Do values and political attitudes affect help-seeking? Exploring reported help-seeking for mental health problems in a general population sample using a milieu framework.

AIMS: Help-seeking for mental health problems is facilitated and hindered by several factors at the individual, interpersonal and community level. The most frequently researched factors contributing to differences in help-seeking behaviour are based on classical socio-demographic variables, such as age, gender and education, but explanations for the observed differences are often absent or remain vague. The present study complements traditional approaches in help-seeking research by introducing a milieu approach, focusing on values and political attitudes as a possible explanation for differences in help-seeking for emotional mental health problems. METHODS: A representative cross-sectional survey of N = 3,042 respondents in Germany was conducted through face-to-face interviews about past help-seeking for mental health problems, socio-demographic characteristics and values and political attitudes. RESULTS: Multivariate logistic regression analyses indicated that belonging to a cosmopolitan intellectual milieu group was significantly associated with an increased likelihood of past help-seeking for mental health issues (psychotherapeutic/psychological help-seeking [OR = 2.09, 95% CI: 1.11-3.93, p < 0.05) and primary care (OR = 2.21, 95% CI: 1.15-4.24, p < 0.05]), whereas members of individualist and conservative milieu groups were less likely to report having sought help from a psychotherapist, but not from a general practitioner. Increased odds ratios were also found for a number of socio-demographic variables, such as being aged 26 years and over, a female gender and more than 12 years of formal education. Associations between socio-demographic variables remained significant, and the explained variance of the used models improved considerably when milieu variables were added. CONCLUSIONS: We discuss how milieu-specific patterns were relevant for explaining differences in mental health service use in addition to socio-demographic factors. It seems promising to consider help-seeking from a milieu perspective to improve disparities in access to and the use of psychotherapy as well as to resource allocation.

The rise in acceptance of mental health professionals: help-seeking recommendations of the German public 1990-2020.

AIMS: We will first examine whether seeking help for depression and schizophrenia from mental health professionals is nowadays more accepted among the German public than it used to be 30 years ago. Next, we will explore whether changes in help-seeking preferences between 1990 and 2020 are specific to mental health professions or are part of changes in attitudes to professional help-seeking in general. Finally, we will study whether a temporal relationship does exist between the advent of awareness-raising and anti-stigma campaigns after the turn of the millennium and changes in the acceptance of mental health care. METHODS: In 1990 (n = 2044), 2001 (n = 4005), 2011 (n = 1984) and 2020 (n = 2449) methodologically identical population-based surveys were conducted in Germany. After presentation of an unlabelled case vignette depicting someone with either schizophrenia or depression, we asked about help-seeking recommendations for the person described. RESULTS: The German public's readiness to recommend seeking help from mental health professionals has markedly grown over the past 30 years. In contrast, in the eyes of the public, turning to a general practitioner has become only slightly more, consulting a priest even less advisable than it used to be three decades ago. Seeing a naturopath is seen with markedly less disapproval today compared to 1990, but explicit recommendation of this helping source has not increased correspondingly in. The most pronounced increase in the German public's propensity to recommend seeking help from mental health professionals occurred already in the 1990s, i.e. before efforts to heighten public awareness had started. CONCLUSIONS: Today, the German public is more in favour of mental health professionals than it used to be three decades ago. This seems to be a specific trend, and not to reflecting an increasing propensity towards professional help-seeking in general. Our findings counter the narrative that mental health communication efforts and initiatives have created more favourable attitudes towards mental health care among the public, since the observed changes in attitudes have preceded any campaigns. Instead, we tend to interpret the rise of the popularity of mental health professionals as a reflection of general cultural changes that have taken place over the past decades in Germany, as in other western countries.

Roles of perception of similarities, continuum beliefs, and social distance toward a person with schizophrenia: a German sample study.

Continuum beliefs (CB) interventions aim to reduce the stigma of schizophrenia by stating that people with and without schizophrenia exist on one mental health-illness continuum. The current study examines the interrelation between perception of similarities (PoS), CB and desire for social distance (SD) in a German population sample (N = 760). Applying linear regression models: PoS and CB were significantly associated with lower SD explaining about 12% variance and PoS was significantly associated with higher CB. CB partially mediated the relation of PoS and SD. Upcoming mental illness stigma interventions applying CB interventions should also aim to increase PoS.

