To our knowledge, this is the first study to compare mental health professionals and the general public with respect to stereotypes and attitudes about restrictions toward people with mental illness. Furthermore, we compared the two samples regarding their ability to recognize mental illness. To sum up, the general public has as many negative stereotypes about people with mental illness as mental health professionals do. The general public accepted restrictions toward people with mental illness to a much higher degree, with the exception of compulsory admission. Independently of how well mental health professionals recognized the case descriptions of schizophrenia and major depression (as persons having a mental illness), they felt the same social distance toward the described persons as the public. As expected, the description of schizophrenia showed the highest level of social distance, while there was no difference between the depression and the non-case vignette in any of the professional groups.
These results demonstrate that it is too simple to assume that psychiatrists and other mental health professionals, though mental health experts, generally have more positive attitudes toward mentally ill people than the general public. Our findings may allow a deeper understanding of how these attitudes are connected. The empirical results can contribute to the design of antistigma campaigns, eg, by identifying deficits of certain groups or recognizing pragmatic pathways.
The ability to recognize mental disorders is a central part of “mental health literacy”8
because it is a prerequisite for appropriate help-seeking. Although health and illness are a continuum and not a simple binary state, the distinction between “health” and “illness” helps us decide in everyday life if somebody needs help and what type is needed. Mental health professionals recognized the depictions of a person suffering from schizophrenia or depression more easily than the general public. However, the “mental health literacy” of professionals seems to be far from perfect: 1 out of 11 psychiatrists or psychologists and every third nurse or therapist considered the depiction of a major depression to be a “crisis,” ie, a normal reaction to a difficult life situation. If one is sensitive to questions of stigma and labeling, one might be reluctant to define a person as “mentally ill.” But if this were the case, why did every fourth or fifth professional assign this stigmatizing term to the “normal person” in the non-case description? As not all mental health professionals could recognize the presented vignettes correctly, it is not to be expected that laypeople could perform that task better.
Even though professionals and the general public differ in their ability to recognize depression as a mental illness, they display an equal level of social distance toward the case vignettes of major depression. Accordingly, the social distance toward the person with schizophrenia was equally high in all professional groups as in the public. This comports with a study including psychiatrists in office practice.11
Social distance is one of the most significant components of stigmatization.16,17
have shown a higher social distance toward people with schizophrenia than people with depression. However, only 2 of these studies applied a non-case vignette as a reference category. Link and colleagues4
used a “troubled person” with subclinical psychiatric symptoms, whereas Eker19
described a “normal person” without any troubles. Our non-case vignette lies between both, as we described a person in a changing life situation but without any psychiatric symptoms. It is socially accepted—even a social norm—to be selective in intimate social contacts. Therefore, using a non-case vignette is a methodological prerequisite, as social distance as a relative measure has to be defined by a reference group. Without doing so, it can merely be stated in relative terms that the stigmatization of people with an alcohol addiction is stronger than that of people with schizophrenia, but it remains unclear if the latter psychiatric disorder comes with any stigmatization at all. The other 2 studies using a non-case vignette found a higher degree of social distance toward major depression in the general public4
and in students.19
Contrary to this, the mental health professionals in our study demonstrated the same amount of social distance toward a person with manifest psychiatric symptoms of major depression and toward a person without any psychiatric symptoms.
If mental health professionals are used as a reference group of how far the social distance toward persons with mental illness can be reduced in the general public, nothing could be improved. Thus, our findings put the reduction of social distance toward people with manifest psychiatric symptoms as one of the most central aspects of antistigma campaigns into question. It seems difficult to educate the public about psychiatric disorders and treatment aspects on the one hand and on the other hand to push people to be less socially distant toward people with manifest psychiatric symptoms.
A more realistic and pragmatic approach would be to acknowledge that people who suffer from mental illness are different from the majority in certain ways but should have equal rights.7
Our study demonstrates that mental health professionals agree to a much lesser extent than the general public to restrictions of political and individual rights of mentally ill persons. In this regard, it is correct to claim that psychiatrists and other mental health professionals have more positive or “better” attitudes than the public. But mental health professionals more strongly approved of compulsory admission, ie, suspending individual rights in order to help a patient. In the public survey people with a higher educational degree, as well as people with treatment experience and their relatives, are in favor of compulsory admission. This probably represents a certain trust in psychiatry and its treatment possibilities rather than a restrictive attitude toward people who are mentally ill.15
However, a study using different case reports of patients with schizophrenia found similar attitudes of mental health professionals and laypeople in Germany and England toward involuntary admission and treatment.12
This study has several limitations. The response rate of mental health professionals was low but was still higher than in other surveys.eg,21
If we included mental health professionals with rather positive attitudes, a higher response rate would have led to a more dismal picture of professionals' attitudes. Due to a lack of administrative data we have no detailed information about the professionals who did not take part in the study. By using an identical questionnaire for mental health professionals and the general public, the methodological comparability was maximized. Because the questionnaire was designed for the general public, some of the professionals considered the questions and answer categories to be too imprecise. The time gap of 5 years between the public and the professional surveys could have influenced the expressed attitudes. For example, a drastic increase in social distance toward an individual suffering from schizophrenia could be attributed to negative reports in the mass media, as has been previously reported in Germany.16
To the best of our knowledge there were no such reports before or during both surveys. As the proportion of the professional groups in the participating psychiatric facilities was very unequal, this resulted in a strongly unbalanced sample size. This is a serious problem to analysis of variance (ANOVA) concerning balancing power and the type I rate. As the Levene test did not find evidence against equal variances across the professional groups, we consider the application of the Tukey post-hoc test by using a harmonic mean acceptable, although it remains a conservative approach. We conducted the mental health professional study only in the German part of Switzerland; therefore, our conclusion strictly applies only to that area. Furthermore, our findings refer to attitudes that do not necessarily entail a corresponding behavior in real life.
As difficult as it may be, we should continue to fight the stigmatization and discrimination of people suffering from mental illness. But before mental health professionals can inform and teach the general public about mental illness and thus help to reduce its stigma, they should carefully examine their own attitudes.22
Our results suggest that mental health professionals (ie, psychiatrists and psychologists) are qualified to instruct laypeople about how to recognize and distinguish psychiatric disorders and about the individual rights of mentally ill people, but that they should not assume that they themselves have no negative stereotypes or are more willing to closely interact with the affected than anyone else.