Vignettes of Common Issues Causing Mental Ill Health

Causes of mental disorders
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We examine whether there are cross-cultural differences in causal beliefs, stigma and emotional reactions. The two aims will be pursued by utilizing an implementation of a path analyses in both subsamples.

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Based on previous work we expect biogenetic causal attributions to be associated with a higher desire for social distance. Intrapersonal and supernatural causal beliefs are likewise predicted to be linked to more desire for social distance. Emotional reactions are assumed to mediate the influence of causal beliefs on the desire for social distance, whereby negative emotions, such as fear and anger, are expected to be associated with more desire for social distance.

Positive prosocial emotions, in turn, are expected to be associated with less desire for social distance. Participants are expected to experience more negative emotions 55 and express more desire for social distance toward a person suffering from schizophrenia compared to depression. Regarding group differences, we assume Turkish immigrants to more frequently attribute mental illness to supernatural and intrapersonal causes, whereas Germans are expected to indorse biogenetic causes more frequently. No specific hypotheses are made about differences in the extent of social distance desired by the two subsamples as well as the nature of differences in its relationship with causal beliefs, thereby taking an exploratory approach in this area.

Participants, native Germans as well as Turkish immigrants, were approached on the street, in citizens registration offices and town halls in different districts of the city of Berlin between March and October The questionnaire took approximately 20 min to complete.

All subjects received written information about study duration as well as the institutions involved and signed an informed consent before participation.

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The consent further emphasized that participation is voluntary and could be canceled at any time. Participants did not receive financial compensation. All survey procedures were approved by the Ethics Committee for Psychological Research at the Humboldt University Berlin and were conducted in accordance with the Helsinki Declaration. Since it became evident the response rate of Turkish immigrants would be low, a problem that has already been reported in other studies 56 , we adapted our data acquisition technique according to a qualitative study by Dingoyan et al.

Thus, we established cooperation with numerous Turkish associations as well as eminent figures of the Turkish community in Berlin and asked them for distribution of the questionnaires among their members, colleagues, friends and acquaintances. Table 1 presents socio-demographic data on the two samples.

Germans and Turkish immigrants did not differ in gender, age and civil status, whereas significant differences were found in education, occupation, income and religion. In the Turkish immigrant subsample, Nearly half of the Turkish immigrant participants were Turkish citizens To adjust for proficiency in German language in the Turkish subsample, subjects with a Turkish background could choose their preferred language of assessment, German or Turkish.

For this purpose, the questionnaire was translated into Turkish using a collaborative and iterative method A native Turkish speaker translated the questionnaires from German into Turkish. Three independent native speakers verified the Turkish translation for comprehension and compared it to the German version for correctness. The survey began with the presentation of an unlabeled ungendered case vignette describing a psychiatric case history.

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The case vignettes described symptoms of either depression or schizophrenia according to criteria of the Diagnostic and Statistical Manual of Mental Disorders, DSM-IV and were validated in numerous previous studies 21 , 29 , 59 , Unlabeled vignettes are a well-established method in the research of attitudes toward people with mental illness. They offer valuable advantages, such as not using a diagnostic label and therefore avoiding possible prejudices associated with it, and the possibility of portraying the clinical picture of the respective mental disorder in its manifold aspects.

Further, using case vignettes allows for standardization of the base of assessment ensuring that every participant is evaluating the same matter at hand. The two vignettes used in the present study were assigned randomly. Participants were presented a checklist of 17 possible causal attributions and asked to indicate their agreement to the respective item being a cause of the clinical symptoms depicted in the vignette.

Adaptations were made on the basis of a qualitative free listing study performed on Turkish immigrants in Berlin 51 , Each item was referring to one of five causal belief categories: biogenetic causes, childhood adversities, current stress, supernatural causes and intrapersonal causes 21 , 29 , A confirmatory factor analysis CFA performed to verify the theorized categories in both groups.

Reflecting this particular methodological issue—by allowing the items to correlate beyond the factorial structure—emended the misfit. Table 2 provides an overview of the specific causal attributions composing the mentioned categories.

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We created factor-based scores for each category and reversed them in order for high values to indicate high agreement with the respective attributional category. Table 2. Attribution categories and the composing items with corresponding standardized factor loadings for both subsamples. Participants were furthermore requested to indicate their agreement to a list of 10 statements of possible emotions evoked by the person presented in the vignette.

We consecutively created factor scores for further analyses and reversed them in order for high numerical values to indicate high emotional reactions. In order to assess the extent of social rejection of people with mental health issues, we implemented the Social Distance Scale [SDS, 17 ]. Participants were requested to indicate how willingly they would accept the person described in the vignette across 7 social situations on a 5-point Likert scale ranging from complete agreement to complete disagreement.

The social situations included renting the described person a room, accepting her as a colleague, as a neighbor, letting her take care of one's children, having her marry into one's family, introducing her to friends and recommending her for a job. The SDS is commonly used in population surveys on social rejection 10 and shows high internal consistencies between.


In line with those findings, Cronbach's alpha in our German and Turkish immigrant subsamples was. A CFA performed to verify a unifactored structure resulted in an initial misfit. A subsequent analysis revealed the misfit in both groups to originate from an item pair with very similar degree of social distance accepting the person as a neighbor and accepting her as a colleague as opposed to the other social situations queried which are socially closer and rather located in the private sphere e.

Allowing the items to correlate beyond the factorial structure corrected the misfit.