Continuum beliefs of mental illness: a systematic review of measures.

PURPOSE: The continuum of mental health/illness has been subject to scientific debate for decades. While current research indicates that continuum belief interventions can reduce mental health stigma and improve treatment seeking in affected populations, no study has yet systematically examined measures of continuum beliefs. METHODS: This preregistered systematic review summarizes measures of continuum beliefs. Following the PRISMA statement, three scientific databases (PubMed, PsycInfo and PsycArticles via EBSCOhost, Web of Science) are searched, instruments are described and discussed regarding their scope, and methodological quality. RESULTS: Overall, 7351 records were identified, with 35 studies reporting relevant findings on 11 measures. Most studies examined general population samples and used vignette-based measures. Schizophrenia and depression were most commonly examined, few studies focused on dementia, ADHD, OCD, eating disorders, and problematic alcohol use, or compared continuum beliefs across disorders. Validity was very good for most measures, but reliability was rarely tested. Measures mostly assessed beliefs in the normality of mental health symptoms or the normality of persons with such symptoms but rarely nosological aspects (i.e., categorical v continuous conceptualization of mental disorders). CONCLUSIONS: Current research provides psychometrically sound instruments to examine continuum beliefs for a variety of mental disorders. While studies suggest utility for general population samples and mental health professionals, more research is necessary to corroborate findings, for instance, regarding age (e.g., in adolescents), gender, or type of mental disorder. Future research should also compare self-report ratings, and vignette-based measures, include measures of nosological concepts to fully grasp the continuum concept of mental illness. PREREGISTRATION: PROSPERO: CRD42019123606.

Continuum beliefs and the perception of similarities and differences to a person with depression.

OBJECTIVE: Both continuum beliefs (i.e., that mental disorder exists on a spectrum of normative behavior patterns) and the perception of similarities to a person with schizophrenia have shown mixed effects on reducing mental illness stigma. To our knowledge, this is the first study to address continuum beliefs and the perception of similarities to a person with depression in the context of depression-related stigma. METHODS: This work is based on an online intervention study in an ethnically diverse sample recruited on Amazon MTurk including previously unanalyzed qualitive responses. Within this cross-sectional, mixed-methods online investigation (N = 304), we examined the relation of perceived similarities to continuum beliefs, social distance, and negative stereotypes in relation to a vignette about depression. A randomly assigned continuum beliefs intervention attempted to induce continuum beliefs about depression. An open-writing task asked participants to describe similarities and/or differences between themselves and the person depicted in the vignette. RESULTS: The continuum beliefs intervention was associated to a greater number of perceived similarities to and fewer perceived differences from the target vignette. Moreover, perceived similarities were associated with increased continuum beliefs, less social distance, and less-negative stereotypes. Perceived differences from a person with depression were associated with increased social distance. LIMITATIONS: Even though the continuum beliefs intervention did not significantly alter stigma measures directly, expressed continuum beliefs were associated to decreased mental illness stigma. CONCLUSIONS: The findings emphasize that perceived similarities to an outgroup member (i.e., a person with depression) might augment the stigma-reducing mechanism of continuum beliefs.

Blind spots in stigma research? Broadening our perspective on mental illness stigma by exploring 'what matters most' in modern Western societies.

