NCOAJ

Nursing & Care Open Access Journal
Research Article
Volume 1 Issue 2 - 2016
Public Perceptions of Stigma towards People Diagnosed with Schizophrenia, Depression and Anxiety
Abd Al Hadi Ibrahim Hasan*
Fakeeh College for Medical Sciences, Saudi Arabia
Received: September 26, 2016 | Published: November 25, 2016
*Corresponding author: Abd Al Hadi Ibrahim Hasan, Fakeeh College for Medical Sciences, Saudi Arabia, Email:
Citation: Hasan AAHI (2016) Public Perceptions of Stigma towards People Diagnosed with Schizophrenia, Depression and Anxiety. Nurse Care Open Acces J 1(2): 00010. DOI: 10.15406/ncoaj.2016.01.00010

Abstract

Aim: Investigate public attitudes towards mental illness, paying particular attention to schizophrenia, depression and anxiety.

Design: A survey was conducted with 564 people diagnosed with a mental illness who are currently being treated at a psychiatric clinic in Amman, Jordan.

Results: The research found that stigma towards mental illness, specifically schizophrenia, depression and anxiety, was based around three factors: preconceived stereotypes, personal responsibility/blame and the perceived inability of a patient to recover. Schizophrenia, in particular, was linked more strongly to negative stereotypes and an inability to recover, and less associated to personal responsibility/blame in comparison to depression and anxiety.

Conclusion: The public perception of mental health conditions, such as schizophrenia, depression and anxiety, have important implications for the planning of anti-stigma and awareness raising programmes. By gaining a thorough understanding of these perceptions and the rationale behind them, it may be possible to develop effective, tailor-made interventions.

Introduction

People diagnosed with mental illness (PDWMI) frequently experience stigma in society [1,2]. However, the intensity of this prejudice is more profound in Asian societies, where interdependent culture is prevalent [3]. Stigma not only directly affects PDWMI, but also extends to the person’s family and caregivers [4]. It also impacts on individuals’ self-esteem and adversely affects their ability to play a meaningful role in society [5] PDWMI are isolated and discriminated against, whilst family and caregivers have fewer social relationships and face social exclusion [6,7]. Some family members and caregivers resort to concealing their relative’s condition and avoid seeking treatment [8,9]. Ultimately, societal attitudes towards mental illness determine the way that PDWMI are treated and live their lives. Negative attitudes, for instance, may lead to people hiding their condition, which in turn hinders their recovery and causes greater problems later in life. PDWMI and their families are often reluctant to seek help from psychiatric services, which increases their vulnerability and susceptibility to violence, exploitation and drug abuse [10]. In contrast, positive and open attitudes facilitate social integration and accelerate the recovery process [11].

Corrigan categorised stigma into two forms: public or self-stigma [6]. The former is related to how the public perceives and behaves towards PDWMI, including attitude (prejudice), beliefs (stereotypes) and behaviour (discrimination). The latter, self-stigma, describes an individual’s internalisation of public stigma, which may result in marginalisation, devaluation, shame, secrecy and withdrawal.In Jordan, there is widespread prejudice and discrimination against PDWMI [12]. A recent report about mental health services in Jordan, which was conducted by the World Health Organization, found that schizophrenia, depression and anxiety are the commonest form of mental illness in the country. It also revealed that the majority of PDWMI live in the community and are cared for by their family [13]. Furthermore, the study found that PDWMI are less likely to be able to secure a job. These factors influence the individual’s perception of stigma and deprive them of their basic human rights [14]. Interestingly, the findings confirmed that the public perception of mental illness varies according to type. For example, people diagnosed with schizophrenia were viewed more negatively, and were seen as more dangerous and unpredictable than individuals with other forms of mental illness [1,15,16].

There is a clear difference between the public perception of mental illness and medical facts around the causes and symptoms of certain conditions [17]. Although the causal factors of schizophrenia, depression and anxiety are almost identical, including, for example, psychosocial dynamics, the public is more aware of schizophrenia as a mental illness and less likely to notice depression or anxiety [18,19]. Several studies have found that people diagnosed with schizophrenia are perceived to be more dangerous and hostile than people diagnosed with depression and anxiety [1,14]. Furthermore, they are often seen to be more dependent on others [16]. Whilst a significant weight of research has been conducted on public perceptions of the stigma faced by people with mental illnesses, comparatively little has focused on the topic in Jordan [6,20].

Aim

A cross-sectional survey was employed to investigate public attitudes towards mental illness, particularly schizophrenia, depression and anxiety. In addition, a factor analysis was carried out to explore the reasons behind people’s perceptions of mental illness, and to identify whether perceptions differ depending on the type of condition.

