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Public Beliefs About and Attitudes Towards People with Mental Illness: A
Review of Population Studies

Article in Acta Psychiatrica Scandinavica · April 2006

DOI: 10.1111/j.1600-0447.2005.00699.x · Source: PubMed

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Acta Psychiatr Scand 2006: 113: 163–179 Copyright
2005 Blackwell Munksgaard
All rights reserved ACTA PSYCHIATRICA
DOI: 10.1111/j.1600-0447.2005.00699.x
SCANDINAVICA

Review article
Public beliefs about and attitudes towards
people with mental illness: a review of
population studies
Angermeyer MC, Dietrich S. Public beliefs about and attitudes M. C. Angermeyer, S. Dietrich
towards people with mental illness: a review of population studies. Department of Psychiatry, University of Leipzig, Leipzig,
Acta Psychiatr Scand 2006: 113: 163–179.
2005 Blackwell Munksgaard. Germany

Objective: To provide a review of population-based attitude research

in psychiatry during the past 15 years.
Method: An electronic search using PubMed, Medline, and Academic
Search Premier plus a hand search of the literature was carried out for
studies on public beliefs about mental illness and attitudes towards the
mentally ill published between 1990 and 2004.
Results: Thirty-three national studies and 29 local and regional studies
were identified, mostly from Europe. Although the majority are of
descriptive nature, more recent publications include studies testing
theory-based models of the stigmatization of mentally ill people,
analyses of time trends and cross-cultural comparisons, and Key words: attitudes; population; mental disorders
evaluations of antistigma interventions. Matthias C Angermeyer, Department of Psychiatry,
Conclusion: Attitude research in psychiatry made considerable University of Leipzig, Johannisallee 20, D-04317 Leipzig,
progress over the past 15 years. However, there is still much to be done Germany.
to provide an empirical basis for evidence-based interventions to E-mail: krausem@medizin.uni-leipzig.de
reduce misconceptions about mental illness and improve attitudes
towards persons with mental illness. Accepted for publication September 28, 2005

Summations
• In the time period since 1990, misconceptions about mental disorders still prevailed among the
general public.
• There are indications of inter-cultural variations of beliefs and attitudes as well as of changes over
time.
• There are marked differences between the various mental disorders with regard to beliefs and
attitudes.

Considerations
• Up until now, population-based attitude research in psychiatry has mainly been descriptive in
nature. Other approaches, e.g. the testing of theory-based models, are still under-represented.
• So far, attitude research was mainly focused on schizophrenia and depression, other mental disorders
have been neglected.
• There is only little known about the relation between attitudes towards people with mental disorders
and the actual behaviour towards them.

