Causal beliefs about mental illness: A scoping review

Research on causal beliefs about mental illness-the beliefs people hold about what causes a particular mental illness, or mental illnesses in general-is split across a number of theories and disciplines. Although research on this subject has provided a number of insights and practical applications, the diversity of theories, terminology, and keywords makes it challenging for a new reader to gain a comprehensive understanding. We sought to address this by conducting a systematic scoping review of research on causal beliefs. This review included English-language articles from any year that mentioned causal beliefs for mental illness in their title or abstract. We identified articles in two stages. In the first stage, we used a narrow set of search terms referring specifically to causal beliefs (1227 records identified, 417 included). In the second stage, we used a comprehensive set of terms relevant to research on causal beliefs (10,418 records identified, 3838 included). We analyzed articles qualitatively, organizing them into one of five theories or categories: the common-sense model of self-regulation, explanatory models, mental health literacy, biogenetic causal beliefs, and other research on causal beliefs. We provide a comprehensive summary of these literatures in terms of their history, typical research questions and study design, findings, and practical applications. These theories differ in their theoretical orientation towards causal beliefs, research methods, findings, and applications. However, they broadly share a view of causal beliefs as multifaceted, culturally determined, and relevant for additional psychosocial variables such as mental illness stigma and help-seeking. We conclude by making recommendations for researchers, clinicians, public health messaging, and for individuals with mental illness.

Latina immigrants' breast and colon cancer causal attributions: genetics is key

Latinos in the US suffer health disparities including stage of disease at time of breast or colon cancer diagnosis. Understanding Latinas' causal attributions of breast and colon cancer may provide insight into some of the individual level determinants of cancer disparities in this population. Cultural consensus analysis (CCA) is one way to study causal beliefs. The objective of this study was to describe Latina immigrants' causal attributions of breast and colon cancer. We conducted Spanish-language interviews with 22 Latina immigrants using a qualitative exploratory design comprised of freelisting, ranking, and open-ended questions. Participants freelisted causes and risk factors for breast and colon cancer then ranked risk factors according to their perceived role in the development of each cancer. CCA was conducted on rank orders to identify whether a cultural consensus model was present. Participants answered semi-structured, open-ended questions regarding the risk factors and rankings. Interviews were transcribed and subjected to thematic analysis. CCA showed no consensus around rank of causes for either cancer, and residual agreement analysis suggested the presence of two subcultural groups. "Genetics" and "hereditary factors" ranked first and second on average across participants for both cancers. Based on interview data, participants were less aware of colon cancer than breast cancer. Participants' endorsement of heredity as a cause of breast and colon cancer was similar to beliefs reported in studies of primarily non-Latina populations.

What do people believe to be the cause of low back pain? A scoping review

OBJECTIVE

To explore how causal beliefs regarding non-specific low back pain (LBP) have been quantitatively investigated.

METHODS

A scoping review based on the guidelines by the JBI (former Joanna Briggs Institute) was conducted. We searched Medline, Embase, Psychinfo, and CINAHL for relevant studies and included peer-reviewed original articles that measured causal beliefs about non-specific LBP among adults and reported results separate from other belief domains.

RESULTS

A total of 81 studies were included, of which 62 (77%) had cross sectional designs, 11 (14%) were cohort studies, 3 (4%) randomized controlled trials, 4 (5%) non-randomized controlled trials, and 1 (1%) case control. Only 15 studies explicitly mentioned cause, triggers, or etiology in the study aim. We identified the use of 6 questionnaires from which a measure of causal beliefs could be obtained. The most frequently used questionnaire was the Illness Perception Questionnaire which was used in 8 of the included studies. The studies covered 308 unique causal belief items which we categorized into 15 categories, the most frequently investigated being causal beliefs related to "structural injury or impairment", which was investigated in 45 (56%) of the studies. The second and third most prevalent categories were related to "lifting and bending" (26 studies [32%]) and "mental or psychological" (24 studies [30%]).

CONCLUSION

There is a large variation in how causal beliefs are measured and a lack of studies designed to investigate causal beliefs, and of studies determining a longitudinal association between such beliefs and patient outcomes. This scoping review identified an evidence gap and can inspire future research in this field.

Lay beliefs about the causes and treatment of depression: Tests of measurement models and associations

BACKGROUND

There is reason to expect beliefs about depression's causes and treatment to influence use of psychotherapy, but the literature is marked by theoretical, methodological, and empirical inconsistencies. This study assessed the factorial validity of measures of beliefs about depression's causes and formal treatment versus self-management. It also tested the links of causal attributions to general treatment/self-management beliefs and endorsement of specific interventions.