Methods

Participants and procedures

This is a cross-sectional survey conducted in Amman, the capital and most populous city of Jordan. This study recruited people diagnosed with a mental illness (schizophrenia, depression and anxiety) according to DSM-V in a period spanning January to July 2016. The study sample comprised individuals with a psychiatric condition. Survey materials were distributed that described the purpose and methods of the study. These included invitation letters, informed consent forms, and survey questionnaires, which were sent to participants at the identified facilities. In total, 593 people consented to take part in the research; 29 individuals refused. The inclusion criteria were twofold: use of the facilities identified by the researchers and the ability to understand and respond in Arabic or English. The exclusion criteria were an intellectual disability or organic brain disease (n=11), and an inability to understand and complete the questions (n=18).

Materials

Eligible participants, after providing consent form, were asked to provide key demographic information, including their age, gender, marital status, education and employment. Each of these questions was multiple choice. The second part of the questionnaire sought to obtain respondents’ views and perceptions of mental illness. Participants were asked to share their attitudes towards mental illness (i.e. schizophrenia, depression and anxiety) by reacting to eight individual statements about each condition. The statements were: danger to others, unpredictable, hard to talk to, have only themselves to blame for their condition, would not improve if given treatment, feel different from the way we feel at times, could pull themselves together if they wanted, and will never recover fully. Each item was scored on a five-point Likert scale of extremes that ranged from positive to negative, for example: would improve if given treatment to would not improve if given treatment. Respondents were not asked whether they had experienced a mental health issue themselves. The study was approved by the Scientific Research Ethics Committee of the Ministry of Health, Jordan (Ref 13245). Written consent was obtained from all participants.

Statistical Analysis

The data was analysed using Statistical Package for the Social Sciences (SPSS) version 23. Data was reversed to ensure that the higher scores represent the most negative attitudes. A factor analysis assumption was then conducted (i.e. sample size, correlation matrix, linearity, normal distribution and outlier) [21]. The ‘attitudes to mental illness’ questionnaire was subjected to a principal components factor analysis, followed by a direct oblimin rotation for schizophrenia, depression and anxiety respectively [21,22]. The factors extracted were those with Eigen values greater than one. The screen plot was also inspected to identify key factors [21]. Factor loading values were reported as significant at over 0.4, as recommended [22]. The factors identified were then entered into standalone, one-way Analysis of Variance (ANOVA) models. The extracted factors were inputted as independent variables and the diagnostic subtype as dependent variables.

Results

Sample socio-demographics

Interviews were conducted with 564 people diagnosed with a mental illness. This is a response rate of 66%.The average age of the sample was 38.40 (18-52; S.D.11.67).Participant demographics are illustrated in Table 1. The most common sample was an individual diagnosed with schizophrenia (47.3%), single (59.45%), unemployed (63.5%) and male (57.75%).

Demographic

N (Percentage)

Gender

Female

241 (42.7%)

Male

323 (57.3%)

Marital status

Single

396 (70.2%)

Married

94 (16.8%)

Divorced

67 (11.8%)

Widowed

7 (1.2%)

Employment status

Employed

218 (38.6%)

Unemployed

346 (61.3%)

Type of mental illness

Schizophrenia

307 (54.4%)

Depression

119 (21.1%)

Anxiety

138 (24.4%)

Table 1: Sample characteristics.

Thoughts of people with a mental illness

The results of a comparison between the percentage of participants who held negative views towards mental illness and findings of previous studies are shown in Table 2 [17,23,24]. Broadly speaking, the findings from this research are comparable with those presented by published studies. The highest scoring percentages in this study in relation to perceptions of schizophrenia were ‘danger to others’, ‘unpredictable’ and ‘hard to talk to’. Somewhat surprisingly, agreement with the statements ‘have only themselves to blame for their condition’ and ‘would not improve if given treatment’ was higher than in previous studies. For depression, ‘unpredictable’ and ‘hard to talk to’ scored highest, which is similar to previous research. The highest scoring statement in relation to anxiety was ‘feel different from the way we feel at times’.

Previous Studies

The Current Study

Schizophrenia
98 03 08

Depression
98 03 08

Anxiety
98 03 08

Schizophrenia

Depression

Anxiety

Danger to others

71 66 63

23 19 21

26 23 20

69

28

24

Unpredictable

77 73 70

56 53 50

50 50 43

71

64

53

Hard to talk to

58 52 50

62 56 53

33 26 24

59

66

28

Have only themselves to blame for their condition

      8   6    9

13 11 14

11 10 10

21

12

11

Would not improve if given treatment

   15  12  15

16 15 18

14 15 18

32

17

15

Feel different from the way we feel at times

57 37 54

43 30 40

39 25 38

45

54

37

Could pull themselves together if they wanted

      8   8   10

19 17 17

22 20 18

11

18

16

Will never recover fully

     51 42  44

23 25 26

22 21 24

49

22

22

Table 2: Percentage that agreed with negative statements in 1998, 2003, 2008 and the current study.