163
Angermeyer and Dietrich
Introduction
In 1989, a review article was published in this
journal by Dinesh Bhugra on ÔAttitudes towards
mental illnessÕ focusing on studies of public atti-
tudes towards mental illness, mentally ill people
and their treatment environs (1). Ever since then, in
many countries reforms of mental health care have
been initiated or have made further progress (2, 3).
One aim of these reforms was to better integrate
mentally ill people into society. However, in recent
years there has been a growing awareness among
mental health professionals that mental illness is
still surrounded by stigma. According to Sartorius
it is the most important obstacle to the provision of
mental health care for people with mental disorders
(4). Moreover, as Jorm (5) was able to show, the
public’s Ômental health literacyÕ is still unsatisfac-
tory and needs to be improved. Otherwise, this may
hinder public acceptance of evidence-based mental
health care. In the 1990s, several programs have
been launched around the globe, aimed at either
improving public knowledge about mental disor-
ders or reducing the stigmatization and discrimin-
ation of those suffering from these disorders (e.g.
6–9). In view of these developments we thought that
it is time to carry out a new literature review on
public beliefs and attitudes, covering the time
period between 1990 and 2004.
Aims of the Study
In particular, the following questions are
addressed:
i) To what extent are mental disorders recog-
nized as such and what beliefs about the
origin, treatment and course of mental disor-
ders prevail among the general public?
ii) What attitudes towards mentally ill people are
prevalent among the general public?
iii) How are beliefs and attitudes related to
people’s socio-demographic characteristics
and how are they influenced by familiarity
with mental illness?
iv) What are the results of studies testing hypo-
theses derived from modern stigma theory?
v) Have there been any changes in attitudes and
beliefs over the years?
vi) Which results yield cross-cultural comparisons
of beliefs about mental disorders and attitudes
towards people with mental disorder?
vii) What are the results of studies evaluating the
effect of interventions aimed at improving the
public’s knowledge and at reducing the stigma
attached to mental disorders?
164
The answers to these questions may give an
impression of the magnitude of the problem, give
some insights into how stigma operates and pro-
vide some clues as to what strategies may be best
suited to modify existing misconceptions about
mental disorders.
Material and methods
We electronically searched PubMed, Medline and
Academic Search Premier for studies covering the
time period from January 1990 to December 2004.
The search was conducted by entering each of the
following keywords (attitudes*), (public attitudes*),
(general public*), (beliefs*), (lay beliefs*),
(stigma*), and (social distance*) in combination
with (mental illness*), (mental disorder*), (schizo-
phrenia*), (depression*), (Alzheimer’s disease*),
(anxiety disorder*), (OCD*), (alcoholism*), (drug
addiction*), (dementia*), (eating disorder*) and
(bipolar disorder*) into each of these databases.
Following the electronic search, hand searches of
the literature identified were undertaken in the form
of citation chasing. From these primary and secon-
dary references, those reports were included in our
review that met the following criteria: first, the paper
was written in English. Second, the focus of the
study was on the general public. Studies investi-
gating attitudes and beliefs of particular subgroups
(e.g. consumers, carers, health professionals, uni-
versity students, etc.) were excluded. Third, studies
were based on random or quota samples drawn
from the general population or from primary care
services. Studies using convenience samples were
not taken into consideration. Searches for articles in
October, November and December issues (2004) of
the main journals publishing relevant articles were
performed to identify any research that had not yet
been entered into any of the above databases. The
following journals were searched: Social Psychiatry
and Psychiatric Epidemiology, Acta Psychiatrica
Scandinavica, British Journal of Psychiatry, Psy-
chological Medicine, European Psychiatry, Inter-
national Journal of Social Psychiatry, American
Journal of Public Health, Social Science and Medi-
cine, European Archives of Psychiatry and Clinical
Neurosciences, Canadian Journal of Psychiatry,
and Schizophrenia Bulletin. All articles included
into our review were systematically screened by both
authors for information relevant to the questions
posed in the Introduction.
Results
The above search strategy yielded an output of 3651
articles. However, this output constitutes a gross
 Public beliefs about and attitudes towards mentally ill
total since a number of studies appeared more than
once after the different keyword combinations were
entered into each of the databases. Of the articles
identified, 110 met the inclusion criteria. While
between 1990 and 1992 only two relevant articles
had been published in the following years, a steep
linear increase can be observed (1993–1995: 11
articles, 1996–1998: 23 articles, 1999–2001: 32
articles), resulting in a maximum of 41 articles
between 2002 and 2004. The articles referred to 62
studies. Differentiating between surveys on a
national level and those on a regional or local
level, the characteristics of the studies included are
reported in Tables 1 and 2. The tables show that a
total of 33 national surveys have been conducted in
14 different countries, with 23 of these having been
carried out in Europe, six in America, and two each
in Asia and Oceania. An additional stock of 29 local
or regional surveys can be added to the collection,
with 14 of them having been conducted in Europe,
five each in America and in Asia, four in Oceania
and one in Africa. The majority of the surveys (44)
are based on random samples of the general
population. The number one interview technique
used was personal interviewing (38), followed by
telephone interviews (13). Only five of the surveys
were conducted by mail. Response rates for the
personal interview surveys varied between 64.0 and
98.3%, between 44.0 and 75.4% for the telephone
surveys and between 34.5 and 60.0% for the mail
surveys. Sample sizes ranged from a minimum of 90
to a maximum of 7278 individuals. While depression
(31 surveys) and schizophrenia (29 surveys) were in
the lead of the illnesses addressed in these studies,
alcoholism (8), anxiety disorders (7), dementia (6)
and drug addiction (4) were studied comparatively
rarely. One survey each paid attention to mania,
obsessive–compulisive disorder, prescription drug
dependency, eating disorders, mental retardation
and childhood hyperactivity. Twenty-six studies
dealt with mental illness in general. Thirty surveys
used vignettes as a stimulus. The majority of surveys
were focused on public beliefs about mental illnesses
(51 surveys) and attitudes towards persons with
mental illnesses (45 surveys). Only 11 surveys
investigated attitudes towards psychiatric facilities.
Articles reporting descriptive data on public
beliefs about mental illness and attitudes towards
people with mental illness made up the lion’s share
(10–19, 21, 22, 26–32, 34, 36, 40–45, 47–55, 58–65,
67, 69, 73–86, 89–95, 98–109, 111–113). In contrast,
articles devoted to testing of theory-based models
of the stigmatization of mentally ill people (33, 35,
37–39, 72, 109) were rare. The same applies to
the analysis of time trends (20, 24, 25, 58, 68, 87),
cross-cultural comparisons of beliefs and attitudes
(23, 40, 42, 44, 46, 47, 49, 51, 53, 54, 66, 70, 71, 83,
105, 111) and the evaluation of interventions aimed
at improving knowledge of mental disorders and
reducing stigmatization of mentally ill people (56,
57, 83, 87, 96, 97, 114–116). In the following, the
major findings of these various approaches of
attitude research are presented.
Descriptive studies on public beliefs about mental disorders
Studies on beliefs about mental disorders take an
interest in the question as to what extent they are
recognized as such and what beliefs about the
causes, the course and the treatment of these
illnesses are prevalent among the public. Several
studies using case vignettes agree that many
members of the lay public cannot correctly recog-
nize mental disorders. Schizophrenic symptoms are
more often seen as an expression of a mental illness
(range 69–88%) than are depressive symptoms (26–
69%) or symptoms of alcoholism (16–49%) (23,
24, 34, 41, 50, 65, 66, 74, 80, 109).
All studies using vignettes conclude that lay
beliefs about the causes of mental disorders clearly
differ from the results of psychiatric research in that
psychosocial factors, particularly psychosocial
stress, are predominating in comparison with bio-
logical factors. This holds even truer for depression
than for schizophrenia (22, 23, 32, 34, 40, 41, 47, 65,
81, 93). If one concentrates on the studies using the
same instrument for the assessment of causal beliefs
(22, 23, 32, 34, 40) the following picture emerges:
acute stress in the form of life events is the
most frequently endorsed cause (schizophrenia:
72.5–87%, depression: 81–85.5%), followed by
(chronic) stress in partnership and family (schizo-
phrenia: 59–64%, depression: 70–74%), brain
disease (schizophrenia: 48.5–71%, depression: 19–
59%) and heredity (schizophrenia: 39–67.5%,
depression: 21–58%). Studies using diagnostic
labels as stimulus come up with somewhat mixed
results: while in the case of depression, psychosocial
stress is again favoured over biological causes as
explanation (57, 60, 87), in the case of schizophre-
nia the situation is different, with biological factors
being as frequently endorsed as a cause (86) or even
more frequently than psychosocial stress (22,
101–103). The results of studies assessing causal
beliefs about mental illness in general are rather
inconsistent in this regard (46, 62, 91, 95, 107, 119).
As far as help-seeking beliefs are concerned, the
results are inconsistent. This may, in part, have to
do with the diversity of the care systems in the
various countries. However, some general tenden-
cies emerge. In the case of depression, the general
practitioner is most frequently recommended as a
165
 Table 1. Overview of national surveys published since 1990

166
Beliefs Attitudes Attitudes
about towards towards
Response Sample mental mentally psychiatric
Country Year Sampling procedure Age Interview rate (%) size Disorder Stimulus illness ill people services References