METHODS

The revised Illness Perception Questionnaire (IPQ-R) adapted for depression was administered online to a non-patient, U.S. sample (N = 319).

RESULTS

Confirmatory factor analyses yielded three causal dimensions, Environmental Stressors, Biological Factors, and Personal Attributes, and two control dimensions, (Formal) Treatment and Personal. Both models fit irrespective of whether respondents believed they had ever experienced depression. A structural equation model (SEM) showed a positive relationship for Environmental and Biological attributions, and an inverse relationship for Personal attributions, in predicting general preferences for Formal Treatment. A second SEM, focusing on specific interventions, linked Environmental causation to endorsement of psychotherapy, dietary changes, and self-help, and Biological causation to endorsement of medication and exercise, with Personal causation inversely associated with endorsement of psychotherapy.

LIMITATIONS

A cross-sectional, correlational design precludes causal inferences. Potential sociocultural influences were not assessed.

CONCLUSIONS

Modifications to the IPQ-R suggested by this study improved its psychometric properties, validated its distinction between Treatment and Personal Control beliefs, and supported examination of both general and specific beliefs about ways to deal with depression. Relationships linking cause and treatment beliefs warrant further investigation as potential intervention targets to increase treatment utilization.

How can the utilisation of help for mental disorders be improved? A quasi-experimental online study on the changeability of stigmatising attitudes and intermediate variables in the process of utilisation

Background

Epidemiological studies show that even in highly developed countries many people with depression do not seek help for their mental health issues, despite promising prevention approaches encouraging people to seek help and reduce self-stigma. Therefore, an anti-stigma intervention study to support help-seeking behaviour will be developed on the basis of the newly explicated “Seeking Mental Health Care Model”.

Methods

A quasi-experimental online study will be carried out to assess the effect of different intervention variables relevant for the help-seeking process. The study is conceived as a fractional factorial design. Participants will be screened for depressive complaints (PHQ-9 sum score ≥ 8) and current psychiatric/psychotherapeutic treatment. After baseline assessment the participants will be randomly allocated into one of the 24 study groups receiving different combinations of the vignette-based intervention aiming to reduce stigma and support help-seeking. Next, relevant outcome measures will be administered a second time. In a 3- and 6-month follow-up help-seeking behaviour will be measured. Gamified elements and avatar-choice techniques will be used to heighten study immersion and adherence.

Discussion

On the basis of the project results, promising research and intervention perspectives can be developed. Results, firstly, allow for a more detailed empirical investigation and conceptualisation of the stages of mental health care utilisation, as well as an examination of theoretical approaches to stigmatisation. Secondly, our online study could provide insights for an evidence-based design and evaluation of online interventions for people with a mental illness.

Trial registration

German Clinical Trials Register: DRKS00023557. Registered 11 December 2020. World Health Organization, Universal Trial Number: U1111–1264-9954. Registered 16 February 2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12125-5.

The role of causal knowledge in stigma considerations in African genomics research: Views of South African Xhosa people

INTRODUCTION

Advances in genomics research have raised several ethical concerns. One concern is the potential impact of genomics research on stigma experienced by people affected by a disease. Studies have found that the type of illness as well as disease causal beliefs impact on the relation between genetic attribution and stigma. This study explored the potential impact of genetic attribution of disease on stigma among Xhosa people with Rheumatic Heart Disease (RHD).

METHODS

Study participants were 46 Xhosa people with RHD living in the Western Cape Province of South Africa. Using video vignettes in 7 focus group discussions we explored whether and how genetic attribution may impact on disease-stigma. Vignettes introduced participants to non-genetic and genetic causal explanations and were followed-up with a series of open-ended questions eliciting their perceptions of non-genetic disease causes as well as genetic causation and its impact on internalised stigma.

RESULTS

This study found that Xhosa people with RHD have a general understanding of genetics and genetic attribution for disease. Additionally, and not withstanding their genetic knowledge, these participants hold multiple disease causal beliefs including genetic, infectious disease, psychosocial, behavioural and cultural explanations. While there was evidence of internalised stigma experiences among participants, these appeared not to be related to a genetic attribution to the disease.

DISCUSSION

The findings of this study provide clues as to why it is unlikely that a genetic conceptualisation of disease impacts internalised stigma experiences of Xhosa people. The causal explanations provided by participants reflect their cultural understandings and their context, namely, living in low-income and poverty-stricken environments. Divergence in these findings from much of the evidence from high-income countries emphasises that context matters when considering the impact of genetic attribution on stigma and caution against generalising findings from one part of the globe to another.

