Biogenetic explanations and public acceptance of mental illness: systematic review of population studies.
ABSTRACT Biological or genetic models of mental illness are commonly expected to increase tolerance towards people with mental illness, by reducing notions of responsibility and blame.
To investigate whether biogenetic causal attributions of mental illness among the general public are associated with more tolerant attitudes, whether such attributions are related to lower perceptions of guilt and responsibility, to what extent notions of responsibility are associated with rejection of people who are mentally ill, and how prevalent notions of responsibility are among the general public with regard to different mental disorders.
A systematic review was conducted of representative population studies examining attitudes towards people with mental illness and beliefs about such disorders.
We identified 33 studies relevant to this review. Generally, biogenetic causal attributions were not associated with more tolerant attitudes; they were related to stronger rejection in most studies examining schizophrenia. No published study reported on associations of biogenetic causal attributions and perceived responsibility. The stereotype of self-responsibility was unrelated to rejection in most studies. Public images of mental disorder are generally dominated by the stereotypes of unpredictability and dangerousness, whereas responsibility is less relevant.
Biogenetic causal models are an inappropriate means of reducing rejection of people with mental illness.
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ABSTRACT: Mental disorders are increasingly understood in terms of biological mechanisms. We examined how such biological explanations of patients' symptoms would affect mental health clinicians' empathy-a crucial component of the relationship between treatment-providers and patients-as well as their clinical judgments and recommendations. In a series of studies, US clinicians read descriptions of potential patients whose symptoms were explained using either biological or psychosocial information. Biological explanations have been thought to make patients appear less accountable for their disorders, which could increase clinicians' empathy. To the contrary, biological explanations evoked significantly less empathy. These results are consistent with other research and theory that has suggested that biological accounts of psychopathology can exacerbate perceptions of patients as abnormal, distinct from the rest of the population, meriting social exclusion, and even less than fully human. Although the ongoing shift toward biomedical conceptualizations has many benefits, our results reveal unintended negative consequences.Proceedings of the National Academy of Sciences 12/2014; · 9.81 Impact Factor
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ABSTRACT: The purpose of this review is to clarify and demystify a set of ideas and assumptions, which pervade the field of psychiatry and cause confusion and unfortunate consequences for the practice and teaching of psychiatry. These crystalize in the so-called mind/body problem or mind/body dualism. Mind/Body dualism has adverse consequences for psychiatry, such as stigmatization of mental illness, restricted funding for research and patient care, discrimination against patients with psychiatric or addictive disease in the insurance market place and leads to cognitive distortions affecting the training and practice of psychiatry. This paper attempts to deconstruct a set of ideas, which tend to under girth our intuitive mind/body dualism and proposes that neuroscience is increasingly capable of describing human cognition, emotion and psychopathology as the manifestations of brain activity. Psychiatry operates in a border region of the neurobiology of the brain and mind. Mind is the overarching concept incorporating notions of consciousness, phenomenological experience, free will and the idea of the soul. Psychiatric practice involves modifying brain functions by the use of medications and other means, as well as interventions broadly described as psychotherapy. Psychiatry as a medical discipline has an ambivalent and uneasy relationship with the idea of mind/brain. In this paper, we attempt to trace this tension to the pervasive, intuitive mind/body dualism that lay people as well as scientists tend to adopt. A rapidly growing empirical literature is eroding the idea of mind/ brain dualism. We will review claims that consciousness, first person phenomenological experience or " qualia, " and free will are ontologically beyond the grasp of empirical study. A growing number of neuroscientific research results are placing increasing constraints on these claims. We suggest an alternative view based on the philosophy of pragmatism, which we believe would recommend a critical reappraisal of our intuitive beliefs, by means of an empirically responsible stance. The literature on these topics is extensive. We restrict our review to very recent results from neurobiology.J Psychiatry 2015, 18:1. 01/2015; 18:1.
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ABSTRACT: Challenges to psychiatric stigma fall between a rock and a hard place. Decreasing one prejudice may inadvertently increase another. Emphasising similarities between mental illness and 'ordinary' experience to escape the fear-related prejudices associated with the imagined 'otherness' of persons with mental illness risks conclusions that mental illness indicates moral weakness and the loss of any benefits of a medical model. An emphasis on illness and difference from normal experience risks a response of fear of the alien. Thus, a 'likeness-based' and 'unlikeness-based' conception of psychiatric stigma can lead to prejudices stemming from paradoxically opposing assumptions about mental illness. This may create a troubling impasse for anti-stigma campaigns.The psychiatric bulletin (2014). 08/2014; 38(4):148-51.
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Matthias C. Angermeyer, Anita Holzinger, Mauro G. Carta and Georg Schomerus
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Biogenetic explanations and public acceptance of mental illness:
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The Royal College of PsychiatristsPublished by
on November 17, 2012http://bjp.rcpsych.org/
go to: The British Journal of PsychiatryTo subscribe to
The impressive advances of neuroscience over the past two
decades have fuelled hope that disseminating knowledge of the
biological and genetic basis of mental illness will ultimately
improve public attitudes towards people with mental illness and
reduce stigma. Many anti-stigma initiatives, such as that launched
by the US National Alliance for Mental Illness, portray mental
disorders explicitly as medical diseases, for example major
depression as ‘a biological, medical illness’,1or schizophrenia as
an illness ‘like many other medical illnesses such as cancer or
diabetes’.2The expectation that biological or genetic (hereinafter
referred to as ‘biogenetic’) causal models of mental illness have
destigmatising consequences rests on two assumptions: first, that
attributing the cause of a mental disorder to biogenetic factors will
reduce ascriptions of responsibility and guilt to the affected
person, since such causes are beyond the person’s control; and
second, that if people are held less responsible for their condition,
they will experience less rejection by their social environment.