Austria 1991 Quota sample 15+ Personal interview – 1443 Schizophrenia Vignette X X (10)
Depression
Anxiety/Panic disorder
Psychosis
1998 Quota sample 14+ Personal interview – 1042 Dementia Vignette X X (11)
Schizophrenia
Angermeyer and Dietrich

Mental illness – X
Germany 1990 Random sample 18+ Personal interview 68.9* 2045* Schizophrenia Vignette X X X (12–17)
Depression
Mental illness –
1990 Random sample 18+ Personal interview 71.9* 2118* Schizophrenia Vignette X X (12–15, 18–20)
Depression
Panic disorder with agoraphobia
1990 Random sample 18+ Personal interview 72.3*/67.4à 1022*/980à Schizophrenia Vignette X X (12–15, 17–19, 21–27)
Depression
Alcoholism
1991 Random sample 18+ Personal interview 70.9* 1912* Schizophrenia Vignette X (12–15)
1991 Random sample 18+ Personal interview 67.8* 2030* Schizophrenia Vignette X (12–15)
Depression
1992 Random sample 18+ Personal interview 70.1* à 5125* à Schizophrenia Vignette X (12–15)
1992 Quota sample 16+ Personal interview – 2176* à Paranoia Vignette X (28, 29)
Depression
Drug addiction
Alcoholism
Addiction to prescribed drugs
Mania
Social phobia
Alzheimer's disease
1993 Random sample 18+ Personal interview 73.0*/71.2à 2143*/2094à Schizophrenia Vignette X X X (12, 14–16, 26, 30, 32)
Depression
Mental illness –
1993 Random sample 18+ Personal interview 70.3* 2024* Schizophrenia Vignette X (12, 14, 15)
2001 Random sample 18+ Personal interview 65.1* à 5025* à Schizophrenia Vignette X X (20, 24, 25, 33, 40)
Depression
Schizophrenia Label
Depression
Alcoholism
Alzheimer's disease
Drug abuse
Mental illness
Italy 2000/2001 Cluster sample§ 18–70 Self-report 98.5 714 Schizophrenia Vignette– X X (41, 42)
questionnaire
Luxembourg Quota sample 15+ Telephone interview – 501 X (43, 83)
Norway 1992 Stratified random sample 15+ Telephone interview – 1063 Mental illness – X X (45)
Switzerland 1994 ? 18–84 Personal interview ? 697** Mental illness – X (46)
1998/1999 Random sample 16–76 Telephone interview 63 1737 Schizophrenia Vignette X X X (47–55)
Depression
 Table 1. (Continued)

Beliefs Attitudes Attitudes

about towards towards
Response Sample mental mentally psychiatric
Country Year Sampling procedure Age Interview rate (%) size Disorder Stimulus illness ill people services References

Mental illness –
UK 1991 Quota sample 15+ Personal interview – 2009 Depression Label X (56, 57)
1995 Quota sample 15+ Personal interview – 2050 Depression Label X (57)
1997 Quota sample 15+ Personal interview – 1946 Depression Label X (57)
1997 Quota sample 15+ Personal review – 1804 Schizophrenia Label X X (58)
1998 Random sample 16+ Personal interview 67 1737 Schizophrenia Label X (59)
Severe depression
Alcohol addiction
Drug addiction
Panic disorder
Eating disorder
Dementia
Ireland 1989 Quota sample 16+ Personal interview – 1403 Depression Label X X (60)
Canada 2002 Random sample ? ? 1000 Dementia Label X (61)
US 1989 Stratified random sample 21+ Telephone interview 44 1326 Mental illness X X X (62)
1990 Random sample 18+ Telephone interview 63 1507 Mental illness – X (63, 64)
1996 Random sample 21+ Personal interview 76.1 1444 Schizophrenia Vignette X X (65–72)
Depression
Alcohol dependence
Drug dependence
Mental illness –
1998 Random sample ? Personal interview 76.4 1387 Mental illness – X (73)
Dominica 1995 Stratified random sampleàà ? Personal interview 64 135 Psychosis Vignette X (74)
Depression
Alcoholism
Childhood
Hyperactivity
Hong Kong 1994 Random sample ? Telephone interview 59.6 1043 Mental illness – X X X (75)
1996 Random sample 18–80 Telephone interview 65 1273 Mental illness – X X X (76)
Australia 1995 Random sample 18–74 Personal interview 85 2031 Schizophrenia Vignette– X X (77–82)
Depression
New Zealand ? Random sample 15–44 Telephone interview 65 1017 Mental illness – X X (83)
Schizophrenia Label X

*Old Laender.
DSM III-R.
àNew Laender.
§In 30 randomly selected geographical areas 25 persons were consecutively recruited in a randomly selected GP unit.
–ICD-10.
**Swiss–German and Swiss–French population only.
DSM IV.
ààParticipants were drawn from the records of community health centres in each of the country's seven health regions. The various communities in the regions were selected to represent both urban and rural areas and to be geographically representative of the
country's population.

167
Public beliefs about and attitudes towards mentally ill
168
Table 2. Overview of regional and local surveys published since 1990

Beliefs Attitudes Attitudes

about towards towards
Response Sample mental mentally psychiatric
Region Year Sampling procedure Age Interview rate (%) size Disorder Stimulus illness ill people services References

Helsinki, Sein
joki, Joensun, 1985 Random sample ? Self-administered 69 514 Mental illness – X (84)
Pieks
m
ki, Tampere, Finland questionnaire
Mannheim/Germany ? Random sample Telephone interview ? 82 Mental illness X (44)
Angermeyer and Dietrich