Views of Catholic Priests Regarding Causes, Treatments and Psychosocial Consequences of Schizophrenia and Depression: A Comparative Study in Italy

This study explored views of Catholic priests about schizophrenia and depression in Italy. Participants completed a questionnaire on their views about either schizophrenia (N = 282) or depression (N = 277). The depression group was surer than the schizophrenia group that: the disorder was due to psychosocial causes; curable; non-requiring long-term pharmacotherapy; the persons with depression could participate in religious activities. The older priests were more convinced than the younger priests that: the prayer and long-term pharmacotherapy are useful; the persons with mental disorders had affective difficulties, are recognizable and kept at distance. Priests should receive education on stigma in mental disorders, particularly schizophrenia.

Communicating evidence about the environment's role in obesity and support for government policies to tackle obesity: a systematic review with meta-analysis

Public support for many policies that tackle obesity by changing environments is low. This may reflect commonly held causal beliefs about obesity, namely that it is due to failures of self-control rather than environmental influences. Several studies have sought to increase public support by changing these and similar causal beliefs, with mixed results. The current review is the first systematic synthesis of these studies. Searches of PsycInfo, Medline, Web of Science, Scopus, and Open Grey yielded 20 eligible studies (N = 8977) from 11,776 abstracts. Eligible studies were controlled experiments with an intervention group that communicated information about the environment’s role in obesity, and a measure of support for environment-based obesity policies. The protocol was prospectively registered on PROSPERO. Meta-analyses showed no evidence that communicating information about the environment’s influence on obesity changed policy support or the belief that the environment influences obesity. A likely explanation for this null effect is the ineffectiveness of interventions that were designed to change the belief that the environment influences obesity. The possibility remains, however, that the association observed between beliefs about the causes of obesity and attitudes towards obesity policies is correlational and not causal.

Biological causal beliefs and depression stigma: the moderating effects of first- and second-hand experience with depression

Background: Essentialist theory (ET) links biological attributions for mental illnesses to pessimistic prognostic beliefs and stigma. The commonsense model (CSM) provides a nuanced framework for studying illness beliefs as shaped by experience.Aims: ET-informed hypotheses linking causal and prognostic beliefs and stigmatizing attitudes concerning depression were tested using CSM constructs with a focus on the moderating effects of self-reported experience with this disorder.Methods: U.S. adults (N = 319) completed online questionnaires assessing depression-related beliefs, attitudes and experience. Multiple regression analysis focused on predictive effects of neurobiological and genetic attributions. Potential mediators (prognosis) and moderators (experience) of the biological attribution-stigma link also were tested.Results: Neurobiological attributions predicted viewing depression as more consequential, longer lasting, and unexpectedly, more treatable. Neurobiological attributions were inversely related to stigma, a link partially mediated by beliefs about depression's consequences and duration. However, both biological attributions' relationships to stigma were moderated by experience. Stronger biological attributions predicted less stigma specifically among participants reporting first- or second-hand experience with depression.Conclusion: Experience with depression may shape the relationships of specific causal and prognostic beliefs with depression stigma. Psychoeducation in clinical and public health contexts may be informed by further research using CSM constructs.

Bad things happen and can drive you crazy: The causal beliefs of 701 people taking antipsychotics

In almost all countries the public prefers psycho-social explanations of 'schizophrenia' to bio-genetic ones. The causal explanations of people who experience psychosis have been under-researched, and, if they diverge from the dominant bio-genetic paradigm, can be dismissed as 'lack of insight'. 701 people, from 30 countries, who completed an online survey about their experiences on antipsychotics, answered an open question about what had caused the problems for which they had been prescribed the drugs. On a 'Bio-Social' likert scale, from 1 = 'Purely Biological' to 5 = 'Purely Social', the mean score was 4.24. Thematic analysis of 1,063 causal statements produced seven themes: Social (49.9%), Psychological (12.1%), Bio-genetic (11.6%), Iatrogenic (11.3%), Drug and Alcohol (6.7%), Medical Condition (4.5%) and Insomnia (4.0%). Respondents were 13 times more likely to report predominantly or exclusively Social causes as to report predominantly or exclusively Bio-genetic causes. Those with a psychosis diagnosis were even more likely than others to report a Social cause. The causal beliefs of this sample are consistent with previous studies of people diagnosed with 'schizophrenia' and the beliefs of the public. They are also aligned with recent research into the social causes of psychosis. It is argued that rather than dismiss the beliefs as 'lack of insight' it is more respectful and productive to listen carefully and adjust our understandings and services accordingly.