This argument reflects attribution theory, which predicts that a
stigmatised condition such as mental illness evokes more anger
and rejection if it is perceived as controllable (and not controlling
it is thus the fault of the ill person), whereas an uncontrollable
condition may evoke more positive responses such as pity and
help.3,4Time trend analyses in Australia, the USA and Germany
following up public attitudes towards mental illness and mentally
ill people have demonstrated an overall rise in biological causal
attributions over the past two decades: increasingly, mental
disorders such as depression or schizophrenia are attributed to
brain disease, chemical imbalances in the brain or genetic
causes.5–8However, at the same time attitudes towards people
with mental illness have not become more tolerant,5,7,8a finding
questioning the destigmatising potential of biogenetic explanations
of mental illness. In this review we examine the argument that
biogenetic causal attributions decrease notions of guilt and
responsibility and subsequently increase tolerance towards people
with mental illness. In a systematic review of representative
population studies of attitudes towards mentally ill people and
beliefs about mental illness, we addressed the following questions:
is attributing mental illness to biogenetic causes associated with
greater acceptance of those with mental disorder? Is attributing
mental illness to biogenetic causes associated with lower
perceptions of guilt and responsibility? How strongly is the
attribution of responsibility associated with rejection of people
with mental illness? To enable conclusions to be drawn concerning
the relative importance of notions of responsibility, we compared
its influence on rejection with the influence of the second
prominent set of stereotypes related to mental disorder, the
belief that people with mental illness are dangerous and
How prevalent is the stereotype of self-
responsibility in mental illness among the general population,
again compared with the stereotypes of dangerousness and
unpredictability? By answering these questions we aimed to find
out whether biogenetic causal explanations of mental illness are
an appropriate means of attempting to reduce the rejection of
people with these disorders.
We systematically reviewed all representative population-based
studies of public beliefs about mental disorders and attitudes
towards people with mental illness published before 30 June
2010. Besides reports published in scientific journals or books,
we included also documents published online and ‘grey’ literature
(reports not published in commercially available books or
journals). To detect all relevant studies, we took a stepwise
approach according to the systematic literature review guidelines
of the Centre for Reviews and Dissemination and the Cochrane
Collaboration.11,12As a starting point we conducted a literature
Biogenetic explanations and public acceptance
of mental illness: systematic review of population
Matthias C. Angermeyer, Anita Holzinger, Mauro G. Carta and Georg Schomerus
Biological or genetic models of mental illness are commonly
expected to increase tolerance towards people with mental
illness, by reducing notions of responsibility and blame.
To investigate whether biogenetic causal attributions of
mental illness among the general public are associated with
more tolerant attitudes, whether such attributions are related
to lower perceptions of guilt and responsibility, to what
extent notions of responsibility are associated with rejection
of people who are mentally ill, and how prevalent notions of
responsibility are among the general public with regard to
different mental disorders.
A systematic review was conducted of representative
population studies examining attitudes towards people with
mental illness and beliefs about such disorders.
We identified 33 studies relevant to this review. Generally,
biogenetic causal attributions were not associated with more
tolerant attitudes; they were related to stronger rejection in
most studies examining schizophrenia. No published study
reported on associations of biogenetic causal attributions and
perceived responsibility. The stereotype of self-responsibility
was unrelated to rejection in most studies. Public images of
mental disorder are generally dominated by the stereotypes
of unpredictability and dangerousness, whereas responsibility
is less relevant.
Biogenetic causal models are an inappropriate means of
reducing rejection of people with mental illness.
Declaration of interest
The British Journal of Psychiatry (2011)
199, 367–372. doi: 10.1192/bjp.bp.110.085563
search in PubMed, PsycINFO and Web of Science using the
terms (‘‘mental illness’’ OR ‘‘mental disorder’’ OR schizophrenia
OR depression OR alcoholism OR ‘‘alcohol abuse’’ OR ‘‘alcohol
depend*’’ OR alcoholic OR ‘‘anxiety disorder’’ OR ‘‘obsessive
compulsive disorder’’ OR dementia OR ‘‘Alzheimer’s disease’’)
AND (attitudes OR stigma OR ‘‘mental health literacy’’ OR
‘‘causal beliefs’’ OR ‘‘causal attributions’’ OR stereotype OR
‘‘social distance’’) AND (representative OR population). There
was no restriction on language. Two independent researchers
(Sarah von Saß and M.C.A.) screened titles, abstracts and (where
appropriate) the full text of all identified reports in order to
minimise the possibility of discarding potentially relevant reports.
All reports on studies that met the following selection criteria were
retained. First, the focus of the study was on the general public.
Studies investigating beliefs or attitudes of particular subgroups
such as consumers, health professionals or students were excluded.