Initial factor analysis

Factor analysis was conducted on the questionnaires to identify the prevalence of negative perceptions. Factors were extracted and retained based on the screen plots, explained variance and Eigen values Table 3. All three scales had the same factor structure. Factor one can be seen as negative stereotypes, factor two can be identified as patient blame, and factor three can be described as the inability to recover. A ‘negative stereotype’ was the primary influencing factor behind the sample results in terms of people with schizophrenia, whilst patient blame was most identified by those with both depression and anxiety.

Schizophrenia

Depression

Anxiety

Factor one

EV= 2.89

EV= 1.87

EV= 2.04

Negative stereotypes

V= 37.5%

V= 18.8%

V = 25.6%

Factor two

EV = 2.54

EV = 1.96

EV = 1.7

Patient blame

V = 26.6%

V = 24.4%

V = 19.3%

Factor three

EV = 1.35

EV = 1.28

EV = 1.6

Inability to recover

V = 13.6%

V = 16.2%

V = 15.3%

Total variance explained

77.70%

59.40%

60.20%

Table 3: Eigen values, individual and total variance explained for rotated factor solutions for schizophrenia, depression and anxiety.

EV: Eigen Value, V: Variance Explained

The factor loadings in Table 4 indicate that ‘a danger to others’, ‘unpredictable’ and ‘hard to talk to’ scored highest in regards to people with schizophrenia. However, in terms of depression and anxiety, this loading is lower. In terms of factor two, ‘feel different to the way we feel’ was reported more likely in depression. Factor three loadings were the highest for schizophrenia, indicating that people diagnosed with the condition viewed their recovery process in an entirely different way to those who have other forms of mental illness.

Item

Factor one: Negative Stereotypes

Factor two: Patient Blame

Factor three: Inability to Recover

S           D             A

S       D       A

S       D        A

Danger to others

0.867    0.567     0.656

Unpredictable

0.887    0.801    0.567

Hard to talk to

0.812    0.782   0.562

Have only themselves to blame for their condition

0.865    0.786   0.667

Feel different from the way we feel at times

0.845   0.812   0.543

Could pull themselves together if they wanted

0.889   0.765   0.786

Would not improve if given treatment

0.876    0.567   0.576

Will never recover fully

0.786    0.456   0.674

Table 4: Rotated solution factor loadings for schizophrenia, depression and anxiety.

S: Schizophrenia; D: Depression; A: Anxiety

The findings of a one-way analysis of variance of factors

Through a factor analysis, individual subscales were generated and compared using three one-way ANOVAs. Scales factors (negative stereotypes, patient blame and inability to recover) were used as independent variables, whilst the types of mental illness were employed as dependent variables. Initial descriptive findings are noted in Table 5.

Schizophrenia

Depression

Anxiety

Factor one: negative stereotypes

14.54 (2.67)

11.98 (2.95)

10.56 (2.13)

1. Danger to others

4.56 (1.39)

2.45 (1.96)

2.22 (1.22)

2. Unpredictable

3.34 (1.03)

2.18 (1.06)

2.34 (1.56)

3. Hard to talk to

3.54 (1.25)

3.21 (2.01)

2.87 (1.54)

Factor two: patient blame

6.76 (2.45)

7.13 (2.87)

7.18 (2.80)

1. Have only themselves to blame for their condition

2.54 (1.17)

2.33 (1.67)

2.41 (1.56)

2. Feel different from the way we feel at times

2.19 (1.07)

2.83 (1.24)

2.93 (1.36)

3. Could pull themselves together if they wanted

2.38 (1.35)

2.48 (1.56)

2.37 (1.46)

Factor three: inability to recover

5.65 (1.76)

5.38 (1.89)

5.31 (1.82)

1. Would not improve if given treatment

2.75 (1.57)

2.39 (1.64)

2.47 (1.59)

2. Will never recover fully

3.01 (1.49)

2.85 (1.48)

2.80 (1.44)

Table 5: Mean and standard deviations of individual items and subscales across targeted mental illnesses.