Individuals with currently untreated mental illness: causal beliefs and readiness to seek help

AIMS

Many people with mental illness do not seek professional help. Beliefs about the causes of their current health problem seem relevant for initiating treatment. Our aim was to find out to what extent the perceived causes of current untreated mental health problems determine whether a person considers herself/himself as having a mental illness, perceives need for professional help and plans to seek help in the near future.

METHODS

In a cross-sectional study, we examined 207 untreated persons with a depressive syndrome, all fulfilling criteria for a current mental illness as confirmed with a structured diagnostic interview (Mini International Neuropsychiatric Interview). The sample was recruited in the community using adverts, flyers and social media. We elicited causal explanations for the present problem, depression literacy, self-identification as having a mental illness, perceived need for professional help, help-seeking intentions, severity of depressive symptoms (Patient Health Questionnaire - Depression), and whether respondents had previously sought mental healthcare.

RESULTS

Most participants fulfilled diagnostic criteria for a mood disorder (n = 181, 87.4%) and/or neurotic, stress-related and somatoform disorders (n = 120, 58.0%) according to the ICD-10. N = 94 (45.4%) participants had never received mental health treatment previously. Exploratory factor analysis of a list of 25 different causal explanations resulted in five factors: biomedical causes, person-related causes, childhood trauma, current stress and unhealthy behaviour. Attributing the present problem to biomedical causes, person-related causes, childhood trauma and stress were all associated with stronger self-identification as having a mental illness. In persons who had never received mental health treatment previously, attribution to biomedical causes was related to greater perceived need and stronger help-seeking intentions. In those with treatment experience, lower attribution to person-related causes and stress were related to greater perceived need for professional help.

CONCLUSIONS

While several causal explanations are associated with self-identification as having a mental illness, only biomedical attributions seem to be related to increase perceived need and help-seeking intentions, especially in individuals with no treatment experiences. Longitudinal studies investigating causal beliefs and help-seeking are needed to find out how causal attributions guide help-seeking behaviour. From this study it seems possible that portraying professional mental health treatment as not being restricted to biomedical problems would contribute to closing the treatment gap for mental disorders.

Public beliefs and attitudes toward schizophrenia and depression in Taiwan: A nationwide survey

Beliefs about and attitudes toward mental illness may be influenced by cultural- or country-specific contexts. Through a national survey, the current study investigated beliefs and attitudes toward people with schizophrenia and depression among the general public in Taiwan. A random-digit-dialing telephone-based cross-sectional survey was administered to Taiwanese adults aged 20-64 years (n = 1600). The data were analyzed through binary logistic regressions to test for differences between these disorders in causal beliefs, stereotypes, emotional reactions, desire for social distance, and help-seeking behavior. The results revealed that respondents were more concerned with biogenetic causal explanations for people with schizophrenia than for those with depression. Significantly more respondents perceived people with schizophrenia as more likely to be unpredictable and violent toward others. A similar trend was observed for the desire for social distance. For both disorders, respondents were significantly more likely to express compassion than to express anger toward the person described in the vignette. Respondents also expressed more desire for social distance from someone like the vignette who have received psychiatric treatment. These findings provide useful directions for the implementation of optimal psychoeducation among such communities. .

The relationship between causal beliefs and desire for social distance towards people with schizophrenia and depression: Results from a survey of young Ghanaian adults

This study examines attitudes of the young Ghanaian population regarding the relationship between causal beliefs and desire for social distance from people with symptoms of schizophrenia and depression. Respondents (n = 507) were presented with depression and schizophrenia symptoms using unlabeled case vignettes. A factor analysis examined three factors for causal beliefs, and multiple linear regression analysis on the desire for social distance was conducted. The desire for social distance was higher when symptoms in both case-vignettes were attributed to childhood adversities and overall lower when respondents lived in northern regions of Ghana. Only, for vignettes depicting schizophrenia, mental illness attribution was associated with more desire for social distance. Significant gender effects were found for depression vignettes only: female respondents reported significantly more desire for social distance, whereas female gendered vignettes were associated with less desire for social distance by respondents of both genders.

Illness beliefs about depression among patients seeking depression care and patients seeking cardiac care: an exploratory analysis using a mixed method design

BACKGROUND

Treatment of depression in cardiac patients is difficult. Patients' illness beliefs regarding depression are associated with outcomes. The aim of the mixed-methods study was to test whether patients in routine care for depression differ from patients with depression in routine care for cardiac diseases regarding illness beliefs about depression.