Berlin, Bonn, Dsseldorf, Essen, 2001 Random sample 16+ Telephone interview 75.4 7278 Schizophrenia Label X X (85, 86)
Cologne, Munich/Germany
Nuremberg, Wrzburg/Germany 2000 Random sample 18+ Telephone interview 51.9 1426 Depression Label X (87)
2001 Random sample Telephone interview 68.5 1508 Depression Label X
Two boroughs in greater 1994 Random sample 19–64 Personal interview ? 360 Mental illness – X (88)
Athens/Greece
Vizcaya/Spain ? Stratified random sample 16–65 Personal interview ? 400 Depression Label X X (89)
Geneva/Switzerland 1996 Quota sample 20–75 ? – 324 Mental illness – X X (90)
Schizophrenia Vignette
Depression
Panic attack
Northtown/UK ? Quota sample ? Personal interview – 154 Schizophrenia Vignette X
ÔPuerperal illnessÕ
Mental illness X (91)
Malvern and Bromsgrove/UK 1989 Quota sample 15+ Personal interview – 1987 Mental illness – X (92, 93)
Schizophrenia Vignette X X
Depression
Herne Hilland and 1993 Random sample ? Personal interview 70 215 Mental illness – X X (94–97)
Streatham Hill/UK
Two urban areas/UK ? Random sample 18+ Postal survey 42.6 208 Mental illness Vignette X X (98)
Scotland/UK 2001 Random sample 16+ Personal interview ? 1061 Alcoholism X (99)
Co. Louth and Co. Meath/Ireland ? Random sample 17–86 Personal interview 77.5 155 Mental illness – X (100)
Calgary, Drumheller, 1998/1999 Random sample 15+ Telephone interview 71.9 1653 Schizophrenia Label X X (101, 102)
Edmonton/Canada
Qubec/Canada ? Stratified random sample 18+ ? 60.7 1001 Schizophrenia Label X X (103)
Delaware County/US 1988 Stratified random sample ? Postal survey 34.5 206 Schizophrenia Vignette* X X (104)
Depression
GAD
San Francisco/US ? Random sampleà 55+ Personal interview ? 209 Dementia Label X (105)
Mexico City/Mexico ? Quota sample 18-60 Personal interview – 800 Mental illness – X X X (106)
2 Kibbutzim/Israel ? A) Random sample 20+ Self-administered 96.4 108 Mental disorders – X X (107)
questionnaire
B) Total population 20+ Self-administered 97.8 90 Psychosis Vignette X
questionnaire Depression
Istanbul/Turkey ? Random sample 15+ Personal interview 98.3 707 Depression Vignette X X (108)
Sancakli/Turkey 2000 Total population 18+ Personal interview 84.9 208 Schizophrenia Vignette X X (109)
Novosibirsk/Russia 2002 Random sample 18+ Personal interview 74.5 745 Schizophrenia Vignette* X X (40, 110)
Depression
Ulaanbaatar/Mongolia 2002 Random sample 18+ Personal interview 95.2 952 Schizophrenia Vignette* X X (40, 110)
Depression
 Public beliefs about and attitudes towards mentally ill

References
helping source (28–30, 52, 74, 78, 89, 118). In the

(112, 113)

(117, 118)
(114–116)
case of schizophrenia, the public is more ready to

(111)

(119)
recommend seeking help from a psychiatrist than
in case of depression (28–30, 52, 58, 74). If mental
psychiatric

disorders are recognized as such, the willingness to

Attitudes
towards

services

address a psychiatrist increases (52).

All studies using case vignettes agree in that the
public’s beliefs about psychological interventions
ill people
Attitudes

mentally

(e.g. psychotherapy or counselling) are predomin-

towards

antly favourable, while very negative views prevail

X

X
about pharmacological treatments (10, 19, 23, 24,
27–29, 41, 52, 78, 80, 82, 118). Surprisingly, with one
mental
Beliefs

illness
about

exception (10), the particular liking of psychother-

X

X
X

apy is more developed for schizophrenia than for

depression (19, 27–29, 52, 78, 80, 82). For example,
Stimulus

Vignette

Vignette

Vignette

in a study from Australia (80) psychotherapy was

Label

considered by 55% of the respondents as being

–

helpful for the treatment of schizophrenia and by

34% as being helpful for the treatment of depression
Mental retardation
Anxiety disorder

while only 23% recommended antipsychotic medi-

Mental illness
Schizophrenia
Disorder

cation and 29% antidepressants. Similar findings

Depression

Depression

Depression

Depression
Alcoholism

have been reported from a study in Switzerland

using the same instrument (52). Similarly to causal
beliefs, the results are somewhat different when
explicit diagnostic labels are used. In the case of
Sample
size

3109

1094

3010
450

164

depression, again, psychosocial interventions are

favoured over medication (57, 87), while in the case
of schizophrenia, medication is more frequently
Response
rate (%)

considered as the appropriate form of treatment (58,

60

70.2
39

55

86, 101). In a survey in the US, most respondents

?

àParticipants were recruited from four public sector primary-care clinics and were randomly selected from clinic logs.

agreed that psychiatric medications are effective,

and fewer than half had concerns regarding poten-
Personal interview

Personal interview

tial problems. However, the majority of the

Interview

Postal survey

Postal survey

Postal survey

respondents would not be willing to take them (72).

In general, in the absence of a treatment, the
course of mental disorders is seen rather pessim-
istically. The deterioration of the mentally ill
17–70

20–59

18–52
Age

person’s state is expected to be severer for schizo-

15+
?

phrenia than for depression. Conversely, on con-

dition that an appropriate treatment is provided,
Sampling procedure

the prognosis for both disorders is assessed quite

Random sample

Random sample

Random sample

Random sample
Random sample

optimistically (10, 23, 34, 58, 67, 78).

No consistent relationships were found between
gender and age of respondents on the one hand,
and their illness beliefs on the other. Respondents
with a higher educational level less frequently
1998
1993
Year

tended to make the person afflicted responsible for

?

his or her illness and were more willing to

recommend psychosocial interventions for treat-
Albury and surrounding rural area
in New South Wales/Australia

ment (23, 47, 69, 81, 111).

New South Wales/Australia
Canberra and south-east

Dunedin/New Zealand
Table 2. (Continued)

Descriptive studies on attitudes towards people with mental

BahirDar/Ethiopia

South Australia

disorders
*DSM III-R.
DSM IV.