AIMS: The theory of 'what matters most' (WMM) has been developed to understand differences in mental illness stigma between cultures, postulating that stigma becomes most pervasive in situations that matter most in a specific cultural context. The rise of populism in Western societies demonstrates that also within one cultural context, different values 'matter most' to different groups. We expand the WMM framework to explore the spectrum of stigma manifestations within Western societies, relating it to both conservative/authoritarian and liberal/modern values. From our findings, we will develop hypotheses on how further research into value orientations and stigma might address potential blind spots in stigma research. METHODS: Based on a narrative review of the literature on mental illness stigma and value orientations, we apply the WMM framework to cultural mechanisms of stigma within modern Western societies. RESULTS: There are several studies showing an association between traditional, authoritarian, conservative values with stronger mental illness stigma, while studies examining the stigma within liberal, modern value orientations are scarce. We hypothesise on situations where encountering a person with mental illness could threaten liberal values and thus might provoke stigma among persons with such value orientations. For example, living with a person with mental illness could be seen as consuming energy and time, thereby jeopardising 'self-actualisation', the modern value of realising one's own full potential. As a result, a person highly valuing self-actualisation might try to avoid contact with persons with mental illness. Instances of potential 'liberal stigma' also include structural stigma or self-stigma, when, e.g. changing assumptions of what is considered 'normal' increase perceptions of being fundamentally different when experiencing mental illness. CONCLUSIONS: 'WMM' appears to be a useful framework to direct research to potential blind spots within the field of stigma research. Looking at instances where liberal values conflict with dealing with a person with mental illness could provide a more comprehensive understanding of stigma experiences among persons with mental illness. However, for measuring stigma, tapping into liberal variations of mental illness stigma is methodologically challenging. Qualitative work could be the first step to elicit potential stigma experiences based on conflicts with liberal values.

[Social milieu: A relevant concept for a better understanding of stigma and help-seeking?] / Soziale Milieus: Ein relevantes Konzept für ein besseres Verständnis von Stigma und psychiatrischer Unterversorgung?

BACKGROUND: The sociocultural interconnections surrounding stigmatizing attitudes and the treatment gap in mental healthcare are complex and insufficiently understood. OBJECTIVE: Is the social milieu including personal values a potentially useful instrument for psychiatric research into attitudes and healthcare provision? METHOD: This article describes individual barriers to treatment which pertain to literacy and attitudes, with contextualization of the social milieu concept. It gives a narrative review of the literature (PubMed, PsycINFO, Google Scholar) relating to the associations of different social milieu dimensions (e.g. sociodemographics, values, place of residence, ethnicity) with stigmatizing attitudes and utilization of psychiatric treatment options. RESULTS: Sociodemographically, lower educational attainment and male gender are often associated with psychiatric undertreatment and prevailing stigmatizing attitudes towards mental illness and its treatment. Simple sociodemographic parameters alone appear to be insufficient for predicting stigma and undertreatment. Stigmatizing attitudes and mental health literacy constitute important individual barriers to treatment. These sociodemographic and individual aspects can culminate in certain social milieus. This could allow the identification of specific target groups and communication requirements for interventions. CONCLUSION: The concept of the social milieu constitutes a potentially important and so far barely used intersection between sociology and medicine. Against the backdrop of rising public polarization and social inequality, the concept could contribute to achieving a better understanding of the stigma of mental illness. It appears to be of relevance in a number of ways for secondary and tertiary preventive considerations regarding the treatment gap in mental healthcare.

Ready, Willing and Able? An Investigation of the Theory of Planned Behaviour in Help-Seeking for a Community Sample with Current Untreated Depressive Symptoms.

Applying health behaviour change models, such as the theory of planned behaviour (TPB), to help-seeking for mental health problems can address the deficit in health care utilisation. However, previous studies largely focused on help-seeking intentions and not behaviour, which might be problematic due to the intention-behaviour gap. Hence, TPB and help-seeking were examined in a German community sample with current untreated depressive symptoms: 188 adults (Mage = 50.34; SD = 16.19; 70.7% female) participated in a baseline interview and survey measuring components of the TPB (attitudes, subjective norms and perceived behavioural control) and help-seeking intentions. They reported actual help-seeking from mental health professionals via telephone surveys 3 and 6 months later. To better understand the potential gap between help-seeking intentions and behaviour and to investigate the contributions of readiness, willingness and ability to seek help, two path models were constructed in accordance with the TPB controlling for covariates. Attitudes (ß = .24), subjective norms (ß = .25) and self-efficacy (ß = .15) were significantly associated with intentions (R2 = 26%), which predicted help-seeking (Cox and Snell's pseudo-R2 = 23%); controllability did not predict help-seeking. In sum, the TPB provides a reliable framework to explore help-seeking behaviour for mental health problems. Based on these findings, prevention efforts should focus on readiness and willingness to seek help (e.g. foster positive attitudes and social support of treatment). However, the role of ability, operationalised as perceived behavioural control and (perceived) barriers to help-seeking, warrants further research, as self-efficacy but not controllability was associated with help-seeking.