METHODS

A consecutive sample of n = 217 patients with depressive disorder was recruited from routine care for depression (N = 148) and routine care for cardiac diseases (N = 69). Beliefs about depression were measured by the Brief-Illness Perception Questionnaire. Causal beliefs were categorized using qualitative methods. To investigate differences regarding other illness beliefs, we performed an ANCOVA controlling for sociodemographic and clinical differences by propensity score matching.

RESULTS

Patients in routine care for cardiac diseases attributed their depression more often to physical illnesses (48% vs. 16%) and less often to their self (30% vs. 47%), problems at work (25% vs. 35%), childhood (25% vs. 30%), and negative life events (19% vs. 25%) in contrast to patients in routine care for depression. Patients in routine care for cardiac diseases reported beliefs of lower disability, burden, and treatment-control and of higher self-control in contrast to patients in routine care for depression.

CONCLUSIONS

Illness beliefs especially causal beliefs differ between patients in routine care for cardiac diseases and routine care for depression. Future research should investigate effects of these illness beliefs. We recommend exploring patients' illness beliefs about depression in routine care for cardiac diseases and routine care for depression.

Why is this happening to me? - a comparison of illness representations between Iranian and German people with mental illness

BACKGROUND

Due to an increase in migration and globalization, cross-cultural encounters in health care are also becoming more frequent. As psychotherapy is grounded in a cultural context and must be congruent with the patient's cultural beliefs of his or her illness in order to be effective, the consideration of cross-cultural differences in illness representations becomes increasingly important. Especially research on illness representations concerning mental disorders is scarce.

METHODS

The aim of the current study was to compare illness representations between Iranian (N = 87) and German (N = 90) patient samples as well as subclinical samples (Iranian N = 264, German N = 102) using a multivariate analysis of covariance (MANCOVA). Illness representations were measured using the Illness Perception Questionnaire Revised (IPQ-R). Initially, a factor analysis was conducted in order to ensure comparability of the IPQ-R between the Iranian and the German sample.

RESULTS

The factor analysis already revealed differences in item compositions of the IPQ-R subscales indicating differences of the conception of illness representations between the samples. Further, the Iranian samples showed a significantly higher amount of supernatural causal beliefs and emotional representation of the illness than the German samples. Surprisingly, the Iranian patient sample showed the highest amount of illness coherence.

CONCLUSION

The current paper contributes to a deeper understanding of cross-cultural differences in illness representations regarding mental disorders. Nevertheless, further research is needed to confirm current findings and to further elaborate on the relationships found.

Youth's Causal Beliefs About Success: Socioeconomic Differences and Prediction of Early Career Development

Youth's career attainment is associated with socioeconomic background, but may also be related to their beliefs about causes of success. Relationships between 17-year-olds' socioeconomic status (SES) and causal beliefs about success, and whether these beliefs predict career attainment after completing a vocational or university degree were examined using data from the German Socio-Economic Panel Study (n = 997, 48.5% female). Youth with higher SES parents and those who attended higher levels of high schools were less likely to believe that success in society is due to external causes, but SES was unrelated to the belief that success is due to personal merit or ability. Youth who believe that success is due to external causes attained lower income, occupational prestige, and job autonomy, and slower increases in income over time. There were also significant indirect effects of youth's parents' SES and their own high school levels on career attainment through such external causal beliefs; merit beliefs, by contrast, were largely unrelated to career attainment. These results suggest that beliefs about external causes of success may uniquely contribute to the transmission and maintenance of SES across generations and over time.

Mental health clinicians' beliefs about the causes of psychosis: Differences between professions and relationship to treatment preferences

BACKGROUND

Previous evidence suggests that how an individual conceptualises the cause of a health problem can impact on subsequent perceptions and behaviour.

AIMS

This study explored the beliefs about the causes of psychosis in a group of mental health professionals. The study also sought to examine the relationship between causal beliefs and the perceived helpfulness of different treatments.

METHODS

A total of 219 clinicians completed a questionnaire about the provision of cognitive behavioural therapy (CBT) and antipsychotic medication for their clients who were experiencing psychosis and their opinions about the helpfulness of these treatments. Causal beliefs were also assessed.