Second, studies were based on representative population samples
obtained by either random or quota sampling methods. This
applied to 310 reports. We then hand-searched the identified
literature for relevant citations and searched electronically for
other relevant publications by authors of the documents thus far
identified. By this method we detected another 168 reports that
met our inclusion criteria. Finally, we contacted experts in the
field of psychiatric attitude research and asked them about any
relevant study not published in peer-reviewed journals or other
relevant ‘grey’ literature known to them, resulting in additional
25 reports. Screening bibliographies and asking experts further
helped to reduce language bias. Our search strategy yielded in total
503 reports, 96 of which were written in languages other than
English. With these 503 reports a full-text analysis was carried
out independently by two researchers (M.C.A. and A.H.), looking
for reports on studies addressing our research questions. If
necessary, native speakers were contacted to provide translations.
Disagreement about inclusion of individual reports was resolved
by discussion. Specifically, we looked for studies examining the
(a) the association of causal attributions with the desire for social
distance from people with mental illness;
(b) the relationship between biogenetic attributions and the
tendency to blame the afflicted individual for his or her illness;
(c) the association between stereotypes related to responsibility,
dangerousness and unpredictability, and desire for social
(d) the prevalence of these stereotypes about mental disorder in
the general population.
We identified 39 reports on 32 suitable representative population
studies (Fig. 1). These studies included a total of 72963
respondents (range 201–29248, mean 2280, median 1126). Details
of these studies can be found online in Table DS1. Two reports
dated from before 1970,13,14two from 1989,15,16and all other
reports were published after 1999. Results of the early studies
did not differ substantially from recent studies. Fourteen studies
were conducted in Europe, eight in North America, seven in Asia
and one each in South America, Africa and Australia. We report
alcoholism, since they were the topics of most studies. Only
regarding our fourth question, five studies additionally reported
on drug misuse,9,17–20and two of them also reported on panic
attack, eating disorder and dementia.17,18
Acceptance of people with mental disorder
Discriminatory attitudes towards people with mental illness are
commonly measured as the desire for social distance, i.e. the
reluctance to engage in several forms of everyday contact with
an affected person.21Findings of studies examining associations
of biogenetic causal attributions with desire for social distance
are summarised in online Table DS2, displaying results separately
for mental illness in general (or for a combined analysis of several
diagnoses), schizophrenia, depression and alcohol dependence. It
shows that overall, most associations between certain biogenetic
causal beliefs and social distance remained insignificant, and
that results varied according to diagnosis. Of the significant
Angermeyer et al
503 full reports assessed
33 suitable studies
identified (39 reports)
Analyses of causal beliefs
and social distance: 13
Web of Science
6588 reports excluded by screening title, abstract or full text;
duplicates, not dealing with attitudes of the general
population or not based on representative samples
168 reports included through reference lists of identified articles
25 reports included as a result of experts’ information
Analyses of causal beliefs
and blame/responsibility: 0
Analyses of stereotypes
and social distance: 7
Analyses of stereotype
Biogenetic explanations of mental illness
associations, most were found for schizophrenia, where biogenetic
causal beliefs in most instances predicted stronger desire for social
distance (Table DS2). A similar picture, although interspersed
with more insignificant associations and one negative association,
emerged for depression. No significant association was reported
for alcoholism. For general or combined mental illness most
associations remained insignificant, but a few studies showed
favourable (negative) associations between biogenetic causes and
social distance. Overall, support for the claim that biogenetic
causal attributions are associated with less stigmatising attitudes
towards people with mental illness is small. Particularly with
schizophrenia, biogenetic causal beliefs seem to increase rather
than decrease rejection of those affected.
Perceptions of guilt and responsibility
We did not detect any published study from population surveys
reporting on associations between biogenetic causal attributions
and perceptions of guilt and responsibility. Unpublished analyses
of the population surveys conducted by our group in Germany (in
2001), Russia (Novosibirsk, in 2002), Mongolia (Ulan Bator, in
2002) and Slovakia (Bratislava, in 2003) revealed that none of
these surveys produced significant associations between biogenetic
causal beliefs and perceived responsibility.22,23
question of our review thus remains unanswered, but there are
indicators against an association between both beliefs on a
Responsibility v. dangerousness and unpredictability
We were able to locate eight studies where the attribution of
responsibility to the individual with mental disorder, as well as
notions of unpredictability or dangerousness, were regressed on
the desire for social distance. Studies conducted in Austria, Turkey
and Germany focused on schizophrenia;24–27in these studies the
attribution of responsibility for the illness to the individual (‘lack
of willpower’, ‘immoral lifestyle’ or ‘weak character’) had no effect
on social distance,25,26or had a considerably weaker effect than
Dangerousness and unpredictability, in contrast, were strongly
associated with preferences for increased social distance in all
studies.24–27Similarly, Kermode et al reported from a rural area
of India that one of the most influential predictors of social
distance for both psychosis and depression was the perception
of dangerousness; in contrast, the attribution to ‘personal
weakness’ was associatedwith
Regression analysis of data from the USA, merging several mental
disorders for a combined analysis, also revealed a strong effect of
the perception of mentally ill people as being violent toward
others and no effect of the attribution to ‘bad character’.29Results
from The Netherlands point in the same direction: although the
desire for social distance was significantly associated with the
stereotype that mentally ill people tend to be aggressive, there
was no statistically significant association with the attribution to
‘character’.30Only one data analysis, from a survey in the
USA on public attitudes towards children with mental health
problems, yielded highly significant effects of both perception
of violence and attribution to ‘bad character’.31Taken together,
these studies do not support a prominent role of perceived
responsibility on social distance towards people with mental
dangerousness or unpredictability.