Negative stereotypes produced significant results in terms of group effect (F (2, 1526) = 255.499, p<0.001), as did patient blame (F (2, 1519 =51.048, p<0.0001) and inability to recover (F (2, 1531) = 51.048, p<0.001). A post-hoc analysis was carried out to identify the notable differences between groups for each individual factor. For negative stereotypes, schizophrenia was significantly higher than depression (0.001) and anxiety (0.001). At the same time, depression was significantly higher than anxiety (0.001). In terms of the second stigma factor (patient blame), depression was significantly higher than both schizophrenia (0.001) and anxiety (0.001), and a marked difference was detected between schizophrenia and anxiety (0.001). The third scale factor (inability to recovery) saw schizophrenia score significantly higher than depression (0.001) and anxiety (0.001).No difference was noted between depression and anxiety.

Discussion

This is the first study of its type to explore public perceptions and stigmas attached to three types of mental illness, schizophrenia, depression and anxiety, in Jordan. The research found that negative views abound, and are more prevalent and severe than those identified in previous studied [16,23,24]. This may in part be explained by cultural factors. Jordanian families, for instance, have close interpersonal relationships and regularly interact with each other [25]. The findings of previous studies indicated that this collectivistic culture has both a positive and negative impact on people with schizophrenia [26-28]. The culture of family collectivism correlates with the exhibition of more severe prejudices against people with mental illnesses [20,25]. Furthermore, social stigma may prevent people from seeking help and treatment, which may increase the burden on the family, negatively influencing the individual’s recovery [6,29].

It is interesting to note that the stigma factors that emerged through the research (in relation to different types of mental illness) reflect themes identified in previous reports. This indicates that similar attitudes are prevalent across all types of mental illness, which is an essential concept to consider in order understanding public perceptions. This study found that schizophrenia was conceived more negatively than depression and anxiety. These results align with those observed in earlier studies. People diagnosed with schizophrenia are considered to be more dangerous and less likely to be able to recover than those who suffer from depression and anxiety. Surprisingly, apportioning blame on oneself for possessing a particular condition (in this case schizophrenia) was higher than reported previously. A possible explanation might be that a lack of understanding of mental illness among the Jordanian population attributes mental illness to either the family or malpractice [3] and cultural factor which attributes mental illness to the family or malpractice [30].

As expected, anxiety was perceived to be ‘more acceptable’ by the public. This could be attributed to the fewer negative stereotypes that surround the condition and a belief that people who suffer with anxiety are more likely to recover. A recent study also indicated that non-psychotic illnesses are less stigmatised by the public [23,24]. Interestingly, in this research, anxiety and depression were noted by respondents to have identical factors, unlike schizophrenia. Moreover, ‘feeling different ’was rated more negatively among people diagnosed with depression than those with schizophrenia and anxiety, which supports previous studies that indicated that depressed people are viewed as lazy, less engaged and more isolated from their environment [14].

Literature has shown that negative public attitudes towards mental illness stem from a lack of understanding about the nature of particular conditions. This may explain why, over time, negative perceptions of schizophrenia, depression and anxiety have reduced, whilst other factors, including patient blame and an inability to recover, have increased [19]. The findings from this piece of research suggest that we need to offer greater support to people who suffer from schizophrenia. The stigma people face has many detrimental effects on their day-to-day lives, and can lead to feelings of guilt and shame, as well as helplessness and hopelessness [31]. In turn, individuals’ self-efficacy and self-esteem may decline. This conclusion is in line with those of Lysaker Buck [31] & Sibitz Amering [32], who argued that when people are diagnosed with schizophrenia they tend to internalise the stigma and stereotype themselves, which can lead to depression. Likewise, Pickett Diehl [33] & Alegría Polo [34] found low knowledge of mental illness linked with low self-efficacy and empowerment levels also have a negative psychological effect, and can lead to people developing harmful coping strategies, such as secrecy and avoidance. A similar, widely recognised concept demonstrated that empowerment and self-efficacy mediate the psychological effects of self-stigmatising among people diagnosed with a mental illness, most notably schizophrenia [5]. The National Institute of Clinical Excellence (NICE) guidelines suggest that psychosocial approaches, including psycho-education and cognitive behaviour therapy, are an effective way of tackling the stigma associated with mental illness.

Strength of the study is its large sample size, which provides a representative and reflective portrayal of the Jordanian population’s attitudes towards mental illness. Furthermore, the response rate in this study was high in comparison to previous research. The major limitation of the study is that it only investigated negative public attitudes towards three mental illnesses. As a result, it is recommended that further research be conducted into other conditions.

Conclusion

This study concludes that negative public attitudes towards mental illness are prevalent in Jordan. These are most prominent in relation to schizophrenia. Such negative perceptions differ depending on the type of mental illness, and as a result substantial efforts, such as awareness raising campaigns, need to be made to change attitudes in the future.

Acknowledgement

The primary researcher thank all the patients for their participation in the study and research assistant (MA) for assistance in recruitment.

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