RESULTS AND CONCLUSIONS

Clients were twice as likely to be offered medication compared to CBT. Clinicians held a multifactorial model of aetiology, but were more likely to endorse psychosocial causes than biological factors. Clinicians with psychosocial beliefs were more likely to rate CBT as effective, whereas those with biological models were more likely to endorse the helpfulness of medication. Clinicians adopt a multi-causal approach when conceptualising the aetiology of psychosis and these beliefs were related to opinions about the helpfulness of treatment. Beliefs about the aetiology of their client's experiences could blind clinicians to the benefits of offering different approaches.

Outcomes of a Randomized Controlled Trial of Genomic Counseling for Patients Receiving Personalized and Actionable Complex Disease Reports

There has been very limited study of patients with chronic disease receiving potentially actionable genomic based results or the utilization of genetic counselors in the online result delivery process. We conducted a randomized controlled trial on 199 patients with chronic disease each receiving eight personalized and actionable complex disease reports online. Primary study aims were to assess the impact of in-person genomic counseling on 1) causal attribution of disease risk, 2) personal awareness of disease risk, and 3) perceived risk of developing a particular disease. Of 98 intervention arm participants (mean age = 57.8; 39% female) randomized for in-person genomic counseling, 76 (78%) were seen. In contrast, control arm participants (n = 101; mean age = 58.5; 54% female) were initially not offered genomic counseling as part of the study protocol but were able to access in-person genomic counseling, if they requested it, 3-months post viewing of at least one test report and post-completion of the study-specific follow-up survey. A total of 64 intervention arm and 59 control arm participants completed follow-up survey measures. We found that participants receiving in-person genomic counseling had enhanced objective understanding of the genetic variant risk contribution for multiple complex diseases. Genomic counseling was associated with lowered participant causal beliefs in genetic influence across all eight diseases, compared to control participants. Our findings also illustrate that for the majority of diseases under study, intervention arm participants believed they knew their genetic risk status better than control arm subjects. Disease risk was modified for the majority during genomic counseling, due to the assessment of more comprehensive family history. In conclusion, for patients receiving personalized and actionable genomic results through a web portal, genomic counseling enhanced their objective understanding of the genetic variant risk contribution to multiple common diseases. These results support the development of additional genomic counseling interventions to ensure a high level of patient comprehension and improve patient-centered health outcomes.

"Did I bring it on myself?" An exploratory study of the beliefs that adolescents referred to mental health services have about the causes of their depression

The causal beliefs which adults have regarding their mental health difficulties have been linked to help-seeking behaviour, treatment preferences, and the outcome of therapy; yet, the topic remains a relatively unexplored one in the adolescent literature. This exploratory study aims to explore the causal beliefs regarding depression among a sample of clinically referred adolescents. Seventy seven adolescents, aged between 11 and 17, all diagnosed with moderate to severe depression, were interviewed using a semi-structured interview schedule, at the beginning of their participation in a randomised controlled trial. Data were analysed qualitatively using framework analysis. The study identified three themes related to causal beliefs: (1) bewilderment about why they were depressed; (2) depression as a result of rejection, victimisation, and stress; and (3) something inside is to blame. Although some adolescents struggled to identify the causes of their depression, many identified stressful life experiences as the cause of their current depression. They also tended to emphasise their own negative ways of interpreting those events, and some believed that their depression was caused by something inside them. Adolescents' causal beliefs are likely to have implications for the way they seek help and engage in treatment, making it important to understand how adolescents understand their difficulties.

The relationships between patients' and caregivers' beliefs about the causes of schizophrenia and clinical outcomes in Latin American countries

Beliefs about the causes of schizophrenia are thought to impact treatment outcomes. We investigated 3 theoretically opposing belief systems (biological, psychosocial, magical-religious) in relation to the severity of positive and negative symptoms and to attitudes towards medications. We recruited 253 patients with schizophrenia and their primary caregivers from public mental health clinics in Bolivia, Chile, and Peru. We assessed patients' and caregivers' beliefs about the causes of schizophrenia, which were used as predictors of symptom severity and medication attitudes in linear regression analyses. Patients' scores on biological, psychosocial, and magical-religious beliefs were positively correlated with one another, indicating that these domains were not, as anticipated, "opposing". Patients with higher levels of biological and psychosocial beliefs had significantly lower levels of positive and negative symptoms; in contrast, higher levels of magical-religious beliefs were associated with increased positive symptoms and less favorable attitudes towards medications. Patients' belief systems are significant predictors of symptom severity and medication attitudes. Research is needed on the extent to which psychotherapeutic treatments for schizophrenia should bolster patients' beliefs in the biological and psychosocial domains and weaken beliefs in the magical-religious domain; this research should also attend to the ethical considerations involved in intervening on belief systems cross-culturally.

