gave a first overview on the three groups and beliefs about depression under study. To test for betweengroups difference Chi square-tests were performed. In order to explore associations between affliction, treatment and beliefs, binary logistic regression analyses were carried out. Odds ratios, 95% confidence intervals and significances are displayed. Regarding attitudes toward different treatment options, response categories were dichotomized, combining ‘very effective’ and ‘rather effective’ in one category and ‘rather not effective’ and
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E. Mnich et al. / Journal of Affective Disorders 164 (2014) 28–32
‘not effective at all’ in another. In terms of the four subscales of causal attributions (conditions of socialization, psychosocial stress, intra-psychic causes and biological causes) the upper tertile was compared with the lower tertiles. All p-values were two-tailed with an excepted significance level of 0.05. All analyses were conducted with the statistical program package SPSS 20.
3. Results About 30% of the respondents (n ¼385) reported that they were or had been suffering from depression in their life. About 55% of them (n ¼216) had been in treatment. Socio-demographic characteristics of the groups under study can be seen in Table 1. Women and respondents with a low education were overrepresented among those who had sought help. When testing for differences between the two depressed groups and the nondepressed group, similar p-values for gender, age and education were obtained (results not displayed). Table 2 shows the distribution of beliefs about depression according to socio-demographic factors (age, gender and education). Some beliefs significantly vary according to age and gender but there are more significant educational differences in depression literacy. Results of the regression analyses are displayed in Table 3. Persons who had been in treatment for depression were
significantly more likely to recognize the vignette presented compared to the group of respondents who never had a depression. Respondents afflicted but not in treatment were significantly less likely to correctly estimate the lifetime prevalence. Regarding beliefs about the general treatability of depression, respondents in treatment were more likely to believe that depression is treatable. With one exception, no significant associations were attained for beliefs about the effectiveness of different forms of treatment. Respondents with depression experiences without treatment were significantly less likely to believe that medication is effective. Concerning psychotherapy, participation in self-help groups and own activities the treatment-group tended to be more likely to positively evaluate these measures. In terms of causal attributions, respondents who had been in treatment were significantly more likely to accept conditions of socialization and psychosocial stress as potential causes for depression while they were less likely to endorse biological causes. Finally, compared to respondents who never had a depression, those who had a history of depression but had not sought help were more likely to think that psychosocial stress is a potential cause of depression.
4. Discussion Based on a population survey in Germany, we examined depression literacy among three groups: people who never had a
Table 1 Socio-demographic characteristics of the sample according to affliction and treatment.
Female (%) Age (mean) Education (%) Low Middle High a b
Total Sample (N ¼ 1293)
No depression (n¼ 908)
Depression, no treatment (n ¼169)
Depression and treatment (n¼ 216)
p
51.6 48.0
49.1 47.5
54.2 47.5
61.6 51.2
0.004a 0.006b
31.5 23.5 45.0
28.7 23.7 47.6
35.2 22.2 42.6
41.1 23.8 35.0
0.004a
Significance of Chi square-test. Kruskal–Wallis.
Table 2 Beliefs about depression according to socio-demographic characteristics of the sample (%). Total
Age groups
N ¼1293 18–40 (n¼ 492) Recognition of depression 71.9 Realistic estimation of 28.2 prevalence Depression is 79.9 treatable (well/very well) Treatments (rather/very effective) Medication 76.2 Psychotherapy 92.9 Self-help groups 91.0 Alternative therapy 44.8 Own activities 91.7 Possible causes (upper tertile) Conditions of 33.3 socialization Psychosocial stress 33.6 Intra-psychic causes 33.3 Biological causes 33.3 a
Significance of Chi-square.