Prevalence of the stereotype of self-responsibility
Findings on the prevalence of the stereotype of self-responsibility
in mental illness, contrasted again with stereotypes related to
dangerousness and unpredictability, are summarised in online
Table DS3. For mental illness and schizophrenia, stereotypes
related to self-responsibility are infrequently endorsed, and
notions of unpredictability and dangerousness are voiced
prominently. For example, all of 30 national surveys conducted
in European countries as part of a Special Eurobarometer study
in 2006 consistently found being unpredictable and being
dangerous more frequently endorsed for mental illness than
being responsible.32Two studies from Asian countries (Malaysia
and Japan) differed from this rule by showing higher ratings
for responsibility-related items
schizophrenia.33,34For depression, studies show mixed patterns.
Self-responsibility related stereotypes such as ‘personal weakness’
or ‘self to blame’ were endorsed by less than one in five
respondents in surveys from Great Britain, Australia and
where instead notions of unpredictability
dominated. Studies from the USA and Scotland showed low
prevalence of both unpredictability/dangerousness and self-
responsibility.8,19,36–38In studies from Germany, Japan, Brazil
and India, stereotypes related to guilt and self-responsibility such
as ‘bad character’, ‘lack of willpower’ and ‘personal weakness’
dominated over ‘being dangerous/unpredictable’.28,34,39–41With
regard to alcohol dependence, both kinds of stereotypes (being
violent, dangerous or unpredictable and being responsible for
the condition) were equally frequently endorsed by more than half
of respondents. These results show that the assumed target of
biologically founded anti-stigma messages, the stereotype of self-
responsibility, is not common among the general public and is
overshadowed by notions of unpredictability and dangerousness
for general mental illness, schizophrenia and – in some countries
Summarising our findings, one can state that in most instances
biological or genetic causal attributions are not associated with
lesser rejection of people with mental illness. For schizophrenia
there is evidence that biogenetic causal beliefs may even increase
the desire for social distance from those affected. No published
evidence links biological causal attributions to low perceptions
of blame and responsibility for mental disorders, and studies
examining the relationship of certain stereotypes to rejection of
people with mental illness almost universally found notions of
dangerousness and unpredictability to be much more relevant
than notions of responsibility, which were mostly unrelated to
public attitudes towards mentally ill persons. Overall, attributions
of responsibility showed a limited prevalence among the public
with regard to general mental illness, schizophrenia and (in some
countries) depression. This leads us to conclude that the
assumption that biogenetic causal models of mental illness reduce
notions of self-responsibility and subsequently increase acceptance
of people with such disorder is only weakly related to public
attitudes and their determinants.
Our findings provoke speculation as to the extent that
attribution theory contributes to the explanation of mental illness
stigma. There are elements of the theory that were not adequately
represented by our data. For example, since most population
surveys elicit perceived causes of mental disorder, they are
concerned with onset responsibility (responsibility for contracting
a disease), but do not enquire about offset responsibility
(responsibility for getting better – by treatment adherence, for
example).4Dependent on the specific illness, perception of offset
responsibility could well be an important predictor of rejection,
for example in conditions that provoke high levels of blame such
Angermeyer et al
as alcoholism.3Another important mediator of reactions to causal
explanations is stability, the perception that a certain cause does
not change. There is evidence that genetic causes are perceived
as stable,42but it is unknown whether this holds true for other
biological causes such as ‘chemical imbalance’ or ‘brain disease’.
So the data available from population surveys do not allow
definite conclusions on the role of attribution theory for the
stigma of mental illness. The data do show, however, that the
simplified adoptionof attribution
biogenetic causal beliefs result in lower perceived responsibility
and more tolerant attitudes is not supported by evidence from
representative population surveys.
There are some indicators that biogenetic causal attributions
possibly have differential effects with regard to different diagnostic
categories and cultural backgrounds. A positive effect of
biogenetic causal models on stigma can clearly be rejected for
schizophrenia, where results of our review even suggest a
detrimental effect. For general mental illness and depression,
results are mixed. In general mental illness, for example, a positive
effect of biogenetic concepts could be expected in Malaysia, where
a majority of respondents expressed blame towards mentally ill
individuals; the same holds true for depression in Japan, India,
Germany and Brazil, where guilt-related stereotypes were quite
prevalent. So far, however, even in these countries a positive effect
of biogenetic causal models on stigma has not been proved. In
India no association between biogenetic causal beliefs and
rejection was found, and in Germany associations were even
unfavourable. Only one study analysing combined data from
surveys in the USA (conducted in 1996 and 2006) found a
desirable positive association between genetic causal beliefs and
tolerance of depression.8For alcoholism we found a deplorable
lack of studies examining associations between causal beliefs,
stereotypes and social distance, given that alcoholism is among
the most severely stigmatised mental disorders.43So, cultural
differences seem to influence the prevalence of certain stereotypes,
and particularly in non-Western cultures, notions of guilt and
responsibility seem to have a more important role. At the time of
this review, however, there was no evidence of a mediating effect
of cultural factors on the influence of biogenetic messages on public
attitudes. Different effects of biogenetic models for different
mental disorders seem also possible, but there is only weak and
inconclusive evidence for positive effects in general mental illness
and depression, and no such evidence for alcohol dependence.