Public beliefs about and attitudes towards bipolar disorder: testing theory based models of stigma

BACKGROUND

Given the vast literature into public beliefs and attitudes towards schizophrenia and depression, there is paucity of research on attitudes towards bipolar disorder despite its similar prevalence to schizophrenia. This study explored public beliefs and attitudes towards bipolar disorder and examined the relationship between these different components of stigma.

METHOD

Using an online questionnaire distributed via email, social networking sites and public institutions, 753 members of the UK population were presented with a vignette depicting someone who met DSM-IV criteria for bipolar disorder. Causal beliefs, beliefs about prognosis, emotional reactions, stereotypes, and social distance were assessed in response to the vignette. Preacher and Hayes procedure for estimating direct and indirect effects of multiple mediators was used to examine the relationship between these components of stigma.

RESULTS

Bipolar disorder was primarily associated with positive beliefs and attitudes and elicited a relatively low desire for social distance. Fear partially mediated the relationship between stereotypes and social distance. Biomedical causal beliefs reduced desire for social distance by increasing compassion, whereas fate causal beliefs increased it through eliciting fear. Psychosocial causal beliefs had mixed effects.

LIMITATIONS

The measurement of stigma using vignettes and self-report questionnaires has implications for ecological validity and participants may have been reluctant to reveal the true extent of their negative attitudes.

CONCLUSIONS

Dissemination of these findings to people with bipolar disorder has implications for the reduction of internalised stigma in this population. Anti-stigma campaigns should attend to causal beliefs, stereotypes and emotional reactions as these all play a vital role in discriminatory behaviour towards people with bipolar disorder.

Beliefs of people taking antidepressants about the causes of their own depression

BACKGROUND

The beliefs of people receiving treatment about the causes of their own mental health problems are researched less often than the causal beliefs of the public, but have important implications for relationships with prescribers, treatment choices and recovery.

METHOD

An online survey on a range of beliefs about depression, and experiences with antidepressants, was completed by 1829 New Zealand adults prescribed anti-depressants in the preceding five years, 97.4% of whom proceeded to take antidepressants.

RESULTS

Six of 17 beliefs about the causes of their own depression were endorsed by more than half the sample: chemical imbalance, family stress, work stress, heredity, relationship problems and distressing events in childhood. There were some marked differences in content, structure and level of conviction of beliefs about one׳s own depression and the sample׳s previously published beliefs about depression in general. There were also significant differences between the beliefs of demographic groupings. Regression analyses revealed that self-reported effectiveness of the antidepressants was positively associated with bio-genetic causal beliefs. The quality of the relationship with the prescribing doctor was positively related to a belief in chemical imbalance as a cause and negatively related to a belief in unemployment as a cause.

LIMITATIONS

The convenience sample may have been biased towards a favourable view of bio-genetic explanations, since 83% reported that the medication reduced their depression.

CONCLUSIONS

People experiencing depression hold complex, multifactorial and idiosyncratic sets of beliefs about the causes of their own depression, apparently based at least in part on their own life experiences and circumstances. Exploring those beliefs may enhance the doctor-patient relationship and selection of appropriate treatment modality.

The Australian public׳s beliefs about the causes of schizophrenia: associated factors and change over 16 years

This study investigated the Australian public׳s beliefs about the causes of schizophrenia and whether these beliefs have changed over a 16-year period. Data came from the 2011 Australian National Survey of Mental Health Literacy and Stigma which involved telephone interviews with 1995 Australians aged 15 or over. The survey interview used the same questions as those of the 2003/4 and 1995 national mental health literacy surveys, in which participants were presented with a case vignette describing either early or chronic schizophrenia. Questions were asked about recognition of, exposure to and causal beliefs about these disorders, including those relating to psychosocial, biogenetic and personality factors. Results showed that most Australians believe in multifactorial causes of schizophrenia and that, between 1995 and 2011, belief in problems from childhood and inherited or genetic causes of early schizophrenia increased while belief in weakness of character decreased. Overall, the findings are consistent with evidence that mental health literacy in Australia has improved over a 16-year period.

Beliefs of people taking antidepressants about causes of depression and reasons for increased prescribing rates

BACKGROUND

Public beliefs about the causes of mental health problems are related to desire for distance and pessimism about recovery, and are therefore frequently studied. The beliefs of people receiving treatment are researched less often.

METHOD

An online survey on causal beliefs about depression and experiences with antidepressants was completed by 1829 New Zealand adults prescribed anti-depressants in the preceding five years, 97.4% of whom proceeded to take antidepressants.