Shame, self-identification with having a mental illness, and willingness to seek help in northeast Germany.

We examined a general population sample (n = 1330) from an epidemiological study (SHIP), investigating whether shame, social distance and reluctance to self-identify as having a mental illness interfere with willingness to seek help for mental health problems. Analyses were stratified for life-time diagnosis of any mental illness. Shame was the strongest negative predictor for willingness to seek help (beta = -0.183, p < .001). Structured Estimation Modelling showed shame being a full mediator of a negative association between social distance and willingness. Our results corroborate the important role of shame as an impediment to help-seeking for mental health problems in the general population.

A Prospective Study on Structural and Attitudinal Barriers to Professional Help-Seeking for Currently Untreated Mental Health Problems in the Community.

To date, little is known about the concurrent impact of structural and attitudinal factors on help-seeking behaviour for mental health problems. Therefore, this study investigated a longitudinal German community sample of adults with currently untreated mental health problems (N = 188, mean age = 50.34, 70.7% female) regarding perceived structural (e.g. accessibility) as well as attitudinal barriers (e.g. anticipated self-stigma) to help-seeking intentions and behaviour. Overall, perceived accessibility, spatial and temporal distance from mental health services predicted help-seeking. Among attitudinal factors, treatment efficacy beliefs were strongly connected to help-seeking. In addition, among people who knew where to find a psychologist or psychotherapist, anticipated self-stigma emerged as a significant barrier to help-seeking. Therefore, creating positive treatment expectancies and dismantling erroneous perceptions of structural aspects of mental health services hold promise to further close the gap in mental health care utilisation. However, the role of anticipated self-stigma within the help-seeking process requires further research.

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

AIMS: Many people with mental illness do not seek professional help. Beliefs about the causes of their current health problem seem relevant for initiating treatment. Our aim was to find out to what extent the perceived causes of current untreated mental health problems determine whether a person considers herself/himself as having a mental illness, perceives need for professional help and plans to seek help in the near future. METHODS: In a cross-sectional study, we examined 207 untreated persons with a depressive syndrome, all fulfilling criteria for a current mental illness as confirmed with a structured diagnostic interview (Mini International Neuropsychiatric Interview). The sample was recruited in the community using adverts, flyers and social media. We elicited causal explanations for the present problem, depression literacy, self-identification as having a mental illness, perceived need for professional help, help-seeking intentions, severity of depressive symptoms (Patient Health Questionnaire - Depression), and whether respondents had previously sought mental healthcare. RESULTS: Most participants fulfilled diagnostic criteria for a mood disorder (n = 181, 87.4%) and/or neurotic, stress-related and somatoform disorders (n = 120, 58.0%) according to the ICD-10. N = 94 (45.4%) participants had never received mental health treatment previously. Exploratory factor analysis of a list of 25 different causal explanations resulted in five factors: biomedical causes, person-related causes, childhood trauma, current stress and unhealthy behaviour. Attributing the present problem to biomedical causes, person-related causes, childhood trauma and stress were all associated with stronger self-identification as having a mental illness. In persons who had never received mental health treatment previously, attribution to biomedical causes was related to greater perceived need and stronger help-seeking intentions. In those with treatment experience, lower attribution to person-related causes and stress were related to greater perceived need for professional help. CONCLUSIONS: While several causal explanations are associated with self-identification as having a mental illness, only biomedical attributions seem to be related to increase perceived need and help-seeking intentions, especially in individuals with no treatment experiences. Longitudinal studies investigating causal beliefs and help-seeking are needed to find out how causal attributions guide help-seeking behaviour. From this study it seems possible that portraying professional mental health treatment as not being restricted to biomedical problems would contribute to closing the treatment gap for mental disorders.

12-year changes in cardiovascular risk factors in people with major depressive or bipolar disorder: a prospective cohort analysis in Germany.