At this stage, promulgating biogenetic causal models of mental
illness cannot be regarded as a rational, evidence-based strategy to
decrease individual discrimination against people with mental
illness, but rather entails a risk of increasing stigma. Indeed, there
seems to be some truth in the argument of those critical of
biogenetic conceptualisations who point out that biogenetic causal
models could have unintended negative consequences, inducing
notions of fundamental, irreversible differences between those
affected and those not, and increasing notions of dangerousness
and unpredictability.44,45There is evidence from population
studies corroborating this concern,8,46,47and along similar lines,
a number of experimental studies have shown that interventions
promulgating biogenetic causal models of mental illness increase
stereotypes of unpredictability and dangerousness.48–51Hence,
besides the low potential of biogenetic illness models to
destigmatise mental disorders, there is a real danger of
unintentionally worsening such stigma. This problematic effect
of biological conceptualisations on the stigma of schizophrenia
has been anticipated by social psychologist Nick Haslam, who
Even if schizophrenia were to become recognized by the lay public as just as much a
disease as diabetes, equally grounded in a chemical malfunction of known cause and
outside of intentional control, the characteristics that lead it to be stigmatized would
remain unchanged. The condition would retain its . . . association with violence, as well
as the apparent unpredictability and incomprehensibility that have made madness so
unsettling to observers through the ages . . . The simple point here is that a great
deal of stigma of mental disorder springs from sources other than responsibility
attributions, and changing these attributions by an uncritical and vulgarized adoption
of the disease model may leave many sources untouched, as well spawning new
Perceived stigma, structural discrimination and
Although population studies show that attributing the cause of
mental disorders to biogenetic mechanisms does little to increase
tolerance towards people with these illnesses, it could still be
beneficial from an individual’s or relative’s perspective. For
instance, Fusar-Poli et al expect that:
Neuroimaging can help to reduce the sense of personal blame and guilt associated
with mental disorders, allowing schizophrenic patients to ask for and receive help
and treatment without shame. Having a malfunctioning brain may be less stigmatizing
than being a mentally ill person.53
among people with depression or bipolar disorder do point in this
direction: in a focus group study of people with depression and
with several cases of depression in the family, a biogenetic
explanation of depression was perceived as having the potential
of diminishing self-stigma.54Interviews with women who had
sought treatment for depression within the previous 5 years
showed that they experienced some relief when they had been
given a biomedical explanation of their depression and had
subsequently adopted it. To them the explanation that their
depression had a physical cause translated (quite in line with
the reasoning explored in this review) into ‘it’s not my fault; I
didn’t do this to myself’, and resulted in less guilt and shame.55
Similarly, a study analysing in-depth interviews with members
of families with a high density of bipolar disorder found that most
of those interviewed felt that a genetic explanation was likely to
decrease the stigma associated with bipolar disorder because it
shifted the locus of control and responsibility away from the
individual towards the role of heredity.56However, quantitative
studies have so far failed to support these findings. A postal survey
among families with several cases of bipolar disorder showed that
having a genetic explanation for the condition had no impact on
perceived stigma among affected family members.57Interviews
with undergraduate students who reported ever experiencing
clinical depression also showed no relationship between biological
explanations and perceived stigma.58
So far, our discussion has only dealt with individual
discrimination, from both a population and a patient or family
perspective. There are other aspects of stigma that might still be
positively affected by biogenetic illness concepts. Structural
discrimination occurs when structures, rules or legislation work
to the disadvantage of a particular group.59Conceivably, for
example, public funding for healthcare could be biased against
conditions that are perceived as self-inflicted. In fact, there is
evidence from a population survey in Germany that in depression
(but not in schizophrenia or alcoholism) the notion of self-
responsibility increases the public’s willingness to cut healthcare
expenditures for this disorder.60Another German survey showed
that for schizophrenia, acceptance of structural discrimination
was related considerably more strongly to notions of self-
unpredictability, a picture complementary to that found for
responsibility might indeed be disadvantageous for people with
mental illness, but less so with regard to individual than to
structural discrimination. A beneficial effect of biogenetic causal
the notionof self-
Biogenetic explanations of mental illness
explanations, however, could only arise if they did indeed reduce
this perception of self-responsibility, and on a population level
there is so far no evidence pointing in this direction.
Effects of biogenetic models on help-seeking
Apart from stigma, biogenetic conceptualisations of mental illness
may have an impact on attitudes towards help-seeking. Population
surveys in Germany, Slovakia and Russia,23as well as in Australia
and in the USA,61–64consistently found beliefs in biological causes
to be positively associated with the endorsement of professional
treatment, particularly that offered by medical providers. Time
trend analyses show that parallel to the growing popularity of
biogenetic illness concepts among the general public, medical
professional help-seeking recommendations for depression and
schizophrenia become more frequent.65–67Medical professional
help-seeking attitudes due to biogenetic causal models of mental
disorders are probably not a sign of destigmatisation, but simply
of modified orientation: a medical definition of the problem
suggests a medical solution. For severe mental illness this is clearly
a desirable outcome. There still is a disadvantage to this
development: experimental51,68,69and population studies42,63also
show that biogenetic causal beliefs or interventions are negatively
associated with expectations of recovery and good prognosis.