RESULTS

The most frequently endorsed of 17 causal beliefs were family stress, relationship problems, loss of loved one, financial problems, isolation, and abuse or neglect in childhood. Factor analysis produced three factors: 'bio-genetic', 'adulthood stress' and 'childhood adversity'. The most strongly endorsed explanations for increases in antidepressant prescribing invoked improved identification, reduced stigma and drug company marketing. The least strongly endorsed was 'Anti-depressants are the best treatment'. Regression analyses revealed that self-reported efficacy of the antidepressants was positively associated with bio-genetic causal beliefs, negatively associated with childhood adversity beliefs and unrelated to adulthood stress beliefs. The belief that 'People cannot׳ get better by themselves even if they try' was positively associated with bio-genetic beliefs.

LIMITATIONS

The convenience sample may have been biased towards a favourable view of bio-genetic explanations, since 83% reported that the medication reduced their depression.

CONCLUSIONS

Clinicians׳ should consider exploring patients׳ causal beliefs. The public, even when taking antidepressants, continues to hold a multi-factorial causal model of depression with a primary emphasis on psycho-social causes. A three factor model of those beliefs may lead to more sophisticated understandings of relationships with stigma variables.

Different biogenetic causal explanations and attitudes towards persons with major depression, schizophrenia and alcohol dependence: is the concept of a chemical imbalance beneficial?

OBJECTIVE

It is unclear whether different biogenetic causal beliefs affect stigmatization of mentally-ill patients differently. It has been argued that in particular believing in a 'chemical imbalance' as a cause of mental disorder might be associated with more tolerant attitudes.

METHOD

In a representative population survey in Germany (n=3642), using unlabelled case vignettes of persons with depression, schizophrenia, or alcohol dependence, we elicited agreement with three different biogenetic explanations of the illness: 'Chemical imbalance of the brain', 'brain disease' and 'heredity'. We further investigated emotional reactions as well as the desire for social distance. For each vignette condition we calculated linear regressions with each biogenetic explanation as independent and emotional reactions as well as social distance as dependent variable controlling for socio-demographic variables.

LIMITATIONS

Our cross-sectional study does not allow statements regarding causality and the explanatory power of our statistical models was low.

RESULTS

'Chemical imbalance of the brain' and 'brain disease' were both associated with a stronger desire for social distance in schizophrenia and depression, and with more social acceptance in alcohol dependence, whereas 'heredity' was not significantly associated with social distance in any of the investigated illnesses. All three biogenetic causal beliefs were associated with more fear in all three illnesses.

CONCLUSION

Our study corroborates findings that biogenetic explanations have different effects in different disorders, and seem to be harmful in depression and schizophrenia. A particular de-stigmatizing potential of the causal belief 'chemical imbalance' could not be found. Implications for useful anti-stigma messages are discussed.

The Australian public's beliefs about the causes of depression: associated factors and changes over 16 years

BACKGROUND

Biological conceptualisations of depression are increasingly prevalent. The current study aimed to investigate the current prevalence of causal beliefs about depression in the Australian public, the factors associated with these beliefs, and changes over time.

METHOD

A nationally representative sample of Australian adults was surveyed as part of the 2011 National Mental Health Literacy and Stigma Survey. Beliefs about the causes of depression were assessed based on responses to vignettes depicting a person with either depression (n=893) or depression with suicidal thoughts (n=903). Socio-demographic characteristics, personal and professional experience with depression, and correct recognition of depression were investigated as predictors of causal beliefs about depression using binary logistic regression. Comparisons were made between the Australian public's current causal beliefs and data obtained in national surveys conducted in 1995 and 2003/4.

RESULTS

Over 80% of the Australian public attributed depression to day to day problems, death of a close friend or relative, a recent traumatic event, childhood problems, and a chemical imbalance in the brain. People who correctly labelled the disorder in the vignettes were more likely to attribute depression to psychosocial reasons and less likely to attribute it to an allergic reaction, a virus, or an infection. Belief in psychosocial and genetic causes has increased over time, whereas belief in infection, allergy and weakness of character has decreased.

LIMITATIONS

Comparisons between the 1995, 2003/4 and 2011 surveys were limited by the differences in the survey methodology at each time point, and by low response rates to the 2003/4 and 2011 surveys. The survey design prevented insight into the reasoning underlying individuals' responses, and lacked sufficient power to explore the beliefs of Australians from cultural minorities.

CONCLUSIONS

The majority of the Australian public believe that both psychosocial and biological factors cause depression.