People with mental disorders are experienced by

Region

the majority of the public to be in need of help and

169
Angermeyer and Dietrich
dependent on others (20, 34, 36). Among the
negative attributes attached to people with mental
disorders the most prevalent one appears to be that
they are unpredictable. This holds true more for
people with schizophrenia (54–85%) or alcoholism
(71%) than for people with depression (28–56%)
or anxiety disorders (50%) (13, 34, 35, 41, 59, 104).
Less frequently, persons with mental disorders are
considered as violent and dangerous. Here, a
similar picture emerges as with unpredictability.
In particular, people with schizophrenia (18–71%)
and alcoholism (65–71%) are seen as dangerous.
To a lesser extent, this also applies to people with
depression (14–33%) and anxiety disorders (26%)
(13, 34, 35, 59, 62, 65, 66, 85, 101). The majority of
the public show pro-social reactions, i.e. they feel
sorry for persons with mental illnesses and they
also feel the need to help them. This is particularly
true for depression. Next come feelings of uneasi-
ness, uncertainty and fear, reactions which are
mostly set off by persons with schizophrenia.
Infrequently, aggressive reactions occur (20, 34).
There is an observable tendency towards distan-
cing from persons with mental illness. With
increasing intimacy of social relationships increases
the desire for social distance. Rejection is most
pronounced towards persons with drug abuse and
alcoholism, followed by those with schizophrenia
and is less pronounced towards people with
depression and anxiety disorders (10, 15, 34, 51,
65, 67, 104, 111). All vignette studies examining the
effect of subject-generated mental illness labels on
public attitudes show that labelling leads to more
rejection and other adverse reactions (20, 33, 41,
51, 66, 98, 109).
Attitudes towards people with mental illness
vary to a small extent only depending on socio-
demographic characteristics. For example, in a
German study, gender, age, education and resi-
dency accounted for only 1.4% of the variance
(36). As concerns gender, the results are quite
inconsistent. In the majority of cases (18 times)
where the influence of gender on attitudes was
examined no association between the two was
observed (12, 15, 20, 40, 53, 54, 60, 66, 69, 88, 107,
109, 119). In 11 instances men expressed more
negative attitudes than women (17, 34, 51, 54, 88,
119), in six instances the opposite was found (17,
34, 75, 76, 86). In most instances (32 times),
negative attitudes were positively associated with
age (12, 15, 20, 40, 41, 51, 54, 60, 66, 67, 69, 84, 88,
92, 93, 107, 109, 119), while the reverse relationship
was reported only once (53). To what extent this
may be due to either ageing or cohort effects
remains an open question. In 10 instances, age did
not matter (34, 66, 67, 88, 94, 100, 109, 119). In 20
170
of 38 observations a positive relationship showed
between educational level and attitudes: persons
with a higher educational level tended to distance
themselves less from the mentally ill and expressed
more liberal views (20, 34, 41, 53, 54, 67, 75, 76, 84,
88, 92–94, 107, 111, 119). In 18 cases, no relation-
ship with education was reported (12, 15, 34, 40,
66, 88, 94, 100, 109, 119). The few studies dealing
with urban–rural differences come up with quite
contradictory results. While two studies found a
stronger desire for social distance among rural
residents (101), another study found the opposite
(66). While in one study the perception of mentally
ill people as being unpredictable was more pro-
nounced among rural residents (42), in two other
studies no urban–rural differences were found with
regard to perceived dangerousness (63, 67).
In 61 cases the relationship between familiarity
with mental illness, i.e. having personally experi-
enced a mental illness or having personal contact
with people suffering from mental illness, and
attitudes was examined. Thirty times it was repor-
ted that people had more positive attitudes if they
were familiar with mental illness (15, 51, 54, 58, 59,
60, 64, 68, 71, 72, 76, 77, 84, 92, 93, 98, 119). The
opposite was found in only one instance (59). In 30
cases no association between familiarity and atti-
tudes was reported (16, 48, 54, 71, 77, 94, 98, 100,
101, 107, 119).
Studies testing theory-based models of the stigmatization of
mentally ill people
Two recently developed conceptualizations of
stigma served as the main theoretical framework
for empirical studies, namely Link and Phelan’s
(120) sociological concept of the Ôstigma processÕ
and Corrigan and Watson’s (121) social–psycho-
logical concept of the Ôpublic stigmaÕ.
According to Link and Phelan (120), the stigma
process sets off by recognizing and labelling a
difference between a person and other people. The
next step involves the linking of the labelled person
with the negative stereotypes that predominate in
society about this group of people. This way, the
person now belongs to a distinct category of people
from whom the beholder dissociates. The stigma
process culminates in that the person concerned
is exposed to different forms of discrimination
and the negative social consequences resulting
from this. The authors differentiate between
individual and structural discrimination as well as
self-stigmatization. The first refers to the beha-
viour of individuals that is directed straight
against the members of a stigmatized group. The
most frequently applied measure of individual
 Public beliefs about and attitudes towards mentally ill
discrimination is the desire for social distance
(122). Structural discrimination describes the neg-
ative consequences that result from the imbalances
and injustice inherent in social structures, political
decisions and legal regulations for the members of
a stigmatized group. The third form of discrimin-
ation (self-stigmatization) comes from within the
mentally ill persons themselves in that they adopt
the stereotypes prevailing in society about people
with mental illness.
The link between the two components of the
stigma process, stereotype and discrimination, has
been investigated in the meantime, with the interest
lying on the impact of the different aspects of the
stereotype of the mentally ill on individual dis-
crimination and on the acceptance of structural
discrimination of people with schizophrenia. Of the
different stereotype components, the idea of
unpredictability and dangerousness had the strong-
est impact on the social distance desired towards a
person with schizophrenia: the more this view was
adopted, the higher was the desire for social
distance. The converse applies to the idea that
people with schizophrenia were particularly intel-
ligent and gifted. The acceptance of structural
discrimination, on the contrary, was mainly influ-
enced by the belief that those affected are to blame
for their own illness: the more distinct the inclina-
tion to blame the ill, the higher the tendency
towards approving of structural discriminations
(35). Of particular interest for the structural
discrimination of mentally ill persons is the result
of a survey in Germany, which investigated the
public’s preferences when it comes to the allocation
of financial resources to health care and medical
research. While somatic illnesses like cancer or
cardiovascular diseases ranked first, depression,
schizophrenia and alcoholism were the taillights
(38, 39). Findings similar to what has been found in
Germany are reported from the US: respondents
who labelled persons with mental disorders as
suffering from mental illness expressed a preference
for greater social distance; and the degree of
dangerousness that the public ascribed to these
persons appeared to mediate the influence of the
labelling effect (66).
According to Corrigan and Watson (121), public
stigma denotes the reaction of the general public to
a certain group of individuals based on the stigma
that is attached to this group. It comprises three
components: stereotype, prejudice and discrimin-
ation. Stereotypes are collectively shared beliefs
about a group of individuals. Most of the people
are familiar with these stereotypes, however, not
everybody adopts them. If they are adopted,
prejudices develop, which result in negative emo-
tional reactions and from these, in turn, discrim-
inatory behaviour may develop.
Using data from a study conducted in Germany,
this model was applied to investigate the effect of
labelling of schizophrenia and depression as mental
illnesses. In the case of schizophrenia, this kind of
labelling elicited the belief that those affected with
this illness are dangerous and unpredictable. Con-
sequences were negative emotional reactions, like
increasing fear and aggression. These resulted in an
increasing desire for social distance. No such
associations could be demonstrated for depressive
disorders (33). Furthermore, the model was used to
study the effect of familiarity with mental illness on
the attitudes towards people with schizophrenia
and depression. It could be shown that with
growing familiarity, the tendency towards consid-
ering the ill person to be dangerous and unpre-
dictable was decreasing, and people had less fear
and social distance was desired less frequently (37).
Analysis of time trends in beliefs about mental illnesses and
attitudes towards people with mental illness
For identifying developmental trends in patterns of
beliefs and attitudes over time, results of cross-
sectional surveys, which were conducted at differ-
ent points in time, were compared with each other.
Unfortunately, there are only a few of these studies
and they came up with rather contradictory results.
The study covering the longest period of time was
undertaken in the US. Phelan et al. (68) compared
the data of a survey dating from 1996 and those
taken from a study conducted by Star back in
1950. They found that while today, the image of
mental disorders is somewhat more differentiated
among the American public, mentally ill individu-
als are nowadays more frequently considered to be
dangerous as compared to the 1950s. Covering a
much shorter time period (only 2 years), a study
from Hong Kong came up with similar results:
while the public’s knowledge of mental illness had
slightly improved, their attitudes towards mental
patients had become slightly more negative (76). In
contrast, Madianos et al. (88) reported that the
residents of two boroughs in greater Athens
expressed more positive attitudes towards the
mentally ill in 1994 than back in 1979/1980.
According to the authors, the results could be
explained in the context of a positive and tolerant
social climate in the Athens area, strengthened by
the implementation of local community mental