BACKGROUND: Major depressive disorder (MDD) and bipolar disorder are associated with certain cardiovascular risk factors (CVRFs), but it is unclear whether they are associated with unfavourable changes of clinically manifest CVRFs over time. METHODS: We used baseline and 12-year follow-up (n = 1887) data from the German Health Interview and Examination Survey 1998. Multivariable linear regression models assessed associations between lifetime CIDI-diagnosed mood disorders at baseline and continuous risk factor-related outcomes (blood pressure, HbA1c, LDL-C, HDL-C, triglycerides, BMI) at follow-up. RESULTS: We did not find consistent deterioration of CVRFs in persons with compared to persons without MDD. Analyses pointed to severity of mood disorder as an important correlate of long-term changes of comorbid hypertension: while a history of mild MDD was not associated with changes in CVRFs, moderate MDD was associated with lower blood pressure [systolic: ß = - 7.5 (CI - 13.2; - 1.9); diastolic: ß = - 4.5 (CI - 7.8; - 1.3)] and a history of bipolar disorder was associated with higher systolic blood pressure at follow-up (ß = 14.6; CI 4.9-24.4). Further, severe MDD was weakly associated with a higher BMI at follow-up [ß = 1.2 (CI 0.0; 2.4)]. These outcomes were not mediated by use of psychotropic medication and remained statistically significant after adjusting for the use of antihypertensive medication. CONCLUSION: Since most investigated parameters showed no associations, participants with a lifetime history of MDD in this cohort did not carry a specific risk for a worsening of pre-existing clinically manifest CVRFs. Our findings extend evidence of MDD severity and bipolar disorder as important correlates of long-term changes of arterial hypertension and obesity.

Is knowledge "half the battle"? The role of depression literacy in help-seeking among a non-clinical sample of adults with currently untreated mental health problems.

BACKGROUNDS: The concept of mental health literacy suggests that higher literacy increases the likelihood of seeking treatment. However, previous studies mostly use vignettes, and do not investigate actual help-seeking behaviour. METHODS: We assessed depression literacy and type of mental illness in a convenience sample of 207 adults with currently untreated mental health problems from the general population. Our analysis sample comprised 152 adults (Mage = 52.12; 73.0% female) with a depressive disorder. Help-seeking behaviour was measured 3 and 6 months after the initial assessment. We conducted multiple logistic regression models to test whether depression literacy predicted help-seeking from mental health professionals, general practitioner, family and friends, or counselling, controlling for sociodemographic data, and depression severity. RESULTS: Depression literacy was lower in men and older participants, and higher in participants with prior treatment experience. Depression literacy was negatively linked to informal help-seeking (aOR = 0.33 [0.13; 0.84]) when included as a dichotomous predictor (i.e., 'high' versus 'low' literacy). LIMITATIONS: Our sample was small, thus we did not differentiate between types of depressive disorders in our analysis. CONCLUSION: We could not corroborate most postulated associations between depression literacy and help-seeking, except for the negative association with informal help. Our findings underline differences between previous vignette-based and community-based investigations of the help-seeking process for mental health problems. To explore underlying mechanisms, future research should investigate the role of intermediary variables and processes in the association between depression literacy and help-seeking, such as self-efficacy and symptom attribution, which might be more clinically relevant in help-seeking for depressive symptoms.

Who is seeking whom? A person-centred approach to help-seeking in adults with currently untreated mental health problems via latent class analysis.

PURPOSE: Global surveys point to a gap in mental health service utilisation. However, contacting more than one source of professional help may influence the estimates of utilisation. Currently, few studies statistically differentiate between different sources of help based on patient characteristics. METHODS: We assessed sociodemographic and psychosocial data in a convenience sample of 188 adults with mental health problems (Mage = 50.34 years; SD = 16.19; 71% female), who reported their help-seeking behaviour during the next 6 months. We analysed their behaviour via latent class analysis and compared baseline characteristics between classes. RESULTS: We found four latent classes: "mental health professionals" (MHP; 9.0%), "multiple sources" (4.3%), "primary care" (35.6%), and "non-seekers" (51.1%). All classes had moderate to high probabilities of seeking help from friends or family. Primary care utilisers were more often in a cohabiting partnership; MHP utilisers were more experienced in mental health treatment and reported lower well-being and more depressive symptoms than non-seekers. By trend, non-seekers were younger, and both non-seekers and primary care utilisers reported fewer depressive and somatic symptoms than utilisers of multiple sources and MHP. CONCLUSIONS: In our analysis, MHP utilisation was even lower (9.0%) than in previous studies. However, MHP utilisers appeared to suffer from more serious conditions than other latent classes. As informal sources such as family and friends were present in all latent classes, help-seeking behaviour seems to transcend traditional MHP-focused approaches. Further research is necessary to investigate tenability and trajectories of different latent classes of help-seeking in larger and representative samples with longer follow-ups.