Gender pa
Female (n¼6590
Education Male (n ¼634)
pa
High (n¼ 590)
o 0.001 60.5 o 0.001 25.7
70.4 18.3
80.4 34.7
o 0.001 o 0.001
0.445 79.1
79.4
80.3
0.899
67.0 89.3 93.7 39.6 91.6
76.5 92.7 93.2 54.7 94.0
82.3 95.1 88.4 43.1 90.8
o 0.001 0.003 0.006 o 0.001 0.257
30.8
0.076 35.1
34.4
31.7
0.542
32.6 36.1 29.1
0.487 27.7 0.057 46.2 0.003 29.8
38.2 36.0 31.1
35.9 22.9 37.5
0.011 o 0.001 0.043
61þ (n¼ 358)
74.7 27.5
79.0 25.3
59.6 32.6
o 0.001 76.8 0.058 22.6
66.5 34.2
80.0
84.4
74.3
0.002 80.8
78.9
74.1 94.2 89.4 45.2 90.9
78.8 94.9 91.5 46.4 90.5
76.0 88.7 92.5 42.3 94.1
0.257 0.001 0.265 0.520 0.113
78.8 93.1 90.4 50.4 91.0
73.6 92.7 91.6 38.8 92.3
37.4
31.6
29.2
0.051 35.8
32.8 40.6 33.1
36.9 24.7 31.7
30.5 33.4 35.8
0.183 34.6 o 0.001 30.6 0.541 37.6
0.035 0.746 0.438 o 0.001 0.423
Low (n¼ 402)
pa
Middle (n¼ 301)
41–60 (n¼ 443)
E. Mnich et al. / Journal of Affective Disorders 164 (2014) 28–32
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Table 3 Affliction, treatment and beliefs about depression: odds ratios, significances and 95% CI (reference group: no depression).a Outcomes
Depression, no treatment
Depression and treatment
Recognition of depression Realistic estimation of prevalence Depression is treatable (well/very well)
0.76 (0.53–1.10) 0.38nnn (0.24–0.61) 1.18 (0.76–1.83)
1.51n (1.05–2.18) 0.75 (0.53–1.08) 1.67n (1.10–2.53)
Treatments (rather/very effective) Medication Psychotherapy Own activities Alternative therapy Self-help groups
0.60n 0.77 0.85 1.29 0.94
(0.41–0.87) (0.42–1.40) (0.48–1.50) (0.89–1.85) (0.53–1.68)
Possible causes (upper tertile) Conditions of socialization Psychosocial stress Intra-psychic causes Biological causes
1.44 1.46n 1.10 0.82
(0.99–2.11) (1.01–2.12) (0.75–1.62) (0.55–1.20)
0.89 1.44 1.62 0.89 1.41
(0.62–1.30) (0.75–2.74) (0.84–3.10) (0.65–1.23) (0.77–2.60)
2.11nnn(1.51–2.94) 1.62nn(1.16–2.27) 0.73 (0.51–1.05) 0.62n (0.43–0.89)
a
Adjusted for gender, age and education. p o 0.05. nn po 0.01. nnn p o0.001. n
depression, people who had or have a depression but never were in treatment and, individuals who reported to be or have been in treatment for depression. About 30% of the respondents in our sample stated to have experienced depression at some point in life. Epidemiological studies in Germany yielded lifetime prevalence rates for depression between 10% and 25% (Robert-KochInstitute, 2010; Bromet et al. 2011; Busch et al., 2013). However, it needs to be considered that the survey was conducted in Hamburg and Munich. The prevalence of depression has been found to be higher in metropolitan areas (Busch et al., 2013). Results of multivariate logistic regression analyses showed that respondents with experience in treatment for depression significantly differed from those who were never afflicted by depression in that they were more likely to correctly recognize the disorder, to positively evaluate treatability and to favor external factors (conditions of socialization and psychosocial stress) as potential causes of depression. However, we did not find significant differences between these two groups regarding beliefs about the effectiveness of five different treatment options (medication, psychotherapy, alternative therapy, self-help groups, own activities). Studies from other countries (Austria and Australia), also examining associations of treatment beliefs with treatment experience found a significantly more positive view of antidepressants among respondents who were afflicted and sought help (Holzinger et al., 2011; Reavley and Jorm, 2012). Inconsistency of the results may be due to methodological aspects (e.g. use of different measures of treatment beliefs) or different countries under study. Overall, our findings only partly support the general assumption that having sought help is associated with beliefs closer to those of professionals (Jorm, 2000), which are for example characterized by a positive evaluation of the effectiveness of medication (Jorm et al., 1997). In terms of respondents who have a history of depression but have not sought help, there were only few significant differences in depression literacy compared to those who were never afflicted. This is in line with results of a study from Australia (Goldney et al., 2001). In our study, people with a depression history were less likely to realistically estimate lifetime prevalence and to think that medication is an effective way to treat depression and were more likely to endorse psychosocial stress as a possible cause. Especially the lower probability of realistic prevalence estimation is striking. When looking at the direction of this ‘misestimation’ those afflicted overestimate the lifetime prevalence of depression (results not shown). This holds true for those who have received treatment. Respondents in both afflicted