In conclusion, reducing discrimination against people with
mental illness is not among the merits of increasing public
knowledge of the biological and genetic basis of mental disorder.
Instead, there seems to be a danger that biogenetic illness concepts
increase rather than decrease public stigma of mental illness. As
psychiatrists, we have to ask ourselves whether a neuroscientific
public image of psychiatry is really in the interest of our patients.
It seems worth contemplating to what extent such an image of our
profession is motivated by our professional interests – for
example, by closing a perceived gap between psychiatry and other
medical disciplines. Anti-stigma initiatives need to be careful to
not rely solely on biological or genetic concepts of mental illness.
A biogenetic illness concept is not a simple way to solve the
problems of discrimination and social exclusion of people with
Matthias C. Angermeyer, Centre for Public Mental Health, Go ¨sing am
Wagram, Austria, and Department of Public Health, University of Cagliari, Italy;
Anita Holzinger, Department of Psychiatry, Medical University, Vienna, Austria;
Mauro G. Carta, Department of Public Health, University of Cagliari, Italy;
Georg Schomerus, Department of Psychiatry, University of Greifswald, Germany
Correspondence: Dr G. Schomerus, Department of Psychiatry, University
of Greifswald, Rostocker Chaussee 70, 18437 Stralsund, Germany. Email:
First received 6 Aug 2010, final revision 23 Dec 2010, accepted 21 Mar 2011
We thank Sarah von Saß for assistance in conducting our database search.
National Alliance for Mental Illness. Major Depression Fact Sheet. NAMI, 2009
National Alliance for Mental Illness. Understanding Schizophrenia and
Recovery. What You Need to Know About this Medical Illness. NAMI, 2008
Corrigan PW. Mental health stigma as social attribution: implications for
research methods and attitude change. Clin Psychol Sci Pract 2000; 7:
4 Weiner B. Judgments of Responsibility: A Foundation for a Theory of Social
Conduct. Guilford, 1995.
5 Angermeyer MC, Holzinger A, Matschinger H. Mental health literacy and
attitude towards people with mental illness: a trend analysis based on
population surveys in the eastern part of Germany. Eur Psychiatry 2009; 24:
6 Jorm AF, Christensen H, Griffiths KM. Public beliefs about causes and risk
factors for mental disorders. Changes in Australia over 8 years. Soc
Psychiatry Psychiatr Epidemiol 2005; 40: 764–7.
7 Angermeyer MC, Matschinger H. Causal beliefs and attitudes to people with
schizophrenia: trend analysis based on data from two population surveys in
Germany. Br J Psychiatry 2005; 186: 331–4.
8 Schnittker J. An uncertain revolution: why the rise of a genetic model of
mental illness has not increased tolerance. Soc Sci Med 2008; 67: 1370–81.
9 Corrigan PW, Kuwabara SA, O’Shaughnessy J. The public stigma of mental
illness and drug addiction: findings from a stratified random sample. J Soc
Work 2009; 9: 139–47.
10 Angermeyer MC, Dietrich S. Public beliefs about and attitudes toward people
with mental illness: a review of population studies. Acta Psychiatr Scand
2006; 113: 163–79.
11 Centre for Reviews and Dissemination. Systematic Reviews. CRD’s Guidance
for Undertaking Reviews in Health-care. CRD, University of York, 2009.
12 Higgins JPT, Green S (eds). Cochrane Handbook for Systematic Reviews of
Interventions Version 5.0.2. Cochrane Collaboration, 2009.
13 Cumming E, Cumming J. Closed Ranks – An Experiment in Mental Health
Education. Harvard University Press, 1957.
14 Maclean U. Community attitudes to mental illness in Edinburgh. Br J Prev Soc
Med 1969; 23: 45–52.
15 Fuchs M, Lamnek S, Tretter F. Psychisch Kranke und Psychiatrie im
Meinungsbild der Mu ¨nchner. Institute of Sociology, Ludwig-Maximilian-
University, Munich, 1989.
16 Kemali D, Maj M, Veltro F, Crepet P, Lobrace S. Survey on the Italian public’s
opinions about mental disorders and psychiatric care [in Italian: Sondaggio
sulle opinioni degli italiani nei riguardi dei malati di mente e della situazione
dell’assistenza psichiatrica]. Riv Sper Freniatr 1989; 113: 1301–51.
17 Crisp AH, Gelder MG, Goddard E, Meltzer HI. Stigmatization of people with
mental illnesses: a follow-up study within the Changing Minds campaign of
the Royal College of Psychiatrists. World Psychiatry 2005; 4: 106–13.
18 Crisp AH, Gelder MG, Rix S, Meltzer HI, Rowlands OJ. Stigmatisation of people
with mental illnesses. Br J Psychiatry 2000; 177: 4–7.