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Predictors of mental illness stigma and attitudes among college students: using vignettes from a campus common reading program. Feeg VD(1), Prager LS. Vignettes describing individuals meeting DSM-IV criteria for major depression the General Social Survey (GSS) and a study of mental health .. And knowing someone receiving treatment for a mental illness was.

Here too, we calculated a scale score. High numerical values indicate a high desire for social distance. All statistical analyses were carried out using R version 3. CFAs were computed using the latent variable analysis lavaan package version 0. Paired t -tests were carried out to test for differences within groups between means for both vignettes combined.

Independent t -tests were performed to examine differences between vignettes within both groups. Since the criterion of variance homogeneity is not met for most of the applied comparisons, we used Welch's modification which does not assume equal variance. P -values were adjusted for multiple comparisons using the Benjamini-Hochberg method as it allows for higher preservation of power than the conservative Bonferroni correction Effect sizes Cohen's d were calculated in order to delineate the magnitude of inspected differences.

To facilitate a better understanding of the relationships between variables Pearson's zero-order correlations are displayed when deemed helpful. To examine the relationship between the desire for social distance and causal beliefs as well as the mediation by emotional reactions, path analysis models were performed in both subsamples separately for each vignette condition.

We determined direct effects, total indirect effects and total effects by computing the corresponding products and sums of products 65 , Coefficients were adjusted for the effect of gender, age and education. The dataset contained 1. This would not only greatly impair statistical power of the subsequent analyses but also potentially bias the results in an unpredictable way if the missing values are not completely at random [MCAR; 67 ].

The MCAR-assumption is very strong and hardly ever applies in practice.

Therefore, the missing values were imputed. We used the mice package version 2. Mice automatically specifies a regression-based imputation model for each of the variables depending on data type by using all relevant predictors available in the data set. It furthermore adds prediction error into the regression yielding more plausibly distributed imputed values than deterministic regression would do through the consideration of noise 69 , The imputed data sets were later pooled to create a single complete data set, rendering our approach technically a single imputation.

Although generally, multiple imputations are preferred over a single imputation, single imputation methods have been shown to perform equally well if the overall number of missing values is small, as in the case our data set All presented analyses are performed on the imputed data set. The invariance of applied measures is a prerequisite for meaningful cross-cultural comparisons in order to ensure that equivalent constructs have been measured across the particular groups Therefore, prior to analyzing cultural differences in our sample, we assessed configural, metric, and scalar invariance of the applied scales.

Configural invariance is given when factors, as well as the pattern of relationships between factors and their indicators, are identical across both groups. We established configural invariance by performing CFAs for each construct of interest in both samples separately see scale descriptions above as well as in both groups combined. Metric invariance is given when factor loadings are identical across both groups. Only with equal factor loadings can the constructs be assumed to have the same meaning across administrations.

Metric invariance is required in order to interpret differences in relationships of variables, such as correlations and regression weights, across cultures Scalar invariance is indicated by equal intercepts of indicators across groups and is required in order to compare differences in factor mean levels across groups and interpret them as meaningful differences. Metric and scalar invariance were assessed by adding constraints of equivalence to the measurement model in accordance with Cheung and Rensvold In order to ensure that group differences can be interpreted as meaningful differences across the two subsamples, measurement invariance was tested for each of the scales implemented.

A summary of the results is presented in Table 3.

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Configural invariance was established for all three constructs. Given the equality of loadings, differences in the relationships of variables such as correlations and regression weights in our sample can be understood to represent meaningful cross-cultural differences. Subsequently, we restricted the item intercepts to be equal across both subsamples. This implementation resulted in a substantial misfit amongst all three constructs, thereby demonstrating a lack of scalar invariance for the applied measures. Hence, differences in the means of variables across both subsamples might result from divergent item difficulty and not represent meaningful cross-cultural differences.

We therefore abstain from comparisons of means across both subsamples. Table 4 provides an overview of the agreement to the different categories of causal attribution in each group for both vignettes combined as well as separately for depression and schizophrenia. In both subsamples, causal attributions to current stress and childhood adversities are the most prevalent for both vignettes combined.

Supernatural causes, on the other hand, received the least endorsement in both groups. Table 4. Summary of causal attributions and comparison of causal attributions between depression and schizophrenia vignettes within both groups. These findings are in line with results reported by previous research. Interestingly, no equivalent differences could be observed in the Turkish immigrant subsample.

Table 5 illustrates zero-order correlations between the categories of causal attributions in both groups. As can be seen, in the Turkish immigrant subsample all categories were correlated which was not the case for the German subsample. All observed correlations in both groups were positive. Table 5. Correlations between the categories of causal beliefs in both subsamples. Thus, in both groups a prosocial emotional reaction was the most prevalent, which is consistent with previous findings.

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In the German subsample, all emotional reactions differed in their intensity across the depression and schizophrenia vignettes. See Table 6 for an overview of means and comparisons between vignettes. Table 6. Summary of emotional reactions and comparison between depression and schizophrenia in both groups. Figures 1 , 2 illustrate the path model between causal beliefs, emotional reactions and desire for social distance for depression and schizophrenia, respectively.

In the depression vignette, the tested model explained In the schizophrenia vignette, the proportion of explained variance of desire for social distance was Figure 1. Path model of the relationship between causal beliefs, emotional reactions, and desire for social distance for depression for both subsamples.