health intervention programmes. Finally, a com-
parison of data from two surveys conducted in
West German states in 1990 and 2001 revealed that
the public’s emotional reactions and their desire for
171
Angermeyer and Dietrich
social distance towards persons with major depres-
sion had by and large remained unchanged (20).
Psychotropic drugs were assessed more favourably
by the German public in 2001 than 11 years ago
(25). Based on a series of surveys conducted in the
years 1990–1992, it could be shown that there was
a marked increase of the preference for social
distance from people with schizophrenia immedi-
ately following violent attacks by two individuals
suffering from schizophrenia against prominent
German politicians (12–14).
Cross-cultural comparisons of beliefs and attitudes
A distinction can be made here between surveys
which investigate variations in the pattern of
beliefs and attitudes within a single country and
others, which investigate variations between differ-
ent countries. Differences in beliefs and attitudes
have been studied in five countries. A comparison
between the old West German states and the New
Laender (former German Democratic Republic,
GDR) in 1990, i.e. shortly after the German
reunification, showed that lay beliefs about schi-
zophrenia were almost identical. However, the
tendency to define depressive symptoms as an
illness and to recommend psychiatric treatment
was less pronounced in the former GDR (23).
Eleven years later these differences had diminished
and the beliefs of the East German population had
become similar to those of the West German
population (24).
Surveys from Switzerland show that, as com-
pared with French-speaking Swiss, there was a
marked reluctance of the German-speaking Swiss
to resort to specialist help, particularly to mental
health professionals, in case of mental illness (46).
Another comparison of the three language regions
in Switzerland revealed that people living in the
Italian-speaking part expressed a stronger desire
for social distance than people living in the
German- and French-speaking parts (51). People
from the French- and Italian-speaking parts were
more willing to accept restrictive measures against
persons with mental illness than those from the
German-speaking part of Switzerland (54). People
living in the French-speaking part were also more
in favour of compulsory admissions (53). Non-
Swiss residents held more positive attitudes
towards volunteering in psychiatry, i.e. they were
more willing to regularly visit a long-term patient
in a psychiatric institution, to help in a club for
ex-patients, or to look after a mentally ill person
not belonging to the household (49).
A study from Italy reported that people living in
southern Italy were less ready to acknowledge
172
patientsÕ social competence and civil rights than
those from other parts of the country (42).
A survey in the US yielded that people from the
South of the US tended to endorse more frequently
that the person’s bad character or stresses in life
are responsible for the occurrence of mental
disorders (70). Their preferences for social distance
from persons with mental disorders were the same
as in the rest of the US (66). Asian and Hispanic
respondents perceived mental patients as signifi-
cantly more dangerous than did white respondents
(71). African Americans were more likely than
whites to reject the idea that mental illnesses are
caused by either genetics or an unhealthy family
upbringing. They also tended to have more negat-
ive attitudes than whites towards professional
mental health treatment (70). The results of a
study among older adults recruited from primary-
care clinics in San Fransisco indicated that Anglo
older adults are significantly more knowledgable
about Alzheimer’s disease than African American,
Asian, and Latino older adults (105).
In New Zealand, as compared to the general
population the awareness of mental illnesses and
the number of mental illnesses recalled was lower
among Maori and much lower among pacific
people. While among Maori the acceptance of
people with mental illness in general or schizo-
phrenia in particular was similar to the general
population it was lower among pacific people (83).
International comparisons are made possible by
surveys conducted in different countries using the
same methodology. Unfortunately, up until now
results from only two representative studies among
the general population addressing the question of
inter-country differences with regard to beliefs and
attitudes have been published. A comparison
between Novosibirsk (Russia), Ulaanbaatar (Mon-
golia) and Germany revealed that people from the
former two cities show a stronger tendency
towards attributing the cause of mental illness to
the afflicted individual (40). The same tendency has
been reported from another non-western culture
(109). As already outlined earlier, there was a close
association for schizophrenia between labelling as
mental illness and the stereotype of dangerousness
in Germany. This association was neither found in
Novosibirsk nor in Ulaanbaatar (110).
In another study the attitudes towards the
mentally ill among the residents of two Central
European regions which were at considerably
different stages of development in moving towards
community-based care were compared. People
living in the community care area (a district of
the city of Mannheim in Germany) showed slightly
more rejection. However, they also took a more
 Public beliefs about and attitudes towards mentally ill
rational and sophisticated position towards the
mentally ill. People living in the custodially orien-
ted catchment area (Grand Duchy of Luxem-
bourg), on the contrary, showed a more vague
pattern in their attitudes (44).
Evaluation of interventions aimed at improving knowledge of
mental illnesses and reducing stigmatization of mentally ill
people
Six studies are available in which population
surveys have been used to evaluate interventions
aimed at transferring knowledge or reducing
stigma. Four studies were focused on depression.
Paykel et al. (57) evaluated the ÔDefeat Depres-
sion CampaignÕ, an activity of the Royal College of
Psychiatrists in association with the Royal College
of General Practitioners between 1992 and 1996 in
the UK (56). Surveys of public attitudes and
knowledge were conducted in late 1991, early
1995 and mid-1997. The share of those subjects
who saw depression as a medical illness increased
significantly. In addition, the acceptance of anti-
depressants increased, with more respondents
regarding them as effective in 1997. In contrast,
the proportion of those regarding antidepressants
as addictive remained almost unchanged: three-
fourth of respondents agreed to this view.
Hegerl et al. (87) evaluated the effect of the
ÔNuremberg Alliance Against DepressionÕ, a cam-
paign aimed at informing the public about the
causes and treatment of depression. Prior to the
beginning of the campaign and 1 year later, tele-
phone surveys were conducted with a random
sample in the cities of Nuremberg and Wurzburg,
the latter functioning as the control region. As
concerns illness beliefs, the result was rather
sobering. Although the share of respondents
making a lack of self-control responsible for the
disorder had decreased in Nuremberg more clearly
than it had in Wurzburg, fewer respondents from
both cities agreed to the view that a dysfunction of
the brain was the cause. RespondentsÕ opinion in
terms of using antidepressants for the treatment
remained almost unchanged, the same applies to
respondentsÕ opinion as to the negative effects of
antidepressants.
Jorm et al. (114) evaluated the effect of a
consumer guide called ÔHelp for Depression: What
Works (and What Doesn’t)Õ, containing evidence-
based information about treatments for depression.
A pretest, which included a scale assessing depres-
sion, was mailed as a screening test for depression
to a random sample of Canberra citizens and
citizens from the area of south-east New South
Wales. The mail package also contained questions
asking about attitudes to different health profes-
sionals and treatments. The consumer guide was
sent to half of a subsample that scored above a set
cut-off point on the depression scale and indicated
interest in participating in the study. The remaining
half of the sample received a brochure providing
basic information about depression. Six months
later, a second postal survey was conducted. Those
who had received the consumer guide more often
rated cognitive-behaviour therapy to be helpful.
The same was true for electroconvulsive therapy
and St John’s wort. However, respondentsÔ views
on antidepressants or interpersonal psychotherapy
remained unchanged.
In another study conducted in the same area, the
effect of two internet depression sites on stigma
have been investigated. A total of 525 individuals
with elevated scores on the depression assessment
scale were randomly allocated to a depression
information website, a cognitive-behavioural skills
training website or an attention control condition.
Personal stigmatizing attitudes to depression and
the perception of what most people believe about
people with mental illness were assessed before and
after the intervention. Relative to the control, the
internet sites significantly reduced personal stig-
matizing attributes, although the effects were small.
While informing the individuals had no effect on
the perceptions of stigma; the cognitive-beha-
vioural component was associated with an increase
in perceived stigma relative to the control (115,
116).
In order to evaluate a national media campaign
to counter stigma and discrimination associated
with mental illness that has been launched in New
Zealand, a series of four surveys had been con-
ducted. It could be shown that advertizing has a
significant impact on the public’s attitudes and
knowledge. There was a significant increase in
reported acceptance of people with experience of
mental illness while the attitude towards people
with schizophrenia remained virtually unchanged.
As compared with the general population, Maori
and pacific people did not show the same level of
improvement in attitudes (83).
Prior to the opening of two staffed group homes
for severely mentally ill people, situated in the
London borough of Lambeth, immediate neigh-
bours living on the same street as these facilities
were interviewed. In one area, an educational
campaign was conducted comprising a primarily
didactic component (an information pack contain-
ing a video and information sheets), a primarily
social component (social events and social over-
tures from staff) and a mixed component (a formal
reception and informal discussion sessions). One
173
Angermeyer and Dietrich