Approval of psychotherapy and medication for the treatment of mental disorders over the lifespan. An age period cohort analysis.

AIMS: Previous cross-sectional studies revealed inconsistent results regarding mental health treatment preferences among the general population. In particular, it is unclear to what extent specific age groups approve psychotherapy or psychotropic medication for the treatment of mental disorders. We explore whether treatment recommendations of either psychotherapy or psychiatric medication change over the lifespan which includes age-related effects due to increasing age of a person, cohort effects that reflect specific opinions during the time a person was born and period effects that reflect societal changes. METHODS: Using data from three identical population surveys in Germany from 1990, 2001 and 2011 (combined n = 9046), we performed age-period-cohort analyses to determine the pure age, birth cohort and time period effects associated with the specific treatment recommendations for a person with either depression or schizophrenia, using logistic Partial Least-Squares regression models. RESULTS: For both disorders, approval of both psychotherapy and medication for a person with mental illness increases with age. At the same time, younger cohorts showed stronger recommendations particularly for psychotherapy (OR around 1.07 per decade). The strongest effects could be observed for time period with an increase in recommendation between 1990 and 2001 with odds ratio of 2.36 in depression and 2.97 in schizophrenia, respectively. In general, the treatment option that showed the strongest increase in recommendation was medication for schizophrenia and psychotherapy for depression. CONCLUSION: Underutilisation of psychotherapy in old age seems not to reflect treatment preferences of older persons. Thus, special treatment approaches need to be offered for this group that seems to be willing for psychotherapy but do not yet use it. Cohort patterns suggest that approval of psychotherapy among older persons will likely further increase in the coming years as these people get older. Finally, strong period effects underpin the importance of changing attitudes in the society. These could reflect reporting changes about psychiatric topics in the media or a general increase in the perception of treatment options. Nevertheless, more treatment offers especially for older people are needed.

State of the art of population-based attitude research on mental health: a systematic review.

AIMS: Population surveys have become a frequently used method to explore stigma, help-seeking and illness beliefs related to mental illness. Methodological quality however differs greatly between studies, and our current knowledge seems heavily biased towards high-income countries. A critical appraisal of advances and shortcomings of psychiatric attitude research is missing. This review summarises and appraises the state of the art in population-based attitude research on mental health. METHODS: Systematic review of all peer-reviewed papers reporting representative population studies on beliefs and attitudes about mental disorders published between January 2005 and December 2014 (n = 478). RESULTS: Over the decade covered by this review considerably more papers on psychiatric attitude research have been published than over the whole time period before. Most papers originated in Europe (36.3%), North America (23.2%) and Australia (22.6%), only 14.6% of all papers included data from low- or middle income countries. The vast majority of papers (80.1%) used correlational cross-sectional analyses, only 4% used experimental or quasi-experimental designs. Data in 45.9% of all papers were obtained with face-to-face interviews, followed by telephone (34.5%), mail (7.3%) and online surveys (4.0%). In almost half of papers (44.6%) case-vignettes served as stimulus for eliciting responses from interviewees. In 20.7% instruments meeting established psychometric criteria were used. The most frequently studied disorder was depression (44.6% of all paper), followed by schizophrenia (33%). 11.7% of papers reported time trend analyses of attitudes and beliefs, 7.5% cross-cultural comparisons. The most common focus of research was on mental health literacy (in total 63.4% of all papers, followed by various forms of stigma (48.3%).There was a scarcity of papers (12.1%) based on established theoretical frameworks. CONCLUSIONS: In the current boom of attitude research, an avant-garde of studies uses profound and innovative methodology, but there are still blind spots and a large proportion of conventional studies. We discuss current and future methodological challenges that psychiatric attitude research needs to embrace. More innovative and methodologically sound studies are needed to provide an empirical basis for evidence-based interventions aimed at reducing misconceptions about mental disorders and improve attitudes towards those afflicted.