groups stated that approximately every other person is suffering from depression at some point in life. Thus, the public overestimation of depression prevalence shown in some population studies (Comas and Alvarez, 2004; Knesebeck et al., 2013b) seems at least in part is due to the responses given by those who are personally affected. In general, the majority of respondents in our study overestimated the lifetime prevalence of depression. This trend was stronger pronounced among females, the younger age groups and among respondents with lower education (results not shown). Regarding causal attributions, our results indicate a gradient, i.e. a linear trend in beliefs beginning with individuals who were never afflicted, followed by those who were afflicted but not in treatment and those who have sought help. This gradient is observable when it comes to the endorsement of external causes (conditions of socialization and psychosocial stress) and to the reluctant evaluation of biological causes (hereditary factors, brain disease). Affliction and treatment experience seems to alter causal beliefs which are known to be associated with stigmatizing attitudes towards people with depression and often are addressed in population-level information campaigns to reduce stigma and increase willingness to seek help (Angermeyer et al., 2011; Clement et al., 2010; Schomerus et al., 2009, 2014). 4.1. Limitations Several methodological limitations should be considered when interpreting our findings. First, about half of the selected eligible persons refused to participate or were not available. Although a response rate of 51% is quite good compared to other telephone surveys in Germany (Schlinzig and Schneiderat, 2009), we cannot rule out a selection bias due to non-response. On the other hand, a comparison with official statistics in the two cities supports the external validity of our study (Knesebeck 2013b). Moreover, rate of respondents in our sample who stated to have experienced depression at some point in life (about 30%) corresponds with results of epidemiological studies in German metropolitan areas (Busch et al., 2013). Given that the numbers of cases in the depressed groups are relatively small (depression, no treatment n¼169; depression and treatment n¼ 216) statistical power to detect differences was limited. While we consider it a strength of our study that we used vignettes that were developed with the input of clinicians based on the ICD-10 criteria, it is possible that the respondents have a notion of depression that differs from the scientific conception. This has to be kept in mind
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when interpreting their beliefs about prevalence, the causes and treatment options. Furthermore, in terms of mental health literacy, in some cases it is difficult to evaluate which beliefs about the effectiveness of treatment options or causes of the disorders are ‘correct’. Furthermore, the three comparison groups (no depression, depression not treated, treated depression) were constituted on the basis of respondents' self-reports, and not medical diagnoses. Finally, as we dichotomized the variables for the logistic regression analyses, results on associations to some extent are crude. We decided to dichotomize the variables and use logistic regression models for the sake of clearness and comprehensibility. However, in no instance did this dichotomization affect the direction or significance of an association reported.
5. Conclusions There were only few significant differences in depression literacy between respondents who have a history of depression but have not sought help and those who never were afflicted. Although there were more differences between respondents with experience in treatment for depression and those who were never afflicted, beliefs about treatment options were similar. Thus, having sought help does not seem to influence important aspects of depression literacy. Putting more effort into the empowerment of patients by improving their knowledge about depression and treatment is one important implication of our findings. In terms of people who have not been afflicted by depression so far and those who were affected but did not seek help, community information campaigns can improve depression literacy by increasing knowledge about symptoms, causes and treatment options. This is important because people often do not know what they can do for prevention, they delay or avoid seeking treatment and view recommended treatments with suspicion (Jorm, 2012).
Role of funding source The study is supported by the Federal Ministry of Education and Research (01KQ1002B) in the frame of “psychenet – Hamburg network mental health” (2011– 2014). In no instance did the Ministry interfere with undertaking and evaluating the study.
Conflict of interest All authors declare that they have no conflicts of interest.
Acknowledgments The study is supported by the Federal Ministry of Education and Research (01KQ1002B) in the frame of “psychenet – Hamburg network mental health” (2011– 2014). The aim of the project is to promote mental health today and in the future, and to achieve an early diagnosis and effective treatment of mental illnesses. Further information and a list of all project partners can be found at www.psychenet.de. We would like to thank all respondents for taking part in the study and USUMA (Berlin) for conducting the telephone survey.
Appendix. Vignette Depression1: 46-year-old Dagmar D. has been constantly depressed and unhappy for the last few months. She worries about the future. Mrs. D. feels useless, has the impression everything she does is wrong and has lost all interest in everyday activities. Besides, she complains about insomnia and feels nerveless and weak, already in the mornings. Mrs. D's capability to work turns out to be declining.
1
Gender of the ‘patient’ in the depression vignette was systematically varied.
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