19 Link BG, Phelan JC, Bresnahan M, Stueve A, Pescosolido BA. Public
conceptions of mental illness: labels, causes, dangerousness, and social
distance. Am J Public Health 1999; 89: 1328–33.
20 Corrigan PW, Watson AC. The stigma of psychiatric disorders and the gender,
ethnicity, and education of the perceiver. Community Ment Health J 2007;
21 Jorm AF, Oh E. Desire for social distance from people with mental disorders.
Aust N Z J Psychiatry 2009; 43: 183–200.
22 Dietrich S, Beck M, Bujantugs B, Kenzine D, Matschinger H, Angermeyer MC.
The relationship between public causal beliefs and social distance toward
mentally ill people. Aust N Z J Psychiatry 2004; 38: 348–54.
23 Angermeyer MC, Breier P, Dietrich S, Kenzine D, Matschinger H. Public
attitudes toward psychiatric treatment: an international comparison. Soc
Psychiatry Psychiatr Epidemiol 2005; 40: 855–64.
24 Grausgruber A, Meise U, Katschnig H, Schony W, Fleischhacker WW. Patterns
of social distance towards people suffering from schizophrenia in Austria: a
comparison between the general public, relatives and mental health staff.
Acta Psychiatr Scand 2007; 115: 310–9.
25 Bag B, Yilmaz S, Kirpinar I. Factors influencing social distance from people
with schizophrenia. Int J Clin Pract 2006; 60: 289–94.
26 Angermeyer MC, Beck M, Matschinger H. Determinants of the public’s
preference for social distance from people with schizophrenia. Can J
Psychiatry 2003; 48: 663–8.
27 Angermeyer MC, Matschinger H. The stereotype of schizophrenia and its
impact on the discrimination against people with schizophrenia: results from
a representative survey in Germany. Schizophr Bull 2004; 30: 1049–61.
28 Kermode M, Bowen K, Arole S, Pathare S, Jorm AF. Attitudes to people with
mental disorders: a mental health literacy survey in a rural area of
Maharashtra, India. Soc Psychiatry Psychiatr Epidemiol 2009; 44: 1087–96.
29 Martin JK, Pescosolido BA, Tuch SA. Of fear and loathing: the role of
’disturbing behavior,’ labels, and causal attributions in shaping public
attitudes toward people with mental illness. J Health Soc Behav 2000; 41:
Angermeyer et al
30 Van ’t Veer JT, Kraan HF, Drosseart SH, Modde JM. Determinants that shape
public attitudes towards the mentally ill: a Dutch public study. Soc Psychiatry
Psychiatr Epidemiol 2006; 41: 310–7.
31 Martin JK, Pescosolido BA, Olafsdottir S, McLeod JD. The construction of fear:
Americans’ preferences for social distance from children and adolescents
with mental health problems. J Health Soc Behav 2007; 48: 50–67.
32 European Commission. Mental Well-being. Special Eurobarometer 248/Wave
64.4. EC, 2006 (http://ec.europa.eu/health/ph_information/documents/
33 Yeap R, Low WY. Mental health knowledge, attitude and help-seeking
tendency: a Malaysian context. Singapore Med J 2009; 50: 1169–76.
34 Griffiths KM, Nakane Y, Christensen H, Yoshioka K, Jorm AF, Nakane H.
Stigma in response to mental disorders: a comparison of Australia and Japan.
BMC Psychiatry 2006; 6: 21.
35 Cook TM, Wang J. Descriptive epidemiology of stigma against depression in a
general population sample in Alberta. BMC Psychiatry 2010; 10: 29.
36 Glendinning R, Buchanan T, Rose N. Well? What Do You Think? A National
Scottish Survey of Public Attitudes to Mental Health, Well Being and Mental
Health Problems. Scottish Government Social Research, 2002.
37 Braunholtz S, Davidson S, King S. Well? What Do You Think? (2004): The
Second National Scottish Survey of Public Attitudes to Mental Health, Mental
Wellbeing and Mental Health Problems. Scottish Government Social
38 Braunholtz S, Davidson S, Myant K, O’Connor R. Well? What Do You Think?
(2006): The Third National Scottish Survey of Public Attitudes to Mental
Health, Mental Wellbeing and Mental Health Problems. Scottish Government
Social Research, 2007.
39 Angermeyer MC, Matschinger H. Public beliefs about schizophrenia and
depression: similarities and differences. Soc Psychiatry Psychiatr Epidemiol
2003; 38: 526–34.
40 Peluso ET, Blay SL. Public stigma in relation to individuals with depression.
J Affect Disord 2009; 115: 201–6.
41 Peluso ET, Blay SL. Public perception of alcohol dependence. Rev Bras
Psiquiatr 2008; 30: 19–24.
42 Phelan JC. Geneticization of deviant behavior and consequences for stigma:
the case of mental illness. J Health Soc Behav 2005; 46: 307–22.
43 Schomerus G, Holzinger A, Matschinger H, Lucht M, Angermeyer MC.
Public attitudes towards alcohol dependence [in German: Einstellung der
Bevo ¨lkerung zu Alkoholkranken]. Psychiatr Prax 2010; 37: 111–8.
44 Phelan JC. Genetic bases of mental illness – a cure for stigma? Trends
Neurosci 2002; 25: 430–1.