year after the start of the educational campaign the illness and the acceptance of people with
survey was repeated in both areas. There was no mental disorders. Consequently, to facilitate
significant difference between increase in know- the contact with people with mental disorders
ledge in the two areas over time. However, there may prove effective in reducing negative
was an overall decrease in the fear and exclusion attitudes.
dimension of the CAMI in the experimental area at vi) Models derived from modern stigma theories
follow-up compared to the control area. The allow to systematically investigate the relations
acceptance of patients increased in the experimen- between the various stigma components as,
tal area (96, 97). for instance, the effect of labeling on attitudes
or that of the different aspects of the stereotype
of the mentally ill on social distance or on
Discussion
the acceptance of structural discrimination.
The main findings of the last 15 years of attitude vii) Up until now, too few trend analyses have
research in psychiatry may be summarized as been carried out to allow firm conclusions to
follows: be drawn as concerns the development of
beliefs and attitudes over time. While there are
i) A substantial part of the public cannot recog-
some indications that the gap between public
nize specific mental disorders. When confron-
beliefs and scientific evidence has become
ted with pathological behaviour, as depicted in
narrower, attitudes do not show a consistent
a vignette, people most frequently tend to
trend in one direction or the other.
adopt psychosocial stress as causal explan-
viii) Comparisons between various regions or
ation and to recommend psychological inter-
ethnic groups within countries as well as
ventions for treatment. If diagnostic labels are
comparisons between countries reveal consid-
being used in case of depression the same is
erable differences in beliefs about mental
found while in case of schizophrenia biological
disorders and in attitudes towards people
explanations are as frequently or even more
with mental illness. There are some indications
frequently endorsed and psychotropic medi-
that people from non-western ethnic groups
cation recommended.
are less aware of and knowledgeable about
ii) The majority of the public consider people
mental illness and tend to attribute the cause
with mental disorders as in need of help and
of the illness more frequently to the afflicted
show pro-social reactions. However, a sub-
individual.
stantial part perceives them as unpredictable
ix) The evaluation of interventions aimed at
and dangerous and reacts with fear. There is
improving the public’s knowledge of depres-
an observable tendency to distance oneself
sion, using population surveys, suggests that
from people with mental disorders.
this may be achieved in some areas while
iii) Although there are various similarities
others, particularly people’s views on medica-
between mental disorders as concerns public
tion, may prove more resistant to change.
beliefs and attitudes, there are also marked
Some findings suggest that informing people
differences. For instance, people with schizo-
may not necessarily affect their attitudes.
phrenia or alcoholism are more frequently
considered as unpredictable and violent than From our review the following conclusions for
people with depression and anxiety disorders. future research may be drawn:
Rejection is most pronounced towards people
i) In recent years, attitude research in psychiatry
with drug abuse and alcoholism, followed by
has made considerable progress. However, the
those with schizophrenia, and is less pro-
vast majority of studies are still dedicated to
nounced towards people with depression and
the descriptive recording of public beliefs
anxiety disorders.
about mental illness and public attitudes
iv) While the association between gender and
towards persons with mental illnesses. There
attitudes is inconsistent, there exists strong
is a pressing need for more studies using more
evidence that negative attitudes are positively
sophisticated approaches, like the testing of
associated with age and negatively with edu-
theory-based models, cross-cultural compari-
cational attainment. However, the explanatory
sons and trend analyses. They only may
power of socio-demographic characteristics is
provide us with insights into the mechanisms
only poor.
of and contextual influences on stigma that are
v) If there is any relationship there is a positive
needed for successful antistigma interventions.
association between familiarity with mental