An online intervention using information on the mental health-mental illness continuum to reduce stigma.

BACKGROUND: A core component of stigma is being set apart as a distinct, dichotomously different kind of person. We examine whether information on a continuum from mental health to mental illness reduces stigma. METHOD: Online survey experiment in a quota sample matching the German population for age, gender and region (n=1679). Participants randomly received information on either (1) a continuum, (2) a strict dichotomy of mental health and mental illness, or (3) no information. We elicited continuity beliefs and stigma toward a person with schizophrenia or depression. RESULTS: The continuum intervention decreased perceived difference by 0.19 standard deviations (SD, P<0.001) and increased social acceptance by 0.18 SD (P=0.003) compared to the no-text condition. These effects were partially mediated by continuity beliefs (proportion mediated, 25% and 26%), which increased by 0.19 SD (P<0.001). The dichotomy intervention, in turn, decreased continuity beliefs and increased notions of difference, but did not affect social acceptance. CONCLUSION: Attitudes towards a person with mental illness can be improved by providing information on a mental health-mental illness continuum.

Trends of barriers to eye care among adults with diagnosed diabetes in Germany, 1997-2012.

BACKGROUND AND AIMS: To study trends of barriers to receiving recommended eye care among subjects with diabetes aged 20-81 years in northeast Germany. METHODS AND RESULTS: We analyzed population-based data from two repeated cross-sectional surveys conducted in 1997-2001 and 2008-2012 (Ns of 4308 and 4402). Andersen's Behavioral Model of Health Services Utilization was used to identify individual-level demographic, financial and health-related barriers to annual eye-care utilization in subjects with a self-reported physician's diabetes and to examine population trends in these barriers. The prevalence of diabetes increased from 6.5% to 11.4%. The prevalence of annual eye-care utilization among persons with diabetes decreased from 69.4% to 56.0% (adjusted relative risk = 0.77, p < 0.001). The decline of eye care utilization over the past decade in eye-care use was more pronounced in groups at risk for diabetes-related complications (i.e., lower socio-economic status, >5 years since diagnosis of diabetes, poor glycemic control, obesity, smoking, lack of physical activity, co-existing diseases). We identified relevant predictors of missed annual eye-care use among diabetics. CONCLUSION: The increase of diabetes prevalence and downward trend of eye-care visits at the recommended level call for development, implementation and evaluation of continued efforts to improve access to eye specialists, particularly among those with poor diabetic control, co-existing diabetic complications, and comorbidities.

Do attitudes towards persons with mental illness worsen during the course of life? An age-period-cohort analysis.

OBJECTIVE: Cross-sectional studies frequently find higher age associated with negative attitudes towards persons with mental illness. We explore whether attitudes worsen over the life span, or follow a cohort pattern. METHOD: Using data from three identical population surveys in Germany from 1990, 2001 and 2011 (combined sample n = 7835), we performed age-period-cohort analyses determining the association of age, time period and birth-cohort with social distance from a person with either depression (n = 3910) or schizophrenia (n = 3925), using linear and nonlinear partial least squares regression models. RESULTS: Social distance increases with age, independent from cohort and period effects, cumulating to an increase of 2.4 (schizophrenia) and 2.3 (depression) on the 28 point social distance scale over the life span (youngest to oldest participant). We found a cohort effect in depression, but not schizophrenia, with decreasing social distance until 1970 and a slight increase in younger cohorts. Period effects were visible particularly in schizophrenia, with growing social distance over time. CONCLUSION: Considering demographic change and the vulnerability of older persons to severe outcomes of mental illness such as suicide, the observed increase of negative attitudes over the life span seems highly relevant. We discuss the role of conservatism and preferences for agreeable social contacts in older age.