45 Read J, Haslam N, Sayce L, Davies E. Prejudice and schizophrenia: a review
of the ’mental illness is an illness like any other’ approach. Acta Psychiatr
Scand 2006; 114: 303–18.
46 Dietrich S, Matschinger H, Angermeyer MC. The relationship between
biogenetic causal explanations and social distance toward people with
mental disorders: results from a population survey in Germany. Int J Soc
Psychiatry 2006; 52: 166–74.
47 Jorm AF, Griffiths KM. The public’s stigmatizing attitudes towards people
with mental disorders: how important are biomedical conceptualizations?
Acta Psychiatr Scand 2008; 118: 315–21.
48 Read J, Law A. The relationship of causal beliefs and contact with users of
mental health services to attitudes to the ’mentally ill’. Int J Soc Psychiatry
1999; 45: 216–29.
49 Walker I, Read J. The differential effectiveness of psychosocial and biogenetic
causal explanations in reducing negative attitudes toward ’mental illness’.
Psychiatry 2002; 65: 313–25.
50 Lam D, Salkovskis P, Warwick H. An experimental investigation of the impact
of biological versus psychological explanations of the cause of ’mental
illness’. J Ment Health 2005; 14: 453–64.
51 Bennett L, Thirlaway K, Murray AJ. The stigmatising implications of
presenting schizophrenia as a genetic disease. J Genet Couns 2008; 17:
52 Haslam N. Psychiatric categories as natural kinds: essentialist thinking about
mental disorder. Soc Res 2000; 67: 1031–58.
53 Fusar-Poli P, Broome M, Cortesi M. Can neuroimaging reduce social stigma
in schizophrenia? Med Hypotheses 2007; 69: 457.
54 Laegsgaard MM, Stamp AS, Hall EO, Mors O. The perceived and predicted
implications of psychiatric genetic knowledge among persons with multiple
cases of depression in the family. Acta Psychiatr Scand 2010; 122: 470–80.
55 Schreiber R, Hartrick G. Keeping it together: how women use the biomedical
explanatory model to manage the stigma of depression. Issues Ment Health
Nurs 2002; 23: 91–105.
56 Meiser B, Mitchell P, McGirr H, Van Herten M, Schofield P. Implications of
genetic risk information in families with a high density of bipolar disorder:
an exploratory study. Soc Sci Med 2005; 60: 109–18.
57 Meiser B, Mitchell PB, Kasparian NA, Strong K, Simpson JM, Mireskandari S,
et al. Attitudes towards childbearing, causal attributions for bipolar disorder
and psychological distress: a study of families with multiple cases of bipolar
disorder. Psychol Med 2007; 37: 1601–11.
58 Nieuwsma JA, Pepper CM. How etiological explanations for depression
impact perceptions of stigma, treatment effectiveness, and controllability
of depression. J Ment Health; 19: 52–61.
59 Corrigan PW, Markowitz FE, Watson AC. Structural levels of mental illness
stigma and discrimination. Schizophr Bull 2004; 30: 481–91.
60 Schomerus G, Matschinger H, Angermeyer MC. Preferences of the public
regarding cutbacks in expenditure for patient care: are there indications of
discrimination against those with mental disorders? Soc Psychiatry Psychiatr
Epidemiol 2006; 41: 369–77.
61 Wrigley S, Jackson H, Judd F, Komiti A. Role of stigma and attitudes toward
help-seeking from a general practitioner for mental health problems in a
rural town. Aust N Z J Psychiatry 2005; 39: 514–21.
62 Kuppin S, Carpiano RM. Public conceptions of serious mental illness and
substance abuse, their causes and treatments: findings from the 1996
General Social Survey. Am J Public Health 2006; 96: 1766–71.
63 Phelan JC, Yang LH, Cruz-Rojas R. Effects of attributing serious mental
illnesses to genetic causes on orientations to treatment. Psychiatr Serv 2006;
64 Olafsdottir S, Pescosolido BA. Drawing the line: the cultural cartography of
utilization recommendations for mental health problems. J Health Soc Behav
2009; 50: 228–44.
65 Jorm AF, Christensen H, Griffiths KM. The public’s ability to recognize mental
disorders and their beliefs about treatment: changes in Australia over 8
years. Aust N Z J Psychiatry 2006; 40: 36–41.
66 Angermeyer MC, Matschinger H. Public attitudes towards psychotropic
drugs: have there been any changes in recent years? Pharmacopsychiatry
2004; 37: 152–6.
67 Angermeyer MC, Matschinger H. Have there been any changes in the
public’s attitudes towards psychiatric treatment? Results from representative
population surveys in Germany in the years 1990 and 2001. Acta Psychiatr
Scand 2005; 111: 68–73.
68 Lam DC, Salkovskis PM. An experimental investigation of the impact of
biological and psychological causal explanations on anxious and depressed
patients’ perception of a person with panic disorder. Behav Res Ther 2007;
69 Lincoln TM, Arens E, Berger C, Rief W. Can antistigma campaigns be
improved? A test of the impact of biogenetic vs psychosocial causal
explanations on implicit and explicit attitudes to schizophrenia. Schizophr
Bull 2008; 34: 984–94.