174
 Public beliefs about and attitudes towards mentally ill
ii) The vast majority of surveys covered by this
review have been conducted in Western coun-
tries and only nine out of 61 originate from the
rest of the world. There is a need for more
transcultural studies using representative sam-
ples [instead of convenience samples as have
been used in a number of previous studies (e.g.
123, 124)].
iii) Current attitude research mainly took an
interest in schizophrenia and depression.
Only a few studies have looked into alcohol-
ism, drug abuse, anxiety disorders and demen-
tia. Other disorders such as bipolar disorder
have not been the focus of population studies
yet. Strictly speaking, the titles of the majority
of papers alluding to Ômental disordersÕ or
Ômental illnessÕ in general (e.g. 10, 15, 16, 23,
26) are somewhat misleading.
iv) Moreover, population surveys have thus far
focused almost exclusively on attitudes
towards mentally ill persons. With the excep-
tion of a few studies only (65, 67, 98),
comparisons with people affected with somatic
illnesses or mentally healthy people (Ônormal
personsÕ) have not been carried out. Thus, it
remains largely unknown to what extent the
public’s beliefs about and attitudes towards
mental disorders differ from the beliefs about
and attitudes towards other social groups.
v) In order to avoid the overgeneralization of
research findings, a clear distinction between
beliefs and attitudes related to pathological
behaviour (as assessed by means of vignettes)
and those related to diagnostic labels (for
instance ÔschizophreniaÕ or ÔdepressionÕ) seems
necessary.
vi) The assessment of beliefs and attitudes about
mentally ill people in general appears of
limited value in view of the marked differences
between the various mental disorders.
vii) An important limitation of the research
reviewed in this paper, with very few excep-
tions (96, 97, 112, 113), is that the relationship
between attitudes and behaviour has not yet
been examined. Thus, it remains an open
question as to what extent beliefs about
mental illnesses and attitudes towards men-
tally ill people are in fact related to actual
behaviour. More research is needed to shed
light on this relationship; however, it must be
acknowledged that this is a very difficult area
of research.
viii) Although some of the mechanisms which form
the basis of discrimination against persons
with mental illnesses have been subjected to a
closer analysis, and with evaluations of edu-
cational programmes having yielded some
useful suggestions for the planning of inter-
ventions aimed at reducing the stigma
attached to mental illness, we are still far
from evidence-based antistigma programmes.
This is not the least due to the fact that
popular strategies for combating mental illness
stigma have received contradictory evalua-
tions, resulting in deep disagreement as to
their effectiveness in actually reducing stigma
and discrimination (125). For instance, while
some studies (66, 101) are supportive of the
mental illness is a brain disease strategy, other
studies (36, 40, 51) found evidence that pro-
mulgating biological concepts among the
public might not contribute to a desired
reduction in social distance towards people
with mental disorders.
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